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Prospects for the worldwide control of colorectal cancer through screening

2002; Elsevier BV; Volume: 55; Issue: 6 Linguagem: Inglês

10.1067/mge.2002.123612

1097-6779

Paul Rozen, Sidney J. Winawer, Jerome D. Waye,

Gastric Cancer Management and Outcomes

Colorectal cancer (CRC) is a major medical burden in the established countries of the western world and is becoming so in the emerging countries as they adopt the dietary and lifestyle habits of Western Europe and North America. This can be seen in Figure 1, which shows that the high incidence areas also include such diverse countries as Argentina, Israel, and the rapidly industrializing areas of Asia.1Ferlay J Bray F Pisani P Parkin DM Globocan 2000: cancer incidence, mortality, and prevalence worldwide. : IARC Press, Lyon2001Google ScholarRecently, there has been a fall in the incidence of CRC in the United States and a reduction in mortality there and in some European countries.1Ferlay J Bray F Pisani P Parkin DM Globocan 2000: cancer incidence, mortality, and prevalence worldwide. : IARC Press, Lyon2001Google Scholar, 2Rozen P Young GP Levin B Spann SJ Colorectal cancer in clinical practice: prevention, early detection and management. : Martin Dunitz, London2002Google Scholar, 3Santa M Capocaccia R Coleman MP Berrino F Gatta G Micheli A et al.Cancer survival increases in Europe, but international differences remain wide.Eur J Cancer. 2001; 37: 1659-1667Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar This has been attributed to the effects of changing lifestyle, earlier diagnosis, screening, cancer-preventive polypectomy, and improved therapy. Conversely, CRC mortality is still high in eastern European countries because of its late diagnosis and less adequate medical services (Fig. 2).1Ferlay J Bray F Pisani P Parkin DM Globocan 2000: cancer incidence, mortality, and prevalence worldwide. : IARC Press, Lyon2001Google Scholar, 2Rozen P Young GP Levin B Spann SJ Colorectal cancer in clinical practice: prevention, early detection and management. : Martin Dunitz, London2002Google Scholar, 3Santa M Capocaccia R Coleman MP Berrino F Gatta G Micheli A et al.Cancer survival increases in Europe, but international differences remain wide.Eur J Cancer. 2001; 37: 1659-1667Abstract Full Text Full Text PDF PubMed Scopus (141) Google ScholarFig. 2Worldwide range of colorectal cancer mortality in men (world age standardized rates/100,000 males), demonstrating the countries having the highest mortality. Note the relatively lower mortality in North America and some Western European countries.2Rozen P Young GP Levin B Spann SJ Colorectal cancer in clinical practice: prevention, early detection and management. : Martin Dunitz, London2002Google Scholar, 3Santa M Capocaccia R Coleman MP Berrino F Gatta G Micheli A et al.Cancer survival increases in Europe, but international differences remain wide.Eur J Cancer. 2001; 37: 1659-1667Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar Prepared by Dr. A. Zauber, New York, and derived from Ferlay et al.1Ferlay J Bray F Pisani P Parkin DM Globocan 2000: cancer incidence, mortality, and prevalence worldwide. : IARC Press, Lyon2001Google ScholarView Large Image Figure ViewerDownload Hi-res image Download (PPT) Four years ago, the World Organization for Digestive Endoscopy (OMED) formed a Colorectal Cancer Screening Committee.4Rozen P The OMED Colorectal Cancer Screening Committee: a report of its aims and activities.Gastrointest Endosc. 1999; 50: 449-454PubMed Google Scholar This multinational committee has the charge to promote the international implementation of CRC screening programs.5Rozen P Colorectal cancer: does early detection matter?.Postgrad Med J. 2001; 77: 289-291Crossref PubMed Scopus (6) Google Scholar The initial activities of this committee were to interact with industry to promote the development of a flexible sigmoidoscope (FS) suitable for screening, and prepare multilanguage videotapes on the standardized preparation and development of the most commonly used guaiac fecal occult blood test (FOBT).4Rozen P The OMED Colorectal Cancer Screening Committee: a report of its aims and activities.Gastrointest Endosc. 1999; 50: 449-454PubMed Google Scholar, 6Rex D Atkin W Hoff G Waye J The flexible sigmoidoscope.Gastrointest Endosc. 