The People's Perspective on Medicine

What Are the Alternatives to Colonoscopy?

How good are the alternatives to colonoscopy, such as FIT or Cologuard, for detecting colorectal cancer?

Colorectal cancer is the third most common type of cancer and the second leading cause of cancer death among American adults. If it is detected early, before it spreads, colorectal cancer can be treated effectively. That’s why gastroenterologists are adamant about the importance of screening for this condition. Currently about 67 percent of eligible people have gone through a screening procedure. The gold standard is colonoscopy, in which a specialist finds and removes growths called polyps. He or she does this during a visual inspection of the lining of the colon. Many people find preparation for colonoscopy (colon cleansing) arduous. In addition, though the cost is usually covered by insurance, some object to the price. Are there viable alternatives to colonoscopy?

Seeking Alternatives to Colonoscopy: 

Q. More than a decade ago, I had a colonoscopy. Not liking that procedure, I chose to use Cologuard at the usual recommended 10-year retest. Both times, the tests were negative. Now, three years later, I asked my doctor to give me a referral to a gastroenterologist for my next Cologuard. She hemmed and hawed about the use of Cologuard, finally stating that her medical group is no longer using Cologuard because of “the inability to correlate the information provided by that test with the outcomes of a colonoscopy.”

My only option if I want a non-invasive screening would be to use an immunochemical fecal occult blood test yearly. Is this test reliable?

A. People at high risk of colorectal cancer due to family history or previous polyps should have regular colonoscopies. That is because the doctor removes any polyp he or she finds during the procedure.

How Reliable Are FIT and Cologuard?

Individuals at average or low risk may utilize one of the alternatives to colonoscopy. They could benefit from an FIT (fecal immunochemical test). This over-the-counter home test reveals blood in the stool. A study published in the Annals of Internal Medicine (Feb. 26, 2019) showed that such tests detect up to 80 percent of cancers. 

A colonoscopy detects up to 95 percent of colorectal cancers. FIT can be adjusted to pick up 91 percent of tumors, but it will also flag false positive cases. Anyone who tests positive on a FIT will need a follow-up colonoscopy.

Cologuard, based on detecting DNA from polyps, can also produce false positives (New England Journal of Medicine, April 3, 2014).

According to an early analysis of this technology, 

“In asymptomatic persons at average risk for colorectal cancer, multitarget stool DNA testing detected significantly more cancers than did FIT but had more false positive results.”

One difference you should note: you should complete FIT screening every year. The doctors who developed Cologuard recommend that you use it every three years. We don’t know exactly why your doctor’s group has soured on Cologuard, as it seems that such alternatives to colonoscopy are viable for those who are not at high risk.

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About the Author
Terry Graedon, PhD, is a medical anthropologist and co-host of The People’s Pharmacy radio show, co-author of The People’s Pharmacy syndicated newspaper columns and numerous books, and co-founder of The People’s Pharmacy website. Terry taught in the Duke University School of Nursing and was an adjunct assistant professor in the Department of Anthropology. She is a Fellow of the Society of Applied Anthropology. Terry is one of the country's leading authorities on the science behind folk remedies. .
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  • Imperiale TF et al, "Performance characteristics of fecal immunochemical tests for colorectal cancer and advanced adenomatous polyps: A systematic review and meta-analysis." Annals of Internal Medicine, March 5, 2019. DOI: 10.7326/M18-2390
  • Imperiale TF et al, "Multitarget stool DNA testing for colorectal-cancer screening." New England Journal of Medicine, April 3, 2014. DOI: 10.1056/NEJMoa1311194
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My husband had this test twice, had 2 polyps removed, and they were negative. The second time he had 3 removed, and they were benign. For your information, these biopsies were not covered by our insurance.

All my regularly-scheduled colonoscopies starting at age 60 were totally clear of polyps until what I thought was my last one at age 75. A ‘bad’ polyp was found and removed, so now I will need another colonoscopy at age 80.

The “Twilight” anesthesia from a colonoscopy made me sick almost immediately (within three minutes) after I woke up, and this continued for the next eight LONG hours. Most people say they go out for breakfast after a colonoscopy, so I guess this was unusual? Never again.

