“No, I’d still rather not,” Mr. W replied with a tone indicating that further discussion would be futile.
I turned from my computer to look Mr. W in the eye. His demeanor seemed more circumspect than argumentative.
“Why not?” I asked.
“I just disagree with you. I don’t think I need it.”
We stared at each other in silence. Across several feet of speckled white tile in the cramped clinic room unexpectedly emerged a large divide. I contemplated the source of our dissonance. Had I not adequately informed him about the importance of the procedure? Had I forgotten some key detail in his medical history? Did he distrust my judgment as a resident physician?
Mr. W was not my first patient to initially refuse a colonoscopy. The idea of having one’s colon examined by an endoscope passed through the anus is not particularly appealing. Nor is the one-to-two-day “prep” required to clear the colon of stool. I was accustomed to spending a significant portion of impossibly short primary care clinic appointments extolling the virtues of colon cancer screening. Some patients were swayed by statistics, others by the thought of one day having to undergo surgery or chemotherapy. The word “cancer” made people more open-minded. Ultimately, even the most reluctant individuals agreed that colon cancer screening was probably a good idea.
Even after hearing the details, however, Mr. W still refused. As his appointment came to a close, I fumbled around the dusty shelf above my desk and found three small fecal occult blood test (FOBT) cards, an older but effective means of screening for colon cancer by detecting blood in stool. I handed him the cards and instructions on his way out the door. At that moment, I had little faith that Mr. W would actually take the time to complete the cards, let alone mail them back to the hospital several weeks later.
But he did. And all three cards tested positive.
According to the National Cancer Institute, colon cancer is the second leading cause of cancer-related deaths in United States. Paradoxically, colon cancer is also one of the most preventable malignancies. The American College of Physicians recommends that average-risk patients initiate colon cancer screening at age 50 and continue through age 75. Most commonly, screening is accomplished with a colonoscopy once every 10 years. Of equivalent benefit, however, is an annual FOBT followed by colonoscopy for any abnormal results.
Until my encounter with Mr. W, I had offered patients a colonoscopy as the only option for screening. Colonoscopy is the most sensitive test to detect colon cancer and enables physicians to directly visualize and remove pre-cancerous polyps. Although less invasive, FOBT requires yearly assessment and possibly a colonoscopy anyway. Despite the prospect of poor compliance, a recent study in the Archives of Internal Medicine actually found that colon cancer screening completion rates increased significantly in a population given the option to undergo colonoscopy versus annual FOBT. The results underscore that no single screening approach is right for every patient.
I was reminded of my conversation with Mr. W. “I just don’t think I need it,” he had said. What had he been trying to tell me? I compared Mr. W to patients I had recently seen in the cancer genetics clinic, many who readily agreed to frequent colonoscopy or even prophylactic colectomy. These individuals had witnessed multiple family members succumb to colon cancer. Some had also tested positive for a genetic trait that significantly increased their risk of cancer.
For Mr. W, a healthy 70-year-old man with no family history of colon cancer, no friends or colleagues with the disease, and no symptoms of any health problem, could it be that my strong recommendation of an invasive screening test was discordant with his perceived personal risk for cancer? His completion of FOBT signified his appreciation for screening in some form. Moreover, the positive results instantly motivated him to undergo the colonoscopy that he had initially refused. His perceived personal risk for cancer had fundamentally changed in a way that made an invasive procedure the most reasonable course of action.
As I feared from the positive FOBT results, Mr. W did in fact have colon cancer. Luckily, it was discovered early enough so that it had not yet spread out of his colon. He underwent an uncomplicated partial colectomy and has since recovered from surgery. I was gratified to see him doing well when he returned to clinic this spring.
One of my most difficult jobs as a resident has been convincing patients to undergo screening for disorders they don’t have. Mr. W taught me an important lesson about how to better discuss preventive medicine with my patients: First consider how individuals perceive their own risk for disease.
Sameer Chopra, MD PhD, is a third-year resident in internal medicine and genetics at Brigham and Women’s Hospital. The opinions expressed are not necessarily those of Harvard Medical School, its affiliated institutions or Harvard University.
