Implications of new colorectal cancer screening technologies for primary care practice

Abstract

Colorectal cancer (CRC) screening reduces the risk of CRC mortality but is currently not well utilized, with adherence only 50% in the eligible U.S. population and rates that lag behind those for breast and cervical cancer. The primary care physician has the pivotal role of facilitating patient adherence to CRC screening by informed choice of the screening tests, follow up of positive tests, and coordination of medical resources when diagnostic intervention is required. Consequently, the primary care setting is where significant improvements can be made in CRC screening adherence. This article provides a summary of the newer CRC screening technologies that can be used by primary care physicians in shared decision making with their patients.

There are now multiple CRC screening tests which vary in their ability to detect the different stages in the adenoma to carcinoma sequence. Current guidelines of the Multi-Society (Gastroenterology) Task Force (1997, 2003, 2006, 2008), the American Cancer Society (2001, 2003, 2007, 2008), and the United States Preventive Services Task Force (2002) recommend a menu of CRC screening options, including fecal occult blood tests (FOBT) (Hemoccult II, Hemoccult SENSA, fecal immunochemical tests (FIT)), double contrast barium enema (DCBE), flexible sigmoidoscopy with or without annual FOBT’s, and colonoscopy. In this report, we assess the options of fecal immunochemical tests, colonoscopy, CT-colonography (CTC or virtual colonoscopy), and fecal DNA tests. The tests are discussed with respect to the evidence in support of their use and within the context of how they could be managed and implemented in primary care practice. Primary care physicians will want to understand the tradeoffs among accuracy, costs, and patient preferences for the current and emerging CRC tests.