Reliability of panel-based guidelines for colonoscopy: an international comparison

Letters to the Editor

REFERENCES 1. World Health Statistics Annual, 1996. Geneva: WHO; 1998. 2. Instituto Nacional de Estadisticas de Chile. Anuario de Demografia, 1996. 3. Ferrecio C, Chianale J, Gonzalez C, Nervi F. Epidemiologia descriptiva del cancer digestivo en Chile (1982-1991); una aproximacion desde la mortalidad. Santiago, Chile: Pontificia Universidad Catolica de Chile; 1995. p. 1-147. 4. Csendes A, Smok G, Medina E, Salgado 0, Rivera R, Quitral M. Caracteristicas evolutivas del cancer gastrico 1958-1990. Rev Med Chile 1992;120:36-42. 5. Rubio CA, Pisano R, Llorens P, Duarte I. A comparative study between the gastric mucosa of Chileans and other dwellers of the Pacific basin. Jpn J Cancer Res 1996;87:117-21. 6. Pisano R, Llorens P, Fluxa F, Barrientos CL, Riquelme N, Meza R, et a1. Presencia de Helicobacter pylori en gastritis erosiva. Gastr Lat 1992;3:37. 7. Japanese Research Society for Gastric Cancer. Results of gastric cancer mass survey in 1993. Jpn J Gastroenterol Mass Surv 1996:34:156. 8. Llorens P, Nakamura K, editors. Diagnostico y tratamiento de las afecciones gastricas. Santiago, Chile: Instituto ChilenoJapones de Enfermedades Digestivas. Hospital Clinico San Borja-Arriaran y Agencia de Cooperacion Internacional de Japon (JICA); 1995. p. 1-458. 9. Otaiza E, Lopetegui G, Csendes A. Operabilidad y resecabilidad del cancer gastrico. Rev Med Valparaiso 1969;22:228-31. 10. Llorens P. Gastric cancer mass survey in Chile. Semin Surg OncoI1991;7:339-43. 11. Csendes A, Braghetto I, Smok G, Nava 0, Medina E. Estudio cooperativo en cancer gastrico incipiente e intermedio: aspectos clinicos, diagnosticos y terapeuticos. Rev Med Chile 1992;120:397-406. 12. Guzman S, Llanos 0, Duarte I. Carcinoma gastrico incipiente. Rev Chil Cir 1982;34:159-63. 13. De Arextabala J, Araya JC, Flores P, Roa I, Fernandez F, Wistuba 0, et a1. Caracteristicas del cancer gastrico en la IX en Chile. Rev Med Chile 1992;120:407-14. 14. Burmeister R. Long-term survival in cases of early and advanced gastric cancer in Chile. GANN Monograph Cancer Res 1986;31:165-70.

Comment. Dr. Pedro Llorens is a pioneer in the early detection, histopathologic diagnosis, and treatment of gastric cancer. Dr. Llorens performed all of the classic investigative methods when he first described the magnitude of the gastric cancer problem in Chile. Dr. Llorens was able to perceive the magnitude of the problem. Research led him to the work being accomplished in Japan to contain this tumor. To learn more about diagnosis and therapeutic techniques, Dr. Llorens traveled to Japan, where he spent several months studying both clinical aspects and laboratory pathologic diagnosis of gastric cancer, in its early and advanced forms. After returning to Chile, Dr. Llorens established widespread screening programs and developed a close relationship with Japanese colleagues in forming the Agency of International Cooperation from Japan. Dr. Llorens has subsequently established an annual review course on GI problems with a strong focus on early detection and prevention of gastric cancer. He continues to have VOLUME 49, NO. 3, PART 1, 1999

Japanese colleagues (clinicians, histopathologists, and laboratory scientists) come to study and teach physicians from South and Central America about this disease. Epidemiologists from around the world can learn how to approach, study, diagnose, and treat diseases from Dr. Pedro Llorens, who continues to disseminate his interest and knowledge about gastric cancer. JEROME

D. WAVE, MD

New York, New York

Reliability of panel-based guidelines for colonoscopy: an international comparison To the Editor: In the article, "Reliability of panel-based guidelines for colonoscopy: an international comparison" (Gastrointest Endosc 1998;47:162), is it true that I am reading that 40% of individuals rate colonoscopy inappropriate in the evaluation of unexplained positive fecal occult blood or iron deficiency anemia and almost 50% find screening for colon cancer in patients with ulcerative colitis, Crohn's disease, or personal history of colorectal carcinoma inappropriate? Although there may be reliability between the United States and Swiss panels, the criteria that they use in establishing indications for colonoscopy seemed surprising at best and unscientific at worst. Robert L. Erickson, MD Montclair, New Jersey

Response:

We thank Dr. Erickson for his comments on our recently published paper reporting on the reliability of the RAND-UCLA appropriateness method, measured by the degree of agreement of appropriateness indications for the use of colonoscopy, developed successively by two panels of experts'! Dr. Erickson wonders how colonoscopy could be deemed inappropriate in the evaluation of fecal occult blood or iron deficiency anemia or for screening for colorectal cancer in inflammatory bowel disease. Lack of awareness of the detailed and specific characteristics of these appropriateness indications might explain Dr. Erickson's sweeping judgment. Each panel examined the appropriateness of over 400 clinically specific detailed indications for colonoscopy, which were established on the basis of an extensive literature review. These indications comprised all situations for which colonoscopy might be considered. Among them, 52 dealt with the evaluation of unexplained fecal GASTROINTESTINAL ENDOSCOPY 411