Effect of Colonoscopy Screening on Risks of Colorectal Cancer and Related Death

Several posters have criticized the title of the news article &quot;In gold-standard trial, colonoscopy fails to reduce rate of cancer deaths&quot;.<p>The actual study is titled &quot;Effect of Colonoscopy Screening on Risks of Colorectal Cancer and Related Death&quot; [1]<p>The authors conclude that &quot;In this randomized trial, the risk of colorectal cancer at 10 years was lower among participants who were invited to undergo screening colonoscopy than among those who were assigned to no screening. &quot;<p>I find it generally more useful link to the (abstract) of the original article, rather than second hand news reports. The abstracts are usually pretty accessible for a somewhat technical audience, they&#x27;re not written for domain experts only. As we see in the discussions here, it&#x27;s questionable whether the rephrasing from journalists really adds anything.<p>[1] <a href="https:&#x2F;&#x2F;www.nejm.org&#x2F;doi&#x2F;full&#x2F;10.1056&#x2F;NEJMoa2208375" rel="nofollow">https:&#x2F;&#x2F;www.nejm.org&#x2F;doi&#x2F;full&#x2F;10.1056&#x2F;NEJMoa2208375</a>

A lot of the comments here seem to come from the perspective that a colonoscopy is the only way to screen for colorectal cancer. There are also fecal sample tests such as FIT and FIT-DNA. Both involve home collection of fecal samples for testing. In the case of FIT yearly and FIT-DNA every 3 years. In the case of both if there is a positive result a colonoscopy is then performed. Outside the US annual FIT testing seems to be the standard of care versus a screening colonoscopy. A similar study with yearly FIT tests would be interesting to see. I suspect you might have a better compliance rate than the 42% seen in this study.

&gt; When the investigators compared just the 42% of participants in the invited group who actually showed up for a colonoscopy to the control group, they saw about a 30% reduction in colon cancer risk and a 50% reduction in colon cancer death.<p>I’m really confused by this data. First of all, are they testing the efficacy of colonoscopy or the efficacy of inviting people to colonoscopy?<p>And then how is the former group’s reduction in deaths 50% and the latter group’s is about 0%?

Sensationalist title to a good news story: there was no intent-to-treat effect, but a low conversion rate. The ETT is a pretty impressive 50% mortality reduction. Also study is limited by a short 10 year follow-up period but there will be a 15 year follow up.<p>So I&#x27;ll still get my colonoscopy, thanks

Years ago I learned that this is the reason why they don&#x27;t do colonoscopies without good reason in Finland. I asked from a doctor who is a friend why you have regular colonoscopies in the US but not in the Finland and he said &quot;no evidence and colonoscopy has a small risk factor&quot;.<p>If you do medicine for profit and are allowed to advertise and market, doing more is always better.

Vinay Prasad, MD (Heme&#x2F;Onc) gives a very good rundown on why this trial is so important. He also points out why having accurate data for screening recommendations is so crucial. USPTF has been making recommendations recently without data to back up them up and get appropriately taken to task for that.<p>[1] <a href="https:&#x2F;&#x2F;m.youtube.com&#x2F;watch?v=SMRS4-ng8T0" rel="nofollow">https:&#x2F;&#x2F;m.youtube.com&#x2F;watch?v=SMRS4-ng8T0</a>

This is about colonoscopy <i>screening</i>. If you give a fecal sample and it comes up as suspicious, the next step will be a colonoscopy anyway.<p>A colonoscopy is quite unpleasant; you starve for a day, and take an enema. They may sedate you before the procedure. If they don&#x27;t, then the procedure is quite uncomfortable; not exactly painful, but unpleasant.<p>Incidentally, if they find and remove a polyp, they will plant a tattoo inside your gut to mark the spot, for the benefit of future spelunking visitors.

I personally advise everyone to get a colonoscopy.<p>I personally know 4 people who had the procedure and cancer was detected. Some further along than others. All still living.<p>Colonoscopy is one of the few procedures that as they screen they can also take action.

This is a very complex subject because the sensitivity of tests for colorectal cancer has improved over time and more testing is being done. This makes it appear as if there is a great increase in colorectal cancer when there really isn&#x27;t.<p>A very interesting related study has become known as &quot;The Norwegian Colorectal Study&quot; found that early testing was a waste of money since only those with a family history of colorectal cancer or IBS symptoms or both actually got colorectal cancer before 55. For most people the polyps which are precursors to colorectal cancer do not appear before age 55. That means that the current push for aggressive testing starting at 50 is a distracting waste of time, money, and effort that should be eased back.

