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Colorectal cancer screening with faecal immunochemical testing, sigmoidoscopy or colonoscopy: a clinical practice guideline

BMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l5515 (Published 02 October 2019) Cite this as: BMJ 2019;367:l5515
Visual summary of recommendation Last updated 19 Jan 2023
No screening FIT Every year FIT Every two years Sigmoidoscopy Single Colonoscopy Single Favours no screening Favours screening We suggest no screening Interventions compared Recommendations Screening options Population We suggest using a tool such as the QCancer® calculator to estimate the risk of colorectal cancer for each person in the next 15 years. This calculates risk, based on: Understanding a person’s risk of cancer can help to determine the benefits and harms of different screening tests for their individual situation. Faecal testing with a faecal immunochemical test (FIT) every year Faecal testing with a faecal immunochemical test (FIT) every two years Endoscopic examination of only the lower part of the colon Endoscopic examination of the entire colon Favours no screening Favours screening Colonoscopy offered if FIT or sigmoidoscopy positive People with an estimated 15 year risk of colorectal cancer below 3% We suggest screening with one of the four screening options People with an estimated 15 year risk of colorectal cancer above 3% Estimating risk Healthy adults with no history of screening Aged 50 to 79 Age Smoking status Medical and family history BMI Sex Ethnicity Link to QCancer® calculator qcancer.org/15yr/colorectal/ Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone. Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone.
Visit the MAGICapp multiple comparison tool to compare and choose options Evidence summaries Screening options should be chosen in shared decision making, based on a person’s individual risk of cancer

For a person with a 2% risk of colorectal cancer within 15 years

Colorectal cancer mortality No screening FIT every year Sigmoidoscopy FIT every two years Colonoscopy 6 3 3 3 2 Events per 1000 people Evidence quality (GRADE score) Low Colorectal cancer mortality Events per 1000 people Evidence quality (GRADE score) Low -1 0 -1 0 -1 -3 -3 -3 -4 0 Colorectal cancer incidence No screening FIT every year Sigmoidoscopy FIT every two years Colonoscopy 20 17 14 19 13 Events per 1000 people Evidence quality (GRADE score) Low Colorectal cancer incidence Events per 1000 people -1 -3 -6 -5 -4 -3 -1 -6 -7 -2 One or more colonoscopies No screening FIT every year Sigmoidoscopy FIT every two years Colonoscopy 0 300 159 203 1000 Events per 1000 people Evidence quality (GRADE score) Low * * High quality for colonoscopy One or more colonoscopies Events per 1000 people -841 -141 -797 -44 -700 -300 -203 -159 -1000 -97 Two or more colonoscopies No screening FIT every year Sigmoidoscopy FIT every two years Colonoscopy 0 66 57 54 68 Events per 1000 people Evidence quality (GRADE score) Low Two or more colonoscopies Events per 1000 people -11 -9 -14 -3 -2 -66 -54 -57 -68 -12 GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low See all outcomes

For a person with a 3% risk of colorectal cancer within 15 years

No screening FIT every year Sigmoidoscopy FIT every two years Colonoscopy 9 3 4 4 3 Colorectal cancer mortality Events per 1000 people Evidence quality (GRADE score) Low Colorectal cancer mortality Events per 1000 people Evidence quality (GRADE score) Low -1 -1 -1 0 0 -6 -5 -5 -6 -1 No screening FIT every year Sigmoidoscopy FIT every two years Colonoscopy 30 26 22 29 20 Colorectal cancer incidence Events per 1000 people Evidence quality (GRADE score) Low Colorectal cancer incidence Events per 1000 people Evidence quality (GRADE score) Low -2 -4 -9 -7 -6 -4 -1 -8 -10 -3 No screening FIT every year Sigmoidoscopy FIT every two years Colonoscopy 0 347 237 246 1000 One or more colonoscopies Events per 1000 people Evidence quality (GRADE score) Low * * High quality for colonoscopy One or more colonoscopies Events per 1000 people Evidence quality (GRADE score) Low * * High quality for colonoscopy -763 -110 -754 -9 -653 -347 -246 -237 -1000 -101 No screening FIT every year Sigmoidoscopy FIT every two years Colonoscopy 0 101 86 83 105 Two or more colonoscopies Events per 1000 people Evidence quality (GRADE score) Low Two or more colonoscopies Events per 1000 people Evidence quality (GRADE score) Low -19 -15 -22 -3 -4 -101 -83 -86 -105 -18 GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low See all outcomes

