The receipt of a screening test does not cause sustained anxiety and the existence of psychiatric morbidity is not a factor affecting a person's decision to accept or refuse a screening test for colorectal cancer.

Aims-To determine the harm that ensues from faecal occult blood (FOB) screening for colorectal cancer. Methods-150 251 people were randomly allocated either to receive biennial Haemoccult FOB tests (n =75 253) or not to be contacted (n=74 998). Study group patients returning positive tests were oVered colonic investigation; 1774 underwent complete investigation of the colon. Results-There was no significant diVerence in the stage at presentation of interval versus control group cancers. Survival in the interval cancer group was significantly prolonged compared with the control group. Sensitivity for colonoscopy or flexible sigmoidoscopy and double contrast barium enema (DCBE) was 96.7%. There were no complications of DCBE but seven (0.5%) complications of colonoscopy, of which six required surgical intervention. There were no colonoscopy related deaths. No patients without colorectal cancer died within 30 days of colonic investigation. Five patients died within 30 days of surgery for screen detected colorectal neoplasia and a further two died without having surgery. Six patients died after 30 days but within two years of surgery for screen detected benign adenomas or stage A cancers; in all cases the cause of death was not related to colorectal cancer. Conclusions-There was investigation related morbidity but no mortality and little to support overdiagnosis bias. The group returning falsely negative tests had a better outcome compared with the whole control group. There is a negative side to any screening programme but mortality reduction in this and other trials suggests that a national programme of colorectal cancer screening should be given consideration. (Gut 1999;45:588-592)

Background Colorectal cancer often presents with obstruction needing urgent, potentially life-saving decompression. The comparative efficacy and safety of endoluminal stenting versus emergency surgery as initial treatment for such patients is uncertain. Methods Patients with left-sided colonic obstruction and radiological features of carcinoma were randomized to endoluminal stenting using a combined endoscopic/fluoroscopic technique followed by elective surgery 1–4 weeks later, or surgical decompression with or without tumour resection. Treatment allocation was via a central randomization service using a minimization procedure stratified by curative intent, primary tumour site, and severity score (Acute Physiology And Chronic Health Evaluation). Co-primary outcome measures were duration of hospital stay and 30-day mortality. Secondary outcomes were stoma formation, stenting completion and complication rates, perioperative morbidity, 6-month survival, 3-year recurrence, resource use, adherence to chemotherapy, and quality of life. Analyses were undertaken by intention to treat. Results Between 23 April 2009 and 22 December 2014, 245 patients from 39 hospitals were randomized. Stenting was attempted in 119 of 123 allocated patients (96.7 per cent), achieving relief of obstruction in 98 of 119 (82.4 per cent). For the 89 per cent treated with curative intent, there were no significant differences in 30-day postoperative mortality (3.6 per cent (4 of 110) versus 5.6 per cent (6 of 107); P = 0.48), or duration of hospital stay (median 19 (i.q.r. 11–34) versus 18 (10–28) days; P = 0.94) between stenting followed by delayed elective surgery and emergency surgery. Among patients undergoing potentially curative treatment, stoma formation occurred less frequently in those allocated to stenting than those allocated to immediate surgery (47 of 99 (47.5 per cent) versus 72 of 106 (67.9 per cent); P = 0.003). There were no significant differences in perioperative morbidity, critical care use, quality of life, 3-year recurrence or mortality between treatment groups. Conclusion Stenting as a bridge to surgery reduces stoma formation without detrimental effects. Registration number: ISRCTN13846816 (http://www.controlled-trials.com).

In comparison with detected disease, undetected ulcerative colitis is relatively common but does usually cause some symptoms. It generally appears to follow a benign course, but a significant proportion have extensive colitis and may therefore be at an increased risk of colorectal cancer.

