Chapter 33: Congressional Testimony about Colorectal Cancer Screening, The Economics of Testing, and Public Awareness
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Description
Dr. Levin begins by explaining why he was selected to speak before Congress in support of Medicare coverage of screening for colorectal cancer (6 March 2000). He notes that he was prepped by people at the American Gastroenterological Association and worked with them on the script he read. The testimony had an impact and led to Medicare legislation to fund screening of colonoscopy and occult blood testing, though not of the double contrast barium enema which Dr. Levin believed should also be covered. He notes the change in public attitudes about screening: now about 60% of Americans get screened. He also explains why physicians are more likely to order a colonoscopy than an occult blood test, though the latter is much less expensive. He then discusses colonoscopy costs (relatively and sometimes unnecessarily high) and what is involved in providing a quality product for a reasonable charge. He notes the other tests that could be done to determine whether a patient needs a colonoscopy. Dr. Levin then explains why it might be difficult to increase the 60% number of Americans screened and notes that the most effective way to educate the public about screening is through a primary care physician or nurse.
Identifier
LevinB_05_20130827_C33
Publication Date
8-27-2013
City
Houston, Texas
Interview Session
Topics Covered
The Interview Subject's Story - The AdministratorActivities Outside Institution Understanding Cancer, the History of Science, Cancer Research The History of Health Care, Patient Care Discovery and Success MD Anderson Impact Institutional Processes Healing, Hope, and the Promise of Research MD Anderson Snapshot Building/Transforming the Institution Multi-disciplinary Approaches Education Information for Patients and the Public Fiscal Realities in Healthcare The Healthcare Industry
Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.
Disciplines
History of Science, Technology, and Medicine | Oncology | Oral History
Transcript
Tacey Ann Rosolowski, PhD:
I see. I wanted to go back to the instance of the congressional testimony which took place in 2000. What did you speak about and why were you selected to present that information?
Bernard Levin, MD:
I was involved with the American Cancer Society as well as chair of its Colorectal Task Force, and I was also a member of the Public Policy Committee of the AGA, American Gastrological Association, around that time. So perhaps because of my interest in colorectal cancer, I was a relatively natural person to be chosen, and I was prepped for that by people at the AGA and was really given a script that relates to Medicare coverage.
Tacey Ann Rosolowski, PhD:
Because this was a hearing before the Special Committee on Aging, isn’t that correct?
Bernard Levin, MD:
Yes. It had to do with Medicare.
Tacey Ann Rosolowski, PhD:
Right. Okay.
Bernard Levin, MD:
And I believe that Mr. Grassley chaired it, or at least he was present.
Tacey Ann Rosolowski, PhD:
Yeah, I could look that—
Bernard Levin, MD:
Sorry?
Tacey Ann Rosolowski, PhD:
No. I think you sent me the proceedings, so I can check that.
Bernard Levin, MD:
Yeah, I think he was there. I wouldn’t say it was a full house of the Senate in attendance. It was a relatively sparse number of people.
Tacey Ann Rosolowski, PhD:
Probably would be now, given the aging population.
Bernard Levin, MD:
Yeah. Right. But I’m saying it wasn’t that interesting to them, but it had great impact in terms of Medicare.
Tacey Ann Rosolowski, PhD:
I want to ask you about the impact, but first I wanted to ask you—because you mentioned you were prepped by people at the AGA and basically given a script. So how was that script created? Did you contribute to it in any way or—
Bernard Levin, MD:
Yes, undoubtedly. I think we all agreed that it was a good idea for Medicare to reimburse screening, and the question was using what mechanism, and, obviously, colonoscopy and occult blood testing were the two that seemed germane. The other test available, double-contrast barium enema, was one that I also thought at the time could be considered [unclear].
Tacey Ann Rosolowski, PhD:
I’m sorry. Could you tell me the name of that again?
Bernard Levin, MD:
The double-contrast barium enema.
Tacey Ann Rosolowski, PhD:
Oh, okay. Mm-hmm.
Bernard Levin, MD:
It was one of the tests the American Cancer Society supported. At the time, though, there was considerable controversy about that because other gastroenterology groups didn’t want radiologists doing screening.
Tacey Ann Rosolowski, PhD:
Oh, gosh.
Bernard Levin, MD:
There was a little bit of internal politics there. But I was just asked to present recommendations and included those modalities: occult blood screening, colonoscopy, and double-contrast barium enema.
Tacey Ann Rosolowski, PhD:
And so the impact? You said it had an impact.
Bernard Levin, MD:
Yes, in Medicare and later Medicare legislation that supported screening for colon cancer with colonoscopy and other tests.
