Thursday, February 14, 2019

“But I Don’t Want A Colonoscopy!” - Alternatives for Colorectal Cancer Screening

By Jason R. McKnight, MD, MS
Family Medicine Physician, Bryan
Clinical Assistant Professor- Texas A&M Family Medicine Residency Program
Member, TMA Leadership College

“But I don’t want a colonoscopy!”

For one reason or another, this response is all too common when asking if an age-appropriate patient is ready for colorectal cancer screening. Anecdotally, it seems the biggest turn off to a colonoscopy is the thought of the “bowel prep” and spending most of the day on the toilet doing what most people don’t care to talk about. Other patients cannot take the necessary half to full day off of work, while others have fear about the sedation. Perhaps the thought of a long flexible camera being inserted into the rectum may be what repulses the patient. Whatever the reason, we as physicians and patients are missing out on too many opportunities to screen for a highly preventable disease. Worldwide, colorectal cancer is the third most commonly diagnosed cancer and the second most common cause of cancer death. Colorectal cancer screening is one of the most effective ways at decreasing the number of new cases of cancer, and cancer-related deaths. One advantage of getting a colonoscopy is that it not only detects cancer, but also pre-cancerous polyps.

The U.S. Preventive Services Task Force (USPSTF), a volunteer panel of national experts in disease prevention and evidence-based medicine, recommends people start getting colorectal cancer screening at age 50 and do so periodically until age 75. The USPSTF says adults older than 75 can decide to screen for colorectal cancer based on their overall health and prior screening history.

But even for patients who decline the “gold standard” colonoscopy, there are other screening alternatives they should consider, including CT colonography, flexible sigmoidoscopy, and capsule endoscopy. A CT colonography, also known as a virtual colonoscopy, utilizes a special type of imaging study (think a “CAT” scan, taken from outside the body) that evaluates the large intestine. However, it does require a bowel prep similar to a colonoscopy. A flexible sigmoidoscopy involves a flexible camera being inserted into the rectum but does not necessarily require anesthesia or a full bowel prep. However, this procedure also does not evaluate the entire colon. Doctors can perform a capsule endoscopy for patients who refuse other strategies. This involves swallowing a “pill” containing a camera that takes pictures of the inside of the gastrointestinal tract. It’s not an invasive procedure, but you might be asked to complete a bowel prep to help improve the quality of the pictures taken so as not to miss an abnormality. Physicians recommend people with normal results get the tests on this schedule: Every 10 years for a colonoscopy, every five years for CT colonography, and every five years for flexible sigmoidoscopy.

National health experts recommend people get colorectal cancer
screenings periodically starting at age 50 until age 75. 
Other screening methods – like fecal immunochemical testing (FIT) and FIT-Fecal DNA testing – may not help prevent cancer by diagnosing pre-cancerous lesions, but they do detect active cancer. This helps catch it early, which decreases the risk of dying from colorectal cancer. FIT testing detects blood in your bowel movements, which can be an indicator of colorectal cancer. A positive test requires more testing for cancer. Patients take this test once a year. FIT-Fecal DNA testing combines the FIT with a test that detects abnormal DNA in bowel movements. Doctors recommend this combined test every three years.

The U.S. Multi-Society Task Force of Colorectal Cancer recommends colonoscopy or FIT as “first choice” options – followed by the other methods depending on patient preference. But remember, the best screening test for colorectal cancer is “the one that gets done.” Just because someone fears a colonoscopy does not mean they are out of options when it comes to screening for this highly prevalent – yet preventable – disease. 

You DO have options. Please choose one. It could save your life.

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