Screening for Colon Cancer

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Screening for Colon Cancer for People at Average Risk.

Although the number of people affected with CRC is declining, it is still the third most common form of cancer, after breast and lung cancer in women, and prostate and lung cancer in men. Approximately 17,600 new cases will be diagnosed in Canada this year, with approximately 6,500 Canadians dying from CRC.(1) Accordingly, it would be useful to have an effective screening test that would allow for earlier detection and treatment. This then begs the question: What are the prerequisites for an effective screening test? It would seem that at least the following conditions should pertain:(2) The disease should be a serious health problem There should be a presymptomatic phase during which treatment can change the course of the disease Both the screening test and subsequent treatment should be acceptable The screening test should have acceptable sensitivity and specificity The screening test and the subsequent treatment should be both effective and cost-effective Let's look at the evidence for the different types of screening that are available. Digital rectal examination: This has actually been studied and found to be an ineffective screening test for colorectal cancer.(3) Fecal occult blood testing: This is by far the best studied screening test for CRC. There have been 3 large randomized trails done in US,(4) UK(5) and Denmark(6) which include a total of ~250,000 participants aged 50-75. All the studies were multiphasic with 2 stool samples taken from 3 consecutive BMs. Various screening intervals were studied. Two of these studies used hemoccult II one with rehydration. A positive test was an indication for colonoscopy. There was a 14%-18% reduction in CRC deaths with biennial screening (UK, Danish) and a 33% reduction in deaths with annual screening using hemoccult II and rehydration (USA) Routine testing has been demonstrated to reduce CRC INCIDENCE by ~20% over 18 years of follow up in the American trial.(14) The test has a Sensitivity of ~40%-50% unrehydrated, and a Specificity 98%-99% unrehydrated. The Likelihood Ratio for positive test is 25 to 50 and the Likelihood Ratio for negative test is 0.5 About 2 per 100 tests will be positive requiring a work up. The probability of

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Screening for Colon Cancer

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carcinoma or large adenoma ranges from 17-46% in people with a positive test. The test will be negative in 50%-60% of people who truly have a cancer. To improve sensitivity slightly, the slide can be rehydrated, or a more sensitive formulation such as Hemoccult II Sensa, used. This results in a great degradation in specificity to 8692% resulting in vastly more colonoscopic work ups required. Current recommendations call for unrehydrated Hemoccult II slides as it has the least impact on overstressed colonoscopy availability - at the cost of reduced sensitivity. (7) Single fob testing as part of a DRE in the office has now been studied and is not recommended due to very poor sensitivity.(10) Flexible Sigmoidoscopy: On the positive side this test can be performed without sedation by trained nonphysicians and can be used to examine up to half the colon. It is highly sensitive and specific for lesions within its reach. On the other hand, it misses the roughly 50% of the lesions not in its reach (Sensitivity 50%). If any adenoma is detected, triggering a colonoscopic exam, sensitivity improves to 70%.(8) Adding FOBT to above strategy increases sensitivity only slightly. (Sensitivity 75%). (9)This test requires a specialist referral in Canada, and has not been studied by RCT. Colonoscopy: Colonoscopy can be used to look at the whole colon and it has a sensitivity >95%. It makes intuitive sense as the way to go, and is actually reimbursed by Medicare in US every 10 years for patients at average risk. On the negative side it requires that laxatives and sedation be used, and there is a 1/1000 risk of perforation vs. 1/10000 with flexible sigmoidoscopy. It requires a highly trained endoscopist and sensitivity varies between 87% and 97% depending on the skill of the endoscopist. The optimal screening interval is unknown and there is a major problem with accessibility in Canada.(11) Virtual Colonoscopy by CT: This investigation requires laxatives but no sedation. There is considerable radiation exposure and sensitivity equals 91% for lesions larger then 1 cm. False positive rate equals 17% which is unacceptably high for a test requiring laxatives. However if future developments eliminate the need for laxatives then virtual colonoscopy may become important.(12) There are no RCTs on this investigation. Barium Enema: The Sensitivity for detection of CRC is approximately 82% for both single and double contrast techniques, although the Sensitivity for polyps 1 cm or larger is only 48%. When compared to screening with colonoscopy, it picks up fewer Duke A tumors.(13) It is currently used as a diagnostic test if colonoscopy is unsuccessful due to technical problems, or unavailable because of accessibility issues. The current expert recommendation is for colonoscopy to be available within 3 weeks of a positive FOBT. Prior to researching this topic I was only offering FOBT

