Expanded Screening Key to Cutting Colon Cancer

The continued decrease in new cases of colorectal cancer represents only a tantalizing peek at what could be achieved if more people took advantage of colon cancer screening, experts say.

National surveys conclude that about half of U.S. citizens eligible for screening undergo the test each year. But despite the steady declines in new colon cancer diagnoses and mortality, a 50% screening rate just isn't good enough, said Dr. Bernard Levin, vice president for cancer prevention and population science at the M.D. Anderson Cancer Center, Houston.

“Although it's high, it's not at the optimal level,” Dr. Levin said in an interview. “What is outstandingly obvious is that we could do so much more.”

According to the American Cancer Society's latest report on cancer trends in the United States, about 112,000 new cases of colorectal cancer will be diagnosed in 2007. That's a 2% decrease from the 2004 report, and a continuation of the decrease that's been in evidence since 1985.

But colorectal cancer is still a killer, ranking third in both prevalence and mortality in men as well as women, according to the report. A concentrated push to increase screening to 80%–-the rate now seen with mammography—could cut by half the 52,000 colorectal cancer deaths expected this year, Dr. Levin said.

Dr. Sidney Winawer, a gastroenterologist at Memorial Sloan Kettering Cancer Center, New York, agreed. “We don't have anything in colorectal cancer like the educational outreach that we see for breast cancer screening. They get their message out consistently, repeatedly, and to many different groups. That's what we need to do—not just talk about screening once a year in March [National Colorectal Cancer Awareness Month.]”

The problem of education is one that must be “attacked on multiple fronts,” said Dr. Winawer, who is also the director of the World Health Organization's Collaborating Center for the Prevention of Colorectal Cancer. “Patient education is only one part of our task. We also need to educate providers— gastroenterologists, primary care physicians, nurses, and health maintenance organizations.”

“We have to emphasize that the risks are equal for men and women; right now, women still don't look upon it as a disease of women. It is an equal-opportunity killer.”

People with a family history of polyps or colorectal cancer are at significantly increased risk of developing the disease; they need to understand that screening is even more important for them, and should begin at a younger age.

“And we simply have to address the fear component of this,” Dr. Winawer said. “People shouldn't be afraid to be screened. The tests are much more comfortable than they were, sedation is much better, we are more experienced, and the instruments are much better.” In addition, he said, most patients don't need to be afraid of what the scope might see, since most colonoscopy findings are easily removed polyps or very early, highly curable cancers.

Because screening picks up these early lesions, it has also contributed to the significant decrease in colorectal cancer mortality noted in the ACS report—about 5,000 fewer deaths are expected this year than were expected according to the 2004 report.

Advances in treatment also play a very strong role, said Dr. Alfred Neugut, head of cancer prevention and control at Herbert Irving Comprehensive Cancer Center, New York. “Colorectal cancer has seen some huge advances in treatment in the last few years, some of the most dramatic treatment changes seen in any cancer. We went from having just one active drug, 5-fluorouracil, to having six or seven.”

Advances in adjuvant therapy for regionally advanced colon cancer have also had a significant impact on mortality. “There has also been an improvement, although less dramatic, in treating metastatic colon cancer,” Dr. Neugut said.

Lifestyle changes have probably also played a part, said Dr. Neugut. “People are more health conscious with regard to diet and exercising.”

Hormone therapy in postmenopausal women might also be exerting a small protective effect, Dr. Levin added. “Women who take hormone therapy have [a] lower incidence of colon cancer, so we may be seeing some of that. And there may be some small effect of the very widespread use of nonsteroidal anti-inflammatories, which are known to reduce both colon polyps and cancer.”

Still, the experts agreed, screening is the area that deserves the most emphasis. “I think we are in an exciting time with regard to developing options for screening,” Dr. Winawer said. “Soon we're going to see better stool screening methods, including a DNA mutation test and an immunochemical test, both of which may be much more accurate than fecal occult blood.”

