Nine years ago, my Uncle Donny got appendicitis. He asked me to be his medical advocate.
"There's something else," the surgeon told my uncle before the operation. "We saw a mass on your abdominal CT. I hate to scare you…but it looks like colon cancer."
"You'd think they would have found cancer on your colonoscopies, right?" I asked Donny.
"My last colonoscopy was 20 years ago." Donny replied, sheepishly.
What followed after his appendectomy was a diagnosis of stage 4 colon cancer. The prognosis was grim. Only about 14% of people with this diagnosis are alive 5 years later.
Speaking of colons, recently a UK-based epidemiologist, Deepti Gurdasani, MD, posted about hers on Twitter. Gurdasani takes an immunosuppressant to treat inflammatory bowel disease (IBD). Her prioritizing of COVID-19 mitigation over other issues and openness about her health have attracted many Twitter followers.
"Had to go in for a flexible sigmoidoscopy without sedation yesterday," tweeted Gurdasani. "I screamed with pain even just when they got to the transverse colon… I don't think I could've taken any more of it," she wrote.
Not a five-star experience. But why skip the sedation? She explained that sedation would have required her to wear nasal cannula for oxygen and the tubing would have broken the seal of her mask, putting her at risk — specifically, for COVID.
There are problems with medical professionals modeling such behavior. Broadly, they have to do with misunderstanding and miscommunicating risk from COVID.
We have known for years that older adults are at the most risk for severe COVID. Gurdasani is in her 40s, a low-risk group. Also at increased risk: patients with certain medical issues and on immunosuppressants, like Gurdasani. But within these broad groups, there are different levels of risk. One example: patients with IBD.
In 2020, members of the British Society of Gastroenterology recommended precautions for how patients with IBD should view COVID. In May, they withdrew these recommendations for additional precautions.
IBD is "not inherently associated with increased risk of severe outcome," the group wrote in Gut. (Perhaps the second-best journal title, behind Blood Advances.)
"Vaccination against SARS-CoV-2 has uncoupled symptomatic infection and poor outcomes.... The major potential risk to date has been of inadequate vaccination responses, which have been largely overcome by adjusted primary vaccine schedules, boosters and availability of antivirals. We, therefore, predict that the disruption from the pandemic for individuals with IBD will largely now be no different to the general population."
Another group, the SECURE-IBD team, looked at patients with IBD who contracted COVID early in the pandemic to determine risks for severe disease. Self-reporting from patients aged 30-49 found that 1.5% required ICU treatment, 0.9% required a ventilator, and 0.3% passed away.
In 2022, the group closed reporting to their database. They stated, "We found that corticosteroids are associated with more severe COVID-19 outcomes, while biologic medications are not." Gurdasani does not use steroids chronically to treat her IBD.
Also important with considering an action's risk is that it must be compared against the risks of not taking the action and the risks of doing something else. Patients with IBD have increased risk for colon cancer, so it's especially important that they get screened. With Gurdasani's choice to skip sedation and the likely instinct of her gastroenterologist to avoid causing her discomfort, what amount of increased risk was there of (1) a suboptimal procedure that missed a lesion or (2) complications like a bowel perforation if she had moved?
Gurdasani further failed to highlight risks of missing colonoscopies. Some of her Twitter followers reacted to her story by reflecting on their perceived risks.
"I desperately need an EGD & colonoscopy thanks to my autoimmune disease, but b/c of my autoimmune disease & everyone's poor COVID practices I can't safely get the care I need," tweeted one follower.
"I'm going to decline future appointments with my consultant. I'm immuno suppressed. Any hospital is now a very dangerous place for me," wrote another.
A third tweeted, "I was written up for a colonoscopy months ago and have postponed because the procedure wouldn't be safe right now."
Let's talk about Ryan Reynolds' butt. The second colonoscopy of this tale belongs to Reynolds, star of Deadpool and Welcome to Wrexham. After turning 45 this year, he filmed the before-and-after (and thankfully not the "during") of his colonoscopy. Reynolds, masked, is seen meeting N95-wearing Jonathan LaPook, MD. After the colonoscopy, LaPook shared with Reynolds that they removed a polyp from his colon.
"This is exactly why we do this…. You are interrupting the natural history of a disease…that could have ended up developing into cancer and causing all sorts of problems," LaPook said on Reynold's YouTube video. "This saves lives, pure and simple."
Back to Uncle Donny. After his diagnosis of stage 4 colon cancer came blood transfusions, a bowel obstruction, another surgery, and chemotherapy. Now, over 5 years after his diagnosis, Donny beat the odds and his cancer is in remission. Despite mild lingering symptoms, he plays golf and takes college classes (free for senior citizens).
At 77, while on immunosuppressants, Donny got COVID this year. I prescribed him nirmatrelvir-ritonavir (Paxlovid) and, after some mild symptoms, despite his risks for severe COVID, Donny fully recovered with no long-term effects.
One of the necessary challenges of medicine is performing multidimensional risk assessments — weighing the multiple risks and benefits of different courses of action. Despite how COVID has dominated the headlines, in 2022 we cannot allow COVID to dominate our medical decision-making, with vaccines and antivirals readily available. We do a disservice to our patients by focusing on one risk of one course of action and making decisions solely based on that measurement.
I will always wonder how Donny's life would have been different if he had not had the good fortune to get appendicitis, or if I had encouraged him to get colonoscopies. I also wonder how, in the future, we will measure the harm done by medical professionals who misunderstand and miscommunicate the risks of COVID.
Disclaimer: Identifying details for "Uncle Donny" have been changed.
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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Michael A. Sharma. A Tale of Two Colonoscopies (and Ryan Reynolds' Butt) - Medscape - Oct 05, 2022.
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