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Health & Medicine for Senior Citizens

Virtual Colonoscopies Suitable for Senior Citizens, Mayo Clinic Research Shows

No sedation needed for virtual colonoscopy, but requires same dreaded cleansing as standard colonoscopy - see video

Virtual colonoscopy image of the inside of a colon. The red colored area indicates a polyp. Image courtesy of Dr. Ronald M. Summers, Diagnostic Radiology Department, Clinical Center, National Institutes of Health.

Polyp (red) seen in colon with virtual colonoscopy.

Feb. 23, 2012 - There is good news for the millions of older Americans who have developed a dread for a colonoscopy. A new study, led by a physician from Mayo Clinic in Arizona, shows that virtual colonoscopy - less invasive than the regular kind, isn't just for younger people anymore. The American College of Radiology Imaging Network study published in Radiology now indicates that virtual colonoscopy is comparable to standard colonoscopy for people better than 65 years old.

 

Related Archive Stories

 
 

Removal of Polyps by Colonoscopy Cuts Colon Cancer Deaths in Half

Removal of these lesions resulted in a 53 percent reduction in colorectal cancer mortality: Memorial Sloan-Kettering Cancer Center - see video, Medicare coverage, about colonoscopy

Feb. 23, 2012


 
 

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Colonoscopy is commonly performed for early detection of colon cancer in people over 50 years old. In the standard procedure, a long, flexible tube is used to view the lining of the colon. After prepping to cleanse the colon, the patient is sedated for the procedure and then generally goes home to rest for the remainder of the day.

Virtual colonoscopy, known more formally as computerized tomographic CT colonography, uses advanced imaging software to produce a three-dimensional view of the entire colon and rectum. The virtual colonoscopy procedure involves insertion of a small enema tip into the rectum, accompanied by carbon dioxide gas to inflate the colon. No sedation is required. The procedure requires the same cleansing preparation as standard colonoscopy.

A Mayo Clinic study published in the New England Journal of Medicine in 2008 indicated that virtual colonoscopy is as good as standard colonoscopy, but the performance in medicare age patients was not specifically analyzed. Questions lingered by some about the effectiveness of virtual colonoscopies in older people because of the increased occurrence of colon polyps. In the new study, data from the 2008 research study was used to evaluate the performance of CTC in patients over age 65 compared to those age 50-65. The study found no statistical significant difference in CTC effectiveness between the two patient groups.

Much more information below news story on virtual colonoscopy,  Medicare coverage, and colorectal screening.

Virtual colonoscopy was found to be highly accurate for detection of intermediate (6-9 mm) and large (greater than 1 cm) polyps. Because the vast majority of patients will not be found to have a polyp, no further workup is necessary. Only the 12 percent of patients identified with a polyp at CTC would need to undergo subsequent colonoscopy. As most colon cancers arise from preexisting polyps, detection and removal of these lesions holds the promise of eradicating this important health menace.

C. Daniel Johnson, M.D., Chair of the Department of Radiology at Mayo Clinic in Arizona, and coauthor of the study hopes this further validates virtual colonoscopy as a colorectal cancer screening option, and will encourage more people to be screened. "The key isn't so much the modality, the key is getting screened," Dr. Johnson says. "We hope that this additional, less-invasive option for cancer screening will lead more people to get screened and will ultimately result in fewer deaths from colorectal cancer."

Dr. Johnson added that how people get screened should be an individual decision based on discussions with their medical providers. Virtual colonoscopies may be considered for patient who:

  ● have had a difficult time with previous colonoscopy procedures

  ● are on anti-coagulant drugs

  ● have a colon obstruction

  ● are unwilling to have a standard colonoscopy.

Despite the known benefits of colorectal screening, other studies indicate that the majority of Americans age 50 and older are not being screened for the disease. Colorectal cancer is the third most frequently diagnosed cancer and the second-leading cause of cancer death in the U.S.

About Mayo Clinic

Mayo Clinic is a non-profit worldwide leader in medical care, research, and education for people from all walks of life. For more information, visit www.mayoclinic.org/about/ and www.mayoclinic.org/news .

 

Virtual Colonoscopy Identifies Large Polyps

Appeared in National Cancer Institute's Cancer Bulletin, September 23, 2008

Also in the Journals

A supplement on "Improving Delivery of Colorectal Cancer Screening in Primary Care Practice" was recently published by the journal Medical Care. The supplement consists of 22 papers from a program of research sponsored by NCI and the Agency for Healthcare Research and Quality (AHRQ) to improve the delivery, utilization, and outcomes of colorectal cancer screening in primary care practice. The supplement presents approaches to delivering colorectal cancer screening in primary care settings and evaluating screening outcomes. This initiative directly addresses efforts to improve colorectal cancer screening uptake in the United States, which remains low - at about 50 percent.

