Tagged Colon and Colorectal Cancer

A Colonoscopy Alternative Comes Home

A Colonoscopy Alternative Comes Home

An at-home test for colon cancer is as reliable as the traditional screening, health experts say, and more agreeable.

Credit…Karlotta Freier

  • Jan. 11, 2021, 1:40 p.m. ET

Most Americans who are due for a colon cancer screening will receive a postcard or a call — or prompting during a doctor’s visit — to remind them that it’s time to schedule a colonoscopy.

But at big health care systems like Kaiser Permanente or the federal Veterans Health Administration, the process has changed. Patients who should be screened regularly (age 50 to 75) and who are of average risk, get a letter telling them about a home test kit arriving by mail.

It’s a FIT, which stands for fecal immunochemical test. The small cardboard mailer contains equipment and instructions for taking a stool sample and returning the test to a lab, to detect microscopic amounts of blood. A week or so later, the results show up on an online patient portal.

Five to 6 percent of patients will have a positive test and need to schedule a follow-up colonoscopy. But the great majority are finished with colon cancer screening for the year — no uncomfortable prep, no need to skip work or find someone to drive them home after anesthesia, no colonoscopy.

Last spring, when the coronavirus pandemic closed many medical facilities and postponed nonemergency procedures, this approach suddenly looked even more desirable.

“We know that from March to May, colon cancer screenings fell by about 90 percent,” said Dr. Rachel Issaka, a gastroenterologist at the University of Washington and the Fred Hutchinson Cancer Research Center. Although testing has resumed, she said, “we’re still not back to where we were.”

Yet colon cancer represents the third-highest cause of cancer deaths, after lung cancer and, tied for second place, breast and prostate cancer. Unlike those, colon cancer can be prevented with early detection.

With many older adults trying to avoid hospitals and surgical centers, even as their risk of colon cancer rises with age, an at-home test provides an alternative to colonoscopy — one that is both safer, with a lower risk of complications and Covid-19 exposure, and does as good a job.

“If your doctor tells you a colonoscopy is better, that’s not accurate,” said Dr. Alex Krist, chairman of the U.S. Preventive Services Task Force, an independent expert panel that reviews evidence and issues recommendations. “The data show the tests are equally effective at saving lives.”

The Task Force is updating its guidelines for colon cancer screening and this year will likely recommend lowering the age at which it should begin, to 45. But the recommendations on the upper end will remain unchanged: Based on strong evidence, adults up to age 75 should be screened regularly.

Beyond that age, the disadvantages begin to mount. The Task Force says the benefit of screening 76- to 85-year-olds is small, and that the decision should be an individual one, reached in consultation with a doctor.

Colon cancer develops slowly, explained Dr. James Goodwin, a geriatrician and researcher at the University of Texas Medical Branch in Galveston. Patients at older ages, who typically contend with several other diseases, may not live long enough to benefit. “You cause more harm than good,” Dr. Goodwin said.

The advice to stop screening isn’t always popular with patients. “People don’t like to hear about not living very long,” he said. But with colonoscopy, he noted, “you go through an unpleasant experience — or an unpleasant experience followed by an unpleasant diagnosis and unpleasant treatment — for something that, if you’d never known about it, wouldn’t cause you harm.”

Even if a test eventually finds colon cancer, surgery plus chemotherapy, the standard treatment, could itself endanger a frail older person. “I would be heavily biased against anyone getting a screening, of any sort, over age 80,” Dr. Goodwin said.

Although Americans still rely mostly on colonoscopy, his research has shown that for many older people, that test is overused, either because of the patients’ ages or because they are tested too frequently.

Yet screening is simultaneously underused. In 2018, according to the Centers for Disease Control and Prevention, only about 70 percent of adults were up-to-date on colorectal cancer testing. About one-fifth of those 65 to 75 had not been screened as recommended. Among those 50 to 65, where lack of Medicare or other insurance probably contributed, only about 63 percent were appropriately screened.

The Task Force has found several kinds of screening tests effective, but the ones used most for people at average risk are colonoscopy, at a recommended 10-year interval, or FIT annually.

A newer entry, an at-home test sold under the brand name Cologuard that detects blood and cancer biomarkers in stool, may be used every three years, but a study found it to be less effective than most other methods and far more expensive than FIT.

When screening is recommended, how does FIT stack up against colonoscopy?

Higher-risk patients — including those who have had colon cancer or parents or siblings with colon cancer, those with inflammatory bowel disorders like Crohn’s disease, and those who have had abnormal previous tests, including multiple or large polyps — should seek out a colonoscopy, often on an accelerated schedule. The procedure involves inserting a viewing instrument through the anus to directly visualize an anesthetized patient’s colon.

