Having "enjoyed" a colonoscopy recently, I looked into this option, but the upside of a colonoscopy is that if they do find polyps, then can usually take care of them right then and there. Plus, they can also look for other things, and generally react to what they find in real time.
Unrelated side note: I did this all during the US election week, so that was a fun few days of stress and weirdness!
The common counter-point is that more invasive tests are more likely to find issues, but that's not the same as being useful. A very controversial test is the (highly invasive) pap smear. I don't take a firm view on the subject, but it does seem to be a complicated subject with valid points on both sides.
Considering these tests detect blood, and not all polyps (cancerous or otherwise) bleed, there is no way that this is as accurate as a colonoscopy. Maybe if you take into account that more people are willing to use this test than a colonoscpy, it can be as effective because more people get tested. But that's on population level and not on the individual level.
One thing the colonoscopy came with but the occult blood stool test didn't: a warning that there was a 1 in 1000-10,000 risk of an accidental tear in the colon leading to peritonitis, an immediate surgical emergency (and life-threatening if undetected and untreated).
So yes, the colonoscopy might pick up some rare non-bleeding cancers and polyps ... but it's also going to lead to unpleasant surgical complications in its own right.
(I have no figures for relative risk: but feel it's worth noting.)
Correct me if I'm wrong, but I believe colonoscopy screenings are every 3 years or so (5?). If the stool sample is performed annually you get a lot more data samples/tests.
That would seem to shift some weight to the stool test.
As I read it, this article is more about the inadequate US healthsystem than anything else, in particular because it forgets to mention that iFOBT is free and automatically sent to all between 50/55-75 in several European countries. No diet required. Return envelop included. Lab results received by postal mail after a few weeks.
In the US, guidelines say people of average risk should have a colonoscopy every ten years, making your point even more salient. To give you an idea, regularly scheduled colonoscopy (ie every ten years unless higher risk) has a specificity of 86%, while stool tests performed annually are in the 90s (FIT is 96.4%, gFOBT is 92.5%)
That's how it works in the Scottish NHS. National stool screening program every two years after you turn 50 (you get mailed a sample tube and send it back to the test centre). If it's a positive, you're called in for a colonoscopy. *But* if you show suspicious symptoms outside of the screening program you get a colonoscopy anyway.
(Source: am at very high risk of hereditary colon cancer, had a colonoscopy when my GP learned of the family history, then screening thereafter. All clear so far ...)
Right, it was only a couple of years back we switched from the old test with the little landing pads to the new one that's a tube. I've only had one of the new ones so far.
Also, should have corrected my comment above... it's two year intervals, as you mentioned.
Oh yes, you're absolutely right, colonoscopies aren't risk-free, especially if anaesthesia is involved. I wonder if those risks can be reduced (better equipment? more experienced doctors?).
I've had two colonoscopies 5 years apart because in the first procedure they found and removed polyps, which put me on the side 5-year plan (every 5 years). In the last procedure polyps were also found and removed. Since at least one of the polyps removed in both procedures were benign but possibly capable of becoming malignant, the FIT test by itself is probably not sufficient for me as the only cancer screening test.
Yes, that's the problem. I was hoping these results for the FIT meant the uninvasive test was approaching the value of the invasive one, but clearly not close enough for my own comfort.
My uncle has created a disposable, biodegradable version and has been doing a lot of work to get this used and known: https://www.mccormackinnovation.co.uk/
Another interesting alternative: the pill camera. You fast, swallow a pill containing a camera, a bright LED and a battery, a video is transmitted through your body recorded by a sensor outside, and someone qualified can glance if anything is wrong.
Pill teardown here [1], images here [2] (without fasting).
The upside is quite clear, especially if you are already used to fasting. The downsides are that you can't control the speed of the pill going through your digestive system, and if a polyp is found, you still need a colonoscopy to remove it (and need to fast again).
They don’t show the same things as a colonoscopy (good for diff stuff), can’t take biopsies, and my understanding is that those are actually more expensive.