2000; 52: 587-589Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar The Committee is now evaluating a DVD on flexible sigmoidoscopy, which could be a useful educational tool for promoting its performance in CRC screening. The present activities have been aimed at identifying populations at risk worldwide, assessing national needs for CRC screening, and jointly working with the World Health Organization (WHO) Collaborating Center for Prevention of CRC (Dr. Sidney Winawer) and the ASGE (Drs. John Bond and Sidney Winawer) in developing an International "Outreach" Program to promote CRC screening. This program is now developing in collaboration with the International Union Against Cancer (UICC) (Dr. Bernard Levin). The UICC is the umbrella organization for National Cancer Societies and provides the key interphase between the professional experts and the lay public. The Committee has received overviews of national CRC screening activities and the results of a worldwide survey of national screening: needs, policy, and limitations on implementing screening (Dr. Winawer et al.).7Winawer SJ Crespi M Zauber AG Carlson MD Rozen P OMED/WHO/ASGE worldwide project for the prevention of colorectal cancer: international survey results (abstract).Gastrointest Endosc. 2001; 53: AB188Google Scholar The following report provides a précis of these national screening reports. Australia, Drs. J. St. John and G.P. Young: Because Australia is a high-risk country for CRC, the Health Authorities and National Government are funding pilot FOBT population screening in 2002 at 2 urban and 1 rural site of 50,000 asymptomatic persons aged 50 to 75 years. Importantly, these studies will operate within the existing medical system so as to learn about service delivery, role of general physicians (GPs), quality control, and so on.8Guidelines for the prevention, early detection and management of colorectal cancer.http://www.health.gov.au/nhmrc/publications/synopses/cp62syn.htmDate: March 15, 2002Google Scholar The obstacles for FOBT screening might be population acceptance, hence the planned pilot studies. FOBT testing is feasible as is the follow-up colonoscopy rate. The obstacles for colonoscopic screening would be the limited colonoscopy facilities, perhaps the cost, and the likely poor public compliance. China, Dr. B.C.Y. Wong: CRC incidence is increasing rapidly in Hong Kong and the large cities of South China. The Ministry of Health has a positive attitude toward CRC screening; however, the large population and demands of other economic priorities are major obstacles to implementing a National Screening Program. This is compounded by the intended change from a National Medical Service to service by payment. Initial screening studies have been performed in China and showed a reduction in CRC mortality.9Zhou DY Feng FC Pan DS Lai ZS Zhang WD Zhang YL et al.Comparative analysis of rectal mucus T antigen test with immunological fecal blood test in screening of colorectal cancer (Chinese).Chin J Digest. 1993; 13: 315-316Google Scholar, 10Zhou DY Feng FC Zhang YL Lai ZS Zhang WD Li LB et al.Comparison of Shams' test for rectal mucus to an immunological test for fecal occult blood in large intestinal carcinoma screening. Analysis of a check-up of 6480 asymptomatic subjects.Chin Med J. 1993; 106: 739-742PubMed Google Scholar, 11Liu XY Zheng S Zhang SZ Ding XF Shun YZ Shun GH et al.Reducing incidence and mortality from rectal cancer by polypectomy: a prospective study (Chinese).Chin J Epidemiol. 2000; 21: 245-248Google Scholar, 12Liu XY Zheng S Chen K Ma XY Zhou L Yu H et al.Randomized controlled trial of sequence mass screening program for colorectal cancer (Chinese).Chin J Epidemiol. 2000; 21: 430-433Google Scholar Pilot studies are now being performed in Hong Kong and South China to evaluate the performance characteristics of guaiac and immunochemical FOBTs and endoscopy in screening for CRC in our population. Czech Republic, Dr. M. Zavoral: Based on data, published in Czech, on prevention studies, it was concluded that CRC mortality reduction after implementation of a global screening program is feasible with a reduction in both direct and indirect costs.13Zavoral M Ladmanová P Friè P Anto SF Horák L Ambruž L et al.Colorectal cancer: guidelines for screening, diagnostics and treatment.Èeská a Slovenská gastroenterologie. (Czech). 