The advertisements on television and in magazines make stool based colorectal cancer screening sound like the greatest thing since sliced bread. And the more you think about it, the better it sounds, especially since you’ve been dreading a colonoscopy ever since you turned the big 5-0 (happy birthday to you!). The ads promise a simple stool test in the privacy of your own home, sent in the mail, and a report in no time. If it’s negative, you’re in the clear and don’t have to worry about colon cancer. If it’s positive, you go to your doctor for the next step. It’s easy, it’s painless, you don’t have to take a day off work, you don’t have to get a ride to and from your colonoscopy procedure, and you don’t have to worry. Right?

Not exactly.

As with everything health-related, there are pros and cons to every decision. The advertising has told you all the pros. Let’s talk a little about potential cons.

1. Stool based colorectal screening isn’t the best choice for everyone.

   In particular, if you have a family history of colon cancer, a personal history of colon polyps, or any digestive symptoms, a stool card is NOT the right test for you. This is because you are considered in a higher than average risk category, and a colonoscopy is needed both as prevention and for helping diagnose the cause of any symptoms you’re experiencing. If you have any doubt about the best choice for screening, talk with your doctor. Be honest about any symptoms you’re having, such as difficulty passing stool, blood in your stool, abdominal pain, or changes in your bowel habits. Your doctor will give you individualized advice about the next step in your care.

2. There’s the possibility of false positives and false negatives.

   A false positive is when the test is positive but in reality, you don’t have colon cancer or a colon polyp. A false negative is when the test is negative, but you really do have colon cancer or a colon polyp. Of the two, a false negative is more likely to be a problem for your health, as it provides a false sense of security. A false positive, on the other hand, is more likely to be a problem for your wallet, as further more invasive testing will then be required (though it could be a problem for your health if you experience complications from further testing).

   A recent study looked at factors contributing to false positive and false negative rates for patients using a stool card (FIT) as their method of colorectal cancer screening. Of note, males, people with high blood pressure, people with high blood sugar, people who were former smokers, and people with a family history of colon cancer were more likely to receive false negative results with stool card-based testing. If you fall into one of these categories, you and your doctor should carefully discuss the best choice for you.

   Statistically, people who use the Cologuard form of stool testing are more likely to have false positive results than if you use the FIT form of stool testing.

3. Your insurance may not cover the cost of a colonoscopy if your stool card comes back positive.

   Remember, each insurance plan is different and you will need to check with your particular company to determine your individual benefits. As a general rule, most insurance companies will cover the cost of a screening colonoscopy. This is defined as a colonoscopy undertaken purely to screen for colon cancer if you aren’t experiencing any symptoms, do not have a family history of colon cancer, AND do not have a personal history of colon cancer or colon polyps. If you are having a colonoscopy for any of those reasons (symptoms, family history, personal history), your colonoscopy is billed as a diagnostic colonoscopy; that’s when your particular insurance benefits come into play regarding your out of pocket cost for the procedure.

   If you have a positive stool card, a colonoscopy is the most commonly recommended next step in your care. Because of the positive stool card, this will be billed as a diagnostic colonoscopy to your insurance company, as you will be considered to have a symptom (microscopic blood loss and/or DNA from polyps or cancer as indicated by the positive stool card). This means you may have to pay more out of pocket for your colonoscopy (again, based on your individual insurance coverage) than if you had gone in for a purely screening colonoscopy in the first place.

4. A colonoscopy is proactive. A stool card is reactive.

   A colonoscopy is considered the gold standard for prevention of colon cancer because precancerous polyps can be removed during the procedure. This means potential cancer is stopped before it has the opportunity to develop into full blown cancer. Many people who have polyps removed during a colonoscopy have no family or personal history of colon cancer or colon polyps, and have no symptoms. Thus, a colonoscopy is being very proactive with your health. Another way of looking at it is a colonoscopy is the best possible prevention for colon cancer.

   A stool card is reactive rather than proactive. This is because it only becomes positive when there is a problem already present. You then need a colonoscopy to find what that problem is.

We hope this information is helpful to you as a patient as you and your healthcare providers work together to make the best decisions for your health.