Category Archives: Colon Cancer

Increased physical activity associated with lower risk of 13 types of cancer


Running shoes full shotFrom the National Institutes of Health

A new study of the relationship between physical activity and cancer has shown that greater levels of leisure-time physical activity were associated with a lower risk of developing 13 different types of cancer.

The risk of developing seven cancer types was 20 percent (or more) lower among the most active participants (90th percentile of activity) as compared with the least active participants (10th percentile of activity). Continue reading


Medicare payment changes lead more men to get colonoscopies


Illustration of the colon from Gray's AnatomyBy Michelle Andrews

Medicare Payment Changes Lead More Men To Get Screening Colonoscopies

Men are getting more screening colonoscopies since the health law reduced how much Medicare beneficiaries pay out of pocket for the preventive tests, a recent study found. The change, however, didn’t affect women’s rates.

, published in the December issue of Health Affairs, compared rates of screening for colorectal cancer among people age 66 to 75 before and after the health law passed in 2010.

Starting in 2011, that law waived the Medicare Part B deductible (which totals $147 annually in 2015) and eliminated the requirement that beneficiaries pay 20 percent of the cost for screening colonoscopies.

The study found that in men, colonoscopy screening rates increased from 18 to 22 percent following implementation of the health law, a 20 percent increase.

The data came from the Centers for Disease Control and Prevention’s annual Behavioral Risk Factor Surveillance System.

The study found that in men, colonoscopy screening rates increased from 18 to 22 percent following implementation of the health law, a 20 percent increase. In women, however, the rate didn’t budge, remaining at 18 percent even after the law passed. Continue reading


U.S.-African diet swap has dramatic impact on colon cancer risk | Reuters


Illustration of the colon from Gray's AnatomyBlack Americans who switched to a high-fiber African diet for just two weeks saw a dramatic drop in risk factors for colon cancer, a study published on Tuesday found.

A group of Africans who went the other way and started eating American food rich in animal proteins and fats saw their risks rise over the same short period, according to the paper in the journal Nature Communications.

Source: U.S.-African diet swap has dramatic impact on colon cancer risk | Reuters


Baby boomers can take steps to live long and healthy lives – CDC


Aging and Health in America, 2013

Longer life spans and aging baby boomers will combine to double the population of older Americans during the next 25 years to about 72 million.

Heart disease, cancer, stroke, chronic lower respiratory diseases, Alzheimer’s disease and diabetes continue to be the leading cause of death among older adults.

State of Aging and Health in America 2013 Adobe PDF file [PDF – 3 MB] provides a snapshot of our nation’s progress in promoting prevention, improving the health and well-being of older adults, and reducing behaviors that contribute to premature death and disability.

The report looks at 15 key health indicators that address health status (physically unhealthy days, frequent mental distress, oral health and disability); health behaviors (physical inactivity, nutrition, obesity and smoking); preventive care and screening (flu and pneumonia vaccine, breast and colorectal cancer screening); and fall injuries for Americans aged 65 years or older.

As the baby boomer population ages, it is important to take steps to ensure older adults live long and healthy lives.

Get Screened

A man and woman huggingLess than half of men and women aged 65 years or older are up-to-date on preventive services including flu vaccine, pneumonia vaccine, colorectal cancer screening, and mammography for women.

Mammography is the best available method to detect breast cancer in its earliest, most treatable stage before it is big enough to feel or cause symptoms. Women aged 50-74 should get mammograms every two years.

Colorectal cancer screening tests can find precancerous polyps so that they can be removed before they turn into cancer.

They can also detect colorectal cancer early, when treatment works best. Older adults should be screened for colorectal cancer by having a fecal occult blood test (FOBT) during the past year, a flexible sigmoidoscopy within 5 years and FOBT within 3 years, or a colonoscopy within 10 years.

Get Vaccinated

Flu and pneumonia is the seventh leading cause of death among adults 65 years or older, despite the availability of effective vaccines. Older adults should get the flu vaccine every year and get the pneumonia vaccine at least once.

Be Physically Active

Women riding bicyclesRegular physical activity is one of the most important things older adults can do for their health. Physical activity can prevent many of the health problems that may come with age, including the risk of falls.

How Much Activity Do Older Adults Need?

2 hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity (i.e., brisk walking) every week and muscle-strengthening activities on 2 or more days a week that work all major muscle groups.


1 hour and 15 minutes (75 minutes) of vigorous-intensity aerobic activity (i.e., jogging or running) every week and muscle-strengthening activities on 2 or more days a week that work all major muscle groups.


An equivalent mix of moderate- and vigorous-intensity aerobic activity and muscle strengthening activities on 2 or more days a week that work all major muscle groups.

Eat Fruits and Vegetables Daily

Diets rich in fruits and vegetables may reduce the risk of some cancers and chronic diseases, such as diabetes and cardiovascular disease. Fruits and vegetables provide essential vitamins and minerals, fiber, and other substances that are important for good health.

Adults aged 65 years or older should eat 5 or more fruits and vegetables daily.

Quit Smoking

Tobacco use remains the single largest preventable cause of disease, disability, and death in the United States. For help quitting, visit www.smokefree.govExternal Web Site Icon or call 1-800-Quit-Now.

Take Medication for High Blood Pressure

High blood pressure is a major risk factor for cardiovascular disease, the leading cause of illness and death among older adults. Of the almost 67 million Americans with high blood pressure, more than half do not have it under control.

Health care providers, such as doctors, nurses, and pharmacists, can track their patients’ blood pressure, prescribe once-a-day medications, and give clear instructions on how to take blood pressure medications.

Patients should take the initiative to monitor their blood pressure between medical visits, take medications as prescribed, tell their doctor about any side effects, and make lifestyle changes, such as eating a low-sodium diet, exercising, and stopping smoking.

 More Information

Illustration of the colon from Gray's Anatomy

New screening tool could increase the use of virtual colonoscopies


Illustration of the colon from Gray's AnatomyBy Michelle Andrews

Colorectal cancer screening can cut a person’s risk of dying from the disease in half, yet about 40 percent of those who should get tested don’t do it.

One reason is that the “gold standard” for screening, an optical colonoscopy, requires a rigorous preparation to empty the colon, and it gives many people pause.

A new method that doesn’t require patients to take laxatives to empty their bowel beforehand could boost screening rates. But some experts question whether it’s a good solution.

During an optical colonoscopy, a doctor inserts a long tube with a lighted camera at the end into the anus and snakes it through the entire colon, looking for and removing tissue masses called polyps that may be cancerous or may become cancerous.

The new test builds on another screening method often referred to as a virtual colonoscopy, the popular term for CT colonography. The virtual colonoscopy is non-invasive, but patients must still undergo bowel cleansing.

They then have a CT scan, which generates three-dimensional images of the colon on a video screen for physicians to examine.

In the new approach, patients drink a contrast dye a day or so before the procedure that “tags” the feces in their colon. The patient then has a virtual colonoscopy, and the feces can be identified and digitally removed from the CT image. No bowel cleansing is necessary.

In a recent study published in the Annals of Internal Medicine, this laxative-free virtual colonoscopy was nearly as effective as the optical colonoscopy at detecting larger polyps of at least 10 millimeters that are responsible for most colorectal cancers.

