The outpatient-based study by Deng et al [World J Gastroenterol 2011 July 14; 17(26): 3133-3139] on the factors that may influence the colorectal cancer (CRC) screening feasibility, encouraged our curiosity. Establishing a simple method for quickly assessing the educational level of patients and modulating a questionnaire for each type of patient, may be an effective protocol to increase the people participation, mainly in countries where sufficient medical resources and financial support are lacking. In fact, the knowledge directly affects the feasibility when screening is offered. Patient educational level influences the understanding of the knowledge and the screening method. This factor may affect patient’s priority level on the study participation, the understanding of questions, and the motivation to complete the questionnaire and, consequently, the screening success. Recent studies have found a relationship between high educational level and CRC screening participation, and emphasized the questionnaire ineffectiveness in the illiterate people. Although the questionnaire is an excellent method for this kind of evaluation, physician’s contribution could be the most important factor associated with the screening method. Thus, further studies should be conducted to explore the compliance of patients with low educational level and to look for the best solutions for their enrollment.

We read with great interest the study by Deng et al[1] on the factors that may influence the colorectal cancer (CRC) screening feasibility [World J Gastroenterol 2011 July 14; 17(26): 3133-3139]. We strongly agree with the authors about the importance of CRC screening knowledge. Indeed, this study shows that a better knowledge leads patients to choose the most accurate test. However, although the questionnaire is an excellent method for this kind of evaluation, bias could affect the results. Thus, the educational level plays a key role in the understanding of questions and the response accuracy. On this regard, we noted that only 6.9% of patients had a low educational level. This factor may affect the patient’s priority level on the study participation, the understanding of questions, the motivation to complete the questionnaire and, consequently, the screening success. In order to get a true picture of the screening results, the percentage of patients with low educational levels should be similar to the other two educational classes of patients. Thus, it would be interesting to know the educational class distribution in sections of “not responding” (14.25%) and “unfilled” (28 patients). In a recent study, Garcia et al[2] found a relationship between high educational level and CRC screening participation. In the illiterate people, the questionnaire had a reduced efficacy. In addition, von Wagner et al[3] demonstrated that lower health literacy had a direct impact on information-seeking. For these reasons, a variation of the questionnaire design would be useful based on the literacy level[4].

On the other hand, the study of Deng et al[1] is associated to a series of studies that emphasize the impact of socioeconomic and cultural factors on the CRC screening feasibility[5,6]. Sung et al[7]’s study, which refers to an “ostrich” strategy of the Chinese population, asserts that in a society as the Chinese one, where the public knowledge of CRC is poor, a physician’s recommendation is the most important factor associated with the acceptance of CRC screening. Even though in this study[7], the percentage of respondents with a low educational level is significantly low (17.5%). In my opinion, the physician’s recommendation, becomes more significant, especially in the population that requires more assurances to be convinced. Thus, this finding is true for various communities worldwide[8-10]. In fact, people with low educational level are less willing to the interview participation.

In conclusion, the protocol used in the study by Deng et al[1], is correct to get a greater adherence to the CRC screening. In this regard, it would be appropriate to study, even in multi-centers, the difference in terms of adherence to the CRC screening among people who would accept physician’s recommendation or other kinds of communications.