Super interesting. I was expecting a kind of microgram camera... this is a monster pill, I have trouble swallowing small ones, I would probably choke on that. Could it work from the other side as a suppository?
"Faecal occult blood" (FOBT) home test kits have been around for years. And they don't require sending a sample back to the lab, you just poke a few holes in a turd with something that looks like a mascara brush, put it in a test tube and wait around for a bit. It's super simple. No lab required. If the result is positive, you talk to your doc and possibly have a colonoscopy scheduled.
Not sure why this article talks about sending samples back to a lab. Maybe the 100% at home self test isn't approved in the US or something?
Make sure it's an iFOBT though ("immunochemical"), not the legacy gFOBT type. Preferably with two test fields - Hb and Hb/Hp (hemoglobin and hemoglobin/haptoglobin complex) - for that extra bit of sensitivity: https://europepmc.org/articles/PMC4927976/table/tab3/
Just buying a couple of those tests (they're cheap!) instead of going through the gatekeepers makes it practical to repeat them over the course of a few days, increasing the chance to catch intermittent bleeding. Obviously go to a doctor if there's any positive result at all.
In colonoscopy, the prep is the worst part if you do it with sedation. The prep is just unpleasant because you spend so much time on the toilet.
For myself and many others, it's not really about the pain (supposedly there is little to none), it's just the unsettling thought of that scope so far up one's...
I was sedated with Propofol and that seemed to be routine in the facility I went to. It was a white fluid that came in through an IV. I remember saying to the nurse as I saw the propfol going in "that tingles..." and she said "that's normal", but it seemed to me that she said her answer before I finished saying "tingles", then a herringbone pattern visual from my tightly shut eyes, then nothing, and I woke as I was being wheeled out to the recovery area and felt no grogginess at all, seemed that only a couple seconds had elapsed from the time I saw the propfol (it was 20 minutes). Powerful drug.
I had Propofol last Friday. I don't even remember going out. I climbed into the surgical seat, moved my limbs to where they could be tied down, while I joked with the nurses and anesthesiologist.
more likely you carried on a conversation you don’t remember. I came out of a procedure and the doctor came out afterward to talk about the results and mentioned things I had absolutely no memory of telling him!
I didn't find it unsettling but I got over body modesty issues a long time ago due to ill health, I'm just a machine for carrying a brain around and they are mechanics.
The last one the doc doing the colonoscopy was training (under supervision) and kept not making the turn, that was somewhat painful but generally yeah they aren't very painful (for me, ymmv etc).
I’m the only person I’ve ever met in the US who did a colonoscopy without any sedation. It was a little uncomfortable the same way bad cramps are uncomfortable, but great being able to go on with my day.
The nurses were very uncomfortable with the whole thing, the doctor had to come in and assure them it was fine. Since it was preventative I didn’t save any money by forgoing anesthesia (I HATE anesthesia, and my mother had had psychotic episodes after coming out of anesthesia, so I’m cautious). The whole procedure was fast and it was interesting to be awake.
They didn't really push one or the other here (UK), they just offered both and explained with one it's 10 minutes in recovery and I'm on my way, with the other I'd need to wait for longer and have someone pick me up and with me.
I had just happened to read that a high percentage of Europeans do it without sedation, which is where I got the idea. Anesthesia is something I avoid as much as I possibly can. I wish now that I’d pushed more to get the endoscopy I had recently done without being completely knocked out, although the doctor (a different doctor) seemed a lot more resistant to that.
Endoscopy without anything but the throat spray was fine, the dry heaving isn’t awesome but unlike the endoscopy not eating the day before is no real challenge.
I asked the gastroenterologist at my last procedure. He said some people find it painful when the doctor moves the camera around. My overall impression was that it's more for the doctor's convenience than the patient's; the doctor wants to work fast and efficiently without having to deal with the patient's immediate comfort.
I've had sedation for previous ones but plan to ask for the gas next time. I always felt dopey for a long time after and worry about long-term effects.
