The guidelines make the point that there is evidence for a screening programme using faecal occult blood assay. Their suggestion that individual PCGs should underwrite such screening suggests that we are not likely to see an initiative in the short term.
I agree with Dr Kennedy that the two main problems are getting the patients with definite suspicious symptoms to present earlier and judging which of the many less certain presentations to refer.
In our practice we have attempted to improve our case management in the latter category by providing an in-house rigid sigmoidoscopy service. Two of our six partners have provided this service for the last 6 years. We trained with the local colorectal surgeon. We use disposable sigmoidoscopes and prescribe a bisacodyl bowel preparation before the test.
A negative investigation is not definitely exclusive as rigid sigmoidoscopy can miss 10–20% of lesions. We do not biopsy. However, even with these restrictions we have found unexpected carcinomas and polyps in patients with minor symptoms. We have been able to diagnose proctitis.
By the time the sigmoidoscopy has been followed by a normal barium enema, many patients' symptoms have subsided, allowing a more confident decision not to refer.
Our practice is not large enough to produce meaningful statistics, but the local colorectal surgeons feel that it has helped to improve our targeting of referrals.
Rigid sigmoidoscopy is cheap and quick to perform. Used cautiously it might add to the GP's armoury in targeting colorectal cancer, until we have a more definitive screening service.
Dr Matthew Lockyer, GP, Ixworth, Suffolk
I understand that the purpose of Phil Hammond's 'Out of Hours' page is to entertain; nevertheless, I found his piece on 'Guidelines for use of the vernacular' (November 1999) disturbing.
He seems to be making the point that it is sometimes necessary for doctors to use colloquial language when communicating with patients about bodily functions.
I'm sure that no-one would disagree with this. But he confuses the vernacular with insults, and implies that it is alright for a nurse to address elderly patients in her care as "bastards", and for a GP to call a patient "jelly belly" over a public address system. Such insults from professionals can never be acceptable because they are an abuse of power.
Jessica Markwell, Reading
I would like to acknowledge the contribution made by King's Mill Centre for Health Care Services during the initial stages of development of the cancer pain guideline discussed in my article 'Local guideline aims to unify approach to cancer pain relief' (Guidelines in Practice, October).
Jayne Wood, Clinical Effectiveness Coordinator, Central Nottinghamshire Healthcare