Colonoscopy Cancer Screening? Not During A Raging Pandemic And With Complication Rates Much Higher Than Previously Thought

 

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Barbara Ehrenreich, in her book,:  'Natural Causes: An Epidemic Of Wellness, The Certainty Of Dying, And Killing Ourselves to Live Longer' , sees no need for colonoscopies after age 74-75.  Many medical experts now concur.

"Most of the medical screenings pressed on me by one medical professional or other fail the evidence- based test...  As for colonoscopies, they may detect potentially cancerous polyps but they are excessively costly and have been found to be no more effective than much cheaper than non-invasive tests such as examination of the feces for traces of blood."- Barbara Ehrenereich,  Natural Causes: An Epidemic Of Wellness, The Certainty Of Dying, And Killing Ourselves to Live Longer' pp. 36-37

The issue of cancer screening during a raging pandemic is probably something each person has to decide for himself.  In particular what is the risk vs. reward?  For PSA testing it's kind of a no brainer as this simple blood test can be done in a Covid-socially distanced lab setting (e.g. at LabCorps) and is non-invasive so there is little to no risk of complication which might send the patient to an ICU.  I can vouch for that having just had this test 3 months ago (noting the PSA had jumped to 6.9).   

On the other hand, a colonoscopy is invasive, and while one might be told by the medical geeks and gurus this also is pretty tame, the facts seem to belie the innocuous patter.  Hence, undertaking this test now might well see one dispatched to an already overcrowded ICU,  say in the event of a perforated bowel.   In this case, after receiving two notices to come in for this procedure I opted to follow former biologist Barbara Ehrenreich's  advice (in her book, 'Natural Causes'), i.e. the risk vs. reward isn't worth it after age 74 or 75.  Colon cancer is generally slow growing and you're more likely to croak of any other ailment, with barely 9-10 years of functional life left.

This is especially given the risk of complications, especially blood clot, bowel perforation, and hemorrhage following polypectomy -  notably after age 70. This is mainly owing to much decreased resiliency of the intestines, coupled with increased frequency of diverticulosis in older patients. 

Basically then, risking such a perforation or other incident now during a pandemic - and having to go to an ICU for attention - is not a promising option. True, the risk might be low, but it if happened the result would be cataclysmic what with overflowing ICUs and not enough medical specialists.   Add to this new research by Yale's Harlan Krumholz and  his team which shows the adverse complication rate for colonoscopy is actually nearly 2 %, not insignificant as the medical cognoscenti might have you believe.

In an event he recounts on a medical website, Krumholz saw a friend rushed to the hospital "with shaking and chills" one day after his colonoscopy a few years ago. He then wondered how often this procedure results in such scary, adverse events.  According to the good doc:

"For about 12 hours he was very, very sick. And it seemed a bit much to think the colonoscopy was unrelated; so maybe there was a micro-perforation, or a contaminant in the IV used to administer sedation during the procedure."

It struck Krumholz, director of the Yale Center for Outcomes Research and Evaluation (CORE), that the frequency and severity of harm from this common cancer screening, performed in roughly 14 million people each year, were poorly quantified. However, he acknowledged it probably varied widely among facilities, depending not just on the skill of their clinicians, but on many other factors related to how the facility functions, he thought.  So Krumholz, whose team has multiple Medicare contracts to develop pay for performance measures for healthcare settings, went to work.  In his words:

"I came back to my group and said, 'We need a measure for this. How often does this happen and how much does it vary among the outpatient centers? Probably the people who performed his colonoscopy didn't even know he showed up in the emergency department. Because today, there's no feedback to let them know.'"

The Yale team then developed a risk-adjusted measure that now has been incorporated in two Centers for Medicare & Medicaid Services quality reporting programs. It provides a count of all healthy fee-for-service Medicare beneficiaries 65 and older who, for any reason, experience an unplanned visit to the hospital within 7 days of their outpatient colonoscopy -- regardless of whether a polyp was removed or biopsy performed.

