Gastrointestinal Endoscopy

Gastrointestinal Endoscopy This issue of Gastrointestinal Endoscopy represents a milestone for the journal and the ASGE: the 8-year term of Dr. Charles J. Lightdale, editor, now comes to a close as set forth in the bylaws of the Society. Eight years is a long time in our present world, and it would be understandable if perhaps Dr. Lightdale transfers responsibility for the journal with mixed feelings of willingness and reluctance. In the time to come, however, he can rightly take great satisfaction and pride in the high levels of quality and credibility achieved for the journal under his able leadership. There can be no doubt that Gastrointestinal Endoscopy has been of eminent benefit to its readership, the ASGE, certainly to the field of gastrointestinal endoscopy and, most importantly, to the fellow h u m a n beings we are privileged to call patients. It is therefore necessary to express our gratitude to Dr. Lightdale, his associate editors, the managing editor, Reina Lightdale, and her editorial team, as well as the many reviewers who have made Gastrointestinal Endoscopy successful. There are four reasons why original work is submitted to a journal: reputation, timely publication, fair treatment in the review process, and an expectation that the work will reach the intended audience. These have always been and must remain the principles on which the integrity of Gastrointestinal Endoscopy rests. There has been substantial growth in both the size and stature of Gastrointestinal Endoscopy. This expansion parallels that of gastrointestinal endoscopy as a field of medicine: continuing growth in the use of endoscopy for diagnosis and treatment of patients, sustained development of new technology and methods, and a growing need for solid data concerning the application of endoscopic methods to clinical problems. In one sense, the journal reflects these attributes, but by the same token it has clearly been instrumental in promoting the evolution of gastrointestinal endoscopy. The expansive phase in the evolution ofgastrointes-

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tinal endoscopy dates to the introduction of the coherent optical bundle in the late 1960s. With this singular technical innovation, endoscopy entered a phase of rapid development that has continued for the last 25 years. In looking to the future, it is essential to ask whether this union of technology and clinical practice will be sustainable. There is ample reason to believe that the technical component of this equation remains valid, and I am certain that many new methods of endoscopic diagnosis and treatment are possible. But there is no doubt that clinical practice is changing, and whether the further development of gastrointestinal endoscopy will be constrained by economic and other factors remains an open question. To the extent that clinical practice is changing, the profile and agenda of the readership of the journal will necessarily change. With the transition to new editorship of the journal, the first change, proclaimed on the masthead, has been a substantial expansion in the size of the editorial team. Given the increases that have occurred in the capacity and quality of the journal, it is evident that the size and structure of the editorial team must expand if continuing growth is to remain a fundamental goal. The composition of this new editorial team also reflects our agenda. The long-established editorial policy of placing emphasis on original articles has been the correct course and will be sustained. In thinking about endoscopy in relation to the health care environment mentioned above, the highest priority for publication will be given to work that demonstrates the utility of endoscopy (or lack thereof) in the resolution of clinical problems, including studies that address the cost of care. Although I am naturally inclined toward papers on technology and technique, there is a greater need to demonstrate the fundamental value of our technology in the care of patients. Any journal that publishes medical papers must have access to expert advice concerning statistical methods. Virtually every original investigation published today utilizes statistical methods; the conclusions set forth in these articles are invariably based on such methods. In a very real sense, therefore, the scientific credibility and integrity of a medical journal rest on the validity of the data, determined by statistical methods, that appear in published articles. Given the importance of biostatistics, Gastrointestinal Endoscopy now has an Editor for Biostatistics, Dr. Sara Debanne. More than half of the manuscripts submitted to Gastrointestinal Endoscopy now come from outside the United States. This clearly demonstrates that the readership of the journal has become interua-

