Should Routine Screening for Coronary Artery Disease Be Recommended? A Comparison With Routine Screening for Colon Cancer

Both colon cancer and atherosclerotic heart disease meet the criteria for disease screening (ie, a prolonged incubation period, an identifiable predisease lesion, and a positive clinical response to treatment when the lesion is detected early). The American Cancer Society (ACS) estimates that 50,000 people in the United States die each year of colon cancer—a preventable disease. Prevention consists of periodic screening for precancerous polyps with either a colonoscopy or a high-sensitivity stool-based test. However, if any of the stool assays is positive, a colonoscopy is required. A colonoscopy costs approximately $3000, involves a thorough bowel prep, requires a day lost from work, and is poorly tolerated by patients. Current 2018 guidelines issued by the ACS recommend screening for colon cancer beginning as early as 45 years of age and repeating the procedure every 5-10 years depending on the assessment of cancer risk.¹

Coronary artery heart disease is also a preventable disease and kills 600,000 people a year in the United States. Prevention depends on reducing cardiac risk factors and identifying individuals with arterial atherosclerotic plaque with a coronary artery calcium scan.² If the scan is positive, indicating coronary artery atherosclerotic disease, aggressive medical therapy to reduce low-density lipoprotein (LDL) cholesterol will significantly reduce the incidence of atherosclerotic cardiovascular disease.³ A coronary artery calcium scan costs $150, takes 10 minutes, and requires no preparation except to avoid caffeine on the day of the test. Except for the short duration of the test, no time is lost from work. The American Heart Association (AHA) recommends using the coronary artery calcium scan only to refine the intermediate-risk category profile and not for diagnosing pre-heart attack coronary artery atherosclerotic plaques.⁴

A comparison shown in Table 1 of routine preventive colonoscopy and not-yet-recommended routine preventive calcium scanning raises the question: Why is there a difference in prevention recommendations when both diseases are diagnosable and preventable? The answers are complex and often confusing.

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-David S. Schade, MD^a, Sanjeev Arora, MD^b, R. Philip Eaton, MD^a