“If somebody’s not getting screened, and it’s because of the prep, we can address this issue” with the laxative-free test, says Michael Zalis, director of CT colonography at Massachusetts General Hospital and the lead author of the study.

The U.S. Preventive Services Task Force, a federal panel that evaluates medical evidence to promote effective prevention efforts, recommends that men and women get screened for colorectal cancer starting at age 50 and continue at intervals until age 75.

It recommends one of three tests to screen for colorectal cancer: an optical colonoscopy once every 10 years; a sigmoidoscopy, which is similar to a colonoscopy but only examines the lower half of the colon, once every five years, or a fecal-occult blood test that looks for blood in the stool, once every year.

Many people don’t get screened when they should. In 2010, 59 percent of people age 50 and older had been screened for colorectal cancer according to recommended guidelines, the American Cancer Society found.

In contrast, 76 percent of women age 18 and older had received Pap tests to screen for cervical cancer within the past three years, and 67 percent of women age 40 and older had mammograms in the prior two years.

The Preventive Services Task Force doesn’t recommend any type of virtual colonoscopy, in part because of concerns about exposing asymptomatic people to unnecessary radiation.

Another downside, experts note, is that other expert groups have recommended that the test must be repeated every five years, twice the frequency of an optical colonoscopy.

The American Cancer Society evaluated the data and decided to recommend the virtual colonoscopy. “It does a good job at finding large polyps and cancers,” says Durado Brooks, the ACS’s director of prostate and colorectal cancers.

ACS provided funding for the laxative-free test study, the results of which are promising, says Brooks, but need to be replicated on a broad scale.

Many clinicians say they support any effective method that increases the likelihood people will get screened. “The best test is the one that gets done,” says Joanne Schottinger, the assistant medical director for quality at Kaiser Permanente in Southern California. (Kaiser Health News is not affiliated with Kaiser Permanente.)

More From This Series: Insuring Your Health

For the past several years, Kaiser Permanente has sent fecal immunochemical testing kits, a type of fecal occult test, to every KP member’s home who should be screened.

Members use the kit to collect a stool sample and send it in a prepaid mailer to the lab, which evaluates whether there is blood in the sample. If the sample is positive, the member is advised to get a colonoscopy.

In Southern California in 2010, 70 percent of privately insured Kaiser Permanente members in the target group for screening for colorectal cancer were tested, as were 84 percent of those on Medicare, says Schottinger.

Sometimes ignorance of screening recommendations is as much a problem as avoidance.

Those figures are significantly higher than the 59 percent nationwide who were up to date with screening in 2010.

Sometimes ignorance of screening recommendations is as much a problem as avoidance. Tom Foeller was diagnosed with rectal cancer in 2006 after he asked his doctor to test him for colorectal cancer as part of a routine physical exam.

Foeller, who was then a supervisor at a federal electrical power marketing agency in Portland, Ore., was thinking of buying a sailboat, he told his doctor, and he jokingly said he wanted to be sure he would live long enough to pay it off.

His doctor did a fecal blood test, and immediately ordered a colonoscopy. The diagnosis: Stage 3 rectal cancer. Foeller had surgery, radiation and chemotherapy. He’s been cancer free for nearly six years.

Like many people, Foeller says he was unaware that he should have been screened for colorectal cancer at age 50.

He wasn’t feeling ill, and his only symptom was occasional irregularity. Foeller thought to ask about colorectal cancer screening only because he had an acquaintance who had been diagnosed with the disease.

His primary care doctor never brought it up. “He never mentioned it, much to my chagrin and subsequent problems,” says Foeller, “and I was ignorant not to ask for it when I should have.”

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This article was reprinted from with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Swedish to open new Women’s Cancer Center


Seattle’s Swedish Medical Center will open a new cancer center that will provide services tailored specifically for women — next Tuesday, June 5th.

The 23,600-square-foot True Family Women’s Cancer Center will occupy the fifth and sixth floor of the medical center’s Arnold Pavilion at 1221 Madison on Swedish’s First Hill campus.

The goal is to bring the Swedish physicians specializing in treating cancer in women into a single location to better coordinate care and to provide women cancer patients with a place where they can find all the services they need under one roof, said Dr. Patricia Dawson, the medical director of the new center and a breast surgeon with the Swedish Cancer Institute.

Although women and men have many of the same kinds of cancer, these cancers often have a different course in women and respond differently to treatment, said Dr. Dawson.

Women with cancer also often seek the kind of community and support services the new center hopes to offer, she said.

In addition to exam rooms, imaging services and procedure rooms, the new center will have support-group meeting rooms, counseling services and an educational resource center.

The facility’s decor and layout was designed to be both practical and “calming and restful” with the aim of enhancing both the quality of care and the quality of the patients’ experience, Dr. Dawson said.

The new center brings together a variety of clinicians and services that in the past have been scattered across the Swedish Medical Center’s main campuses.

Alexis Vanden Bos, a patient of Dr. Dawson who has been treated for two breast cancers, remembers having to shuttle between campuses during her treatments, often carrying her radiology films under her arm.

Alexis Vanden Bos

“It wasn’t bad, but how much easier this will be,” Vanden Bos said. “Now, I’ll be able to talk to both my surgeon and my oncologist in one place. I’ll love having all my people together.”

Construction of the $11 million facility was funded entirely from philanthropic gifts. The families of Patricia True, Doug and Janet True, and Bill and Ruth True began the fund-raising effort with $2 million donation.

Other major contributors include Eve and Chap Alvord, Robin Knepper, the Norcliffe Foundation, Bruce and Jeannie Nordstrom, Seattle Radiology, and Sellen Construction.

Additional support came from more that 2,500 individual donors.

The center’s staff will include oncologists, surgeons, onsite radiologists, psychological and genetic counselors, physical therapists, social workers and patient education specialists.

The center will provide resources for women with most cancers, including bladder, brain, breast, cervical, colorectal, esophageal, head and neck, leukemia, liver, lung, lymphoma, multiple myeloma, ovarian, pancreatic, renal/kidney, skin, thyroid and uterine.

surgeons performing surgery in operating room

Higher cost of cancer care in the U.S. may be ‘worth it’ — study


By Sarah Barr

Higher U.S. spending for cancer care pays off in almost two years of additional life for American cancer patients on average compared to their European counterparts — a value that offsets the higher costs –according to a study in the April issue of the journal Health Affairs.

While previous studies have suggested U.S. cancer patients have better survival prospects than their European counterparts, the researchers wanted to examine whether those prospects justify higher U.S. costs.

To do so, they translated the longer lives of U.S. patients into dollar amounts using a conservative estimate of the value of a human life year — in the context of the tradeoffs people are willing to make to reduce their risk of death — and compared those amounts to U.S. spending on cancer care.  The method does not take into account quality of life or individuals’ earnings.

“We found that the value of the survival gains greatly outweighed the costs, which suggests that the costs of cancer care were indeed ‘worth it,’” the researchers wrote in the study. They cautioned the findings do not prove that all treatments are cost-effective or a that a causal link exists between spending on cancer care and survival gains.

“We found that the value of the survival gains greatly outweighed the costs, which suggests that the costs of cancer care were indeed ‘worth it.”

The study found that the longer lives of U.S. patients were worth an average value of $61,000 per individual, or $598 billion total, in constant dollars, for those diagnosed between 1983 and 1999 — more than the additional amount the U.S. spent on treatment compared to other countries.

