Men's Health

In My Humble Opinion
21

You are correct I should have looked up the actual facts, and you clearly got yours from very reliable sources. However, I am having a problem with you figures.

Here’s a very rough estimate:

Quote:
Originally Posted by Medscape
Of the 16,318 eligible colonoscopies (96% performed by board-certified gastroenterologists), the incidence of serious complications was 5/1000 procedures (95% confidence interval [CI]: 4.0-6.2). The 82 cases of serious complications that occurred involved 15 perforations, 6 cases of postpolypectomy syndrome, 53 cases of bleeding requiring hospitalization (15 requiring surgery or transfusion), 38 cases of bleeding requiring inpatient observation, 6 cases of diverticulitis, and 2 unusual complications (1 snare caught in a large polyp requiring surgery and 1 case of diabetic ketoacidosis associated with the colon preparation). There were 10 deaths (0.6/1000) within 30 days of the procedure, but only 1 of these was directly related to colonoscopy (a patient with congestive heart failure and sepsis after a transfusion for postpolypectomy-related bleeding).
Meanwhile, here’s the latest study on colonoscopy benefits from the NEJM:
Quote:
Originally Posted by NEJM
Among 2602 patients who had adenomas removed during participation in the study, after a median of 15.8 years, 1246 patients had died from any cause and 12 had died from colorectal cancer. Given an estimated 25.4 expected deaths from colorectal cancer in the general population, the standardized incidence-based mortality ratio was 0.47 (95% confidence interval [CI], 0.26 to 0.80) with colonoscopic polypectomy, suggesting a 53% reduction in mortality. Mortality from colorectal cancer was similar among patients with adenomas and those with nonadenomatous polyps during the first 10 years after polypectomy (relative risk, 1.2; 95% CI, 0.1 to 10.6).
The missing information here is the percentage of colonoscopies which find polyps. The NYTimes article about the NEJM study implies it’s about 20 percent, but I’d welcome corrections on that.

Take 1 million people in the right age range and give them colonoscopies. Let’s say 1/16,000 die as a result of the procedure, so you cause 62.5 deaths. Meanwhile, you remove polyps from 20% of the patients. The NEJM study says that the colorectal cancer mortality rate over their follow-up period was about 0.5% in the treated group vs. 1% in the general population. Of the 200,000 patients who had polyps removed, 1000 die of colorectal cancer, compared to 2000 in the general population, so you have saved 1000 - 62.5 = 937.5 lives.

First, according to the figures quoted the death rate is 0.3/1000 in the thirty days following colonoscopy. Some of these where deaths by other causes such as heart attack, some doubtless do to the colonoscopy. Anyway this comes to 300 deaths per million. Now for the complications, the rate is about 67/million or 67,000. This is a huge number of people getting very very sick. If I am “lucky” and have cancer I have made a good choice. If no adenomatous polyps are found I just made an incredibly risky decision.

The huge mistake in your argument is that you need to realize that the death rate and morbidity rate is based on the 1,000,000 examined, not only those in whom polyps were found.

22

I started having yearly physicals around 38. My first “finger check” was at 40, but thankfully it can now be done via a blood test. My situation is rather unique in that I have to go to the doctor once a month for chronic pain issues. Because of that I am checked quite frequently for blood pressure, weight and general health. Also, the meds that I am on require a PSA test every six months. If anything, check with your insurance and see if they pay for an annual physical. Most do and it gives the doctor a baseline to compare to.

23

As far as I know, it is a federal mandate that all health insurance fully pay for a yearly general physical exam. Not that I am advocating this, but it should be available.

24

I’m not entirely sure what you’re trying to say, but I’ll try to respond to your points.

I’m not convinced that what the authors of the Medscape article see as a “serious complications” equates to “very very sick” in layman’s terms. For example, half of the “serious complications” were bleeding which only required inpatient observation. Not exactly a fun way to spend a day or two, but probably not something with long term negative effects. Also, 5/1000 is 50,000 per million.

The other issue is that the NEJM study only looked at mortality differences from colorectal cancer. It seems likely to me that there is also reduced morbidity; plenty of people get colorectal cancer and don’t die from it, and presumably those numbers are reduced in the treated group as well. That’s why I focused on mortality from complications rather than morbidity.

