Virtual Colonoscopy Webcast January 26, 2009 Fergus Coakley, M.D. Please remember the opinions expressed on Patient Power are not necessarily the views of UCSF Medical Center, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That s how you ll get care that s most appropriate for you. Introduction Virtual colonoscopy is less invasive and faster than standard colonoscopy for colon cancer screening, and colon cancer screening is very important these days. Virtual colonoscopy doesn t require sedation. Meet an expert in virtual colonoscopy next on Patient Power sponsored by UCSF Medical Center. This is Andrew Schorr with Patient Power. Thank you for joining us. This is where we connect you with a leading medical expert from UCSF Medical Center and learn about a significant medical topic. I know in my family one topic that we think about is colon cancer, which has happened in our family. We re very concerned about it. We want to be screened. We don t want anybody to be affected by it as we move forward, and so the question is well how do you screen for it? Do you simply have a simple exam with your primary care doctor or do you need a colonoscopy, which many people have heard about. Some people know they d rather not have it because there s some preparation, but that s not the best way to go if you really want to screen for colon cancer. Recently now there s also something called virtual colonoscopy, so we wanted to understand where that fits in. Joining us now is Dr. Fergus Coakley. He s Chief of the abdominal imaging section of Radiology at UCSF Medical Center. Dr. Coakley, so virtual colonoscopy, what is it? Is it a CT exam exactly? Correct. It s a special type of a CT scan where we take images through the patient s abdomen, and then we use a computer to reconstruct those images and give us a view that looks just like the Innerspace movie where we can fly through the large bowel, that is the colon, and see if we see polyps that may eventually turn into cancer, and that is the primary purpose of this test. I should of course I guess say that patients and your listeners should be aware that this is still a study that needs a routine preparation, which is somewhat unpleasant, 1
but the colon needs to be empty before we do this study, and so it involves essentially the same preparation that you would need for a regular endoscopy. However, we don t need to sedate patients for this test. So, for example, you could go back to work that same day if you needed to. We only insert a very small tube and inflate some air during the test so that the colon is inflated. That gives us better pictures, but it s not the very long tube that gets pushed all the way into the large bowel that s used during a colonoscopy, and for better or worse I think a lot of patients are reluctant to have regular colonoscopy even though the recommendation is that everyone over fifty should have that done. So virtual colonoscopy offers as it were a second line option for people who want an alternative. The Importance of Screening for Colon Cancer Let s talk about screening for colon cancer in the first place. Why is it so important? Where are we with the incidence of colon cancer today and as our population ages and why is screening so important? Well it s really regrettable, and I do a lot of scans on patients who have advanced colon cancer that s incurable, and we believe that most of those patients could have been spared their disease if they had had their screening test of colonoscopy, be it a regular colonoscopy of virtual colonoscopy, to detect the early cancer, that is, those small polyps that turn into cancer, and colon cancer because not enough patients get screened remains the second leading cause of cancer death after lung cancer, so it s a really big public health problem that we still need to get our hands around. So people then should have screening, and of course in my family we know that all too well. What is the recommendation now? Is it for anyone over fifty should have that screening or if there s bleeding or a family history it starts earlier? What s the recommendation? Of course if you have some special risk factor, either family history or bleeding, that is if you have some symptom, you should obviously talk to your primary care doctor and see what is right for you, but for the general population the current recommendations are that you should start screening at age fifty with either a regular colonoscopy or nowadays you also have the option of virtual colonoscopy. 2
Upsides and Downsides of Virtual Colonoscopy Now UCSF is one of the early centers, and you re one of the leading experts in this. Dr. Coakley, tell us where it fits in. So since you re not putting something inside where you could snip out polyps if you needed to right then or do biopsies, then when does virtual colonoscopy fit in somebody s screening over possibly many years. When would it be right? That s a very good question, and I should add that one of the leaders in this field is Dr. Judy Yee who s another faculty member who works with the VA but also in my department that is radiology, and she has the luxury of having a gastroenterologist that she works very closely with, and so if she finds something abnormal at the CT colonoscopy, her patients can go straightaway to a regular colonoscopy if they need a biopsy. That s not a service that we re able to offer yet outside of the VA Medical Center. It s logistically challenging and administratively difficult, so again this is one of the downsides at a lot of places of virtual colonoscopy is if we find something, which will happens in maybe five to ten percent of cases, that you will then need to go on and have a regular endoscopy to have that finding confirmed and potentially have a biopsy performed. As I said, CT colonoscopy I think is a good option for some patients, particularly those patients who are afraid or reluctant to have a regular endoscopy. If you re very frail or there are other reasons you don t want to have sedation for example or if for example you ve had a previous colonoscopy that was totally normal so you re pretty unlikely to have a new finding those kinds of patients I think would be good candidates to have virtual colonoscopy. It may not be for everybody. It shows how the field is moving though too and radiology being able to look inside the body without having to kind of poke up in there. So where is this headed? One of the big issues this year that we expect is to get a decision from Medicare as to whether they will reimburse for a virtual colonoscopy, and that of course would give huge momentum to this technology. At the moment reimbursement is somewhat variable and will depend on your insurance carrier. We can t guarantee that we ll be reimbursed. Some patients do opt to pay for it themselves, which is also an option, but as I say if Medicare does decide to reimburse that could really push this forward and open the gates to this being used much more widely. 3
