1. FIRST TWO AND HALF YEAR OF NATIONAL SCREENING PROGRAM FOR COLORECTAL CANCERS IN REPUBLIC CROATIA Miroslava Katicic 1, Milan Kujundzic 2, Davor Stimac 3, Marija Strnad 4, Danica Kramaric 4, Valerija Stamenic 4, Nataša Antoljak 5, Mirko Samija 6, 1 University Hospital Merkur, Zagreb, Croatia 2 University Hospital Dubrava, Zagreb, Croatia 3 University Center Rijeka, Croatia 4 Ministry of Health and Social Welfere, Zagreb, Croatia 5 Croatian National Insitute of Public Health, Zagreb, Croatia 6 University Hospital for tumors, Zagreb, Croatia

2. Average rates of CRC incidence and mortality in Croatia are parallel to those in developed countries with unfortunately clear increase in incidence rate during the last 30 ys, for 364 percent from 1970 till 2004.Average rates of CRC incidence and mortality in Croatia are parallel to those in developed countries with unfortunately clear increase in incidence rate during the last 30 ys, for 364 percent from 1970 till 2004. Background (I) What makes the situation in Croatia even worse in What makes the situation in Croatia even worse in comparison to developed countries, is comparison to developed countries, is the high mortality rate, steadily reaching 60–70% of incidence rate.

3. Fig. 1. DIGESTIVE ORGAN CANCER INCIDENCE, 1970-2003- Share in total incidence 28% Croatian National Institute of Public Health Prof. Marija Strnad, M.D., Ph.D. +C-433% +R-329% -23% +183% +10% +151% +77%

4. Fig. 2. Incidence and mortality of CRC in Repoblic Croatia, 1970-2005 The Croatian Institute for Public Health Prof. dr. sc. Marija Strnad

5. Background (II) The incidence rate CRC/100 000 inhabitants The incidence rate CRC/100 000 inhabitants 65/100 000 (2005), The mortality rate The mortality rate 40.6/100 000 (2006) Incidence increases rapidly for the group aged 60 and older. Incidence increases rapidly for the group aged 60 and older. Main reason: the most cases of cancer are detected too late at an advanced stage with poor prognosis Less than 10% of CRC are limited to bowel wall in the time of diagnosis. Five-years relative survival is only 49% for men and 50% for women.

6. Aim National screening program for colorectal cancers started in September 2007. Campaign targets: 1.Reducing colorectal cancer mortality 2.Cancer detection; 3.Detection and cure all precancerous colorectal lesions; 4.Detection of other colorectal diseases characterized by occult bleeding; 5.Compliance of 60%. Study population: all inhabitants of Republic Croatia aged 50 – 75 who are at an average risk for CRC.

7. PUBLIC HEALTH INSTITUTE COLONOSCOPY PATHOLOGY (PHD) CROATIAN PUBLIC HEALTH INSTITUTE MINISTRY OF HEALTH AND WELFARE GENERAL PHYSICIAN MALE AND FEMALE AT AGE 50-74 YRS. Croatian model for CRC screening

8. Croatian National program for CRC screening was established by Ministry of Health and Social Welfare and has been implemented since the September 2007. MINISTRY OF HEALTH AND WELFARE 1.

9. The network of coordinators in each county institute of public health are obliged to ensure performing of fecal occult blood testing (FOBT.) The FOBT is performed by guaiac-based Hemognost card test with detection limit of 0.2 ml blood in 500 g of stool. PUBLIC HEALTH INSTITUTE CROATIAN PUBLIC HEALTH INSTITUTE 2.

10. Test and short questionnaire are delivered to home address of all citizens age 50–74 consecutively during two years. Each participant has to fulfill the questionnaire, and send it together with test specimen back to the institute for further analysis. MALE AND FEMALE AT AGE 50-74 YRS. 3.

11. Colonoscopy will be offered and organised for all FOBT- positive persons. COLONOSCOPY PATHOLOGY (PHD) 4.

12. Methods Anticipated numeric data of campaign: Total Croatian inhabitants - 4 600 000; aged 50–74 - 1 200 000. According screening results of other authors, it was expected that 4% FOBT positive cases would be found in normal risk population and model calculations pointed out a need for 24000 colonoscopies per year.

13. From study will be excluded patients with: è already known CRC è other tumours spread to the colorectum è benigne tumours such as lipoma, fibroma, haemangioma... haemangioma... è already detected polyps who had undergone polypectomy and who are under regular follow-up polypectomy and who are under regular follow-up

14. Results Distributed (since September 2007.) letters (epidemiological questioner, FOBT tester) 307.206 Returned 23,3% 10,2 – 36,8% Positive FOBT 9,1% 3,8 – 29,9% Colonoscopy already done 2651 (compliance 70,3%)

15. 23,3% 34,7% 28,9% 16,0% 25,8% 16,8% 25,1% 31,2% 30,0% 36,8% 10,2% 23,4%22,2% 28,1% 25,0% 20,9% 22,1% 20,0% 29,0% 26,0% 23,7% Fig. 3. Number of returned FOBT from different counties

16. Colonoscopy findings (Preliminary report) Normal 564 (21,3%) 10 – 42% Noduli haemorrh. 477 (17,8%) 14 – 32% Diverticulosis 318 (12,1) 8 – 34% Polyps 928 (34,2%) 23 – 60% Cancers 182 (4,1%) 2 –12% Cancers 182 (4,1%) 2 – 12%

17. Characteristics of Croatian campaign in first year : low percentage of returned FOBT low percentage of returned FOBT high number of pathologic findings (polyps and cancers) high number of pathologic findings (polyps and cancers) Main problems: very old population (population aged over 65 ys) very old population (population aged over 65 ys) low Programs budget low Programs budget The ultimate goal: to increase general awareness about CRC and the value of screening. to increase general awareness about CRC and the value of screening. to increase compliance to increase compliance to decreasing the fear from examination to decreasing the fear from examination Conclusion

18. CRC Screening Program Committee Prof. Dr. Milan Kujundžić – gastroenterologist (President) Prof. Dr. Milan Kujundžić – gastroenterologist (President) Prof. Dr. Miroslava Katičić – gastroenterologist Prof. Dr. Miroslava Katičić – gastroenterologist Prof. Dr. Davor Štimac – gastroenterologist Prof. Dr. Davor Štimac – gastroenterologist Prof. Dr. Marija Strnad - epidemiologist Prof. Dr. Marija Strnad - epidemiologist Prof. Dr. Mirko Šamija – oncologist Prof. Dr. Mirko Šamija – oncologist Prof. Dr. Zdravko Ebling – general practitioner Prof. Dr. Zdravko Ebling – general practitioner Doc. Dr. Nataša Antoljak – epidemiologist Doc. Dr. Nataša Antoljak – epidemiologist Dr. Valerija Stamenić – Ministry od Health RC representative Dr. Valerija Stamenić – Ministry od Health RC representative Dr. Danica Kramarić – Ministry od Health RC representative Dr. Danica Kramarić – Ministry od Health RC representative Public Health Institutes are responsible for Program coordination.