Survey of internal medicine residents' use of the fecal occult blood test and their understanding of colorectal cancer screening and surveillance

OBJECTIVE: Primary care physicians have imperfect understanding of current colorectal cancer screening guidelines and recommendations. Furthermore, compliance with colorectal cancer screening by internal medicine residents has been demonstrated to be poor. We sought to identify whether current trainees in internal medicine had adequate understanding of colorectal cancer screening and surveillance and test utilization. METHODS: We applied a structured questionnaire about colorectal cancer screening and the use of fecal occult blood tests to 168 internal medicine residents at four accredited programs in the U.S. They were also asked for recommendations about six hypothetical patients who may have been candidates for screening or surveillance. RESULTS: Seventy-one percent identified 50 yr as the currently recommended age to commence screening in an average-risk individual; 64.3% would begin screening with fecal occult blood testing and flexible sigmoidoscopy and 4.8% with colonoscopy. Most perform fecal occult blood testing on stool obtained at digital rectal exam and without prior dietary restrictions. Many use fecal occult blood testing for indications other than colorectal cancer screening. Only 29% recommended colonoscopy to evaluate a positive fecal occult blood test. Most residents plan to be screened for colorectal neoplasia at the appropriate age; significantly more opted for colonoscopy than recommended it for their patients. CONCLUSIONS: Internal medicine residents have many misperceptions regarding colorectal cancer screening and the utility of the fecal occult blood test. Educational efforts should be directed at internal medicine residents, many of whom plan careers in primary care, where most colorectal cancer screening is currently performed.     

Survey of the opinions, knowledge, and practices of gastroenterologists regarding colorectal cancer screening and use of the fecal occult blood test

OBJECTIVES: Primary care physicians and internal medicine residents have poor understanding of colorectal cancer screening and the use of fecal occult blood tests. If acceptance and implementation of colorectal cancer screening is to improve, gastroenterologists may have to take a more leading role in the education of their primary care colleagues, physicians in training, and the general public. However, before this can be recommended, it is necessary to determine how closely gastroenterologists follow currently recommended guidelines and how they use fecal occult blood tests. METHODS: We mailed a two-page, structured questionnaire about colorectal cancer screening and use of fecal occult blood tests to 8000 randomly selected gastroenterologists in the United States. RESULTS: We received responses from 24% of the gastroenterologists. Almost all used fecal occult blood tests in the office setting, 86% on stool obtained at rectal examination. The test was frequently used for reasons other than colorectal cancer screening, and often without adequate patient instruction on dietary and medication restrictions. Of the respondents, 98% commenced screening at age < or = 50 yr, whereas 37% either continued screening into advanced age or never stopped. Annual fecal occult blood testing with flexible sigmoidoscopy every 5 yr was the screening strategy recommended by 71% of the respondents, whereas 25% recommended colonoscopy every 10 yr. However, 77% of the gastroenterologists chose colonoscopy for personal colorectal cancer screening. CONCLUSIONS: Gastroenterologists usually give appropriate advice on colorectal cancer screening but often misuse fecal occult blood tests. This may produce excessively high false-positive screening rates, leading to unnecessary diagnostic testing without apparent benefit.     

Which colon cancer screening test? A comparison of costs, effectiveness, and compliance.

