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 Foundation’s 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 aren’t 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 remarkable statement."
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 effective treatment."
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."