My husband and a dear family friend both carried out the hemoccult blood test which our Australian government sends out every year to older residents. Both tests came back negative. My dear friend has since died of colorectal cancer but after my husband had a bleed he has so far been fortunate: after a surgical removal of the cancerous polyp he is doing well. It did not spread. Now he has a yearly colonoscopy, MRI and blood test. So for me the home tests might pick up some cases of cancer but are not 100% safe.

Sadly one of the reasons for the doctor group cited above preferring colonoscopy to Cologuard is simple: $$$. Fee for service is a bane of our healthcare system and one of the reasons our costs are so high, even as our outcomes are lower than most advanced countries.

Since I had internal bleeding 13 years ago I have been doing the FIT test (Hemoccult) at home every month and recently started the Cologuard (and will repeat in 3 years). I don’t know if anyone has been doing this but I expect the Cologuard and the FIT together are probably more accurate than either by itself.

Although I have had a colonoscopy several times in the past, my Dr. suggested the Cologaurd test since, due to a twisted colon, the colonoscopy it is difficult to do. The test came back positive so I needed the colonoscopy anyhow. For three weeks I stressed over the worry that I had colon cancer but everything was fine. I am sorry the insurance had to pay so much for the Cologaurd test also, and I will not be using it again.

An interesting and timely Q&A. IMHO, the high false positive rate of Cologuard is a major concern, and I have read that many doctors are no longer recommending the test to their patients. In my case, I had negative results from FIT and positive results from Cologuard, tests completed within a week of each other. Yes, the two tests are screening for different things but this type of conflict should not occur.

As I cannot metabolize sedation, I elected to have a CT colonography, also known as a virtual colonoscopy. My insurance pays for this procedure when used as either a screening tool or as a diagnostic follow up. I had heard horrible tales about the prep for a traditional colonoscopy but the prep for the CT scan was not arduous. All of the liquids were palatable. Also, carbon dioxide is used to expand the colon so you get the sensation of bloating but no gas pains. And, an additional perk, as CO2 is quickly absorbed by the body, once the source of CO2 is removed, the bloating goes away. A downside is that is something suspicious is observed on the scan, a regular colonoscopy is required. However, a CT colonography is an acceptable from of CRC screening.

What is your opinion on Trazodone for sleep aid?

Seven years ago, my company sent out Cologuard to all employees. I don’t recall that there was a warning that it doesn’t work for those at high risk, and only recently have the commercials added this fact. I have had colonoscopies that have detected and removed pre-cancerous polyps twice and will continue to have them as recommended. It is not that difficult to do. I feel the commercials are misleading by emphasizing how terrible colonoscopies are. You might not know you are high risk until you have one!

I think that most insurance only covers colonoscopy every 10 years. If your doctor says you need one more often due to family history, it can be a BIG bill.

I get both FIT and Cologuard every three years to increase detection chances. I will make sure to get FIT in the off two years. Good info.

Change doctors!

My husband thinks the objections to the less invasive screening is largely related to $$$$$. It is discouraging to think this might be a significant factor in what influences some medical decisions, but it probably is a distinct possibility.

I found having a colonoscopy not to be a big deal. The hardest part was not eating. The doctor who preformed the procedure told me that a colonoscopy was the ONLY way to prevent colon cancer. By using the other tests you find out only that you already have cancer and then have to go through the procedure anyway, and who knows what else, to treat the cancer or you don’t have it at the moment of the test. It could develop a month after the test and go undetected until you test again which could be to late.

Get a colonoscopy.

I was told by the doctor who took out my polyps in me, that if they don’t remove all of the polyp, it comes back with a vengeance Have you heard this? How are we to know? This can keep you coming back forever. It feels like we are at their mercy.

My family practitioner was totally supportive of Cologuard, since I have had two colonoscopies that were normal.

Last year I experienced sudden senseoneural hearing loss in both ears. Many dr visits and failed treatments later I was told to get a hearing aid. Two failed hearing aids later, I started using essential oils topically with a roller. Gradually my hearing has improved but is not completely restored, and I am hoping for complete restoration. I still have tinnitis and have trouble in noisy environments.

I have had 2 colonoscopies and never felt a thing during either of them. The prep is not fun, but not that bad, either.

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