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Colon Screening saves lives: Massachusetts Success Story

Thursday, July 11, 2013 0 comments

A new report by our CNiC team summarizes the rapid changes in colorectal cancer screening in Massachusetts and more broadly through New England over 15 years from 1997 onwards. The move from scientific evidence to public health strategy hinged on a sustained strategy described by the collective impact approach where common goals, a shared measurement system, mutually reinforcing activities, and continuous communication with a backbone organization sustain changes that lead to improved population health outcomes.

The Massachusetts Colorectal Cancer Workgroup united academics and clinicians from medical and public health schools across the state, and together with the American Cancer Society, the Massachusetts Medical Society, and the Massachusetts Department of Public Health, coordinated and facilitated a broad range of outreach and education activities for providers and the general public. The goal of these activities was to increase awareness and use of colon cancer screening tests.

The results, summarized in a new short report show a marked increase in screening in Massachusetts, to the highest level in the nation, and a drop in mortality from colon cancer by 27%.

More will be done to sustain these changes. Of course, many states and regions of the country still have much lower levels of colorectal screening. Renewed effort to bring access to colorectal cancer screen are needed as this strategy clearly saves lives. Other prevention approaches to complement screening are also summarized in or 8ightWays to prevent colon cancer and other tools available from this CNiC site under the "extras" button.

See related posts

Cancer News in Context: 8IGHT WAYS to Prevent Colon Cancer

Preventing colon cancer: Screening works – mortality down 30

Of Aspirin, Ibuprofen, and Blood Tests: A Big Week in Liver Cancer Prevention

Friday, November 30, 2012 0 comments

It's been a big week for liver cancer prevention - not something we often get a chance to write here at CNiC.

As we reported on Tuesday, the US Preventive Services Task Force released new draft screening recommendations for the hepatitis C virus (HCV) - an infection that can greatly increase the risk of liver damage and later cancer. Testing can find those who are infected and lead to therapies that can reduce risk.

Now, come new results from a large government study linking aspirin use to a significantly lower risk of liver cancer. The study, the National Institutes of Health-AARP Diet and Health Study followed over 300,000 men and women age 50 - 71 for multiple years and found that the use of aspirin and other non-steriodal anti-inflammatories (NSAIDS) - like ibuprofen and indomethacin - lowered the risk of liver cancer by close to 40 percent and the risk of death from liver disease by just over 50 percent (study). Aspirin use alone (without any other NSAIDS) was linked to a nearly 50 percent lower risk of liver cancer. Just taking NSAIDS other than aspirin did not appear to lower risk of liver cancer but did lower the risk of death from liver disease by about 25 percent.

The study didn't have information on the dosage of aspirin used by those in the study; so it's unclear whether low-dose aspirin (approximately 81mg) had similar benefits to full dose aspirin (typically 325mg). Same for the non-aspirin NSAIDS.

Previous studies looking at the link between aspirin/NSAIDS and liver disease were much smaller than this recent study and had inconclusive results. Yet, the manner in which aspirin works in the body fits nicely with a hypothesis of cancer prevention. Inflammation is thought to play a potential role in the pathway from normal cells to cancer, so interrupting this pathway by keeping down inflammation - as aspirin and other NSAIDS do - is believed to be one possible way to cut the risk of certain cancers.

Regular long-term aspirin use is also linked to a lower risk of colon cancer (CNiC post). And men age 45-79 and women age 55-79 are generally encouraged to take a daily aspirin to prevent cardiovascular disease (UPSTF guideline). If these promising early results for liver cancer are replicated in other studies, it'll add even more weight to the evidence of health benefits with regular aspirin use.

As with all drugs, though, aspirin and other NSAIDS are not without certain risks. Intestinal bleeding is a particular concern with aspirin and can be a very serious condition. Those prone to bleeding - and other potentially serious side effects of NSAIDS - are usually discouraged from taking them. Talking with a doctor is the best way to determine if the benefits of a regular aspirin outweigh the risks.

It's estimated that Americans alone take an astounding 30 billion aspirins each year. Increasingly, it seems this may be money well spent.

