NEUGUT AND LEBWOHL RESPOND

Abstract

Woolf et al., in response to our recent editorial,1 argue that alternatives to screening colonoscopy are necessary to accommodate diverse patient preferences and may be crucial in settings where colonoscopy capacity is limited. We agree with both assertions. However, in regions with adequate capacity, we maintain that screening should be framed in such a way that colonoscopy is presented as the preferred test, though not the only test available. To limit the options to two modalities, colonoscopy and fecal occult blood testing (FOBT), simplifies the choice but does so at the risk of erroneously equating the tests in terms of effectiveness. The sensitivity of FOBT for the detection of colorectal cancer may be as low as 13%, mandating repeated tests annually.2 Certainly, use of FOBT is an evidence-based strategy and should be employed when a patient indicates a preference for this modality. But whereas some patients may prefer the FOBT option, adherence to an annual FOBT program in practice is generally poor, with an average adherence rate of less than 40%.3 Moreover, the reduction in incidence of colorectal cancer in such a program is dependent on the subsequent colonoscopy of those patients who have a positive test result; follow-up of positive results is also poor, with 41% of patients with positive results failing to receive follow-up testing.4 For this reason, we agree with the approach of the New York City Department of Health and Mental Hygiene, which offers FOBT as an alternative for those who decline colonoscopy as a primary screening modality.5 As for the statement that the increase in screening rates in New York City reflects the secular trend nationally, we have two comments. First, this national increase in screening rates from 2002 through 2006 is largely because of an increase in colonoscopy; in fact, FOBT use declined during these years, which belies the notion of a sizeable population preferring FOBT.6 Second, the increase in screening in New York City during this time period was accompanied by an elimination of disparities in screening rates between Whites, Blacks, and Hispanics.7 Such disparities have persisted nationally.6 The elimination of screening disparities in New York City may not necessarily result from the Health Department's hierarchical screening recommendations, but it is an impressive accomplishment that warrants further investigation.