This is, um, Number 2 in our two-part series. Part One is here.
At the end of Part One,we promised:
Tune in tomorrow, when we will conclude with:
Three observations that seem to have eluded everyone commenting on NORDiCC
Five recommendations for employers based on the data and the rebuttals, and
Three misinformed objections to this NORDiCC study.
Observation #1: This conclusion does not account for the costs.
Screening 455 people to find 1 case of colon cancer (that, according to the all-cause death rate stat, wouldn’t kill them anyway) costs about a million dollars.
That doesn’t include the “cost” of employees missing work to get screened and also, for reasons that would be apparent to anyone who has “prepped” for a colonoscopy, not being terribly productive the day before. (Or, to quote the immortal words of the great philosopher Dave Barry: “I don’t know what’s in that stuff, but it must never be allowed to fall into the hands of America’s enemies.”)
This is not to say you should stop incentivizing them. Just compare this to other things that you could spend $1 million on to improve employee health.
Observation #2: This conclusion does not account for the risk of complications.
No one is quite sure what the exact complication rate is, but 1.6% is a good guess. https://bit.ly/3eoruQc. 1.6% far exceeds the 1-in-455 odds (about 0.2%) of finding a case. Of course, many of those complications are minor, and the rate is much lower for younger patients, but even so, it's worthy of mention that these are not risk-free. (The study had a complication rate of only 0.13%.)
Observation #3: This conclusion is not age-adjusted.
A couple of years ago, it was decided that the colon cancer rate among younger people had risen by 22% and therefore screening should start at age 45. True enough about the 22%, but even with that increase, the rate of colon cancer among young people with no prior symptoms or first-degree relatives with colon cancer (meaning people who would be screened for no reason other than being 45) is still very, very, very low. A trivially low number can increase 22% and still be trivially low. So if there is even a good chance the study is correct in that these screens do nothing for the population as a whole, they would (on balance) do less than nothing for those at the youngest age with no risk factors, with the chances of a complication overwhelming the chance of finding a significant cancer.
Observation #4: One size does not even come close to fitting all.
Some people are at very high risk for colon cancer. And as it stands they don't get their colonoscopies free. One might argue that it's in everyone's best interest that they do. While free/deep-discounted telehealth or onsite clinics encourage overuse, I seriously doubt that anybody is going to want more colonoscopies than they already get, so it's not like making extra ones free would create overutilization.
Observation #5: Scans are far from a sure thing in preventing cancer.
Plenty of people die of colon (or other) cancers even though they get screened. The reason for this is that the fastest-growing, most aggressive, tumors might have a short gestation period that takes place entirely between conscientiously scheduled scans.
Our recommendations for employers are as follows.
Keep a low profile. This choice is a nuanced decision (the rebuttal has merit!) best left to employees and their doctors. Different employees and doctors will have different perspectives, and staying out of it allows those perspectives to be shared by the two people who are closest to the issue.
Employers should only incentivize screens where (1) the evidence is quite overwhelming and (2) there really aren’t any risks of complications from the screens.
Cover follow-up colonoscopies at 100% for employees who start by using the non-invasive screens that we have posted about here in our usual boring academic style (not!), but then need a follow-up colonoscopy due to testing positive. The preliminary non-invasive tests are generally sensitive but not specific, meaning few cancers will sneak by them, though many positive results will be false. Just like Medicare will do starting 1/1/23, you should cover all colon screening at 100%.
You may even already cover that follow-up colonoscopy at 100%, except that employees don’t know you do (and hence jump right into the colonoscopy as their first screen, for perceived economic reasons only). That brings us to the third recommendation…
…Educate employees on colon screening, using Quizzify. For what it costs to screen a very small percentage of your employees for colon cancer, you could implement Quizzify for your entire population – educating them on the harms and hazards of everything from added sugar to overtreatment, giving them questions to ask the doctor for 165 topics from abdominal pain to zoster, and of course, preventing ER overcharges. And you’ll have plenty of money left over besides. And this includes questions on colonoscopies. We want to make sure that your folks know about the non-invasive options, and whether you cover any follow-up colonoscopy.
As an example of the last recommendation, I once again quote Alert Reader Owen Muir:
The time and energy we are spending on sticking scopes into people might be better addressed by sticking vegetables into them by the more accessible, albeit more distal, junction between the GI tract and the outside world.
Ask yourself: is there anything I can do with that million dollars that would save more lives? Quizzify might have saved my life (and certainly saved me a world of hurt) by my learning the answer to just one of our questions: "What's the only dental problem that could kill you in a week?" Hence one good way to spend that $million is to enhance what are almost always very skimpy dental benefits.
Oh, yeah, and just to head off the expected objections to this “too hot for Quizzify” posting:
“I got screened and they found a polyp that could have become cancer.” Polyps are no longer always allowed to be called “pre-cancerous” because some aren’t while others take a long enough time to turn into cancers that they would show up on one of the non-invasive tests (which are done more frequently).
"I was having digestive issues and I got a colonoscopy and found a small tumor.” Your doctor quite appropriately ordered a test. That is not the same as a screen. Screens are done on everyone. Tests require a reason. Far be it from us to object to decisions between you and your doctor to test you if you are having symptoms. Even so, you might want to read this first before assuming you need one...
“My family has a history of colon cancer so I am going to get screened.” That is a good reason to get a colonoscopy. But it still isn’t a population-wide screen. It is a decision to test, made between you and your doctor, for good reason.