5 ms·

My doctor recommended a combination FIT+DNA test instead of colonoscopy (brand name "Cologuard"). She said it's not quite as good as the "gold standard" colonos

by panarky 5mo ago

My doctor recommended a combination FIT+DNA test instead of colonoscopy (brand name "Cologuard"). She said it's not quite as good as the "gold standard" colonoscopy, but it also doesn't have the risks of colonoscopy. And the FIT+DNA test is so cheap and easy, you can do it every year or three instead of every 10 years with the colonoscopy. She still recommends colonoscopies for high-risk patients, but she thinks the risks outweigh the benefits for low-risk patients, so she recommends Cologuard in those situations. I appreciate this risk-adjusted and probabilistic approach rather than one-size-fits all recommendations.

antinomicus 5mo ago
Risks? The risks of a colonoscopy are crazy low though.
- amanaplanacanal 5mo ago
  There is still the rush of perferating the colon, but I assume it doesn't happen very often. Cologuard has got to be cheaper though.
  - newtonianrules 5mo ago
    [dead]
- ramesh31 5mo ago
  >"Risks? The risks of a colonoscopy are crazy low though." Not at the statistical level. Death rate from complications is about 1 in 10,000: https://www.endoscopy-campus.com/ec-news/risk-of-death-from-colonoscopy-in-a-fit-positive-program/ https://www.endoscopy-campus.com/ec-news/risk-of-death-from-...
  - panarky 5mo ago
    The risk of serious complications like major bleeding or perforation is closer to 40-80 per 10,000, significantly higher than the roughly 3-5 per 10,000 annual chance of actually having colorectal cancer for low-risk groups. My doctor says that since Cologuard catches a large percentage of those 3-5 per 10,000 without any of the colonoscopy risk, the marginal benefits from colonoscopy really aren't justified since FIT+DNA testing is almost as good, at least for low-risk cohorts. Very few things in medicine are zero risk. I wish more doctors would help balance the risk of doing A vs. the risk of doing B vs. the risk of doing nothing. It's all Bayesian conditional probabilities, considering your own individual risk factors, and considering the false positive rate and false negative rate of each test.
    - bonsai_spool 5mo ago
      > The risk of serious complications like major bleeding or perforation is closer to 40-80 per 10,000 What's your reference for this? That's incredibly (read, unbelievable) high for a routine procedure.
      - genewitch 5mo ago
        not who you asked but the perforation is 3-5 per 10,000; cardiovascular issues is 52 per 10,000, polyp removal carries risks of bleeding or perforation, and underlying patient physiology. RESULTS Among the 30,818 records identified, 82 population-based studies from 24 countries were included, involving a total of 38.5 million colonoscopies. The estimated incidence per 10,000 colonoscopies was as follows: gastrointestinal AEs, including perforation (5.15; 95% confidence interval [CI] 4.19-6.34, I2 = 99%), bleeding (18.39; 95% CI 13.53-24.99, I2 = 100%), and splenic injury (0.61; 95% CI 0.43-0.85, I2 = 93%); nongastrointestinal AEs, including cardiovascular events (52.11; 95% CI 18.67-144.59, I2 = 100%), respiratory events (4.26; 95% CI 0.73-24.99, I2 = 100%), and deaths related to colonoscopy (0.18; 95% CI 0.10-0.34, I2 = 74%). Subgroup analyses yielded partially divergent findings. The majority of the included studies exhibited a low to moderate risk of bias. just ask any AI, i don't got time to play tic-tac-toe with the NIH.gov website gating me behind click bus images for 10 minutes
        bonsai_spool 5mo ago
        You are hardly describing "serious complications" ('bleeding', and 'respiratory events' are very non specific, and the fact that this is an uncited meta-analysis across nations makes the whole enterprise suspect), even less so since your source averages 24 countries while we are speaking about US colonoscopy recommendations. My source is not seeing one perforation each week at work. > just ask any AI These do not give reliable answers, as I am sure you know
        genewitch 5mo ago
        they give citations which i was going through and literally copied and pasted the CITE to you, not the AI. i only answered the specific question of where the number "48" or the range 40-80 came from. my cite even shows perforations are 3-5 per 10000 so i don't know what you're on me about
  - bonsai_spool 5mo ago
    >>"Risks? The risks of a colonoscopy are crazy low though." > Not at the statistical level. Death rate from complications is about 1 in 10,000: THAT IS NOT what this paper says. Please avoid commenting about things that you do not understand! Here is the actual article: https://www.cghjournal.org/article/S1542-3565(20)31076-4/fulltext https://www.cghjournal.org/article/S1542-3565(20)31076-4/ful... First, the study looks at people who had a positive screening Cologuard/FIT test. These are not normal people! Second, the test looks at DEATHS WITHIN THIRTY DAYS of the procedure. In fact, the article goes on to say that there are ZERO deaths related to the actual procedure. ZERO.