My doctor requested that I get a diagnostic colonoscopy. Because I needed one under my insurance plan I had to pay the full cost, over $3k. If I didn't need one it would be a "screening" colonoscopy, and covered in full by the insurance.
Under what logic does that make sense, that you get insurance coverage for a procedure but only if you don't really need it? Does it work like that anywhere outside of the U.S.?
The colonoscopy was completely clear. Two years later I was having constipation and bloating problems and went to a gastroenterologist. He examined me, asked a bunch of questions, and I asked for his advice. He said he really couldn't tell me anything ... without a colonoscopy. The two year old one didn't tell him enough, he said.
Now I'm supposed to drop another $3k, very likely for another clear test result, just to hear what the doctor says I should do about my constipation and bloating?
It felt like a scam. Instead of getting advice from a specialist M.D. I was driven to get it from the internet. And dang if it didn't work. I went on a low-residue diet that resolved my digestive problems almost immediately and has had numerous other benefits. My diabetes is in complete remission, I've lost weight, etc. But when I asked the gastroenterologist if diet changes would help, his answer was short and simple: "No."
So I'm very happy to see far less expensive alternatives. One less leverage point for the health care system to empty my wallet.
Your doctor is not good at his job or he doesn't like you. Filling out codes so that insurance pays for things is a skill that good doctors develop rapidly. The proper codes can also change rapidly, and often there is no easy way to find out what price a procedure is or how much insurance will pay for a particular code. MDs do usually have a hand up on others in figuring this out because healthcare and insurance companies will return their calls. (They also discuss it among themselves)
If you are not an MD it may take 3-4weeks to find out what a code costs and what coverage will be. They'll call you about the single code and coverage that you requested, when they get around to it. However, if they have mis-billed you (eg 45min for a 15min visit) then you can get them to reverse and rebill the procedure. Personal experience.
I would agree he isn't good at his job based on what you said, but also not even considering your diet. I've had stomach issues for a lot of my life, and my doctor was very good about asking my questions, and helping me figure out what might help me, including diet changes.
I think it's safe to say that whenever there is a policy that requires professionals to be less-than-truthful to get the outcome they want, probably the system needs to be considered for reform.
To answer your question : No, this shouldn't be a part of an MD (or their paperwork writing partners in the office) job.
In the U.S. do I personally seek MDs that excel at writing insurance codes? You bet I do.
It's important to achieve any decent level of personal care without breaking the bank -- keeping in mind that i'm not particularly wealthy.
I live in Finland but am lucky enough to have access to private health care through my employer's insurance. (private health care often works faster and the queues are shorter.)
The MDs will in fact help structure your treatment such that the insurance covers it, though I don't think that includes outright lying. It's also admittedly less of a necessity because the prices aren't ridiculous.
>Your doctor is not good at his job or he doesn't like you. Filling out codes so that insurance pays for things is a skill that good doctors develop rapidly.
My Doctor is great, and has zero skill w/r to filling out codes for insurance purposes. Socialized medicine for the win.
> My doctor requested that I get a diagnostic colonoscopy. Because I needed one under my insurance plan I had to pay the full cost, over $3k. If I didn't need one it would be a "screening" colonoscopy, and covered in full by the insurance.
A similar, but at least nowhere near as expensive, gotcha in many US insurance plans happens with annual checkups. Many plans fully cover an annual check up with no deductible or co-pay.
But during that checkup if you mention some issue that the doctor does not specifically find or ask about as part of the standard checkup, you might find that your insurance company counts that visit as a diagnostic visit or a treatment visit, not a checkup visit, and you pay the normal office visit deductible or co-pay.
If you ask something that takes significant time for the doctor to deal with that might make sense, but I’ve read of it happening for things like you tell the doctor that you get sore wrists after a full day on the keyboard and the doctor spends a minute telling you about taking breaks and giving you some ergonomics tips.
> Under what logic does that make sense, that you get insurance coverage for a procedure but only if you don't really need it? Does it work like that anywhere outside of the U.S.?
