Colon Cancer Screening Doesn't Have to Start with a Colonoscopy

I know from seeing so many people that it's always kind of in the back of their mind, like, "Ooh, I know I should do something."

It's like a car wash.

Hopefully not.

You take it for the detail, clean it up. It's all one-stop shop. Check your pooper.

Check your pooper.

Welcome to Please, Health Me!? I'm Tristin, and each week, I bring real health questions from around the internet to my mom, Rebecca, a board-certified family nurse practitioner with 45 years of experience. Together, we try to make healthcare a little easier to understand so you know more about what's happening, what questions to ask, and what options you might have.

We're here to educate, not diagnose or treat medical conditions. What we discuss should never replace advice from your own healthcare provider.

I lost one of my best friends from high school to colon cancer. His name was Nick, and he was only 37 when he passed away. I can't overstate how important this episode is to me.

My mom knew him well, too. Whenever I came home from college, Nick would ride with her to pick me up from the airport. I'd get off the plane and find the two of them standing off to the side, laughing hysterically.

They had spent half the day shopping, people-watching, and creating another collection of inside jokes while they waited for me. Nick, I know you're somewhere dancing hard to Madonna's Ray of Light album.

Colon cancer is affecting younger adults more than many people realize. At the same time, a lot of people delay screening because it feels too expensive, too invasive, or they simply don't know what their options are.

In this episode, my mom and I sit down to talk about colorectal cancer screening, the different tests that are available, how family history changes the conversation, and what you can do if cost has kept you from getting screened.

We start with one of my favorite stories from her clinic. So, Mom, let's go back. Why did you put these posters up in your office, and what was so great about them?

We had a big box of tests in the lab, and we were either forgetting to talk about them or maybe the patient had so many complaints that we didn't have time. We wanted to offer the tests, yet we were forgetting about them.

So we said, "Let's put a sign in each exam room." We made a sign that talked about this test. It was only $25, and the sign talked about the high rate of colon cancer and how people either didn't want to do a colonoscopy or absolutely couldn't afford it.

We included a little more information and put it on the wall opposite where the person was sitting. After that, it was amazing. I'd walk into the room to see the person, and they would point at the sign and say, "I want to do that." It really made an impact on screening.

We didn't have to rely on ourselves to remember. They might be there for a sore throat, but they would read that and say, "I could do that. I can afford that." I would talk more about it, they'd leave with their kit to take home, and we felt really good about that.

We have a question from Michelle, who said, "I keep hearing about home colon cancer screening kits like Cologuard, and I've even seen cheaper stool tests online. Are those actually reliable, or is a colonoscopy still the only screening that really counts?" Is that the kind of thing you were trying to address?

Yeah. What we offered, the iFOBT kit, is not Cologuard. It's a step below Cologuard. The test we offered tests for blood, or hemoglobin, which is a protein found in red blood cells. It'll find hidden blood in the stool that you would never see.

That's one test, and it's really affordable. You can get those from labs or from Walmart.

Do you have to have a prescription, or can you just get it off the shelf?

You can just buy it. You can buy one from your local lab or, like I said, from Walmart.

Cologuard is a little more expensive—between $300 and $600.

Yeah, it's a big jump. But not only does it do that part of the testing; it also tests for DNA shed by cancerous or precancerous cells. So it gives you a double whammy.

It is more expensive, but you only have to do that one every three years. The one we offered is best done each year.

The most expensive is the colonoscopy, and most people can't afford that. They can cost as little as $1,500 and as much as $5,000 or $6,000. As well as not being able to afford it, most people don't want to do it. It's a big process.

Because you have to not eat—

You've got to prepare.

Drink a lot of water—

That's the thing about these other tests: you don't have to do any dietary restrictions or anything like that. These have been out long enough for studies to be done. With a colonoscopy, if you're an average-risk person and it looks clean, they won't have you do another one for 10 years.

To me, I felt like maybe I'd rather look at this every year or every three years than wait 10 years to get another colonoscopy.

Obviously, the three things are not apples to apples, but over a 10-year span, studies show that they come out very similar in detecting cancer. In fact, they don't do screening colonoscopies in Europe; they use these home tests. Obviously, if you have a positive result, you're going to have to get a colonoscopy.

I used to let people do one maybe twice if one was positive because they might think, "I don't know if I did it right." So I'd say, "Okay, do one more. It's cheap." If they're positive, you have to have a colonoscopy. There isn't any choice about that.