That doesn’t make sense. As I showed, when you apply the numbers to a population you can see that people are much more likely to benefit than to be harmed from having a colonoscopy.

If you look at my calculations, you will see that I did indeed base the numbers on the 1,000,000 examined.

25

I’m 33 and with a change in insurance providers at work this year, we’ve got an incentive on our deductible if we’ve had a physical prior to any problems (i.e. my deductible is $1500, but my employer will pick up the first $500 if I’ve had a physical this year). How does one go about finding a doctor for a physical? I haven’t had one in years. I could go by word of mouth, but is there anything specifically to look for? Or is it going to be as much a crapshoot as finding a dentist?

26

First of all, see if your insurance provider has a physician listing on their web site. Such listings may include some manner of ratings.

Secondly, there are independent web sites that allow patients to rate their doctors. Angie’s List does this (though, you have to pay for a membership). Google “physician ratings”, and you’ll find a number of them.

I’d suggest finding some GPs which your insurance covers, and which are conveniently located for you, then check out the third-party rating sites.

27

Actually, no.

If you get an “all-clear” on a colonoscopy, and have no other symptoms, your gastroenterologist may give you a free pass anywhere from five to ten years. That means your chances of developing colorectal cancer are almost nil.

If the doctor found polyps, but they are benign, your chances of survival greatly increase if you have yearly colonoscopies forevermore. Polyps often become cancerous, which is why they are always removed and examined. If you don’t have any polyps, your chances decrease. Polyps are social entities–if you find one, there are almost always gonna be more.

It doesn’t make sense to argue statistics, because I’ve discovered over the years that statistics can be manipulated to say just about anything.

The basics as I accept it are this: get your first colonoscopy at fifty, unless problems present sooner. Depending on what the findings are, schedule future colonoscopies as recommended.

Your chances of dying are greater by doing absolutely nothing, than they are by getting scoped.

THAT’S my motivation for putting up with that damnable prep.
~VOW

28

Your last statement makes a statistical claim, which is odd if you think statistics are useless.

29

Just to fight some ignorance: a digital rectal examination (DRE) is NOT the same thing as a blood test for prostate cancer (PSA). Current recommendations for prostate screening do not recommend routine screening but instead recommend a discussion between the doctor and patient because of the high incidence of false positives and the fact that many prostate cancers found are low grade and will not affect lifespan while the treatment can have severe side effects.

If screening is done, a PSA (with or without DRE) should be done at age 50 except in men with a family history of prostate cancer or African-American men, who are at higher risk.

A DRE can also be part of colon cancer screening, to check for occult blood and as such is a useful test to do regularly.

As far as routine screening, there is little data showing that routine yearly physicals are effective. I usually recommend at least a blood pressure screening yearly starting at age 50.

For women, the current recommendation is a gynecologic exam every 3 years unless there is a higher risk for cervical cancer. There is no reason an Internist or Family Practitioner cannot do routine gynecologic care; I do for about half of my female patients.

While it’s hard to find an simple guideline, the one from the Cleveland Clinic is only two pages and contains the current recommendations. (warning pdf)

30

I’m not sure where you get this information but it is not correct. While most private insurances pay for a yearly physical examination most government insurances do not. Medicare, for example pays for one physical examination in a lifetime, the “Welcome to Medicare” physical which must be done within 12 months of enrollment. The Affordable Care Act also provides for yearly “Wellness Checks” which consist of checking vital signs, assessing cognition and for depression and establishing a schedule of recommended screening. It does not, however, include things like actually listening to the heart and lungs or otherwise examining the patient, although doctors are not penalized for doing them. A list of the included tests is available here.

31

Good summary of the difference between the Medicare wellness exam and a physical exam.

32

dauerbach has a point: there are potential risks of screening and those need to be adequately factored in. For colorectal cancer screening though the balance is clearly on the benefit of screening, even if how to screen best may be a subject of some ongoing debate.

The U.S. Preventative Task Force actually does the best job requiring evidence of greater benefit over harm. That’s why they recently made headlines by officially advising against prostate screening for those over 75, and stating that the evidence for benefit over harm is insufficient to advise it for men under 75.

