Are colonoscopies worth it? | Hacker News Reader

Are colonoscopies worth it?

asteriskmag.com

292 pointsTheIronYuppie278 comments

It’s time to share something personal again.

When I was 20, I vividly remember being in the bathroom at my workplace when a large amount of blood started coming out. I did what any smart, effective 20yo would do: ignored it because I was embarrassed.

Fast forward 10 years, and I’d been ignoring it for a decade. It had continued to happen every few months. Sometimes the blood was so bad I’d have to wait up to 20 minutes for it to stop. Other times I would see blood, but no bleeding.

These are bad signs. If you see this, don’t do what I did. I was gambling with my life. Remember that popular video game commenter that died from this? Totalbiscuit? He concealed his, and he lost.

The most unexpected thing is that when I actually wanted one, the process took over two years. And that was after a year or so of periodically mentioning it to the doctors, who would give me a sheet of numbers to call and I never bothered. Those three years could have been the difference.

Turns out, there’s nothing wrong with me. It was hemorrhoids. You might think you’re smart enough to tell the difference. I thought so. I was a cocky idiot who could’ve died from cancer before seeing my daughter get married.

Just get one if you see something. The final paragraph of the article pleads you to. The peace of mind alone was worth the small unpleasantness and major logistical annoyance.

Jesus Christ, next time start with the fact that you’re not one thoracic tumor .

I’m a dude that had GERD but got both ends checked and they found polyps, so I randomly got incredibly lucky.

I was 26, and had less of a fight because of history, but it’s way worth it.

Also, ask about the Miralax option!

Seconding the Miralax option, just be sure to mix it with a flavor of sports drink that you don't plan on enjoying ever again :P

Same situation, but 10 years later for me. I’m now on a 3 year cycle due to the type of polyps.

> worth the small unpleasantness and major logistical annoyance.

I’ve gone through it twice now. Both times, the most annoying part was the 2 or so hours they make you sit there in a hospital gown with no phone or electronics and nothing to do, while you are starving and uncomfortable and waiting to have the procedure.

I don’t know if it’s like that everywhere. But would it really be that bad to let people hang on to their phones? Why make this more difficult than it needs to be?

Give me phone or give me ativan. Either will suffice. Both is even better, but...

I went in, put the hospital robe on, 20 min later I was under anesthesia.

I could keep my phone anytime (why would you not?).

Now, in France you prepare yourself before and that's another horrifying story :)

> But would it really be that bad to let people hang on to their phones?

Yes, it would. The last time I had an EGD (same facilities as colonoscopy), there were 5 small rooms on each side of an aisle for patients. Some of the rooms had TVs turned on, some had patients' family members talking loudly, and of course the nurses were running all over the place, with many talking about what they did over the weekend, etc.

Would it be so bad if people learned how to chill out for 2 hours without constant stimulation?

I can happily chill out without my phone. I think it's something that more people should practice. I don't think that pre-colonoscopy is the time to expect people to go without comforting distractions.

> The most unexpected thing is that when I actually wanted one, the process took over two years.

The doctors probably thought it sounded more like hemorrhoids, but weren't going to stop you from getting the colonoscopy. Hopefully they at least did a digital exam and gave you recommendations.

When the symptoms first happen, absolutely go to the doctor. Where it gets tricky is when it's probably nothing, but it might be something, and there's a disagreement on if more tests are worth it.

Thank you for sharing.

I'll share a story to help destigmatize. A few months ago I was taken completely out of commission by GI symptoms, just hours and hours of pain and vomiting. It turned out I had an infection, but the infection caused there to be shapes on my intestine that apparently looked vaguely like Crohn's disease on the MRI (or something, I'm not a radiologist, my understanding is pretty vague. There were bubbles in my intestine from bacterial respiration).

So I got a colonoscopy. And it turns out I'm fine. Drinking the prep isn't my favorite thing, but it's a task that gets done.

If two gallons of salt water and a trip to the doctor is all that stands between you and seeing your daughter's wedding, make it happen and you have nothing to be embarrassed about. Everybody poops and everybody gets a colonoscopy.

I got hemorrhoids afterwards too. Cutting corn kernels (if you know, you know) out of my diet made them go away. Afterwards I could eat them again. Life is strange.

The prep is even easier these days, my last colonoscopy earlier this year it was a few pills and then just drinking a lot of normal water.

I vividly remember the old "disgusting powder downed with 4-5 litres of water in two hours" followed by thebsame time on the toilette. Nowadys, while still not delicious, the stuff is acceptable taste-wise, takes all of 1 litre of liquid and after three trips to the bathroom you're good.

No idea ehy people are so afraid of that. Ifbyou have nothong, fine. If you do, it migjt very well save your live or very serious surgery down the road. After all, whatever it is, it wont go away just because it remains undiagnosed. After all, a falling tree in the woods without anyone next to it still makes the same noise.

Yeh, the prep is the worst…

Might be the skill of the surgeon who did my three colonoscopies (and the fentanyl sedation) but I didn’t fund the actual procedure too bad

It’s quite interesting seeing you own insides and the colonoscope they used for me had a transmitter the the head so you could see it’s shape as it snaked through the colon

I find the prep really hard to take. It doesn't taste nice, and it involves drinking much more fluid than I'm used to. I had a sigmoidoscopy about 20 years ago; instead of laxatives, they gave me an enema, whose effects I found surprisingly swift and violent. An enema won't work for a colonoscopy, because it only cleans out the sigmoid colon.

The colonoscopy is also extremely unpleasant; not exactly painful, but it made me groan repeatedly. The procedure lasts about an hour. I wasn't allowed sedatives, because I drink a lot; and no gas either, because something something, like I was going home under my own steam.

I've had three colonoscopies in the last five years, two last year (the second was to check up on the sites of the plaque removals from the first. They're threatening to send me for another check in January. I'm not yet sure if I will comply - I'm feeling overtreated.

I was sent for these procedures as a result of the self-administered fecal blood test, that everyone over (I think) 60 gets on the NHS. These were not screening tests.

> Might be the skill of the surgeon

My procedures were performed by a specialist colonoscopist, supported by a roomful of nurses and technicians (about 5 of them, I think). Plaque removal might be termed "surgery", but it's quite a long way from the scalpels-and-forceps type. The machine is very cool, and probably very expensive; in addition to the camera, it carries a wire loop for removing plaques, and another device for tattooing the sites of removed plaques. And they track the location of the tube with a continuous X-ray. But I guess most of the cost is the staff.

I had rectal cancer 18 years ago, and part of my followup was annual colonoscopies for the first decade. So I'm pretty familiar with the procedure, at least how my thoracic surgeon performed them.

Yes, the prep can be unpleasant. I tolerated it because of how close I had come to dying, and really didn't want my ticket punched. But the procedure itself was never unpleasant. When you say you weren't allowed sedatives because "I drink a lot;" were you referring to alcohol? My surgeon typically used propofol to induce twilight sedation. It was the best sleep I've ever had, though I understand that I never lost consciousness. The colonoscopy has NEVER been painful for me.

I would recommend finding a new doctor. Doing a colonoscopy without sedation sounds barbaric.

> were you referring to alcohol?

Yes.

> The colonoscopy has NEVER been painful for me.

You've always been medicated.

> I would recommend finding a new doctor. Doing a colonoscopy without sedation sounds barbaric.

"My doctor" is what I call my GP; he's not involved in this process. I was referred for colonoscopy based on a fecal blood test that was centrally-administered. Several consultants (including the dental consultant that did my root canals) have denied me sedation on those grounds. In general, I'm inclined to agree that anaesthesia and sedation are dangerous for drinkers, and should be avoided if they aren't essential. And they aren't essential for a colonoscopy.

I want to do my next one awake, but still treated to relax, how terrible was it? I assume the root canal was worse, right??

Root canal was much worse, even with good local anaesthesia. Unmedicated colonoscopy is just very uncomfortable.

If it is RED blood, it is a vein that breaks when the your stool passes. Most likely hemorrhoids.

The problem is when you have BLACK blood in the stool. That may be an internal bleeding.

Red blood consistently still deserves to be checked out.

I had a misdiagnosed anal fissure for a year. Get the ass doctor involved early, my GP was clueless about it and had me trying hemorrhoid/lidocaine creams for a year while in agonizing pain. The first thing the ass doctor asked was; do you know what a fissure is? before the exam even started. I learned to skip past the general doctors to the specialist from this experience. Also, the anus is the fulcrum of your body, treat it well.

> I learned to skip past the general doctors to the specialist from this experience.

What concerns is that where I live, it's my understanding that, with a few exceptions [0], you can't skip a GP and go directly to a specialist. And I'm not convinced that GPs here are any better than in the US or elsewhere. Bonus points for large parts of the country not even having enough GPs for their population.

---

[0] You can go see an eye doctor or a dentist without seeing a GP first.

If you're in the UK (you used "GP", so I'm guessing), then you absolutely can. Just go private. (https://www.nhs.uk/common-health-questions/nhs-services-and-...).

Don't bother with the NHS, it's a carwreck. See this, for example: https://www.bbc.co.uk/news/health-67239548

Last month, after years of waiting, I got a letter again delaying my assessment for a growth on my neck, for the foreseeable future. It's a good job that I'd gone private a year ago, as it turned out to be extremely advanced, with neural invasion, requiring two rounds of surgery to be removed.

Nationalised healthcare ought to be means-tested to target help at the people who need it, and not delay others who can afford to pay their way. The population 'pyramid' as it stands can't support the health and social care model we're using, and the lack of market incentives means that we don't train enough medics.

I'm in France, I used GP since that's the term that seems to be used in the Anglosphere. It also seems like a reasonable translation of the French term – médecin généraliste.

I'm hearing bad things about UK's NHS, and while I don't have any firsthand experience with it, I do get the feeling that the French system is going down the same path.

It's true that I don't usually think about going the private route. I'm not 100% sure, but I think you can probably see a private specialist directly. I also don't know how much it would cost, but probably quite a lot, given the prices in the public hospitals, and I don't think it's covered by the insurance, even though I carry insurance above the standard national scheme.

I was actually in France last year, and arrived having lost (in transit; baggage handlers) some medicine for my son which had been prescribed in the UK by our GP the previous day, as he'd had stomach symptoms.

