Better, Saver And Cheaper Than Colonoscopy

Colorectal cancer is the 3rd commonest cancer in North America. The media often mention colonoscopy as the best screening test for this cancer and its pre-cursor (polyp - more precisely adenomatous polyp). However, there is a test which is better, saver and cheaper. It is the barium enema. However, this test is almost always ignored by the media.

REASONS FOR THE PREJUDICE:
- MEDIA HYPE: Colonoscopy is sexy (this adjective was used by Dr. Ping Y, an urologist) whereas barium enema is often the butt of jokes. If a well known Canadian politician undergoes a colonoscopy it will be reported on CBC and CTV whereas if the test is a barium enema it won’t even make it in a free week-end newspaper.
- PRICE/PAY CONTROL: Under the Canadian public healthcare system colonoscopy is relatively well paid whereas barium enema is poorly remunerated. For this reason, colonoscopy is welcomed by most gastroenterologists whereas barium enema is shunned by many radiologists. Additionally, obtaining high quality X-ray images can be exhausting both intellectually as well as physically. The return is not worth the effort. Consequently, most X-ray offices stop performing barium enema especially in British Columbia.
- AMNESIA: Horror stories related to colonoscopy are seldom talked about whereas discomfort of barium enemas is often a topic of conversation. Colonoscopy is performed under heavy sedation and patients have totally amnesia of the discomfort whereas they do remember cramps induced by the introduction of barium into the colon.

COLORECTAL CANCER/POLYP DETECTION:
- Recent studies revealed (also reported by CTV on December 15, 2008) colonoscopy has false negative rates of 30% in the left colon and 100% in the right colon.
- To date, the efficacy of CT colonography (a.k.a. virtual colonoscopy) has not been accurately determined.
- There are two varieties of barium enema: 1. Double contrast exam. 2. Fluoroscopic exam (single contrast with vigorous compression). Each has a false negative rate of 10 to 15% for the entire colon. Over 35 years of personal experience tells me the double contrast exam has a false negative rate of slightly less than 10% in the left colon and the fluoroscopic exam has a false negative rate of well below 10% in the right colon.
- Performing a double contrast exam is intellectually challenging but is only minimally demanding physically. Performing a fluoroscopic exam is extremely physically exhausting if performed properly. Every inch of the colon has to be compressed vigorously at least twice - when slightly filled and fully distended.
- I personally opt for the double contrast exam on almost every adult patient. Images are scrutinized before the patient is taken off the table. If every inch of the colon is definitely normal or an abnormality is unequivocally demonstrated, the examination is terminated. If there is any doubt regarding the absence/presence of an abnormality, the barium is drained back into the bag and warm water is added to thin the mixture down to the optimal density for a fluoroscopic exam. Vigorous compression is applied to the suspicious area as well as to every inch of the right colon, irrespective of the presence/absence of an abnormality in this segment of the colon.

WELL KEPT SECRETS OF COLONOSCOPY:
- The high false negative rate is routinely denied by gastroenterologists with few exceptions until recently.
- Serious complication/death rate is high being 1/1,000 as compared to 2/1,000,000 or less for barium enema.
- There are complications associated with the heavy sedation being 1/10,000 as compared to nil for barium enema.
- About 25% of colonoscopies are incomplete/failed exams due to technical factors.
- Incomplete/failed cases are rarely followed up. During a period of over 35 years, I have heard of only 2 cases that the patient was referred by a gastroenterologist for a supplementary barium enema after an incomplete/failed colonoscopy.
- Gastroenterologists often argue that if a polyp is found it can be removed at the same sitting. However, due to the high incomplete/failed rate of colonoscopy, 25% of the cases should have a second exam - barium enema. If a barium enema is performed first only 12 % of the patients require a second procedure - colonoscopy for polypectomy.
- Sodium phosphates oral solution is usually used as preparation for colonoscopy. This is sometimes followed by acute renal failure and decade-long delayed chronic renal impairment. Magnesium citrate (and bisacodyl) is usually used for preparartion of a barium enema. Few serious side effects have been reported.

SOLUTION:
- A barium enema should be performed prior to a colonoscopy.
- Legalize the setting up of a private system in Canada. And, vice versa for countries with only a private system. Let the two systems compete freely with each other. It is believed by many that if a private system is not prohibited, all the good doctors in Canada will go to the private system and only the bad ones will be left in the public system. However, before the Medical Care Act of 1966, Canada had both public and private hospitals as well as public and private doctors. The cutting edge equipments were all in public hospitals and the doctors with the state of the art knowledge/skills practiced mainly in public hospitals. The success the Medical Care Act of 1966, if any, is built on the demise of free market system. WITH DUE RESPECT, PRESIDENT OBAMA YOU HAVE IT ALL WRONG, IF YOU ARE CONTEMPLATING TO COPY THE CANADIAN SYSTEM. This opinion is similar to that of Dr. Brian Day, 2007-2008 president of the Canadian Medical Association.

SPECIAL NOTES:
This article is dedicated to Ms. Wen M (wife of my good friend, Dr. Tommy Y) who was found to have an obstructing carcinoma of the sigmoid during a trip overseas. She had a colonoscopy 4 years earlier as well as 2 flexible sigmoidoscopies (left-sided colonoscopies) within 18 months prior to the trip (all performed in Canada).

Thanks to Dr. Tony M for talking me to come out of retirement to contribute to the care that few radiologists in British Columbia are passionate about. It has been proven to be very beneficial to my "brain age". Special thanks to Dr. Julian L for allowing me to use up overhead (in terms of technician and room time) well in excess of what the British Columbia system would pay for.

OPEN CHALLENGE TO ALL GASTROENTEROLOGISTS:
If you disagree with any of my assertions above, please send rebuttal to "Comments" of this article or post a new free email address there. Do NOT use your regular address. I will respond to all reasonable rebuttals.