Guidelines on colon cancer screening pegged for update

Researchers suggest refinements to reflect gender differences on neoplasia findings, as well as new technologies.

By Susan J. Landers — Posted Dec. 4, 2006

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

A new study delineating possible revisions in colorectal cancer screening guidelines likely will attract the attention of physicians from an across-the-specialty spectrum who are engaged in debate and discussion in preparation for next year's release of updated recommendations.

Gastroenterologists, radiologists, surgeons, primary care physicians and others have joined forces as the U.S. Multisociety Task Force on Colorectal Cancer and are considering new data and new technologies in updates to their 1997 guidelines, which were last modified in 2003.

Meanwhile, the U.S. Preventive Services Task Force plans to review its 2002 guidelines and could publish a new version next year that reflects changes in the field.

The study, "Colonoscopy in Colorectal-Cancer Screening for Detection of Advanced Neoplasia," which appeared in the Nov. 2 New England Journal of Medicine, could provide key talking points as efforts move forward. Conducted in Poland, the study analyzed data from a screening program of more than 50,000 participants. Researchers concluded that men had a considerably higher risk than women of harboring advanced neoplasia. This finding led them to suggest that screening requirements be revised to reflect this difference.

Currently men and women at average risk are urged to begin having screenings at age 50.

Colon cancer is the most frequently detected cancer in Europe and the second leading cause of cancer deaths in the United States, said the study's authors. The Centers for Disease Control and Prevention reports that 28,471 men and 28,132 women in the nation died of the cancer in 2002.

If everyone age 50 and older had regular screening tests, at least one-third of the deaths could be avoided, the CDC predicts.

That colon cancer is a major killer in Poland was a driving factor behind the study, said Dr. Jaroslaw Regula, the study's lead author and a physician in the gastroenterology department at the Maria Skodowska-Curie Memorial Cancer Center in Warsaw. The researchers coupled this information with the knowledge that colonoscopy is emerging as a gold standard screening technique for detecting precancerous lesions.

"It was our initial intention to find subgroups that have the highest benefit from screening to increase its effectiveness. Because the lifetime risk of colorectal cancer is similar for men and women, it is a bit surprising to find that advanced neoplasia can be found in a greater proportion of men than of women," he said. "Our study may suggest that screening in men should start earlier than at age 50 years."

Weighing risk factors

Experts contacted about Dr. Regula's study cautioned that it may be premature to consider changes in guidelines along male-versus-female lines. Although gender could be a consideration in new recommendations, it would be included for more complex reasons and as just one of many factors, such as family history.

"It's been appreciated for a long time that men are slightly more susceptible to developing colorectal cancer," said Durado Brooks, MD, MPH, the American Cancer Society's director of prostate and colorectal cancers. "The problem is that women, and maybe the public in general, have viewed it as a man's disease, and that's just not at all accurate."

"At any particular point in time, men have a higher proportion of cancers due to their gender," said Bernard Levin, MD, vice president of cancer prevention at the University of Texas M.D. Anderson Cancer Center in Houston. "But it's over a lifetime that men and women come close to having the same incidence rate of colon cancer, because women live longer."

What's missing from the study is information on where in the colon the lesions were found, Dr. Brooks said. But Dr. Regula said those data will be published in a future article.

Tumor location is important because current evidence suggests that women are more likely to have lesions in a part of the colon that can be reached only by colonoscopy. Lesions in men are frequently found in the distal part of the colon, which can be reached with flexible sigmoidoscopy.

Gender-based testing?

This finding has led to thoughts that different kinds of tests could be recommended for men and women, Dr. Brooks said.

"We continue to debate whether we should offer screening differently for women and men, or should we offer a different mix of screenings depending on age," said Sidney J. Winawer, MD, a gastroenterologist at Memorial Sloan-Kettering Cancer Center in New York City and an author of the multisociety task force's 1997 guidelines. For example, perhaps fecal occult blood testing could be offered early, saving the colonoscopy for later -- a practice common in Germany, Dr. Winawer said.

"We are looking at all the currently available technologies including FOBT, flexible sigmoidoscopy, colonoscopy and double-contrast barium enema," said Dr. Levin, who co-chairs the multisociety task force's guidelines efforts.

Dr. Levin also provided a glimpse of the technologies that are not quite ready for prime time but are factors in the group's discussions. Virtual colonoscopy, also called computed tomographic colonography, and stool DNA testing are among them. Capsule endoscopy already is in use to examine the lining of the gastrointestinal tract, and the Aer-O-Scope, in development in Israel, is billed by its manufacturer as a miniaturized, self-propelling, self-navigating colonoscopy. Dr. Levin serves on that company's scientific board.

"But don't wait," for a noninvasive yet comprehensive exam, he advises. "We have great technology already."

Back to top


Risk factors

Individual characteristics increase the risk of colon cancer. Among those identified by the American Cancer Society:

Age: More than 90% of people diagnosed with colorectal cancer are older than 50.

Previous cancer: The chances of developing new cancers in other areas of the colon and rectum are greater if a first colorectal cancer was found before age 60.

Colorectal polyps: An adenomatous-type polyp increases chances of developing colorectal cancer, especially if polyps are large or numerous.

Chronic inflammatory bowel disease: Screening colonoscopy should begin eight to 12 years after a diagnosis of IBD, and testing should be repeated every one to two years.

Family history: Colorectal cancers or adenomatous polyps in any first-degree relative younger than age 60, or in two or more first-degree relatives of any age, increases risk.

Back to top

External links

U.S. Preventive Services Task Force recommendations on colon cancer screening, July 2002 (link)

American Cancer Society, "Five Myths About Colon Cancer" (link)

Centers for Disease Control and Prevention on colorectal cancer (link)

"Colorectal cancer screening and surveillance: Clinical guidelines and rationale--Update based on new evidence," abstract, Gastroenterology, February 2003 (link)

"Colonoscopy in Colorectal-Cancer Screening for Detection of Advanced Neoplasia," abstract, New England Journal of Medicine, Nov. 2 (link)

Back to top



Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story

Read story


American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story

Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story

Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story

Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story

Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story

Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story

Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story

  • Stay informed
  • Twitter
  • Facebook
  • RSS
  • LinkedIn