A screening procedure is considered preventive. Obamacare requires preventive care to be 100% covered. Before that, your plan might have also charged for preventive procedures.
The test in the article screens for colon cancer, which is one of many reasons to have a colonoscopy. It sounds like the GI doctors you consulted performed colonoscopies to assess the cause of your digestive symptoms by looking at your GI tract. The test in the article could not replace that.
Most gastroenterologists are like that. You want a diagnosis then you need a very recent colonoscopy. And that's a quick $1000+ hour for them, of which they will do many in a given week. But what else can they do?
It's possible that his "No." was a hard answer to whether diet changes would affect your symptoms in general, but it's also possible that it's was a response in the context of whether it would help the things that he would find on a colonoscopy. If possible I would ask him to clarify.
Some doctors I've been to assume that I've already tried simple things to help with whatever issues I've had, and that is sometimes an inaccurate assumption.
An employer can pay for medical checkups (which can run up to many ££££ full body medicals and scans - the works) without any tax implications for the employee or the business, but not for similar things being done as 'treatment' for something (unless it relates to an issue caused by or within the employment itself, like if you crushed an arm in a warehouse accident, say).
I live Serbia, to use Trump's words - in a "shithole country" (and I fully admit it is :-( ). I've never had a colonoscopy but I had a gastroscopy two months ago and it was fully covered by our single payer insurance.
At the same time a friend of mine needed to have a gastroscopy and a colonoscopy. He decided to go the private route and also chose a full anesthesia. That costed him 30.000 serbian dinars (~255 euros).
So it seems to me that you could buy a return plane ticket to Serbia, stay here for a few days, do a colonoscopy here and it would still cost less than what you need to pay there.
The thing is, American healthcare prices are horribly overblown. IDK why, maybe the need for malpractice insurance in a litiguous society, but I am always shocked when I learn how much do relatively routine things (LASIK, uncomplicated birth) cost in the USA. Usually at least ten times as much as in Europe.
It’s a complex question but the problem is that _everyone_ that points out one reason or another is usually right - we disagree upon which factor is the biggest. Malpractice, bloated administrations in insurance and hospitals (just like our educational and corporate systems), a dysfunctional market leading to profiteering, bad / outdated regulations, Medicare being unable to negotiate costs, bad patient health across the country, and so forth. What I will argue against is that we have the best healthcare - maybe only if you exclude the outcomes for our poor, but even the outcomes for our wealthy are no better than the middle class in other developed Western countries.
LASIK is generally a few hundred dollars per eye. Is it really $50 in Europe?
As far as births, the lifetime cost of the injuries that do happen are built into the price. Maybe not a good system, but it's clear enough where the money goes.
Haha, nope ! As a convenience procedure, and as such exposed to liability risks, and because of the extremely high cost of the lasers, you'll have to pay 2-3000 euros for both eyes (in France, at least). It is in fact cheaper in the US.
However, I'm always surprised by the cost of health in the US. The most surprising thing is that it looks like most Americans seem to not realize that it is perfectly possible to have high quality medicine and well payed doctors if the insurances don't suck all the money between the healthcare system and the patient. Our system has flaws, sure, but the US system looks like crazy to me.
I underwent LASIK in 2002. At that time, it cost me about 1000 USD here in Czechia. On American web discussions, mostly quoted amounts were USD 5-7000.
American health care prices are a constant series of traps. If you are not careful, the insurance won't pay, or the hospital will out of network doctors or they will run tests you don't need or want. And pretty much everything is way overpriced without the patient having a realistic chance to determine the fair price. All in the pursuit of sucking more money out of you.
And it's almost impossible to avoid these traps. It's basically a gamble every time.
The system is so convoluted that nobody knows where the money is going. Every player can point their finger at someone else and say: "Those people are gouging you." But every player has an investment stake in the other players[0]. It means, when it comes right down to it, they're all gouging us.
[0] For instance I read that the majority of stock in malpractice insurance companies is held by doctors.
