Manitoba 'late to the game' in adding colon cancer test that could reduce endoscopy waitlists

A gastrointestinal expert is encouraged Manitoba is taking steps to catch up with other provinces by offering a less invasive form of colorectal cancer screening, but he's skeptical the test will help much in chipping away at the province's significant waitlist for colonoscopies.

Last week, the provincial surgery backlog task force announced Manitoba will begin performing fecal immunochemical testing (FIT) as a way of reducing the need for endoscopies, which includes colonoscopies.

Using FIT broadly might lead to quicker screenings and free up operating room spaces for other procedures, according to the task force.

Dr. Charles Bernstein, a gastroenterology expert, says Manitoba is the last province to begin using FIT.

"We are late to the game in Manitoba," said Bernstein, distinguished professor of medicine at the Max Rady College of Medicine at the University of Manitoba.

Up to now, Manitoba has been using what's known as guaiac testing, in addition to colonoscopies, to screen for and treat pre-cancerous and cancerous polyps and lesions in the colon.

Guaiac tests screen for the presence of blood in a patient's stool, but the test has limitations, Bernstein says. In order to be most accurate, it must be done on a day when a lesion or polyp in the colon is bleeding.

That can lead to a false negative that suggests there are no problem polyps when in fact they might have simply evaded detection.

FIT-based tests are "much better" than guaiac — about 75 to 80 per cent accurate at detecting the presence of lesions or polyps, Bernstein says. They're even more accurate at detecting large polyps or cancerous lesions.

FIT is also more expensive than guaiac, something Bernstein speculates could have something to do with why Manitoba held off on implementing it sooner.

A 'ding' not 'dent' on waitlists

The province estimates introducing FIT could drop the number of endoscopies needed, including colonoscopies, by 10 to 15 per cent.

Bernstein isn't so sure.

"In terms of the task force and the notion that this can help reduce the vast endoscopy waitlists, I would say that this may put a ding in it as opposed to a dent," Bernstein said.

He estimates there were roughly 1,500 people waiting for endoscopies pre-pandemic. That number has ballooned to about 11,000, Bernstein said. 

When a FIT or guaiac sample comes back positive, the patient still needs a colonoscopy, which is more invasive but can reveal, diagnose and remove problem polyps.

With minimally invasive FIT tests more widely accessible, Bernstein says it's possible more Manitobans over the age of 50 could begin to seek them out. Those averse to getting a colonoscopy might elect to start making FIT — offered as at-home tests in other provinces — part of their annual or biannual colon health routines.

That could mean more screening tests performed, more positive results and more people on waitlists for colonoscopies, Bernstein says.

Paul Ullrich, 71, understands why it could lead to an uptick in tests. 

"It might encourage a lot of people to have tests like this because a colonoscopy is not a very pleasant experience," he said. "It's extremely invasive and no one likes it, but at the same time, it is very effective."

Due to family history, Ullrich has been having guaiac tests or colonoscopies regularly since he was 50, when the risk of colon cancer goes up for men and women.

A guaiac test he took in October came back positive. Ullrich has a colonoscopy appointment next month.

'Pretty appalling'

Christine Layne, 40, had one this month, though she waited longer than Ullrich.

Layne had a potentially pre-cancerous polyp removed during a colonoscopy in 2019. She was told to get another done a year later to make sure it hadn't grown back.

She received a date of September 2020 initially. At nearly eight months pregnant at the time, Layne didn't feel comfortable having the procedure, so she asked to reschedule. 

Last summer, still with no colonoscopy date, she experienced rectal bleeding and sought help at a Winnipeg hospital emergency room. 

"That was … concerning to me to be bleeding with no obvious cause, especially knowing that they had had a pre-cancerous polyp or potentially precancerous policy prior," Layne said.

The bleeding had stopped more than seven hours later when she and her baby were finally seen by an ER doctor.

Happily, there were no obvious signs of cancer in her January colonoscopy, she says. Layne is still waiting on biopsy results.

Layne supports Manitoba doing FIT. She's also frustrated by the backlogs.

"It's pretty appalling," Layne said. "It's not like they couldn't see this coming. It was already a problem before COVID, and I think we've had an underinvestment in health care."

Bernstein has investment recommendations, too.

He proposes expanding the number of allowed endoscopies by doing more later into the day or evening, and on weekends.

He also says there should be an endoscopist on the task force "championing endoscopy."

"It's a big part of diagnostics and it's really suffering," Bernstein said.

This story was possible in part thanks to Manitobans who filled out CBC's survey on the pronounced effect COVID-19 is having on Manitoba's health-care system. In it, we asked health-care workers, patients and their loved ones to send us their top concerns and questions about care during the pandemic.