A colonoscopy offers one distinct advantage: if the gastroenterologist spots polyps, growths that over time could become cancerous (although most don’t), these can be removed immediately. “You’re preventing cancer, snipping out the things that could lead to cancer,” Dr. Goodwin said. After a negative colonoscopy, patients don’t need another for a decade.

But the procedure’s complications increase with age, although they remain low; the most serious, a perforated colon, requires hospitalization. Cleaning out the bowel on the day before the procedure, in preparation, is disruptive and disagreeable, and Dr. Goodwin notes that older patients sometimes experience cycles of diarrhea and constipation for weeks afterward.

Rural residents may find traveling to a facility difficult. The use of anesthesia means that every patient needs someone to drive or escort them home afterward. The prospect of spending two to four hours in a facility, even one using rigorous safety measures, will cause some older adults to postpone testing because of Covid-19 fears.

The FIT, which is far more widely used in other countries, avoids many of those difficulties. A marked improvement over earlier at-home stool tests, it requires a sample from one day instead of samples from three, and imposes no food or drug restrictions. A positive result still calls for a colonoscopy, but the great majority of patients avoid that outcome.

Why do so many Americans still undergo colonoscopies, then? “There’s a large financial incentive for people who do colonoscopies to do colonoscopies,” Dr. Goodwin said, so patients may not hear much about the alternatives.

“Many of my own patients are surprised to learn that there’s another way,” said Dr. Krist, also a family physician at Virginia Commonwealth University. “As they age, they want less invasive methods” and may be happy to switch.

Wider adoption of FIT could also save patients and insurers, notably Medicare, a boatload. The home test, which is available through several manufacturers, generally costs less than $20; a colonoscopy can easily exceed $1,000.

Moreover, with personalized messages to patients and follow-up reminders to return the kit, FIT use can result in more people being screened. That could prove important when the Preventive Services Task Force lowers the recommended age to 45, which would add 22 million Americans to the list of people advised to undergo colon cancer screening. Their needs, plus a backlog of patients who postponed tests during the pandemic, could swamp gastroenterology practices.

“If a provider doesn’t bring up” the possibility of an at-home test, Dr. Issaka said, “patients should feel empowered to ask about it.” Colon cancer screenings, of any type, “are considered non-urgent,” she said. “But they’re not optional.”

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Despite Pandemic Shutdowns, Cancer Doesn’t Take a Break

While a raging pandemic continues to force shutdowns and slowdowns throughout the country, another major risk to human health is not taking a sabbatical: cancer.

In the early months of the pandemic, millions of people heeded warnings and fears about contracting the coronavirus and avoided, or couldn’t even get, in-person medical visits and cancer screenings, allowing newly developed cancers to escape detection and perhaps progress unimpeded.

During this time, there was a steep decline in screenings for cancer, as well as a reluctance of patients with cancer to participate in clinical trials for cancer treatments. Many mammography centers, dermatology offices and other venues for cancer screenings remained closed for months, and routine colonoscopies, which should be done in hospitals or surgical centers, were actively discouraged to minimize strain on medical personnel and equipment and reduce the risk of contagion.

Still, Dr. Norman E. Sharpless, director of the National Cancer Institute, warned in June that missed routine screenings could lead to 10,000 or more excess deaths from breast and colorectal cancers within the next decade.

Cancers cannot be treated unless they’re detected, and a review of 34 studies published in October in the BMJ reported that for every four-week delay in cancer detection and treatment, the risk of death from cancer rises nearly 10 percent, on average. The study found increased mortality following delays in treatment for 13 of 17 cancer types. Following a four-week delay in surgery for breast cancer, the death rate increased by 8 percent; for colorectal cancer, it rose 6 percent.

The hazard of delayed screenings is greatest for people with known risk factors for cancer: a family or personal history of the disease, a previous abnormal Pap smear, prior findings of polyps in the colon or rectum, or, in the case of breast and certain other cancers, having genetic mutations that seriously increase cancer risk.

Most screening facilities have since put safety procedures in place that greatly reduce the chance of contracting the coronavirus, both for staff and patients. Although I had postponed my annual mammogram for four months, when I did go in September I was impressed with how well the facility was run — no one else in the waiting room, everyone masked and hand sanitizer everywhere.

Dr. Barry P. Sleckman, director of the O’Neal Comprehensive Cancer Center at the University of Alabama at Birmingham, said in an interview, “When it comes to screening for cancer, people should balance the possibility of contracting the virus with their potential cancer risk. People should do everything possible to keep up with cancer screenings.”

