1. Lang CA, Ransohoff DF.
Fecal occult blood screening for colorectal cancer: is
mortality reduced by chance selection for screening colonoscopy? JAMA. 1994;271:
1011-1013.
2. Fleischer DE, Goldberg SB, Browning TH. Detection and surveillance of colorec-
tal cancer. JAMA. 1989;261:580-585.
To the Editor.\p=m-\Wefound the article by Drs Lang and Ran-
sohoff1 on the utility of the FOBT screening for CRC very
interesting. Their results suggest that one third to one half
of the mortality reduction observed in the widely cited Min-
nesota Colon Cancer Control Study of FOBT screening using
rehydrated slides2 may be attributable to chance selection for
colonoscopy. They further assert that with long-term annual
FOBT screening with rehydration the chance of undergoing
colonoscopy approaches 100% and, therefore, it may be a
more effective strategy to simply screen everyone directly
with colonoscopy (eg, when a person reaches a certain age).
We agree that universal endoscopic screening would be a
more direct approach to screening for CRC. Such a direct
approach would eliminate the annual costs of laboratory pro-
cessing, record keeping, and follow-up associated with doing
annual FOBT screening. We would further suggest that any
universal endoscopic screening effort should use a single
screening examination strategy as has been proposed by
Atkin et al.3 That is, all persons of a certain age (eg, 55 years)
would undergo a screening endoscopie examination. Only
those persons found to have cancerous or precancerous le¬
sions (polyps) would be risk-stratified to receive repeat screen¬
ing examinations in the future. Our recent study4 questions
the value of doing repeat screening sigmoidoscopic exami¬
nations in persons with prior negative results on sigmoido¬
scopic examinations.
In order for a CRC screening program to be cost-effective,
it must be direct in its approach and it must minimize un¬
necessary examinations. We applaud Lang and Ransohoff for
their critical analysis of FOBT screening; FOBT screening
for CRC is a strategy that is not direct and does not minimize
unnecessary examinations.
Milton S. Sakamoto, MD
Jay M. Schlumpberger, MD
Kaiser Permanente Los Angeles Medical Center
Los Angeles, Calif
1. Lang CA, Ransohoff DF. Fecal occult blood screening for colorectal cancer: is
mortality reduced by chance selection for screening colonoscopy? JAMA. 1994;271:
1011-1013.
2. Mandel JS, Bond JH, Church TR, et al. Reducing mortality from colorectal can-
cer by screening for fecal occult blood. N Engl J Med. 1993;328:1365-1371.
3. Atkin WS, Cuzick J, Northover JMA, Whynes DK. Prevention of colorectal can-
cer by once-only sigmoidoscopy. Lancet. 1993;341:736-740.
4. Sakamoto MS, Hara JH, Schlumpberger JM. Screening flexible sigmoidoscopy in
a low-risk, highly screened population. J Fam Pract. 1994;38:245-248.
In Reply.\p=m-\DrMandel and colleagues provide new data from
the Minnesota Colon Cancer Control Study and observe cor-
rectly that these data could be used to further elucidate the
mechanism by which FOBT screening with slide rehydration
reduces CRC mortality. We agree that the cumulative rate
of colonoscopy in the screened group will have an important
effect on any projection of the degree to which random screen-
ing colonoscopy, done for workup of false-positive FOBT
results, contributes to CRC mortality reductions. The values
used in our model were based on the published data.1 We
agree that the results also depend on the degree and duration
of protective effect from endoscopy screening, so we provided
tables showing results for different durations and degrees of
protection from endoscopy screening. New insights from the
Minnesota study's data might be obtained by considering the
types of neoplasms detected in the screened group (ie, early
cancers vs large adenomas). We eagerly await the additional
analyses from the Minnesota group.
We agree with Dr Pickover and Drs Sakamoto and Schlump-
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berger that the implementation of CRC screening remains
problematic despite compelling direct1 and indirect2 evidence
demonstrating that it is effective. Although it might be tempt¬
ing, as Pickover suggests, to endorse FOBT screening with
rehydration and to be unconcerned about how such screening
works (ie, direct detection of neoplasms by FOBT vs random
selection for colonoscopy screening), we believe that a na¬
tional policy about screening can be made more efficient and
rational if the details of mechanism are understood. Overall,
we are not optimistic that FOBT screening will be considered
reasonably efficient, either with or without slide rehydration.
The degree of CRC mortality reduction is likely to be rela¬
tively limited, on the order of 20% to 30%, and FOBT screen¬
ing misses many cancers while incurring a large effort to
evaluate positive test results. For these reasons, we believe
it to be a clumsy method for CRC screening.
