Colon cancer screening is more effective than breast cancer screening, but uptake in Ontario is still low. Screening more individuals each year would prevent many needless deaths.
Nurses can safely and effectively screen patients for colon cancer.
Despite this, efforts to increase the number of screening procedures performed by nurses in Ontario are not widespread.
Colon cancer screening – the nuts and bolts
Colon cancer is the leading cause of cancer death among non-smokers in Ontario, and second only to lung cancer overall. Many cancers are curable if caught early. Colon cancer is one such cancer – if detected early, there is a 90% chance of survival. But if diagnosed once it has spread beyond the colon, most patients die within a few years.
Screening for colon cancer has been proven to save lives. About 500 people need to be screened to prevent one death from colon cancer. In contrast, about 2000 women need to be screened to prevent one death from breast cancer.
Because colon cancer screening is so effective, the Ontario Ministry of Health and Long-Term Care launched a province-wide screening program in 2008. Despite this, only about one-third of eligible adults in Ontario are screened for colon cancer. Clearly we could do much better.
Somewhat confusingly, there are a number of different screening tests that can be performed to detect colon cancer. The list includes a number of stool tests, colonoscopy and flexible sigmoidoscopy. All of the tests have a significant ‘ick’ factor because they involve collecting feces or having a tube with a camera inserted into the rectum.
Barry Stein, a colon cancer survivor and president of the Canadian Colorectal Cancer Association says that the best screening test is “the one that people will do.” None of the screening tests are pleasant, but they can make the difference between life and death in some people.
There is a debate, however, about which screening test is best, and whether doctors or nurses should be doing it.
The Ontario screening program recommends that adults over the age of 50 with no risk factors for colon cancer (no family history, no history of inflammatory bowel disease, no rectal bleeding and no history of polyps) should be screened with a fecal occult blood test. This test is cheap, has no side effects, and doesn’t require a wait for a procedure. Patients simply collect samples of their own feces and send them to a laboratory.
Fecal occult blood testing is not as accurate as colonoscopy, a test in which a tube with a camera is passed into the rectum and advanced through the colon. Another advantage of colonoscopy is that pre-cancerous lesions can be detected and removed during the procedure. But colonoscopy has several disadvantages – the preparation is time consuming and uncomfortable, there is a small risk that the bowel can be punctured during the procedure and the test costs more money. Also, because colonoscopy in Ontario is only performed by specially trained doctors, there are long waiting lists.
Another screening test is also available – flexible sigmoidoscopy. Flexible sigmoidoscopy does not visualize as much of the colon as colonoscopy does, but it is an easier procedure for patients. As well, it requires no sedation, less preparation, it can be done in less time and at lower cost than a colonoscopy.
Although flexible sigmoidoscopy and colonoscopy have not been compared in head-to-head research trials, many physicians believe that colonoscopy is the superior screening test. Mike Evans, a Toronto-based family doctor and researcher, agrees, saying that “colonoscopy is the gold standard” for colon cancer screening and “gastroenterologists often feel that after doing the procedure, they can better reassure the patient.” Evans says “patients will often say to me that if they are going to go for the procedure, they want the full exam.”
Nurse-performed flexible sigmoidoscopy
Linda Rabeneck, a University of Toronto gastroenterologist, researcher, and Vice-President, Prevention and Cancer Control at Cancer Care Ontario, sees flexible sigmoidoscopy as an opportunity to “expand capacity to screen for colon cancer.” Rabeneck recruited Dr. Mary Anne Cooper to develop a week-long training program teaching Ontario nurses how to perform flexible sigmoidoscopy under the supervision of a doctor. Since the program started in 2006, 29 nurses have been certified as being competent to perform flexible sigmoidoscopy. The program has been recognized for its innovation, and even won an ‘Innovation in Health Care’ Award from the Ontario Ministry of Health and Long-Term Care.
However, only 6 of the 29 nurses who have been trained to perform flexible sigmoidoscopy have found jobs where they screen for colon cancer as part of their duties, and these nurses are only allowed to work under a doctor’s supervision. The program is still considered to be a pilot, and long-term funding remains insecure.
In contrast, in the United Kingdom, both doctors and nurses are put through the same endoscopy training program, and members of either profession can be trained to perform both flexible sigmoidoscopy and colonoscopy. Maggie Vance, a London-based nurse consultant in gastroenterology, says that “as long as nurses have the technical skill, attitude and ability to perform these procedures … the sky’s the limit.” Like Vance, Stein also argues that “if a nurse can be trained to go half way up [the colon], they can go all the way up.” A small study in the Netherlands provided evidence to support this claim. In the UK, nurses even act as examiners for colonoscopy clinics associated with the UK screening program.
Moving beyond the sigmoidoscopy vs. colonoscopy debate
In the UK, nurse-performed flexible sigmoidoscopy is being phased in as a colon cancer screening tool. Because they are paid less than doctors, nurses can do the procedure at lower cost. Vance also notes that there are simply not enough doctors to screen everyone, and nurses help the health system meet the burgeoning need. Vance also points out that “in the NHS doctors are salaried, they aren’t paid fee for service,” which in her view reduces the incentive for doctors to want to keep colonoscopy to themselves.