One reason for this is the artificially limited supply of doctors. The AMA combined with the government keeps the number of doctors down by keeping the number of medical schools and medical residencies low, driving up prices.
Yeah, health insurance is interesting over here. I've been fortunate and never had many problems with health insurance. Once or twice we got a surprise bill because a doctor deceptively ordered a test that our insurance wouldn't cover, and we had to pay the full cost (probably 1-2K). In one instance, we explained the issue to the company that produced the test and they comped it to us (and somehow the cost counted toward our deductible, which was really nice). Anyway, IIRC, there's legislation to make this kind of deceptive practice illegal (doctors can't refer you out of network or order tests without your explicit approval), but I might be misremembering.
None of the above is to make any sort of political point. I still want universal healthcare. Too many people aren't insured or are under insured and it's far too easy for hospitals and insurance companies to screw you and leave you with no recourse, especially if you're already vulnerable. There was a time when I was undecided on the issue, but it seems like every country that has universal healthcare really likes it even if some of them complain endlessly that their healthcare system is a financial black hole (e.g., my UK friends complaining about NHS always getting more money and yet the quality of care doesn't improve perceptively--although that was a pre-COVID sentiment).
I also know American friends who have flown to India to have lasik and paid full price for a reputable Indian doctor to perform it because all-in it was cheaper than paying for it domestically (it's possible that their insurance didn't cover lasik? I'm not really sure how that worked out).
There are two things that UKans seem to consistently complain about with respect to NHS: taxes and queues. You don’t have to pay for individual procedures but you have to wait for them because the politicians don’t necessarily take enough of the tax paid in and apply it to care.
The gist is that they found a significantly higher false positive rate - probably between 2.4x higher and 4.8x higher - and in absolute terms, a meaningful FP rate (15% without or 25% with other abnormalities):
> Among 3946 participants, 704 (17.8%) showed positive FIT results and 1303 (33.0%) had hemorrhoids. Of the 704 participants with positive FIT results, 165 had advanced colorectal neoplasia (ACRN) and 539 had no ACRN (FP results). Of the 1303 participants with hemorrhoids, 291 showed FP results, of whom 81 showed FP results because of hemorrhoids only. Participants with hemorrhoids had a higher rate of FP results than those without hemorrhoids (291/1176, 24.7% vs. 248/2361, 10.5%; p<0.001). Additionally, the participants with hemorrhoids as the only abnormality had a higher rate of FP results than those experiencing no such abnormalities (81/531, 15.3% vs. 38/1173, 3.2%; p<0.001).
Also, everything is different for a patient than a population. If a patient has reasonable expectations (ie, that a positive result could easily be false, and is nowhere near conclusive), and they would otherwise obtain a colonoscopy rather than putting it off, then by far the bigger concern is false negatives. That is, if you can take a FIT (or two a few months apart) and skip a colonoscopy based on negative results, the false positive rate doesn't matter much - you're replacing something annoying with something not at all annoying. I couldn't find any good studies of false negatives.
After reading this stuff, the one thing I wouldn't do is completely replace colonoscopies in favor of FIT.
Just as I thought: A test that bases its effectiveness on occult fecal blood will obviously stumble around the very common phenomenon of hemorrhoids, and only a colonoscopy can clarify better. On the other hand, if no blood is detected, there still exists the possibility of polyps or tumor growth which have not recently or yet started to release blood, making this test more than a bit unreliable as a measure of something that could be life or death.
Just finished a checkup with my Doctor who told me I'm likely to have a FIT at 45 rather than colonoscopy at 50. They've wanted to lower the screening age for a while, but the resources just aren't there to do colonoscopies on everyone 45+.
Naming the product "Cologuard" was a great opportunity squandered.
I can't wait until the people who spent their formative years sharing shock images on IRC and calling people nasty things on 4chan and don't get offended easily (i.e. the people who graduated high-school after the internet became common but before "real name" social media became common) are old enough to be the ones calling the shots in the workplace. We're already starting to see the effect in low stakes and low formality area, e.g. Wendy's twitter account but it hasn't really taken off yet.
