In Reply Dr Doubeni agrees with me1 that we lack evidence on comparative effectiveness of various methods of colorectal cancer (CRC) screening. However, he feels that because clinicians already believe that colonoscopy is better than other strategies, it is not possible to perform a randomized clinical trial (RCT). There are many examples where our best assumptions (eg, that estrogen prevents cardiovascular disease in postmenopausal women or that tight diabetic control prevents complications in elderly persons) were later proven wrong by an RCT. He also does not consider the harms of colonoscopy; besides the several hours lost from work or other productive pursuits, there are the risks associated with the colonic preparation, with the anesthesia, and with the procedure itself, such as perforations. Because an increasing percentage of colonoscopies are being done with propofol, the risks and costs associated with colonoscopy have actually increased in the last few years.2,3
Redberg RF. Colorectal Cancer Screening Comparative Effectiveness—Clinical Trials Are Not Always The Answer—Reply. JAMA Intern Med. 2017;177(1):144. doi:10.1001/jamainternmed.2016.7834
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