Tagged Colon

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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Simple Remedies for Constipation

Photo

Credit Paul Rogers

Chronic constipation is an all-too-common problem rarely discussed in polite company and only reluctantly mentioned to doctors during checkups. Although it accounts for eight million doctor visits annually, only “a minority of those with constipation seek medical attention,” Dr. Arnold Wald, a leading expert on the problem, reports.

Yet this hesitance can perpetuate mistaken beliefs about its consequences, causes and treatment, and often results in failure to get effective relief. Most of the time, relatively simple treatments prove adequate. Even more complex cases, like those that involve a disorder of muscle action in the pelvis, usually respond well to currently available remedies.

Chronic constipation can accompany a long list of medical problems – mechanical ones like a stricture or tumor; neurological disorders like Parkinson’s disease or multiple sclerosis; or metabolic conditions like severe low thyroid or low blood levels of magnesium.

Constipation can also be a side effect of medications, especially opiates like Percocet and OxyContin, as well as some antidepressants, anticonvulsants and antihistamines.

As someone who has dealt with constipation, with varying degrees of success, for most of my life, I had more than an academic interest in learning more about it. Hence this column, prompted by a friend’s excruciatingly painful problem that seemed to emerge from nowhere and by a new review of studies on the topic published in JAMA by Dr. Wald, a gastroenterologist at the University of Wisconsin School of Medicine and Public Health.

Many strongly held beliefs about constipation are not based on medical evidence, Dr. Wald and his colleagues have noted.

One of the oldest yet most persistent of these unsubstantiated notions is that failure to empty one’s bowels each and every day can result in so-called autointoxication – the absorption of poisonous substances produced from partially digested food and food byproducts in the intestines. Through the years, autointoxication has been erroneously blamed for a host of ailments, including high blood pressure, arthritis, atherosclerosis, gall bladder disease, various cancers and skin disorders.

Autointoxication is often cited as a reason for the common but mistaken belief that a daily bowel movement is essential to good health. But there’s no evidence that food that sits in the intestine leads to the buildup of toxins. The medically accepted definition of constipation is “fewer than three bowel movements a week, or hard, dry and small bowel movements that are painful or difficult to pass,” often resulting in abdominal pain or bloating.

Unfortunately, as a college freshman, I met those criteria. An astute physician provided advice that has helped to minimize the problem ever since. She gave me a list of “constipating” foods to avoid – white rice and other refined grains, unripe bananas, tea, cheese and chocolate – and even more important, foods to eat regularly: beans, whole grain cereals (especially bran) and breads, vegetables, fruits (especially dried fruits) and nuts. Eating more of these and other high-fiber foods can be very effective in curbing constipation. And she recommended drinking a full glass of water before bed to help soften the stool and another after awakening to stimulate my bowel.

Following this advice I’ve never had to rely on laxatives, although those medications are associated as well with myths and misconceptions that are important to dispel. One mistaken belief Dr. Wald and others have cited is that long-term use of stimulatory laxatives like senna and bisacodyl (Senokot and Dulcolax, respectively) can impair normal function of the colon and cause dependency on the medication.

While it is true that using stimulatory laxatives for many years at more than a dozen times the suggested dosage can damage the colon’s nerves and muscles, Dr. Wald and others say that properly designed studies of these laxatives have shown no harm to the colon when they are taken in recommended amounts.

Yet many doctors still warn – inappropriately, Dr. Wald says — against taking stimulatory laxatives for more than a few days. Indeed, the website FamilyDoctor.org states, “When these laxatives are taken for a long time, the bowel can lose its muscle tone and ‘forget’ how to push the stool out on its own.” Best to forget this outdated idea as long as you stick to the recommended dose if you must take these products.

Short of potent laxatives, other milder remedies often prove helpful. One is exercise, the more vigorously done the better. Another is to establish a regular bathroom time and respond promptly to the urge to defecate. I am among many who have found that a large cup of hot coffee in the morning is often a very effective stimulus.

However, as my ability to prevent constipation has diminished with age, I’ve added two other over-the-counter aids: a daily soluble fiber supplement of psyllium dissolved in juice or water (other fiber products like methyl cellulose, calcium polycarbophil and wheat dextrin can also be effective) and a twice-daily dose of a stool softener, both of which can safely be used indefinitely.

However good dietary fiber normally is for maintaining a healthy gut, it can be harmful when the cause of constipation is muscle weakness or a nerve problem, Dr. Wald said. Such patients often do better by eating less fiber and instead taking a secretory drug like lubiprostone (Amitiza) or linaclotide (Linzess) that adds water to the colon and softens the stool.

Sometimes, too, standard remedies for chronic constipation are ineffective. None worked for my friend, a New Yorker who suddenly developed an extremely painful problem at age 73 that was finally diagnosed as a failure of her pelvic floor muscles to relax when they are supposed to and allow the stool to pass through. Instead of relaxing, the muscles around the rectum contract. “It is a learned unconscious act that can be unlearned,” Dr. Wald explained.

Despite the usual remedies of diet, exercise and a costly prescription-only stool softener, the problem has recurred every eight days or so, she said. She is now being treated with deep breathing exercises 10 times a day and abdominal massage above the colon twice a day, and has begun biofeedback to “retrain” the muscles that are responsible for normal colorectal action. Dr. Wald said that biofeedback training, when done properly, is effective in about 80 percent of cases.

My friend’s experience underscores the importance of consulting an expert when constipation persists and fails to respond adequately to self-help measures of diet, exercise and over-the-counter remedies.

st dosing oneself prematurely with widely touted substances like resveratrol, the antioxidant found in red grapes and wine, or growth hormone.

Consumers must exercise caution, he warned, because “there’s an entire industry out there trying to market the products we’re testing before they are adequately evaluated.”

He also emphasized that taking a drug found to ward off age-related ills is not a license to abandon a healthy lifestyle. Doing so “could completely negate the benefit of a compound that slows aging,” he said.

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