Screening for gastrointestinal neoplasia: efficacy and cost of two different approaches in a clinical rehabilitation centre.

Mortality from colorectal cancer (CRC) can be reduced by screening of asymptomatic individuals and by removal of colorectal adenomas (CRA). It is still under debate which screening method should be used. In a clinical rehabilitation centre we compared two widely different approaches: faecal occult blood testing (FOBT) with subsequent endoscopy of test-positives in an unselected patient group, and primary sigmoidoscopy of asymptomatic persons between 50 and 60 years of age. Between January 1988 and October 1991 a FOBT was offered to all--symptomatic and asymptomatic--6,500 in-patients of a clinical rehabilitation centre and lower/upper GI-endoscopy was suggested to test-positives (study A). In the latter half of this period 1,166 persons without bowel symptoms and/or disease and aged 50-60 years were invited to a screening sigmoidoscopy (study B). In study A 95% of the patients (n = 6,234) returned a complete FOBT, which was positive in 186 (2.98%). 126 of these 186 patients (68%) accepted further investigation, and a total of 78 sigmoidoscopies, 78 colonoscopies and 47 gastroscopies were performed. Six patients in whom a malignancy was detected (1 gastric, 1 rectal and 4 colonic; all in a curable stage) underwent surgery. In 28 patients CRA were identified and removed by snare excision. In study B 658/1,166 asymptomatic in-patients accepted the screening sigmoidoscopy (56%). Rectosigmoid adenomas were identified in 153 (23%). One rectal cancer was found. Of these cases, 116 underwent an additional colonoscopy, disclosing proximal adenomas in 39 patients (33.6%). The cost of identifying one CRA-bearer was $1,436 in study A and $271 in study B (assuming: FOBT = $3.00; sigmoidoscopy = $63.00; colonoscopy = $135; gastroscopy = $108). In study A, the cost of identifying one patient with cancer would have been $5,435, if the cost of identifying one CRA-bearer was set to $271 as in study B. Screening for CRC was well-accepted in the health-orientated environment of a rehabilitation centre. The cost of identifying a CRA-bearer with screening sigmoidoscopy was about one-fifth of that using preselection with a FOBT. However, with FOBT a higher number of cancers was found. For the discovery of CRA, mass-screening with sigmoidoscopy of persons above the age of 50 years can be advised. For the detection of both CRA and CRC, screening with FOBT and subsequent endoscopy is an acceptable and cost-effective method.