I contacted the local French doctor, who brought us in that day, gave my son an actual examination (the UK GP didn't do this), asked if I was aware that he had an ear infection (I wasn't, the UK doctor didn't check), and revised the course of treatment which resolved the problem quickly.

I was extremely impressed by the French doctor; he was in a different league to the standard in the UK.

> the lack of market incentives means that we don't train enough medics.

I don't think so; the number of medics we train in the UK is mainly controlled by the medical colleges.

That makes my point doesn't it?

OK, I supose it does, in the sense that market incentives is one way we might get more doctors trained. But on the other hand the market incentives are plainly there; plenty more people want to train as doctors, than there are training places. That is, the market incentives don't seem to be working to increase training places.

ANY blood deserves to be checked out.

Black stool (melena) indicates an upper GI source: esophagus, stomach, duodenum chiefly.

But _any_ source of colonic bleeding is likely to be red to bright red. The possible pathologies are numerous: hemorrhoidal - as you mention, tumours, inflammatory bowel disease, arteriovenous malformations, diverticular disease, etc.

Wrong. There is melena, which is a generally unmistakable consistency of black sticky stool (nothing anyone would identify as "blood") that is indicative of upper GI bleeding - not the colon. It doesn't really indicate severity because it may be fast or relatively slow. Both upper and lower GI bleeding can be serious in terms of acuity or seriousness of disease (cancer).

However if the internal bleeding from the upper GI system is brisk/fast enough it will come out bright red. This can happen to people with esophageal varices (sequela of liver disease and cirrhosis) or brisk stomach or duodenal ulcers and the prognosis is usually poor, but very likely they will be getting emergent endoscopies and/or mass transfusion if they make it out of the ED.

You can't tell by color.

> That may be an internal bleeding.

Colonic bleeding is just as internal and will typically be red or maroon.

Just a little aside for those doing a search in the future: many things you consume can also turn poop reddish so be sure to think about what you had for dinner if you've just noticed it. For example; beetroot, red wine, berries, stuff with food colouring etc.

In particular what you ate the past sveral days since it takes time to go through (exactly how long depends on your diet and body, but I think 2-3 days is common and a another couple of days is not uncommon). It takes long enough that it is easy to forget.

It’s also good know that if you’re seeing bright red blood then it’s a higher chance it’s hemorrhoids whereas dark red you definitely should get it checked because it’s coming from inside your colon.

Also there’s supposedly a poop test called fecal occult blood test that has a high rate of detecting colorectal cancer that you do over the course of 3 years. I saw this on nhk Doctor's Insight: https://www3.nhk.or.jp/nhkworld/en/ondemand/video/2086035/

Bright red blood can also be a sign of inflammation/bleeding in the low low colon, e.g., proctitis. (Ask me how I know, lol.)

As a rule of thumb, the farther the blood has to travel, the darker it'll be. Blood from high up enough in your GI tract will be a black, tarry substance, NOT red, but it's absolutely blood and you need to get that checked out ASAP.

Advice too simplistic, end of colon can emit blood also and then it’s brighter

“Recurrent bleeding from colon is bad, go see a doctor.” Is a fairly simple rule.

IMHO depends on the amount. If you are severely dehydrated and you notice your stool physically hurt coming out. A small amount of blood might honestly not be unexpected.

Edit: To be clear “severely dehydrated” is kinda an important factor here. Point being that if the cause is obvious I dont see why you’d get a colonoscopy. Please correct me if im wrong instead of just downvoting for anyone who knows more about this thx ^^

It doesn’t matter. Go. See. A. Doctor.

Why is the amount that you care for your own ass so ant-sized?

If you are consistently severely dehydrated that’s also a good reason to see the doctor ;)

But yeah, if it happens once it’s not necessarily a problem. It’s when you keep having bloody stool that it’s a good idea to get checked.

Just get ur ass checked, end of story. Medical emergency or not. You're paygrade is way to low to make that call (fuguratively speaking)

Edit: i can only lead an ass to the proctologist, i cannot make it "drink" ;)

Unless, of course, you uave both: the office worker hemorrhoids and colon cancer. Ask me how I know that! So no, if ypi start bleeding from your body without having injured yourself, see a doctor and get it checked out.

Wrll, actually, if thebimjury is beyond "a self applied band aid can fix it", see a doctor as well!

Bright red "live" blood can come from any part of the lower intestines. Strong-smelling feces with dark blood are called melena and are associated with bleeding in the upper gastrointestinal tract, peptic ulcers are a common cause. The reason for the difference is the blood gets digested as it passes through the gastrointestinal tract. It's not a 100% exact science, bleeding in the lower intestines might still spend enough time in the body to be digested and bleeding in the upper gastrointestinal tract might come out fast enough that it still looks red. Additional symptoms usually provide enough context for a clinical decision to be made.

> fecal occult blood test

Often used to screen patients for colonoscopies. Screening is looking for disease in the asymptomatic: "occult" means it's not visible to the naked eye, you're looking for blood even though the patient has not noticed any. The symptomatic don't need screening, they need diagnosis and thus proceed directly to colonoscopy. Or endoscopy if upper gastrointestinal tract bleeding is suspected.

I've had the experience that... I was told when I was separating from the military, at 25b(I don't know why and I didn't ask...), to expect a colonoscopy. It didn't happen. I mentioned it to my GP a couple of years later, he said probably between 30 and 35... Now I'm in my 40s. It's perpetually a couple of years away.

I get the sense from this, and from other anecdotes in life, that preventative maintenance, of all flavors, is something we used to do, for a brief period of time, but that we don't really do anymore.

In the Netherlands they begin with preventive colonoscopies when you turn 55. Then you get one every 5 years.

The newest science says they should even begin at 45.

> The newest science says

I was speaking with my Dr. about these exploratory procedures and asked if early diagnosis extends life. He responded with general recommendations. Every procedure has a risk.

I have no symptoms, so what science studies with control groups show extending life?

Since my mom had colorectal cancer at 45 I was expected to start colonoscopy at 35 and then every 5 yrs

I did the first only so far and no polips.

There's nothing to be scared. It takes less than an hour and is painless. The worst part is the prep you do at home a day before. It's very powerful stuff. You'll be shitting clear water by the time they do the exam.

Lucky you. I am color blind. I cannot see certain hues which in poop is very critical. Although once I did drink prune juice and I freaked the hell out after going to the bathroom (I had forgotten I had taken few cans) The color was so strong. But yeah, I think men in general like to postpone having to bring this to anyones attention and it sucks.

My dad was also colourblind, and it was only when my mum saw the blood in the toilet that he got tested (at 57). Stage 4 metastatic bowel cancer. He got 8 more years of life but I wouldn't say they were all good years. He died nearly 20 years ago now. Mum is still in good health at 81. I'm 53 now and have had 5 yearly colonoscopies since I was 35, I'm not taking any chances. I don't mind the prep, and don't feel a thing or remember anything about the procedures themselves.

There might be "apps" for that although you should heartily review their privacy policy and alway have internet off for it

I've had two colonoscopies done in the last 10 years. The second was possibly unnecessary, but I pushed for it because I just really enjoy propofol. Maybe if more people knew that the sedative drugs used in the procedure are fun, they'd be more inclined to have it done.

Edit: downvotes? Really!? I'm 100% fucking serious! Work any angle to get people to test!

I am really curious as to why you enjoy propofol: is this in any way producing euphoria? Normally you should just feel really sedated then pass out, with little difference between this experience and being just tired then asleep. is the large-ish quantity of white fluid getting into you not off-putting?

Nah, it's fine. At colonoscopy doses, if you fight it, you can remain semi-conscious, and the process of coming out from sedation is pretty trippy as bits of your brain that have been muted come back online at different rates. It's unique, it's legal, it won't show up on a drug test, and it's as near to 100% safe as any drug use can be. (You're in a hospital, for crying out loud!)

(Plus I like watching the video feed from the camera. How many other people have seen the inside of their colon, live? It's cool!)

Cartoons are amazing in this context ;)

> I pushed for it because I just really enjoy propofol

After about the 4th? time I had it (I've had 9 cardioversions, along with many types of surgeries), I realized I liked propofol. By the 6th time, it was the highlight of any procedure. I found that the high comes from trying to fight the anesthetic and the amazing quality of sleep you get, plus I will agree the wakeup is tricky. Be careful about what you're really obsessed with, as you'll likely talk about random aspects of your hobby as you come out of the stupor.

The next best thing, I would say is Demoral, which gives me the instant feeling of being peak-drunk without the need for all the troublesome alcohol. Anything acute and severe, that cannot be immediately triaged, can justify getting an injection. This drug is very tightly controlled now.

I do avoid pain killers as a personal policy, to ensure I am aware of what's going on in my body at all time (since it's a delicate thing). That being said, I can understand Michael Jackson's addiction.

This one knows what's up

You avoid pain killers but love Demoral?

I don’t understand.

Sedatives are not mandatory. They take you out for a day and in my personal (informed by direct experience) opinion are not worth it (I would rather have the time to spend doing things I want to rather than have a day of recovery from sedatives).

People really shouldn't get tested unless they meet several criteria. Obviously any bleeding from your rectum should get checked out, and if hemorrhoids are rules out, a colonoscopy is probably the next course of action. And around 45, you should have one since that's the most likely age for colo/rectal cancer occurring.

Family history can also affect this timeline. My kids are now stuck having colonoscopies five years earlier than the normal recommendation since I had rectal cancer at 40.

And while I've found colonoscopies to be uneventful, they can have side effects. A perforated colon can happen in the worst case, or bleeding and infection. These are considered rare though and colonoscopies are considered pretty safe overall. But this doesn't mean you should get one just because you like getting high...

In the end, hehe, it was a medical doctor who greenlit the procedure. Patients don't get to decide their own treatment trajectory, but they can certainly respond enthusiastically when the Certified Medical Doctor suggests it as a possible route.

And yes, I was bleeding heavily out my ass and had recurrent stomach and intestinal pain for months that went away and then came back the next year. Not as if I went in for a cut finger and demanded an anal probe for it.

Turns out I'm sporadically - not consistently - lactose intolerant. Russian Roulette. Makes me shit acid that tears up all my soft tissue causing bleeding and eventually clotting. FODMAP, or just lots of oatmeal until it clears up, is the way out again. The lactose sugar-based colon purge laxatives they give you to prep for the procedure work REALLY well on me.