Tacey Ann Rosolowski, PhD:
What kind of questions did you receive? Did you feel as though it was a controversial set of proposals or—in terms of speaking with Congress?
Bernard Levin, MD:
I don’t remember. I didn’t think it was highly controversial.
Tacey Ann Rosolowski, PhD:
Well, that’s good news.
Bernard Levin, MD:
Yeah.
Tacey Ann Rosolowski, PhD:
] Why do you think people are reluctant to get screening, or has it changed over the years?
Bernard Levin, MD:
Oh, I think it’s changed substantially. It’s estimated now that almost 65, 68 percent of people in the United States get screened—
Tacey Ann Rosolowski, PhD:
Oh, really?
Bernard Levin, MD:
—[unclear] age group, yeah.
Tacey Ann Rosolowski, PhD:
Wow.
Bernard Levin, MD:
So it’s come up a long way, and has a lot to do with availability of colonoscopy, being a one-time test, easy to administer for the general primary-care physician, just clicks a box, “Go and get a colonoscopy every ten years,” as opposed to other tests, which at the moment include testing for hidden blood, where the primary-care physician’s office has to get involved in instructing the patient, explaining it, ensuring that the sample is collected properly. I mean, there are a lot of different logistic issues, as opposed to a colonoscopy, which doesn’t have to be done by the primary-care physician. It’s done by somebody else. It’s very easy to order. It’s a one-time test. Now, of course, on the other hand, colonoscopy is an invasive test, it’s expensive, it takes time, takes up someone’s spouse’s time or companion’s time because you have to need someone to take you home because you’re sedated most of the time. So there are issues, but from the point of view of the primary-care physician, colonoscopy fits a niche.
Tacey Ann Rosolowski, PhD:
I was curious what your response has been to some of the articles that have been coming out. I mean, there’ve been a lot of articles recently because of the Affordable Care Act about the expense of various kinds of tests in American hospitals, and one of them that’s been singled out for analysis is the colonoscopy and, you know, in some situations, the incredible expense of the colonoscopy. Do you think that discussion—I’m sorry? You were going to respond.
Bernard Levin, MD:
No, no, go ahead. Sorry.
Tacey Ann Rosolowski, PhD:
Oh, I was just going to ask if you thought singling out the colonoscopy for that kind of scrutiny might have an effect on whether or not people get them.
Bernard Levin, MD:
Yeah, I’m afraid it might. On the other hand, I think that’s it’s unconscionable to charge someone $1,800 for a procedure of that kind. I think it’s totally unwarranted. I think that the point has been made that a colonoscopy is not just the act of insertion of a lighted tube into the colon by a chimpanzee; it’s not as simple as that. I mean, you could certainly train someone to do that, but there’s more to it than that. There’s the understanding, being able to really accurately identify abnormalities or landmarks, making sure the test is done with high quality and that if any abnormalities are found, that they are treated appropriately, so it does take skill. But I don’t believe it takes $1,800 worth of skill. But on the other hand, the story does not end with just doing the procedure. There’s the appropriate follow-up if abnormalities are found, recommendations for the future. There are a number of issues involved in providing a quality product that not just relates to the endoscopic aspect of it. But having said all that, I think it’s overpriced, and there is reason for saying that this should end and that a reasonable charge should be computed and agreed on, and that would be adequate. I think that the high charges of colonoscopy have leant themselves to abuse. People do them more often than they need to be done, which is one issue, and they may be done for the wrong reasons and repeated for the wrong reasons. So there are a number of possible ways in which economy could be achieved, but I hope that the attention won’t in some way detract from the real value of the test. Having said that, there is also no doubt in my mind that other tests could equally be done on a population basis with lower costs. The more sophisticated test for occult blood is an immunochemical test, and maybe genetic tests which are still being worked on, and maybe blood tests. There are new blood tests that are required to be proven, but I believe, in the long run, a simple blood test, if accurate, sensitive, and specific, that would be a much better way of finding out who really needs to have a colonoscopy, not doing a colonoscopy on everyone, because most people don’t have abnormalities.
Tacey Ann Rosolowski, PhD:
Oh, I see. So these would be tests to actually see who should go further and get a colonoscopy, which would be a more detailed examination.
Bernard Levin, MD:
Correct.
Tacey Ann Rosolowski, PhD:
I see. Hmm.
Bernard Levin, MD:
You could say that 80 percent of the time that nothing is found, and maybe even 85 percent of the time nothing is found.
Tacey Ann Rosolowski, PhD:
Which is good news, but you can use another way to get there.
Bernard Levin, MD:
Right. And to spend $1,800 to get there is clearly a misuse of funds.
