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Accurate
assessment of the current level of understanding of colorectal cancer
risk, individuals’ willingness to obtain screening and how physicians
offer and promote screening to their patients is crucial to determining
effective ways to reduce incidence and mortality in Texas. While more
comprehensive research is needed to establish these baselines, some
data are available and of interest.
Public Although as many as 80% of colorectal cancers are diagnosed in individuals whose risk for the disease was deemed average, fewer than 35% of the Texas population surveyed by the Texas Department of Health reported ever having had a colorectal cancer screening test beyond the simple digital rectal exam (Table 5). Vernon’s comprehensive review [ 16 ] of published literature on adherence to colorectal cancer screening by fecal occult blood test and flexible sigmoidoscopy documents the reasons given most frequently for nonparticipation, including practicality (scheduling conflicts, inconvenience, lack of interest, cost), not having signs or symptoms of colorectal cancer, embarrassment or concerns about discomfort and not wanting to know the results. Committee discussions identified barriers to screening as lack of understanding both of the procedures used and of quality standards for them, low interest and perception of risk, lack of awareness of family incidence and inadequate promotion by physicians. Perceived barriers to diagnosis and treatment were believed to include economic limitations, cultural aversion to showing one’s body, lack of knowledge about colorectal cancer, fear, denial, fatalism, bureaucracy and hardship on the family.
Department of Health In 1999 the Texas Department of Health surveyed the healthcare providers under contract for breast and cervical cancer screening — usually community or county clinics within the 11 public health regions in the state — about their provision of colorectal cancer screening services. While clinic medical directors have latitude to implement new programs, the determining factor is almost entirely the availability of funding. Of 27 respondents to the survey, 11 reported that they do provide screening for colorectal cancer and eight more plan to initiate such a program. Six indicated that their client populations have expressed interest in this service. Primary Care Physicians A statewide
survey of primary care physicians sponsored jointly by the Texas
Medical Association, the American Cancer Society, Texas Division,
and the Texas Cancer Council has yielded preliminary findings about
their knowledge and perceptions regarding colorectal cancer screening.
Most respondents reported that they believe this cancer is largely
preventable and that available screening procedures are at least
somewhat effective in reducing mortality among average-risk, asymptomatic
individuals age 50 or over (except colonoscopy, which the great
majority agree is “very effective”). Most of the first-wave
respondents say they either recommend, perform themselves or order
either FOBTs or flexible sigmoidoscopies for such individuals. Physicians
perceived the most serious patient barriers to FOBT to be the time
and trouble the test takes, embarrassment or that it was not recommended
by a physician;
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top barriers to sigmoidoscopy were believed to be embarrassment,
the time and trouble and the cost. The most serious physician barriers
to recommending FOBTs to their patients were reported as poor patient
compliance and the questionable efficacy of the test, while for
sigmoidoscopy they were lack of training or equipment, expense and
poor patient compliance. (Appendix B includes the survey instrument
and an analysis of preliminary results. Final results are expected
by the end of August 2000.)
| Table
4 |
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ACS Guidelines
for Screening and Surveillance |
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Recommendation
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Age
to Begin
|
Interval
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|
| Average Risk | |||
| All people 50 years or older who are not in the categories below | One of the following: FOBT plus flecible sigmoidoscopy (2) or TCE (3) | Age 50 | FOBT every year and flexible sigmiodoscopy every 5 years; colonoscopy every 10 years or DCBE every 5-10 years |
| Moderate Risk | |||
| People with single, small (<1cm) ademonatous polyps | Colonoscopy | At time of initial diagnosis | TCE within 3 years after initial polyp removal; if normal, as per average risk recommendations (above) |
| People with large (³1cm) or multiple adenomatous polyps of any size | Colonoscopy | At time of inital polyp diagnosis | TCE within 3 years after inital polyp removal; if normal, TCE every 5 years |
| Personal history of curative-intene resection of colorectal cancer | TCE (4) | Within 1 year resection |
If normal,TCE in 3 years; if still normal, TCE every 5 years |
| Colorectal cancer or adenomatous polyps in 1st degree relative younger than age 60, or in 2 or more 1st degree relatives of any age | TCE | Age 40 or 10 years before the youngest case in the family, wichever is earlier | Every 5 years |
| Colorectal cancer in other relatives (not included above) | As per average rick recommendations (above); may condsider beginning svreening before age 50 | ||
| High Risk | |||
| Family History | Early surveillance with endoscopy, counseling to consider genetic testing and referral to a specialty center | Puberty | If genetic test positive, or polyposis confirmed, consider colectomy; otherwise, endoscopy every 1-2 years |
| Family history of hereditary non-polyposis colon cancer | Colonoscopy and counseling to consider genetic testing | Age 21 | If genetic test positive, or if patient has not had gentic testing, colonoscopy every 2 years until ate 40, then every year |
| Inflammatory bowel disease | Colonoscopies with biopsies for dysplasia | 8 years after the start of pancolitis; 12-15 after the start of left-sided colitis | Every 1-2 years |
| FOBT=fecal
occult blood test
DCBE=double-contrast barium enema
TCE=total colon endoscopy |
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* Approximately 70-80% of cases are from average-risk individuals; approximately 15-20% are from moderate-risk individuals; and 5-10% are from high-risk individuals.
SOURCE: The American Cancer Society [ 15 ] |
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