Charlotte doctors suggest alternative to colonoscopy

If you’re older than 50, your doctor has probably advised you to get a colonoscopy.

It’s an effective test for detecting colon cancer. But only if you get it.

Many people delay getting one – or just plain refuse – because of the hassle. There’s the messy prep – drinking lots of laxative and spending so much time in the bathroom – as well as the need to take the day off to recover.

Even Mecklenburg County Health Director Dr. Marcus Plescia, who led cancer prevention programs for the U.S. Centers for Disease Control and Prevention, has avoided a colonoscopy because it’s “a little bit of an ordeal.”

He’s joined a national campaign to make people more aware of an alternative – a home screening kit called FIT, or fecal immunochemical test. Although it’s been around for years, it’s not commonly offered by doctors as a substitute for colonoscopies.

Today, 60 percent of Americans age 50-75 get screened for colon cancer. The American Cancer Society has started a campaign to increase that number to 80 percent by 2018.

“We’ll never reach 80 percent with colonoscopy alone,” said Dr. Richard Wender, chief cancer control officer for the cancer society. “A certain percentage of people just are not willing to do that test.”

So, Wender and others are suggesting the FIT test for people who are reluctant to have a colonoscopy.

In recent years, the U.S. Preventive Services Task Force, a panel of national experts who make research-based recommendations about preventive services, has concluded that, for most people, an annual FIT test prevents as many colon cancer deaths as a colonoscopy every decade. In other words, it’s a good alternative.

“The best test is the test that gets done,” said Plescia, quoting the campaign’s motto. “The story about there being two tests needs to be told more.”

Availability is a problem

While some people might prefer the convenience of a home test, there’s one problem: “I’m having a hard time even finding a FIT test in Charlotte,” Plescia said.

Most Charlotte-area doctors’ offices are owned by two major hospital systems, Novant Health and Carolinas HealthCare System, and policies on colon cancer screening differ.

Novant’s physician practices currently don’t offer FIT testing, said spokeswoman Robin Baltimore. But they are aware of the cancer society’s campaign and are discussing the idea of promoting fecal testing as an alternative to colonoscopy. In the meantime, if patients are under-insured or uninsured, the system offers financial assistance to help patients get colonoscopies.

At Carolinas HealthCare, internists and primary care physicians do offer FIT tests, but most physicians prefer colonoscopy, partly because it’s “one and done,” every 10 years, said Dr. Scott Furney, chairman of internal medicine at Carolinas Medical Center.

“It’s really a matter of patient preference,” Furney said. “We know there are 20 to 30 percent of patients who will not get a colonoscopy. I want to get whatever test I can done to make sure the patient has been screened.”

Across the country, many doctors still don’t mention the home test to their patients, said the cancer society’s Wender. If patients hesitate or refuse to get colonoscopies, “the doc just writes down ‘patient refuses’ rather than ordering an alternative test,” Wender said. “That’s happening every day in America.”

Personally, Wender chose to have a colonoscopy because “getting something once every 10 years is easier for me.” But for many people, it’s inconvenient. Colonoscopy patients are advised not to drive home after the test, so they need to find a ride. And taking the day off work is “a big deal for a lot of people,” Wender said.

Debate over which test is best

Doctors disagree about the effectiveness of FIT versus colonoscopy.

“I’m still a little bit on the fence in terms of which way to go,” said Dr. Derek Raghavan, president of Levine Cancer Institute at Carolinas HealthCare.

Raghavan and many other cancer and gastrointestinal specialists say colonoscopy is the “gold standard” because it offers a direct view of the colon, and if questionable polyps are detected, they can be removed immediately.

“Colon cancer is a killer if left undiagnosed. If diagnosed, it is curable,” Raghavan said. “Our position here is that colonoscopy is the most reliable approach.”

At Levine Cancer Institute, doctors generally don’t recommend FIT for patients with insurance. Raghavan said doctors are available who volunteer to perform free colonoscopies for uninsured patients at high risk for colon cancer.

Dr. Stephen Deal, a gastroenterologist with Carolina Digestive Health Associates, said colonoscopies have become “more tolerable” in recent years. Liquid laxatives are better tasting and smaller in volume, allowing patients to supplement with a drink they like – water, iced tea, juice or soda.

Sedation has also improved so patients are asleep during the procedure and don’t feel groggy afterward, Deal said.

Convincing patients to get a colonoscopy every 10 years may be easier than getting them to perform a home test every year, Deal said. “It becomes very difficult to talk about doing something on an annual basis. People don’t want to collect their poop.”

Also, Deal said, surveys show that 50 percent of patients who get home kits don’t complete them. “The problem with almost any stool test is the difficulty of getting people to return it.”

Still, to meet the goal of increasing colon cancer screening, both Deal and Raghavan agreed offering FIT is the right thing to do.

“We want people to get tested. We want people to live,” Deal said. “The gold standard remains colonoscopy. But if you’re reluctant, please do the FIT test. Any test is better than no test.”

Health director’s decision

When the health department’s Plescia turned 50 two years ago, he ordered the FIT test. He did another test a year later and plans to complete a third test now that he’s 52. He’s planning to meet with local hospital officials to make sure the tests are more widely available.

He noted that about 1 in 3 Americans don’t get screened for colon cancer as recommended, even though most of them are covered by insurance. That shows cost isn’t the major factor. “There’s obviously something about the test,” Plescia said.

That’s why he’ll continue to make a point by choosing FIT: “I’m saying these tests are equivalent, and we should be offering them more.”

Colon cancer facts

▪ Colon cancer is the second leading cause of cancer death in the United States. Each year, 145,000 people are diagnosed and 57,000 die.

▪ Ninety percent of people live five or more years when colorectal cancer is found early through screening.

▪ About 23 million Americans (about 1 in 3) between 50 and 75 years old are not getting tested as recommended.

▪ About 2 of 3 adults who have never been tested have a regular doctor and health insurance that would pay for the test.

▪ Colon cancer screening is covered 100 percent by Medicare and private insurance.

▪ Centers for Disease Control and Prevention: www.cdc.gov/vitalsigns/colorectalcancerscreening/

How FIT works

FIT is one type of fecal occult blood test that can be done at home. It detects the presence of rectal bleeding that could be a sign of precancerous polyps or colon cancer.

The test comes as a kit that includes a piece of paper to place on the water in the toilet bowl. Patients use a stick to collect a sample of feces from a bowel movement. The sticks are placed in a container and sent to a laboratory. Patients with positive FIT results are referred for a colonoscopy during which potentially cancerous polyps can be removed.

The newest version of FIT requires patients to send only one, instead of three, samples to the lab. It is also less likely to show false positive results if, for example, a patient has eaten undercooked meat the night before.

Sources: Mecklenburg County Health Director Dr. Marcus Plescia, Colon Cancer Alliance, Centers for Disease Control and Prevention.

Charlotte doctors suggest alternative to colonoscopy