Editorials

Screening Options for Colorectal Cancer

THEODORE G. GANIATS, M.D.
University of California, San Diego, School of Medicine,
La Jolla, California

HERBERT F. YOUNG, M.D., M.A.
American Academy of Family Physicians
Kansas City, Missouri

Colorectal cancer is a significant disease in both men and women. The American Academy of Family Physicians (AAFP) in 1996 established policy recommending routine screening of persons age 50 years and over for colorectal cancer.¹ More recently, the AAFP participated in developing a national guideline on screening for colorectal cancer.² The AAFP and a large number of other groups that are a part of the National Colorectal Cancer Roundtable are all in agreement that such screening should be done. The guideline is reviewed in this issue of American Family Physician.³

The guideline is important for several reasons. First, it is the product of an evidence-based guideline development process. Second, it explicitly recognizes the role of polyps as precursors of colon cancer. The recognition of polyps as having a role in colon cancer is significant because while direct evidence supporting the use of barium enema and colonoscopy as screening procedures is lacking, explicitly recognizing polyps as a precursor of colon cancer along with other indirect evidence is sufficient to recommend these procedures as screening tools for detecting polyps. Third, the guideline gives five different clinical options for screening in practice (fecal occult blood testing [FOBT], flexible sigmoidoscopy, FOBT plus flexible sigmoidoscopy, barium enema, and colonoscopy), instead of dictating a single way of screening all patients.

See article in this issue.

At first blush, having five options for screening sounds great. Five options should increase compliance: those who are not interested in one method are able to choose another method. It eases access problems, too. Patients without easy access to colonoscopy, for example, have four other options to consider.

However, having five options for colorectal cancer screening could have a tremendous downside. First, five options confuse patients and perhaps even physicians. It is known, for example, that giving a person more options makes it more difficult for the person to make a decision.⁴ Second, providing five options burdens the health care system even more; it is less efficient to have five options than only one option. And finally, having five options creates a time burden for both the clinician and the patient, because the five options must be described in sufficient detail for the patient to be able to make an informed decision. The irony is that five options are available because it is not clear which one is the better option, and the system may not allow patients a voice in the decision of which screening method they prefer.

Recently, Leard and colleagues⁵ attempted to measure patients' preferences for the different colorectal cancer screening options. They showed that patient preferences for these options varied tremendously, even in a fairly homogenous population. This begs the question of not only which options should be presented to patients but also what methods can be used to present these options in ways that patients will find helpful within the confines of a busy family practice. Clearly, more research is needed. Until then, however, it is comforting to know that colon cancer, while producing a significant amount of morbidity and mortality in this country, can to a varying degree be prevented.

Dr. Ganiats is associate professor and vice-chair, Department of Family and Preventive Medicine at the University of California, San Diego, School of Medicine. He is a member of the AAFP Commission on Clinical Policies and Research. Dr. Young is director of the AAFP Division of Scientific Activities and the staff executive of the Commission on Clinical Policies and Research.

REFERENCES

1. Summary of policy recommendations for periodic health examination. American Academy of Family Physicians, Kansas City, Mo., 1996.
2. Winawer SJ, Fletcher RH, Miller L, et al. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology 1997;112:594-642.
3. Read TE, Kodner IF. Colorectal cancer: risk factors and recommendations for early detection. Am Fam Physician 1999;59:3083-92.
4. Redelmeier DA, Shafir E. Medical decision making in decisions that offer multiple alternatives. JAMA 1995;273:302-5.
5. Leard LE, Savides TJ, Ganiats TG. Patient preferences for colorectal cancer screening. J Fam Pract 1997;45:211-8.

Labeling the Somatically Preoccupied: Have We Gone Too Far?

MARGARET E. MCCAHILL, M.D.
University of California, San Diego, School of Medicine,
La Jolla, California

In their article on somatically preoccupied patients in this issue of American Family Physician,¹ Righter and Sansone point out that patients who have multiple, physically unexplainable symptoms are a heterogeneous group presenting great challenge and, sometimes, frustration to physicians. Such patients have long been described in the medical literature. In recent years, interest in the somatoform spectrum disorders seems to have been growing, as indicated in part by increased attention in medical textbooks^2,3 and in the medical literature noted in the reference list of the Righter and Sansone article.¹ The diagnostic approach described by Righter and Sansone, however, would provide many more patients with a diagnosis of somatic preoccupation than would the use of diagnostic criteria for the better defined somatoform disorders.⁴ The question can be reasonably posed: Is this diagnostic approach too broad and over-inclusive?

See article in this issue.

Righter and Sansone state that, in the primary care setting, few patients meet the full criteria for a somatoform disorder.¹ While it is true that few patients have medical records that actually bear the written diagnosis of somatization disorder, or hypochondriasis, some studies show that somatoform disorders are common in primary care. Certain authors have estimated that 25 to 75 percent of visits to primary care physicians are related to psychosocial problems with somatic presentations.^5-7 These patients may consume nearly one half of a family physician's time. Ten years ago, somatization disorder alone was called the fourth most common problem seen in family practice, although another diagnostic label was usually used.⁷ In addition, 10 to 15 percent of adults per year in the United States have disability from pain disorder with back pain alone.⁴ Regardless of the estimates of fully recognized somatoform disorders, far more patients have unexplained symptoms and do not meet the full criteria for one of the somatoform disorders. Will the formal recognition of patients with a diagnosis of somatic preoccupation benefit anyone, particularly those patients?

