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We read with interest the debate on population based endoscopic screening for colorectal cancer (Gut 2003;52:323–6). While we agree that the case for population screening is compelling, we believe that Macafee and Scholefield’s statement that “earlier diagnosis is unlikely to occur through increased awareness or patient education alone” is unnecessarily pessimistic.
We have recently had the opportunity to audit the impact of a dedicated rapid access flexible sigmoidoscopy clinic established in the endoscopy department of Dewsbury and District Hospital in January 1997. General practitioners were invited to use a proforma to refer patients to the clinic who were over 40 years old and had presented with a history of a recent change in bowel habit, rectal bleeding, or iron deficiency anaemia. Following initial consultation using a structured history form and clinical examination, flexible sigmoidoscopy was carried out by a consultant surgeon or a nurse endoscopist. If significant pathology was encountered, biopsy material was obtained and further investigations and management were planned as appropriate.
During the period January 1993 to December 1999, 167 patients underwent surgery for histologically confirmed adenocarcinoma of the rectum. Introduction of the dedicated rapid access flexible sigmoidoscopy clinic occurred 48 months into this audit period, with 87 patients treated before the introduction (clinic period 1) and 80 patients after (clinic period 2). Comparison of the groups of patients treated before and after reorganisation of the colorectal service demonstrated significant differences in several important clinical variables, with early stage tumour resection, complete circumferential margin clearance, and absence of visible residual tumour following excision all commoner in the later period (table 1).
There are several possible factors that may have contributed to the observed clinicopathological differences in the two time periods, including increased public awareness of suspicious symptoms, decreased embarrassment about reporting these symptoms, and increased GP education. Creation of a fast track flexible sigmoidoscopy clinic may also have contributed to the improved patient outcomes observed in our institution, and we believe that the debate around screening for colorectal cancer should take into account the improving results of the investigation of symptomatic colorectal disease. Not to do so may prevent the improvement of service provision in the hospital sector and is unnecessarily nihilistic.