Message To CDC – When It Comes To Colon Cancer, All Tests Are Not Created Equal.

Mike Magee

The CDC made news this week with the latest statistics on colon cancer in the US. (1) They hit the facts but missed the point.

First the good news:

Colon cancer declined significantly from 2003 to 2007. Deaths declined in 49 states(Mississippi being the outlier). The rate of new cases of colorectal cancer fell from 52 per 100,000 in 2003 to 45 in 2007. That’s a nearly 14% drop in just 4 years, with a 12% decline in mortality. (1,2)

The bad news:

The good news will only get better if messaging from the CDC and other public and private health sources is clear – colonoscopy is far, far superior to sigmoidoscopy, and fecal occult blood testing is prehistoric as a stand-alone, colon cancer screening method. The CDC emphasizes that 1/3 of Americans are still not screened without acknowledging that the numbers of those inadequately screened (by virtue of these markedly inferior tests) is much, much higher. (1,2)

Why the subterfuge? Money and a “can’t do” attitude. It costs more for colonoscopy then sigmoidoscopy and occult blood monitoring; and we have an attitude that by choice or circumstance, less advantaged individuals will not be able to access colonoscopy, so let’s at least do sigmoidoscopy – and if not that, monitor for fecal occult blood. Even in an era of cost control – especially in an era of cost control – this approach is profoundly wrong-headed.

The debate on Health Care Reform is now focused on predicting cost accurately. Logic suggests that investing in prevention will save money long term. Besides it’s clearly the right thing to do. Colorectal cancer, the second leading cancer killer in the United States, is a prime example.(3) Some 90 million Americans are at risk of developing the disease – most from a slow process that changes silent, asymptomatic colon polyps into deadly cancers. Of those stricken with the disease, 58 percent are men, and 42 percent are women. Sadly, many of the cancerous tumors are discovered too late, mainly because preventive screening is not universal.(4,5)

The fact is, screening can prevent many cases of this disease because most colorectal cancers evolve from benign polyps that develop during a 10-year silent window. A single colonoscopy exam, using fiber optics to visualize the entire large bowel from the inside through a tube inserted through the rectum, can remove polyps when they are still harmless and decrease the life-long risk of colon cancer death by 31 percent.(5) And that’s just one exam. Repeating the exam every 10 years does much more. Early diagnosis of colon cancer carries an excellent five-year survival rate of 90 percent with treatment. But late diagnosis, after the tumor has already spread, lowers the five-year survival rate to 10 percent.(4)

Relatively few people are properly screened for colon cancer. In 2008, approximately 20% of adults over 50 had had a colonoscopy in the last five years. If we separate out individuals between ages 50 and 64, the prevalence rates of these tests are lower, and they’re particularly lower among individuals who are non-white, female, have fewer years of education, lack health care coverage, and are recent immigrants. (3)

Of the various screenings available, only one is thorough, diagnostic and therapeutic – colonoscopy. The barriers to proper screening for colon cancer involve misperceptions, money, and mindset. The misperceptions include the thought that this disease only strikes older men. The reality is, if you are male or female, age 50 or older, you’re well within striking distance.(3) Another misperception – that screening for colon cancer is terribly painful and uncomfortable. The reality – the bowel prep is somewhat annoying but quite manageable at home, and colonoscopy with light sedation is painless.

The expense of the tests can be a roadblock, but insurance companies are coming on board, as they should because colonoscopy to screen for this cancer has been proven to be as cost effective as mammography for breast cancer.(5) Compared to the cost of the disease – it’s a bargain. Direct medical costs for colon cancer in 2010 were $14 billion with an additional $15.3 billion in productivity losses. (1,2)

But we’ll never reach our full potential in preventive health care if we skate around the truth. In the CDC press conference, CDC Director Dr. Thomas R. Frieden said “I turned 50 a few months ago and I do have a strong family history of colorectal cancer, so I did have a colonoscopy at age 40. It was normal. At age 50, I had another colonoscopy. I had four polyps — two of them large — all of them removed before they became cancerous.” (1)

So he had the appropriate screening. Would sigmoidoscopy or fecal occult blood have revealed his four polyps. Depending on location and bleeding, there’s a good chance the answer is no. But then – in emphasizing that screening saves lives – Dr. Frieden went on to present colonoscopy, sigmoidoscopy and fecal occult blood testing – 3 options – as if they were equivalent.

Nothing could be farther from the truth – and that’s what the CDC needs to make clear.

For Health Commentary, I’m Mike Magee.

References

1. CDC healthfinder.gov. Colon Cancer Death Rates Continue To Drop, CDC Reports. July 5, 2011. http://www.healthfinder.gov/news/newsstory.aspx?docID=654607

2. MMWR: Vital Signs: Colorectal Cancer Screening Incidence and Mortality. http://1.usa.gov/rurcDp

3. American Cancer Society. Colorectal Cancer: Facts and Figures. 2009.

4. American Cancer Society. Frequently Asked Questions About Colon Cancer.

5. AAFP. Colon Cancer Screening: What You Should Know. American Academy of Family Physicians.

6. Podolsky DK. Going the distance – the case for true colorectal cancer screening. NEJM. 2000;343:207-208. http://www.nejm.org/doi/full/10.1056/NEJM200011303432214