Preventing colon cancer: Screening works – mortality down 30% nationwide from 1992 through 2009.

Monday, August 20, 2012 0 comments

The evidence on screening as an effective strategy to reduce colorectal cancer mortality has its roots in studies of fecal occult blood testing (FOBT) that showed a reduction in colorectal cancer mortality^1-3. These three independent trials were conducted in the US, England and Scandinavia. Completing the clinical trials of fecal occult blood testing case-control sampling frames were also used to analyze prospective data from the Kaiser Permanente Health Plan ^4,5, showing significant reductions in colorectal cancer mortality. In 1997, the combined efforts of gastroenterologists and others led to the seminal paper recommending colorectal cancer screening ⁶ and ACS also adopted a guideline recommending screening for colorectal cancer ⁷. Congress subsequently approved screening for colorectal cancer to be covered by Medicare, providing coverage for Americans over age 65. Many other activities at the local and national level to promote colon screening have led to increase in screening and reduction in colorectal cancer mortality.

In the figure below, we see that there is a steady decline in mortality from colorectal cancer form 1992 through 2009.

The goals of the American Cancer Society included a target of 55% of the population being screened and up to date for CRC screening by 2015 ⁸. We have already met this national goal. Data from CDC indicate that in 2010 we already have met this goal, in fact the national average was 64.5% of adults 50 to 75 years of age were up to date ⁹. Variability is substantial – in Massachusetts screening increased to 75% of the population.

Does screening reduce colon cancer? – yes.

Randomized trial evidence now builds on the evidence available in 1997 and confirms the value of screening to reduce mortality. In 2010, Atkin and colleagues published a randomized trial of once-only flexible sigmoidoscopy conducted in the United Kingdom ¹⁰. Both incidence and mortality from colorectal cancer were reduced among those randomized screening compared to the control arm. Most recently, data from the PLCO randomized trial also show a reduction in incidence and mortality ¹¹.

Despite national access to screening through Medicare, rates of screening vary substantially between states. Massachusetts has the highest uptake of screening as of 2010. Rates of screening by 2010 varied from 54 to 59% in the bottom quartile of States to 70 to 75% in New England, Maryland and Washington State ⁹. Likewise the drop in colorectal cancer mortality varies substantially over the past 20 years. New England states and New York have had the highest drop in colorectal cancer mortality – rates declining by 30 to 37% from 1994 to 2007 ¹².

Promoting population health through reduction in colorectal cancer mortality requires successfully moving from knowledge through translation to implementation in widespread practice. Preventive action usually lags behind the science. Colorectal cancer is the second ranked leading cause of cancer mortality. Yet screening within the US has substantial variation in the rate of uptake and the associated decline in mortality. However, the overall national average of 64% exceeds the ACS challenge goals of 55% up to date by 2010 ⁸.

National changes in access through Medicare coverage and in professional awareness through publication of prevention guidelines recommending screening alone do not speed translation to practice ¹³. Components of implementation, for example within health systems ¹⁴, show how changes can be made to speed implementation of new guidelines such as screening for colorectal cancer. But much of the colorectal prevention and screening effort promoted over the past 15 years extends beyond individual provider systems and insurance providers.

To be effective public health programs must engage providers but also build community support for the preventive efforts. This requires education and awareness beyond the clinical care setting. Massachusetts led many education and outreach efforts that spread across New England from a partnership of academics, the ACS, and the Massachusetts Medical Society. Alas, to this day CDC still only funds about half of all states to promote colorectal cancer screening ¹⁵.

One might contrast the substantial decline in mortality across New England, New York, New Jersey, and Maryland (all greater than 30% decline in mortality) with states such as Mississippi, Wyoming and Alabama where in the same time period mortality has declined by less than 10% ¹².

Why do we have such variation in the implementation of a program that can almost halve mortality from colorectal cancer? The Richmond model of health policy and prevention offers a unifying approach to this and many cancer prevention issues ^16,17. In the model, Richmond sets forth the interplay of three interrelated forces: the scientific knowledge base; political will to allocate resources towards a prevention program; and a social strategy to implement the prevention activity and reduce the burden of illness. This model developed in part through the design of Healthy People, 1979 ¹⁸, offers a structure to evaluate the strategies that have been employed to promote screening over more than 15 years. A social strategy includes a multilevel approach promoting health through healthcare providers, through regulatory changes, and through individual and community changes. A multilevel set of issues must be addressed to implement a comprehensive social strategy. Particularly in Massachusetts where a broad coalition came together to promote awareness and work to implement screening such an approach appears to have paid off.

