Kirstie Alley’s untimely death highlights the importance of colon screening

Actress Kirstie Alley’s death recently from colon cancer brought attention to the disease and the importance of screening. Alley died at the age of 71 after recently learning she had a late stage of the disease, her children and manager reported.

Colon cancer kills more than 52,000 people every year, according to the American Cancer Society. Many could be prevented, because it is one of the few cancers for which there are numerous screening methods.

But, even though screening is available, not everyone avails themselves of it. Roughly 40 percent of Americans who are eligible for a colonoscopy do not actually get one, often because they don’t want one.

“There are a lot of reasons people don’t get screened,” said cancer specialist and surgeon Peter Hopewood, MD, FACS, of Cape Cod Surgeons in Falmouth.

The most common reasons, according to Dr. Hopewood, are:

• They don’t think they need to get screened because they have not been educated about the benefits.
• They know they should get screened but think it’s not necessary because no one in their family has ever had colon cancer. Dr. Hopewood calls these people “the unworried well.”
• Their healthcare providers have not recommended it.
• They are underinsured. Under the Affordable Care Act, all screening colonoscopies should be covered but not everyone is signed up for insurance and there are complications in billing if a polyp is actually found.
• They can’t afford it because they can’t miss work.
• They’ve had a family member who had a complication and they are frightened of the procedure.
• They are scared of doctors and don’t trust the healthcare system.

Screening rates also depend on what part of the country you live in, Dr. Hopewood said. New England has the highest rates, with an average of about 75 percent of the population getting screened by at least one method. The states with the lowest rates of screening are mostly in the western part of the country.

“Actually, Barnstable County and Middlesex County have the highest rates for screening in Massachusetts, with 74 percent or greater,” he said. “The lowest rates in the state are Nantucket, and Bristol and Berkshire Counties. They are under 60 percent. So, we’re pretty good, but there are pockets that might be lower because with an average of 74 percent, that means that some areas could be 85 percent and other areas are 45 percent.”

Colonoscopy Still Golden

A colonoscopy has always been considered the gold standard for screening. In 2000, the American Cancer Society estimated that if 80 percent of the population got colonoscopies by the year 2020, by 2040 we would prevent more than 20,000 cancer deaths and 40,000 cancer cases. It takes time to achieve these benefits, Dr. Hopewood said.

The current guidelines for someone with no family history or risk factors are to get a colonoscopy screening beginning at age 45 instead of 50 and then every 10 years until 75. After 75, additional screenings may be recommended by your physician.

But in recent years, there has been some controversy about how necessary colonoscopies are, in light of the newer and less invasive screening tools like the fecal immunochemical test (FIT test) and the DNA FIT test Cologuard. A study recently published in the New England Journal of Medicine, called the Northern-European Initiative on Colon Cancer (NordICC), suggested the benefits of a colonoscopy may be overestimated.

The study included more than 84,000 men and women ages 55 to 64 from Poland, Norway and Sweden. None had ever had a colonoscopy. The participants were randomly invited to get a colonoscopy screening. Forty-two percent agreed to the screening. Both groups were followed for 10 years. The end result was that participants who got the procedure had an 18 percent lower risk of getting colorectal cancer, but there was no significant reduction in the risk of death.

The results were slightly better when researchers restricted the results to just those who had a colonoscopy, but the benefits were still much lower than the researchers expected when they began the study.

“The best colon cancer screening is basically any colon cancer screening,” Dr. Hopewood said. “That includes a stool test for blood, a stool test for blood and any DNA changes, a flexible sigmoidoscopy scope or a colonoscopy.”

Colonoscopies do have a few advantages, according to Dr. Hopewood. A colonoscopy not only detects cancer, but it also allows the physician to remove any precancerous polyps before they can develop into colon cancer. Plus, a colonoscopy is 100 percent effective at detecting colon cancer.

A FIT test that detects blood in the stool is about 70 percent effective, he said. It needs to be repeated every year but it is inexpensive and can be done in the privacy of your own home. You simply collect a stool sample and mail it to a lab. A FIT DNA test like Cologuard uses a similar procedure. It looks for high-risk genetic mutations and blood in the stool and should be repeated every three years. The effectiveness of that test is in the high 80s, Dr. Hopewood said.

“If you have a positive stool test for either blood or blood with DNA mutations, then you need to move forward and get the full colonoscopy,” Dr. Hopewood said.

At that point it would be a diagnostic colonoscopy, not a screening colonoscopy. The other reason someone might need a diagnostic colonoscopy is if they were having symptoms of colon cancer. Symptoms include:

• Abdominal cramps
• Change in the bowels
• Blood in the bowels
• A bowel blockage
• Weight loss

A screening colonoscopy is covered by insurance, while a diagnostic colonoscopy may not be completely covered.

There is also a problem with insurance coverage if a doctor does find polyps during a screening colonoscopy. The doctor removes them, which is great, but it then becomes a diagnostic colonoscopy and the patient may end up with surprise bills for the procedure, the doctor, the anesthesiologist and the pathologist. Dr. Hopewood regularly meets with our representatives and senators on Capitol Hill to discuss the importance of passing laws to eliminate these surprise bills.

Early Detection is Crucial

Ultimately, the most important thing about colon cancer screening is detecting cancer at an early stage. Cape Cod Healthcare’s rate of diagnosing of colon cancer is very similar to both the state and national average. In 2020, 27 percent of patients had metastatic colon cancer at diagnosis and another 23 percent had node positive or stage three colon cancer, which is also considered advanced colon cancer. Fifty percent were caught at earlier stages.

“We want to catch it at that early stage, so you don’t need chemo and you’re less likely to die of it,” Dr. Hopewood said. “That’s where the colonoscopies make all of the difference, but any screening is better than no screening.”