Colon Cancer Screening by FOBT Only - Not Cadillac Care, but Good Enough for Government Work
September 15, 2011
By: Joe Callahan
Not all that that long ago I was representing a veteran in connection with a claim for delayed diagnosis of colon cancer. Like far too many vets, his VA primary care clinic had done a slap-dash job of providing regular colon cancer screening. Although he was 66 years old, he had never received or been offered a colonoscopy for purposes of cancer screening. Instead, once every couple of years his primary care clinic handed him a fecal occult blood testing (FOBT) kit to be completed at home. This consisted of a package of sample cards and an envelope. The enclosed instructions told him to observe dietary restrictions for several days, and then smear a small amount of his own stool from three successive bowel movements onto the sample cards. The cards were to be returned to the VA medical center’s lab by means of an enclosed envelope.
Over the years, my veteran client did his best to comply with these instructions, and he returned his samples as directed. All were evaluated and found to be negative for the presence of blood (which would signal the possible presence of a cancerous lesion). Meanwhile, he was busy dying from a relentlessly advancing colon cancer.
His disease was finally diagnosed when he reached age 65 and became eligible for Medicare. At that point he switched his primary care to the doc in his local neighborhood. In light of his age, his new doctor saw that he had never received a screening colonoscopy and ordered one immediately. That exam disclosed the presence of an advanced colon cancer which had obviously been present and undetected for several years. It eventually took his life.
Before he died, and after the VA had denied his administrative tort claim, we filed suit on this veteran’s behalf. Eventually it came time to hold a settlement conference. I recall being in a room at the Federal Courthouse with a lawyer from the VA, one from the Justice Department, the Federal Magistrate Judge, and my client. All of us present were males over age 50. As discussions progressed, it turned out that the only person there who had not been more or less automatically referred for colon cancer screening by colonoscopy was the dying veteran seated at my side. In due course we were able to obtain a substantial settlement.
For most of my own life I’ve been blessed with good health. For the first eight years after retiring from the Navy I don’t believe I visited my (private) doctor more than twice – and then for routine matters like flu or back ache. When I reached 50 years of age, however, I dutifully made an appointment for a comprehensive exam – thinking it was ‘the thing to do.’ My doctor noted my age and, among many other matters, asked about my family history for colon cancer. I told him there was none so far as I knew, but he still recommended that I schedule a colonoscopy for screening purposes. I did.
A few weeks later I reported to a local gastroenterology clinic for my colonoscopy. There was nothing to the exam itself (it felt like I blinked and missed it), although the stuff I had to drink as a bowel-prep beforehand tasted truly lousy. A week following the procedure, the doc who performed my exam called me and said that the three tiny polyps he had plucked out during the procedure had been identified by the lab as adenomas – and were potentially pre-cancerous. Not all adenomas grow into cancer, he explained, but enough of them do that I should be sure to undergo a repeat colonoscopy in three years. I did so, and since that second exam found no further polyps, I was told to get ‘scoped’ in future at five-year intervals. Ten years would have been the recommended interval for a repeat screening test if I had been clean as a whistle the first time around. Anyway, I’m about two years out from my next colonoscopy right now.
Most of the veterans I represent don’t have the option of private health care. In almost every case where I have filed claims on their behalf alleging negligent colon-cancer screening, they had been under the sole care of VA or military primary care clinics for a decade or more. None received colonoscopy, or were even offered it. Most received FOBT kits every so often, generally without much explanation as to their purpose, and with no idea of their limitations. In many cases the kits were simply handed out in an envelope or paper bag by the clinic receptionist on the way out of the office. Sort of like when we used to go to the barber shop as little kids and get a taffy on the way out if we behaved and didn’t fuss too much in the chair. In turn, my clients figured out how to sample and return their stools for analysis with varying degrees of success and compliance. When stool samples were returned they were sometimes lost or at least not evaluated and recorded by VA labs. Those samples which were returned were uniformly found to be “normal.” Meanwhile, all of these veterans were harboring developing cancers.
