Why colonoscopy for all those over 50?

[spaslam]

Standard practice from what I have seen is colonoscopy for everyone over 50 who will acquiesce. I have yet to be presented with evidence for this. Any thoughts?

http://www.aafp.org/afp/20070601/cochrane.html

"Fecal occult blood testing is a cost-effective, noninvasive screening method for colon cancer. Although endoscopy has higher specificity for colorectal cancer, screening recommendations for colonoscopy and flexible sigmoidoscopy are based on case-control studies. In fact, there is no direct evidence that endoscopic screening reduces all-cause or colorectal cancer mortality.1 These tests also require more patient preparation and have a higher risk."

1. U.S. Preventive Services Task Force. Screening for colorectal cancer: recommendations and rationale. Ann Intern Med 2002;137:129-31.

---

Members don't see this ad.

 

[kaygrace]

$$$$

 

[Art Vandelay]

Read the guidelines that came out a few months back. There is fantastic prospective data on colonoscopy not to mention that every trial uses colonoscopy as the standard after any positive test. Personally, I would want the full shabang and be done for ~10 years. My practice is to lay out the options and decide w/ the pt. what makes the most sense.

 

[gastrodoc]

Remember that colo is the final common pathway for all testing. Only taking out polyps prevents colon cancer.
Take a look at the PPV and NPV for FOBT. Not good.
Also remember with FOBT it's yearly testing. If you go the flex sig route it's flex q 5 years AND FOBT yearly.

 

[friguy3]

FOBT is no longer recommended as a screening tool. The amount of incidental colon cancer that I have personally seen makes it almost laughable when someone says, why do screening colonoscopies? And $$$? the reimbursement aint that great.

 

[JayneCobb]

FOBT is no longer recommended as a screening tool.

Which guidelines are you referring too? The only ones I can find on Guidelines.gov still list FOBT as a viable option.

 

[HMSBeagle]

Which guidelines are you referring too? The only ones I can find on Guidelines.gov still list FOBT as a viable option.

Ok dude. When you hit 50 you get a FOBT as screening for cancer. I know I'm getting a colonoscopy. Better play it safe than be sorry later. Colonoscopy as an early intervention saves lives. FOBT may not always.

 

[JayneCobb]

Ok dude. When you hit 50 you get a FOBT as screening for cancer. I know I'm getting a colonoscopy. Better play it safe than be sorry later. Colonoscopy as an early intervention saves lives. FOBT may not always.

So you'd perform a colonoscopy on absolutely everyone? Think about that really carefully before you answer.

And for clarification, I was asking for evidence that "FOBT is no longer recommended as a screening tool" because I like to know when major changes are made in guidelines. But since it seems that you're only a medical student, you probably have no experience with patients who absolutely refuse to have a "screening" c-scope. And for that matter, I have a couple of patients who lungs and heart are so bad that I know that the GI docs we routinly use would be hesitant to use conscious sedation on these people, while their other issues will likely be the cause of their demise, I don't want to be the one holding the chart when they live long enough to develop a Colon cancer I never screened for.

Ironincally, just prior to seeing this post I had sent one of my patients home with FOBT cards for screening because his 15% EF and recent MI make him less than an ideal canidate. And I revistited the guidelines prior to sending him home with the cards. That is my interest in asking for clarification in the statement, for my education, not because I disagree with screening c-scopes.

 

[BlackNDecker]

The exceptions and contraindications to accepted guidelines is dizzying...it seems overwhelming enough to learn the guidelines let alone the exceptions to the rule.

 

[Gastrapathy]

So you'd perform a colonoscopy on absolutely everyone? Think about that really carefully before you answer.

And for clarification, I was asking for evidence that "FOBT is no longer recommended as a screening tool" because I like to know when major changes are made in guidelines. But since it seems that you're only a medical student, you probably have no experience with patients who absolutely refuse to have a "screening" c-scope. And for that matter, I have a couple of patients who lungs and heart are so bad that I know that the GI docs we routinly use would be hesitant to use conscious sedation on these people, while their other issues will likely be the cause of their demise, I don't want to be the one holding the chart when they live long enough to develop a Colon cancer I never screened for.

Ironincally, just prior to seeing this post I had sent one of my patients home with FOBT cards for screening because his 15% EF and recent MI make him less than an ideal canidate. And I revistited the guidelines prior to sending him home with the cards. That is my interest in asking for clarification in the statement, for my education, not because I disagree with screening c-scopes.

The new guidelines for colon cancer screening (not from the GI societies incidentally) break the options for screening tests into 2 groups, those that detect adenomas and those that detect cancer. FOBT, FIT and stool DNA fall into the cancer detection category. Flex sig, CT colonography, BE and colonoscopy are the adenoma detection group. The guidelines keep FOBT in the list of approved tests for economic and access reasons, not because it is equivalent. If you have access to an adenoma detection test, this is what you should offer your patients.

Of these, patients clearly prefer colonoscopy and are more likely to return for repeat screening/surveillance if their first test is a colonoscopy (nice DDW presentation, should be out in a journal in the next few months). My patients tell me over and over that "virtual colonoscopy" is anything but virtual. Also, unless you are an academic center doing same day colonoscopy, CT colonography requires 2 bowel preps. BE is on the list but will disappear because CT colonography is better, so hardly any BE's are ordered anymore.

My question for you would be, you have a poor operative candidate, so what are you going to do with a positive FOBT? If you think someone is too sick to safely undergo a very low risk procedure like colonoscopy, why are you screening him at all?

Here is the reference.

http://caonline.amcancersoc.org/cgi/content/full/CA.2007.0018v1

BTW, I was quite disappointed in these guidelines for their emphasis on CT colonography despite its limited data (these are such political documents) and the lack of a recommendation to screen African Americans starting at an earlier age. I really think we're doing that group a disservice.

