Colorectal Cancer Screening Practice Recommendations

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Colorectal Cancer ScreeningPractice
Recommendations

• 2007

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Practice Recommendation 1

• Individuals with an increased risk of colorectal
  cancer diagnosis and death can be identified

An individuals risk of colorectal cancer is
elevated if There is a first degree relative
with CRC or an adenomatous polyp under age
60 There are two relatives of any age with CRC
or with an adenomatous polyp There is a history
of chronic inflammatory bowel disease for 8
years or a hereditary syndrome.
Evidence - meta-analysis of 27 studies that
assessed familial risk of colorectal cancer and
adenomatous polyps (Johns et al, 2001)
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Practice Recommendation 2

• Individuals should be encouraged to decrease
  their risk of colorectal cancer incidence and
  death through appropriate dietary and behavioral
  interventions

An individuals risk of colorectal cancer can be
decreased if they Limit intake of red meats and
processed meats Avoid tobacco Maintain an ideal
body weight Limit alcohol intake
Evidence data from a number of longitudinal
studies of cancer risks and protective factors
(see refs)
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Practice Recommendation 3

• In-Office FOBT is NOT Evidence Based

FOBT testing must be done on 3 separate
occasions. ONLY the at-home 3-card, 6-sample
FOBT is recommended. A single FOBT in the
office is NOT recommended.
Evidence - prospective cohort study of more than
2600 asymptomatic patients who underwent both a
digital FOBT and a 6 sample at home FOBT prior to
colonoscopy. Sensitivity was nearly 5 times
greater for the 3-card, 6-sample home test than
the digital FOBT findings (Collins et al, 2005)
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Practice Recommendation 4

• All positive screening tests should be evaluated
  by colonoscopy

Colonoscopy is superior to FOBT, flexible
sigmoidoscopy and barium enema in detecting
polyps and cancers. Any positive
non-colonoscopy screening test should be followed
up with colonoscopy
Evidence three randomized controlled trials of
fecal occult blood testing with colonoscopy
follow up for positives demonstrated a mortality
reduction, and one also documented a decrease in
colorectal cancer incidence (see refs). The
National Polyp Study documented the benefits of
colonoscopic polypectomy and post-polypectomy
surveillance, as well as its superiority to
barium enema (Winawar et al, 1993 and 2000) while
others have demonstrated the superior performance
of colonoscopy compared to flexible sigmoidoscopy
(Imperiale et al, 2000)
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Practice Recommendation 5

• The physicians recommendation is the most
  consistently
• influential factor in cancer screening

Sources American Journal of Preventive Medicine
(Kalbunde, 2006 and Zapka, 2002) Website
http//www.elsevier.com/wps/find/journaldescriptio
n.cws_home/600644/descriptiondescription Cancer
(Etzioni, 2004) Website http//www3.interscience.
wiley.com/cgi-bin/jissue/109793815
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Strength of Evidence

• Kalbunde Data from a telephone survey, random
  sample of Medicare consumers residing in North
  and South Carolina were used to examine barriers
  to CRC screening, focusing on consumers reports
  of receiving a physicians recommendation to
  obtain CRC screening and reasons for not being
  screened. N 1901)
• Zapka Data from a cross-sectional,
  random-digit-dial survey of 1002 Massachusetts
  residents aged _50.
• Etzioni The CHIS 2001 sample and questionnaire
  were designed to represent Californias
  ethnically diverse population 55,428 households
  were selected randomly from within the state for
  a random-digit dial telephone survey. From each
  participating household, one randomly selected
  adult was interviewed. Respondents age _ 50 years
  were asked about their use of CRC tests.

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Practice Recommendation 6

• FOBT testing must be done on 3 separate
  occasions.
• ONLY the at-home 3-card, 6-sample FOBT is
  recommended.
• A single FOBT in the office is NOT recommended.

Source Annals of Internal Medicine
(Collins) Website http//www.annals.org/cgi/cont
ent/abstract/142/2/812 Strength of Evidence
Prospective cohort study of more than 2600
asymptomatic patients who underwent both a
digital FOBT and a 6 sample at home FOBT prior to
colonoscopy. Sensitivity was nearly 5 times
greater for the 3-card, 6-sample home test than
the digital FOBT findings
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Practice Recommendation 7

• The following colon cancer screening tests have
  been
• shown to reduce the mortality from colon cancer
• and are recommended
• Stool Blood Tests
• Flexible Sigmoidoscopy
• Colonoscopy

Sources Journal of the National Cancer Institute
(Winawer, 1993) Website http//jnci.oxfordjournal
s.org/content/vol85/issue16/index.dtlARTICLES An
nals of Oncology (Bleiberg, 2006) Website
http//annonc.oxfordjournals.org/cgi/content/full/
17/8/1328 CA A Cancer Journal for Clinicians
(Winawer, 2006) Website http//caonline.amcancers
oc.org/cgi/reprint/56/3/143
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Strength of Evidence

• Winawer Data from 21,756 patients who agrees to
  annual screening
• Bleiberg Data from screening of 1,912 patients
  at cancer screening clinic
• Winawer Meta-analysis of RCTs or observational
  cohort studies ( 49 articles), Consensus
  recommendation

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Practice Recommendation 8
Patient reminders are effective in increasing
screening rates.
Source Cancer Epidemiology Biomarkers and
Prevention (Yabroff and Mandelblatt, 1999)
Website http//cebp.aacrjournals.org/cgi/content/
abstract/8/9/749
Strength of Evidence Meta-analysis of 45 RCT
studies on mammography that evaluated patient
interventions with letters, phone reminders, and
prescriptions. The improvement in rates of
screening was 13-17.6. Two options worked
better than one.
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Evidence Based CME

• References
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• Cho E, Smith-Warner SA, Ritz J, et al. Alcohol
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• Mandel JS, Church TR, Bond JH, Ederer F, Geisser
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