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The New York Times

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July 12, 2005

Put Your Embarrassment Aside: Get the Colonoscopy

Mickey Martinez was a vigorous 64-year-old with a smashing smile and a backhand to match. Fluent in four languages, he devoted his professional life to public service and his personal life to being a good husband, father, grandfather and neighbor.

But there Mr. Martinez's good fortune ended. Although he saw a physician regularly, his doctor never prescribed a routine colonoscopy, an examination of the colon and rectum that can stop cancer, often even before it begins.

The American Cancer Society recommends the test at age 50 and again at age 60. But by the time Mr. Martinez realized something was not quite right with his digestive tract and had a colonoscopy, it was too late. Colon cancer had already invaded his liver.

A strong and otherwise healthy man, Mr. Martinez bounced back quickly from two major operations, tolerated three years of chemotherapy better than most people weather a bad cold and continued winning tennis tournaments. But eventually cancer claimed the ultimate victory.

Most colon cancers arise in an adenomatous polyp. It typically takes about 10 years for a benign polyp to become cancerous, and removing such polyps through colonoscopy can stop any cancer formation. More frequent exams - say, once every two years - are recommended for anyone found to have polyps or colon cancer and for those whose close relatives have had the disease.

To Vanquish a Major Killer

Though it commands far less attention than, say, cancers of the breast or prostate, colorectal cancer is the leading nonsmoking-related cancer killer of Americans. It is the third most common type of cancer and the second leading cause of cancer deaths. This year, the cancer society predicts, about 145,290 cases will be diagnosed and 56,290 people will die of it.

Both statistics represent needless deaths: this disease is largely preventable, and if diagnosed early, nearly always curable, often with surgery alone. Though there have been notable exceptions (Darryl Strawberry, for one), this cancer rarely occurs before age 50 in those without a family history. Over a lifetime, 1 person in 20 in the United States gets colorectal cancer; three-fourths have no known hereditary link.

But fewer than a third of Americans over 50 have ever had a colonoscopy, the test that can beat this cancer into the ground by finding the polyps that give rise to the disease.

The excuses made for avoiding the test - fear of discomfort, cost, inconvenience, embarrassment - are, in my view, lame. I speak from experience. At 63, I recently underwent my second screening colonoscopy. It was a painless outpatient procedure done under sedation, and my colon got a clean bill of health. I probably won't have to give it another thought for 10 years.

While colonoscopy is hardly my favorite medical exam, it is not half as challenging as most people who've never had one seem to think.

By far the worst part is the preparation - a thorough cleansing of the bowel so that the gastroenterologist can get a clear view of the lining of the entire large intestine.

For most patients, even the cleansing may now be less arduous than it once was. For my first exam five years ago, I was restricted to a diet of clear liquids and Jell-O for a day and had to consume a gallon of a laxative drink, staying close to a toilet for many hours.

But for the second exam, my pretest diet included yogurt and ice cream (without pieces), which assuaged my hunger, and the cleansing was stimulated by a glass of salty liquid midafternoon.

This is often enough to cleanse the bowel, though a second glass of the same foul-tasting drink may be needed the morning of the exam. (Hint: Hold your nose until the drink is down.)

There is no standard preparatory procedure, however.

As Dr. David A. Peura, president of the American Gastroenterological Association noted, different "preps" are prescribed by different doctors in different parts of the country.

Some doctors call for a restricted diet for three days, not one. Some insist on a total fast starting at midnight, while others allow liquids up to two to four hours before the exam. Avoid foods with lots of seeds for a few days before the exam and stop taking medications that can cause bleeding a week before. Also, do not drink anything red.

The gallon-size prep is often recommended for people with a sluggish colon and those who may experience ill effects from dehydration, like patients with kidney disease or congestive heart failure.

For healthy people, however, one or two doses of Fleet Phospho-Soda or its generic equivalent, followed by lots of clear liquids, is fine, he said.

"Most important," Dr. Peura emphasized, "is to comply with whatever prep is recommended. An inadequate prep can render the exam useless."

The exam itself involves insertion of a long, narrow flexible tube with a light at the end that allows the physician to view the lining of the entire colon and rectum on a screen.

If a suspicious area is detected, a biopsy instrument can be threaded through the tube to collect a tissue sample. If a polyp is found, it can be removed through the tube and the blood vessels cauterized to prevent bleeding.

The exam is usually done under sedation unless the patient requests otherwise (some like to watch the screen or go back to work right away) and can tolerate the discomfort. With sedation, administered intravenously, there is no discomfort. Both times I dozed off just as the exam began.

Throughout the test, which generally takes 20 to 30 minutes, the anesthesiologist monitors blood pressure and oxygen level. For patients who are sedated, about an hour is spent in recovery; then, someone must take them home. The cost, about $1,500 to $2,000, is covered by Medicare and most health insurers.

A Virtual Alternative

Much publicity has been given of late to what is called a virtual colonoscopy - an examination of the colon done via a CT scan (or, sometimes, an M.R.I.). Since no tube is inserted, there is no discomfort or need for sedation. There is also no risk of complications, like a reaction to the sedative, excessive bleeding or accidental perforation of the colon, which occurs in about 1 exam in 1,000. But the CT scan involves exposure to a lot of radiation.

There are other downsides. The most unpleasant part of a colonoscopy, the prep, is necessary as well when undergoing a virtual exam. And if any abnormality is suspected, a regular colonoscopy, along with a second prep, will have to be done so that tissue samples can be taken or polyps removed.

Furthermore, Dr. Peura said: "Virtual colonoscopy hasn't yet reached prime time throughout the country. Most institutions don't have the equipment needed to do a high-quality exam, and more radiologists have to be trained in interpreting the results." And since it is considered experimental, the costs are not yet covered by insurers.

Still, Dr. Peura expects a day when virtual colonoscopy will be the screening method of choice, as well as a time when no bowel cleansing will be needed before the exam. "Patients may be able to drink a substance that permeates the stool and the computer can subtract that material, leaving a clean image of the colon," he explained.

Jane E. Brody can be reached at