==== Front Ann Saudi MedAnn Saudi MedAnnals of Saudi Medicine0256-49470975-4466King Faisal Specialist Hospital and Research Centre 2650696610.5144/0256-4947.2015.341asm-5-341EditorialInitial guidelines for colorectal cancer screening in Saudi Arabia: a beginning Almadi Majid A. abBarkun Alan N. bc a Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia b Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, Montreal, Canada c Division of Clinical Epidemiology, The McGill University Health Center, Montreal General Hospital, McGill University, Montreal, CanadaCorrespondence: Majid A. Almadi, MBBS, MSc, FRCPC, Division of Gastroenterology, Department of Medicine, King Khalid University Hospital, King Saud University, PO Box 2925 (59), Riyadh 11461, Saudi Arabia, T: +966-11-4679167, F: +966-11-4671217, maalmadi@ksu.edu.saSep-Oct 2015 35 5 341 342 Copyright © 2015, Annals of Saudi Medicine2015This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. ==== Body Colorectal cancer (CRC) has become a public health concern in Saudi Arabia given its incidence, relatively early median age at diagnosis, and because the presentation is usually at an advanced stage. Alsanea and colleagues1 have put forth the first national guidelines for CRC screening in Saudi Arabia, which is a long awaited major milestone in an attempt to establish a coherent national policy aimed at decreasing the incidence and mortality from CRC in this country. The guideline presents recommendations on the age of initiating and stopping screening for CRC in average-risk individuals. It also contrasts different screening modalities, which is an important issue at this stage in which a nationwide CRC screening program is being considered. Unfortunately, the guidelines do not discuss the possible risk factors that might be associated with the development of CRC in the Saudi population, nor the approach to high-risk groups of patients, or important considerations relating to the use of fecal immunochemical testing (FIT) as opposed to guaiac-based fecal occult blood testing or fecal DNA detection. Cost-effectiveness analyses for CRC screening in the Saudi population are lacking, but extrapolating from other populations, the guidelines recommend multiple options for screening, but mainly colonoscopy and stool testing. In contrast, it appears that fecal DNA detection, computed tomographic colonography (CTC), and capsule endoscopy are not cost-effective compared to other modalities.2 Recently, the draft recommendations from the United States Preventative Service Task Force (USPSTF) on CRC screening raises a number of issues that need to be addressed when considering these technologies as a CRC screening modality.3 Furthermore, the European Society of Gastrointestinal Endoscopy and European Society of Gastrointestinal and Abdominal Radiology did not recommend CTC as a primary test for population screening or in individuals with a positive first-degree family history of CRC.4 In the current guidelines, CTC use was only recommended in certain circumstances, which is in keeping with the European guidelines. Also, the test performance of different screening modalities in the Saudi population is limited5 and data on the acceptability of CRC screening are lacking.1,6,7 This limitation in local data has resulted in recommendations for screening and surveillance intervals after an initial screening modality that are extrapolated from other populations, but this has also been the case in other guidelines.8 The USPSTF on CRC screening also addressed the issue of extending screening for CRC beyond the age of 75 years and recommended only continuing screening in older patients under specific circumstances and not as a general rule. The optimal screening strategies for CRC according to a set of new decision models completed for the USPSTF include annual use of FIT, flexible sigmoidoscopy every ten years with an annual FIT test, or a colonoscopy every ten years, respectively, resulting in gradually increasing years of quality of life, but also increasing the need for more colonoscopies to be performed at the society level.3 In addition to the issues mentioned earlier, the upcoming guidelines should address whether to use qualitative or quantitative FIT as the latter has the advantage of flexibility in adjusting the cutoff value at which a test is considered positive, depending on available data from the literature and local resources (number of downstream colonoscopies), as was endorsed by the Asia Pacific consensus recommendations on CRC screening.8 If a colonoscopy based strategy is adopted, a strict quality-control process should be emphasized, as we know that there is wide variability in adenoma detection rates between endoscopists.9 This wide variability results in an increased incidence of interval CRC after a negative colonoscopy10,11 in addition to the variability that occurs in the performance of an individual endoscopist depending on his or her workload.12 The current guidelines only briefly mention this issue. This current guideline will promote opportunistic CRC screening on a healthcare provider level; however, to harness the maximum benefit of a population-based screening program, multiple levels of intervention should be targeted at the level of policy makers and healthcare