Michael Eber, a senior analyst at Precision Health Economics, a health care consulting company, and a co-author of the study, said that the findings point to the need for further research into what drives the survival differences between U.S. and European patients.

“It calls for a closer look at the value of individual treatments and interventions,” he said.

For the study, the researchers looked at the survival outcomes for U.S. patients compared with those from 10 European countries and found that for most cancer types, U.S. patients lived longer.

Specifically, from 1995 to 1999, U.S. patients lived an average of 11.1 years after diagnosis, while European patients lived 9.3 years.

The researchers used those numbers as a baseline and based their findings on how survival gains improved in each country over time.

They also found that from 1983 through 1999, U.S. spending increased from $47,000 to $70,000 per cancer case, while in the 10 European countries, spending on cancer care increased from $38,000 to $44,000 per case.

The additional U.S. spending during that time period on the kinds of cancer the researchers examined totaled $158 billion.

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This article was reprinted from with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.


U.S. cancer deaths continue steady decline


By Sharon Reynolds
NCI Cancer Bulletin Staff Writer 

According to the latest data on nationwide death rates from cancer, overall mortality from cancer declined from 1999 to 2008, maintaining a trend seen since the early 1990s.

Mortality fell for most cancer types, including the four most common types of cancer in the United States (lungcolorectalbreast, and prostate), although the rate of decline varied by cancer type and across racial and ethnic groups.

The complete Annual Report to the Nation on the Status of Cancer, 1975–2008 appeared March 28 in Cancer.

The declines in cancer death rates (mortality) averaged 1.7 percent per year for men and 1.3 percent per year for women from 1999 through 2008.

Among men, the overall rate of new cancer cases (incidence) fell by an average of 0.6 percent annually from 1999 to 2008.

Among women, incidence dropped by an average of 0.5 percent annually from 1999 to 2006 but held steady from 2006 to 2008.

Cancer incidence in children ages 0 to 14 rose from 1999 to 2008 (by 0.5 percent a year), continuing a trend seen in previous Annual Reports to the Nation.

However, advances in treatment contributed to a steady decline in mortality rates for children with cancer in the last 5 years (an average of 2.8 percent per year).

“Steady progress, as measured by declines in cancer death rates for many cancers, is good because we have an aging, growing population,” said Dr. Brenda K. Edwards, NCI’s senior advisor for surveillance.

“While the number of people diagnosed with cancer or who die of the disease may be increasing, the decline in cancer death rates for more than a decade is the best indicator of progress due to prevention, screening, diagnosis, and treatment,” she added.

NCI, the American Cancer Society, the Centers for Disease Control and Prevention (CDC), and the North American Association of Central Cancer Registries (NAACCR) collaborated on the report. Cancer incidence data came from NCI’s Surveillance, Epidemiology, and End Results (SEER) database and from the CDC, with analyses of pooled data by NAACCR. Mortality data came from the CDC’s National Center for Health Statistics.

Not All Good News

There were some notable exceptions to the overall decreases in incidence and mortality. From 1999 to 2008, death rates rose for pancreatic cancer in men and women, for liver cancer and melanoma in men, and for endometrial cancer in women.

The cervical cancer death rate, which had been falling for decades, showed no further decrease over the last 5 years.

And, although incidence rates fell overall for men and women from 1999 to 2008, the decline was not distributed evenly across racial and ethnic groups.

Cancer incidence rates did not decrease significantly among American Indian/Alaska Native men and women combined or among black, Asian and Pacific Islander, and American Indian/Alaska Native women.

Although incidence rates in black men did decline, this group still had the highest cancer incidence rate of any racial and ethnic group, 15 percent higher than that of white men and nearly double that of Asian and Pacific Islander men.

Major Modifiable Risk Factors

Each Annual Report to the Nation includes a special feature that focuses on a topic of importance to the cancer research community and the public.

This year’s report featured an analysis on the contribution of excess weight (overweight and obesity) and insufficient physical activity to the nation’s cancer burden.

More than 60 percent of the U.S. adult population is estimated to be overweight or obese, and a similar percentage of adults do not get the recommended amount of physical activity.

The rates of insufficient physical activity are even worse for children; for example, up to 90 percent of high school girls do not engage in recommended levels of physical activity.

Excess weight “is a major modifiable risk factor for cancer and other diseases—probably second only to tobacco use in terms of its impact on cancer incidence and mortality,” said Dr. Edwards. “The risk may be modest but it’s so pervasive that we felt this was the time to look at [cancer] incidence in this context.” Physical inactivity not only contributes to excess weight but is itself a risk factor for several cancer types.

The report was not designed to quantitatively link the trends in excess weight and lack of physical activity to the national trends for cancer, explained Dr. Rachel Ballard-Barbash, associate director of the Applied Research Program in NCI’s Division of Cancer Control and Population Sciences.

Many other studies have shown convincing links between excess weight and several cancer types, including endometrial, postmenopausal breast, colorectal, kidneyesophageal, and pancreatic cancer.

The point of the special feature, she noted, “is to highlight specific types of cancer that are related to [excess weight and lack of sufficient physical activity], show how these behaviors relate to these cancers in terms of their relative risks, and briefly describe some of the mechanisms by which they relate.”

The special feature also highlights national- and state-level prevention strategies in policy and environmental change that are intended to help people achieve recommended changes in their diets and physical activity levels.

As the nation’s weight has risen, so has the incidence of some, although not all, types of cancer related to excess weight and lack of sufficient physical activity. From 1999 to 2008, incidence rates of kidney cancer and of adenocarcinoma of the esophagus each rose about 3 percent per year for men and women, while incidence of pancreatic cancer rose 1.2 percent per year among men and women.

In addition, incidence rates of endometrial cancer rose significantly among black, Asian and Pacific Islander, and Hispanic women. Incidence of postmenopausal breast cancer stabilized from 2005 to 2008, after a period of decline.

“Although all of these cancers are influenced by multiple factors, the high prevalence of excess weight and insufficient physical activity likely contributed to these observed increases and to the lack of decline in breast cancer,” the authors wrote. “Continued progress in reducing cancer incidence and mortality rates will be difficult without success in promoting healthy weight and physical activity, particularly among youth.”

Excess weight and lack of physical activity also influence cancer survivorship, explained Dr. Ballard-Barbash, as both can negatively affect outcomes after a cancer diagnosis, further increasing the need for these risk factors to be addressed on a personal and societal level.

The NCI Cancer Bulletin is an award-winning biweekly online newsletter designed to provide useful, timely information about cancer research to the cancer community. The newsletter is published approximately 24 times per year by the National Cancer Institute (NCI), with day-to-day operational oversight conducted by federal and contract staff in the NCI Office of Communications and Education. The material is entirely in the public domain and can be repurposed or reproduced without permission. Citation of the source is appreciated.

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$100-dollar bill inside a capsule

New cancer drugs offer hope — but at an often staggering cost


High Cost Of New Cancer Drugs Sparks New Care Struggle

By Merrill Goozner, The Fiscal Times
This story comes from our partner 

Julie Grabow, an oncologist at the Fred Hutchinson Cancer Center in Seattle, recently prescribed an exciting new therapy for a 60-year-old woman with metastatic breast cancer.

Three-and-a-half years into her battle against the disease, the patient had already exhausted three different anti-estrogen therapies, each of which only put a temporary check on the spreading tumors.

