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.
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.