Morten Rasmusen Overlæge Ph.-D Abdominalcenter K Bispebjerg Hospital Chef for tarmkræftscreening i Region Hovedstaden
Definition af screening Examinations of asymptomatic people in order to classify them as likely or unlikely to have the disease that is the object of screening. The goal of screening is to reduce morbidity or mortality from the disease among the people screened; this goal is attained by early treatment of the cases discovered Morrison 1 Important health problem 2 accepted treatment for recognized disease 3 facilities for diagnosis and treatment 4 suitable latent and symptomatic stage 5 suitable test or examination 6 test acceptable to population 7 natural history of condition understood 8 agreed on policy on whom to treat 9 Cost of finding economically balanced with overall health 10 case finding should be continuous process WHO
CRC incidence & mortality CRC screening Years of age Incidence male Incidence female mortality male mortality female
Aldersstandardiseret forekomst af nye tilfælde & dødsfald af CRC fra 1943-2006
CRC Incidence & Mortality Livstidsrisiko: 5 % Incidence Colon Rectum Total Female 1.329 489 1.818 Male 1.399 818 2.217 Total 2.728 1.307 4.035 DCCG 2013 Mortality Years 0-49 50-74 > 75 Total Female 29 387 592 1.008 Male 25 506 494 1.025 Total 54 893 1.086 2.033 Cancer registret 2008
Fecal occult blood test G-FOBT Hemoccult-II I-FOBT OC-Sensor
Instruktion
Cochrane Review Reduktion af CRC dødelighed Studie GFOBT Kontrol RR 95%CI Minnesota 1999 Nottingham 2002 269/31157 177/15394 0.75 0.62-0.91 593/76466 684/76384 0.87 0.78-0.91 Fyn 2004 362/30967 431/30966 0.84 0.71-0.99 Göteborg 2005 Total inviterede Total deltager 252/34144 300/34164 0.84 0.78-0.90 1476/172734 1507/156908 0.84 0.78-0.90 0.75 0.66-0.84 Hewitson et al. 2008
Mortalitets reduktion ved GFOBT RCT s Minnesota Nottingham Funen Inviterede Gennemførte (%) Positiv test (%) Nedsættelse af CRC mortalitet (%) Median follow-up tid (år) 15,587 76,466 30,967 78 60 67 9.8 1.5 1.5 21 15 15 18 8 13
Dødelighed følger stadie Hewitson et al. 2008
Overlevelse efter stadie Stadie Antal % 5-års overlevelse Dukes A 26.727 8.7 93.2 Dukes B 74.784 24.2 77.0 Dukes C 72.806 23.6 47.7 Dukes D 28.377 34.3 35.4 Ukendt 106.040 34.3 35.4 Total 308.734 100 50.7 England Diagnosetidspunkt1996-2006
Stadiefordeling i Danmark Stadie DK 2001-06 København Vejle Fyn Screening FOBT + + + Dukes A 10 29 47 40 Dukes B 36 26 29 36 Dukes C 29 34 18 16 Metastaser 18 11 5 7 Andet 7
Forekomst af nye CRC efter FOBT screening Mandel et al.2000 FOBT Hvert år Hvert andet år Kontrol CRC 417 435 507 Incidens ratio 0.80 (0.70-0.90) 0.83 (0.73-0.94) 1.0 P-værdi < 0.001 < 0.002
Gennemførlighedsundersøgelse Vejle og Københavns amt 2005-06 Inviterede (50-74 år) Deltagere (%) Positive test(%) 177.353 85.579 (48) 2085 (2.5) Overlevelse med CRC (Cox-Mantel hazard ratio) CRC fundet ved Ratio 95%CI P-værdi Screening/DCCG 0.44 0.36-0.55 < 0.01 Screening/nægtere 0.32 0.32-0.46 < 0.01 Negativ/DCCG 0.94 0.75-1.16 0.55 Lindebjerg Dan Med J 2014
Hemocullt-II i England Total (%) 60-69 år Mænd (%) Kvinder (%) Inviterede 2.074.107 1.029.311 1.044.796 Deltagere 1.079.293 (52) 510.864 (50) 568.429 (54) Positiv test 21.106 (2.0) 12.776 (2.5) 8.330 (1.5) Kræft 1.772 (10) 1.230 (12) 542 (7.8) Høj og mellem risiko adenomer 4.771 (27) 3.336 (31) 1.435 (21) Clean colon 5.198 (30) 2.576 (24) 2.622 (38) 83% af positive undersøgt 98% koloskopi Logan RFA et al. GUT 2012
Calvados study GFOBT versus IFOBT 20.322 persons Between 50 and 74 years Population screening IFOBT 2 Immudia/RPHA GFOBT Hemmocult-II 6 tests Positive test followed by colonoscopi No follow-up Guittet et al. GUT 2007 Guittet et al. Br. J.Cancer 2009
Relative sensitivity Rate G-POS I-POS G-POS I-NEG G-NEG I-POS RSN (95% CI) Cancer (43) 25 2 16 1.48 (1.16-1.89) Retum 11 0 12 2.09 (1.36-3.20) Distal colon 9 2 3 1.09 (0.74-1.60) Proximal colon 6 0 1 1.17 (0.86-1.58) Advance adenomas (283) 58 21 204 3.32 (2.70-4.07) Rectum 11 4 40 3.40 (2.12-5.44) Distal colon 44 11 22 3.02 (2.38-3.82) Proximal colon 3 6 42 5.00 (2.55-9.82) Non-advanced adenomas (251) 17 40 194 3.70 (2.82-4.87) Guittet et al. Br. J. Cancer 2009
