At-home test for colon cancer is as reliable as traditional screening: experts
nytimes.com
nytimes.com
Unrelated side note: I did this all during the US election week, so that was a fun few days of stress and weirdness!
One thing the colonoscopy came with but the occult blood stool test didn't: a warning that there was a 1 in 1000-10,000 risk of an accidental tear in the colon leading to peritonitis, an immediate surgical emergency (and life-threatening if undetected and untreated).
So yes, the colonoscopy might pick up some rare non-bleeding cancers and polyps ... but it's also going to lead to unpleasant surgical complications in its own right.
(I have no figures for relative risk: but feel it's worth noting.)
So, for simple screening purposes I'd say good enough. If there are any other indications a full colonoscopy would be more reliable.
(Source: am at very high risk of hereditary colon cancer, had a colonoscopy when my GP learned of the family history, then screening thereafter. All clear so far ...)
Also, should have corrected my comment above... it's two year intervals, as you mentioned.
Lang may yer lum reek, neighbour.
That would seem to shift some weight to the stool test.
As I read it, this article is more about the inadequate US healthsystem than anything else, in particular because it forgets to mention that iFOBT is free and automatically sent to all between 50/55-75 in several European countries. No diet required. Return envelop included. Lab results received by postal mail after a few weeks.
edit: https://www.mccormackinnovation.co.uk/flushaway-stool-collec...
Pill teardown here [1], images here [2] (without fasting).
The upside is quite clear, especially if you are already used to fasting. The downsides are that you can't control the speed of the pill going through your digestive system, and if a polyp is found, you still need a colonoscopy to remove it (and need to fast again).
Annual and free in most of the UK for a couple of years now. Thank you, NHS.
Not sure why this article talks about sending samples back to a lab. Maybe the 100% at home self test isn't approved in the US or something?
Just buying a couple of those tests (they're cheap!) instead of going through the gatekeepers makes it practical to repeat them over the course of a few days, increasing the chance to catch intermittent bleeding. Obviously go to a doctor if there's any positive result at all.
https://www.pblabs.com/products/second-generation-fit-fecal-...
They offered sedation or gas and air though.
I went for gas and air as it meant I didn’t need anyone to come pick me up and I could go home straight after.
Honestly the prep is the worst part.
For myself and many others, it's not really about the pain (supposedly there is little to none), it's just the unsettling thought of that scope so far up one's...
I was sedated with Propofol and that seemed to be routine in the facility I went to. It was a white fluid that came in through an IV. I remember saying to the nurse as I saw the propfol going in "that tingles..." and she said "that's normal", but it seemed to me that she said her answer before I finished saying "tingles", then a herringbone pattern visual from my tightly shut eyes, then nothing, and I woke as I was being wheeled out to the recovery area and felt no grogginess at all, seemed that only a couple seconds had elapsed from the time I saw the propfol (it was 20 minutes). Powerful drug.
I wonder if I just passed out mid-sentence?
The last one the doc doing the colonoscopy was training (under supervision) and kept not making the turn, that was somewhat painful but generally yeah they aren't very painful (for me, ymmv etc).
The nurses were very uncomfortable with the whole thing, the doctor had to come in and assure them it was fine. Since it was preventative I didn’t save any money by forgoing anesthesia (I HATE anesthesia, and my mother had had psychotic episodes after coming out of anesthesia, so I’m cautious). The whole procedure was fast and it was interesting to be awake.
So I went for the simpler option.
Not to mention the follow up bill from the out of network anesthesiologist.
Under what logic does that make sense, that you get insurance coverage for a procedure but only if you don't really need it? Does it work like that anywhere outside of the U.S.?
The colonoscopy was completely clear. Two years later I was having constipation and bloating problems and went to a gastroenterologist. He examined me, asked a bunch of questions, and I asked for his advice. He said he really couldn't tell me anything ... without a colonoscopy. The two year old one didn't tell him enough, he said.
Now I'm supposed to drop another $3k, very likely for another clear test result, just to hear what the doctor says I should do about my constipation and bloating?
It felt like a scam. Instead of getting advice from a specialist M.D. I was driven to get it from the internet. And dang if it didn't work. I went on a low-residue diet that resolved my digestive problems almost immediately and has had numerous other benefits. My diabetes is in complete remission, I've lost weight, etc. But when I asked the gastroenterologist if diet changes would help, his answer was short and simple: "No."