Box of the drug AfinitorThe newly prescribed drug, Novartis’ Afinitor, is one of the recently approved targeted therapies that have generated a lot of excitement among cancer patients and oncologists in recent years.

Drugs that target just the cancer cells promise the same or better results as toxic chemotherapy, but with far fewer side effects.

There was a catch, though. Like many of the latest cancer drugs, Novartis is charging exorbitant amounts for the treatment – in this case, $10,000 per month.

That quickly put an end to that possibility for Grabow’s patient. Her monthly co-payment, even after her insurance company agreed to pay its share of the off-label use the drug (the Food and Drug Administration has only approved Afinitor for kidney and pancreatic cancer, not breast cancer), was $2,900.

“She can’t afford this, even though it’s potentially a less toxic and potentially equally effective regimen,” Grabow said. “Chemo will help her, and it’s a reasonable choice. But that choice is 100 percent driven by economics.”

Over the past year, official Washington and candidates on the campaign trail have locked horns over the best way to curb rising health insurance costs. The public has been bombarded with dueling slogans – Republicans vowing to fight the “death panels” and “rationing” of Obamacare while Democrats promise “guaranteed access” and “affordability” with the Affordable Care Act.

But an economic drama that neither side wants to confront is playing itself out in cancer wards and oncologists’ offices across the country.

Unaffordable new drugs, even when they’re covered by insurance, are being rationed by price as patients, doctors and hospital officials struggle with what is likely to be the most pressing problem for the nation’s health care system over the next decade: how to pay for the spectacular rise in the cost of cancer care, especially drugs and diagnostic tests.

“In the real world of private practice where most care is delivered, it would be a mistake to say rising costs haven’t affected care,” said Eric Nadler, a head, neck and lung cancer specialist at Baylor University Medical Center.

84 percent of oncologists say their patients’ out-of-pocket spending influences treatment recommendations.

A recent survey published in Health Affairs found a stunning 84 percent of oncologists say their patients’ out-of-pocket spending influences treatment recommendations.

The growing cost of cancer care will impose its greatest burden on the nation’s Medicare system, since 55 percent of all cancers are diagnosed in individuals 65 or older.

A recent study by the National Cancer Institute projected the cost of treating the 29 most common cancers in men and women will rise 27 percent by 2020, even though incidence of the disease is going down due to successful public health campaigns like the war on smoking.

Among the six new drugs approved in 2011, the cheapest . . . cost $44,000 a year.

 That estimate is based on a relatively static cost of care per case. If costs increase just 2 percent more a year than previous trends in the first and last years of care, the study said, then costs would soar to $173 billion, a 39 percent increase.

The study pointed out that its projections were based on 2006 Medicare claims data, which predated the development of most of the latest targeted therapies.

There’s no doubt that there will be many new therapies for cancer coming to market in the years ahead. The nation’s $150 billion public investment in understanding the biology of cancer – the science side of the War on Cancer launched by President Richard Nixon in 1971 – is beginning to bear fruit.

The pharmaceutical industry, which draws on that publicly funded science to develop drug candidates, now has 887 new cancer drugs in development, over 30 percent of its total portfolio of new drug candidates, according to the Pharmaceutical Research and Manufacturers of America, the industry trade group. That’s up from 646 or 26 percent of the total devoted to cancer in 2006.

The industry is pouring increased research and development resources in cancer therapeutics in hopes that it will replace the revenue being lost from the expiration of patents on blockbusters like Lipitor.

However, since there are fewer cancer patients than there are people with chronic conditions like elevated cholesterol, and many don’t live very long, the prices needed to support the industry’s current size and structure, and profits must be substantially higher.

“They’re trying to maximize profits given their incentives,” said Peter Neumann, director of the Center for the Evaluation of Value and Risk in Health at Tufts Medical Center, which receives funding from the drug industry.

Possible solutions, he said, include letting Medicare set prices based on the medical value of adding extra months to life. That’s a variation on Great Britain’s cost-effectiveness model, which has been roundly condemned by most U.S. politicians and the press.

The other path is to turn to a bundled payment for every for every episode of cancer care and let the health care delivery organizations and private insurers sort it out. (Bundled payments account for all medical services associated with a given episode of care—doctors, nurses, technicians, etc.) That approach, in essence, would force the marketplace to execute the rationing.

“Bundled payment isn’t a panacea, but it does create incentives,” Neumann said. Some private insurers are experimenting with bundled payments for cancer care.

A quick review of the new cancer drugs approved by the Food and Drug Administration last year reveals how fast drug prices are rising.

Most of the older chemotherapy regimens for cancer, some of which have been around since the 1950s, are generic and relatively inexpensive.

But among the six new drugs approved in 2011, the cheapest – Johnson & Johnson’s Zytiga for advanced prostate cancer – cost $44,000 a year. The drug extended life by an average of less than 5 months to 16 months, according to a company spokesperson.

At the high end of the spectrum was Adcetris, a biotech product from Seattle Genetics that treats recurrences of Hodgkin’s lymphoma. A highly curable disease when initially treated in the 8,830 mostly middle-aged patients who get the disease every year, it is usually fatal if a drug-resistant strain emerges later in life.

Adcetris, the first new treatment to come along since 1977, kept the cancer in check for nearly 7 months in the single small trial that led to its quick FDA approval. It’s price tag: $216,000 for a full course of treatment.

Skin cancer specialists had a lot to cheer about in 2011 with two new therapies coming on the market for metastatic melanoma, which is fatal within one year for about 75 percent of the 10,000 people stricken each year.

But Roche/Genentech’s Zelboraf cost $61,400 a year and Bristol-Myers Squibb’s Yervoy, which nearly doubled the one-year survival rate from 25 percent to 46 percent, cost $120,000 for a four-month course of treatment.

“We price our medicines based on a number of factors including the value they deliver to patients and the scientific innovation they represent,” said Sarah Koenig, a spokeswoman for Bristol-Myers. “We have one of the most robust patient assistance programs for cancer patients in the industry.”

Most drug companies have patient assistance programs for poor or struggling patients, but many only come into play if patients are poor or families have exhausted their savings.

And since many of the latest therapies, like the older chemotherapies they are replacing or supplementing, extend life for brief periods of time, patients wind up weighing whether they want to deplete their children’s inheritances for a couple extra months of being very, very sick.

A study released at last June’s annual conference of the American Society of Clinical Oncology, which represents the nation’s 25,000 oncologists, revealed that patients with co-payments over $500 a month were four times more likely to refuse treatment than those whose co-payments were under $100 a month.

“The price of drugs can’t be set so outrageously high,” study author Lee Schwartzberg told Reuters. Schwartzberg is the chief medical officer at Acorn Research, which conducted the study.

“All stake holders have to get together and compromise to translate this great science into great patient care without breaking the bank.

This article was reprinted from with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

Doctor inspects mammogram. Photo by Bill Branson/NCI

Do the elderly get too many medical tests?


By Sandra G. Boodman
This story was produced in collaboration with wapo

Every year like clockwork, Anna Peterson has a mammogram. Peterson, who will turn 80 next year, undergoes screening colonoscopies at three- or five-year intervals as recommended by her doctor, although she has never had cancerous polyps that would warrant such frequent testing. Her 83-year-old husband faithfully gets regular PSA tests to check for prostate cancer.

