The Dreaded Turning-50 Test => One of the joys of turning 50 is that your doctor will start recommending a colonoscopy. Many people dread the test, which involves having a tube inserted into the rectum to look for cancers and precancers. Even so, acceptance has grown tremendously. In 2010, 55 percent of Americans ages 50 to 65 had been tested, nearly three times the rate in 2000, and the figure was even higher, 64 percent, in people over 65. All that screening seems to be paying off: The incidence of colon cancer in people over 50 has dropped 30 percent in the last 10 years, and deaths have also declined, according to a report published last week by the American Cancer Society. Good news, but not good enough, experts say. Too many people are still dying: 50,310 expected this year, along with 136,830 new cases. Incidence and death rates are significantly higher in blacks than in whites, for reasons that are not fully understood. More poverty among blacks appears to account for some of the difference, but not all. This is a disease that can often be cured if it is found early. It is also one of the few types of cancer that can be prevented, by using colonoscopy to find and remove abnormal growths, called adenomatous polyps, which can turn cancerous. Experts can detect about 95 percent of cancers and large polyps with a colonoscopy, but smaller polyps are more easily missed. Many of the deaths occur in patients who were not tested, according to the cancer society, which estimates that about 23 million people ages 50 to 75 are not up to date on screening. One problem: A colonoscopy is expensive, costing hundreds or thousands of dollars, depending on whether polyps are removed and in what part of the country it is done. Medicare and some other insurers pay in full for the exam, but not for polyp removal. Patients sometimes receive an unexpected bill for hundreds of dollars or more. A colonoscopy also requires time off from work and a regimen of strong laxatives, and the procedure poses small but real risks of bleeding or injury to the intestine. For all of its perceived drawbacks, a colonoscopy at least does not have to be done very often — once every 10 years for most people if no polyps are found. Those with polyps or other risk factors are usually advised to have the test done more often. There are other screening tests, which look for blood in the stool or examine the lower part of the intestine. But many people dislike them because they require handling stool samples or having instruments poked into the rectum. And the stool tests must be done once a year, a schedule that many people fail to follow. But doctors keep hoping that if more methods become available, more people will find a screening test they can tolerate. Last week, a study of a new type of stool test was published in The New England Journal of Medicine. The test, Cologuard, checks DNA from intestinal cells that have been shed into the stool and looks for alterations that may signal cancer. If abnormalities are found, the patient is told to have a colonoscopy. The goal of the study was to compare the DNA method with an existing test for blood in the stool, called the fecal immunochemical test, or FIT. Nearly 10,000 people at average risk for colon cancer had the two tests, and then underwent a colonoscopy. Then the two stool tests were measured against colonoscopy. Colonoscopy found 65 cancers, and the DNA test detected 92 percent of the 65. The DNA test also detected 42 percent of the 757 potentially precancerous polyps that colonoscopy found. The older stool test, FIT, did not perform as well, detecting 74 percent of the cancers and 24 percent of the polyps. But the DNA test had more false-positive results than the other stool test: 13 percent, compared with 5 percent for the FIT, meaning that 13 percent of healthy patients would get a false alarm and be urged to have colonoscopy. Unlike the current stool test, which uses a brush to collect a tiny bit of stool from the toilet, the DNA test requires that patients send an entire bowel movement (but no more than 300 grams, or two-thirds of a pound) to a laboratory. The test kit includes a quart-size container with a bracket that holds it just below the opening in a toilet seat. “You can’t miss,” said Kevin Conroy, the president of Exact Sciences, which makes Cologuard. The test is not available yet, but an advisory panel of the Food and Drug Administration is expected to review it this week and vote on whether to recommend approving it. The panel will also consider a blood test that can detect about 70 percent of colon cancers. A final decision from the federal agency will come later. Dr. Robert A. Smith, senior director for cancer control at the American Cancer Society, said the group thinks a DNA stool test is a good idea because people need all the options they can get. The cancer society and other health groups announced a campaign last week to increase the screening rate in people over 50 to 80 percent by 2018, and Dr. Smith said he thought a new type of test could help. But Dr. David A. Rothenberger, chairman of the department of surgery at the University of Minnesota, had concerns about the DNA test finding only 42 percent of polyps. The great advantage of colonoscopy, he said, was its ability to prevent cancer entirely by finding these growths so that they could be removed. Sometimes a test’s overall detection rate can be increased if it is done often — say, once a year, which is recommended for the standard stool tests. But the optimal test interval for Cologuard is not clear. Its price has not been set, either, but could be about $500, Mr. Conroy said. The standard FIT costs about $25. Even if the new test is approved, it will not replace colonoscopy or even the existing stool test, which people may prefer because it is cheaper and requires a much smaller sample. Anyone with a positive finding on the DNA test will still be urged to have a colonoscopy. And a colonoscopy will still be recommended for people at high risk because of family history or their own history of polyps or other problems, Dr. Smith said. -- NYTimes*
Posted on: Tue, 25 Mar 2014 20:12:31 +0000
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