Inside look at the virtual-colonoscopy debate

NEWARK, Del. — The Colon Health Center of Delaware has been selling an alternative to one of medicine's most unloved procedures: the colonoscopy.

Rather than insert several feet of tubing into the lower intestines, clinicians slide patients into a CT imaging machine that can quickly scan the abdomen for signs of cancer.

The procedure has sparked a battle in Washington, D.C., becoming a prime example of how difficult it can be to ensure that health-care dollars are spent efficiently, a key goal of the Obama administration.

The procedure is cheaper and more comfortable than the traditional method. Proponents contend it will save lives by increasing the number of people getting screened.

About 50,000 people die every year from colorectal cancer, many because they avoided the traditional colonoscopy.

No consensus

But there is no consensus about the effectiveness of the new procedure. Some critics contend it could inflate the nation's skyrocketing health-care tab because a traditional colonoscopy is required if anything is found in the imaging.

Federal officials are deciding if Medicare should cover virtual colonoscopy for senior citizens, a determination that could have a wide-ranging impact on all consumers, doctors, hospitals and device makers. The decision is expected next month.

"This may be a bellwether for how the hard choices around expanding access and controlling costs will play out," said Dr. Sean Tunis, chief medical officer at the Centers for Medicare and Medicaid Services in the last Bush administration.

Colorectal cancer is highly treatable if detected early, but it remains the nation's second-deadliest cancer, in large part because half of adults older than 50 do not get screened.

For years, the most reliable method has been optical colonoscopy, in which a scope is used to inspect the walls of the intestine and remove abnormal growths, or polyps. But many people shy away from getting screened because they don't want to be sedated, as is sometimes necessary, or prodded by a tube inserted through the rectum.

Rosemarie Blair was such a person. "I don't like operations or needles or anything too invasive," the legal assistant from Delaware said.

But prompted by the death of a friend's daughter, Blair, 60, made an appointment to get a virtual colonoscopy.

The procedure, which produces a three-dimensional image of the patient's lower intestine, can be unpleasant. As with a normal colonoscopy, patients must drink large quantities of unpalatable liquids to cleanse their bowels. Before the scan, air is injected into the lower intestine, which can be uncomfortable.

Blair's scan identified two polyps that were removed that morning by a gastroenterologist using traditional colonoscopy. The scan also picked up something suspicious in Blair's right kidney.

Follow-up tests identified a 1 1/2-inch round cancer. Last month, Blair had the kidney removed.

Recommendation

Stories like Blair's have fueled enthusiasm for wider use of virtual colonoscopies. Last year, the American Cancer Society added the procedure to its list of recommended screening options.

Also backing the new procedure is the medical-imaging industry, which by one estimate reached $7.8 billion in 2007, and health-care providers eager to use their CT scanners.

Like many new medical technologies, however, virtual colonoscopy poses a challenge for policymakers.

Medicare, which will spend more than $500 billion this year, is under increasing pressure to contain spending.

The government has attempted to control health-care costs in part by carefully evaluating new technologies before Medicare agrees to pay for them, and the agency did a yearlong review of virtual colonoscopy.

Some studies indicated the procedure can detect most polyps as well as traditional colonoscopy. But others have suggested it is not as good at detecting some smaller polyps or spotting flat lesions, another possible sign of cancer.

Disputes over the procedure's cost-effectiveness complicated Medicare's analysis.

The procedure, which typically costs less than $1,000, can be half as expensive as a traditional colonoscopy. But up to 20 percent of patients will have a polyp requiring that they get a follow-up optical colonoscopy to have the growth removed.

That has fueled criticism that virtual colonoscopy is needlessly duplicative.

On Feb. 11, the federal agency issued its conclusion: "The evidence is inadequate." It recommended Medicare not cover virtual colonoscopy.

A backlash ensued.

Working with a lobbying and public-affairs firm, the Colon Cancer Alliance, American College of Radiology and Medical Imaging and Technology Alliance, a device-industry group, briefed lawmakers in the Capitol.

Subsequently, more than 50 members of Congress mounted a letter-writing campaign addressing the recommendation.

To some, that kind of political pressure is one reason the health-care system has become so inefficient.

But Dr. Len Lichtenfeld, deputy chief medical officer the American Cancer Society, said, "The issue is: Who is going to make the decisions about what we do and what we don't do in medicine? Let's not kid ourselves. That is a political question."