Screening and the family physician

The true aim of medicine is not to make men virtuous, it is to safeguard and rescue them from the consequences of their vices. The physician does not preach repentance; he offers absolution.

H.L. Mencken

Whenever I think about my role as a family physician in the provision of preventive care and screening, I often think of this quote from the American writer H.L. Mencken. There is a prevailing belief among physicians, politicians, and the public that screening tests and programs are wholly good. They save lives and in so doing save money that would otherwise have to have been spent treating established disease. One of the most thoughtful commentators on the risks and benefits of screening and preventive care was Dr Ken Marshall, a former Professor of Family Medicine at the University of Western Ontario in London.1–4 When Cancer Care Ontario and the Ontario Ministry of Health first recommended population-based fecal occult blood testing (FOBT) be implemented in Ontario to screen for colorectal cancer, the harms and benefits were hotly debated.5,6

Colorectal cancer remains a concern in Canada—it is the third most commonly diagnosed cancer and the third and second most common cause of cancer death in women and men, respectively.7 Although some of the controversies remain, to date the best evidence that we have for an effective screening intervention remains FOBT—it is recommended for average-risk individuals age 50 and older by the Canadian Task Force on Preventive Health Care. Although most family physicians are recommending FOBT to their patients, and despite Cancer Care Ontario and the Ontario Ministry of Health having launched a population-based screening program (http://coloncancercheck.ca), an interesting study by Ritvo et al published in this month’s issue of Canadian Family Physician ( page 176) reveals that public awareness and readiness for the program were lacking.8 In addition to the Colon Cancer Check campaign now under way, there is clearly a substantial role for family physicians in discussing and promoting this intervention with their patients.

Many of my patients, and apparently many physicians too,9,10 prefer to skip FOBT and go directly to colonoscopy for colorectal cancer screening in spite of the lack of evidence to support it on a population basis. Some have argued that colonoscopy is a more sensitive—and therefore a better—test than FOBT, although there are concerns about risks, cost-effectiveness, and availability.11 In the future it is conceivable that a colonoscopy every 10 years will replace FOBT as the preferred screening test for colorectal cancer prevention, and physicians will have to preach what they practise. At the moment there are likely not enough clinicians trained in colonoscopy to allow such an approach. In the future, however, such screening might be provided by family physicians with additional training in the procedure. The excellent quality assurance practice audit by Kolber et al ( page 170) in this month’s issue shows that a trained family physician can perform endoscopy with competence and with findings and complication rates that compare favourably with current quality assurance guidelines for endoscopy.12

The third among this month’s research articles ( page 178) also focuses on preventive care. Wang et al show that there are obstacles to accurately measuring true rates of preventive health care (influenza vaccination, mammography, and Papanicolaou smears in this study) in Ontario.13 In addition, the authors showed that there are important regional and socioeconomic variations in the delivery of some preventive maneuvers that still need to be addressed.

The provision of preventive care and screening for conditions such as colorectal cancer is among the most important and challenging aspects of our work as family physicians. While it might not be our aim to “make men virtuous,” where it is safe, effective, equitable, and affordable it is our aim to deliver preventive care to all of our patients.

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