For a person with a 4% risk of colorectal cancer within 15 years

No screening FIT every year Sigmoidoscopy FIT every two years Colonoscopy 13 6 6 7 5 Colorectal cancer mortality Events per 1000 people Evidence quality (GRADE score) Low Colorectal cancer mortality Events per 1000 people Evidence quality (GRADE score) Low -1 0 -2 -1 -1 -7 -6 -7 -8 -1 No screening FIT every year Sigmoidoscopy FIT every two years Colonoscopy 40 34 29 38 26 Colorectal cancer incidence Events per 1000 people Evidence quality (GRADE score) Low Colorectal cancer incidence Events per 1000 people Evidence quality (GRADE score) Low -3 -5 -12 -9 -8 -6 -2 -11 -14 -4 No screening FIT every year Sigmoidoscopy FIT every two years Colonoscopy 0 391 312 288 1000 One or more colonoscopies Events per 1000 people Evidence quality (GRADE score) Low * * High quality for colonoscopy One or more colonoscopies Events per 1000 people Evidence quality (GRADE score) Low * * High quality for colonoscopy -688 -79 -712 -24 -609 -391 -288 -312 -1000 -103 No screening FIT every year Sigmoidoscopy FIT every two years Colonoscopy 0 138 119 112 144 Two or more colonoscopies Events per 1000 people Evidence quality (GRADE score) Low Two or more colonoscopies Events per 1000 people Evidence quality (GRADE score) Low -25 -19 -32 -7 -6 -138 -112 -119 -144 -26 GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low See all outcomes
Key practical issues While most of the evidence relates to people aged 50-79, these recommendations may also apply to those aged below 50. However, as cancer risk is usually very low in this group, few people will have a 15 year colorectal cancer risk over 3% Other ages The panel found convincing evidence that people’s values and preferences on whether to test and what test to have varies considerably, and this is one factor driving a weak recommendation Values and preferences FIT Sigmoidoscopy Done at home every year or every two years for 15 years Done once in 15 years at an outpatient clinic/hospital Stool from one bowel movement is collected with a stick and mailed for analysis Preparation with bowel enema on the day of the procedure. Sometimes combined with oral laxatives Preparation with oral laxatives starting the day before procedure Individuals with a positive test are offered colonoscopy Usually performed with no sedation, so no recovery time necessary after procedure Often performed under conscious sedation. Also performed under general anesthesia or with no sedation Most individuals will experience no or only mild pain during and shortly after the procedure, but some will experience moderate to severe pain If sedation or anesthesia is used, recovery time will be needed after the procedure If performed without sedation, the majority of individuals will experience no or only mild pain during and shortly after the procedure, but some will experience moderate to severe pain Colonoscopy Preparation During theprocess Afterwards Timing

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Re: Colorectal cancer screening with faecal immunochemical testing, sigmoidoscopy or colonoscopy: a clinical practice guideline

