“It’s a terrible way to die” The oncology fellow told me bluntly as we walked to the room. “There is nothing okay about this.”
Knocking on the open door, we entered his room. The blinds were raised to reveal a stunning view of the area surrounding the VA hospital, and light poured in.
Our patient reclined in bed, his eyes closed although he was not asleep. He opened his eyes at the sound of our entrance, and the eyes seemed to bulge, too large for his shrunken face with wasted muscles. A plastic tube, taped to the bridge of his nose, entered his nostril and disappeared. The other end of the tubing led to a canister filled with dark green liquid that had been suctioned from his gastrointestinal tract. Despite this invasion, his stomach remained distended, protuberant compared with his otherwise frail frame.
The man had an aggressive colon cancer. The tumor in his colon had grown so large that the hollow of his bowel had closed off, allowing no food to pass through. With nowhere else to go, the contents of his bowel backed up, puffing out his stomach and causing terrible nausea and vomiting. Even worse, the tumor invaded outwards too, anchoring tendrils into the surrounding tissue so that there was no longer any hope of removing the tumor surgically. “Palliative” chemotherapy to try to shrink the tumor would be offered, but it had no chance of curing his disease. The oncologist’s note summarized the situation: “Prognosis is extremely poor.”
It was a good learning case, a late presentation of a disease increasingly diagnosed at early stages by screening colonoscopies. This patient had not undergone screening, which might have diagnosed the cancer while there was still time for a cure. As an African American, this patient was more likely to develop this cancer than Caucasian patients his age.
The VA hospital system is a model of preventative care, and such late presentations are rare. March is Colon Cancer Awareness Month, and at the VA hospital where I work, announcements flash on computer screensavers, reminding doctors to talk to patients about screening. Compliance rates with colon cancer screening have been shown to be 82% within the VA system, compared with around 60% outside.[i]
But we’re not screening everyone who is at risk. The VA’s system of clinical reminders leaves one group of patients without adequate screening, despite adjustments in guidelines. African Americans are more vulnerable to colon cancers, with a 25% higher risk and a 50% higher mortality rate.[ii] The mechanism of this disparity is poorly understood, and is likely from a combination of genetic and social factors, including lower rates of screening. In an effort to combat this disparity, U.S. Multi-Society Task Force of Colorectal Cancer (MSTF) revised their guidelines to recommend colon cancer screening for African American patients starting at age 45, rather than age 50, which is still recommended for everyone else based on the United State Preventative Services Task Force (USPSTF) guideline last updated in 2016. [iii] [iv]
Currently the VA’s National Center for Health Promotion and Disease Prevention fails to acknowledge this risk[v]. The website lists screening recommendations in a color-coded grid: green is recommended, yellow acknowledges that the evidence is mixed, and depends on individual patient factors. For ages 50-75, the box is green. For patients 76-85 the box is yellow, despite the USPSTF’s caution that, “The rate of serious adverse events from colorectal cancer screening increases with age.” For ages 45-50, there is a red box: not recommended, without acknowledgement of the most recent guidelines. This policy has practical effects. Practicing primary care at the VA, I only receive automatic reminders to consider screening my patients above age 50, even if they are African American and might want to consider earlier screening.
To be sure, screening tests are only effective if they are offered and if patients adhere to recommendations. The patient I described was offered a colonoscopy and refused. And the harms of over screening are real, including complications from screening procedures or over-treatment of incidental findings. But in an area where the consequences for our patients could be dire, and the disparities are great, the Veteran’s Health Administration has a duty to continue to lead the nation in providing the best possible care. Colon Cancer awareness month is coming to an end; before it’s over let’s change the box to yellow, and encourage VA doctors to discuss the most up-to-date guidelines with their patients.