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The Big Screen

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Gastroenterologist Amy Patrick and Edward C. White Jr., a co-founder of Colon Health Centers of America, say the controversial virtual colonoscopy will increase colon cancer screening rates. Photograph by Greg SachsThough medical experts have been telling us for years that colon cancer is treatable and preventable, it ranks second in cancer fatalities in Delaware, for one main reason: “People aren’t doing the screening,” says gastroenterologist Amy Patrick.

Apprehension and misconceptions about the preparation and colonoscopy, one of the most common screening methods, may be the biggest factor in dismal screening rates. To combat them, the new Delaware Colon Health Center, owned by Mid-Atlantic GI Consultants, is offering a new technology: the virtual colonoscopy.

The virtual colonoscopy, or CT colonography, is considered a less invasive procedure than traditional colonoscopy. CT scans use specialized X-ray equipment and computers to produce images of the colon. The technology has been around for about 15 years, but recent advances have earned the endorsements of several national medical organizations, including the American Cancer Society, the American College of Radiology and the Multi-Society Task Force on Colorectal Screening, as a preferred test for colon cancer.

What makes the Delaware Colon Health Center approach different is that it integrates virtual colonoscopy with traditional colonoscopy, which requires inserting a long, flexible instrument attached to a camera through the patient’s rectum to examine the colon.

Physicians and other healthcare professionals disagree, however, about the comfort and effectiveness of the two procedures, though many say any test that could save someone’s life is good.

Mark Baumel, founder and CEO of Colon Health Centers of America and husband of Dr. Patrick, of Mid-Atlantic GI Consultants in Newark, is pleased to see Delaware as the first of what he hopes are many screening sites across the country.

“MAGIC (Mid-Atlantic GI Consultants) is the first community GI practice in the nation that is offering integrated colon screening as an option for their patients,” says Baumel. “The reason they are able to is because Blue Cross Blue Shield of Delaware has recognized the value of the virtual colonoscopy. They are the first major commercial payer in the nation to pay to cover screenings using virtual colonoscopies.”

Though most insurance companies will not cover a virtual colonoscopy, Blue Cross Blue Shield of Delaware was interested enough in the approach that it initiated a pilot program with Delaware Colon Health Center.

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“We want to have 100 percent of our members screened,” says Dr. Paul Kaplan, chief medical officer of Blue Cross Blue Shield of Delaware. “Our colon cancer screening rates are higher than the national average. They’re still only around 60 percent, which means 40 percent of our eligible members are not getting screened for colon cancer. Our goal was to find another viable option.”

The pilot program, which began September 1, targeted eligible members in New Castle County and bordering counties. About 22,500 members and 500 primary care providers were informed of the program by mail. If it proves successful, BCBS of Delaware intends to use it as a model.

In a virtual colonoscopy, or CT colonography, a scanner creates images of the colon after it has been inflated with carbon dioxide, in 15 minutes or less. At the Colon Health Center of Delaware, patients can wait about 45 minutes while a CT-certified radiologist reads their images. Though the procedure does not require anesthesia, it does require the same 24-hour colon preparation that a traditional colonoscopy requires. Unlike traditional colonoscopy, however, polyps on the colon cannot be removed, if found.

So far, results at Colon Health Center of Delaware mirror the national trend, according to Baumel. Eighty percent of patients are cleared to go home or back to work. The 20 percent with polyps can proceed with a traditional colonoscopy for removal that day, thus avoiding the burdensome prospect of a second bowel preparation. From September through November, the Colon Health Center screened about 300 patients, according to Baumel. Of them, 40 went on to have colonoscopies that same day.

Baumel hopes to create similar operations with GI practices across the nation. “We have dozens of GI groups around the country who are interested,” he says. “We want to turn Colon Health Centers of America into the most compelling consumer brand for colon cancer screening. The reason why we are so intent on creating a consumer brand is because, right now, we are doing a highly inadequate job of getting Americans screened for colon cancer.”

This new technology, the Colon Health Center approach, and the BCBS of Delaware pilot program are being closely watched by many in the local medical community.

Dr. Nicholas Petrilli, head of the Helen F. Graham Cancer Center at Christiana Hospital, views the virtual colonoscopy as another useful screening option. “Colorectal cancer is a preventable cancer,” Petrilli says. “Any screening is better than no screening at all, but the gold standard is the colonoscopy.”
 

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Dr. Parag Lodhavia, a gastroenterologist in Dover, is concerned about the sensitivity of the virtual colonoscopy, as well as the overall experience and comfort of the patient. Lodhavia points to a 2006 study published in the American Journal of Medicine that compared traditional and virtual colonoscopy.

“As far as patient satisfaction is concerned, patients found colonoscopy much more acceptable based on overall experience,” says Lodhavia. The virtual colonoscopy, performed without anesthesia, can be quite uncomfortable for some patients, he says. “The hardest part about this is the preparation, and you have to do that with both of them.”

Among his concerns about effectiveness, “There is a lot of variability with the CT colonography,” Lodhavia says. “It’s a question of what percentage of the actual disease do you actually pick up.”

One criticism of virtual colonoscopy is that it misses polyps smaller than a centimeter. Lodhavia says that, with traditional colonoscopy, “most of what we find are less than a centimeter.” Though polyps measuring larger than a centimeter indicate a greater risk for cancer, “Size is not the only factor,” says Lodhavia. “Pathology of polyps is just as important as the dysplasia of the cells.”

Patrick disagrees. “I wouldn’t want people to be alarmed by diminutive polyps (under 6 millimeters), because it is generally well accepted that these extremely small lesions represent little to no risk,” she says.

Patrick also notes the advances in the virtual colonoscopy. “In the last five years, the technology has really gotten to where it needs to be a great screener,” she says.

She points to a study on virtual colonoscopies in the September 2008 New England Journal of Medicine that she says validates the technology. The article concludes that “virtual colonoscopies and the traditional colonoscopies are on a par with each other.”

“It’s a great choice,” she says. “We’re not saying one over the other because some people are not coming in for anything, and that’s why colon cancer rates are so high. No test is perfect, but when you look at what the test can add by increasing the screening rates by 25 percent, the concerns are surmountable.”

“It’s very politically charged because the current practice models could be disrupted, especially if radiologists did virtual colonoscopies,” Patrick says. “It’s a bit of a turf war between radiologists and GIs.” She believes “the integrated approach is good for patients and good for GIs.”

Kaplan says Blue Cross hopes for open communication with all doctors about the pilot program. “Our goal is also to understand what integrating this technology into the community means,” he says. He points to a “potential for improvement in health care—and potential for disruption in health care.”

Patricia Hogue, chief mission officer with the American Cancer Society, says that the virtual colonoscopy is another good screening tool, with advantages and disadvantages compared to traditional colonoscopy. “Anything that can convince people to have a colon exam is better than nothing,” she says. “The best colon screening test is the one that a person takes.”

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