Algeria CroatiaEgypt France Greece

Italy Jordan Lebanon Lybia Morocco

Portugal Syria Slovenia Spain Tunisia TurkeyPalestine

Albania Cyprus

Macedonia Malta

Mediterranean Task Force for Cancer Control (MTCC)

AIMS: To unify efforts to eliminate suffering and reduce mortality of cancer through decreasing incidence of adv. disease

How screening is crucial in ensuring How screening is crucial in ensuring better cure and improved survival better cure and improved survival

How screening is crucial in ensuring How screening is crucial in ensuring better cure and improved survival better cure and improved survival

Massimo CRESPIMassimo CRESPINational Cancer InstituteNational Cancer Institute

““Regina Elena”, Roma - ItalyRegina Elena”, Roma - Italy

CRC Incidence and Mortality in “Less” and “More” Developed Countries

CRC Incidence and Mortality in “Less” and “More” Developed Countries

Globocan 2002

In brutal figures …

More Developed

Less Developed

Incidence

M 353,390 M 196,037

F 312,341 F 159,664

T 665,731

65.2 %

T 355,70134.8 %

Mortality

M 159,914 M 118,025

F 153,980 F 96,184

T 313,894

59.4%

T 214,20940.6 %

COLON cancer Incidence and Mortality COLON cancer Incidence and Mortality

in Mediterranean areain Mediterranean area

TerminologyTerminologyTerminologyTerminology

PrevalencePrevalenceNumber of subjects diagnosed with a disease Number of subjects diagnosed with a disease (CRC) still alive after (CRC) still alive after xx years (or months) years (or months)

SurvivalSurvivalTime interval between diagnosis and death. Time interval between diagnosis and death. Actuarial survival takes into consideration deaths Actuarial survival takes into consideration deaths by causes different from the index disease.by causes different from the index disease.It’s considered like an ultimate parameter of It’s considered like an ultimate parameter of efficiency of the Health System (timely diagnosis, efficiency of the Health System (timely diagnosis, stage of disease, level of treatment and post-stage of disease, level of treatment and post-treatment care, etc.)treatment care, etc.)

PrevalencePrevalenceNumber of subjects diagnosed with a disease Number of subjects diagnosed with a disease (CRC) still alive after (CRC) still alive after xx years (or months) years (or months)

SurvivalSurvivalTime interval between diagnosis and death. Time interval between diagnosis and death. Actuarial survival takes into consideration deaths Actuarial survival takes into consideration deaths by causes different from the index disease.by causes different from the index disease.It’s considered like an ultimate parameter of It’s considered like an ultimate parameter of efficiency of the Health System (timely diagnosis, efficiency of the Health System (timely diagnosis, stage of disease, level of treatment and post-stage of disease, level of treatment and post-treatment care, etc.)treatment care, etc.)

Prevalence at 5y of CRC patientsPrevalence at 5y of CRC patients

5y prevalence

North America 618,403

Central America 28,350

South America 98,150

Europe 999,612

Africa 38,614

Asia 1,003,456

Australia and Pacific 43,630

(Globocan 2002)

EPICENTRO.ISS.IT

EUROCARE.IT

Eurocare-3 study Annals of Oncology

2003 (Suppl. 5) vol. 14

(Not EU)

(Not EU)

(Not EU)

England

Scotland

Wales

5y survival of CRC from Cancer

Registries

Possible actions for Possible actions for CRC PreventionCRC Prevention

Physical activityEnergy intake

Fresh fruit and vegetableDietary fat

CalciumFiber

Anti-oxidant vitaminesSelenium

SCREENINGAnti-inflammatory drugs

Summary of action with level II or III of evidence

Level II: Obtained from at least one properly designed RCT

Level III: Obtained from a control trial without randomisation, “ “ cohort or case-control analytic studies, “ “ multiple time-series with/without the intervention

Mass screening

protocol under Health authorities

selected population target

covers all degrees of risk

evaluation requiredentry test (FOBTs / CTcolonography?) + 2nd level test (Colonoscopy)

or Colonoscopy as entry test when feasible and accepted

.

.

.

.

.

Opportunistic screening

In volunteers subjects using primary diagnostic test as in screening

Low risk less compliant than high risk

Disadvantage: end-points not evaluable

Ensures further coverage of the population

.

.

.

