Category Archives: Health

An update on that colonoscopy study

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I appreciate feedback received from a couple of friends to my recent post about the new study on colonoscopies.

One pointed out:

Appears that the NordICC researchers are intent on focusing their
attention on the entire population of”invited” subjects, as opposed to
finding out more about what distinguishes the members of that group
who opted to have a colonoscopy from those who did not.

The opt-ins many be very different from the opt-outs (and from the
general population), so we cannot generalize from the colonoscopy
results of the opt-ins to the general population. Opt-ins may be older
and generally less healthy than the opt-outs, and they may have been
urged to by their physicians to have the colonoscopy.

Then another friend weighed in with his very useful and informative expert opinion, which I’m taking the liberty of sharing in full. Among other things, he points out the pressure of the colonoscopy industry which appears to have skewed the types of screening most often recommended to patients.

Aloha Ian:

It’s Dr.John Garvie retired gastroenterologist and neighbor. Have a few thoughts for you and your readers consideration.

1. This is the FIRST randomized controlled trial ever performed to evaluate the efficacy of colonoscopy screening despite the fact that widespread screening was adopted in the US in 2000.

2. The study was performed on patients from Sweden, Norway and Poland which all have socialized health care systems with the intent to determine if the enormous cost of mass colonoscopy screening was cost effective (worth it).

2. Once Medicare agreed to cover CRC screening all insurers gradually followed suit.

3. The impetus to cover was accelerated by a study performed at OHSU (Oregon Health Sciences University) late 1990’s and published in the NEJM showing @3% incidence of right colon premalignant pathology not detected by the more limited flexible sigmoidoscopy which only examined the left colon.

4. Understand that screening applies to healthy average risk patients. The generally accepted lifetime average risk for CRC is 5%.

5. Also understand that screening recommendations include an option menu to include stool testing for blood, stool testing for DNA abnormalities, sigmoidoscopy, virtual colonoscopy (done w CT) and colonoscopy.

6. Over time GI docs abandoned virtually all options except colonoscopy and a burgeoning industry was started. The argument was the progenitor lesion (premalignant polyp) could be identified and removed

7. Today 85% of GI docs income is derived from colonoscopy. I personally know multiple GI docs who perform 60-80 colonoscopies each week.

8. CRC incidence started to decline before 2000 before widespread screening was adopted.

9. Back to the study: it is well-designed and the numbers are robust enough to show statistical significance. The bottom line conclusion was that the ABSOLUTE risk reduction between the examined and the un- examined groups was not significant. The result was published after 10 years of follow up and the authors with continue to follow for an additional 5 years.

10. The authors queried whether the more limited and cheaper sigmoidoscopy may be just as good as the more invasive and expensive colonoscopy.

11. More studies are in progress and will be important to validate or refute this report.

12. My bias is that a good procedure (colonoscopy) has been oversold and overused. A single high quality normal colonoscopy after age 50 followed by less invasive stool tests until age 75 will prevent colon cancer virtually all average risk patinas.

Regards,
John

Can headlines cost lives?

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Well, if the headlines discourage people from getting medically beneficial cancer screenings, the answer is likely an unfortunate “yes.” And that’s been the case with much of the coverage of a newly published study.

It’s only been a week since I turned myself over the Straub’s Endoscopy department for an overdue colonoscopy, so I was immediately interested when I saw the headlines reporting on an article published in the New England Journal of Medicine. The most prominent stories featured headlines questioning the efficacy of the procedure.

Screening Procedure Fails to Prevent Colon Cancer Deaths in Large Study (msnNow)

New study suggests benefits of colonoscopies may be overestimated (The Hill)

New study questions the effectiveness of colonoscopies (Philadelphia Tribune)

Colonoscopies: Major trial reveals uncomfortable procedure does not cut risk of cancer deaths (Daily Mail)

You get the idea. The dominant message was that this particular study concluded colonoscopies don’t work, or don’t work as well as previously thought.

Then I started reading a few of the stories.

