Six Ways to Get Screened That Are Safer Than Colonoscopy

Back in 2008, I released an investigative report entitled “Colonoscopy: Is it worth the risk?”[1]. Here is what I wrote in the Introduction to this report:

Despite all these “shortcomings,” screening colonoscopies are still considered the “gold standard” of colon cancer prevention in the United States. Naturally, my research was universally ignored by medical community in the US. To boot, a lot of otherwise totally tolerant and judicious people began questioning the state of my mental health.

Not that that surprised me. After all, screening colonoscopies generate well over $10 billion dollars in revenues for hospitals and GI physicians [3], and a lot more from treating the side effects of these procedures.

Canada to the rescue. Unlike in the United States, our enlightened neighbor up North provides free health care to all of her citizens. The business of medicine there isn’t a bottomless piggy bank for profit-focused medical-industrial complex in the United States, but a social enterprise with a keen eye on the quality of care and bottom line.

When profit motives are taken out from the healthcare equation, the benefits to risks ratios of performing screening colonoscopies are assessed thoroughly and responsibly, so no money and lives are wasted.

In this context ­– sound policy vs. sound profit – it was only a matter of time before the Canadian gastroenterologists, epidemiologists, primary care physicians, and statisticians would have come to exact same conclusions as I have back in 2008:

Ironically, back in 2001, the same Task Force, pointed out the following undeniable fact:

So, what else has happened between then and now that has made them change their minds so radically and to come up, finally, with unequivocal rejection of colonoscopies “as a primary screening test for colorectal cancer” among asymptomatic, healthy adults?

Several factors, I believe:

• Unsustainable costs. The costs and resources required to conduct colonoscopies across the entire adult population of Canada have become unsustainable relative to the minimal benefits and considerable risks;
• The preponderance of negative evidence. The amount of factual and anecdotal evidence about the futility and harms of screening colonoscopies become too large to ignore on a national scale.
• Advances in early detection technology. New tests and technologies to detect early stage colorectal cancers have become available. Some of them are non-invasive and free of side effects. Most of them are offering detection rates that are comparable or better than the outcomes of screening colonoscopies, and at a lower cost.

So, let’s go over these newer tests:

1. Fecal Immunochemical Test (FIT) [6] for Colorectal Cancer

The fecal immunochemical test (FIT) is also known as immunochemical fecal occult blood test (iFOBT). It detects hidden blood in the stool and acts differently than the original guaiac-based FOBT [7]. The FIT test reacts only to a part of the human hemoglobin -- a protein located in the red blood cells.[8]

Comparing to the FOBT test, the FIT test will detect the blood emanating from the large intestine.[9]  Colonoscopy may still be needed if test results are positive (i.e. abnormal).[10]

Advantages: Foods, medicines, and the traces of blood from red meat do not interfere with the FIT test. For these reasons, it has fewer false-positives and is more accurate than other tests. No prep is required to take the FIT test for colorectal cancer. You can purchase the FIT test online [11] for a relatively low price.

Disadvantages: Unlike colonoscopy, the FIT doesn’t detect polyps and flat lesions that may precede colon cancer. This isn’t a limitation of the test per se because even the best colonoscopy can’t “remove” flat lesions, because >95% of the polyps are benign, and because many small polyps and tumors are routinely missed.

Limitations: None

Risks: There are no direct (i.e. related to the use) risks or side effects from using the FIT because it is a noninvasive procedure.

Test accuracy:  Studies show that the FIT is extremely sensitive to detecting hemoglobin in the stool, offering a 33% greater sensitivity to the presence of hemoglobin than guaiac-based FOB (fecal occult blood) test.[12]

Manufacturers’ sites: PINNACLE Biolabs, Clinical Genomics Company

Clinical research: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4040749/

Price: Starts from approx. $26 per test. Also, available on Amazon: https://www.amazon.com/Second-Generation-Immunochemical-Colorectal-Cancer/dp/B00ICK0ZPK

2.Cologuard [13]

Description: Cologuard is the first cancer screening based on the DNA technology to detect altered hemoglobin or DNA in stool samples. It is capable of detecting tumors and other cancerous growths within the colon.

Advantages: Cologuard may detect up to 92% of cancers and up to 69% of high-risk precancerous lesions also known as high-grade dysplasia. Cologuard is a noninvasive test. Patients collect stool samples using the Cologuard collection kit, and ship them back to the lab. No dietary restrictions or bowel preparations are required before the collection.

Disadvantages: Cologuard is only available directly from medical doctors, and can’t be purchased at pharmacies or online. As with all colon cancer screening tests, there is always the possibility for false-positive and false-negative results. 

Limitations: Cologuard's manufacturer states that Cologuard should not replace a periodic surveillance or diagnostic colonoscopies in people with a high risk of developing colorectal cancer. In addition, results of a Cologuard test for people over 75 years old should be accepted with caution because of the increasing rate of false positives among elderly. It`s recommended to repeat Cologuard test every 3 years.

