Bowel cancer screening pain bias

[BuckingFrolics]

Toddled along to the hospital last week for bowel cancer screening test as now 55 and it's free.

Not unduly concerned about pain as leaflet and all online stuff said "may be uncomfortable" in which case pain relief will be provided.

Meet first nurse who says before I have sat down, "we'll give you gas and air before the procedure starts". What? No I'm fine, I say, if it's uncomfortable I'll grit my teeth.

Meet the nurse doing the procedure who again offers gas and air before we start.

What? I thought this was "uncomfortable" - what's with the gas and air?

She says - of fucking course -"oh men find it uncomfortable but because of the womb and bladder position it's more painful for women and we offer gas and air - particularly if you've had a cesarian as there may be adhesions."

Yet another example of men being taken as the norm.

(And yes it fucking hurt like a bastard.)

but we all know women are better with pain

Jesus. The zombie lies never die, do they?

In my view two things are at play here. One, the leaflet minimises the pain in order to encourage take up. This is a voluntary screening procedure, if the leaflet said "it'll bloody hurt" no one would go.

Also, the leaflet takes the male as the default human body. A woman has a uterus - that sits in front of the colon and thus will feel the pressure of the procedure, which increases the potential pain impact. A woman who has had a cesarian is likely to have adhesions where some of the uterine tissue is now stuck to the outside of the colon. Likely to increase pain.

This has nothing to do with individual levels of pain tolerance, or me in particular - my point was this is an example of gendered medical information.

Ive had a full colonoscopy with gas and air. It was ok, not too bad. I was warned some people find it very painful and offered the sedation if I wanted it. They said some people tolerate the pain better than others, here are both pain relief options, up to you. I didnt really feel any of it was genedered.

Whether bowel screening is worth doing is open to contention more generally though.

McCartney, as a doctor who advocates for evidence based medicine and informed consent, really isn't a fan and questions just how useful it is. Her argument is that it stops you dying of bowel cancer but doesn't improve your life expectancy.

She references a Cochrane Review which stated:

Combining the four trials did not show any significant difference in all-cause mortality between the screen and control groups

So basically the point is, if you get bowel cancer it's a sign that your body is giving up on you completely anyway, and it's basically a choice over your cause of death and the manner in which you go.

Of course, if you have a history of bowel cancer in your family or an identified higher risk of it, you might be wiser to play the odds and go for screening as you might well benefit from it more than someone in the general population.

I'm not against screening but I do find it a highly dubious area of medicine which few people really look at and understand.

I find the subject fascinating because of its approach to getting people to participate and how programmes are generally aimed at women. The language of compliance and the idea that you can't make an informed choice to opt out (without being selfish, scared, insert your aggressive and almost coercive appeal to emotion here).

Whether your personal interests and health considerations are really thought about come second to a GP achieving their target for screening (and therefore the funding that goes with it). The conflict of interest is one I find concerning.

I think the anti vaxx movement probably muddies the waters here

my point was this is an example of gendered medical information

Yes...it was very clear

I read a quote from that book and it said something along the lines that females feel pain more but are less likely to receive pain relief

I was sedated for my colonoscopy

Wasn’t even offered just gas and air

Though i think it was done privately so that might be why

I think the anti vaxx movement probably muddies the waters here

Who said anything about anti vaxx? Sorry why have you brought the subject up on a thread about screening and how women are second class patients who are treated differently?

There's a world of difference between an individual decision over cancer screening and a decision over vaccination which isn't an individual decision due to the way in which infectious diseases are spread.

Why are you deliberately trying and conflate the two?

sorry, wasn't very clear. posting on my phone

anti vaxx was on my mind as I was reading an article about it recently

my clearly badly expressed point was, in some cases (as with vaccinations) questioning medical orthodoxy is daft, and leads to harm, both to indviduals and society

in other cases it is quite legitimate, as it's very important to remember that medicine is not practiced in a vaccuum, and all the discrimination and blind spots you suffer from in the rest of your life will also be present when you visit the doctor

it's always OK to question orthodoxy, but it's also important to be able to have sufficient understanding of the evidence to be able to weigh up the answers. and clearly not everyone does.

still not expressing myself very well - talking particularly about whether to follow medical advice on screening....

Ah that does make sense.

I think it's about learning to understand data and agendas and quality of information.

It's not an easy thing to do.

