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Rapid Responses: Rapid Responses published:
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Without considering Oncological Terrain, cancer efficacious primary prevention and screening are not possible.
- Sergio Stagnaro (16 July 2004)
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Age range 50-69 is right
- Dr Linda Garvican (18 July 2004)
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Screening should reduce deaths - does it ?
- Christoph Pechlaner (21 July 2004)
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Possible biases when estimating the outcome of colorectal cancer screening
- John Brodersen (21 July 2004)
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"So do I have cancer, doctor?"
- Jamie S Robertson (22 July 2004)
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Screening for colorectal cancer
- Ala Szczepura (30 July 2004)
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Colour blindness may be of importance in screening for colorectal cancer.
- John L Campbell (3 September 2004)
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Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseases. Researcher in Biophysical Semeiotics. Via Erasmo Piaggio 23/8 16037 Riva Trigoso (Genova) Italy.
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Sirs, I don’t understand, once again, what accounts for the reason that screening for colorectal cancer, e.g., by testing for faecal occult blood, certainly feasible within the context of the United Kingdom's NHS, should be applied to “all” people aged 50-69 years. I agree with the statement that “Screening should lead to a reduction in deaths from colorectal cancer in the population offered screening”, if such as screening is performed properly, correctly and early, in individuals involved by Oncological Terrain, and possibly by colon cancer real risk (1, 2) (See HONCOde website 233736, www.semeioticabiofisica.it). In fact, doctors must first (i.e., before whatever research) investigate and ascertain the presence and intensity of the Congenital Acidosic Enzyme-Acidosic Histangiopathy (CAEMH = functional mitochindrial cytopathology) in the "tested" population, and soon thereafter assessing prevalence and intensity of the "Oncological Terrain", which always develops on the basis of the above-mentioned congenital cytopathology (2, 3, 4). In fact, without this alteration of psycho-neuro-endocrine-immunological system, oncogenesis is not possible. Moreover, it is possible with the aid of Biophysical Semeiotics to recognize also cancer “real risk” in the colon, and therefore to select people in a rational matter obtaining the best results with relatively scarse expense. This accounts for the reason that “Planning for the EU public Health Portal” all’URL: http://europa.eu.int/comm/health/ph_information/documents/ev_20030710_co01_en.pdf, suggests the SPBM (Single Patient Based Medicine, in above-cited website) as useful tool in the primary prevention against malignancy. In conclusion, a 46-year-long clinical experience, allows me to state that without Oncological Terrain, cancer efficacious primary prevention and screening are not possible at all. 1) Kingdom UK Colorectal Cancer Screening Pilot Group .BMJ 2004;329:133 (17 July), doi:10.1136/bmj.38153.491887.7C (published 5 July 2004) 2) Stagnaro-Neri Marina, Stagnaro Sergio. Introduzione alla Semeiotica Biofisica. Il Terreno oncologico”. Travel Factory SRL., Roma, 2004. http://www.travelfactory.it/semeiotica_biofisica.htm 3) Stagnaro S., Stagnaro-Neri M., La Melatonina nella Terapia del Terreno Oncologico e del “Reale Rischio” Oncologico. Ediz. Travel Factory, Roma, 2004. 4) Stagnaro-Neri M., Stagnaro S., Cancro della mammella: prevenzione primaria e diagnosi precoce con la percussione ascoltata. Gazz. Med. It. – Arch. Sc. Med. 152, 447 1993 Competing interests: None declared |
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Dr Linda Garvican, Public Health Director, Sussex Cancer Network 36-38 Friars Walk, Lewes, East Sussex, BN7 2PB
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I was very interested to read the results from the pilot sites for colorectal cancer screening1 as I developed the original plans2 for this service for the UK National Screening Committee (UKNSC) in 1996, which the pilots have been testing. The plans were based on the previous experience of the three large trials 3-5, adapted for a general UK population, to provide for a sustainable national programme. I estimated that an additional 60,000 colonoscopies would be required for a bi-annual faecal- occult blood testing (FOBT) programme offered to all those aged 50 to 69 years- hence the current initiative to develop endoscopy training before any bowel screening programme can be implemented. Most of my predictions have proved to be accurate, but I underestimated the pathology which would be found in patients recalled for colonoscopy following