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October 25, 2012 By:
By Diane McManus, Special Sections Feature
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Most advice on avoiding cancer can be followed painlessly enough: Don’t smoke; limit sun exposure; eat healthy, low-fat foods; exercise regularly. None of these requires time in a doctor’s office. Follow these words of wisdom, and we’ll be fine, correct?

To an extent, yes: a healthy lifestyle can help minimize visits to the doctor, and countless studies show the positive effects of these good habits. Passing up the sugar-laden treat for a piece of fruit or scheduling a morning walk or run might at times involve some will power, but the taste of that crisp, sweet apple, or the invigorating effect of the exercise offers relatively quick rewards for the efforts.

But then there are those screenings we’re urged to undergo. That’s where we balk, especially if the test requires not only a doctor’s appointment but preparation that could take two to three days.

And a colonoscopy, in particular, strikes fear in the hearts of patients, as noted by Roni Rabin, in her January 2011, New York Times Well Blog article, “Why People Aren’t Screened for Colon Cancer.”

Reactions to her blog showed that for many, the most intimidating aspect of the procedure is the preparation; in particular, the vile-tasting pre-test fluids that are intended to clear the colon so as to allow the doctor to see a clear image during the test. Such preparation makes for multiple bathroom visits and much discomfort — and, for some, even serious complications, if their bodies don’t tolerate the prep fluids (not to mention the requirement that patients fast except for clear liquids the day before the test).
This is hardly an inviting scenario, despite the potentially life-saving nature of the colonoscopy, which can detect and allows the physician to remove safely precancerous polyps. Many of those responding to Rabin’s article express a resolve not to undergo another colonoscopy, or even to submit to a single one.

But is there an alternative to this kind of prep that would encourage more screenings? Can a person come to a screening reasonably well fed and with a good night’s rest and later leave wide awake, having experienced little or no discomfort?
A new type of test might offer just such hope — with reservations.

A recent article by Dr. Michael E. Zalis in the Annals of Internal Medicine describes a type of virtual colonoscopy, Computed Tomographic Colonography, that requires no fast and no laxative, but instead involves consuming a tagging agent the day before undergoing the test.

A non-invasive scan is taken of the colon, and the tagging agent is detected by special software which digitally removes from the image all but the colon wall. Thus, without the use of laxatives, the colon still appears clean, thus allowing testers to easily identify polyps.

According to Zalis’ study, CTC “was accurate in detecting adenomas 10 mm or larger,” the study said of benign tumors,  “but less so for smaller lesions.”
This rate of detection is slightly less than with a colonoscopy requiring pre-test laxatives. But with a less stressful pre-test preparation, it would seem the ideal way to encourage more patients to be tested, and would thus save more lives.
But the new test is not without its drawbacks, according to the study.

If precancerous growths are detected with a regular colonoscopy, the doctor can remove them immediately, whereas the newer test requires a return visit for removal of polyps, and thus undergoing the very process the patient had tried to avoid to begin with.
All the same, for low-risk patients and those willing to accept that another medical step may be needed, this could offer a better, less invasive option — although cost could be a factor, since the test is recommended every 5 years, rather than the 10-year interval for a colonoscopy.  

Finally, not all insurance covers the procedure, whereas free colonoscopy screenings are mandated under the Affordable Care Act (with some complications: If a doctor finds and removes polyps, some insurance companies and Medicare change the classification from screening to treatment and charge accordingly).

Dr. Barbara Turner, formerly a professor at the University of Pennsylvania School of Medicine, who studied the influence of peer coach support on attending a scheduled colonoscopy, cautioned in an email that “virtual colonoscopy involves radiation and that is increasingly a concern as we do more and more procedures that involve X-rays.”

Turner further notes that “it images your whole abdomen and often there are incidental findings that lead to other tests” which “usually does not result in any substantive benefit.”
Her recommendation:  a flexible sigmoidoscopy employing an endoscope whose use “has been shown to save lives from cancer.”

Turner alludes to a recent study that appeared in the June issue of The New England Journal of Medicine. That study, authored by Robert E. Schoen and others, showed a 21 percent reduction in cases of colon cancer and 26 percent fewer deaths in the group undergoing flexible sigmoidoscopy than for another group undergoing “usual care,” which varied.  

Because some patients in the “usual care group” received screenings, the authors maintain that the differences between the two groups were less than they might have been.

While a colonoscopy may still be necessary as a follow-up to the sigmoid test, it has the benefit of being considerably cheaper, according to Turner.
Like the CTC, says Turner, it does not require anesthesia, and involves less pre-test prep. It can be done in a doctor’s office; there is less risk of colon perforation than with a colonoscopy. However, as previously noted, it does need to be performed more frequently. While it involves less prep and no sedation, some prep is still needed (clear fluids several hours before the test, and an enema).

Still, if patients are presented with more options in colon cancer screening, it’s less likely such screenings will be postponed, and so more lives will be saved, agree the experts.

After all, a postponed test will catch no cancer, no matter how effective it is.

Diane McManus is a much-published Philadelphia writer and editor. This article originally appeared in a special "Fighting Cancer" section of the Exponent.

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