Risks: There are no direct (i.e. related to the use) risks or side effects from using Cologuard because it is a noninvasive stool test.

Test accuracy:  In a study involving 10,000 patients, Cologuard had a colon cancer detection rate of 92%.

Manufacturer’s site: http://www.cologuardtest.com/

Clinical research: http://www.nejm.org/doi/full/10.1056/NEJMoa1311194#t=article

Price: Cologuard test costs around $650.

3.Epi proColon Blood Test [14]

Description: Epi proColon test is the only FDA-approved blood test for identifying colorectal cancer cells with excellent accuracy. By detecting methylated Septin 9 DNA in the blood, Epi proColon may indicate a tumor or a polyp that is shedding (releasing) this type of DNA into the bloodstream. 

Advantages: Patients don`t need to change their diet or medicine intake before the blood draw. Epi proColon is another option for screening colorectal cancer (CRC) when a patient is rejecting the colonoscopy or other recommended screening methods.[15]

Disadvantages: Epi proColon is only available by prescription.

Limitations: Epi proColon is not intended for home use. Blood samples must be drawn at a doctor's office. The sample is then sent to a laboratory for testing.

Risks: There are no direct (i.e. related to the use) risks or side effects from using Epi proColon  test. 

Test accuracy: In clinical trials, Epi proColon demonstrated a 95% sensitivity and specificity rate.  Comparing Fecal Immunochemical Tests to Epi proColon tests revealed the latter to be statistically superior to FITs in regards to sensitivity.

Manufacturer’s site: http://www.epiprocolon.com/us/patients/getting-tested-with-epi-procolon.html

Clinical research: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4046970/

Price: From $110 to $180.

4. Capsule Endoscopy [16] 

Description:  Capsule endoscopy procedure begins when a patient swallows a vitamin-size capsule that contains a battery, hi-res video camera, light, and video signal transmitter. While the capsule travels through the digestive tract, the camera takes thousands of pictures. These pictures are transmitted to a belt-worn recorder [17] After several days, the capsule is eliminated with a bowel movement.

Advantages: Unlike the traditional endoscopy methods, capsule endoscopy allows to examine the stomach and the small intestine. [18] It is completely painless and, technically, non-invasive.

Disadvantages: Patients need to fast for 12 hours prior to ingesting the capsule. If the large intestine is the target of the investigation, patients require a complete bowel prep prior to the examination.

Limitations: Patients with a small or large bowel obstruction should not undergo capsule endoscopy. People with swallowing disorders may not be able to ingest a large capsule. Patients with implantable cardiac devices require an approval from the cardiologist. [19]

Risks: There is always a possibility of the endoscopic capsule to get lodged in the abnormally narrow areas along the digestive tract. Crohn's Disease may increase the risk up to 5%. Occurrences of this type are rare, and usually involve ongoing inflammation, tumor, or intestinal strictures from earlier surgeries.

Accuracy: Research indicates that capsule endoscopies are useful for detecting smaller, infrequently diagnosed colon malignancies. It offers acceptable accuracy rates for identifying clinically suspected tumors or when other diagnostic imaging methods fail to detect the existence of suspected polyps or tumors. 

Manufacturer’s site: OMOM Capsule Endoscopy System (by Chongqing Jinshan Science & Technology), PillCam COLON (by Given imaging), MicroCam (by IntroMedic), Olympus Capsule Endoscopy System & ENDOCAPSULE 10 System and ENDOCAPSULE Recorder Set (by Olympus) [20]

Clinical research: https://www.clinicaltrialsregister.eu/ctr-search/search?query=Capsule+Endoscopy

Price: The cost of a capsule endoscopy starts from $500 [21]

5.Virtual Colonoscopy (CT Scan or MRI) [22]

Description: By using advanced imaging techniques such MRIs and CT scans, radiologists can identify lesions and precancerous polyps without sedation. Virtual colonoscopies support incomplete colonoscopies and patients who can’t have a conventional colonoscopy for medical reasons.

Advantages: Virtual colonoscopy is non-invasive, and takes less time than conventional colonoscopy. It can examine the right colon and bling gut, two areas are missed in 10% of optical colonoscopies. Virtual colonoscopy also helps to identify abnormalities outside the colon. [23]

Disadvantages: CT scans and MRIs can’t detect aggregations of cancer cells that have not assumed polyp or tumor size.  Patients undergoing a virtual colonoscopy must prepare for the procedure by changing their diet, cleansing their bowels and drinking contrast fluid to enhance the imaging. Contrast medium may cause bloating, abdominal pain and GI disturbances in some people. CT scans expose patients to the very high levels of ionizing radiation that may increase one`s risk of all cancer. [24] Insurance coverage is sparse. [25]

Risks: Since the large intestine is inflated with air prior to the scanning, there is always a small risk of intestinal perforation.