  - m3047 5mo ago
    This is funny. I've had an unbelievable string of bad doctors / clinics... almost as though something is wrong with medical care around here. Couple of years ago the latest doctor who I fired started talking colonoscopies. I asked some basic questions like how do they get paid? How much do they get paid? Who inspects their facilities? He took great umbrage at the notion that the doctors were getting "bounties" for nipping pieces of tissue for lab review, refused to discuss that. (Tell me you know something without telling me you know something.) He also took umbrage at the notion that his clinic wasn't "clean" and that it was inspected regularly... didn't say by whom. So here's the deal. Here in Washington State, USA his clinic gets a "wet work" inspection, just like a slaughterhouse or restaurant, as part of the occupancy / doing business license. But there is no ongoing inspection, and fuck no there is no "safe to eat here" poster in the window of his clinic. It gets more interesting when you start looking at the datasets an inquiry like that turns up. Like: how many deaths / hospitalizations are there per 1K procedures? Actuarily we have a number. Now clinics, at least the ones doing things on a regular basis, have to report adverse events leading to hospitalization: the reporting rate is impossibly lower than the actuarial rate, complications leading to hospitalization are not being reported. But.. there's more! The State collects "foreign contamination" stats from pathologists; you can look at this by pathologist, if they do enough of them. The majority of pathologists scoring colonoscopy samples report ZERO foreign contamination; among the pathologists actually reporting, the rate for presence of foreign contamination is around 25%.
    - kelvinjps10 5mo ago
      What is your point?
      - deleted 5mo ago
        [deleted]
    - boppo1 5mo ago
      What an interesting and obvious approach, wish I'd thought of it. Tell me more about your inquiry for the answers the doctor avoided.
- deleted 5mo ago
  [deleted]
- NotGMan 5mo ago
  2 to 3 colonoscopies per ~1k to 2k people cause severe rupture of the intestines that require urgent surgery.
- aprdm 5mo ago
  They are until they aren't. My grandmother had a puncture and almost died
  - newtonianrules 5mo ago
    [dead]
- goosejuice 5mo ago
  The risk is the primary reason the age for first colonoscopy is so high. Even with cologuard it's not typical before 40 unless you have family history. There's also risks of false positives/negatives for some tests which complicate matters as well.
  - bonsai_spool 5mo ago
    > The risk is the primary reason the age for first colonoscopy is so high What? I have a hard time understanding this, what is your primary reference. Colonoscopies take a lot of resources and GI docs are in high demand—these seem much more plausible limiting factors than undefined 'risks' inherent to the procedure.
    - goosejuice 5mo ago
      Those are also factors for sure, but the the risks from complications aren't undefined. Even cheap and non invasive screening carry risk due to false positives inviting unnecessary downstream procedures. Not an MD but have worked in cancer prevention for a while in a software capacity. See figure 5 https://pubmed.ncbi.nlm.nih.gov/34003219/ https://pubmed.ncbi.nlm.nih.gov/34003219/
      - bonsai_spool 5mo ago
        > https://pmc.ncbi.nlm.nih.gov/articles/PMC8409520/figure/F5/ https://pmc.ncbi.nlm.nih.gov/articles/PMC8409520/figure/F5/ You can link to the figures directly for PMC articles. My point is that the risks aren't the limit for how we think about testing (though they exist), but instead the low marginal improvement in diagnostic yield and life expectancy.
- Double_a_92 5mo ago
  I remember reading somewhere that the highest risk is you falling off the table while you are sedated.
jghn 5mo ago
The main issue with those tests is they have a relatively high false positive rate. If you pop on that one you need to follow up with a colonoscopy to confirm. The big issue has been that in the US, the followup colonoscopy was often no longer covered by insurance as it was no longer classified as part of the preventative medicine tier, and instead was now a different sort of procedure. My understanding is that this is no longer true though.
- genewitch 5mo ago
  my PCP thinks i am over 50 twice a year and mentions i should get one, and he knows i won't pay for anything, so that means my insurance covers it. This is anecdote by induction.
- xocnad 5mo ago
  Got burned by exactly this when on a high deductible HSA plan.
deaton 5mo ago
Kinda annoying that the minimum age is 45 and its explicitly not for high risk individuals though. Like you would think having a non-invasive test would be incredibly important for that.