Reduction in mortalitybut lead time and delay time bias

Improved survivaldown-staging

Reduction in incidencein some cases like cervix and colon-rectum because of pre-cancer lesions

 

 

Expected effects of screeningExpected effects of screening

Reduction in mortalitybut lead time and delay time bias

Improved survivaldown-staging

Reduction in incidencein some cases like cervix and colon-rectum because of pre-cancer lesions

Expected effects of screeningExpected effects of screening

CRC screening is feasible:CRC screening is feasible:

by historical methods of proven efficacy and efficiency (G-FOBT)

by actual methods I-FOBT or HeSENSAEndoscopy (invasive, costly, but highly efficient in reducing also incidence by polypectomy)

by methods in development Virtual Colonoscopy

Pill camStool-DNA

by historical methods of proven efficacy and efficiency (G-FOBT)

by actual methods I-FOBT or HeSENSAEndoscopy (invasive, costly, but highly efficient in reducing also incidence by polypectomy)

by methods in development Virtual Colonoscopy

Pill camStool-DNA

FOBTs: for a fair evaluation FOBTs: for a fair evaluation … ... an important … ... an important

definitiondefinition

FOBTs: for a fair evaluation FOBTs: for a fair evaluation … ... an important … ... an important

definitiondefinitionapplication sensitivity application sensitivity

(once only testing)(once only testing)

vs.vs.

programmatic sensitivity programmatic sensitivity (repeated testing every 1 or 2)(repeated testing every 1 or 2)

application sensitivity application sensitivity (once only testing)(once only testing)

vs.vs.

programmatic sensitivity programmatic sensitivity (repeated testing every 1 or 2)(repeated testing every 1 or 2)

J E Allison AJG 2010

What is What is average riskaverage risk for colorectal cancer?for colorectal cancer?

Getting old!Getting old!

Age (years)Age (years)40-4440-4445-5045-5050-5450-5455-5955-5960-6460-6465-6965-6970-7470-7475-7975-79

IncidenceIncidence13.313.327.627.655.155.197.097.0

153.4153.4226.9226.9318.6318.6412.0412.0

MortalityMortality4.64.69.69.6

19.019.034.434.455.455.485.685.6

125.9125.9171.9171.9

from Miller et al.from Miller et al.

INCIDENCE AND MORTALITY RATES OF CRCINCIDENCE AND MORTALITY RATES OF CRCBY AGE (x 100,000/YEAR)BY AGE (x 100,000/YEAR)

75%

18%5%1%1%

Sporadic

Familiarity

HNPCC

FAP

Crohn / RCU

Who is atWho is at average risk ? average risk ?

Stool Tests Stool Tests

G-FOBTG-FOBT

ImmunoImmunoFOBTFOBT

sDNAsDNA

Relative efficiency of G-FOBT and I-FOBT Relative efficiency of G-FOBT and I-FOBT for CRC and AA for CRC and AA (330 subj. undergoing OC)(330 subj. undergoing OC)

Rozen P. et al. 2009

Sensitivity Sensitivity %%

Specificity Specificity %%

No. of OC / No. of OC / NeoplasiaNeoplasia

G-FOBT G-FOBT (3samples)(3samples) 53.1 59.4 8.1

I-FOBT I-FOBT (1 (1 sample)sample)

53.1 94.0 2.1

I-FOBT I-FOBT (2 samples)(2 samples) 68.868.8 91.991.9 2.12.1

AA not identified #AA not identified #

G-FOBTG-FOBT 15

I-FOBTI-FOBT 8 bothboth 77

# mostly flat lesions in right colon

Comparison g-FOBT vs i-FOBT (100 ng/ml)Comparison g-FOBT vs i-FOBT (100 ng/ml)

Park D AJG 2010Park D AJG 2010

770 subj. at average risk 770 subj. at average risk both FOBTs (3 samples) + Colonoscopy (CS)both FOBTs (3 samples) + Colonoscopy (CS)

770 subj. at average risk 770 subj. at average risk both FOBTs (3 samples) + Colonoscopy (CS)both FOBTs (3 samples) + Colonoscopy (CS)

