Digestive Diseases and Sciences, Vol. 47, No. 9 (September 2002), pp.
1982–1983 (© 2002)
REVIEW ARTICLE
How Should We Screen for Colorectal
Cancer?
SOLOMON SINGH, MD and JAMIE S. BARKIN, MD, FACP, MACG
Screening for colon cancer with the use of fecal occult
blood test or sigmoidoscopy of asymptomatic patients
who are over the age of 50 and are at average risk for
colonic disease has been shown to reduce mortality
from colon cancer. The aim of this multicenter study
was to evaluate the prevalence of neoplasia and the
sensitivity of one-time screening with a fecal occult
blood test plus sigmoidoscopy. It was conducted at 13
Veterans Affairs medical centers from February 1994
to January 1997. Patient inclusion criteria were in-
formed consent and returning of guaiac-impregnated
cards with two stool samples on each for three con-
secutive days before bowel preparation. The cards
were rehydrated with one drop of water prior to
application of developer. Exclusion criteria included
rectal bleeding on more than one occasion in the
previous six months, symptoms of disease of the lower
gastrointestinal tract, a marked change in bowel hab-
its, or lower abdominal pain that would normally
require medical evaluation. Patients were also ex-
cluded if they had prior disease of the colon (colitis,
polyps, cancer, or a condition requiring surgery), ex-
amination of the colon within the previous 10 years
(including sigmoidoscopy, colonoscopy, and barium
enema), serious medical conditions that could in-
crease the risk associated with colonoscopy or were so
severely ill that screening would have no benefit, a
need for special precautions in performing colonos-
copy (including anticoagulation and antibiotic pro-
phylaxis), and childbearing potential. Subjects with
psychiatric disorders, unstable living conditions, or
lack of transportation were also excluded. The study
was a subgroup analysis of a previous study that was
Manuscript received March 12, 2002; accepted April 29, 2002.
From the University of Miami, School of Medicine/Mount Sinai
Medical Center, Division of Gastroenterology, Miami, Florida,
USA.
Address for reprint requests: Dr. Jamie S. Barkin, Division of
Gastroenterology, Mount Sinai Medical Center, 4300 Alton Road,
Miami Beach, Florida 33140, USA.
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0163-2116/02/0900-1982/0 © 2002 Plenum Publishing Corporation
published in the New England Journal of Medicine by
Lieberman and Weiss (1).
Analysis was of 2885 adults who had a complete
examination of the colon to the cecum and returned
their test cards before colonoscopy was performed. The
mean age of the group was 63.0 years: 96.8% of the
subjects were men, and 14.2% reported having a first-
degree relative with colorectal cancer. Among the 2885
subjects, 1319 (45.7%) had no polypoid lesion. In 472
(16.4%) the most advanced lesions were hyperplastic
polyps or nonadenomatous polyps, and in 788 (27.3%),
the most advanced finding was one or more tubular
adenomas ⬍10 mm diam. Advanced neoplasia (tubular
adenoma ⱖ10 mm, villous adenoma, high-grade dyspla-
sia, cancer) was detected in 306 subjects (10.6%). Of the
advanced neoplasias, 182 were in the distal colon and
150 were in the proximal colon.
At least one test card was positive for fecal occult
blood in the case of 239 subjects (8.3%). Among all
306 subjects with advanced neoplasia, 73 (23.9%) had
a positive test for fecal occult blood. This resulted in
a sensitivity of 35.6%, a positive predictive value of
39.7%, and a negative predictive value of 87.8%.
There was a strong association between the number
of test cards with positive results and the likelihood of
advanced neoplasia (P ⬍ 0.001). In this study 30.5%
of the subjects with a positive test for fecal occult
blood had advanced neoplasia, as compared with
8.8% of those with a negative test [relative risk: 3.47;
95% confidence interval (CI): 2.76 – 4.35]. Testing
with one-time sigmoidoscopy alone would detect
70.3% percent (95% CI: 65.2–75.4) of patients with
advanced neoplasia. One-time combined testing
would fail to identify 24% of patients with advanced
neoplasia.
COMMENT
Colorectal cancer is the second most frequently
occurring cancer in both sexes (2). In spite of the
Digestive Diseases and Sciences, Vol. 47, No. 9 (September 2002)
COLORECTAL CANCER SCREENING
advances in the treatment of this disease, the 5-year
survival is only about 55% (3). Studies have shown
that survival improves with diagnosis at an earlier
stage, thus providing a rationale for screening (4). It
is accepted that precursor lesions (polyps) almost
always precede the development of neoplasm by sev-
eral years, and removing polyps may reduce the risk
of cancer (5). Of all the screening modalities avail-
able, the most evidence exists for fecal occult blood
testing and sigmoidoscopy. Despite its low sensitivity
(25–50%), four large-scale randomized trials have
shown that annual or biennial screening of people
without symptoms by means of fecal occult blood
testing reduces mortality from colorectal cancer
(CRC) (6). An extension of CRC screening with
sigmoidoscopy and one-time hemoccult testing was
reported by Lieberman and Weiss on 2885 asymp-
tomatic subjects. The information obtained during
examination of the rectum and sigmoid during
colonoscopy was extrapolated to that which would be
obtained at sigmoidoscopy. They found that 24% of
advanced neoplasias, defined as adenoma of ⱖ10 mm
diam., a villous adenoma, an adenoma with high-
grade dysplasia, or invasive cancer were missed with
sigmoidoscopy and one-time fecal occult blood tests.
In his editorial, Detsky elegantly illustrates five
reasons why colonoscopy is not recommended by
most clinical-practice guidelines. First, there is lack of
randomized large-scale trials involving colonoscopy
as a screening modality. Second, the lack of adher-
ence to recommendations and patient preference is a
concern. Third, there are higher risks of bleeding and
perforations involved with colonoscopy. Fourth,
colonoscopy has been deemed by some to not be cost
effective. Fifth, there is substantial variability in the
cost of colonoscopy, resulting in some questions.
However, Provenzal et al showed that the incremen-
Digestive Diseases and Sciences, Vol. 47, No. 9 (September 2002)
tal cost-effectiveness ratio for screening colonoscopy
was $6,600/life year gained compared to $22,000/life
year gained for breast cancer screening (7).
Does the new data of fecal occult blood testing and
sigmoidoscopy that misses approximately 24% of ad-
vanced neoplasia finally favor moving away from
these modalities? The data reinforces the obvious:
that we must see the entire colon to make an ade-
quate screening decision. With these new data, per-
haps it would be best to describe the cost, risks, and
benefits involved with all the screening modalities to
asymptomatic people and allow them to make the
decisions as to which screening modality they would
prefer. Thus, as Congress has done, we can embrace
colonoscopy as the modality of choice for CRC.
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