Re: breast density- please! V. Interested in your learnings. I have dense breast but not sure what that means I should do for prevention tests. 🤷♀️ notified each year after my mammo about my dense breast but what next?
A couple thoughts from experience in primary care. Maybe it’s just my suburban patient population, but I feel like our colon ca screening rates (Cologuard or colonoscopy) are more like 80%. We track that and have benchmarks.
I don’t think most insurers would cover Cologuard every year. It also seems like fairly close benefits between q1 vs q3 years in that slide (?)
And adenoma detection rate does seem important, but like any quality metric leads naturally to clinicians playing the game. I wonder what your GI friend would say candidly about that. I’ll ask some of mine someday. But there are lots of risk factors for having more adenomas like obesity, high fat diet, being male, older age, previous adenomas, etc:
So there really should be some adjusted ADRates to keep comparisons fair.
And finally the US is pretty colonoscopy happy compared to Europe, where stool based testing is the norm, with pretty similar outcomes. For me, getting a baseline colonoscopy was important in case I had some polyps like ticking time bombs to remove, with follow up Cologuard or colonoscopy in the future less tilted towards the scope.
People seem to hate the prep, like the propofol 🤨, and experience a colon cleansing if framed that way…
Any metric can be gamed. But IVF metrics are reported and can be looked up, so tracking is becoming acceptable. And CMS requires it for colonoscopies now, so it's tied to funding. Data shows it is a quality metric linked with interval cancers. Just reporting what the expert said. My buddy says they take it pretty seriously.
NHS bowel cancer screening initially looked at offering everyone one flexi sigmoidoscopy and then stool screening, but the initial scope has now been removed. They are currently bringing the FIT screening down to age 50 now, from 60.
As I was saying yesterday to a new patient who's just moved here from the US (and was very unhappy that he didn't meet the NHS criteria for me to continue prescribing the meds he's been on in the US) the rationing in the US is by who has money or insurance, and what that insurance will pay for, in the UK we ration by which conditions and severity of condition merit access to particular drugs/procedures instead ...
I am not sure what the statistics are in the UK, but different countries have different rates and ages of cancer, and I am not sure how much that factors into the guidelines. But it's an interesting point if the rates are different because someone who has lived in the US and moved might have a different risk than someone who lived their whole life in the UK.
It is a very good point. He wanted obesity drugs, not screening, and for many things we have some clinical discretion - I can ask for a FIT on anyone I want to, but would have to justify a referral for a colonoscopy. But some of the guidelines do take national background and where someone's lived into consideration - being a nation richly comprised of wave after wave of immigrants ... there were 50 languages spoken by the 200 kids in my son's small primary school.
And Ryan, I agree - we're seeing the impact of rising obesity on disease incidence here too. It still shocks me to diagnose Type 2 diabetes in kids.
Doctors in my area will not order a FIT test every year, every 2 years and a colonoscopy if nothing found every 10 years. Once we get over 70 we no longer qualify unless there is a medical need. Just like hormones nope, my opinion once we are over 59 we have done what is required of us in life (a family, work etc) and then overlooked. We wait for appointments for months here and in some cases a year which means the hour glass empties and there is no more they will do to help. One GP admitted to me that this is the case.
YouTube sent me this video suggestion after I Googled colonoscopy vs FIT. Vinay Prasad MD is an oncologist and epidemiologist and he teaches med students how to evaluate research. He's been called a contrarian by other docs and I'm not savvy enough to what the deal is with that; however he's opposed to the use of therapies and tests that don't have good research behind them. He does state that he will not have any cancer screenings.
I would not recommend any advice from this person, who is profiting by being a medical contrarian. He is anti-vaccine and doesn't think COVID is a big deal. I guess all those people who died don't mean much to him.
Thanks so much for this! I was quite surprised when our medical director asked me why I was planning for a colonoscopy. I said because I was fifty (it was a few years ago); he asked whether I had risk factors or symptoms, and when I said I didn't, suggested cologuard instead. I did, and it was clear. I'll continue with this as long as it's appropriate. Invasive does not equal better in all cases!
A tad off topic but in this province women over the age of 70 do not qualify for a mammogram but can insist on an ultrasound, no colonoscopy over 70 unless there are symptoms of colon cancer (includes a FIT test). Estrogen is supposed to be colon protective yet because of the WHI everyone became terrified of any form of estrogen (including me). Women can be treated with estrogen between 50-59 then what??? all the issues of low estrogen back again and bone health, moods, skin issues, dental and the list continues all comes back and at that point not one Dr. will touch us. Menopause experts are hard to find and the wait time here is over 20 months, the clock does not stop for us but symptoms persist. Since low thyroid and menopause have the same symptoms, and even NAMS states it is difficult to determine which one is the issue, so many women who take thyroid medication assume their dose is too low (or possibily too high) and try to adjust it. Then they try to go back to estrogen and the door slams in their faces. Not a vent at all in this post, reality. We can make an informed decision to use estrogen over 60 and even 65 but who will prescribe it to us, a GP with little to no knowledge.
