DI EUROPE VOLUME 28, NUMBER 3


eDiTorial aDvisory BoarD Andreas Adam, London


Frits H. Barneveld Binkhuysen,


Amersfoort Filipe Caseiro Alves, Coimbra Maksim Cela, Tirana


Katarzyna Gruszczynska, Katowice


Andrea Klauser, Innsbruck Gabriele Krombach, Giessen Philippe Lefere, Roeselare Luis Martí-Bonmatí, Valencia


Richard P. Baum, Bad Berka Elias Brountzos, Athens


Carlo Catalano, Rome


Patrick Cozzone, Marseille Anne Grethe Jurik, Arhus


Gabriel Krestin, Rotterdam Christiane Kuhl, Bonn


Heinz U. Lemke, Kuessaberg Thoralf Niendorf, Berlin


Christiane Nyhsen, Sunderland Anne Paterson, Belfast Anders Persson, Linköping Gustav von Schulthess, Zurich Patrick Veit-Haibach, Lucerne


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he recent publication of a post-hoc analysis of a cohort of subjects selected from the previously published data of


the 2008 United States CT colonogra- phy trial looks as though it might briefly fan the embers of what appears to be a slow, ongoing controversy or turf war over the optimal method of screen- ing for colorectal cancer (CRC). The previously published trial, the huge US ACRIN National CT colonography trial showed that CT colonography (CTC, or virtual colonoscopy) was comparable to standard colonoscopy in its ability — in patients over 50 years of age but younger than 65 — to accurately detect cancer and precancerous polyps. The newly published data now show that the same conclusions about the equivalence of standard and virtual colonoscopy can be drawn in subjects aged over 65. The publication of


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2008 ACRIN data threatened, for a time, to trigger a full-blown turf war between standard colonoscopists on the one hand and radiologists on the other as each group vaunted the mer- its of their approach. For the radiolo- gists, virtual colonoscopy promised a less invasive and therefore more acceptable method of screening for the adenomatous polyps which have the potential to advance to carci- noma. On their side, the colonosco- pists jumped to the defence of their discipline, pointing out the advantage of the lack of ionizing radiation and even the possibility of resection or biopsy sampling at the same time as the original examination. Both lobbies were anxious to be in at the ground floor of the long-promised utopia of population wide screening programs for the early detection of colorectal cancer. In the event, despite the similar


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yields of CTC and colonoscopy in the detection of advanced neoplasias, the threatened turf war never really broke out


if mainly because the full-blown


population screening never really took off. This in turn was because the cost- effectiveness of CTC and even colo- noscopy in wide-spread screening pro- grams has never been fully quantified. It’s not as though there isn’t an urgent need for such screening programs in


APRIL/MAY 2012 DI EUROPE


colorectal cancer. In Europe, CRC is the second most common cancer, as well as being the second most common cause of death from cancer. As de Haan and colleagues from the Academic Medical Center in Amsterdam have recently pointed out, no fewer than 432 414 European citizens received a new diagnosis of CRC in 2008, the last year for which complete data are avail- able. What’s more, the relatively slow development of the disease lends itself to screening programs. The majority of cancers develop from adenomatous polyps, the benign precursors with a long premalignant phase.


It is esti-


mated that the adenoma to carcinoma transition takes at least 10 years. In addition, the potential effect of


screening on CRC-mortality has been shown to be potentially dramatic. Several randomized trials using fecal occult blood testing (FOBT) have shown that mortality reduction can be approximately 14% after ten years of screening;


flexible sigmoidoscopy has


been shown to result in a decrease in mortality of nearly 40% of subjects who were screened. It is therefore reasonable to assume that similar reduction rates could be achieved with colonoscopy or CTC. Tellingly however, there are as yet no published data describing the real decrease in mortality achievable with colonoscopy or CTC although the on- going Nordic Initiative on Colorectal cancer promises to provide such data for colonoscopy. There are no on-going trials in CT colonography in Europe. The absence of such data has had its impact on the recommendations of the European Union, who, while recom- mending screening for men and women between 50 and 74, only specify FOBT or faecal immunochemical tests. The problem with FOBT is that the diag- nostic yield (the number of confirmed malignancies as a proportion of peo- ple tested) is lower than what can be achieved with colonoscopy or CTC. One day there may be a “real” turf


war between colonscopists and radi- ologists. At least then there is a like- lihood that considerable numbers of pre- or established cancers will be being treated successfully. In that context the choice of technology is of less importance n


3


BY ALAN BARCLAY, PH.D. FROM THE EDITOR Screening for colorectal cancer


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