Tacey Ann Rosolowski, PhD:
I was going to ask you what—I mean, I was surprised when you said that 60 percent of the American population gets screened, but that still leaves 40 percent that doesn’t, and I’m wondering, you know, what do you think needs to be done to increase that?
Bernard Levin, MD:
] Of the remaining 40 percent, there are some who are going to be beyond the age where screening is useful, and most people now would probably cut off that age at eighty-five, so there are going to be some people above that where screening may not be appropriate because of other factors. There are also going to be some people in that remaining40 percent who have significant co-morbidities, who have other serious illness. Cardiac disease, for example, screening wouldn’t be helpful, because if you found something, you wouldn’t do anything about it anyway.
Tacey Ann Rosolowski, PhD:
I see.
Bernard Levin, MD:
So perhaps that’s another 5 percent. So of that [unclear] percent, you probably can take off 10, 12 percent for whom screening isn’t going to work, so that remains another perhaps 15, maybe 20 percent of people who are hard to reach for whatever reason. They don’t perceive the value of screening. They just don’t want it. It may be very difficult to close that gap. They may be ignorant. They maybe have no resources. There are all sorts of things. They’re homeless. So it may not be possible to reach them, actually.
Tacey Ann Rosolowski, PhD:
So you’re—
Bernard Levin, MD:
I—sorry.
Tacey Ann Rosolowski, PhD:
No, go ahead.
Bernard Levin, MD:
I think, to the best of my knowledge, the terms of the 60 percent figure of screening does not exclude the groups that I mentioned: the over eighty-five, the infirm. It doesn’t exclude those people, so they’re all lumped together.
Tacey Ann Rosolowski, PhD:
Hmm. I guess I was going to ask if you felt that sort of the awareness has reached a saturation point right now with the American public and, you know, if you feel that the public is satisfactorily educated about the need for screening.
Bernard Levin, MD:
You know, I think that the best way to educate a member of the public is through their own physicians. If a physician recommends it, it mostly will happen. Public campaigns only go so far. They don’t have enough specificity. Tell people to go and get a screen for colon cancer sort of leaves one in the air. How do I do it? What do I do? Who do I see? For many people, I’m talking about relatively unsophisticated people who may not have a gastroenterologist in the garage. I live in New York. The screening test of choice here is colonoscopy. It’s the one that the New York City Health Department recommends because it’s feasible. Probably the only place in the—certainly the only place in the U.S. So I think it’s the primary-care physician or nurse who plays the role in clinching that awareness, the conversation being, “You’ve reached age fifty. It’s time to be screened.” I don’t know that more public campaigns can achieve a greater public acceptance. I don’t think it hurts, but I’m not sure it’s effective enough.
Tacey Ann Rosolowski, PhD:
Well, I think these other methods, too, that you mentioned, with the gene based screening and the blood tests, you know, are pretty interesting alternatives if the primary-care physician can begin to suggest some of those as a precursor to colonoscopy too.
Bernard Levin, MD:
Absolutely. I think, to my opinion, the blood test is the most likely to succeed. Now, there are a couple of people working on blood tests, but they’re far away from being commercially available. But in the same way, if your doctor could just order a cholesterol, they could order a blood test. It’s going to be very simple. Think of the complexity and the time of an office explaining any of these other procedures. It’s just too much work.
Tacey Ann Rosolowski, PhD:
Mm-hmm. Well, I have to say, you know, I was recommended to go and get a colonoscopy, and so I dutifully went in, and I read—you know, they make you sign this thing to say that the hospital is not responsible for you or that they’ve made you aware of all the risks, and I was like, “Oh, my god, I’m not sure I even want to have this.” I mean, I’m sure that the chances of some of those things happening are pretty small, but, nonetheless, I almost walked out at that point. So a blood test is a much easier thing to—
Bernard Levin, MD:
That’s right. The chances of having serious outcome, I mean a perforation, are estimated 1 in 6,000 in good hands, experienced hands. It is important to remember that a positive (abnormal) blood test will need to be followed by a colonoscopy that will have a highly predictive value baased on an abnormal bllod test.
Tacey Ann Rosolowski, PhD:
Right, right.
Bernard Levin, MD:
] So somewhere out there, there will be one, I’m sure. But it goes up if you have to have a polypectomy, and bleeding can occur in probably 1 in 1,000. But for the screening, perforation, which is the only major complication of just looking inside, has been 1 in 6,000.
Recommended Citation
Levin, Bernard MD and Rosolowski, Tacey A. PhD, "Chapter 33: Congressional Testimony about Colorectal Cancer Screening, The Economics of Testing, and Public Awareness" (2013). Interview Chapters. 1369.
https://openworks.mdanderson.org/mchv_interviewchapters/1369
Conditions Governing Access
Open
