Bill Fullington doesn't remember exactly where he read that all adults over age 50 should be screened for colon cancer. A magazine? Maybe the local paper?
In any case, Mr. Fullington, a retired teacher in Birmingham, Ala., takes excellent care of his health; he never smoked, doesn't drink, hits the gym daily. "Everybody thinks I'm 30 years younger than I am, because of my zip," Mr. Fullington said in an interview. So he dutifully arranged to have a colonoscopy in 2008, when he was 80.
The doctor removed two small polyps — "the size of BBs," Mr. Fullington said — and sent him home to recover. The next day, "I woke up screaming in pain."
At the emergency room at Brookwood Medical Center, tests showed that the procedure had perforated his colon. Mr. Fullington underwent a colostomy and spent a week in intensive care — and that was just the beginning.
March is Colorectal Cancer Awareness Month, so you may be reading and hearing a lot about the importance of screening. You may even get to walk through the eight-foot-high inflatable simulated colon that makes appearances around the country — and see what polyps look like from the inside. But you may not hear much about when colon cancer screening should stop.
Even the Fight Colorectal Cancer Web site, from the major advocacy group working to make Americans aware of the disease and its prevention, says that all adults over age 50 should be screened. "Don't wait. Talk to your doctor," it urges.
But in 2008, just a few months after Mr. Fullington's colonoscopy, the United States Preventive Services Task Force reviewed years of research andrecommended against routine screening for colorectal cancer in adults over age 75 and against any screening in those over 85.
Let's be clear: Screening those over age 50, the group most at risk, makes complete sense. Removing the polyps that may become cancerous years later (but also may not) can prevent the disease. But while colonoscopy is underused by the poor and uninsured, it's overused by the elderly.
Dr. James Goodwin, a geriatrician at the University of Texas Medical Branch in Galveston, has led much of the overtesting research. In 2011, using a 5 percent national sample of Medicare beneficiaries, his team showed that older people underwent colonoscopies too often. Medical guidelines call for a repeat test 10 years after the first negative colonoscopy, but their study found that nearly half of patients with negative colonoscopies had another in less than seven years, often within three or five. About a quarter took place without any clear medical indication.
Now, using Medicare data for every patient over age 70 who had a screening colonoscopy in Texas in 2008 or 2009, Dr. Goodwin and company have found that 23 percent were "potentially inappropriate" because the patients were over age 75 or because they had a repeat screening too soon after the last one for no clear medical reason. The study appeared on Monday in the journal JAMA Internal Medicine.
Gastroenterologists more likely to perform inappropriate colonoscopies were older, male, graduates of United States rather than overseas medical schools, and working in high-volume practices. "There are these factories that do colonoscopies on everyone they see," Dr. Goodwin said.
Why not screen everyone? Because, he explained, at older ages the benefits diminish. "It's difficult to have this conversation, to say, 'You don't need this because you're not going to live long enough to benefit,'" he acknowledged. But colon cancer develops slowly, and in the many years it takes for small polyps to evolve into cancer, if they do, most old people will have died of other diseases.
Meanwhile, the risks increase. Mr. Fullington, who'd lost 30 pounds, returned to the hospital two months after his perforation to have his colostomy reversed. Discharged, he developed a painful "crimp" in the stomach. Doctors call it ileus, and it's not uncommon after bowel surgery at older ages.
He returned to the hospital, where the ileus uncrimped without further surgery. But trying to get to the bathroom, "I sat up and went headfirst onto the floor," Mr. Fullington said. Bloodied and bruised, he needed head X-rays and stitches.
He's fine today, happily. And complications like his are very rare.
But, Dr. Goodwin noted, for older patients the prep for the colonoscopy itself can cause weeks of cycling between diarrhea and constipation. "It's not death, it's not hospitalization, but it's feeling sick and humiliated and helpless," he said. "That is a big price."
Yet public health campaigns have done such a persuasive job that some people, data to the contrary notwithstanding, believe they need routine mammograms and Pap smears and colonoscopies forever. As another study in this week's JAMA Internal Medicine shows, older adults may feel "a strong moral obligation" to continue testing and are skeptical of government panels and statistics telling them to stop.
Bill Fullington, however, vows he'll never have another colonoscopy. And at 85, he's not a candidate for one. "This whole thing would've killed 9 out of 10 80-year-olds," he said. "I'm one tough nut."
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