Sensitivity Specificity No. of CS to detect a lesion

g-FOBT i-FOBT g-FOBT i-FOBT g-FOBT i-FOBT

Ad.Ad. 13.7 34.5 92.4 90.4 7.6 4.4

CRC 30.8 84.5 92.4 89.8 15.2 7.3

Both 16.7 43.7 92.9 91.9 5.1 2.7

CRC stool screening testsCRC stool screening tests

Imperiale TF et al, NEJM (2008) 351:274-14

DNADNA Hemoccult II Hemoccult II (guaiac)(guaiac)

SensitivitySensitivityAdc

Adc N-Adenom-

HGDAdv.ad+

ADC

51.6 56.0

32.518.2

12.913.015.010.8

Cost (USD)Cost (USD) 400 to 800400 to 800 55

In most developing nations, Africa, Asia (3.8 billion population), CRC screening is not a priority, resources are limited, awareness still low or restricted to the more affluent (private care)

The preferred and more affordable screening strategy worldwide is FOBT (trend towards iFOBT). Bleeding from worm infestation is a problem in developing countries

Primary TC / FS screening offered only in a few affluent nations (US, UK Germany, Italy, Austria, Luxemburg, Poland), FOBT as alternative

In most developing nations, Africa, Asia (3.8 billion population), CRC screening is not a priority, resources are limited, awareness still low or restricted to the more affluent (private care)

The preferred and more affordable screening strategy worldwide is FOBT (trend towards iFOBT). Bleeding from worm infestation is a problem in developing countries

Primary TC / FS screening offered only in a few affluent nations (US, UK Germany, Italy, Austria, Luxemburg, Poland), FOBT as alternative

SCREENING STRATEGIES AND SCREENING STRATEGIES AND AVAILABLE RESOURCESAVAILABLE RESOURCES

Alternate strategies in low Alternate strategies in low resource settingsresource settings

To aim at familiar / genetic risk for CRCTo aim at familiar / genetic risk for CRC (just few key questions by a health professional)(just few key questions by a health professional)

In subjects aged <45 years (rates on total In subjects aged <45 years (rates on total cases)cases) More

DevelopedLess Developed

Incidence M 3.6 % M 16.4 %

F 3.8 % F 15.4 %

EndoscopyEndoscopy

What is HIGH RISK for CRC: impact offamiliar and hereditary factors

What is HIGH RISK for CRC: impact offamiliar and hereditary factors

0

10

20

30

40

50

60

70

80

90

100

%

Average risk 1 first degreerelative

2 first degreerelatives or 1

less 50 y

HNPCC FAP

Rosalind U. Clinics of North America Gastro. End. 2002Rosalind U. Clinics of North America Gastro. End. 2002

Average risk

High risk

18%5%1%1%

Sporadic

Familiarity

HNPCC

FAP

Crohn / RCU

Who is at high Who is at high risk ?risk ?

25%

COLONOSCOPY

COLONOSCOPY

A specific dedication by General Practitioners is suggested being crucial in selecting subjects, by simple questions, for:

Genetic syndromes Familiar risk

These patients NEED COLONOSCOPY

A specific dedication by General Practitioners is suggested being crucial in selecting subjects, by simple questions, for:

Genetic syndromes Familiar risk

These patients NEED COLONOSCOPY

A bit of culture, a minimal effort, a great yield!A bit of culture, a minimal effort, a great yield!

HOW identify them ?? … by a simple questionHOW identify them ??

… by a simple question

Accuracy 80 %Accuracy 80 %Church, Dis Colon Rectum, 2000Church, Dis Colon Rectum, 2000

Advanced Adenoma (AA)Advanced Adenoma (AA)Advanced Adenoma (AA)Advanced Adenoma (AA)

AA includes a range of lesions with variable (or different) cancer risk that was established as surrogate endpoint, more frequent than CRC

Endoscopic screening of CRCEndoscopic screening of CRC

ColonoscopyColonoscopy FlexibleFlexiblesigmoidoscopysigmoidoscopy

Miss rate of Flexible Sigmoidoscopy Miss rate of Flexible Sigmoidoscopy for proximal lesions in subjects with for proximal lesions in subjects with

no-distal lesionsno-distal lesions

Miss rate of Flexible Sigmoidoscopy Miss rate of Flexible Sigmoidoscopy for proximal lesions in subjects with for proximal lesions in subjects with

no-distal lesionsno-distal lesions

Range from 22.8 % to 65 %Range from 22.8 % to 65 %

(results of more than 50 studies)(results of more than 50 studies)

