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ORIGINAL ARTICLE
Lessons learnt from a population-based pilot programme for colorectal cancer screening in Catalonia (Spain) MerceØ Peris, Josep A EspinaØs, Laura Munoz, Matilde Navarro, Gemma Binefa and Josep M BorraØs, and Catalan Colorectal Cancer Screening Pilot Programme Group
.................................................................................................. J Med Screen 2007;14:81–86
See end of article for authors’ affiliations
............... Correspondence to: Dr Merce` Peris, Cancer Prevention and Control Department, Catalan Institute of Oncology, Avda. Gran Via s/n km. 2.7, 08190 L’Hospitalet de Llobregat. Barcelona, Spain;
[email protected] Accepted for publication 27 April 2007
...............
Study objective To assess the feasibility of a colorectal cancer population-based screening programme in Catalonia (Spain). Design and setting A pilot colorectal cancer screening programme based on faecal occult blood (FOB) test was introduced in February 2000 in Hospitalet de Llobregat (Barcelona, Spain), a city of 239,000 inhabitants. Participants All the residents from the selected area, aged 50–69 years old, were invited by mail to participate in the screening programme. Overall, 63,880 persons were invited to the first screening round and 66,534, to the second round. Colonoscopy was the first choice of procedure for the positive FOB test. Results The participation rate was 17.2% in the first screening round and 22.3% in the second round. The overall rate of positive FOBT was 3.4% in the first round and 0.8% in the second round. In the first round, the prevalence of screen-detected cancer was 2.1 per 1000 screened people, 7.2 for high-risk adenomas (HRA) and 11.3 for neoplasm (cancer and/or adenoma). The positive predictive value (PPV) was 6.2% for cancer, 21.2% for HRA and 33.3% for advanced neoplasm. In the second round, the prevalence of screen-detected cancer was 0.9 per 1000 people screened, 2.8 per 1000 for HRA and 4.2 per 1000 for neoplasm. The PPV was 10.6% for cancer, 34.1% for HRA and 50.4% for any neoplasm. Conclusions Regardless of the moderate participation rate, population-based colorectal cancer screening would be feasible in Catalonia, with good results in terms of prevalence of screen-detected neoplasms.
INTRODUCTION
C
olorectal cancer is among the leading cancers in Western countries, considering both sexes together.1,2 In Catalonia, almost 4000 new cases are diagnosed annually, causing 1959 deaths.3 In Spain, colorectal cancer incidence increased about 3% yearly.2 Primary prevention, early detection and improvements in diagnosis and therapy are the three possible strategies to reduce the burden of this disease.4 Among available screening strategies for colorectal cancer, faecal occult blood (FOB) detection is the only one associated with an actual decrease in mortality and incidence of this disease.5–11 Although the magnitude of the reduction of colorectal cancer mortality obtained in trials testing for FOB is moderate (15–18% in biennial screening),1,5 it is estimated that mortality could be reduced by up to 30% in those who participate.6,12 Endoscopy screening (flexible sigmoidoscopy and colonoscopy) may be far more effective than FOB testing, but results from large-scale randomized trials are still awaited.13–16 In the USA, colorectal cancer incidence rates have decreased over the past two decades, reflecting an increase in screening which can detect and remove colorectal polyps before progression to cancer.17 The European Code Against Cancer and the European Union (EU) encourage its member states to initiate colorectal cancer screening in organized programmes.18 Scientific evidence on benefits is a necessary but not sufficient condition to choose to implement a
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screening programme. The success of such a screening will depend on how the programme is organized, its compliance rates and on the extent to which it is able to achieve outcomes similar to those obtained in randomized trials.19 A well-designed and implemented pilot programme can provide decision-makers and policy planners with the necessary background data to inform their decisions. With this aim, the Government of Catalonia launched a pilot study to evaluate the feasibility and acceptability of a population screening for colorectal cancer by FOB testing.20 The final objective would be to extend the screening programme to the Catalonian population with average risk of colorectal cancer. This pilot study is the first initiative designed to analyse short- and middle-term outcomes of a colorectal screening programme at the population level in Spain. This article is intended to analyse critical issues relating to the feasibility of colorectal cancer screening in the local context based on participation and detection rates.