As a kind of test, Krumholz and colleagues applied the measure, which factors in the patients' procedures and conditions in the prior year, to Medicare claims databases in four states (New York, California, Florida, and Nebraska) that track unique patient identifiers. With that, they could see what care patients required within 7 days of their colonoscopies.  What frequency did they find for complications?

Two of Every 125 Patients get sucker pnched:

What they found might surprise many, although it's not out of line with the literature: 1.6% of 325,000 otherwise low-risk healthy patients who had a colonoscopy in a given year experienced a complication serious enough to send them to a hospital or emergency department within 7 days.

For some, "that 1.6% may not seem high," according to Elizabeth Drye, MD, director of quality measurement programs at the Yale Center.   Adding:  "But not when you think of how so many healthy people have these procedures. It's important for us to know how many could be having a bad result."

The Yale team's results were published as the lead article in the January issue of the journal Gastroenterology, accompanied by a video interview with Drye.

What's more, the team found wide variation in the rates of emergency visits and hospitalizations across facilities, from 8.4 per 1,000 up to 20, she said.

Extrapolating to a national population of 1.7 million Medicare fee for service beneficiaries undergoing colonoscopies each year, Drye and colleagues estimated about 27,000 would have an unplanned hospital visit within 7 days. That's just over one fourth the patients now hospitalized in the U.S. for Covid. Also, it does not include Medicare Advantage enrollees or younger patients 50 to 64 who have an adverse reaction from their colonoscopy bad enough to send them to the hospital.

A lot of things can go wrong even after colonoscopy in an outpatient setting, such as a hospital outpatient department or an ambulatory surgery center.

Drye noted that perforations or lacerations can cause bleeding and hemorrhage or even infections that don't show up for a day or more; sedative drugs can also cause reactions resulting in hypoxia, aspirational pneumonia, and cardiac arrhythmias. Abdominal pain or nausea can also result, possibly from preparation.

Beyond 7 Days

Most colonoscopy adverse events occur within 7 days, but even more occur beyond the 7-day period. In a mid-2014 handout, the CMS agency noted: "Hospital visit rates after outpatient colonoscopy range from 0.8 to 1.0 percent at 7-14 days." And in its rule establishing ASC-12 as a reporting requirement, it estimated the range of hospital visits to be between "2.4 to 3.8% at 30 days post procedure."

But Drye noted also that 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.

Additionally, the measure also only captures the risk for healthier patients; Those with conditions such as diverticulitis or inflammatory bowel disease, and those with serious chronic illnesses are more likely to experience complications from colonoscopy were excluded from this measure's denominator.

"We were very conservative," Drye said. Also, the 1.6% meshed more or less with what the Yale team found in the medical literature, where a variety of studies using different time frames and definitions of "hospitalization" found rates of colonoscopy complications ranging from .8 to 3.8%.

Rates were somewhat different between hospital outpatient departments and ambulatory surgical centers, Drye added. Their study found that the ASC measure scores "ranged from a minimum of 6.5 per 1,000 procedures to a maximum of 13 per 1,000." Hospital outpatient department averages were slightly higher "with a minimum of 7.3 and a maximum of 16.6 per 1,000."

Those who still want to do a colon cancer screening have another, less invasive option to colonoscopy. That would be the  FIT: fecal immuno-chemical test.    This test has been recommended by Dr. Deborah Fisher of Duke University,

For more about her and  the FIT comparisons to other tests, recommendations, see:

http://www.medpagetoday.com/Gastroenterology/GeneralGastroenterology/47428

The choice now becomes that of the patient, especially elder ones, as opposed to being dinged to pad the pockets of medical specialists using Medicare's coffers.  In a time of crowded ICUs nationwide it would seem the better option for older patients - certainly in their 70s- is to avoid the risker, invasive choice - never mind any "gold standards". If you're in an ICU being intubated for Covid there is no "gold standard".