Our priority going forward is to understand how other states can emulate the success in prevention achieved in New England. Where do you think our priorities for prevention should be now?

Related posts

More than half of cancer is preventable now

Web resources

Your Disease Risk

Literature cited

1. Mandel JS, Bond JH, Church TR, et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study. N Engl J Med. May 13 1993;328(19):1365-1371.

2. Hardcastle JD, Chamberlain JO, Robinson MH, et al. Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet. Nov 30 1996;348(9040):1472-1477.

3. Kronborg O, Fenger C, Olsen J, Jorgensen OD, Sondergaard O. Randomised study of screening for colorectal cancer with faecal-occult-blood test. Lancet. Nov 30 1996;348(9040):1467-1471.

4. Selby JV, Friedman GD, Quesenberry CP, Jr., Weiss NS. A case-control study of screening sigmoidoscopy and mortality from colorectal cancer. N Engl J Med. Mar 5 1992;326(10):653-657.

5. Selby JV, Friedman GD, Quesenberry CP, Jr., Weiss NS. Effect of fecal occult blood testing on mortality from colorectal cancer. A case-control study. Annals of Internal Medicine. Jan 1 1993;118(1):1-6.

6. Winawer SJ, Fletcher RH, Miller L, et al. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology. Feb 1997;112(2):594-642.

7. Byers T, Levin B, Rothenberger D, Dodd GD, Smith RA. American Cancer Society guidelines for screening and surveillance for early detection of colorectal polyps and cancer: update 1997. American Cancer Society Detection and Treatment Advisory Group on Colorectal Cancer. CA Cancer J Clin. May-Jun 1997;47(3):154-160.

8. Byers T, Mouchawar J, Marks J, et al. The American Cancer Society challenge goals. How far can cancer rates decline in the U.S. by the year 2015? Cancer. 1999;86:715-727.

9. Joseph DA, King JB, Miller JW, Richardson LC. Prevalence of colorectal cancer screening among adults - behavioral risk factor surveillance system, United States, 2010. Morbidity and mortality weekly report. Surveillance summaries. Jun 15 2012;61(2):51-56.

10. Atkin WS, Edwards R, Kralj-Hans I, et al. Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet. May 8 2010;375(9726):1624-1633.

11. Schoen RE, Pinsky PF, Weissfeld JL, et al. Colorectal-cancer incidence and mortality with screening flexible sigmoidoscopy. N Engl J Med. Jun 21 2012;366(25):2345-2357.

12. Naishadham D, Lansdorp-Vogelaar I, Siegel R, Cokkinides V, Jemal A. State disparities in colorectal cancer mortality patterns in the United States. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology. Jul 2011;20(7):1296-1302.

13. Bero L, Grillr R, Grimshaw J, Harvey E, Oxman AD, Thompson M. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. BMJ. 1998;317:465-468.

14. Yano EM, Green LW, Glanz K, et al. Implementation and spread of interventions into the multilevel context of routine practice and policy: implications for the cancer care continuum. Journal of the National Cancer Institute. Monographs. May 2012;2012(44):86-99.

15. Joseph DA, DeGroff AS, Hayes NS, Wong FL, Plescia M. The Colorectal Cancer Control Program: partnering to increase population level screening. Gastrointest Endosc. Mar 2011;73(3):429-434.

16. Richmond J, Kotelchuck M. Coordination and development of strategies and policy for public health promotion in the United States. In: Holland W, Detel R, Know G, eds. Oxford Textbook of Public Health.Vol 1. Oxford: Oxford University Press; 1991.

17. Atwood K, Colditz GA, Kawachi I. From public health science to prevention policy: placing science in its social and political contexts. Am J Public Health. Oct 1997;87(10):1603-1606.

