My grandfather recently went into the hospital with appendicitis. Appendectomies are simple – open the abdomen, sew the patient up, send him home. Unfortunately, when the doctors opened him up, they discovered that the real source of his illness was not bacteria, but a tumor; he had stage four colon cancer. As I write this, he has just undergone his third round of chemotherapy.
My grandfather has always taken good care of himself. He eats healthy food, gets plenty of exercise, has regular checkups, and has had all of the basic prophylactic tests, including regular colonoscopies. So, when I was first told he had colon cancer, I could not understand how it had gone undetected. It turned out that the tumor was not in his colon, but right outside of it. His cancer is a rare form of colorectal cancer that no colonoscopy could have discovered. However, more extensive and different types of screening might have discovered it.
When colorectal cancer is found early, the survival rate increases exponentially. But only forty percent of colorectal cancers are discovered in early stages. Why is this? Although there are many tests of varying degrees of reliability and invasiveness that doctors use to detect colon cancers – with colonoscopies being the most generally sound – a recent New York Times study reveals that doctors increasingly rely on less invasive screening measures as a preventive measure against colorectal cancer:1
- Fecal occult blood test – examine stool for the presence of cancer-marking blood or DNA; COST: $10-25.
- Flexible sigmoidoscopies – look into only the lower portion of the colon; COST: $150-300.
- Virtual colonoscopies – take a CT scan of the colon; COST: $500-900.
- Double contrast barium enemas – use contrast dye and x-raying to check for abnormalities; COST: $250-500.2, 3, 4
Patients may prefer these methods of colorectal examination for their affordability and simplicity. It does not usually seem necessary to get further screening and it is better to get these tests than to do nothing at all. But the accessibility and ease of these tests recommended by trusted doctors leads patients to believe that the tests are a more effective diagnostic tool than they actually are. A more invasive colonoscopy, which consists of inserting a tube into and evaluating the entire colon, is actually the most effective and comprehensive testing mechanism for colorectal cancer. So why doesn’t everyone get a colonoscopy? Perhaps because they cannot afford to spend the $800-2000 that the examination can cost;3 perhaps because the procedure requires several days of difficult preparation and some recovery time; perhaps because the whole experience is fairly unpleasant. Patients are nearly twice as likely to get screened if they are offered other tests, whereas if offered just a colonoscopy, they may not get screened at all.1
But given the importance of early detection, should we not find ways around these issues, or even consider additional forms of screening, perhaps doing blood and stool tests as well as colonoscopies? The colonoscopy may be the best screening for colon cancer but, as my grandfather has found, it has its limitations: “A colonoscopy is the most useful and accurate test, but it is not one hundred percent sensitive or specific. A colonoscopy does not mean every lesion will be captured,” says Dr. Shu-Yuan Xiao, Professor of Pathology at the University of Chicago Medical Center.5 If we know that there is a possibility that the colonoscopy will miss something, paranoia sets in to some extent – but how far should we let it go? How much testing is enough, how many extra miles should we go to test for rare or abnormal cancer? And where do we draw the line between inclusion and exclusion?
Perhaps we require more individual analysis; perhaps there are certain tests that everyone must get and certain ones that are time-dependent, history-dependent, etcetera. “Any person over the age of fifty should have their first colonoscopy to check for any suspicious lesions or polyps,” says Dr. Xiao. “Some people should be screened more stringently: African Americans are more likely to get colorectal cancer. People with first degree family history – that means that at least two relatives had colorectal cancer – are more likely to have polyps develop early on in their colon. People with Inflammatory Bowel Disease should be screened annually.”5 Furthermore, personal health maintenance is essential. We, as the charges of our own bodies, must take care of ourselves: eat well, exercise, minimize stress, especially as we age and our risk of cancer increases.6 That, in and of itself, is the easiest and least costly preventative measure.
Medical professionals and patients must sift through a plethora of factors when assessing how aggressive to be in screening for potential illness. An understandable desire for thoroughness – for more cancer screenings, more blood tests, full body scans – runs up against the question of whether it is worth it to spend scarce medical dollars for such inclusivity. When does the cost of prevention outweigh the possibility of finding a rare illness? This number seems unquantifiable; the question is subject to severe ethical doubt and subjectivity. Tests eliminate risk, but at what point do we go from being extensive to excessive? We cannot all assume that every patient is, like my grandfather, an outlier outside of the realm of even the most inclusive basic tests. The trick is to figure out how to be inclusive without being excessive in an age when we have the ability to know more than we need – or perhaps want – to know about our bodies. Furthermore, we must sometimes admit defeat: “despite all of the screenings,” says Dr. Xiao, “cases will still be missed.”5
- O’Connor, Anahad. New York Times Well Blog. 2012. “Giving Patients Choices in Colon Cancer Screening.”
- Rodriguez, Diana. Everyday Health. “Screening Options for Colon Cancer Prevention.” Last modified March 20, 2009.
- Myers, Donna. About.com. “Colon Cancer Screening for the Uninsured.” Last modified July 5, 2008.
- Lab Tests Online. “Screening Tests for Adults (Ages 30-49): Colorectal Cancer.” Last modified April 27, 2012.
- Xiao, Shu-Yuan. Interview with the author. May 24, 2012.
- National Cancer Institute. “Colorectal Cancer Screening.” Reviewed December 30, 2011.
- Image credit (public domain): Bascom, Chad A. “110405-N-KA543-028.” Wikimedia Commons. Last modified April 5, 2011.