How many more must die before virtual colonoscopy becomes available?

Each year there are approximately 150,000 new cases and 50,000 deaths attributed to colorectal cancer (CRC). The medical community is well aware that many CRC deaths are preventable through regular screening to identify early stage cancers and precancerous polyps. Although several tests exist today, the data shows that less than half of eligible adults have undergone any of these. Screening rates are even lower in minority populations, particularly African Americans, where the disease exacts an even greater toll. These unacceptably low screening rates indicate that more patient-friendly options are required.

I am a radiologist at the University of Texas M.D. Anderson Cancer Center who invented virtual colonography (VC) in 1993. The VC procedure combines CT scanning and virtual reality computer technology to allow a radiologist to inspect the internal surface of the colon for abnormal growths. Over the past decade, I have watched this technology grow from being a novel idea to now being capable of having a major impact on the incidence of CRC by offering the public a procedure that is quick, accurate, cost-effective, minimally invasive, and safe—key points that make VC appealing to most people and a valuable alternative for those who wish to avoid or cannot undergo conventional colonoscopy. In fact, data shows that more opt for screening when VC is an option—the National Naval Medical Center in Bethesda, Md, reported a 70% increase in CRC screening after VC became available as an option!

Despite the endorsement of VC by the American Cancer Society, the American College of Radiology, and the U.S. Multi-Society Task Force on Colorectal Cancer in March 2008, the Centers for Medicare and Medicaid Services (CMS) recently announced its decision to deny coverage for Medicare patients—a decision that will undoubtedly result in many senior Americans continuing to avoid CRC screening due to the rigors and risks associated with traditional colonoscopy; consequently, more people will continue to die from this disease!

CMS stated that its denial of coverage stems from a lack of evidence proving that VC is effective in the Medicare population —yet several studies, including research from the University of Wisconsin, was presented to CMS prior to its decision that proved otherwise.

Probably the most important driver of this adverse decision is the perceived costs associated with the widespread use of VC and the costs associated with evaluating extracolonic findings (ECFs). Although VC can identify significant ECFs, such as renal cell carcinoma that would be impossible to see with conventional colonoscopy, this added benefit can also be a curse whenever significant time, money, and risky invasive procedures are used to work up benign findings. Rather than burying our heads in the sand and abandoning VC altogether because of ECFs, I believe that more efficient and cost-effective guidelines for evaluating ECFs are needed, and that these guidelines must be supported by pay-for-performance initiatives, especially as we enter the realm of health care reform.

Universal insurance coverage for VC is coming as evidenced by several private insurers leading the way ahead of CMS; eventually, CMS will reverse its decision because of a growing body of evidence in favor of VC as well as political pressure in response to a public outcry in favor of less invasive and more cost-effective screening technologies.

However, as we sit in this lull awaiting coverage, I believe that a great opportunity exists for radiology leaders to take charge and create viable VC practice standards, similar to what was done with the Mammography Quality Standards Act (MQSA) of 1992 to guarantee that quality VC is practiced and that it does not earn a bad reputation in the hands of rogue providers.

As a physician working in the world’s foremost cancer hospital, I am all too familiar with the personal stories of people battling colorectal cancer. Therefore, I strongly support insurance coverage for all screening technologies, but particularly VC because of its potential to increase screening compliance among people who refuse to undergo conventional colonoscopy. However, radiology leaders must also act to ensure that high-quality VC is practiced whenever insurance coverage finally arrives.

David Vining, MD, inventor of CT colonography, specializes in body imaging especially as it relates to cancer detection. He is currently working with the Division of Cancer Prevention and Population Sciences at M.D. Anderson Cancer Center to build a comprehensive colorectal cancer screening program in the Houston metropolitan area.