I haven’t had hemorrhoids since I installed a bidet. Just passing on some info from one sensitive butthole to any others out there!

Pretty much the same thing happened to me but the bleeding started in my 40s and I was very embarrassed about it. The bleeding was so bad that I developed anemia and had to be on iron supplements. It would cone and go and eventually my doctors convinced me to see a GI specialist and to get a colonoscopy, but I kept putting it off because of fear - fear of the process and fear of what they might find.

The GI specialist I eventually saw turned out to be one of the best in the country and, based on my symptoms alone (especially the anemia), he was 99% confident it was just hemorrhoids but opted for the colonoscopy anyway. Since I have GERD as well he did an upper endoscopy at the same time while I was under. Turns my colon is completely normal, and I don’t even have any polyps (which my father had several at my age). Don’t need another one for 10 years.

Honestly my biggest fear was going under with propofol. A lot of people I spoke with said it felt great but I didn’t have that experience. I hated the feeling of slipping into unconsciousness in a way that was not similar to other anesthetics I had been under, and I felt like complete garbage the whole rest of the day. Other than that, the prep was perfect fine and I had never taken a more legendary shit in my life.

I’m the only person I know who has a consistently bad time with THC gummies. I wonder if there’s a connection it’s your experience with propofol.

(Yes I vary dosage, mindset, brand, delta 8 vs delta 9, sativa vs indica vs hybrid, empty stomach, full stomach).

When I was 12 or 13 (in the early 1980s), the same thing happened to me. I told my mom, who scheduled an appointment at the doctor. At the appointment the doctor needed to prove around with his finger and said “mom, maybe you should wait outside”. My mom said no, she’d be there with me. I looked at her and said “no, you are going outside”. I was not going to get fingered while my mom watched. She left and the doctor did his job. Turned out to be harmless.

> The most unexpected thing is that when I actually wanted one, the process took over two years. And that was after a year or so of periodically mentioning it to the doctors, who would give me a sheet of numbers to call

What? When my GP decided I was at risk for cancer of the colon I was scheduled for a colonoscopy within a couple of months and I didn't have to call anyone. This was in Norway.

But also, didn't your GP examine you?

I OTOH, took a dump in the woods and noticed the entire top of the pile was fresh blood. Freaked out. Started paying attention and saw some evidence in the toilet a couple times. Called bunch of drs the following monday, setup an apt with digestive dr, took 4 weeks to see him, and another two before the colonoscopy and a bunch of tests. By then, nothing no idea where it came from, no evidence of anything.

"Probably hemorrhoids" and $1200 out of pocket after insurance.

And people wonder why no one goes to the Dr in the USA before they are 1/2 dead.

Agreed.

I only had one sign something was amiss - a small amount of bright red blood in my stools, once. No pain, no discomfort. But it alarmed me enough to schedule a colonoscopy, a procedure I hadn't had before. The doc told me not to worry, as it was probably just a hemorrhoid.

Before the procedure, the doctor was cordial and animated. As I was waking up afterward, his composure was totally changed - a sign something was wrong. He told me he found a mass, and scheduled a CT scan for the next day. That scan showed I had stage IV colon cancer, with metastases in my lymph nodes and liver.

Other than that single blood sign, I had no indicator whatsoever of the dire situation. Thankfully, I was admitted to MD Anderson, where I firmly believe I had the best team possible treating me. I have a good amount of collateral damage as a result of the treatment, but remain cancer free. I am grateful to still be here, as several of my friends with similar diagnoses aren't.

I am definitely pro-colonoscopy. The short-term discomfort of the prep is nothing in comparison with 12 rounds of chemo.

I do regular colonoscopies because of a condition. People are worried about the procedure, as I was my first times. Here are some things that I wish someone had told me:

- Taking the meds for cleaning out your system the day before is far worse than the procedure itself.

- Have a lollipop to stick in your mouth after Each time you take a shot of the laxatives. It helps with the vile taste of it.

- If you need relaxing meds or something for the pain and discomfort, they have good stuff handy when doing the procedure.

- It only ever hurts if your colon are in bad shape. Colonoscopy doesn’t hurt if you are healthy (and even if it does, they have meds for the pain).

- Don’t be embarrassed, the hospital staff do this all the time. They don’t really care about the things you are worried that they might care about.

- Wear loose fitting clothes that are easy to change in and out of when you go to the hospital.

- Try to relax.

> It only ever hurts if your colon are in bad shape. Colonoscopy doesn’t hurt if you are healthy (and even if it does, they have meds for the pain).

I’m sure there will be a few people popping up to disagree with this and I think you kind of disagreed with yourself in that sentence anyway.

I got the all-clear in the end, and my guts are not in bad shape (don’t drink much, never smoked, eat healthy), and I’ve generally got a high pain threshold… but the procedure (only a flexi-sigmoidoscopy) hurt like hell and I wish I’d had some form of pain control beforehand.

> It only ever hurts if your colon are in bad shape. Colonoscopy doesn’t hurt if you are healthy (and even if it does, they have meds for the pain).

Ha, the procedure itself was painless for me since I was out cold, but during the prep I distinctly remember thinking (between waves of cramps) "Damn, maybe I do have Crohn's..."

Was a total breeze for me for the same reason, except I felt great right before it because apparently one way to get IBS relief is to have nothing in your bowels at all.

O man I did one of these last week and I so wish I had known that lollipop trick then. The cleaning out of my system the day before really was the worst part for me.

Depending on where you are and what the doctor prescribes, you might also have several days before that, on which you are not allowed to eat many simple things like tomatos, because their skin could linger in you digestive system for a longer time and make seeing things more confusing or difficult. Then after not having eaten properly for a few days, you top it off with that day or two before the actual thing.

M&Ms work better. Just take a mouthful, chew a bit, and swallow, and then take another mouthful.

No. This is not a good idea. You are not supposed to eat stuff. The whole point is to empty out your system. It would not be great to be half way through the procedure when they say: “oh. Here is a bunch of M&Ms, we can’t see anything. We need to redo this procedure in a week. And this time don’t eat stuff…”

(As well as making sure you don't have actual matter blocking the view, you also want to avoid staining the bowels with something that could be mistaken for blood; so also don't drink red stuff.)

Moviprep doesn't taste that bad. The results are more unpleasant than the taste.

Regarding pain, can confirm, it felt incredibly unpleasant for a short initial time but wasn't exactly painful.

For future colonoscopies, ask if you can do the Gatorade + MiraLAX prep. You can pick your flavor (but there are color restrictions) and it is way better than the other prep fluids.

Just don't plan on drinking that flavor of Gatorade again. The association with miralax etc will ruin it for you forever.

I didn't end up with a negative association at all.

> Don’t be embarrassed, the hospital staff do this all the time. They don’t really care about the things you are worried that they might care about.

Facts. My mom was an Endo nurse for 40 years, and it's true that they don't care. That said, the single most important thing you can do is just be a nice person. They see a lot of people at their worst, and a nice, kind person will put a smile on their faces.

> Taking the meds for cleaning out your system the day before is far worse than the procedure itself.

It depends... in the US I just had to count backwards from 10 and fall asleep -- but I've tried being give a wooden stick to bite -- that was a different experience.

In Denmark they usually just use local drugs, no sleeping, but last time it was no big deal anyways :)

The article doesn't cover this, but it's worth pointing out why the study asks this particular question. With a single-payer system the Nordic countries want to know what the ROI is if we sent letters out to everyone above a certain age offering a free colonoscopy. The study is well-designed to answer that question.

The study does a poor job of helping an individual asking a similar but different question: Is it worthwhile for me to pay out of pocket for a colonoscopy?

The latter question is very important in a system that isn't single-payer and so this has sparked a lot of debate in e.g the US.

The intention-to-screen design of the trial depends heavily on the effectiveness of recruitment and the pre-existing “prevalence” of the test in the setting in which the study is conducted. I can see rejecting an unpleasant, rarely used screening test. But if it were presented in a less impersonal (but still unbiased) way, I imagine recruitment would have been higher, skewing the data towards cost-effectiveness, as re-analyses showed.

I did a colonoscopy last year, and it was covered by my insurance (in the US). I was referred by my primary care physician. My insurance is nothing special, it's the standard type of insurance people have access to when they get a corporate job.

The type of question "are colonoscopies worth it" is not actually people should ask themselves. This is a question your primary care physician should answer, and you should follow their advice. If you don't trust them, just go find another one.

>3. It’s irresponsible to call colonoscopies “invasive” (as CNN did) since that might make people think they are unpleasant and not do them.

LOL. It hard to imagine anything much more invasive than having a metal tube (with light and camera) shoved up your arse. It is definitely unpleasant. I speak from personal experience. That said, it is less unpleasant than bowel cancer. So don't be put off if you really need to get it done. It's not that bad.

It is invasive, as are most gynecological procedures. It sounds disingenuous to try and sugar coat this. My female acquaintances have long been lamenting the trauma of gynecologists especially in India telling them “please get a scan in the next room it’s a simple procedure” only to get a probing that’s not just invasive but even painful at times.

Yeah. It's definitely a simple procedure... To the doctors who do it all day every single day for decades. To the patient who's going to be examined, it's extremely invasive.

I have not had one but closely monitored people that had a colonoscopy. The prep looks like worse than the colonoscopy itself.

I was under general anaesthetic for mine. But also smart phones and bidet toilet seat made the prep no problem as well.

They use Midazolam in Australia, which is great as it's very sedating and causes anterograde amnesia, so you don't remember a thing.

I've had two. They were a breeze. In and out in 45 minutes, no discomfort, not a big deal. But sure, the prep is a little annoying.

"Little" annoying? God, having your rectum just spewing out urine-like shit as if it were a water tap is absolutely awful. I can't imagine doing that and then having a tube going up your damaged ass without anesthesia

Colonoscopy is fine, but it’s uncomfortable. It’s not something I’d want to have without a suspicion anything is wrong.

Especially given the non-zero risk of complications, such as perforating your colon wall.

> It hard to imagine anything much more invasive than having a metal tube (with light and camera) shoved up your arse.

Well, how about an operation where sharp tools are used to slice open parts of your body that are otherwise entirely sealed, by design? To my mind, that's at least an order of magnitude more unpleasant and invasive.

> It's not that bad.

Totally agree. At commented elsewhere here, the prep process isn't that bad, and is still much worse than the procedure itself.