Colorectal screening 50 to 75 OTOH gets an A recommendation. The basis of that decision is explained here and here. The big still not completely answered question in their analysis is determining the best balance between the decreased risk but less sensitivity and specificity of some methods, with the greater accuracy but greater risk of another (colonoscopy). For example flex-sig has a sensitivity of only 58 to 75% (so will miss from one out of four to more than one out of three colorectal cancers), while colonoscopy will miss very few, but the risk of serious harm per procedure - “are about ten times more common with colonoscopy (3.1 per 1000 procedures) than with FS (3.4 per 10,000 procedures)” “Harm”, not death. That extrapoloation made by dauerbach is not very scientific. The harms were mostly ones that merely needed observation. There was only one death that seemed to be directly related to the procedure, and that was in someone whose death would not have occurred unless he also had had congestive heart failure. Among those who were healthy going into the procedure there were NO deaths directly caused the procedure. Here’s the actual study being referenced. Note also: these were NOT screening exams in healthy individuals. More informative may be this study, and in particular this table. Note huge overlap between the 95% CI between no procedure and the screening groups, and the huge increases both when the procedure is being done for cause (as in the study dauerbach linked to) and with advancing age.

I look at that data and see a very safe procedure when done for screening an apparently healthy individual, with significantly greater benefits over possible harm.

33

My colleagues have said most of what I was going to say. There’s no evidence-based answer to the question of how often anyone should be seen for anything, much less the relatively young and healthy.

When asked, I suggest that people without any chronic illnesses have a basic workup (BP, review of systems, basic lab work including cholesterol) once in their 20s, twice in their 30s, and every two or three years in their 40s. If they’re lucky enough to make it to 50 without any problems a yearly checkup probably isn’t a bad idea. Most people encounter the health care system incidentally at least this often and ideally most of this stuff can be dealt with then.

There just isn’t much to screen a healthy guy for until he turns 50. But recommendations change, which is why a checkup every few years is probably a good idea.

IMO, the sooner we can eliminate the digital rectal exam from the routine physical, the better. There’s no evidence that it’s beneficial in guys without elevated risk factors, and there are plenty of guys who stay away from the doctor because they don’t want it done, leaving their hypertension, cholesterol, diabetes, etc. untreated. If there were evidence of benefit I’d tell guys to suck it up and deal with it, but there isn’t. (As psychobunny says, you can check for occult blood with a DRE, but you can also send home a stool card kit, which gives you the benefits of serial tests and of not having a relative stranger’s finger up the patoot.)

34

I agree that a DRE has not been shown to necessarily be beneficial in preventing disease and believe me I would skip it if I could. However…

Aside from embarrassment-it is a test that is cheap, fast, (relatively) painless, and has almost no risk of complications

In my experience, only about 10-20% of people will do a home stool card test which requires them to follow a restricted diet for about a week and then take three separate stool tests and mail the cards back.

The DRE besides allowing me to feel the prostate also allows me to assess for hemorrhoids, fissures, polyps, and many other problems. Given the risk/benefit ratio-I continue to do them unless the patient objects strongly. And yes, I have picked up both colon and prostate cancers as well as herpes, anal warts, and perianal abscesses that the patient thought were hemorrhoids or local irritation by doing this exam. Some of these may have been picked up by other screening but having your doctor tell you she feels a mass is a much greater motivation in getting you to a specialist than telling you that a lab test is a little high.

Then, again, I was trained in an era when we did much more complete exams, where you could diagnose pneumonia by listening to the chest without an X-ray and where we were taught that the only two reasons for not doing a DRE on every patient were 1)no rectum and 2) no finger.

35

You’re right when it comes to the motivated patient with the ability to get over it, in which case there isn’t that much of a downside. I suspect you see a LOT more of those patients than I do.

It’s also possible that I overestimate how much chronic care goes undone or gets done late because guys don’t want the DRE. I certainly shouldn’t extrapolate my rural, mostly indigent, particularly homophobic population to everybody. But I really do see guys all the time who have gone months without their BP meds or years without seeing a doctor at all, and when I ask them why the DRE comes up as a big part of it. (I’m actually trying to get a study together to quantify this.)

So from a global perspective, the question is whether the ancillary benefits you describe outweigh the detriment that comes from the extra reluctance to come in. My belief has always been that it probably doesn’t, but again my experience may be further from typical than I know.

I was taught the same rule about the DRE, but I consider it my duty as an academic physician to question dogma. :slight_smile: