Thursday, February 4, 2010

NIH Recommendations and Colorectal Cancer

The NIH released some guidelines for screening of colorectal cancer today. The report states at the beginning:

Colorectal cancer is the third most common cancer, and the second leading cause of cancer deaths, in the United States. Each year, nearly 150,000 people are newly diagnosed with colorectal cancer and 50,000 die. Polyps are abnormal growths of tissue along the lining of the colon. Many polyps are harmless, but a common type of polyp, the adenoma, can develop over time into a colorectal cancer. An effective way to reduce mortality from colorectal cancer is to screen for it and its precursor, the adenomatous polyp. Although screening methods have been available for decades and new methods continue to develop, screening rates remain low. The purpose of this conference is to analyze national screening rates for colorectal cancer, identify the barriers to screening, and propose solutions to increase screening rates. Evaluating or establishing the comparative effectiveness of the various colorectal cancer screening options was beyond the scope of this conference and not part of the charge to this panel.

As we have argued before this cancer can, if properly managed early, be reduced to an almost zero mortality rate. The 150,000 new cases themselves can be reduced also to near zero if the polyp can be detected before malignant, namely at the early stage. The costs of doing so are approximately $1,000 to $1,500 per 3-5 years per person. At the low end it is $200 per year per person. Even if the patient shared in the cost, at say $100 per year, that is less than $10 per month! That would result in almost total elimination. The problem however is the availability of competent endoscopists. There are about only 20,000 highly competent ones in the US today and that would be about 200 million procedures every 5 years per 20,000 physicians, or 20 million per year, or 2,000 per year per physician! That is 10 per day! At the minimum.

The recommendations were:

The panel found that despite substantial progress toward higher colorectal cancer screening rates nationally, screening rates fall short of desirable levels. Targeted initiatives to improve screening rates and reduce disparities in underscreened communities and population subgroups could further reduce colorectal cancer morbidity and mortality. This could be achieved by utilizing the full range of screening options and evidence-based interventions for
increasing screening rates. With additional investments in quality monitoring, Americans could
be assured that all screening achieves high rates of cancer detection. To close the gap in screening, this report identifies the following priority areas for implementation and research opportunities to enhance the use and quality of colorectal cancer screening:

• Widely implement interventions that have proven effective at increasing colorectal cancer screening, including patient reminder systems and one-on-one interactions with providers, educators, or navigators.

• Tailor specific approaches to match characteristics and preferences of target population groups to increase colorectal cancer screening.

• Implement systems to ensure appropriate follow-up of positive colorectal cancer screening results.

• Eliminate financial barriers to colorectal cancer screening and appropriate follow-up.

• Develop systems to assure high quality of colorectal cancer screening programs.

The recommendations are quite reasonable and professional as are most if not all from NIH as contrast to the breast screening recommendations of a few months ago. This is a worthwhile read since it poses a process for moving forward. Yet as we develop better genetic tests as well as means to detect cancers early via sampling of the outputs of genes controlling cell growth, we can see in the next 10-20 years the need for colonoscopies being reduced as we detect aberrant cells at an earlier stage. Markers of those cells must also be developed so that they can be removed or hopefully genetically deactivated.

The ideal would be a fully genetic based detection and inactivation and thus the ability to achieve scale economies in medicine. The need for mass colonoscopies is costly and lacks any scale economies.