The American Cancer Society (ACS) recommends a colonoscopy for everyone beginning around age 50. The purpose of the screening procedure is to look for existing colorectal cancer or signs the disease might develop. Additional colonoscopies are recommended thereafter at 10-year intervals, assuming no problems are discovered. At the ACS website, the procedure is called "uncomfortable and invasive" and suggests "someone drive you home after the procedure." Preparation for colonoscopy requires "cleaning of the bowel" using a special diet and laxatives for a day before the procedure. There are several potential complications associated with a colonoscopy, including perforation, bleeding and death, again according to the American Cancer Society. The most common complication is perforation, occurring roughly once in every 1,000 procedures, according to a 2009 review published in "Genetics in Medicine." Death occurs in every 12,500 procedures.
There are other, less invasive options for colorectal cancer screening, including virtual colonoscopy and stool tests, such as fecal immunological tests or fecal DNA. Of course, these are not what American doctors call "the gold standard." A colonoscopy is the gold standard.
A colonoscopy involves the insertion of a thin, tube-like instrument equipped with a small camera called a "colonoscope" (what else-a periscope?). This mini-dildo-like device is inserted up the rectum where it is threaded throughout the entire colon. The colonoscope enables a visual diagnosis of any incipient colorectal cancer and a biopsy and removal of suspicious lesions. If no lesions are found, suspicious or otherwise, two things happen before the device is removed while the patient is still under sedation: 1) The doctor who performed the procedure is given enough time to get out of town and begin a new life under a government witness protection-like program; and 2) When the drugs wear off and the patient is fully revived, a skilled counselor says something like this to the patient: "Sorry, we did not find a thing wrong with you. You really did not have to go through this. Your colon is fine. Come back and see us again in ten years. We'll do this to you again. "
No, I'm just kidding-I made that up because here is the really amazing truth of the matter: The patient has been prepared for this highly probable eventuality! And he went through with it, anyway. He is not gobsmacked to learn that it was for naught-he would have been fine if he skipped the whole thing. All he has is some reassurance that he does not have this particular disease or likely to get it soon. There are still hundreds of others laying in wait for the passage of time. How many more tests will he have to learn that he does not have one of them? In any case, this is what he actually hoped to be told about the results of the colonoscopy. At this point, the patient is not only expected NOT to seize the throat of the medicos who did this to him but, on the contrary, he has been programmed to be happy about it all. Thus, he is likely to say something like this: "Oh, thank you so much. Thank you, thank you. I am sooo delighted. You people are the best. I can hardly wait till you do it again to me in ten years . "
I have never paid much attention to what the ACS or other medical organizations recommend concerning one test or another. I have been wary of medical tests, checkups, preventive examinations, risk assessments and all such medical imprecations. There is way too much of this. Such activities have been a part of the medicalization of health for at least half a century. I became aware of the problem as a health planner beginning in the late 60's. I was immersed in medical policy and research for five years before transitioning into my current role of wellness promoter. I have a Ph.D. in health and public policy. I saw up close and personal the reality and the wasteful, often dangerous consequences of our bloated, dysfunctional medical system. I have written extensively about it.
The problem of health being made a medical issue has only gotten worse. In a recent Progressive Policy Institute (PPI) report, Peter Orszag, director of the Congressional Budget Office, is cited for his estimate that 5 percent of the nation's gross domestic product - $ 700 billion per year - goes to tests and procedures that do not actually improve health outcomes. He believes that the "unreasonably high cost of health care in the United States is a deeply entrenched problem that must be attacked at its root."
Physicians claim that colonoscopies are the gold standard of preventive medicine. Well, that may be, but who really needs the gold standard? Everyone over 50, every ten years? The jury is out. What's more, if you are 50 or over (or someday make it that far), you might want to do some checking to ascertain if the jury has sufficiently rendered a verdict on colonoscopies-and a lot of other tests and procedures done routinely.
In 2008 the American Cancer Society deemed the colonoscopy as the preferred test. Medicare pays for colonoscopies and the new health reform law (PPACA) compels insurance companies to cover them.
Yet, I have reasons for resisting this procedure, besides a general awareness that the medical system is rife with unnecessary testing, some of which can be hazardous to health and wealth. For example, a colonoscopy is three to four times more expensive than a simpler test-a sigmoidoscopy. This entails but a partial "probe" that lasts but a few minutes. There is no sedation, no need to take time off from exercise or work, no jug of laxatives or ghastly emptying of the colon the night before and maybe no need for a gastroenterologist-family or primary care doctor can often do the procedure.) Best of all, the risk of complications (infections, bleeding, incontinence or, worst case scenario death), is seven times less than for the Full Monte big C ordeal.
