New York City Dept. of Health & Mental Hygiene Colon 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 Guidelines U.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 Cancer Screening Rates
20.6% FOBT Previous Year
33.6% Sigmoidoscopy or Colonoscopy Previous 5 yrs.
CDCP. Trends in screening for colorectal cancer — U.S. 1997 & 1999 MMWR 2001;50:162-6
Adenoma to Carcinoma Pathway APC loss Normal Epithelium Early Adenoma Cancer Hyper- proliferation Intermediate Adenoma Late Adenoma K-ras mutation Chrom 18 loss p53 loss Adenoma Normal Cancer
FOBT Flex Sig. Virtual Colonoscopy Stool DNA Mutations One-Stage Screening Two-Stage Screening Colonoscopy
FOBT Screening Randomized Controlled Trials
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 slides Winawer et al, GE 1997
COLORECTAL CANCER MORTALITY REDUCTION BY SIGMOIDOSCOPY
Colorectal Cancer Mortality Study Design Reduction Published
Kaiser Retrospective, 30% Selby, NEJM Permanente, Case Control 1992 USA
Univ. Retrospective, 40% Newcomb, Wisconsin, Case Control JNCI 1992 USA
Reviewed in Colorectal Cancer Screening: Clinical Guidelines and Rationale. Winawer, Fletcher, et al., Gastroenterology, Feb. 1997.
Screening Colonoscopy Studies
National Colonoscopy 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 2000 CONCERN – Schoenfeld et al. DDW 2001, 2002 (Gastroenterology) Lilly-Imperiale et al. – NEJM 2000, 2002
Effect of Colonoscopic Polypectomy on Incidence of Colorectal Cancer
* 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 Screening in Average Risk Men & Women 50 Years of Age or Older
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 Screening Advisory Panel to the New York City Department of Health and Mental Hygiene
Drs. Harold Freeman (Chair), Robert Schiller, Thomas Weber, Susan Williams, Sidney Winawer
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 beginning age 40 or earlier.
Colorectal Cancer Screening Advisory Panel Rationale
About 1,500 NYC residents die annually from colorectal cancer
Most deaths are preventable
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)
**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 for Average-Risk Adults Aged 50+, Survey of Colorectal Cancer Screening Practices, 1999–2000
N.Y.C. Dept. of Health & Mental Hygiene Colorectal Cancer Control Campaign