Mass screening for colorectal cancer: the French program

I read with interest the article by Dr. Pox et al. [1], which reviewed the current status of screening colonoscopy in Europe and the United States, and would like to report on the historical development and current position of this type of screening in France. In May 2005, the French Ministry of Health decided to launch a program of mass screening for colorectal cancer, which is be made available to the general population at the end of 2007. The whole of the French population aged between 54 and 74 years will take part in this screening.

Pr. J. Faivre from Dijon was the French pioneer of mass screening for colorectal cancer [2]. A study he conducted with colleagues in Bourgogne demonstrated that screening with the fecal occult blood test (FOBT) reduced the mortality from colorectal cancer, confirming the findings of other studies carried out using the same test in England and Denmark. Pr. Faivre and the French National Society of Gastroenterology (SNFGE) then submitted a proposal to the French Ministry of Health and to the National Health Insurance Funds concerning the generalization of FOBT screening to the whole population in France.

The French Ministry of Health agreed to launch a program of colorectal cancer screening in France, starting with a feasibility pilot phase in approximately one fifth of the country (in 23 regions [départements] out of 100). This feasibility phase was carried out to assess whether the results of the initial studies could be replicated, in particular with regard to patient compliance.

Each of the 23 regions organized its own screening program according to a regional management structure, but they all strictly followed the highly accurate national specifications. This pilot phase took off in 2002 and yielded positive results: data analysis showed that patient compliance with the FOBT could exceed 50 % and that in cases where the FOBT was positive, compliance with colonoscopy reached levels greater than 85 % among the French population. In view of these results, it was decided in May 2005 to generalize the screening to the whole population.

What does this mean in real terms for the individual? The general practitioner is the key person who takes the decision concerning the need for screening. All people aged between 50 years and 74 years are to be invited every 2 years to attend their general practitioner in order to receive a screening test. The general practitioner will explain the key features of the program and the procedure and provides the FOBT; most importantly, this physician should also look out for high-risk patients (i. e. patients with a family or personal history of polyps or of cancers), who should not take part in the mass screening program but who should immediately undergo colonoscopy. In fact, mass screening is only aimed at the medium-risk population; high-risk patients undergo individual screening with immediate colonoscopy. In parallel to the mass screening program, individual screening will be reinforced by the Société Française d’Endoscopie Digestive (SFED) using a variety of methods, including posters and letters to families and general practitioners. If a person does not consult his general practitioner, he will receive a second letter. In cases of failure to respond to the second letter, a test will be sent to his home.

Once the person performs the test, it is sent by mail to a regional test reading center. This test reading center, selected through an invitation to tender, must have a large amount of experience and a positive response rate of 2 % - 3 %. Both the screened person and the general practitioner are sent the test result. When this is positive, a colonoscopy (performed by a hepatogastroenterologist) is organized.

What are the organizational features of the screening program? A large-scale infrastructure has been set up. The whole of the French population aged between 50 and 74 years has been entered in a register that has been compiled using the databases of the Health Insurance Funds and screening is offered to people on this list. The smooth running of the screening program is assured at national level (by a national survey committee) by the Ministry of Health and the National Agency for Cancer. Specialists in gastroenterology also participate in the monitoring of the program. However, the management has been relocated in a way that allows the various regions to manage the register of their own region’s population and to deal with the results and the screened people and the general practitioners. Each of these management structures also manages the breast cancer screening and treatment programs (together with the radiologists). For example, in the Rhone département, which comprises the city of Lyon (population 1.5 million), the management structure includes 19 salaried employees. All of the data are nominative and entered into a database and it is possible to monitor both compliance and test results.

This level of infrastructure is considered mandatory in order to achieve good compliance with the screening program and for the screening to be efficient and effective. In addition, studies and clinical research aiming to evaluate new screening tests (such as immunologic tests) can be easily appended to such a structure with the approval of the national survey committee.

All these aspects of the service indicate that this screening should be a success in the public health field in France. The choice of the FOBT as a selection test is based on evidence from the recent literature and on the facts that the test must be specific, easy to perform (in order to be accepted by the population), and cheap. It is not anticipated that this screening will lead to a drastic change in the number of colonoscopies performed. At present, 1 million colonoscopies are performed per year in France, and this number will only be increased by 10 % by the mass screening.

Another advantage of the choice of a two-step screening program, FOBT followed by a colonoscopy, is that if an alternative to the FOBT is validated in future, it will be relatively easy to replace the FOBT within the program. Finally, the last advantage of the program is that mass screening for colorectal cancer seems to have a beneficial effect in terms of promoting individual screening by direct colonoscopy in high-risk patients.

Competing interests: None

References

• 1 Pox C, Schmiegel W, Classen M. Current status of screening colonoscopy in Europe and in the United States.  Endoscopy. 2007;  39 168-173
• 2 Bretagne J F, Faivre J. The French National Society of Gastroenterology recommends systematic organized screening for colorectal cancer in France.  Gastroenterol Clin Biol. 2000;  24 (5) 492-493