In the vast majority of cases, we can stop tens of thousands of American from dying of colorectal cancer. Let that sink in for a moment. With the exception of lung cancer, colorectal cancer will kill more Americans than any other cancer in 2022. And for many, death is preventable.
In the United States this year, the National Cancer Institute estimates that more than fifty thousand Americans will die from colorectal cancer. Those are our parents, siblings, spouses, and children. And recent news coverage of a study published in the New England Journal of Medicine (NEJM) earlier this month has made the situation worse.
The NEJM publication concluded that although colonoscopy is widely used as a dependable screening test to detect colorectal cancer, its overall effect on the risks of colorectal cancer death is potentially less clear than previously reported. The doubt sprouting from this study is misplaced, dangerous, and will potentially lead to more deaths from this disease.
It is important to point to what the study truly concluded. Colonoscopies prevented cancer in the study, something very few tests accomplish. It is also important to note that this study did not examine the efficacy of colonoscopy as a procedure, which has been well-established for decades. Rather, this study investigated how patients react to colonoscopies in a real-world setting, a far and much different setting than a controlled clinical trial. Only 42 percent of the patients who were invited to have a colonoscopy underwent the test, limiting how well we can truly interpret these results. In addition, these patients were not followed long enough to likely notice the well-demonstrated cancer-related survival benefit in those diagnosed with early stage disease or with precancerous polyps.
If important takeaways exist from this study about colonoscopies, we must take these in context. A myriad reasons may exist for the fact that only 42 percent of the study participants actually underwent the procedure. Time away from work or family, or perhaps concern about the procedure or the preparation needed to achieve a successful high-quality colonoscopy are all reasons I have heard from my patients. Responsibility falls to my colleagues but indeed also to our patients in those cases to find a different, more tolerable, and accepted way to screen for colorectal cancer. For those unwilling to undergo a colonoscopy or who prefer another evidence-supported screening modality, we can offer a multi-target stool DNA test (Cologuard). Unlike colonoscopy, there is no bowel preparation required and this screening test can be done in the privacy of one’s home.
Colonoscopies are effective. Colonoscopies remain crucial in helping find colorectal cancer. Decades of quality, peer-reviewed data support the continued use of screening colonoscopy.
Healthy debate based upon well-designed clinical studies is essential. However, misconceptions of this particular study and certain media responses that followed have gone directly from the clinical pages of NEJM into my office consultation rooms. I already have patients raising questions as to whether they wish to be screened. I suspect (and am concerned) that my colleagues and I have only seen the initial wave of patients who will doubt the well-established validity of colorectal cancer screening, let alone those who may not make it to our offices as a result.
Of the 84,585 participants in the study, less than half agreed to screening colonoscopy, leaving us to wonder why study investigators failed to screen so many in the study. Early reports from this research raise flags about the quality of the examinations in the study. Nearly one-third of proceduralists did not meet expected standards for adenoma detection rates, an evidenced-based recommended data point measuring the quality of colonoscopy examination. Despite this, the authors of this study actually did show improvement in colorectal cancer detection in those undergoing screening and would have shown a more significant effect had more of the patients offered colonoscopy undergone the procedure. Longer-term studies have also shown a decrease in mortality rate from colorectal cancer in similar patient groups.
This study and others highlight the need for open communication between physicians and their patients, focused on the essential nature of screening to decrease cancer-related death, and highlighting that different tests exist. We should offer the best test for a patient, and discuss the risks and benefits of each to encourage educated screening choices. Ultimately, the best colorectal cancer test is the one that someone understands, and is willing and able to perform and complete appropriately.
Colorectal cancer is somewhat unique in cancer. Along with cervical, lung, and breast cancers, colorectal cancer has guideline-endorsed and FDA approved screening tests. In fact, unlike most other cancers, various and diverse options exist to screen for colorectal cancer, offering people the right test for their personal needs, and providing those 45 and older, and certainly their healthcare providers, ample opportunity to encourage and accomplish screening – and to decrease death from this highly preventable disease.