A recent New York Times front page story on health care in the U.S. in general, and colonoscopy in particular, raised a vexing question: Is our health care system rife with individuals and businesses jacking up the cost of this potentially lifesaving procedure, as the article implies? If so, shame on them.
I hope readers -- after hearing about the wild cost variations for colonoscopy and the horror stories of people getting stuck with sizable portions of huge bills -- don't throw the proverbial baby out with the bath water by questioning the essential value of colorectal cancer screening. Watching a loved one die of cancer is devastating, particularly if the death -- indeed the cancer itself -- could have been prevented. And that, more often than not, is the case with colorectal cancer.
Sixteen years have passed since the day my seemingly healthy husband, Jay Monahan, doubled over in pain. With a tumor the size of an orange completely obstructing his bowels, the diagnosis was bleak: Stage IV colon cancer. I will never forget the courage, grace, and humor Jay showed as he was forced to confront his impending mortality from that terrible day until his death nine months later.
My mind can still quickly go to an endless loop of "coulda, woulda, shoulda..." Was Jay's sensitive stomach, and the ever-present roll of TUMS in his pocket, an indication something was terribly wrong? Should I have forced him to see a doctor? His new, second career as a television legal analyst was exciting, but flying all over the country -- covering trials like O.J. Simpson's and Timothy McVeigh's -- left Jay feeling tired... or so we thought. I've asked myself a million times: was Jay's fatigue a function of a hectic work schedule or the result of cancer that had likely been growing and spreading for years?
If we had been educated about these symptoms, and had Jay been tested, he might be alive today. That's why, after his tragic and premature death, I have made it my mission to talk to anyone who will listen about screening, prevention, and early detection.
The disease often can be prevented entirely when precancerous polyps are detected through screening and removed before they turn into cancer. Last year, a New England Journal of Medicine paper (Zauber AG, Winawer SJ, O'Brien MJ, et al. Colonoscopic Polypectomy and Long-Term Prevention of Colorectal-Cancer Deaths. N Engl J Med 2012; 366:687-696), confirmed that colonoscopies save lives. Researchers found "an estimated 53 percent reduction in mortality from colorectal cancer" in patients who had precancerous polyps removed during a colonoscopy.
Colorectal cancer often has no symptoms, which is one reason being tested is so important -- even for people who feel perfectly healthy. Some small, malignant growths can be removed during a colonoscopy, and when detected at an early stage, colorectal cancer is highly curable.
JAMA Surgery -- an American Medical Association journal -- recently published a paper reaffirming the benefits of screening colonoscopy, in which the authors wrote: "Compliance to screening colonoscopy guidelines can play an important role in prolonging longevity, improving quality of life, and reducing health care costs through early detection of colon cancer." (Amri R, Bordeianou LG, Sylla P, Berger DL. Impact of Screening Colonoscopy on Outcomes in Colon Cancer Surgery. JAMA Surg. 2013;():1-7.)
I also have firsthand evidence of colonoscopy's lifesaving value, in the form of many letters I've received with feedback like this: "You had a colonoscopy on TV and you urged people to get checked. I was having problems and did have a colonoscopy. Polyps were removed and a mass was discovered. I had surgery... and about a foot of the colon, along with the mass, which was cancer, were removed. Thank you for encouraging people to have a colonoscopy. I know it saved my life."
We've made good strides in reducing the number of lives taken by colorectal cancer in the past decade. The Centers for Disease Control and Prevention (CDC) reported that the colorectal cancer death rate fell by an average of 3 percent per year from 2003 to 2007 -- meaning this disease took the lives of 31,800 fewer Americans than expected during this period. Half of that decrease can be attributed to more people being screened. But colorectal cancer remains the second-leading cancer killer of men and women combined in the U.S., and about 22 million people who should be screened haven't been, or their screenings are not up to date in accordance with the suggested guidelines.
The U.S. Preventive Services Task Force (USPSTF), an independent panel of experts appointed by the federal government to develop guidelines for preventive services like cancer screening, recommends that people at average risk of developing colorectal cancer get screened beginning at age 50, through age 75, using one of three methods; colonoscopy every ten years is among them. People over 75 should talk to their doctors about whether they need to be screened. Complications are relatively rare, but asking about a physician's adherence to the national quality standards for colonoscopy is part of being an educated health care consumer.
Flexible sigmoidoscopy is a similar procedure, also approved by the USPSTF, and should be done every five years, accompanied by a high-sensitivity fecal occult blood test (FOBT) every three years. But the so called flex sig examines only the interior of the rectum and lower part of the colon, and research suggests that certain ethnic groups -- African-Americans, to name one -- have a higher risk than others of developing polyps in the upper part of the colon.
The third screening methodology that the USPSTF recommends is an annual screening with the high-sensitivity FOBT, a test that looks for occult (hidden) blood in stool samples. The presence of blood may indicate cancer or other abnormalities. If blood is found, follow-up testing -- using colonoscopy -- is necessary to determine the source and cause. An accurate FOBT, while valuable, cannot identify and prevent potential cancers when they are still benign polyps the way colonoscopy can.
So for me, colonoscopy was the test I wanted to have done. At age 43, I chose to have mine televised to help demystify an invasive, but potentially lifesaving procedure -- with an unappealing prep -- to which many people had a knee-jerk aversion. Several cancer advocacy groups have worked to open up an important public dialogue about screening for this largely preventable disease.
As a society, we clearly HAVE to figure out a way to manage our health care costs more effectively. Giving patients more information about the cost of a procedure (and what their share will be) before it happens could help people make smarter choices about their health care. The cancer research community is also doing its part: scientists are working to achieve the promise of a colon cancer blood test that would be non-invasive and potentially less expensive than colonoscopy.
I hope no one -- the average-risk 50-year-old who should be screened nor insurance company executives responsible for reimbursement policies -- concluded, after reading theTimes article, that colonoscopy is somehow not worth it. Colonoscopies save lives.
But the best test, of course, is the one that gets done.
My older daughter, who was six when she lost her Dad, just graduated from college. At events big and small in my girls' lives, I think about how proud Jay would be if he were there. He can't be, but the lives of other dads, mothers, sisters, brothers, colleagues, and friends can be saved.
More than 50,000 Americans are expected to die from colorectal cancer this year alone. We need to reduce that number by seeing that everyone who should be screened for colorectal cancer gets screened -- whatever method is used. I'll continue to honor my husband's memory by encouraging people to do just that.
The author is a television journalist and cancer advocate. She is a co-founder of The National Colorectal Cancer Research Alliance and Stand Up To Cancer, programs of the Entertainment Industry Foundation.
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