In contrast to FOBT screening, endoscopie screening will
miss fewer cancers (ie, those within the reach of an endo¬
scope). However, endoscopie screening would require a large
effort. Sigmoidoscopic screening has never been popular de¬
spite the fact that several major organizations have recom¬
mended it for more than a decade. The successful implemen¬
tation of endoscopie screening, suggested by Sakamoto and
Schlumpberger, would require that several substantial bar¬
riers be overcome.3 Colonoscopic screening once or perhaps
twice at older ages may have merit if the large effort can be
focused on those most likely to benefit.4
In 1994, we know that screening can reduce CRC mortality.
Much work is yet to be done to identify screening strategies
that are practical and reasonably efficient. After clinicians
and policymakers have agreed on a suitable approach to screen¬
ing, reimbursement incentives can be appropriately revised.
Christopher A. Lang, MD
Denver, Colo
David F. Ransohoff, MD
Chapel Hill, NC
1. Mandel JS, Bond JH, Church TR, et al. Reducing mortality from colorectal can-
cer by screening for fecal occult blood. N Engl J Med. 1993;328:1365-1371.
2. Selby JV, Friedman GD, Quesenberry CPJ, Weiss NS. A case-control study of
screening sigmoidoscopy and mortality from colorectal cancer. N Engl J Med. 1992;
326:653-657.
3. Ransohoff DF, Lang CA. Sigmoidoscopic screening in the 1990s. JAMA. 1993;
269:1278-1281.
4. Ransohoff DF, Lang CA. Cost-effectiveness of one-time colonoscopy screening to
reduce colorectal cancer mortality. Gastroenterology. 1994;106:A24. Abstract.
Hantavirus Infection in the Domestic Cat
To the Editor.\p=m-\Recentlywe have presented serological evi-
dence that domestic cats are susceptible to Hantavirus infec-
tion.1 Five percent of cats that had been allowed to roam
outside and to hunt showed antibodies to the European Pu-
umala serotype of Hantavirus. Our serological findings are in
accordance with the results found in British cats in a study by
Bennett et al,2 which found an even higher prevalence of feline
infection in some regions (up to 23%, with a mean of 9.6%). The
severity of hantaviral disease in humans encouraged us to
obtain more data on feline Hantavirus infection, especially as
a Hantavirus species was recently found to be the cause of a
highly fatal pulmonary syndrome in North America.3,4
We therefore looked by immunofluorescence for Hantavi-
rus antigen in the lungs and kidneys of 100 domestic cats that
had been received for necropsy from 1991 to 1994. For our
study only cats that had had the chance to hunt rodents and
that had not died from a known feline disease were selected.
To our knowledge, this is the first such report. Paraffin sec¬
tions were made and prepared according to standard meth¬
ods. Three different polyclonal anti-Puumala serum speci¬
mens were used; lung sections of infected mice served as
positive controls.
 Hantavirus antigen was detected in the lungs of two of the
100 cats. Granular fluorescence was found in a few very small
areas of about 10 to 20 cells each, adjacent to small bronchi.
The small size of Hantavirus foci in the feline lungs contrasts
sharply to that found in rodents: in these animals, it is not
unusual to find antigen throughout the lung. The case his¬
tories of the two cats with positive results revealed no res¬
piratory disorders, and no lung lesions were found histologi-
cally. Although one of the two cats showed an interstitial
nephritis, no antigen was detected in the kidney; in fact, all
kidneys examined were free of antigen.
We explain our findings as follows: we suggest that Han¬
tavirus infection in the domestic cat takes an asymptomatic
course with a low risk of excretion of larger amounts of virus.
Furthermore, there is no evidence for a persistent infection
ofthe domestic cat, as it is regularly found in different species
of rodents. Although cat ownership in Asia has been reported
to be a risk factor for hantaviral disease,5 there seems to
be—according to the case histories of diseased people—no
such epidemiological link in North America and Europe. In
summary, based on our results with 100 animals, we believe
that the domestic cat does not play a role in Hantavirus
transmission to humans.
Norbert Nowotny, PhD
Herbert Weissenboeck, DVM
Veterinary University of Vienna
Vienna, Austria
Stephan Aberle, MD
University of Vienna
Vienna, Austria
Friedrich Hinterdorfer,DVM
National Veterinary Institute
Graz, Austria
1. Nowotny N. The domestic cat: a possible transmitter of viruses from rodents to
man. Lancet. 1994;343:921.
2. Bennett M, Lloyd G, Jones N, et al. Prevalence of antibody to Hantavirus in some
cat populations in Britain. Vet Rec. 1990;127:548-549.
