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Comment by paulpauper | Hacker News Reader

Yeah cancer is the big killer nowadays. Survival rates for stage 4 cancer still poor after many decades of research. Worse yet, in many instances there are no obvious risk factors, such as people in their 30s or 40s who get colon cancer and were not eligible for screening .

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Would screening improve the outcomes or just create more patients getting unnecessary treatment?

Catching colorectal cancer at an early stage improves survival rates tremendously. You have to weigh the risk of complications from the colonoscopy (primarily bowel perforation) with the improved outcomes. There's a cost element as well, since colonoscopies (without complications) can be several thousand dollars.

That's the calculations that go into screening guidelines. It's a lot of weighing now much benefit early detection provides vs how much harm testing and false positives do.

Guidelines do change however. When I first was diagnosed at age 41, my doctors were all pretty surprised due to my age. Not shocked, just surprised. Five years later, they were all pretty consistent in their views that the age guidelines should be lower, and that viewing colorectal cancer as something primarily limited to 50+ was outdated.

Yes, colorectal cancer screening is estimated to reduce colorectal cancer mortality by 50% to 73%.

https://pmc.ncbi.nlm.nih.gov/articles/PMC10093633/

https://www.nejm.org/doi/full/10.1056/NEJMoa2208375

Progressive screening using non-invasive assays like Cologuard and FIT is a valuable screening mode. The non-invasive assays are not perfect but they are improving.

What about overall mortality?

> not eligible for screening

Is this a thing? I thought I could walk into my PCP's office and schedule a screening any time, provided I may need to pay more out of pocket or something.

PCP is certainly not going to be the one doing the colonoscopy.

maybe they’d do the stool sample or some silly blood test if you are extremely insistent and can somehow demonstrate a risk factor.

I’ve dealt with a few PCPs and they seem less informed about their own area than a 30 sec google search.

They’re basically L6 tech support…

I read here (on Hacker News) that the stool test is actually really valuable and cheap enough to pay out of pocket prior to trying to justify an out-of-schedule colonoscopy.

Not to mention the prepare for a colonoscopy is not pleasant.

And colonoscopies are invasive procedures that have their own risks. Perforated bowel can turn this "routine" procedure into an emergency.

Gentle reminder for Australian folks here, you can get a bowel screening test kit for free, if you're between 45 - 74 years of age.

https://www.health.gov.au/our-work/national-bowel-cancer-scr...

Is it at home ones or ones that you send sample to get sequenced?

Colonoscopies here (midwestern US) are upwards of a couple thousand outside of the usual schedules enforced by insurance companies.

If there’s a complication they can easily skyrocket into the tens of thousands.

Most people around here can’t soak that.

Grandfather died of colon cancer at 43.

Went into my PCP at 40 asking for a colonoscopy, he said insurance wouldn’t cover it until I was 50.

…

Ask him to do a hemoccult (done in the office - doc sticks his finger up your a** and dabs it on a test material) or request a cologuard test (shit in a box at home and mail it to the lab! - loads of laughs driving cautiously to FEDEX!)

The hemoccult (FIT or FOBT) tests are <$100 and the cologuard ~$700. Your insurance will likely cover (esp. the hemoccult test) all the more if you tell doctor of your family background. Hemoccult tests were part of my routine annual physical for decades and there are no familial tendencies.

There are some caveats: e.g., avoid bloody foods in the days preceding these test (Chinese pigs' blood cubes, yummm!)

You shouldn't have to do this, but have you tried calling the colonoscopy practice and asking for a cash price? It might not be as expensive as you think.

Screenings are not risk-free. There are always some false positives which then may lead to more invasive and unnecessary tests or treatment. There are a lot of rare conditions (based on age and/or history) that we don't screen for on a routine basis.

that’s to be expected, after we do the adequate screening for one older population and mitigate many of the advanced versions of that, then the previously edge case becomes more prevalent amongst all cases

there is still a limited resource for the screening at this point, so that’s a friction to expanding screening

It's not just a question of scaling up the screening effort. Doctors are also concerned with potential harms caused by false positives.

What false positive would come out of a colonoscopy? You are visually looking for masses, and removing suspect polyps that are sent in for evaluation. The major potential harm of a colonoscopy is a bowel perforation. Serious complications occur roughly 0.3% of the time.

> Serious complications occur roughly 0.3% of the time.

https://www.cancer.org/cancer/types/colon-rectal-cancer/abou..., “the lifetime risk of developing colorectal cancer is about 1 in 24 for men and 1 in 26 for women.”

So, it’s a 4% lifetime risk versus a 0.3% per colonoscopy risk. The outcomes for the two risks also are different, but I would think that for many healthy people (e.g. those under 40 years old), the risk of doing such a check are greater than that of not taking it.

Reading https://en.wikipedia.org/wiki/Colorectal_cancer#Screening, that’s one of the reasons frequent colonoscopies aren’t advised.

As you said, the outcomes are wildly different. A 0.3% risk of colonoscopy complications vs missing out on catching a mass when it's relatively easy to treat.

No, heart disease still #1 (it's closer, like 680K vs 600K deaths)

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