August 27, 2010
Topic Nominations, Center for Primary Care, Prevention & Clinical Partnerships
Agency for Healthcare Research and Quality
540 Gaither Road, Room 6117
Rockville, MD 20850
Dear Ms. Washington:
The CTC Coalition, a working group of physician providers, colon cancer patient advocates and imaging technology developers, is submitting this request in response to the August 5, 2010 announcement in the Federal Register regarding the “Solicitation for Nominations for New Clinical Preventive Health Topics To Be Considered for Review by the United States Preventive Services Task Force.” Our Coalition requests that the USPSTF consider for review their recommendation on screening for colorectal cancer as it relates to computed tomographic colonography, or CTC. In their most recent published recommendation on screening for colorectal cancer, the USPSTF issued an “I” Statement for CTC. We feel that CTC is soundly supported by evidence that it is safe and effective in detecting colon cancer. We also believe it is an important arsenal in the fight against colon cancer, the second leading cause of cancer death in our nation despite being one of the most preventable.
As you may know, CTC is able to detect the precursor colorectal polyp before malignancy develops and it is able to detect colorectal cancer early before it is symptomatic as well as after symptoms occur. Application of colorectal cancer screening generally will begin with a discussion with a primary care physician on risk factors including age, race, family history, and findings of contributory conditions such as those with inflammatory bowel disease. If found to be in the appropriate category for screening, the majority of current procedures occur following the recommendation of a primary care physician to a gastroenterologist for a traditional colonoscopy. With the addition of CTC, screening will be increased and the burden of those screenings would be shared likely by both gastroenterologists and radiologists, following a referral from a primary care physician.
Our coalition appreciates the understanding of the USPSTF with regards to the importance of screening for colorectal cancer as they currently recommend, with an “A” grade, screening through the use of fecal occult blood testing (unlike CTC it is ineffective for detecting the precursor polyp and it is meant to only detect the cancer after it has developed), sigmoidoscopy (which misses about 25% of cases of advanced neoplasia), and colonoscopy (equally as effective as CTC) for adults beginning at age 50 and continuing to age 75. However, this deadly disease remains a leading killer of Americans. Close to 150,000 Americans are diagnosed with colorectal cancer every year with nearly 50,000 dying because it is detected too late. Colorectal cancer is the third most frequently diagnosed cancer and the second leading cause of cancer death in both men and women in the United States, despite having a 90 percent cure rate when detected early. By increasing screening rates for those at the greatest risk of colorectal cancer, those over the age of 50, a great majority of these cancers and deaths could be prevented. Concurrently there would be a significant cost savings with fewer Americans having to undergo expensive surgeries and treatments such as chemotherapy and radiation therapy.
The bottom line is that millions of Americans are continuing to forgo screening with traditional colonoscopy. CT Colonography can be a life-saving option for these people because it is just as effective as traditional colonoscopy but it is less expensive, minimally invasive, requires no sedation and has fewer potential complications.
While the CTC Working Group is encouraged that screening rates rose from 52 percent in 2002 to 63 percent in 2008, more remains to be done for the thousands who die needlessly each year from colon cancer – one of the most preventable, detectable and curable types of cancer when identified through recommended screening. Screening rates are still far too low, especially among certain populations, including African Americans and Hispanics, as well as those with low income and education and those without health insurance.
Data collected by the National Naval Medical Center in Bethesda, MD demonstrates that access to CTC raises screening levels. According to Dr. Brooks Cash, Integrated Chief of Medicine and Staff Gastroenterologist at the National Naval Medical Center/Walter Reed Army Medical Center, when given the option, 40 percent of patients chose to undergo CT Colonography. Moreover, 37 percent of patients who underwent colon cancer screening said they would not have been screened without CT Colonography. A similar effect has been seen at the University of Wisconsin, where overall screening rates for colorectal cancer have more than doubled per quarter over a five-year period, following the introduction of CTC as an additional screening option.
In addition to the benefit of increasing screening rates, CTC is proven to be as effective as traditional colonoscopy for detecting significant colorectal polyps and cancer, and it is more effective than flexible sigmoidoscopy and fecal occult blood tests, the other two tests recommended for colorectal cancer screening. A 2008 multi-site national CTC trial by the American College of Radiology Imaging Network (ACRIN) found that CTC is comparable to standard colonoscopy in its ability to accurately detect cancer and precancerous polyps. The study was sponsored by the National Cancer Institute and published in the New England Journal of Medicine. Importantly, the ACRIN trial was released very close to the publishing date of the USPSTF’s last recommendations cycle for colorectal cancer screening. Our coalition fears that this information may not have had the necessary time for full consideration by the USPSTF.
We therefore ask that the USPSTF reconsider the “I” statement for the use of CTC for the screening of colorectal cancer. Attached, please find a list of recent and upcoming publications that support our request, as well as the recently published ACR Appropriateness Criteria® on Colorectal Cancer Screening, which gives CTC an “8” rating (“usually appropriate”) for average risk individuals over age 50. This is higher than the appropriateness rating for double-contrast barium enema (rating of “7”).
Thank you for your consideration of our request.
Colon Cancer Alliance (CCA)
American College of Radiology (ACR)
Medical Imaging & Technology Alliance (MITA)
August 27, 2010