A comparative case study of bowel cancer screening in the UK and Australia: evidence lost in translation?

OBJECTIVES: (i) To document the current state of the English, Scottish, Welsh, Northern Irish and Australian bowel cancer screening programmes, according to seven key characteristics, and (ii) to explore the policy trade-offs resulting from inadequate funding. SETTING: United Kingdom and Australia. METHODS: A comparative case study design using document and key informant interview analysis. Data were collated for each national jurisdiction on seven key programme characteristics: screening frequency, population coverage, quality of test, programme model, quality of follow-up, quality of colonoscopy and quality of data collection. A list of optimal features for each of the seven characteristics was compiled, based on the FOBT screening literature and our detailed examination of each programme. RESULTS: Each country made different implementation choices or trade-offs intended to conserve costs and/or manage limited and expensive resources. The overall outcome of these trade-offs was probable lower programme effectiveness as a result of compromises such as reduced screening frequency, restricted target age range, the use of less accurate tests, the deliberate setting of low programme positivity rates or increased inconvenience to participants from re-testing. CONCLUSIONS: Insufficient funding has forced programme administrators to make trade-offs that may undermine the potential net population benefits achieved in randomized controlled trials. Such policy compromise contravenes the principle of evidence-based practice which is dependent on adequate funding being made available.

Review article: Population screening for colorectal cancer.

Colorectal cancer is a common cancer and common cause of death. The mortality rate from colorectal cancer can be reduced by identification and removal of cancer precursors, adenomas, or by detection of cancer at an earlier stage. Pilot screening programmes have demonstrated decreased colorectal cancer mortality; as a result many countries are developing colorectal cancer screening programmes. The most common modalities being evaluated are faecal occult blood testing, flexible sigmoidoscopy and colonoscopy. Implementation of screening tests has been hampered by cost, invasiveness, availability of resources and patient acceptance. New technologies such at computed tomographic colonography and stool screening for molecular markers of neoplasia are in development as potential minimally invasive tools. This review considers who should be screened, which test to use and how often to screen.

Meta-analysis of dietary restriction during fecal occult blood testing.

CONTEXT: Dietary restriction is often recommended during fecal occult blood testing (FOBT) as a means of increasing test accuracy, but concern surrounds whether such restriction also reduces the chance that patients will complete the test. PURPOSE: We conducted a systematic review and meta-analysis to determine if advice about dietary restrictions affects the rate of completion of FOBT and the rate of positive results. METHODS: We searched the MEDLINE database and hand-searched the bibliographies of other systematic reviews and clinical practice guidelines to identify randomized trials of advice to perform dietary restriction during FOBT. We included only trials that reported the proportion of patients who completed the occult blood tests (completion rate). When such information was available, we also recorded the proportion of patients who had positive test results (positivity rate). RESULTS: Five randomized trials met our inclusion criteria. All used guaiac-based Hemoccult tests; none reported results from rehydrated test slides. In four trials, there was little or no difference in test completion between patients assigned to dietary restriction and those with no restriction. In one small trial that used an especially restrictive diet, completion was 21 percentage points lower in the restricted group. Positivity rates were reported in four trials, none of which found a statistically significant difference between groups. Meta-analysis showed no difference in the summary positivity rate between those assigned to dietary restriction versus those not restricted (difference in positivity rate, 0%; 95% CI, -1% to 1%). CONCLUSIONS: Available data suggest that advice to perform modest dietary restriction during unrehydrated FOBT does not affect the completion rate, but more severe restrictions may. Dietary restriction also does not appear to affect positivity rates. On the basis of these data, physicians do not need to advise patients to restrict their diet for nonrehydrated FOBTs.

The art and science of incorporating cost effectiveness into evidence-based recommendations for clinical preventive services.