I've had one colonoscopy. I don't even remember the procedure itself. I got wheeled into the room, the doctor made a couple of jokes while the anesthesiologist put a tube in my arm, then I was out like a light. Then I woke up and it was over.

The prep, however, was pretty bad...

Let's discuss what "invasive" means.

Putting something in the body and getting it back out without tearing, is not invasive. Eating and vomiting would be categorized as invasive, in context.

A colonoscopy/endoscopy is internal and dangerous, which is not the same thing as being invasive, so the term "minimally invasive" is sometimes used as a happy middleground, which has then been sensationalized.

The first relevant definition I found online was:

"(of medical procedures) involving the introduction of instruments or other objects into the body or body cavities."

YMMV

Maybe it's something more like the insertion of a foreign instrument through the epidermis or into a body cavity that...

I dunno. Ears (eardrums), colons, etc are tricky to cover all at once. I don't envy the authors of medical literature.

Ah. So vaginal probes are not invasive. Interesting take you have.

Not in medical terminology, no. I certainly wouldn't call a pap smear an invasive procedure.

> Let's discuss what "invasive" means.

> Putting something in the body and getting it back out without tearing, is not invasive.

Just for clarity colonoscopy is an invasive procedure.

> Let's discuss what "invasive" means.

> Just for clarity colonoscopy is an invasive procedure.

The definition is the point at hand. Stating that it is intrinsically a truism, is not compelling.

In The Value of Colon Cancer Screening (https://www.blackliszt.com/2023/01/value-of-colon-cancer-scr...), David B. Black argues that colonoscopies are a net negative, based on the “high confidence result of harm based on millions of patients [1], vs. the nearly identical low-confidence results of benefit from the NordiCC study”.

[1] “14.6 major bleeding events per 10,000 colonoscopies (95% CI, 9.4-19.9; 20 studies; n = 5,172,508) and 3.1 perforations per 10,000 colonoscopies (95% CI, 2.3-4.0; 26 studies; n = 5,272,600)”

Given people don’t read the full article, and that feels pretty important in this discussion, I will quote the way it ends:

> One thing is clear: Screening works. If you’re of the appropriate age, please get screened. If your tubes are acting funny, please get screened without delay. The best method and the level of benefit are debatable, but we know it helps. Use a stool test if you want (multitarget DNA test if you can), or a colonoscopy, or a sigmoidoscopy, or a “virtual” CT colonoscopy, or a crazy edible camera. Do one of them. Statistics show colorectal cancer is highly curable when caught early, and now that we have feisty checkpoint inhibitor immunotherapies,it’s probably even better now. Just do it. Your tubes will thank you.

That's unfortunate, because it's a poor summary of the actual paper the article is discussing. If you bother to read the rest of the article, you'll see the actual summary of the trial, and it's pretty darned easy to interpret for yourself:

https://asteriskmag.com/media/pages/issues/04/you-re-invited...

to wit:

> The 18% reduction in colorectal cancer incidence was statistically significant, while the 10% reduction in colorectal cancer mortality and 1% reduction in overall mortality were not.

(Those reductions are relative risks, which are on very small baseline numbers.)

Then the article goes on for many pages about how American gastroenterologists do not agree...which isn't terribly shocking, considering the source of the argument. But a number of rebuttals are made, some of which are reasonable (i.e. colonoscopies are one of the few screening tests to actually do something to prevent disease, in the form of clipping polyps), and others of which are quite simply lies ("other studies have estimated larger benefits for colonoscopies" -- yeah, but those studies were bad, and this one was good, which is why we're talking about it!)

Note that American gastroenterologists do a lot of colonoscopies, mostly without good evidence. This was the first major RCT in decades to consider the question at all. The other screening methods have even worse evidence, and certainly no good evidence at the young ages we do them in the USA (currently 40 in men; the studies are all in much older age groups).

Overall, the NORDICC trial paints an incredibly ambiguous picture for the effectiveness of colonoscopy at preventing severe illness or death -- at the very least, the benefits are likely dramatically overstated. Discussing all of this, then turning around and claiming "it works" is an insult to evidence-based medicine.

(FWIW, I'm personally torn on the meaning of the study. I just think that "one thing is clear" line is a particularly odious bit of "journalism" -- not the least because it confuses symptom-free screening with doing something in reaction to symptoms. The rest of the article is pretty fair, IMO, but that line is substituting the opinion of the author for an actual summary of the data.)

Thanks for taking the time to distill the article a bit (more).

I really wish the trial included stool testing. I suspect it would perform very favorably to the colonoscopy, which seems to have very modest benefits to begin with. And the stool test is infinitely easier (and cheaper on a healthcare system).

>The sensitivity of detection of carcinoma is a remarkably acceptable comparison. The multi-targeted stool DNA test is 92% sensitive for finding cancers, which is almost equal to colonoscopy, reportedly at 95%.

https://www.facs.org/for-medical-professionals/news-publicat...

The stool test isn’t as good at detecting polyps but the Nordic study would have shed some light on how much that reduces cancer mortality anyway. This study suggests stool testing compares very favorably to colonoscopy.

https://medicine.iu.edu/news/2019/02/new-study-shows-annual-...

Me too. It would be good to see an RCT between the approaches for asymptomatic people who seek screening.

If i recall, it is important to note that the main analysis in the NORDICC trial was on patients invited to receive screening. As an intent to treat study, not all received screening. There was a subgroup analysis on those that actually received screening, which showed a decent improvement in hazard ratio. The question I had (and will look for when I’m off mobile) is was there a demographic bias in those invited who chose to screen? (Eg higher risk driving their decision). Either way I can control decisions that are not tractable from a public health study point of view. The down side is limited to me— the prep was gross, but my procedure was a breeze. And if something had been found, they can act at that moment. Screening was a no brainer for me.

Yes, this is the main, common counterargument that the OP addresses. This does a pretty good job of showing why that argument is overstated (if not entirely in bad faith), so I direct you back to it.

> There was a subgroup analysis on those that actually received screening, which showed a decent improvement in hazard ratio.

I can't emphasize this enough: read the article. Per-protocol analysis (what you're describing) is incredibly biased. OP shows that it's an overestimate of true effect, and I'd go so far to say that it's completely useless (in general; not just for this paper).

People who argue that NORDICC was wrong because per-protocol showed a bigger effect size should be ignored with prejudice. They don't know how to read or interpret scientific studies, and have a poor understanding of statistics.

> One thing is clear: Screening works. If you’re of the appropriate age, please get screened. If your tubes are acting funny, please get screened without delay.

Screening is for people without symptoms.

If you have symptoms it's not screening, it's diagnostic testing. Diagnosis is important - if you bleed from anywhere you need it to be explained - but there are big differences in how you look at a test that's done for screening vs diagnosis.

If you're worried about getting a colonoscopy, don't be.

I got one last year and it was the best sleep I ever got.

It was two days of the prep stuff you drink to shit your brains out which is a little rough, but I have a bidet, no big deal.

Then you go to the hospital, you dress down into a gown, nurses come in, they put some things on your chest, you get a little cold, they put a nice warm blanket on you, they start an IV, they wheel you into the procedure room, and then you pass out.

You suddenly wake up and I felt like I had an amazing nap and I was incredibly comfortable. Then you have someone drive you home and that's all there is to it.

It was really no big deal.

The only thing that sucks is you pretty much just drink powerade and eat chicken broth during the prep.

Honestly, even without any anesthesia or sedatives, the worst part is drinking the laxative for prep. If you can sit through a visit to a dentist, you can likely handle the procedure itself without any meds. I was actually surprised they even do general anesthesia for it in the US.

> If you can sit through a visit to a dentist

Do you mean with local anesthetics?

Yes, dentist with local anesthesia is worse than a colonoscopy without meds.

That's not my experience. Dental local anaesthesia has improved hugely since I ws a kid; the only really unpleasant dental procedure I've had recently was a root-canal. Routine filling replacements were uncomfortable, but painless, and much quicker than a colonoscopy.

Honestly the picolax part of the prep is okay for me, I hate the low fibre diet of the prior 3 days. White bread, boiled skinless potatoes and chicken breast. Nothing with any colour or texture. Blech.

I ended up declining general anesthesia at the last moment when the doctor offered a consent doc to using my data in the training set for ML detection, leading to a quick discussion of being in the computing field, and he offered that I could stay awake and watch the video feed instead. Hell yes, I’d prefer that!

So, I got some kind of pain relief or relaxant but no anesthesia and it was really interesting and enjoyable to watch the procedure.

The prep was only slightly inconvenient and the overall process didn’t come anywhere near to how people talk about or build it up.

> they wheel you into the procedure room, and then you pass out.

This is the bit that a lot of people have a problem with, and there's usually some choices in the amount and type of sedation you get.

In the US they use much heavier sedation than other countries - use of propofol is not uncommon in the US - and it's one of the things that makes colonoscopy more risky than it needs to be.

I didn't have any sedation or other medication when I had a colonoscopy (in Norway). It was uncomfortable but not painful.

This is actually a nice summary of how a clinical trial is more than just "did it have a positive or negative result?".

Every single trial introduces some bias through the way it's designed. Good trials try to minimize bias or at least limit it to things we know don't introduce bias.

The article does a nice job at digging into the nuances of the trial design and how it may influence (or not influence) the results.

That's why the "reference wars" you see on HN are so pointless. It's easy to just find a paper that supports your position. But trials are of varying quality.

What you see in this article is what normally happens with most major trials - results get discussed, challenged, discussed some more. After a few months doctors finally settle on the main takeaways. Sometimes it takes years.

Yeah, I thought the discussion of how you couldn't just directly compare people that accepted the colonoscopy invitation with the control group was really interesting, and non-obvious (at least to people like me that don't design studies). It reminds me of the fundamental problem that all surveys have in terms of the bias introduced by being limited to "people who agree to take surveys".

Any self-selection where higher risk individuals opt-in more, increases benefit/cost ratios.

That seems like a pro invitation argument. (I.e. pro treatment for the invited + opt-in cohort.)

But alternative screenings with a wider acceptance could have a higher 'benefit-cost' for a lower 'benefit/cost'.

As far as I know, countries outside the USA that recommend it are Switzerland, Germany, and Austria: https://publichealthreviews.biomedcentral.com/articles/10.11...

