Pros and cons of screening for 3 cancers

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( Conclusion )

Medicare began reimbursing for screening colonoscopy last year.

While prominent medical organizations have endorse a range of screening techniques, far fewer patients are screened for colorectal cancer than for breast cancer. One doctor pointed out that less than 30 percent of patients 50 and older received FOBT screening and less than 15 percent undergo flexible sigmoidoscopy. What’s behind those low numbers? Physicians don’t recommend colorectal cancer screening. It’s something we have to stop being shy about.

Also, ordering screening colonoscopy is more complicated and time-consuming than ordering a mammogram, and reimbursement for several screening tests – including flexible sigmoidoscopy, which general internists have performed for years – have fallen. While screening for colorectal cancer may be efficacious, many of the dilemmas seen in other types of cancer screening apply. How, for example, can physicians distinguish potentially deadly cancers or pre-cancerous lesions from more innocuous growths to avoid over diagnosis and over-treatment?

We need to figure out which of those neoplasms we need to remove. We also need to figure out which adenomas after removal indicate a high future risk of colon cancer. Adenomatous polyps, which are the precursors to cancer, are common: About 30 percent to 50 percent of patients above age 50 have one or more. But only 10 percent of those adenomas are 1 cm or bigger, and only one percent of polyps over 1 cm will become cancerous in any given year.

Experts agree that average risk-patients over 50 should be screened, but they still argue about how to manage those who have had adenomas removed, as well as other highrisk patients. Some experts now believe that a patient with a single small adenoma doesn’t need surveillance colonoscopy, while other groups are considering lengthening the intervals for recommended surveillance. Post-screening follow-up and surveillance will be huge cost drivers. We need to sort this out over the next few years.