Robert E. Schoen, MD MPH Associate Professor of Medicine and Epidemiology Division of Gastroenterology University of Pittsburgh Organizing Colorectal Cancer Screening
Feb 21, 2016
Robert E. Schoen, MD MPH
Associate Professor of Medicine and Epidemiology
Division of Gastroenterology
University of Pittsburgh
Organizing Colorectal Cancer Screening
Lifetime Risk of CRC (%)
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
Male, Female
LR Dx LR Death
SEER, 1996 - 98
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Prevalence of Adenomatous Polyps
Diminutive or Small - 15 - 30%
Large - 3 - 5%
Cancer - 0.3 - 1%
Screening
for
Colorectal Cancer
CRC Often Diagnosed Late
U.S. CRC, By Stage, 1992 - 1997
Localized 37%
Regional 38%
Distant 20%
SEER: 1973 - 1998
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. 1997:112;594
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
Mandel, JNCI 1999;91:434
# enrolled
PYO
CRC Mortality Ratio*
*Overall mortality not changed
Decreased Incidence of CRC in the Minnesota FOBT Study
Mandel JS et al. N Engl J Med 2000:343:1603-7
17% in biennial
20% in annual
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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
%
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 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 - Complications
Cecum - 97+%Perforation - 1/5115 or 0.02%
NEJM 2000: Screening Colonoscopy Studies
VA Study: Major morbidity - 0.32% (GI bleed, MI, CVA)
VA Colonoscopy Study 380
Adenoma 37.5% Advanced Adenoma* 10.7%
Tubular 5.0% Villous 3.0% HGD 1.7%
CA 1.0%
N=3121, 97% male, mean age 63
Lieberman et al, NEJM 2000* 1 cm, Villous, HGD, CA
Lilly Cohort
Adenoma 20%Advanced Adenoma* 5.6%CA 0.6%
*Villous, HGD (not 1 cm)
N=1994, 58.9% male, mean age 60
Imperiale et al, NEJM 2000
What Does Screening Colonoscopy Detect That Sigmoidoscopy Doesn’t?
VA Study Lilly Cohort
Neoplasia 37.5% 20%
Advanced ProximalNeoplasia 4.1% 2.5%
“Missed” AdvancedProximal Neoplasia 2.1% 1.2%
Older age, males higher risk
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%
Incident CRC After Colonoscopy
Winawer (NPS)
Schatzkin (PPT)
Alberts (Wheat Bran)
N
1418
1905
1303
Observed (yrs)
5.9
3.05
2.91
PYO
8401
5810
3789
CRC Cases
5
14
9
Incidence/1000 PYO
0.6
2.4
2.4
Sigmoidoscopy vs. Colonoscopy
More sensitive
More invasive, safe?
Expensive
Less frequent (1/10 yr)?
Less accessible
Better satisfaction
Sensitive enough?
Safer
Less expensive
Frequency (1/5 yr)?
Accessible?
Satisfied?
Colonoscopy SigmoidoscopyVs.