In the longer term, he said, nurses and technicians will be able to use self-propelling colonoscopes; an endoscopist will only get involved if the imaging reveals polyps that need attention. And computed tomographic colonography, also known as virtual colonoscopy, will make imaging studies much more acceptable to a wider pool of patients.

Computed tomographic colonography employs standard CT scanning to created 3-D images similar to those seen through a colonoscope. The colon is inflated with air during the study, which takes only 10–20 minutes and requires no sedation.

“Both the DNA test and virtual colonoscopy will become options for screening, and perhaps very soon,” Dr. Winawer said. “They are both being used on an ad hoc basis at a number of institutions and may get into the screening guidelines at some point.”

There are also demographic disparities to address, Dr. Levin said. “African Americans have a higher incidence and a higher mortality from colorectal cancer. It may be a mix of biology—the cancers themselves may be different—and access to medical care. There is evidence that screening rates are not as good in underserved populations, and that adjuvant therapy might not be given as aggressively to minority populations.”

Again, he said, education of patients and physicians is key. While it's unreasonable to expect every primary care physician to spend 5 minutes discussing the importance of screening with every eligible patient, “It's not unreasonable to take 7 seconds and give a simple message: 'Don't die of embarrassment. Get screened.'”

ELSEVIER GLOBAL MEDICAL NEWS

Trends in Other Cancers Get Noticed

The decline in colorectal cancer grabbed the most attention in the American Cancer Society's 2007 report, but the paper also highlighted some interesting trends in other gastrointestinal cancers.

Gastric cancer decreased slightly, continuing its dramatic 60-year decline, said Dr. Alfred Neugut. “Gastric cancer was the No. 1 cancer in the U.S. for years. Now it's almost negligible. The reasons probably are dietary, reflecting refrigeration and the increase in the consumption of fresh foods, rather than smoked and cured foods that contained cancer-causing nitrates and nitrites.”

There is also some speculation that the widespread use of antibiotics in childhood has decreased the prevalence of Helicobacter pylori, leading to decreased rates of gastric cancer in adults.

This cancer is still on the rise worldwide, however, said Dr. Sidney Winawer. “This is especially true in China, and probably is related to the prevalence of H. pylori.” American physicians may see more stomach cancer as immigration increases, he added.

There have been no significant improvements in pancreatic cancer incidence or mortality, the report noted. It is not as common as other cancers (it ranks last in incidence for males and doesn't rank in the top 10 for women), but is a virulent killer, ranking fourth in mortality for both genders. The report predicts 33,000 deaths, equally divided between the genders, for 2007.

“These numbers [show] that we don't know much about pancreatic cancer,” said Dr. Neugut. The small declines that have occurred are probably related to a general decrease in smoking.

But there is reason for hope, Dr. Winawer noted. International studies are looking at the best methods of screening for the disease in familial pancreatic cancer. “The protocols include multiple tumor markers, CT scanning, and endoscopic ultrasound,” Dr. Winawer said. “Once we figure out how to detect it in these families, we may be able to apply those techniques to the general population.”

There have been a very few minor advances in treating the disease, but the expense is enormous and the payoff, minimal, said Dr. Bernard Levin. “We are measuring gains in weeks of survival.”

Overall esophageal cancer rates are steady, but this trend masks changes within the disease, said Dr. Neugut. “Adenocarcinoma continues to increase, but squamous cell carcinomas are decreasing, and they are really compensating for each other in terms of the overall incidence.” Increasing obesity and untreated gastroesophageal reflux disease leading to Barrett's are probably the driving forces behind the rise in esophageal adenocarcinoma. The decrease in squamous cell cancer is probably related to the decline in smoking, he said.

The ACS report estimates more than 19,000 new cases of liver cancer for 2007, the majority of which will occur in men. Liver cancer had been increasing up until about 1999, the report said, but now seems to be stabilizing. The incidence of the disease is directly related to the prevalence of hepatitis C infections, Dr. Neugut said.