Doctor inspects mammogram. Photo by Bill Branson/NCI

“I just think it’s a good idea,” says Peterson, who considers the frequent tests essential to maintaining the couple’s mostly good health. The Fairfax County resident brushes aside concerns about the downside of their screenings, which exceed what many experts recommend. “Most older people do what their doctors tell them. People our age tend to be fairly unquestioning.”

But increasingly, questions are being raised about the overtesting of older patients, part of a growing skepticism about the widespread practice of routine screening for cancer and other ailments of people in their 70s, 80s and even 90s.

Critics say there is little evidence of benefit — and considerable risk — from common tests for colon, breast and prostate cancer, particularly for those with serious problems such as heart disease or dementia that are more likely to kill them.

Too often these tests, some doctors and researchers say, trigger a cascade of expensive, anxiety-producing diagnostic procedures and invasive treatments for slow-growing diseases that may never cause problems, leaving patients worse off than if they had never been tested. In other cases, they say, treatment, rather than extending or improving life, actually reduces its quality in the final months.

“An ounce of prevention can be a ton of trouble,” observed geriatrician Robert Jayes, an associate professor of medicine at George Washington University School of Medicine. “Screening can label someone with a disease they were blissfully unaware of.”

Dartmouth physician Lisa M. Schwartz cites one such case: a healthy 78-year-old man who was left incontinent and impotent by radiation treatments for prostate cancer, a disease that typically grows so slowly that many men die with — but not of — it.

The U.S. Preventive Services Task Force, an independent panel of experts that evaluates the risks and benefits of screening tests, does not endorse PSA testing or routine colon screening after age 75.

The panel, whose recommendations will guidesome coverage decisions under the 2010 federal health law that expands access to screening, says there is no evidence for or against mammography after age 74 and recommends that most women stop getting Pap smears to detect cervical cancer after 65.

So far the task force’s guidelines appear to have had limited impact. Researchers in June reported in the journal Cancer that nearly half of primary-care doctors would advise a woman with terminal lung cancer to get a routine mammogram — even if she was 80 years old.

“More is not always better.”

A 2010 study in the Journal of the American Medical Association of more than 87,000 Medicare patients found that a “sizeable proportion” with advanced cancers continued to be screened for other malignancies.

Last May, Texas researchers reported in the Archives of Internal Medicine that 46 percent of 24,000 Medicare recipients with a previous normal test underwent a repeat colonoscopy in less than seven years and sometimes as few as three — compared with the 10 years recommended by the task force.

In nearly a quarter of cases, the repeat test was performed for no discernible reason. (Medicare is supposed to cover the screening test, which can cost about $2,000, only once a decade if no cancer or polyps have been found, but the program paid for all but 2 percent of the procedures reviewed by the Texas researchers.)

“More is not always better, and that becomes particularly true in older Americans where the dangers of medical care grow,”said Michael LeFevre, a professor of family medicine at the University of Missouri School of Medicine who is co-vice chair of the task force. “The older you get, the more likely it is that something else is going to make you sick or die.”

Colon polyps take 10 to 20 years to become cancerous, while the risks from colonoscopy, including intestinal perforation and heart attack, substantially increase after age 80.

Experts point to several reasons for the persistence of overscreening: habit; incentives that pay doctors and hospitals for individual procedures; quality assessments that rely on how many patients receive such tests; physicians’ fears of missing something important or of upsetting elderly patients — or their children — by suggesting that screening is unnecessary because a patient is too old or too sick to benefit.

In an era where discussions about end-of-life care are branded as “death panels” and curtailing unnecessary and expensive testing is regarded by some as rationing, experts say it is not surprising that overtesting endures. Many doctors say it’s easier to simply order a test than to discuss its risks and benefits with patients.

But some doctors believe it’s time to resist. “I think we need to say we can’t do everything for everybody, and it doesn’t make sense,” said Washington radiologist Mark Klein, who recently performed a virtual colonoscopy on a 99-year-old woman. Klein said he considered not doing the procedure but decided to go ahead because he didn’t learn how old the patient was until she was lying on the table, having undergone the prep.

“The most important thing on any referral is the date of birth,” said Klein, who said he tries to talk some older patients and their doctors out of pursuing tests and treatments he considers overly aggressive. “The game is not finding things, it’s can you improve mortality? And if you do find something, it’s very hard for a doctor to say, ‘Don’t do anything.’ ”

While cancer screenings are most common, other tests are overused among the elderly, Klein and others say. They include cholesterol testing, which can lead to the prescription of statin drugs that require regular blood tests to check liver function; typically, cholesterol plaque takes years to accumulate, and statins confer only a modest benefit in the elderly.

Likewise, CT scans of the heart or whole body can unearth suspicious findings, such as lung nodules, which trigger a painful and risky lung biopsy, but often turn out to be benign.

First Mammogram — At 100

Schwartz, a professor at the Dartmouth Institute for Health Policy and Clinical Practice and an author of the 2011 book “Overdiagnosed,” said that overtesting may reflect in part the use of screening tests as a barometer of quality. “Unfortunately that’s how we’ve measured quality: Did they get tests? And doctors are being judged and paid accordingly. So all these crazy things get done that don’t help people.”

“I makes absolutely no sense whatsoever to put a 100-year-old woman through a mammogram.”

Patients feel the pressure, too, Schwartz maintains. Screening has become a mantra, she said, trumpeted by advocacy groups. “The message is that you’re a good person if you get screened.”

The American Cancer Society doesn’t support an upper age limit for colonoscopy or mammography, although the group does not endorse PSA testing.

The society’s director of cancer screening, Robert C. Smith, said he thinks underscreening is a bigger problem than overtesting. “As long as a patient is in good health and a candidate for treatment, they are a candidate for screening indefinitely,” he said.

But Smith says there are limits. He recalls the loud cheer at a medical meeting after it was announced that a 100-year-old woman had just undergone her first mammogram.

“Several of us were just shaking our heads in disbelief because it makes absolutely no sense whatsoever to put a 100-year-old woman through a mammogram,” he said.

Telling someone that screening is no longer necessary can be dicey, as California family physician Pamela Davis discovered when she advised her robust 86-year-old mother to stop getting mammograms and routine colon tests.

Why do doctors continue to screen terminally ill patients? 

Her mother was incensed, Davis recounted in a recent Los Angeles Times article, accusing her of wanting to “save money to spend on the young people and just let us old folks die.” Davis was even more taken aback by the wave of hate mail she received after the article was published, some of it from doctors, accusing her of essentially the same thing.

“I have many, many patients who are like my mother,” said Davis, who directs the family medicine residency program at Northridge Hospital Medical Center. “It’s not about shortchanging them” but about putting screening in context. “Part of keeping people healthy and elderly is keeping them away from the hospital. Sometimes I’ll say, ‘Well, if we do this heart test and then find something then you’ll need a procedure.’ And they’ll say, ‘Oh, I don’t want heart surgery.’ And I’ll say, ‘Why do the test?'”

Baltimore internist Mary Newman said she largely hews to the task force recommendations, and she jokes to patients that “after 85, everything’s optional.” She considers Medicare’s new annual wellness exam, part of the health law, a good time to raise the subject of screening. Newman said she focuses on concerns that geriatrics specialists say matter most in old age: maintaining hearing and vision, stabilizing blood pressure and addressing problems related to dementia and mobility.