18. U. S. Department of Health E, and Welfare,. Healhty People. The Suregeon General's report on health promotion and disease prevention, 1979. Washington, DC: Office of the Assistant Secretary for Health and Surgeon General;1979.

Medical interventions to prevent cancer

Tuesday, January 3, 2012 0 comments

Much has been written over the past few months on progress against cancer. For example, in the New York Times, Kolata summarizes funding for cancer research and shows the percentage of health research funding spent on cancer treatment research, cancer biology, and cancer causation, with only a small fraction on early detection and prevention (1). This reflects the commitment made forty years ago, when the U.S. declared war on cancer, and promised a cure. While treatment and biology gain the predominant funding, we should remember that there are proven ways to prevent cancer, some through lifestyle changes, and others through medical interventions. While medical interventions may most often be focused on high-risk men and women, we know that smoking cessation – a population wide strategy – can reduce both incidence of many cancers and mortality from cancer.

Smoking cessation powerfully reduces lung cancer and total mortality as demonstrated in Figure 1. Compared to continuing smokers, those who successfully quit have a 20% reduction in lung cancer mortality within 1 to 4 years of quitting and a 40% reduction within 5 to 9 years (2). Smoking cessation also reduces total mortality by 13% in less than 5 years and by 33% in less than 10 years, due to the additional benefits of reduced risk of cardiovascular death and other smoking-related cancer deaths (2). Thus, the benefits for smoking cessation are unarguable.

On the other hand, seeking technologic solutions, the randomized clinical trial for screening smokers with CT scans, showed a 20% reduction in lung cancer mortality after an average of 6 years of follow-up, and a reduction in total mortality of 6.7% (9).

But there are other research-proven strategies and interventions to prevent much of cancer outright.

We might consider these as drugs (aspirin, selective estrogen receptor modulators), vaccines, and screening or surgical interventions. While the time frame from intervention to benefit varies for the cancers, most of these medical interventions result in substantial benefits and typically the benefits outweigh the risks of exposing the population to the medical procedures. For example, we estimated that a large proportion of postmenopausal women would benefit from Raloxifene (a SERM) and given its relative positive trade off of benefits to risk, its widespread use could result in a substantial reduction in postmenopausal breast cancer (3). Likewise, for aspirin which is recommended for men over 45 to reduce risk of cardiovascular disease, and for women over 55 to reduce risk of cerebrovascular disease (4), the benefits for colon and other cancer risk reduction over 20 or more years of use are substantial (5). Perhaps the reduction in cancer is an unintended benefit of widespread use to reduce cardiovascular disease risk.

Vaccines, on the other hand, more typically considered a population-wide interventions, take decades to observe the benefit of reduced cancer incidence, and require broad implementation to achieve reduction in the cancer burden for the whole population. Several countries have embarked on more traditional public health strategies for HPV vaccine (Australia, mandatory) and hepatitis vaccine programs (e.g., Taiwan) to achieve reductions in the burden of cancer.

In the table below, we summarize the target for each intervention, the magnitude of reduction in cancer that has been observed following interventions, and the source of evidence for each intervention.

Table. Proven cancer prevention interventions using medical interventions

Intervention	Target	Magnitude of reduction	Evidence
Aspirin	Total cancer mortality	20% reduction	Follow-up of 8 RCT (5)
Aspirin	Colon cancer	40%	Five RCTs (6) and RCT in Lynch syndrome (7)
SERMs Tamoxifen Raloxifene	Breast cancer incidence	40 to 50%	RCT (8, 9)
Salpingo oophorectomy	Familial risk of breast cancer	50%	Observational data synthesis (10)
Screening for colon cancer Sigmoidoscopy (RCT) Colonoscopy	Colon cancer mortality	Sigmoiodoscopy 30% to 40% in 10 years Colonoscopy – 50%	UK RCT sigmoidoscopy (11) observational data
Vaccines HPV Hepatitis, etc	Cervical cancer Liver cancer		(12, 13)
Mammography	Breast mortality	30%	RCT refs
Spiral CT for lung cancer	Lung ca mortality	20% in 6.5 yrs	RCT (14)