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Colonoscopies: Life-Saving Breakthrough or $24 Billion Boondoggle? · Intellectual Medicine

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  Is colon cancer screening A multibillion dollar boondoggle,
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  strapping us with fear and extracting money?
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  Or is it an incredible step forward in preventing death from
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  colon cancer? Let's look at colon cancer and
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  what we can do to protect ourselves.
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  What tests should you do? Should you do a test?
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  And if you decide to do one, well, which one should it be?
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  Is colon cancer screening A multibillion dollar boondoggle,
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  strapping us with fear and extracting money?
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  Or is it an incredible step forward in preventing death from
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  colon cancer? The answer to both is actually
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  yes, It's a little of both. So let's look at colon cancer
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  and what we can do to protect ourselves.
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  What makes sense, and distinguishing the dogma of
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  conventional medicine from advances in the field is a
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  concern. I have a concern whenever an
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  industry starts to become petrified.
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  Maybe that's the word here, right?
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  Something that becomes so established and so profitable
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  that change becomes difficult to impose.
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  So colon cancer screening is a $24 billion a year industry in
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  the United States. Your gastroenterologist drives
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  anywhere from 5 to 20% of their annual income from screening
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  colonoscopies. So right away we can sense that
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  they'll be resistance to change. So let's look at the current
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  state-of-the-art. And I'm going to conclude with
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  my recommendations. What do you do with all this
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  information? Well, you know, every cancer is
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  quite different from one another, and in the realm of
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  screening for cancers, I think a lot of this is overplayed.
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  Those of you that are wasting money on total body Mris, just
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  stop already. This is silly.
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  You're chasing shadows with no benefit.
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  I don't care how much money you have and how psychologically
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  satisfying it may seem, Right? This is silly.
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  On the other hand, a colonoscopy, not a colonoscopy,
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  but let's look at colon cancer, very prevalent relative to other
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  cancers #2 cause of death. And it's an awful cancer to get.
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  The treatments are awful. So this is something that can be
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  prevented, can be avoided. The colon and the rectum is a
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  hollow tube, folks. You can't feel this disease when
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  it starts, and it starts slowly, and we can determine even before
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  it begins some of the risks and we can look for them.
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  Colon cancer starts as a polyp. There are two kinds of polyps
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  that you can get. One of them is hyperplastic.
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  That's nothing. The other one is adenoma, which
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  is considered precancerous. So we know that it's a hollow
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  tube. We know you can't feel the
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  symptoms. We know that they can be
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  detected early and cancer can actually be prevented.
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  But the question revolves around what tests should you do?
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  Should you do a test? And if you decide to do one
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  well, which one should it be and how do you protect yourself from
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  the machine? The machine, in my view, is the
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  the conventional medicine of treadmill of automatic
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  recommendation. We do know, for instance, that
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  the majority of people who die from colon cancer have not had
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  recommended screening performed. The problem isn't our fault,
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  it's that the screening is awful.
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  The gold standard is considered colonoscopy.
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  When I was 50, I had my colonoscopy done.
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  I lost 2 days of my life to the procedure, one in the prep, the
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  other in the day of the scoping. After it was completed, I threw
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  up in the parking lot from the anesthesia.
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  So we have to look at cost and risks.
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  Colonoscopy is the current sort of gold standard if you will,
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  but most people don't get that study.
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  It's expensive. It's $2500 on average, give or
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  take. As I mentioned, the prep is
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  annoying, the procedure's annoying, and there are
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  complications. Piercing of the viscum, that is
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  a hole in your colon. That can happen.
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  It could lead to hospitalized care.
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  Sepsis and bleeding can occur leading to anemia.
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  Emergency room visits. How about strokes and heart
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  attacks? They actually occur more often
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  than bleeding complications in people over 75.
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  A major stress to your system. Folks.
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  This is not a benign procedure. So what can you do?
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  Or should you do anything as an alternative?
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  I do believe that this is a cancer worthy of the effort for
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  screening, but I also feel that a colonoscopy presents far too
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  many risks and far too much of an imposition on your quality of
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  life to justify its routine use. Over the past 10 years, there
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  have been advances made in biomarkers.
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  We now can test stool. There's the Cologuard test, a
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  new one, the Cologuard Plus. Those are trade names.
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  I like these tests as a in many ways superior to the
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  colonoscopy. Why #1 No particular prep
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  required. No special diet you have to be
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  on. The test can be done in the
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  privacy of your home. I get it, it's uncomfortable
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  taking some of your poop and putting it in a box.
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  But move that aside for a moment.
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  No prep, no downtime. You can't hurt yourself with
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  this test. Nobody had a stroke or a heart
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  attack or sepsis or an infection or a reaction to anesthesia from
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  a stool test. So I advocate this.
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  It can be done every three years.
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  Most insurances cover it if it's an out of pocket expense.
