|Julia Draznin Maltzman, MD|
|The Abramson Cancer Center of the University of Pennsylvania|
What is the Couric Effect?
This term was coined by researcher at the University of Michigan and Iowa after noting the remarkable impact NBC morning show's, TODAY, co-host Katie Couric had on the number of people undergoing a colonoscopy to screen for colon cancer.
What did Katie Couric do and why did she do it?
Ms. Couric became a strong advocate for colorectal cancer screening after the death of her husband, 42-year old lawyer Jay Monahan, to this disease in 1998. Subsequently she founded the National Colorectal Cancer Research Alliance and the Jay Monahan Center for Gastrointestinal Health in New York.
To raise public awareness and promote screening for colon cancer, Ms. Couric underwent a screening colonoscopy in March 2000. The entire procedure was highlighted on the Today show; including the preparation, the scope itself, and the follow up she received after the procedure. At the time, Ms. Couric was only 43 years old and had none of the risk factors that would make her a candidate for the screening procedure. Her willingness to pursue this invasive and personal test in a very public forum with a step-by-step explanation, galvanized thousands of Americans to get screened for colorectal cancer.
An increase in colonoscopies
A national study completed by researchers at the University of Michigan and Iowa noted that Katie Couric's efforts lead to a 20% increase in colonoscopies preformed nationwide in the months following the airing of this show. The higher rate of colonoscopies last even to this day and the proportion of the colonoscopies preformed on people under the age of 50 increased.
In an article published in the Archives of Internal Medicine, researchers did a population based observational study. They used two different data sources: the Clinical Outcomes Research Initiative (CORI) database – a voluntary consortium of 400 gastroenterologists who preformed 95,000 colonoscopies from July 1998 to December 2000, and a managed care organization that caters to 44,000 adult members. Using sophisticated statistical manipulations they compared the frequency of colonoscopies preformed before and after Ms. Couric's broadcast. The results showed that the number of colonoscopies preformed per CORI physician after the broadcast increased from 15 to 18.1 per month. This was a statistically significant change. Furthermore, this trend was sustained for nine months. A subset analysis also demonstrated a trend toward an increase in the number of colonoscopies preformed on women – 43.4% before the airing of the Today show, and 47.4% after. These trends are consistent with the demographics of the Today show viewers who are 60% female with a median age of 47.5 years. There was a commensurate increase in colonoscopies seen in the managed care organization after the television broadcast from 1.3 people out of every 1000 members per month to 1.8 people. This was also found to be statistically significant.
The authors concluded that Katie Couric's public exposé of the colonoscopy successfully raised public awareness and was associated with an increase in its demand in two different data sets. They further go on to say, that a celebrity spokesperson, even one without the disease he or she is promoting, can have a substantial impact on the public's health practices, habits and beliefs. It is important to note that what the study could not distinguish, is whether the people who decided to get colonoscopies after watching the Today show were those with high risk for the disease or not.
March is National Colorectal Cancer Awareness Month
The US Senate declared March 2000 as the first National Colorectal Cancer Awareness Month. Colorectal cancer is the second leading cause of death from Cancer in the US. It is estimated that it will be responsible for over 57,000 deaths this year but only 53% of Americans over the age of 50 will be screened. When it is diagnosed early, colon cancer is a curable disease. The goal of screening is to find lesions called polyps that are thought to be precancerous lesions. Polyps can be removed during the colonoscopy procedure itself requiring no additional procedures. If a precancerous lesion is identified and removed, and the cancer never has the chance to develop, then many lives would be saved.
There are other modalities of screening for colon cancer, but few patients choose them. Fecal occult blood testing (FOBT) is a test for blood in the stool. Critics site that this test looks for cancer and not pre-cancerous lesions. By the time the patient is bleeding, he or she is likely to already have a malignancy. Although the test is painless, the sensitivity and specificity of this test is quite low diminishing its utility as a screening tool. A flexible sigmoidoscopy has the disadvantage of only examining part of the colon. There was an influential and disparaging editorial in the New England Journal of Medicine published in 2000 that made this option less attractive to most patients and referring physicians. A double contrast barium enema is an unpleasant, time-consuming test whose sensitivity by most studies does not exceed 50%. Colonoscopy has become the most demanded test for colorectal screening. Most attribute this to both Katie Couric's televised procedure in 2000 and medicare's decision in 2001 to pay for them (once every two years for high risk patients and once every ten years for low risk individuals). A newer method is called virtual colonoscopy, although promising, is not yet universally available.
What are the numbers?
Medicare data show the increase in colonoscopies after the airing of Ms. Couric's experience. The number of colonoscopies among Medicare recipients increased by 42% from 2000 to 2002, the most recent year for which full data is available. In the year 2000, Medicare reportedly paid for 2,211,925 colonoscopies. By 2002 that number increased to 3,150,738. At the same time, the number of sigmoidoscopies preformed decreased by 57% – from 543,502 in the year 2000 to 236,139 in the year 2002. Similarly, in the year 2000, Medicare paid for 1,759,880 fecal occult blood tests and 208 barium enemas; but by 2002 those figures dropped to 1,609,391 and 139 respectively.
Who is at high risk for the disease?
Patients are considered to be at high risk for colon cancer if they have a prior experience of colon cancer or a precursor lesion such as a polyp, a history of chronic inflammatory bowel diseases such as Crohn's or ulcerative colitis, a strong family history of the disease, or the presence of certain gene markers.
Tips to avoid colon cancer from the National Colorectal Cancer Research Alliance
The NCCRA posted general guidelines to avoid getting colon cancer. These are good tips and apply for all cancers. 1) Exercise daily – even a small amount, 2) avoid smoking, 3) keep your weight in check, 4) limit your alcohol intake, and 5) talk to your physician about nutrition, screening tests, family history, and any other factors that may increase your chances of getting cancer.