There are a couple of medical genetic gifts we all get that are inescapable. One of them for me is one copy of the gene for Factor V Leiden. The other is a family history of colon polyps.

I saw some blood in my stool a few years back and immediately arranged to have a colonoscopy performed. Nothing was found but it gave me significant peace of mind.

It is sometimes difficult to avoid the appearance of being self-serving in medicine.

It gave me some pause about a decade ago when the American College of Gastroenterology made colonoscopy the preferred screening method for colorectal cancer. It was catching the wave made when Katie Couric's husband died of colon cancer.

Why did it give me pause? Even to this day colonoscopy is only given a 1B in the recommendations. The "B" means there are not randomized clinical trials to back the practice. Ten years ago when the test could not have been given more than a "C."

There was and remains significant financial incentive for gastroenterologists to have colonoscopy be the preferred test for screening. That has been brought up as a reason why there has been resistance to adopting CT Colonography (Virtual Colonoscopy) as a screening test.

The truth is less sinister. The United State Preventive Services Task Force, now infamous for their statement on breast cancer, left CT Colonography off of their recommendations due to a lack of data. It is easy to understand since the data remains scattered and it is being compared to is colonoscopy, a test still with some questions.

Colonoscopy is the right preferred recommendation. Observational studies, computer models, and trends in death rates from colorectal cancer since the change was made all back the change. There is also a trend towards statistical significance in important factors in the trials that have been done, especially the National Polyp Study.

The recent literature trend has been to evaluate colonoscopy and how it is performed. This became an issue when multiple prevention studies suggested the rate of cancer diagnosis within 3 years of a colonoscopy was 2 to 3 times that seen in the National Polyp Study.

Three of the articles reviewed at the Anchorage Gastroenterology Journal Club this week addressed quality of endoscopy. It is becoming clearer that training in how to do the procedure correctly is extremely important. Two of the studies (Am J Gastroenterol 2010; 105:663–673; doi:10.1038/ajg.2009.650 and here) reviewed showed patients who had their colonoscopy performed by a gastroenterologist were statistically far less likely to have cancer diagnosed in the next 3 years than if the procedure were performed by a surgeon or primary care physician.

The third study showed that it may take as many as 400-500 colonoscopies to train a physician to do the procedure correctly. There are significant issues with the study but it backs other data that suggests threshholds for training may be too low.

One thing that is being lost in the discussion is other tests. This is an especially important point when talking about large rural areas that may not have access to quality colonoscopy. An attitude that only colonoscopy can be considered can lead to patients not receiving any screening.

Review of published guidelines show fecal occult blood testing and flexible sigmoidoscopy can still play a role. Emerging tests such as fecal DNA testing and CT Colonography should also be considered.

March is colorectal cancer awareness month. It was my intention to not talk about the issue due to the potential conflict of interest.

Alaska needs to think about colorectal cancer. The Alaska Native population has one of the highest rates in the country but it often gets lost in national data because it gets lumped in with Native American populations in the lower 48 which have lower than average rates. It is a constant topic of discussion at Alaska Colorectal Cancer Partnership Meetings. It is a challenge to screen a population scattered across a large area.

My heart drops every time I turn a corner in a colon and see a cancer. It has happened to me nine times since the start of the year. It is the worst run of colon cancer diagnosis in my 13 year gastroenterology career. The latest was this morning and led to this column being written.

Every year I see patients who shun the idea of colonoscopy. The excuses can be everything from, "I feel fine," to "I Have never been sick," to "You do what?" The problem with colon cancer is that if you wait for symptoms it may be too late.

The best screening test is the one that gets done. The resources exist in Alaska to get everybody screened. The challenge is to get as close to 100% appropriate screening as possible.

I was the worst colonoscopy patient ever. I kept saying "left" and "right" and tried to give myself abdominal pressure. I survived and now I can tell everyone you will too and potentially a lot longer if you do it.