Colonoscopy at 45 -- Is This the Right Cut Point?

Kate Hitchcock, MD, PhD

Disclosures

June 11, 2021

This month, the US Preventive Services Task Force (USPSTF) joined the US Multi-Society Task Force on Colorectal Cancer (2017) and the American Cancer Society (2018) in recommending that routine colonoscopies begin at age 45. The current one is the decision that matters the most, because the Affordable Care Act indicates that anything recommended by the USPSTF with an A or B rating (this is a B) must be completely covered by insurance. The change was discussed in the May 18 edition of JAMA, in which the authors of the guideline paper explain that there are increasing rates of colorectal cancers in all age groups younger than 50, and that the complex models that they employed in balancing risks and benefits demonstrate that the move is justified. The discussion across news sites and social media is about the safety of these younger patients.

When it comes down to it, though, this is an insurance/societal decision. Right? It has little to do with the safety of any individual patient.

Because the best thing for individuals would be to perform screening colonoscopies on everyone age 20 and older. As explained by Dr Ng in a nice editorial in the same issue of JAMA, "The majority of young-onset colorectal cancer occurs among people aged 45 to 49, with an estimated incidence of 33.3 per 100 000 population vs 19.4, 10.8, 6.1, and 3.1 per 100 000 adults aged 40-45, 35-39, 30-34, and 25-29, respectively. Most young-onset colorectal cancer deaths also occur in patients aged 45 to 49. However, data from 1974-2013 suggest that the rate of increase in young-onset colorectal cancer is actually steepest in the very youngest patients, with colon cancer incidence increasing by 2% per year among 20- to 29-year-olds vs 1.3% among 40- to 49-year-olds and rectal cancer incidence increasing by 3.2% per year among 20- to 29-year-olds and 30- to 39-year-olds vs 2.3% among 40- to 49-year-olds." Austria, says Dr Ng, begins screening at age 40.

This is something that has bothered me for a while. My patients' families, looking on as their loved one slogs through cancer treatment, ask me, "When should we get our first colonoscopy?" Speaking doctor to patient, my truthful answer should be, "NOW!" Speaking as a steward of our national health resources, my answer would be, "At the age recommended for your risk group." To some extent, I'm supposed to be both of those things, but the answers do not, and cannot, match.

One could argue that "as soon as possible" is not correct, because there is some risk associated with the procedure itself. Anesthesia complications are rare but exist. False-positive findings lead to unnecessary stress and expense. Although rare in the hands of an experienced endoscopist, injury to the bowel can occur. So, for example, getting a colonoscopy every year from an early age, while being the best chance to remove polyps before malignant transformation, would result in a real risk for harm. Even that risk, though, would be very low.

In this article about the new decision, the models tell us that lowering the starting age to 45 means about 475 additional lifetime colonoscopies per 1000 people, and about one additional complication. If you're that one person, that's bad for you. But some people are going to gain 25 life-years from that activity, they say. That's a lot of birthdays and meals with the family and tax paying to weigh against a single complication. So why wasn't the decision made sooner?

Well, here comes the dollar. Because 475 colonoscopies aren't cheap in this country. How very not cheap they are is cleverly hidden behind the smoke and mirrors of the current medical billing system which makes relativistic physics look like a lovely afternoon idyll. In a great article on the subject in The New York Times, Elisabeth Rosenthal says, "[A] gastroenterologist, assisted by an anesthesiologist and a nurse, performed the routine cancer screening procedure in less than an hour. The test, which found nothing worrisome, racked up what is likely her most expensive medical bill of the year: $6,385." Other patients she interviewed in other cities were billed $6385, $7563.56, $9142.84, and $19,438, this last amount including removal of a single precancerous polyp. "While their insurers negotiated down the price, the final tab for each test was more than $3,500."

~475 x ~$9000 = a heck of a lot of money. Whose pocket will supply it?

And yet, how important is that money compared with 25 life-years?

Difficult questions that by and large are taken out of my hands in the US by our nation's employer-driven health insurance system. My real answer to the patients' families is, "Insurance won't pay for it until..." Those prices being what they are, that's the end of the discussion.

How do you handle the question "When should I start getting [any expensive screening exam]" when it's your patient who is asking?

What about when it's your family member?

Here's an additional article on the hidden costs of colonoscopies.

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About Dr Kate Hitchcock
Kate Hitchcock, MD, PhD, is a radiation oncologist, biomedical engineer, and retired aircraft carrier driver who grew up as a Wyoming cowgirl. When she is not at the hospital, you can find her with Carolyn, Mary, Tyler, Nick, Marlee, and Colby the barking dog, enjoying the natural splendor of the great state of Florida. She thinks you should visit sometime and try to solve the puzzle of why the natives have so carefully shunted all of the tourists toward the House of Mouse. Connect with her on Twitter: @hitchcock_kate

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