Results from the American College of Radiology Imaging Network (ACRIN) National CT Colonography Trial, published in the September 18 New England Journal of Medicine, show that computed tomography (CT) colonography - also known as virtual colonoscopy - can detect 90 percent of adenomas (noncancerous tumors that can progress to cancer) or colorectal cancers measuring 1 centimeter or more in diameter.

These results compare favorably with standard optical colonoscopy, "which misses roughly 8 to 10 percent" of lesions of this size, says Dr. Carl Jaffe, chief of the NCI Cancer Imaging Program's Diagnostic Imaging Branch.

Both CT colonography and colonoscopy can be employed to screen for precancerous polyps, the removal of which helps prevent the development of colorectal cancer. While colonoscopy uses a thin, tube-like instrument to physically examine the inside of the colon and rectum, CT colonography takes 2- or 3-dimentional pictures of the colon and rectum using a high-powered x-ray machine linked to a computer. The computed tomography technology required for CT colonography is already found in almost all hospitals, explains Dr. Jaffe.

Virtual colonoscopy image of the inside of a colon. The red colored area indicates a polyp. Image courtesy of Dr. Ronald M. Summers, Diagnostic Radiology Department, Clinical Center, National Institutes of Health.

Virtual colonoscopy image of the inside of a colon. The red colored area indicates a polyp. Image courtesy of Dr. Ronald M. Summers, Diagnostic Radiology Department, Clinical Center, National Institutes of Health.
 
"The less invasive nature of CT colonography and the low risk of procedure-related complications, as compared to colonoscopy, may be attractive to patients and may improve screening-adherence rates by addressing certain concerns of both patients and providers," state the authors.

Investigators at 15 hospitals participated in the ACRIN trial and enrolled more than 2,500 participants aged 50 or older who were scheduled for a screening colonoscopy. Participants first underwent CT colonography followed by standard colonoscopy, which was performed on the same day for 99 percent of participants.

The investigators compared results from the CT colonography exam to colonoscopy results for each patient, for the detection of lesions 5 millimeters or more in diameter, and calculated the false negative and false positive rates for CT colonography - the likelihood of missing a lesion (false negative) or falsely identifying a lesion that could not be found on follow-up colonoscopy (false positive).

While CT colonography could correctly identify 90 percent of people who had at least one polyp 10 millimeters in diameter or greater, the ability to correctly identify people who had smaller polyps was lower - down to 65 percent for polyps 5 millimeters in diameter.

A still frame of an NIH Clinical Center video, which shows a virtual colonoscopy of the rectosigmoid colon performed in a retrograde fashion. The entire video can be viewed at http://www.cc.nih.gov/drd/colonoscopy.html on the NIH Clinical Center's Web site.

A still frame of an NIH Clinical Center video, which shows a virtual colonoscopy   of the rectosigmoid colon performed in a retrograde fashion. The entire video can be viewed by clicking here to the  the NIH Clinical Center's Web site.
The significance of these smaller lesions remains under debate. "Traditionally we've said that advanced adenomas are the ones with the most potential for developing into cancer," says Dr. Barry Kramer, associate director for disease prevention at the National Institutes of Health. The risk posed by smaller polyps "is the nub of a debate that's already started and will continue between radiologists and gastroenterologists," he explains.

Some additional questions about CT colonography remain to be answered, explains Dr. Robert Fletcher, professor emeritus from Harvard Medical School, in an accompanying editorial; in particular, whether CT colongraphy may miss some flat or depressed adenomas and what cumulative radiation dose may result from exposure to regular CT scans for screening.

The difficulty with flat and depressed adenomas, says Dr. Kramer, is that "we don't really yet know their natural history. We don't know how important it is to catch every last one," he explains. Both CT colonography and colonoscopy techniques need to be refined to better detect this type of adenoma.

Dr. Jaffe does not think that the radiation exposure, which is less than a standard CT scan, will be a large concern in this population. "For people over 50, the risk becomes diminutive, and if you use newer CT techniques, you can keep the exposure relatively low," he says.

For him, the most exciting thing about CT colonography is the ability to potentially reserve colonoscopy - which is more expensive and invasive, and currently requires specialists who are in short supply in the United States - for patients who have identified polyps, "so that [gastroenterologists] can concentrate on cases that merit polyp removal," he concludes.

— Sharon Reynolds

>> Link to this Bulletin

The current U.S. Preventive Services Task Force guidelines on colorectal cancer screening are available online at http://www.ahrq.gov/clinic/uspstf/uspscolo.htm.

Medicare on Colon Cancer Screenings (Colorectal)

How often is it covered?

