My Friend’s Endoscopy, Part II

Sorry for the delay in the next blog post.  Family vacation called!

In my last blog, my friend Alan, a healthy 39-year old man, had just gotten an upper endoscopy and a colonoscopy for reasons that were “soft” as we say…

So the first major question that I want to ask is :

Should Alan have had these procedures?

Let me make sure I get this out there.  I am not saying outright that Alan should not have had the procedures.  But this piece is really meant to spur thinking among those of you out there in the medical blogosphere who are reading my blog.

The answer to the question depends on whom you ask.  Apparently his doctor thought so.  (Who am I to judge what his doctor thought?  Just a peer)  And so did his mother.  Or maybe it was the other way around.

First his mother thought so. She asked him go to the doctor because she was worried, and she went with him to make sure that he got the best treatment. Perfectly reasonable approach for any parent to be worried about their child. But it is possible that her presence actually strengthened the doctor’s resolve to do the tests.  Mothers can have such a convincing effect on doctors.

I do not know what the interaction was that ensued, but I am certain that her presence was convincing enough for the doctor to squelch any question in his mind about whether or not to scope Alan.  He had no symptoms and he is young.  Thus, the procedure was being done for screening purposes only.

In general, screening for esophageal cancer in a patient with no symptoms is an effort in futility.  This is not to say that some patients may not benefit, but it is not like screening for breast cancer or colon cancer.  Esophageal cancer is an uncommon enough disease in the US that the cost-effectiveness of screening is poor.  One of the principal reasons for this is that there is very little evidence that any intervention — medical, surgical, dietary, homeopathic, etc — has any effect on the natural history of esophageal cancer.  Once a suspicious lesion is found, periodic surveillance is undertaken, but the likelihood of a suspicious lesion becoming cancerous (malignant) is quite low.

Are there populations that are at higher risk?  Probably, but this group tends to have symptoms of GERD (gastroesophageal reflux disease), like heartburn and acid regurgitation.  They may have a history of smoking or drinking alcohol.  There are other risk factors, but just having family history of esophageal cancer is a debatable risk factor.

And of course, there are grades of strength to a family history.  Suffice it to say, a first-degree relative (parent, sibling, child) with cancer is stronger than a second-degree relative (grandparent, aunt/uncle, etc.).  However age of the relative also plays a role, and physicians often overlook this.  I get much more concerned when someone tells me that their parent got cancer in their 40’s than if they got it in their 60’s or beyond.  Again, this is not to say that genetics is not important.  But as people age there are so many additional factors that play into cancer developing at older ages that the relative contribution of genetics fades out as the decades progress.

Couple an asymptomatic patient with an already low yield of screening.  In my mind, the fact that his father was diagnosed with cancer (in his 60’s I believe) would not signficantly change Alan’s risk.  He also is 20 years (or more) younger than the age his father got cancer.  I did not even go into the colonoscopy, or the risk for colon cancer, but as far as I am concerned, neither procedure seemed to be significantly indicated (needed).

So then…Why did he get the endoscopies?  I can give you 2 “F”s that will help explain it: Fear and Finances.  (Certainly Fun would not be the third F).

  1. Fear: Fear drives a lot that happens in medicine.    Actually, Alan wasn’t scared.  His mother was scared.  The doctor was scared.  Scared that he might miss a cancer.  Doctors fear missing a cancer probably more than anything else.  Scared that he might miss a precancerous lesion that could prevent something down the road.  What would happen if 10 or 15 or 20 years from now, Alan develops cancer? Could it have been prevented? Would he be sued?
  2. Finances: Alan had insurance.  Procedures cost money.  More often than not, there are financial incentives on the doc to do more procedures and less face-to-face patient care.  More talking means less money.  More explaining why a test is not necessary means less money in my pocket as a doctor.  I am not defending the justification, but this does come into play.  Fortunately, as Alan told me, the insurance company would cover it.  (Well isn’t that reassuring!!  If I were the insurance company exec I would deny paying the doc unless he could cogently explain why I should spend thousands of dollars for a low-yield exam.)  And doubly fortunately, these procedures are generally safe.  In summary, Alan passed what is affectionately known in some circles as the “wallet biopsy”.

Was the doc really afraid that Alan’s health might suffer if he didn’t get the procedures?  It’s highly unlikely.  Would he have gotten the endoscopy if Alan didn’t have insurance?  Maybe.  But would Alan have really paid hundreds (if not thousands) of dollars for a screening test?  Would you?  In actuality, the benefit was really in reassuring the mother.  But now there are more problems:

What are the ramifications of the results of the procedure?

As I said in the last blog, he was instructed to take a medication every day; stop drinking soda; and return in 5 years for another check–because he might develop cancer.  Now he also has a “diagnosis” (esophagitis) that could be used against him if he applies for life insurance or other health insurance.

Does he need to follow the instructions he was given?

All Alan really cared about was drinking his soda.  I am not going to advocate drinking soda (even though I do it too much as well).  Is drinking soda really going to lead to cancer?  Moreso, is stopping going to prevent cancer?  And how much is that medication going to change his long-term outcome?

It is very difficult to estimate someone’s lifetime risk of developing a certain type of cancer for numerous reasons.  What might his lifetime risk be? Five percent (a one-in-twenty chance)? Ten percent (a one-in-ten chance)?  Or is it more?  This is extremely unlikely considering that esophageal cancer in the United States is a fairly rare tumor.   One source (Kubo and Corley, Am J Gastroenterol 2004) estimated that the annual risk in a Caucasian male is about 1 in 10,000.  And that estimate is not taking age into consideration.  If Alan lives another 40 years, his lifetime risk is about 40 in 10,000 (not exactly, but almost).  That equates to a chance that he will ever get esophageal cancer of less than one half of one percent.

