Peg Bradford lost a grandmother to colon cancer, and knew her family was right when they nagged her to get checked. But she dreaded the unpleasant prep required for a colonoscopy and the slim possibility that her colon would be punctured during the procedure.
"I was a scaredy cat. I didn't want to deal with it," Bradford said. "I built my own fears up and put it off."
In December, shortly after turning 50, her South Jersey gastroenterologist discovered four polyps, fleshy growths sprouting from the walls of the colon that sometimes turn cancerous. He could remove only three. The last, a little over the diameter of a dime, was tucked in her cecum, the most distant portion of the bowel. She would need to see a specialist in Philadelphia for a second colonoscopy.
"I never expected this to happen," said Bradford, who runs a Facebook group, Steps to Good Health, that has more than 20,000 members. "I was a wreck."
Biopsies showed that all four polyps were benign, and she recovered without any problems. Bradford believes a colonoscopy was the right choice for her.
But colonoscopy - the most common and costly form of screening for colorectal cancer - isn't the only test available. It's often called the "gold standard," and generally gets more publicity in March, the month designated for colon cancer awareness.
Even so, some public health officials say it shouldn't be the preferred option. In Canada last month, an independent task force came out against routine screening colonoscopies.
In the United States, several cancer experts said more Americans likely would get screened if their doctors offered them options.
The most commonly suggested alternative: a simple take-at-home stool test that may suffice for healthy people who have no family history of the disease and aren't suffering from irritable bowel syndrome.
If done annually, fecal immunochemical tests (FIT) have a strong track record for detecting hidden blood in the stool, an early sign of malignancy. A FIT doesn't require any inconvenient, uncomfortable preparation, anesthesia, or even a visit to a doctor's office. The completed test can be mailed to a lab. If it comes back positive - about 5 percent do - a colonoscopy is recommended to investigate further.
"We haven't done a good job telling people that there are two good, viable screening processes," said Marcus Plescia, former director of the Division of Cancer Prevention and Control at the U.S. Centers for Disease Control and Prevention. "There's colonoscopy and fecal testing, and each one is a good approach."
Early detection is a key
Last year, about 133,000 Americans were diagnosed with colorectal cancer. An estimated 50,000 died.
Early detection can prevent most deaths attributable to the disease, which is the second leading cause of cancer deaths among men and women combined in the U.S. The American Cancer Society strongly recommends screening for everyone between age 50 and 75. For patients such as Bradford with a family history of the disease, the ACS recommends screening starting at age 40.
In addition to colonoscopy and FIT, the U.S. Preventive Services Task Force suggests a third option, the rarely performed sigmoidoscopy, every 10 years with a FIT test.
"There is no empiric data to suggest that any of the recommended strategies provide a greater net benefit," the independent group of experts stated in a draft of new guidelines released in 2015.
Most doctors agree that the best method is the one that gets done.
"Any form of colorectal screening that's been approved is reasonable," said Mitchell Conn, a gastroenterologist at Thomas Jefferson University. "But someone who already has symptoms needs to have a more thorough procedure to evaluate the colon."
Outside of the U.S., the fecal test is preferred. Last month, the Canadian Task Force on Preventive Health Care came out strongly against colonoscopy for routine screening, citing "the level of uncertainty over [colonoscopy's] effectiveness and harms."
The statement riled the Ontario Association of Gastroenterologists. "Colonoscopy is probably the best colon cancer screening test," the group retorted. "It's just not proven yet."
Four randomized controlled trials are underway, one in the U.S. by the Veterans Administration, but results aren't expected for several years. The USPSTF commissioned a review using existing observational data, which found all three strategies were effective and provided similar benefits.
While the jury is out, colonoscopy, as gastroenterologists are quick to point out, has its advantages. For starters, a patient needs only one every 10 years, unless polyps are found. The test, in which a thin, flexible tube is used to inspect the colon while the patient is under anesthesia, can spot most of the polyps that emerge from the colon wall or rectum, and remove them on the spot. Most will never become cancerous, but there's no way to know which will and which won't.
The procedure got a big public boost 16 years ago when TV journalist Katie Couric underwent one after her husband died of colon cancer. Still, a third of American adults have never had any kind of screening.
A campaign called "80 by 2018" aims to get 80 percent of adults screened during the next two years. The initiative is sponsored by the American Cancer Society, the CDC, and the National Colorectal Cancer Roundtable.
As Bradford's story shows, anxiety is one reason that people avoid testing.
"For some it's the ick factor; for others, it's true fear," said Richard Wender, chief cancer control officer at the American Cancer Society. "One patient asked, "Why are you sticking something where the sun don't shine when you're feeling perfectly fine?' "
Time can also be a concern. For the popular "split-dose prep," the first dose of the formula is taken at around 5 p.m. the day before the test, and can make for a sleepless night before the second dose early on the morning of the test. Patients are advised to take it easy for a day after the test, as it is done under general anesthesia. So it takes at least a day off work.
Cost is a barrier
But the biggest barrier to screening is cost, said Wender, a physician at Thomas Jefferson University Hospital who also serves as the chairman of the National Colorectal Cancer Roundtable.
Without insurance, a colonoscopy with anesthesia can run several thousand dollars.
Screening colonoscopies are covered by most private insurance plans. But once a polyp is detected and removed, the screening becomes a diagnostic procedure and costs rise.
"People face an out-of-pocket expense if they're getting a colonoscopy. They also have to take a day off from work," Wender said.
"You can afford a fecal blood test," which runs $15 to $27.
Of course, if the fecal test suggests there is a problem, you need a colonoscopy, but 95 percent of fecal tests don't indicate a need for further testing.
Some people don't know about screening because their doctors fail to recommend it, Wender said. Others think they need to get screened only if they have symptoms or have a family history of colorectal cancer.
"The majority of people who develop colorectal cancer don't have a family history," Wender said. "If you have a strong family history, screen earlier, but the absence of family history doesn't get you off the hook."
Patients should be offered a choice of screening tests after a careful discussion with their doctor, said Minhhuyen T. Nguyen, director of clinical gastroenterology at Fox Chase Cancer Center.
"Screening rates are highest when patients self-selected a screening method," she said. "If we can bring the screening rate way up, then it would be a win-win situation all around."