My Preference for Screening the Average Risk Population

Although ideal, due to time constraints and other issues, it is not feasible for each physician to present to every patient the advantages and disadvantages of five screening options. Rather, I believe that each individual health care delivery system (large and small) needs to evaluate its resources and capacity to screen, and then choose one or two options for its patients. Due to limited colonoscopy capacity in my institution, my current screening practice is still a program of annual FOBTs plus flexible sigmoidoscopy every 5 years. Colonoscopy is performed, of course, whenever there is a positive screen, a patient has signs or symptoms possibly due to colorectal cancer, or a patient is identified as being above-average risk. It is my opinion that neither FOBT alone or flexible sigmoidoscopy alone is a satisfactory way to screen because of their appreciable miss rates for advanced neo-plasia. Because of its low sensitivity and specificity, I would not consider DCBE as an acceptable screening option.

If resources and capacity exist, my preference for col-orectal cancer screening is direct colonoscopy performed by a well-trained, experienced endoscopist. Colonoscopy clearly is the only screening method capable of fulfilling most of the criteria of an ideal screening test.* It is feasible, acceptable and safe, and it accurately detects almost all cancers and advanced adenomas. It allows for biopsy of suspicious lesions and immediate resection of advanced adenomas throughout the colon, all at a single sitting with a single bowel cleansing preparation. Although relatively expensive, it is cost effective and infrequent screening is possible (Wagner et al, 1996). Anyone who undergoes direct colonoscopy screening as recommended by the guidelines should have a very low chance of developing or dying from colorectal cancer, the second most common cancer killer of Americans.

*Editor's Note: Virtual colonoscopy, three-dimensional CT scan reconstructions are being used for patients in whom a complete colonoscopy is not possible. As the techniques improve, this procedure may assume a role in colorectal cancer screening.

Constipation Prescription

Constipation Prescription

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