It also depends on your family history. If you have a strong family history, you need to be on top of this. Maybe you don't have insurance or money, but you should be motivated to do one of these once a year, if not Cologuard every three years.

Ashley is 41. She exercises, eats well, and feels perfectly healthy. Her mother was diagnosed with colon cancer in her early 50s. She's unsure whether that changes when or how she should be screened. She said, "My mom was diagnosed with colon cancer a few years ago, but I'm only 41 and feel perfectly healthy. Does having a close family member with colon cancer mean I should be screened earlier, and would a home test still be enough for someone like me?"

Yes. It always depends: Can you afford a colonoscopy? Will you do one? With that strong family history, go get yourself a colonoscopy. If you can't do those things, do these tests. This is way better than just saying, "I can't afford one." They have lowered the screening age to 45 for average-risk people.

That's because the number-one cause of cancer in adults under 50 years old is colon cancer. That's pretty remarkable, and there has been a big increase in younger people getting colon cancer.

Well, Nick didn't make it to 40.

That's very scary, and it's scary for providers because we would never have thought to say, "Nick, you need to be screened for colon cancer." You just wouldn't at that age, but he died of colon cancer.

This is happening more and more. Ashley has a high risk because her mother is a first-degree relative. She should start screening at 40 or 45.

She's 41, so she probably should get a screening.

Are there tiers? A colonoscopy would probably be recommended for her, but it is very expensive. If she absolutely couldn't afford that, would the next level be something like Cologuard?

It would be great if she could do Cologuard. Again, go online and look at the prices. I said $300 to $600 because that's what I was seeing, but it could be cheaper or closer to $300.

Can you get it on Amazon?

I don't know. I didn't check Amazon.

Can you just look up Cologuard?

Cologuard. Like I said, Walmart has everything.

There's ColonOx. Cola Test.

Cologuard also has a little more to it. With the other test, you have a little kit at home with a bottle of fluid and a small brush. You dot it in the stool six times, put it back in the bottle, shake it up, and send it in or bring it in. That's really easy.

I tell people when I send them home, "Just put this in your bathroom. Otherwise, you're going to forget about it. Don't leave it on your kitchen counter." Put it where you're going to see it.

You also need to have a normal bowel movement. You don't want diarrhea or loose stools. There's no dietary restriction, but you don't want anything going on that might cause blood, such as hemorrhoids or a period. If your stomach isn't quite right, don't do it then. Have a normal bowel movement and do it on that.

Pick a good poop.

Yes, a good poop. Cologuard is a bigger deal. They send you a box in the mail, you have a big jar of fluid, and there are more precise instructions. Then you mail it back in the same box. They give you everything you need to mail it back.

This says—and this is Gemini—that it costs around $599 to $681 if paying out of pocket, but over 96% of eligible patients with insurance or Medicare have no out-of-pocket costs.

I think insurance does cover it. When Dad and I did ours, we didn't pay anything. Our insurance covered it. Like I said, it's a step above. It's a better test.

Again, these all have different timeframes. The iFOBT is once a year. Cologuard is every three years. A colonoscopy is every 10 years. When studies lumped that together over 10 years, if you're good about following those timeframes, you have pretty similar cancer detection.

That's really hopeful. It means that what I'm doing at home on the cheaper end is going to work for me.

A word about colonoscopies: Occasionally, I had to tell people, "You just have to get a colonoscopy." I don't know if many people know, but there's a nationwide facility called ColonoscopyAssist. It's designed to help cash-pay or underinsured patients. They use accredited facilities and board-certified physicians.

In some cases, you need a referral, but not always. Go online, and it will give you all the information. I sent two or three people there before I closed the clinic. It was around $1,500, which included everything. Even if they saw a polyp and took it out, that was included.

I was going to ask what that includes. Don't they just go in and take a look around?

They do go in and look, but if they see a little polyp, they want to take it out. That was included, along with a detailed analysis and pictures. The patient brought everything back to me.

It's a really good place, and that's all they do all day long. Wouldn't you want a physician who does that all day long to do your colonoscopy? They're really good at what they do.

It's a good thing to fall back on because it's nationwide.

What's that called?

It's called ColonoscopyAssist, and there's a website for it. It's a great place. If you know you need a colonoscopy but can't afford it, this is much more affordable than going to a general surgeon.

