WASHINGTON--The advent of Medicare-funded colorectal cancer screening
this year followed on the heels of new colorectal screening
guidelines issued last year. Some of the physicians and researchers
who developed those guidelines gathered in Washington to celebrate
the new Medicare benefit.
"This truly is a wonderful day, one we all have been waiting for
and worked for," said John Bond, MD, chief of gastroenterology
at the Minneapolis Veterans Administration Medical Center. Dr. Bond
is also chairman of the American Digestive Health Foundations
colorectal cancer education campaign. "Hopefully," he
added, "we can use this as a springboard to work hard to bring
colon cancer screening benefits to the rest of the population who are
at risk for this disease and not yet covered because they arent
in the Medicare group."
He noted that the United States is a high-risk country for colorectal
cancer: 55,000 people a year die of the disease and about 145,000 new
cases a year are diagnosed. "All of us living in the United
States have, on average, about a 6% likelihood of developing
colorectal cancer sometime during our lifetimes," he said.
The disease is the only major malignancy that affects men and women
almost equally. "For that reason, part of our message is that
women in the United States have to be as concerned about screening
for this disease as they rightfully are about screening for breast
and cervical cancer," he said.
Colorectal cancer screening guidelines were developed over the last 2
years by a consortium of five medical and surgical gastrointestinal
societies and by the American Cancer Society.
"Widespread adoption of these screening recommendations would
reduce the death rate of this cancer by over 50%, saving 25,000 to
30,000 lives each year in the United States," Dr. Bond said.
"I know of no other medical condition where we can make that
Sidney J. Winawer, MD, of Memorial Sloan-Kettering Cancer Center, and
co-chair of the panel that developed the GI consortium guidelines for
colorectal cancer screening, outlined how the new guidelines came about.
"We had outstanding progress in research in our understanding of
who is at risk for colorectal cancer, how it develops, and how to
prevent it." Dr. Winawer said. "Also, over the last two
decades, the entire screening package had evolved--screening tests,
diagnostic tests for people who have a positive screening test, plus
Yet, Dr. Winawer said, in spite of these advances, the Agency for
Health Care Policy and Research (AHCPR) found that screening rates in
the United States were "dismally low and unacceptable." In
1995, he said, the AHCPR issued a request for proposals to examine
screening guidelines and develop new ones.
A consortium of five national societies responded to the request by
forming an interdisciplinary panel of primary care physicians,
nurses, patient advocates, economists, oncologists,
gastroenterologists, and a surgeon.
Over a 2-year period, the panel reviewed 3,000 papers in the
literature and selected 350 for intensive review. The panel came to
the conclusion that there was strong evidence that annual screening
is of benefit to men and women over age 50 and to the general
population under 50 with special increased risk.
Their guidelines were published in the beginning of 1997, and within
a year, the American Cancer Society had updated its guidelines to
match. "The controversy about the benefit of screening should be
eliminated in the minds of the public and the medical community. This
has culminated in the Medicare legislation we are celebrating
today," Dr. Winawer said.
Robert A. Smith, PhD, of the American Cancer Society, said that
"it was highly gratifying to find we had all reached the same
conclusion. We have seen how differences in screening guidelines can
result in ambivalence about a preventive service until the experts
reach consensus." The current situation regarding the ability of
colorectal cancer screening to reduce morbidity and mortality, he
suggested, is similar to that of mammography and breast cancer in the
late 1980s. "That is, we have an unrealized potential. The
American Cancer Society believes these data represent a call to
action," he said.
The American Cancer Society has initiated the National Colorectal
Roundtable to hasten progress in colorectal cancer control and gather
baseline data for programming and evaluation. It will be holding
focus groups with medical directors of managed care organizations and
primary care providers, and conducting a national survey of
physicians, he said.
"We will have greater success if we take a systems approach
where the roles of the important players are interrelated," Dr.
Smith said. "By working together, we can establish collective
goals and fashion unique roles and long-term planning for each
organization. Perhaps sooner than later, we will contribute to
reducing the burden of this disease."