Efficacy of colonoscopy in Efficacy of colonoscopy in reducing incidence of CRCreducing incidence of CRCEfficacy of colonoscopy in Efficacy of colonoscopy in reducing incidence of CRCreducing incidence of CRC

Results of two multi-center studies based on long-term follow-up of asymptomatic subjects after a colonoscopy with polypectomy

US National Polyp Study (prospective) - 76 %

Italian Multicenter Study (retrospective) - 66 %

An alternative screening method

But COMPLIANCE in general population is low

Screening Colonoscopy (OC) in Screening Colonoscopy (OC) in asymptomatic subjectsasymptomatic subjects

Meta-analysis of 10 studies, 68,324 participantsMeta-analysis of 10 studies, 68,324 participants

Screening Colonoscopy (OC) in Screening Colonoscopy (OC) in asymptomatic subjectsasymptomatic subjects

Meta-analysis of 10 studies, 68,324 participantsMeta-analysis of 10 studies, 68,324 participants

Niv Y et al, 2007Niv Y et al, 2007

Complete (OC)Complete (OC) 97 % 97 % (94 – 98 %)(94 – 98 %)

CRCCRC 0.78 % 0.78 % (0.13 – 2.97 %)(0.13 – 2.97 %)

Stage Stage II or or IIII 77 % 77 %

AdenomaAdenoma 19 % 19 % (15 - 23 %)(15 - 23 %)

Advanced Aden.Advanced Aden. 5 % 5 % (4 – 6 %)(4 – 6 %)

ComplicationComplication Perforation 0.01 %Perforation 0.01 %

Bleeding 0.05 %Bleeding 0.05 %

Miss rate of right sided CRC by colonoscopy in Ontario in usual clinical

practice (1997 – 2001)

Miss rate of right sided CRC by colonoscopy in Ontario in usual clinical

practice (1997 – 2001)

CRC patients database: 4920 subjects

Missed cancers: 4% by colonoscopy performed between 6 – 36 months beforeCRC diagnosis.

(Byrd RL 1989: missed lesions: 3%)

CRC patients database: 4920 subjects

Missed cancers: 4% by colonoscopy performed between 6 – 36 months beforeCRC diagnosis.

(Byrd RL 1989: missed lesions: 3%)

CRC cannot be completely eliminated CRC cannot be completely eliminated even with very intensive screeningeven with very intensive screening

Bressler B et al 2004Bressler B et al 2004

Risk of CRC after negative colonoscopyRisk of CRC after negative colonoscopyRisk of CRC after negative colonoscopyRisk of CRC after negative colonoscopy

RRRR

OverallOverall 0.550.55

Left colonLeft colon 0.160.16 0.12 – 0.330.12 – 0.33

Right colonRight colon 0.670.67 0.800.80Singh 2009Singh 2009 Ransohoff 2009Ransohoff 2009

Geul K et al, 2007Geul K et al, 2007

About 80% subjects with CRC between 50 – 58y About 80% subjects with CRC between 50 – 58y have already one adenoma at 50yhave already one adenoma at 50y

QUALITY of OC !? QUALITY of OC !? Fast-growing lesions !?Fast-growing lesions !?

QUALITY of OC !? QUALITY of OC !? Fast-growing lesions !?Fast-growing lesions !?

Differences in protection against right/left

sided CRC after a negative index CS ? Differences in protection against right/left

sided CRC after a negative index CS ?

Quality of CSQuality of CS (gastroent. Vs non-gastroent.?)(gastroent. Vs non-gastroent.?)

Flat non polypoid lesionsFlat non polypoid lesions (more in right colon ?)(more in right colon ?)

Biology of proximal lesionBiology of proximal lesion (MSI and CIMP status ?)(MSI and CIMP status ?)

Why women worst ?Why women worst ? (RR 0.99 vs 0.89 men)(RR 0.99 vs 0.89 men)

Quality of CSQuality of CS (gastroent. Vs non-gastroent.?)(gastroent. Vs non-gastroent.?)

Flat non polypoid lesionsFlat non polypoid lesions (more in right colon ?)(more in right colon ?)

Biology of proximal lesionBiology of proximal lesion (MSI and CIMP status ?)(MSI and CIMP status ?)