PURPOSE: Recent media reports have advocated the use of colonoscopy for colorectal cancer screening. However, colonoscopy is expensive compared with other screening modalities, such as fecal occult blood testing and flexible sigmoidoscopy. We sought to determine the cost effectiveness of different screening strategies for colorectal cancer at levels of compliance likely to be achieved in clinical practice. METHODS: A Markov decision model was used to examine screening strategies, including fecal occult blood testing alone, fecal occult blood testing combined with flexible sigmoidoscopy, flexible sigmoidoscopy alone, and colonoscopy. The timing and frequency of screening was varied to assess optimal screening intervals. Sensitivity analyses were conducted to assess the factors that have the greatest effect on the cost effectiveness of screening. RESULTS: All strategies are cost effective versus no screening, at less than $20,000 per life-year saved. Direct comparison suggests that the most effective strategies are twice-lifetime colonoscopy and flexible sigmoidoscopy combined with fecal occult blood testing. Assuming perfect compliance, flexible sigmoidoscopy combined with fecal occult blood testing is slightly more effective than twice-lifetime colonoscopy (at ages 50 and 60 years) but is substantially more expensive, with an incremental cost effectiveness of $390,000 per additional life-year saved. However, compliance with primary screening tests and colonoscopic follow-up for polyps affect screening decisions. Colonoscopy at ages 50 and 60 years is the preferred test regardless of compliance with the primary screening test. However, if follow-up colonoscopy for polyps is less than 75%, then even once-lifetime colonoscopy is preferred over most combinations of flexible sigmoidoscopy and fecal occult blood testing. Costs of colonoscopy and proportion of cancer arising from polyps also affect cost effectiveness. CONCLUSIONS: Colonoscopic screening for colorectal cancer appears preferable to current screening recommendations. Screening recommendations should be tailored to the compliance levels achievable in different practice settings.     

Cost-effectiveness of colorectal cancer screening: comparison of community-based flexible sigmoidoscopy with fecal occult blood testing and colonoscopy

BACKGROUND AND AIMS: To determine the cost-effectiveness of screening for colorectal cancer using flexible sigmoidoscopy once every 10 years, compared with annual and biennial rehydrated Hemoccult fecal occult blood testing and colonoscopy once every 10 years, or no screening. METHODS: A Markov model was developed in order to simulate the progression of a cohort of asymptomatic, average-risk individuals aged 55-64 years who were moving through a defined series of states towards death. The main outcome measures were: cases of colorectal cancer averted, colorectal cancer deaths averted, and cost per life-year saved. RESULTS: Colonoscopy averted the greatest number of cases of colorectal cancer (35%), followed by flexible sigmoidoscopy (25%), and annual (24%) and biennial (14%) fecal occult blood testing. Colonoscopy averted the greatest number of deaths from colorectal cancer (31%), followed by annual fecal occult blood testing (29%), flexible sigmoidoscopy (21%) and biennial fecal occult blood testing (19%). Flexible sigmoidoscopy was the most efficient in terms of cost per life-year saved (16,801 Australian dollars), followed by colonoscopy (19,285 Australian dollars), biennial (41,183 Australian dollars), and annual (46,900 Australian dollars) fecal occult blood testing. CONCLUSIONS: Flexible sigmoidoscopy and colonoscopy are cost-effective strategies for reducing the disease burden of colorectal cancer.     

Fecal occult blood and flexible sigmoidoscopy screening for colorectal cancer: modeling the impact on colonoscopy requirements and cancer detection rates

AiM: The aim of this study was to estimate the colonoscopy requirements and the likely impact of fecal occult blood and flexible sigmoidoscopy screening on the detection of colorectal cancer by using previously published data. METHODS: Fecal occult blood and flexible sigmoidoscopy screening programs were applied to the 2.04 million subjects aged 50-65 years, at a participation rate of 40%. The following strategies were evaluated: Fecal occult blood testing with colonoscopy follow up of all positive tests; flexible sigmoidoscopy with colonoscopy follow up of all adenomatous polyps; and flexible sigmoidoscopy with colonoscopy follow up of all adenomatous polyps > 10 mm in size. RESULTS: The fecal occult blood program detected 5.6% of all colorectal cancer cases at a rate of 2,914 colonoscopies/percentage of detection of colorectal cancer. The flexible sigmoidoscopy program detected 14% of all colorectal cancer cases at a rate of 8,160 colonoscopies/percentage of detection of colorectal cancer. The flexible sigmoidoscopy program with follow up of adenomatous polyps > 10 mm in size detected 13% of all colorectal cancer cases at a rate of 1,230 colonoscopies/percentage of detection of colorectal cancer. CONCLUSIONS: Flexible sigmoidoscopy screening followed by colonoscopic follow up of adenomatous polyps > 10 mm in size is the most efficient screening strategy in terms of colonoscopies generated and cases of colorectal cancer detected.     

