Screening for colorectal cancer

In 1993 Winawer [1] declared that colorectal cancer screening had come of age. Fifteen years later we have not yet achieved the goal of screening most of the eligible population despite the availability of multiple screening tests. Current screening rates in the United States are inadequate, with particularly poor rates in some segments of the population [2,3]. The Behavioral Risk Factor Surveillance System has reported that among people aged 50 years or older only 18.7% had a fecal occult blood test (FOBT) within the prior year, 50.6% had either flexible sigmoidoscopy or colonoscopy within the past 10 years, and 57.3% had one or both of these tests within these time periods [2]. In a national household survey using in-person interviews conducted by the National Health Interview Survey, about 50% of adults older than 50 years of age never had colorectal cancer screening and only 37.1% were current in their screening [3]. This study reported small variability in screening rates according to age and between men and women but reported large variability based on educational level, insurance availability, family history of colorectal cancer, and race, with black women less likely to be screened than white women. Somewhat surprising was the relatively low rate of colorectal cancer screening in the Medicare population despite the insurance coverage available for this screening and governmental efforts to increase screening in this population [4]. Results from randomized controlled clinical trials (RCT) have shown that with current technology, screening can greatly reduce colorectal cancer mortality and incidence [5-8]. The development and implementation of population-based screening programs has so far not successfully achieved what was envisioned in 1993. In the United States, colorectal cancers represent 10% of incident cancers and cancer deaths [9]. About 6% of the population will develop colorectal cancer in their lifetime. In 2007, there will be an estimated 153,760 new cases and 52,180 deaths from colorectal cancer [9]. Globally, there are about I million new cases and about 500,000 deaths per year [10].