  • Fecal Occult Blood Test: Once every 12 months.
  • Flexible Sigmoidoscopy: Generally, once every 48 months, or 120 months after a previous screening colonoscopy for people not at high risk.
  • Screening Colonoscopy: Generally once every 120 months (once every 24 months if you're at high risk), or 48 months after a previous flexible sigmoidoscopy.
  • Barium Enema: Your doctor can decide to use this test instead of a flexible sigmoidoscopy or colonoscopy. This test is covered every 24 months if you are at high risk for colorectal cancer and every 48 months if you aren't at high risk.

You're at high risk if you have any of the following risk factors:

  • A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp (a type of polyp that could become cancerous)
  • A family history of familial adenomatous polyposis (this involves multiple adenomatous polyps, often in the hundreds, and carries a very high risk of colon cancer)
  • A family history of hereditary nonpolyposis colorectal cancer (a type of colorectal cancer that runs in families and tends to cause cancer at a relatively young age - under 45 years)
  • A personal history of adenomatous polyps
  • A personal history of colorectal cancer
  • A personal history of inflammatory bowel disease, including Crohn's Disease and ulcerative colitis

Who’s eligible?

All people with Medicare are eligible for a screening colonoscopy. All other colorectal screenings are available to people with Medicare age 50 and older.

Your costs in Original Medicare

  • You pay nothing for the fecal occult blood test. You pay nothing for the flexible sigmoidoscopy or screening colonoscopy, if your doctor accepts assignment.
  • For barium enemas, you pay 20% of the Medicare-approved amount for the doctor's services. The Part B deductible doesn't apply. If it's done in a hospital outpatient setting, you pay a copayment.

Colorectal Cancer Resources

 

Background on Colorectal Screening

By American Society for Gastrointestinal Endoscopy (ASGE)

Colorectal Cancer Screening

Facts About Colorectal Cancer
Colorectal cancer (CRC), often referred to as colon cancer, develops in the colon or the rectum (known as the large bowel or large intestine). The colon and rectum are parts of the digestive system, which is also called the gastrointestinal (GI) tract. The digestive system processes food for energy and eliminates solid waste. CRC usually develops slowly over many years. Most colorectal cancer begins as a noncancerous (benign) adenoma or polyp (abnormal growth) that develops on the lining of the colon or rectum. Polyps can be removed to significantly reduce cancer risk. Colonoscopy plays an important role in colorectal cancer prevention because precancerous polyps can be detected and removed during the same exam when they are discovered.

·        CRC is the third-leading cause of death from cancer in the United States for men and women. It is the third most commonly diagnosed cancer in the United States (excluding skin cancers).

·        More than 140,000 people in the United States are diagnosed with colorectal cancer each year, and over 50,000 die because of it annually.

·        The majority of CRC can be prevented with proper screening, early detection and removal of adenomatous polyps. Screening helps prevent CRC by finding precancerous polyps so they can be removed before they turn into cancer.

·        Only about 50 percent of adults who should have colonoscopies comply with recommended guidelines. More than 60 percent of Americans aged 50 or older, approximately 42 million people, have not utilized any screening method for CRC.

·        Exercise and eating healthy foods such as vegetables and fruits can help decrease the risk of colorectal cancer.

·        As of November 2010, there is no federal law requiring all insurers to cover the cost of preventative CRC screenings. However, the recent enactment of the Affordable Care Act requires coverage of CRC screenings for certain populations depending on individual’s insurance plan. So far only 30 states have passed laws requiring coverage for screening of CRC-a cancer causing 50,000 deaths per year. In contrast, 50 states have passed legislation requiring coverage of screening for breast cancer-a cancer causing 40,000 deaths per year. Additional efforts to improve colorectal cancer screening are needed. Medicare covers colonoscopy once every ten years for those 65 and over at average risk.

·        The incidence of CRC and the death rate from the disease has dropped for the past 15 years. Scientists believe that the decrease is probably because polyps are being found and removed by colonoscopy before becoming cancer. Also, CRC is being found earlier when it is easier to cure, and treatments for cancer once it has occurred have improved. There are approximately one million CRC survivors in the United States, and that number is growing.

·        The five-year survival rate for people with CRC discovered early is greater than 90 percent. But only 39 percent of CRCs are found at that early stage. Five-year survival rapidly declines when the cancer has spread to nearby organs or lymph nodes.

·        Individuals who have a family member (parent, brother or sister, or child) with colorectal cancer or polyps are at increased risk for developing the disease themselves and may need to undergo more aggressive screening starting at a younger age. Individuals who have more than one family member with colorectal cancer or with other types of cancers may be at even higher risk.