Using widely colon cancer screening would seem to be a good thing like you mentioned. You don t have to be sedated. I know for me it s kind of like a two-day affair if you re having a traditional colonoscopy where the first day you re kind of preparing yourself and cleansing yourself and then the next day because of the sedation you re kind of out of it. So it would seem like just from a productivity point of view if we re trying to screen many more people it would have its place. Not everybody necessarily wants to go back to work after having their colon examined, but for those who do certainly virtual colonoscopy is an option. I would emphasize you still need the preparation and the colon cleansing. So yes, you can t get out of that, but the good part of it is that you will skip the sedation so if you want to drive yourself to the clinic or the hospital for this test you can do that. If you want to drive home or go back to work that s an option as well. Let s understand radiology in this regard at UCSF. You all though are leaders in this field, so as you said Dr. Yee is working out procedures, and it sounds like though you continue to push the envelope to see how can this best be used. Correct. We re still teasing out the details. There was a very important study in the New England Journal of Medicine last year that showed this technique had about ninety-percent accuracy when compared with standard colonoscopy, so we now know how accurate it is. There are still some unanswered questions. What is the appropriate amount of colon cleansing that is needed? Can we make this a gentler, kinder exam for the patient that doesn t need maybe quite so much prep work? What is the best way to look at these images after we get them? There is some debate about using computer-assisted diagnosis and other advanced technology, but I think the headline question of is it accurate that has been answered, and these background questions are probably of less interest to the general public. Let s ask about computing technology and power for a second because a lot of that helps drive radiology for you to see more less-invasively. So I know where we are now. So virtual colonoscopy is new on the scene, and you re understanding who it s right for and when, but all of us would love for you to be able to look in the body without being inside it, and if as you said these cleansing procedures were kindler and gentler. As computer power increases, do you think you ll have imaging whether it s a year from now or five years from now so that this will be shorter and simpler? 4
There is some interest in doing what s called the prepless virtual colonoscopy where you don t need any cleansing at all, and there may be ways we can do that, and there are some studies looking at that. We re not there yet. You would probably still need to have the colon inflated because that s an important part of this study, so we would still be inserting a small tube into the rectum to inflate the colon and get good distension, so I don t think we ll ever be able to avoid that part of it, but it may become as I say less unpleasant for the patient as the prep and the technology to look at these images after the fact gets better. Just so we understand what we have now at UCSF. So that would be an option for some people, and you talked about the different groups where it may apply, a virtual colonoscopy, and so you re not sedated; you still have to be cleansed; and there s this small amount of gas I guess that you re putting in so that you can inflate the colon to see it most appropriately. Did I get it right? Yes absolutely, and let me just say we use carbon dioxide to inflate the colon, and there s a reason we do that. That gas gets absorbed very quickly. If you just use room air to inflate the colon it turns out patients get a lot of cramping and bloating and discomfort afterwards, but we at UCSF, and some other centers use carbon dioxide to make this, again, a kinder, gentler procedure for the patient. How long does the procedure take? The actual set of images is probably acquired in the matter of ten to twenty seconds. We get two sets of images. Realistically from the moment you arrive at the outpatient imaging clinic to when you leave would probably be about an hour. Okay, and if someone is sedated it s usually what two to three hours? Yes. We want to make sure that they come around and they ve woken up, and of course we recommend that they don t drive themselves home and then you need to have someone to come with you and who can take you home. So it makes it a little bit more complicated for patients to organize. At the end of the day then it s really in consultation with your doctor whether or not this procedure, which is now available, is right for your personal situation? 5
I think that s absolutely true as with any of these new technologies and test. You should make the decision and get the information you need from your primary care doc, but we also have some information on our website for those who are interested. Okay, well I think we ve covered it pretty well with you Dr. Fergus Coakley, Chief of Abdominal Imaging at UCSF. I wish you well with this new virtual colonoscopy, and I hope people that it s right for will take advantage of it at UCSF, which is one of the leading centers for this. As with all our programs I just want to mention that for more information about either the physicians or the services at UCSF just call the UCSF Physician Referral Service, and that number is 888-689-UCSF(8273). Dr. Coakley, thank you so much for being with us on Patient Power. We wish you well as you continue to advance abdominal imaging at UCSF. You re welcome, and the last thing I would say to your listeners is irrespective of whether you get a regular colonoscopy or a virtual colonoscopy is it s really critically important that anyone who should be screened for colon cancer get screened because this is a preventable disease, and we really want to see less and less of the advanced disease that we can t cure. Absolutely, and having lost a dear family member to advanced colon cancer I couldn t agree more. I m Andrew Schorr. You ve been listening to Patient Power sponsored by UCSF Medical Center. Remember, knowledge can be the best medicine of all. Please remember the opinions expressed on Patient Power are not necessarily the views of UCSF Medical Center, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That s how you ll get care that s most appropriate for you. 6