The continued decrease in new cases of colorectal cancer represents only a tantalizing peek at what could be achieved if more people took advantage of colon cancer screening, experts say.

National surveys conclude that about half of U.S. citizens eligible for screening undergo the test each year. But despite the steady declines in new colon cancer diagnoses and mortality, a 50% screening rate just isn't good enough, said Dr. Bernard Levin, vice president for cancer prevention and population science at the M.D. Anderson Cancer Center, Houston.

“Although it's high, it's not at the optimal level,” Dr. Levin said in an interview. “What is outstandingly obvious is that we could do so much more.”

According to the American Cancer Society's latest report on cancer trends in the United States, about 112,000 new cases of colorectal cancer will be diagnosed in 2007. That's a 2% decrease from the 2004 report, and a continuation of the decrease that's been in evidence since 1985.

But colorectal cancer is still a killer, ranking third in both prevalence and mortality in men as well as women, according to the report. A concentrated push to increase screening to 80%–-the rate now seen with mammography—could cut by half the 52,000 colorectal cancer deaths expected this year, Dr. Levin said.

Dr. Sidney Winawer, a gastroenterologist at Memorial Sloan Kettering Cancer Center, New York, agreed. “We don't have anything in colorectal cancer like the educational outreach that we see for breast cancer screening. They get their message out consistently, repeatedly, and to many different groups. That's what we need to do—not just talk about screening once a year in March [National Colorectal Cancer Awareness Month.]”

The problem of education is one that must be “attacked on multiple fronts,” said Dr. Winawer, who is also the director of the World Health Organization's Collaborating Center for the Prevention of Colorectal Cancer. “Patient education is only one part of our task. We also need to educate providers— gastroenterologists, primary care physicians, nurses, and health maintenance organizations.”

“We have to emphasize that the risks are equal for men and women; right now, women still don't look upon it as a disease of women. It is an equal-opportunity killer.”

People with a family history of polyps or colorectal cancer are at significantly increased risk of developing the disease; they need to understand that screening is even more important for them, and should begin at a younger age.

“And we simply have to address the fear component of this,” Dr. Winawer said. “People shouldn't be afraid to be screened. The tests are much more comfortable than they were, sedation is much better, we are more experienced, and the instruments are much better.” In addition, he said, most patients don't need to be afraid of what the scope might see, since most colonoscopy findings are easily removed polyps or very early, highly curable cancers.

Because screening picks up these early lesions, it has also contributed to the significant decrease in colorectal cancer mortality noted in the ACS report—about 5,000 fewer deaths are expected this year than were expected according to the 2004 report.

Advances in treatment also play a very strong role, said Dr. Alfred Neugut, head of cancer prevention and control at Herbert Irving Comprehensive Cancer Center, New York. “Colorectal cancer has seen some huge advances in treatment in the last few years, some of the most dramatic treatment changes seen in any cancer. We went from having just one active drug, 5-fluorouracil, to having six or seven.”

Advances in adjuvant therapy for regionally advanced colon cancer have also had a significant impact on mortality. “There has also been an improvement, although less dramatic, in treating metastatic colon cancer,” Dr. Neugut said.

Lifestyle changes have probably also played a part, said Dr. Neugut. “People are more health conscious with regard to diet and exercising.”

Hormone therapy in postmenopausal women might also be exerting a small protective effect, Dr. Levin added. “Women who take hormone therapy have [a] lower incidence of colon cancer, so we may be seeing some of that. And there may be some small effect of the very widespread use of nonsteroidal anti-inflammatories, which are known to reduce both colon polyps and cancer.”

Still, the experts agreed, screening is the area that deserves the most emphasis. “I think we are in an exciting time with regard to developing options for screening,” Dr. Winawer said. “Soon we're going to see better stool screening methods, including a DNA mutation test and an immunochemical test, both of which may be much more accurate than fecal occult blood.”

