U.S. government task force recommends against using CT colonography and fecal DNA testing
Executive Update—New colorectral screening guidelines were issued several days ago by the U.S. Preventive Services Task Force (USPSTF) in the Annals of Internal Medicine. They are the result of a systematic review of colorectal screening literature, which USPSTF requested from the Oregon Evidence-based Practice Center (EPC) to update 2002 recommendations. As the Principal Investigator for the Oregon EPC, CHR’s Dr. Evelyn Whitlock led the team of scientists that conducted the exhaustive and comprehensive research effort.
What the recommendations say
Much of the buzz around the new recommendations focuses on CT colonography and fecal DNA testing—which the USPSTF advocates against using for routine screening. Several months ago, these two methods were endorsed by the American Cancer Society, the U.S. Multi-Society Task Force, and the American College of Radiology.
Also creating a stir are new age recommendations for colorectal screening. In 2002, USPSTF recommended that starting at age 50, everyone be screened regularly using one of three methods: annual fecal occult blood testing; sigmoidoscopic exams every five years with fecal occult testing between exams; or colonoscopy every 10 years. The new guidelines recommend against routine screening for average-risk adults over 75 and against all screening for adults older than 85. After 75, the task force said, risks begin to outweigh benefits; after 85, evidence does not suggest that screening extends lives. This recommendation was supported by a decision analysis conducted by Memorial Sloan-Kettering Cancer Center.
Regarding CT colonography, Whitlock and her team pointed out many uncertainties about downsides of this relatively new screening method—including patient exposure to radiation and increased referrals for additional invasive, potentially unnecessary procedures for extra-colonic findings. Further, it is uncertain that CT colonography in the community will have the same accuracy as trials, given variability among even experienced radiologist readers. On the matter of fecal DNA testing, TCHR investigators reported that the jury is still out on the effectiveness and reliability of this evolving and costly technology.
Guidelines based on objective evidence and transparent research
The editorial in the accompanying issue of Annals candidly evaluated the “current state of the art in making guidelines” and supported USPSTF’s objective methodology, led by Dr. Whitlock. “We think the public is best served,” write editors Michael Pignone, MD, MPH, and Harold C. Sox, MD, “by a relatively structured, comprehensive, transparent approach in which the entire body of evidence drives the recommendations.”
Certainly a lot is at stake with USPSTF recommendations, which not only guide Medicare coverage decisions here in the United States but also shape national health care policy in countries around the world. “The American public and primary care physicians are influenced by the USPSTF guidelines, so it’s critically important to highlight evidence showing that several tests—not just colonoscopy—are effective in early detection and prevention of colorectal cancer,” said Dr. James Allison, an adjunct investigator at the Kaiser Division of Research and clinical professor of medicine emeritus at UCSF who at Kaiser Permanente for 24 years. “This is a major contribution to patient and clinician understanding of what the effective screening tests are for colorectal cancer.”
Population-based health care
Conflict around these recommendations gets at the very heart of what’s important to Kaiser Permanente specifically and managed care in general. Our philosophy of care delivery is fundamentally based on protecting the health of the whole population, using new technologies appropriately and responsibly, and balancing the big picture of risks and benefits.
Colorectal cancer is the 3rd most common cancer in the United States. Each year 150,000 Americans are diagnosed and 50,000 die from this disease. Yet if caught early, prognosis can be quite good; USPSTF has reported that up to 60% of colorectal cancers may be preventable with appropriate screening at the right time. Unfortunately, nearly half of average-risk Americans have not undergone appropriate screening for colorectal cancer, according to the CDC. That’s an astounding 40 million people—who could be helped by these new guidelines.
The new USPSTF colorectal screening recommendations work at this vast scale. Population-based health care is the right approach for a national advisory group dedicated to protecting America’s health. It’s the right path toward our ultimate goal—in this case, screening as many people as we can as efficiently as we can for maximum benefit and minimal risk.
The new USPSTF colorectal cancer screening guidelines are posted on the Agency for Healthcare Research and Quality website.