Screening Colonoscopy

A recent study proved what physicians and scientists suspected for years – early detection of colon cancer by screening colonoscopies saves lives. The current guidelines call for asymptomatic individuals to begin having a digital rectal exam at age 40. If there are no high risk situations for the patient then it is recommended that they start having screening colonoscopies at age 50. If their screening colonoscopy is negative then they can start scheduling follow-up colonoscopies for screening purposes every ten years.

Experts are now suggesting we stop performing screening colonoscopies at age 80.  At that age, the risk of a complication from the preparation for the test, plus the risk of a complication of the test (primarily perforation of the colon) make the risks far higher than the benefits. We certainly would continue to screen with annual digital rectal exams, and fecal occult blood tests, but the decision to perform a colonoscopy would be individualized based on the patients health, quality of life and expected longevity.

For high risk individuals, those with inflammatory bowel disease (Crohn’s Disease or Ulcerative Colitis), a history of polyps or a family history of colon cancer or inflammatory bowel disease the schedule is more stringent and starts earlier. The same would apply to individuals with a family history of premalignant colon polyps.  The interval of time between colonoscopies is shortened as well. For example, if a patient had a first degree relative who developed colon cancer at age 50 we would start screening that patient at age forty.

Recent studies and evaluations of screening colonoscopies have actually shown that primary care physicians are recommending colonoscopies too frequently with too short of a time interval between studies.  If you are low risk and have no symptoms you begin at age 50 and space the colonoscopies every ten years if the studies are negative.

Within the past few years radiologists have developed the CT Colonoscopy. The prep is less arduous than a traditional colonoscopy. The films, when read by an experienced radiologist, are as detailed and accurate as a fiber-optic traditional colonoscopy. The down sides are the amount of radiation you are exposed to and the need to do a traditional colonoscopy to biopsy any suspicious lesions found on the CT Colonoscopy. Cost is a factor as well with many insurance companies refusing to use this technology for screening purposes.

“Colonoscopies Are Overdone In The Entire Population.”

Current recommendations by the American College of Gastroenterology call for colonoscopy as a screening test for colon cancer beginning at age 50 for Caucasians and 45 years old for African Americans. If the initial test is negative, and you have no symptoms, the recommended interval for follow-up colonoscopy is 10 years.  Despite this, a recent study published in the Archives of Internal Medicine revealed that nearly half of the the Medicare patients with negative findings on colonoscopy underwent repeat exams much sooner than the guideline recommended interval of 10 years.

The study looked at 24,000 Medicare enrollees who had a negative colonoscopy from 2001 through 2003.  Forty six percent of these individuals had a repeat exam in less than seven years.  According to lead author James S. Goodwin, M.D. of the University of Texas Medical Branch in Galveston, there was “no clear indication for the early repeated examination “in just under half of the recipients.   He said that even in patients 80 years of age and older repeat exams were done within 7 years in 32.9 % of the study group even though these patients were much more likely to die of something other than colorectal cancer in the near future.

Goodwin and his associates were surprised by the frequency of the repeat colonoscopies since Medicare regulations preclude reimbursement for screening colonoscopy within 10 years of a negative examination result. Despite this, only 2% of the repeat exams were denied by Medicare and not paid.

Brooks Cash, M.D., chief of medicine at the National Naval Medical Center in Bethesda, MD said, “I think colonoscopies are overdone in the entire population. “  He believes some of the frequent studies are provider driven and many are patient driven.

Colonoscopy is an invasive test with risks. The preparation can lead to fluid and electrolyte and volume problems in some individuals and the chance of a bowel perforation is rare but always present.  Patients need to talk to their personal physician about the need for a follow-up colonoscopy and the appropriateness of the timing suggested by the gastroenterologist before scheduling one.