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Six Ways to Get Screened That Are Safer Than Colonoscopy

Back in 2008, I released an investigative report entitled “Colonoscopy: Is it worth the risk?”[1]. Here is what I wrote in the Introduction to this report:

“Each year over 14 million Americans are getting screened for colon cancer. Of these, according to the report “Complications of Colonoscopy in an Integrated Health Care Delivery System” by the Annals of Internal Medicine, an estimated 70,000 (0.5%) may be killed or injured by colonoscopy-related complications.[2] This figure is higher than the total number of annual deaths from colon cancer itself, 22% higher.

 The number of casualties above doesn't include deferred complications from colon prep and general anesthesia, such as kidney failure, stroke, heart attack, pulmonary embolism, pneumonia, intestinal obstruction, and numerous others. Nor does it include the increased risk of all other cancers from radiation exposure caused by x-ray-based (CT scans) virtual colonoscopies.”

Despite all these “shortcomings,” screening colonoscopies are still considered the “gold standard” of colon cancer prevention in the United States. Naturally, my research was universally ignored by medical community in the US. To boot, a lot of otherwise totally tolerant and judicious people began questioning the state of my mental health.

Not that that surprised me. After all, screening colonoscopies generate well over $10 billion dollars in revenues for hospitals and GI physicians [3], and a lot more from treating the side effects of these procedures.

Canada to the rescue. Unlike in the United States, our enlightened neighbor up North provides free health care to all of her citizens. The business of medicine there isn’t a bottomless piggy bank for profit-focused medical-industrial complex in the United States, but a social enterprise with a keen eye on the quality of care and bottom line.

When profit motives are taken out from the healthcare equation, the benefits to risks ratios of performing screening colonoscopies are assessed thoroughly and responsibly, so no money and lives are wasted.

In this context ­– sound policy vs. sound profit – it was only a matter of time before the Canadian gastroenterologists, epidemiologists, primary care physicians, and statisticians would have come to exact same conclusions as I have back in 2008:

We recommend not using colonoscopy as a primary screening test for colorectal cancer. (Weak recommendation; low-quality evidence).”

Canadian Task Force on Preventive Health Care; Feb 16, 2016 [4]

Ironically, back in 2001, the same Task Force, pointed out the following undeniable fact:

There is no direct evidence that colonoscopy is an effective screening manoeuvre in people at normal risk, even though it is the best method for detecting adenomas and carcinomas.”

Colorectal cancer screening: Recommendation statement from the Canadian Task Force on Preventive Health Care; July 26, 2001 [5]

So, what else has happened between then and now that has made them change their minds so radically and to come up, finally, with unequivocal rejection of colonoscopies “as a primary screening test for colorectal cancer” among asymptomatic, healthy adults?

Several factors, I believe:

So, let’s go over these newer tests:

1. Fecal Immunochemical Test (FIT) [6] for Colorectal Cancer

The fecal immunochemical test (FIT) is also known as immunochemical fecal occult blood test (iFOBT). It detects hidden blood in the stool and acts differently than the original guaiac-based FOBT [7]. The FIT test reacts only to a part of the human hemoglobin -- a protein located in the red blood cells.[8]

Comparing to the FOBT test, the FIT test will detect the blood emanating from the large intestine.[9]  Colonoscopy may still be needed if test results are positive (i.e. abnormal).[10]

Advantages: Foods, medicines, and the traces of blood from red meat do not interfere with the FIT test. For these reasons, it has fewer false-positives and is more accurate than other tests. No prep is required to take the FIT test for colorectal cancer. You can purchase the FIT test online [11] for a relatively low price.

Disadvantages: Unlike colonoscopy, the FIT doesn’t detect polyps and flat lesions that may precede colon cancer. This isn’t a limitation of the test per se because even the best colonoscopy can’t “remove” flat lesions, because >95% of the polyps are benign, and because many small polyps and tumors are routinely missed.

Limitations: None

Risks: There are no direct (i.e. related to the use) risks or side effects from using the FIT because it is a noninvasive procedure.

