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Colorectal Cancer Screening, Ethics and Evidence-based Public Policy

Malila et al. report on the Finnish colorectal cancer screening programme using a Faecal Occult Blood Test (FOBT), which was launched in 2004 for one-third of the population. Several points merit attention. The reported uptake is a marked success, increasing from 62% in men and 77% in women for the first round to 68% and 80%, respectively, for the second. This is in marked contrast with other countries. In France, for example, uptake for the first screening round, implemented in 2003 in 23 of 100 districts, only reached 42% (five territories were over 50%, the best reaching 54% and five territories were below 35%). Generalization to all 100 districts only occurred late in 2008, and the second round is still characterized by low participation. As for every rich country, however, the delay in implementation of the programme should be questioned. Why was there such a delay in responding to and acting on scientific evidence? Data from two randomized controlled trials were available in 1994, and experts published calls for screening as early as 1995. The 2003 recommendation of the European Council for FOBT screening for colorectal cancer in men and women aged 50–74 hopefully challenged this inertia. Finally, the Finnish programme is ethically questionable. Why did the authorities perform a controlled trial with randomization? This choice deliberately ignored the weight of evidence from trials published since 1995 confirming effectiveness and of reports showing that the effect can be achieved within normal public health care. Why was the control arm a placebo arm? The population in the control arm could have received, at least, an intervention to promote healthy behaviour. This denial of an effective intervention in a population which was not informed is a double breach of the Helsinki declaration which requires, in point 32, ‘that patients are not randomized to a clearly inferior treatment’. Screening programmes have advantages and limitations, and the issue is complex. In 2010, the American Cancer Society recommended that programmes should ‘prefer the tests that are designed to find both early cancer and polyps’: flexible sigmoidoscopy every five years, or colonoscopy every 10 years, or double-contrast barium enema every five years, or CT colonography (virtual colonoscopy) . . . ‘if you are willing to have one of these more invasive tests’. This was hardly novel; the American College of Gastroenterology in 2000 had endorsed colonoscopy as the preferred strategy. Indeed, for themselves gastroenterologists relied on colonoscopy not on FOBT and recently, President Obama at age 49 underwent virtual colonoscopy. By contrast, in Europe, lay people have no choice but to rely on outdated health policies because policy makers are flying in the face of best evidence and ethics.