A Merry Colonoscopy…to All!

NOTE (revised as of December 17, 2017): I have recently been accused of spreading falsehoods with this post; in particular regarding my use of statistics as a fear-mongering tactic. That is not my intent at all, and I want to make it clear that my main points here are that:

1) The idea that a third-party payer company can (seemingly) restrict an individual patient’s freedom of choice, and make them feel that they are unable to access potentially life-saving health care technology is a travesty.

2) Most of the patients whom I’ve talked to about a colonoscopy believe that they are safe from the disease, until they turn 50. This “once you reach 50” cutoff – as established by expert panels and used by health insurance companies to determine eligibility for coverage – gives the false impression (not to mention a sense of assurance) that colon cancer doesn’t occur in people under the age of 50. It does.

Furthermore, there is a crowd of physicians, health policy wonks, and academics who are on a “less is more” campaign. In other words, these folks decry the idea of screening for cancer because statistical analyses of large populations has apparently shown no benefit to overall survival. This is in large part due to the so-called (and as I’ve shown arbitrarily high) “costs” of such procedures, with the mantra being “how many people do we need to screen before we save one life?”

Well, I say as many as it takes. Because to me staying healthy means taking advantage of existing technology that may detect disease like cancer at its earliest stages, so the patient – along with their physician – can make a fully informed decision as to how best to proceed given the risks, benefits, and alternatives. And this already existent technology should be affordable, accessible, and available to patients who might not otherwise fit into a pre-packaged set of criteria; theirs for the asking, if you will.

That being said, I would also like to say that undergoing a colonoscopy is not without its inherent (albeit statistically small) set of risks – the possibility of colon perforation, bleeding, infection, and adverse reactions to medications administered during the procedure certainly need to be considered. And they will be, if you make the decision to discuss potential testing with your physician.

This post is adapted from my upcoming book: Your Money AND Your Life, available Spring 2018:

In December of 2016, contestant Cindy Stowell racked up an impressive six wins in a row on the game show Jeopardy!. Even more impressive than her winning streak though, was the fact that, thanks to technology she did it all in front of a national audience – after she had passed away from colon cancer at age 41.

Ms. Stowell’s appearances were taped a few months prior in August, when she was suffering from pain, nausea, and the effects of cancer treatment, but the episodes didn’t air until a week after her death. It’s a tragic irony that would have made even Shakespeare misty-eyed at her final curtain.

Even more tragically ironic however is the fact that, thanks also to technology, Ms. Stowell’s untimely death might have been prevented. See, we have screening tools that give us the ability to find – and beat – colon cancer, yet these procedures (such as the fecal immunochemical test, CT colonography, and colonoscopy) are almost never performed on those under the age of 50.

That’s because of our good old-fashioned health insurance industry, and its stranglehold on the American health care system.

Or I should say it’s because statistical data shows that “only” about 5% of all colon cancer cases occur in those who haven’t reached the magical age of 50.

Let me be clear: I am not saying that 5% of everyone under the age of 50 is going to get colon cancer. Rather, studies have shown that of all colon cancer cases, 5% do actually occur in those under the age of 50.

Now the idea that only 5% of cases involving a particular disease should strike people below the age of 50 may sound like a small number, but consider this: colon cancer is the second leading cause of death due to cancer in the US, and accounts for the deaths of approximately 50,000 Americans, every year. And the last time I checked, 5% of 50,000 is 2,500 people under the age of 50, who could die from a disease that in many cases can be cured – if caught early enough.

So why is it again that insurance companies get to pooh pooh the notion that only those over the age of 50 warrant colon cancer screening? Because that’s when 95% of all colon cancer cases occur.

And this is the real danger I’m writing about. By advocating “Get your colon screened at 50!” the health insurance industry – aided and abetted by the US Preventive Services Task Force – firmly entrenches in the minds of millions that, well, colon cancer just doesn’t happen in people, until they hit 50.

But colon cancer does occur in people before they turn 50. To a lot of them – and it kills thousands of Americans a year.