Test accuracy:  Studies show that the FIT is extremely sensitive to detecting hemoglobin in the stool, offering a 33% greater sensitivity to the presence of hemoglobin than guaiac-based FOB (fecal occult blood) test.[12]

Manufacturers’ sites: PINNACLE Biolabs, Clinical Genomics Company

Clinical research:

Price: Starts from approx. $26 per test. Also, available on Amazon:

2.Cologuard [13]

Description: Cologuard is the first cancer screening based on the DNA technology to detect altered hemoglobin or DNA in stool samples. It is capable of detecting tumors and other cancerous growths within the colon.

Advantages: Cologuard may detect up to 92% of cancers and up to 69% of high-risk precancerous lesions also known as high-grade dysplasia. Cologuard is a noninvasive test. Patients collect stool samples using the Cologuard collection kit, and ship them back to the lab. No dietary restrictions or bowel preparations are required before the collection.

Disadvantages: Cologuard is only available directly from medical doctors, and can’t be purchased at pharmacies or online. As with all colon cancer screening tests, there is always the possibility for false-positive and false-negative results. 

Limitations: Cologuard's manufacturer states that Cologuard should not replace a periodic surveillance or diagnostic colonoscopies in people with a high risk of developing colorectal cancer. In addition, results of a Cologuard test for people over 75 years old should be accepted with caution because of the increasing rate of false positives among elderly. It`s recommended to repeat Cologuard test every 3 years.

Risks: There are no direct (i.e. related to the use) risks or side effects from using Cologuard because it is a noninvasive stool test.

Test accuracy:  In a study involving 10,000 patients, Cologuard had a colon cancer detection rate of 92%.

Manufacturer’s site:

Clinical research:

Price: Cologuard test costs around $650.

3.Epi proColon Blood Test [14]

Description: Epi proColon test is the only FDA-approved blood test for identifying colorectal cancer cells with excellent accuracy. By detecting methylated Septin 9 DNA in the blood, Epi proColon may indicate a tumor or a polyp that is shedding (releasing) this type of DNA into the bloodstream. 

Advantages: Patients don`t need to change their diet or medicine intake before the blood draw. Epi proColon is another option for screening colorectal cancer (CRC) when a patient is rejecting the colonoscopy or other recommended screening methods.[15]

Disadvantages: Epi proColon is only available by prescription.

Limitations: Epi proColon is not intended for home use. Blood samples must be drawn at a doctor's office. The sample is then sent to a laboratory for testing.

Risks: There are no direct (i.e. related to the use) risks or side effects from using Epi proColon  test. 

Test accuracy: In clinical trials, Epi proColon demonstrated a 95% sensitivity and specificity rate.  Comparing Fecal Immunochemical Tests to Epi proColon tests revealed the latter to be statistically superior to FITs in regards to sensitivity.

Manufacturer’s site:

Clinical research:

Price: From $110 to $180.

4. Capsule Endoscopy [16] 

Description:  Capsule endoscopy procedure begins when a patient swallows a vitamin-size capsule that contains a battery, hi-res video camera, light, and video signal transmitter. While the capsule travels through the digestive tract, the camera takes thousands of pictures. These pictures are transmitted to a belt-worn recorder [17] After several days, the capsule is eliminated with a bowel movement.

Advantages: Unlike the traditional endoscopy methods, capsule endoscopy allows to examine the stomach and the small intestine. [18] It is completely painless and, technically, non-invasive.

Disadvantages: Patients need to fast for 12 hours prior to ingesting the capsule. If the large intestine is the target of the investigation, patients require a complete bowel prep prior to the examination.

Limitations: Patients with a small or large bowel obstruction should not undergo capsule endoscopy. People with swallowing disorders may not be able to ingest a large capsule. Patients with implantable cardiac devices require an approval from the cardiologist. [19]

Risks: There is always a possibility of the endoscopic capsule to get lodged in the abnormally narrow areas along the digestive tract. Crohn's Disease may increase the risk up to 5%. Occurrences of this type are rare, and usually involve ongoing inflammation, tumor, or intestinal strictures from earlier surgeries.