Dear Editor

Letter to: “Colorectal cancer screening with faecal immunochemical testing, sigmoidoscopy or colonoscopy: a clinical practice guideline”
An international panel of experts in different fields published recommendations for individuals, regarding screening for colorectal cancer (CRC) related to the most commonly used options, based on the most solid evidence base. Guidelines were given considering clinical important outcomes such as all-cause mortality, colorectal cancer mortality but also serious adverse events, emotional stress and anxiety related to a positive test. The recommendations compared different screening procedures for healthy individuals aged 50-79 years, taking into account the balance between benefits, burdens and harm. The manuscript suggests to do a CRC screening only if an individual’s estimated 15-year risk of colorectal cancer is 3% or more. The recommendations are based on a prediction models characterised by an area under the receiver operating curve (AUC) of 0.85 for women and 0.86 for men in the development cohort, and 0.66 for women and 0.70 for men in the external validation cohort 1.
In the era of “precision medicine”, we agree with the authors that it is important to personalize screening programs based on individual risk. It is reasonable not to screen subjects with low cancer risk, given the serious adverse events, emotional stress and anxiety related to a positive test if the latter is not certainly related to the presence of cancer. On the other hand there is the need for a better risk level discrimination and the development of more accurate tests to provide a personalised screening program.
Recently faecal microbiota analysis has been shown to be reproducible and reliable, and it should be considered as an additional or alternative tool for CRC screening. In a validated study, the accuracy of metagenomic CRC detection was similar to the standard fecal occult blood test (FOBT) and when both approaches were combined, sensitivity improved >45% relative to the FOBT, while maintaining its specificity. The study was validated in independent patient and control populations (N=335) from different countries 2
We carried out a case-control study that was included in a pooled analysis published recently in Nature medicine where we showed that microbiome signatures, trained on multiple datasets, showed consistently high accuracy in both training and independent validation cohorts (average AUC=0.84) 3. . A signature of 12 strains was identified as characterizing the CRC population.
In addition, in our case-control study we were able to assess the role of a risk score similar to the one proposed by the guidelines (smoking, BMI and information from a short questionnaire on alcohol consumption, physical activity and diet) and we found that considering microbiome reproducible biomarkers and also a personal risk score a considerable increased in sensitivity and specificity could be obtained (from 0.85 to 0.95, manuscript in preparation).
With technology improvement also molecular tests are becoming affordable and fecal microbiome signature together with personal risk score will be the base for next generation secondary prevention to improve this detection and decrease risks of false positives.

Reference List

1. Helsingen LM, Vandvik PO, Jodal HC, et al. Colorectal cancer screening with faecal immunochemical testing, sigmoidoscopy or colonoscopy: a clinical practice guideline. BMJ 2019;367:l5515.
2. Zeller G, Tap J, Voigt AY, et al. Potential of fecal microbiota for early-stage detection of colorectal cancer. Mol Syst Biol 2014;10:766.
3. Thomas AM, Manghi P, Asnicar F, et al. Metagenomic analysis of colorectal cancer datasets identifies cross-cohort microbial diagnostic signatures and a link with choline degradation. Nat Med 2019;25:667-78.

Competing interests: No competing interests

23 December 2019
Davide Serrano
Medical Doctor
Maria Rescigno PhD, Sara Gandini PhD
European Institute of Oncology, IRCCS
Via Ripamonti 435

Re: Re: Colorectal cancer screening based on predicted risk: proceed with caution

We agree with the authors on the importance of shared decision making based on the best available evidence. We certainly do not mean to misrepresent the guideline. However, we do not believe that our statements are misleading. They are based on genuine concerns about how guidelines can be implemented in the context of a busy clinical practice with multiple competing demands and priorities.

We fear that it is possible for busy clinicians to rely on the Recommendation in the Abstract ["For individuals with an estimated 15-year colorectal cancer risk below 3%, we suggest no screening (weak recommendation)”] and the infographic ("People with an estimated 15 year risk of colorectal cancer below 3% — We suggest no screening”) as a short cut to a decision, without truly engaging in shared decision making, which is time consuming and challenging.

Such implementation would result in effectively withholding screening based on a controversial risk threshold and a personalized risk estimate that may not be reliable enough given the limitations of current risk prediction tools.

Competing interests: No competing interests

25 November 2019
Reinier GS Meester
Researcher
Prof. Uri Ladabaum. Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA.
Department of Public Health, Erasmus University
Rotterdam, The Netherlands.

Re: Colorectal cancer screening based on predicted risk: Proceed with caution

We view the following points as incontrovertible

1) That many people, particularly those at lower risk, will view the benefits of CRC screening as small or very small when presented with the absolute numbers.
2) That people's values and preferences regarding screening will differ substantially.