RCT GFOBT versus IFOBT 2 population RCT 30.634 persons between 50-74 years of aged Randomized between GFOBT og IFOBT IFOBT OC-Sensor one fecal sampel GFOBT Hemoccult-II 6 fecal sampels Positive tests followed by colonoscopy Van Rossum et al. Gastroenterology 2008 Hol et al. Br. J. Cancer 2009
RCT GFOBT versus IFOBT Participation rate Rinjnmond Nijmegen GFOBT IFOBT GFOBT IFOBT Invited 5004 5007 10301 10322 Performed 2375 (50%) 2979 (62%) 4836 (47%) 6157 (60%) Positive test 65 (2.8%) 241 (8.1%) 117 (2.4%) 339 (5.5)
Diagnostic yield GFOBT versus IFOBT Rinjnmond Nijmegen GFOBT IFOBT GFOBT IFOBT CRC 11 24 Advanced 46 121 adenomas Advanced 28 95 57 145 neoplacia
Colonoscopy & OC-Sensor 9989 persons 50-74 years Colonoscopy IFOBT sensitivity 95 %CI CRC 65 48 73.8 61.5-84.0 Advance adenomas 757 180 23.8 20.8-27.0 Specificity 95%CI Clean colon 4457 162 96.4 95.8-96.9 CRC False-negative rate IFOBT 0.18 % NNS koloskopi 154 NNS IFOBT 208 (15 colonoscopies) Imperiale NEJM 2014
IFOBT versus colonoscopy Aged 50-69 years Colonoscopy OC-Sensor Randomized 26.703 26.599 Performed 4.953 (19%) 8.983 (34%) CRC 26 32 Advanced adenomas 482 220 Non-advanced adenomer 1.100 103 Quintero et al. NEJM 2012
Diagnostisk udbytte efter 4 runder med OC-Sensor Screningsrunder 1 2 3 4 Inviterede 2956 2556 2056 1862 Deltagelse (%) 1660 (56) 1600 (63) 1179 (57) 1165 (63) Positive test (%) 72 (4.3) 67 (4.2) 43 (3.6) 51 (4.4) Avanceret neoplasia (%) 25 (1.51) 21 (1.31) 15 (1.27) 15 (1.29) CRC 5 (0.30) 1 (0,06) 2 (0.17) 1 (0.09) Crotta et al. 2014
Complications Colonoscopy Per 1.000 koloskopier Bleeding 1.64 Perforation 0.85 Death 0.074 Rabeneck et al. 2008 Odds-ratio for complication according to annual colonoscopy volume of endoscopist
30 days complications Colonoscopy Complication per 1.000 (1997-2004) 2.315.126 Bleeding 1.35 Perforation 0.33 complications Total Bleeding Perforation Endoscopist volumen < 300/year 1.18 (1.07-1.30) 1.13 (1.02-1.25) 1.49 (1.23-1.80) Biopsi 1.21 (1.01-1.44) 1.84 (1.47-2.30) 0.66 (0.50-0.87) Polypectomy by hot biopsi 5.63 (4.97-6.39) 10.90 (9.33-12.74) 1.22 (0.97-1.55) Polypectomy by snare 7.75 (6.98-8.64) 15.13 (13.18-17.35) 1.56 (1.29-1.89) Chukmaitov et al. Endosc 2013
Invitations algoritme År Fødsels måned 2014 Juni april september 2015 November august januar 2016 Maj juli oktober 2017 Marts februar december Borgere der ikke er inviterede tidligere inviteres 1 mdr. før 75 år Borgere der bliver 50 år inviteres 1 mdr. Før deres fødselsdag
Den estimerede belastning 400.000 personer 60% deltagelse 8 års karantæne 240.000 Personer Positiv 5.4% Ingen koloskopi 1.500 Personer 11.000 personer Clean colon 2750 personer Lav risiko adenomer 2.500 Personer Høj/mellem risiko adenomer 4.750 Persons CRC 1.000 Personer
Behov for koloskopi incl follow-up Antal koloudredninger DK 2012 Hospital Speciallæge I alt 65.607 14.291 79.898 Antal koloskopier i Danmark 2014 2015 2016 2017 2018 2022 12.158 13.883 13.883 17.385 24.953 25.487
Deltagelse per uge 100,0% 90,0% 80,0% 70,0% 60,0% Region Nord Region Midt Region Syddanmark Region hovedstaden Region Sjælland 50,0% 40,0% 30,0% 20,0% 10,0% 0,0% 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46
Deltagelse 11 november 2014 Region Antal udsendt invitationer Uge 10-45 Svarprocent Uge 10-36 svarprocent Nord 39.227 54.4 64.0 Midt 70.092 57.8 63.9 Syddanmark 89.666 53.2 63.4 Hovedstaden 98.662 45.9 56.5 Sjælland 41.982 49.2 59.0 Hele landet 339.639 51.6 61.1
Deltagelse og alder Alder (år) Antal Inviterede Deltagelsesprocent 50-54 56.296 54.1 55-59 9.837 59.4 60-64 9.295 64.3 65-69 16.335 67.5 70-74 32.107 62.6 Total 123.870 60
Antal positive Region Modtaget Uegnet Positive svar Positiv % Nord 21.322 153 1.487 7.0 Midt 40.481 328 2.686 6.7 Syddanmark 47.686 296 2.995 6.3 Hovedstaden 45.254 229 3.082 6.8 Sjælland 20.676 71 1.534 7.4 Hele landet 175.423 1.077 11.784 6.8
Positive Alder N Antal Positive test % Mænd % Kvinder % 50-54 31.400 1.312 4.2 4.5 3.9 55-59 6.757 358 5.3 6.3 4.5 60-64 7.045 518 7.4 9.0 6.0 65-69 12.401 1.057 8.5 10 7.1 70-74 22.486 2.334 10.4 12.3 8.6 Total 80.089 5.579 7.0 8.2 5.9