In the longer term, he said, nurses and technicians will be able to use self-propelling colonoscopes; an endoscopist will only get involved if the imaging reveals polyps that need attention. And computed tomographic colonography, also known as virtual colonoscopy, will make imaging studies much more acceptable to a wider pool of patients.

Computed tomographic colonography employs standard CT scanning to created 3-D images similar to those seen through a colonoscope. The colon is inflated with air during the study, which takes only 10–20 minutes and requires no sedation.

“Both the DNA test and virtual colonoscopy will become options for screening, and perhaps very soon,” Dr. Winawer said. “They are both being used on an ad hoc basis at a number of institutions and may get into the screening guidelines at some point.”

There are also demographic disparities to address, Dr. Levin said. “African Americans have a higher incidence and a higher mortality from colorectal cancer. It may be a mix of biology—the cancers themselves may be different—and access to medical care. There is evidence that screening rates are not as good in underserved populations, and that adjuvant therapy might not be given as aggressively to minority populations.”

Again, he said, education of patients and physicians is key. While it's unreasonable to expect every primary care physician to spend 5 minutes discussing the importance of screening with every eligible patient, “It's not unreasonable to take 7 seconds and give a simple message: 'Don't die of embarrassment. Get screened.'”

ELSEVIER GLOBAL MEDICAL NEWS

Trends in Other Cancers Get Noticed

The decline in colorectal cancer grabbed the most attention in the American Cancer Society's 2007 report, but the paper also highlighted some interesting trends in other gastrointestinal cancers.

Gastric cancer decreased slightly, continuing its dramatic 60-year decline, said Dr. Alfred Neugut. “Gastric cancer was the No. 1 cancer in the U.S. for years. Now it's almost negligible. The reasons probably are dietary, reflecting refrigeration and the increase in the consumption of fresh foods, rather than smoked and cured foods that contained cancer-causing nitrates and nitrites.”

There is also some speculation that the widespread use of antibiotics in childhood has decreased the prevalence of Helicobacter pylori, leading to decreased rates of gastric cancer in adults.

This cancer is still on the rise worldwide, however, said Dr. Sidney Winawer. “This is especially true in China, and probably is related to the prevalence of H. pylori.” American physicians may see more stomach cancer as immigration increases, he added.

There have been no significant improvements in pancreatic cancer incidence or mortality, the report noted. It is not as common as other cancers (it ranks last in incidence for males and doesn't rank in the top 10 for women), but is a virulent killer, ranking fourth in mortality for both genders. The report predicts 33,000 deaths, equally divided between the genders, for 2007.

“These numbers [show] that we don't know much about pancreatic cancer,” said Dr. Neugut. The small declines that have occurred are probably related to a general decrease in smoking.

But there is reason for hope, Dr. Winawer noted. International studies are looking at the best methods of screening for the disease in familial pancreatic cancer. “The protocols include multiple tumor markers, CT scanning, and endoscopic ultrasound,” Dr. Winawer said. “Once we figure out how to detect it in these families, we may be able to apply those techniques to the general population.”

There have been a very few minor advances in treating the disease, but the expense is enormous and the payoff, minimal, said Dr. Bernard Levin. “We are measuring gains in weeks of survival.”

Overall esophageal cancer rates are steady, but this trend masks changes within the disease, said Dr. Neugut. “Adenocarcinoma continues to increase, but squamous cell carcinomas are decreasing, and they are really compensating for each other in terms of the overall incidence.” Increasing obesity and untreated gastroesophageal reflux disease leading to Barrett's are probably the driving forces behind the rise in esophageal adenocarcinoma. The decrease in squamous cell cancer is probably related to the decline in smoking, he said.

The ACS report estimates more than 19,000 new cases of liver cancer for 2007, the majority of which will occur in men. Liver cancer had been increasing up until about 1999, the report said, but now seems to be stabilizing. The incidence of the disease is directly related to the prevalence of hepatitis C infections, Dr. Neugut said.

