Colon Cancer Screening in 2005: Status and Challenges
Section snippets
1990–2000: evidence and guidelines evolve to support colorectal cancer screening
In 1990, no strong evidence existed from an RCT showing that screening reduces CRC mortality. Some recommending organizations had supported it, but screening was not reimbursed or widely practiced. However, after 3 RCTs in the mid 1990s provided evidence of efficacy, a broad consensus developed among recommending organizations about performing screening and about which testing programs to recommend.2, 3, 4 Particularly important were the USPSTF’s decision in 1996 to endorse screening2 and
Implementation of any kind of colorectal cancer screening
Achieving implementation of any kind of CRC screening is a major challenge in 2005. The reasons that screening rates are low compared with those for breast cancer or cervical cancer screening are critical to understand and address, and they are receiving detailed attention from the research and policy communities; they are not discussed further here.28, 31, 32, 33, 34, 35, 36, 37, 38 It seems likely that the current low rates will improve over time,27 building in part on lessons learned from
Beyond guidelines: forces affecting decision making in the larger environment
After guidelines have recommended screening and reimbursement has begun, other forces become prominent in a postguideline environment of decision making. In this environment, decisions are driven by considerations different from those assessed in the idealized and evidence-based process that recommending organizations use to develop guidelines.
Each of the 3 decision makers in clinical care—professional policy-making organizations, physicians, and patients—uses different sources of evidence,
Postpolypectomy surveillance
Surveillance is a separate topic whose importance will increase as screening is increasingly performed, because so many persons screened will be found to have adenomas and thus will be potentially eligible for postpolypectomy surveillance. Surveillance is the follow-up of persons thought to have an increased risk of subsequent CRC. Because 30%–50% of Americans older than 50 years have one or more adenomatous polyps, surveillance could become the most common reason for colonoscopy, involving a
Conclusions
Fifteen years ago, the primary unanswered question in this field concerned whether CRC screening was effective in reducing CRC mortality and whether screening should be implemented and reimbursed. Because that question has been answered and because guidelines and reimbursement are leading to implementation, the next set of challenges is emerging. These challenges concern making choices among different screening tests and strategies and concern details of decisions about postpolypectomy
References (84)
- et al.
Colorectal cancer screeningclinical guidelines and rationale
Gastroenterology
(1997) - et al.
Randomised study of screening for colorectal cancer with faecal-occult-blood test
Lancet
(1996) - et al.
Randomised controlled trial of faecal-occult-blood screening for colorectal cancer
Lancet
(1996) Lessons from the UK sigmoidoscopy screening trial
Lancet
(2002)- et al.
Design of the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial
Control Clin Trials
(2000) - et al.
A national survey of primary care physicians’ colorectal cancer screening recommendations and practices
Prev Med
(2003) Barriers to screening for colorectal cancer
Gastrointest Endosc Clin North Am
(2002)- et al.
Workgroup IV: public education. UICC International Workshop on Facilitating Screening for Colorectal Cancer, Oslo, Norway (29 and 30 June 2002)
Ann Oncol
(2005) - et al.
Achieving quality in flexible sigmoidoscopy screening for colorectal cancer
Am J Med
(2001) Rationale for colonoscopy screening and estimated effectiveness in clinical practice
Gastrointest Endosc Clin North Am
(2002)