Thank you so much for this informative post. How do we civilians find a good operator? Just call around and ask for their adenoma stats? Is this published anywhere (like the ASRM for IVF clinics)? Asking bc I’m due for one and can’t figure this out.
As far as I can tell, they aren't publicly available, like with ASRM, which is a shame. My GI buddy said you can ask. He was quite proud of his adenoma detection rate. I might be hesitant if someone were unwilling to share.
I just went through colonoscopy prep for the second time in about 10 years. My first colonoscopy was done about 10 years ago due to a stomach issue I was experiencing. I passed out during prep but they still went forward with the procedure. I thought it was a fluke. I am now 49 and had a screening colonoscopy scheduled for last Friday. I passed out during prep again and this time hit my head so they could not do the procedure. At this point, I am paranoid about the prep. It’s apparently a vasovagal response. Sounds like FIT test may be good option.
I am "lucky" in that I had bowel problems and went for a colonoscopy, picked up several polyps including sessile serrated polyps and therefore need a repeat in a year -at age 32. Here in NZ screening starts with a FIT test at age 60, and that's a new thing. Colonoscopy isn't publicly funded for screening, so unless you have symptoms or private insurance, you're out in the cold. It's terrible! The US seems much more preventative with screening options, same goes for mammograms (from age 45, funded only every 2 years).
The new ACP guidelines recommend against stool DNA testing so my internist colleagues are avoiding Cologuard now. Apparently this is still controversial however. (And I missed this lecture at the meeting!)
It was on the slides as a valid choice, but I did mention it may have more false positives. It doesn't seem to offer any real advantage over FIT and it is more cumbersome. After watching the video on how to collect it, I'm sold that FIT is the better self collection option.
The previous test used in Canada (home test) was sent home with us from the GP now they order it and a lab mails it to us. The old test samples over three days.
another great informative post - thank you
:)
Kaiser's standard policy is Fit testing yearly with Colonoscopy when indicated by Fit results - based on your post, this seems reasonable - right?
Re: breast density- please! V. Interested in your learnings. I have dense breast but not sure what that means I should do for prevention tests. 🤷♀️ notified each year after my mammo about my dense breast but what next?
I hear you. I have dense breasts too. This was part of the aggravation as there were different opinions from speakers. But I will be getting to it.
Awesome! Thank you for your reply & I’ll keep a watch out for your future post on this👍
A couple thoughts from experience in primary care. Maybe it’s just my suburban patient population, but I feel like our colon ca screening rates (Cologuard or colonoscopy) are more like 80%. We track that and have benchmarks.
I don’t think most insurers would cover Cologuard every year. It also seems like fairly close benefits between q1 vs q3 years in that slide (?)
And adenoma detection rate does seem important, but like any quality metric leads naturally to clinicians playing the game. I wonder what your GI friend would say candidly about that. I’ll ask some of mine someday. But there are lots of risk factors for having more adenomas like obesity, high fat diet, being male, older age, previous adenomas, etc:
https://www.gutnliver.org/journal/view.html?doi=10.5009/gnl19097
So there really should be some adjusted ADRates to keep comparisons fair.
And finally the US is pretty colonoscopy happy compared to Europe, where stool based testing is the norm, with pretty similar outcomes. For me, getting a baseline colonoscopy was important in case I had some polyps like ticking time bombs to remove, with follow up Cologuard or colonoscopy in the future less tilted towards the scope.
People seem to hate the prep, like the propofol 🤨, and experience a colon cleansing if framed that way…
Any metric can be gamed. But IVF metrics are reported and can be looked up, so tracking is becoming acceptable. And CMS requires it for colonoscopies now, so it's tied to funding. Data shows it is a quality metric linked with interval cancers. Just reporting what the expert said. My buddy says they take it pretty seriously.
NHS bowel cancer screening initially looked at offering everyone one flexi sigmoidoscopy and then stool screening, but the initial scope has now been removed. They are currently bringing the FIT screening down to age 50 now, from 60.
As I was saying yesterday to a new patient who's just moved here from the US (and was very unhappy that he didn't meet the NHS criteria for me to continue prescribing the meds he's been on in the US) the rationing in the US is by who has money or insurance, and what that insurance will pay for, in the UK we ration by which conditions and severity of condition merit access to particular drugs/procedures instead ...
I am not sure what the statistics are in the UK, but different countries have different rates and ages of cancer, and I am not sure how much that factors into the guidelines. But it's an interesting point if the rates are different because someone who has lived in the US and moved might have a different risk than someone who lived their whole life in the UK.
It is a very good point. He wanted obesity drugs, not screening, and for many things we have some clinical discretion - I can ask for a FIT on anyone I want to, but would have to justify a referral for a colonoscopy. But some of the guidelines do take national background and where someone's lived into consideration - being a nation richly comprised of wave after wave of immigrants ... there were 50 languages spoken by the 200 kids in my son's small primary school.
