“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.

Prostate Cancer: Progress in Detection and Treatment

Until recently, prostate cancer was considered by many to be a disease of “old men” only.  As a result, science for the detection and treatment of prostate cancer was lagging decades behind that of breast cancer.  In fact, it was commonly believed that if doctors performed a biopsy on the prostate of all men eighty years old or older, at the time of their death from non-prostate related issues, we could expect to find evidence of undetected prostate cancer in close to 100% of those patients.

The discovery and use of the PSA (Prostate Specific Antigen) led to detection of prostate cancer in younger men. The PSA test was fairly inexact and could become elevated as a result of any of several non-cancerous conditions. It led to numerous biopsies in men who had no clinical findings consistent with prostate cancer but who turned out to have the disease. These young men were treated aggressively, and at times the treatment was as bad if not worse than the disease. The problem was that when we found a prostate cancer we had no idea if it was destined to be aggressive or whether it was going to lie quietly and be indolent for decades.

Different treatment strategies emerged in Europe and the United States.  In Europe the PCA3 test was employed to detect genetic markers of men with elevated PSA’s and normal prostate gland examination who should be biopsied. This test is now gaining acceptance in the USA.

In a February 2011 article published in Nature magazine, researchers announced that they had found a genetic test for prostate cancer  samples that predicted whether the disease would be aggressive (and spread) or not. This new test, coupled with the existing Gleason scoring system, accurately predicted who needed to be treated aggressively and who could be watched instead. A commercial version of this genetic test should be available within two years.  At the same time, another article showed that in patients with minimal prostate cancerous disease, it is safe to observe them rather than aggressively operate on them immediately.

Health experts recommend all men 40 and over have a digital rectal exam on an annual basis. The decision to obtain a PSA is based on history, family history of prostate disease and clinical exam of the prostate. There are no current recommendations by the US Public Health Task Force on Preventive care for screening for prostate cancer with a PSA level. Despite this, I generally obtain a PSA annually on men over 50 after explaining to them the pros and cons of following the current guidelines.

If the new genetic test to predict prostate cancer aggressiveness turns out to be as accurate as suspected, we are finally on the road to being able to treat those who need aggressive treatment and spare others who don’t.