It arrived much too quickly, the Cologuard box, sitting on my front stoop like a guest who shows up too early for a party. I kind of resented it, though I had invited it. The company who makes the box had already texted my personal cell phone and emailed me about its imminent arrival. Multiple times. I picked up the box, unlocked my front door, and headed inside. Inside to the basement where I stowed the box away from actual future guests.
Ironically I had probably ordered several Cologuard tests for other people that day at work, but this box was different. It was for me, as a patient, and I knew what had to be done next. Everyone poops, as the famous book by the same name reassures us. There is no shame or embarrassment in that. All animals do it. And yet something about collecting it, processing it, wrapping it up, driving it to the local UPS store, and then handing it over to another human being like a baton to be passed on down the line felt like something I should procrastinate about.
And procrastinate I did. For about three months the Cologuard box stayed in the basement. I would see it almost daily, but it was never a good time. I wanted to be home alone, to suffer the jarring indignity without the added mortification of a witness of any kind. The company kept texting me, emailing me, and even called me while I was seeing a patient. Did you finish your test yet? Is there anything we can do to assist you in completing your test? Uh, I’m actually seeing a patient right now, and no, this is something I need to do all by myself. I’ve got this, don’t worry.
So I finally opened the box, followed the instructions, and took care of business. It wasn’t a big deal. Like most things we procrastinate about.
About a week later I got the results. All good.
I’ve had a colonoscopy before, by the way. Cologuard was another option for staying up to date with colon cancer screening for now.
You can log on and read about your result if positive or negative. Here is what a negative test result looks like:
NEGATIVE TEST RESULT. A negative Cologuard result indicates a low likelihood that a colorectal cancer (CRC) or advanced adenoma (adenomatous polyps with more advanced pre-malignant features) is present. The chance that a person with a negative Cologuard test has a colorectal cancer is less than 1 in 1500 (negative predictive value >99.9%) or has an advanced adenoma is less than 5.3% (negative predictive value 94.7%). These data are based on a prospective cross-sectional study of 10,000 individuals at average risk for colorectal cancer who were screened with both Cologuard and colonoscopy. (Imperiale T. et al, N Engl J Med 2014;370(14):1286-1297)
COLOGUARD RE-SCREENING RECOMMENDATION: Periodic colorectal cancer screening is an important part of preventive healthcare for asymptomatic individuals at average risk for colorectal cancer. Following a negative Cologuard result, the American Cancer Society and U.S. Multi-Society Task Force screening guidelines recommend a Cologuard re-screening interval of 3 years.
Not bad. I’ll take those odds for now.
Cologuard tests for cancer-related mutations in cells passed in the stool, as well as for blood. [For any highly scientific readers, that means it checks for DNA KRAS mutations, aberrant NDRG4 and BMP3 methylation, β-actin, and a bonus hemoglobin immunoassay.]
And for those people whose test results come back positive, and therefore are referred for a colonoscopy, usually the final result will be that no actual cancer is present. But there is a better than even chance that at least some polyps will be found and removed, which can actually help prevent colon cancer from developing. Specifically:
Colonoscopies performed for a positive result may find as the most clinically significant lesion:
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colorectal cancer [4.0%]
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advanced adenoma (including sessile serrated polyps greater than or equal to 1cm diameter) [20%]
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non-advanced adenoma [31%]
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no colorectal neoplasia [45%]
People with an average risk of colorectal cancer should begin screening at age 45. Any one of the following screening strategies is recommended. I have highlighted the options that most people choose, and that most doctors recommend for various reasons:
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Colonoscopy every 10 years
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Stool testing for blood every year (using guaiac or FIT test)
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Computed tomographic colonography every 5 years
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Flexible sigmoidoscopy every 5 years, with or without a fecal immunochemical (FIT) stool test for blood
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Stool testing using FIT + DNA testing every 1 to 3 years (this is Cologuard)
People at higher risk of colon cancer, such as those with a family history of colon cancer or advanced polyps, previously diagnosed colorectal cancer, certain types of polyps found on previous colonoscopies, conditions like Crohn’s disease/ulcerative colitis, and some other situations should be screened earlier, more frequently, and usually with a colonoscopy. Here is a great resource for anyone wanting a deeper educational dive.
Having had both a colonoscopy and presently a Cologuard test, I can now speak with professional and personal experience. Both the colonoscopy prep and to a lesser degree the stool collection are humbling experiences, quite good for undermining the ego.
More importantly screening can save lives, perhaps close to 22 lives saved per 1,000 people screened over their lifetimes if following the guidelines.
Thanks to the workers at UPS, particularly for handling millions of boxed up Cologuard samples each year.
Colon cancer screening? It’s usually not that bad. Most people have a good story or two, or can at least commiserate with the process. From propofol to potpourri, I’ve shared some laughter and cringes. How about your experiences?
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This post originally published on Examined, where I write about vital and overlooked ideas your family doc might share, if only we had more time. You can receive more letters by signing up here.
