Organizing Colorectal Cancer Screening

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Organizing Colorectal Cancer Screening
Robert E. Schoen, MD MPH Associate Professor of
Medicine and Epidemiology Division of
Gastroenterology University of Pittsburgh
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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
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Prevalence of Adenomatous Polyps
Diminutive or Small - 15 - 30 Large -
3 - 5 Cancer - 0.3 - 1
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Screening for Colorectal Cancer
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CRC Often Diagnosed Late
U.S. CRC, By Stage, 1992 - 1997
Localized 37 Regional 38
Distant 20
SEER 1973 - 1998
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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. 1997112594
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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 199991434
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Decreased Incidence of CRC in the Minnesota FOBT
Study
17 in biennial 20 in annual
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Mandel JS et al. N Engl J Med 20003431603-7
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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
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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 1992326653
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Is Sigmoidoscopy Half a Mammogram?
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Screening Colonoscopy Studies
Imperiale et al - Lilly Cohort NEJM
2000 343162 Lieberman et al - VA Cooperative
380 NEJM 2000 343169
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Success - Complications
NEJM 2000 Screening Colonoscopy Studies
Cecum - 97 Perforation - 1/5115 or 0.02
VA Study Major morbidity - 0.32 (GI bleed, MI,
CVA)
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VA Colonoscopy Study 380
N3121, 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
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Lilly Cohort
N1994, 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
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What Does Screening Colonoscopy Detect That
Sigmoidoscopy Doesnt?
VA Study Lilly 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
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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
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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
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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