However, Dr. Sleckman added, “If a woman is young and has no family history of breast cancer, she can probably wait six months for her next screening mammogram.” He also suggested discussing the matter with one’s personal physician, who probably also knows the safest facilities for screening.

If someone is found to have cancer, he emphasized, “There’s no reason to delay treatment. If a woman has cancer in a breast, it needs to be removed, and she should go to a hospital where she can be treated safely.”

Dr. David E. Cohn, chief medical officer at The Ohio State University Comprehensive Cancer Center, said that in the early months of the pandemic “we experienced a significant decline in new patients. Even some patients with symptoms were afraid to come in or couldn’t even see their doctors because the offices were closed. This could result in a delayed diagnosis, more complex care and potentially a worse outcome.”

But he said his center has since returned to baseline, suggesting that, despite the fall’s surge in Covid-19 cases, few cancer patients now remain undiagnosed and untreated.

“We made creative adaptations to Covid” to maximize patient safety, Dr. Cohn said in an interview. “For certain cancers, instead of doing surgery upfront, we treated patients with radiation and chemotherapy first, then did surgery later” when there was less stress on hospital facilities and personnel and patients could be better protected against the virus.

Dr. Cohn said that certain kinds of supportive care can be delivered remotely to cancer patients and their families — even genetic counseling, if a DNA sample is sent in. However, he added, “the majority of cancer treatment has to be administered in person, and surveillance of cancer patients is best done in face-to-face visits.”

Now with the virus surging around the country, many medical centers may be forced to again limit elective procedures, those not deemed urgent. But, Dr. Sleckman said, “Cancer treatment is not elective — it’s urgent and should not be delayed.”

Learning that one has cancer, even when it is early and potentially highly curable, is likely to strain a person’s ability to cope with adversity, all the more so when the diagnosis occurs in the midst of an already highly stressful and frightening pandemic.

Kristen Carpenter, a psychologist at the Ohio cancer center, said the constraints of the pandemic are “using up a lot of people’s reserve for dealing with adversity.” Adding a cancer diagnosis on top of that may initially cause people to fear they can’t deal with it, she said in an interview.

But it is nearly always possible to make more room in a person’s “bucket of reserve,” she said, for example, by identifying things that bring joy or a sense of accomplishment. Even though the pandemic may preclude great joys, Dr. Carpenter said, “people can create a constellation of smaller joys, for example, by reading a book, taking a walk or even a long shower. A little goes a long way to relieve the stresses of the day and build up the reserve needed to help you deal with the cancer.”

Noting that many people have found new ways to interact with others during the pandemic, “this is all the more important to do in the face of cancer,” Dr. Carpenter said. “Remember, you’re not just your cancer. You’re a whole person experiencing something. Take time to identify your needs and tell people what they are — don’t wait for them to ask.”

This advice is especially critical to cancer patients whose disease or treatment has compromised their immunity, leaving them especially vulnerable to infection by the coronavirus. A friend with chronic lymphoma who must avoid in-person contact with her five young grandchildren visits them through a glass door and observes their delight in retrieving the little treats she leaves for them on her porch.

Think, too, of how you’ve faced difficulties in the past, “how you’ve adapted to things you previously believed to be unimaginably difficult,” Dr. Carpenter suggested. Resiliency in the face of cancer during Covid need not have a limit, she said.

Ovary Removal Tied to Colon Cancer Risk

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Removal of the ovaries — a procedure known as oophorectomy — may increase the risk for colorectal cancer, a new study concludes.

In some cases, such as cancer, the ovaries must be removed. They are commonly also removed electively during surgery for hysterectomy to avoid the risk of ovarian cancer.

The study, in the British Journal of Surgery, included 195,973 women in a Swedish health registry who had undergone oophorectomy either prophylactically or for benign conditions between 1965 and 2011. After an average follow-up of 18 years, 3,150 had been diagnosed with colorectal cancer. That rate — 1.6 percent — is about 30 percent higher than the rate in the general population.

The scientists found that the rate of colorectal cancer was lower in younger women and highest in the first four years after oophorectomy.

Oophorectomy has other risks too, said the study’s lead author, Dr. Josefin Segelman, a surgeon at the Karolinska Institute in Stockholm. Androgen levels drop after the operation, and this is tied to osteoporosis, decreased sexual desire and other problems.

Still, she said, “If you find abnormal ovaries at the time of surgery, they should be removed. But prophylactic oophorectomy should not be performed where there is no clear risk of ovarian cancer.”