Why do doctors in the United States continue to recommend colonoscopies when most other countries recommend less invasive colon cancer screening methods?
Should We All Get Colonoscopies Starting at Age 50?
4.4/5 - (145 votes)
Though colonoscopies can cause serious harm in about 1 in every 350 cases, sigmoidoscopies, which are shorter and smaller scopes, have ten times fewer complications. But, do colonoscopies work better? We don’t know, since we don’t have any randomized controlled colonoscopy trials, and we won’t until the mid 2020’s. So, what should we do?
The USPSTF, the official prevention guidelines body, considers colonoscopies just one of three acceptable colon cancer screening strategies. Starting at age 50, we should either: get our stool tested for hidden blood every year, no scoping at all; or a sigmoidoscopy every five years, along with stool testing every three; or a colonoscopy every 10 years. And, in terms of virtual colonoscopies or the new DNA stool testing, there is insufficient evidence to recommend either of those two.
Though they recommend ending routine screening at age 75, that’s assuming you’ve been testing negative for 25 years since your 50th birthday. If you’re 75 and have never been screened, then it’s probably a good idea to be screened at least into one’s 80s.
If there are three acceptable screening strategies, how should one decide? They recommend that patients work with their physician in selecting one after considering the risks and benefits of each option. For patients to participate in the decision-making process, though, they have to be given the information. The degree to which health providers communicate the necessary information was not known, until this study was published. They audiotaped clinic visits looking for the nine elements of informed decision-making. Discussing the patient’s role in making the decision, what kind of decision has to be made, what are the alternatives, what are the pros and cons of each option, the uncertainties, making sure the patient understands their options, and then finally asking them what they would prefer. That’s the role of a good doctor. It’s your body; it’s your informed decision.
How many of these nine crucial elements of informed decision making were communicated to patients when it came to colon cancer screening? Care to hazard a guess? In most of the patients, none. The average number nine addressed? One out of nine. As an editorial in the Journal of the American Medical Association put it, “There are too many probabilities and uncertainties for patients to consider and too little time for clinicians to discuss them with patients.” So, doctors just make up the patients’ minds for them, and what do they choose? Most often, as in this survey of a thousand physicians, doctors recommend colonoscopy. Why? Other developed countries mostly use the stool tests, the FOBT tests, with only a few recommending colonoscopies or sigmoidoscopies. That may be because most physicians in the world don’t get paid by procedure. As one gastroenterologist put it, “Colonoscopy is the goose that laid the golden egg.”
A New York Times exposé concluded that the reason doctors rake in so much money is less about top notch patient care and more about business plans maximizing revenue, plus lobbying, marketing, and turf battles. Who sets the prices for procedures? The American Medical Association, the chief lobbying group for physicians. No wonder gastroenterologists pull in nearly a half million dollars a year.
And, the American Gastroenterological Association wants to keep it that way. Referring to these exposés, the president of the Association warned that gastroenterology is under attack. Colorectal cancer screening and prevention may be reduced in volume and discounted. But, they have tips for how to succeed in the coming nightmarish world of accountability and transparency.
Why would primary care docs push colonoscopies though? Because many doctors get what are essentially financial kickbacks for procedure referrals. Studying doctor behavior before and after they started profiting from their own referrals, it’s estimated that doctors make nearly a million more referrals every year than they would have if they there were not personally profiting.
To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video. This is just an approximation of the audio contributed by Katie Schloer.
Please consider volunteering to help out on the site.
- H Brenner, C Stock, M Hoffmeister. Effect of screening sigmoidoscopy and screening colonoscopy on colorectal cancer incidence and mortality: systematic review and meta-analysis of randomised controlled trials and observational studies. BMJ. 2014 Apr 9;348:g2467.
- A S Brett. Flexible sigmoidoscopy for colorectal cancer screening: more evidence, persistent ironies. JAMA. 2014 Aug 13;312(6):601-2.
