Amir Qaseem, MD, PhD, MHA; Thomas D. Denberg, MD, PhD; Robert H. Hopkins, MD; Linda L. Humphrey, MD, MPH; Joel Levine, MD; Donna E. Sweet, MD; Paul Shekelle, MD, PhD; for the Clinical Guidelines Committee of the American College of Physicians*
* This paper, written by Amir Qaseem, MD, PhD, MHA; Thomas D. Denberg, MD, PhD; Robert H. Hopkins Jr., MD; Linda L. Humphrey, MD, MPH; Joel Levine, MD; Donna E. Sweet, MD; and Paul Shekelle, MD, PhD, was developed for the Clinical Guidelines Committee of the American College of Physicians: Paul Shekelle, MD, PhD (Chair); Roger Chou, MD; Paul Dallas, MD; Thomas D. Denberg, MD, PhD; Nick Fitterman, MD; Mary Ann Forciea, MD; Robert H. Hopkins Jr., MD; Linda L. Humphrey, MD, MPH; Tanveer P. Mir, MD; Holger J. Schünemann, MD, PhD; Donna E. Sweet, MD; and David S. Weinberg, MD, MSc. Approved by the ACP Board of Regents on 19 November 2011.
Note: Clinical guidance statements are “guides” only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP clinical guidance statements are considered automatically withdrawn or invalid 5 years after publication, or once an update has been issued.
Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations.
Financial Support: Financial support for the development of this guidance statement comes exclusively from the ACP operating budget.
Potential Conflicts of Interest: Any financial and nonfinancial conflicts of interest of the group members were declared, discussed, and resolved. A record of conflicts of interest is kept for each Clinical Guidelines Committee meeting and conference call and can be viewed at www.acponline.org/clinical_information/guidelines/guidelines/conflicts_cgc.htm. Drs. Denberg, Hopkins, and Humphrey: Support for travel to meetings for the study or other purposes: ACP. Dr. Hopkins: Board membership: National Foundation for Infectious Diseases; Consultancy: Qualchoice of Arkansas, MedStudy Corporation; Payment for lectures including service on speakers bureaus: VEMCO MedEd Corp. Dr. Shekelle: Consultancy: ECRI; Employment: VA; Grants/grants pending (money to institution): AHRQ, VA, CMS, NINR-NIH, DHHS; Royalties: UpToDate. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-3122.
Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190. N Independence Mall West, Philadelphia, PA 19106; e-mail, email@example.com.
Current Author Addresses: Dr. Qaseem: 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Denberg: 275 Grove Street, Auburndale, MA 02466.
Dr. Hopkins: 4301 West Markham Street, Little Rock, AR 72205.
Dr. Humphrey: 3710 SW U.S. Veterans Hospital Road, Portland, OR 97201.
Dr. Levine: Academic Office Building 1, PO Box 6511, 12631 East 17th Avenue, Room 7614, Aurora, CO 80045.
Dr. Sweet: 1010 N. Kansas, Wichita, KS 67214.
Dr. Shekelle: 11301 Wilshire Boulevard, Los Angeles, CA 90073.
Author Contributions: Conception and design: A. Qaseem, R.H. Hopkins, D.E. Sweet, P. Shekelle.
Analysis and interpretation of the data: A. Qaseem, R.H. Hopkins, L.L. Humphrey, J. Levine, D.E. Sweet.
Drafting of the article: A. Qaseem, T.D. Denberg, R.H. Hopkins, D.L. Sweet.
Critical revision for important intellectual content: A. Qaseem, T.D. Denberg, R.H. Hopkins, L.L. Humphrey, D.E. Sweet, P. Shekelle.
Final approval of the article: A. Qaseem, T.D. Denberg, R.H. Hopkins, L.L. Humphrey, J. Levine, D.E. Sweet, P. Shekelle.
Provision of study materials or patients: A. Qaseem.
Statistical expertise: A. Qaseem, D.E. Sweet.
Administrative, technical, or logistic support: A. Qaseem.
Collection and assembly of data: A. Qaseem.