And here is the gripper: the inventor of the colonoscopy, Al Neugut, wrote an editorial in the JAMA this summer stating that he regrets inventing the colonoscopy. Neugut said, "If today, we were where we were in 1988, I would not institute colonoscopy based on the current evidence."
As one wag put it, the gold standard of preventive medicine may only be golden from the point of view of physician salaries.
All this is personal. I am almost 74 and I have never had one. Many of my friends find this appalling. My wife and my son have been after me to get it done. And, one of my best mates, a person who I hold in the highest esteem for half a dozen different reasons, has pulled out nearly all stops to persuade me to turn myself in to the colon corps else drastic steps will be taken, including unmasking me as a false wellness prophet.
Charlie Chaplin said, "Life is a tragedy when seen in close-up, but a comedy in long-shot." When pondering the pros and cons of this procedure, I continue to wrestle with a go / no go decision. I have consulted my ouija board, astrology chart and prayer book. Still, the cases for and against having a colonoscopy seem to balance out. (Yes, of course I'm kidding about the astrology chart and prayer book.)
I admit that, in weighing the two choices, I began and remain biased in favor of the "give it a pass" option. To paraphrase Mr. Chaplin, when seen in close-up, the prospect of undergoing this indignity seems tragic. However, I suspect that if I were to go through with it and discover that the test results enable me to stay on the surface of the planet a good while longer, my hesitation would seem comedic, in retrospect.
Influential people in my life have been after me for many years to have this procedure. This influential group includes my primary care doctor, my son and my wife. Their well-intended concerns are of course highly regarded and appreciated. However, I suspect they are influenced by an excess of caution about lurking future problems combined with too little concern for the unpleasantness of the entire process, and the high probability that it will prove to have been unnecessary. Unfortunately, the pressure to resist no more-to just do it, has been nearly insufferable.
The latest onslaught began about a month ago during a training ride. A cycling friend and champion athlete about my age whom I'll call "Sandy" asked me if I have had a colonoscopy, lately. I replied that I had not. Upon further interrogation, I had to admit that I had no plans to have one anytime soon. I thought that was the end of it. Not so. Later that morning, I got a lengthy e-mail from him. He claimed that as a "guru of wellness," my audience expects that I will also take an interest in my own health. He claims that modern colonoscopies (versus what - the kind doctors performed in the Middle Ages?) Are quite simplistic and that, at my advanced age, I readily grow things (other than nose hair). By this, he meant there is a high likelihood that one or more polyps would be found in my colon. He called me "a stubborn old goat." But he softened that by adding that "those of us who admire and love you will be sad if my resistance proves fatal. He ended by warning that if I do not get a colonoscopy and colon cancer causes my demise, he'll boycott my funeral and stop reading my weekly wellness newsletter.
All this was very effective and motivational, especially the parts involving flattery. I asked a few associates, including several physician friends, for their opinions on the matter. About half suggested it was unnecessary; the rest said it's a good idea. The latter, however, did so for reasons that amounted to this: "It will make everyone who is concerned about your best interests feel good if you have it done."
I realized that if I did have this test, it would be done in order to please my son, my wife, my doctor, Sandy and others who are big fans of colonoscopy. These people all prefer a little discomfort now in order to be on the safe side.
However, a doctor friend in Perth pointed out that some medical groups, including the Preventive Services Task Force, set 75 as the age to stop routine colon cancer screening. His view is that those (like myself) who consume a diet rich in fiber and otherwise live wisely probably do not need the procedure. He also pointed out that colonoscopies are not promoted in Australia nor are they covered by the Aussie universal health insurance system. He basically does not recommend it. Many others expressed a similar position, some quite strongly given the history in this country of excessive testing, which can be hazardous as well as costly to society.
Well, I'm still on the proverbial fence. I made an appointment with a doctor highly recommended for early February. I plan to take my hesitations and concerns along. Maybe the good doctor will help me to see the light. Maybe not.
Needless to say, at this point I am not recommending for or against the colon screen for anyone else. But, I do recommend you do what I did-read up on the pros and cons and gather all your concerns and questions-and discuss them with a knowledgeable health care professional. If necessary, get a second or third opinion. This is a good idea when considering any kind of invasive medical test or procedure. Then, do what you think is rational. Do not submit to testing or anything else to please relatives or friends. Even if they threaten to boycott your funeral.
Be well.
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