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  It's between 5:00 and $700.00. So that's a nice test to have
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  done. Of course, if it's positive, you
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  end up with a diagnostic colonoscopy.
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  That's a different study altogether.
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  If you have an abnormal screening test, it behooves you
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  to go forward to get the next step, a diagnostic colonoscopy.
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  That's different from mass screening.
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  The mass screening of colonoscopies had some some
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  impact. The rate of colon cancer in
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  older people is actually going down over the past 20 years.
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  The rate of death from colon cancer also is going down over
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  the past 20 years. It has ticked up in young
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  people. It's a separate issue
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  altogether. In fact, the real risk of
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  getting colon cancer is having a colon in the United States in
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  today's era, and it has a lot to do with the chronic toxic
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  exposure. Colon cancer, by and large, is
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  environmental. It's based upon what we expose
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  ourselves to or what we're exposed to.
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  Talk in a moment and more about prevention.
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  But back to the screening studies, some exciting advances.
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  There's now a blood test that can be done.
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  It looks at methylation markers. This is called the Septin Dash 9
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  test, commercially available. The blood test is good at
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  detecting colon cancer. It's good at screening for
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  precancerous polyps. It's not as good as the
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  Cologuard of the stool testing, nor is it as good as a
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  colonoscopy if you're just strictly looking at diagnostic
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  yield. But if you look at convenience
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  and you look at cost, it's pretty good.
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  For $200 you can do a blood test that has value.
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  That is cool because I would rather do a blood test than put
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  my poop in a box. It's 200 bucks, which I would
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  write that check tomorrow to avoid a colonoscopy 100%.
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  Is it perfect? No, nothing is.
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  Nothing is. Now those who advocate the
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  colonoscopy as a screening test are holding on to really a dated
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  screening procedure that I think should be really bypassed with
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  the stool testing and now the blood testing.
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  They're less expensive. They're safer.
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  They're pretty good at screening.
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  There's nothing that's perfect, folks.
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  You can get a totally clean colonoscopy.
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  They call it the gold standard. But here's the problem prep.
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  Many times there's stool. There's a there's a veneer of
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  stool left in the colon. The doctor can't see through
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  that. A polyp can hide behind that.
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  Look at I've performed colonoscopies on patients in the
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  past. It's not easy.
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  There are lots of folds, nooks and crannies.
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  A good doctor has to take time and look around corners and
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  examine things. And here's a paradox.
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  The more time the doctor takes doing the colonoscopy, the fewer
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  that can be done, the less dollars per day.
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  If your doctor also has a vested interest in the colonoscopy
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  center, they're making more money out of the pull procedure.
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  I'm not implying that it's illegitimate, it's not, but it's
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  an influence. It's an influence on
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  recommendations. So you got to consider that when
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  you're contemplating the advice that you're getting.
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  If you've had a normal colonoscopy, by all means, in my
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  view, you shouldn't get another one switched to the stool
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  testing. Much safer, much safer.
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  If you choose to get a colonoscopy, here's what you
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  need to know. You need to know the adenoma
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  rate, the adenoma discovery rate of your doctor, and that means
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  the percentage of scopes that they do that reveal adenomatous
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  polyps or precancerous polyps. It's a known statistic that
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  every doctor should be aware of. Doctor, what is your adenoma
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  detection rate? You should ask your doc.
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  If you're going to get a colonoscopy.
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  It should be in the neighborhood of 30%.
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  That's the average. If they primarily are scoping
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  women, it's 20% because women have a lower rate of adenomas.
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  Now, if your doctor doesn't know what his or her adenoma
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  detection rate is, find another doctor.
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  That's a stat that they should have and they should be
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  comfortable sharing with you. They should bang it out like
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  their name. Yeah, my adenoma detection rate
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  is 35%. Next question, how long do you
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  take doing the colonoscopies? On average, it should be about
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  20 to 40 minutes. A fast colonoscopy is not
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  necessarily a good thing. It may be that they're
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  withdrawing it too quickly, not slowly enough to detect every
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  detail. So if you choose to get
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  colonoscopy now, you have some information you can use, some
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  questions you can ask, fair questions you should be
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  comfortable posing. They're not intrusive, it's not
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  disrespectful, the doctor takes offense.
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  It's because their ego is weak and they don't have good stats
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  to share in my opinion. So do that.
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  Now who should get colonoscopies?
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  Listen, if you have a hereditary genetic form of risk for colon
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  cancer, then the colonoscopy is the way to go.
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  There's something called Lynch syndrome, a genetically
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  inherited trait, a horrible risk of colon cancer.
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  So bad that sometimes they recommend a colectomy, cutting
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  the colon out as a means of protection.
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  You likely know if you have this or if it's in your family.
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  Familia polyposis, people that get clusters and clusters of
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  polyps all over the colon. It can be tested for.