It follows from the above that the only way to respect people's choices regarding screening is through providing them with the best evidence available, including its limitations, and then engaging in shared decision-making.

Meester and Ladabaum raise a number of challenges in arriving at an optimal recommendation for CRC screening including choice of an optimal time frame and limitations in risk prediction tools. We are disappointed, though, that the authors are misleading in some of their statements. They are "concerned that clinicians may withhold screening from people with an estimated 15-year CRC risk <3% based on this guideline" and yet they are fully aware that any clinician who "withheld" screening would be violating the guideline. Similarly, the authors end their piece with a plea to practitioners "not to withhold screening resources at present based on current CRC risk prediction tools" as if that is what we were suggesting. We of course would echo their plea, and add another to engage in shared decision-making based on the best available evidence.

Competing interests: No competing interests

22 November 2019
Lise M. Helsingen
Researcher
Michael Bretthauer, Per Olav Vandvik and Gordon Guyatt
Oslo University Hospital and University of Oslo
Sognsvannsveien 21

Colorectal cancer screening based on predicted risk: Proceed with caution

We read with interest the new clinical practice guideline for colorectal cancer (CRC) screening by Helsingen et al.[1] Risk-stratified screening holds great promise, and we commend this panel for attempting to define a preference-based risk threshold rather than simple age criteria for screening. However, we are concerned that clinicians may withhold screening from people with an estimated 15-year CRC risk <3% based on this guideline, which in our view, is premature given the uncertainties regarding the threshold level of CRC risk that would make screening acceptable, the current accuracy of CRC risk prediction, the potential benefits of screening beyond 15 years, and the implications for screening participation in those who might benefit from screening.

Although the panel acknowledged that “people’s view on the net benefit of screening varies substantially,” the members arrived at the 3% threshold by using “their own experience to hypothesise what benefit of screening they thought people would require to undergo screening.”[1] We question whether the methods used are reliable. The panel included patient partners with experience of CRC screening, but might the estimate have differed, for instance, if the panel had included persons with experience of CRC and its treatment, or of screening that led to probable prevention of CRC, or of CRC death in a loved one? More broadly, a single estimate does not consider wide variation in preferences. U.S. CRC screening participation rates are approximately 43% for 50-54 year-olds and 57% for 55-59 year-olds.[2] As the panel points out, the 15-year CRC risk starting at age 50 is 1-2% in North America and Europe. While most persons do not arrive at medical decisions based on quantitative analysis, one can ask whether so many U.S. 50-59 year-olds are making uninformed decisions, or whether current participation patterns provide evidence for a different threshold from the panel’s, even if it is implicit. Given the substantial uncertainty regarding the appropriateness of a single-estimate threshold, we believe that it is not recommendable to adopt a 3% 15-year risk threshold, which is considerably more stringent than other recommendations based on the acceptable “number needed to colonoscope” to avert one additional death[3] or incremental cost-effectiveness criteria.[4]

Furthermore, there is currently substantial misclassification in CRC risk prediction. The guideline and supporting simulations do not consider this seriously enough. In a UK validation study, the risk prediction tool recommended by the panel, QCancer10, had AUCs of 0.66 and 0.70 for 5-year predictions in women and men, respectively.[5] Based on extrapolation of the 5-year QCancer10 calibration graphs,[5] we estimate that acceptance of a 15-year CRC risk threshold of 3% would lead to screening being offered to only 10-30% of women and 40-60% of men in the UK study cohort, leaving approximately 48-81% of women and 15-32% of men who would develop CRC outside of screening inclusion. Moreover, QCancer10 may be less reliable outside the UK or for 15-year risk predictions.[5] Our recent decision analysis suggests that misclassification of risk could actually worsen the harms-benefit ratio of risk-stratified screening vs. uniform screening, particularly if risk-stratification is used to recommend no screening to a substantial fraction of the population.[6]