In some cases doctors counsel against testing — but patients demand it. Alan Pocinki, an internist who practices in the District, said he tried to persuade an 80-year-old patient, a survivor of several heart attacks, to stop PSA testing. The man’s son, a Boston oncologist, agreed with Pocinki, but the patient insisted.

The elevated reading led to a biopsy, which found cancer. Pocinki said the patient contracted a serious infection from the biopsy, his cancer is being monitored through “watchful waiting,” and he has repeatedly said he wishes he’d never had the test. “He always tells me, ‘I know you told me not to do it.’ ”

Screening The Dying

Why do doctors continue to screen terminally ill patients? Smith, of the American Cancer Society, thinks a primary reason is that they avoid difficult conversations that would involve telling patients they won’t live long enough to benefit.

“Just because it’s hard for doctors doesn’t mean it’s not a conversation worth having,” said Camelia Sima, a biostatistician at Memorial Sloan-Kettering Cancer Center in New York and lead author of the 2010 JAMA study. Doctors may regard additional tests as relatively inconsequential, but Sima notes that they can cause additional pain and suffering in the form of biopsies, surgery and chemotherapy.

To Dartmouth’s Schwartz, the message for older patients, regardless of the state of their health, is essentially the same: “It’s not always in your best interest to do more or to keep looking. But we never seem to talk about the downside of testing.”

We want to hear from you: Contact Kaiser Health News

This article was reprinted from with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.


Answers to readers’ insurance questions


Michelle Andrews answers your insurance questions:

My son was denied coverage on the basis that he had been drinking before going to the ER with a broken shoulder. Is drinking a legitimate reason for denial of coverage? John Johnson, Tucson, Ariz.

Sign for an emergency room.As of 2008, 36 states allowed insurers to exclude coverage for injuries related to alcohol and/or drug consumption, according to research from George Washington University’s Department of Health Policy at the School of Public Health and Health Services.

The practice dates to 1947 when, as a way to discourage drinking, the National Association of Insurance Commissioners adopted a model statute that excluded coverage of alcohol-related health claims. More than 40 states and the District subsequently passed such laws.

But as the benefits of drug and alcohol treatment programs became apparent, these laws were recognized as counterproductive, since they discouraged emergency department and other medical personnel from screening people for and counseling them about drug and alcohol abuse. In 2001, the NAIC reversed course and recommended that such laws be scrapped.

My husband had a stroke in December, and the insurance reps refused to discuss his account with me because they didn’t have his signature on a form, and he couldn’t tell them over the phone it was okay to talk to me. And it is MY insurance! They said they had to follow HIPAA [the Health Insurance Portability and Accountability Act, which protects patients’ medical privacy]. Is this true? Name withheld, Lawrenceville, Ga.

It’s a common misperception by health-care providers and insurers that HIPAA prohibits them from discussing patients’ medical information with family members, says Deven McGraw, director of the health privacy project at the Center for Democracy and Technology, a civil liberties group that promotes health privacy.

“It’s not true; it has never been true,” she says. Unless the patient objects, such information can be shared with family members.

Advance planning documents can help avoid confusion and heartache, say experts. A living will spells out what if any measures you wish to have taken to prolong your life — being put on a breathing machine or on dialysis, for example. A health care proxy names the person you choose to make medical decisions for you in the event that you can’t do so yourself.

In addition, most states have surrogacy laws that assign decision-making responsibility to family members based on their relationship to the patient.

Typically, if someone is incapacitated, state law would assign decision-making to the patient’s spouse, says Jay Horton, clinical program manager at the Lilian and Benjamin Hertzberg Palliative Care Institute at Mount Sinai School of Medicine in New York.

If there is no spouse, the laws spell out who would be assigned to make decisions instead, based on their relationship to the patient.

Our doctor recommended that my husband get a preventive colonoscopy since it had been five years since his last one. The doctor found two benign polyps and removed them. Our [health] plan was to cover 100 percent for a preventive colonoscopy. Because the doctor removed the polyps during the procedure, it is now not covered. We have to pay the deductible, and the balance owed. I can assure you that many, many people will not have this procedure done (as I will not) when they are made aware of the additional costs involved. Pam Nevin, Rutherfordton, N.C.

Illustration of the colon from Gray's AnatomyUnder the new federal health law, Medicare beneficiaries and members of new private health plans starting this year can generally receive free colonoscopies to screen for colon cancer if they meet age and other criteria.

Unfortunately, like you, others have been hit with sometimes substantial charges if a growth or mass called a polyp is discovered during a routine screening colonoscopy they thought would be free.

Once a preventive procedure turns into a diagnostic procedure or other type of treatment, providers can charge you for it under the new law.

According to the interim final rules: “A plan or issuer may impose cost-sharing requirements for a treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service.”

Some experts have expressed concern that colonoscopy charges raise questions about what other newly free preventive services might incur similar hidden costs.

Fortunately, it doesn’t appear that it will be a widespread problem, says Stephen Finan, senior director of policy for the American Cancer Society’s Cancer Action Network.

The reason: Colonoscopies appear to be the only procedure covered under the new guidelines for free preventive care where both prevention and diagnosis happen during the same procedure.

Usually they’re separate, as when something suspicious turns up on a woman’s mammogram. In that case, a separate procedure such as a biopsy would be scheduled to diagnose the problem, says Finan. “Colonoscopy is a very unique scenario,” he says.

Got a question for Michelle Andrews to answer in a future column?

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This article was reprinted from with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.


U.S. colorectal cancer death rates continue to drop, but not equally


By Carmen Phillips
NCI Cancer Bulletin

Findings from two new studies show that death rates from colorectal cancer in the United States continue to fall, a trend that began more than two decades ago.

The mortality decline has been geographically uneven, however, with far greater decreases in the Northeast than in many other areas, particularly in a number of southeastern states.

Colorectal cancer death rates by state, 1990– 1994 (Adapted and reprinted by permission from the American Association for Cancer Research: D Naishadham et al., State Disparities in Colorectal Cancer Mortality Patterns in the United States, Cancer Epidemiol, Biomarkers & Prev, 2011, 20(7); 1296-302)

Colorectal cancer death rates by state, 2003– 2007 ((Adapted and reprinted by permission from the American Association for Cancer Research: D Naishadham et al., State Disparities in Colorectal Cancer Mortality Patterns in the United States, Cancer Epidemiol, Biomarkers & Prev, 2011, 20(7); 1296-302)

Although the studies are ecologic in nature and can’t directly demonstrate a cause-and-effect relationship, authors of both studies agreed that substantial improvements in colorectal cancer screening rates have been the chief contributor to the national downward trend in mortality.

Other factors, such as reductions in smoking prevalence and better treatments, have also played a role, they noted.

Socioeconomic disparities that have been proven to influence cancer screening rates and the treatment of diagnosed cancers likely help explain the geographic discrepancies in cancer mortality rates, several researchers said.

“That’s a key point,” said Dr. Ahmedin Jemal of the American Cancer Society, who led one of the studies. “Poverty affects not only access to screening and treatment but also prevalence of known risk factors for colorectal cancer, including smoking and obesity.”

