routine colonoscopies and the relationship to overdiagnosis

‘ROUTINE’ COLONOSCOPIES
OFTEN ANYTHING BUT ROUTINE

Colonoscopy Side Effects

“Not surprisingly, the studies in the endoscopy literature do not mention overdiagnosis at all in their discussions of complications and harm. The recent JNCI (Journal of the National Cancer Institute) editorial points out that overdiagnosis is a significant issue in colonoscopic screening, noting that the majority of findings at colonoscopy are small low-risk adenomas and non-adenomatous polyps, not cancers.”  Written by a neurologist for the website Patient Safety Solutions (Rethinking Colonoscopy)

“The new analyses may show that primary colonoscopy screening is best limited to subgroups. For most of the population, going the distance [colonoscopies for everyone of a certain age] may well provide small benefits with larger costs and harms.”  From the editorial mentioned above

“H. Gilbert Welch has told us this before, but he doesn’t think we’ve been listening: The central problem with U.S. medical care is not that it’s expensive or complicated or impersonal — it’s that there’s too much of it, and too much of it is ineffective.”  Nancy Szokan’s opening paragraph from last year’s article she wrote for the Washington Post (Do You Really Need that Colonoscopy?)

“Many European countries with national population based screening programs have, after thorough evaluation of all evidence, reached the conclusion that fecal testing, rather than colonoscopy is their best option for reducing death from colorectal cancer.”  From the November, 2012 issue of Practical Gastroenterology (Chronic Polyps: The Harm of Overdiagnosis)

“Another analysis of British data on colon cancer, by the watchdog group Straight Statistics, concluded that screening 1,000 patients for 10 years will prevent two deaths from the disease. Meanwhile, colonoscopies lead to “serious medical complications” in 5 out of every 1,000 patients, according to a 2006 report in the Annals of Internal Medicine. Given these risks, my guess is that a rigorous examination of colonoscopies will find that their benefits do not outweigh their downside.”  From John Horgan’s 2012 article for Scientific American (Why I Won’t Get a Colonoscopy)

I cannot begin to tell you how many times I’ve heard it — usually from little old ladies as opposed to older men.  “Ever since I had that colonoscopy, I’ve had pain.”  When I ask where the pain is, they can never really tell me other than to describe it in vague terms such as deep inside, while pointing to multiple areas of their abdomen.  In light of a brand new study from the director of Yale’s CORE (Center for Outcomes Research and Evaluation), we shouldn’t be surprised.

Dr. Harlan Krumholz and his team discovered that of the estimated 14 million “routine” colonoscopes performed in the US each year on patients 65 and older, 1.6% had serious enough complications to require hospitalization within one week of the procedure.  The study, published in last month’s issue of Gastroenterology (Differences in Colonoscopy Quality Among Facilities: Development of a Post-Colonoscopy Risk-Standardized Rate of Unplanned Hospital Visits) provided some hard-hitting conclusions.  Of the patients the authors looked at, colonoscopies were followed by 5412 unplanned hospital visits within 7 days. Hemorrhage, abdominal pain, and perforation were the most common causes of unplanned hospital visits

Mind you, these stats do not count the little old ladies (or men) I mentioned earlier.  Why not?  Even though they are having pain (and likely ended up at their doctor’s office or the ER), most are not hospitalized.  They usually end up going back to be re-scoped to look for damage caused from the first scope. These patients are then told by their doctors that they couldn’t find anything.  When said patients continue complaining about the pain, they are invariably told that it will eventually go away.  My experience is that sometimes it does, and sometimes it doesn’t.   But what about complication rates that extend beyond the seven days looked at in this study?

A 2014 memo from CMS (Medicare), published in the July 14 issue of the Federal Register goes on to say that, says that the rate of hospitalization is, “2.4 to 3.8% at 30 days post procedure.”  This estimate more than doubles the potential rate estimated for one week after the test.  But even this doesn’t tell the entire story.

Sick people (those with polyps, diverticulitis, INFLAMMATORY BOWEL DISEASE, or any number of others) are the people most likely to have an “Adverse Event” following their scope.  None of these people were counted for the studies mentioned, as the authors were only looking at “routine” scopes — periodic scopes for those without known problems.  Cheryl Clark of Medpage Today (Colonoscopy Complications Occur at Surprisingly High Rate) lets us know that the problem is actually worse than this (if you took “Statistics” in college, this will make more sense).

“The risk is even higher on a per-person basis, because one must consider that patients who undergo colonoscopies at recommended intervals — every 10 years, or every 5 years if polyps are found — would have from three to six colonoscopies before age 76.” 

Add it all up, and we see that of the reported complications for ‘routine’ Colonoscopies (we already know that THE VAST MAJORITY OF ADVERSE EVENTS FOR ALL PROCEDURES ARE NEVER REPORTED), the number of people requiring hospitalization is going to be at least 5% — maybe significantly higher.  Once we factor in the whole OVERDIAGNOSIS / OVERTREATMENT thing, you have to start wondering if it’s worth it.   Dr. Gil Welch sums it up in this quote taken from a book he wrote on the subject a few years ago.

“Screening apparently healthy potentially saves a few lives (although the National Cancer Institute couldn’t find any evidence for this in its recent large studies of prostate and ovarian cancer screening). But it definitely drags many others into the system needlessly—into needless appointments, needless tests, needless drugs and needless operations (not to mention all the accompanying needless insurance forms). This process doesn’t promote health; it promotes disease.  People suffer from more anxiety about their health, from drug side effects, from complications of surgery.  A few die.  And remember: these people all felt fine when they entered the health care system.”   From H. Gilbert Welch’s 2011 offering, Overdiagnosed: Making People Sick in the Pursuit of Health.    Dr. Welch is a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice

In other words, scoping the colon is a search for disease, but does absolutely nothing to promote health (a WIDESPREAD PROBLEM IN MEDICINE).  All of which begs the question of why we are so concerned with Colon Cancer in the first place?  Probably because it’s the third most common form of CANCER in the US.  And like another common form of Cancer (Lung Cancer) is largely preventable via diet and / or lifestyle. 

In following the logic of Dr. Welch’s statement above (that screening actually promotes disease), my suggestion would be to start leading that healthy lifestyle now.  And if you are of the age where your doctor is pushing you to be tested for Colon Cancer, whether you decide to have the test or not, make it a point to STAY FIT AND HEALTHY.  It’s a much different concept than living however you please, getting routinely tested for various diseases, then using drugs and surgery to treat said diseases.  You’d be surprised to learn how many people don’t care about changing their diet and lifestyle as long as someone else is paying for the scenario in the previous sentence. 

Listen to the expert himself (Dr. Gil Welch) describe the phenomenon of overdiagnosis as it pertains to Cancer.  Oh; and as an interesting side note to this issue, THIS ARTICLE on the Canadian recommendations for Colonoscopies was published just days after my post.

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