So the fact that 95% of all colon cancer cases occur after the age of 50 gives health insurers the excuse they need to not cover any screening tests in those who haven’t yet had their 50th birthday. Which in turn makes policyholders believe they’re immune from colon cancer until they turn…50.

This notion of an arbitrary cutoff age has even been signed into federal law; the Affordable Care Act mandates that all health insurance plans must cover colorectal cancer screening, but only “for adults over 50.” On paper it sounds good; after all 95% of colon cancer cases occur in this age group. But the law absolutely fails to address the fact that colon cancer can – and does – strike people in their 40’s, 30’s, and even 20’s. Even those who have no significant risk factors.

Like Gemma Wood, an English woman who was diagnosed at age 25. Or Brad Sumrall, the brother of my friend who died at 40 from this horrible disease. Oh, and let’s not forget about me, and my scare.

I went to the bathroom one day back in 2001, and noticed fresh blood on the toilet paper. I was 33 years old.

Recognizing the significance, I immediately set up an appointment with a GI specialist and the very next week I was rolled into my first colonoscopy. And every five years since then I’ve had a follow-up study. In fact, I’m due for my fourth colonoscopy next month, and I’m really looking forward to it.

No, really I am. All kidding aside, I want to know if anything is going on inside of me – that shouldn’t be.

And a colonoscopy is the best way to have a look. It’s an extremely common outpatient procedure that is considered the gold standard for finding colon cancer, even in its earliest stages, before it can grow, spread, and then kill.

I may not have inflammatory bowel disease, a family history, or any other factors that would put me at an abnormally increased risk for colon cancer, but I do have the strongest risk factor that can predispose one to the disease: I have a colon. And during each of my previous four colonoscopies (in 2001, 2006, 2011, and again in March of 2017) I’ve had at least one polyp removed.

Now in each case the polyps were benign, but that’s not to say that they couldn’t – or wouldn’t – have turned cancerous, without me even knowing.  And although 50 may still be a year away for me, there is a chance that I would have been long gone by now, if I hadn’t been lucky enough to have that rectal bleeding way back when, as a warning sign.

So thank goodness I did. And thank goodness for colonoscopies because, as I like to tell my patients, “you could say that you’re looking at a four-time colon cancer survivor.” And as a result of my personal experience, I encourage all my adult patients to consider getting screened as early as possible. Even my 20-something year olds, who stare at me in amazement.

I am not saying that health insurance will – or should – pay for such screenings, though. In a perfect world colonoscopies (and many other kinds of health care technology) would be affordable, and available to patients who “just want to know.” Alas, today they are neither affordable nor available just for the asking, which is the whole point I am making with this post.

And yes, I know, I know. Undergoing a colonoscopy can be a pain in the backside, but the effort might just be well worth it. Especially since colon cancer is such a slow growing tumor – the general consensus is that a colonoscopy in low-risk individuals every ten years is a safe interval between checks, as long as no abnormalities (like polyps) are found. Which means that in a best case scenario, a 20-something year old would have to go through the procedure only 7-8 more times throughout their life.

Which didn’t happen for Brad Sumrall, Cindy Stowell, and countless others.

The odds of winning six Jeopardy! games in a row have got to be way astronomically low, and a big hats off to Cindy Stowell for her accomplishment.

But a big thumbs down for yet another outrage brought to us by our health insurance industry, for making Americans believe that they don’t need to consider a screening that can save lives, until they turn 50. If they make it to 50, that is.

So if I could have my holiday wish list come true this year, right near the top would be to educate Americans about the benefits – and the risks – of colon cancer screenings, and in so doing dispel the notion that this deadly disease only happens to people older than 50. I would also like to see colonoscopies (and many other kinds of health care technology) become affordable, so that everyone who desires one, regardless of risk factors, or age, can get it without having to beg permission from a corporation.

In other words, I would wish a merry colonoscopy to all. And to all, a good night!

It’s not the COSTS of health care that are outrageous…it’s the CHARGES.