- F van Hees, J D Habbema, R G Meester, I Lansdorp-Vogelaar, M van Ballegooijen, A G Zauber. Should colorectal cancer screening be considered in elderly persons without previous screening? A cost-effectiveness analysis. Ann Intern Med. 2014 Jun 3;160(11):750-9.
- J I Allen. The value of colonoscopy. Gastroenterology. 2014 Feb;146(2):573-5.
- B S Ling, J M Trauth, M J Fine, M K Mor, A Resnick, C H Braddock, S Bereknyei, J L Weissfeld, R E Schoen, E M Ricci, J Whittle. Informed decision-making and colorectal cancer screening: is it occurring in primary care? Med Care. 2008 Sep;46(9 Suppl 1):S23-9.
- K R Yabroff, C N Klabunde, G Yuan, T S McNeel, M L Brown, D Casciotti, D W Buckman, S Taplin. Are physicians' recommendations for colorectal cancer screening guideline-consistent? J Gen Intern Med. 2011 Feb;26(2):177-84.
- E P Whitlock, J Lin, E Liles, T Beil, R Fu. Screening for colorectal cancer: a targeted, updated systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008 Nov 4;149(9):638-58.
- GAO Medicare:Action Needed to Address Higher Use of Anatomic Pathology Services by Providers Who Self-Refer. GAO-13-445: Published: Jun 24, 2013. Publicly Released: Jul 15, 2013.
- Rosenthal, E. June 1, 2013. “The $2.7 Trillion Medical Bill: Colonoscopies Explain Why U.S. Leads the World in Health Expenditures.” The New York Times.
- Whoriskey, P. and Keating, D. July 20, 2013. “How a secretive panel uses data that distorts doctors’ pay.” The Washington Post.
Images thanks to Mamin via Flickr.
Though colonoscopies can cause serious harm in about 1 in every 350 cases, sigmoidoscopies, which are shorter and smaller scopes, have ten times fewer complications. But, do colonoscopies work better? We don’t know, since we don’t have any randomized controlled colonoscopy trials, and we won’t until the mid 2020’s. So, what should we do?
The USPSTF, the official prevention guidelines body, considers colonoscopies just one of three acceptable colon cancer screening strategies. Starting at age 50, we should either: get our stool tested for hidden blood every year, no scoping at all; or a sigmoidoscopy every five years, along with stool testing every three; or a colonoscopy every 10 years. And, in terms of virtual colonoscopies or the new DNA stool testing, there is insufficient evidence to recommend either of those two.
Though they recommend ending routine screening at age 75, that’s assuming you’ve been testing negative for 25 years since your 50th birthday. If you’re 75 and have never been screened, then it’s probably a good idea to be screened at least into one’s 80s.
If there are three acceptable screening strategies, how should one decide? They recommend that patients work with their physician in selecting one after considering the risks and benefits of each option. For patients to participate in the decision-making process, though, they have to be given the information. The degree to which health providers communicate the necessary information was not known, until this study was published. They audiotaped clinic visits looking for the nine elements of informed decision-making. Discussing the patient’s role in making the decision, what kind of decision has to be made, what are the alternatives, what are the pros and cons of each option, the uncertainties, making sure the patient understands their options, and then finally asking them what they would prefer. That’s the role of a good doctor. It’s your body; it’s your informed decision.
How many of these nine crucial elements of informed decision making were communicated to patients when it came to colon cancer screening? Care to hazard a guess? In most of the patients, none. The average number nine addressed? One out of nine. As an editorial in the Journal of the American Medical Association put it, “There are too many probabilities and uncertainties for patients to consider and too little time for clinicians to discuss them with patients.” So, doctors just make up the patients’ minds for them, and what do they choose? Most often, as in this survey of a thousand physicians, doctors recommend colonoscopy. Why? Other developed countries mostly use the stool tests, the FOBT tests, with only a few recommending colonoscopies or sigmoidoscopies. That may be because most physicians in the world don’t get paid by procedure. As one gastroenterologist put it, “Colonoscopy is the goose that laid the golden egg.”
