Should the colonoscopy be the ‘gold standard’?
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CORRECTION: Earlier this week, we told you how an expensive procedure — the colonoscopy — became a new standard for colorectal cancer screening. We incorrectly described the American Cancer Society’s position, in noting its role. Two years ago, the society issued new screening guidelines that, for the first time, made colonoscopies a preferred test. The text has been corrected.
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KAI RYSSDAL: A lot of what was in the health care reform law is going to roll out over time. This coming January there’s going to be a biggie. After New Year’s, your health insurance company is going to have to pick up the entire tab when you go for certain screening tests. No patient co-pays at all. Preventive screening in this country has always been a mix of science and big business. The cost-benefit and life or death analysis of doing a given test versus not doing it. A dilemma neatly summed up by the story of one of the most frequently done tests out there: The humble colonoscopy.
From the Marketplace Health Desk at WHYY in Philadelphia, Gregory Warner reports.
GREGORY WARNER: If you’re over 50 years old, your doctor’s probably told you to get screened for colorectal cancer — and that the best test is a colonoscopy.
The story of how colonoscopy became one of the most common medical procedures in the country begins with a fiery editorial in a gastroenterology journal. Its writer a young oncologist named Alfred Neugut. The year was 1988.
ALFRED NEUGUT: To me, it was so obvious, that it was going to be the future of colon screening.
Though he never quite imagined how fast it would catch on.
NEUGUT: That 50 percent of the American public allows themselves to have a tube that’s four feet long inserted up their, uh, backside is to me absolutely incredible.
Back in the 80s when Neugut was writing his editorial, doctors were using a shorter tube. It’s a simpler test called a sigmoidoscopy. It looks at only half the colon. In that test, there’s no sedation, no day off from work, no jug of laxatives the night before and maybe no gastroenterologist. Your primary care doctor could probably do the procedure himself.
So why’d we trade up? From the simpler test to the more specialized one?
DEBORAH FISHER: The thought was if looking at part of the colon is good, looking at the whole colon must be better.
Deborah Fisher is a gastroenterologist at the VA Medical Center in Durham, N.C. She says there has never been any hard evidence — no clinical trial — showing colonoscopy screening saved more lives.
FISHER: And it wasn’t always acknowledged that doing one test versus the other test also increased the cost and the risk.
Colonoscopy is three to four times more expensive than the simpler sigmoidoscopy test. And the risk of complication is seven times higher. Still the idea caught on. And as it did, it transformed the profession of gastroenterology. We went from too many specialists to a national shortage.
MAURICE LEONARD: If I just wanted to do that I could! Just, screening colonoscopies all day.
Maurice Leonard is a gastroenterologist I meet in Lumberton, N.J. His group practice has grown on colonoscopy’s rising tide.
LEONARD: We started in 1990…
Two years after Neugut’s editorial.
LEONARD: …with one room the size of a bathroom.
Then in 2000, Katie Couric had her colonoscopy on national TV, causing a 20 percent spike in screenings. The next year, Congress ordered Medicare to cover the procedure. Private insurers followed suit, and Dr. Leonard took over two floors.
LEONARD: A good number of the people we see every day are otherwise healthy people who are here ’cause they’re screening colonoscopy. And the expansion has really been driven by that.
In 2008, the American Cancer Society took an extra step. It issued guidelines that for the first time made colonoscopies a preferred test. Dr. Leonard took over a whole new building.
LEONARD: The new expanded room? This is one of them, yes.
Now he’s expanding again. The new health care law will compel insurance companies to pay, in full, for colorectal cancer screening. Right now, a patient’s out-of-pocket costs can range up to a thousand dollars or more.
WARNER: So there will be a bump.
LEONARD: Yeah, I think that’ll be an increase in the number of procedures when the barrier of deductibles and co-pays decreases.
No one knows exactly how big a business colonoscopy screening has become. Some 37 million Americans over the age of 50 have had one. And yet the first good study of its effectiveness only came out last year. A large study out of Ontario. It found that colonoscopy did not do better than that older, cheaper test, the sigmoidoscopy, to reduce cancer deaths in the more hard-to-reach half of the colon. In other words, if looking at part of the colon is good, looking at the whole colon may not be any better.
Again, here’s Deborah Fisher.
FISHER: The first reaction from a lot of gastroenterologists was just, well, they clearly don’t know what they’re doing. Who the heck is doing colonoscopy in Canada what are they thinking? But now there’s several studies and they’re all telling the same story.
NEUGUT: That’s the point. There are only three studies and all three of them have exactly, exactly the same finding.
This summer, Al Neugut wrote a new editorial in the Journal of the American Medical Association this summer. He said his thoughts had changed.
NEUGUT: If today, we were where we were in 1988, I would not institute colonoscopy based on the current evidence.
As Neugut has discovered, it’s easier to start a revolution than stop one.
DOUGLAS REX: It’s hard to slow the train down when it’s runnin’. You gotta have a pretty clear reason before you switch tracks.
Dr. Doug Rex is one of the world’s experts in colonoscopy technique. He’s done over 30,000 of them himself. He says the new studies are a wake-up call.
REX: But I don’t think we’ve seen enough evidence yet that means that we have to all of a sudden slam on the brakes.
And nobody is, yet. On the contrary, the American Cancer Society is lobbying the White House to adopt its guidelines.
STEPHEN FINAN: We stand very strongly behind our guidelines.
Stephen Finan is senior policy director.
FINAN: Colonoscopy is one of the tests that we really should be pushing very hard to increase.
Al Neugut hopes that the scientific debate will resolve in the next year or two as more evidence emerges. But science does not progress in a vacuum.
NEUGUT: So that becomes now a political issue, and is an insurance company not going to pay for it?
Because in the science of preventive medicine, there’s more than just science.
In Philadelphia, I’m Gregory Warner for Marketplace.
Ryssdal: If you and your doctor are pondering a screening test for you, you can head on over to our website to check the list of which screenings will be covered.
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