As a media doctor, I’ve been asked to do plenty of buttock-clenchingly embarrassing stunts. Perhaps the worst was to be a team captain on an execrable TV medical quiz called Tibs and Fibs. In one episode, we had a bemused Janet Street-Porter standing on a chair miming polycystic ovary syndrome. Enough said.
And I once stripped down to my boxer shorts for a photo shoot for Men’s Health magazine. Big mistake. But I do have some pride – I turned down the offer to have a sigmoidoscopy on prime time TV. "But you’ll be famous," said the producer. "Yes," I replied, "but not for my face."
To be fair, the programme was trying to destigmatise bowel cancer, and get those at risk to come forward for screening. And the producer tried very hard to overcome my objections.
"I’ve got no family history or symptoms, so I’m not high risk," I said. "Yes, but some consultants now recommend everyone is screened once before the age of 50." "Yes, but if I’m going to be screened, I wouldn’t choose sigmoidoscopy – remember, 20% of cancers occur in the caecum and ascending colon." "Great! Then let’s film your colonoscopy!"
You’ll be pleased to hear I managed to hold out, and if I remain symptom-free, I won’t ever let anything long, flexible and fibrous near me.
I’m not a great fan of medicalisation and screening if you’re feeling well, and I haven’t got a clue what my blood pressure, lipids and prostate are doing. But I know a few asymptomatic doctors who’ve taken the colonoscopy challenge (in private) because they think the risk of a Western diet is sufficient to warrant it.
As ever, it all comes down to numbers. In the UK, there are 50 000 new cases of colorectal cancer each year, and 30 000 deaths.Your lifetime risk is 1 in 50, rising to 1 in 17 if you have a first degree relative with colorectal cancer and 1 in 10 if the relative is under 45. If everyone in your family including the au pair and the Labrador has had colorectal cancer, then you’re clearly at very high risk.
We also know that 70% of colorectal cancer cases present too late for cure and that most bowel surgeons believe they’ve saved far more lives by picking up polyps on colonoscopy than doing valiant bowel resections.
Naturally, you want a skilled scope-artist who carefully reaches the caecum in 98% of cases and has a minimal perforation rate. On average, perforation occurs in 1 in 1000 cases so we kill one patient for every 11 saved. But if you use the inside track to find a really smooth operator, your risk is much reduced.
Explaining the numerical risks and benefits of a given procedure takes long enough, and in everyday practice informed consent is merely asking, "Do you agree to do as I recommend?" Colonoscopy is the gold standard, so let’s stick with that.
But in these days of patient choice, we’re supposed to offer all the options. When a hundred Californian patients were given full information on five options: nothing, faecal occult blood testing, barium enema, flexible sigmoidoscopy, or colonoscopy, they chose very different options.1
This led the BMJ’s editor Richard Smith to conclude that if they’d all just been offered one option, as many as 90% would have suffered "a form of abuse" by denial of choice.2 It’s a contentious point and highlights the complexity of screening in the consumer age.
But it’s not as abusive as having it done live on TV.
- Woolf SH. Shared decision-making: the case for letting patients decide which choice is best. J Fam Pract 1997; 45: 205-8.
- Smith R. Editor’s choice: Abusing patients by denying them choice. Br Med J 2004; 328.