Dr. Edward Pensa specializes in gastroenterology at University Gastroenterology in Providence, where he routinely sees patients with colon issues. He discusses a campaign that the practice has launched in order to inform patients on how best to use over-the-counter cancer screening products.
PBN: University Gastroenterology says it recently launched an information campaign to spread the word about a potential misuse of a colon cancer screening test. Please explain a little bit about the campaign.
PENSA: This campaign is an effort to educate patients about the appropriate use, benefits and limitations of the Cologuard stool test for colorectal cancer screening. This is a test approved only for use in average-risk patients, meaning individuals without a close relative with colon cancer or a prior history of precancerous polyps. It is quite effective in detecting colon cancer but far less effective in detecting precancerous polyps, suggesting that it will be less helpful in preventing the onset of colon cancer than colonoscopy.
As the use of Cologuard has become more prevalent, we at University Gastroenterology have seen many patients who have undergone stool testing with Cologuard who either did not meet the criteria for its use or had not been educated about the limitations of the test with regard to the detection of precancerous polyps. This educational campaign was initiated in an attempt to provide further information to patients and providers in our community.
PBN: How do you respond to the argument that gastroenterologists don’t like alternatives to colonoscopies because it cuts into their business?
PENSA: There is a tremendous unmet need with regard to colorectal cancer screening with current national screening rates of only 60-65% of the population. Any advances in testing modalities, which can increase the number of patients screened, would be welcomed by most gastroenterologists.
In fact, since many of the patients who have Cologuard testing were previously declining screening and about 1 in 6 patients have a positive Cologuard test – for which a subsequent colonoscopy is recommended, increased use of noninvasive testing such as Cologuard may ultimately lead to increased numbers of colonoscopies being performed.
Ultimately, our goal as physicians is to provide the best care possible to patients and that includes allowing patients and their families to make informed decisions about their care.
PBN: Is there any current debate on best practice when it comes to colon cancer screening for typical patients?
PENSA: We as physicians strive to improve and optimize the ability to provide good quality care to our patients. This struggle will naturally lead to debate, as all approaches have their pros and cons.
Currently, there are multiple debates with regards to colon cancer screening. Two of the more prominent ones are the age that we screen patients and the method we use.
Age of screening: Most societies currently recommend starting screening for colon cancer at age 50 for adults at average risk for colon cancer. For some time now, it has been suggested that earlier screening at age 45 is appropriate for African American patients due to a higher incidence of colon cancer in this population.
More recently, the American Cancer Society has issued a recommendation that screening should be considered for all patients at age 45 regardless of ethnicity or gender, as colon cancer in younger patients seems to be on the rise. There is controversy regarding the evidence to support this, and so it remains to be seen whether this recommendation is more widely adopted.
In light of the fact that there are still many patients over the age of 50 who have not been screened yet, all societies promote efforts to encourage these patients to pursue screening.
Method of screening: Currently colonoscopy remains the gold standard of screening for colon cancer, as it offers both the ability to detect precancerous polyps and to remove them. But for multiple reasons, this test may not be acceptable or appropriate for everyone.
As the number of screening options grows, so does the debate about which test is best. It is important for patients to discuss options with their physicians to help them arrive at a decision that addresses their needs most completely. It is likewise important to educate primary care physicians about the relative benefits and drawbacks of each screening option, so they can better guide their patients.
PBN: Do you find that advertising campaigns often persuade patients to ask for medicines or tests that may not be beneficial to them or are not intended for their specific needs?
PENSA: Yes. Direct-to-patient marketing has been shown to be very persuasive and increase sales of medications and testing. Unfortunately, the limited time allotted in a radio or television ad often does not allow for a detailed discussion of the risks, benefits and appropriate use of testing. With respect to Cologuard testing, this can have significant implications for patient care. For example, a negative test in a high-risk patient may provide false reassurance and prevent that patient from seeking further testing.
PBN: Do you foresee an effective alternative to an invasive colon cancer screening hitting the market anytime soon?
PENSA: There are a number of alternatives being studied, although no single effective test appears ready for the marketplace in the very near future. Possibilities include advances in stool testing to allow for better detection of precancerous polyps, blood tests to assess for serum markers associated with colon polyps/cancer and capsule endoscopy whereby a pill camera is used to visualize the colon. Colonoscopy will remain a critical part of the screening process, however, as patients with positive noninvasive tests will require colonoscopy for removal of colon polyps.
Elizabeth Graham is a PBN staff writer. She can be reached at Graham@PBN.com.