The rubrics you describe basically cover a whole spectrum of people who also fit into the millennial category, and in my experience they're among the most easily, absurdly offended and politically correct people in modern society... I have more hope for younger generations than them.
My understanding has always been that colonoscopy is long proven to be one of the highest benefit ratio procedures in all of medicine. Let me see if there's a solid source for that... OK, here's the American College of Surgeons fact sheet - https://www.facs.org/~/media/files/education/patient%20ed/co...
Unambiguously stating that up to 90% of polyps or the tumors they grow into can be detected and removed. Also that lifetime risk of these cancers is 4.5%, versus a low risk of complications from the procedure. Compare to much lower detection rates for non-invasive procedures, and note that a positive from a FIT or FOBT will get you a referral for... a colonoscopy.
I don't have any expertise here, only marginal interest, and hoping like hell that it always stays that way. But it's not comforting to read that the odds of a serious horror show are higher than flipping a coin and getting heads 5 times in a row. Seems unlikely but do you want to bet your life on it?
Also not comforting to see the low rate of detection for the lab tests. FOBT misses 2 to 4 out of 10. FIT misses 97% of advanced cancer? That must be a typo. Checking... "FIT has been extensively evaluated for screening, with sensitivity estimates of a single low-threshold FIT for CRC approaching 90%." (https://gut.bmj.com/content/68/9/1642) But of course, that's once you have something that bleeds. The scope finds those earlier.
All very unnerving. A lot depends on the goal: catch your own cancer early, which suggests getting a scope early, or increase detection broadly among a population, which suggests focusing on easy-to-take tests that more people complete.
The goal is longer survial or more disability-adjusted life years. The sources as far as I see do not really tell us much better we do with a colonoscopy every 10 years for a total of 3 times in your life than without.
Huge disclaimer: I don't know much of anything more about this than I've already said herein, but the basic info seems fairly easy to find and parse.
- A colonoscopy will detect *most* precursor or active anomalies.
- A FIT or FOBT will detect *many* active anomalies once they are bad enough to start releasing traces of blood.
What's plain from even a quick read of the info out there is that national health systems and big insurers can't afford to do colonoscopies on everyone, so they have a huge interest in these lower cost lab tests. If enough people take them, then the headline can be "we caught more cancer earlier, and helped a lot of people". But "helped" means things like surviving a few years, which, thanks, but that's not the same as surviving full stop.
As an individual, a lab test is way better than nothing, but if your health system or insurance will cover the cost, or if you can afford to pay for it out of pocket, then a colonoscopy will reveal most problems, even fairly early and small ones, and give the surgeon a chance to snip out polyps and such right then and there. If the scope comes back reasonably clear, you can be 10 years until the next one.
Keep in mind there is a low risk of "serious complications" (one paper concludes ~2.8 per 1000) or death (~0.34 per 1000) from the colonoscopy procedure. If you'd like to have nightmares about it, source is https://www.giejournal.org/article/S0016-5107(11)01965-1/pdf
Please, anyone, correct me if anything there isn't a fair generalization.
> Compared with no endoscopic screening, receipt of a screening colonoscopy was associated with a 67% reduction in the risk of death from any colorectal cancer (adjusted OR (aOR)=0.33, 95% CI 0.21 to 0.52). By cancer location, screening colonoscopy was associated with a 65% reduction in risk of death for right-colon cancers (aOR=0.35, CI 0.18 to 0.65) and a 75% reduction for left-colon/rectal cancers (aOR=0.25, CI 0.12 to 0.53).
My impression is that colonoscopy is less controversial than other forms of screening, even among people who tend to see cancer screening very critical.
I think that one advantage is that the procedure it's not only for screening but preventive. They use it for, at the same time they are checking for problems, remove polyps, that can be precursors of cancer.
Unrelated side note: I did this all during the US election week, so that was a fun few days of stress and weirdness!