Why women worst ?Why women worst ? (RR 0.99 vs 0.89 men)(RR 0.99 vs 0.89 men)

Low public compliance to screening colonoscopy Low public compliance to screening colonoscopy (from Jack Tippit, Saturday Evening Post)(from Jack Tippit, Saturday Evening Post)

Virtual Colonoscopy(CTC)

CTC ACCURACY CTC ACCURACY

>5>5 mmmm

>6>6 mmmm

>7>7 mmmm

>8>8 mmmm

>9>9 mmmm

>10>10 mmmm

SensitivitySensitivity 65% 78% 84% 87% 90% 90%

Johnson CD, NEJM 2008

PPVPPV 45%45% 40%40% 35%35% 31%31% 25%25% 23%

SpecificitySpecificity 89%89% 88%88% 87%87% 87%87% 86%86% 86%

Distribution of advanced neoplasia according to polyp size at screening

colonoscopy (data from 4 studies with 20,562 subjects)

Advanced adenomas detected in 1155 subjects (5.6% overall)

of these

in diminutive polyps (≤ 5mm) 4.6%

in small polyps (6-9mm) 7.9%in large polyps (≥ 10mm) 87.5%

Hassan C et al, 2009

Colon capsule (CE)

Ø11

mm

31 mm

Courtesy Dr Hassan

Important factors to Important factors to improve compliance to improve compliance to

screeningscreening

Awareness !!Awareness !!

The data from US and Europe The data from US and Europe show substantial differencesshow substantial differences

10

15

20

25

30

35

40

45

50

55

60

1970 1975 1980 1985 1990 1995 2000 2005

Years

Rat

es x

100

.000

(w

orld

std

.)

Italy EstoniaFrance NetherlandPoland SloveniaSlovakia SpainSEERall races

The EUROPREVAL project

Estimated

Trends in Incidence (M + F) of CRC in Europe vs USA Seer

selected Countries

Trends in Incidence (M + F) of CRC in Europe vs USA Seer

selected Countries

Prevalence of lower GI testing (CS, FS, FOBTs) in the last 10 years

Result of the SHARE program on 18,139 subj.aged more than 50y in 11 European Countries

Prevalence of lower GI testing (CS, FS, FOBTs) in the last 10 years

Result of the SHARE program on 18,139 subj.aged more than 50y in 11 European Countries

Stock C, Brenner H 2010Stock C, Brenner H 2010

WHAT A DISASTER !!WHAT A DISASTER !!

Lower GI Endoscopy from 6.1% Greece to 25.1 % France

FOBTs from 4.1 % Netherlandsto 61.1 % Austria

Lower GI Endoscopy from 6.1% Greece to 25.1 % France

FOBTs from 4.1 % Netherlandsto 61.1 % Austria

Ongoing CRC screening activities in ItalyOngoing CRC screening activities in ItalyOngoing CRC screening activities in ItalyOngoing CRC screening activities in Italy

M. Zorzi et al 2006 survey - National Centre for Screening Monitoring

20052005 20062006

ProgramsPrograms 52 69

InvitedInvited 827,473 2,107,000

ComplianceCompliance 47.1% (6.7–78.1%)

46.5 % (4.8 – 81 %)

I-Fobt +I-Fobt + I 5.8 – II 4.1 I 5.3 – II 3.9

OC adherenceOC adherence 82 % (56 – 100 %) 81.2%(69.2 – 90.7%)

11stst screen screen CRC 0.37 % AA 1.68 %

CRC 0.31 % AA 1.46 %

22ndnd screen screen CRC 0.11 % AA 0.49 %

CRC 0.13 % AA 0.77 %

TNM TNM II or or IIII 55 % 56 %

Ongoing CRC screening activities in Italy 2006Ongoing CRC screening activities in Italy 2006

Regional variations Regional variations

Ongoing CRC screening activities in Italy 2006Ongoing CRC screening activities in Italy 2006

Regional variations Regional variations

M. Zorzi et al 2006 survey - National Centre for Screening Monitoring

Theoretical Theoretical extention #extention #

Actual Actual extension extension (invited)(invited)

NorthNorth 66.1 % 50.2

CenterCenter 48.5 % 22.8

SouthSouth 10.0 % 4.8

# Population covered by organized screening programs

Screened Screened by TCby TC

11.311.3

14.214.2

2.82.8

Compliance to screening tests in Compliance to screening tests in average practice average practice (in the real world !!)(in the real world !!) Compliance to screening tests in Compliance to screening tests in

average practice average practice (in the real world !!)(in the real world !!)

