Viewpoints of the target population regarding barriers and facilitators of colorectal cancer screening in the Czech Republic

BACKGROUND Public awareness of colorectal cancer(CRC) and uptake of CRC screening remain challenges. The viewpoints of the target population(asymptomatic individuals older than 50) regarding CRC screening information sources and the reasons for and against participation in CRC screening are not well known in the Czech Republic. This study aimed to acquire independent opinions from the target population independently on the health system.AIM To investigate the viewpoints of the target population regarding the source of information for and barriers and facilitators of CRC screening.METHODS A survey among relatives(aged 50 and older) of university students was conducted. Participants answered a questionnaire about sources of awareness regarding CRC screening, reasons for and against participation, and suggestions for improvements in CRC screening. The effect of certain variables on participation in CRC screening was analyzed.RESULTS Of 498 participants, 478(96%) respondents had some information about CRC screening and 375(75.3%) had participated in a CRC screening test. General practitioners(GPs)(n = 319, 64.1%) and traditional media(n = 166, 33.3%) were the most common information sources regarding CRC screening. A lack of interest or time and a fear of colonoscopy or positive results were reported as reasons for non-participation. Individuals aged > 60 years [adjusted odds ratio(aOR) = 2.30, 95% confidence interval(CI)(1.42-3.71), P = 0.001], females(aOR =1.95, 95%CI(1.26-3.01) P = 0.003), and relatives of CRC patients(aOR = 4.17,95%CI(1.82-9.58) P = 0.001) were more likely to participate in screening.Information regarding screening provided by physicians-GPs:(aOR = 8.11,95%CI(4.90-13.41), P < 0.001) and other specialists(aOR = 4.19, 95%CI(1.87-9.38),P = 0.001) increased participation in screening. Respondents suggested that providing better explanations regarding screening procedures and equipment for stool capturing could improve CRC screening uptake.CONCLUSION GPs and other specialists play crucial roles in the successful uptake of CRC screening. Reduction of the fear of colonoscopy and simple equipment for stool sampling might assist in improving the uptake of CRC screening.     

医院就诊人群与普查人群中大肠癌患者临床资料的比较

背景:在我国有无必要开展大肠癌普查仍存在一定争议。目的:比较、分析医院就诊人群与普查人群中大肠癌患者临床资料的异同,探讨普查在大肠癌早期诊断中的作用。方法:就诊组:由协作组各成员医院按统一设计的调查表,前瞻性地登记2002年4月1日～2003年3月31日到医院就诊,并接受结肠镜检查的大肠癌患者的全部临床资料。普查组:采用“序贯粪便隐血筛检技术”,于2001年3～6月对北京地区约2万名35岁以上的自然人群进行大肠癌普查。两组大肠癌患者的诊断均经术后病理检查证实。结果:就诊组和普查组患者中,≥50岁者分别占81.9%和83.3%。就诊组DukesA、B期患者占41.1%,普查组占91.7%(P<0.001)。普查人群中存在大肠癌高危因素者的大肠癌检出率为0.28%,无高危因素者的检出率为0.05%(P<0.001)。就诊组中,内镜表现为隆起型病变者44.7%是DukesA、B期患者,溃疡型病变者仅10.0%是DukesA、B期患者(P<0.001);DukesA、B期患者的粪便隐血试验阳性率为78.5%,C、D期患者为81.9%(P>0.05),提示粪便隐血试验阳性率与大肠癌分期无关;DukesC、D期患者的血清CEA阳性率显著高于A、B期患者(P=0.019);高、中分化癌中DukesA、B期患者占51.8%,低分化癌中DukesA、B期患者仅占26.5%(P<0.001)。结论:近年北京地区的大肠癌发病率较以前明显上升     