Accuracy: Research indicates that capsule endoscopies are useful for detecting smaller, infrequently diagnosed colon malignancies. It offers acceptable accuracy rates for identifying clinically suspected tumors or when other diagnostic imaging methods fail to detect the existence of suspected polyps or tumors. 

Manufacturer’s site: OMOM Capsule Endoscopy System (by Chongqing Jinshan Science & Technology), PillCam COLON (by Given imaging), MicroCam (by IntroMedic), Olympus Capsule Endoscopy System & ENDOCAPSULE 10 System and ENDOCAPSULE Recorder Set (by Olympus) [20]

Clinical research:

Price: The cost of a capsule endoscopy starts from $500 [21]

5.Virtual Colonoscopy (CT Scan or MRI) [22]

Description: By using advanced imaging techniques such MRIs and CT scans, radiologists can identify lesions and precancerous polyps without sedation. Virtual colonoscopies support incomplete colonoscopies and patients who can’t have a conventional colonoscopy for medical reasons.

Advantages: Virtual colonoscopy is non-invasive, and takes less time than conventional colonoscopy. It can examine the right colon and bling gut, two areas are missed in 10% of optical colonoscopies. Virtual colonoscopy also helps to identify abnormalities outside the colon. [23]

Disadvantages: CT scans and MRIs can’t detect aggregations of cancer cells that have not assumed polyp or tumor size.  Patients undergoing a virtual colonoscopy must prepare for the procedure by changing their diet, cleansing their bowels and drinking contrast fluid to enhance the imaging. Contrast medium may cause bloating, abdominal pain and GI disturbances in some people. CT scans expose patients to the very high levels of ionizing radiation that may increase one`s risk of all cancer. [24] Insurance coverage is sparse. [25]

Risks: Since the large intestine is inflated with air prior to the scanning, there is always a small risk of intestinal perforation.

Accuracy: Lesions less than 5 millimeters are difficult to detect with virtual colonoscopy [26]. However, virtual colonoscopies can detect most of the clinically important polyps and lesions, and its accuracy is superior to optical colonoscopy.

Limitations: Patient weighing over 450 pounds may not fit into the scanner. Virtual colonoscopy may increase the risk of colon perforation in patients with Crohn's disease, ulcerative colitis, or diverticulitis. If you experience a severe pain or cramps on the day of the test or have a history of bowel perforation, virtual colonoscopy iscontraindicated.

Manufacturer’s site: Viatronix V3D® Colon system

Clinical research:

Price: The price depends on the insurance plan (coverage, deductibles, co-pays) and at average may cost between $400 and $800. [27]

6. Flexible Sigmoidoscopy [28]

Description: Flexible sigmoidoscopy allows doctors to visualize the rectum and the lower part of the colon (the sigmoid colon) with a sigmoidoscope ­– a narrow flexible tube with a high-res color camera and light at its end [29].

Advantages: Flexible Sigmoidoscopy is relatively quick simple to perform. It has fewer side effects and is less expensive than a conventional colonoscopy. The risk of a bowel perforation is low. [30]

Disadvantages: Preparing for a flexible sigmoidoscopy involves having at least one enema before the procedure. Patients may also be asked to change their diet or take laxatives. To maximizing the accuracy of the test, complete emptying of the colon and rectum is recommended.

Risks: This colorectal screening test is safe and effective when performed by physicians experienced with providing endoscopic procedures. Rarely do complications occur with a flexible sigmoidoscopy.

Accuracy: Flexible sigmoidoscopies offer more accurate diagnostic results than those provided by fecal blood tests and virtual colonoscopies.

Limitations: Flexible sigmoidoscopy can only examine the final portion and left side of the colon. Lesions, tumors or polyps existing higher in the large intestine are not detectable during a flexible sigmoidoscopy procedure.

Manufacturer`s site: Braun Melsungen, Brainlab, GE Healthcare, Medtronic, Stryker, Smith&Naphew (Blue Belt Technologies), MAKO, Claron Technology and others.[31]

Clinical research:

Price: The cost of a flexible sigmoidoscopy may vary from $500 to $1,400, depending on your insurance coverage, hospital, physician, geographical location, and other similar factors.

