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Organizing Colorectal Cancer Screening

Organizing Colorectal Cancer Screening. Robert E. Schoen, MD MPH Associate Professor of Medicine and Epidemiology Division of Gastroenterology University of Pittsburgh. Lifetime Risk of CRC (%). Male, Female. LR Dx. LR Death. All Races 5.95, 5.63 2.43, 2.40

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Organizing Colorectal Cancer Screening

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  1. Organizing Colorectal Cancer Screening Robert E. Schoen, MD MPH Associate Professor of Medicine and Epidemiology Division of Gastroenterology University of Pittsburgh

  2. Lifetime Risk of CRC (%) Male, Female LR Dx LR Death All Races 5.95, 5.63 2.43, 2.40 Whites 6.00, 5.64 2.45, 2.38 Blacks 4.73, 5.31 2.34, 2.65 SEER, 1996 - 98

  3. Click for larger picture

  4. Prevalence of Adenomatous Polyps Diminutive or Small - 15 - 30% Large - 3 - 5% Cancer - 0.3 - 1%

  5. Screening for Colorectal Cancer

  6. CRC Often Diagnosed Late U.S. CRC, By Stage, 1992 - 1997 Localized 37% Regional 38% Distant 20% SEER: 1973 - 1998

  7. Consensus Guidelines  50  Options:  Annual FOBT  FS q 5 yrs  FOBT + FS  DCBE q 5-10 yr  Colon q 10 yr  + TCE: Colonoscopy or DCBE + FS Gastro. 1997:112;594

  8. Minnesota FOBT Trial: 18 Yr Follow Up Annual Biennial Control 15,570 15,587 15,394 240,325 240,163 237,420 .67 (.51-.83) .79 (.62-.97) 1.0 # enrolled PYO CRC Mortality Ratio* *Overall mortality not changed Mandel, JNCI 1999;91:434

  9. Decreased Incidence of CRC in the Minnesota FOBT Study 17% in biennial 20% in annual Click for larger picture Mandel JS et al. N Engl J Med 2000:343:1603-7

  10. Highlights of Trials of Non-Rehydrated FOBT % Compliance % with positive test (initial screen) % with positive test found to have cancer % reduction in CRC mortality (biennial testing) 60 - 69 0.6 - 4.4 5 - 17.2 15 - 18

  11. Screening Sigmoidoscopy - Efficacy Case Control Study: Compared Rigid Sig Use in 261 pts who died of distal CRC to 868 matched age/sex) controls 8.8% of Cases Screened VS. 24.2% of Controls OR for CRC Mortality w/ Sigmo = .41 or  59%* • * adjusted for polyp hx, fam hx, check ups • Benefits persisted 10 years • No difference in screening in 268 • cases/controls with CA above rectosigmoid Selby et al. NEJM 1992;326:653

  12. Is Sigmoidoscopy Half a Mammogram?

  13. Screening Colonoscopy Studies Imperiale et al - “Lilly Cohort” NEJM 2000; 343:162 Lieberman et al - “VA Cooperative 380” NEJM 2000; 343:169

  14. Success - Complications NEJM 2000: Screening Colonoscopy Studies Cecum - 97+% Perforation - 1/5115 or 0.02% VAStudy: Major morbidity - 0.32% (GI bleed, MI, CVA)

  15. VA Colonoscopy Study 380 N=3121, 97% male, mean age 63 Adenoma 37.5% Advanced Adenoma* 10.7% Tubular 5.0% Villous 3.0% HGD 1.7% CA 1.0% * 1 cm, Villous, HGD, CA Lieberman et al, NEJM 2000

  16. Lilly Cohort N=1994, 58.9% male, mean age 60 Adenoma 20% Advanced Adenoma* 5.6% CA 0.6% *Villous, HGD (not  1 cm) Imperiale et al, NEJM 2000

  17. What Does Screening Colonoscopy Detect That Sigmoidoscopy Doesn’t? VA StudyLilly Cohort Neoplasia 37.5%  20% Advanced Proximal Neoplasia 4.1% 2.5% “Missed” Advanced Proximal Neoplasia 2.1% 1.2% Older age, males higher risk

  18. Missed Advanced Proximal Neoplasia VA - 52% “missed” (67/128) or 2.1% Limit Advanced Definition to HGD or CA: VA - 14.8% missed (12/81) or 0.4%

  19. Incident CRC After Colonoscopy Incidence/ 1000 PYO PYO CRC Cases Observed (yrs) N 1418 1905 1303 5.9 3.05 2.91 8401 5810 3789 5 14 9 Winawer (NPS) Schatzkin (PPT) Alberts (Wheat Bran) 0.6 2.4 2.4

  20. Sigmoidoscopy vs. Colonoscopy Colonoscopy Sigmoidoscopy Vs. Sensitive enough? Safer Less expensive Frequency (1/5 yr)? Accessible? Satisfied? More sensitive More invasive, safe? Expensive Less frequent (1/10 yr)? Less accessible Better satisfaction

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