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  There's a genetic test that can be done that is rare.
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  There are other familial correlations.
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  Now, these are not necessarily an inheritable gene that we can
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  identify, but it's a case where your mom, your dad, sister or
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  brother, first re relative had colon care.
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  So that takes up your risk, right?
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  An aunt and uncle or grandparent does not is not relevant to your
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  personal risk. Now, why would the family
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  connection increase risk if there's no gene that can be
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  detected? You grew up in the same house,
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  didn't you? You breathe the same air, you
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  ate the same food. Radon, gas, tobacco, secondary
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  smoke, food. All these variables are common
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  denominators amongst families. So it doesn't necessarily mean
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  that the environment is subordinate to the genetic.
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  I don't think it ever is. I think the environment is
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  always the primary trigger here. So when it comes to screening,
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  when should you consider it? Now, recent recommendations have
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  dropped it to age 45. That's because more younger
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  people are popping up with colon cancer than they had in the
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  past. It's not because the the
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  incidence is greater in younger people.
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  It's not it's still greater in older folks.
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  It's just that for an for some reason, they've increased.
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  Well, it's not hard to speculate why the toxins in the
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  environment and the obesity rates.
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  Obesity is a huge risk factor for colon cancer.
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  People talk about fat. I shouldn't eat fat.
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  No, you shouldn't be fat. It's the adiposity, the waist
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  circumference. So when it comes to preventing
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  cancer that is critical when it comes to screening, should you
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  start at age 45 now? Maybe if you're obese, I'd say
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  yes. If you have a family history,
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  I'd say yes. How about if you're a lean,
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  athletic, non-smoking, organic, healthy?
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  No, I don't think you should start that young.
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  You're going to be low yield, risk of false positive.
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  You have to protect yourself, people from exposure to the
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  medical system. Anytime somebody wants to put a
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  scope, a needle, anytime they want to invade your body, you
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  got to be very cautious. Bad things can happen.
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  So screening at a young age, it's not a universal
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  recommendation, although it it's advocated.
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  I think you want to profile it based upon your risk.
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  And even then, if you're going to screen at a young age, I like
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  the stool test. Now this blood test is
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  interesting. The stool test is superior,
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  greater sensitivity, greater specificity.
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  But if you're totally adverse to getting it done, the blood test
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  is reasonable and it can be ordered today.
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  It's available, it's on the market.
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  This is so cool. This stuff is good to go, right?
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  And it all happened in the last few years.
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  And it's a, it's an enormous threat to those colonoscopy
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  centers, endoscopy suites that are just churning and churning.
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  And look, when I was in medical school, they we used to joke
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  that the indication for colonoscopy is do you have a
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  colon and do you have insurance? Another joke, we used to call it
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  scoping for dollars. Dad, that's a little bit
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  callous, but not completely untrue.
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  Profit motive drives human behavior, whether they're
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  doctors, accountants, lawyers. Now we physicians, we like to
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  believe that we're insulated. I would say that we're not as
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  profit driven in some cases, but it's still there.
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  So you want to be thoughtful about where the advice comes
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  from. If it's your gastroenterologist
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  who owns an endoscopy center, they're going to tell you that
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  the stool testing is not the gold standard, that it misses
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  cases. Technically that's correct, but
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  so too does colonoscopy. There's nothing perfect.
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  So in my view, stool testing, number one, blood testing, not
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  unreasonable. Colonoscopy as a screening test,
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  I think it's day has passed. I don't think it should be your
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  go to now. Can you do it?
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  Certainly you can. Does it have value?
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  It appears to, but at what price?
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  At what risk? And here's a point of emphasis,
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  folks. If you're over 75, take the
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  colonoscopy off your agenda. In my view, the risks are far
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  too great. Stroke and heart attack is a
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  high price to pay for a screening test when you have an
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  alternative available that puts no risk in front of you at all.
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  That's the stool test. That's the blood test.
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  All right, so we're clear colon cancer is a killer.
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  It can be. Risk can be diminished with
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  thoughtful screening. The problem with colonoscopy is
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  that they're intrusive infection, piercing the visca,
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  sepsis, heart attack, stroke, reaction to the anesthesia,
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  pneumonia, A lot of things I don't like about it, not the
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  least of which is who cleaned that scope before it went up my
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  butt and, and how many butts has it been up today?
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  And how old is that scope? And it just kind of grosses me
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  out, right? So, and there's a reason why a
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  lot of people don't get it, for all the reasons I just stated.
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  And because of that, ironically, there may be a resistance to
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  screening. So a few people get screened.
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  Now, you already know because I just told you the majority of
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  people who die from colon cancer are folks who never had a
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  screening done. So yeah, you should get
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  screened. Not with a colonoscopy unless,
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  but there's some high degree of familial risk or genetic
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  inheritance. Not familial risk, no.
