Screening for colorectal cancer.

Abstract

To the Editor: In their Scientific Review article, Drs Walsh and Terdiman concluded that screening for colorectal cancer is clinically effective. Like other authors, they also concluded that the optimal screening method remains uncertain. On behalf of the New York City Department of Health and Mental Hygiene, we recently established guidelines recommending colonoscopy as the preferred method of screening for colon cancer, with annual fecal occult blood tests (FOBTs) as an acceptable, although not optimal, alternative for patients unable or unwilling to undergo colonoscopy. Our reasoning was based on the capabilities of colonoscopy to visualize the entire colon and to prevent colon cancer by performing a polypectomy at the time of the screening examination, as well as the large capacity of and the high quality of medical institutions in New York City. Separately, we surveyed 41 primary care physician opinion leaders (24 internists, 10 family physicians, and 7 obstetriciangynecology physicians) cited as the “best doctors in New York” by New York Magazine. We asked each physician to choose a preferred method of colon cancer screening for patients aged 50 years or older, for their friends and family, and for themselves, from among the following screening options: endoscopic colonoscopy, flexible sigmoidoscopy, fecal occult blood testing (FOBT), FOBT in combination with flexible sigmoidoscopy, computed tomographic colography (virtual colonoscopy), or double contrast barium enema. Of these physicians, 36 (88%) recommended colonoscopy as the preferred screening alternative for friends and family. The FOBT was preferred by 3 (7%), flexible sigmoidoscopy by 1 (2%), and the combination of FOBT and flexible sigmoidoscopy was preferred by 1 (2%). Thirty-five respondents (85%) preferred colonoscopy for themselves. This survey suggests that many clinician opinion leaders, at least those in New York City, recommend colonoscopy as their colorectal cancer screening method of choice. We estimate our citywide colonoscopy capacity at approximately 150000 annually (New York City Department of Health and Mental Hygiene, unpublished data), which is sufficient to meet the demand for colonoscopy screening every 10 years for residents aged 50 years to 75 years. Reimbursement issues and safety monitoring will be important components of any effort to provide colonoscopy screening to the entire population at risk.