As medical technology continues to expand and the cost of using all effective clinical services exceeds available resources, decisions about health care delivery may increasingly rely on assessing the cost-effectiveness of medical services. Cost-effectiveness is particularly relevant for decisions about how to implement preventive services, because these decisions typically represent major investments in the future health of large populations. As such, decisions regarding the implementation of preventive services frequently involve, implicitly if not explicitly, consideration of costs. Cost-effectiveness analysis summarizes the expected benefits, harms, and costs of alternative strategies to improve health and has become an important tool for explicitly incorporating economic considerations into clinical decision making. Acknowledging the usefulness of this tool, the third U.S. Preventive Services Task Force (USPSTF) has initiated a process for systematically reviewing cost-effectiveness analyses as an aid in making recommendations about clinical preventive services. In this paper, we provide an overview and examples of roles for using cost-effectiveness analyses to inform preventive services recommendations, discuss limitations of cost-effectiveness data in shaping evidence-based preventive health care policies, outline the USPSTF approach to using cost-effectiveness analyses, and discuss the methods the USPSTF is developing to assess the quality and results of cost-effectiveness studies. While this paper focuses on clinical preventive services (i.e., screening, counseling, immunizations, and chemoprevention), the framework we have developed should be broadly portable to other health care services.

Screening and treating adults for lipid disorders.

CONTEXT: Screening and treatment of lipid disorders in people at high risk for future coronary heart disease (CHD) events has gained wide acceptance, especially for patients with known CHD, but the proper role in people with low to medium risk is controversial. OBJECTIVE: To examine the evidence about the benefits and harms of screening and treatment of lipid disorders in adults without known cardiovascular disease for the U.S. Preventive Services Task Force. DATA SOURCES: We identified English-language articles on drug therapy, diet and exercise therapy, and screening for lipid disorders from comprehensive searches of the MEDLINE database from 1994 through July 1999. We used published systematic reviews, hand searching of relevant articles, the second Guide to Clinical Preventive Services, and extensive peer review to identify important older articles and to ensure completeness. DATA SYNTHESIS: There is strong, direct evidence that drug therapy reduces CHD events, CHD mortality, and possibly total mortality in middle-aged men (35 to 65 years) with abnormal lipids and a potential risk of CHD events greater than 1% to 2% per year. Indirect evidence suggests that drug therapy is also effective in other adults with similar levels of risk. The evidence is insufficient about benefits and harms of treating men younger than 35 years and women younger than 45 years who have abnormal lipids but no other risk factors for heart disease and low risk for CHD events (less than 1% per year). Trials of diet therapy for primary prevention have led to long-term reductions in cholesterol of 3% to 6% but have not demonstrated a reduction in CHD events overall. Exercise programs that maintain or reduce body weight can produce short-term reductions in total cholesterol of 3% to 6%, but longer-term results in unselected populations have found smaller or no effect. To identify accurately people with abnormal lipids, at least two measurements of total cholesterol and high-density lipoprotein cholesterol are required. The role of measuring triglycerides and the optimal screening interval are unclear from the available evidence. CONCLUSIONS: On the basis of the effectiveness of treatment, the availability of accurate and reliable tests, and the likelihood of identifying people with abnormal lipids and increased CHD risk, screening appears to be effective in middle-aged and older adults and in young adults with additional cardiovascular risk factors.

Videotape-based decision aid for colon cancer screening. A randomized, controlled trial.

BACKGROUND: Rates of colon cancer screening in the United States are low, in part because of poor communication between patients and providers about the availability of effective screening options. OBJECTIVE: To test whether a decision aid consisting of an educational video, targeted brochure, and chart marker increased performance of colon cancer screening in primary care practices. DESIGN: Randomized, controlled trial. SETTING: Three community primary care practices in central North Carolina. PATIENTS: 1657 consecutive adult patients 50 to 75 years of age were contacted. Of these, 651 (39%) agreed to participate; 249 of the 651 participants (38%) were eligible. Eligible patients had no personal or family history of colon cancer and had not had fecal occult blood testing in the past year or flexible sigmoidoscopy, colonoscopy, or barium enema in the past 5 years. INTERVENTION: The 249 participants were randomly assigned to view an 11-minute video about colon cancer screening (intervention group) or a video about automobile safety (control group). After viewing the video, intervention group participants chose a color-coded educational brochure (based on stages of change) to indicate their degree of interest in screening. A chart marker of the same color was attached to their charts. Controls received a generic brochure on automobile safety, and no chart marker was attached. MEASUREMENTS: Frequency of screening test ordering as reported by participants and frequency of completion of screening tests as verified by chart review. RESULTS: Fecal occult blood testing or flexible sigmoidoscopy was ordered for 47.2% of intervention participants and 26.4% of controls (difference, 20.8 percentage points [95% CI, 8.6 to 32.9 percentage points]). Screening tests were completed by 36.8% of the intervention group and 22.6% of the control group (difference, 14.2 percentage points [CI, 3.0 to 25.4 percentage points]). CONCLUSION: A decision aid consisting of an educational video, brochure, and chart marker increased ordering and performance of colon cancer screening tests.

Use of lipid lowering drugs for primary prevention of coronary heart disease: meta-analysis of randomised trials.

OBJECTIVE: To summarise the effect of primary prevention with lipid lowering drugs on coronary heart disease events, coronary heart disease mortality, and all cause mortality. DESIGN: Meta-analysis. IDENTIFICATION: Systematic search of the Medline database from January 1994 to June 1999 for English language studies examining drug treatment for lipid disorders (use of the MeSH terms "hyperlipidemia" and "anticholesteremic agents," keyword searches for individual drug names, and a search strategy for identifying randomised trials to capture relevant articles); identification of older studies through systematic reviews and hand search of bibliographies. INCLUSION CRITERIA: All randomised trials of at least one year's duration that examined drug treatment for patients with no known coronary heart disease, cerebrovascular disease, or peripheral vascular disease and that measured clinical end points, including all cause mortality, coronary heart disease mortality, and non-fatal myocardial infarctions. DATA EXTRACTION: Review of the articles and extracted relevant data by two authors separately, with disagreements resolved by consensus. RESULTS: Four studies met eligibility criteria. Drug treatment reduced the odds of a coronary heart disease event by 30% (summary odds ratio 0.70, 95% confidence interval 0.62 to 0.79) but not the odds of all cause mortality (0.94, 0.81 to 1.09). When statin drugs were considered alone, no substantial differences in results were found. CONCLUSIONS: Treatment with lipid lowering drugs lasting five to seven years reduces coronary heart disease events but not all cause mortality in people with no known cardiovascular disease.

Lipid screening in women.

Evidence of the benefits of lowering cholesterol in various populations continues to grow, but questions persist about screening and treatment of lipid disorders in women. In this paper, we review the distinct features of the epidemiology of lipids and coronary heart disease in women and data from recent long-term treatment trials specific to women. Although data from primary prevention trials in women remain sparse, recent trials demonstrating benefits of cholesterol reduction across a broad range of cholesterol levels and cardiac risk in men and women bolster the conclusion that benefits may extend to asymptomatic women who are otherwise at high risk for coronary disease. Periodic lipid screening beginning in middle age will identify most women who are at high enough risk to merit drug therapy or more intensive individual lifestyle interventions. More detailed consideration of age, diabetes, blood pressure, specific lipid levels, or the ratio of total cholesterol to high-density lipoprotein cholesterol, and other risk factors can more accurately estimate individual risk of coronary heart disease and identify high-risk women most likely to benefit from lipid reduction. Advice about healthy diet, weight control, and physical activity can benefit all women, but authorities differ on the benefits of routine lipid screening in low-risk younger women.

Patient preferences for colon cancer screening.

OBJECTIVE: To measure patient preferences for four different screening strategies: annual fecal occult blood testing (FOBT) alone; flexible sigmoidoscopy (FSIG) every 5 years alone; both annual FOBT and FSIG every 5 years; or no screening. DESIGN: Survey. SETTING: University internal medicine clinic. PATIENTS: Convenience sample of 146 adults (aged 50-75 years) with no previous history of colon cancer. INTERVENTION: Three-part educational program on colon cancer screening administered verbally by trained research assistants. MEASUREMENTS AND MAIN RESULTS: Patient preferences for screening were measured at three points: after descriptive information about colon cancer and screening options (testing procedure information); after information about test performance but with no out-of-pocket costs (test performance information); and finally with hypothetical out-of-pocket costs (cost information). After only descriptive test information, the most popular strategies were FOBT alone (45%) or both tests (38%). Fewer patients preferred FSIG alone (13%). After information about test performance, more subjects preferred both tests (47%), and fewer subjects preferred FOBT alone (36%) (p =.12). With hypothetical out-of-pocket costs, the proportion preferring FOBT alone increased to 53%, while those preferring both tests decreased to 31% (p <.001). Less than 5% of patients preferred no screening. CONCLUSIONS: Patient preferences for colon cancer screening were modestly sensitive to information about test performance and strongly sensitive to out-of-pocket costs. The heterogeneity of patients' preferences for how to be screened supports informed shared decision making as a possible means of improving colon cancer screening.