And Ryan, I agree - we're seeing the impact of rising obesity on disease incidence here too. It still shocks me to diagnose Type 2 diabetes in kids.
True, and colon ca rates are rising here in the US for people in their 40s, I think most closely correlate with the rise in obesity
Doctors in my area will not order a FIT test every year, every 2 years and a colonoscopy if nothing found every 10 years. Once we get over 70 we no longer qualify unless there is a medical need. Just like hormones nope, my opinion once we are over 59 we have done what is required of us in life (a family, work etc) and then overlooked. We wait for appointments for months here and in some cases a year which means the hour glass empties and there is no more they will do to help. One GP admitted to me that this is the case.
YouTube sent me this video suggestion after I Googled colonoscopy vs FIT. Vinay Prasad MD is an oncologist and epidemiologist and he teaches med students how to evaluate research. He's been called a contrarian by other docs and I'm not savvy enough to what the deal is with that; however he's opposed to the use of therapies and tests that don't have good research behind them. He does state that he will not have any cancer screenings.
https://youtu.be/SMRS4-ng8T0?si=WyzHoBU6X3EBtSvR
I would not recommend any advice from this person, who is profiting by being a medical contrarian. He is anti-vaccine and doesn't think COVID is a big deal. I guess all those people who died don't mean much to him.
Thanks so much for this! I was quite surprised when our medical director asked me why I was planning for a colonoscopy. I said because I was fifty (it was a few years ago); he asked whether I had risk factors or symptoms, and when I said I didn't, suggested cologuard instead. I did, and it was clear. I'll continue with this as long as it's appropriate. Invasive does not equal better in all cases!
The data tells us that having options are good! And I was really interested in the comment about younger patients driving at-home screening.
A tad off topic but in this province women over the age of 70 do not qualify for a mammogram but can insist on an ultrasound, no colonoscopy over 70 unless there are symptoms of colon cancer (includes a FIT test). Estrogen is supposed to be colon protective yet because of the WHI everyone became terrified of any form of estrogen (including me). Women can be treated with estrogen between 50-59 then what??? all the issues of low estrogen back again and bone health, moods, skin issues, dental and the list continues all comes back and at that point not one Dr. will touch us. Menopause experts are hard to find and the wait time here is over 20 months, the clock does not stop for us but symptoms persist. Since low thyroid and menopause have the same symptoms, and even NAMS states it is difficult to determine which one is the issue, so many women who take thyroid medication assume their dose is too low (or possibily too high) and try to adjust it. Then they try to go back to estrogen and the door slams in their faces. Not a vent at all in this post, reality. We can make an informed decision to use estrogen over 60 and even 65 but who will prescribe it to us, a GP with little to no knowledge.
Thank you so much for this informative post. How do we civilians find a good operator? Just call around and ask for their adenoma stats? Is this published anywhere (like the ASRM for IVF clinics)? Asking bc I’m due for one and can’t figure this out.
As far as I can tell, they aren't publicly available, like with ASRM, which is a shame. My GI buddy said you can ask. He was quite proud of his adenoma detection rate. I might be hesitant if someone were unwilling to share.
I just went through colonoscopy prep for the second time in about 10 years. My first colonoscopy was done about 10 years ago due to a stomach issue I was experiencing. I passed out during prep but they still went forward with the procedure. I thought it was a fluke. I am now 49 and had a screening colonoscopy scheduled for last Friday. I passed out during prep again and this time hit my head so they could not do the procedure. At this point, I am paranoid about the prep. It’s apparently a vasovagal response. Sounds like FIT test may be good option.
I am here for the breast density convo!
I am "lucky" in that I had bowel problems and went for a colonoscopy, picked up several polyps including sessile serrated polyps and therefore need a repeat in a year -at age 32. Here in NZ screening starts with a FIT test at age 60, and that's a new thing. Colonoscopy isn't publicly funded for screening, so unless you have symptoms or private insurance, you're out in the cold. It's terrible! The US seems much more preventative with screening options, same goes for mammograms (from age 45, funded only every 2 years).
Symptoms are an entirely different situation; so glad that you got screened.
The new ACP guidelines recommend against stool DNA testing so my internist colleagues are avoiding Cologuard now. Apparently this is still controversial however. (And I missed this lecture at the meeting!)
It was on the slides as a valid choice, but I did mention it may have more false positives. It doesn't seem to offer any real advantage over FIT and it is more cumbersome. After watching the video on how to collect it, I'm sold that FIT is the better self collection option.
The previous test used in Canada (home test) was sent home with us from the GP now they order it and a lab mails it to us. The old test samples over three days.
Do you know anything about the update to change it back to 50?
https://www.medicalnewstoday.com/articles/colorectal-cancer-screening-can-start-at-age-50-acp-guidelines
No, the speaker had a slide with age 45 in big, bold print as the start for screening.