MATERIAL AND METHODS A biennial screening programme was implemented in 2000 in the 12 health-care centres of Hospitalet de Llobregat, an industrial city of 239,000 inhabitants located in the metropolitan area of Barcelona (Catalonia, Spain). The target population included all men and women aged 50–69 years who lived in the city. Demographic data on this population was gathered using the Primary Health Care Journal of Medical Screening
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Information System, the most comprehensive population register of the Catalan Health Service, which is the public body responsible for guaranteeing the provision of public cover health services for all the citizens of the entire population of Catalonia. Two screening rounds were successively performed. The study population included 64,866 persons in the first screening round and 67,239 persons in the second round. Subjects with a personal history of colorectal cancer or adenoma or inflammatory bowel disease, and those with criteria for hereditary colorectal cancer syndromes were excluded. The overall eligible invited population was 63,880 in the initial screening and 66,534 in the subsequent one. The screening test used was a guaiac-based FOB test (Hema-screens, Immunostics Inc.). Eligible subjects were mailed a personal invitation letter, signed by the person in charge of the screening programme, including information about colorectal cancer, the screening programme and a short questionnaire focused on exclusion criteria. Those people willing to be tested used the postage-paid reply envelope to request the FOB test kit to be mailed to them. In the second round, the FOB test kit was directly mailed to those who had participated in the previous round. The kit included instructions on how to use and return the test to the central laboratory. A reminder letter was sent out after six weeks to all subjects who did not return the kit. Eligible subjects were asked to collect two stool samples in three consecutive bowel movements. No dietary restrictions were required for the initial test.5,21 Dietary restrictions were indicated when a repeat test was requested because an initially weak positive result (1–4 positive spots) was obtained. A reminder letter, stressing the importance of performing a second test to confirm the results, was sent out to those participants who had to repeat the test and had not submitted it after six weeks. Participation was defined as those invited subjects who met eligible criteria and returned a complete kit. Adequate FOB test was defined as a kit with correctly smeared stools, with a sample in all six spots, or with any number of spots smeared if at least one was positive. The lack of date was considered important and led to the rejection of the kits with negative results due to the possibility of expiration of the test; in that case, a repetition of the test was indicated. The kits without date that showed positive results were included in the study given that the possibility of real positive cases was considered high. Subjects with negative test results were informed by mail. Subjects who had five or six positive spots at initial testing, or any of the spots under dietary restriction in a repeat test, were personally informed by the central screening office and offered an appointment date for a colonoscopy. These subjects were advised to contact their general practitioner (GP) to confirm that they did not present contraindications for the colonoscopy. Colonoscopies were performed with sedation on an outpatient basis at the Endoscopy Unit of the Bellvitge University Hospital. During colonoscopy, the location and size of all tumours were recorded. Any polyp found was removed and biopsies of any mass were performed if technically possible. A complete examination was defined when the endoscope reached the caecum. When colonoscopy was incomplete or not possible, patients were offered a barium enema. Polyps’ specimens and biopsies were analysed by pathologists at the Bellvitge University Hospital and classified according to criteria established by the World Health Organization.22 The criterion for cancer diagnosis was an invasion of malignant cells beyond the muscularis Journal of Medical Screening
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mucosa. High-risk adenoma (HRA) was defined as adenoma with severe dysplasia, adenoma bigger than 10 mm, more than two adenomas or any adenoma with tubulovillous or villous histology. Carcinoma in situ was classified as HRA. Low-risk adenoma (LRA) was defined as those of smaller size, tubular type and low-grade dysplasia. In case of multiple polyps, patients were classified according to the most advanced lesion. Neoplasms included cancer and all adenomas. Advanced colonic neoplasms were defined as HRA or cancer. Tumour was defined as any polyp, adenoma or cancer. Procedure-related complications were documented following each colonoscopy. Subjects with cancer, or those who had polyps that were too large or too complicated to be removed endoscopically, were referred for surgery. Tumour staging was performed according to the tumour node metastasis (TNM) system.23 Follow-up colonoscopy was recommended for patients with adenomatous polyps detected in the screening.24 A central screening unit was established within the Cancer Prevention and Control Department at the Catalan Institute of Oncology for the organization, management, quality control and evaluation of the pilot programme results. Specific human and material resources were set up at the screening centre to process FOB testing and to perform colonoscopies. A computerized information system was set up to manage the pilot programme. The information system included data on patient identification, age, sex, participation in the programme, appointment dates, FOB test and colonoscopy results. The positive FOB test rate was based on participants with adequate tests. The prevalence of screen-detected tumours was calculated per 1000 screened subjects and the predictive positive value (PPV) was calculated based on participants with positive FOB tests. Differences in categorical variables were compared using the w2 test. The test for linear trend for age was performed using the age groups as a continuous variable. Differences in advanced neoplasm detection between sex and age were analysed using multiple logistic regression. These results were expressed as odds ratios (ORs) with 95% confidence intervals (95% CIs). Statistical significance was considered for Po0.05. All analyses were performed using Stata software, release 9.2 (StataCorp, College Station, TX, USA).
