COLORECTAL CANCER SCREENING Chaired by: Heather Bryant (Canada) Alan Barkun (Canada) Proposed by the Canadian Partnership Against Cancer
OUTLINE OF SESSION ! The Thailand Colorectal Cancer Screening (CRC) Pilot Demonstration Project in Lampang Province Christopher P Wild (IARC, France) ! Endoscopy and imaging in colorectal cancer detection Alan Barkun (PQDCCR, Canada) ! The role of the Global Rating Scale in Colonoscopy Quality Don Macintosh (NSCRCSP, Canada) ! Quality and access issues David Armstrong (CAG, Canada)
Endoscopy and imaging in colorectal cancer detection Alan N. Barkun Clinical co-Lead, Le Programme Québecois de Dépistage du Cancer Colorectal Division of Gastroenterology, McGill University and the McGill University Health Center
CONFLICTS OF INTEREST ! Consultant and recipient of research support from • Olympus Canada Inc. • Cook Inc. • Boston Scientific Inc.
OUTLINE ! Background ! Flexible sigmoidoscopy ! Colonoscopy ! CT colography ! The colonic wireless videocapsule ! Conclusion
Incidence(and(mortality(of(Colorectal(cancer( CDHF.ca( Worldwide, colorectal cancer (CRC) is the second most common cancer diagnosed in women and third most common in men Jemal CA Cancer J Clin 2011 Canadian Cancer Statistics 2011 2011 Digestive Health Summit for Health Care Professionals
Most(common(risk(factor:(age( CDHF.ca( Canadian Cancer Statistics 2011 2011 Digestive Health Summit for Health Care Professionals
Colorectal(Cancer(–(biology( CDHF.ca( • If)diagnosed)early) 95%(will(survive ;))presently)))))))))))) only) 35% )of)cases)diagnosed))at)this)stage) • (60%(will(die( if)cancer) spreads)to)lymph)nodes) • (95%(will(die( if)cancer) spreads)to)distant)organs) Polyp-cancer sequence 8-12 yrs 2011 Digestive Health Summit for Health Care Professionals
Advantages(of(early(diagnosis( CDHF.ca( • Survival rates are improved if treated in its early stages Cancer Free 5 Year Survival 100 99% 80 85% Percentage 60 67% 40 20 14% 0 A B C D Duke's Classification 2011 Digestive Health Summit for Health Care Professionals
RECOMMENDATIONS – main CRC screening technologies ! Cancer detecting technologies • FOBT " Guaiac " FIT • Stool DNA • Other specialized tests ! Cancer preventing technologies • Flexible sigmoidoscopy • Colonoscopy • CT colography • Colonic wireless capsule endoscopy • ? Stool DNA
FLEXIBLE SIGMOIDOSCOPY www.edoctor.co.in image.healthhaven.com
Flexible Sigmoidoscopy: Randomized Controlled Trials
RCT Flexible sigmoidoscopy: Incidence CRC NORCAP PLCO (USA): 134.5 v 131.9 CRC reduction 21% cases per (RR: 0.79; 95%CI, 0.72 100 000 person - 0.85) years UK (Atkin trial): CRC reduction of 23% in the intervention (B) group (HR: 0 · 77,95% CI 0 · 70–0 · 84) Score (Italy) CRC reduction 18% (RR: 0.82, 95% CI: 0.69 to 0.96) A 5 th Dutch RCT has just initiated f/u Hol et al. Hof et al. BMI 2009 Segnan et al. JNCI 2011 Atkin et al. Lancet 2010 Schoen et al. NEJM 2012
Screened Unscreened CRC incidence Left CC incidence Right CC incidence CRC mortality Atkin, Lancet, 2010
RCT Flexible sigmoidoscopy Incidence Mortality
RCTS OF SCREENING FLEXIBLE SIGMOIDOSCOPY Country ) Female ) Population ) /Year ) Mean age (std) ) Mortality Enrolment duration ) Study ) Comparison (n) ) CRC detection ) Publication N (randomized) ) due to CRC ) Attendance rate ) type ) Screening group: ) PP: n=13 823 ) ITT: n=13 653 ) population based ) (8846 screened, 4807 not screened)* ) age 55-64 years ) Flexible sigmoidoscopy only ) 123 24 ) January 1999 to December 2001 ) Norway ) (after 6-8 years FU) ) (PP n=6915) ) 50% (by randomization) ) 2009 ) Median follow-up after inclusion in the Combined flexible sigmoidoscopy and Hoff G et al. ) 59 years old ) RCT ) faecal ) trial was seven years for incident N=55 736 ) NORCCAP ) occult blood testing ) colorectal cancer and six (range five to seven) years for mortality ) (PP n=6908) ) 64.8% attendance rate ) Control: Not contacted ) 362 PP: n=41 913 ) 99 ) (after 6-8 years FU) ) ITT: n=41 092 ) 51% ) Intervention: flexible sigmoidoscopy ) 60 years (SD 2 · 9) ) PP: 57 237 ) age 55 and 64 years ) N=170 432 ) ITT: 57 099 ) 706 ) 221 ) UK ) November 1994 to March 1999. ) (40 621: screened, 16 478 not 2010 ) Atkin et al. ) Median follow-up of 11 · 2 years (IQR screened)* ) RCT ) 10 · 7–11 · 9). ) Control: Not contacted ) 71% attendance rate ) PP: 113 195 ) 1818 ) 637 ) ITT: 112 939 ) 52.3% ) Intervention: flexible sigmoidoscopy ) Intervention: 59.7 years ) PP: 17 148 ) Population based ) Control: 59.6 years ) 251 ITT: 17 136 ) 65 ) Italy ) age aged 55–64 years ) N= 34 292 ) 2011 ) June 14 1995 to 1999 ) (9911 screened and 7225 not Segan et al. ) screened)* ) RCT ) Median follow-up: 10.5 years for SCORE ) incidence and 11.4 years for mortality; ) Control: Not contacted ) 58.3% attendance rate ) 306 PP: 17 144 ) 83 ) ITT: 17 136 ) 50.5% ) Population base age 55 to 74 years ) Intervention: flexible sigmoidoscopy ) USA ) N= 154 900 ) 1012 ) 252 ) 1993 to 2001 ) PP: 77 445 ) 2012 ) Schoen et al. ) Median follow-up time for incidence RCT ) Control: usual care ) was 11.9 years and for mortality was PLCO ) 1287 ) 341 ) PP: 77 455 ) 12.1 years. )
