Author's reply: More data are needed on General Practitioners in colorectal cancer screening

Abstract

We read with interest the letter by Grattagliano et al. in which the authors question the interpretation of the results of a previous randomized study, in which we showed a disappointing uptake of colorectal cancer (CRC) screening with guaiac-based faecal testing and especially colonoscopy, when the study population was directly invited by General Practitioners (GPs) [ [1] Lisi D. Hassan C.C. Crespi M. AMOD Study Group Participation in colorectal cancer screening with FOBT and colonoscopy: an Italian, multicentre, randomized population study. Dig Liver Dis. 2010; 42: 371-376 Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar ]. In detail, Grattagliano et al. suggested that the GPs involved in the study could have underperformed because of lack of training or established collaboration with other health professionals. Although we cannot completely rule out such a possibility, it should be clarified that every effort to minimize such a bias was undertaken in the study [ [1] Lisi D. Hassan C.C. Crespi M. AMOD Study Group Participation in colorectal cancer screening with FOBT and colonoscopy: an Italian, multicentre, randomized population study. Dig Liver Dis. 2010; 42: 371-376 Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar ]. In particular, all the involved GPs attended a pre-study course in which both general (epidemiology of CRC, efficacy of screening techniques, etc.) and specific (how to administer a faecal test, efficacy and safety of colonoscopy, patient interaction, etc.) information on CRC screening strategies were provided. This course was also exploited to create a direct channel of communication between the GPs and the Endoscopy centres in their area to facilitate the interaction between these two figures. To avoid lack of motivation, we also provided a financial grant for any subject that was invited by the GPs. Despite all these measures, the adherence rate of the study population was only 30% in the faecal test arm and about 10% in the colonoscopy arm. Such rates are greatly disappointing when compared with the much higher attendance rates achieved by breast and cervical cancer screenings in our country. Grattagliano et al. stated that our results do not fully represent the Italian situation, since a much higher adherence to faecal testing has been achieved in some Italian regions, mainly thanks to an active participation by primary care physicians: with this point we do not fully agree. First, although we agree that in some Italian regions participation to faecal test screening is higher than 50%, it is also true that the general adherence to this test in Italy is much closer to 30% (as found in our nationwide study) than to the >50% achieved in a few Italian regions. Secondly, there is no clear evidence that the very high adherence reached in these Italian regions was actually due to GP involvement, as other health professionals could be responsible for this result (i.e. epidemiologists, mass media coverage, etc.). Finally, it should be noted that similarly poor results were achieved in an Italian region (Lazio) in which a pilot study of GP-based invitation for CRC screening was attempted, forcing the region to radically change its screening protocol [ 2 Federici A. Barca A. Baiocchi D. et al. Can colorectal cancer mass-screening organization be evidence-based? Lessons from failures: the experimental and pilot phases of the Lazio program. BMC Public Health. 2008; 8: 318 Crossref PubMed Scopus (7) Google Scholar , 3 Federici A. Marinacci C. Mangia M. et al. Is the type of test used for mass colorectal cancer screening a determinant of compliance? A cluster-randomized controlled trial comparing fecal occult blood testing with flexible sigmoidoscopy. Cancer Detect Prev. 2006; 30: 347-353 Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar ].