It’s exceedingly uncommon for a healthy middle-aged man to walk into his doctor’s office and demand a colonoscopy. But even though he lacked a family history, Stanley Thornton, an African-American engineer who was then in his mid-40s, wouldn’t take no for an answer.
“I was concerned that African Americans do get colorectal cancer earlier, and I said, ‘hey, let me lead by example,’” he said. “We argued about it for a month or two. He felt I should wait until I was 50.”
Eventually, Thornton got the test, and was found to be clear of cancer. He describes the “prep” – the liquid that he had to drink to clean out his intestines the night before the procedure – as “not the nicest thing in the world” – and said he was apprehensive as his wife drove him to his appointment that morning, since he didn’t know what to expect. But he said the only uncomfortable part of the test, in which a doctor put a thin tube up his rectum in order to inspect his large intestine, was when the nurse inserted an intravenous needle to give him a sedative. “All I remember is talking and then being wheeled back to the room.”
Colorectal cancer is the second leading cause of cancer death in the United States, after lung cancer. It’s one of the easiest cancers to detect early, since it usually begins as a growth called a polyp that grows silently for many years before spreading into the body. Screening people between the ages of 50 and 75 for colorectal cancer is so effective at preventing deaths that the United States Preventive Services Task Force (USPSTF) gives it an “A” rating, higher than its ratings for breast and prostate cancer screening.
People who have a family history or medical condition that increase their risk of colorectal cancer usually need to start getting colonoscopies before age 50. One doctors’ group, the American College of Gastroenterology, recommends that black men start getting colonoscopies at age 45, because they are at higher risk of being diagnosed with colorectal cancer after it’s already spread (and is thus more difficult to treat), and dying of the disease.
A colonoscopy is considered the “gold standard” screening test for colorectal cancer, since it’s the best at detecting pre-cancerous changes and since it’s the only test in which the doctor can remove the polyp right away. But it can be expensive (running anywhere from $500 to $3,000 if you’re paying out of pocket) and has some small risks, such as perforating the colon (which occurs in fewer than 1 out of 100 people) and bleeding, which is more of a risk if you are on a medicine that interferes with clotting.
For most people, the most bothersome thing about a colonoscopy is the “prep,” or strong laxative that they must use to clean out their colon in advance of the test. Colonoscopies need to be done in a closely monitored environment, since they require that the person receive a sedative. If the first screening colonoscopy doesn’t show anything abnormal, most “average risk” people can wait 10 years before repeating the test.
Many, if not most, insurance plans cover screening colonoscopy in people 50 and older. But what if you lack insurance, have a plan that doesn’t cover it, are at high risk for a complication, or simply can’t stand the thought of the test? The USPSTF says it’s also OK to screen “average risk” people with fecal occult blood tests, which look for blood that’s concealed in the stool. This test is a lot less expensive (usually costing under $20 if you are paying out of pocket; many insurance plans will cover it), but it must be repeated every year to be most effective at catching colorectal cancer early. To do the fecal occult blood test correctly, you have to take home three cards on which you will smear your stool after three different bowel movements. The doctor’s office or lab will then put a chemical on the cards to detect any blood that might be hidden in the stool. You should also be aware that simply having your stool smeared on a single card (which doctors sometimes do as part of an office rectal exam) is not an adequate screening test for colorectal cancer.
The USPSTF also says it’s acceptable to do a flexible sigmoidoscopy every five years as a screening test. This test is similar to a colonoscopy, except that the tube the doctor uses is shorter, so that he or she can only see the lower part of the large intestine, and might miss a cancer that’s higher up. It’s often done in combination with the fecal occult blood test, in order to pick up more cancers. It doesn’t require sedation and is less expensive, usually running less than $300 if you are paying the full cost
Keep in mind that if your fecal occult blood test or flexible sigmoidoscopy show anything concerning for cancer, you’ll need to undergo a full colonoscopy, so that the doctor can look more thoroughly and remove any suspicious tissue for additional tests. Also, even if you’ve had a clean colonoscopy within the past 10 years, you may need to repeat the test if you notice blood or other changes in your stool – so don’t ignore such symptoms.
In recent years, many doctors have been offering their patients a slightly easier colonoscopy prep, involving either a smaller amount of liquid laxative than in the past, or laxative pills instead. It’s important to drink plenty of water and/or clear fluids on the day before the test, to keep yourself hydrated. (Avoid anything red or pink, though). Some people also suggest putting yellow lemonade Crystal Light powder in the liquid prep and refrigerating it for a day to make it a bit more palatable. If you have a history of kidney problems, tell your doctor, since there are certain types of preps that you may need to avoid.
Thornton, who is now in his 50s, underwent a second screening colonoscopy recently, and said the prep was “much cleaner and nicer.”
Many of my patients want to get a colonoscopy, but simply can’t afford the upfront costs. The U.S. Centers for Disease Control and Prevention funds some limited programs (http://wwwtest.cdc.gov/cancer/crccp/about.htm) to screen low-income people for colorectal cancer. New York City has a relatively generous colonoscopy screening program for people who lack insurance.
Thornton, who is active in the American Cancer Society, urges everyone 50 and older with financial access to a colonoscopy to get the test.
“The ‘big C’ is something we don’t like to talk about in the black community, but we need to take charge of our health and get it done,” he said. “Anything short of that, we’re shortchanging ourselves.”