Reviewer's report 
 Colorectal cancer screening awareness in Greece Title: 
 1  15 March 2006 Version: Date: 
 Grazia Grazzini Reviewer: 
Reviewer's report: 
General 
------------------------------------------------------------------------------- 
Major Compulsory Revisions (that the author must respond to before a decision on publication can be reached) 
------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the author can be trusted to correct) 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) The manuscript by Apostolos Xilomenos and co-workers deals with a very important topic, given the 
great epidemiological relevance of colorectal cancer in western countries, and the evidence- based 
benefit in reducing mortality from this disease through screening activities. I agree with the authors about the poor information available on screening recommendations by European physicians, and for this reason consider the paper noteworthy. 
However, I would like to focus some aspects: 
It is very important to distinguish an organised screening programme from an opportunistic 
screening practice (also named case-finding). Organised screening programmes are based on a 
coherent structure, offering a standardised system of care, with nationally implemented guidelines 
defining the target population, the frequency of screening tests, the diagnostic procedure, the treatment and the follow-up protocol. Organised programmes also monitor the quality of the overall program according to indicators that are already available for colorectal cancer screening. These 
include population uptake rates, cancer and advanced adenomas detection rates, and false-positive 
and false-negative rates. In an organised screening programme, moreover, costs are carefully evaluated. Since the potential benefits of screening depend on a balance between advantages and adverse 
effects, screening that is organised and controlled for quality in any phase of its process, should 
have greater potential ability to yield maximum benefit in the early detection and prevention of cancer. In opportunistic screening, quality controls are variable, and few opportunities exist to monitor the 
achievements and failures of the service as a whole. 
In conclusion, the aim of cancer screening is to reduce cancer mortality, and, in the case of colorectal cancer, also the cancer incidence in the screened population. High levels of population up-take, high-quality of screening process, and effective follow-up are necessary to reach these 
goals. For these reasons, organised screening is more likely to be successful than opportunistic 
screening. 
In Europe, many countries such as The UK, Finland, and The Netherlands etc, are planning national 
screening programmes, mainly using a faecal occult blood test (FOBT) approach. In Italy, 
region-wide screening programmes have already started. In all these programmes, the model is an 
organised screening programme. 
Authors write that in Greece, an established sanitary system is at the beginning stages, and that in 
the future, it may be possible to plan coordinated screening activities. It would be beneficial in any 
case, that the authors take into account the aspects mentioned above. 2. The results of the study show a poor level of colorectal cancer screening awareness among primary care physicians. As known, subjects who are advised to have screening tests (either FOBT 
or sigmoidoscopy) should undergo total colonoscopy if FOBT is positive or sigmoidoscopy shows 
significant findings in the distal tract, in order to detect proximal lesions. However, authors didn’t provide any information about the availability of local endoscopic services where physicians can refer patients with positive screening test results for diagnostic assessment. A lack of adequate 
endoscopic services can discourage physicians in recommending a screening practice. 
3. In an organized screening programme it’s mandatory to create a multi-professional and multidisciplinary network, where gastroenterologists, laboratory staff, epidemiologists, general practitioners, primary care physicians, etc. are involved, with the aim at defining and sharing 
decisional protocols. This process can significantly improve screening awareness among health 
operators, also by means continual training systems and accessibility for all the operators to screening results. 
 Accept after discretionary revisions What next?: 
 An article whose findings are important to those with closely related research Level of interest: 
interests 
 Acceptable Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
I declare that I have no competing interests 
Reviewer's report 
 Colorectal cancer screening awareness in Greece Title: 
 1  15 March 2006 Version: Date: 
 Grazia Grazzini Reviewer: 
Reviewer's report: 
General 
------------------------------------------------------------------------------- 
Major Compulsory Revisions (that the author must respond to before a decision on publication can be reached) 
------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the author can be trusted to correct) 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) The manuscript by Apostolos Xilomenos and co-workers deals with a very important topic, given the 
great epidemiological relevance of colorectal cancer in western countries, and the evidence- based 
benefit in reducing mortality from this disease through screening activities. I agree with the authors about the poor information available on screening recommendations by European physicians, and for this reason consider the paper noteworthy. 
However, I would like to focus some aspects: 
It is very important to distinguish an organised screening programme from an opportunistic 
screening practice (also named case-finding). Organised screening programmes are based on a 
coherent structure, offering a standardised system of care, with nationally implemented guidelines 
defining the target population, the frequency of screening tests, the diagnostic procedure, the treatment and the follow-up protocol. Organised programmes also monitor the quality of the overall program according to indicators that are already available for colorectal cancer screening. These 
include population uptake rates, cancer and advanced adenomas detection rates, and false-positive 
and false-negative rates. In an organised screening programme, moreover, costs are carefully evaluated. Since the potential benefits of screening depend on a balance between advantages and adverse 
effects, screening that is organised and controlled for quality in any phase of its process, should 
have greater potential ability to yield maximum benefit in the early detection and prevention of cancer. In opportunistic screening, quality controls are variable, and few opportunities exist to monitor the 
achievements and failures of the service as a whole. 
