"Should We All Get Colonoscopies Starting at Age 50?"
Though colonoscopies can cause serious harm in about 1 in every 350 cases,
sigmoidoscopies, which are shorter and smaller scopes,
have ten times fewer complications.
But do colonoscopies work better? Is the total risk-benefit better?
We don't know since we don't have any randomized controlled colonoscopy trials,
and we won't until the mid 2020's.
So what should we do in the mean while?
The USPSTF, the official prevention guidelines body, considers colonoscopies
just one of three acceptable colon cancer screening strategies.
Starting at age 50, we should either get our stool tested for hidden blood every year,
no scoping at all; or a sigmoidoscopy every 5 years, along with stool testing every 3;
or a colonoscopy every 10 years.
And in terms of virtual colonoscopies or the new DNA stool testing,
there is insufficient evidence to recommend either of those two.
Though they recommend ending routine screening at age 75,
that's assuming you've been testing negative for 25 years since your 50th birthday.
If you're 75 and you've never been screened, then it's probably a good idea
at least into one's 80s.
If there are three acceptable screening strategies, how should one decide?
They recommend that patients work with their physician in selecting one
after considering the risks and benefits of each option.
For patients to participate in the decision-making process, though,
they have to be given the information.
The degree to which health providers communicate the necessary information
was not known until this study was published.
They audiotaped clinic visits looking for the 9 elements of informed decision-making:
discussing the patient's role in making the decision,
what kind of decision has to be made, what are the alternatives,
what are the pros and cons of each option, the uncertainties,
making sure the patient understands their options, and then finally
ask them what would they prefer?
That's the role of a good doctor. It's your body; it's your informed decision.
How many of these 9 crucial elements of informed decision making
were communicated to patients when it came to colon cancer screening?
Care to hazard a guess? In most of the patients: none.
The average number addressed? One out of nine.
As an editorial in the Journal of the American Medical Association put it,
"There are too many probabilities and uncertainties for patients to consider
and too little time for clinicians to discuss them with patients."
So doctors just end up making the patients' mind up for them, and what do they choose?
Most often, as in this survey of a thousand physicians,
doctors recommend colonoscopy. Why?
Other developed countries mostly use the stool tests, the FOBT tests,
with only a few recommending colonoscopies or sigmoidoscopies.
This may be because most physicians in the world don't get paid by procedure.
As one US gastroenterologist put it,
"Colonoscopy is the goose that laid the golden egg."
A New York Times exposé concluded that the reason doctors rake in
so much money is less about top notch patient care
and more about business plans, maximizing revenue,
and lobbying, marketing, and turf battles.
Who sets the prices for procedures?
The American Medical Association, the chief lobbying group for physicians.
They set the prices. No wonder gastroenterologists pull in
nearly a half million dollars a year.
And the American Gastroenterological Association wants to keep it that way.
Referring to these exposés the president of the Association
warned that gastroenterology is under attack.
Colorectal cancer screening and prevention may be reduced
in volume and discounted.
But they have tips for how to succeed in the coming nightmarish world
of accountability and transparency.
Why would primary care docs push colonoscopies though?
Because many doctors get what are essentially financial kickbacks
for procedure referrals.
Studying doctor behavior before and after they started profiting from their own referrals,
it's estimated that doctors make nearly a million more referrals every year
than they would have if they were not personally profiting.