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tional, and it is readily evident that Gastrointestinal Endoscopy enjoys a worldwide leadership position in its field. As the world becomes smaller, as developing nations become more prosperous, gastrointestinal endoscopy will have an ever increasing role in the care of patients. Even though the world, figuratively speaking, continues to shrink, it also retains its tremendous diversity. This can be problematic for an editor in many respects. Nevertheless, the journal must continue to serve the interests of a wider constituency, one that extends far beyond the borders of the United States. In keeping with this geopolitical agenda, one initiative has been the appointment of an International Editor, Dr. Peter Cotton. A further initiative will be the establishment of a working International Editorial Board with an expanded number of International Editors from throughout the world. My 28-year professional career exactly parallels the remarkable expansion and development of gastrointestinal endoscopy and I have devoted virtually all of it to gastrointestinal endoscopy, including patient care, teaching, and clinical research. The attraction that I feel for endoscopes remains as compelling as on the day of my first procedure. I take immense pride in the ASGE, its integrity, ideals, and purpose and look back on my many years of service to the Society with satisfaction and a sense of accomplishment. I cannot, in fact, think of many roles within the Society that I have not had at one time or another. I find the role of editor immensely appealing and have some experience in this capacity. I enjoy writing and especially admire clarity of thought and expression in the use of the English language. Aside from the pure enjoyment of setting things down on paper correctly, the editorship is a unique position of responsibility and power. If I were to state a guiding principle in the exercise of this power, it would be that endoscopic technology has been and will continue to be of great benefit to patients. A medical journal belongs in any final analysis not to an editor or a society but to its readership; it exists on the intellectual level only for its readers. It is also the work of many individuals, not least of which are those who submit manuscripts and those who participate in the tedious process of peer review. It is by engaging the allegiance of everyone who opens its cover that Gastrointestinal Endoscopy has been successful. For myself and on behalf of the Associate and Assistant Editors, Managing Editor, and our very capable coworkers at Mosby Year-Book, we ask that you welcome us to your journal.

Michael V. Sivak, Jr., MD C/eve/and, Ohio

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Screening for colorectal cancer: confuting the refuters* Confute: To overwhelm in argument; to disprove what is false or erroneous (Funk and Wagnalls 1947). The U.S. Preventive Services Task Force for the first time in December 1995 recommended screening of the average-risk asymptomatic population for colorectal cancer.1 The task force is an independent panel charged by the U.S. Department of Health and Human Services with recommending preventive services for primary care clinicians. They conduct impartial assessments of scientific evidence and base recommendations solely on the strength of available data. During the release of its new guideline, Dr. Harold Sox, Chairman of the Task Force, stressed that there is strong new evidence of efficacy for both flexible sigmoidoscopy and fecal occult blood test screening in reducing the great mortality and morbidity of colorectal cancer. Although the data supporting screening for colorectal cancer are as compelling as that for any of the major cancers, a number of recent publications and presentations continue to question the value of this approach. 2-4 I will briefly review these supporting data, and then, using the evidence, will objectively confute those who c,ontinue to argue against implementation of standard colorectal cancer screening. Colorectal cancer definitely is a major health problem in the United States. We see about 155,000 new cases each year, and the disease causes nearly 55,000 deaths. 5 The lifetime risk in this country is now over 6%. In spite of all the advances that have been made in medical and surgical care over the past 30 years, survival from the disease is still only about 52%. Colorectal cancer thus causes great personal pain and suffering, substantial loss of productivity, and the expenditure of billions of health care dollars. It is a tragic fact that the disease causes this much loss and yet is actually one of the most preventable or curable cancers when detected early. By its purest definition, screening is the use of a simple, affordable, and acceptable test to identify a subgroup of the at-risk population more likely to have a clinically significant lesion or abnormality in which it would be justified to perform more complex, expensive, and possibly invasive diagnostic tests. Compared * A S G E D i s t i n g u i s h e d Lecture 1996. 0016-5107/97/4501-010555.00 + 0 GASTROINTESTINAL ENDOSCOPY Copyright © 1997 by the American Society for Gastrointestinal Endoscopy 37/70/78061

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