Health News Review

The following is a guest post by Dr. Richard Hoffman, one of our expert editors on HealthNewsReview.org.

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The New York Times story, “The $2.7 Trillion Medical Bill: Colonoscopies Explain Why U.S. Leads the World in Health Expenditures,” about how the exorbitant costs associated with colonoscopy contribute to the high costs of American medicine has provoked some interesting responses.

Ronald Vender, the President of the American College of Gastroenterology has written a strident letter to the editor in defense of colonoscopy, claiming that colonoscopy is a public health success story — and “the one and only preventive cancer test that has been demonstrated to significantly reduce the incidence of colon cancer and death from the disease.”

Unfortunately, this statement is wrong.   The only colorectal cancer screening tests that have been proven efficacious in reducing colorectal cancer incidence and mortality, i.e., evaluated in randomized controlled trials,  are the far less expensive fecal blood tests and flexible sigmoidoscopy.

Colonoscopy is being evaluated in several randomized controlled trials in the US and Europe, but incidence and mortality results will not be available for many years.

While Dr. Vender noted that an article published in the New England Journal of Medicine (and reported by the New York Times in an article entitled “Report Affirms Lifesaving Role of Colonoscopy“) was evidence for the benefit of colonoscopy, the study was actually an observational study that was subject to important biases.

While journalistic hyperbole may be disappointing, so are the misleading statements from the American College of Gastroenterology.

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Comments

Greg Pawelski posted on June 6, 2013 at 12:08 pm

ACS’ Dr. Otis Brawley said in an interview for Reuters, the $10 stool test for colon cancer screening has been shown (via RCT’s) to save lives, but in the United States, the $3,000 colonoscopy is mostly commonly used. “Everyone is getting the expensive test, even though the cheaper test is better. But the cheaper test involves stool and no one can make money off of it.” But I may add, the efficaciousness of FOBT is only 30%. Now who does that help? The infamous Taxol was only 30% efficacious for FDA approval for ovarian cancer in 1992. Again, who does that help?

Gary Schwitzer posted on June 6, 2013 at 10:55 pm

On Twitter, a Tennessee colorectal surgeon wrote, in response to the blog post above: ” the only reason that fecal occult blood testing decreased mortality was with the use of colonoscopy ”

And an Arizona physician wrote: “I recommend not getting colonoscopy. Then I will have more colectomies to perform for advanced cancer!”

I asked Dr. Hoffman to respond to all of these comments. His response follows.

Richard Hoffman posted on June 6, 2013 at 10:58 pm

While randomized trials have shown that fecal blood tests and sigmoidoscopy reduce cancer mortality by 20% to 30%, I want to be clear that the 53% reduction cited by Ronald Vender in his letter to the editor of the New York Times is an artificial number that does not represent the benefit of screening colonoscopy. The number comes from the National Polyp Study. In the 1980s healthy patients at average-risk for colorectal cancer underwent colonoscopy performed by highly skilled endoscopists. Those with polyps had them removed and were subsequently entered into a clinical trial comparing different intervals for performing surveillance colonoscopy. After a median follow-up of nearly 16 years, the investigators found that 12 patients had died from colorectal cancer. The investigators then used data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) tumor registries to estimate that 25.4 deaths would have occurred during that time in a matched general population cohort. Because only 12 colorectal cancer deaths occurred, the investigators concluded that polypectomy—not screening–reduced the mortality risk by 53%. This comparison could not account for important differences between the study subjects and the general population—including general health, risk factors, health behaviors, and access to care,

Certainly fecal blood tests and flexible sigmoidoscopy reduce cancer incidence and mortality because patients with abnormal screening tests will undergo colonoscopy–and often polypectomy. However, this does not mean that colonoscopy should be the preferred screening test, particularly for average-risk patients. Aside from expense, colonoscopy requires an onerous bowel preparation, sedation, and carries risks for perforation and bleeding. When informed about these factors, many patients opt for alternative tests.

Laurence Alter posted on June 20, 2013 at 7:02 am

A Professor Kenneth Prager of clinical medicine at Columbia College of Physicians and Surgeons writes in the ‘Letters’ column of “The New York Times” article in question: “Overcoming an American culture that believes that more medical testing is better.”

Look at your language and it’s proverbial wisdom: “It’s not quantity but quality that counts.”

Show me its daily practice. What’s in practice is: “Numbers numb, making one look Dumb.” What’s in practice is the (doctoral) advice to: “Get a 2nd opinion” as if such a small number will tell you anything about a medical condition. Professionals in any field of study should advise the general public on the value of Quality over Quantity (and small numbers – like getting a “2nd opinion” – hardly even counts as quantity). Professionals at the highest level of their Profession are hardly professional advice-givers.

The professor/doctor I’ve quoted is HARDLY ALONE. He can talk a good talk about not trusting the number of testing procedures, but professionals and specialists and experts and authorities throughout the world live (and speak!) otherwise. A sampling:

1. “I have the experience” (meaning “number of hours/years” practicing) to have the good judgement so listen and follow me.

2. “I am the senior ______ (meaning status conferred on amount of experience) at this facility” so listen and follow me.

3. “I have done this procedure/test/operation _______ times” so listen and follow me.

4. “This clinic/department/hospital was the first of its kind” (meaning the oldest with the most experience) so listen and follow me.

I am currently writing “The Q Revolt” which includes the quantity as quality practice.

Respectfully submitted,

Laurence Alter
E-mail: questioning@mail.com