"Nearly 45 percent of all individuals recommended for a colonoscopy ignore these guidelines, largely due to fear of the test."
Expensive colonoscopies that cost a patient over $1,000 on average could soon be replaced by simpler and much cheaper tests as non-invasive screening options become more available and more sophisticated.
In October, Cologuard became the first at-home stool test which detects cancerous and pre-cancerous DNA approved by the Centers for Medicare & Medicaid. The test, made by Exact Sciences, will be reimbursed at $502 per screening.
The fecal immunochemical test and the fecal occult blood test are much cheaper than that, and are provided or distributed by primary care providers and simply detect blood in stool as an indicator of colon polyps, while colonoscopies are invasive and carried out in gastroenterology clinics.
The FIT is especially convenient because patients don't have to restrict eating beforehand, and it can even be carried out at home and then mailed back to the clinic. It costs just $22 without insurance, but it's usually completely covered.
In addition to convenience, "the FIT test is a very sensitive test for colon polyps," said Pankaj Vashi, MD, national clinical director of gastroenterology, nutrition and metabolic support at Cancer Treatment Centers of America.
"Nearly 45 percent of all individuals recommended for a colonoscopy ignore these guidelines, largely due to fear of the test," said Vashi.
Kaiser Permanente conducted a study that found that colon cancer screenings increased by 40 percent when FITs were mailed to patients' homes. Kaiser Permanente also reported that the FIT detects about four out of five colon cancers.
Despite increases in screening due to the convenience and the low cost of these non-invasive tests, it looks like gastroenterology clinics need not worry about losing their colonoscopy business. Utilization of non-invasive tests is not recommended for every patient for first-time screening.
"Each screening test has a place depending upon patients' personal and family medical history," said Stephanie Guiffre, prevention and research director at the Colon Cancer Alliance.
Both Vashi and Guiffre emphasized that the FIT and FOBT are normally utilized for average risk patients. Using the tests for first time screening is also not recommended for symptomatic patients.
The FIT and FOBT are merely capable of detecting abnormalities and are not as comprehensive as the colonoscopy. They also do not have the diagnostic capability the colonoscopy provides.
"An FOBT detects blood in the upper gastrointestinal tract and an FIT detects blood in the lower gastrointestinal tract," said Guiffre. "A colonoscopy looks at the entire colon" and "if polyps are found they can be removed before they become cancer."
Nevertheless, Vashi said he "strongly believe[s] that these tests can play a role in helping to diagnosis colon cancer and that physicians, including primary care physicians, should take advantage of these non-invasive tests when appropriate for their patients."
"Offering a non-invasive test, such as the FOBT or FIT, can help increase the likelihood that patients with abnormal results will have a colonoscopy as follow up and improve overall compliance with screening recommendations," he said.
He also noted that the FOBT and FIT tests can be used to help identify people who may benefit from the more detailed exploration offered by a colonoscopy sooner than every 10 years, since they are meant to be repeated annually.
"At the end of the day, the best test is the one that gets done," said Guiffre. "There is enough business to be shared by both the GI and primary care practices."
Primary care providers can attract more patients by offering a simple test. If an abnormality is detected the patient is referred to a GI clinic for a follow up colonoscopy, and if colon cancer or polyps are found the patient can be treated immediately.