When Katie Couric, then-host of NBC’s Today show, let the cameras roll while doctors probed her colon during her nationally televised colonoscopy in March 2000, a perfect storm was brewing. In this case, it was a storm that has been good news for Americans and the physicians who treat colon cancer, the second leading cause of death from cancer in the United States. Colonoscopies are considered the gold standard for physicians to detect and remove growths on the colon wall, called polyps, which can turn into cancer.

“There is no debate on this,” says Dr. Manish M. Chokshi, a gastroenterologist and assistant chair of the Endoscopy Department at The Christ Hospital. “This is the best method. And this is one test where it is not just screening; it’s prevention,” says Dr. Chokshi, who is a member of the Greater Cincinnati Gastroenterology Association (soon to be Ohio Gastroenterolgy and Liver Institute).

Couric’s broadcast came the same month as the first National Colorectal Cancer Awareness Month, as declared by the U.S. Senate, and just as Medicare was considering expanding its reimbursement policy for colonoscopies. Medicare soon came through, deciding in 2001 to cover colonoscopy screenings for individuals. Since 1998, the procedures had only been covered for those at increased risk for colon cancer.
 
Medicare’s decision, plus the awareness that Couric and the colon health month created, led to never-before-seen numbers of people getting screened. Private insurers followed suit, and now most of them cover the procedure.
A Life-Saving Procedure

A colonoscopy is a procedure whereby a gastroenterologist examines the colon with a colonoscope, a long, thin, flexible tube with a tiny video camera and a light on the end. The physician guides the colonoscope through the colon, which is about five-feet long and stores unabsorbed food products prior to elimination. The camera attached to the instrument projects a high-resolution image onto a television monitor, and the physician is able to vigilantly check for suspicious-looking polyps. The abnormal growths on the inside lining of the intestine can be painlessly removed with an instrument passed through the colonoscope. This procedure is called a polypectomy.

The polyps are then sent for testing to see if they’re malignant. Some polyps are harmless, but others are dangerous. “It’s a process,” says Dr. Allen Peck, a gastroenterologist with Gastroenterology Associates of Greater Cincinnati. “A polyp will start out as a small seed and turn into a colon cancer. Most colon cancers take some time to grow.” Catching it early is critical: Colon cancer will cause an estimated 57,000 deaths in the United States this year. But it’s 90 percent curable when it’s caught in the early polyp stage. Death rates go up precipitously the later it’s caught, as it spreads to the lymph nodes and liver. It’s difficult to tell by looking at a polyp which ones are dangerous, so removing them while they’re still small eliminates their threat.

The American Cancer Society recommends that men and women have colorectal cancer screening beginning at age 50, and follow up every three years, or as a doctor recommends or depending on the test results. Patients with a strong family history of colorectal cancer or polyps should be screened earlier and more often. African-Americans should be screened beginning at age 45 because of the high incidence of colorectal cancer in that population, according to Chokshi.

The awareness that Couric created has saved lives, doctors say. Judy Staley, manager of the endoscopy department at Bethesda North Hospital, has seen the change first hand at her office, which schedules 40 to 70 patients a day. “We do more colonoscopies now than anything,” she says. “The word is out that this is the gold standard, and apparently a lot of referring doctors in Cincinnati are passing that along to their patients.”

A study published in 2003 in the Archives of Internal Medicine found that colonoscopy rates across the nation increased more than 20 percent after Couric’s exam. Other studies, including one published in the Journal of the American Medical Association (JAMA) in December, found that the agreement by Medicare to cover colonoscopies had a major impact, as well, in getting people screened.

In the world of medical screening, 20 percent is such a large number that researchers have dubbed the increase as the “Couric Effect.” 
  
Some Still Avoid Diagnostic Exams

But "The Couric Effect" hasn’t been a magic bullet. It’s estimated that only 53 percent of Americans over the age of 50 have been screened. Most insurance companies pay for the procedure, Peck says, and all do if a patient has what’s called “alarm symptoms” such as bleeding from the bowel, weight loss, abdominal bleeding, rectal pain, or a change in bowel habits.

So why are nearly half of those who should be screened avoiding it? It’s not because the procedure itself is painful, according to specialists. In fact, patients are in a conscious sedation during the colonoscopy, and a medication is used that has a mild amnesiac effect. So they don’t feel it, and they often don’t remember it, either. “When we’re done, I’ve had people ask when we’re going to get started,” Peck comments.
Staley adds that once the 45-minute procedure is done, patients are generally ready to go home within an hour. It’s recommended that they don’t do anything that requires mental alertness, like driving, for the rest of the day. Other than cramping caused by air put in the colon during the procedure, most people have few — if any — complications.

But the myth that the procedure is painful has endured, Peck mentions. “From a modesty and squeamishness standpoint, it’s uncomfortable,” Peck says. “But not from a physical standpoint.” The prep can be inconvenient, though. The night before a colonoscopy, a patient must adhere to a liquid diet and drink a solution that forces them to spend an inordinate amount of time in the bathroom to clear the bowels. “That’s the biggest complaint we get in terms of the process,” Peck adds.

That probably has something to do with the avoidance. But what’s probably keeping many people away is the fact that the procedure requires that someone insert an instrument in a place that is, well, somewhere that’s generally kept private. The experts understand that reluctance. Peck says it’s important for primary care physicians to push patients to get their colonoscopy. “They need to make it known that it’s important to do this.”

Of those who do have the procedure, about half are found to have polyps, according to Chokshi. He calls patients often to deliver the news, always telling them it’s a good thing they came in when they did. “You came in, we found it, and you will not get colon cancer,” he says.
There are other tests often done for colon problems, including a fecal occult blood test used to detect blood in stool, and a sigmoidoscopy, done with an instrument used to screen the lower part of the large bowel only. The colonoscope is long enough to inspect all of the large bowel and part of the small intestine.

Just as the number of colonoscopies have increased, the number of people diagnosed with colon cancer has decreased. A recent study, Chokshi reports, found that overall cancer death rates have decreased nationally, with the drop in colon cancer being the biggest contributing factor.

Virtual Screening an Option
 
Non-invasive virtual colonoscopies, using a CT scanner and computer graphic software to view the bowel, are the cutting edge of cancer screening, but they probably won’t altogether replace conventional colonoscopies anytime soon.

Unlike a conventional colonoscopy, where a physician guides a thin instrument equipped with a tiny camera through the colon, virtual colonoscopy is not invasive. It does not require sedation or a scope. But it’s not completely free of discomfort.

Patients still have to do the same prep as they do for a conventional colonoscopy, says Dr. Allen Peck, a gastroenterologist with Gastroenterology Associates of Greater Cincinnati. That means they must ingest a solution that cleans out their bowel the night before. “That’s the part of the colonoscopy that most people complain about,” Peck says. They’re sedated for a conventional colonoscopy and hardly remember the procedure itself.

And while virtual colonoscopies are considered highly accurate, there’s some question whether the virtual exam can pick up the smallest of polyps that a colonoscopy can spot. If one is seen in a virtual colonoscopy, it can only be removed with an actual colonoscopy — so about half of all screened patients who have polyps have to undergo the conventional colonoscopy anyway.

But that doesn’t mean there isn’t an important place for virtual screening. It makes sense for people who are fearful of sedation, for instance, or have less time to devote to the screening. The virtual procedure takes a bit less time. “And there is, obviously, no question of complications from anesthesia,” Peck says. The virtual procedure, which could run about $800, isn’t covered by insurance, while the conventional method is.
“There is definitely a need for it,” Peck adds. “But I’m not sure it’s right for all cases.”