Population based extent of CRC screening Population based extent of CRC screening in Ontario (Canada) in Ontario (Canada)

<20%<20% (Rabeneck L. et al. 2004)(Rabeneck L. et al. 2004)

Participation in colonoscopy population Participation in colonoscopy population screening in Australia screening in Australia

18.2%18.2% (Scott RG et al. 2004)

Population based extent of CRC screening Population based extent of CRC screening in Ontario (Canada) in Ontario (Canada)

<20%<20% (Rabeneck L. et al. 2004)(Rabeneck L. et al. 2004)

Participation in colonoscopy population Participation in colonoscopy population screening in Australia screening in Australia

18.2%18.2% (Scott RG et al. 2004)

??How to increase compliance ?

How to increase compliance ?

The problem is: compliance to any screening test … …

The problem is: compliance to any screening test … …

Sampdoria - Parma Sampdoria - Parma (21 Feb (21 Feb 04)04)

TV: March 2005

Established conceptsEstablished concepts

For For early detectionearly detection and and preventionprevention of CRC and polypsof CRC and polyps

ColonoscopyColonoscopy

For For early detectionearly detection of Advanced neoplasiaof Advanced neoplasia FOBTsFOBTs

In the real world….In the real world….• Uptake of screening opportunities is Uptake of screening opportunities is not exceeding 40 not exceeding 40

to 50%to 50% even in the more developed, wealthy nations even in the more developed, wealthy nations

• In unselected general population it is as In unselected general population it is as low as 20%low as 20% (Australia, Canada)(Australia, Canada)

• The The scarce convincememnt of GPsscarce convincememnt of GPs in advising CRC in advising CRC screening and the screening and the embarassmentembarassment to discuss bowel to discuss bowel matters are problems that only a strong action towards matters are problems that only a strong action towards increased awareness may overcomeincreased awareness may overcome

Results of European / USA RCTs Results of European / USA RCTs based on FOBTbased on FOBT

Results of European / USA RCTs Results of European / USA RCTs based on FOBTbased on FOBT

Europe (4 studies - biennial FOBT - 320,000 subjects) 15 – 18 % reduction in mortality

In subjects complying to all periodic recalls, reduction was 43 %

Early stage were 41 % in intervention arm vs 11% in controls

USA (Minnesota), annual FOBT, reduction in mortality in participating subjects was 55 %

FOBT is the method of choice worldwideFOBT is the method of choice worldwideFOBT is the method of choice worldwideFOBT is the method of choice worldwide

Mortality reduction in the Mortality reduction in the activeactive participating participating

populationpopulation - Funen : - 33 %

- Nottingham : - 39%

- Burgundy : - 33%

- Minnesota : - 55 %

FOBT long-term resultsFOBT long-term resultsThe Danish RCT studyThe Danish RCT study

FOBT long-term resultsFOBT long-term resultsThe Danish RCT studyThe Danish RCT study

• Biennial guaiac-FOBT on 3 fecal samples

• 9-rounds of screening completed

Compliance 1st invitation 67%

“ to re-testing 90%

Overall colonoscopy rate 5.3%

Dukes A in screened 36% (11% controls)

Overall reduction in mortality 11%

Reduction in mortality in those attending all 9-rounds 43 %

• Biennial guaiac-FOBT on 3 fecal samples

• 9-rounds of screening completed

Compliance 1st invitation 67%

“ to re-testing 90%

Overall colonoscopy rate 5.3%

Dukes A in screened 36% (11% controls)

Overall reduction in mortality 11%

Reduction in mortality in those attending all 9-rounds 43 %Kronborg O. 2004

Proportion of TNM stage 1 cancer in the Proportion of TNM stage 1 cancer in the screened and control populationscreened and control population

DownstagingDownstaging

Positive test

Test not

done

Control population

Funen 40% 9% 11%

Nottingham

44% 11% 12%

Burgundy 40% 16% 20%

RESULTS OF A CRUCIAL COHORT STUDY (JPHC) RESULTS OF A CRUCIAL COHORT STUDY (JPHC) ON CRC SCREENING IN JAPANON CRC SCREENING IN JAPAN

