Colonoscopy Screening: Issues and Controversies Symposium on GI - - PowerPoint PPT Presentation
Colonoscopy Screening: Issues and Controversies Symposium on GI Cancers St. Louis 9-12-09 David Lieberman MD Chief, Division of Gastroenterology and Hepatology Oregon Health Sciences University Portland VAMC Risk Factors for CRC HNPCC
Symposium on GI Cancers
9-12-09 David Lieberman MD Chief, Division of Gastroenterology and Hepatology Oregon Health Sciences University Portland VAMC
Sporadic/ Average Risk 75% IBD-1% Colitis Family History 15-20% HNPCC 3% FAP-1% World wide:
in USA
Normal Colon Advanced Adenoma
10-20% Lifetime Risk Genetic Environmental Lifestyle 5-6% Lifetime Risk
MD
Early Colon Cancer Detection Colon Cancer Prevention
Screening Test ACS-MSTF- ACR* USPSTF* ACG gFOBT YES; requires >50% sensitivity for CRC YES; “sensitive” test
Yes; only sensitive test FIT YES; requires >50% sensitivity for CRC YES Preferred as cancer detection test Stool DNA YES; requires >50% sensitivity for CRC NO YES; every 3 years
American College of Radiology
Tests which “primarily” detect early cancer:
Screening Test ACS-MSTF- ACR* USPSTF* ACG CT Colonography YES – every 5 years NO – insufficient evidence YES; every 5 years Flex Sig YES – every 5 years YES – every 5 years with sensitive FOBT YES; every 5-10 years
Colonoscopy
YES – every 10 years YES – every 10 years YES - preferred
ACS-MSFT-SCR = American Cancer Society; Multi-Society Task Force CRC; American College of Radiology USPSTF = United States Preventive Services Task Force; ACG = Am College of Gastroenterology
Tests which can detect early cancer and cancer precursor lesions
Test Cancer Advanced Adenoma Standard gFOBT 33-50% 11% Sensitive gFOBT 50-75% 20-25% FIT 60-85% 20-50% Stool DNA (old version) 51% 18% Stool DNA (new version) 80+% 40% Key new references: sDNA: Ahlquist et al; Ann Intern Med 2008; 149;441-50 FIT: Hundt et al; Ann Intern Med 2009; 150: 162-9
adherence with (+) and (-) tests
much cancer prevention UNKNOWN
Structural Colon Exams: Sensitivity of one-time test
Test Cancer Advanced Adenoma CT Colonography (CTC) Uncertain; likely >90% 90% if >10mm 78% for all polyps >6mm Sigmoidoscopy >95% distal colon 60-70% Proximal colon 70% Colonoscopy >95% 88-98%
Key new references: CTC: Johnson et al; NEJM 2008; 359; 1207-17
10 20 30 40 50 60 2000 2001 2002 2003 2004 2005
National Health Interview Survey Sigmoid FOBT
– Lieberman et al; 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)
– 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 = > 2 million )
Results: 5-10% with Advanced Neoplasia 0.5-1.0% with Cancer
– Cohort Studies: feasibility and safety – Case-Control Studies
Study Mortality Incidence Muller/Sonnenberg; 1995
Singh; 2006
5 yrs: SIR 0.55 10 yrs: SIR 0.28 Baxter; 2009 Left colon: OR 0.33 Right colon: OR 0.99 Kahi; 2009 SMR 0.35 SIR 0.33 Case- Control Cohort
– Sawhney et al; Gastroenterology 2006; 131: 1700-5
– Pabby et al; Gastrointest Endosc 2005; 61: 385-91
–2-12% of polyps >1cm are missed
Soetikno et al; JAMA 2008; Lieberman; JAMA 2008
Submucosal cancer Indigocarmine
– CRC (any) : OR 0.63 (0.57-0.69) – Left colon: OR 0.33 (0.278-0.39)
– Proximal colon: OR 0.99 (0.86-1.14)
– Biology – Quality
Baxter et al; Ann Intern Med 2009; 150: 1-8
Colonoscopy: Serious Adverse Events /1000
Setting Year n Bleed Perforation Other*
VACSP 380-13 centers Screening only; 30d f/u 2002 3196 1.9 1.0 * hospitalization Teaching Hosp Australia 2003 23,508 2 1
USA 2003 116,000
2004 9223
Age >65 yrs 2003 39,286
USA-Wisconsin 2006 12,407 2 0.16
2006 16,318 3.2 0.9
Screening only 2006 50148 0.26 0.1 0.7 * hospitalization Outpatient-Canada Claims data 2008 97,091 1.6 0.85
Claims data 2009 277,434
30d f/u 2009 21,191 0.86 1.18 Medicare; Claims data 30d f/u 2009 53,220* 6.4 0.6 CV events with polypectomy
0.3-3.2 per 1000 0-1.3 per 1000
Colon Cancer Screening: Colonoscopy
removed lesions
Effectiveness depends on:
Rex, 2006 Lieberman et al; Gastrointest Endosc 2007; 65:757-66 Lieberman et al; Gastrointest Endosc 2009; 65: 757-66
100 200 300 400 500 600 45-50 55-60 65-70 75-80
AGE per 100,000 Male Incidence Mortality Female
Does it make sense to screen women at the same age as men?
% with Polyp(s) > 9mm
Lieberman et al, CGH 2005: 3: 798-805
Number needed to endoscope: NNE
5 10 15 20 25 30 35 40 45 Male Female <50 50-59 60-69 70-79 >79
Asymptomatic Screening To identify one patient with polyp > 9mm
50 59 50 59
Incidence Mortality Male Female Male Female White 58.9 43.2 22.1 15.3 Black 71.2 54.5 31.8 22.4 Asian 48.0 35.4 14.4 10.2 Hispanic 47.3 32.8 16.5 10.8 Native 46.0 41.2 20.5 14.2 ALL 59.2 43.8 22.7 15.9 Stage White Black Local 40% 35% Regional 37% 35% Distant 19% 24%
Source: American Cancer Society; 2008
– Lack of access to health care – Lower insurance
– Failure of MD to recommend screening – Failure of patient to accept screening
1 2 3 4 5 6 7 8 9 10 <50 50-59 60-69 70-79 >79 ALL White Black
% with polyp (s) > 9mm
Lieberman et al; JAMA 2008; 300: 1417-22
2 4 6 8 10 12 14 16 18 < 50 50-59 60-69 70-79 >79 ALL White Black
Women: OR 1.62 (1.39-1.89) Men: OR 1.161.01,1.34
When barriers to screening are not an issue, asymptomatic black men and women are more likely to have polyp(s) >9mm compared to whites
based on :
– Sex – consider screening women later – Race – consider screening Blacks with colonoscopy, since they represent a high-risk group
– No routine screening for adults 75-85 years – Against any screening after age 85 years
USPSTF; Ann Intern Med 2008; 149: 627-37 Lieberman et al, CGH 2005: 3: 798-805
100 200 300 400 500 600 45-50 55-60 65-70 75-80
Male Female
per 100,000 Incidence Mortality Polyp(s) >9mm
studies
QUALITY and Adherence