I was going to post the same thing – Poland launched a nationwide campaign two years ago to get all people over 50 years old (above 40 if they had family history) in for a colonoscopy. However, the linked article is working with a European study done a decade ago (EDIT: I’m wrong about that). There may have once been greater differences between American and European approaches.

Data does not seem to indicate better survival odds so whats the point?

There would be an reduction of 37% in diagnoses if everyone would have accepted the treatment (but no data for mortality).

How significant is reducing a small risk (1%) significantly?

(Base rate fallacy)

"The right graph compares those results to the observed outcomes for acceptors in our branch of the multiverse, where they did have colonoscopies. At the end of the trial, there’s a reduction of 37%. Unfortunately, data aren’t available to do this for mortality,..."

https://asteriskmag.com/media/pages/issues/04/you-re-invited...

Actually I am confused by this graph (right side):

1% of refusers are diagnosed with CRC

versus

1.4% of would be acceptors would be diagnosed with CRC.

So refusing is better than accepting.

I guess I am missing something.

It's in the article. You should read it.

tl;dr - healthy individual without family history could be more likely to refuse the screening (less refuses were diagnosed with CRC than the control). This is the reason the study can't omit refuser from calculations.

> (but no data for mortality).

I have seen the data for mortality before in at least one publication if not more, and it clearly showed that the increase rate in diagnosis did not result in improved outcomes for survival, which is precisely why colonoscopy has a very bad ROI right now

The nordicc trial was published last year. This is recent results, trials with 10 year followup take a long time to run.

https://www.nejm.org/doi/full/10.1056/NEJMoa2208375

Canada as well.

Actually I just got a letter in Ontario for stool testing not a colonoscopy.

You can opt for colonoscopy every 10 years instead.

Yeah gastroenterologists in Germany are a shitshow (no pun intended). They all invested heavily into colonoscopy equipment and now must always do them for financial reasons. I was outright refused treatment when i didn't want colonoscopy for celiac disease. Practical medicine in Germany is totally stuck in the 90s, cause of some deadlock between doctors, pharma and health insurance.

My uncle had one, it almost killed him when the probe breached his colon causing an internal bleeding. It was done with anesthesia, which according to him could be a major contributor to the incident.

> It was done with anesthesia, which according to him could be a major contributor to the incident.

The article suggests his reasoning could be well founded.

This is actually what killed my grandmother back in the 80s, for the same reason. I'd hoped they'd be safer by now...

Do any countries apart from US routinely do it under general anaesthesia? I don’t know anyone who was under during the procedure.

I don't know any gastroenterologist over 40 that hasn't had one (Australia). Do I take the government advice or copy what the doctors themselves are doing?

This is a large, randomized control trial, so obviously you should value this significantly higher than whatever doctors are doing to themselves. (history has more than a few examples of doctors practicing medicine that didn't make a whole lot of sense).

If only Semmelweis wasn’t such a strange chap, we’d have been much more further forward now.

I don't know what this means. Can you expand on your statement? Who is this person? What would we be farther forward to?

https://en.m.wikipedia.org/wiki/Ignaz_Semmelweis

He had very sensible ideas about hand washing a hundred years before it was accepted by most doctors. He was a bit weird though, and ended up being ignored.

Weird as in saying the common practices are not correct, and here is my proposal for a better practice, as supported by statistics.

I can just imagine both how desperate you might feel when you discover that you've been (unwillingly) killing your patients, how you might refuse this reality of being a vector of health instead of the saviour or helper you picture yourself as and also how personable and convincing you'd need to be to get people past that.

Semmelweiss was apparently lacking in social graces, but I wouldn't be able to behave normally if I'd discovered what he discovered.

(Edit for coquilles and spacing)

I've seen a doctor literally commit suicide when faced with the mere possibility that he caused harm to another human being.

Here's a tip for the future: typing a name into Wikipedia usually yields great results.

Why would you waste the chance to tell the story of Ignaz Semmelweis? I wish people asked about him more often.

Doctors used to perform procedures with their bare hands, sometimes immediately after performing necropsies on dead bodies. This guy made the connection that such contamination was causing post-birth complications such as infections. He had his medical students wash their hands in an antiseptic solution, compiled statistics which showed lower mortality rates, was ignored, started publicly denouncing the negligence of the other doctors and ended up interned in some sanatorium and killed for his trouble.

Doctors used to believe they were such gentlemen their hands could not possibly be dirty and contaminated.

It wasn’t just doctors, “a gentleman never washes his hands because a gentleman’s hands are never dirty.” Was the common thought.

NB, not all men were considered gentlemen.

See also surgeons cuffs on coats (blazers), so as to avoid getting blood on one’s clothes when operating, which are still called the same thing today.

Clearly they mixed up cause and effect.

"A gentleman's hands are never dirty" should have meant that he keeps them clean, not that his gentlemanliness somehow keeps them from being dirty.

Doctors routinely washed their hands before Semmelweis, whose innovation was chlorinated hand washing; he ended up in a sanatorium because he went crazy (he likely had an advanced case of syphilis); the connection he made was that "cadaveric particles" were causing illness in hospitals, which is problematic because the phenomenon occurred in circumstances where no cadavers availed, but he was apparently absolutely hung up on the cadaveric nature of the threat.

He's a complicated dude.

> Doctors routinely washed their hands before Semmelweis

The cringeworthy "gentlemen don't wash their hands" culture contradicts that.

> he ended up in a sanatorium because he went crazy (he likely had an advanced case of syphilis)

I see no evidence of this so called "craziness". Even the people who speculated about the cause included "emotional exhaustion from overwork and stress" as a possibility. That's the simplest explanation, probably what happened and it's absolutely to be expected when you discover you've been unwittingly killing your patients due to the ignorance of mankind, successfully devise countermeasures and prove their effectiveness only to have your peers and the scientific community all band together to gaslight you. He ended up in an asylum because he "embarrassed" them.

> the connection he made was that "cadaveric particles" were causing illness in hospitals

Of course. More women died when he and his medical students delivered their children after working with corpses than when they didn't. The connection is there, the fact it did not fully explain the phenomena does not invalidate it. Nor does it invalidate the reduction in mortality after hand sanitization was implemented.

That this was denied despite reproducible statistical evidence is absolutely shameful for all involved and a heavy lesson for all time. Women died because of it. Don't minimize it.

You can just go look this up instead of trying to rebut it through axiomatic derivation from a meme. Doctors washed their hands in Semmelweiss's time. There's a reason writeups of his contributions often include the recipe for his decontamination solution; that's the novelty, of antiseptic washes versus ordinary soap and water.

Similarly, you can just go look up Semmelweis' mental state at the time of his commitment.

The difference between Semmelweis's incorrect theory of what was causing childbed fever and reality is a big part of why his interventions were rejected (that, and the fact that he was apparently an unholy asshole) --- he was trying to convince his colleagues to disinfect their hands from particles that sometimes could not have existed, and the colleagues noticed that. If you're trying to evangelize a new medical intervention, don't get hung up on an explanation that can't possibly be correct, is one lesson to take from this.

Complicated dude. Read more about him than you have. It's interesting stuff. His story is more than just the airport bookstore management parable that it's become.

later

As a quick PS: the "gentleman's hands" thing came up on an AskHistorians thread I just read, and it's apparently a misquote. It's not "gentleman don't wash their hands"; it's "a gentleman's hands are clean". As in, doctors already keep their hands clean. What they didn't do was chlorinate the water they used (or clean all that hard).

That's obviously false! The contagionists and aseptics were right, the spontaneous generation people were wrong, and obviously aseptic procedure before Gordon and later Holmes and later Semmelweis was inadequate. I'm not defending the guy who said that. But he didn't say what you think he said.

The incompleteness of the theory is completely irrelevant. He published results and reproduced his findings. He correlated a rise in mortality to the time the necropsies started, and he demonstrated a decrease in mortality after implementing his hand sanitization method twice. That's more trustworthy than quite a bit of what passses for science even today. Doesn't matter how much of an asshole he was, when faced with that undeniable evidence clearly showing that women were dying less the last thing those scientists should have done was dismiss it out of hand and condemn women to death for their negligence. To me it sounds like they deserved every bit of denouncing they got and then some.

All of this matters. You write as if he provided a succinct record of a series of experiments he conducted; in fact, he infamously wrote ponderous and impenetrable litanies on the precise cadaveric origin of the particles he thought he was combating. I understand the message board rhetorical strategy of trying to put me on the other side of the aseptic revolution, but (1) no and (2) that has nothing to do with what I'm writing. The bar you need to clear here is much higher than "Semmelweis was correct about chlorinated lime".

> he infamously wrote ponderous and impenetrable litanies on the precise cadaveric origin of the particles he thought he was combating

Which doesn't invalidate the fact that women provably died less after his methods of combating those particles were implemented and published. Faced with that evidence, they should have accepted the method even if they don't agree simply because you can't argue with results. They could have saved women and followed up with further study on the exact nature of the problem which would only become clear when Pasteur came along. They chose to institutionalize him out of embarrassment.

I'm not "putting you on the other side" of anything. I don't agree with your minimization of the guy's achievements nor with your characterization of him as "crazy".

The scholarly debate about Semmelweiss is whether he had syphilis or young-onset dementia. He was not committed to a sanitarium out of pique over his demands that people chlorinate water. Again: you can just look this stuff up!

These points might seem kind of nitpicky, but Semmelweis has become a sort of patron saint for brooding nerds with strong but iconoclastic ideas, a shibboleth for "history will show I was right all along". Semmelweis was not, in fact, right all along, and his evident failure to persuade his peers --- stemming from what was in a sense an opposition to the germ theory of disease --- probably set science back a little bit, on margin. Not by much, though; Semmelweis was in his time one of several people expounding the same intervention.

> Semmelweis was not, in fact, right all along

His results have NOT been refuted. Sanitizing hands saved lives. Not sanitizing hands cost lives.

https://pubmed.ncbi.nlm.nih.gov/17553179/

https://pubmed.ncbi.nlm.nih.gov/35486338/

Whether or not it happened due to "cadaveric particles" is a completely irrelevant detail. People died less. That's enough for public health policy decisions even today. The fact his contemporaries did not accept it would be criminal negligence today.

The "scholarly debate" about his mental state is mere speculation. Here's the first result of looking it up:

> It is impossible to appraise the nature of Semmelweis's disorder.