The continued decrease in new cases of colorectal cancer represents only a tantalizing peek at what could be achieved if more people took advantage of colon cancer screening, experts say.

National surveys conclude that about half of U.S. citizens eligible for screening undergo the test each year. But despite the steady declines in new colon cancer diagnoses and mortality, a 50% screening rate just isn't good enough, said Dr. Bernard Levin, vice president for cancer prevention and population science at the M.D. Anderson Cancer Center, Houston.

“Although it's high, it's not at the optimal level,” Dr. Levin said in an interview. “What is outstandingly obvious is that we could do so much more.”

According to the American Cancer Society's latest report on cancer trends in the United States, about 112,000 new cases of colorectal cancer will be diagnosed in 2007. That's a 2% decrease from the 2004 report, and a continuation of the decrease that's been in evidence since 1985.

But colorectal cancer is still a killer, ranking third in both prevalence and mortality in men as well as women, according to the report. A concentrated push to increase screening to 80%–-the rate now seen with mammography—could cut by half the 52,000 colorectal cancer deaths expected this year, Dr. Levin said.

Dr. Sidney Winawer, a gastroenterologist at Memorial Sloan Kettering Cancer Center, New York, agreed. “We don't have anything in colorectal cancer like the educational outreach that we see for breast cancer screening. They get their message out consistently, repeatedly, and to many different groups. That's what we need to do—not just talk about screening once a year in March [National Colorectal Cancer Awareness Month.]”

The problem of education is one that must be “attacked on multiple fronts,” said Dr. Winawer, who is also the director of the World Health Organization's Collaborating Center for the Prevention of Colorectal Cancer. “Patient education is only one part of our task. We also need to educate providers— gastroenterologists, primary care physicians, nurses, and health maintenance organizations.”

“We have to emphasize that the risks are equal for men and women; right now, women still don't look upon it as a disease of women. It is an equal-opportunity killer.”

People with a family history of polyps or colorectal cancer are at significantly increased risk of developing the disease; they need to understand that screening is even more important for them, and should begin at a younger age.

“And we simply have to address the fear component of this,” Dr. Winawer said. “People shouldn't be afraid to be screened. The tests are much more comfortable than they were, sedation is much better, we are more experienced, and the instruments are much better.” In addition, he said, most patients don't need to be afraid of what the scope might see, since most colonoscopy findings are easily removed polyps or very early, highly curable cancers.

Because screening picks up these early lesions, it has also contributed to the significant decrease in colorectal cancer mortality noted in the ACS report—about 5,000 fewer deaths are expected this year than were expected according to the 2004 report.

Advances in treatment also play a very strong role, said Dr. Alfred Neugut, head of cancer prevention and control at Herbert Irving Comprehensive Cancer Center, New York. “Colorectal cancer has seen some huge advances in treatment in the last few years, some of the most dramatic treatment changes seen in any cancer. We went from having just one active drug, 5-fluorouracil, to having six or seven.”

Advances in adjuvant therapy for regionally advanced colon cancer have also had a significant impact on mortality. “There has also been an improvement, although less dramatic, in treating metastatic colon cancer,” Dr. Neugut said.

Lifestyle changes have probably also played a part, said Dr. Neugut. “People are more health conscious with regard to diet and exercising.”

Hormone therapy in postmenopausal women might also be exerting a small protective effect, Dr. Levin added. “Women who take hormone therapy have [a] lower incidence of colon cancer, so we may be seeing some of that. And there may be some small effect of the very widespread use of nonsteroidal anti-inflammatories, which are known to reduce both colon polyps and cancer.”

Still, the experts agreed, screening is the area that deserves the most emphasis. “I think we are in an exciting time with regard to developing options for screening,” Dr. Winawer said. “Soon we're going to see better stool screening methods, including a DNA mutation test and an immunochemical test, both of which may be much more accurate than fecal occult blood.”