Disparities Drive Geographical Differences

In the first study, published online July 5 in Morbidity and Mortality Weekly Report, researchers from the Centers for Disease Control and Prevention (CDC) showed that the age-adjusted colorectal cancer death rate fell by 3 percent per year from 2003 through 2007, from 19 per 100,000 people to 16.7 per 100,000 people, yielding a difference of approximately 32,000 fewer deaths. The rate of new cases of colorectal cancer also declined during this period, the CDC reported, from 52.3 per 100,000 in 2003 to 45.5 per 100,000 in 2007.

Using data from the agency’s Behavioral Risk Factor Surveillance System phone survey, the CDC study showed that, nationally, the percentage of people who were screened for colorectal cancer according to commonly accepted clinical guidelines rose from 52.3 percent in 2002 to 65.4 percent in 2010.

Mortality fell furthest “in states with some of the highest screening prevalence,” wrote Dr. Lisa Richardson and her colleagues.

In the second study, Dr. Jemal and his colleagues, reporting in the July 7 Cancer Epidemiology, Biomarkers & Prevention (CEBP), identified significant geographic disparities in colorectal mortality rates. In the northeastern states of Massachusetts, Rhode Island, and New York (as well as Alaska) mortality fell more than 33 percent between 1990–1994 and 2003–2007. In many southern states, particularly along the Appalachian corridor, the decreases were much smaller; in Mississippi (as well as Wyoming), the rates were nearly unchanged between the early 1990s and mid-2000s.

Why Have Colorectal Cancer Mortality Rates Fallen?

Several years ago, research groups supported by NCI’s Cancer Intervention and Surveillance Modeling Network, or CISNET, developed computer models that estimated the impact of different factors on colorectal cancer mortality rates in the United States.

They estimated that approximately half of the reduction in colorectal cancer mortality was due to increased screening, just over a third was due to reductions in risk factors such as smoking, and a smaller proportion, 12 percent, was due to improved treatment.

The overall colorectal cancer mortality rate decline is welcome news, said Dr. Electra Paskett of the Ohio State University Research Foundation Comprehensive Cancer Center, a leading researcher on cancer health disparities. The higher mortality rates in the Appalachian corridor, however, were not a surprise, she continued. Her research group at Ohio State has been studying the problem for some time and is investigating ways to improve screening rates there. (See the box at the bottom of the page.)

“Detecting colorectal cancer early and getting it treated—that’s what affects mortality,” she said.

When it comes to screening uptake, the role of socioeconomic disparities can’t be ignored, Dr. Jemal and colleagues stressed. “Southern states have a larger proportion of the population that is poor and uninsured, among whom screening rates are lower,” they wrote.

Lower socioeconomic status, lower education levels, and lack of health insurance affect whether people get screened and whether they receive the appropriate follow-up and treatment after diagnosis, Dr. Jemal said in an interview.

For example, a 2010 study by NCI researchers showed that, among participants in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial who had been screened for colorectal cancer via sigmoidoscopy, black participants were substantially less likely to undergo a prescribed follow-up colonoscopy than white patients. Although study participants’ socioeconomic status was not known, black participants had lower education levels—which often correlate with lower socioeconomic status—than white participants.

Dr. Paul Doria-Rose of NCI’s Division of Cancer Control and Population Sciences (DCCPS) agreed with the study authors on the likely primary cause of the differences. “The disparities in colorectal cancer are well established at this point,” he said. “I think the regional differences we’re seeing reflect those disparities.”

Improving Screening Rates

A number of research groups are studying ways to improve screening rates for various cancers, particularly in populations for which notable disparities have been identified in cancer incidence and mortality and for whom barriers, such as lack of access to care, exist.

A major step forward came with the passage of the Affordable Care Act, which, as of January 2011, mandates that Medicare beneficiaries and individuals with new health insurance plans or policies beginning on or after September 23, 2010, receive certain recommended preventive health screenings, including those for colorectal and breast cancer, for free.

In addition, DCCPS staff have just finished reviewing applications for an NCI-funded initiative called Population-Based Research Optimizing Screening through Personalized Regimens, or PROSPR, that aims to improve the screening process for all cancers for which there are established, effective tests.

The aim of the initiative is “to take a holistic approach to the entire screening process, see where the shortcomings are, and identify ways to improve them,” Dr. Doria-Rose explained. “In many cases, we have screening tests that work. The biggest opportunities now are in getting more people to be appropriately screened.”

An Intervention Tailored to the Community

Working with several community-based coalitions in the Appalachian region of Ohio, Dr. Electra Paskett is leading a study aimed at reducing the high colorectal cancer death rates in that region by increasing screening.

Based on feedback from community leaders, the study’s primary intervention uses a decidedly low-tech tool. “They said that fancy things like the Internet and smart phones don’t work here,” Dr. Paskett explained. “The best thing to use, they said, is billboards.”

The billboards in some counties advertise the importance of getting screened, whereas billboards in the “control” counties encourage eating more fruits and vegetables. Phone surveys will be used to measure outcomes, such as awareness of the need for people 50 years of age and older to be screened and whether more people are being screened. Dr. Paskett and her research team are also working with community groups to help residents who are screened obtain appropriate follow-up care.

Interventions to improve screening awareness and uptake have to be tailored to target communities, Dr. Paskett stressed. “An approach that works in New York City may not work very well in rural Ohio,” she said.

The NCI Cancer Bulletin is an award-winning biweekly online newsletter designed to provide useful, timely information about cancer research to the cancer community. The newsletter is published approximately 24 times per year by the National Cancer Institute (NCI), with day-to-day operational oversight conducted by federal and contract staff in the NCI Office of Communications and Education. The material is entirely in the public domain and can be repurposed or reproduced without permission. Citation of the source is appreciated.

Maps: Adapted and reprinted by permission from the American Association for Cancer Research: D Naishadham et al., State Disparities in Colorectal Cancer Mortality Patterns in the United States, Cancer Epidemiol, Biomarkers & Prev, 2011, 20(7); 1296-302.

Illustration of the colon from Gray's Anatomy

Under health law, colonoscopies are free—but it doesn’t always work that way


By Harris Meyer
This story was produced in collaboration with

Illustration of the colon from Gray's AnatomyFor years, doctors have urged patients over the age of 50 to get colonoscopies to check for colorectal cancer, which kills 50,000 Americans a year. Their efforts were boosted last year by the federal health care law, which requires that key preventive services, including colonoscopies, be provided to patients at no out-of-pocket cost.

But there’s a wrinkle in the highly touted benefit. If doctors find and remove a polyp, which can be cancerous, some private insurers and Medicare hit the patient with a surprise: charges that could run several hundred dollars.

That’s because once the doctor takes action, the colonoscopy morphs from a preventive test into a treatment procedure.

The situation is causing confusion among doctors and the insurance industry. And it’s raising concerns among the American Cancer Society, the American College of Gastroenterology, and other physician and patient advocacy groups that consumers could be unprepared for the extra expenses, which can include deductibles, copayments and coinsurance. Medicare and at least two large private insurers, Kaiser Permanente, with 8.6 million members across the country, and Health Net, with 2.9 million members in several Western states, are charging the fees. Seven other major insurers said they would not charge enrollees.

Charging fees is “just dumb.”

Charging fees is “just dumb,” said Dr. Virginia Moyer, a pediatrics professor at Baylor University who heads the U.S. Preventive Services Task Force, a panel of primary care experts that evaluates medical screening and preventive care. “We need to be sensible. … It sounds like looking for a way not to pay for something.”