&gt; The risk of death from any cause was 11.03% in the invited group and 11.04% in the usual-care group<p>IIUC, there was still a reduction in colon cancer deaths, but the populations still experienced the same % of deaths from all causes.<p><a href="https:&#x2F;&#x2F;www.nejm.org&#x2F;doi&#x2F;full&#x2F;10.1056&#x2F;NEJMoa2208375" rel="nofollow">https:&#x2F;&#x2F;www.nejm.org&#x2F;doi&#x2F;full&#x2F;10.1056&#x2F;NEJMoa2208375</a>

“They’re doing a 15-year follow, and I would expect to see a significant reduction in cancer mortality in the long term,” Dominitz said. “Time will tell.”<p>After all the debate here in HN about the interpretation of the data and the statistics, I&#x27;m really looking forward to see a post in 15 years with the new study.

I would suggest reading the editorial also. Study has major limitations. From the doctor who wrote the editorial on Facebook Dr Jason Dominitz: &quot;I&#x27;m honored to have been invited to write an editorial for the NEJM about the landmark NordICC study comparing screening colonoscopy to usual care (no screening) in Norway, Poland and Sweden. The NordICC results were somewhat disappointing in that colonoscopy only reduced colorectal cancer incidence by 18% at 10 years, with no significant mortality benefit. But only 42% of individuals who were invited to have a colonoscopy followed through. For those that did have colonoscopy, mortality was reduced by 50%. This study highlights the importance of adherence with screening. Also, we know that colonoscopy quality is variable and 29% of the endoscopists were not meeting quality benchmarks for polyp detection. So if you are getting a colonoscopy, ask your doctor what their &quot;ADR&quot; (adenoma detection rate) is. If they don&#x27;t know, find another doctor to do your colonoscopy. The ADR should be well over 25% and, ideally, over 40%. &quot; <a href="https:&#x2F;&#x2F;www.nejm.org&#x2F;doi&#x2F;full&#x2F;10.1056&#x2F;NEJMe2211595" rel="nofollow">https:&#x2F;&#x2F;www.nejm.org&#x2F;doi&#x2F;full&#x2F;10.1056&#x2F;NEJMe2211595</a> <a href="https:&#x2F;&#x2F;www.nejm.org&#x2F;doi&#x2F;full&#x2F;10.1056&#x2F;NEJMoa2208375" rel="nofollow">https:&#x2F;&#x2F;www.nejm.org&#x2F;doi&#x2F;full&#x2F;10.1056&#x2F;NEJMoa2208375</a>...

Shouldn&#x27;t this study properly be called &quot;Effect of <i>Offering</i> Colonoscopy Screening on Risks...&quot;? The headline result is based on the 18% decrease in CR cancer among people who were <i>offered</i> a colonoscopy. Of the people offered, only 42% actually got a colonoscopy. That means in the &quot;colonoscopy group&quot; 58% never even had one. Among those who did get one, there was a 31% decrease in CR cancer, and a 50% reduction in deaths from CR cancer.<p>All the study really proves is that offering someone a colonoscopy isn&#x27;t the same thing as giving them one.

The problem with this study is that the analysis is based upon intention to treat. Only 42% of those who were randomized to get a colonoscopy actually got one. The cancer incidence was 18% lower among all people who were invited to get a colonoscopy. If we assume rate among people who were invited to get a colonoscopy but did not go through with it is the same as the rate of people who did not get a colonoscopy then the cancer rate would be more like -2&#x2F;3 among those who got a colonoscopy.

&gt; The trial’s primary analysis found that colonoscopy only cut colon cancer risk by roughly a fifth<p>Perhaps it was oversold, but a 20% reduction still seems significant.

Irresponsible click bait title. If you are over 40,take a colonoscopy. I lost my brother (44) from colon cancer which could have been totally prevented. It was a very painful and depressing experience, multiple rounds of chemotherapy and surgeries that lasted over four years and sent his family into bankruptcy. He stopped eating solid foods weighing only 47 kilos and died from suffocation, pretty much liquid accumulating and pressing against his lungs until he could no longer breath. It&#x27;s a slow and horrible dead that can be prevented with a simple one hour procedure done once every 5-10 years and in many cases 100% covered by insurance.