Qaseem A, Denberg TD, Hopkins RH, Humphrey LL, Levine J, Sweet DE, et al. Screening for Colorectal Cancer: A Guidance Statement From the American College of Physicians. Ann Intern Med. 2012;156:378-386. doi: 10.7326/0003-4819-156-5-201203060-00010
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Published: Ann Intern Med. 2012;156(5):378-386.
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CharlesMaltz, Associate Professor of Clinical Medicine
Weill Cornell Medical College
March 10, 2012
Adenomas, Dysplasia, and Colorectal Cancer
The authors describe the evolution of colorectal cancer "as an adenomatous polyp that slowly increases in size, followed by dysplasia and finally cancer." However, an adenoma does not become dysplastic, but is already dysplastic. An adenoma of the colon is by definition a visible mass of dysplastic cells in the colon. The cells are determined to be dysplastic by cellular atypia as well as architectural abnormalities. These abnormalities reflect underlying genetic abnormalities in the cells. As long as the abnormal cells are above the muscularis mucosa, one is dealing with an adenoma. If additional genetic mutations develop these cells may penetrate the muscularis mucosa and then cancer is present. Colonoscopy is believed to prevent colon cancer by allowing the identification and removal of these dysplastic lesions (adenomas) before they can penetrate the muscularis mucosa and thus becomes cancer with the potential to metastasize.
David L.Keller, Internal Medicine Physician
Providence Medical Group
March 15, 2012
Comments on the Clinical Guideline on Colorectal Cancer Screening
1) Qaseem A, et. al. Screening for colorectal cancer, Ann Intern Med. 2012;156:378-386
2) Neri E, et al. CT colonography versus double-contrast barium enema for screening of colorectal cancer: comparison of radiation burden. Abdom Imaging. 2010 Oct;35(5):596-601
3) Johnson CD, et al. Comparison of the relative sensitivity of CT colonography and double-contrast barium enema for screen detection of colorectal polyps. Clin Gastroenterol Hepatol. 2004 Apr;2(4):314-21.
4)http://www.uspreventiveservicestaskforce.org/uspstf08/colocancer/colors.htm accessed on 3/14/12.
Steven PArmbruster, Gastroenterology Department, Fouad Moawad
Walter Reed National Military Medical Center
March 22, 2012
Colorectal Cancer Screening in African Americans
To the Editor:
We read with great interest the recent article by Qaseem et al. (1) regarding a guidance statement for the screening of colorectal cancer (CRC). We agree that African Americans denote a higher risk population for the development of CRC, and should be screened earlier compared to other ethnicities as endorsed by the American College of Gastroenterology (ACG), the only society to date recommending early screening for African Americans (2). However, we are not in support of the statement that CRC screening should begin at age 40 in African Americans, as recommended in the guidance statement by Qaseem et al.
In 2009, the ACG published their consensus statement recommending CRC screening for African Americans starting at age 45 for several reasons. African Americans have the highest incidence of CRC of any racial group, and survival from CRC in African Americans is lower than other ethnicities (3). Further, African Americans may present with CRC at a median age 6 years younger than Caucasians (4) and are more likely to have a polyp greater than 9mm in size compared to age-matched Caucasians (5). Specifically, colonoscopy has been recommended as the preferred CRC screening modality in African Americans given their higher rate of proximal colon cancers compared to other races (6). However, despite the increased risks of CRC in African Americans, the current recommendation to screen at age 45 is based on only grade2 C evidence (weak evidence), and there is no evidence that screening this patient population with colonoscopy at age 40 is cost-effective, practical, or beneficial.
While it is clear that CRC is the 2nd leading cause of cancer death in the U.S. and colonoscopy reduces the mortality associated with CRC (7), resource constraints will probably not allow additional colonoscopy screening for the approximately 50% of the population who currently does not undergo CRC screening (8). Further, given the cost associated with colonoscopy screening, it is crucial that primary care providers refer the appropriate patient for screening, particularly when a colonoscopy may not be reimbursed by insurance companies in a 40 year old patient without alarm or high risk features. Thus, given these constraints of available resources, that on average African Americans appear to present with CRC younger than Caucasians, and the lack of evidence to support CRC screening at age 40, we would continue to recommend routine colon cancer screening in African Americans at age 45 years in the absence of alarm symptoms.