Accuracy: Lesions less than 5 millimeters are difficult to detect with virtual colonoscopy [26]. However, virtual colonoscopies can detect most of the clinically important polyps and lesions, and its accuracy is superior to optical colonoscopy.

Limitations: Patient weighing over 450 pounds may not fit into the scanner. Virtual colonoscopy may increase the risk of colon perforation in patients with Crohn's disease, ulcerative colitis, or diverticulitis. If you experience a severe pain or cramps on the day of the test or have a history of bowel perforation, virtual colonoscopy iscontraindicated.

Manufacturer’s site: Viatronix V3D® Colon system

Clinical research: http://www.nejm.org/doi/full/10.1056/NEJMoa0800996#t=article

Price: The price depends on the insurance plan (coverage, deductibles, co-pays) and at average may cost between $400 and $800. [27]

6. Flexible Sigmoidoscopy [28]

Description: Flexible sigmoidoscopy allows doctors to visualize the rectum and the lower part of the colon (the sigmoid colon) with a sigmoidoscope ­– a narrow flexible tube with a high-res color camera and light at its end [29].

Advantages: Flexible Sigmoidoscopy is relatively quick simple to perform. It has fewer side effects and is less expensive than a conventional colonoscopy. The risk of a bowel perforation is low. [30]

Disadvantages: Preparing for a flexible sigmoidoscopy involves having at least one enema before the procedure. Patients may also be asked to change their diet or take laxatives. To maximizing the accuracy of the test, complete emptying of the colon and rectum is recommended.

Risks: This colorectal screening test is safe and effective when performed by physicians experienced with providing endoscopic procedures. Rarely do complications occur with a flexible sigmoidoscopy.

Accuracy: Flexible sigmoidoscopies offer more accurate diagnostic results than those provided by fecal blood tests and virtual colonoscopies.

Limitations: Flexible sigmoidoscopy can only examine the final portion and left side of the colon. Lesions, tumors or polyps existing higher in the large intestine are not detectable during a flexible sigmoidoscopy procedure.

Manufacturer`s site: Braun Melsungen, Brainlab, GE Healthcare, Medtronic, Stryker, Smith&Naphew (Blue Belt Technologies), MAKO, Claron Technology and others.[31]

Clinical research: https://www.ncbi.nlm.nih.gov/pubmed/25117129

Price: The cost of a flexible sigmoidoscopy may vary from $500 to $1,400, depending on your insurance coverage, hospital, physician, geographical location, and other similar factors.

“Catch-me-if-you-can” vs. the “nip-in-the-bud” approach

As you can see, there are plenty of viable options to get tested for colorectal cancer without incurring risks associated with colonoscopies. And, just like with colonoscopy, none of these tests are foolproof. Some are better than others. Many are the fraction of the cost. So, what’s the catch?

There isn’t one with just one exception: all the above tests are intended to diagnose colorectal cancer already in progress, ideally, as early as possible.  And, comparatively to having colonoscopies ten years apart after the age 50, inexpensive and relatively accurate annual FIT or Epi proColon tests win the “screening” race hands down. 

Another difference is that unlike all of the six diagnostic tests listed above, screening colonoscopy is promoted as an infallible preventative because it promises to catch and remove polyps and small tumors long before they become malignant cancer.

There is, however, one serious problem with this “nip-in-the-bud” approach: it is, as they say, a “big fat lie” for the reasons I thoroughly outlined back in 2008 [link]:

To summarize, a screening colonoscopy for asymptomatic healthy adults in a low-risk group for colon cancer is a crapshoot at best, a Russian roulette – at worse.

The moment when screening colonoscopy turns into a life-saving procedure.

The following symptoms and signs are typical for colorectal cancer in full bloom, particularly when present in combination of more than one:

• Rectal bleeding (tarry stools) or blood streaks on the stool;
• Mucus appearing on stools, in the toilet bowl, or on toilet paper;
• Stools that smells rotten over a considerable stretch of time. This smell is caused by the rotting of necrotized tissue shedded by the tumor. It is the smell that the dogs trained to recognize colon cancer are responding to.
• Unexplained and sustained changes in your bowel movements, such intermittent constipation and diarrhea along with abdominal bloating, cramping, or discomfort;
• Stools that are thinner than usual in the absence of any other changes in your diet and/or the use of laxatives. This change of shape results from a tumor obstructing the colon.
• A sudden fecal impaction or obstruction (the cause is the same as in the preceding bullet);
• Unexplained gradual weight loss;
• Weakness or chronic fatigue related to iron-deficiency anemia;

Please note that some people may experience other symptoms, some may experience none, and any of the above symptoms may also be caused by conditions other than colon cancer. Thus, if in doubt, see a doctor first.

The Colon Cancer Risk Factors page outlines the circumstances that may elevate your risk of “catching” colorectal cancer. If any one of these risks apply to you, then you must test as often as recommended by your doctors without waiting for any symptoms to appear.

References