Colorectal cancer screening: physicians' knowledge of risk assessment and guidelines, practice, and description of barriers and facilitators.

BACKGROUND: Physician nonadherence to colorectal cancer (CRC) screening recommendations contributes to underuse of screening. OBJECTIVE: To assess physicians' knowledge of CRC screening guidelines for average-risk individuals, perceived barriers to screening and practice behaviours. METHODS: Between October 2004 and March 2005, staff physicians working in three university-affiliated hospitals in Montreal, Quebec, were surveyed. Self-administered questionnaires assessed knowledge of risk classification and current guidelines for average-risk individuals, as well as perceptions of barriers to screening and practice behaviours. RESULTS: All 65 invited physicians participated in the survey, including 46 (70.8%) family medicine physicians and 19 (29.2%) general internists. Most physicians knew that screening should begin at 50 years of age, all knew to screen men and women and 92% said they screened average-risk patients. Fifty-seven (87.7%) physicians correctly identified three common characteristics associated with high risk for developing CRC. Physicians who screened average-risk patients preferred fecal occult blood testing (88.3%) and colonoscopy (88.3%) to flexible sigmoidoscopy (10.0%) and double-contrast barium enema (30.0%). Most physicians knew the correct screening periodicity for fecal occult blood testing (87.6%), but only 40% or fewer could identify correct screening periodicities for the other modalities. Barriers and facilitators focused on health care delivery system improvements, better evidence on which to base recommendations and development of practical screening modalities. CONCLUSIONS: Physicians lacked knowledge of the recommended screening modalities and periodicities to appropriately screen average-risk individuals. Because CRC screening can reduce mortality, efforts to improve physician delivery should focus on physician knowledge and changes to the health care delivery system.     

Colorectal cancer screening and surveillance practices by primary care physicians: results of a national survey

OBJECTIVE: Screening for colorectal cancer reduces its morbidity and mortality and is cost-effective. Screening is usually the responsibility of primary care physicians who may be unsure about its implementation. We aimed to assess primary care physicians' knowledge and practice regarding colorectal cancer screening, and to compare their responses with those of three national experts and with published guidelines. METHODS: We mailed a postal questionnaire to 2,310 primary care physicians regarding demographics, nature of practice, use of screening tests, and six hypothetical patients who may have been candidates for screening or surveillance. We used published national guidelines and the collective opinions of the three external experts as the so-called "gold standard." RESULTS: Of all respondents, 85.1% offered colorectal cancer screening. Most used suitable tests, starting at an appropriate age; 49.8% continued screening indefinitely irrespective of patients' age and 43.6% performed fecal occult blood testing without appropriate dietary advice to patients. Also, respondents frequently performed this test for inappropriate indications. Only 51.8% would follow a positive fecal occult blood test with colonoscopy. CONCLUSIONS: Colorectal cancer screening practices by primary care physicians vary considerably from those recommended. Many offer screening to individuals in whom it is not appropriate, and continue it into advanced age. Frequent, inappropriate use of fecal occult blood tests will produce many false positives. Primary care physicians often do not appropriately follow a positive test. Further educational efforts are needed in an attempt to improve practice and further reduce the morbidity and mortality from colorectal cancer.     

