Testing for Colon Cancer Offers Mixed Messages

A recent series of articles published in the New England Journal of Medicine (NEJM) presented a less than clear picture of colon cancer screening. Gary Schwitzer, writing on HealthNewsReview.org took on the muddled message offered by the science journal, and the popular media’s woeful effort to offer context and meaningful advice to consumers. We’ve tackled the topic before as well.

Here’s the latest advice from our Better Health Care newsletter on how to sort out your colon cancer screening options.

As Schwitzer notes, one NEJM study championed the benefits of colonoscopy screening, one trumpeted the potential benefits of a blood stool testing procedure called Fecal Immunochemical Testing (FIT) and an editorial pondered both.

Readers interested in seeing how medical journalism grapples with material that requires some depth might enjoy HealthNewsReview’s explanation of who went right, who went wrong and who is wandering around in the middle. But if you’re looking for the best, most concise information to enable you to take care of yourself, Schwitzer, a widely respected health news analyst, points to the Reuters coverage. We agree.

Its take-away message, gleaned from the NEJM editorial and explained with additional interviews, was that the best colon-health practice appeared to be colonoscopy screening for everyone who’s 60. The results would tell you if you’re high risk or low risk. High risk people get regular colon follow-ups; everybody else stops worrying.

Here’s how a competent report helps readers objectively judge the information: Reuters was the only news organization that quoted the FIT researchers about their study as much as it allowed the colonoscopy researchers to tout their work. According to the FIT researchers, “the numbers of subjects who needed to be screened to find one colorectal cancer were 191 in the colonoscopy group and 281 in the FIT group, and the numbers who needed to be screened to find any advanced (cancer) were 10 and 36.”

This simple numerical analysis reflects a larger discussion we had in a recent edition of our patient safety newsletter about a concept called “numbers needed to treat”.

As Reuters notes, such objective qualities are important because the FIT test is much less expensive than a colonoscopy. “This simple, noninvasive and cheap test is equally good at detecting colorectal cancer and identifying the high-risk individual that should undergo a colonoscopy.”

Reuters also explained that the complication rate-bleeding, low blood pressure and slow heartbeat-was nearly five times higher in the colonoscopy group.

And just as important is the percentage of patients who follow the advice to get one or the other screening techniques. In both screening tests, the follow-through rate is low — understandably, because the tests are bothersome and unpleasant at a minimum. But the FIT test was more popular than colonoscopy — one in three patients went ahead and got the FIT test while only one in four got a colonoscopy.

Schwitzer’s report included further analysis from Harold DeMonaco, director of the Innovation Support Center at Massachusetts General Hospital. Of particular note for people considering colonoscopy or other colon diagnostic measures, he said:

  • Early detection and removal of adenomatous polyps (benign tissue with the potential to become malignant) appears to reduce the risk of colon cancer. A considerable minority of adults will have adenomatous polyps on colonoscopy, including as many as 1 in 4 males.
  • Colon cancer grows slowly. Good followup for people who have had an adenomatous polyp removed appears to reduce the risk of dying from colon cancer over several decades of observation.
  • FIT appears to be as useful as a screening tool for colon cancer, but it’s not as good in detecting existing adenomatous polyps.
  • FIT is easier, much less expensive and does not have the rare but important potential complications associated with colonoscopy.
  • The right combination of colonoscopy and FIT remains unclear, as does the role of CT colonoscopy.
  • If a conclusive approach to colon polyps screening remains elusive, at least some things are clearer, and patients can make more informed choices.

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