You normally have to go to a provider, get an order, and go to a facility. I can tell you that ours here in town are $5,000 or $6,000. Who can afford that?

And how long is the wait?

Exactly. You're waiting a long time.

Going to this place, that's probably all they do. It's like a car wash.

Hopefully not.

You take it for the detail, clean it up, and it's all one-stop shopping. Like you said, that's all they do. That's what they specialize in.

That's what I would want—somebody who does that all the time—because a lot of providers do that kind of on the side.

Think of general surgeons and GI people. That's not all they do, but they do colonoscopies. I would rather have somebody for whom that's what they do, because they're really good at it.

There's somebody named Tom, and he is 57. He was laid off a few months ago, so he lost his employer-sponsored health insurance. Now he's trying to make every dollar count until he qualifies for Medicare. He was thinking of waiting until Medicare kicks in to get a colonoscopy. If he doesn't have any symptoms, is waiting really that risky?

Well, he's 57, not 64. At 65, Medicare will pay for a screening colonoscopy, and they'll pay for screening colonoscopies every 10 years.

I think they'll pay 80% if you need to have one. Actually, I think they'll pay every two years if you're very high-risk. If you have to have something done, such as having something removed, they pay 80% of that.

It appears that he's not high-risk, so a great thing for him is to do an iFOBT once a year until he's 65. He can feel more comfortable and not worry about it. It's not 100%, but it's way better than doing nothing.

If he did that religiously once a year, that's great. He has kept up on it until he turns 65. If he wants to get a colonoscopy then, Medicare will pay for it.

That's an option for people who are not insured.

It's like Nick. You think, "I'm healthy. I have normal bowel movements. I'm okay." But you can't count on that.

It was a nurse in an office who noticed something. Nick worked for Eli Lilly and was doing his rounds with different offices. This nurse said, "Nick, you look extremely pale. Let me listen to your heart. Let me take a few vitals."

Then she said, "You're not right. You need to go see a doctor," and that's what led to the diagnosis. He was stage four. He was walking around doing his normal activities.

He didn't have a chance.

He didn't have a chance, and I think he was about 37.

That's the thing with these tests: At least you get an earlier chance to see what's going on.

I always wondered if he had done that.

It's like our relative Paul. He had terrible stomach pain all the time, and he did get an appointment to see a GI. That appointment was four, five, or six months out. He was waiting and waiting. Finally, he had such terrible pain that he went to the ER. He had a huge abscess in his abdomen, and that was from colon cancer.

Oh my gosh. That's a situation where you can't even get in to see anyone.

Right. It's so hard now. You cannot get care quickly. These kinds of things are nice stopgap measures. You can do a little something for yourself at home and keep on top of things. It's hard to get a provider, and it's hard to get in for months. It's not helpful.

There's also something called adenomas. Those are the polyps you hear about all the time.

What's a polyp? It sounds like a flower.

A polyp is like an adenoma. They're little growths along the colon wall. They're benign, but they can be a precursor to cancer. That's why, when they do a colonoscopy, they'll take those out. Why leave them? It's like skin cancer in reverse, when you have a mole.

It could change and become precancerous. If they're doing a colonoscopy and see one, they're going to take it out.

Say you go in and they find at least one polyp. They remove it, you go home, and they say it was fine and wasn't cancer. What are the next steps? Does that mean I need to come back for another colonoscopy very soon?

Usually, if it's just one polyp and it's benign, they'll say five years.

For another colonoscopy?

Yeah. Some people don't have a strong family history of colon cancer, but they have a history of multiple adenomas or polyps—growths along the wall. They'll have those people come back every five years to keep an eye on that.

If you have a bunch of them, they probably want you back.

Yeah, they want you back. But if someone is nervous, they could still do this once-a-year test while they're waiting for their colonoscopy. I think I would do that.

If I had an iffy colonoscopy and they said, "You're good for five years," I know they're slow-growing. That's one reason for waiting. But I would still feel like maybe I'd just do this. It's easy.

Would those two other tests, the FIT test and Cologuard, catch that?

They would catch bleeding.

That's what's causing the blood?

That would give you a tip-off. Cologuard would try to catch DNA shedding from a precancerous or cancerous lesion. Then you'd think, "I have to get back in there for a colonoscopy." Cologuard is only every three years, so if you're looking at five years, you could probably do one in three years, wait two more years, and do your colonoscopy.

That sounds like a good plan.