Screening colonoscopy use among individuals at higher colorectal cancer risk

GOALS: To describe screening colonoscopy use in those with a family history of colorectal cancer (CRC). BACKGROUND: Colonoscopy is an effective means of screening for CRC and is preferred for individuals at higher risk. We therefore derived population-based estimates of colonoscopy use and analyzed how individual characteristics and family history correlate with colonoscopy. STUDY: Individuals between the ages of 41 and 75 years who responded to the Cancer Control Module of the 2000 National Health Interview Study were analyzed. Screening colonoscopy was defined as having a colonoscopy for screening purposes within the last 10 years. Screening colonoscopy was the dependent variable and family history was the independent variable in a logistic regression model that included self-described sociodemographic characteristics. RESULTS: Of the 13,160 individuals in the analysis, 6.8% had a family history of CRC, corresponding to approximately 5.5 million individuals in the United States. Those with a family history were significantly more likely to report screening colonoscopy (27.8%) than those without a family history (7.7%; P<0.001). In those with a family history, screening colonoscopy significantly correlated with tobacco use, education, and age. There was no trend for increased screening colonoscopy with having multiple family members or a young family member with CRC. CONCLUSIONS: Over 5.5 million people in the US have a family history of CRC, and only 1 in 4 report having had a screening colonoscopy by the year 2000. Improving knowledge about CRC and addressing other barriers to screening in this group will be important components of improving screening colonoscopy utilization.     

Barriers to colorectal cancer screening： A case-control study

AIM： To investigate barriers to colorectal cancer （CRC） screening in a community population. METHODS： We conducted a community-based case-control study in an urban Chinese population by questionnaire. Cases were selected from those completing both a fecal occult blood test （FOBT） case and colonoscopy in a CRC screening program in 2004. Control groups were matched by gender, age group and community. Control 1 included those having a positive FOBT but refusing a colonoscopy. Control 2 included those who refused both an FOBT and colonoscopy. RESULTS： The impact of occupation on willingness to attend a colorectal screening program differed by gender. P for heterogeneity was 0.009 for case vs control group 1, 0.01 for case versus control group 2, and 0.80 for control group 1 vs 2. Poor awareness of CRC and its screening program, characteristics of screening tests, and lack of time affected thescreening rate. Financial support, fear of pain and bowel preparation were barriers to a colonoscopy as a screening test. Eighty-two percent of control group 1 and 87.1% of control group 2 were willing attend if the colonoscopy was free, but only 56.3% and 53.1%, respectively, if it was self-paid. Multivariate odds ratios for case vs control group 1 were 0.10 among those unwilling to attend a free colonoscopy and 0.50 among those unwilling to attend a self-paid colonoscopy. CONCLUSION： Raising the public awareness of CRC and its screening, integrating CRC screening into the health care system, and using a painless colonoscopy would increase its screening rate.     

Would general practitioners support a population-based colorectal cancer screening programme of faecal-occult blood testing?

BACKGROUND: The success of a population-based screening for colorectal cancer (CRC) is determined to a large extent by general practitioner (GP) attitudes, beliefs and support. The extent to which GPs support population-based CRC screening remains unclear. AIMS: To assess the knowledge, attitudes and practices of GPs in relation to CRC screening, and to identify the determinants of GP support for population-based faecal-occult blood testing (FOBT). METHODS: A cross-sectional postal survey was conducted with a random sample of 692 GPs in Queensland, -Australia. We assessed GP knowledge, attitudes and practices concerning CRC screening in relation to their stance on population-based FOBT screening. RESULTS: Although the response rate was low (41%), participants were representative of Queensland GPs in general. Of 284 participating GPs, 143 (50.5%) indicated that they would support a population-based FOBT screening programme, 42 (14.8%) would not and 98 (34.6%) were unsure. Belief in FOBT test efficacy (P <0.001), possession of CRC guidelines (P <0.05) and belief in earlier stage detection (P <0.05) were major determinants of support for population-based FOBT screening. No significant association was observed for doctor's sex, location of practice, age, year completed medical training, membership of a Division of General Practice, number of weekly consultations, number of patients investigated for CRC per month, size of practice, own family history of CRC, interest in further information on CRC screening or treatment, and current use of FOBT with asymptomatic patients aged > or =40 years. CONCLUSIONS: GP support for FOBT population-based screening appears to have increased over recent years. The knowledge and attitudes/beliefs of GPs are key determinants of their support.     