RESULTS The FOB test participation rate was 17.2% in the first round, and increased to 22.3% in the second one. A total of 25,829 screening tests were performed on 18,405 subjects (8389 men and 10,016 women) (Table 1). Table 2 shows FOB test participation rates by sex, age and screening round. Overall, compliance with FOB test was higher in women (20.8%) than in men (18.7%) (Po0.001). The participation rate varied among the health-care areas, ranging from 10.6% to 26.8% in the first round and from 14.6% to 28.9% in the second round. An adequate FOB test was obtained for 96.4% of participants of the first screening round and for 95.5% of the second screening round. The overall rate of positive FOB test was 3.4% for the first screening round and 0.8% for the second screening round (Table 1). The positivity rate decreased in the second round for both sexes and for all age groups (Table 3). Men had higher values as compared with women in all age groups except in the youngest one (Po0.001). The positive FOB test rate increased with age in men (P for trend o0.001) and, to a lower extent, in women www.jmedscreen.com
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Table1 First and second screening programme activities First round
Invited Screened Invited and screened at first screening Invited and not screened at first screening New subjects invited and screened at second screening Unfinished process Positivity rate Colonoscopy assessment attendance
Second round
n
%
n
%
63,880 11,011 — — — 383 372 334
17.2 — — — 3.5 3.4 89.8
66,534 14,818 7424 4439 2955 636 123 108
22.3 50.1 30.0 19.9 4.3 0.8 87.8
Table 2 Screening uptake by age, sex and screening round First round Age group (years) 50–54 55–59 60–64 65–69 Total P value for trend
Female n (%) 1333 1834 1361 1370
Second round Male n (%)
(18.7) (20.3) (18.8) (14.4)
5898 (17.9) o0.001
Female n(%)
1122 1462 1221 1308
Total Male n (%)
(17.5) (17.0) (16.6) (15.1)
1778 (22.0) 2283 (24.5) 2063 (24.8) 1957(22.7)
5113 (16.5) o0.001
8,081 (23.5) 0.334
Female n (%)
1339 1718 1786 1894
(17.7) (20.7) (21.9) (23.1)
6737 (20.9) o0.001
Male n (%)
3111 4117 3424 3327
(20.5) (22.4) (22.0) (18.4)
13,979 (20.8) o0.001
2461 3180 3007 3202
(17.6) (18.8) (19.4) (19.0)
11,850 (18.7) 0.002
All percentages were calculated using invited population
Table 3 Faecal occult blood (FOB) test positive rate by age, sex and screening round First round Age group (years) 50–54 55–59 60–64 65–69 Total P value for trend
Female n (%) 28 52 43 48
(2.1) (2.8) (3.2) (3.5)
171 (2.9) 0.028
Second round Male n (%)
Female n (%) 26 57 42 76
(2.3) (3.9) (3.4) (5.8)
201 (3.9) o0.001
16 14 5 17
Total Male n (%)
(0.9) (0.6) (0.2) (0.9)
52 (0.6) 0.606
9 13 30 19
Female n (%) (0.7) (0.8) (1.7) (1.0)
71 (1.0) 0.118
44 66 48 65
Male n (%)
(1.4) (1.6) (1.4) (1.9)
223 (1.6) 0.154
35 70 72 95
(1.4) (2.2) (2.4) (3.0)
272 (2.3) o0.001
All percentages were calculated using screened subjects
(P for trend ¼ 0.15). There were differences in the positive FOB test rates among health areas, ranging from 1.5% to 7.3% in the first screening round and from 0.2% to 2.6% in the second one. The uptake of colonoscopy among subjects with a positive test was 89.3% (442/495). Fifty-three subjects did not attend for colonoscopy: 16 subjects had a colonoscopy outside the screening programme; 11 subjects presented medical contraindications; 10 subjects refused to have a colonoscopy and 16 subjects could not be reached. There were no statistically significant differences in colonoscopy compliance according to sex and screening round. When women and men were analysed together, colonoscopy compliance decreased in the oldest age group (P ¼ 0.021). The median delay time between positive FOB test and colonoscopy examination was 41 days for the first screening round and 47 days for the second one. Colonoscopy was performed within 60 days after a positive FOB test result in 86.6% of cases. Complete colonoscopies were obtained in 92.3% (408 out of 442). Among the 34 subjects with an incomplete examination, a second colonoscopy was performed on four individuals; a barium enema was performed on three www.jmedscreen.com