LCDR Steven P. Armbruster, MD MAJ Fouad J. Moawad, MD Walter Reed National Military Medical Center Bethesda, MD 20889
1. Qaseem A, Denberg T, Hopkins R, et al. Screening for Colorectal Cancer: A Guidance Statement From the American College of Physicians. Ann Intern Med 2012;156;378-386.
2. Rex D, Johnson D, Anderson J, et al. American College of Gastroenterology Guidelines for Colorectal Screening 2008. Am J Gastroenterol 2009;104:739-750.
3. Agrawal S, Bhupinderjit A, Bhutani M, et al. Colorectal Cancer in African Americans. Am J Gastroenterol 2005;100:515-523.
4. Karami S, Young HA, Henson DE. Earlier age at diagnosis: another dimension in cancer disparity? Cancer Detect Prev 2007;31:29-34.
5. Lieberman D, Holub J, Moravec M, et al. Prevalence of Colon Polyps Detected by Colonoscopy Screening in Asymptomatic Black and White Patients. JAMA 2008;300:1417-1422.
6. Rex D, Khan A, Shah P, et al. Screening colonoscopy in asymptomatic average-risk African Americans. Gastrointest Endosc 2000;51:524-7.
7. Zauber A, Winawer S, O'Brien M, et al. Colonoscopy Polypectomy and Long-Term Prevention of Colorectal -Cancer Deaths. N Engl J Med 2012;366:687-696.
8. Roy HK, Bianchi LK. Colorectal Cancer Risk Black, White, or Shades of Gray? JAMA 2008;300:1459-1461.
Ayokunle T.Abegunde, MBBS, MSc, DTM&H
John H. Stroger Jr hospital of Cook County, Chicago, Illinois
March 26, 2012
ACP CRC Guidelines
TO THE EDITOR,
The evidence supporting the effectiveness of early screening of African- Americans at average risk of colorectal cancer (CRC) is scarce. It is surprising that the ACP guideline is recommending CRC screening at 40 years of age in African-Americans (1) when there is no evidence that such a strategy is effective. Gupta et al recently showed that increasing colonoscopy participation by 5% and 10% among African-Americans aged 50 years or older, detected 53% and 57% of CRC respectively, in contrast, early CRC screening of African Americans at 45 years of age detected 52% of CRC (2).
You et al, further demonstrate that young-onset CRC was more prevalent among patients with non-white race/ethnicity who were uninsured or insured by Medicaid (3). The results of these two studies have several implications, which feed into the wider debate on social determinants of health and access to healthcare by the underserved, who are often disproportionately African-American. Firstly, simply implementing race specific early age CRC screening policy for African- Americans is unlikely to increase early CRC detection rates significantly. Secondly, factors leading to reduced colonoscopy participation among AA need to be identified, and appropriately addressed. African -Americans are a diverse group of self- identified Americans with varying amounts of African genetic admixture. Classifying this group as above average risk for CRC presupposes that race, as a proxy of ancestral African genomic identification, predicts CRC disease clusters in the African-American population. If that is the case, biological markers, which make African-Americans more likely to develop CRC earlier should be identifiable, and would lend credence to the argument of those advocating for earlier screening. Furthermore, there should be a corresponding clustering of CRC in ancestral populations in Africa. However, this is not the case, because the available evidence shows that the incidence of CRC in Africa is low (4). Therefore, the observed increased incidence of CRC among African- Americans is more likely related to environmental, lifestyle, and socio-economic factors rather than biological or genetic factors (4). While the medical community eagerly awaits the outcome of ongoing studies on the effectiveness of initiating early CRC screening in African- Americans, strategies to improve access to CRC screening and colonoscopy participation among African-Americans aged 50 years and above should be actively pursued, in addition to timely case detection of symptomatic young adults, and sustained advocacy on healthier lifestyle choices.
