A new study from American Cancer Society researchers makes a revealing finding about colorectal cancer (CRC) screening that is at once good news and perhaps a bit concerning. Colorectal cancer is the third leading cause of cancer death among men and women in the U.S., but there are several options for patients to catch the cancer early and reduce death and suffering. Experts recommend beginning screening at age 50.
And while several screening options are available, recently released joint guidelines from the American Cancer Society and other groups for the first time expressed a preference for tests that detect and remove precancerous polyps. That means colonoscopy, as well as flexible sigmoidoscopy, which collectively are known as endoscopy. The other most frequently used test is a home-based one called fecal occult blood testing (FOBT), which people know more commonly as “the stool test.” It’s cheaper and non-invasive, but unlike endoscopy, which is done every 5 to 10 years, has to be done every year.
For this new study, the first of its kind, researchers led by epidemiologist Priti Bandi found that between 2000 and 2008, there was a shift in higher socioeconomic status groups from the stool test towards endoscopic screening.
But in lower socioeconomic groups (uninsured and publicly insured, those without a usual source of care, with lower education levels, less income, and immigrants to the United States), that shift was not as strong. Why? Cost was surely one factor.
“[T]he burden of cost-sharing requirements may force lower SES groups to opt for lower cost procedures, such as FOBT, versus more expensive colonoscopy screening.”
An FOBT costs about $30. A colonoscopy about $3,000. The authors point out the mixed takeaway message from this finding:
“Although, ideally, all adults should have a choice among test options, the potential to achieve high near-term rates of population CRC screening with high sensitivity stool tests in populations with less access to colonoscopy is a sensible and affordable public health strategy. However, population programs promoting high sensitivity FOBT testing for CRC screening must fully consider the role of patient and physician attitudes, knowledge, and preferences and systems issues related to cost, referral, adherence, test quality assurance, and adequate follow-up of positive test results if these programs are to be effective alternatives to colonoscopy programs.”
But while it’s easy to decry the apparent two-level standard of care, with the rich getting the more expensive test and the poor relying on the cheaper one, in fact this is one case where money may not buy better care. Here’s what Otis Brawley, MD, chief medical officer, had to say about the study and the issue.
“Interestingly, we have strong scientific studies to support the effectiveness of FOBT, but studies of that quality have not been completed for colonoscopy, even though many consider it to be the preferred test. The most important colorectal cancer control message that can be conveyed is that all commonly used screening tests save lives, but unfortunately only 60% or so of Americans 50 and over are getting any type of regular screening.”