2001; 2: A11Google Scholar, 14Fric P Zavoral M Dvorakova H Zoubek V Roth Z An adapted program of colorectal cancer screening — 7 years experience and cost—benefit analysis.Hepatogastroenterology. 1994; 5: 413-416Google Scholar As of 2001, biennial guaiac FOBT will be offered to asymptomatic individuals starting at age 50 years. This will be performed by GPs during free health examinations. Because the workload for FOBT distribution and evaluation is focused on GPs, cooperation with these colleagues is crucial. Any administrative problems, especially regarding the reimbursement of payments from the medical insurance companies, could possibly break the fragile balance that has been reached during negotiations.13Zavoral M Ladmanová P Friè P Anto SF Horák L Ambruž L et al.Colorectal cancer: guidelines for screening, diagnostics and treatment.Èeská a Slovenská gastroenterologie. (Czech). 2001; 2: A11Google Scholar The program has received wide media exposure, and the Czech gastroenterologists have issued screening guidelines. Financial support has been promised for the additional colonoscopies that will be required. If the Czech Society of Gastroenterology succeeds in its campaign for state subsidies to extend and improve the network of endoscopy suites providing complete colonoscopy care (estimated cost $8 million), there will be a good chance to launch a study comparing direct colonoscopy versus FOBT screening. European Union (EU) and France, Dr. R. Lambert: The EU recommends CRC screening to member states if the professional expertise is available and when taking into account other healthcare priorities. They recommend screening by the guaiac FOBT; other screening modalities need to be evaluated.15Lynge E Advisory Committee on Cancer Prevention Recommendations on cancer screening in the European Union.Eur J Cancer. 2000; 36: 1473-1478Abstract Full Text Full Text PDF PubMed Scopus (239) Google Scholar, 16Towler B Irwig L Glasziou P Kewenter D Weller D Silagy C A systematic review of the effects of screening for colorectal cancer using the faecal occult blood test, hemoccult.Brit Med J. 1998; 317: 559-565Crossref PubMed Scopus (427) Google Scholar Pilot screening studies have started in the United Kingdom, Spain, and Austria, and screening is already provided routinely in Germany. In France, the Ministry of Health has accepted the principle of a National CRC Screening Program but is awaiting funding for implementation. The Social Security System has selected the target population in some regions of France, and awareness and education campaigns need to be implemented. Costs will be included in the Social Security benefits. Germany, Dr. R. Gnauck: In Germany, the annual death toll from colon cancer is 30,000 in a population of 80 million. There appears to be a slight decrease in mortality and a definite improvement of survival rates related to the introduction of population screening in West Germany in 1977, especially in comparison with East Germany where this screening was started only in 1990 after reunification. The main obstacle to broader population screening is the low participation in the present FOBT screening programs. Since 1977, annual FOBT screening is offered from age 45 years as part of a free "cancer check-up."17Gnauck R Screening for colon cancer in Germany.Tumori. 1995; 81: 30-37PubMed Google Scholar About 3.1 million women (22% of the population at risk) and 1.2 million men (10%) participate repeatedly, so the number of CRCs detected has continuously decreased. In order to promote FOBT screening, pilot studies were initiated so as to offer FOBT screening separately from the "cancer check-up," to provide special reimbursement to the physician for the FOBT and to guarantee reimbursement for colonoscopy because of a positive FOBT.18Altenhofen L Brenner C Flatten G Hofstadrer F Kutz R Oliveira J Modellprojekt Früherkennung des kolorektalen Karzinoms. : Verlag, Köln, Deutscher Ärzte1999Google Scholar This resulted in a 36% increase in participation by women and 54% by men; 256,000 were tested and 4.3% had a positive FOBT. Colonoscopy was scheduled and performed in 59% of those with positive tests. CRC was found in 4.3%, 54.5% were Dukes A or B, and adenomatous polyps were present in 27% of these examinations. Discussions have taken place about using screening sigmoidoscopy, colonoscopy, or both. Colonoscopy as a screening tool is feasible in Germany considering the