Awareness and attitudes of Greek medical students on colorectal cancer screening

AIM: To prospectively assess the knowledge and attitudes of medical students (MS), as tomorrow’s physicians, about colorectal cancer (CRC) and its screening modalities.METHODS: Three hundred fourth year MS of the University of Athens were enrolled in this survey. Their selection was random, based on student identification card number. All participants completed an anonymous written questionnaire over a 4 month period. The questionnaire was divided into 4 sections and included queries about CRC-related symptoms, screening with colonoscopy and MS awareness and attitudes in this field. Following collection and analysis of the data, the results are presented as percentages of answers for each separate question. RESULTS: Two hundred and sixty-five students an-swered the questionnaire over a 4 mo period. Interestingly, only 69% of the study population considered CRC to be a high-risk condition for public health. However, the vast majority of participants identified CRC-related symptoms and acknowledged its screening to be of great value in reducing CRC incidence and mortality. A very small proportion (38%) had received information material regarding CRC screening (either during their medical training or as a part of information provided to the general public) and only 60% of the participants declared willingness to receive further information. Regarding colonoscopy, 85% would prefer an alternative to colonoscopy methods for CRC screening. Moreover, 53% considered it to be a painful method and 68% would appreciate more information about the examination.CONCLUSION: MS in Greece need to be better informed about CRC screening and screening colonoscopy.     

Family history and colorectal cancer screening: a survey of physician knowledge and practice patterns

OBJECTIVES: Risk stratification is essential to effective implementation of colorectal cancer (CRC) screening strategies. The objectives of this study were to assess and compare the current knowledge and practice patterns of gastroenterologists and primary care physicians regarding familial risk of CRC. METHODS: We conducted a survey of regional gastroenterologists and a sample of university- and community-based primary care physicians. The survey instrument assessed physician knowledge of screening recommendations and current practices for individuals with family histories of CRC, adenomatous polyps (APs), familial adenomatous polyposis (FAP), and hereditary nonpolyposis cancer (HNPCC). The instrument also elicited data about familial risk assessment, documentation, and notification of at-risk family members. RESULTS: Thirty-five gastroenterologists (65%) and 58 primary care physicians (92%) completed the survey. Most gastroenterologists and primary care physicians (85% vs 72%) chose age 40 as the appropriate age to begin screening for a family history of CRC, but relatively few (37% vs 36%) recommended screening at age 40 for a family history of APs. Gastroenterologists were significantly more likely to recommend screening for FAP at puberty (80% vs 27%, p < 0.001) and for HNPCC at age 25 (73% vs 50%, p = 0.04). Colonoscopy was the preferred screening strategy by both groups for family histories of CRC (97%), HNPCC (97%), and APs (77%); primary care physicians also preferred colonoscopy for family histories of CRC (72%) and HNPCC (76%) but flexible sigmoidoscopy plus fecal occult blood testing for a family history of APs (38%). Gastroenterologists were more likely to recommend genetic testing for persons at risk of FAP (91% vs 71%, p = 0.03) and HNPCC (72% vs 57%, p = 0.18), routinely inquire about a family history of CRC or APs (93% vs 63%, p < 0.001), and recommend notification of at-risk first-degree relatives with family histories of CRC (94% vs 55%, p < 0.001) or AP (53% v.s 6%, p < 0.001). CONCLUSION: Although gastroenterologists are more likely than primary care physicians to elicit a family history of colorectal neoplasia and implement appropriate screening strategies, overall compliance with recommended guidelines and notification of at-risk relatives are suboptimal. Novel approaches for improving awareness of the available screening guidelines are needed.     