Determinants of colorectal cancer screening in women undergoing mammography

OBJECTIVES: Women who participate in screening for breast cancer are more likely to participate in screening for colorectal cancer. We studied such a motivated group of women to identify predictors of, and barriers to, participation in colorectal cancer screening by endoscopy. METHODS: We distributed surveys to 551 women > or = 50 yr of age while they were awaiting mammography at four sites in and around Boston, MA from June to September, 2000. The 40-question survey assessed knowledge, attitudes, and beliefs about, and behaviors toward, breast and colorectal cancer screening. Regression models were used to determine factors associated with having had sigmoidoscopy or colonoscopy. RESULTS: Seventy-nine percent of the women completed all or part of the survey. Half (221/438) reported ever having had sigmoidoscopy or colonoscopy. Of these, 93% did so at the recommendation of their primary care provider. Factors associated with participation in endoscopic screening included compliance with annual fecal occult blood testing, a family history of colorectal cancer, and indifference toward the gender of the doctor performing the endoscopy. CONCLUSIONS: Women undergoing mammography overwhelmingly cite the recommendation of their primary care provider as the reason for participating in colorectal cancer screening by endoscopy. Women who preferred a female endoscopist were less likely to have been screened. Whenever possible, primary care providers should offer women the choice of a female endoscopist for colorectal cancer screening.     

Flexible sigmoidoscopy for colorectal cancer screening: valid approach or short-sighted?

Flexible sigmoidoscopy is a safe, effective test that may be delivered feasibly on a large scale for mass colorectal cancer screening. Flexible sigmoidoscopy is 67% to 80% as sensitive as colonoscopy in a screening population, but is probably 10 to 20 times safer than colonoscopy in terms of complications. Several national guidelines recommend combining flexible sigmoidoscopy with fecal occult blood tests. There is limited evidence to support this practice, and the added benefit to an existing flexible sigmoidoscopy screening program although real, may be marginal. In the future, it is likely that flexible sigmoidoscopy screening among patients aged 50 to 65 will be supplemented with total colonic screening, using molecular-based fecal tests or virtual colonoscopy, after age 65.     

Cost-effectiveness of colonoscopy in screening for colorectal cancer

BACKGROUND: Fecal occult blood testing, flexible sigmoidoscopy, and colonoscopy are used to screen patients for colorectal cancer. OBJECTIVE: To compare the cost-effectiveness of fecal occult blood testing, flexible sigmoidoscopy, and colonoscopy. DESIGN: The cost-effectiveness of the three screening strategies was compared by using computer models of a Markov process. In the model, a hypothetical population of 100 000 persons 50 years of age undergoes annual fecal occult blood testing, sigmoidoscopy every 5 years, or colonoscopy every 10 years. Positive results on fecal occult blood testing or adenomatous polyps found during sigmoidoscopy are worked up by using colonoscopy. After polypectomy, colonoscopy is repeated every 3 years until no polyps are found. DATA SOURCES: Transition rates were estimated from U.S. vital statistics and cancer statistics and from published data on the sensitivity, specificity, and efficacy of various screening techniques. Costs of screening and cancer care were estimated from Medicare reimbursement data. TARGET POPULATION: Persons 50 years of age in the general population. TIME HORIZON: The study population was followed annually until death. PERSPECTIVE: Third-party payer. OUTCOME MEASURE: Incremental cost-effectiveness ratio. RESULTS OF BASE-CASE ANALYSIS: Compared with colonoscopy, annual screening with fecal occult blood testing costs less but saves fewer life-years. A screening strategy based on flexible sigmoidoscopy every 5 or 10 years is less cost-effective than the other two screening methods. RESULTS OF SENSITIVITY ANALYSIS: Screening with fecal occult blood testing is more sensitive to changes in compliance rates, and it becomes easily dominated by colonoscopy under most conditions assuming less than perfect compliance. Other assumptions about the sensitivity and specificity of fecal occult blood testing, screening frequency, efficacy of colonoscopy in preventing cancer, and polyp incidence have a lesser influence on the differences in cost-effectiveness between colonoscopy and fecal occult blood testing. CONCLUSIONS: Colonoscopy represents a cost-effective means of screening for colorectal cancer because it reduces mortality at relatively low incremental costs. Low compliance rates render colonoscopy every 10 years the most cost-effective primary screening strategy for colorectal cancer.     

