Colorectal cancer screening: with pain, no gain

Colorectal cancer (CRC) screening has been demonstrated to reduce the incidence and mortality of this disease. Currently, CRC screening is spreading throughout Europe and North America in the form of different screening strategies, such as immunochemical fecal occult blood test (FIT) or flexible sigmoidoscopy, followed by a work-up colonoscopy in positive cases, or primary screening colonoscopy in asymptomatic people aged between 50 and 74 years [1]. However, participation in CRC screening programs is still suboptimal, and indeed lower than that achieved in other screening programs [2], owing to barriers that make participation in these screening programs difficult, despite its efficacy and usefulness. In this issue of Endoscopy, Kirkøen et al. have analyzed some of these potential barriers in a study nested in the pilot Norwegian Bowel Cancer Screening (BCSN) trial, a randomized clinical trial comparing the effect of two different screening modalities (FIT and unsedated flexible sigmoidoscopy) on CRC incidence and mortality [3] [4]. The primary aim of this nested study was to compare the willingness of FIT and flexible sigmoidoscopy attendees to repeat screening, as well as the participants’ satisfaction with their decision to attend screening. A sample of the participants in the BCSN trial received a baseline questionnaire together with the invitation to participate in this screening trial, followed by three follow-up questionnaires extending to 1 year after the baseline study. In these questionnaires, patients were asked about their satisfaction with their healthcare decision, their willingness to repeat CRC screening in the future, and their willingness to recommend CRC screening to a friend or relative. The main results were that, in general, participants had high levels of short- and long-term willingness to repeat screening, satisfaction, and willingness to recommend CRC screening, but participants in the flexible sigmoidoscopy arm of the trial exhibited significantly less willingness to repeat screening than participants in the FIT arm. Moreover, there was a sex difference among flexible sigmoidoscopy participants only, with significantly less willingness among women than men. This sex difference is partially explained by pain experienced during the flexible sigmoidoscopy procedure; women more frequently experienced pain than men, and after adjusting for self-reported pain there were no longer sex-related differences in the willingness to repeat or in satisfaction with the decision to participate in screening.

“Kirkøen et al. emphasize the role of pain in CRC screening with flexible sigmoidoscopy and its importance, especially in women.”

This study nicely illustrates the role of pain as a barrier to CRC screening. A number of reasons can explain the lack of participation in organized or opportunistic CRC screening programs, including fear, embarrassment, need for an invasive test, misperception of cancer risk, cultural beliefs, or interferences with work or daily activities. However, the more plausible explanations could be fear of cancer or the possibility of living an unpleasant experience with invasive colonic examinations such as flexible sigmoidoscopy or colonoscopy [2] [5].

Flexible sigmoidoscopy has been considered as only a slightly invasive examination and, therefore, not requiring sedation or any kind of pain relief. However, for the first time, Kirkøen et al. found that self-reported pain related to the procedure is a clear determining factor for screening participation, and although some programs recommend once-only flexible sigmoidoscopy as the screening procedure, in order to provide screening participants with the best possible experience [6], the perception of flexible sigmoidoscopy as a non-pain technique should be changed.

Pain during colonoscopy or flexible sigmoidoscopy can be related to the technical skills of the endoscopist, anatomic determinants, cultural factors, pre-procedural anxiety, or anticipated pain, among others [7]. Although pain clearly influences patients’ experience and satisfaction [8], there are huge differences between countries and facilities in how this pain is considered. Therefore, the use of sedation in endoscopy is enormously variable, particularly between countries. For example, in Spain, the rate of sedation in colonoscopy is rapidly increasing, especially endoscopist-driven propofol sedation, with a proactive policy of the Spanish Society of Gastrointestinal Endoscopy to provide training for endoscopists and endoscopy nurses in this kind of sedation [9] [10]. In contrast, in other countries, such as the Netherlands and the UK, deep sedation rates are lower, and sedation is rarely used in others (e. g. Norway) [11]. There is no clear explanation for this variable use of sedation and, in the majority of cases, the opinion of the endoscopist is the only reason for using or not using sedation in colonoscopy. This opinion is hugely influenced by cultural determinants, pre-established ideas, and even a prevailing paternalist view of the practice of medicine, but it is not related to robust scientific evidence. Comparative studies of patients’ experience and reasons for use of sedation in colonoscopy, with patient-reported outcomes [12], and appropriate and unbiased use of satisfaction scales with adequate adjustment for the use of sedation and type of sedation, are the only way to determine the level of pain relief needed by our patients. In addition, the role of cultural determinants and their view of tolerance to pain must be taken into account in this potential research.

Another aspect addressed by Kirkøen et al. is the sex differences found in CRC screening, especially in the satisfaction with different screening modalities. Although mainly explained by differences in pain, sex differences were found in satisfaction and willingness to repeat screening among flexible sigmoidoscopy participants, but not among FIT participants. Previous research has also reported this same result [13] and, again, cultural and psychological differences can explain sex biases in the perception of invasive tests, such as flexible sigmoidoscopy or colonoscopy. Thus, research is needed to investigate the real reasons and how to deal with these differences.

In summary, Kirkøen et al. emphasize the role of pain in CRC screening with flexible sigmoidoscopy and its importance, especially in women. More research is needed to investigate how to deal with pain as a barrier to participation in flexible sigmoidoscopy screening, the determinants of pain, and the need for sedation in colonoscopy at a time when this technique is quickly becoming a common procedure. What our population can gain from colonoscopy could be great in terms of CRC prevention, but in this case we need to modify the old aphorism to: in CRC screening, with pain, no gain.

• References

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