title: [National colorectal cancer screening program in the Republic of Croatia--experiences, outcomes and obstacles in the program implementation in the Medimurje County].
abstract: BACKGROUND
  In the Medimurje County, colorectal cancer (CRC) poses a serious health problem. According to the incidence of CRC in men and women, and mortality in men, it is the second most common malignancy, and the leading one in women. Compared with the average in Croatia, the CRC mortality rate in Medimurje County is higher. CRC mortality can be reduced by repeat screening by fecal occult blood testing (FOBT). It is important to ensure successful implementation and continuous improvement of the national CRC program it Medimurje County.
  
  
  OBJECTIVE
  This report describes the implementation of CRC screening in Medimurje County and performance indicators from the first 2.5 years. The main obstacles and suggestion for improvement are presented. Study results are compared with international references. The Institute of Public Health of Medimurje County has to collect data on the uptake, tests, lesions and key indicators needed for monitoring and epidemiologic evaluation of the program.
  
  
  RESULTS
  Medimurje County is located in the northern part of the Republic of Croatia. The target group includes approximately 30,000 individuals suitable for CRC screening (aged 50-74 years). In the first screening round, between January 2008 and September 2010, 19,722 invitation letters with test kits (gFOBT) were sent to people born 1933-1945 and 1955-1957. The overall attendance to screening was 28.1%. Blood in the stool was detected in 12.6% of the individuals presenting for screening. The waiting time for follow up colonoscopy was too long (median 113 days). Colonoscopy rate reached 87.7/100 people with positive test. A total of 22 individuals were diagnosed with cancer and the percentage of cancer detected by colonoscopy was 6.4% (results were available for a total of 346 colonoscopies performed in people born between 1933 and 1942). The main limitations to program implementation are inappropriate software for data collection and the lack of a protocol for standardized data collection; the rate of positive test results is unacceptably high, local colonoscopy service is insufficient and waiting time for colonoscopy too long. Also, the inclusion of general practitioners (GPs) in the program has proved inadequate. The role of local public health institutes as coordinators is of crucial importance, but financial and human resources are inadequate.
  
  
  CONCLUSIONS
  The participation rate in Medimurje County is higher than the national average, but lower in comparison with other neighboring countries that also use the same methods. Immunochemical FOBT had higher participation rate than guaiac test, so we should consider the choice of iFOBT in our program. Reminder letters had a significant impact on participation, so this strategy should be adopted. For better success of the program, the involvement of GPs should increase and it is important to make a strategic plan to improve the population and GP awareness of the screening program importance.
  
  
  CONCLUSIONS
  The national program is tested in local conditions and it needs change based on the difficulties observed. The results of program implementation are quite satisfactory considering the conditions in which it is carried out, but less satisfactory than those reported from the neighboring countries. In the next period, the program should be allocated due financial and human resources, and it is important to agree upon a strategy that would yield the best results.
authors.affiliation: Institute of Public Health of Medimurje County, Cakovec, Croatia.
authors.forename: Renata Kutnjak
authors.initials: RK
authors.lastname: Kis
mesh_terms: D000368:Aged; D003113:Colonoscopy; D015179:Colorectal Neoplasms / Q000175:diagnosis*; D017523:Croatia; D005260:Female; D006801:Humans; D008297:Male; D008403:Mass Screening; D008875:Middle Aged; D009780:Occult Blood