In conclusion, the aim of cancer screening is to reduce cancer mortality, and, in the case of colorectal cancer, also the cancer incidence in the screened population. High levels of population up-take, high-quality of screening process, and effective follow-up are necessary to reach these 
goals. For these reasons, organised screening is more likely to be successful than opportunistic 
screening. 
In Europe, many countries such as The UK, Finland, and The Netherlands etc, are planning national 
screening programmes, mainly using a faecal occult blood test (FOBT) approach. In Italy, 
region-wide screening programmes have already started. In all these programmes, the model is an 
organised screening programme. 
Authors write that in Greece, an established sanitary system is at the beginning stages, and that in 
the future, it may be possible to plan coordinated screening activities. It would be beneficial in any 
case, that the authors take into account the aspects mentioned above. 2. The results of the study show a poor level of colorectal cancer screening awareness among primary care physicians. As known, subjects who are advised to have screening tests (either FOBT 
or sigmoidoscopy) should undergo total colonoscopy if FOBT is positive or sigmoidoscopy shows 
significant findings in the distal tract, in order to detect proximal lesions. However, authors didn’t provide any information about the availability of local endoscopic services where physicians can refer patients with positive screening test results for diagnostic assessment. A lack of adequate 
endoscopic services can discourage physicians in recommending a screening practice. 
3. In an organized screening programme it’s mandatory to create a multi-professional and multidisciplinary network, where gastroenterologists, laboratory staff, epidemiologists, general practitioners, primary care physicians, etc. are involved, with the aim at defining and sharing 
decisional protocols. This process can significantly improve screening awareness among health 
operators, also by means continual training systems and accessibility for all the operators to screening results. 
 Accept after discretionary revisions What next?: 
 An article whose findings are important to those with closely related research Level of interest: 
interests 
 Acceptable Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
I declare that I have no competing interests 
Please review this paper.
user
Reviewer's report 
 Colorectal cancer screening awareness in Greece Title: 
 1  15 March 2006 Version: Date: 
 Grazia Grazzini Reviewer: 
Reviewer's report: 
General 
------------------------------------------------------------------------------- 
Major Compulsory Revisions (that the author must respond to before a decision on publication can be reached) 
------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the author can be trusted to correct) 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) The manuscript by Apostolos Xilomenos and co-workers deals with a very important topic, given the 
great epidemiological relevance of colorectal cancer in western countries, and the evidence- based 
benefit in reducing mortality from this disease through screening activities. I agree with the authors about the poor information available on screening recommendations by European physicians, and for this reason consider the paper noteworthy. 
However, I would like to focus some aspects: 
It is very important to distinguish an organised screening programme from an opportunistic 
screening practice (also named case-finding). Organised screening programmes are based on a 
coherent structure, offering a standardised system of care, with nationally implemented guidelines 
defining the target population, the frequency of screening tests, the diagnostic procedure, the treatment and the follow-up protocol. Organised programmes also monitor the quality of the overall program according to indicators that are already available for colorectal cancer screening. These 
include population uptake rates, cancer and advanced adenomas detection rates, and false-positive 
and false-negative rates. In an organised screening programme, moreover, costs are carefully evaluated. Since the potential benefits of screening depend on a balance between advantages and adverse 
effects, screening that is organised and controlled for quality in any phase of its process, should 
have greater potential ability to yield maximum benefit in the early detection and prevention of cancer. In opportunistic screening, quality controls are variable, and few opportunities exist to monitor the 
achievements and failures of the service as a whole. 
In conclusion, the aim of cancer screening is to reduce cancer mortality, and, in the case of colorectal cancer, also the cancer incidence in the screened population. High levels of population up-take, high-quality of screening process, and effective follow-up are necessary to reach these 
goals. For these reasons, organised screening is more likely to be successful than opportunistic 
screening. 
In Europe, many countries such as The UK, Finland, and The Netherlands etc, are planning national 
screening programmes, mainly using a faecal occult blood test (FOBT) approach. In Italy, 
region-wide screening programmes have already started. In all these programmes, the model is an 
organised screening programme. 
Authors write that in Greece, an established sanitary system is at the beginning stages, and that in 
the future, it may be possible to plan coordinated screening activities. It would be beneficial in any 
case, that the authors take into account the aspects mentioned above. 2. The results of the study show a poor level of colorectal cancer screening awareness among primary care physicians. As known, subjects who are advised to have screening tests (either FOBT 
or sigmoidoscopy) should undergo total colonoscopy if FOBT is positive or sigmoidoscopy shows 
significant findings in the distal tract, in order to detect proximal lesions. However, authors didn’t provide any information about the availability of local endoscopic services where physicians can refer patients with positive screening test results for diagnostic assessment. A lack of adequate 
endoscopic services can discourage physicians in recommending a screening practice. 
3. In an organized screening programme it’s mandatory to create a multi-professional and multidisciplinary network, where gastroenterologists, laboratory staff, epidemiologists, general practitioners, primary care physicians, etc. are involved, with the aim at defining and sharing 
decisional protocols. This process can significantly improve screening awareness among health 
operators, also by means continual training systems and accessibility for all the operators to screening results. 
 Accept after discretionary revisions What next?: 
 An article whose findings are important to those with closely related research Level of interest: 
interests 
 Acceptable Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
I declare that I have no competing interests 
assistant