Feasible economic strategies to improve screening compliance for colorectal cancer in Korea

ABM: While colorectal cancer (CRC) is an ideal target for population screening, physician and patient attitudes contribute to low levels of screening uptake. This study was carried out to find feasible economic strategies to improve the CRC screening compliance in Korea. METHODS: The natural history of a simulated cohort of 50-year-old Korean in the general population was modeled with CRC screening until the age of 80 years. Cases of positive results were worked up with colonoscopy. After polypectomy, colonoscopy was repeated every 3 years. Baseline screening compliance without insurance coverage by the national health insurance (NHI) was assumed to be 30%. If NHI covered the CRC screening or the reimbursement of screening to physicians increased, the compliance was assumed to increase. We evaluated 16 different CRC screening strategies based on Markov model. RESULTS: When the NHI did not cover the screening and compliance was 30%, non-dominated strategies were colonoscopy every 5 years (COL5) and colonoscopy every 3 years (COL3). In all scenarios of various compliance rates with raised coverage of the NHI and increased reimbursement of colonoscopy, COL10, COL5 and COL3 were non-dominated strategies, and COL10 had lower or minimal incremental medical cost and financial burden on the NHI than the strategy of no screening. These results were stable with sensitivity analyses. CONCLUSION: Economic strategies for promoting screening compliance can be accompanied by expanding insurance coverage by the NHI and by increasing reimbursement for CRC screening to providers. COL10 was a cost-effective and cost saving screening strategy for CRC in Korea.     

Palliation by laser photoablation: a multidisciplinary quality assessment.

To evaluate the quality of life and degree of palliation by laser photoablation for gastrointestinal cancer, a questionnaire was sent to general practitioners (GPs) and referring specialists. The response was 85%. General practitioners considered palliation by laser to be effective in 74% compared with 50% for referring specialists (p less than 0.001). Specialists felt themselves unable to answer in 17% compared with no GPs (p less than 0.001). The differences in assessment between specialists and GPs were most pronounced in colorectal cancers. There was a striking consensus of opinion about the rate of failed palliation among endoscopist, referring specialist, and GP. On the other hand, the rating of success by specialists and GPs was significantly lower than the endoscopist's evaluation. The endoscopist and GP were more at variance than the endoscopist and specialist. Above all, the GPs seemed to outweigh the burden against the benefits of treatment. Disagreement of the specialists and the GPs with the endoscopist about the outcome appeared to be related to unrealistic expectations, to a shift in presenting symptoms or to complications, misinterpreted as being laser-induced but mainly due to progression of disease.     

Colon cancer prevention in Italy: Cost-effectiveness analysis with CT colonography and endoscopy

BACKGROUND: Colorectal cancer (CRC) is a major cause of mortality in Italy. Although prevention of CRC is possible, its cost-effectiveness when applied to the Italian population is unknown. Recently, computerized tomographic colonography (CTC) has been proposed for CRC screening. AIM: To compare the efficacy and cost-effectiveness of CTC screening in a simulated Italian population with those of colonoscopy and flexible sigmoidoscopy (FS). METHODS: The cost-effectiveness of different screening strategies was compared using a Markov process computer model, in which in a hypothetical population of 100,000 50 year-olds were investigated by CTC, colonoscopy or FS every decade. Outcomes were projected to the Italian national level. RESULTS: CRC incidence reduction was calculated at 40.9%, 38.2%, and 31.8% with colonoscopy, CTC and FS, respectively. As compared to no screening, all screening programs were shown to be cost-saving, allowing a saving of 11 Euro, 17 Euro, and 48 Euro per person with colonoscopy, FS and CTC, respectively. FS appeared to be less cost-effective than CTC, whilst colonoscopy appeared to be an expensive option as compared to CTC. Undiscounted national expenditure was calculated to be 1,042,489,512 Euro, 1,093,268,285 Euro, and 1,198,783,428 Euro for FS, CTC and colonoscopy, respectively, as compared to 695,818,078 Euro without screening. CONCLUSION: CRC screening is cost-saving in Italy, irrespective of the technique applied. CTC appeared to be more cost-effective than FS, and it may also become a valid alternative to colonoscopy.     

