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Grin and bear it

A colonoscopy is no fun, but it's one of the most reliable cancer screening tests around.

Dr. Daniel Von Hoff was feeling especially fond of his wife this past Christmas. So he gave her 'something special': a gift certificate for a nice, thorough . . . colonoscopy? "I want to have her around for as long as possible," explains Von Hoff, who heads the Arizona Cancer Center in Tucson.

This unique gift item didn't start a holiday trend: No one likes the thought of having his or her entire colon examined with a lighted tube inserted through the rectum. But increasing numbers of people are getting the message that colon cancer screening after age 50 is one of the most effective early cancer detection tests available. Even the low-tech, noninvasive test for blood in the stool, known as the fecal occult blood test, has proven in a recent study to save lives and reduce cases of colon cancer. The test is done on a stool sample, usually annually.

Colon and rectal cancer (lumped together as colo rectal cancer) are the number two cancer killers after lung cancer. Affecting men and women in equal numbers, they will be diagnosed this year in about 130,000 people in the United States and will take 49,000 lives. Unlike many cancers, early detection makes a huge difference. Caught promptly, colon and rectal cancer are nearly 100 percent curable, but after they have invaded the intestinal wall, that rate drops dramatically.

Nevertheless, it's estimated that only 30 percent of people who should be tested for colon cancer have undergone screening, so there's a lot of room for improvement.

The most invasive but most reliable early detection test is colonoscopy. In the Boston area, colonoscopy has become a brisk business for hospitals, where the test is usually done, and for the gastrointestinal specialists who perform it.

"Everyone's getting in line," says Jeanette Clough, chief executive officer of Mt. Auburn Hospital in Cambridge. "Our waiting time is three to four months," and the unit where colonoscopies are done has added two rooms. "We have five rooms going from 7:30 a.m. to 5:30 p.m.," she says.

Massachusetts General Hospital built a new unit several years ago for performing colonoscopies and endoscopies (similar examinations of the stomach). "It was expected to be adequate until 2007, but it's already swamped," says Dr. Paul Shellito, a colo rectal and general surgeon at MGH, where doctors perform 90 to 100 of the exams daily.

Many link an upsurge in screenings to news woman Katie Couric's efforts - she even underwent a colonoscopy on live TV - following her husband's death from colon cancer in 1998 at age 42.

The American Cancer Society recommends that most patients start colon cancer screening at age 50. (For those with a family history of colon cancer, talk to your doctor.) The society advises:

A fecal occult blood test every year.

A sigmoidoscopy every four to five years. In this procedure, the doctor uses a flexible viewing tube to inspect the lower part of the colon on the left side of the body, where about half of colon cancers are thought to begin. You can have a sigmoidoscopy in your doctor's office without anesthesia. Either the fecal blood test or sigmoidoscopy alone is also acceptable, say Cancer Society officials, although the combination is better.

An alternative to sigmoidoscopy would be to have the more expensive, but more thorough, colonoscopy every 10 years. Its longer tube reaches the entire colon and has snippers that can remove precancerous polyps painlessly. Heavy sedation eases the discomfort.

Colonoscopy has a slight risk of puncturing the intestine, which would require immediate treatment. It also costs more - from about $500 to as much as $1,500. Also, patients usually require several hours to recover from the sedation.

An alternative to the sigmoidoscopy or colonoscopy is a barium enema followed by X-rays to look for cancer or precancerous growths. It's less accurate than the more invasive tests but cheaper and more widely available.

Some who have undergone colonoscopy say they were much less bothered by the procedure than they expected. In fact, many are barely aware of it, because modern sedating and anesthetic drugs rapidly induce sleep or near-sleep and just as rapidly reverse it with few aftereffects (though some experience nausea). "We try to make the procedure itself as pleasant and painless as possible," says Mt. Auburn's Clough.

It's actually the preparation for either a colonoscopy or a sigmoidoscopy that most patients find annoying. To cleanse the intestine, you're required to eat lightly two days before a procedure. The day before the procedure, you are only allowed certain liquids and no food. In addition, you must take an oral laxative and use a suppository laxative just before the procedure in order to cleanse the colon so that any small polyps can be spotted.

In a more aggressive preparation that some doctors believe works better, you have to drink a gallon of salty fluid that washes you out stem to stern.

Medicare covers sigmoidoscopy and colonoscopy, the latter as a followup to an initial screening test with positive results. A bill is pending in Congress that would direct Medicare to pay for colonoscopy as a screening test itself.

Some private insurers will cover screening colonoscopies; it depends on the specific contract.

It may be an annoyance, but colonoscopy is such a successful screening tool - more effective than PSA (prostate-specific antigen) testing for prostate cancer or mammography for breast cancer - that it's well worth the trouble. And, just think: If nothing abnormal is found, you won't need one for another 10 years.