Physician. Health Insurance Agent. Author. Health care humorist. Medical satirist. Disruptor. At your service. My name is Kevin Wacasey, and I’ve been practicing medicine since 1994. When I graduated from medical school, I took an oath to do no harm to my patients. To me, that includes financial harm. But since health insurance took over health care over 40 years ago, health care prices have skyrocketed. And despite what we’re told by the media every day, it isn’t the costs of health care that are outrageous; it’s the charges. So if you’ve ever wondered why we spend so much on health insurance and health care, then come along and join me as I explore the crazy world of Healthcareonomics. Health care doesn’t have to be expensive. Let me show you how. For speaking opportunities and to pass along your questions/comments, please email me at drw@healthcareonomics.com.

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  1. Mary Robb

    What is your opinion of the newly advertised home test kits for those with no “family history”, or low risk category patients? Are they effective as a primary screening tool, or just a waste of time and money?

    • To me, these are a good “extra” step, especially if done on a routine basis – say every year in between colonoscopies. But I think the colonoscopy will always be the best choice, because it provides direct visualization of the mucous membrane lining of the colon, where cancer can produce subtle changes before forming a distinct mass. Sort of like oral cancer lesions, Doctor… 🙂

  2. Chad Sumrall DO,FACEP

    Very good article Kevin. I agree. Thank you

  3. Jay Yepuri

    Kevin – your analysis is (as always) impeccable. Colon cancer is completely preventable if people get screened and as you have rightly pointed out there are screening options other than a colonoscopy.

    The one thing I point out to my patients who are considering an alternative to a screening colonoscopy is that if the test comes back positive – guess what? You still need a colonoscopy! Why? While the noninvasive options can detect changes suggestive of a precancerous polyp or cancer, those tests do not allow for removal of the polyp – only a colonoscopy allows you to see and remove the polyp at the same time. Bottom line (pun intended) – if you are going to do one screening test, just get a colonoscopy!

  4. Mary Winter Peterson

    And while we’re talking about this, could some people quit griping about having mammograms, Pap smears as well as colonoscopies? I mean, get over it. None of these tests are that bad to endure. We should all be thankful that the tests and technology exist and that they really do save lives. But then, there’s always someone who’ll complain about anything.

  5. Donna Urgo

    I know that the Navy at one time set up dedicated CT scanners next to the GI surgery suite, so after the CT colonoscopy, they could go into the suite and take out any polyps (I am not sure exactly their percentage of those who required both). I would still think that the added risk of anesthesia should be taken into account for the colonoscopy. In the same way that there is a slight risk of breast cancer from irradiating a tissue sensitive to radiation. I, by the way, work in the radiation safety (medical physics) field.

    • Thanks for the comment. Most colonoscopies are performed nowadays under what is called conscious sedation, which involves giving the patient a dose of a sedative that helps them relax but also causes amnesia – which is why most folks don’t remember the procedure (a very, very good thing if you ask me). This type of sedation is much less risky than general anesthesia, and is commonly used in operating and emergency rooms across the country.

      Although “virtual” colonoscopies – or CT scans of the colon – are becoming increasingly popular, I’m not a fan of them because they do involve radiation exposure and can only find comparatively large tumors. I don’t think any current competing technology beats the colonoscopy, where not only can abnormalities in the colon be detected when they are small and at a much earlier stage, but the involved tissue can also be biopsied (or in the case of polyps like I’ve had) removed. So undergoing a colonoscopy at regular, recommended intervals can be not only diagnostic, but also therapeutic.

  6. Bill Bryant

    Enjoyed your spot on Rick Roberts show today. My next colonoscopy is a week from tomorrow, February 9. Number 3. 😝

    • I hope everything goes well for you, Bill. As I say, it’s not the procedure itself that stinks; it’s the prep. And since I have my fourth colonoscopy scheduled for later this month too, may I join you in saying “bottoms up!”

  7. It sounds like getting a colonoscopy is a good idea. I didn’t know you might need them as young as 33 years old! If it helped you, maybe I should look into getting one. I’m only 45, but I guess that’s getting old enough.

  8. Dr. Joseph Benerakis, DPM

    Agree completely

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