Colorectal cancer screening in HIV-infected patients 50 years of age and older: missed opportunities for prevention

OBJECTIVES: Although human immunodeficiency virus (HIV)-infected patients are now living longer, there are no published data on colorectal cancer (CRC) screening in this population. We hypothesized that HIV-infected patients were less likely to be screened for CRC compared to patients without HIV. METHODS: Consecutive HIV-infected patients > or =50 yr old seen in our outpatient clinic from 1/1/01 to 6/30/02 were identified. For each HIV-infected patient, we selected one age- and gender-matched control subject without HIV infection who was seen during the same time period. The electronic medical records were reviewed to determine the proportion of patients that had a fecal occult blood test (FOBT), flexible sigmoidoscopy, air-contrast barium enema (ACBE), or colonoscopy. RESULTS: During the 18-month study period, 538 HIV-infected outpatients were seen and 302 (56.1%) were > or =50 yr old. Despite significantly more visits with their primary care provider, HIV-infected patients were less likely to have ever had at least one CRC screening test (55.6%vs 77.8%, p < 0.001). The proportion of HIV-infected patients who ever had a FOBT (43.0%vs 66.6%, p < 0.001), flexible sigmoidoscopy (5.3%vs 17.5%, p < 0.001), ACBE (2.6%vs 7.9%, p= 0.004), or colonoscopy (17.2%vs 27.5%, p= 0.002) was significantly lower than in control subjects. In addition, HIV-infected patients were significantly less likely to be up-to-date with at least one CRC screening test according to current guidelines (49.3%vs 65.6%, p < 0.001). CONCLUSIONS: A substantial number of HIV-infected patients are > or =50 yr of age and CRC screening is underutilized in this population. Public health strategies to improve CRC screening in HIV-infected patients are needed.     

Projected national impact of colorectal cancer screening on clinical and economic outcomes and health services demand

BACKGROUND & AIMS: Colorectal cancer (CRC) screening is effective and cost-effective, but the potential national impact of widespread screening is uncertain. It is controversial whether screening colonoscopy can be offered widely and how emerging tests may impact health services demand. Our aim was to produce integrated, comprehensive estimates of the impact of widespread screening on national clinical and economic outcomes and health services demand. METHODS: We used a Markov model and census data to estimate the national consequences of screening 75% of the US population with conventional and emerging strategies. RESULTS: Screening decreased CRC incidence by 17%-54% to as few as 66,000 cases per year and CRC mortality by 28%-60% to as few as 23,000 deaths per year. With no screening, total annual national CRC-related expenditures were 8.4 US billion dollars. With screening, expenditures for CRC care decreased by 1.5-4.4 US billion dollars but total expenditures increased to 9.2-15.4 US billion dollars. Screening colonoscopy every 10 years required 8.1 million colonoscopies per year including surveillance, with other strategies requiring 17%-58% as many colonoscopies. With improved screening uptake, total colonoscopy demand increased in general, even assuming substantial use of virtual colonoscopy. CONCLUSIONS: Despite savings in CRC care, widespread screening is unlikely to be cost saving and may increase national expenditures by 0.8-2.8 US billion dollars per year with conventional tests. The current national endoscopic capacity, as recently estimated, may be adequate to support widespread use of screening colonoscopy in the steady state. The impact of emerging tests on colonoscopy demand will depend on the extent to which they replace screening colonoscopy or increase screening uptake in the population.     

Participation in colorectal cancer screening with FOBT and colonoscopy: An Italian,multicentre, randomized population study

BackgroundData on the adherence rate to screening colonoscopy (OC) in the average-risk general population are limited and variable. Aim of this study was to compare the uptake of OC screening with that of fecal occult blood (FOBT).MethodsA nationwide, population-based, multicentre, randomized trial comparing attendance to OC with that to FOBT was performed. Sixty-four general practitioners (GPs), overall including in their lists 9889 average-risk subjects aged 55–64 years, were randomized between OC and FOBT screening programs. Eligible subjects were mailed a personal invitation letter co-signed by their GP and the coordinator of the area-reference GI centre. Attendance rate and detection rate for advanced neoplasia (colorectal cancer, adenoma >10 mm or with villous histology or high-grade dysplasia) for each arm of the study were assessed.ResultsThe overall attendance rate was 18.7% (1563/8378 eligible subjects). It was markedly lower in the OC than in the FOBT strategy (10% vs. 27.1%; OR 0.28, 95% CI: 0.25–0.32; P < 0.0001). In particular, participation in OC screening arm was extremely low in South Italy (2.8%), whilst it was higher in North-Central Italy (12.4%; P < 0.0001). Compliance to colonoscopy in those with a positive FOBT was only 58%. Advanced neoplasia was detected in 28 (6.8%) patients in the OC arm and in 6 (18%) in those with a positive FOBT submitted to OC.ConclusionsThe results of our study underline the difficulties and barriers to implement a OC population screening in Italy, at least through primary care. Although attendance to FOBT was higher, it was disappointingly less than 30%. Significant actions to improve awareness amongst GPs and the population are a high priority.     

