THE PRIORITY IS SCREENING, NOT COLONOSCOPY

Like Neugut and Lebwohl,¹ we welcome the recent successes in promoting colorectal cancer screening. We also agree that offering too many testing options can dampen enthusiasm for screening, but we disagree with their solution: to promote a “preferred” test. Setting aside the question of whether colonoscopy is the “best” test—Neugut and Lebwohl themselves acknowledge that only fecal occult blood testing (FOBT) has been proven to lower mortality rates²—promoting a single test is risky because patient preferences are heterogeneous. A sizable proportion of the 50% of the population the authors wish to reach will decline an invasive examination and bowel preparation for screening but will undergo FOBT (and undergo colonoscopy if the results are abnormal). A campaign that makes colorectal cancer screening synonymous with colonoscopy, as espoused by the authors, could potentially “turn off” those reluctant patients who might consider screening by other means.

The revamped Web site of Twitter, a social networking and microblogging service utilizing instant messaging, SMS (short message service, usually mobile-to-mobile text messages), or a Web interface. Photograph by David Brabyn. Printed with permission of Corbis.

Although we agree that presenting 7 options for screening is excessive, it seems reasonable to offer at least 2 alternatives—FOBT and colonoscopy—which exhibit comparable effectiveness in empirical and modeling studies.^2,3 Having options is important not only to accommodate patient preferences and extend screening to people who are averse to colonoscopy but also for communities that cannot supply enough endoscopists⁴ or offer colonoscopy at an affordable cost but can provide FOBT. FOBT limits the volume of screening colonoscopies, lowering costs⁵ without compromising health benefits.³ Choosing between colonoscopy and FOBT need not overwhelm patients if clinicians succinctly explain the contrasts—in frequency, invasiveness, and logistics—and present both tests as excellent choices, with a decision to forego screening being the only bad choice.

Although gastroenterologists understandably prefer colonoscopy and favor guidelines that invoke a hierarchy⁶ over those that emphasize choices,² Neugut and Lebwohl offer little evidence that their approach improves screening rates. The increase in screening that they observed in New York City between 2003 and 2006 (from 40% to 60%) is not unlike the secular trend observed nationally. Between 2002 and 2006, rates for screening by lower endoscopy (approximately 80% involving colonoscopy^7,8) increased from 45% to 56% in the United States⁹ (to 61% in New York State¹⁰). Clearly, the increase in New York City is only partly attributable to promoting colonoscopy. A controlled study would help clarify whether “it's time for a colonoscopy” is a message that achieves better results than one emphasizing choices in colorectal cancer screening.