Robert E. Schoen, MD MPH Associate Professor of Medicine and Epidemiology Division of Gastroenterology University of Pittsburgh Organizing Colorectal Cancer Screening

Lifetime Risk of CRC (%) All Races 5.95, , 2.40 Whites 6.00, , 2.38 Blacks 4.73, , 2.65 Male, Female LR DxLR Death SEER,

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Prevalence of Adenomatous Polyps Diminutive or Small % Large % Cancer %

Screening for Colorectal Cancer

CRC Often Diagnosed Late U.S. CRC, By Stage, Localized37% Regional38% Distant20% SEER:

Consensus Guidelines  50  Options:  Annual FOBT  FS q 5 yrs  FOBT + FS  DCBE q 5-10 yr  Colon q 10 yr  + TCE: Colonoscopy or DCBE + FS Gastro. 1997:112;594

Minnesota FOBT Trial: 18 Yr Follow Up AnnualBiennialControl 15,570 15,587 15, ,325240,163237, ( ).79 ( )1.0 Mandel, JNCI 1999;91:434 # enrolled PYO CRC Mortality Ratio* *Overall mortality not changed

Decreased Incidence of CRC in the Minnesota FOBT Study Mandel JS et al. N Engl J Med 2000:343: % in biennial 20% in annual Click for larger picture

Highlights of Trials of Non-Rehydrated FOBT Compliance % with positive test (initial screen) % with positive test found to have cancer % reduction in CRC mortality (biennial testing) %

Screening Sigmoidoscopy - Efficacy Case Control Study: Compared Rigid Sig Use in 261 pts who died of distal CRC to 868 matched age/sex) controls 8.8% of Cases Screened VS. 24.2% of Controls OR for CRC Mortality w/ Sigmo =.41 or  59%* * adjusted for polyp hx, fam hx, check ups Benefits persisted 10 years No difference in screening in 268 cases/controls with CA above rectosigmoid Selby et al. NEJM 1992;326:653

Is Sigmoidoscopy Half a Mammogram?

Screening Colonoscopy Studies Imperiale et al - “Lilly Cohort” NEJM 2000; 343:162 Lieberman et al - “VA Cooperative 380” NEJM 2000; 343:169

Success - Complications Cecum - 97+% Perforation - 1/5115 or 0.02% NEJM 2000: Screening Colonoscopy Studies VA Study : Major morbidity % (GI bleed, MI, CVA)

VA Colonoscopy Study 380 Adenoma37.5% Advanced Adenoma* 10.7% Tubular 5.0% Villous 3.0% HGD 1.7% CA 1.0% N=3121, 97% male, mean age 63 Lieberman et al, NEJM 2000 *  1 cm, Villous, HGD, CA

Lilly Cohort Adenoma20% Advanced Adenoma*5.6% CA 0.6% *Villous, HGD (not  1 cm) N=1994, 58.9% male, mean age 60 Imperiale et al, NEJM 2000

What Does Screening Colonoscopy Detect That Sigmoidoscopy Doesn’t? VA StudyLilly Cohort Neoplasia37.5%  20% Advanced Proximal Neoplasia4.1%2.5% “Missed” Advanced Proximal Neoplasia2.1%1.2% Older age, males higher risk

Missed Advanced Proximal Neoplasia VA - 52% “missed” (67/128) or 2.1% Limit Advanced Definition to HGD or CA: VA % missed (12/81) or 0.4%

Incident CRC After Colonoscopy Winawer (NPS) Schatzkin (PPT) Alberts (Wheat Bran) N Observed (yrs) PYO CRC Cases Incidence / 1000 PYO

Sigmoidoscopy vs. Colonoscopy More sensitive More invasive, safe? Expensive Less frequent (1/10 yr)? Less accessible Better satisfaction Sensitive enough? Safer Less expensive Frequency (1/5 yr)? Accessible? Satisfied? ColonoscopySigmoidoscopy Vs.