My main takeaway? There are headline writers who need to go back to school, as their headlines are misleading at best, and mostly dangerously wrong.

I haven’t been able to read the complete study because of the New England Journal of Medicine pay wall, but the abstract is available online.

Here’s its description of the study.

METHODS We performed a pragmatic, randomized trial involving presumptively healthy men and
women 55 to 64 years of age drawn from population registries in Poland, Norway, Sweden, and the
Netherlands between 2009 and 2014. The participants were randomly assigned in a 1:2 ratio to either
receive an invitation to undergo a single screening colonoscopy (the invited group) or to receive no
invitation or screening (the usual-care group). The primary end points were the risks of colorectal
cancer and related death, and the secondary end point was death from any cause.

Two groups were compared. One group that received an invitation to get a colonoscopy, and a larger group that did not receive an invitation or undergo screening.

And here’s how the abstract summarized the findings:

CONCLUSIONS In this randomized trial, the risk of colorectal cancer at 10 years was lower among
participants who were invited to undergo screening colonoscopy than among those who were assigned
to no screening.

So right off the bat, you have to wonder where the headline writers got their wrongheaded story line that there was no effect?

First, the study wasn’t focused on the benefits of the colonoscopy procedure itself, but rather on the benefits of inviting a large population to undergo a colonoscopy screening. And even at this level, the study found measurable benefits.

But many news stories were similar to the one appearing in the Globe and Mail, which reported: “Screenings only reduced cancer cases by 18% compared to those not given one.”

That’s startlingly wrong. Merely an “invitation” to be screened, with some that actually went ahead and had the colonoscopy done, was enough to produce the 18% decline in cancer cases.

Second, although this finding is buried in the various news stories, when a direct comparison was made between those who had a colonoscopy, and those who did not, the beneficial results were substantial.

“For that slice of the population, the risk of colon cancer was about 30% lower, and their risk of death was roughly cut in half compared to the people who did not receive one,” according to the Washington Post.

It seems to me that is the most important point, misleading headlines aside.

Another cousin battles with cancer

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Sad news from a Lind cousin who could use some kokua.

Our grandfathers were both born in Scotland. Their fathers were brothers. And I think that makes John and I third cousins.

Both of our grandfathers emigrated to the US in the first decade of the 20th century. My grandfather lived and worked in California, and his son, my father, came to Hawaii in 1939. John’s grandfather made it all the way to Hawaii.

Although my parents had known that there was another Lind family that ended up in Hana, they did not know whether we were related.

It was my late sister, Bonnie, who finally was able to piece together the family relationship, part based on information she gathered in a visit to Scotland. She discovered that the town the original John Lind (the my grandfather’s cousin) had come from was actually a family farm where the Linds had lived and worked for several generations.

In any case, John and his family have been very active and contributed so much to the Hana-Kipahulu community.

The photo of the two of us was taken back in 2013 when John was in Honolulu.

If you ever ran into John, or even if you didn’t, I’m sure any contribution will be very much appreciated.

Here is a link to the Gofundme page for the John Lind of Kipahulu, Maui Cancer Fund.

Using Honolulu 311, and my hearing aid adventure

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Just a couple of routine items.

First, a “thank you” to the city’s refuse folks. Two weeks ago, I submitted a photo of some junk that had been sitting along the roadway just down the street from our house. There was a stuffed chair, and what looked like perhaps part of an old bed, and they had been sitting there for well over a month, and perhaps as long as a couple of months.

We had been seeing them in the mornings, and thought they had been put out for a scheduled bulky item pickup, but that never happened. So finally I got around to submitting a request through the Honolulu 311 system. That was two weeks ago. Then last Friday, I received a telephone call asking whether the junk was still there, and assuring me that someone would be out to assess it. I had to explain that the pile was growing, including what appeared to be a pickup truck’s load of yard waste. Then, just yesterday, lo and behold, the chair and other furniture were gone, but the yard waste was still there. But when we walked past the spot before dawn this morning, even the yard waste had been cleaned up.