Adding to the uncertainty is the high-profile campaign by administration officials—including President Barack Obama and his wife, Michelle — to drum up support for the health law by highlighting the guarantee of free preventive care.  “If you join or purchase a new plan, the insurance company will be required to provide preventive care like mammograms, colonoscopies, immunizations, pre-natal and baby care without charging you any out of pocket costs,” the president wrote to supporters in an e-mail marking the six-month anniversary of the law.

Although colonoscopy is the most obvious example of the confusion, it is not the only one. Dr. Roland Goertz, president of the American Academy of Family Physicians, said it remains unclear how doctors and insurers are supposed to handle patient cost sharing for preventive checkups that turn up medical findings such as a skin lesion or breast lump needing a biopsy or excision during that visit.

Colonoscopies find a polyp in at least 25 percent of men and 15 percent of women. Thus, many people face financial “post-procedure shock.”

“Then it becomes a therapeutic visit,” he said. “Should this be a preventive visit with a modifying code, should it be considered only therapeutic, or should the patient be brought back for the needed care? It will take some clarification and time to work this through.”

Last July, the administration released regulations for insurers on the preventive care benefits. They prohibit health plans from imposing cost sharing for preventive services that were part of a visit to a doctor that was focused on prevention, if the services are not billed separately from the office visit.

However, an insurer “may impose cost-sharing requirements for a treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service.”

Robert Zirkelbach, a spokesman for America’s Health Insurance Plans, said the colonoscopy issue illustrates the need for a clarification from administration officials about services such as colonoscopy where physicians provide both preventive and therapeutic care in the same visit.

In written comments on the federal regulation last year, his group said physicians must understand how to appropriately code preventive services so that insurers know when to waive the deductible and coinsurance.

The federal health law specifies that insurers must fully cover services that have earned an A or B rating from the U.S. Preventive Services Task Force, plus immunizations recommended by the Centers for Disease Control and Prevention, and preventive care for women and children recommended by the federal Health Resources and Services Administration.

That coverage rule took effect last September. It applies to an estimated 31 million Americans in group health plans this year and 10 million in individual plans, and will cover 88 million by 2013.

To qualify for the free coverage, patients must go to providers in their health plan network.

Colonoscopy is on the U.S. Preventive Services Task Force’s recommended list, with an A rating, for all adults 50 and older. It checks for colorectal cancer, which is preventable with screening and highly treatable if caught early. A National Institutes of Health report last year said cost sharing likely affects people’s willingness to have such screening.

If a patient with no symptoms goes in for a screening colonoscopy and the gastroenterologist finds no pre-cancerous or cancerous polyps, everyone agrees that Medicare and commercial insurers are required to cover the expensive test 100 percent. But when the doctor removes a polyp, some insurers apply charges– meaning the insurer pays less of the bill.

Critics say charging cost-sharing defeats the purpose of the law. Studies show that colonoscopies find a polyp in at least 25 percent of men and 15 percent of women. Thus, many people face financial “post-procedure shock,” according to medical and consumer groups that are lobbying to stop insurers and Medicare from applying cost-sharing in this situation.

“We raised this with insurers and they wouldn’t budge,” said Dr. David Johnson, past president of the American College of Gastroenterology. Since the law took effect, “it’s still an ongoing problem,” he added.

Medicare is waiving the deductible for its beneficiaries but charges patients a copay of $186 plus 20 percent of the doctor’s fee, according to a Medicare spokeswoman.  She said there have been few complaints from beneficiaries about the policy.

In addition to Kaiser Permanente and Health Net, Regence BlueShield, which has 3 million enrollees in four Northwest states, initially said it charged members the deductible and coinsurance if a colonoscopy found and removed a polyp. But Regence spokeswoman Rachelle Cunningham subsequently said that was a mistake, there should be no cost sharing charges, and the company was “re-evaluating and re-processing some claims.”

A Health Net spokeswoman said that in an effort to help enrollees understand the situation, her company has trained its customer service staff to better explain colonoscopy coverage. Kaiser Permanente officials said the insurer “strongly supports” the health law’s guarantee of preventive services but when “services extend beyond preventive and require diagnostic or therapeutic services” the cost sharing will apply, depending on the specific plan details. (KHN is not affiliated with Kaiser Permanente.)

Aetna, Cigna, Group Health Cooperative, Humana, United Healthcare and Wellpoint/Anthem all said members pay no cost-sharing when a polyp is found. Assurant refused to comment.

We want to hear from you: Contact Kaiser Health News

This article was reprinted from with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

Illustration of the colon from Gray's Anatomy

Colon cancer screening can save your life – Health tips from The Polyclinic


Illustration of the colon from Gray's AnatomyHow far would you go to prevent colon cancer? Is your life worth a little inconvenience, a rather unpleasant tasting bottle of “bowel prep,” and perhaps a touch of embarrassment?

More and more people have decided their lives are well worth a little sacrifice, and for good reason.

Colon cancer is the second most common cause of cancer death in the U.S. (Lung cancer remains number one.)

But colon cancer death rates have been falling steadily since the mid-1980s, in large part due to increased colon cancer screening.

First of all, early detection of a colon cancer—before it has spread—greatly increases the chances of a cure.

But colonoscopy screening can actually reduce the chances you will ever develop colon cancer because it is possible to identify and remove growths, called polyps, that can develop into cancer over time.

Dr. Headstrom

“Thanks to the widespread increase in screening, there has been a significant decrease in new colon cancer diagnoses,” explains Peggy Headstrom, M.D., a gastroenterologist with The Polyclinic in Seattle. “My colleagues and I would much rather help our patients prevent cancer through timely screenings than have to treat a patient for colon cancer down the road.”

Colon cancer is one of the most preventable types of cancer, explains Dr. Headstrom. “Colon polyps generally grow very slowly – about .5 mm a year – making it possible to detect and remove them before they turn into cancer.”


From the Centers for Disease Control and Prevention

When Should You Begin to Get Screened?

You should begin screening for colorectal cancer soon after turning 50, then continue getting screened at regular intervals. However, you may need to be tested earlier or more often than other people if:

  • You or a close relative have had colorectal polyps or colorectal cancer; or
  • You have inflammatory bowel disease.

If you are aged 50 or older, or think you may be at increased risk for colorectal cancer, speak with your doctor about getting screened.

The U.S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer for all people until they reach 75 years old and for some people when they are older than 75. If you are in this age group, ask your doctor if you should be screened.


What’s involved?

A colonoscopy requires the patient to first follow a clear liquid diet for a day and then drink a chalky tasting laxative that helps clear the colon for easier identification of polyps. For the procedure itself, the patient is sedated.

During colonoscopy, the doctor inserts a flexible, lighted tube with a small camera mounted on it, called a colonoscope, into the anus. The intestine is inflated with air to give the doctor a better view, and the tube is guided through the rectum and into the colon (large intestine).

The doctor views the image from the camera on a screen, looking for any unusual growths on the intestinal lining. The doctor can remove polyps using a small wire snare in the scope during the colonoscopy so they can be tested for signs of cancer. The procedure usually takes 30 to 60 minutes, and the patient remains at the clinic for an additional hour until the sedative wears off.

“The screening serves a dual purpose – not only identifying whether a patient has a polyp, but actually removing potentially cancerous tissue during the procedure,” says Dr. Headstrom.

To learn more: