SPED Statement: Colorectal cancer screening in Portugal
25 July 2019 (online)
The Portuguese Society of Digestive Endoscopy (SPED) throughout its history has always been focused on colorectal cancer (CRC) and the promotion of its population-based screening. CRC is a major health problem due to its high incidence and mortality . In 2018 in Portugal about 10 000 people were diagnosed with this disease (1st place in incidence, surpassing breast and prostate cancer) with a mortality around 45 % (1st cause of cancer death, representing 16 % of deaths due to neoplasia). In reality, there are 11 Portuguese who die every day from this disease, potentially avoidable by screening    !
In 2017, the Portuguese Government finally legislated the implementation of a national population-based screening program. Accordingly, in its sequence, the Directorate-General for Health has withdrawn its recommendation about opportunistic screening of CRC . In this regard, SPED promotes the current opinion paper that consists of a series of recommendations/statements based on the available scientific evidence and on guidelines published by similar scientific societies.
SPED recommends that:
Physicians should suggest CRC screening to all asymptomatic individuals of both sexes, aged between 50 and 74, without family history of CRC, and whenever life expectancy is longer than 10 years  . SPED deems it necessary to continuously promote informative actions to the general population and the medical community about this subject, as well as the known forms of primary and secondary prevention. SPED also acknowledges observations of an increase in the incidence of CRC under the age of 50, which may determine a change in the age at which screening might start in the near future.
CRC screening should be organized in a national, population-based model  . CRC screening has demonstrated to be cost-effective in reducing mortality in several countries. CRC should be a public health priority in Portugal and SPED considers it is vital that the various entities involved in the screening process are aligned with the ultimate purpose of implementation and adherence to procedures, aiming to achieve a reduction in mortality due to CRC.
According to international recommendations, colonoscopy and fecal immunochemical test (FIT) are the first-line screening methods to be proposed  . These two methods have different levels of efficacy, population adherence, costs and endoscopic capacity requirements: a) colonoscopy is most effective in reducing mortality and is also effective in reducing incidence but has much higher costs and the lowest rates of population adherence (being this parameter unknown in Portugal) ; b) FIT is an alternative that consistently presents higher adhesion rates and therefore is equally effective, being much cheaper, even if, when positive, determines the performance of colonoscopy.
In Portugal, the FIT model followed by colonoscopy is cost-effective . SPED believes that other options may be considered, such as sigmoidoscopy or total colonoscopy with different periodicities, but they require assumptions regarding the populationʼs adherence not yet verified and a greater demand for endoscopic resources. For these reasons, implementation difficulties are expected and should be anticipated.
Whichever model is adopted in population terms, the performance of a quality colonoscopy is central because it generates immediate indicators related to the ultimate outcome of cancer death prevention  . Colonoscopy quality indicators include parameters (such as the adenoma detection rate) that are directly related to the rate of interval cancers (cancers diagnosed before the proposed date for the next control colonoscopy) and the risk of death from colorectal cancer . SPED finds it essential to audit the quality of colonoscopies as a pillar of the quality and effectiveness of a CRC screening program. In conjunction with other national and international Societies, SPED will promote the evaluation of measurable quality criteria, as well as the development of ways to facilitate this process through safety checklists, certification of endoscopic reports programs and training actions.
Individuals and groups constituted in units and/or departments should measure, audit and report colonoscopy quality indicators. All colonoscopies must meet a quality threshold, which must be maintained over time. Quality indicators have already been defined and should be the basis for this process .
SPED considers fundamental for the national and universal implementation of CRC screening the use of all the existing endoscopic capacity in Portugal, regardless of its contractual relationship and form of payment, provided that it meets the quality criteria already mentioned. The cost-effectiveness model in Portugal assumed the use of all available human resources for the implementation of the current proposal of FIT followed by colonoscopy .
SPED believes that the current payment assigned to the colonoscopy should be revised and increased. The current price does not take into consideration the quality of the colonoscopy. Faced with the most current quality parameters such as procedural time, quality of bowel preparation, assumptions of adenoma detection rate, polyps removal and ability to resolve any associated complications, as well as disinfection, endoscopic material wear and cost of endoscopic accessories, it is essential and urgent to revise the colonoscopy value. The cost-effectiveness model in Portugal of FIT followed by colonoscopy showed that the price of colonoscopy can clearly be increased without compromising its cost-effectiveness .
- 1 Jemal A, Bray F, Center MM. et al. Global cancer statistics. CA: a cancer journal for clinicians 2011; 61: 69-90
- 2 Ferlay J, Steliarova-Foucher E, Lortet-Tieulent J. et al. Cancer incidence and mortality patterns in Europe: estimates for 40 countries in 2012. Eur J Cancer 2013; 49: 1374-1403
- 3 Zorzi M, Fedeli U, Schievano E. et al. Impact on colorectal cancer mortality of screening programmes based on the faecal immunochemical test. Gut 2015; 64: 784-790
- 4 Lin JS, Piper MA, Perdue LA. et al. Screening for Colorectal Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA : the journal of the American Medical Association 2016; 315: 2576-2594
- 5 World Health Organization. Mortality database In, Department of Information, Evidence and Research.
- 6 Despacho 8254/2017, DOI, (21/09/2017 2017).
- 7 Lansdorp-Vogelaar I, von Karsa L. European Colorectal Cancer Screening Guidelines Working Group. European guidelines for quality assurance in colorectal cancer screening and diagnosis. First Edition--Introduction. Endoscopy 2012; 44 (Suppl. 03) SE15-30
- 8 Rembacken B, Hassan C, Riemann JF. et al. Quality in screening colonoscopy: position statement of the European Society of Gastrointestinal Endoscopy (ESGE). Endoscopy 2012; 44: 957-968
- 9 Rex DK, Boland CR, Dominitz JA. et al. Colorectal cancer screening: Recommendations for physicians and patients from the U.S. Multi-Society Task Force on Colorectal Cancer. Gastrointestinal endoscopy 2017; 86: 18-33
- 10 Wolf AMD, Fontham ETH, Church TR. et al. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA: a cancer journal for clinicians 2018; 68: 250-281
- 11 Areia M, Fuccio L, Hassan C. et al. Cost-utility analysis of colonoscopy or faecal immunochemical test for population-based organised colorectal cancer screening. United European Gastroenterol J 2019; 7: 105-113
- 12 Kaminski MF, Thomas-Gibson S, Bugajski M. et al. Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2017; 49: 378-397
- 13 Corley DA, Jensen CD, Marks AR. et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med 2014; 370: 1298-1306