Removing Colonoscopy Misconceptions with Dr. Joshua Evans

Colonoscopies are one of the most powerful tools we have in the fight against colon cancer, yet many patients are putting them off due to a few major misconceptions. Dr. Josh Evans is a Nebraska gastroenterology specialist and the President of the Great Plains Colon Cancer Task Force. In this interview, he shares the latest information about colonoscopy prep, procedure, and policies to help remove colonoscopy misconceptions and empower patients with accurate and powerful information.

Prepping for a Colonoscopy 

Myth #1: You have to drink 4 L of prep the day before your procedure in order to have a clean colon. 

Busted: There are now more powerful, lower-volume bowel preparations that require the patient to drink less volume in order to cleanse the bowel prior to colonoscopy.

Dr. Evans has heard all too many times from his colonoscopy patients that going through prep is a difficult experience. Some patients actually put off this potentially life-saving procedure to avoid drinking the 4 liters of “swamp water,” as he refers to the standard 4 liter bowel preparation.

While some doctors still prefer the higher volume of prep to ensure a clean colon, especially if the patient has chronic constipation, newer prep solutions are more palatable and require less liquid to get the job done. One option is very affordable for patients, and requires only two over-the-counter pills and two 32 oz. bottles of Gatorade. Each bottle can be drunk separately, one the day before the procedure and one the day of, which solves the major patient aversion of consuming 4 L of prep in a single day. 

The second option is more expensive regarding out-of-pocket costs to patients, reportedly costing between $100-$200, but requires only one liter of prep solution. If a patient chooses this prep option, it’s still important that they drink plenty of water or other clear liquids before the procedure to ensure a clean colon. 

“One of the worst conversations to have with a patient following a colonoscopy is telling them that their colon wasn’t clean enough and that the procedure will need to be repeated.” The purpose of prep is to ensure that the bowel is clean enough for the scope to identify small, precancerous polyps. No matter which prep solution you choose, drinking a substantial amount of clear liquids is an important aspect of preparing for your colonoscopy.

“I explain to patients that although the bowel preparation is not always pleasant, it is far better than chemotherapy and having a portion of your colon removed, or possibly having to wear a colostomy bag for the rest of your life.”

Procedure 

Myth #2: Colonoscopies are looking for colon cancer.

Busted: Most colonoscopies are a preventative procedure looking for precancerous polyps, which typically take 7-10 years to become colon cancer.

Dr. Evans often has patients who have been dreading their colonoscopy because they’re under the impression that the procedure is looking for an existing cancer. However, most colonoscopies are “preventative” which is important to distinguish to patients. “A lot of patients ‘exhale’ when I clarify that I’m not looking for cancer, but preventing it.”

Many patients don't fully realize how a colonoscopy can prevent colon cancer entirely. “This is truly unique in medicine.” Dr. Evans explains. “Most screening tests, such as mammograms, look for cancers that are already there - but hope to catch them in their early stages. Colonoscopies actually can remove precancerous lesions (polyps) before they turn into cancer.”

Because colonoscopies are capable of preventing over 90% of colon cancer occurrences by removing precancerous polyps, educating patients on the purpose of regular colonoscopies is an important motivator to help them take a more active approach to their preventative care.

It’s also important to communicate expectations about the results of screening tests to patients. One of the many screening options currently available is Cologuard, who has reported that only 3.7% of their positive tests actually result in colon cancer being found in the following diagnostic colonoscopy. Helping patients understand this risk of false positives in screening tests will help reduce anxieties around colonoscopies.

Policy 

Myth #3: For average risk patients, regular colonoscopies should only begin at age 50.

Busted: For over a decade, leading health organizations have been recommending that regular colonoscopies for average risk patients begin at age 45. 

The US Preventive Services Task Force recently accepted the recommendation to lower the age of colonoscopy screenings in individual, average-risk patients from 50 to 45. This change in policy is a monumental win for the American Cancer Society, the American College of Gastroenterology, and many more health organizations who have been advocating that this preventive procedure be available to younger patients for over a decade. 

Insurance coverage is a large cost-barrier to getting a colonoscopy before the officially recommended age of 50, which has been known to disproportionately affect African Americans because they often present with a later stage of the disease at younger ages at the time of diagnosis. It's anticipated that most insurances will cover 45 year old colonoscopy patients when this policy is adopted later this calendar year.

“We’re seeing more younger patients with polyps… It remains to be seen whether we’ll see a decrease or increase in colon cancer incidence when this policy is adopted, depending on which type of test is recommended first.” Dr. Evans explains that cancer screening tests, like mammograms for breast cancer, increase the reported incidences of that type of cancer because they’re meant to catch the disease in its early stages. Colonoscopies are preventative tests, meaning that they can reduce the reported occurrences of colon cancer in patients under 50 by removing precancerous polyps. 

For health organizations communicating colon cancer information to patients, understanding how this policy change could impact trends in reported colon cancer occurrences is an important aspect of educating patients with accurate messaging.

Prevention:

Myth #4: If you’re healthy and don’t have a family history, you aren’t at risk for colon cancer.

Busted: Colon cancer is an “equal opportunity disease.”

While there are some trends seen in occurrences of polyps - such as diets heavy in red meat, obesity, and diabetes - the cause of colon cancer remains undetermined. Every day, Dr. Evans sees patients who had no symptoms prior to diagnosis. “The number one symptom of colon cancer is nothing.” It’s important to note that the vast majority of patients who do develop colon cancer have absolutely no family history of colon cancer.

So misconceptions about colon cancer risk factors like gender, overall health, and family history have become barriers to getting patients in for preventive colonoscopies. Dr. Evans emphasises that “the biggest modifiable risk factor for colon cancer is the failure to get a colonoscopy.”  Dr. Evans explains that “The latest data shows that at least 90% of colon cancers are preventable, if the patient had had routine colonoscopies.”

Nothing can decrease the risk of colon cancer as much as getting a colonoscopy, and reducing the stigmas around this life-saving procedure through patient education is one of the most powerful ways we can fight back against the disease.