A New York Times exposé concluded that the reason doctors rake in so much money is less about top notch patient care and more about business plans maximizing revenue, plus lobbying, marketing, and turf battles. Who sets the prices for procedures? The American Medical Association, the chief lobbying group for physicians. No wonder gastroenterologists pull in nearly a half million dollars a year.
And, the American Gastroenterological Association wants to keep it that way. Referring to these exposés, the president of the Association warned that gastroenterology is under attack. Colorectal cancer screening and prevention may be reduced in volume and discounted. But, they have tips for how to succeed in the coming nightmarish world of accountability and transparency.
Why would primary care docs push colonoscopies though? Because many doctors get what are essentially financial kickbacks for procedure referrals. Studying doctor behavior before and after they started profiting from their own referrals, it’s estimated that doctors make nearly a million more referrals every year than they would have if they there were not personally profiting.
To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video. This is just an approximation of the audio contributed by Katie Schloer.
Please consider volunteering to help out on the site.
- H Brenner, C Stock, M Hoffmeister. Effect of screening sigmoidoscopy and screening colonoscopy on colorectal cancer incidence and mortality: systematic review and meta-analysis of randomised controlled trials and observational studies. BMJ. 2014 Apr 9;348:g2467.
- A S Brett. Flexible sigmoidoscopy for colorectal cancer screening: more evidence, persistent ironies. JAMA. 2014 Aug 13;312(6):601-2.
- F van Hees, J D Habbema, R G Meester, I Lansdorp-Vogelaar, M van Ballegooijen, A G Zauber. Should colorectal cancer screening be considered in elderly persons without previous screening? A cost-effectiveness analysis. Ann Intern Med. 2014 Jun 3;160(11):750-9.
- J I Allen. The value of colonoscopy. Gastroenterology. 2014 Feb;146(2):573-5.
- B S Ling, J M Trauth, M J Fine, M K Mor, A Resnick, C H Braddock, S Bereknyei, J L Weissfeld, R E Schoen, E M Ricci, J Whittle. Informed decision-making and colorectal cancer screening: is it occurring in primary care? Med Care. 2008 Sep;46(9 Suppl 1):S23-9.
- K R Yabroff, C N Klabunde, G Yuan, T S McNeel, M L Brown, D Casciotti, D W Buckman, S Taplin. Are physicians' recommendations for colorectal cancer screening guideline-consistent? J Gen Intern Med. 2011 Feb;26(2):177-84.
- E P Whitlock, J Lin, E Liles, T Beil, R Fu. Screening for colorectal cancer: a targeted, updated systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008 Nov 4;149(9):638-58.
- GAO Medicare:Action Needed to Address Higher Use of Anatomic Pathology Services by Providers Who Self-Refer. GAO-13-445: Published: Jun 24, 2013. Publicly Released: Jul 15, 2013.
- Rosenthal, E. June 1, 2013. “The $2.7 Trillion Medical Bill: Colonoscopies Explain Why U.S. Leads the World in Health Expenditures.” The New York Times.
- Whoriskey, P. and Keating, D. July 20, 2013. “How a secretive panel uses data that distorts doctors’ pay.” The Washington Post.
Images thanks to Mamin via Flickr.
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Should We All Get Colonoscopies Starting at Age 50?
LicenseCreative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)
Content URLDoctor's Note
Serious harm in 1 out of 350 colonoscopies? See What to Take Before a Colonoscopy for all the gory details.
Too often, truly informed consent is a joke in modern medicine. For more on this, see:
- The Actual Benefit of Diet vs. Drugs
- Why Prevention Is Worth a Ton of Cure
- Fully Consensual Heart Disease Treatment
- Everything in Moderation? Even Heart Disease?
- Drugs and the Demise of the Rice Diet
How do you know if your doctor is on the take? Check out Find Out If Your Doctor Takes Drug Company Money.
2018 Update: Another common test is mammograms, and I just launched a new series about them. Check out the first one: 9 out of 10 Women Misinformed About Mammograms.
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