Esther Green, the provincial head of nursing and psychosocial oncology at Cancer Care Ontario, agrees with this sentiment. She says that “some doctors in Ontario have opened up private colonoscopy clinics, and so finances are a driver for the doctors, and there is a sense out there that these nurses are potentially taking away an income source from doctors.”
However, some experts argue that the answer is not to train nurses to do colonoscopy, but rather to educate doctors and the public about the merits of flexible sigmoidoscopy. A recent editorial in a leading medical journal argued that “from a public health and policy perspective, [the] apparent limitations of colonoscopy can no longer be ignored. The accumulating evidence has not established the long-held belief that colonoscopy carries greater benefits than sigmoidoscopy.”
But the bottom line is that any test is better than no test. With so few Ontarians receiving any of the colon cancer screening tests, we should consider all the available options.
Watch a video of Terry Sullivan, the former CEO of Cancer Care Ontario, on the need to increase colon cancer screening and the opportunity of nurses trained in flexible sigmoidoscopy to do this.
The comments section is closed.
We need:
1. Nurses to do colonscopy (GIs are one of the HIGHEST paid specialists, mostly because colonoscopy procedures pay a lot)
2. Crack down on private clinics – check out this report that suggests the private clinics tend to suggest a repeat scope much SOONER than those in the hospital.. hmm, suspicious! Not to mention patients getting told they can ‘pay a little bit’ to be seen earlier in a private colonoscopy clinic – this is NOT legal by the Canada Health Act. In the study, 31% of patients reported paying a fee – http://www.ncbi.nlm.nih.gov/pubmed/21321678
3. Streamline our referrals as done with wait times strategy, so I dont keep telling patients to wait a year for a screening scope, when someone else may be doing them sooner.
It’s not necessarily true that charging fees at private screening clinics is illegal. It depends a great deal on what the fee is for. If the fee is a form of extra billing, where the entire procedure is paid for through the public system and the extra money is going right into the clinic’s pocket, then it’s certainly prohibited. However, if the fees only cover those costs of a procedure that are not covered by the public system, then the fee is perfectly legal. So in the case of colonoscopy, which is it?
A conlonscopy procedure usually involves two staff: a gastroenterologist and an anesthesiologist. The fee is not going to pay these physicians, they are both paid under the province’s fee for service system.
My understanding is that the fee charged by many private screening clinics is for the anesthetic they use to put the patient into “twilight sedation.” Hospitals don’t have to charge that fee, because our public system pays for nearly all medications that are administered within a hospital. If you are in a hospital, everything from Tylenol to birth control pills are covered by the public system. But as we all know, outside of the hospital we are all on the hook for the costs of our medication. The same is true in private clinics – the medications they administer have to be paid for out of pocket. That is just how our public system works.
From what I can see, many private screening clinics are not out there trying to fleece the public. The Kensignton Screening Clinic (http://www.kensingtonscreeningclinic.org/), for example, is a not-for-profit, private clinic that charges a $50 fee to cover the cost of anesthetic. They are not-for-profit. They are not charging the fee to get rich, they’re charging it because the government won’t cover the anesthetic since the procedure is not being carried out in a hospital.
So from what I can tell, these fees are legal. But at the same time the fees do undermine equity in the public system. Any patient at high risk of colon cancer should be able to access screening promptly, regardless of ability to pay. But rather than argue for a “crack down,” it seems to me that the best way forward is to lobby the government in favor of a special provision for screening clinics that would cover all of the costs (not just physician costs) of screening procedures covered in private clinics. This would be analogous to the special provision in Ontario that covers all costs associated with pregnancy terminations performed in private clinics. This would provide three benefits: 1. It would improve equity by removing any barriers to prompt screening, 2. Take even more pressure off of hospitals, 3. Make it easier to spot the handful of unscrupulous clinics who are charging very large user fees that are going straight into their pockets.
Of course, none of this gets at nurses performing flexible sigmoidoscopy, which sounds to me like a great complement to FOBT and colonoscopy.
As one of the Ontario nurses trained to perform flexible sigmoidoscopy, I have had the privilege of interviewing and educating several hundred patients within our catchment area. Once the steps of the screening process are explained very few have declined to have a flexible sigmoidoscopy. Having the opportunity and time to educate the target group enhances their understanding of screening options and compliance for the minimal preparation required to complete a flexible sigmoidoscopy. Many patients express thankfulness that this asymtomatic group is not being neglected.
Most approach the screening with a proactive mindset stating that they would rather know their own status. A normal exam or early detection/ treatment are both ‘win- win’ situations for Ontarians.
I think along with educating primary care physicians and the public about all the screeening options in Ontario, more nursing roles is a safe, cost effective, patient focused way to improve our current system. I found it very interesting to see that though breast cancer screening is less effective than cancer screening it has more public acceptance. What an interesting and thought provoking article.
Great article and an important idea for saving the health care system $ and making it more efficient and effective. Now, let’s hope our provincial political parties are paying attention (in this, an election year).
We need to educate physicians of the health and financial benefits of increased screening!