It's very individualized based on your history. Most people hope they're average-risk, so they follow the guidelines for an average-risk person.

I don't even think anybody knows what average-risk means.

Average-risk means no family history and no personal history. You're just a normal Joe Blow or Jane Blow who has never had a problem. But from seeing so many people, I know it's always kind of in the back of their minds: "Ooh, I know I should do something."

Chances are somebody knows someone who had colon cancer. I've already had a friend die of colon cancer, and he wasn't even 40.

That's scary—knowing someone so young. It's very disconcerting for providers because we think, "We don't usually test people that young." You feel really bad. Nick also needed to pay attention to how he was feeling and looking and maybe go see somebody before that.

He always had a sensitive stomach, even in high school. I remember sometimes we'd have to run around looking for a bathroom. I have an old video of us on a trip. He came out of a restaurant with a Coke or something and said, "I felt bad. I bought a Coke because I needed to use their restroom."

He always had a sensitive stomach. It almost feels like, if he had done one of those tests, he would have been the first person willing to do it.

Once again, though, why would he have even thought about it at that age? He wouldn't have. It was just a strange, unfortunate thing.

We didn't used to think we needed to worry about anybody until 55 or 60 or older. Now we realize that colon cancer is the number-one cause of cancer under 50. That's why they kept lowering the screening age: We weren't catching enough people.

They're not sure why it's increasing in young people. They have multiple ideas, but they really don't have an answer.

You just need to be aware. It's wonderful that we have the ability to do a little of our own preventive care and sort things out a little on our own, because so many people don't have insurance. They're losing insurance or can't afford it. It's a real healthcare crisis, because on top of people getting kicked off insurance, you can't get a provider.

Right. I still don't have one, stupidly.

It's difficult, and if you get a provider you like, you need to hang on to them. I'm glad there are things like this that you can learn about and say, "I'm going to do this and hopefully prevent something from happening, or at least have a chance to prevent something."

Check your pooper.

Check your pooper.

I love it. There are three things people should take away from this. Number one, there are three different levels of testing at pretty variable price points. There's the Honda Accord, maybe the Jetta, and then the BMW.

They're all different prices, different kinds of screening, and different screening timeframes. But 10 years down the road, they're very close in detection. All of them will detect cancer at almost the same rate if you stick to the guidelines: once a year, once every three years, or once every 10 years. They all kind of wash out the same.

Age matters, and your family history matters.

Family history matters a lot. Many people don't know their history, especially farther back in the family tree. You don't even know that older relatives had colon cancer or what they died from. Sometimes, you need to investigate your family.

It's important to know your family medical history. When my brother had prostate cancer, he said, "There's none in the family." I said, "Grandma had breast cancer."

Breast cancer can translate to prostate cancer in men in a successive generation. He never knew she had breast cancer. He said, "I thought she had bone cancer." I said, "No, those were metastatic areas from her breast cancer."

He didn't realize that he did have a risk factor. You need to try to investigate that. It's good to know what people died of in the last couple of generations.

If you don't know and you're healthy, ask. Keep a record for the future and for your children. It really makes a difference. That's how you know whether you're high-risk.

Family history is extremely important—a couple of generations' worth. Going back, age doesn't matter. We just said that.

Age is mattering less.

I don't know why I said age. These tests are simple for people to do when they're young, so they can get ahead of it and have a higher chance of survival.

With these kinds of tests, you're not going to get a 30- or 40-year-old to have a colonoscopy, and maybe they'll never have one. But you can do these tests at home, send one off, and feel good if it's negative.

Everybody could do it. Everybody should be able to do it at home. Just mail it.

If you need a colonoscopy, get one. ColonoscopyAssist is the place to try if you don't have insurance or need a cash-pay price.

I'll put a link to the website.

It's a really good facility.

If this conversation did one thing, I hope it helped you realize that screening isn't all or nothing. There are different options, different price points, and different recommendations depending on your age and family history. If you've been putting it off because of cost or because you weren't sure where to start, I hope today's conversation gives you a reason to take that first step.

We'll include links to the resources we talked about in the show notes.

Please, Health Me!? is for general educational and informational purposes only. This podcast is not medical advice and does not replace care from your own qualified healthcare professional. Screening recommendations can vary based on your age, symptoms, personal history, and family history. If you have symptoms or concerns about colon cancer, contact a healthcare professional rather than relying on a home screening test or this conversation.

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