large number of endoscopists available. However, aside from costs for the procedure, motivation of healthy people for this type of "invasive" screening appears questionable. There is now a public campaign to reduce CRC mortality by 50% in the next 5 years. Iceland, Dr. A. Theodors: The CRC Screening Committee has recommended a National Screening Program, and this awaits governmental approval. This was preceded by several workshops with addresses by invited international speakers. Israel, Dr. P. Rozen: CRC is the most common malignancy afflicting both men and women, and the National Compulsory Health Insurance includes free annual FOBT screening for those at average risk and endoscopy if at higher risk. In contrast to breast cancer screening, enrollment in FOBT screening is not high because there is no directive from the Ministry of Health to actively enroll persons into CRC screening. A move toward implementing this step has been put on hold because of the outbreak of regional violence. Italy, Dr. M. Crespi: After a series of successful National and Regional Conferences on CRC Screening, the Health Authorities have recommended national FOBT screening and initiation of pilot studies with screening flexible sigmoidoscopy. However, screening colonoscopy will now be free every 5 years for the average-risk population from the age of 45 years.19Citarda F Tomaselli G Capocaccia R Barcherini S Crespi M The Italian Multicentre Study Group Efficacy in standard clinical practice of colonoscopic polypectomy in reducing colorectal cancer incidence.Gut. 2001; 48: 812-815Crossref PubMed Scopus (618) Google Scholar Screening guidelines have been distributed to physicians and health care providers as both a brochure and as a CD-ROM. A public awareness campaign has begun with the assistance of a well-known public relations company. Japan, Dr. H. Saito: CRC is the third most important cause of cancer mortality in Japan. Since 1992, annual FOBT screening has been recommended from age 40 years by using a 2-day immunochemical test,20Saito H Screening for colorectal cancer by immunochemical fecal occult blood testing.Jpn J Cancer Res. 1996; 87: 101-124Crossref Scopus (57) Google Scholar which has higher efficacy than the guaiac test.21Saito H Soma Y Koeda J Wada T Kawaguchi H Sobue T et al.Reduction in risk of mortality from colorectal cancer by fecal occult blood screening with immunochemical hemagglutination test. A case-control study.Int J Cancer. 1995; 61: 465-469Crossref PubMed Scopus (162) Google Scholar, 22Saito H Soma Y Nakajima M Koeda J Kawaguchi H Kakizaki R et al.A case-control study evaluating occult blood screening for colorectal cancer with Hemoccult test and an immunochemical hemagglutination test.Oncol Reports. 2000; 7: 815-818PubMed Google Scholar, 23Saito H Screening for colorectal cancer: current status in Japan.Dis Colon Rectum. 2000; 43: 78-84Crossref Google Scholar Screening and diagnostic costs are at least partially covered by local government and National Health Insurance.20Saito H Screening for colorectal cancer by immunochemical fecal occult blood testing.Jpn J Cancer Res. 1996; 87: 101-124Crossref Scopus (57) Google Scholar In 1998, over 5 million persons participated in the program (approximately 14% of the target population, exclusive of company sponsored programs), with the FOBT being positive in 7% and at least 7400 cancers detected. The predictive positive value was 3.4% but the compliance for investigation was only 60%. To reduce CRC mortality significantly, a higher compliance for CRC screening and follow-up is needed, as is better data management to facilitate the program evaluation. Latin America, Dr. J.L. Rainoldi: Argentina has a high incidence of CRC, and this has been addressed at several National Meetings. A committee was established to try to initiate CRC screening but, because of competing medical priorities, there is no available financial support. It is impossible to perform average-risk colonoscopy screening because of its high cost. Our best possibilities are to develop a program to screen persons at high risk of CRC by colonoscopy and to screen the average-risk population over 50 years old by means of FOBT. In our country, it will be extremely important to develop an awareness campaign about the risk of CRC. Uruguay has a high incidence and mortality from CRC. An agreement was reached between