Ayokunle T. Abegunde, MBBS, MSc, DTM&H John H. Stroger Jr hospital of Cook County, Chicago, Illinois, 60612
1. Qassem A, Denberg TD et al. Screening for Colorectal Cancer: A guidance statement from the American College of Physicians. Ann Intern Med. 2012 Mar 6;156 (5):378-386.
2. Gupta S, Shah J et al. Strategies for reducing colorectal cancer among blacks. Arch Intern Med 172(2)182-3
3. You YN, Yan X et al. Young-onset colorectal cancer: Is it time to pay attention. Arch Intern
Med .172( 3) 287-8
4. O'Keefe SJ, Chung S et al. Why Do African Americans Get More Colon Cancer than Native Africans ? J Nutr. 2007 Jan;137(1 Suppl):175S-182S
Tazia K.Stagg, preventive medicine physician
James A. Haley Veterans' Hospital
April 2, 2012
Screening for Colorectal Cancer: Guidance Statement 4
The authors' recommendation regarding when to stop screening for colorectal cancer is problematic. In seeking clarification, I was unable to trace the origin of Guidance Statement 4. Did it arise from the "rigorous review of the available guidelines"... or from new evidence not referenced? According to the summaries in the article, only one of the guidelines reviewed--that of the USPSTF--provided guidance related to when to stop screening. However, judging from the fact that the Qaseem et al. used different words to express Guidance Statement 4 (because I don't really know how to interpret it), it seems to depart from the USPSTF's recommendation statement. I believe that for the sake of everyone involved, most importantly patients', the best policy is to acknowledge and present good evidence to defend any such public disagreement. Otherwise, we risk undermining the credibility of the medical/scientific community... and, at least, not accomplishing adherence to the statement with the weaker support.
The statement as it is written is open to interpretation in a significant way because the authors did not specify "...whichever is earlier." If that was the intended message, this should be regarded as a very controversial statement. I intuitively want to instead interpret it in a way that actually means simply, "stop screening for colorectal cancer in patients with a life expectancy of less than 10 years." Since estimating life expectancy, one way or another, introduces uncertainty, and doctors tend to err on the side of being generous with screening tests (when we do remember to offer them), the impact of adherence to this latter interpretation would likely be to increase the upper age limit of screening. Whether this is net-beneficial might depend on how accurately we estimate life expectancy.
Effectively tailoring recommendations is a foundation of excellent preventive service delivery. The idea of basing the decision to stop screening on life expectancy, rather than on chronological age alone, is appealing. (The USPSTF's recommendation leaves room for doing this in their "C" statement and from the premise of what clinical guidelines are: just guidelines.) I don't know how to accurately calculate life expectancy, but if doing so is possible and worthwhile, I'd like to learn. The theory that basing screening on life expectancy is beneficial deserves to be tested. In order to test it, we would need to make it measureable.
Furthermore, I would expect the College to address challenges related to implementation, but the suggestion of a tool for estimating life expectancy, or a discussion of various types of such tools, is conspicuously absent from your Guidance Statement.
Guidance Statement 4 is less practical and more opinion-based than what preceded it; it fails to meet the objectives stated in your Reference 6, and I wonder what motivated it.
AmirQaseem, MD, PhD, MHA, Linda Humphrey, MD, Oregon Health and Science University, 3710 SW US Veterans Hospital Road, Portland, OR 97201, Thomas Denberg, MD, PhD, Harvard Vanguard Medical Associates and Atrius Health, 275 Grove St, Auburndale, MA 02466, Paul Shekelle, MD, PhD, Gr
American College of Physicians, 190 N. Independence Mall W. Philadelphia, PA 19106
April 26, 2012
Race and Upper Age Limit for Colorectal Cancer Screening
We thank Drs. Abegunde, Keller, and Stagg for their comments regarding the American College of Physicians' recent guidance statement on colorectal cancer screening (1).