positive FOBT, which has meant that the time allowed for each endoscopy has had to be increased. Part of my brief from the UKNSC was to justify the age range, which has now been piloted. Participants in the Minnesota study3 were aged 50-80 whilst those in the Danish4 and Nottingham5 studies were 45-74. However, colorectal cancer is rare in those under 50, with only 5% of cases diagnosed, and these may have genetic implications. About 50% of cases occur in the age range 50-69 6. In the Nottingham trial uptake at initial invitation was significantly lower both in those aged 45-49, (only 37%) and in those aged over 70 (48%) than in the 50-69 age group (55%). The mortality benefit was divided into two age groups. It was 19% better for those under 65 at the start of the study but only a non-significant 10% better for those 65 or over, giving the quoted 15% overall figure. I therefore recommended an age range of 50-69 based on these results and the experience of the NHS Breast Screening Programme, where an age upper limit of 64 had proved too low7. The authors now suggest that we should go back to the Danish trial and invite up to age 74, since the incidence continues to increase with age. This argument ignores the natural history of colorectal cancer in the context of an established national screening programme, which would provide benefit by both primary and secondary prevention, through the removal of precancerous lesions during colonoscopy as well as the detection of invasive disease. As with screening for cervical cancer the risk would be lower in those who had already been screened several times before their 70th birthdays. The clinical and cost effectiveness of continuing beyond this age would be decreased and it would be possible to do more harm than good. 1. UK Colorectal Cancer Screening Pilot Group. Results of the first round of a demonstration pilot of screening for colorectal cancer in the United Kingdom. BMJ 2004;329:133-5. 2. Garvican L. Planning for a possible National Colorectal Cancer Screening Programme. J Med Screen 1998;5:187-94. 3. Mandel JS, Bard JH, Church TR, Snover DC, Bradley GM, Schuman LM & Ederer F for the Minnesota Colon Cancer Control Study. Reducing Mortality from Colorectal Cancer by Screening for Faecal Occult Blood. N.Eng.J.Med. 1993;328:1365-71. 4. Kronborg O, Fenger C, Olsen J, Jorgensen OD, Sandergaard O. Randomised study of screening for colorectal cancer with faecal occult blood test. Lancet 1996;348:1467-71. 5. Hardcastle JD, Camberlain JO, Robinson MHE, Moss SM, Amar SA, Balfour TW, James PD, Mangham CM. Randomised controlled trial of faecal occult blood screening for colorectal cancer. Lancet 1996;348:1472-7. 6. Lieberman D, Sleisenger MH. Is it time to recommend screening for colorectal cancer? (Commentary) Lancet 1996;348:1463-4 7. Moss S, Brown J, Garvican L, Coleman DA, Johns L, Blanks RG et al. Routine breast screening for women aged 65-69: Three year results from evaluation of the demonstration sites. Br J Cancer 2001; 85:1289-94. Competing interests: None declared |
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Christoph Pechlaner, Associate professor of medicine Innsbruck A-6020, Austria
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The UK Colorectal Cancer Screening Pilot Group concluded that foecal occult blood screening should reduce deaths from coloretal cancer. The results do not support such a conclusion, because the investigators did not present any death numbers. Competing interests: None declared |
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John Brodersen, MD, GP, PhD student Department of General Practice, University of Copenhagen, Blegdamsvej 3, 2200 Copenhagen, Denmark
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The UK Colorectal Cancer Screening Pilot Group writes it is a fact that “Population based randomised controlled trials have shown that screening by faecal occult blood testing for colorectal cancer can reduce mortality”. One of the studies this fact is based on is the Funen study from Denmark (1) and this study has some biases that favours the effect of screening: Persons in the control-group were not told about the study and continued to use health-care facilities as normal. Between 1985 and 1995 the usual practice in Denmark was for the general practitioner to perform a rectoscopy on a patient with symptoms of colorectal cancer and to refer the patient for an X-ray examination of the colon at the local hospital. In contrast, nearly all participants in the Funen study with a positive FOB test had a colonoscopy. Consequently, the outcome of the Funen study is not only related to the FOB test but also to the fact that colonoscopy is a better diagnostic method than X-ray of the colon (2). The age of the participants was 45 – 84 years, but the suggested age group is 50 – 69 or 50 - 74 years. Since the incidence of colorectal cancer is higher in the elderly, the positive predictive value of the FOB test plus colonoscopy