At a recent dinner, I was seated next to a good friend’s mother, who, I learned, was in treatment for Stage 4 colon cancer. As a cancer survivor myself, I felt an instant kinship with her.
I felt sad, because the mother had recently finished a tough course of treatment; she looked weak and vulnerable. I was also troubled, because regular screening for colorectal cancer has demonstrably saved lives. The death rate from colorectal cancer in 2018 was 55 percent less than what it was in 1970, thanks to more widespread screening and more effective treatments. Why would anyone not get screened — especially my friend, given her family history that more than doubles her risk?
Unfortunately, my friend and her husband are hardly alone. Although colon cancer screening rates have increased substantially in the past two decades, the bad news is that fully one-third of those over 50 aren’t screened. This is a cancer where screening really matters — doctors can find and remove polyps before they turn cancerous in the first place.
I’ve certainly heard my friends talk — and post — about how awful the “prep” is. (You need a very clean bowel for the test, so you’ll have to fast the day before — and as one friend put it, “poop your brains out.”) Some fear the procedure will hurt. So they put it off, again and again.
I’m a veteran, having had three colonoscopies, and I can attest: No, the prep is not fun, but it’s far from awful. Yes, I got hungry while fasting. Yes, I pooped a lot. But no, when done under sedation, which is how it is done, there’s nothing painful about a colonoscopy. The benefits, on the other hand, are quantifiable. On my second time around, the gastroenterologist found three polyps (known as adenomas), which he removed and sent off for biopsy. They were deemed precancerous, so I was lucky to have had them detected and removed before they could develop into cancer.
John Kisiel, a gastroenterologist at the Mayo Clinic, told me there are other barriers to screening, including cost, if insurance does not cover it or a person does not have insurance, taking time off from work and the need for sedation, which requires someone to accompany you to and from the procedure. (After my divorce, I missed my next colonoscopy because I was hesitant to ask a friend to accompany me. Unlike many other procedures, this one feels personal.)
Some people have difficulty accessing screening services, especially in rural, underserved or socioeconomically disadvantaged areas. In too many instances, Kisiel says, patients tell him their doctors don’t recommend screening because they lack a family history and they don’t have any symptoms, which include bleeding from the rectum, blood in the stool, dark or black stools, and bowel habit changes.
That’s bad advice, Kisiel told me, because most people who learn they have colorectal cancer did not have any symptoms. That’s why we have mass screening guidelines.
Only eight months ago, the United States Preventive Services Task Force lowered the recommended threshold for screening to age 45 from 50 for everyone because the rate of new cases in younger people is increasing. (Regardless of your age, those with a family history should discuss their personal risk with a doctor; screening before even age 45 may be recommended.)
While a colonoscopy is considered the gold standard for colon cancer screening, there are other options. These other methods, according to the American Cancer Society, “have a comparable ability to improve life expectancy when performed at the appropriate time intervals and with the recommended follow-up.” They include:
Fecal immunochemical testing, or FIT, which is a stool-based test. The primary advantage is that it can be done at home and doesn’t require bowel prep. Another benefit is that FIT can detect colon cancer early, still at a treatable stage, which is great — but of course, colonoscopies can prevent these cancers from developing in the first place by identifying polyps and removing them. On the downside, it’s an annual test (colonoscopies, when normal, should be done every five to 10 years), although an abnormal result will then require a follow-up sooner than the usual schedule. My own gastroenterologist told me the FIT test was not for me, given my previous history of polyps. He added that “the FIT test is not nearly as sensitive for diagnosing precancerous polyps, which is the whole point of screening.” If resources are limited, though, it’s on the table.
Virtual or CT colonoscopy: This consists of a CT scan of your colon and rectum; a small catheter is placed inside your rectum and filled with air or carbon dioxide. The procedure takes about 10 minutes, and if your results are normal you’ll be asked to come back in five years. There’s no sedation or colon cleansing needed. You will need to drink a solution of a contrast medium for the scan, and there’s a very low level of radiation exposure. If polyps are discovered, your doctor won’t be able to remove them or take tissue samples. You’ll then need to have a colonoscopy, which may require a co-pay because some insurers will consider it “diagnostic” rather than “screening,” which really makes no sense. A colonoscopy is a colonoscopy.
Stool DNA test (Cologuard): With this approach, you collect a stool sample at home and mail it to the laboratory for testing. The results show whether you have DNA changes in cells, which could mean you have colon cancer or a precancerous condition. If normal, expect to be tested every three years. If not, you’ll be scheduled for a colonoscopy.
How do you decide which approach is right for you? I really appreciated what Daniel Reuland, director of the Carolina Cancer Screening Initiative at the UNC Lineberger Comprehensive Cancer Center in Chapel Hill, N.C., told me: “The best colon cancer screening test is the one the patient will do.”
To that end, Mayo Clinic has a digital brochure that helps patients decide, in consultation with their primary care physician, which method suits them best. Among the factors:
Convenience: How long does the test take, will you need sedation, how often does it need to be repeated and will you need other tests if the results are abnormal?
Cost and insurance: Most health insurance plans cover the cost of colorectal screening, but if the results show you need more tests or treatment you may be required to pay a deductible or co-pay.
Individual risk: If you have a history of polyps or a close relative who had the disease or if there is a family history of Lynch syndrome (also known as hereditary nonpolyposis colorectal cancer) or inflammatory bowel disease, your doctor may recommend a colonoscopy.
Feelings about tests: Some methods have higher rates of finding cancer or polyps. Some are more of a bother to prepare for. Some have higher or lower risks of complications. Again, experts recommend you talk with your doctor.
While researching this column, I heard from a friend who had lost three siblings to cancer within a five-year period — two of them to breast and one to colon.
His sisters had avoided mammograms even though they had been recommended. His brother, age 50 at the time of diagnosis, had actually had colon cancer symptoms for several years but wasn’t eligible for no-cost screening because of the guidelines then in place. “He kept delaying until it was late and he was Stage 4. He died at age 55.”
What did my friend learn? “Being proactive about my health, I know, has prevented the same fate as my siblings.”
Or, I might put it this way: Screening matters. It really matters.