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Scoping Out the Controversy on Colonoscopies — Is Somebody Exaggerating the Need?

Commentary by three physicians in the medical journal Annals of Internal Medicine is raising questions on what the American Cancer Society (ACS) is trying to accomplish by suggesting colon cancer screenings begin at age 45, rather than 50. According to Forbes, it boils down to three issues:

  1. Exaggerated risk
  2. Unproven benefits
  3. Lead time bias

In other words, the physicians questioning the new guidelines say colonoscopy proponents may be exaggerating the relative risk of a cancer diagnosis in 45- to 50-year-olds, with no randomized trials proving that screening at 45 ultimately saves lives. Plus, death rates — which haven’t changed — suggest there’s an unnecessary bias in arbitrarily suggesting screener earlier will save more lives.


The facts are an estimated 135,000 people are diagnosed with colorectal cancer each year (about 95,500 cases of colon cancer and 39,900 cases of rectal cancer), and more than 50,000 die from it. So, if colonoscopies are finding all these cancers, then, indeed, there may be rationale for their use — in certain circumstances.

On the other hand, when you consider that the risk of death from colonoscopy may be as high as 1 in every 1,000 procedures, it certainly gives you pause to think. This is especially concerning since, as the featured article explains, historically colon cancer has been confined to those over the age of 50.

Today, however, the rates of colon cancer among younger persons appear to be increasing. But does this mean you should run right out and get a colonoscopy if you’re in your mid-40s? Look at it this way:

• With some 15 million colonoscopies being done each year in the U.S., that means as many as 15,000 Americans die as a result of this routine screening test, and numbers are likely to increase further if guidelines are changed to encourage people under 50 to get tested.

• Again, an estimated 13,500 new cases of colon and rectal cancers will be diagnosed in adults under the age of 50 this year, and if you extrapolate the potential number of deaths at 37 percent (the average death rate for all age groups), then less than 5,000 individuals under the age of 50 will die from colorectal cancer.

• This means you may be three times more likely to die from the screening procedure than the disease itself. Serious complications for colonoscopy also occur at a rate of about 1 per 200 to 350 procedures, again depending on the source of the data.

• In other words, large studies have found that 1.5 to 3 colon cancer deaths are prevented for every 1,000 people screened once every 10 years, while 2.5 per 1,000 people screened are severely harmed or killed. 

That seems like a toss-up in terms of risk, but at least if you’re older and are in a higher risk category, screening becomes a more reasonable risk.

So what are the specific risks of a colonoscopy? Aside from the chance of death, they are:

Perforation of the colon, which occurs at a rate of 1 in 800 (people at higher risk include those with diverticulitis, diseases of the colon and adhesions from pelvic surgery)

Dysbiosis and other gut imbalances, caused by the process of flushing out your intestinal tract before the procedure with harsh laxatives

Complications from the anesthesia — Many experts agree you should opt for the lightest level of sedation possible, or none at all, as full anesthesia increases risks

Infections caused by poorly disinfected scopes

False positivesFalse positives lead to unnecessary treatments that are nearly always harmful, in addition to the anxiety a cancer diagnosis brings

The bottom line is, if your doctor suggests it might be time to have a colonoscopy, be sure to discuss the risks and benefits thoroughly before undergoing the procedure. You might also ask if a sigmoidoscopy, which tends to have 10 times fewer complications, may be a better alternative.

Additionally, if you do decide to undergo either procedure, be sure to ask how the endoscopes are cleaned between uses. If the hospital or clinic uses peracetic acid to clean the scopes, your likelihood of contracting an infection from a previous patient is slim.

However, if glutaraldehyde, or the brand name Cidex (which is what 80 percent of clinics use), is the cleaning solution your health center uses, find a different clinic that uses peracetic acid.