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  A a genetic risk. There's a difference if mom or
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  dad, brother or sister had colon cancer.
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  I still advocate the stool testing as being quite
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  excellent. Not perfect, but extraordinarily
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  safe and perfection is not achievable.
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  So let's get back to primary prevention.
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  Can we do that? Can you take charge of your
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  health? Nobody cares about your health.
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  Remember, you don't have health insurance.
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  You have sick insurance, and insurance will not pay for you
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  to be healthy. This is your job.
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  And the cool part about this, there's a common denominator.
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  When you do things to preserve your health, when you do things
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  to diminish your colon cancer risk, all cancer risks are going
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  to go down with it, starting with percent body fat.
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  You know, I've been treating obesity for decades and I've
• 19:12
  been pursuing interventions for cancer as long and people often
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  ask me, you know, what should I eat?
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  What should I avoid? The most dangerous food to eat
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  is simply this. Too much percent body fat is the
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  number one consideration when it comes to nutrition.
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  I don't care how organic and clean you eat, by the way.
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  I do like organic food, but it's expensive, so I don't want you
• 19:39
  to feel like everything has to be organic.
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  Be thoughtful about how you spend your money because you
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  can't dodge toxicity. Organic food can still have
• 19:50
  heavy metals in them. There's no way to avoid them.
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  It's in the dirt. So we have minimized that, you
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  know, by modifying volume. What we eat is relevant.
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  What we drink is relevant. Alcohol.
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  It's OK, I'm not against it. Recreational, One or two oz at a
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  feeding time, a nice glass of wine, all good.
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  You want to have 6 beers every night, you're going to take up
• 20:16
  your risk across the board. Now, tobacco, of course, is a
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  risk. You know what else is a risk?
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  Cannabis, no, it's not a health food.
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  No, it doesn't prevent anything. Yes, it's a risk.
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  Sorry you want to use a recreation to get high.
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  I have no objection. If you think it's a a health
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  adjunct, you're fooled. It's not.
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  Now other things of primary prevention, aspirin, non
• 20:43
  steroidal anti-inflammatory drugs like ibuprofen.
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  And here's another one that's kind of weird.
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  Statin drugs, people that use these types of drugs on a
• 20:53
  regular basis have a somewhat lower incidence of of cancer.
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  Now why would that be? What do these things have in
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  common? They're all anti-inflammatory
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  agents. So we know the statin drugs have
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  an anti-inflammatory effect. So does aspirin.
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  So do non steroidal drugs. Interesting.
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  Should you then take them as a prevention?
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  Not necessarily, but it's interesting to note the
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  inflammation as a component of it, which gets us back to food.
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  If your gut's constantly irritated, if you're finding
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  yourself after you eat having problems of bloating and
• 21:32
  discomfort, it behooves you to have your food inflammations
• 21:37
  testing performed and to modify your diet accordingly.
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  Not necessarily allergy to food. You may not have celiac sprue,
• 21:49
  you may not have a gluten allergy, but you may be gluten
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  sensitive. And if that's the case, anytime
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  there's chronic inflammatory irritation along the gut, you
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  got a risk increase. You're going to increase your
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  risk of cancer manifesting. So again, screening for colon
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  cancer is a little different than other malignancies.
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  I think it has a place. I think you should be cautious
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  about how it's done and how it's interpreted.
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  Don't like colonoscopies for screening purposes anymore.
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  It had its day, its day is done. I think the time is now to do
• 22:24
  safe screening stool and blood. Make that your first step.
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  A colonoscopy for diagnostic purposes.
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  If you're bleeding rectally, the stool test is not worth doing.
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  That's a whole nother pursued a whole nother pathway.
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  But for healthy folks that want to try to not get cancer or not
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  die from colon cancer, I think you should I think you should
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  put this on your To Do List. It's a place of merit prevention
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  always, you know, healthy living.
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  Yes. Why?
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  Because we don't want to wait around.
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  We don't want to wait around to get sick.
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  We want to be proactive. So we'll talk more about
• 23:05
  preventative measures and podcasts to come, but today I
• 23:08
  wanted to highlight screening and give you this information.
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  Remember, if you choose to get a colonoscopy, it's not the wrong
• 23:16
  choice. It's not the one I recommend,
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  but it's your body. You got to be comfortable.
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  Make sure you ask your doctor what the adenoma detection rate
• 23:25
  is. Be cautious about who you choose
• 23:28
  as your provider. And as far as the stool testing,
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  any doc can order that. Your primary care doc can order
• 23:34
  that for you. It's covered by most insurance
• 23:37
  blood testing, less broad coverage but hey it's only 200
• 23:40
  bucks. I would pay that to avoid a
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  colonoscopy every day. My team.
• 23:45
  Until next time, thanks for listening and we'll see you
• 23:48
  then.