3. Nichol ST, Spiropoulou OF, Morzunov S, et al. Genetic identification of a Hanta-
virus associated with an outbreak of acute respiratory illness. Science. 1993;262:914\x=req-\
917.
4. Duchin JS, Koster FT, Peters CJ, et al. Hantavirus pulmonary syndrome: a clini-
cal description of 17 patients with a newly recognized disease. N Engl J Med. 1994;
330:949-955.
5. Xu ZY, Tang YW, Kan LY, Tsai TF. Cats\p=m-\sourceof protection or infection? a
case-control study of hemorrhagic fever with renal syndrome. Am J Epidemiol.
1987;126:942-948.
Health System Reform:
The Case for a Single-Payer Approach
To the Editor.\p=m-\Whilegenerally agreeing with Representa-
tive McDermott1 on the need for a single-payer approach to
health system finance, I would point out a fundamental flaw
in his plan. I was particularly surprised at this missing ele-
ment given that the author has worked overseas and had the
opportunity to observe health care systems in a number of
countries. The examples he cites of single-payer systems are,
in fact, not. In every case, while the government coordinates
the bulk of health care expenditures, individuals retain the
right to directly purchase health care services outside the
governmental financing mechanism and may do so without
penalty. In Australia, this is what is meant by "right of
private practice." In England, the National Health Service
has occasion to buy surgical services from the private sector
when it is overloaded. Throughout the Middle East and Af-
rica, when the wealthy want a medical service, they hop on
a jet to Europe or the United States to buy the health care
they desire (this despite the fact that most countries have
single-payer systems and universal access).
I would challenge proponents of pure single-payer systems
to cite one example of a system where private practice does
not exist alongside or where corruption does not flourish as
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people attempted to buy services they are not willing to wait
for. The latter can readily be seen in the Third World today
as well as in the days of the communist regimes. Even the
Canadian system relies on a private-sector safety valve; it's
called the US private health care system. As we look for a
new model for our system, we must not lose sight of two facts:
first, successful systems retain a true private sector, which
both relieves pressure on public systems and allows indi¬
viduals to exercise full choice in their care; and second, sys¬
tems that restrict choice of physician by the patient and
choice of patient by the physician, whether through money or
the queue, eventually get corrupted or bypassed. To the
extent that the American Health Security Act and the Clinton
plans fail to address these market forces, they are doomed to
failure.
Francis X. Brickfield, MD
US Embassy
Addis Ababa, Ethiopia
1. McDermott J. Evaluating health system reform: the case for a single-payer ap-
proach. JAMA. 1994;271:782-784.
To the Editor.\p=m-\RepresentativeMcDermott's1 article advises
us to throw out the myths of the past to embrace a single\x=req-\
payer system. If we first throw out the Madison Avenue
nomenclature, then we can turn to the lessons of the past, not
the myths, to consider the supposed virtues of socialized
medicine.
One of those lessons is that socialized medicine leads to
rationing as surely as our current system.2 A second lesson
is that government does not keep its promises. If you doubt
this, recall that governmental promises that Medicare would
pay usual, customary, and reasonable fees were out the win-
dow in less than 20 years. Budget pressures have led Medi-
care to progressive restrictions on allowable procedures and
use of assistants and to reduced fees for many procedures.
Once there is full government control of the entire health
sector of the economy, all promises made now about how the
system will work will be abandoned. A third and related
lesson is the British experience. Several years ago, the dis¬
tinguished British otolaryngologist, Professor Harrison, lec¬
turing in the United States, made in my presence the com¬
ment that the Labor government after World War II had
bought physician acquiescence to the national health scheme
by initially providing a very satisfactory pay scale. Subse¬
quently, inflation was allowed to erode this to a level of pay
the government thought appropriate (as was the case in most
states with Medicaid; in California, the fees paid, which began
at nearly 80% of usual, customary, and reasonable, are now
approximately 40%.) Keep this in mind as you read Repre¬
sentative McDermott's attempt to bribe his readers with
assurances of high incomes.
The problem with socialized medicine is that it is just a
scheme to force one segment of the population to pay for the
health care of another. There is nothing else to recommend
it. No study of which I am aware can be quoted that supports
the notion that socialized care is higher quality care. Com¬
paring his socialized medicine scheme with national defense
is the quintessential "apples and oranges" exercise. HR 1200
makes the same sense as would collectivizing all the farms in
the United States and creating a single-payer food system.
The late, unlamented Soviet Union proved the fallacy ofthat
method, as Canada, Germany, and Britain, all quoted by
Representative McDermott, are gradually being forced to
recognize and correct the failures of their own health sys¬
tems. I agree completely that providing for the health care
of the indigent is an appropriate thing to do voluntarily.
Using the force of the federal tax system is another thing
entirely.