In response to Dr. Abegunde, we agree that the evidence regarding the benefits of screening African Americans starting at the age of 40 is scarce. ACG recommends initiating screening at age 45 for African Americans, ACS/ACR/ USMSTF recommends beginning at age 40 for high-risk groups (with no mention of race), and the USPSTF does not address high- risk groups in their recommendations. Since this is a guidance statement, we based this recommendation on a review of the existing colorectal cancer screening guidelines, and we felt that it would be more straightforward to have one age to initiate screening for all high-risk groups. Using a different age for each risk group might make it more difficult for clinicians to practically implement the guidance statement and our intent was to simplify the recommendation. We agree that new evidence, such as the emergence of accurate biomarkers, would warrant a change in the recommendation.
We agree with Dr. Keller that the harms of a screening test exist regardless of whether a test is necessary or unnecessary. Since the Best Practice Advice figure focuses on overused testing, we included the word "unnecessary" to further emphasize that the potential harms outweigh the potential benefits. Regarding including double contrast barium enema (DCBE) as a potential screening option, although the USPSTF did not recommend DCBE, both the ACR and ACS/ACR/ USMSTF guidelines included DCBE as a screening option. We believe that the evidence is insufficient to assess the benefits and harms of computed tomography colonography. We agree that it was an oversight on our part not to include radiation exposure as a potential harm for DCBE.
Dr. Keller and Dr. Stagg both brought up the issue of the age to stop screening. We understand that estimating life expectancy can be a difficult task and that there are currently no validated tools available. However, we believe that the evidence does not show that the benefits outweigh the harms of screening for colorectal cancer in the majority of adults over the age of 75. Yet, a study showed that more than 45% of adults aged 75-79 were screened (2). Guidance statements are guides only and may not apply to all patients or clinical situations. The guidance statements do not override physicians' judgment, and if there is a 75 year old with a reasonable life expectancy who desires colorectal cancer screening, this guidance statement does not discourage physicians from screening such an individual.
Authors: Thomas Denberg, MD, PhD Harvard Vanguard Medical Associates and Atrius Health, 275 Grove St, Auburndale, MA 02466
Linda Humphrey, MD Oregon Health and Science University, 3710 SW US Veterans Hospital Road, Portland, OR 97201
Paul Shekelle, MD, PhD Greater Los Angeles VA Health Center/RAND, 1776 Main Street, Santa Monica, CA 90401
Amir Qaseem, MD, PhD, MHA American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106
1. Qaseem A, Denberg TD, Hopkins RH Jr, Humphrey LL, Levine J, Sweet DE, Shekelle P. Screening for colorectal cancer: a guidance statement from the American College of Physicians. Ann Intern Med. 2012. Mar 6;156(5):378-86.
2. Louise C. Walter L, Lindquist K, Nugent S, Schult T, Lee S, Casadei M, Partin M. Impact of Age and Comorbidity on Colorectal Cancer Screening Among Older Veterans. Ann Intern Med. 2009. 150: 465-73.
UT Southwestern Medical Center
May 15, 2012
Re:ACP CRC Guidelines
I agree with the comments by Dr Abegunde raising concern that the ACP colorectal cancer screening guideline goes beyond supporting evidence in recommending earlier screening for African Americans.
High rates of colorectal cancer among African Americans need to be addressed, but, as our prior work suggests, think this is much more likely to be addressed effectively and efficiently by boosting screening among African Americans age 50 and older, rather than recommending screening at an earlier age(1).
Moreover, it seems very unlikely that insurance companies will consistently get behind a race specific recommendation for earlier age of screening for one racial/ethnic group, but not others.
In sum, I am concerned that the ACP guideline issues a guideline for African Americans that is neither evidence based, nor that can be readily implemented.
The ACP should focus efforts on promoting development and implementation of evidence based strategies to reduce colorectal cancer mortality among African Americans.
Samir Gupta, MD, MSCS UT Southwestern Medical Center Dallas, TX
1. Arch Intern Med. 2012 Jan 23;172(2):182-4.
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