Can colorectal cancer mass-screening organization be evidence-based? Lessons from failures: the experimental and pilot phases of the Lazio program

Abstract

Background: Screening programmes should be organized to translate theoretical efficacy into effectiveness. An evidence-based organizational model of colorectal cancer screening (CRCS) should assure feasibility and high compliance.

Methods: A multidisciplinary Working Group (WG), reviewed literature and guidelines to define evidence-based recommendations. The WG identified the need for further local studies: physicians' CRCS attitudes, the effect of test type and provider on compliance, and individual reasons for non-compliance. A survey of digestive endoscopy services was conducted. A feasibility study on a target population of 300.000 has begun.

Results: Based on the results of population trials and on literature review the screening strategy adopted was Faecal Occult Blood Test (FOBT) every two years for 50-74 year olds and, for positives, colonoscopy. The immunochemical test was chosen because it has 20% higher compliance than the Guaiac. GPs were chosen as the preferred provider also for higher compliance. Since we observed that distance is the major determinant of non-compliance, we choose GPs because they are the closest providers, both geographically and emotionally, to the public. The feasibility study showed several barriers: GP participation was low, there were administrative problems to involve GPs; opportunistic testing by the GPs; difficulties in access to Gastroenterology centres; difficulties in gathering colonoscopy results; little time given to screening activity by the gastroenterology centre.

Conclusion: The feasibility study highlighted several limits of the model. Most of the barriers that emerged were consequences of organisational choices not supported by evidence. The principal limit was a lack of accountability by the participating centres.

Figure 1

The dotted lines represents the information flow, the solid lines represents the material flows. The test tubes represents the faecal samples transported from the GPs' clinics to the gastroenterology centre; the men represent the target population going to the test provider to pick up and return the samples; the letter envelopes represent the invitation by the program to the target population. In the region there are 12 Local Health Units and 20 gastroenterology centres, the target population of each GP and gastroenterology centre is not necessarily restricted to the LHU borders.