Report in English with a Dutch summary (KCE reports 45A)

KCE reports vol.45 Screening for Colorectal Cancer: Appendices 157
9 CONCLUSIONS AND RECOMMENDATIONS
The purpose of this HTA on Colorectal Cancer (CRC) Screening was to
evaluate whether, and under which conditions, CRC screening could become an
effective and cost-effective method to reduce the burden of CRC in Belgium.
Therefore, we analysed and evaluated the available evidence about CRC
screening. We also evaluated the uncertainties surrounding CRC screening and
identified areas where specific additional data are necessary before such a
program can successfully be implemented in this country.
9.1 CONCLUSIONS
Provided that the organisational conditions are met, colorectal cancer screening
clearly fulfils the original Wilson and Jung criteria and also the more recent
extended criteria regarding practical and ethical issues. These extensions of the
criteria mainly emphasize that screening programs should be concerted actions,
with adequate quality assurance, broadly accessible and with full information
about potential benefits and harms but without any moral pressure on
individuals to participate. In the case of CRC screening we observed that in
most countries opportunistic screening, historically, is the main form of
screening. Recently, however, several countries started pilot projects to find
out how to organise a programmed mass screening for CRC.
In Belgium, colorectal cancer is the third most common cancer in men and the
second most common cancer in women. It is also the second most common
cause of cancer death. Its incidence rises with age and every year CRC is
diagnosed in approximately 7700 Belgians. Even though men have, at every age,
a higher incidence of CRC, the absolute number of CRC in women is also high
because of their longer life expectancy. Survival after the diagnosis of CRC is
strongly associated with stage of disease at diagnosis: the more localised the
tumor, the better the prognosis. Therefore, early identification of the
malignancy through screening is considered important.
Most CRC occur sporadically, i.e. in individuals without apparent evidence of
increased risk. However, about 25 to 30% of CRC occur in individuals who are
known to be at increased risk, either through a family history of CRC
occurrence or through personal predisposing conditions. Although to date no
exact numbers are available for Belgium, it can be estimated that this population
amounts to about 15% of the general population, assuming an average twofold
risk in this subpopulation as a whole. Those individuals should not be the target
of mass screening programs but nevertheless should be cared for. Therefore,
we included in this report reviews of general recommendations for risk
stratification for CRC and of guidelines for taking care of individuals at
increased or at high risk. Those individuals should be referred to appropriate
regular healthcare.
Many guidelines on CRC screening and surveillance are available worldwide,
including the position paper on cancer screening in the European Union, and we
described many of those. All guidelines recommend CRC screening to be
offered to low risk patients starting at age 50, and all guidelines also
recommend using colonoscopy for the follow-up of individuals with a positive
screening test. However, guidelines disagree on optimal age span of screening
and on optimal screening techniques. If FOBT is chosen as screening technique
the unrehydrated home-administered FOBT is univocally recommended. All
guidelines also recommend total colonoscopy as the first choice method for
individuals at increased CRC risk as well as for surveillance. Guidelines on