their Ministry of Health and the Japanese Government to begin a CRC screening program, but this has not yet started. Other Latin American Countries are not screening for CRC because, so far, it is not of clinical importance. Scandinavia, Dr. G. Hoff: There has been a markedly increased incidence of CRC in Norway, as compared with other Scandinavian countries, indicating the need for some preventive action. There are no national CRC screening programs in the Nordic countries, but there is an ongoing biennial FOBT trial in Denmark,24Kronborg O Fenger C Olsen J Jørgensen OD Søndergaard O Randomized study of screening for colorectal cancer with faecal-occult-blood test.Lancet. 1996; 48: 1467-1471Abstract Full Text Full Text PDF Scopus (2191) Google Scholar which has documented a mortality reduction, and an FS screening trial, with or without FOBT in Norway.25Hoff G Grotmol T Bretthauer M Gondal G Hofstad B Efskind P et al.Flexible sigmoidoscopy screening: a randomised, controlled study of the population in the South of Norway.Gastroenterology. 2001; 120 (The Norwegian Colorectal Cancer Prevention study (NORCCAP) [abstract]): A228Google Scholar, 26Thiis-Evensen E Hoff G Sauar J Langmark F Majak BM Vatn MH Population based surveillance by colonoscopy. Effect on the incidence of colorectal cancer. Telemark polyp study No. 1.Scand J Gastroenterol. 1999; 34: 414-420Crossref PubMed Scopus (410) Google Scholar The Norwegian policy has been to await mortality data because there is reluctance to accept surrogate endpoints, especially because a recent analysis showed that screening itself may have an unfavorable influence on lifestyle and overall mortality.27Hoff G Thiis-Evensen E Grotmol T Sauar J Vatn MH Moen IE Do unwanted effects of screening affect all cause mortality in flexible sigmoidoscopy screening programs?.Eur J Cancer Prev. 2001; 10: 31-37Crossref Scopus (38) Google Scholar The population has been shown to have a high attendance rate both for FS25Hoff G Grotmol T Bretthauer M Gondal G Hofstad B Efskind P et al.Flexible sigmoidoscopy screening: a randomised, controlled study of the population in the South of Norway.Gastroenterology. 2001; 120 (The Norwegian Colorectal Cancer Prevention study (NORCCAP) [abstract]): A228Google Scholar, 27Hoff G Thiis-Evensen E Grotmol T Sauar J Vatn MH Moen IE Do unwanted effects of screening affect all cause mortality in flexible sigmoidoscopy screening programs?.Eur J Cancer Prev. 2001; 10: 31-37Crossref Scopus (38) Google Scholar and for a small-scale colonoscopy trial,26Thiis-Evensen E Hoff G Sauar J Langmark F Majak BM Vatn MH Population based surveillance by colonoscopy. Effect on the incidence of colorectal cancer. Telemark polyp study No. 1.Scand J Gastroenterol. 1999; 34: 414-420Crossref PubMed Scopus (410) Google Scholar indicating a potential role for both modalities in CRC prevention and mortality reduction. Analysis of follow-up results of the NORCCAP flexible sigmoidoscopy screening trial25Hoff G Grotmol T Bretthauer M Gondal G Hofstad B Efskind P et al.Flexible sigmoidoscopy screening: a randomised, controlled study of the population in the South of Norway.Gastroenterology. 2001; 120 (The Norwegian Colorectal Cancer Prevention study (NORCCAP) [abstract]): A228Google Scholar will start in 2005. There is currently an increased focus on colonoscopy training programs so as to secure quality assurance and the capacity to eradicate waiting lists of patients referred with symptoms and to prepare for CRC screening. United Kingdom, Dr. W. Atkin: There is no national screening program, but a national pilot study has been funded for biennial FOBT screening in 2 centers, each having a population of 200,000 aged 50 to 69 years.28National Screening Committee A summary of the colorectal cancer screening workshops and background papers.http://www.doh.gov.uk/nsc/pdfs/summaryDate: March 15, 2002Google Scholar Randomized trials of the efficacy and feasibility of offering a single flexible sigmoidoscopy examination at age 55 to 64 years have completed enrollment in 14 centers in the United Kingdom and in 6 centers in Italy.29Atkin WS Hart A Edwards R McIntyre P Aubrey R Wardle J et al.Uptake, yield of neoplasia and adverse effects of flexible sigmoidoscopy.Gut. 1998; 42: 560-565Crossref PubMed Scopus (124) Google Scholar A total of 40,674 attended for screening in the United Kingdom and 10,004 