Effect of Medicare coverage on use of invasive colorectal cancer screening tests

BACKGROUND: Colorectal cancer is the second leading cause of cancer death in the United States. Screening for colorectal cancer is now widely recommended but underused. Lack of insurance coverage for screening tests may be one reason patients do not undergo these procedures. OBJECTIVE: To determine the effect of Medicare reimbursement on utilization rates of invasive screening tests. Use of fecal occult blood testing was not studied before 1998. METHODS: We performed a retrospective analysis of ambulatory claims data for Washington State Medicare beneficiaries in 1994, 1995, and 1998. We determined the proportion of patients undergoing diagnostic and screening flexible sigmoidoscopy, colonoscopy, or double-contrast barium enema in 1994, 1995, and 1998 and the proportion receiving fecal occult blood testing in 1998. RESULTS: Use of diagnostic and screening colon tests was low in all years. Fewer than 6% of beneficiaries received any colon test, and fewer than 4% received a screening test. Although more patients underwent diagnostic testing after Medicare coverage began, use of screening tests did not significantly change (odds ratio, 0.99; 95% confidence interval, 0.97-1.01 comparing 1994 and 1998 [P =.33]). Women, individuals older than 80 years, and nonwhite patients were statistically significantly less likely to be screened in all 3 years (P<.001). In 1998, fewer than 7% of patients underwent fecal occult blood testing, with men and nonwhites statistically significantly less likely to have this test (P<.001). CONCLUSIONS: Colorectal cancer screening tests are underused in the Washington State Medicare population, and insurance coverage for these tests did not substantially affect utilization rates in the period studied.     

Screening for colorectal cancer

PURPOSE: Screening for colorectal cancer using a guaiac-based fecal occult blood, or Hemoccult®, test has been demonstrated to reduce colorectal cancer mortality. However, the magnitude of effectiveness is relatively low because of poor sensitivity of the Hemoccult® test. The immunochemical fecal occult blood test has been shown to be much more sensitive than the Hemoccult® test in detecting preclinical colorectal cancer in an asymptomatic population. The purpose of this article is to discuss the validity of the immunochemical fecal occult blood test and the efficacy of a population-based screening program using the test. METHODS: Relevant articles were primarily identified through MEDLINE search. Review was focused on the studies of population screening programs with the immunochemical fecal occult blood test. RESULTS: Sensitivities for colorectal cancer calculated in the same population were reported to be 67 to 89 percent and only 33 to 37 percent for the immunochemical test and Hemoccult® test, respectively. Case-control studies and other observational studies showed that screening programs using the immunochemical fecal occult blood test by hemagglutination reaction would reduce the risk of dying of colorectal cancer by 60 percent or more for those screened annually compared with those unscreened. It was also shown that a screening strategy using the immunochemical fecal occult blood test had the best cost-effectiveness ratio among the methods available. Nearly 5 million persons are currently screened per year in Japan, yielding 0.15 to 0.2 percent colorectal cancer cases among persons with positive fecal occult blood test results. CONCLUSIONS: These results strongly suggest that a screening program with immunochemical fecal occult blood test has promising advantages in terms of effectiveness over programs with the Hemocult® test. More stress is warranted on introduction of immunochemical fecal occult blood testing as a screening test in place of the guaiac fecal occult blood test.     

The impact of colorectal cancer screening on life expectancy

METHODS: The purpose of this study was to assess the effect of screening for colorectal cancer on life expectancy and estimate the number of colonoscopies needed per life year saved. The declining exponential approximation of life expectancy was used to calculate the effect of colorectal cancer screening on expected remaining lifetime. The annual number of deaths from colorectal cancer and the size of the population were obtained from the vital statistics of the United States. Published reports were consulted to determine the decrease in mortality from colorectal cancer achieved by fecal occult blood testing, screening sigmoidoscopy or colonoscopy. A Markov chain analysis was used to determine the endoscopic resources required to screen and survey the entire population of U.S. residents age 50 years until death or age 85 years. RESULTS: Colorectal cancer decreases the life expectancy of U.S. residents aged 50 to 54 years by 292 days and those aged 70 to 74 years by 70 days. Screening with fecal occult blood tests extends expected lifetime of the 2 age groups by 51 and 12 days, respectively, whereas screening with sigmoidoscopy leads to increases of 86 and 21 days. Colonoscopic screening increases expected lifetime by 170 and 41 days, respectively. The number of colonoscopies needed to save 1 year of expected life ranges from 2.9 to 6.0, depending on the type of screening regimen used. CONCLUSIONS: The extension of life through screening colonoscopy is two or three times longer than the extension achieved through flexible sigmoidoscopy or fecal occult blood test, respectively. Although a large number of colonoscopies are required to screen the U.S. population, relatively few colonoscopies need to be invested per year of life expectancy saved.     