 

[JayneCobb]

The new guidelines for colon cancer screening

Thank you for the link, all I could find were 2006 recommendations.

And I'll be honest, I debated quite a bit about giving out the cards to begin with, I don't have access to FIT/Stool DNA especially for this pt. I did it for a combination of reasons, 1) I've been after him to get a scope for almost a year, 2) I don't really want to scope him at this very moment considering his MI was 1 month ago, 3) the echo which shows 15% EF was taken immediately after his STEMI so I would like to repeat it again in 5 months 4) no insurance and 5) I'll admit that I'm training in one of the most litigious counties in the Nation and that's always on the back of my Attendings minds and part of the discussion when they critique my plans. I'm well aware that Statistically speaking, even if he turns up to have Stage IV Colon CA, his heart dz has just as bad if not worse prognosis as colon ca but I'm not quite cynical enough to stop screening all those with bad prognosis yet.

 

[elwademd]

Thank you for the link, all I could find were 2006 recommendations.

And I'll be honest, I debated quite a bit about giving out the cards to begin with, I don't have access to FIT/Stool DNA especially for this pt. I did it for a combination of reasons, 1) I've been after him to get a scope for almost a year, 2) I don't really want to scope him at this very moment considering his MI was 1 month ago, 3) the echo which shows 15% EF was taken immediately after his STEMI so I would like to repeat it again in 5 months 4) no insurance and 5) I'll admit that I'm training in one of the most litigious counties in the Nation and that's always on the back of my Attendings minds and part of the discussion when they critique my plans. I'm well aware that Statistically speaking, even if he turns up to have Stage IV Colon CA, his heart dz has just as bad if not worse prognosis as colon ca but I'm not quite cynical enough to stop screening all those with bad prognosis yet.

its not cynical, its practical. if he's a high risk candidate for a colonoscopy, he's not a candidate for treatment (surgery nor chemo) for the thing you're trying to screen for.

add to that, given that he's had a stemi, he should be on anti-platelet therapy... which may increase his risk of having a positive fobt... that turns out to be nothing at all!

i think you should just tell your attendings that there's no reason to screen for it, because you're not going to do anything with the information that you receive from said screening test.

what would make more sense, to me at least, would be to get the fobt in a few months when his cardiac issues are a little more clear. as you stated, it's not as if he'd be able to undergo any further evaluation/testing (save for a cbc to check for anemia, and perhaps an anemia work up if warranted) ... so if the test is positive, you're going to sit on it for months anyway.

on the one hand, you could hold off screening and he ends up with cancer... on the other hand, you could get the screening now, and he potentially has cancer but you can't do anything about it! sounds like a lose-lose.

unfortunately, these scenarios seem more and more common these days.

 

[JayneCobb]

on the one hand, you could hold off screening and he ends up with cancer... on the other hand, you could get the screening now, and he potentially has cancer but you can't do anything about it! sounds like a lose-lose.

Currently my line of thought is that it is easier to document why you didn't follow up on a test with documentation that you talked to the patient than not running recommended screening tests.

 

[elwademd]

Currently my line of thought is that it is easier to document why you didn't follow up on a test with documentation that you talked to the patient than not running recommended screening tests.

we have different solutions with the same end point, as i would rather document why not to pursue said screening test and discuss that with the patient! it's why oftentimes its an art.

 

[Gastrapathy]

Currently my line of thought is that it is easier to document why you didn't follow up on a test with documentation that you talked to the patient than not running recommended screening tests.

I really have a problem with this line of thought. The point at which you educate the patient about risks/benefits is prior to screening, not halfway through. All your path does is waste resources, cost the patient copays and increase patient anxiety. If you are going to screen, you need to be prepared to act on a positive result.

 

[JayneCobb]

I really have a problem with this line of thought. The point at which you educate the patient about risks/benefits is prior to screening, not halfway through. All your path does is waste resources, cost the patient copays and increase patient anxiety. If you are going to screen, you need to be prepared to act on a positive result.

I never said I didn't educate the patient on what would probably happen if the test was positive, nor did I say that I wouldn't have him scoped, I believe the wording was "don't really want to scope him at this very moment". If it's positive, it's positive and we'll discuss the risks/benefits of going further in the work up and see what the GI docs here say.

 

[tussy]

Okay, i have to weigh in on this discussion.

First, FOBT is the only screening modality that has level 1 evidence. However, most agree that the end pathway is still colonoscopy and that's where the benefit it had. This is further supported by the national polyp study that showed that removing polyps significantly decreases the incidence of colorectal cancer. However, in order for colonoscopy to be effective as a screening tool there has to be an acceptably low rate of complications (perforation/bleeding/sedation complications,etc). Therefore, a patient that is very high risk for colonoscopy may not see a benefit. I agree that in such a patient FOBT may be a good initial screening test with much lower risk, recognizing that a positive test would definitely have to be followed up with a scope.

I am talking screening here - for average risk individuals. In someone with a strong family history or symptoms then the risk benefit profile changes and there is a benefit to colonoscopy.

It drives me crazy as a colorectal surgeon that a patient with symptoms is denied a scope because of comorbidities and then present with a lesion that can't be removed through the scope (ie the polyp becomes a cancer) or present as a emergency (the resectable cancer becomes unresectable, or they present with perforation/bleeding/obstruction). Dealing with these patients on an elective basis is always preferable. Colon resection is fairly low risk surgery if the patient is properly optimized prior, but becomes extremely high risk when they come in in extremis with complication.

So with your guy with the recent MI - if he's asymptomatic then i would wait until he's more stable from a cardiac point before doing a colonoscopy. FOBT may be a good compromise in this situation. However, if he is symptomatic from a GI standpoint then an diagnostic scope would not be that risky and would be indicated.