I’ve previously reported graffiti at the beach park, and other issues, and have found the 311 system to always get a meaningful response from the city.

Now, just a brief word about the new pair of hearing aids purchased at Costco and picked up yesterday.

It seems that I overestimated how long I’ve been depending on hearing aids. I thought it had to be at least 15 years, maybe more, but after digging into whatever info I could find, it looks like I bought my first pair in 2008, and this is my third pair, the second via Costco.

For a long time, I hadn’t realized that the problem was my own hearing rather than the world being full of people who mumbled. The last straw was realizing that I couldn’t hear the judge in a court hearing even while I sat in the front row, about as close as I could get without being a defendant. I was going to interrupt and ask the judge to speak up, but luckily noticed that other in the audience weren’t having the same problem.

So off I went for a check on my hearing, first to a fancy ear, nose, and throat doctor, notable for doing an exam and then trying to sell me on an outrageously priced pair of hearing aids. I grabbed my hearing test results and got out of there fast before I was trapped or tricked into that unnecessary investment. Next stop, Ohana Hearing Care, a small shop on South Beretania where my mom had been going for years. Small place, personal attention, good service, less expensive than the premium spread.

But by the time I went looking for my next paid about five years later, I had read about the wonders of Costco’s hearing centers. An excellent guarantee, including a period of coverage if you lose one of your devices. All at a much lower costs, with service available through any Costco that has a hearing center.

That first pair of hearing aids from Costco were purchased in October 2013. And they were still working pretty well, except that they lacked the ability to work directly with my iPhone, and I figured that hearing technology had probably advanced quite a bit in those eight long years.

Anyway, I sat through another hearing test two weeks ago, and was steered to the two products that make up most of their sales, Costco’s own Kirkland model, a very reasonably priced set by a major manufacturer with most bells and whistles included, and the Jabra Enhance Pro PM, which cost several hundred dollars more.

I spent some time trying to figure out meaningful differences between them. Both have small receivers that sit up behind your ear, with a small wire and speaker that fits into your ear. Very similar in size and appearance. The Jabra offers a choice of rechargeable batteries or regular batteries, while the Kirkland was available as rechargeable only.

The Jabra brags of lasting up to 30 hours on a charge, which claimed to be “best in class.” That appealed to me. Then I saw that the Jabra is on Apple’s list of “Certified for iPhone” models that, they say, should work well if you live within the Apple environment. And that’s certainly where I reside, with my Mac laptop, iPhone, iPad, and Apple Watch. In the end, that swayed my choice, and I went with the Jabra.

There was a two-week wait for delivery from the mainland, and my appointment to have it set up was on Tuesday.

That involved close to an hour of “calibration,” setting the hearing aids to compensate for the specific problems in my own hearing, frequency by frequency. A lot of fine tuning, it seems, then getting linked properly to my iPhone, doing a training lap after downloading the iPhone app, and then I was on my way with a new level of hearing.

I did experience a very noticeable improvement. If my ears were eyes, they world was starting to look just a bit blurry, like letters on a vision chart that were legible but didn’t qualify as “sharp.”

Now the world I’m hearing is again quite “sharp,” and I’m hearing more of conversations, and while watching television, than I have been hearing recently. So far–although it’s been not much over 24 hours–I’m quite impressed. Now I still have to fiddle with the app’s “programs,” settings designed for common situations, being in a restaurant, concentrating on hearing one person you’re in conversation with or, alternatively, trying to function in a group. There’s another program for listening to music or watching television. Another that offers an “ultra focus” on someone in front of you in a noisy environment. There are probably more that I just haven’t fiddled with yet.

Costco delivers this with a three-year warranty, including two years of replacement if lost. Free cleaning recommended every few months, which can be done while we’re shopping at Costco.

I’m still getting used to how the world sounds, and I would image my aging brain will take a week or so to become accustomed to it all. Right now, count me as a very happy camper.

That’s my experience. Your mileage may vary.