Avoiding a Colonoscopy? You’re Not Alone

If the sight of a colonoscope like this one makes you shudder, there are other options for colorectal cancer screening.

Colorectal cancer is one of the five most common cancers in both men and women, and it kills more than 43,000 Americans each year. As we learned today, colonoscopy is a successful screening method–it cuts the death rate of colorectal cancer in half.

Still, getting a colonoscopy has a problem: the yuck factor. That’s why a study in today’s New England Journal of Medicine caught my eye. Researchers in Spain looked at colonoscopy versus “FIT,” a non-invasive test to screen for colorectal cancer. FIT–fecal immunochemical testing–looks for the presence of blood in the stool, a marker for benign polyps or cancer. Patients have either one colonoscopy during the ten years of the study or FIT every other year. (Note that the American Cancer Society has a great explainer of the different screening methods available and pros and cons of each).

“In order to get a large proportion of a population screened, you have to offer an alternative to colonoscopy.”
In today’s study researchers say colonoscopy and FIT detected roughly the same number of cancers. The report comes at the two year point of what will be a ten year study. We have to wait the full ten years to see how death rates from colorectal cancer compare between the two types of screening.

In the meantime, some interesting factoids that hint at the yuck factor popped up in the breakdown of which patients participated in which screening. Fully 94 percent of patients who responded to an invitation to participate in the FIT trial completed the test. But in the colonoscopy group, the rate dropped to 67 percent. In addition, more than 20 percent of the people who were assigned to colonoscopy opted for FIT instead. Apparently, they weren’t so interested in having a colonoscopy. But they WERE interested in being screened.

For a little perspective on the study, I called Dr. Theodore Levin, who heads up Colon Cancer Screening for Kaiser Permanente in Northern California. “What’s clearly shown here,” he told me, “is that in order to get a large proportion of a population screened, you have to offer an alternative to colonoscopy.”

For the last several years, Kaiser Permanente has been making aggressive strides to screen its own patient population. Individual doctors may still continue to recommend colonoscopy to patients ages 50 to 75 — the recommended ages for colorectal cancer screening. But Levin says that Kaiser wanted something they could mail out — something that people could do at home, then mail back to the lab. Kaiser put in place an automated system of phone calls and reminder postcards to encourage people to complete the FIT test and send it in. Unlike the study in Spain, Kaiser recommends patients get a FIT test every year, instead of every other year.

The effort has been working. Levin says Kaiser has seen their colorectal cancer screening rates “march up.” In 2011, 80 percent of its members ages 50 to 75 had been screened, he says. About twice as many people had FIT as colonoscopy. And the screening appears to be leading to earlier diagnosis. “We’re diagnosing much earlier stage cancers and fewer of them,” Levin says. “Two hundred fewer colon cancer in 2010 than in 2009 across Northern California Kaiser, even with membership growth.”

Levin cautions that he is waiting for one more year of data to be sure Kaiser is on the right track. As for cost, Levin also believes the screening will save money. “Cost of treating advanced colon cancer keeps getting more expensive, so we think any way you can get people screened is a cost saving endeavor through the whole cycle of screening through treatment.”

Choice in screening also speaks to the importance of patient decision-making. “We’re definitely making a difference,” Levin says, “and we’ll be most effective in giving patients what they want, instead of telling them what they need.”

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