The best screening program for colorectal cancer: “Why make it complicated when it could be simple?”
Holme et al investigated the effectiveness of flexible sigmoidoscopy in screening for colorectal cancer by patient sex and age. Their conclusion, “flexible sigmoidoscopy is an effective tool in men and younger women. The benefit is … not statistically significant for women aged over 60” and the warning in the accompanying editorial that “uniform recommendations can lead to sex related inequity regarding the benefit from screening” deserve comment.(1,2)
First, Holme et al’s finding is challenging because age-specific prevalence for advanced colorectal neoplasms is more than twice as high in men than in women.(3) How could younger women benefit from screening, having the lowest risk?
Second, Haug’s concern for sex-equity must not mask that socio-cultural status is a major barrier for access to health. Doubeni questioned how to improve colorectal cancer screening by targeting populations when commenting on a study stratifying risk with an algorithm (age, sex, waist circumference, smoking, family history of colorectal cancer).(4,5) However, risk prediction remains the Holy Grail of cancer screening: no health care system has succeeded yet in implementing screening programs targeting populations with algorithms in the real life setting. Accordingly, the present challenge may not be different outcomes in men and women. The first step in optimizing colorectal cancer screening is to provide patients with the choice of the tests (colonoscopy, flexible sigmoidoscopy, computed tomographic colonography, faecal immunochemical …) they are willing and able to complete with high fidelity.(4) That is the best program. While waiting for robust comparative effectiveness studies, you can question a senior gastroenterologist and a senior radiologist about their personal choice.
1 Holme Ø, Schoen RE, Senore C et al. Effectiveness of flexible sigmoidoscopy screening in men and women and different age groups: pooled analysis of randomised trials. BMJ 2017;356:i6673.
2 Haug U. Flexible sigmoidoscopy screening for colorectal cancer. BMJ2017;356:j75.
3 Brenner H, Altenhofen L, Hoffmeister M. Sex, age, and birth cohort effects in colorectal neoplasms: a cohort analysis. Ann Intern Med 2010;152:697-703.
4 Doubeni CA. Precision screening for colorectal cancer: promise and challenges. Ann Intern Med. 2015;163:390-1.
5 Imperiale TF, Monahan PO, Stump TE, Glowinski EA, Ransohoff DF. Derivation and validation of a scoring system to stratify risk for advanced colorectal neoplasia in asymptomatic adults. A crosssectional study. Ann Intern Med. 2015;163:339-46.
Competing interests: No competing interests