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"The Definition of Insanity is doing the same thing over and over and expecting different results"
Quote most often attributed to Albert Einstein
Dear Editors
The English Bowel Scope Screening (BSS) programme, which has invited adults aged 55 for a one off Flexible Sigmoidoscopy (FS only) at 6 major English NHS centres since 2013, is being discussed in your news article. No regular follow up screening occurs if the FS found no abnormality, though patients are asked to be 'bowel aware' and seek medical help when there are changes in bowel habits or symptoms.
Christian von Wagner, leader of the featured study, is reported to be looking into the reasons behind the differential uptake of flexible sigmoidoscopy (FS) as part of the pilot NHS Bowel Screening Programme, ranging from 33% to 53% thought to reflect social inequity and cultural acceptance; this is still far short of the alleged target goal of 75% by 2020 determined by the Independent Cancer Taskforce.
However, keeping perspective of previous studies based in the UK and Europe which investigated the use of the flexible sigmoidoscopy as a first-line screening modality, with various target population criteria, the true uptake rate (accepted invitation AND undergone investigation) ranges from 30 to 58% at best (1-4); only a few studies, for example, NORCCAP from Norway (5) showed better results than this range.
While I believe that there should a target goal above average for implementation of measured outcome as to promote continuing innovations to improve the status quo, I understand that most cost effectiveness analyses involving flexible sigmoidoscopy as a firstline screening tool (6,7) are based on assumption of actual uptake/compliance rate of 54-60% for concurrently running FS and gFOBT program as opposed to the FS only (single examination by scope, no follow up faecal testing) programme of this pilot study. In fact the net monetary benefit of only FS at 55 years screen is second lowest, trumped only by a 5 yearly gFOBT testing (7). I cannot detect the effect of a higher than 54% uptake rate for the FS only screening scheme. Such analyses do not infer a higher uptake rate will result in a better cost-effective programme profile. In fact, biennial iFOBT 60–74' was associated with slightly greater benefits than one-off FS at age 55 (7)
Irish researchers suggest "Population-based screening based on FIT is expected to result in greater health gains than a policy of gFOBT (with reflex FIT) or once-only FSIG, but would require significantly more colonoscopy resources and result in more individuals experiencing adverse effects."(8)
I am not sure of the accuracy of the statement "The Independent Cancer Taskforce has called for the bowel scope screening test to reach 75% uptake in all areas of the country by 2020" in the BMJ News article. The actual wording of the 2015 Taskforce report was: "NHS England should incentivise GPs to take responsibility for driving increased uptake of FIT and bowel scope in their populations, with an ambition of achieving 75% uptake in all CCGs by 2020. " (9) (ie concurrent faecal testing and scope programs)
As such, therefore, looking for way to achieve a 75% uptake goal in the FS only screening programme is better cost-effectiveness-wise than 54% is no longer an issue of putting the carrot in front of the horse, but is akin to putting the cart in front of the horse!
Perhaps the surprise is that health professionals and researchers are still expecting the dictum "more is better" is true, whereas the basis of public health screening is always been economic and cost-effectiveness driven.
1. Hol L, van Leerdam ME, van Ballegooijen M, et al. Screening for colorectal cancer: randomised trial comparing guaiac-based and immunochemical faecal occult blood testing and flexible sigmoidoscopy. Gut 2010; 59: 62-68.
2. Castigloine G. Screening for colorectal cancer: flexible sigmoidoscopy and faecal occult blood immunochemical testing. Which test is superior? Gut 2010; 59: 9-10.
3. Robb K, Power E, Kralj-Hans I, Edwards R, Vance M, Atkin W, Wardle J. Flexible sigmoidoscopy screening for colorectal cancer: uptake in a population-based pilot programme. J Med Screen. 2010;17:75–78.
4. Atkin WS, Edwards R, Kralj-Hans I, Wooldrage K, Hart AR, Northover JMA, Parkin DM, Wardle J, Duffy SW, Cuzick J. Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomized controlled trial. Lancet. 2010;375(9726):1624-33.
5. Hoff G, Grotmol T, Skovlund E, Bretthauer M. Risk of colorectal cancer seven years after flexible sigmoidoscopy screening: randomised controlled trial. BMJ. 2009;338:b1846.
6. Tappenden P1, Chilcott J, Eggington S, Patnick J, Sakai H, Karnon J. Option appraisal of population-based colorectal cancer screening programmes in England. Gut. 2007 May;56(5):677-84. Epub 2006 Dec 1.
7. Whyte S, Chilcott J, Halloran S. Reappraisal of the options for colorectal cancer screening in England. Colorectal Dis. 2012 Sep;14(9):e547-61.
8. Sharp L, Tilson L, Whyte S, O'Ceilleachair A, Walsh C, Usher C, Tappenden P, Chilcott J, Staines A, Barry M, Comber H. Cost-effectiveness of population-based screening for colorectal cancer: a comparison of guaiac-based faecal occult blood testing, faecal immunochemical testing and flexible sigmoidoscopy.Br J Cancer. 2012 Feb 28;106(5):805-16.
9. Independent Cancer Taskforce (2015) Achieving World-Class Cancer Outcomes: A Strategy for England 2015-2020. Page 21
Competing interests:
I have previously written about concerns regarding the economics of flexible sigmoidoscopy as the main tool for bowel cancer screen as well as the issues relating to expansion of endoscopic screening services involving non-doctor operators.
