Costly colonoscopies get skeptical scrutiny in big European study

colonoscopynatinstitute-300x292Colorectal cancer remains  the third most commonly diagnosed form of cancer  in this country. It kills tens of thousands of Americans annually. Although detection of the illness is declining overall, and especially among older adults, specialists have expressed growing concern about its rising rates in younger patients. This has prompted experts to push for more screenings to discover this cancer earlier.

But a new, decade-long European study involving 80,000 participants has given experts in the field at least a pause and may be forcing a more nuanced consideration of colonoscopies — long considered a pricey, inconvenient, intrusive, but “gold standard” test in the battle against colorectal cancer.

The study offered a brusque reminder, especially to regular folks, that testing and early detection of serious illnesses do not automatically result in optimal outcomes that improve or extend lives. As Stat, the science and medical news site reported:

“For decades, gastroenterologists put colonoscopies on a pedestal. If everyone would get the screening just once a decade, clinicians believed it could practically make colorectal cancer ‘extinct,’ said Michael Bretthauer, a gastroenterologist and researcher in Norway. But new results from a clinical trial that he led throw confidence in colonoscopy’s dominance into doubt. The trial’s primary analysis found that colonoscopy only cut colon cancer risk by roughly a fifth, far below past estimates of the test’s efficacy, and didn’t provide any significant reduction in colon cancer mortality.

“Gastroenterologists, including Bretthauer, reacted to the trial’s results with a mixture of shock, disappointment, and even some mild disbelief. ‘This is a landmark study. It’s the first randomized trial showing outcomes of exposing people to colonoscopy screening versus no colonoscopy. And I think we were all expecting colonoscopy to do better,’ said Samir Gupta, a gastroenterologist at the University of California, San Diego and the VA who didn’t work on the trial. And, he said, it raises an uncomfortable question for doctors. ‘Maybe colonoscopy isn’t as good as we always thought it is.’”

To be sure, the study has been the subject of considerable discussion among medical specialists since its publication in the New England Journal of Medicine. The reported consensus, for now, holds that colonoscopies continue to be important, worthwhile, and valued procedures, especially if other screenings — such as less costly and invasive tests for blood, DNA, or chemicals in the stool, or lesser checks of the colon (sigmoidoscopy) — raise serious worries for diagnosticians.

Still, as Drs. Jason Dominitz and Douglas Robertson wrote in an accompanying editorial in the medical journal about the European research:

“Given the modest effectiveness of screening colonoscopy in the NordICC trial, what should we conclude about the role of this test? If the trial truly represents the real-world performance of population-based screening colonoscopy, it might be hard to justify the risk and expense of this form of screening when simpler, less-invasive strategies (e.g., sigmoidoscopy and FIT) are available. However, with increased levels of participation in screening and with high-quality examinations, greater reductions in the incidence of colorectal cancer and related death would be expected. Although the results reported by Bretthauer et al. may, in the near term, temper enthusiasm for screening colonoscopy, additional analyses, including longer follow-up and results from other ongoing comparative effectiveness trials, will help us to fully understand the benefits of this test.”

In news reporting about the European study, specialists noted a nuance of the research involving what is described as participants’ responses to the “invitation” to undergo colonoscopies and whether a key finding for doctors to consider is the data on this topic. In brief, fewer than half of those “invited” to undergo the procedure did so, and the results followed from those that underwent colonoscopies.

The procedure, which involves unpleasant prep, and in this country — but not necessarily in Europe, which is a key point — anesthesia, cost, and loss of time is dreaded, with reason, by many, even if done only once a decade. Sure, it also provides on-the-spot medical response, aka a surgical removal, to growths or polyps detected during the procedure.

Patients, of course, should discuss with their doctors the pros and cons of colonoscopies, particularly taking into account their individual health and family history. If patients have concerns about the discomfort and cost of colonoscopies, these should be aired fully. The U.S. Preventive Services Task Force, an independent expert advisory to the federal government on medical tests and procedures, offers its endorsement of colorectal screening, given an “A” recommendation for those aged 50 to 75 and a “B” for those 45 to 49 — with a detailed and nuanced discussion about different ways this can be done and which patients may best benefit.

In my practice, I see not only the harms that patients suffer while seeking medical services, but also the damage that can be inflicted on them and their loved ones by defensive and excessive over testing, over diagnosis, misdiagnosis, and over-treatment. Patients struggle too much already to afford needed medical services much less those that are invasive, painful, wasteful, and unnecessary.

Up to a third of medical spending goes for over-treatment and over-testing, with an estimated $200 billion in the U.S. expended on medical services with little benefit to patients. But getting doctors and hospitals to stop this excess isn’t easy, nor is it a snap to get patients to understand what this problem’s all about so they’ll push their health care providers to do something about it.

As the news reporting on the European study pointed out, a complication for doctors discussing colonoscopies is their own financial benefit from the procedure, which typically is covered by insurance but can cost thousands of dollars and provide a significant portion of the income for specialists. Patients should be greatly concerned and even more skeptical about the reported rise of big interest by private investors, aka hedge funds, in a “golden age” of colonoscopies in our graying nation and big profits in gastroenterology practices.

Let’s give most doctors some benefit of the doubt, simply insisting that if they really want patients to undergo colonoscopies, they can take the time to explain, in full and in detail, with a persuasive why. They also can discuss other less expensive and invasive options, if appropriate, right?

We have much work to do to ensure that all medical tests and procedures are safe, accessible, affordable, efficient, necessary, and excellent.

Illustration credit: National Institute of Diabetes and Digestive and Kidney Diseases
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