I look at their experience and I sometimes ask myself, if I had been in their shoes, and knowing that my local VA hospital would not have provided me with a screening colonoscopy at age 50, whether I would have gone on to become a victim of advanced colon cancer – but for the fortuitous removal of those polyps several years back. A voice in the back of my head tells me there’s a good chance I would not be alive to write this.
Medical authorities have long known that FOBT kits, while certainly better than no colon-cancer screening at all, are a poor substitute for colonoscopy. The reason for this is simple: FOBT kits are designed to detect traces of blood in one’s stool, but colon cancers don’t bleed continuously. Instead, the expectation (gamble, really) is that by taking three successive stool samples, and doing it every year, you are eventually going to show evidence of bleeding if cancer is indeed present in your GI tract.
Sadly, just as in the case of my client mentioned at the outset, pinning your life on that sort of random chance doesn’t always work out. Even in those cases where cancer is discovered as a result of a ‘positive’ fecal occult blood test (which should normally lead to colonoscopy if reasonable standards are observed), that discovery often comes too late to save the patient . This is true even though it is generally acknowledged to take as long as a decade for most colon cancers to progress from a tiny polyp to a life-threatening, metastatic mass.
Yes, colonoscopy can lead to serious complications in a tiny percentage of cases. Yes, colonoscopy is a lot more expensive than even several years’ worth of FOBT testing. If you put 1000 primary care doctors who have researched the subject in a ballroom and ask them whether FOBT alone is an acceptable means of colon cancer screening, a lot of them will raise their hands in agreement.
Still, I have never spoken to a doctor who was willing to swear that screening for colon cancer by means of FOBT alone was, objectively, a preferred option; or to one over age 50 who had not him/herself opted for cancer screening via colonoscopy. This is because at a personal level the good docs understand all too well that FOBT, while cheap and expedient, is so “non-specific” and random in its ability to catch cancer at an early, curable stage that it is only really effective when used in addition to periodic screening by colonoscopy.
Nonetheless, in the view of many health care organizations, screening for colon cancer by FOBT alone is a useful and acceptable practice since it has the potential to eventually discover the presence of cancer. What it doesn’t have is anything like the ability of colonoscopy to find many colon cancers at an early, curable stage – or like for me, in the pre-cancerous, no big deal stage.
Similarly, I have never found a VA or military service or Justice Department attorney willing to focus his expert witnesses’ testimony on the argument that government health care systems (such as the VA and military) shouldn’t be expected to provide the sort of ‘Cadillac care’ that folks with private insurance have come to expect, including colon cancer screening by colonoscopy. Government healthcare bean counters may think that, and the VA and military may shape their cancer screening guidelines accordingly, but their lawyers know not to stress that argument.
Commendably, it seems that at least some VA healthcare centers have recently started to provide colon cancer screening by colonoscopy for low-moderate risk patients, but the waiting list for those exams is long. The decision to undergo colon cancer screening by colonoscopy should be the product of an informed decision by the patient, based on reasonable (and candid) information from their primary care provider about the risks and benefits of various screening methods. If you are a low-to-moderate risk patient (which basically includes everybody age 50 and over with no family history for colon cancer) and conclude that you are in need of colon cancer screening by colonoscopy, there is no harm in asking that your VA health care provider refer you for a prompt screening colonoscopy. If they won’t, sound off. Let your VA medical center ombudsman, the chief of that facility’s medical staff, and your congressperson hear about it. The same goes double if you are a high-risk candidate for screening (blood relatives with colon cancer, or a personal history of colon polyps).
Finally, if you detect signs of rectal bleeding on toilet paper or in your stool, let your primary health care provider know about it ASAP, and ask them whether you should receive prompt colonoscopy for diagnostic (not screening) purposes in order to rule-out the presence of cancer.
Joe Callahan
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