I don’t really believe that Alan’s risk of esophageal cancer is going to change all that much with any of the interventions proposed.  And I certainly don’t think he needs to go back in 5 years.  How much risk is acceptable to him?  That is for Alan to decide.  Granted, drinking multiple sodas a day is not the epitome of a healthy lifestyle, and limiting the soda may help him in other ways.

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About Ryan Madanick, MD

I am a gastroenterologist at the University of North Carolina School of Medicine, as well as the Program Director for the GI & Hepatology Fellowship Program. I specialize in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD. I can be followed on Twitter: @RyanMadanickMD (he/him)
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6 Responses to My Friend’s Endoscopy, Part II

  1. Nat says:

    Where is point #3? Why is a 39 year old taking his mother to the doctor visit?

    Placing the blame on the physician for not taking the time to explain why a test isn’t necessary due to dollar reasons is pretty short sighted, if not the trendy thing to do. I know that academic physicians look down on private practice guys, but money doesn’t drive every decision. There are patients who show up to visits with something in their head and won’t be swayed (and a grown adult who brings his mother to his GI doctor likely falls in that category.) I spend plenty of time explaining why MRI’s aren’t necessary (and I make money on MRI) and sometimes, it falls on deaf ears.

    Right or wrong, plenty people feel entitled to some of these treatments. They are paying good money for insurance and the “insurance paid for it” is a common sentiment.

    • Since Alan is a good friend of mine, and I know his mother well, I certainly understand why they went together (although I was tempted to bring it up in the blog; I didn’t).

      Nat, I agree with your medical points. There is definitely an entitlement, as well as preconceived notions, that some patients maintain that can’t be swayed. I won’t say that I would not have done an upper if I were the same doctor in the identical situation — I queried one of my senior colleagues, and he basically said that he probably would have done it too, even though he knew that there would be extremely low yield…since there is a “soft” indication and the risk is very low — however, the consequences still have ramifications, and I would certainly not have (1) recommended a follow up EGD in 5 yrs; or (2) scared Alan about the risk of cancer when his endoscopy was negative. In an asymptomatic patient, I’m not sure even why the omeprazole was prescribed.

      I am still not sure at all why Alan had the colonoscopy, unless the doc in good faith thought Alan’s risk was markedly higher than average. From what Alan described to me, if I were the GI guy, I would have said that he could wait until 50 unless there were symptoms.

      That being said, the path of least resistance is often to accede to a patient’s request if it is not unreasonable. At least some, not all, of that reason is financial, even if the “money” is measured as a function of time spent (or in this case, not spent) in the same patient’s room. Part is fear, but part is just the simplicity in doing it. But acceding to a patient’s request is a slippery slope. Think about this…

      It is easy to order a lab test (say, a CBC), because a patient requests it. A blood draw is innocuous, and the lab test costs little. But someone pays for it (the insurance company, who then passes a fraction of that cost on). Same thing with a routine radiograph. Ultrasound. CT scan. MRI… All non-invasive and generally innocuous, but the price goes up with each, and there are small, but known, risks with CT and MRI. We generally underplay them but we consider them in our decision-making. >> Risk very low; Benefit probably low…as long as the risk isn’t greater than the benefit, then ordering these tests is probably not going to hurt anyone, although the cumulative effect of multiple doctors doing it nationwide does affect the bottom line of how much medical care costs in this country.

      Let’s take this one step further now. The tests in question here were invasive, as opposed to the others I just mentioned. They are not therapeutic for the most part, so they are still diagnostic or screening tests. But they are still invasive nonetheless. So how invasive is “requestable”? I’m sure you see where I’m going with this.

      Patients often walk into a surgeon’s office and request surgery for various ailments. Back pain, abdominal pain, neck pain, etc. Most surgeons would spend the time to figure out if the surgery was required, and not just take that patient straight to the OR. And if it weren’t strongly indicated, then there would hopefully be a frank discussion about why the surgeon did not feel the need to do the procedure. I didn’t even mention non-surgical therapies (drugs, etc), which often get requested, even moreso now that direct-to-consumer advertising is so prevalent.

      I appreciate your comment, Nat. Of course this blog was merely meant to stimulate thought from both medical and non-medical readers. Believe me, I am not saying that academic docs are any better at turning down requests than private docs (the difference is often in the “retrospectoscope”, which has 20/20 vision…right?). I wish we all had unlimited time and energy to explain everything to each patient, but we don’t.

  2. Nat says:

    I guess point #4 could be whether a guy who can’t make a simple reply to a blog should be able to order MRI’s? Sorry for the duplicate post, feel free to delete.

  3. Janet says:

    Alan’s father had symptoms in his early 20’s, as did his aunt, grandfather, etc. Alan’s father would probably be alive today if he was diagnosed earlier…his 70th birthday was yesterday. As a mother, you want to do everything & anything you can for your child, no matter what; and if anything was found at this screening, would you be as glib?

  4. Ray says:

    Our family doc has scheduled my wife for an endoscopy during a fifteen minute interview/exam. She, will have the procedure tomorrow morning.
    Last year, he wanted me to have a cardiac cath. As a veteran, I went to the VA. Every thing ok, very little plaque build up, no blockages. Cost me $50.00;civilian hospital would have been $30,000 if I had used Medicare.

    I know why, it was recommended and I was happy with the result. However, I feel bad for the folks without insurance who live with this kind of sword over their heads.

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