Info

Patient (at home)

Not 85

reported

Not Not reported reported

Not Not reported reported

Not Not reported reported

Not 96

reported

Not 93-

reported

Patient (at home)

Patient (at home)

Radiologist

Radiologist/CT technician

Not on market

Primary care 17%

physician, physician's assistant, nurse, gastroenterologist

Primary care 10%-17%

physician, physician's assistant, nurse, gastroenterologist (patient for FOBT) Gastroenterologist >5 %

Not available

Colonoscopy or DCBE with flexible sigmoidoscopy

Colonoscopy or DCBE with flexible sigmoidoscopy

Colonoscopy or DCBE with flexible sigmoidoscopy

Colonoscopy

Colonoscopy

Colonoscopy + or DCBE

Endoscopic or surgical resection

Optical colonoscopy

Not on market

Not reported

Not on market

Not on market

Annual repetition of FOBT yields higher sensitivity than single FOBT. Screening FOBT in physician's office is not recommended.

In RCT by Mandel et al., rehydration increased positive test from 2.4% to 9.8%.

Combination FOBT/IFOBT tests may have higher sensitivity than either type of test alone.

Sensitivity of barium enema has been shown to vary by hospital & practitioner.115

Positive rate includes all adenomas.

The addition of FOBT increased the sensitivity by 0.05% in the one study with a direct of Sig vs. Sig plus FOBT.137

Sensitivity of colonoscopy has been shown to vary by hospital and practitioner.115 Sensitivity for high-risk lesions and cancer.

*This represents the proportion of positives followed up with the recommended procedure (e.g., colonoscopy). In the Lurie study, close to 100% of Medicare recipients with a positive FOBT were followed up, but only 34% had either colonoscopy or FS with barium enema, which were considered the recommended procedures for follow-up.

**Advanced neoplasias defined as cancer or high-risk adenomas >1 cm or with villous/dysplastic features.

reduces mortality by 15% to 21 %.102-106'130'131 Although research has suggested that CRC screening by IFOBT would also reduce mortality from CRC,132 more needs to be done to evaluate its cost, accuracy, and adherence to its use by people to whom it is recommended.94,132

Evidence for the benefit of sigmoidoscopy has been demonstrated in two case-control studies showing that people who died of CRC were 59% to 79% less likely than controls to have been screened even once by sigmoidoscopy.18,133 Research also suggests that using FOBT in conjunction with sigmoidoscopy could confer additional benefit compared with sigmoidoscopy alone because it may detect cancers in the proximal sigmoid colon that are missed by sigmoidoscopy.134 Two ongoing randomized clinical trials (RCTs) to evaluate flexible sigmoidoscopy will report their initial results within the next several years,135,136 and an ongoing trial in Norway is evaluating the benefit of flexible sigmoidoscopy and flexible sigmoidoscopy combined with FOBT.137 Consistent with the reduction in mortality conferred by screening endoscopy, several studies have shown reductions of 42% to 76% in CRC incidence among those offered endoscopy compared with those who were not offered the test.133,138,139

There is little direct evidence of the efficacy of colonoscopy in reducing CRC incidence and mortality, although there is indirect evidence of its benefit from studies of other CRC screening methods (Table 24.6).90,112,140 The direct evidence to date consists of a case-control study of U.S. veterans that found that people who died of colon cancer were less likely than controls to have had colonoscopy (OR, 0.43; 95% CI, 0.30-0.63).138 In this study, people with either colon or rectal cancer were also less likely to have had colonoscopy (OR, 0.47; 95% CI, 0.37-0.58; OR, 0.61; 95% CI, 0.48-0.77).138 Colonoscopic polypectomy has been found to reduce the incidence of CRC, suggesting that the removal of polyps is the proximal reason for screening-based reductions in CRC incidence and mortality.140,141

Emerging technologies such as virtual colonoscopy or stool DNA screening have not been demonstrated to reduce CRC incidence or mortality. Studies suggest that these methods hold promise for the future, and ongoing research is comparing emerging to current screening methods.

Recommendations

The ACS, USPSTF, U.S. Multisociety Task Force on Colorectal Cancer, and American College of Gastroenterology (ACG) agree that CRC screening is effective in reducing CRC incidence and mortality, and each has developed recommen-dations.8,10,112 The USPSTF strongly recommends screening for men and women 50 years of age and older but has concluded that there are insufficient data to determine which strategy is best in terms of the balance between benefits and potential harms.8,112

Similar to the USPSTF, the ACS10 and U.S. Multisociety Task Force on Colorectal Cancer90 recommend a range of options for screening average-risk individuals beginning at age 50. Both recommend annual FOBT, flexible sigmoi-doscopy every 5 years, annual FOBT plus flexible sigmoi-doscopy every 5 years, DCBE every 5 years, or colonoscopy every 10 years.

Despite strong expert consensus on the benefits of screening for colorectal cancer, actual screening rates in the popu lation remain low for all available CRC screening tests. In general, individuals at higher risk, such as those with familial adenomatous polyposis (FAP) or HNPCC, should be screened more aggressively than those at average risk.8,10,90,112 Genetic tests exist for individuals suspected to have a hereditary syndrome such as HNPCC or FAP. Chapter 26 covers genetic screening and counseling for high-risk populations.

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