Primary care — the hard parts
===============================


Your first patient, Mr. Gilpen-Brown, a well-known entrepreneur who has just returned from a trade fair in Singapore where he managed to sell $4 million worth of rice harvesters, refuses your offer of the cardboard container with 3 small flaps — for 2 samples of stool on 3 successive days — by saying that while travelling he learned, on CNN, that colonoscopy was the only way to go to detect colon cancer.

What a start to the day. Of course, he is right. A new study of colorectal screening procedures in men over 501 (see page 1248)2 shows that fecal occult blood testing misses 76% of advanced cancers, and that fecal occult blood testing in combination with sigmoidoscopy misses 24%. You refer him to a gastroenterologist.

But should you recommend colonoscopy for all your patients? And at what frequency? The only unambivalent recommendation in guidelines published before this recent study was for fecal occult blood testing.3 But colonoscopy is much more sensitive and has the additional advantage of being both a screening test and extirpative therapy.

Mrs. Nguyen is scheduled later in the day for her annual examination. Arriving almost 30 years ago from Vietnam via a refugee camp, she now owns the convenience store she once worked in and has raised 2 children, now both departed and in university. She doesn't watch CNN. It was hard enough convincing Mrs. Nguyen to have regular Pap smears and then, later, mammograms. How will you tell her about fecal occult blood testing and colonoscopy — in less than the allotted 20 minutes?

You begin thinking that each patient's access to quality care is determined by many things, including where he or she is positioned on the band-width of education, experience, culture and language. Mrs. Nguyen will walk into your office free of symptoms and complaints; she will leave, as she always seems to, with an eroded sense of confidence in the state of her own health. Mr. Gilpen-Brown, who seems a robust member of the worried well, is one step ahead of guidelines. You know that when he has his colonoscopy 1 of 2 benefits will result. Either an abnormality will be caught and dealt with, or his mind will be put at rest.

But your mind is not at rest. How often have you heard patients say, “Oh doctor, I don't know. You decide.” or “You know best,” thus tranferring the responsibility for their medical decisions back to you. Add to this the notion that you may have not just a moral duty to share this information with Mrs. Nguyen, but a legal responsibility to explain that the best available means of preventive detection of colon cancer is now colonoscopy. But, colonoscopy does seem a fairly invasive and complicated strategy, and there are conflicting views about its benefits and harms.4,5,6,7

This is the vital and tough core of primary care. It would be easier to follow the guidelines and just hand Mrs. Nguyen the little cardboard packet. Although … perhaps … . But, at any rate, your next patient has arrived. — *CMAJ*

## References

1.  1. Lieberman DA, Weiss DG, for the Veterans Affairs Cooperative Study Group 380. One-time screening for colorectal cancer with combined fecal occult-blood testing and examination of the distal colon. N Engl J Med 2001;345(8):555-60.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1056/NEJMoa010328&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=11529208&link_type=MED&atom=%2Fcmaj%2F165%2F9%2F1181.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000170562900001&link_type=ISI) 

2.  2. Hoey J, Wooltorton E. Colorectal cancer screening: you can't be positive about a negative result. CMAJ 2001;165(9):1248.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMDoiMTY1LzkvMTI0OCI7czo0OiJhdG9tIjtzOjIxOiIvY21hai8xNjUvOS8xMTgxLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

3.  3. Canadian Task Force on Preventive Health Care. Colorectal cancer screening. CMAJ 2001; 165 (2):206-8.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxNjUvMi8yMDYiO3M6NDoiYXRvbSI7czoyMToiL2NtYWovMTY1LzkvMTE4MS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

4.  4. Winawer SJ, Zauber AG. Colorectal cancer screening: Now is the time [editorial]. CMAJ 2000; 163 (5): 543-4.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxNjMvNS81NDMiO3M6NDoiYXRvbSI7czoyMToiL2NtYWovMTY1LzkvMTE4MS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

5.  5. Marshall KG. Population-based fecal occult blood screening for colon cancer: Will the benefits outweigh the harm? [editorial]. CMAJ 2000;163(5): 545-6.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxNjMvNS81NDUiO3M6NDoiYXRvbSI7czoyMToiL2NtYWovMTY1LzkvMTE4MS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

6.  6. Detsky AS. Screening for colon cancer: Can we afford colonoscopy? N Engl J Med 2001;345(8): 607-8.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1056/NEJM200108233450809&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=11529216&link_type=MED&atom=%2Fcmaj%2F165%2F9%2F1181.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000170562900009&link_type=ISI) 

7.  7. Simon JB. Screening colonoscopy: Is it time? [editorial]. CMAJ 2000;163(10):1277-8.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTYzLzEwLzEyNzciO3M6NDoiYXRvbSI7czoyMToiL2NtYWovMTY1LzkvMTE4MS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=)