The items glide slowly toward checkout. To the keen observer, your destiny is clear: green Jell-O, chicken broth, lemon Crystal Light, white grape juice, lemons and limes, yellow popsicles, soothing "personal care" wipes and a large package of toilet paper. No red, blue or purple food. This can only mean one thing. Someone is having a colonoscopy.
It's a process, and a not altogether pleasant one. You have to adjust your diet for a couple of days. Only clear liquids and nothing purple, red or blue to eat the day before. You may have to set up camp in the bathroom once you've started the bowel-cleansing regimen; this ensures doctors get a clear view of the rectum and large intestine so they can see any polyps, or growths, that may eventually change into cancer — they'll be removed during the colonoscopy.
But really, the procedure has evolved over the years and isn't that bad anymore, despite what you may have heard or been through 10 years ago. Take it from Dr. Laura Arline, who had her first colonoscopy last September at age 41. She started screening earlier than the recommended age of 50 because of a strong family history of colon cancer and other bowel disorders. "The prep was easy: just two cups of liquid with the medication. One taken the day before, one taken the day of the procedure," said Arline, an internal medicine specialist with BayCare Medical Group.
Note that she didn't have to drink gallons of a horrible solution, just two cups, plus whatever she needed to stay hydrated. The solution wasn't salty, slimy, thick or bad-tasting, either. "It was sweet," she said. "A normal liquid consistency."
The anesthesia has changed, too, so you aren't knocked out for the whole day. "Most anesthesiologists now offer a quick-on, quick-off medication that you wake up from almost right after the procedure," said Arline, now 42 and the mother of two. "Of course you need someone to drive you home from the procedure, but I was home playing with my kids that afternoon."
Because of her family history and high-risk status, she'll have to repeat the procedure in five years. But people of average risk won't have to do it again for 10 years. "It's a small inconvenience for the prevention of colon cancer as far as I'm concerned," Arline said.
Despite the changes, according to the Centers for Disease Control and Prevention about a quarter of eligible adults have never been screened for colon cancer. Some are just afraid of medical procedures. Some are squeamish about the prep. Others have heard about the rare risk of complications, such as accidental perforation or tearing of the colon. Still others may not have the luxury of insurance coverage for the procedure (although a 2013 CDC report found that 76 percent of never-tested adults were insured), or the copays are too high. There are lots of reasons for not having a colonoscopy. That's why many doctors are relieved to be able to offer an alternative to certain patients.
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Several colon cancer screening tests are on the market now that can be completed in the comfort and privacy of your home ... bathroom, that is. They don't require any bowel prep and there's no need to take time off from work. You may have to avoid certain foods or medications for a few days and you'll have to set aside some time to collect a stool sample. Ew. Yes, you will have to do that. With a gloved hand and a little plastic probe included in the kit, it's not that bad.
"These stool tests have value, but they are detecting cancer, not polyps. They will find cancer after it has already developed," said Dr. Jorge Marcet, director of the Division of Colon and Rectal Surgery at the USF Morsani College of Medicine. "Colonoscopy is still best because it prevents cancer. We find and remove polyps with colonoscopy. But if you have no symptoms, one of these (take-home) tests is better than no test."
Colorectal cancers and, less often, polyps can bleed, and you may or may not be able to see the blood after a bowel movement. These tests look for any blood in the stool; one also looks for altered DNA. They range in price from less than $50 to more than $500.
The guaiac fecal occult blood test uses a chemical to detect heme, a hemoglobin blood protein, in the stool. But it can also detect heme found in red meat, so you have to be very careful not to eat beef, lamb and certain other meats before
taking the test. It's done once a year.
The FIT test uses antibodies to detect human hemoglobin specifically, so you don't have to restrict your diet for this test. It's also done annually.
Dr. Pushpak Taunk, an assistant professor of medicine and director of the Advanced Endoscopy Fellowship at the USF Morsani College of Medicine, said he typically recommends the FIT test for patients of average risk with no symptoms if they have refused a colonoscopy. "Most insurance companies will cover the cost of the FIT kit and lab testing and we see about 80 to 90 percent follow-through with patients because it's easy to use," said Taunk, noting that when a colonoscopy has been recommended "follow-through is in the 60 percent range."
Cologuard is the only DNA-based test currently FDA approved. It looks for blood and altered DNA cells in the stool, cells shed by cancerous growths in the rectum and lining of the colon. It is more expensive than the other two tests but is usually covered by insurance. It requires a doctor's prescription, patients must collect a stool sample and the completed kit is shipped by the patient to a lab for analysis. Like the other tests, Cologuard is done once a year, although some patients may do it every three years.
All three take-home tests have a certain percentage of false positives, a result that suggests something might be wrong when it's not. If you do get a positive test result your doctor will recommend a colonoscopy.
"All roads lead to colonoscopy," said Arline, who also is medical director of clinical quality for BayCare Medical Group. "If anything is abnormal, you will still need a colonoscopy, so you might as well start there. I always recommend colonoscopy first."
The take-home tests are recommended for people with no symptoms of colon cancer who aren't considered at high risk for the disease. So, someone with no outward signs of colon cancer, including: no persistent unexplained abdominal pain, no visible blood in the toilet or stool, no change in bowel habits, no unexplained weight loss or fatigue. If your take-home test comes back positive and a colonoscopy confirms cancer, there's still reason to be optimistic. "Then you very likely have an early-stage colon cancer and things are probably going to be okay," said Marcet, a 26-year colon and rectal surgeon whose practice is based at Tampa General Hospital. It's later-stage colon cancers that tend to produce symptoms.
Still, he adds, if the patient had started with a colonoscopy, the growth most likely would have been found before it ever became cancer.
Contact Irene Maher at firstname.lastname@example.org.