was higher than would be obtained in practice, and rates of false positive tests lower. The adverse effects of screening could therefore be underestimated in the Funen study. In the intervention group all patients received their operation at the University Hospital, where it is likely that the surgeons were more competent than at local hospitals where the control group underwent surgery. Since surgery now is centralised the benefits of a colorectal screening program might be smaller today. In the Funen study, experienced staff probably conducted most of the colonoscopies. In a real life situation non-specialists in training would undertake some of the colonoscopies and, consequently, it would be expected that more cancers would be missed and more false positive tests occur, as has been the case with breast screening (3). It is likely that some of these biases are also relevant for other studies of colorectal cancer screening e.g. the Nottingham study (4). 1. Kronborg O, Fenger C, Olsen J, Jorgensen OD, Sondergaard. Randomised study of screening for colorectal cancer with faecal-occult- blood test [see comments]. Lancet 1996;348:1467-71. 2. Rex DK, Rahmani EY, Haseman JH, Lemmel GT, Kaster S, Buckley JS. Relative sensitivity of colonoscopy and barium enema for detection of colorectal cancer in clinical practice. Gastroenterology 1997;112:17-23. 3. Sickles EA, Wolverton DE, Dee KE. Performance parameters for screening and diagnostic mammography: specialist and general radiologists. Radiology 2002;224:861-9. 4. Hardcastle JD, Chamberlain JO, Robinson MH, Moss SM, Amar SS, Balfour TW et al. Randomised controlled trial of faecal-occult-blood screening for colorectal cancer [see comments]. Lancet 1996;348:1472-7. Competing interests: None declared |
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Jamie S Robertson, Intercalating Medical Student (Immunology) University of Glasgow, G12
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"about half of all colonoscopies carried out on the basis of a positive test result show no evidence of neoplasia" As a medical student at Glasgow I was lucky enough to be exposed, during our colon cancer PBL, to 2 doctors with different views of FOB screening. Whilst this process will probably save lives, we were also told that simply brushing your teeth in the morning before the test could give you a positive result. FOB is clearly NOT a specific test, and I'm not sure it's really worth it to call hoards of patients back, and presumably scare them to death in the process, on the grounds that "well, there might be something wrong with you, maybe", and then proceed to inflict a colonoscopy in them. The same argument applies to the sensitivity of the test - do we really want to send 50% of colon cancer patients home with an ill-founded "all clear"? I get the feeling that, despite the promising results of this study, there is still some debate to come on the validity of this screening programme. Competing interests: None declared |
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Ala Szczepura, Director, CHESS & UK Centre for Evidence in Ethicity, Health & Diversity (CEEHD) University of Warwick, Coventry CV4 7AL
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The UK colorectal cancer screening pilot group report the results from the first round of the demonstration pilot set up by the UK health departments in March 2000 (1). This pilot covered two geographical areas, one in Scotland and one in England, and the main evaluation group presents very positive findings in terms of observed population uptake, outcomes, and consequences. In July 2001, following the Race Relations (Amendment) Act 2000 which came into force in April 2001 (2), the Department of Health extended the feasibility study to include examination of issues of access, and progress through the colorectal cancer screening process, by ethnic minority groups. The new Act places a statutory duty on bodies such as the NHS to make explicit the implications for racial equality of every new policy, such as a cancer screening programme. The UK colorectal cancer screening (ethnicity) pilot group worked closely with the main pilot group, with some academic members common to both groups. The study on ethnicity was carried out in the English pilot site (Coventry and Warwickshire), since the Scottish site did not cover an ethnically diverse population. The findings from our group are far less positive than those reported by the main pilot group. Even after controlling for the influence of socio-economic status, a major disparity is evident in terms of observed outcomes for this section of the population, indicating that the programme, as piloted, may not meet emerging guidelines for culturally and linguistically appropriate services (3). South Asian sub-groups demonstrated a significantly (p<0.01) lower faecal occult blood test uptake rate, ranging from 31.9% (Muslims) and 34.6% (Sikhs) to 42.6% (Hindu-Gujeratis) and 