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Screening for Colon Cancer

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to people who asked about cancer screening, due to lack of colonoscopy access, i.e. I did not bring it up. Now I offer it routinely when patients go for any routine blood work and they must live with the wait for colonoscopy, which can be several months. - Farokh Buhariwalla Thanks to Dr. Robert Sers, Chair of the Department of Surgery at St. Martha's Regional Hospital in Antigonish, Nova Scotia, for reviewing the draft copy of this article. References: 1. http://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/colorectal_e.html 2. WHO accepted criteria for a screening test http://www.nt.gov.au/health/healthdev/health_promotion/bushbook/volume1/screening2.html 3. Herinton LJ, et al Case-control study of digital-rectal screening in relation to mortality from cancer of the distal rectum. AM J Epidemiol 1995;142:961-64 4. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study. Mandel JS, Bond JH, Church TR, Snover DC, Bradley GM, Schuman LM, Ederer F. N Engl J Med. 1993 May 13;328(19):1365-71. 5. Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Hardcastle JD, Chamberlain JO, Robinson MH, Moss SM, Amar SS, Balfour TW, James PD, Mangham CM. Lancet. 1996 Nov 30;348(9040):14727 6. Randomised study of screening for colorectal cancer with faecal-occult-blood test. Kronborg O, Fenger C, Olsen J, Jorgensen OD, Sondergaard O. Lancet. 1996 Nov 30;348(9040):1467-71 7. http://www.ctfphc.org/ under colorectal 2001 recommendations 8. Risk of advanced proximal neoplasms in asymptomatic adults according to the distal colorectal findings. Imperiale TF, Wagner DR, Lin CY, Larkin GN, Rogge JD, Ransohoff DF. N Engl J Med. 2000 Jul 20;343(3):169-74 9. One-time screening for colorectal cancer with combined fecal occult-blood testing and examination of the distal colon. Lieberman DA, Weiss DG; Veterans Affairs Cooperative Study Group 380. N Engl J Med. 2001 Aug 23;345(8):555-60. 10. Accuracy of screening for fecal occult blood on a single stool sample obtained by digital rectal examination: a comparison with recommended sampling practice. Collins JF, Lieberman DA, Durbin TE, Weiss DG; Veterans Affairs

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Screening for Colon Cancer

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Cooperative Study #380 Group. Ann Intern Med. 2005 Jan 18;142(2):81-5. 11. Clinical practice. Screening for colorectal cancer. Ransohoff DF, Sandler RS. N Engl J Med. 2002 Jan 3;346(1):40-4. 12. A comparison of virtual and conventional colonoscopy for the detection of colorectal polyps. Fenlon HM, Nunes DP, Schroy PC 3rd, Barish MA, Clarke PD, Ferrucci JT. N Engl J Med. 1999 Nov 11;341(20):1496-503. 13. Relative sensitivity of colonoscopy and barium enema for detection of colorectal cancer in clinical practice. Rex DK, Rahmani EY, Haseman JH, Lemmel GT, Kaster S, Buckley JS. Gastroenterology. 1997 Jan;112(1):17-23. 14. The Effect of Fecal Occult-Blood Screening on the Incidence of Colorectal Cancer Jack S. Mandel, Ph.D., M.P.H., Timothy R. Church, Ph.D., John H. Bond, M.D., Fred Ederer, M.A., Mindy S. Geisser, M.S., Steven J. Mongin, M.S., Dale C. Snover, M.D., and Leonard M. Schuman, M.D. NEJM Volume 343:1603-1607 Return to Archives Page ] [ Berries Home Page

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