If you’ve got a shaker of salt, you may want to empty it on recent news coverage of the American Cancer Society’s announcement about its new guidelines on the age to start colorectal screening. That’s because the organization’s advisory and more than a few health journalists show a shaky grasp of basic disease statistical math.
Cancer specialists, correctly, are concerned because they say they are seeing the disease in younger people, with more colon and rectum cancers detected in patients in their 20s and even in their teens. They’re unsure what’s causing this. But just how many diagnosed cases have there been — and do the numbers mean there’s enough hard science to support a new recommendation that patients get colorectal screening five years earlier than they do now, at age 45 instead of 50?
As Kevin Lomangino, managing editor of Healthnewsreview.org, a health news watchdog site, points out, too many reporters became too accepting of experts’ fuzzy math when describing a screening change that could result in patient harms. The society, and specialists contacted by many reporters, spoke often of “doubled risks,” or impressive seeming percentage increases in colorectal cancer diagnoses — but without providing actual numbers of cases.
Lomangino dug around and provided this math translation about some of the cancer experts’ figures, explaining what the society describes as “all too common” colorectal cases:
Missing from all of these stories, however, is any quantification of the actual rate of colon cancer in these [younger] groups … As the New York Times noted last year, a person who was born in 1950 had a three in a million risk of developing colon cancer in their twenties, compared with a five per million risk for someone born in 1990. The risk of rectal cancer for someone in their twenties increased from 0.9 per million for those born in 1950, compared with 4 per million for someone born in 1990. Those increases are in the same ballpark as the risk of being struck by lightning.
Let’s look at the numbers in a different way. The New York Times did report actual numbers on what cancer experts described as a “game changer,” and a “very, very big deal.” (And which has not been adopted by other expert groups). The American Cancer Society, the newspaper said, “estimates some 16,450 new cases of colon or rectal cancers will be diagnosed this year in Americans under 50.” (Emphasis added because they’re suddenly talking about two-thirds of the U.S. population).
So, let’s see, there are 323 million Americans, the U.S. Census says, with 13 percent of them ages 40-49. Let’s halve that figure to guesstimate the age 45 to 49 group, with roughly 6.5 percent of the population amounting to 21 million adults. Keep that number in mind.
The new cancer society guidelines carried another nuance that may not come through, for patients and physicians alike: They suggest that heightened colorectal screening occur via a half dozen options, “ from the most invasive procedure, colonoscopy, which can be done every 10 years, to lab tests done on stool samples that can be collected at home, which must be repeated more often and followed by colonoscopy if results are positive,” the New York Times reported. The Washington Post helpfully informs that one cancer society recommended screening would use Cologuard, a branded fecal test.
Here’s the money part of this deal: Cologuard lists for $649 per test. A colonoscopy, consumer sites say, goes for $3,000 or so. Now do a little multiplication of the new group that the cancer society urges screenings for, 21 million adults, ages 45 to 49, and this advisory annually would add, if 100 percent adopted, somewhere between $13 billion to $63 billion in testing costs, right? A West Coast colleague, with a play-it-safe family doctor, just had a most basic screen, an in-office fecal blood test, as part of a bi-annual physical. He was billed $40, which, costed out for 21 million 45- to 49-year-olds, still would amount to $840 million a year.
Lomangino reported that cancer specialists he talked to had other concerns with the society’s screening guideline change: It was based on mathematical modeling, not rigorous clinical trials to affirm that earlier detection of colorectal cancers in younger patients would be beneficial in treatment or harms, including death, or quality of life. Respondents to Lomangino’s on-line post also pointed out that the society and supporting specialists fuzzed up the reason for the guideline change by talking about detected colorectal cancers in teens and 20-somethings, without explaining well why, then, it mattered to lower the screening age to 45 from 50?
In my practice, I see the major harms that patients suffer while seeking medical services, and their struggles to access and afford safe, efficient, and excellent medical care. Increased colorectal screenings inevitably will result in false positives, adding to a perceived need for additional costly and discomforting tests and potentially risky procedures, including the more invasive and expensive colonoscopies. Haven’t we been down this path before about aggressive screening with prostate and breast cancer? Aren’t we past due in asking tough questions on how many lives have been saved or improved by medical tests, especially for cancer?
Colonoscopies may have become a routine though unpleasant procedure, but they are hardly risk-free. Their complications, including perforations and infections, may be under-reported, and can require costly, further treatment and hospitalization for tens of thousands of patients. There also may be cause for extra concern over complications with colonoscopies and endoscopies performed at specialized, out-patient centers.
Further, over-screening and over-treatment already create nightmares for Americans trying to keep up with skyrocketing medical costs. Wasteful spending of this kind may add $765 billion in unneeded costs to the country’s $3 trillion annual spending on health care, experts estimate.
Colorectal cancers are a serious problem, not to be ignored. As the New York Times reported:
[More than] 140,000 Americans are expected to be given a diagnosis of colon or rectal cancer this year. The disease leads to over 50,000 deaths annually, making it the second leading cause of cancer fatalities among American adults. The vast majority of colorectal cancers are still found in older people, with nearly 90 percent of all cases diagnosed in people over 50. But [the] incidence and deaths among those 55 and older have been declining in recent decades, at least in part because of screening that results in removal of precancerous polyps and early detection of cancer …
Even with increased efforts to get insurers to up their payment for colorectal screening, notably through preventive treatments covered under the Affordable Care Act, aka Obamacare, many Americans 50 and older still do not get tests that research has shown could be beneficial to them. It’s perplexing to experts quoted by Lomangino why the cancer society didn’t put more effort into getting more older adults, who are highest risk, to get screened, rather than expanding the number of patients.
If you have a family history with colorectal cancers, or if you have other higher risk factors, including obesity, smoking, or if you are African American (a group with higher incidence), you may wish to talk to your doctor about earlier, more intensive screening. Colorectal cancer warning signs include “persistent and concerning gastrointestinal symptoms,” change in bowel habits (diarrhea or constipation, that lasts more than a few days), rectal bleeding; and cramping or abdominal pain.
Don’t ignore these symptoms, and experts quoted by The New York Times, make the point that young people should persist with physicians who may try to dismiss their concerns about rectal bleeding, blaming it on hemorrhoids.