Colonoscopy Could Save Thousands of Lives Annually

The use of colonoscopy to identify colon cancer should increase due to the Beneficiary Improvement and Protection Act, effective July 1, 2001. The act added coverage for Medicare members who are not at high risk for colorectal cancer to receive a colonoscopy every 10 years. According to the Centers for Disease Control and Prevention (CDC), at least a third of deaths due to colorectal cancer could be prevented if people 50 years and older were screened regularly.

An estimated 56,700 people will die from colorectal cancer in the US in 2001, making it the second leading cancer killer. Both men and women are at risk, but if colorectal cancer is found and treated early, about 90% of patients survive.

Colonoscopy is one of four colorectal screening tests covered by Medicare. Under mild anesthesia, colonoscopy involves inserting a thin, flexible tube into the rectum and passing it up through the entire colon (large bowel). A tiny camera allows the physician to look for small growths (polyps) that can become cancerous if not removed. During a colonoscopy, the physician can remove or biopsy polyps. A typical colonoscopy takes 15-30 minutes and can be performed in a hospital outpatient department, clinic or doctor's office

The CDC recommends regular screening for colorectal cancer beginning at age 50. Colonoscopy is the most thorough screening method. Other screening methods for colorectal cancer include: fecal occult blood tests, in which stools are tested for signs of hidden bleeding; flexible sigmoidoscopies, which are similar to colonoscopies but only reach about two feet into the left side of the colon; and barium enemas, which are X-rays used to demonstrate abnormalities in the colon.

For beneficiaries aged 50 or older, Medicare covers fecal occult blood tests annually or flexible sigmoidoscopies every four years. Medicare also covers colonoscopies every two years for beneficiaries with a high risk of colon cancer (including those with a family history of the disease), no matter what their age. Medicare coverage allows barium enemas to be substituted for either colonoscopies for high-risk individuals or flexible sigmoidoscopies.

However, two recent studies showed that half of the cases of advanced polyps found by colonoscopy in the right colon would have been missed by flexible sigmoidoscopy. Of 3,000 veterans in the study at the VA center in Portland, Oregon, 128 had advanced polyps in the right colon; 52% of these had no polyps in the left colon, which is accessible to sigmoidoscopy. Likewise, in a study conducted at the Indiana University Medical Center, 2,000 people received colonoscopies. About half of the 50 cases of advanced polyps would have been missed by sigmoidoscopy because they were in the right colon.

Colonoscopy is not without risk, such as gastrointestinal bleeding or even perforation of the colon. It also requires anesthesia and preparation to cleanse the bowel, which can deter patients. Some patients are embarrassed about the procedure or concerned about discomfort.

American Cancer Society guidelines

The American Cancer Society (ACS) also recommends that at age 50 both men and women begin colorectal cancer screening. For typical individuals, it recommends a fecal occult blood test annually and a flexible sigmoidoscopy every five years, or a double contrast barium enema every five years, or a colonoscopy every 10 years.

Colorectal screening should begin earlier and be conducted more often if there are risk factors, such as a family history of colorectal cancer or polyps in a first-degree relative (parent, sibling or child) younger than age 60, or in two first-degree relatives of any age. Typically, screening should begin 10 years before the age of the relative's diagnosis. An individual with a personal history of colorectal cancer or polyps or chronic inflammatory bowel disease is also at greater risk and should be followed more closely.

Colonoscopy is the preferred method of screening individuals at higher risk, although a double contrast barium enema alone, or with a flexible sigmoidoscopy, is an acceptable alternative, according to the ACS. A genetic test to assess colorectal cancer risk is available for individuals with a very strong family history of the disease.

It is hoped that Medicare's new colonoscopy coverage for beneficiaries not at high risk will encourage healthcare providers to recommend screening more often. It may also encourage private health insurance plans to cover the procedure if they don't already. It is equally important that patients realize that any embarrassment or slight discomfort associated with colonoscopy is insignificant compared to the potential for saving their life.

Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.