From the HN guidelines:<p>&gt; please use the original title, unless it is misleading or linkbait; don&#x27;t editorialize<p>I&#x27;m finding myself disappointed with the application of guidelines here. The title has been changed to a completely made up headline, differing from the original, which is editorializing. It&#x27;s the second time this happens in the past 24 hours - yesterday the &quot;.. you idiot&quot; part was removed from a blog post completely numbing the post&#x27;s intention. Neither was misleading or clickbait.<p>EDIT: while typing this comment, the title has been changed yet again to reflect the paper&#x27;s title &quot;Effect of Colonoscopy Screening on Risks of Colorectal Cancer and Related Death&quot;.

I’m quite surprised in 2022 that news coverage is not mentioning the now well-known risks associated with colonoscopies. AIUI they are no longer recommended in the EU for routine screening because of the very high rate of dangerous side effects, on net increasing all cause mortality in the general population.<p>The article here just looks at cancer mortality, which is not what anyone should care about.<p>For more recent commentary, an example is <a href="https:&#x2F;&#x2F;blogs.scientificamerican.com&#x2F;cross-check&#x2F;why-i-wont-get-a-colonoscopy&#x2F;" rel="nofollow">https:&#x2F;&#x2F;blogs.scientificamerican.com&#x2F;cross-check&#x2F;why-i-wont-...</a>

Many years ago I learned about Japanese doctor Shinya. He pioneered the colonoscopy an found that diet was a big factor in intestinal health.<p>Here some videos (may be NSFW):<p><a href="https:&#x2F;&#x2F;www.youtube.com&#x2F;watch?v=B1LREA1ZuUE" rel="nofollow">https:&#x2F;&#x2F;www.youtube.com&#x2F;watch?v=B1LREA1ZuUE</a><p>But there are lots more to see.<p>I believe what he discovered is important. Not that I believe his advice to drink ionized water (Kangen water) is scientifically sound. But that does not matter for the discovery that switching to eat rice and veggies cleans your intestine.

I’m unique guess in the world. We’re all going to die. If you make it to 57, awesome. After that it’s all a bonus. Take that attitude, and you really don’t put off much. You don’t turn down any invites. And do wake up with the Sun. Life is awesome!<p>Don’t be so afraid of death. It’s not that bad. Really.<p>Source: survived an NDE. Was not my time was told, but did get a great tour of the afterlife. Don’t worry so much.<p>And treat strangers with kindness, they were very insistent on that. They keep score. Heaven or Hell. It’s your decision.<p>:-)

Title and end conclusion of the article are contradicting. Last paragraph says, &quot;If you cannot take 2 days off, then you have other options. If you want to take test once in 10 years, Colonoscopy is the king&quot;. This means Colonoscopy is still the king if you can take 2 days off from your work ( which I believe most workers should be able to as this is important for one&#x27;s life ). Not sure how this is beneficial for the readers of this article.

&gt; If the endoscopist discovers a suspicious polyp, then it’s promptly removed, thus nipping the cancer before it spreads<p>So, kind of like how pruning a plant does not necessarily weaken it.

Does the patient population play a role? I see mostly Europeans here.<p>The Japanese have a higher colon cancer rate, what percent die there?

You might not die if you leave that cancer alone, but you might get part of your colon removed, or get a colostomy bag, or get your anus surgically sewn shut til death -all of which not necessarily changes your life expectancy.<p>Looking for death vs no-death alone as an outcome for medical diagnosis&#x2F;treatment is short sighted.

Good discussion here, but I think the main message might get lost in the noise:<p>* Colonoscopies reduce incidence of colon cancer but apparently not death from colon cancer.<p>* This is probably because colon cancer therapies are good, so even if you get colon cancer your prognosis is good.<p>* The take-away is not that colonoscopies reduce your chances of death, but that they reduce your chances of having to suffer colon cancer and subsequent therapies. That might still be a good trade-off.

the result reported by the article is impressive - 50% reduction in cancer death for those who actually did at least one colonoscopy in 10 years.<p>surely your risk can be further reduced by having annual colonoscopy if you are in the high risk group, e.g. with family history.

&quot;Gold-standard trial&quot; sounds about as good as Genuine Leather does for leather. (Genuine leather is the cheapest leather, for those that don&#x27;t know).