WASHINGTON--Myles Cunningham, MD, president of the American Cancer Society
(ACS), announced new ACS guidelines for screening and surveillance for
early detection of colorectal polyps and cancer. The announcement came
at a press briefing held during Digestive Disease Week.
For years, Dr. Cunningham said, the medical and scientific community
was skeptical about the effectiveness of screening for colorectal cancer.
"That," he said, "is no longer true." Current testing
procedures, he said, are widely available, accurate, and underutilized.
The latest ACS update is meant to be clear and simple so that both patients
and physicians can understand them.
The previous 1992 ACS recommendations called for everyone over age 50
and not at high risk to be screened with annual fecal occult blood testing
(FOBT) and sigmoidoscopy every three to five years. Those considered at
higher risk were advised simply to seek the advice of their physicians.
The new guidelines divide the population into three categories--average,
moderate, and high risk--with specific recommendations for each.
Average risk--Men and women at average risk should begin screening
by age 50 with an annual FOBT plus either sigmoidoscopy (every five years)
or a total colon examination either by colon-oscopy (every 10 years) or
by double-contrast barium enema (every five to 10 years). Digital rectal
examination should be performed at the time of the sigmoid-oscopy or the
total colon exam.
The ACS decision to include periodic sigmoidoscopy is an important difference
between the ACS and the AHCPR Task Force recommendations.
Moderate risk--Because colorectal adenomas are clearly precursor
lesions for almost all colorectal cancers, and because adenomas are usually
present for several years before they develop into cancer, persons diagnosed
as having adeno-matous polyps are considered to be at moderate risk.
The ACS guidelines recommend that such persons have a colonoscopy at
the time of diagnosis and total colon examination within three years of
polyp removal. If the colon exam proves normal, the patient can then be
considered as being average risk.
High risk--High-risk patients, those with a family history of
adenomatous polyposis or with nonpolyposis colon cancer, are advised to
have much more intensive supervision at an earlier age. The guidelines
suggest surveillance with endoscopy beginning at puberty and counseling
to consider genetic testing.
Those with a personal history of inflammatory bowel disease are also
considered to be at high risk, but a somewhat less intensive screening
schedule is recommended for these patients.
If genetic testing proves positive or if polyposis is confirmed, the
patient is advised to consider colectomy. If genetic testing is negative,
the ACS recommends endoscopy at one- to two-year intervals.
Physician Cooperation Needed
Fewer than 30% of eligible adults have had colorectal cancer screening.
Dr. Cunningham called upon physicians for their cooperation in applying
the guidelines. "We have a unique opportunity to use medical screening
tools for a prevention strategy," he said.
Dr. Cunningham described the current situation with colorectal cancer
as "analogous to that of breast cancer a decade ago." A majority
of women aged 40 and older have had at least one mammo-gram, and a growing
proportion of women now participate in periodic screening. "It is
time," he said, " that we begin making similar progress in our
fight against colorectal cancer."
Senator Bob Graham (D-Fla), sponsor of new preventive health benefits
legislation, joined Dr. Cunningham at the briefing to discuss the efforts
in Congress to improve Medicare coverage of cancer prevention measures,
including colorectal and prostate cancer screening.
In an interview with Oncology News International, Dr. Cunningham said
that different versions of this legislation are being considered in the
House and Senate, and that some bill to improve preventive coverage has
a high probability of passage, perhaps by August.
"We hope the coverage will conform to the ACS guidelines, but the
final form of the legislation is not yet known," he commented.