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Gary, Colleagues, I wonder if the issue is that despite large outcome studies showing what you describe, some may think that their best guess is that because the test sees the while colon that a well done study will find better outcomes with colonoscopy. And that it just hasn't been done yet. I am not saying that is right or wrong but it may be an example of what people choose to do with differing levels and even absence of evidence. Best Rich Sent from my Verizon Wireless BlackBerry -----Original Message----- From: "Gary Jackson (CMDHB)" <[log in to unmask]> Sender: "Evidence based health (EBH)" <[log in to unmask]> Date: Thu, 29 Jul 2010 07:29:19 To: <[log in to unmask]> Reply-To: "Gary Jackson (CMDHB)" <[log in to unmask]> Subject: Re: Colorectal cancer screening article in JAMA I guess that I considered that "further evidence" wasn't needed - you have a more expensive and more harmful intervention that (on best reading) doesn't seem to give particularly better results - until such time as you are convinced that it will give better results enough to counteract the harm caused you should be switching to sigmoidoscopy if you wish to pursue a population screening approach regardless of whether colonsocopy is general use or not. The balance of evidence proof should be the other way around - unlesss you are certain it is better you shouldn't be doing it, rather than being unclear if it better/at best it is only slightly better. Even if you can bill higher. Agree the decision is easier if you were just starting out designing a programme, but the logic seems the same to me, and the switch straightforward in practice. Regards Gary ________________________________ From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Bill Cayley, Jr Sent: Thursday, 29 July 2010 02:24 To: [log in to unmask] Subject: Re: Colorectal cancer screening article in JAMA I think Mike is right. The statement quoted is from the 2nd to last paragraph, and they are just talking about the higher standard of evidence that is needed to overcome the intertia of "we've always done it that way" The final paragraph concludes with: "It is crucial to explore further the potential benefits and limitations of colonoscopy and to develop methods to improve its efficacy in the proximal colon. Nonetheless, if further evidence supports a lack of efficacy of colonoscopy for reducing incidence and mortality for right-sided colorectal cancer, the medical community should be prepared to consider returning to sigmoidoscopy for endoscopic screening of average-risk individuals." (italics added) BC Bill Cayley, Jr, MD MDiv <http://www.fammed.wisc.edu/directory?firstname=&lastname=cayley> [log in to unmask] Work: Augusta Family Medicine 207 W Lincoln, Augusta, WI 54722 <http://maps.yahoo.com/maps_result?q1=207+W+Lincoln%2C+Augusta%2C+WI+547 22+> Tel: 715-286-2270 Pager: 715-838-7940 Home: 3604 Sharon Drive, Eau Claire, WI 54701 Tel: 715-830-0932 Mobile: 715-828-4636 A cheerful heart is good medicine... (Proverbs 17:22) --- On Tue, 7/27/10, Mike Bennett <[log in to unmask]> wrote: From: Mike Bennett <[log in to unmask]> Subject: Re: Colorectal cancer screening article in JAMA To: [log in to unmask] Date: Tuesday, July 27, 2010, 6:58 PM Hi Gary, Agree with your sentiments but wonder whether it is a conclusion of the authors or a statement of 'real politik'. It reads to me like the authors don't like it, but that is the way they see the world is. They could have been clearer if that is the case... Mike Bennett ________________________________ From: Evidence based health (EBH) [[log in to unmask]] On Behalf Of Gary Jackson (CMDHB) [[log in to unmask]] Sent: Wednesday, 28 July 2010 7:44 AM To: [log in to unmask] Subject: Colorectal cancer screening article in JAMA I would be interested in peoples reactions to a 'Commentary' piece in this week's JAMA. Colonoscopy vs Sigmoidoscopy Screening <http://jama.ama-assn.org/cgi/content/full/304/4/461?etoc> by Alfred Neugut and Benjamin Lebwohl To me they do a great job of succinctly comparing the two modalities in light of the evidence, concluding that sigmoidoscopy now is seen to have comparable effectiveness to colonoscopy for screening. But then comes the penultimate paragraph: "Colonoscopy, similar to other screening tests, came into widespread use based on a common sense appeal to clinicians regarding its potential efficacy. Much of medicine operates in a similar absence of definitive evidence, and this is not unreasonable. However, as evidence subsequently accumulates, physicians must be prepared to reevaluate even a long-standing clinical practice. If de novo decisions were being made today about whether to initiate colonoscopy as a screening tool in place of sigmoidoscopy for average-risk individuals, in light of the available evidence (Table) doing so would probably be inappropriate. " With them so far.. "However, because colonoscopy is well established with a high acceptance rate among both clinicians and patients, the level of evidence necessary to modify an existing standard-of-care practice is higher." Having discussed the increased complication rates, and mentioned the increased cost, after demonstrating that on available evidence there is similar efficacy for the 2 modalities as a population screening tool I can't see how you can come to that conclusion. Why would you accept increased harm for your patients for the same outcome? Regards Gary ________________________________________________________________________ ___ Gary Jackson, Clinical Director Health Intelligence Counties Manukau District Health Board 19 Lambie Drive, Manukau City Private Bag 94052, South Auckland Mail Centre ph 64-9-262 9535 fax 64-9-262 9501 mob: 021 286 1815 [log in to unmask] This e-mail message and any accompanying attachments may contain information that is confidential and subject to legal privilege. If you are not the intended recipient, do not read, use, disseminate, distribute or copy this message or attachments. If you have received this message in error, please notify the sender immediately and delete this message. For exciting career opportunities at WDHB, CMDHB and healthAlliance visit www.aucklandhealthjobs.co.nz <http://www.aucklandhealthjobs.co.nz/> This e-mail message and any accompanying attachments may contain information that is confidential and subject to legal privilege. 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