“Catch-me-if-you-can” vs. the “nip-in-the-bud” approach

As you can see, there are plenty of viable options to get tested for colorectal cancer without incurring risks associated with colonoscopies. And, just like with colonoscopy, none of these tests are foolproof. Some are better than others. Many are the fraction of the cost. So, what’s the catch?

There isn’t one with just one exception: all the above tests are intended to diagnose colorectal cancer already in progress, ideally, as early as possible.  And, comparatively to having colonoscopies ten years apart after the age 50, inexpensive and relatively accurate annual FIT or Epi proColon tests win the “screening” race hands down. 

Another difference is that unlike all of the six diagnostic tests listed above, screening colonoscopy is promoted as an infallible preventative because it promises to catch and remove polyps and small tumors long before they become malignant cancer.

There is, however, one serious problem with this “nip-in-the-bud” approach: it is, as they say, a “big fat lie” for the reasons I thoroughly outlined back in 2008 [link]:

  • More polyps are missed than found. Up to a third of colonoscopies routinely miss polyps and cancerous tumors. According to the report I cited at the beginning of this page, practically 100% of all polyps are missed in the right (ascending) colon.
  • Polypectomy doesn't prevent cancers. According to the research published back in 2006, the screened patients in all of the studies developed colorectal cancer “at the same rate as would be expected in the general population without screening” in the next few years, even though they have removed all found polyps.
  • An estimated 95% of all polyps are benign. They will never become cancers, so removing them makes just as much sense as zapping the moles off your buttocks to prevent melanoma.
  • Not all colorectal cancers are preceded by detectable polyps. It is believed an even larger share of colon cancers start from flat lesions that no one is suggesting to remove, even though they are considered five times as cancerous as large polyps.
  • Increased cancer risk. Removing polyps or even doing biopsies releases cancer cells into the bloodstream and the colon's lumen. In turn, these cells may seed all other cancers throughout the body.
  • Unreliable procedure. Even the most thorough endoscopists may miss up to 30% of detectable polyps. The less rigorous routinely miss up to 60%, including actual cancer tumors. All of them, regardless of skill or attention, miss near 100% of polyps in the right colon.
  • Unnecessary procedure. The average age for colorectal cancer diagnosis is 72. Commencing invasive screening and polypectomies in asymptomatic people at age 50 is just as absurd as taking contraceptives after menopause.
  • High risk of internal bleeding. Polypectomy profoundly increases patients' risk of death from hard-to-detect internal bleeding, which may lead to ischemic stroke, myocardial ischemia, cardiac arrest, or sudden cardiac death.
  • No demonstrable benefit. If polypectomies were, indeed, effective, with about half of Americans past age fifty getting screened, we should have enjoyed at least a 50% reduction in the incidence and mortality of colon cancer. Instead, we have a 22% increase in the incidence of colorectal cancer. Most likely, this increase is related to polypectomies.”

To summarize, a screening colonoscopy for asymptomatic healthy adults in a low-risk group for colon cancer is a crapshoot at best, a Russian roulette – at worse.

The moment when screening colonoscopy turns into a life-saving procedure.

The following symptoms and signs are typical for colorectal cancer in full bloom, particularly when present in combination of more than one:

Please note that some people may experience other symptoms, some may experience none, and any of the above symptoms may also be caused by conditions other than colon cancer. Thus, if in doubt, see a doctor first.

The Colon Cancer Risk Factors page outlines the circumstances that may elevate your risk of “catching” colorectal cancer. If any one of these risks apply to you, then you must test as often as recommended by your doctors without waiting for any symptoms to appear.





4 Guidelines: Recommendations on screening for colorectal cancer in primary care; CMAJ March 15, 2016 vol. 188 no. 5 First published February 22, 2016, doi: 10.1503/cmaj.151125 [link]

5 Colorectal cancer screening: Recommendation statement from the Canadian Task Force on Preventive Health Care; CMAJ July 24, 2001 vol. 165 no. 2 206-208; [link]