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

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78 Screening for Colorectal Cancer KCE reports vol.45 Study 1. Nottingham 348, 363 2. Funen 350, 351, 208 3. Göteborg 359-362 4. Minnesota 354, 357, 358 5. Burgundy 364, 207 Towler B. & Cochrane CDSR 24 per 1.000 in screening group c, (95% CI) Number needed to screen in screening group, over follow-up time c (95% CI) Relative risk reduction for overall mortality c, point estimate (95% CI) Absolute risk reduction for overall mortality per 1.000 c, point estimate (95% CI) 834 (473 3.484) 0% (-2% 1%) -0,6 (-5,1 3,8) 595 (280 ) 0% (-2% 2%) 1,4 (-6,3 9,1) - - - 268 (169 644) 0% (-3% 3%) 0,6 (-9,9 11,1) 499 (234 ) 1% (-2% 4%) 2,4 (-8,1 13,0) 903 (472 10.449) 1.173 (741 2.807) - - - - * At least 1 screening completed a Case notes revealed that patient had been in the screening group b CRC was considered as the cause of death when occuring 30 days post CRC surgery, in case of clinically or histologically demonstrated recurrence, or if patient received palliative treatment without evidence of another underlying cause of death c Using UBC Clinical Significance Calculator: http://www.healthcare.ubc.ca/calc/clinsig.html
KCE reports vol.45 Screening for Colorectal Cancer 79 A recently published meta-analysis of controlled trials on colorectal cancer screening by FOBT 209 reviewed in depth the effectiveness of screening for CRC with FOBT and they also included the French study results, not taken up in previous meta-analyses. The aim was to consider the reduction in mortality during or after screening and to try to identify factors associated with a significant mortality reduction. A meta-analysis of four controlled trials, selected for their biennial and population-based design, was conducted. The main outcome measurements were mortality (RR and 95% CI) of biennial FOBT during short (10 years, i.e. five or six rounds) or long-term (six or more rounds) screening periods, as well as after stopping screening and follow-up during 5 - 7 years. The meta-analysis used the Mantel-Haenszel method with fixed effects when the heterogeneity test was not significant, and to additionally test for potential impact of heterogeneity they excluded each of the studies in turn. Analysis was on an 'intention to screen' basis. Although the quality of the four trials was high, only three were randomized (Nottingham, Funnen and Minnesota), and one (Minnesota) used rehydrated biennial FOBT associated with a high colonoscopy rates (28%) due to the higher sensitivity and the lower specificity of the rehydrated test. A meta-analysis of mortality results showed that subjects allocated to screening had a 14% reduction of CRC mortality during a 10-year period (RR 0,86; CI: 0,79 - 0,94), although CRC mortality was not decreased during the 5 to 7 years after the 10-year (six rounds) screening period, nor in the last phase (8 - 16 years after the onset of screening) of a long-term (16 years or nine rounds) biennial screening. Whatever the design or the period of ongoing FOBT, CRC incidence neither decreased nor increased, although it was reduced for 5 - 7 years after the 10-year screening period. Neither the design nor the clinical or demographic parameters of these trials could be shown to be independently associated with CRC mortality reduction. Whatever the endpoint chosen for mortality assessment in the meta-analysis, there was never a significant decrease in overall mortality from all causes. This is, however, not surprising because CRC mortality represents only a small proportion of overall mortality in both the intervention groups and the control groups (range 2,84 to 3,59%). The authors concluded that biennial FOBT screening decreased CRC mortality by 14% when performed over 10 years, without evidence-based benefit on CRC mortality when performed over a longer period. In conclusion: performing an annual fecal occult blood test (FOBT) is one of several recommended options for colorectal cancer screening in the average risk population beginning at age 50. Annual or biennial screening with gFOBT has been shown in large, randomized trials to have a significant and beneficial effect on colorectal cancer incidence and mortality, but there was never a significant decrease in overall mortality from all causes. Furthermore, while the specificity of these tests is generally high, sensitivity is poor. Complicated dietary restrictions prior to testing and sampling instructions may limit patient compliance. 5.5.2 Immunochemical Fecal Occult Blood Tests Newer immunochemical FOBTs (iFOBT) are reported to have improved performance characteristics compared to guaiac tests without a need for dietary restrictions. However, no large scale prospective RCTs of iFOBT screening and CRC incidence or mortality outcomes have been reported so far. On the other hand, if iFOBTs perform at least as well as gFOBT, it is likely that iFOBTs used for CRC screening would have at least the same efficacy in decreasing CRC mortality as gFOBTs 270.
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KCE reports vol.45A Colorectale Kan
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KCE reports 1. Effectiviteit en kos
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