Latest updates colorectal cancer (CRC) screening guidance from the American College of Physicians (ACP) has raised concerns among some experts.
The clinical guidance for ACP is was announced on Annual report of internal medicine In late July, the government called for colon cancer screening to begin at age 50 for asymptomatic people at average risk. However, this recommendation conflicts with guidelines from the American Cancer Society (ACS) and the United States Preventive Services Task Force (USPSTF). Lowered recommended starting age Up to 45 for screening.
Following the ACP’s announcement, several professional organizations, including the American College of Radiology, criticized the new guidelines as a “step backwards.” Warnings that may interfere with Recent victory over CRC.
Some physicians believe this discrepancy confuses patients and leads to variation in referral practices among primary care physicians. Additionally, while insurance companies will likely continue to pay for tests based on the USPSTF guidelines for coverage, some doctors believe that insurance companies may create further hurdles in colorectal cancer test coverage. I am concerned that there is. Prior permission required.
“We are at odds as a nation on this issue,” said John L. Marshall, M.D., a gastrointestinal oncologist and director of Georgetown University’s Roush Gastrointestinal Cancer Treatment Center in Washington, D.C.
At the end of the day, the medical community wants affordable screening tests that are effective at preventing cancer and death, but the evidence so far doesn’t necessarily support that. colonoscopy Marshall, who is also chief medical officer at Lombardi Comprehensive Cancer Center, said that the test.
Colonoscopies can prevent colorectal cancer and reduce cancer deaths by removing precancerous polyps, but have not been shown to reduce all-cause mortality, Marshall said. explained. For example, a recent meta-analysis showed that, apart from sigmoidoscopy, colon cancer Screening did not significantly change life expectancy with other cancer screening methods.
“That’s why we’re struggling,” Marshall said. “We are keen to make sure young people have access to testing because colon cancer occurs in young people too, so we want it to happen early. It’s expensive and invasive.”
Different guidance in document discussion
The new ACP guidance is based on a critical review of existing guidelines, evidence, and modeling studies., argue that the potential harms of screening average-risk individuals under age 50 may outweigh the potential benefits.
Of course, the benefits of screening include identifying and eliminating precancerous lesions and local cancers, but the potential harms include false positives that can lead to unnecessary additional tests, treatments, and costs. Contains positives. More invasive screening procedures, such as colonoscopies, can also come with risks such as serious bleeding or perforation.
for colonoscopyFor example, the ACP team found that starting screening at age 45 vs. 50 would result in an additional 3 cases of colorectal cancer (58 vs. 61) and 1 colorectal cancer case per 1,000 people screened over the recommended screening period. It was determined that cancer deaths (27 vs. 28) could be prevented. Conversely, starting screening at age 45 may increase the incidence of gastrointestinal and cardiovascular events (14 vs. 16).
“Even assuming there are no limitations to the modeling study and accepting the results at face value, the estimated small benefits and harms largely offset each other, justifying colorectal cancer screening in average-risk adults. You will likely come to the conclusion that there will be insufficient net income to support you from age 45 to age 49.” Amir Kaseem, MDACP co-authors write:
Family physician Kenny Lin, MD, MPH, believes the latest ACP guidelines are reasonable and notes that ACP is not the first organization to disagree with the USPSTF’s recommendations.
“I think so [ACP] The guidelines make a lot of sense,” said Dr. Lin, who practices in Lancaster, Pennsylvania. The American Academy of Family Physicians also “did not support the recommendation to begin testing at age 45.” Updated guidancethe AAFP recommended that colorectal cancer screening begin at age 50, concluding that there was “insufficient evidence to assess the benefits and harms of screening” in the 45- to 49-year-old population.
But Dr. Jason R. Wolowski, a family physician based in Wilkes-Barre, Pennsylvania, expressed concern that the differences in guidelines could confuse patients and pose challenges for primary care physicians.
