New York City Dept. of Health & Mental HygieneColon Cancer Control Summit

March 11, 2003

Summit Background& Advisory Group Recommendations

Sidney J. Winawer, M.D.

Memorial Sloan-Kettering Cancer Center

U.S. Burden of Colorectal Cancer

147,500 new cases in 2003

57,100 deaths in 2003

11% of all cancer deaths

758,000 person-years of life lost

Cost of treatment $6 billion

U.S. Colorectal Cancer Screening Guidelines

Consensus

U.S. Preventive Services Task Force 1996

GI Consortium 1997

American Cancer Society 1997

“Screening for colorectal cancer and adenomatous polyps should be offered to all men and women without risk factors

beginning at age 50.”

Colorectal cancer screening; clinical guidelines and rationale. Winawer, Fletcher et al., Gastroenterology, 1997

Colorectal Cancer Screening GuidelinesU.S. Preventive Services Task Force

(USPTSF)*

“The USPSTF strongly recommends that clinicians screen men and women

50 years of age or older for colorectal cancer. Grade A Recommendation.”

*USPSTF. Ann Int. Med. 2002

Colorectal CancerScreening Rates

20.6% FOBT Previous Year

33.6% Sigmoidoscopy or Colonoscopy Previous 5 yrs.

CDCP. Trends in screening for colorectal cancer — U.S. 1997 & 1999MMWR 2001;50:162-6

Adenoma to Carcinoma Pathway

APCloss

NormalEpithelium

EarlyAdenoma

CancerHyper-

proliferationIntermediate

AdenomaLate

Adenoma

K-rasmutation

Chrom 18loss

p53loss

AdenomaNormal Cancer

Screening Strategies

Colonoscopy

FOBTFlex Sig.Virtual ColonoscopyStool DNA Mutations

One-Stage Screening Two-Stage Screening

Colonoscopy

FOBT Screening Randomized Controlled Trials

Mortality Reduction

Biennial Annual Compliers

Minn* 21% 33% 45%47,000/18 yrs.

Denmark 18% – 30%140,000/10yrs.

U.K 15% – –153,000/7.8 yrs.

*Rehydrated slidesWinawer et al, GE 1997

COLORECTAL CANCER MORTALITY REDUCTION BY SIGMOIDOSCOPY

Colorectal Cancer Mortality Study Design Reduction Published

Kaiser Retrospective, 30% Selby, NEJMPermanente, Case Control 1992USA

Univ. Retrospective, 40% Newcomb,Wisconsin, Case Control JNCI 1992USA

Reviewed in Colorectal Cancer Screening: Clinical Guidelines and Rationale.Winawer, Fletcher, et al., Gastroenterology, Feb. 1997.

Screening Colonoscopy Studies

NationalColonoscopy

Study VA CONCERN Lilly

Gender Men/Women Men Women Men/Women

Adenomas 18% 37.5% 21% 11% (distal)or Cancer

Advanced 6% 11% 5% 5%Neoplasia

NCS – Winawer et al. DDW 2002 (Gastroenterology)VA – Lieberman et al. NEJM 2000CONCERN – Schoenfeld et al. DDW 2001, 2002 (Gastroenterology)Lilly-Imperiale et al. – NEJM 2000, 2002

Effect of Colonoscopic Polypectomy on Incidence of Colorectal Cancer

Incidence

*U.S. National Polyp Study 76–90%

+Italian Multicenter Study Group 66%

*Winawer, Zauber et al NEJM 1993+Citarda et al GUT 2001

Virtual Colonoscopy*

Sensitivity Sensitivity, Specificity

% Per pt. % Per pt. %

Polyps >1cm 45 –91 38–100 74–100

Polyps 6–9 mm 16–82 20–94 63–92

*Rex. Rev. in GI Disorders. 2002/ 2(3):97-105.

DNA Mutations in Stool

Approximately 50% of Advanced Neoplasia Detected

Ahlquist et al GE 2000

Traverso et al NEJM 2002

Traverso et al Lancet 2002

Guidelines for Colorectal Cancer Screeningin Average Risk Men & Women

50 Years of Age or Older

OPTIONS

Digital Rectal Flex FOBT &Exam FOBT Sig. Flex Sig. DCBE Co.

U.S. Multi Society w/endoscopy Annual 5 yrs. Ann. FOBT 5 yrs. 10 yrs.Task Force (2003) 5 yrs. FS(GI Consortium,1997)

American CA w/endoscopy Annual 5 yrs. Ann. FOBT 5 yrs. 10 yrs.Society (2001) 5 yrs. FS

Colorectal Cancer ScreeningAdvisory Panel to the New York City

Department of Health and Mental Hygiene

Drs. Harold Freeman (Chair),Robert Schiller, Thomas Weber,Susan Williams, Sidney Winawer

Recommendations

Average Risk Men & Women Age 50 & Older

Colonoscopy q 10 yrs. preferred.

Fecal Occult Blood Tests Annually is an alternative with diagnostic work-up if positive.

High-Risk Patients: Colonoscopy beginningage 40 or earlier.

Colorectal Cancer Screening Advisory PanelRationale

About 1,500 NYC residents die annually from colorectal cancer

Most deaths are preventable

Colonoscopy Preferred Examines entire colon Sensitive & Specific for adenomas and cancer Provides screening, diagnosis, treatment Sufficient Capacity in N.Y.C. Preferred recommendation may reduce confusion

Other options are available (National Guidelines)

0 20 40 60 80 100

DCBE

Colonoscopy*

Flex Sig**

FOBT

% Responding "Very Effective"

Family Practice

General Practice

General IM

OB/GYN

**Differences by specialty are significant at P <0.001; *at P <0.05.

Klabunde, C.N. et al. In Press, Preventive Medicine

Primary Care Physicians’ Perceived Effectiveness of Colorectal Cancer Screening Tests forAverage-Risk Adults Aged 50+, Survey of

Colorectal Cancer Screening Practices, 1999–2000

N.Y.C. Dept. of Health & Mental HygieneColorectal Cancer Control Campaign

Screening Guidelines

Lifestyle Guidelines

Provider Education

Public Education

Reimbursement

Capacity and Access

Barriers

Evaluation

Campaign Goals

Increase Awareness

Increase Screening

Reduce Incidence

Reduce Mortality

Reduce Burden

Improve Quality of Life