Limitations of Flexible sigmoidosopy in screening ! Resources • Equipment • Manpower (?nurse-endoscopists) ! Patient acceptability, especially in North America (versus a full colonoscopy)
COLONOSCOPY www.flickr.com www.tcnj.edu db2.photoresearchers.com image.healthhaven.com
EFFECT OF SCREENING (COLONOSCOPY) ON CRC INCIDENCE Population-level decreases (NIS) in rates of resection for distal CRC are associated with screening, in general, and that implementation of screening colonoscopy, specifically, might be an important factor that contributes to population-level decreases Myer, Gastro, 2012
LONG-TERM IMPACT OF COLONOSCOPIC POLYPECTOMY ON CRC MORTALITY 2602 patients in the NPS with adenomas removed at colonoscopy after a median of 15.8 years follow-up compared to expected outcomes from SEER Zauber NEJM,2012
EFFECT OF COLONOSCOPY ON CRC INCIDENCE AND MORTALITY The study cohort contained 1,089,998 persons, 7.9% of whom had undergone a colonoscopy between 1996 and 2000 (Ontario registry data) Increased use of colonoscopy procedures is associated with a reduction in the incidence (*rel 48%) and mortality (*rel 81%) of CRC in the population studied Jacob, GIE 2012
" 1688 cases with CRC & 1932 controls >50 yrs " Rhine-Neckar region of Germany; colonoscopy last 10 yrs 2011
" Colonoscopy in the preceding 10 years was associated with decreased risks of # any CRC 0.23 (95% CI,0.19 to 0.27), # right-sided CRC 0.44 (CI, 0.35 to 0.55), and # Left-sided CRC 0.16 (CI, 0.12 to 0.20) " Strong risk reduction observed for all cancer stages and all ages, except for right-sided cancer in 50-59 yrs " Risk reduction increased over the years in both the right and the left colon. 2011
Missed cancer rates by colonoscopy Canadian administrative database of new diagnosis of right-sided, ! transverse, splenic flexure/descending, rectal or sigmoid CRC in Ontario (1997 to 2002), undergoing a colonoscopy within 3 years of diagnosis. Patients with new or missed cancers were those whose most ! recent colonoscopy was 6 to 36 months before diagnosis. CRC diagnosed in 3288 (right sided), 777 (transverse), 710 (splenic ! flexure/ descending), and 7712 (rectal or sigmoid) patients. ! The rates of new or missed cancers were 5.9%, 5.5%, 2.1%, and 2.3%, respectively. Independent risk factors for these cancers in men and women ! were older age; diverticular disease; right-sided or transverse CRC; colonoscopy by an internist or family physician; and colonoscopy in an office. Rabeneck, Gastro, 2007
THE IMPORTANCE OF COLONOSCOPY QUALITY 155 cases &260 controls with physician-validated polyp detection in the past 10 years Brenner, AIM, 2012
Alternative strategies: colonoscopy Data collected from 186 endoscopists who were involved in a colonoscopy-based colorectal-cancer screening program involving 45,026 subjects in Poland Kaminski, NEJM, 2010
Colonoscopy vs FIT screening RCT Higher adherence in FIT than colonoscopy (34.2% vs. 24.6%, P<0.001) First of 5 RCTs of colonoscopy, 4 population-based Quintero, NEJM, 2012
CT COLOGRAPHY (virtual colonoscopy) www.agfahealthcare.com www.ultimatehealthguide.com www.ebook3000.com lsgimaging.com
Average sensitivity and specificity of screening methods Systematic review included: • 20 studies for colonoscopy • 12 studies for sigmoidoscopy • 26 studies for Barium enema • 62 studies for CT colonography Allameh et al. Iran J Cancer Prev. 2011
CT Colonoscopy: Sensitivity/ Specificity ! 3 Meta-analysis: Study Country Number of studies /Year Database and period searched Publication type Number of patients 20 studies for colonoscopy 12 studies for sigmoidoscopy 26 studies for Barium enema 62 studies for CT colonography Iranian Allameh et al. 2010 8 studies (5 fully published, 3 abstracts) Pubmed, Cochrane and CRD database systematically until Jan 2009. 49 studies comparing CT to colonoscopy USA Pickhardt et al. PubMed search from 1994 to 2009 2011 11 151 patients 5 studies CT colonography for screening. The Netherlands PubMed, Embase and Cochrane de Haan et al. 2011 4,086 participants (<1% high risk).
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