> It might have been Alzheimer's disease, a type of dementia, which is associated with rapid cognitive decline and mood changes.

> It might have been third-stage syphilis, a then-common disease of obstetricians who examined thousands of women at gratis institutions

> or it might have been emotional exhaustion from overwork and stress.

You clearly believe the first two options. I don't believe that even for a second.

> He was not committed to a sanitarium out of pique over his demands that people chlorinate water.

Here's the second result of looking it up:

> With this etiology, Semmelweis identified childbed fever as purely an iatrogenic disease — that is, one caused by doctors.

> Friedrich Wilhelm Scanzoni von Lichtenfels took personal offense at this, and never forgave Semmelweis for it

> Scanzoni remained one of the most ardent critics of Semmelweis.

The third result of looking it up:

> Semmelweis also angered his conservative medical colleagues — and especially his boss, Johann Klein, who was head of the Department of Obstetrics and Gynecology

> Klein rejected Semmelweis' arguments concerning cleanliness, as did his colleagues.

> He probably felt angry that this precocious Hungarian was making orthodox practices and practitioners look not only ridiculous but also dangerous.

> It was Klein, incidentally, who had insisted that medical students examine cadavers in the first place, and it was he who had relaxed constraints on conducting vaginal examinations during labor.

> Semmelweis seemed to be saying that Klein's policies were the direct cause of the epidemic

> When Semmelweis' temporary appointment came up for renewal in March 1849, Klein blocked his application, despite appeals from senior medical colleagues

> The second part [of his publication] attacked his critics. This was the part that got him into serious trouble. Many leaders in obstetrics in Europe were vilified.

> While the book collected all of Semmelweis' investigations into one volume for the first time, it met with harsh reviews and had little impact in preventing the dreaded puerperal fever.

> Probably as a consequence, Semmelweis' mental state deteriorated.

> He roamed the streets of Budapest muttering to himself and distributing pamphlets directed against those who refused to follow his teachings.

> He seemed to swing from periods of excitement and energy to periods of paralyzed depression. By July 1865, he was clearly deranged.

They clearly hated this guy and found several ways punish him for his insubordination. It's entirely possible and very likely that this was the reason he ended up in the asylum where he was killed.

1. Childbed fever was not, in fact, caused by cadaveric particles.

2. Nobody here disputes aseptic technique.

3. You've misconstrued the point about Semmelweis' commitment. Alzheimers, syphilis, exhaustion: the point is that he was symptomatic, as you yourself just quoted.

I don't think anybody else is reading us at this point.

no strange no change

But it cuts both ways: Walter Freeman[1] was only banned from performing lobotomies after 100 patients of his had died of hemorrhage.

[1]: https://www.econtalk.org/megan-mcardle-on-the-oedipus-trap/

Did he have a lobotomy prior to performing 100 of them?

The point at the beginning of the thread is to do as they do, not to do as they say...

Randomized controlled trials are great, they are incredibly certain to be right. But experience has a whole other quality, it is much less reliable but a whole lot more comprehensive. An RCT can only measure effects on what can be used to select a large group of people. It cannot measure the effects of a weird anomaly that is recorded nowhere. Meanwhile experience can extrapolate from a very few examples.

So it is not at all obvious that we should favor RCTs over experience. Because they have very different things they can measure.

Where is the government advice sourced from? Why are you so confident in anecdotal evidence but skeptical of broader research?

My doctor recommended Cologuard, a test of your stool sample for cancerous DNA, instead of a colonoscopy. I can't imagine taking a colonoscopy now.

Colonoscopy has a big advantage in that they are already in there. If they see anything forming that is pre-cancerous they can take it out before it turns into a problem that would show up on a Cologuard test.

But that’s also highly dependent on how good the doctor is at finding the problems. Apparently doctors in the US find precancerous polyps 40% of the time according to the article. That may not be so great given the time between screenings (ten years) if one is missed.

It’s great if you’re in the 40%.

And the big disadvantage that to get there your need to book 2 professionals (?) and take pretty much one day off, and there are risks associated with anesthesia and the procedure itself

I don't think it scales

(Not to mention the interests of doctors of suggesting things that make them more money)

Edit: now I see TFA mentions risk of perforation and that the risk is smaller without anesthesia

Well, in the US, they're following normal protocol. It would probably be irresponsible for them to try to dissuade you from a colonoscopy. But, yes, it's a day involving a gastroenterologist, typically an anesthesiologist, nurses presumably, and someone to take to back and forth from the procedure. It's definitely not standard lab work.

In Japan, everyone over 40 gets yearly colonoscopies as part of a general health check up.

That should be a really good source of data, someone should take a look at that.

But what I was getting at is that it can scale.

Source? Yearly colonoscopies sound dubious - my google search results said they use fecal occult blood tests yearly with a follow-up colonoscopy if you test positive which sounds more reasonable to me.

The source is that I live here and everyone talks about it.

Poop tests are for everyone over 30

Yearly? That's crazy. I had yearly colos AFTER I had rectal cancer, but now I'm on the 10 year plan. I can't see yearly being both cost-effective and safe.

You also need to find someone to transport you to/from the procedure.

I moved to a new city and didn't know anyone. I was told to get a colonoscopy for no other reason than I was 50. There was literally no one I could ask to take off half a weekday to accompany me.

Ended up doing the FIT test (stool sample) instead (and once/year thereafter) and 6 years on still haven't had a colonoscopy.

*small advantage (according to this study).

Cologuard has a significantly high false positive rate, as far as I’m aware.

False positives are bad but not disastrous. How bad are the false negatives?

Manufacturer claims around 8% false negatives, 92%-94% sensitivity, 87%-90% specificity and 99.94% negative predictive value.

Published study:

https://pubmed.ncbi.nlm.nih.gov/24645800/

It appears they calculated the negative predictive value based on the population sample of that study. It may differ significantly from the negative predictive value for the general population.

All screening tests do. In general, cancer screening employs highly sensitive tests which are supposed to react to anything that even remotely looks like cancer. Negative results are relatively trustworthy while positive results justify further testing with more specific tests which may be more risky, more expensive or both. Colonoscopy is an example of a test that is both expensive and risky.

does a cologuard false positive indicate a colonoscopy? if so, as long as the false negatives aren't substantially worse, it sounds like a win.

Yes. If it finds anything you get called very high risk and get right in. My doctor sent me to cologuard because the people doing colonoscopies had a year long waiting list, I don't need to get in, but if the test found something they would let me skip the line and i'd be in a few weeks later. Since it didn't i'm not in line at all, but I need a new test in three years, while the colonoscopie is good for ten.

My father died of colon cancer at 52, so I've been getting colonoscopies every 3-5 years since I was 22. Yes, that's really early, but in the span between age 30-33, I grew a large polyp. My doctor removed it and it turned out non-cancerous, but if I waited until 40+ to start who knows?

The article theorized that some of the acceptors in the study likely looked at their family history when making the decision. They might not be especially helpful on average, but because of your father, they're much more helpful for you.

One thing I'm having trouble parsing from the study relates to exactly the point you're raising. If it's assessed as like a national program applied to everyone, that's one way of understanding its value. But if you believe yourself to be a part of a special at risk population and can have good reason for making that determination, to me it raises a new question about the wisdom of proceeding.

This is very common in France. I think all my 50+ acquitances had one.

There is a national screening campaign based on sending a sample of your stool, but getting a colonoscopy is a matter of asking your doctor.

It is true that colonoscopy is not the first mine of prevention but anyone who asks will get one. Free of charge.

This is also they way in the UK.

A large screen of everyone over 60 via stool sample. Then ONLY if that shows issues then a CT scan and then a colonoscopy.

In France you can ask for a colonoscopy and your MD will order it (and if they are reluctant or want to have a string reason you just say that there is family history).

People here talking about you deciding whether or not you got cancer from the colour of your stool. Here is another piece of medical advice:

If you have blood in your stool, see a doctor. Period.

People struggle with binaries. It is very likely that regular colonoscopies are net harmful for most people, and very beneficial for some.

The population isnt homogeneous.

Some people have significant risk factors, like family history, others do not.

We don't ask if everyone should start wearing glasses at 40, so why this?

But people with healthcare / vision care usually have their eyes checked yearly.

Yes, but eye exams don’t carry a risk of death. It is a noninterventional screening. It is more like a stool sample or questionnaire than a colonoscopy

There's an interesting point made in a podcast (Huberman, perhaps) - which is that Colon Cancer could be totally eliminated as a cause of death, if we used screening via colonoscopy optimally.

As in, play a thought experiment:

* First, imagine everyone in the world gets a colonoscopy every day --> obviously, all cancers would be picked up, but this is infeasible for some reasons (e.g. cost, economic impact) and suboptimal for others (e.g. iatrogenic harm, human cost).

* So, using data, apply colonoscopies more sparingly, based on risk factors such as age, genetics, family history --> if this is done right you'd be able to pick up every colon cancer in its very early stages, either at a pre-cancerous stage, or an entirely curable stage.

> colonoscopy every day --> obviously, all cancers would be picked up

Would be the first medical test with 100% sensitivity probably?

Would detecting all cancer cells there be useful? The immune system being the first line of defense.

What's the prevalence of colon cancer within the general population? Per Bayes' rule, I doubt it's enough to decrease the level of false positives to an acceptable level.

Since you can't eat for a day before, colonoscopies daily would also prevent death by heart attack as everyone would starve to death in a couple months.

Colonoscopies come with potential for complications.

There are actually a number of companies which have either released or plan to release non-invasive colorectal cancer screening based on blood dna sequencing.

GRAIL, Freenome, and Guardant all have tests out or coming down the pipeline.

I got a letter from the government last year saying they wanted some of my poo, so I sent them some. The whole thing was weird, but much better than visiting a doctor.

I'm in Australia.

They have your DNA now.

Colonoscopies also have a big advantage in that while the doctors are in there, if they see anything forming that is pre-cancerous they can take it out before it turns into a problem that would show up on a blood test.

* props to @nwellinghof whose response I stole and adapted

Which is why after another screening method sees something you are offered a colonoscopy to look further and if early enough do a simple removal which is much less of a risk and has less side effects than a full operation to remove parts of the bowel.

Sure but procedural complications are actually quite rare, as alluded to in this article.

Misses from operator error, suboptimal bowel prep, or inability to complete the examination are more common and where we have the most potential for benefit from novel screening tests.

