Colon checks rising — which test is best?

WASHINGTON — Sam Monismith was prepped and ready to begin his colonoscopy when health workers brought the university professor awkward news: His insurance wasn’t going to cover the colon cancer check. They wanted a signed promise to pay, or the test was off.id/17802801/ns/health-cancer/t/colon-checks-rising-which-test-best/

And is the pricey colonoscopy that studies suggest more people prefer really the better test?

“Here’s where the problem lies: I think people are willing to undergo colonoscopy,” says Dr. Arden Morris, a colon cancer surgeon at the University of Michigan. They’re less willing to do fecal testing — many “think it’s really gross” — or other options that don’t give as full a view of the colon.

“On the other hand, if everybody who’s eligible gets a colonoscopy, we’re going to break the bank,” Morris warns. “Then who gets screening when we don’t have money left? I think this is a really intriguing question.”

Some 153,760 Americans will be diagnosed with colorectal cancer this year, and more than 52,000 will die.

The government says up to 60 percent of those deaths could be prevented if everyone over age 50 underwent routine screening.

Monismith hesitated only briefly — and the test uncovered nine polyps, precancerous growths in his colon. Even better, because doctors removed them on the spot, the bill switched from a cancer screening that insurance wouldn’t pay into a surgical procedure it did.

“The irony of it is if I hadn’t had any polyps, I would have had to pay,” says Monismith, 54, of Harrisburg, Pa., who has had additional polyps removed in the four years since that first check. “I’m just glad I got the test.”

Insurers insist Monismith is a rarity and that most insurance does cover colon cancer screening once people hit age 50, when the risk starts to rise. Still, cancer advocacy groups have begun a push to ensure the last holdouts cover all four government-recommended options — from the $20 annual stool sample to once-a-decade colonoscopies that can exceed $1,000.

Fifteen states are considering legislative mandates, by the American Cancer Society’s count; 19 other states have long had such laws.

The legislative tussle actually highlights tougher issues: Insurance aside, people are reluctant to get checked for the nation’s No. 2 cancer killer. Nearly 42 million Americans over 50 aren’t getting screened. Even though Medicare has long covered the checks for those over 65 — and colonoscopies are rising — only about half of its recipients get properly screened.

“It is a patient education” issue, contends Mohit Ghose, spokesman for America’s Health Insurance Plans, which opposes the mandates.

People prefer colonoscopy 
It’s not just a matter of catching the cancer when it’s still small and more easily treated. The disease usually starts with toadstool-like growths called polyps that can take a decade to turn cancerous. Remove them in time, and the cancer never even forms.

The government backs four screening options. Most used are annual at-home fecal tests to detect hidden blood in the stool and once-a-decade colonoscopies, where doctors use a long, flexible tube to visually inspect the colon. (The others are sigmoidoscopy, an exam of the lower colon only, and a less-used barium enema, repeated every five years.)

The good news: Deaths are declining faster for colorectal cancer than for any other cancer, a 5.7 percent drop between 2003 and 2004 that scientists credit to small upticks in screening.

Where’s the improvement? Mostly, it’s in increasing colonoscopies, says Michigan’s Morris. A study published in December found an almost sevenfold increase in routine colonoscopies once Medicare started covering them in 2001.

Even though for most people the cheaper fecal-blood tests are equally effective, other studies have found problems getting people to repeat them year after year as required, Morris says. “People hate doing” them.

As for the middle ground of a sigmoidoscopy, blacks, women and the elderly are more likely to have cancer in part of the colon that doesn’t reach, she adds.

Where does the legislative fight fit in? The cancer society found that colonoscopies and sigmoidoscopies rose faster between 1999 and 2004 in states that mandated coverage of all the options.

Ghose’s industry group argues that almost every insurer already covers some colon screening. A 2004 congressional probe, the latest available data, surveyed a few dozen insurers in states without mandates. Just 16 percent of small-employer plans and 31 percent of large-employer plans covered fewer than all four options. Least likely to be covered were colonoscopies and barium enemas.

Morris says the key is ensuring enough choices are available — not just for the insured but the uninsured, too — that people simply pick something. “Once we’re used to the notion, it might be easier to talk about the less expensive choices.”