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New York City Dept. of Health & Mental HygieneColon Cancer Control Summit
March 11, 2003
Summit Background& Advisory Group Recommendations
Sidney J. Winawer, M.D.
Memorial Sloan-Kettering Cancer Center
U.S. Burden of Colorectal Cancer
147,500 new cases in 2003
57,100 deaths in 2003
11% of all cancer deaths
758,000 person-years of life lost
Cost of treatment $6 billion
U.S. Colorectal Cancer Screening Guidelines
Consensus
U.S. Preventive Services Task Force 1996
GI Consortium 1997
American Cancer Society 1997
“Screening for colorectal cancer and adenomatous polyps should be offered to all men and women without risk factors
beginning at age 50.”
Colorectal cancer screening; clinical guidelines and rationale. Winawer, Fletcher et al., Gastroenterology, 1997
Colorectal Cancer Screening GuidelinesU.S. Preventive Services Task Force
(USPTSF)*
“The USPSTF strongly recommends that clinicians screen men and women
50 years of age or older for colorectal cancer. Grade A Recommendation.”
*USPSTF. Ann Int. Med. 2002
Colorectal CancerScreening Rates
20.6% FOBT Previous Year
33.6% Sigmoidoscopy or Colonoscopy Previous 5 yrs.
CDCP. Trends in screening for colorectal cancer — U.S. 1997 & 1999MMWR 2001;50:162-6
Adenoma to Carcinoma Pathway
APCloss
NormalEpithelium
EarlyAdenoma
CancerHyper-
proliferationIntermediate
AdenomaLate
Adenoma
K-rasmutation
Chrom 18loss
p53loss
AdenomaNormal Cancer
Screening Strategies
Colonoscopy
FOBTFlex Sig.Virtual ColonoscopyStool DNA Mutations
One-Stage Screening Two-Stage Screening
Colonoscopy
FOBT Screening Randomized Controlled Trials
Mortality Reduction
Biennial Annual Compliers
Minn* 21% 33% 45%47,000/18 yrs.
Denmark 18% – 30%140,000/10yrs.
U.K 15% – –153,000/7.8 yrs.
*Rehydrated slidesWinawer et al, GE 1997
COLORECTAL CANCER MORTALITY REDUCTION BY SIGMOIDOSCOPY
Colorectal Cancer Mortality Study Design Reduction Published
Kaiser Retrospective, 30% Selby, NEJMPermanente, Case Control 1992USA
Univ. Retrospective, 40% Newcomb,Wisconsin, Case Control JNCI 1992USA
Reviewed in Colorectal Cancer Screening: Clinical Guidelines and Rationale.Winawer, Fletcher, et al., Gastroenterology, Feb. 1997.
Screening Colonoscopy Studies
NationalColonoscopy
Study VA CONCERN Lilly
Gender Men/Women Men Women Men/Women
Adenomas 18% 37.5% 21% 11% (distal)or Cancer
Advanced 6% 11% 5% 5%Neoplasia
NCS – Winawer et al. DDW 2002 (Gastroenterology)VA – Lieberman et al. NEJM 2000CONCERN – Schoenfeld et al. DDW 2001, 2002 (Gastroenterology)Lilly-Imperiale et al. – NEJM 2000, 2002
Effect of Colonoscopic Polypectomy on Incidence of Colorectal Cancer
Incidence
*U.S. National Polyp Study 76–90%
+Italian Multicenter Study Group 66%
*Winawer, Zauber et al NEJM 1993+Citarda et al GUT 2001
Virtual Colonoscopy*
Sensitivity Sensitivity, Specificity
% Per pt. % Per pt. %
Polyps >1cm 45 –91 38–100 74–100
Polyps 6–9 mm 16–82 20–94 63–92
*Rex. Rev. in GI Disorders. 2002/ 2(3):97-105.
DNA Mutations in Stool
Approximately 50% of Advanced Neoplasia Detected
Ahlquist et al GE 2000
Traverso et al NEJM 2002
Traverso et al Lancet 2002
Guidelines for Colorectal Cancer Screeningin Average Risk Men & Women
50 Years of Age or Older
OPTIONS
Digital Rectal Flex FOBT &Exam FOBT Sig. Flex Sig. DCBE Co.
U.S. Multi Society w/endoscopy Annual 5 yrs. Ann. FOBT 5 yrs. 10 yrs.Task Force (2003) 5 yrs. FS(GI Consortium,1997)
American CA w/endoscopy Annual 5 yrs. Ann. FOBT 5 yrs. 10 yrs.Society (2001) 5 yrs. FS
Colorectal Cancer ScreeningAdvisory Panel to the New York City
Department of Health and Mental Hygiene
Drs. Harold Freeman (Chair),Robert Schiller, Thomas Weber,Susan Williams, Sidney Winawer
Recommendations
Average Risk Men & Women Age 50 & Older
Colonoscopy q 10 yrs. preferred.
Fecal Occult Blood Tests Annually is an alternative with diagnostic work-up if positive.
High-Risk Patients: Colonoscopy beginningage 40 or earlier.
Colorectal Cancer Screening Advisory PanelRationale
About 1,500 NYC residents die annually from colorectal cancer
Most deaths are preventable
Colonoscopy Preferred Examines entire colon Sensitive & Specific for adenomas and cancer Provides screening, diagnosis, treatment Sufficient Capacity in N.Y.C. Preferred recommendation may reduce confusion
Other options are available (National Guidelines)
0 20 40 60 80 100
DCBE
Colonoscopy*
Flex Sig**
FOBT
% Responding "Very Effective"
Family Practice
General Practice
General IM
OB/GYN
**Differences by specialty are significant at P <0.001; *at P <0.05.
Klabunde, C.N. et al. In Press, Preventive Medicine
Primary Care Physicians’ Perceived Effectiveness of Colorectal Cancer Screening Tests forAverage-Risk Adults Aged 50+, Survey of
Colorectal Cancer Screening Practices, 1999–2000
N.Y.C. Dept. of Health & Mental HygieneColorectal Cancer Control Campaign
Screening Guidelines
Lifestyle Guidelines
Provider Education
Public Education
Reimbursement
Capacity and Access
Barriers
Evaluation
Campaign Goals
Increase Awareness
Increase Screening
Reduce Incidence
Reduce Mortality
Reduce Burden
Improve Quality of Life