So I'm very happy to see far less expensive alternatives. One less leverage point for the health care system to empty my wallet.
I live Serbia, to use Trump's words - in a "shithole country" (and I fully admit it is :-( ). I've never had a colonoscopy but I had a gastroscopy two months ago and it was fully covered by our single payer insurance.
At the same time a friend of mine needed to have a gastroscopy and a colonoscopy. He decided to go the private route and also chose a full anesthesia. That costed him 30.000 serbian dinars (~255 euros).
So it seems to me that you could buy a return plane ticket to Serbia, stay here for a few days, do a colonoscopy here and it would still cost less than what you need to pay there.
[0] For instance I read that the majority of stock in malpractice insurance companies is held by doctors.
As far as births, the lifetime cost of the injuries that do happen are built into the price. Maybe not a good system, but it's clear enough where the money goes.
However, I'm always surprised by the cost of health in the US. The most surprising thing is that it looks like most Americans seem to not realize that it is perfectly possible to have high quality medicine and well payed doctors if the insurances don't suck all the money between the healthcare system and the patient. Our system has flaws, sure, but the US system looks like crazy to me.
I underwent LASIK in 2002. At that time, it cost me about 1000 USD here in Czechia. On American web discussions, mostly quoted amounts were USD 5-7000.
Among many other big factors.
And it's almost impossible to avoid these traps. It's basically a gamble every time.
None of the above is to make any sort of political point. I still want universal healthcare. Too many people aren't insured or are under insured and it's far too easy for hospitals and insurance companies to screw you and leave you with no recourse, especially if you're already vulnerable. There was a time when I was undecided on the issue, but it seems like every country that has universal healthcare really likes it even if some of them complain endlessly that their healthcare system is a financial black hole (e.g., my UK friends complaining about NHS always getting more money and yet the quality of care doesn't improve perceptively--although that was a pre-COVID sentiment).
I also know American friends who have flown to India to have lasik and paid full price for a reputable Indian doctor to perform it because all-in it was cheaper than paying for it domestically (it's possible that their insurance didn't cover lasik? I'm not really sure how that worked out).
A similar, but at least nowhere near as expensive, gotcha in many US insurance plans happens with annual checkups. Many plans fully cover an annual check up with no deductible or co-pay.
But during that checkup if you mention some issue that the doctor does not specifically find or ask about as part of the standard checkup, you might find that your insurance company counts that visit as a diagnostic visit or a treatment visit, not a checkup visit, and you pay the normal office visit deductible or co-pay.
If you ask something that takes significant time for the doctor to deal with that might make sense, but I’ve read of it happening for things like you tell the doctor that you get sore wrists after a full day on the keyboard and the doctor spends a minute telling you about taking breaks and giving you some ergonomics tips.
An employer can pay for medical checkups (which can run up to many ££££ full body medicals and scans - the works) without any tax implications for the employee or the business, but not for similar things being done as 'treatment' for something (unless it relates to an issue caused by or within the employment itself, like if you crushed an arm in a warehouse accident, say).
If you are not an MD it may take 3-4weeks to find out what a code costs and what coverage will be. They'll call you about the single code and coverage that you requested, when they get around to it. However, if they have mis-billed you (eg 45min for a 15min visit) then you can get them to reverse and rebill the procedure. Personal experience.
My Doctor is great, and has zero skill w/r to filling out codes for insurance purposes. Socialized medicine for the win.
It's why doctors in America get paid the big bucks. /s
The MDs will in fact help structure your treatment such that the insurance covers it, though I don't think that includes outright lying. It's also admittedly less of a necessity because the prices aren't ridiculous.
To answer your question : No, this shouldn't be a part of an MD (or their paperwork writing partners in the office) job.
In the U.S. do I personally seek MDs that excel at writing insurance codes? You bet I do.
It's important to achieve any decent level of personal care without breaking the bank -- keeping in mind that i'm not particularly wealthy.
Some doctors I've been to assume that I've already tried simple things to help with whatever issues I've had, and that is sometimes an inaccurate assumption.
A screening procedure is considered preventive. Obamacare requires preventive care to be 100% covered. Before that, your plan might have also charged for preventive procedures.
