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. Lifetime Risk of CRC (%). Male, Female. LR Dx. LR Death. All Races 5.95, 5.632.43, 2.40 - PowerPoint PPT Presentation

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  • Organizing Colorectal Cancer Screening Robert E. Schoen, MD MPHAssociate Professor of Medicine and EpidemiologyDivision of GastroenterologyUniversity of Pittsburgh

  • Lifetime Risk of CRC (%)All Races 5.95, 5.632.43, 2.40Whites 6.00, 5.64 2.45, 2.38Blacks 4.73, 5.312.34, 2.65Male, FemaleLR DxLR DeathSEER, 1996 - 98

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  • Prevalence of Adenomatous Polyps Diminutive or Small - 15 - 30%

    Large - 3 - 5%

    Cancer - 0.3 - 1%

  • ScreeningforColorectal Cancer

  • CRC Often Diagnosed Late U.S. CRC, By Stage, 1992 - 1997 Localized37% Regional38% Distant20%SEER: 1973 - 1998

  • Consensus Guidelines 50Options: Annual FOBT FS q 5 yrs FOBT + FS DCBE q 5-10 yr Colon q 10 yr +TCE: Colonoscopy or DCBE + FSGastro. 1997:112;594

  • Minnesota FOBT Trial: 18 Yr Follow Up AnnualBiennialControl 15,570 15,587 15,394 240,325240,163237,420 .67 (.51-.83).79 (.62-.97)1.0Mandel, JNCI 1999;91:434# enrolled PYOCRC Mortality Ratio**Overall mortality not changed

  • Decreased Incidence of CRC in the Minnesota FOBT StudyMandel JS et al. N Engl J Med 2000:343:1603-717% in biennial20% in annualClick for larger picture

  • 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 - 690.6 - 4.45 - 17.215 - 18%

  • 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 rectosigmoidSelby et al. NEJM 1992;326:653

  • Is Sigmoidoscopy Half a Mammogram?

  • Screening Colonoscopy Studies Imperiale et al - Lilly Cohort NEJM 2000; 343:162

    Lieberman et al - VA Cooperative 380 NEJM 2000; 343:169

  • Success - ComplicationsCecum - 97+%Perforation - 1/5115 or 0.02%NEJM 2000: Screening Colonoscopy StudiesVA Study: Major morbidity - 0.32% (GI bleed, MI, CVA)

  • VA Colonoscopy Study 380 Adenoma37.5% Advanced Adenoma* 10.7% Tubular 5.0% Villous 3.0% HGD 1.7% CA 1.0%N=3121, 97% male, mean age 63Lieberman et al, NEJM 2000* 1 cm, Villous, HGD, CA

  • Lilly CohortAdenoma20%Advanced Adenoma*5.6%CA 0.6%

    *Villous, HGD (not 1 cm)N=1994, 58.9% male, mean age 60Imperiale et al, NEJM 2000

  • What Does Screening Colonoscopy Detect That Sigmoidoscopy Doesnt?VA StudyLilly Cohort

    Neoplasia37.5% 20%

    Advanced ProximalNeoplasia4.1%2.5%

    Missed AdvancedProximal Neoplasia2.1%1.2%

    Older age, males higher risk

  • Missed Advanced Proximal NeoplasiaVA - 52% missed (67/128) or 2.1%Limit Advanced Definition to HGD or CA:VA - 14.8% missed (12/81) or 0.4%

  • Incident CRC After ColonoscopyWinawer (NPS)Schatzkin (PPT)Alberts (Wheat Bran)N141819051303Observed (yrs)5.93.052.91

    PYO840158103789

    CRC Cases 5 14 9

    Incidence/1000 PYO 0.6 2.4 2.4

  • Sigmoidoscopy vs. ColonoscopyMore sensitiveMore invasive, safe?ExpensiveLess frequent (1/10 yr)?Less accessibleBetter satisfactionSensitive enough?SaferLess expensiveFrequency (1/5 yr)?Accessible?Satisfied?ColonoscopySigmoidoscopyVs.