Symptoms of CRC
Certain symptoms might indicate this cancer:

·        blood in the stool

·        narrower than normal stools

·        unexplained abdominal pain

·        unexplained change in bowel habits

·        unexplained anemia

If you experience any of these symptoms, talk with your physician. CRC can also occur without symptoms, family history, or any predisposing conditions such as inflammatory bowel disease. When a patient is being evaluated for symptoms, this is NOT considered screening but diagnostic evaluation. The term screening is reserved for healthy, asymptomatic patients.

SCREENING RECOMMENDATIONS FOR THOSE AT AVERAGE RISK:
Beginning at age 50, both men and women at average risk for developing CRC should have a colonoscopy every 10 years. The risk of developing CRC increases with age, with more than 90 percent of cases occurring in persons aged 50 or older.

Men and women should begin screening earlier and more often if they have any of the following CRC risk factors: a family history of CRC or polyps, a known family history of inherited CRC syndromes, a personal history of CRC, or a personal history of chronic inflammatory bowel disease (ulcerative colitis or Crohn's Disease).

People with risk factors for CRC or family history of CRC should talk with a gastroenterologist about screening at an earlier age and find out how often they need to be screened. Read ASGE’s colorectal cancer screening guidelines.

There are several screening methods which have different abilities to detect or prevent CRC: stool blood test known as Fecal Occult Blood Test (FOBT) or Fecal Immunochemical Test (FIT), flexible sigmoidoscopy, colonoscopy, CT colonography, barium enema with air contrast, and stool DNA testing. Tests which mainly detect cancer include FOBT and stool DNA. Tests which mainly detect polyps or cancer include colonoscopy, flexible sigmoidoscopy, CT colonography and barium enema. Colonoscopy is considered the gold standard of colorectal cancer screening methods for its ability to view the entire colon and both detect and remove polyps during the same procedure.

Patients should speak with their physician about the screening method that is best for them. To learn more about CRC prevention and available screening options, log on to ASGE’s colorectal cancer awareness Web site www.screen4coloncancer.org.

DIET AND LIFESTYLE:
There are no foods that directly cause colorectal cancer. However, studies of different populations have identified associations that may affect your risk of developing colorectal cancer. Smoking clearly increases the risk of colorectal cancer and other cancers. Studies have shown a slight increased risk of developing colorectal cancer among individuals with higher red meat or non-dairy (meat-associated) fat intake. Studies have also shown that getting an adequate amount of calcium and vitamin D in the diet or from supplements can reduce the risk of polyps and cancer. Use of aspirin and NSAIDs (such as celecoxib and sulindac) has been proven to decrease the risk of colorectal polyps. There may be a decreased risk of colorectal cancer in patients taking aspirin. However, the use of these agents is reserved for individuals at high risk for colorectal polyps and cancer.

Ongoing studies evaluating the role of vitamins and other natural products are underway to examine their role in colorectal cancer prevention. Few studies, though, have been able to show that modifying lifestyle reduces the risk of colorectal polyps or cancer. Nonetheless, lifestyle modifications such as reducing dietary fat, increasing fruits and vegetables, ensuring adequate vitamin and micro-nutrient intake, and exercise, may improve general health.

Regardless of your dietary and lifestyle habits, screening for colorectal polyps is the key in preventing colorectal cancer.

WHAT AFRICAN-AMERICANS SHOULD KNOW ABOUT CRC:
Although all men and women are at risk for CRC, some people are at higher risk for the disease because of age, lifestyle or personal and family medical history. According to studies, African-Americans are at a higher risk for the disease than other populations. Starting at age 50, everyone should begin routine screening tests. Research shows that African-Americans are being diagnosed at a younger average age than other people. Therefore, some experts suggest that African-Americans should begin their screening at age 45.

·        The incidence of CRC is higher among African-Americans than any other population group in the United States.

·        Death rates from CRC are higher among African-Americans than any other population group in the United States.

·        There is evidence that African-Americans are less likely than Caucasians to get screening tests for CRC.

·        African-Americans are less likely than Caucasians to have colorectal polyps detected at a time when they can easily be removed.

·        African-Americans are more likely to be diagnosed with CRC in advanced stages when there are fewer treatment options available. They are less likely to live five or more years after being diagnosed with CRC than other populations.

·        There may be genetic factors that contribute to the higher incidence of CRC among some African-Americans.

·        African-American women have the same chance of getting CRC as men, and are more likely to die of CRC than are women of any other ethnic or racial group.

·        African-American patients are more likely to have polyps deeper in the colon (on the right side of the colon).

WHAT HISPANICS SHOULD KNOW ABOUT CRC:

·        Hispanic Americans are less likely to get screened for the disease than either Caucasians or African-Americans.

For more information about colorectal cancer prevention or to find a qualified doctor in your area, visit ASGE's colorectal cancer awareness Web site at www.screen4coloncancer.org

Reviewed November 2010

Click here to current version and updates.

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