The panel focused on 15-year outcomes based on the availability of follow-up data from randomized trials. However, it is recognized that CRC screening frontloads burden that may reap benefits later. Looking at 15-year outcomes almost certainly underestimates the real benefit of screening, given both the relatively slow progression from CRC precursors to CRC,[7] and no sign of a plateau in cumulative benefit around 15 years after screening.[8, 9]

As the authors of the risk prediction validation study point out,[5] their findings do not allow for specific recommendations regarding risk-based screening vs. the current age-based criteria, and they suggest that decision-analytic studies be performed, followed by implementation studies. Our recent decision analysis highlights the liabilities of CRC risk misclassification.[6] Even if a risk tool is deemed to have acceptable discrimination ability, complex risk-based screening approaches could have unintended negative impact on screening participation by persons not at low risk of CRC.[10] Thus, we agree that implementation studies are needed before guidelines endorse such an approach.

In summary, although this guideline is provocative as a case for how risk-based screening may be implemented in the future, we caution practitioners not to withhold screening resources at present based on current CRC risk prediction tools.

1. Helsingen LM, Vandvik PO, Jodal HC, et al. Colorectal cancer screening with faecal immunochemical testing, sigmoidoscopy or colonoscopy: a clinical practice guideline. BMJ 2019;367:l5515.
2. Sauer AG, Liu B, Siegel RL, et al. Comparing cancer screening estimates: Behavioral Risk Factor Surveillance System and National Health Interview Survey. Prev Med 2018;106:94-100.
3. Peterse EFP, Meester RGS, Siegel RL, et al. The impact of the rising colorectal cancer incidence in young adults on the optimal age to start screening: Microsimulation analysis I to inform the American Cancer Society colorectal cancer screening guideline. Cancer. 2018; 124: 2964-73.
4. Ladabaum U, Mannalithara A, Meester RGS, et al. Cost-Effectiveness and National Effects of Initiating Colorectal Cancer Screening for Average-Risk Persons at Age 45 Years Instead of 50 Years. Gastroenterology 2019;157:137-148.
5. Usher-Smith JA, Harshfield A, Saunders CL, et al. External validation of risk prediction models for incident colorectal cancer using UK Biobank. Br J Cancer 2018;118:750-759.
6. Ladabaum U, Mannalithara A, Mitani A, Desai M. Clinical and Economic Impact of Tailoring Screening to Predicted Colorectal Cancer Risk: A Decision Analytic Modeling Study. Cancer Epidemiology, Biomarkers & Prevention 2019; In Press.
7. Stryker SJ, Wolff BG, Culp CE, et al. Natural history of untreated colonic polyps. Gastroenterology 1987;93:1009-13.
8. Atkin W, Wooldrage K, Parkin DM, et al. Long term effects of once-only flexible sigmoidoscopy screening after 17 years of follow-up: the UK Flexible Sigmoidoscopy Screening randomised controlled trial. Lancet 2017;389:1299-1311.
9. Shaukat A, Mongin SJ, Geisser MS, et al. Long-term mortality after screening for colorectal cancer. N Engl J Med 2013;369:1106-14.
10. Smith SK, TrevenaL, SimpsonJM, et al. A decision aid to support informed choices about bowel cancer screening among adults with low education: randomised controlled trial. BMJ 2010;341:c5370. 10.1136/bmj.c5370 20978060

Competing interests: No competing interests

20 November 2019
Reinier GS Meester
Researcher
Prof. Uri Ladabaum. Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway Street, Redwood City, California.
Department of Public Health, Erasmus University Medical Center
Wytemaweg 80, 3015 CN Rotterdam, The Netherlands

Re: Colorectal cancer screening with faecal immunochemical testing, sigmoidoscopy or colonoscopy: a clinical practice guideline

We agree with Dr. Anand that availability of treatment is an absolute requirement for implementation of all screening (1). Our recommendations apply to those settings. Without access to post-screening patient care, it is unethical to introduce screening. Priority of health care and preventive services should take into account the absolute risk for disease and disease burden, costs and resources needed, and values and preferences of the population.

