March has again been designated as National Colorectal Cancer Awareness month. This is important, as an estimated 102,480 cases of colon cancer and 40,340 cases of rectal cancer are estimated to have occurred in 2013.1 Colorectal cancer is the third most common cancer in both men and women. An estimated 50,830 deaths from colon and rectal cancer occurred in 2013, accounting for almost 9% of all cancer deaths. Mortality rates from colorectal cancer have declined in both men and women over the past two decades, reflecting declining incidence rates and improvements in early detection and treatment.
As physicians, we know that colorectal cancer fulfills the criteria for a disease in which screening is appropriate. Unfortunately, screening rates are not adequate to eliminate this important cancer. Only 50% of those eligible are estimated to have received colorectal cancer screening. Even physicians and their families are not uniformly screened. Several factors may explain this failure.
Colonoscopy is the gold standard screening method for colorectal cancer. A major issue with the procedure has been the required bowel preparation. We currently have several methods to clean the colon prior to a colonoscopy: the traditional lavage preparation (GoLYTELY, NuLYTELY, TriLyte, etc), and low-volume lavage preparations (MoviPrep, SurPrep, HalfLytely, MiraLAX, etc). Each of these methods has some advantages and limitations, but we can usually select an acceptable method. Additional information on colonoscopy and bowel preparation is available on the Ochsner website (www.ochsner.org/CRS).
Economics is often an issue. While our economy is slowly improving, newer catastrophic or high-deductible health plans, as well as copay issues, have limited screening. In this cost-conscious environment, we must critically analyze our recommendations. Screening is cheaper than treating colorectal cancer if compliance rates are high and the cost of screening tests is reasonable.2 In perspective, the health advantages of screening should certainly outweigh the equivalent of several months of cable television or cell phone service. Current recommendations for screening for colorectal cancer range from annual fecal occult blood testing with flexible sigmoidoscopy at 3- to 5-year intervals to colonoscopy at 10-year intervals starting at age 50 for average risk individuals. These screening methods have reduced mortality.3-5
As colonoscopy allows the physician to view the entire colon and treat polyps, it is the preferred method. Medicare has realized this and began reimbursement for screening colonoscopy in 2001. Another option, available at Ochsner, is computed tomography (CT) colography. Studies of this procedure have shown it to be reasonably accurate in detecting significant lesions, but bowel preparation is still currently required, availability of the test is limited, and reimbursement issues have not been resolved. Currently CT colography is best for patients with coagulation issues or a technical inability to have a complete colonoscopy.
On the national and local level, multiple efforts are underway to expand colorectal screening. The National Colorectal Cancer Roundtable6 is spearheading an effort to get 85% of at-risk individuals screened by 2018. Groups such as Coaches Against Cancer, activities such as Get Your Rear in Gear, television programs, radio spots, print articles, and local lectures contribute, but physician encouragement of screening must become a daily component of our patient care. Upgrades to our electronic medical records will soon provide timely reminders on screening status. We must also lead by example and ensure that each of us, as well as our family members at risk, gets screened. Progress is occurring, but each of us needs to continue to increase our efforts to expand screening until it becomes universal. Remember, the recommendation and example of a trusted physician remain major determinants of patient action.
Additional information is available from any of our colon and rectal surgeons or gastroenterologists and from the Ochsner website (www.ochsner.org). Open access colonoscopies can be scheduled by calling one of the Ochsner endoscopy scheduling nurses at (504) 842-4060. Saturday scheduling is available to minimize the impact on patients' daily schedules.
- © Academic Division of Ochsner Clinic Foundation