What is the real surprise? Much Ado About Nothing?
"The Definition of Insanity is doing the same thing over and over and expecting different results"
Quote most often attributed to Albert Einstein
Dear Editors
The English Bowel Scope Screening (BSS) programme, which has invited adults aged 55 for a one off Flexible Sigmoidoscopy (FS only) at 6 major English NHS centres since 2013, is being discussed in your news article. No regular follow up screening occurs if the FS found no abnormality, though patients are asked to be 'bowel aware' and seek medical help when there are changes in bowel habits or symptoms.
Christian von Wagner, leader of the featured study, is reported to be looking into the reasons behind the differential uptake of flexible sigmoidoscopy (FS) as part of the pilot NHS Bowel Screening Programme, ranging from 33% to 53% thought to reflect social inequity and cultural acceptance; this is still far short of the alleged target goal of 75% by 2020 determined by the Independent Cancer Taskforce.
However, keeping perspective of previous studies based in the UK and Europe which investigated the use of the flexible sigmoidoscopy as a first-line screening modality, with various target population criteria, the true uptake rate (accepted invitation AND undergone investigation) ranges from 30 to 58% at best (1-4); only a few studies, for example, NORCCAP from Norway (5) showed better results than this range.
While I believe that there should a target goal above average for implementation of measured outcome as to promote continuing innovations to improve the status quo, I understand that most cost effectiveness analyses involving flexible sigmoidoscopy as a firstline screening tool (6,7) are based on assumption of actual uptake/compliance rate of 54-60% for concurrently running FS and gFOBT program as opposed to the FS only (single examination by scope, no follow up faecal testing) programme of this pilot study. In fact the net monetary benefit of only FS at 55 years screen is second lowest, trumped only by a 5 yearly gFOBT testing (7). I cannot detect the effect of a higher than 54% uptake rate for the FS only screening scheme. Such analyses do not infer a higher uptake rate will result in a better cost-effective programme profile. In fact, biennial iFOBT 60–74' was associated with slightly greater benefits than one-off FS at age 55 (7)
Irish researchers suggest "Population-based screening based on FIT is expected to result in greater health gains than a policy of gFOBT (with reflex FIT) or once-only FSIG, but would require significantly more colonoscopy resources and result in more individuals experiencing adverse effects."(8)
I am not sure of the accuracy of the statement "The Independent Cancer Taskforce has called for the bowel scope screening test to reach 75% uptake in all areas of the country by 2020" in the BMJ News article. The actual wording of the 2015 Taskforce report was: "NHS England should incentivise GPs to take responsibility for driving increased uptake of FIT and bowel scope in their populations, with an ambition of achieving 75% uptake in all CCGs by 2020. " (9) (ie concurrent faecal testing and scope programs)
As such, therefore, looking for way to achieve a 75% uptake goal in the FS only screening programme is better cost-effectiveness-wise than 54% is no longer an issue of putting the carrot in front of the horse, but is akin to putting the cart in front of the horse!
Perhaps the surprise is that health professionals and researchers are still expecting the dictum "more is better" is true, whereas the basis of public health screening is always been economic and cost-effectiveness driven.
1. Hol L, van Leerdam ME, van Ballegooijen M, et al. Screening for colorectal cancer: randomised trial comparing guaiac-based and immunochemical faecal occult blood testing and flexible sigmoidoscopy. Gut 2010; 59: 62-68.
2. Castigloine G. Screening for colorectal cancer: flexible sigmoidoscopy and faecal occult blood immunochemical testing. Which test is superior? Gut 2010; 59: 9-10.
3. Robb K, Power E, Kralj-Hans I, Edwards R, Vance M, Atkin W, Wardle J. Flexible sigmoidoscopy screening for colorectal cancer: uptake in a population-based pilot programme. J Med Screen. 2010;17:75–78.
4. Atkin WS, Edwards R, Kralj-Hans I, Wooldrage K, Hart AR, Northover JMA, Parkin DM, Wardle J, Duffy SW, Cuzick J. Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomized controlled trial. Lancet. 2010;375(9726):1624-33.
5. Hoff G, Grotmol T, Skovlund E, Bretthauer M. Risk of colorectal cancer seven years after flexible sigmoidoscopy screening: randomised controlled trial. BMJ. 2009;338:b1846.
6. Tappenden P1, Chilcott J, Eggington S, Patnick J, Sakai H, Karnon J. Option appraisal of population-based colorectal cancer screening programmes in England. Gut. 2007 May;56(5):677-84. Epub 2006 Dec 1.
7. Whyte S, Chilcott J, Halloran S. Reappraisal of the options for colorectal cancer screening in England. Colorectal Dis. 2012 Sep;14(9):e547-61.
8. Sharp L, Tilson L, Whyte S, O'Ceilleachair A, Walsh C, Usher C, Tappenden P, Chilcott J, Staines A, Barry M, Comber H. Cost-effectiveness of population-based screening for colorectal cancer: a comparison of guaiac-based faecal occult blood testing, faecal immunochemical testing and flexible sigmoidoscopy.Br J Cancer. 2012 Feb 28;106(5):805-16.
9. Independent Cancer Taskforce (2015) Achieving World-Class Cancer Outcomes: A Strategy for England 2015-2020. Page 21
Competing interests: I have previously written about concerns regarding the economics of flexible sigmoidoscopy as the main tool for bowel cancer screen as well as the issues relating to expansion of endoscopic screening services involving non-doctor operators.