“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.
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Good read. It was really alarming when I read – Colon cancer is the third leading cause of cancer-related deaths in the United States in both men and women.
One side note about Colon Cancer screening. I am led to believe that screening with endoscopy is less accurate for ascending colon cancers than for descending colon cancers. There is a low incidence of colon cancers located in the ascending colon that originate and metastasize very quickly as in <2-3 years as compared to 5-10 years for the descending colon. Twenty years ago, it was common knowledge that two long-term screening studies were nearly finished with the purpose of evaluating the benefit of complete colon endoscopy for colon cancer. Both were described as occurring in Europe. To date, no results have been published. The silence is deafening. If they were terminated, the question is WHY.
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Putting aside the Population based issues, This case study also reveals a possible lack of palliative measures such as a diversionary, terminal ileostomy (using the end of the small intestine to empty itself through a tunnel in the abdominal wall to open outside the abdomen) which is possible to do through laparoscopy. There is no place for a tube in the nose to compensate for a colon blockage. Its possible that it occurred the next day after the scenario was witnessed as described above.
We owe our veterans so much. Let’s start to repay our debt with truly comprehensive health care for them. Discussing colon cancer screening with veterans seems the least we can do.
Once again, the LACK of a nationally sanctioned and locally managed tradition of assuring that each citizen is offered “enhanced Primary Healthcare” continues to exhibit many attributes of ineffective healthcare. Promoting equitably available and ecologically accessible Primary Healthcare will require a community by community process involving its relevant stakeholders. The various Silos of healthcare, however defined, inadvertently create enough ‘lack of focus’ for each community’s COMMON GOOD to discourage long-term Trust.
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The most powerful study for this appeared in a 2015 edition of the Journal of Epidemiology and Community Health published by the British Medical Journal (doi:10.1136/jech-2015-205822), title TRUST AND HEALTH: TESTING THE REVERSE CAUSALITY HYPOTHESIS. I cite the CONCLUSION
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“The circular relationship between trust and health, as shown in this study, suggests that pathways other than direct positive (causal) effects are present. Nor did we find evidence to fully support the existence of a positive (mutually reinforcing) feed-back loop between health and trust. We noted that the strength and stability of the association between “self-rated health” was cohort dependent. Our results, therefore, offered some empirical support to other theories postulated to describe the complex mechanisms behind the trust/health relationship. Further longitudinal research to disentangle the ways that trust and health appear to affect each other over time.”
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So, the underlying issue would represent the proposition that a community’s Social Capital character directly affects the neighborhood network of each citizens family, AND as a result, this good or bad character can have devastating effects on a person’s HEALTH for good or bad. The above study was a Trail-head study, as it was the First reported to test the reverse hypothesis: “Does health promote Trust?” Yes, but in complex ways.