> Sure but procedural complications are actually quite rare, as alluded to in this article.

article actually says that perforation (requires emergency surgery as per article) is between 1 to 100 and 1 to 20000 base on some studies, which sounds very high if it is not mistake.

The high end of that range is much higher than the baseline rates of colon cancer (also mentioned in the article), which are 90/100,000 in the USA.

That's one thing that I wish the author had spent more time on.

90/100k cancer rate is likely annual rate, while complication rate is likely per procedure, so you would need to multiply cancer rate by 3 (avg years between procedures) to have reasonable comparison.

You can't just multiply by 3 (it's smaller than that), but yes, you need to adjust both.

https://planetcalc.com/7044/

(Just to be clear: this is the wrong model. An annual rate of cancer (X%) at a population aggregate does not mean that you have X% independent probability of getting cancer per year. But even assuming that was true, you couldn't just multiply by 3.)

1 in 100 is old data, 1 to 20000 is not high. The study they cited had 0 in 12000.

The real number is closer to 20000, both from more recent literature and personal experience.

>3. It’s irresponsible to call colonoscopies “invasive” (as CNN did) since that might make people think they are unpleasant and not do them.

They are invasive, they are also unpleasant. It isn’t irresponsible to say those things it’s just true.

I have a friend that avoided it for most of his life.

When he finally got one (in his late fifties), it showed stage IV colorectal cancer.

He went through seven months of channeling Uncle Fester, but seems almost completely back to normal, now.

He is much more into taking care of himself, these days.

Article doesn't actually answer the question? Certainly interesting information about the topic and efficacy, but it doesn't really explain how the current situation came about.

Why is my neighbor driving around on a donut? I could write 3000 words on the history of tires, the assorted trade offs of trunk storage vs spare diameter, the geographical distribution of potholes, etc., but none of that explains why the donut is there.

> Why is my neighbor driving around on a donut?

Complications from a colonoscopy?

I was satisfied with the answer given in the Discussion section at the end of the article.

Okay, thanks, went back and read it again. I may have preferred more, but it is there.

If someone else hasn't clicked on the article link (people still do that?) it says literally this:

  Are colonoscopies better than other screening methods? I don’t know. Maybe!

I see several personal accounts and I could also share mine but given that colonoscopies "rarely — but not that rarely — have serious side effects" and that there was only an overall 1% difference of all cause mortality between the groups in the trial, is it worth risking the side effects if you are healthy and don't have any symptoms?

The side effects are only mentioned in the first paragraph of the article. I wonder how many people have died (or suffered considerable and possible lasting harm) as a result of colonoscopies performed during the period of the investigation and who were otherwise healthy.

I have a genetic predisposition for colon cancer, and have had nine colonoscopies: one every one–two years. As others have said: if your colon is otherwise healthy, it is safe and the worst part is the prep.

However, the last time 10 months ago, my body's immune system was stressed by another cancer, and so a tumour developed in only nine months. Because of the risk of more colon cancer during the treatment of the other cancer, the doctors removed my colon, despite it otherwise being "strong, young and healthy". I now poop fluids in a bag glued to my belly: it is better than being dead, but something you'd definitely want to avoid.

I actually miss colonoscopies now. I always watched the screens: it was beautiful and fascinating.

>I always watched the screens: it was beautiful and fascinating.

It is a weird experience. The ultimate form of introspection!

In Denmark, when you turn 50 you start sending in a stool sample every other year. If it works, I think I like that model better.

My mother in law had a negative stool sample and died of colon cancer 9 months later.

And colonoscopies miss 60% of the precancerous polyps. There's no such thing as a guarantee in healthcare.

> The skill of a doctor doing a colonoscopy is often measured by their adenoma detection rate — how often they find a precancerous polyp. American doctors find them 40% of the time.

My brother had stage 3b colon cancer caught by a colonoscopy. He was treated and is still alive, so… that seems pretty good to me.

My company health plan recently announced that starting next year you can get a free Colonoscopy every year.

It's interesting that the harm of the prep is not discussed. Not eating for one or two days and cleaning out your gut entirely with laxatives is bound to have consequences. Maybe this affects the gut microbiome?

At the very least, this triggers days of migraine in myself. Just skipping one meal does that, skipping several and ingesting awful laxatives results in feeling awful for days.

When you're dealing with such vast quantities of people, these effects might add up.

Here's another me too. When I turned 55 my GP started to nag me to get a colonoscopy, and my wife too. But in the small western town that we lived, there's only a very small number of specialists and for 1.5 years "they" kept accusing us of not submitting the paper work. (We did, each time). It all sounded unpleasant and I was riding fast times in centuries so how bad could it be? Finally the GP needed a colonoscopy and the specialists did to her what they did to us and she got pissed off and forced the issue. And her nagging was effective and got us through the procedure. My wife was fine. I was Stage IIa. I did not get the IIa diagnosis until after 10+ weeks, including 4 weeks after the 18" resection. Only thing anyone would say is "your diagnosis is unknown, could be Stage 4". Which, you know, kinda sucks, and I can tell you it might suck harder for your life partner, than yourself. You'll be gone, and they go on alone.

So I get (used to get) colonoscopies every six months and the very good surgeon down in Phoenix chops out the polyps. Weirdly he can fit me in on a couple of weeks notice. But COVID fucked all that up. And then we moved across the country. So now I'm starting all over with the fact that we can't find anyone local to do the colonoscopies. But it MUST GET DONE. (Reminding myself).

So yes indeed it's annoying but if you've got cramps or occasional blood in the stool or are over 55 and never had one do not avoid the colonoscopy. Everyone who loves you will appreciate it.

BTW I started riding centuries again about six months later and the next year I set my life record in the Tour de Tuscon. I tell people the resection was my weight loss plan. I get weird looks. I enjoy it.

I was very, very worried about mine earlier this year.

It was 100% a nonevent. My doc's prep regime was fairly mild (basically, a jug of gatorade with a whole jar of miralax in it at 6pm, and then another at 1am, for an 0800 call). I had no cramping or bloating to speak of. I didn't sleep in the bed with my wife after the 1am dose, mostly b/c I didn't want to disturb her by getting up over and over, but also slightly b/c I was a LITTLE afraid of not making it to the loo in time. This fear proved completely unfounded.

The "worst" part for me really ended up being that I (wisely) did NOT go cycling on the Sunday before, since I know that ramps up my metabolism and leaves me very hungry the day after. I missed my ride, but it made the clear-diet Monday much more tolerable.

I had to fight with my doctors as a late 20-something to get one. Polyps, the Doctor who performed it told me he was proud of me for being persistent and made it clear that colon cancer is not an old man’s disease anymore.

I knew this because my brothers best friend died at 30 from it.

Nevermind the prep, the embarrassment, and the physical discomfort.

It was totally worth it because I got to watch it live on a big screen TV!

I had a heart catheterization recently. No prep, no embarassment, and only a bit painful where it went in at the wrist and bent at my elbow.

Also super cool to watch!

When a friend of mine had one he told the staff "too bad I'm not gay or I would have enjoyed this".

Which made me wonder if any research had been done on how many times per day doctors and nurses administering colonoscopies have to hear this line.

I had an abdominal MRI done a few years ago to look for intestinal issues, and was surprised at the resolution. Ever since I've wondered why we don't just do that regularly to see if there's anything that looks worrisome, before going through such an invasive process as a colonoscopy.

Actually, I just looked it up. Apparently it's a thing and called "virtual colonoscopy" [1]. Seems like the future to me.

1. https://www.mayoclinic.org/tests-procedures/virtual-colonosc...

MRI machines are much more expensive than colonoscopy machines. Orders of magnitude more expensive.

But the MRI machine can do a more thorough investigation is less time with less inconvenience to the patient and with fewer medical staff. The colonoscopy I had essentially occupied a doctor and a nurse for close to half an hour. The MRI that I had more recently for the same purpose took one radiologist and the part involving me was over in less than fifteen minutes.

And the capital cost of the machine is not necessarily the relevant measure. If the MRI machine is idle then it is wasting money so if you have one it should be used as much as possible which means that the marginal cost of the MRI might well compete with colonoscopy.

I have also read that many colonoscopy patients, especially in the US, require sedation which of course is not necessary with MRI.

A family member was going to get screened, and the insurer would only pay for a sigmoidoscopy since there were no indications of any issues. He paid for the full deal, and they found cancer they would not have found otherwise. He paid because a coworker had died due to undetected cancer - undetected because they didn't do the whole colon.

A paper may talk about percentages, but that doesn't represent you - it represents what an insurer or provider might find interesting to lower costs. You either have cancer or you don't. If you want to find out, you need to check.

I just got one two days ago because my family has a history of it. Other than having to go on a no fiber diet and ingesting specific sets of salts to empty the bowel for the procedure, it was pretty in and out, and no pain at all afterwords (probably because they didn't find any polyps). I went home with neat pictures of my clean colon.

Also lost 10 lbs in the past week but already seemed to have gained back a little in the past two days from eating normally again.

> (probably because they didn't find any polyps)

They found polyps in mine, and removed them; no pain after. The colon doesn't have pain nerves.

That's good to hear they found and removed them before it can become a bigger problem. Does that mean you have to do a visit every 2-3 years now?

I have no first hand knowledge of this but I've heard that colonoscopies are very common in S. Korea, even starting at younger ages.

Can anybody comment on this?

I have heard they have a massive drinking culture without the genes to handle it so stomach and colon cancers show up a lot.

I don't think genetics really play any part in handling alcohol's part in the forming of cancer.

If it did then Finland shouldn't really have the incident rates of alcohol caused cancers as they do.

The same probably goes for other nations where heavy alcohol consumption has been a norm for centuries.

Alcohol causes cancer, and there is no intake amount that is beneficial to the body.

So here's my story...

Age 39. Presented to family GP with rectal bleeding. He did no exam, pretty much dismissed it as a hemorrhoid. Age 40. Complained again to GP that bleeding was continuing (sporadically). GP finally decides to refer me to the local thoracic surgeon. This surgeon gives me a go over with an anoscope and schedules a colonoscopy the next day. Turns out I had a 5cm tumor...

I was married with two very small kids. Not the best time to get cancer.

