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The overuse of screening colonoscopy

Posted by medconsumers on August 24, 2011

After an all-clear, no-polyps screening colonoscopy, there is no need to undergo another one for at least ten years. This is the standard recommendation for all people over age 50 from organizations like the American Cancer Society. A new study, however, found a large portion of the Medicare enrollees with no sign of colon cancer on the screening colonoscopy are coming back too soon for another one. The perils of doing so include the risk of perforated colon, biopsy-related infection and other serious complications thought to occur more often in older people. That the repeat procedure is unnecessary means symptom-free elderly people are putting themselves at risk for no apparent benefit.

Virtually all colon cancer screening research concentrates on the underuse of colonoscopy, specifically by the uninsured and the minority populations who do not undergo screening colonoscopies in large numbers. The new study, led by James S. Goodwin, MD, and colleagues at the University of Texas, made the rare decision to look at overuse.

It is based on a random sample (5%) of over 24,000 Medicare beneficiaries whose records showed they had a negative screening colonoscopy. The Medicare claims database showed that a sizable minority underwent a repeat procedure prematurely. In people, aged 75 to 79 years, or 80 years or older at the time of the initial negative screening colonoscopy result, 47% and 33%, respectively, received a repeated examination within 7 years. This study was published recently in Archives of Internal Medicine as part of its excellent ongoing “Less is more” series.

Keep in mind that people over the age of 75 are underrepresented in screening studies so the risk of complications cannot be quantified with accuracy. This is part of the reason why the U.S. Preventive Services Task Force advises people to stop screening colonoscopy entirely at age 75 click here.

Dr. Goodwin and colleagues explained the implications of overuse: “First, screening colonoscopy can have adverse effects, including hospitalization and death. Too frequent performance of the examination may shift the benefit to risk ratio by increasing complications without additional benefit. Second, colonoscopy screening is costly; it is important to restrain expenditures for unnecessary procedures. Third, colonoscopy is a limited resource, in terms of facilities and practitioners. Identifying and decreasing overuse of screening colonoscopy should free up resources to increase appropriate colonoscopy in inadequately screened populations.”

In an e-mail message, Dr. Goodwin was asked to elaborate. “The point about screening is that you have to look at the effect on a population. If you harm more people in a population than you help, then screening is a bad idea. Almost all authorities think that to be the case with early repeat colonoscopies,” he wrote, in response.  “You also have to remember that the overwhelming majority of people are neither helped nor harmed. Since your lifetime chance of getting colon cancer is only about 5%, then for 95% of the population screening colonoscopies were unnecessary. It would be nice if we could identify that 5%, but we can’t. But we can certainly work harder to restrict colonoscopy to those who at least MIGHT benefit (i.e., not those with a normal one in past 10 years).”

Added June 28, 2012: Want to make a truly informed decision prior to a screening colonoscopy?  Read this excellent article from  Its anonymous author provides an insider’s look at the downsides of screening colonoscopy, rarely explained to the people about to undergo this procedure.

Maryann Napoli, Center for Medical Consumers©

Related articles: “How accurate are colonoscopies?” and “Best way to screen for colon cancer?”  and this (apparently, you’re never too old or too debilitated for a screening test) “Screening right to the grave”.

7 Responses to “The overuse of screening colonoscopy”

  1. Anne P. said

    The colonoscopy article from Salon you posted a link to is terrific! The article really hit home because of two personal reasons/experiences:

    1) I had cataract surgery last fall and found that for me versed is truly a “date rape” drug in that I was fully conscious and much more terrified than before taking the drug but also pretty much immobilized. Fortunately I discovered this on cataract surgery not at a colonoscopy or something. The surgery was not painful and my surgeon conducted himself in an excellent way both during the first surgery (when he did not know I was aware) and during the second one when I refused versed/midazolam and he did know. But the first surgery was a bad experience and after that I learned of all the people who have had a variety of bad experiences with midazolam – the “vast rage on the internet” the article referred to. (I also checked a number of books on sedation meant for medical personnel and found these common experiences are by and large NOT mentioned when training medical people, which is deplorable.)

    2) This spring, my ex-sister-in-law who lives alone and had done the prep for a diagnostic colonoscopy because of some problems arrived and had engaged a taxi driver to take her both to and from the surgical center, he had said fine if she might need some help when he picked her up. When they found out it was not a relative they absolutely refused to sedate her and since she had done the bowel prep she did go forward with the procedure. She found herself in extremely acute pain, she said she could barely restrain herself from screaming. She confronted the GI specialist immediately afterward about the cruelty and he said not one word in reply or apology but left the room. Later when she talked to her general doctor, the doctor says she has several patients who simply cannot and do not get colonoscopies because of the rigid rules and they are alone without family or friends to escort them. My kind ex-sister-in-law offered to provide transport and claim to be a friend or relative, but this does not solve the general problem of colonoscopists and their rigid and inappropriate rules.

  2. Anonymous said

    Subscriber in SF: All my MDs (oncologist, gyn, internist) agree that I should continue with colonoscopies every five years because I had breast cancer. (I’m over 75)

    Any comment?

    • We do not know of any studies that show colonoscopy screening saves lives for people over age 75 whether they have breast cancer or not. Ask your doctors to provide citations for their advice.

  3. Bonnie Bernstein said

    Is more frequent testing called for if one has Crohn’s disease and a family history of stomach cancer?

  4. Bonnie Loewenstein said

    This is important information, but it doesn’t tell me whether getting an all-clear, no-polyps result means it’s appropriate to wait ten years even if one has a significant family history of colon cancer. In other words, does the normal result supersede the family risk factor in importance?

    • Your question was e-mailed to Dr. James Goodwin for reply. Here is his answer: “If a first degree relative (parent, children, sibling) has been diagnosed with colon cancer (real colon cancer – not a polyp) then some authorities recommend screening colonoscopy every five years, even with negative results.”

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