Colorectal cancer screening in Europe: compliance and the choice of test

Prevention of colorectal cancer (CRC) is a major and increasing challenge worldwide. However, it is important to know whether the prevalence of CRC is different across different countries. To date, there is no common screening program for the prevention of CRC in the countries of the European Union. Countries such as France have established organized screening programs in which individuals are invited to take a fecal occult blood test (FOBT), whereas in Germany in addition to the FOBT opportunistic colonoscopy is the procedure of choice for the detection and simultaneous treatment of precursor lesions and early CRC. The acceptance of preventive strategies and compliance by patients may also differ, even within countries. Many factors such as social status, sex, location, and income may influence the behavior of people invited to take part in screening programs [1].

From this perspective, the paper by Stock and Brenner in this issue of Endoscopy deserves special attention [2]. This is the first investigation in a large number of European Union countries to estimate the use and acceptance of lower gastrointestinal endoscopy and FOBT. This study was based on a European research project, the Survey of Health, Aging, and Retirement in Europe (SHARE), which combines extensive cross-national information on health and living conditions of people aged 50 years and over. The authors confirmed what was already suspected, that there are large differences in the screening methods used and in the acceptance rates of screening populations in different European countries. In most of the countries studied screening relies on FOBT or sigmoidoscopy. However, of the 11 countries studied, only Austria and Germany offer routine colonoscopy screening, with excellent follow-up data available [3]. In all countries FOBT is used but with variable uptake; use varies from as low as 4 % in The Netherlands to over 60 % in Austria. Unfortunately, no Eastern European country, where high incidences of CRC have been reported, is included in the study, although Poland for example is known to use colonoscopy as a screening tool.

European guidelines for the prevention of CRC will be published by the European Cancer Network this summer. The guidelines include the introduction of immunochemical stool tests (iFOBT) instead of guaiac-based FOBT (gFOBT) due to the comparable specificity but significantly higher sensitivity, particularly with regard to large adenomas [4] [5]. Organized screening rather than opportunistic screening is also proposed. The results of the paper by Stock and Brenner show that the latter is warranted: in 2006 nearly 300 000 new CRC cases were reported in the European Union and there were nearly 140 000 cancer deaths. There is therefore a need to act in order to substantially increase the acceptance rate of preventive strategies. Clearly informed decision-making by individuals will be important for the success of screening programs [6].

From an outcomes research point of view, this study presents excellent data to discuss cross-national data and time-trends of CRC and describes tools and techniques to predict, and later investigate, the kind of change we will see if organized screening programs are introduced Europe-wide. To start though, the type of screening tool needs to be decided: FOBT, sigmoidoscopy or colonoscopy? The most evidence-based data relate to the use of gFOBT [7]. A recent study has shown good evidence supporting the use of sigmoidoscopy in a screening program [8]. For colonoscopy, some cohort studies (no randomized controlled studies are available) have shown convincing results [9]. These data on screening colonoscopy demonstrate a significant reduction of CRC in Germany since its introduction [10], and a low risk of recurrent large-bowel lesions after an initial normal colonoscopy [9].

In countries where lower gastrointestinal endoscopy is offered for screening, quality assurance programs need to be established in order to ensure the safety of the screening population. In fact, the European Society of Gastrointestinal Endoscopy (ESGE) has set up a quality program for screening colonoscopy.

Stock and Brenner should be congratulated for their study, which provides basic data and an insight into the current use of screening procedures in different European countries. It will be necessary in the future to include more countries in order to get a more detailed insight into screening behavior across Europe. Especially in the current economic climate when costs are an issue, not only in the health system, there is a growing need to increase the use of preventive strategies to fight diseases such as CRC, which are associated with high mortality and costly treatment. Future outcomes research may rely heavily on the results from this study, particularly after the introduction of the new European guidelines for the prevention of CRC.

Competing interests: None

References

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