subjects; no other exploration was done on 14 subjects and an occlusive invasive cancer was found on 13 patients. Sex differences were observed, with higher rates of incomplete colonoscopies in men as compared with women. Colonoscopy results were without findings in 229 subjects, being higher at the first screening round (55.4%) than at the second screening round (40.7%) (Po0.001). Repeated colonoscopy for polipectomy was necessary in 32.7% subjects of the initial screening and in 19.3% subjects of the second round (P ¼ 0.05). Clinical complications occurred in six of the 623 performed colonoscopies: bradycardia occurred in two cases, bleeding in three cases and perforation in one case. Table 4 shows the number and type of screen-detected tumours and PPV. Among the 442 participants who had a colonoscopy, 36 invasive cancers, 121 HRA, 29 LRA and 27 non-neoplastic polyps were detected. The prevalence of screen-detected advanced neoplasm was almost threefold higher in the first screening round (9.3 versus 3.7 per 1000 persons screened). The prevalence of screen-detected advanced neoplasm increased with age in all considered groups (3.9 per 1000 screened and 8.1 per 1000 were found among the subjects aged 50–54 and 65–69 years, Journal of Medical Screening
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Table 4 Prevalence of screen-detected tumours per 1000 people screened and positive predictive value of positive faecal occult blood (FOB) test First round
Polyps (no adenoma) Adenomas High risk adenomas Low-risk adenomas Cancer Neoplasmw Advanced neoplasmz
Second round
n
Prevalence of screen-detected tumours
PPV (%)
25 101 79 22 23 124 102
2.3 9.2 7.2 2.0 2.1 11.3 9.3
6.7 27.1 21.2 5.9 6.2 33.3 27.4
Total
n
Prevalence of screen-detected tumours
PPV (%)
2 49 42 7 13 62 55
0.1 3.3 2.8 0.5 0.9 4.2 3.7
1.6 39.8 34.1 5.7 10.6 50.4 44.7
n
Prevalence of screen-detected tumours
PPV (%)
27 150 121 29 36 186 157
1.0 5.8 4.7 1.1 1.4 7.2 6.1
5.4 30.3 24.4 5.8 7.3 37.6 31.7
First screening: 27 in situ; second screening: 13 in situ; PPV ¼ predictive positive value w z
Cancer+adenomas Cancer+high-risk adenomas
respectively,, Po0.001). The prevalence of screen-detected cancers was higher in men than in women (2.2 versus 0.7, Po0.001). The prevalence of screen-detected advanced neoplasm showed similar features (6.7 versus 2.9, Po0.001). PPV for cancer and for HRA were higher in the second screening round than in the first screening round (10.6% versus 6.2% for invasive cancer, and 34.1% versus 21.2% for HRA). Using multiple logistic regression, sex was associated with advanced neoplasm detection (adjusted OR for men versus women: 2.4, 95% CI 1.6–3.6) and age was not (adjusted OR 55–59 years: 1.1, 95% CI 0.6–2.1; adjusted OR 60–64 years: 1.1, 95% CI 0.6–2.0; adjusted OR 65–69 years: 1.3, 95% CI: 0.7–2.5). Overall, the age-adjusted odds ratio of cancer and HRA among men as compared with women was 2.4 (95% CI: 1.58–3.58). According to the TNM staging criteria, 15 cancers were stage I (41.7%); seven were stage II (19.4%); 10 were stage III (27.8) and four were stage IV (11.1%). Forty of the 7424 subjects who participated in both screening rounds had a positive FOB test result at the second screening round. Colonoscopy was done in 34 of them, resulting in 22 examinations without findings, three cancers, eight HRA and one LRA (advanced neoplasm detection rate ¼ 1.48 per 1000 persons screened and PPV ¼ 27.5%).