In the longer term, he said, nurses and technicians will be able to use self-propelling colonoscopes; an endoscopist will only get involved if the imaging reveals polyps that need attention. And computed tomographic colonography, also known as virtual colonoscopy, will make imaging studies much more acceptable to a wider pool of patients.

Computed tomographic colonography employs standard CT scanning to created 3-D images similar to those seen through a colonoscope. The colon is inflated with air during the study, which takes only 10–20 minutes and requires no sedation.

“Both the DNA test and virtual colonoscopy will become options for screening, and perhaps very soon,” Dr. Winawer said. “They are both being used on an ad hoc basis at a number of institutions and may get into the screening guidelines at some point.”

There are also demographic disparities to address, Dr. Levin said. “African Americans have a higher incidence and a higher mortality from colorectal cancer. It may be a mix of biology—the cancers themselves may be different—and access to medical care. There is evidence that screening rates are not as good in underserved populations, and that adjuvant therapy might not be given as aggressively to minority populations.”

Again, he said, education of patients and physicians is key. While it's unreasonable to expect every primary care physician to spend 5 minutes discussing the importance of screening with every eligible patient, “It's not unreasonable to take 7 seconds and give a simple message: 'Don't die of embarrassment. Get screened.'”

ELSEVIER GLOBAL MEDICAL NEWS

Trends in Other Cancers Get Noticed

The decline in colorectal cancer grabbed the most attention in the American Cancer Society's 2007 report, but the paper also highlighted some interesting trends in other gastrointestinal cancers.

Gastric cancer decreased slightly, continuing its dramatic 60-year decline, said Dr. Alfred Neugut. “Gastric cancer was the No. 1 cancer in the U.S. for years. Now it's almost negligible. The reasons probably are dietary, reflecting refrigeration and the increase in the consumption of fresh foods, rather than smoked and cured foods that contained cancer-causing nitrates and nitrites.”

There is also some speculation that the widespread use of antibiotics in childhood has decreased the prevalence of Helicobacter pylori, leading to decreased rates of gastric cancer in adults.

This cancer is still on the rise worldwide, however, said Dr. Sidney Winawer. “This is especially true in China, and probably is related to the prevalence of H. pylori.” American physicians may see more stomach cancer as immigration increases, he added.

There have been no significant improvements in pancreatic cancer incidence or mortality, the report noted. It is not as common as other cancers (it ranks last in incidence for males and doesn't rank in the top 10 for women), but is a virulent killer, ranking fourth in mortality for both genders. The report predicts 33,000 deaths, equally divided between the genders, for 2007.

“These numbers [show] that we don't know much about pancreatic cancer,” said Dr. Neugut. The small declines that have occurred are probably related to a general decrease in smoking.

But there is reason for hope, Dr. Winawer noted. International studies are looking at the best methods of screening for the disease in familial pancreatic cancer. “The protocols include multiple tumor markers, CT scanning, and endoscopic ultrasound,” Dr. Winawer said. “Once we figure out how to detect it in these families, we may be able to apply those techniques to the general population.”

There have been a very few minor advances in treating the disease, but the expense is enormous and the payoff, minimal, said Dr. Bernard Levin. “We are measuring gains in weeks of survival.”

Overall esophageal cancer rates are steady, but this trend masks changes within the disease, said Dr. Neugut. “Adenocarcinoma continues to increase, but squamous cell carcinomas are decreasing, and they are really compensating for each other in terms of the overall incidence.” Increasing obesity and untreated gastroesophageal reflux disease leading to Barrett's are probably the driving forces behind the rise in esophageal adenocarcinoma. The decrease in squamous cell cancer is probably related to the decline in smoking, he said.

The ACS report estimates more than 19,000 new cases of liver cancer for 2007, the majority of which will occur in men. Liver cancer had been increasing up until about 1999, the report said, but now seems to be stabilizing. The incidence of the disease is directly related to the prevalence of hepatitis C infections, Dr. Neugut said.