43.7% (Hindu-Others), versus 63.7% for the non-south Asian population in the area. Gender and age uptake patterns were also different from those of the majority population. Multivariate analyses, including other descriptors such as age, gender and deprivation, still indicate that the level of successfully completed screening is half in the South Asian population (adjusted OR 0.439 (CI 0.414 - 0.465), p<0.01); this difference remains significant (p<0.01) at individual ethnic sub- group level. More worryingly, colonoscopy uptake is similarly half the level members of the for South Asian population with a positive faecal occult blood test result (p<0.01). Our findings indicate that, if colorectal cancer screening is implemented in the UK, ethnic minority populations will require special attention, including targeted interventions in order to achieve equitable uptake rates. The implications for roll-out are likely to be particularly significant in areas such as inner London, Leicester, Bradford and Birmingham (with south Asian populations reaching up to 40%). Areas with Muslim or Sikh communities, in particular, will require interventions to improve access since these Asian sub-groups are both at higher risk, as meat eaters, and also have been found to have the lowest uptake rates. From the main pilot group findings, the evidence indicates that the UK colorectal cancer screening programme as piloted should be very cost- effective (£5,900 per life year saved). It would appear, therefore, that there is considerable leeway in terms of NHS investment in interventions to improve uptake for ethnic minority populations while maintaining the overall cost-effectiveness of such a programme. However, the literature review we have undertaken as part of our research indicates that there is as yet limited research evidence available on effective interventions for improving colorectal cancer screening uptake by ethnic minorities. Professor Ala Szczepura [on behalf of UK Colorectal Cancer Screening (Ethnicity) Pilot Group*] Director, Centre for Health Services Studies (CHESS) Co-Director, UK Centre for Evidence in Ethnicity, Health and diversity (CEEHD) 1. UK Colorectal Cancer Screening Pilot Group. Results of the first round of a demonstration pilot of screening for colorectal cancer in the United Kingdom. BMJ 2004; 329: 133-135. (17 July) 2. Parliament. Race Relations (Amendment) Act 2000: Elizabeth II: Chapter 34. London: Stationery Office, 2000. 3. Shaw-Taylor, Y. (2002). Culturally and linguistically appropriate health care for racial or ethnic minorities: analysis of the US Office of Minority Health's recommended standards. Health Policy. 62(2): 211 - 221. * UK colorectal cancer screening (ethnicity) pilot group membership: Professor Ala Szczepura Centre for Health Services Studies (CHESS), University of Warwick: Project lead. Dr Anil Gumber CHESS, University of Warwick: Analyses of uptake rates. Professor Mark Johnson Mary Seacole Research Centre, De Montfort University: Focus group study. Professor Sheina Orbell Department of Psychology, University of Essex: Psychosocial survey. Dr Ian O’Sullivan Department of Psychology, University of Essex: Psychosocial survey. Diane Clay CHESS, University of Warwick): Literature review searches. Dr David Owen Centre for Research in Ethnic Relations (CRER), University of Warwick: Geographical extrapolation of pilot findings. Competing interests: None declared |
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John L Campbell, Professor of General Practice and Primary Care Peninsula Medical School, EX2 5DW
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Your recent publication1 highlighted the potential for screening for colorectal cancer by testing for faecal occult blood. One important factor not referred to, but previously described2 relates to the potential importance of the presence of colour vision deficiency (“colour blindness”), a disorder affecting around 8% of the male population. In our study, some doctors, especially those with more severe colour vision deficiencies, had difficulty in detecting blood in stool specimens. It may be of importance that such doctors should be aware not simply of the presence of colour vision deficiency, but of its severity. Furthermore, the use of technologies such as faecal occult blood testing may be an important technology by which the lack of confidence reported by doctors with colour vision deficiency2 might be addressed, to the overall benefit of patient care. Yours sincerely, 1. UK Colorectal Cancer Screening Pilot Group Results of the first round of a demonstration pilot of screening for colorectal cancer in the United Kingdom British Medical Journal 2004 329 133-138 2. Campbell JL, Spalding A, Mir F, Birch J Doctors and the assessment of clinical photographs. Does colour blindness matter? British Journal of General Practice 1999 49 459-461 Competing interests: None declared |
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