providers as well as the general public.13 The challenge will be how to implement such a program in the current healthcare system in Saudi Arabia and whether the private sector would be included in this program; if so what would be the best way to assure the quality of the screening process and adherence to the recommendations put forth. Indeed, this has been a challenge in the United States where half of those screened who had a normal colonoscopy had a repeat colonoscopy in less than 7 years,14 and about a third of those in Canada in less than six years.15 Furthermore, such a national program would require a robust health information system that integrates data from population registries, cancer registries, laboratories, endoscopy centers and primary healthcare providers similar to the Dutch system.16 A further resource to be developed could be clinics devoted to CRC screening with dedicated staff, which has been shown to have a strong positive impact on the use of screening services.13 The Joint Advisory Group (JAG) on gastrointestinal endoscopy is a model worthy of examination. The JAG provides accreditation for endoscopist performing screening colonoscopies within the NHS bowel cancer screening program with strict criteria, with the aim of increasing the yield of colonoscopies performed and decreasing complications resulting from inaccurate as well as incomplete examinations. We hope that this guideline marks the beginning of a process that will incorporate both policy and organizational changes that will ensure that eligible individuals are systematically enrolled in some form of organized CRC screening program, and that specialized professional bodies are actively involved and contributing their expertise to such an initiative. ==== Refs REFERENCES 1 Alsanea N Almadi MA Abduljabbar AS Alhomoud S Alshaban TA Alsuhaibani A National Guidelines for Colorectal Cancer Screening in Saudi Arabia with strength of recommendations and quality of evidence Annals of Saudi Medicine 2015 May-Jun 35 3 189 95 26409792 2 Cruzado J Sanchez FI Abellan JM Perez-Riquelme F Carballo F Economic evaluation of colorectal cancer (CRC) screening Best practice & research Clinical gastroenterology 2013 12 27 6 867 80 24182607 3 Draft Recommendation Statement: Colorectal Cancer: Screening U.S. Preventive Services Task Force 10 2015 http://www.uspreventiveservicestaskforce.org/Page/Document/draft-recommendation-statement38/colorectal-cancer-screening2 4 Spada C Stoker J Alarcon O Barbaro F Bellini D Bretthauer M Clinical indications for computed tomographic colonography: European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastrointestinal and Abdominal Radiology (ESGAR) Guideline Endoscopy 2014 10 46 10 897 915 25268304 5 Elsafi SH Alqahtani NI Zakary NY Al Zahrani EM The sensitivity, specificity, predictive values, and likelihood ratios of fecal occult blood test for the detection of colorectal cancer in hospital settings Clinical and experimental gastroenterology 2015 8 279 84 26392783 6 Zubaidi AM AlSubaie NM AlHumaid AA Shaik SA AlKhayal KA AlObeed OA Public awareness of colorectal cancer in Saudi Arabia: A survey of 1070 participants in Riyadh Saudi journal of gastroenterology : official journal of the Saudi Gastroenterology Association 2015 Mar-Apr 21 2 78 83 25843193 7 Almadi MA Mosli MH Bohlega MS Al Essa MA AlDohan MS Alabdallatif TA Effect of public knowledge, attitudes, and behavior on willingness to undergo colorectal cancer screening using the health belief model Saudi journal of gastroenterology : official journal of the Saudi Gastroenterology Association 2015 Mar-Apr 21 2 71 7 25843192 8 Sung JJ Ng SC Chan FK Chiu HM Kim HS Matsuda T An updated Asia Pacific Consensus Recommendations on colorectal cancer screening Gut 2015 1 64 1 121 32 24647008 9 Jiang M Sewitch MJ Barkun AN Joseph L Hilsden RJ Endoscopist specialty is associated with colonoscopy quality BMC gastroenterology 2013 13 78 23638769 10 Baxter NN Sutradhar R Forbes SS Paszat LF Saskin R Rabeneck L Analysis of administrative data finds endoscopist quality measures associated with postcolonoscopy colorectal cancer Gastroenterology 2011 1 140 1 65 72 20854818 11 Rabeneck L Paszat LF Saskin R Endoscopist specialty is associated with incident colorectal cancer after a negative colonoscopy Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association 2010 3 8 3 275 9 19879970 12 Almadi MA Sewitch M Barkun AN Martel M Joseph L Adenoma detection rates decline with increasing procedural hours in an endoscopist’s workload Canadian journal of gastroenterology & hepatology 2015 Aug-Sep 29 6 304 8 25996612 13 Senore C Inadomi J Segnan N Bellisario C Hassan C Optimising colorectal cancer screening acceptance: a review Gut 2015 7 64 7 1158 77 26059765 14 Goodwin JS Singh A Reddy N Riall TS Kuo YF Overuse of screening colonoscopy in the Medicare population Archives of internal medicine 2011 8 8 171 15 1335 43 21555653 15 Hol L Sutradhar R Gu S Baxter NN Rabeneck L Tinmouth JM Repeat colonoscopy after a colonoscopy with a negative result in Ontario: a population-based cohort study CMAJ open 2015 Apr-Jun 3 2 E244 50 16 Kuipers EJ Rosch T Bretthauer M Colorectal cancer screening--optimizing current strategies and new directions Nature reviews Clinical oncology 2013 3 10 3 130 42