in Italy. Analysis of the effects of screening on CRC incidence and mortality will start in 2004. United States, Drs. S.J. Winawer and A. Zauber: CRC has been identified as a major medical burden in the United States. There is no national screening initiative, but more evidence for the late benefit of screening has come from the Minnesota FOBT Trial with a further reduction in CRC probably because of removal of large (>1 cm) adenomatous polyps.30Mandel JS Church TR Bond JH Ederer F Geisser MS Mongin SJ et al.The effect of fecal occult-blood screening on the incidence of colorectal cancer.N Engl J Med. 2000; 343: 1603-1607Crossref PubMed Scopus (1242) Google Scholar Two feasibility trials of screening colonoscopy were completed and demonstrated excellent performance characteristics, low complication rates, and a 10% prevalence of advanced neoplasia.31Lieberman D Weiss DG Bond JH Ahnen DJ Garewal H Chejfee G Use of colonoscopy to screen asymptomatic adults for colorectal cancer. Veterans Affairs Cooperative Study group 380.N Engl J Med. 2000; 343: 162-168Crossref PubMed Scopus (1616) Google Scholar, 32Imperiale TF Wagner DR Lin CY Larkin GN Rogge JD Ransohoff DF Risk of advanced proximal neoplasms in asymptomatic adults according to the distal colorectal findings.N Engl J Med. 2000; 343: 169-174Crossref PubMed Scopus (924) Google Scholar Two further (one randomized) population colonoscopy trials have started. Medicare will now pay for a screening colonoscopy every 10 years in average-risk men and women. Trials are planned to evaluate a new fecal DNA test in comparison to colonoscopy.33Ahlquist DA Skoletsky JE Boynton KA Harington JJ Mahoney DW Pierceall WE et al.Colorectal cancer screening by detection of altered human DNA in stool: feasibility of a multi-target assay panel.Gastroenterology. 2000; 119: 1219-1227Abstract Full Text Full Text PDF PubMed Scopus (492) Google Scholar The National Polyp Study showed that colonoscopy was twice as effective as double contrast barium enema for detecting advanced adenomas.34Winawer SJ Stewart ES Zauber AG Bond JH Ansel H Waye JD et al.A comparison of colonoscopy and double-contrast barium enema for surveillance after polypectomy.N Engl J Med. 2000; 342: 1766-1772Crossref PubMed Scopus (519) Google Scholar The American Cancer Society Guidelines have been updated to recommend screening by annual FOBT, flexible sigmoidoscopy, or both together.35Smith RA Cokkinides V von E Levin B Cohen C Runowicz CD et al.American Cancer Society guidelines for the early detection of cancer.CA Cancer J Clin. 2002; 52: 8-422Crossref PubMed Scopus (370) Google Scholar There have been many public campaigns by professional bodies, public personalities, and TV series to promote CRC screening. National legislation is now proposed to require private insurances to follow Medicare CRC screening guidelines. The above reports are clearly not all-inclusive of all screening activities nationally or worldwide. They do indicate that CRC is recognized as a major medical burden in westernizing countries, but most medical services lack the financial ability to implement even FOBT screening and the infrastructure needed for endoscopic screening. This can only come about, as in the United States, Germany, or Japan, when there is public and political support for CRC screening. In addition, participation in screening can only be successful when its performance is adequately compensated and it is actively promoted by the HMOs or Health Authorities. The OMED Colorectal Cancer Screening Committee has formed an Outreach Program for the International Promotion of CRC Screening. A list of International Consultants has been developed who are willing to advise on the various facets of CRC screening, and they have already visited, lectured, or advised in Australia, Argentina, China, Iceland, and Italy. Further information can be obtained from Dr. Rozen or the OMED website (www.omed.org). This OMED CRC Screening Program will now be complemented by an OMGE (World Organization for Gastroenterology) Committee on Digestive Cancer chaired by Dr. S.J. Winawer. In general, the OMGE Committee will address the etiology, prevention (including chemoprevention), and treatment of common GI malignancies. A fruitful cooperation can be anticipated among the international bodies: OMED, ASGE, WHO, UICC, and now OMGE in a concerted attack on GI cancer.