EGD: Indications 20002001

1
New US CRC Guidelines Prevention vs. Early
Detection C5 Summit New York June 5, 2008
David Lieberman MD Chief, Division of
Gastroenterology Oregon Health Sciences
University Portland VAMC
2
Risk Factors for CRC
Sporadic/ Average Risk 75
3
Colorectal Cancer
Normal Colon
Cancer
5-6 Lifetime Risk
4
Guideline Process

• Prior guidelines from multiple organizations
• Consensus guideline included
• American Cancer Society
• Multi-Society Task Force on Colorectal Cancer
• GI organizations and American College of
  Physicians
• American College of Radiology
• U.S. Preventive Services Task Force

5
Guideline Process

• Rules of evidence
• Where evidence was lacking
• Expert opinion
• Areas for research noted
• Emphasis on Quality in each program

6
Lifestyle and Diet
Lieberman JAMA 2003 Vogelaar, Cancer 2006
1071624
7
New CRC Guideline Key Principles

• Distinguish between
• Early cancer detection tests
• Cancer prevention tests
• Establish minimum standard for early cancer
  detection tests
• Emphasis on quality

8
Raising the bar
9
Average-Risk CRC Screening
Levin B, Lieberman D, McFarland B et al 2008 CRC
Guideline
Tests which detect both cancer and adenomas
Tests which primarily detect early cancer
10
Fecal Occult Blood Test FOBT
11
FOBT- One-time testing
of patients with cancer who have () test
of patients with serious Polyps who have () test
33-60
11-50
Lieberman et alNEJM 2001345555-60 Imperiale et
al NEJM 20043512704-14 Collins, Lieberman et
al Ann Intern Med 2005 14281-5
Imperiale et al NEJM 20043512704-14 Young et
al Am J Med 2002 97 2499-2507 Morikawa et al
Gastroenterology 2005 129 422-8 Levi et al Ann
Intern Med 2007 146244-55
12
Stool Genetic Tests - Issues
Imperiale et al NEJM 20043512704-14 Itzkowitz
et al Clin Gastro Hep 2007 5 111-7

• One-time test can detect more than 50 of
  cancers
• Evolving
• Costly

13
FOBT Mortality Reduction
Potential Mortality Reduction
Adherence at Every level 100
40
14
Early Cancer Detection Tests

• Requires programmaticadherence with () and (-)
  tests
• Programmatic performance
• Unlikely to result in much cancer prevention

UNKNOWN
15
Adenoma and Cancer Detection Tests
Sigmoidoscopy Evidence Case-Control
Studies Efficacy Mortality reduction left
colon No benefit right
colon Program performance under study
PLCO, UK, Italy
16
CT Colonography
NEJM 2003 349 2191 JAMA 2004 2911713-9
Rockey Lancet 2005365 305-11
17
CT Colonography Who should be referred for
Colonoscopy ?
NEJM 2003 349 2191 JAMA 2004 2911713-9
Lancet 2005365 305-11Levin B, Lieberman D,
McFarland B et al 2008 CRC Screening Guideline
YES
YES
If largest polyp is 1-5mm ??????
18
CT Colonography Issues

• Inter-observer variability
• Detection of flat polyps
• Bowel Prep
• Radiation
• Extracolonic findings
• Intervals uncertain
• After negative exam
• After exam with small polyps

19
Adenoma and Cancer Detection Tests
Colonoscopy Evidence Cohort Studies Efficacy
Uncertain, but extrapolated from
FOBT and Sig studies Quality in practice
unknown Program performance unknown National
colonoscopy study (Winawer)
20
Colonoscopy Screening Studies (n 1000)

• Studies 2000-2004
• VA Cooperative Study NEJM 2000 343 162-8 (n
  3121)
• Indiana Study NEJM 2000 343 169-74 (n 1994)
• CT Colonography studies (n 2447) (Pickhardt,
  Rockey, Cotton)
• Fecal DNA Study NEJM 2004 351 2704-14 (n
  4404)
• Spain, Am J Gastroenterol 2003 98 2648-54 (n
  2210)
• Studies 2005-2006
• Women (Schoenfeld) NEJM 2005 352 2061-8 (n
  1463)
• Taiwan Gastrointest Endosc 2005 61 547-53 (n
  1708)
• Japan, Gastroenterology 2005 129 422-8 (n
  21,805 with iFOBT)
• Seattle, JAMA 2006 295 2357-65 (N 1244)
• Poland, NEJM 2006 355 1863-72 (n 50,148)
• Germany (n 1.14M)

21
Colonoscopy
22
Colonoscopy
Depends on

• Appropriate utilization
• High-quality exam to cecum
• Low rate of missed lesions
• Low rate of incompletely removed lesions
• Low rate of adverse events

23
Colonoscopy Issues

• Bowel Prep
• Quality Issues
• Missed lesions
• Safety

24
Obstacles to ScreeningPerceptions

• Patient educationScreening works !!!

25
Obstacles to ScreeningPerceptions

• It is not fun
• It is not effective
• It is not clear what test to use
• It costs too much

FOBT
Flex-Sig
BaE
Colon

26
Cost of not screening
Cost of Cancer Care Emotional Costs Missed
opportunity for prevention
27
Overcoming Obstacles

• Patient Education
• Provider Education
• Understanding obstaclesto compliance

28
Colon Screening in USA
Rate of - FOBT, - Flexible Sigmoidoscopy -
Colonoscopy

29
CRC Age-adjusted incidence rates/100,000210,452
white Americans 21 yrs
SEER data Rabeneck et al. Am J Gastroenterol
2003 98 1400
FOBT/Flex sig
Right Colon No Change
Lieberman et al NEJM 2000 343 162-8 Imperiale
et al NEJM 2000 343 169-74
30
Summary of 2008 CRC Screening Guideline

• Distinguishes
• Tests which detect early cancer vs
• Tests which detect both adenomas and cancer
• Adherence to programmatic testing is a problem
• Therefore any one-time test should detect more
  than 50 of cancers
• Emphasis on Quality

Stool-Based Tests
Colonoscopy or CT Colonography
31
Raising the bar
Colon Cancer Detection
1970s