Experiences from Croatia in involving family physicians in programs of early cancer detection

The leaders of the Department of Family Medicine of the Osijek University School of Medicine and the Health Center Osijek, have recently introduced the project "A Model of Early Cancer Detection Integrated in Practice of Family Physicians", to test the idea that screening and early diagnosis of cancer are more efficient if integrated in practice of family physicians, compared to the National Program, centrally directed and supplied by the public services (Ebling/Project, 2007, as cited in Majnaric-Trtica, 2008b). The Project has started after two years of preparations and education of subjects from the target groups and family physicians, included in the Project, on screening and early detection methods. The computer program, specifically designed for keeping the records on data and for follow up of patients with positive screening tests, was installed into a total of twenty GP offices included in the Project. This program has allowed the continuous recruitment of new patients into the surveillance system automatically, by using personal data on sex and age only (Majnaric-Trtica, 2008b). Up to date, the Project has yielded its results in colorectal and breast cancer screening. The Project of early detection of colorectal cancer

To avoid overalpping with the National Program, subjects were included in the Project for early detection of colorectal cancer to belong to either the 5-year lower age class (45-49) or the 5-year upper age class (75-79), than it is recommended according to the National Program (50-74). These defined target groups encompassed approximately 4 000 people, randomly selected from the large sample of a total of 27 000 subjects, recorded on the lists of family physicians included in the Project (Majnaric-Trtica, 2008b; Pribic, 2011).

The screening protocol can be described as follows. Family physicians call the patients from the defined target groups by phone, deliver them letters of invitation in envelops together with three testing cards, brochure for their use and a questionnaire on risk factors. A physician also provides instructions on how to correctly apply the testing cards and other issues the patients may be interested in. A physician reads the applied testing cards when patients return them back and keeps a record on the results. Patients with positive tests are referred for further diagnostics by colonoscopy. A physician also keeps a record on the results of follow up and treatments (Pribic, 2011).

From the beginning of April to the end of May 2009, a total number of 516 testing sets on occult faecal blood were delivered to patients from these two defined target groups. A high responding rate of 69,76% (360 cases) was recorded. This was an advantage in comparison with low responding rates of about 20%, obtained by the National Program. In the Project, there were in average 2,5% (13 cases) with positive tests, predominantely in the older age group, 3,5% (11 cases), compared to 1% (2 cases) recorded in the younger age group. These results showed that in the middle age population groups (45-49), a very low rate of positive tests, in systematically and non selectively performed screening on occult faecal bleeding, might be expected (1% positive tests). This further indicates that, for younger population groups, a selection of subjects at higher risk for the development of colon cancer should be made, prior entering the screening cycle. The Project of early detection of breast cancer

The study group comprised the women from ten GP offices who have not yet been invited by the County Institute of Public Health to screening with mammography (Pribic, 2010). These women were invited during their visits for reasons other than mammography (opportunistic screening), or actively, by surface mail or phone. Women who did not respond at the first invitation, were included in the four-phased motivation program, carried out by a family physician and a home visiting nurse. If their decisions remaind unchanged after the period of three months of follow-up, they were classified as resisted the screening with mammography. Although a high level of responsiveness, of 80%, was achieved, a critical appraisal upon this study includes a suggestion for the post-hoc testing, to decide on whether a long-lasting and highly suggestive motivation activities are applicable as a routine advising procedure. In addition, results obtained here indicate, similar as in the case with the Project of early detection of colorectal cancer, that there is a need for more thoroughly prepared selection procedure, before someone starts motivating women to screening.

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