DISCUSSION The results of the present pilot programme showed that population-based FOB test screening would be feasible in Catalonia. However, before implementing a regional or national screening programme, it would be necessary to explore in depth some screening participation-related factors. The participation rate in our study was low in comparison with other population-based colorectal cancer screening programmes.25–27 In the same way, when a populationbased breast cancer screening was introduced in the late 1980s in our country, the participation rate was rather low (37%).28 Lack of awareness of colorectal cancer and screening may partially explain this low participation rate. Indeed, even if colorectal cancer is the second most common cancer among women and the third most common among men (4000 new cases each year for both men and women), the popular appreciation of the risk of colorectal cancer is low by comparison with the risk perception for other cancer sites.3 Journal of Medical Screening
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Previous screening initiatives for colorectal cancer in Spain have showed higher acceptance rates than our pilot programme.29–31 However, those studies were not readily comparable to our programme because most of them had a smaller target population, with few primary health-care centres involving general practitioners (GPs) who expressed great interest in the initiative, or they were not directly addressed to the general population. Several studies have reported the influence of the active implication of primary health-care physicians in motivating patients to participate in screening programmes.25,32 A reason for the less-than-ideal release of preventive care is limited GPs time coupled with the difficulty of integrating multiple competing preventive recommendations.33 Furthermore, our pilot programme showed a wide variability in participation among different health-care areas, which could be explained by differences in the socioeconomic status and major implications of GPs. Moreover, among the participants of the first round, 67% completed the second screening round indicating that health education and information on screening benefits is a relevant measure. Fear of cancer and the belief that cancer is not curable, as well as some misconceptions about cancer risk, have also been reported as barriers to screening.34–38,39 A gender-based difference in participation on colorectal cancer screening programmes is a matter of concern.40 Involvement in routine preventive practices is usually higher among women than among men. It is quite likely that women have a more positive attitude towards screening. The screening test itself might be a barrier to increase participation. Performing an immunological test which only needs one bowel movement sample might improve the acceptance. Evidence in favour of the substitution of guaiac FOB test by immunological FOB test as a primary screening test is increasing.41 Furthermore, the immunological screening test could avoid the repetition of a number of faecal samples in those subjects with an initial weak positive guaiac FOB test.42 In our study, 65% of the FOBT-positive results arose from repeated FOB test results of initial weak positive tests. Almost 27.8% of the subjects with initial weak positive tests refused to finish the process because they were reluctant to complete another test. The opportunity to choose a screening test did not seem to increase participation.43 A higher participation rate could be achieved in the context of a national fully established screening programme and be reinforced through mass media campaigns, which was not the scenario of this pilot programme. As the pilot www.jmedscreen.com
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programme was limited to a particular area, it was difficult to set up a wide coverage in the media that could have been helpful to improve participation. The positive FOB test rate in the first round was much higher than in the second round (3.4% versus 0.8%). This difference could be explained by the fact that more than 50% of the participants in the second round had already been screened in the first round. Additionally, this programme was the first undertaken in Catalonia, and we therefore suspect that even though we provided full information and a questionnaire to exclude people at risk from the screening population, some of them may have participated. Global prevalence of screen-detected neoplasms and PPV were in accordance with those reported in previous studies,5,13,25,44 using a similar screening test, unlike the English Pilot Bowel Cancer Screening.45 Of the colonoscopies performed in the first round, tumours were detected in 44.6% of the subjects screened, while in the second round tumours were detected in 59.3% of the subjects. The PPVs in the second round were higher than in the first round. This may be due to an increase in the prevalence of the disease in the second round, partially attributable to a higher participation by people in the upper age groups (in the first round, 47.7% of participants were 60–69 years old and in the second round, 52%). This increase could also be explained by the decrease in the false-positive rates usually observed in screening programmes between the first and subsequent rounds. Advanced neoplasm was detected in 6.1 per 1000 participants, representing one-third of all subjects who had a colonoscopy. The number of advanced neoplasms detected in our study was lower among women than among men.46,47 However, it is widely accepted that the lifetime risk of colorectal cancer is similar for both sexes, and the recommendations of the screening guidelines do not include differences between men and women. The prevalence of screen-detected high-risk adenomas compared with low-risk adenomas has been described in other