Screening des kolorektalen Karzinoms

Colorectal cancer is common and suitable for screening. There is general agreement that screening for colorectal cancer in the asymptomatic population without familial risk should begin at age 50. The different screening methods can be separated into methods that mainly detect cancers (fecal occult blood tests, genetic stool tests, blood tests, and the M2-PK test) and methods that diagnose cancers and polyps (colonoscopy, sigmoidoscopy, CT/MRI colonography, and colon capsule endoscopy). Endoscopic methods enable detection and treatment of preneoplastic adenomas and, thus, make cancer prevention possible. In the current German S3 guideline, colonoscopy is recommended as the preferred screening test. For people unwilling to undergo endoscopic screening, the fecal occult blood test is an alternative. Colonoscopy has been part of the German Cancer Screening Program since 2002.     

Many participants in fecal occult blood test population screening have a higher-than-average risk for colorectal cancer

OBJECTIVES: Population-based colorectal cancer screening by fecal occult blood testing reduces cancer-specific mortality. Current guidelines recommend this strategy for average risk individuals. This study investigated the prevalence of higher-than-average risk characteristics, and rate of prior colonoscopy, in participants in fecal occult blood test screening programs. METHODS: Randomly selected individuals aged 50-74 years in urban Adelaide were offered free fecal occult blood test screening by mail, without prior knowledge of their medical status. Each invitation included a questionnaire to record the prevalence of higher-than-average risk characteristics related to symptoms, family history or comorbidity, as well as prior colonoscopy. The definition of average risk was taken from updated guidelines published by the US Multisociety Task Force on Colorectal Cancer. RESULTS: Of 2538 responses analyzed, 425 individuals had had a colonoscopy within the last 5 years, 106 fulfilled family history criteria for an initial screening colonoscopy, 209 had past polyps and 26 had had colorectal cancer. Eighty-three reported recent rectal bleeding. By current guidelines, 23% of the screened population did not warrant fecal occult blood test, because either prior colonoscopy rendered it unnecessary or particular patient characteristics made colonoscopy a more appropriate initial investigation. CONCLUSIONS: Fecal occult blood test screening programs capture a sizeable number of higher-than-average risk individuals that may warrant colonoscopic rather than fecal occult blood test screening. Other participants have had a recent colonoscopy and probably warrant a delay in screening. Mass population fecal occult blood test-based screening programs need to more effectively target those at average risk and should divert those of higher or lower risk to more individualized assessment.     

The practices and attitudes of primary care nurse practitioners and physician assistants with respect to colorectal cancer screening