RESULTS OF A CRUCIAL COHORT STUDY (JPHC) RESULTS OF A CRUCIAL COHORT STUDY (JPHC) ON CRC SCREENING IN JAPANON CRC SCREENING IN JAPAN

42,150 subject – 551,459 person/years f.u. (13 years)

RR death from CRC in screened 0.28 (0.13 - 0.61) a 70% reduction

RR death from all causes 0.70 (0.61 - 0.79) a 30% reduction

Incidence of CRC similar but RR 0.41 for advanced CRC

Conclusions: no need for RCTs to implement screening (not ethical)

KJ Lee et al, 2007

Reduction in mortalitybeyond lead time and delay time bias

 

 

Summary: effects of CRC Summary: effects of CRC screening as shown by RCTsscreening as shown by RCTs

achieved: -15 to -55 %

Improved survival (down-staging)

Reduction in incidenceby removals of precancerous lesions (polyps)

achieved: up to 65%

achieved: up to

70%

Results of a large ecological study on colonoscopy coverage and CRC mortality / incidence in Ontario

Results of a large ecological study on colonoscopy coverage and CRC mortality / incidence in Ontario

Rabeneck L AJG 2010 Rabeneck L AJG 2010

2,412,077 subj. (mean age 64y, female 53%)2,412,077 subj. (mean age 64y, female 53%)14y follow-up (1993 – 2006)14y follow-up (1993 – 2006)

CRCCRC Incidence Incidence 62,819 cases (2.6 %)62,819 cases (2.6 %)MortalityMortality 23,743 deaths (0.9 %)23,743 deaths (0.9 %)

Result: Result: for every 1% increase in for every 1% increase in Colonoscopy Colonoscopy rate, 3% decrease in rate, 3% decrease in CRC mortalityCRC mortality

2,412,077 subj. (mean age 64y, female 53%)2,412,077 subj. (mean age 64y, female 53%)14y follow-up (1993 – 2006)14y follow-up (1993 – 2006)

CRCCRC Incidence Incidence 62,819 cases (2.6 %)62,819 cases (2.6 %)MortalityMortality 23,743 deaths (0.9 %)23,743 deaths (0.9 %)

Result: Result: for every 1% increase in for every 1% increase in Colonoscopy Colonoscopy rate, 3% decrease in rate, 3% decrease in CRC mortalityCRC mortality

Colorectal Cancer (Males) 5y Survival (%)

EPICENTRO.ISS.IT

EUROCARE.IT

Eurocare-3 study Annals of Oncology

2003 (Suppl. 5) vol. 14

CONCLUSIONS CONCLUSIONS i-FOBT (every 12 months) is the best accepted i-FOBT (every 12 months) is the best accepted and affordable at population level (crucial and affordable at population level (crucial awareness by GPs and public)awareness by GPs and public)

CTcolonography is possibly a 1CTcolonography is possibly a 1stst step step substitute, but technical and professional skills substitute, but technical and professional skills are crucialare crucial

A “good” colonoscopy is still the gold standard A “good” colonoscopy is still the gold standard if feasible (health facilities) and accepted if feasible (health facilities) and accepted (awareness)... test of choice in (awareness)... test of choice in high risk high risk subjectssubjects

i-FOBT (every 12 months) is the best accepted i-FOBT (every 12 months) is the best accepted and affordable at population level (crucial and affordable at population level (crucial awareness by GPs and public)awareness by GPs and public)

CTcolonography is possibly a 1CTcolonography is possibly a 1stst step step substitute, but technical and professional skills substitute, but technical and professional skills are crucialare crucial

A “good” colonoscopy is still the gold standard A “good” colonoscopy is still the gold standard if feasible (health facilities) and accepted if feasible (health facilities) and accepted (awareness)... test of choice in (awareness)... test of choice in high risk high risk subjectssubjectsThe best screening test is

the one which is done The best screening test is

the one which is done

Finally . . . Finally . . .

What would you advise as What would you advise as optimal screening test for optimal screening test for yourself or your beloved yourself or your beloved ones ?ones ?

For me: Colonoscopy !!For me: Colonoscopy !!

And for you ???And for you ???

What would you advise as What would you advise as optimal screening test for optimal screening test for yourself or your beloved yourself or your beloved ones ?ones ?

For me: Colonoscopy !!For me: Colonoscopy !!

And for you ???And for you ???