by panarky 5mo ago

antinomicus 5mo ago

Risks? The risks of a colonoscopy are crazy low though.

amanaplanacanal 5mo ago
There is still the rush of perferating the colon, but I assume it doesn't happen very often. Cologuard has got to be cheaper though.
- newtonianrules 5mo ago
  [dead]
ramesh31 5mo ago
>"Risks? The risks of a colonoscopy are crazy low though." Not at the statistical level. Death rate from complications is about 1 in 10,000: https://www.endoscopy-campus.com/ec-news/risk-of-death-from-colonoscopy-in-a-fit-positive-program/ https://www.endoscopy-campus.com/ec-news/risk-of-death-from-...
- panarky 5mo ago
  The risk of serious complications like major bleeding or perforation is closer to 40-80 per 10,000, significantly higher than the roughly 3-5 per 10,000 annual chance of actually having colorectal cancer for low-risk groups. My doctor says that since Cologuard catches a large percentage of those 3-5 per 10,000 without any of the colonoscopy risk, the marginal benefits from colonoscopy really aren't justified since FIT+DNA testing is almost as good, at least for low-risk cohorts. Very few things in medicine are zero risk. I wish more doctors would help balance the risk of doing A vs. the risk of doing B vs. the risk of doing nothing. It's all Bayesian conditional probabilities, considering your own individual risk factors, and considering the false positive rate and false negative rate of each test.
  - bonsai_spool 5mo ago
    > The risk of serious complications like major bleeding or perforation is closer to 40-80 per 10,000 What's your reference for this? That's incredibly (read, unbelievable) high for a routine procedure.
    - genewitch 5mo ago
      not who you asked but the perforation is 3-5 per 10,000; cardiovascular issues is 52 per 10,000, polyp removal carries risks of bleeding or perforation, and underlying patient physiology. RESULTS Among the 30,818 records identified, 82 population-based studies from 24 countries were included, involving a total of 38.5 million colonoscopies. The estimated incidence per 10,000 colonoscopies was as follows: gastrointestinal AEs, including perforation (5.15; 95% confidence interval [CI] 4.19-6.34, I2 = 99%), bleeding (18.39; 95% CI 13.53-24.99, I2 = 100%), and splenic injury (0.61; 95% CI 0.43-0.85, I2 = 93%); nongastrointestinal AEs, including cardiovascular events (52.11; 95% CI 18.67-144.59, I2 = 100%), respiratory events (4.26; 95% CI 0.73-24.99, I2 = 100%), and deaths related to colonoscopy (0.18; 95% CI 0.10-0.34, I2 = 74%). Subgroup analyses yielded partially divergent findings. The majority of the included studies exhibited a low to moderate risk of bias. just ask any AI, i don't got time to play tic-tac-toe with the NIH.gov website gating me behind click bus images for 10 minutes
      - bonsai_spool 5mo ago
        You are hardly describing "serious complications" ('bleeding', and 'respiratory events' are very non specific, and the fact that this is an uncited meta-analysis across nations makes the whole enterprise suspect), even less so since your source averages 24 countries while we are speaking about US colonoscopy recommendations. My source is not seeing one perforation each week at work. > just ask any AI These do not give reliable answers, as I am sure you know
        genewitch 5mo ago
        they give citations which i was going through and literally copied and pasted the CITE to you, not the AI. i only answered the specific question of where the number "48" or the range 40-80 came from. my cite even shows perforations are 3-5 per 10000 so i don't know what you're on me about
- bonsai_spool 5mo ago
  >>"Risks? The risks of a colonoscopy are crazy low though." > Not at the statistical level. Death rate from complications is about 1 in 10,000: THAT IS NOT what this paper says. Please avoid commenting about things that you do not understand! Here is the actual article: https://www.cghjournal.org/article/S1542-3565(20)31076-4/fulltext https://www.cghjournal.org/article/S1542-3565(20)31076-4/ful... First, the study looks at people who had a positive screening Cologuard/FIT test. These are not normal people! Second, the test looks at DEATHS WITHIN THIRTY DAYS of the procedure. In fact, the article goes on to say that there are ZERO deaths related to the actual procedure. ZERO.
- m3047 5mo ago