Screening Colonoscopy for Colorectal Cancer in Asymptomatic People: A Meta-Analysis

Objective The preferred method for screening asymptomatic people for colorectal cancer (CRC) is colonoscopy, according to the new American guidelines. The aim of our study was to perform a meta-analysis of the prospective cohorts using total colonoscopy for screening this population for CRC. We looked for the diagnostic yield of the procedure as well as for its safety in a screening setting. Methods We included papers with more than 500 participants and only those reporting diagnostic yield of adenoma (and/or advanced adenoma) and CRC. Nested analysis were performed for secondary endpoints of complications and CRC stages when this information was available. All analyses were performed with StatDirect Statistical software, version 2.6.1 (). Results Our search yielded ten studies of screening colonoscopy conducted in asymptomatic people that met our inclusion criteria, with a total of 68,324 participants. Colonoscopy was complete and reached the cecum in 97% of the procedures. Colorectal cancer was found in 0.78% of the participants (95% confidence interval 0.13–2.97%). Stage I or II were found in 77% of the patients with CRC. Advanced adenoma was found in 5% of the cases (95% confidence interval 4–6%). Complications were rare and described in five cohorts. Perforation developed in 0.01% of the cases (95% confidence interval 0.006–0.02%) and bleeding in 0.05% (95% confidence interval 0.02–0.09%). Conclusions Our findings support the notion that colonoscopy is feasible and a suitable method for screening for CRC in asymptomatic people.     

Yearly diagnostic yield of colonoscopy in patients age 80 years or older,with a special interest in colorectal cancer

Aim: A high diagnostic yield of colonoscopy has been reported in elderly patients, but there is no data on the yearly yield. Our aim was to detect the yearly yield of colonoscopy in elderly patients. Methods: All consecutive endoscopies in the years 1992–2009 were included. Important endoscopic diagnoses were defined as colorectal cancer (CRC), polyps, diverticuli and inflammation. Results: In total, 19 569 endoscopies were performed, of which 1706 (8.7%) were in patients age 80 years or older. The number of women was significantly higher (P < 0.001). The percentage of patients who were 80 years or older was higher than in the general population and remained stable during the study period, though there has been a proportional increase of elderly people in the general population. Inconclusive procedures were present in 106 (6.2%) elderly patients compared with 277 (1.6%) patients under 80 years of age (P < 0.001). There were no significant changes in the consecutive years. A procedure revealing no endoscopic diagnosis was observed less often in patients who were 80 years or older (P < 0.001). CRC was diagnosed in 221 (19.6%) older patients. This figure remained more or less constant each year. Polyps were seen in 448 (8.8%) patients 80 years of age or older. The percentage of patients with diverticuli and inflammation was constant. The number of patients 80 years or older with CRC and polyps rose at a lower rate than the number of older people in the general population. Conclusion: The yield of colonoscopy in patients 80 years or older was high and constant over the years. The number of tumors rose less than expected compared to the increase of elderly in the general population. Geriatr Gerontol Int 2012; 12: 298–303.     