The gist is that they found a significantly higher false positive rate - probably between 2.4x higher and 4.8x higher - and in absolute terms, a meaningful FP rate (15% without or 25% with other abnormalities):
> Among 3946 participants, 704 (17.8%) showed positive FIT results and 1303 (33.0%) had hemorrhoids. Of the 704 participants with positive FIT results, 165 had advanced colorectal neoplasia (ACRN) and 539 had no ACRN (FP results). Of the 1303 participants with hemorrhoids, 291 showed FP results, of whom 81 showed FP results because of hemorrhoids only. Participants with hemorrhoids had a higher rate of FP results than those without hemorrhoids (291/1176, 24.7% vs. 248/2361, 10.5%; p<0.001). Additionally, the participants with hemorrhoids as the only abnormality had a higher rate of FP results than those experiencing no such abnormalities (81/531, 15.3% vs. 38/1173, 3.2%; p<0.001).
The discussion section (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5122631/#__sec1...) has more, particularly some conflicting results with past studies.
Also, everything is different for a patient than a population. If a patient has reasonable expectations (ie, that a positive result could easily be false, and is nowhere near conclusive), and they would otherwise obtain a colonoscopy rather than putting it off, then by far the bigger concern is false negatives. That is, if you can take a FIT (or two a few months apart) and skip a colonoscopy based on negative results, the false positive rate doesn't matter much - you're replacing something annoying with something not at all annoying. I couldn't find any good studies of false negatives.
After reading this stuff, the one thing I wouldn't do is completely replace colonoscopies in favor of FIT.
I can't wait until the people who spent their formative years sharing shock images on IRC and calling people nasty things on 4chan and don't get offended easily (i.e. the people who graduated high-school after the internet became common but before "real name" social media became common) are old enough to be the ones calling the shots in the workplace. We're already starting to see the effect in low stakes and low formality area, e.g. Wendy's twitter account but it hasn't really taken off yet.
http://dx.doi.org/10.1136/gutjnl-2016-312712
As a rule of thumb, the earlier it is detected, the better any type of cancer is treatable.
The USPSTF tends to advise against cancer screenings without good evidence, and they are positive about colonoscopy: https://uspreventiveservicestaskforce.org/uspstf/draft-recom...
Unambiguously stating that up to 90% of polyps or the tumors they grow into can be detected and removed. Also that lifetime risk of these cancers is 4.5%, versus a low risk of complications from the procedure. Compare to much lower detection rates for non-invasive procedures, and note that a positive from a FIT or FOBT will get you a referral for... a colonoscopy.
I don't have any expertise here, only marginal interest, and hoping like hell that it always stays that way. But it's not comforting to read that the odds of a serious horror show are higher than flipping a coin and getting heads 5 times in a row. Seems unlikely but do you want to bet your life on it?
Also not comforting to see the low rate of detection for the lab tests. FOBT misses 2 to 4 out of 10. FIT misses 97% of advanced cancer? That must be a typo. Checking... "FIT has been extensively evaluated for screening, with sensitivity estimates of a single low-threshold FIT for CRC approaching 90%." (https://gut.bmj.com/content/68/9/1642) But of course, that's once you have something that bleeds. The scope finds those earlier.
All very unnerving. A lot depends on the goal: catch your own cancer early, which suggests getting a scope early, or increase detection broadly among a population, which suggests focusing on easy-to-take tests that more people complete.
- A colonoscopy will detect *most* precursor or active anomalies.
- A FIT or FOBT will detect *many* active anomalies once they are bad enough to start releasing traces of blood.
As an individual, a lab test is way better than nothing, but if your health system or insurance will cover the cost, or if you can afford to pay for it out of pocket, then a colonoscopy will reveal most problems, even fairly early and small ones, and give the surgeon a chance to snip out polyps and such right then and there. If the scope comes back reasonably clear, you can be 10 years until the next one.
Keep in mind there is a low risk of "serious complications" (one paper concludes ~2.8 per 1000) or death (~0.34 per 1000) from the colonoscopy procedure. If you'd like to have nightmares about it, source is https://www.giejournal.org/article/S0016-5107(11)01965-1/pdf
Please, anyone, correct me if anything there isn't a fair generalization.