Reply to S. Sciallero et al
Authors: Sharon L. Manne, Neal J. Meropol, David S. Weinberg, Hetal Vig, Zohra Alikhan Catts, Cheri Manning, Eric Ross, Kristen Shannon, Daniel C. Chung
Journal: Journal of Clinical Oncology (2010)

We appreciate the concerns raised by Sciallero and Sobrero 1 regarding potential biases in our study population and the possible need to adapt the CD educational aid for more widespread use. 2 In terms of study bias, there were three sources described in the letter.The first source of bias was the possibility that patients who were approached for the study and declined participation were more distressed than patients who participated.We agree that this is a possibility.Unfortunately, our study design did not permit collection of data regarding the level of anxiety experienced by the 64 patients who refused study participation.Thus, we cannot rule this possibility out.We also acknowledge that it is possible that participants' stated reasons for nonparticipation may not actually reflect the actual reason for nonparticipation, and perhaps study refusers did not want to know the results of the microsatellite instability (MSI) test and/or felt that information regarding personal and familial risk for cancer would be too threatening.These potential biases are common in randomized intervention studies, and they suggest the need for confirmatory study.The second potential source of bias is that individuals who enrolled on the study, completed the baseline, and completed the intervention but did not complete the follow-up survey may have been more distressed and/or had more decisional conflict than participants who completed the study follow-up assessment.We evaluated this possibility by comparing individuals who completed the study with those who did not, and we did not find significant differences between these two groups.The third source of bias raised by Sciallero and Sobrero regards participants who completed the study but did not decide to undergo MSI testing.We would like to point out that the purpose of this educational aid was not to influence the decision to have or not have MSI testing but rather to educate the participant about the test.Nevertheless, we compared participants who consented to the MSI test with the participants who decided against testing and those who were undecided at the point of the follow-up assessment with regard to their scores on the cancer-specific distress measure.Results did not indicate a significant difference.Overall, there is not a great deal of evidence to suggest a bias with regard to our sample, but we agree that we could not assess all sources of bias.A second concern raised regarded our suggestion that the current CD-ROM could be adapted for use among patients considering adjuvant chemotherapy as well as in other contexts.We acknowledge that our aid may need to be adapted for this purpose.There is a lack of consensus about whether and when to adopt screening for Lynch syndrome in the general population. 3However, our educational CD-ROM could easily be adapted to either prepare individuals before undergoing the test or assist individuals receiving abnormal results.Our educational aid could ultimately prove useful in these contexts.