While medicine is completely male dominated in 2019 ( never used to be years ago) the "what about the menners" will be pleased to hear me say that it's not just women who suffer. Once a man is classed as a patient and therefore vulnerable he is subject to similar dehumanizing treatment as women are. Male patients have been known to say they felt they were being treated "like a woman" by the system, in other words "like shit". Women get it worse of course.

The husband of a friend of mine recently died at the age of 33. He was diagnosed with cancer and complied with all procedures. They gave him a heinous liver operation which created all kinds of unspeakable problems for him such as completely swollen legs, yellow skin and eyes and a lot more. He died about a month after the operation. It's clear to me the operation slightly prolonged his life but massively increased the suffering and created a significant loss of dignity. If he's been left alone he would've died slightly earlier but probably in a better state.

I think dignity is a word sometimes lost in medicine.

So basically the point is, if you get bowel cancer it's a sign that your body is giving up on you completely anyway, and it's basically a choice over your cause of death and the manner in which you go.
That sounds very bleak. The conclusion might be that unscreened people notice changes in their bowel movement anyway, and so get treatment and don't die of bowel cancer.

Getting bowel cancer surely isn't a sign that your body is giving up. My aunt got it when she was in her early 60s, and lived to 90, dying of something completely different.

My friend was successfully treated for bowel cancer in her 30s. I’m not sure she’d agree it was her body shutting down anyway. Not that it was found by screening of course.

legacyscreening.phe.org.uk/bowelcancer

According to section 6.9 of Last external review - 2. Optimising Bowel Cancer Screening Phase 1 Report,
Population gender subgroups Total costs are estimated to be higher in males than in females, because of increased treatment costs due to higher CRC incidence rate in males. Similarly, total QALYs gained are lower in males than females. However, ICERs are much higher in women than men as incremental QALYs are much lower in females, as they have less capacity to benefit from screening.

see also section 4

Another you are right.

Statistics can only give you one interpretation and so much information.

That's where freedom to chose whether to opt in or out from screening is a relevant debate.

The effectiveness of screening programmes for the general population from a governmental point of view though is its supposed to improve the life expectancy of the population as a whole. If a screening programme is failing to do that, it brings the entire programme into question and asks whether money would be better spent elsewhere to target health improvement in another way.

On an individual level if you do beat the statistics then screening is great but does come at the cost of harm to others. Screening isn't a neutral game in terms of health cost / benefit.

Unless this is understood then there are problems.

I’m not sure she’d agree it was her body shutting down anyway. Not that it was found by screening of course.

Treatment for a diagnosis is also often confused with treatment following screening which muddies the water.

Yeah I know people who got bowel cancer in their 30s who survived cancer-free after treatment. Don’t agree with the “body giving up thing”; especially as someone from a family with hereditary cancer (not bowel). It just means your cells have gone wonky. Someone with Crohn's or ulcerative colitis is at higher risk as our some other populations. It is also one of the few screenings that can also be a treatment or preventative at the same time (removal of concerning polyps). Mortality from bowel cancer is higher as you get older, but that is true for most cancers and diseases.

Personally I would never even consider getting a colonoscopy without sedation and it seems to be the default here in Canada; it also seems to increase “effectiveness” of screening but it seems costs and resources can be an issue in some places as to why it is not used:

From a 2009 survey of sedation practices in Canada:

www.ncbi.nlm.nih.gov/pmc/articles/PMC3115005/

*Most endoscopists reported using sedation for more than 90% of colonoscopies. The most common sedation regimen was a combination of midazolam and fentanyl. Propofol, either alone or with another drug, was used in 12% of cases. A higher proportion (94%) of adult gastroenterologists who routinely used propofol were highly satisfied compared with those using other sedative agents (45%; P

OP I agree this is really poor and sexist as well

in general I am wary of screening anyway but this particular thing seems to be completely built round men which is insane.

Are there any figures to show that women find the procedure more painful than men, though, other than what the nurse said in the OP? Or has the research not been done, or only been done on men? I think that pain thresholds vary considerably between people. Perhaps men may be less willing to admit to pain. (I'm a woman, and have had two full colonoscopies with no sedative or gas and air, and it was fine for me.)

"Are there any figures to show that women find the procedure more painful than men, though, other than what the nurse said in the OP?"

No. The nurse is wrong. The important variable is degree of inflammation.

Build a case of unfortunate levels of default to make, but not in this sort of erroneous stuff