OBJECTIVES: Although nurse practitioners and physician assistants form a large and growing portion of the primary care workforce, little is known about their colorectal cancer screening practices. The aim of this study was to assess the colorectal cancer screening practices, training, and attitudes of nurse practitioners and physician assistants practicing primary care medicine. METHODS: All nurse practitioners (827) and physician assistants (1178) licensed by the Medical Board of the State of North Carolina were surveyed by mail. Both groups were further divided into primary care versus non-primary care by self-described roles. Self-reported practices, training, and attitudes with respect to colorectal cancer screening were elicited. RESULTS: Response rates were 71.4% and 61.2%, for nurse practitioners and physician assistants respectively. A total of 51.3% of nurse practitioners and 50.3% of physician assistants described themselves as adult primary care providers. No primary care nurse practitioners and only 3.8% of primary care physician assistants performed screening flexible sigmoidoscopy. However, 76% of primary care physician assistants and 69% of primary care nurse practitioners reported recommending screening flexible sigmoidoscopy. A total of 95% primary care physician assistants and 92% of primary care nurse practitioners reported performing fecal occult blood testing. Only 9.4% of physician assistants and 2.8% of nurse practitioners received any formal instruction in flexible sigmoidoscopy while in their training. Additionally, 41.4% of primary care physician assistants and 27.7% of primary care nurse practitioners reported that they would be interested in obtaining formal training in flexible sigmoidoscopy. CONCLUSIONS: Physician assistants and nurse practitioners are motivated, willing and underutilized groups with respect to CRC screening. Efforts to increase education and training of these professionals may improve the availability of CRC screening modalities.     

Flexible sigmoidoscopy as a screening test for colorectal cancer

Flexible sigmoidoscopy (FS) is one of the screening modalities for colorectal cancer. The rationale for screening with flexible sigmoidoscopy is that it provides direct visualisation of the colon, and suspicious lesions can be biopsied. The most obvious disadvantage is that it examines only the lower third of the colon. The technical aspects of FS are sufficiently clear to enable us to define what FS can and cannot do. From the point of view of screening, FS clearly cannot completely exclude the presence of colon cancer in all asymptomatic people. A distinction must be made between screening the general population and testing the individual seeking screening. For the former, obtaining the greatest mortality benefit safely and at an acceptable cost to the nation is the crux of the matter. Recently published data indicate that FS is a cost-effective screening strategy, although colonoscopy and annual fecal occult blood test avert a greater number of cancer deaths. The results of randomised controlled trials of screening FS and colonoscopy, currently being conducted, will allow us to make a more accurate comparison with the established data regarding fecal occult blood test. In conclusion, flexible sigmoidoscopy every 5 years with or without FOBT is one of the screening methods recommended by major professional organizations. It identifies 50 to 70% of the advanced neoplasms, if any discovery of a distal neoplasia is followed up with a total examination of the colon by colonoscopy.     

The use of screening colonoscopy for patients cared for by the Department of Veterans Affairs

BACKGROUND: Medicare data indicate an increase in colorectal cancer (CRC) screening using colonoscopy and a decline in fecal occult blood testing, flexible sigmoidoscopy, and double-contrast barium enema. Because of differences in the delivery of health care, this trend in use of colonoscopy in fee-for-service settings might not be paralleled in the Department of Veterans Affairs (VA). METHODS: National inpatient and outpatient VA databases were searched for codes indicative of colonoscopy, flexible sigmoidoscopy, fecal occult blood testing, and double-contrast barium enema during fiscal years 1998 to 2003 among VA users aged 49 to 75 years. RESULTS: The frequency of tests for CRC screening increased from 432,778 in 1998 to 1,179,764 in 2003. Of those who were screened, only the proportion of subjects screened with fecal occult blood testing increased from 81.7% to 90.4%, while screening colonoscopy declined from 5.7% to 4.7%; flexible sigmoidoscopy declined from 8.3% to 3.6%; and double-contrast barium enema declined from 4.1% to 1.3%. The total use of screening colonoscopy procedures increased from 24,955 in 1998 to 55,199 in 2003, but the proportion of colonoscopy procedures performed for CRC screening purposes increased only slightly from 34.3% to 38.4%. In regression models adjusting for age, race, and sex, there was no consistent secular trend in the likelihood of undergoing screening colonoscopy for patients cared for in the VA health care system. CONCLUSIONS: Colorectal cancer screening has dramatically increased in the VA, but unlike in other practice settings, fecal occult blood testing is the dominant mode of screening. Although screening colonoscopy more than doubled in frequency, it constitutes a small proportion of the total CRC screening procedures used in the VA health care setting.