As early as 1986, controlled studies demonstrated that psychiatric consultation in the care of patients who had somatization disorder reduced health care costs and improved their health status.⁸ This same beneficial effect was demonstrated again, with a broader range of somatizing patients, in a 1995 study.⁹ Another brief six-week behavioral medicine intervention was shown to benefit a broad range of somatizing patients.¹⁰ The somatoform disorders have been recognized as a spectrum of disorders in which the patient may appear at different times to have somatization disorder, pain disorder or hypochondriasis, or to have insufficient diagnostic criteria to fit neatly into any one of those categories.^3,11

Righter and Sansone¹ suggest that physicians should recognize these patients and develop a plan of management similar to that of the other somatoform spectrum disorders. This suggestion is consistent with those of other authors who have referred to this group of patients as having "subsyndromal somatization disorder,"¹⁰ "abridged somatization disorder"¹¹ or "multisomatoform disorder."¹² These patients are now classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as having "undifferentiated somatoform disorder."⁴

Other psychiatric diagnoses have been similarly viewed and defined in their "subsyndromal" forms, and treatment of patients with milder symptoms has been shown to be beneficial. These diagnoses include "subsyndromal panic disorder,"¹³ "subsyndromal depression"¹⁴ and "subsyndromal (mixed) anxiety-depression."¹⁵ Recognizing the patient who does not meet the full criteria for one of the better defined somatoform disorders allows the physician to develop a management plan that will help the patient achieve and maintain his or her optimal health outcome. Using this perspective in practice is also consistent with the conceptualization of other common conditions, such as depression, panic disorder and other anxiety disorders.

Whatever label is used to define patients with multiple, physically unexplained symptoms, the management approach is similar. Righter and Sansone also provide an important reminder that, as the number of physical symptoms increases, so does the probability that the patient has a mood disorder or an anxiety disorder.¹ After the patient's symptoms are evaluated and no general medical or psychiatric disorder is found that needs treatment, the management described by Righter and Sansone¹ and the tables presented with the article represent an approach that is most likely to help these patients. The proposed treatment approach is also cost-effective, empathic and the most personally rewarding approach for the physicians who care for these challenging patients.

Dr. McCahill is an associate clinical professor in the Department of Family and Preventive Medicine and in the Department of Psychiatry at the University of California, San Diego, School of Medicine. She is also the medical director of St. Vincent de Paul Village Medical Clinic, San Diego, and director of the UCSD combined family medicine and psychiatry residency program.

REFERENCES

1. Righter EL, Sansone RA. Managing somatic preoccupation. Am Fam Physician 1999;59:3113-20.
2. Ford CV. Dimensions of somatization and hypochondriasis. Neurol Clin 1995;13:241-53.
3. McCahill ME. Somatoform disorders and related syndromes. In: Taylor RB, ed. Family medicine: principles and practice. 5th ed. Springer, New York, 1998:297-303.
4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association 1994:445-75.
5. Purcell TB. The somatic patient. Emerg Med Clin North Am 1991; 9:137-59.
6. Kaplan C, Lipkin M Jr, Gordon GH. Somatization in primary care. J Gen Intern Med 1988;3:177-90.
7. Rasmussen NH, Avant RF. Somatization disorder in family practice. Am Fam Physician 1989;40:206-14.
8. Smith GR Jr, Monson RA, Ray DC. Psychiatric consultation in somatization disorder. A randomized controlled study. N Engl J Med 1986; 314:1407-13.
9. Smith GR Jr, Rost K, Kashner TM. A trial of the effect of a standardized psychiatric consultation on health outcomes and costs in somatizing patients. Arch Gen Psychiatry 1995;52:238-43.
10. McLeod CC, Budd MA, McClelland DC. Treatment of somatization in primary care. Gen Hosp Psychiatry 1997;19:251-8.
11. Katon W, Lin E, Von Korff M, Russo J, Lipscomb P, Bush T. Somatization: a spectrum of severity. Am J Psychiatry 1991;148:34-40.
12. Kroenke K, Spitzer RL, deGruy FV 3d, Hahn SR, Linzer M, Williams JB, et al. Multisomatoform disorder: an alternative to undifferentiated somatoform disorder for the somatizing patient in primary care. Arch Gen Psychiatry 1997;54:352-8.
13. Katerndahl DA, Realini JP. Associations with subsyndromal panic and the validity of DSM-IV criteria. Depress Anxiety 1998;8:33-8.
14. Judd LL, Akiskal HS, Maser JD, Zeller PJ, Endicott J, Coryell W, et al. A prospective 12-year study of subsyndromal and syndromal depressive symptoms in unipolar major depressive disorders. Arch Gen Psychiatry 1998;55:694-700.
15. Roy-Byrne P, Katon W, Broadhead WE, Lepine JP, Richards J, Brantley PJ, et al. Subsyndromal ("mixed") anxiety--depression in primary care. J Gen Intern Med 1994;9:507-12.

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