A study was carried out to investigate the change in stage at presentation of patients with colorectal cancer over 10 years. Cases were identified from the control group of subjects enrolled into a randomized controlled study based on Haemoccult screening for colorectal neoplasia. Of 405 subjects in the control group (presenting with symptomatic colorectal cancer, 206 presented before 1989 and 199 since then. The number of patients with Dukes' stage A carcinoma diagnosed since 1989 rose from 21 (10.4 per cent) to 35 (18.1 per cent); this change occurred for rectosigmoid tumours (9.9 per cent before 1989, 28 per cent after 1989) but not for colonic cancer (10.9 per cent before 1989, 11.5 per cent thereafter). An increase in the proportion of patients with symptomatic early-stage rectosigmoid cancer has been observed in the past 10 years. No such change occurred in those with colonic cancer. This may reflect a change in awareness of te disease and its symptoms by patients and general practitioners.

Screening for colorectal cancer by means of faecal occult blood testing improved survival among subjects with screen-detected cancers. Differences in prognostic factors largely explain the differences in survival between both non-responders and subjects with interval cancers and those in the control group, but not the improved prognosis for patients with screen-detected cancers. The use of such factors as surrogate outcome measures may therefore be inappropriate.

SNUMMARY We report a case of the brown bowel syndrome presenting as major dilatation of the colon which resembled 'toxik dilatation' and necessitated subtotal colectomy. We confirm the reported association between the brown bowel syndrome, malabsorption, and hypovitaminosis E. Furthermore we document failure of the brown pigmentation to resolve after six months in spite of vitamin E supplements and correction of the malabsorption. Finally we suggest that, although the brown bowel syndrome is rare, it should be considered in cases of major colonic dilatation where the patient is or may be suffering from a malabsorption syndrome, and where the sigmoidoscopic appearances do not suggest severe inflammatory bowel disease.

Cause specific mortality statistics derived from death certificates are highly dependent upon the accuracy of certification by the attending physician. In the Nottingham colorectal cancer screening trial, there were 12 624 deaths among the screening group and 12 515 among the control group during the period under consideration. There was no significant diVerence in all cause mortality rate (excluding deaths due to colorectal cancer) between the two study groups (rate ratio = 1.01, 95% confidence interval = 0.99 to 1.03). Disease specific mortality rates did not diVer significantly between the two groups either. Overall, the agreement between verified and certified cause of death was 86%. Using the certified cause of death would have resulted in an underestimation bias of 6.27% for colorectal cancer deaths. 2 Cause specific mortality statistics such as these are derived from the underlying cause of death (UCD) on death certificates, and are highly dependent upon the accuracy of certification. This depends upon the level of training and experience of the certifying doctor.3 Cancers are better recorded than other causes of death, but there are diVerences in recording among the various cancer sites. Some, like breast cancer, are better recorded while internal cancers have a higher chance of being missed.4 5 A small degree of inaccuracy may be due to the low necropsy rate. Verification of patient records allows the use of additional information in order to determine the cause of death more accurately. This is important within the setting of a randomised controlled trial where reduction in disease specific mortality is the end point being measured. This report describes the verification process used in the Nottingham trial. MethodsThe study design and methodology have been described in detail elsewhere.1 Briefly, 152 850 individuals aged 45 to 74 were randomly allocated to a screening group (invited to screening using Haemoccult FOB test kit every two years) or control group (no intervention). All deaths occurring from the date of entry into the study up to 30 June 1995 were analysed. The UCDs were coded from death certificates according to the International Classification of Diseases.6 Case notes were obtained for all deaths among study participants diagnosed with CRC, and those who had CRC or carcinomatosis (without specification of the primary tumour) on the death certificate. The initial verifier used a structured review form to classify deaths as definite, probable, possible, and unlikely CRC deaths; cause of death unknown/unverified; and deaths definitely not due to CRC. All cases in the probable, possible, and unlikely categories underwent a second review; a third reviewer coded any cases of disagreement. Causes of death were categorised as CRC (definite or probable CRC deaths) or "other causes" (deaths not due to CRC).Assuming the assessors' verdict to be correct, we calculated the proportions of deaths that had changed categories (from CRC to "other causes" and from "other causes" to CRC) as a result ...