1. Wilson JMG, Junger G. Principles and Practice of Screening for Disease. Geneva, Switzerland: World Health Organization; 1968

Competing interests: No competing interests

05 November 2019
Lise M. Helsingen
Researcher
Gordon Guyatt
Oslo University Hospital and University of Oslo
Arnes Vei 3

Cancer Charities should guide not lead astray.

Cancer charities do a marvellous job of supporting cancer patients as well as funding innovative cancer research. But cancer charities exist primarily to minimise suffering from cancer. As such they should promote discussion and disseminate information about the pit falls of cancer screening. Hopefully, the cancer charities will be at the forefront supporting the risk calculators which are an integral part of these bowel screening guidelines.[1].

The potential lack of overall benefit with early diagnosis of some primary cancers is similarly noted with early diagnosis of secondary cancers as well. Multiple randomised studies show no benefit for early diagnosis of relapse (secondary cancer) in asymptomatic cancer patients with intensive follow up investigations.[2].

Unfortunately a recent press release from a breast cancer charity unintentionally promotes the impression that early diagnosis of relapse is beneficial and that GPs are misdiagnosing relapse [3].

‘Fear of recurrence ‘causes significant psychological burden for cancer patients. [4]. Encouraging them to be on constant look out for relapse symptoms and encouraging GPs to look out for relapse would certainly increase psychological morbidity without any meaningful long term benefit.

Cancer charities do need to promote the information that intensive follow up and very early diagnosis of asymptomatic relapse does not improve survival in most cases. Even worse, a high quality randomised trial in ovarian cancer indicates that early diagnosis of relapse can actually impair quality of life.[5].

References
1 Helsingen LM, Vandvik PO, Jodal HC, et al. Colorectal cancer screening with faecal immunochemical testing, sigmoidoscopy or colonoscopy: a clinical practice guideline. BMJ 2019;367:l5515. doi:10.1136/bmj.l5515

2 Moschetti I, Cinquini M, Lambertini M, et al. Follow-up strategies for women treated for early breast cancer. Cochrane Database Syst Rev 2016;:CD001768. doi:10.1002/14651858.CD001768.pub3

3 Secondary cancer diagnosis delays ‘unacceptable’. BBC News. 2019. https://www.bbc.com/news/health-49999404 (accessed 17 Oct 2019).

4 Glaser AW, Fraser LK, Corner J, et al. Patient-reported outcomes of cancer survivors in England 1-5 years after diagnosis: a cross-sectional survey. BMJ Open 2013;3. doi:10.1136/bmjopen-2012-002317

5 Clarke T, Galaal K, Bryant A, et al. Evaluation of follow-up strategies for patients with epithelial ovarian cancer following completion of primary treatment. Cochrane Database Syst Rev 2014;:CD006119. doi:10.1002/14651858.CD006119.pub3

Competing interests: No competing interests

17 October 2019
Santhanam Sundar
Consultant Oncologist
Nottingham University Hospital NHS Trust
Nottingham. NG5 1PB

Re: Colorectal cancer screening with faecal immunochemical testing, sigmoidoscopy or colonoscopy: a clinical practice guideline

I found the article regarding individualised risk in relation to various methods of colorectal cancer screening interesting. I was disappointed however that whilst it referred to faecal immunochemical testing (FIT) within the title and throughout the article, it was illustrated with images of guaiac FOBT test kits.

Competing interests: No competing interests

11 October 2019
Judith M Stein
Lead specialist bowel cancer screening practitioner
University College London Hospitals
GI Services, University College London Hospitals, 250 Euston Road, London, NW1 2PG, UK

Re: Colorectal cancer screening

The first requirement before you screen someone, is to be able to treat the person , and to support the family. If the patient can have his colon whipped out but not on the NHS, then you are leaving him untreated - he may not have the money to “ go private”.
If there is LOW EVIDENCE for screening, then you must tell the prospective “ subject” in so many words.
The same principle applies to other varieties of screening.
The currrent minister of health has spoken of his passion for prostate screening.
Public Health England has already instituted screening for pre-diabetes. Previously healthy persons now labelled as diseased.
The NHS has too few doctors, consultants. It probably has too few properly trained nurses too.
To create more ill people and not to be able to treat them does not seem sensible.