“I feel like it took the last few years to convince people that the sooner the better,” said Wolosky, an associate professor of family medicine at Geisinger Commonwealth School of Medicine. “It could send a mixed message to patients, after all we have emphasized so far about its importance. [screening]And I said, “Maybe we were wrong.” It might have been okay at first. ”
Gastrointestinal oncologist Dr. Mark A. Lewis had a similar initial reaction when he heard about the latest guidelines. He said, “There will be confusion among patients because of the lack of synchronization between groups.”
Since he only sees patients with advanced colorectal cancer, he can’t say for sure whether this recommendation will affect gastrointestinal oncologists, but he says the demands of primary care and gastroenterology are changing. Looking.
“It’s going to have a much bigger impact on primary care physicians and gastroenterologists,” said Lewis, chief of gastrointestinal oncology at Intermountain Healthcare in Murray, Utah. “My best guess is that primary care physicians ordering more stool tests will reduce the procedural burden on the latter. It may be natural to prefer non-invasiveness, but FIT is a plus. [fecal immunochemical test] Screening is incomplete without follow-up coverage. ”
But Mr. Marshall saw it differently. He does not believe the updated guidelines will have a practical impact on doctors’ practices. She said most parts of the country already lack adequate colon cancer testing. Research shows that more than 40% of Americans skip standard colon cancer tests. Anecdotally, he noted, friends in their 60s come up to him and admit they haven’t had a colonoscopy yet.
Potential impact on patient outcomes and costs
Beyond the mixed message, some experts worry that delaying colorectal cancer testing could mean the cancer is not detected at a more advanced stage.
Wolosky explained that early colorectal cancer screening is worthwhile if the cancer is detected early and is easy and inexpensive to treat.
Lewis believes early screening is a way to stop tumors from progressing before they really gain traction.
“For me, the biggest benefit of colonoscopy is that it interrupts the adenoma-to-carcinoma chain, so polyps that are completely removed don’t become invasive adenocarcinomas.” said Lewis. “We have over 10 years of evidence that: flexible sigmoidoscopyAlthough it falls short of visualization of the entire colon, it may provide a survival benefit. ”
Another concern is the potential impact on insurance coverage.
Medicare and other insurance companies use USPSTF guidelines to determine coverage. But the mixed messages led Wolosky to wonder if there are additional challenges with coverage. “Does that mean primary care physicians have to pre-authorize many of these tests, even if they share decision-making with the patient?” he asked.
When it comes to screening referrals, Douglas A. Coley, MD, a gastroenterologist at Kaiser Permanente in Northern California, recommends that primary care physicians educate patients about the benefits and harms of screening, as well as differing views on different screens. He said it was important to do so. option.
“Given the differing opinions, it is important that people in this age group know that testing is an option that is being recommended by some groups,” Coley said. “Colorectal cancer screening is highly effective in reducing the risk of dying from colorectal cancer, the second leading cause of cancer death in the United States. We need to make sure this is an option for everyone. It is in the patient’s best interest to inform them.” Make an informed choice. ”
Lin has already begun talking to patients about different recommendations. He said it helps to simplify the issue and focus the conversation on what patients value most. For more assertive patients who prioritize early detection of all possible cancers, it may make sense to start screening at age 45, but other patients may find it difficult to understand the process or the risks that may arise. The side effects may not be worth it, he said.
“And then there’s the middle group who decide, “Yes, I want to start at age 45, but I want to get a stool test. I don’t want to suddenly get a colonoscopy,” says Hayashi. I did. “It’s kind of a compromise where you start screening earlier but don’t expose yourself to something that could cause more harm.”
Wolosky said he plans to continue the inquiry based on the USPSTF’s recommendations.
“Informed decision-making with patients is important with all testing, but for now, the USPSTF remains supportive of early testing, so we will likely stick to providing testing early.” he said.
However, Lewis added that the most important difference in determining the appropriate time to evaluate for CRC is the difference between screening and diagnosis.
“The former is only appropriate for truly asymptomatic, truly average-risk patients,” he said. “The latter is very important for symptomatic patients. Blood in the stool can be diagnosed as hemorrhoids without the use of tests, rectal fingers, or even endoscopy to prove the presence of hemorrhoids and the cause of the blood. I can’t tell you how many times I’ve seen it disrespected.” Loss. “