  This is funny. I've had an unbelievable string of bad doctors / clinics... almost as though something is wrong with medical care around here. Couple of years ago the latest doctor who I fired started talking colonoscopies. I asked some basic questions like how do they get paid? How much do they get paid? Who inspects their facilities? He took great umbrage at the notion that the doctors were getting "bounties" for nipping pieces of tissue for lab review, refused to discuss that. (Tell me you know something without telling me you know something.) He also took umbrage at the notion that his clinic wasn't "clean" and that it was inspected regularly... didn't say by whom. So here's the deal. Here in Washington State, USA his clinic gets a "wet work" inspection, just like a slaughterhouse or restaurant, as part of the occupancy / doing business license. But there is no ongoing inspection, and fuck no there is no "safe to eat here" poster in the window of his clinic. It gets more interesting when you start looking at the datasets an inquiry like that turns up. Like: how many deaths / hospitalizations are there per 1K procedures? Actuarily we have a number. Now clinics, at least the ones doing things on a regular basis, have to report adverse events leading to hospitalization: the reporting rate is impossibly lower than the actuarial rate, complications leading to hospitalization are not being reported. But.. there's more! The State collects "foreign contamination" stats from pathologists; you can look at this by pathologist, if they do enough of them. The majority of pathologists scoring colonoscopy samples report ZERO foreign contamination; among the pathologists actually reporting, the rate for presence of foreign contamination is around 25%.
  - kelvinjps10 5mo ago
    What is your point?
    - deleted 5mo ago
      [deleted]
  - boppo1 5mo ago
    What an interesting and obvious approach, wish I'd thought of it. Tell me more about your inquiry for the answers the doctor avoided.
deleted 5mo ago
[deleted]
NotGMan 5mo ago
2 to 3 colonoscopies per ~1k to 2k people cause severe rupture of the intestines that require urgent surgery.
aprdm 5mo ago
They are until they aren't. My grandmother had a puncture and almost died
- newtonianrules 5mo ago
  [dead]
goosejuice 5mo ago
The risk is the primary reason the age for first colonoscopy is so high. Even with cologuard it's not typical before 40 unless you have family history. There's also risks of false positives/negatives for some tests which complicate matters as well.
- bonsai_spool 5mo ago
  > The risk is the primary reason the age for first colonoscopy is so high What? I have a hard time understanding this, what is your primary reference. Colonoscopies take a lot of resources and GI docs are in high demand—these seem much more plausible limiting factors than undefined 'risks' inherent to the procedure.
  - goosejuice 5mo ago
    Those are also factors for sure, but the the risks from complications aren't undefined. Even cheap and non invasive screening carry risk due to false positives inviting unnecessary downstream procedures. Not an MD but have worked in cancer prevention for a while in a software capacity. See figure 5 https://pubmed.ncbi.nlm.nih.gov/34003219/ https://pubmed.ncbi.nlm.nih.gov/34003219/
    - bonsai_spool 5mo ago
      > https://pmc.ncbi.nlm.nih.gov/articles/PMC8409520/figure/F5/ https://pmc.ncbi.nlm.nih.gov/articles/PMC8409520/figure/F5/ You can link to the figures directly for PMC articles. My point is that the risks aren't the limit for how we think about testing (though they exist), but instead the low marginal improvement in diagnostic yield and life expectancy.
Double_a_92 5mo ago
I remember reading somewhere that the highest risk is you falling off the table while you are sedated.

jghn 5mo ago

The main issue with those tests is they have a relatively high false positive rate. If you pop on that one you need to follow up with a colonoscopy to confirm. The big issue has been that in the US, the followup colonoscopy was often no longer covered by insurance as it was no longer classified as part of the preventative medicine tier, and instead was now a different sort of procedure. My understanding is that this is no longer true though.

genewitch 5mo ago
my PCP thinks i am over 50 twice a year and mentions i should get one, and he knows i won't pay for anything, so that means my insurance covers it. This is anecdote by induction.
xocnad 5mo ago
Got burned by exactly this when on a high deductible HSA plan.

deaton 5mo ago

Kinda annoying that the minimum age is 45 and its explicitly not for high risk individuals though. Like you would think having a non-invasive test would be incredibly important for that.