Screening for Colorectal Cancer in Personnel of an Academic Medical Center

The colorectal cancer (CRC) screening program in Israel offers the average-risk population fecal occult blood tests from the age of 50 years. Compliance, however, is very low, reaching only 6% of eligible persons in 2005. Our aim in this study was to describe the results of an improved CRC screening program directed at the in-house staff of Beilinson Hospital. All employees of Beilinson Hospital over age 50 years were sent a letter explaining the new CRC screening program and an accompanying questionnaire. Responders who reported a family history of CRC or related cancers or symptoms were offered colonoscopy; the remainder were offered sigmoidoscopy or, if they preferred, colonoscopy. Two hundred twenty of the 888 candidates (24.7%) completed the questionnaire, of whom 144 (16.2%) agreed to further investigation. These included 90 of 105 patients with a positive questionnaire and 20 of 115 with a negative questionnaire who underwent colonoscopy and 34 of 115 with a negative questionnaire who underwent sigmoidoscopy. The colonoscopy group included 26 of the 30 patients (86.6%) with a positive family history. Early-stage CRC was diagnosed in three patients (1.36%), all with a positive questionnaire. There were no pathologic findings on sigmoidoscopy. The sensitivity, specificity, and positive and negative predictive values of the questionnaire for identifying subjects with CRC or advanced adenoma were 100.00%, 18.86%, 2.27%, and 100.00%, respectively. In conclusion, using hospital facilities, we initiated a unique CRC screening program for employees. Our method may be applicable in other medical centers for the detection of adenomas and CRCs in the early, curative stages.     

Case-control study of screening colonoscopy in relatives of patients with colorectal cancer

OBJECTIVES: The efficacy of colonoscopic screening and polypectomy for the prevention of colorectal cancer (CRC) is well accepted but has never been documented in a prospective, controlled study. Screening by sigmoidoscopy has been found to reduce mortality from cancer of the rectum and distal colon. Case-control studies provide an alternative method for determining the efficacy of screening methods. METHODS: Between 1998 and 2000, a total of 40 subjects were found to have CRC (study group) and 160 had a normal colon (control group) among asymptomatic individuals participating in a screening colonoscopy program for a high-risk population of first-degree relatives of CRC patients. We compared these groups for screening by fecal occult blood testing, flexible sigmoidoscopy, barium enema, and colonoscopy in the 10-yr period before the index colonoscopy. RESULTS: Screening colonoscopy was performed in only 2.5% of the case subjects and 48.7% of controls (p < 0.0001), and all screening procedures in 12.5% and 73.7%, respectively (p < 0.0001). A statistically significant difference was also found for screening with fecal occult blood test, but not for flexible sigmoidoscopy or barium enema. Significant adenomatous polyps >1 cm in diameter were detected and removed in 19% of the control group within 10 yr of the index colonoscopy. Six (15%) of the patients in the study group died of CRC. CONCLUSIONS: Screening by colonoscopy can prevent progression to CRC from adenomatous polyps and may reduce the mortality associated with this devastating disease.     

Reduction in colorectal cancer mortality by fecal occult blood screening in a French controlled study

BACKGROUND & AIMS: Several randomized population-based studies have shown that screening for colorectal cancer (CRC) by fecal occult blood tests (FOBTs) can reduce CRC mortality. The aim of this French population-based study was to assess whether a similar benefit could be obtained in countries characterized by high performances in the diagnosis and management of CRC. METHODS: Small-sized geographic areas, including 91,199 individuals aged 45-74 years, were allocated to either FOBT screening or no screening. Six screening rounds were performed. The FOBT was performed without diet restriction and was sent to a central analysis center and processed without rehydration. Screening group participants who had a positive test result were offered a full colonoscopy. The entire population was followed up for 11 years after study entry. RESULTS: Acceptability of the test was 52.8% at the first screening round and varied between 53.8% and 58.3% in the successive rounds. Positivity rates were 2.1% initially and 1.4% on average in the successive rounds. CRC mortality was significantly lower in the screening population compared with the control population (mortality ratio, 0.84; 95% confidence interval, 0.71-0.99). The reduction in CRC mortality was more pronounced in those who participated at least once (mortality ratio, 0.67; 95% confidence interval, 0.56-0.81). CONCLUSIONS: Our findings, together with the results of other trials, suggest that biennial screening by FOBTs can reduce CRC mortality regardless of the quality of the health system and support attempts to introduce large-scale screening programs into the general population.