A week later I'm starting radiation therapy to try and shrink the tumor. A week or so after that (things tend to blur when medicine moves fast), I'm started on chemotherapy treatments. I start to lose weight (I was 6'2"/240lb at the start of this). I get a portacath above my heart so chemo drugs can go straight into a big vein. I carry a pump around to push my chemo drugs in on a reliable schedule. This combined treatment goes on for a month before I go through surgery. I'm experiencing neuropathy from the oxaliplatin, which makes your extremities very sensitive to the cold (and of course I live where you have real winters). Foods taste wrong too.

Go in for surgery and come out with an ostomy. The surgeon had tried to save enough stuff so I didn't need a bag, but well, sometimes biology has other ideas. The tumor was too large and too close to all the rectal muscles. At least the surgeon said there were good margins, and no signs of metastasizing. So now I have a bag. At this point I way about 160lbs. Nothing tastes good except candy, and the docs are worried about my weight loss. So I get the green light to eat as much candy as I want.

Now I'm alive, with a bag, but alive. I'm taking some experimental oral post-surgical chemo pill 4x daily to try and kill any little bastard tumor cells that might have been released. These suck. Chemo is always a race to kill cancer cells before the chemo drugs kill you. My oncologist is always checking white cell counts, but now has some DNA test that looks for tumor markers. This is pretty cool. My cell counts improve and the tumor market analysis looks good. So I'm eventually sent home. On my way out of my last meeting with my oncologist and his nurse, I ask him how often he gets to send someone home in my situation. The look in his eyes made it apparent how tough a job these folks have.

So now 18 years later, I've been able to run a full marathon, finish my basement by myself, build the coolest shed in my back yard. Settle into a good IT career at a company where I can retire. And most importantly, be there when my kids graduated from school. Be there for my wife when her dad passed away from cancer. Just be there...

So if a colonoscopy scares you, as they say in The Wire; ain't no thing. Don't be like Farrah Fawcett who died of anal cancer because she avoided treatment. 150K new cases of colorectal cancer are diagnosed annually in the US. And if discovered early, it can be treated far less invasively and less life-altering than if found later.

Here a colonoscopy is adviced by my doctor for anyone aged 50.

She told me the free screening kits for bowel cancer the government sends out is mostly an awareness campaign as those tests are extremely unreliable.

Those kits if run every few years (not sure which they are running, different kits have different schedules) are pretty good and a lot cheaper than colonoscopies every ten. In single payer systems cost effective matters differently and so they may choose to use them instead.

You can debate if they have the correct numbers when.counting cost effective.

> When setting recommendations, the U.S. Preventative Service Task Force explicitly does not consider costs.

This is a great summary of the difference between US and European preventive medicine.

Can we stop referring to Europe as "the rest of the world"?

Colonoscopies are pretty common in some european countries, so I don't think most of the world means Europe.

What about swallowing a pill camera? Could these be a slightly less invasive way to screen your colon? The technology for pill cameras along with AI should keep improving.

One benefit of a "proper" colonoscopy is that the scope has a little wire that's used to remove polyps. Polyps have a high chance to progress to tumors, so nipping them in the bud is a good idea. Can't do that with a pill camera setup.

You mean I get scoped every few years and it’s not even a thing??!

The problem with medical interventions, especially tests, is that they sometimes work. There will always be success stories.

The big question is: are those success stories worth it, and are there other paths to those same success stories.

> The problem with medical interventions, especially tests, is that they sometimes work. There will always be success stories.

Do you prefer medical interventions that never work?

> are there other paths to those same success stories.

Yes, in the US other options include high sensitivity FOBT, FIT, sDNA-FIT and CT colonography.

CT as in X-ray computed tomography? If so, it's dubious if that's safer than a colonoscopy, depending on what ionizing radiation harm model you use.

For my procedures, they used a continuous X-ray to monitor the location of the equipment. I'm pretty sure I was more irradiated than by a CT scan.

We are required to use LNT in the United States and Canada.

The attributable cancer risk for CT colonography is a rounding error, and considerably lower than the quoted perforation risk.

That said as a radiologist I personally still opt for colonoscopy screening, it is however an option for patients.

I think the original sentence was meant more like 'the problem with unproductive tests is...'

Where unproductive means that the total cost benefit of doing the test is negative. And even procedures that never help can 'cure' people just by regression to the mean.

> Do you prefer medical interventions that never work?

Are there medical interventions that never work - aside from bad faith hypotheticals? Even placebo works pretty often.

The article under discussion is all about teasing apart confusing and conflicting data in medical studies. The comment I replied to asks why they have been directed to do something useless.

>> are there other paths to those same success stories.

> Yes, in the US other options include high sensitivity FOBT, FIT, sDNA-FIT and CT colonography.

Statistically, yes - but individual humans don't really think in statistics, we think in stories. My buddy won big at the casino, maybe I will too. I'm sure my dear fellows on this website will never be so stupid as to be motivated by a story about winning at a casino, but it is very EXPENSIVE to apply this level of rational rigor to every part of your life.

I don’t understand what you mean by statistically?

All of those are endorsed by the USPSTF I.e. reimbursed by insurance and available in the US.

Dont think its suppose to be every few years. I was told it’s good for 10 years. Unless you are in high risk category. Specifically one with a family history of colon cancer. That’s what I was told when I got one as soon as I turned 50. I don’t have to get another one until I’m closer to 60.

Today there are ColoFIT and Cologuard tests, which have high precision and are less invasive.

I'm still flabbergasted that anyone in the face of the planet even considers doing a colonoscopy without sedation.

I had it done twice, both times without sedation by choice. I did have analgesics, and a cannula in my wrist in case I changed my mind mid-way.

It was quite tolerable, just a few moments of short lived cramping pains (similar to diarrhea pains) as the endoscope turned the corners of my insides. My recovery was about half an hour of sitting up and having tea and toast, while those that were sedated slept off the drugs.

I'd do the same again if ever I get another one, and recommend it to anyone who can't have or doesn't want sedation.

This is about people between 55 and 64 years old at the start of the study.

After 10 years:

The risk of getting colorectal cancer is about 1%.

The risk of dying because of colorectal cancer is about 0.3%.

Getting an invitation the study does not change much. Actually getting a colonoscopy helps more (37% reduction in getting the cancer, no data for dying).

If you read the article thoroughly it explains exactly why your reasoning is incorrect.

Tldr; comparing control group to acceptors group is not right because who accepts and who doesn't isn't random.

We don't know the exact bias introduced but the author theorizes that people who are at higher risk are more likely to accept the invitation(e.g. someone with a colon cancer in family, someone having weird feeling about her tubed as the article calls it., etc.)

You are both right. The study at only 10 years didn't run long enough for us to expect to see much. That is one reason medical studies are hard, we are often interested in changes we could make today that won't matter for decades.

Just stopped eating three days before. Forget the drugs and liquids.

Took no anesthetic for the procedure. Not really bad; just embarrassing, get over yourself.

Drove myself home ten minutes after. No problems.

Have to be good with fasting. Mostly it's a matter of habit, remembering not to graze in the evening. I don't feel hunger as a big deal; your mileage may vary.

- In assessing risks vs. benefits, it isn't sufficient to use a single figure (e.g. 5-year relative survival rate). It's not binary. Screening which detects potential cancer does not just prevent death. It prevents the suffering and disability which may accompany late-stage detection (even if you're still alive after 5 years). Early detection could have prevented the two surgeries and rounds of chemo a friend of mine went through. Or the death of another friend after 3 rounds of surgery and 2 rounds of chemo. It could prevent living the rest of your life without normal bowel function.

Figures can't capture individual assessment of risk/benefit. Many of us buy insurance of various kinds even though the insurance companies have done some figures and expect to make money - in fact, they count on us valuing certain things above what is indicated by the raw numbers.

- The NordICC study [0] is cited by some as showing modest benefits from colonoscopies. It looks pretty good, but there's something I don't understand. They say: "Follow-up data were available for 84,585 participants in Poland, Norway, and Sweden — 28,220 in the invited group, 11,843 of whom (42.0%) underwent screening, and 56,365 in the usual-care group. A total of 15 participants had major bleeding after polyp removal. No perforations or screening-related deaths occurred within 30 days after colonoscopy." Given the number of screenings, I don't see how there could be no perforations. For example, the USPTF study [1] (see their "Supporting evidence" link) reports 5.4 perforations per 10,000 colonoscopies from colonoscopy to follow-up positive screening results and 3.1 perforations per 10,000 colonoscopies from screening colonoscopy. No perforations seems unrealistically low - maybe someone can explain this.

- Discomfort from the prep or procedure depend on the individual, and I don't think one can usefully generalize. I've had 4 colonoscopies, the first two with sedation and the last two without. I had 3 polyps removed the first time, none during the second, 2 polyps removed during the third, and none during the fourth. The advantages of no sedation are that I don't feel groggy afterward, and I can drive myself to and from. The procedures without sedation felt no worse than a bad case of gas (not surprisingly!). I watched the polyp removal during the third colonoscopy and didn't feel anything above the ambient gas pain. But some people might find the procedure very painful, or might get queasy watching. Everyone's different. And if you start without sedation and decide you want to stop in the middle, they might abandon the procedure and require you to come back again (in which case insurance is unlikely to pick up the second try). If you have one of these done with sedation, you might find it interesting to look at the itemized insurance docs and see how much they charged for the sedation (often done by an outfit independent from the GI practice). As for prep, the miralax with Gatorade is much better than the old stuff (which is damning with faint praise).

[0] https://www.nejm.org/doi/full/10.1056/NEJMoa2208375 [1] https://www.uspreventiveservicestaskforce.org/uspstf/recomme...

Because it was colon-ized?

The sad thing about the article is that skirts around mentioning the possibility that the American disease industry hates this trial because it will reduce their income.

The good thing about the article is that it has a colonoscopy joke that also involves (bonus for the HN crowd) Bayesians.

Did you read the whole article? It definitely mentions cost and financial interest in the discussion section.

It didn't mention the bias from those that don't want to pay for the procedure which was a little unbalanced, perhaps.

Did you read my comment?

I'm saying that the Americans want colonoscopies to remain unchallenged because they make money out of it. This has little (or nothing) to do with the cost-benefit trade-off that the article discusses.

I didn't find this (self-evident) idea anywhere in the article.

Isn't asking people if they read the article frowned upon here on HN?

Reply on news.ycombinator.com