colorectal cancer screening programmes based on FOB test.13 As the prevalence of HRA in colonoscopy was higher than the prevalence of LRA, the findings suggest a higher tendency to bleed for advanced adenoma, and FOB test might thus select tumours at higher risk of progression to carcinoma. The detection of HRA plays an important role in the prevention of colorectal cancer. Obtaining high attendance rates for the colonoscopy is of major importance because a positive FOB test identifies subjects with high probabilities of tumours. Overall, 89% of the patients attended the diagnostic assessment, showing a higher participation rate as compared with other programmes.26,27,48 This fact indicates that once participation is accepted, further assessment derived from the initial test is also highly accepted. Although a percentage of noncompliance is unavoidable, achieving a higher diagnostic attendance is possible by implementing informative strategies about the implications of a positive screening result with active follow-up. Information of the health benefits and risks of screening is necessary in order to improve participation.49–51 The proportion of complete colonoscopies is an important indicator to be monitored when evaluating a screening programme. In our study, the completion rate for colonoscopy was 92.3%, a figure similar to those obtained in other colorectal screening initiatives.26,52 Although colonoscopies were performed in a well-experienced endoscopy unit , one serious complication (perforation) associated with the www.jmedscreen.com
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procedure arose. This finding underlines the importance of having a high-quality endoscopy service and an adequate management of any possible complications to optimize benefit–risk estimations. What are the lessons learnt from this experience in relation to the extension of this programme to the rest of Catalonia? Even though the planning and implementation approach was similar to the routine provision of health-care services, some conditions may still differ. We believe that participation has to cope with the difficulty that colorectal cancer is not a high-profile health issue in our community. Taking these facts into account, as well as the results of this study, the Catalan Cancer Plan convened an external group of experts not related with the pilot programme to evaluate it and issue recommendations about the future approach of this screening programme in our country. The group recommended the extension of the biennial programme using FOB test for the whole Catalan population aged 50–69 years, considering the evidence of effectiveness, the burden of the disease and the feasibility of the programme. A need to achieve an active participation of primary health-care teams and to increase awareness about the benefits of participation was recommended. In addition, recent costeffective models of FOB test screening for colorectal cancer have shown its cost-effectiveness even with low rates of participation.53 The fact that there are other screening options, whose effectiveness has not yet been fully evaluated, leaves the final decision about the screening test open.54 In conclusion, the low participation rate should be interpreted within the context of a pilot programme carried out in an area without any previous colorectal cancer preventive initiatives at a population-based level. The prevalence of screen-detected cancers and the predictive values of positive tests do not differ substantially from those observed in randomized trials. Additional strategies must be undertaken to improve participation among the population, as well as organizational changes to increase primary health-care involvement. Specific research efforts should be carried out in order to better understand the factors associated with the determinants of colorectal cancer screening participation in our population. Regardless of the moderate participation rate, this pilot study has shown the feasibility of an organized, populationbased colorectal cancer screening programme in Catalonia.
ACKNOWLEDGEMENTS We thank Esteve Fernandez and Montse Garcia for their very helpful comments and review of this manuscript. We also appreciate the contribution of Cristina Rajo in the review of the English translation of the manuscript. This project received funds from de Salud Carlos III, grant FIS 00/ 0027-01.
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Authors’ affiliations ` Peris, Head of Cancer Prevention and Control Department, Merce Catalan Institute of Oncology, Barcelona, Spain. Head of the Cancer Screening Office, Catalan Cancer Plan, Catalan Health Government, Spain ` s, Senior Epidemiologist, Catalan Cancer Plan, Josep A Espina Catalan Health Government, Barcelona, Spain Laura Mun ˜ oz, Statistician, Cancer Prevention and Control Department, Catalan Institute of Oncology, Barcelona, Spain Matilde Navarro, Senior Medical Oncologist, Cancer Prevention and Control Department, Catalan Institute of Oncology, Barcelona, Spain
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Gemma Binefa, Preventive Medicine and Public Health Specialist, Cancer Prevention and Control Department, Catalan Institute of Oncology, Barcelona, Spain ` s, Director, Catalan Cancer Plan, Catalan Health Josep M Borra Government, Barcelona, Spain The Catalan Colorectal Cancer Pilot Screening Programme Group: M Peris, G Binefa, M Navarro, L Mun ˜oz, J R Gonza´lez, I Blanco, A Clopes, V Moreno, G Capella` (Catalan Institute of Oncology); M Peris, J A Espina`s, J M Borra`s (Catalan Cancer Plan); J M Miquel, J M Nogueira, G Garcı´a Mora, J Martı´-Rague´, D Pares, A Vidal (University Hospital of Bellvitge); P Barrios (Hospital General de l’Hospitalet); S Calero (Catalan Institute of Health, Primary Health Care Division).
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