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I had very mixed reactions to the Ontario Health Minister's announcement (January 23, 2007) about launching Canada's first province-wide screening program to provide early detection of colorectal cancer. Bowel cancer is a topic that I wrestle with each and every day. On the one hand, I rejoiced at the government's decision to take this battle on. I sat mesmerized, eyes glued to the news. TV seems to be the new norm of how us docs learn about medical break-throughs. A "new" test available to everyone seemed to be the implication. It may even find its way into pharmacies, church pews and farmers' markets. Doctors were going to receive training in administering and interpreting it?? Whilst gasping with excitement, I missed the name of this new test. I needed to know the name. I rushed over and dragged Dr. Remtulla out of his noon therapy appointment, leaving the patient to ponder the fate of a Leafs vs. Habs (from "Les Habitants" = Montreal Canadiens) match-up on his own. "You mean the FOBT (Fecal Occult Blood Test)," he said. "It can't be the "poop-card", the FOBT has been in use for over forty years," I replied. Sure enough, the "new" test is the FOBT.
Before anyone else comes running in for one or missed his or her own doctor's lecture, I will review the basic premise. The test itself was developed in the days when Maple Leafs won Stanley Cups, and most doctors have been including it as part of your annual physical ever since. It does not find cancer directly, but looks for blood present in your stool. It is also referred to as the guaiac smear, stool test and a few unprintable adjectives. Basically, you take a little envelope home with a cardboard slide inside. You then wait for the call of nature, collect a small sample of stool, smear it on the slide. The test is more accurate if you stay in the game for at least 3 innings. You then drop or return the envelope by mail. Care should be taken to ensure the return address is correct. It does resemble an RSVP card.
A sensitive dye is dropped onto the slide to check for traces of blood. I will likely have to attend a refresher course on dropping dye on stool. A positive test does not mean you have cancer. Conditions such as hemorrhoids, infection, colitis, menstruation and many others can result in abnormal amounts of blood getting mixed in with the stool. Even some medications, eating red meats, beets, turnips and cantaloupes can give false readings. Some large polyps and bowel cancers can slowly bleed and hence the reason for the test. The major drawback is the poor ability to detect very early disease. My pathologist pal, Dr. Tim Feltis, lovingly refers to it as the test from the dark ages.
A positive test does increase the likelihood of obtaining a colonoscopy which is how the cancer is discovered. Colonoscopy refers to the camera mounted on a hose with a snipper sent through the service entrance. It is the best method to detect, treat and even cure early cancers and more importantly, pre-cancerous lesions. There has been a bottleneck in our system for some time for colonoscopic examination. I fear that the new screening program may only congest the system further. I was disappointed at the vagueness of how this truly life-saving part of the program will be expanded. Dr. Roger Hollingsworth compares colonoscopy to fishing, because it takes experience, patience and the right bait. Anytime the government dangles large amounts of money, health-care bureaucrats begin to salivate about how to spend it. Sometimes the original intention of a wonderful idea is lost due to dilution and lack of quality control. This screening program has the potential to do much good, but only if all the cogs are found and fit properly. It's as much about the know-how as it is about the tools. Building and staffing facilities to perform quality colonoscopies will be the true measure of success.
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