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Perspective | Health Care Reform

Ascertaining Costs and Benefits of Colonoscopy More Difficult Than the Procedure Itself

Michael F. Cannon, MA, JM1
[+] Author Affiliations
1Health Policy Studies, Cato Institute, Washington, DC
JAMA Intern Med. 2016;176(8):1055-1056. doi:10.1001/jamainternmed.2016.3292.
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My grandfather died of colorectal cancer when my mother was 13 years old, a catastrophic event that tore his family apart.1 When I was a child and even a young adult, his death seemed to me more an abstraction than a tragedy that unfolded slowly, devastating people I love.

Things change. In my 20s, I saw up close what this illness does to its middle-aged victims and their families. In my 30s, I watched my father-in-law suffer in much the same way before saying good-bye to his daughters and grandchildren. And after decades of watching young faces turn slowly into old ones, I started to see, in my mother, a girl who lost the most important man in her life just as she was about to enter high school, a girl who was then uprooted and sent to live 200 miles from home.

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Costs and Benefits of Colonoscopy
Posted on August 2, 2016
Stephen B. Strum MD
Internist & Medical Oncologist
Conflict of Interest: None Declared
Practicing cancer medicine for over 40 years yields perspective to keen observers having front-line patient experience and consistent reading of the peer-reviewed literature. All of the points Cannon has raised regarding about costs incurred to the patient are routinely faced by anyone with a medical condition. Medicine has devolved into big business, with the annual cost per individual in the United States being over $10,000, a 5.5% increase in national health spending in 2015 having a price tag of $3.2 trillion (Keehan SP, Poisal JA, Cuckler GA, et al: National Health Expenditure Projections, 2015-25: Economy, Prices, And Aging Expected To Shape Spending And Enrollment. Health Aff, 2016.)

With the above said, I absolutely concur with Cannon that family history of cancer i.e. context of the patient, should alter the medical strategy insofar as: what physicians discuss with family members, how we might emphasize various aspects of the review of systems, physical examination, lab & imaging testing. My approach to patients involves what I call the Achilles heel assessment-- what could harm or end the life of this particular patient. In Cannon's case, a discussion of diet & the importance of fiber, preventative use of specific drugs like NSAIDs or Sulindac associated with a decrease in colorectal cancer, an annual rectal examination with lab testing for occult blood using FIT (fecal immunological test) or abnormal DNA in the stool (Cologuard). A recent patient in my practice had a family history of pancreatic, breast, lung and melanoma, but no physician suggested any pro-active measures which could also have included genetic testing. He was diagnosed with node positive colon cancer & underwent surgery, chemotherapy and radiation. He was placed on testosterone for hypogonadism and despite serial increases in PSA and the aforementioned history was diagnosed with advanced prostate cancer with bone metastases. Yet this patient had been evaluated in major academic centers in Boston.

In Cannon's case history he did not mention the pathology findings of the sessile polyp removed. Was it a tubular adenoma or and adenomatous polyp? Both are premalignant lesions, that over time can progress to malignancy. Or was it a hyperplastic polyp that has no association with malignant transformation.

All of us, physicians, organizations like the USPSTF, and patients have one thing in common: we get too soon old and too late smart. We do not learn that prevention is the best medicine. We do not learn the downsides of being penny-wise and life foolish. We do not learn how valuable each life is, that this should be the prime directive for all involved in sincere health care, and far more important than taking the patient to the proverbial cleaners.
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