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2003-12-08 -- Long Wait for Colonoscopy in ... the US

A news story you'll never read:

"The famed Ambassador Bridge connecting Detroit, Michigan and Windsor,
Canada was jammed for twelve hours yesterday, as thousands of US
seniors streamed into Canada to avoid months-long waits for a
life-saving screening procedure for colon cancer .  The cacophony of
blasting car horns could be heard from both shores, as .... "


New York Times, December 8, 2003

50 and Ready for a Colonoscopy?
Doctors Say Wait Is Often Long

By GINA KOLATA

Doctors in many parts of the country say the demand for colonoscopies
to screen for colon cancer has surged so much in recent years that
patients are having to wait months or are simply being turned away.

The colonoscopy is widely viewed as the most accurate screening test,
but it is also the most expensive and risky, and there are other ways
to screen for colon cancer. But while most professional organizations
say the choice of a test should be up to the patient, fewer Americans
are choosing the other options, which include flexible sigmoidoscopy,
fecal occult blood tests and barium enemas. Regular screening is
recommended for everyone 50 and over, once a year to once a decade,
depending on the patient and the procedure.

Colonoscopy "has become a fashion," said Dr. Daniel Sulmasy, an
ethicist and internist at St. Vincent's Hospital in New York, adding,
"All these other options just drop off the radar screen."

Doctors attribute the soaring popularity of colonoscopies to several
factors. There was Medicare's decision in 2001 to pay for
colonoscopies for screening healthy people. There was an influential
editorial published in 2000 in The New England Journal of Medicine
disparaging the sigmoidoscopy as "a suboptimal approach." And there
was what many call the Katie Couric effect - the publicity Ms. Couric
received in 2000 with her televised colonoscopy.

As a result, while most medical procedures in this country are
abundantly available, this $2,000 test is entering the realm of
rationing.

"It's a real concern," said Dr. John H. Bond, who is chief of
gastroenterology at the Veterans Affairs Medical Center in
Minneapolis. Healthy patients at the center cannot have colonoscopies
because the waiting lists are closed, he said.

"It's fine to say everyone should have a colonoscopy," Dr. Bond said.
"But we are talking about 70 million people. It is unclear whether
that is even feasible in the United States."

While healthy people are unlikely to be harmed by waiting, doctors say
many just do not show up when the long-scheduled day finally arrives.

"If you're urging people to be screened and then you say, O.K., the
colonoscopy will be a year from now, you shoot yourself in the foot,"
said Dr. Robert H. Fletcher, a professor of ambulatory care and
prevention at Harvard Medical School. "The meta-message from the
health care community is, well, it's not that important after all."

Medicare data illustrate the trend, with the number of colonoscopies
among Medicare recipients increasing by 42 percent from 2000 until
2002, the most recent year for which data are available. In 2000,
Medicare paid for 2,211,925 colonoscopies; by 2002 the figure had
risen to 3,150,738. The data combine colonoscopies for screening with
those for people with symptoms; before 2001, some doctors say, doctors
encouraged patients to find symptoms like blood in the stool that
would allow them to have a colonoscopy paid for by Medicare. Yet,
doctors say, 2002 was just the start of the demand.

At the same time, the number of sigmoidoscopies, which look only at
the lower part of the colon, where most cancers occur, dropped 57
percent among Medicare recipients, to 236,139 in 2002 from 543,502 in
2000.

In 2000, Medicare paid for 1,759,880 fecal occult blood tests, a
yearly screening for blood in the stool, which can be a sign of
polyps. In 2002, the number was 1,609,391. And in 2000, there were 208
barium enemas provided to Medicare patients. In 2002, that number was
139.

The colonoscopy is widely regarded as the most accurate test because
it allows the doctor to see the entire colon and remove polyps. But it
has drawbacks. Dr. Fletcher notes that 2 patients in 1,000 have an
accidental perforation of the colon, which may necessitate immediate
major abdominal surgery. While that risk is low for an individual,
"when you start screening a nation, you put a lot of people in peril."

Moreover, colonoscopy requires an uncomfortable bowel cleansing, and
patients are almost always sedated for the procedure. Healthy patients
need a test only once a decade.

Sigmoidoscopy involves a less onerous cleansing and no sedation. But
it does not show the entire colon and should be repeated every five
years. Fecal occult blood testing must be repeated every year or two
to be sure that polyps, which periodically ooze blood, are found.

While doctors in a few places, like New York, say there are so many
specialists ready to do colonoscopies that patients rarely have to
wait, specialists elsewhere are overwhelmed. An alternative test,
so-called virtual colonoscopy, which uses C.T. scanners to look for
colon polyps, may eventually help meet the demand, medical experts
say. But the procedure is still under study, and insurers do not pay
for it.

At the Oschner Clinic in New Orleans, the number of colonoscopies
doubled in the last few years, according to Dr. David E. Beck, the
clinic's chairman of colon and rectal surgery. Now, the wait is three
months, even though the doctors increased their efficiency, getting
one patient ready while they work on another, and began working
Saturdays.

The doctors at Gastroenterology Associates in Rockford, Ill., also
added Saturday hours just for screening colonoscopies. Still, the wait
is several months. The colonoscopy boom took the Rockford doctors
aback, changing the nature of their practice, said Dr. James T.
Frakes, a gastroenterologist with the group.

"It's been huge," Dr. Frakes said. "We get several hundred colonoscopy
referrals a week."

In Chapel Hill, N.C., where the routine wait is as much as six to
eight months, Dr. Michael Pignone, an internist at the University of
North Carolina, worries about patients with potentially serious
symptoms, like blood in the stool, being put in a queue for a test. "I
go around the system," he says, calling gastroenterologists himself
for appointments.

In DeForest, Wis., 20 minutes from Madison, the waiting lists for the
colonoscopies are closed to healthy patients. Dr. Peter Pickhardt, a
family practitioner, says he has learned to be blunt with patients. "I
tell them up front," he said. "If they want a colonoscopy, it's not
available."

Still, Dr. Pickhardt says, it is the best procedure. Sigmoidoscopy
does not show the entire colon, and the fecal occult blood test has
too many false positives and false negatives.

Dr. Beck also believes that colonoscopy is best. "You visualize the
entire mucosa," he says. "If we find something, we can treat it. The
other tests don't completely examine the colon, they are not as
accurate, and if we find something, you have to have a colonoscopy."

That reasoning is persuasive, said Dr. Robert Smith, director of
screening at the American Cancer Society. Still, "we recommend and
encourage options because the public does not have universal access to
screening colonoscopy, and studies have shown that a significant
proportion of the public prefers a different test."

Dr. Pignone says that informed patients are divided on which test they
prefer. "People think they know what patients want," he said. "If you
don't ask them, you have no idea."

Dr. Sulmasy, at St. Vincent's, said informed consent should be the
rule. "Most in my practice pick stool cards," he said, adding that he
would choose that test himself when he turns 50 in three years.

Not Dr. Beck, 50, who chose a colonoscopy, without sedation. It was no
big deal, he said. "You just have to go a little slower."