Competing interests: No competing interests

09 October 2019
JK Anand
Retiired doctor
Free spirt
Peterborough , England

Clinical practice guideline from a microsimulation model of colorectal cancer screening methods: Confessing ignorance.

The acknowledgement of the lack of evidence in the “clinical practice guideline” for colorectal cancer screening methods (1) _two recommendations (both rated weak) and a dozen of pictograms about benefits (all rated “low evidence”)_ must be commended as it contrasts with the too usual craze for spin overlooking the “garbage in, garbage out” warning when using mathematical models. However, the use “most informed individuals“ in the conclusion (1) could not have been completed with “of our ignorance”.
The use of “may” in the conclusion of the microsimulation modelling study “over a 15 year period, all screening strategies (faecal immunochemical testing, sigmoidoscopy or colonoscopy) may reduce colorectal cancer mortality” is careful but IMHO overoptimistic.(2) Indeed, in the real life setting, there is no evidence yet that screening reduces colorectal cancer mortality: In the US were the risk of developing cancer is 4.2% in life time, the number of deaths is now 1.45/10,000 per year, having failed very steadily from 2.45 in 1990,far before screening has been promoted).(https://seer.cancer.gov/statfacts/html/colorect.html) Moreover, the Taiwanese FIT Screening Program showed no evidence for effectiveness with a follow-up of 6 years when adjusting for the self-selection bias(Figure 2B in 3)

However, I regret:

a) the lack of pictograms for harms,(1) overdiagnosis cannot be avoided when screening healthy individuals, even more with endoscopy; not only perforations but also postendoscopic infections which are more common than previously though.(4)

b) no assessment of CT colonography which President Obama chose at age 49 in 2010.(5) The preliminary report of a randomized trial comparing FIT vs endoscopy and CT-colonography showing detection rates for advanced neoplasia are 1.7% for first-round FIT vs 5.5% for CT-colonography and 7.2% for endoscopy.(6)

c) the lack of concern for a mandatory prerequisite, funding for quality-assurance and monitoring, as screening is not about a test as it should be a public health program. No countries provide adequate indicators for faecal testing yet, only the uptake for one round is available, a very poor surrogate: serial tests for at least a decade are required for effectiveness in randomized controlled trial where compliance to fecal test was optimum as the uptake of endoscopy when positive.(7) At the other end of serial processes of the program is the endoscopy, again no adequate quality indicator: current interval for rate of adenoma detected are wide and are not standardized for age, smoking, alcohol use and obesity or waist circumference …(8)

The present state of affairs is “opportunistic screening” an euphemism for harms without benefits. The Emperor’s new clothes.

1 Helsingen LM, Vandvik PO, Jodal HC et al. Colorectal cancer screening with faecal immunochemical testing, sigmoidoscopy or colonoscopy: a clinical practice guideline. BMJ 2019;367:l5515.

2 Buskermolen M, Cenin DR, Helsingen LM et al. Harms are rare and Colorectal cancer screening with faecal immunochemicaltesting, sigmoidoscopy or colonoscopy: a microsimulation modelling. BMJ 2019;367:l5383.

3 Chiu HM, Chen SL, Yen AM, Chiu SY, Fann JC, Lee YC et al. Effectiveness of fecal immunochemical testing in reducing colorectal cancer mortality from the One Million Taiwanese Screening Program. Cancer 2015,121:3221-9.

4 Wang , Xu T, Ngamruengphong S, Makary MA, Kalloo , Hutfless S. Rates of infection after colonoscopy and osophagogastroduodenoscopy in ambulatory surgery centres in the USA. Gut 2018;67:1626-1636.

5 Braillon, A. Colorectal cancer screening: from perspectives to reality. Gastroenterology 2010;139:1065.

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Competing interests: No competing interests

09 October 2019
alain braillon
senior consultant
University hospital. 80000 Amiens. France.
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