Reply: Screening for colorectal cancer with immunological FOBT

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Evaluation of the benefits, harms and cost‐effectiveness of potential alternatives to iFOBT testing for colorectal cancer screening in Australia

The Australian National Bowel Cancer Screening Program (NBCSP) will fully roll‐out 2‐yearly screening using the immunochemical Faecal Occult Blood Testing (iFOBT) in people aged 50 to 74 years by 2020. In this study, we aimed to estimate the comparative health benefits, harms, and cost‐effectiveness of screening with iFOBT, versus other potential alternative or adjunctive technologies. A comprehensive validated microsimulation model, Policy1‐Bowel, was used to simulate a total of 13 screening approaches involving use of iFOBT, colonoscopy, sigmoidoscopy, computed tomographic colonography (CTC), faecal DNA (fDNA) and plasma DNA (pDNA), in people aged 50 to 74 years. All strategies were evaluated in three scenarios: (i) perfect adherence, (ii) high (but imperfect) adherence, and (iii) low adherence. When assuming perfect adherence, the most effective strategies involved using iFOBT (annually, or biennially with/without adjunct sigmoidoscopy either at 50, or at 54, 64 and 74 years for individuals with negative iFOBT), or colonoscopy (10‐yearly, or once‐off at 50 years combined with biennial iFOBT). Colorectal cancer incidence (mortality) reductions for these strategies were 51–67(74–80)% in comparison with no screening; 2‐yearly iFOBT screening (i.e. the NBCSP) would be associated with reductions of 51(74)%. Only 2‐yearly iFOBT screening was found to be cost‐effective in all scenarios in context of an indicative willingness‐to‐pay threshold of A$50,000/life‐year saved (LYS); this strategy was associated with an incremental cost‐effectiveness ratio of A$2,984/LYS–A$5,981/LYS (depending on adherence). The fully rolled‐out NBCSP is highly cost‐effective, and is also one of the most effective approaches for bowel cancer screening in Australia

Fecal Tests: From Blood to Molecular Markers

Detection of molecular markers for colorectal neoplasia in feces has the potential to improve performance of simple noninvasive screening tests for colorectal cancer. Most research has explored the value of DNA-based, RNA-based, and protein-based markers. In all cases there has been a trend to move from a single marker to a panel of markers to improve sensitivity. Unfortunately, no type of molecular marker has proved specific for neoplasia. DNA tests have been improved by combining mutation detection with assessment of DNA integrity plus epigenetic markers of neoplasia. RNA-based approaches are just beginning to explore the full power of transcriptomics. So far, no protein-based fecal test has proved better than fecal immunochemical tests for hemoglobin. Finally, no marker or panel of markers has yet been developed to the point where it has been evaluated in large unbiased population studies to assess performance across all stages of neoplasia and in all practical environments

Estimating the referral rate for cancer genetic assessment from a systematic review of the evidence

To estimate the optimal proportion of new patients diagnosed with cancer who require assessment and evaluation for familial cancer genetic risk, based on the best evidence available. We identified evidence of the patients who require assessment for familial genetic risk when diagnosed with cancer through extensive literature reviews and searches of guidelines. Epidemiological data on the distribution of cancer type, presence of a family history, age and other factors that influence referral for genetic assessment were identified. Decision trees were constructed to merge the evidence-based recommendations with the epidemiological data to calculate the optimal proportion of patients who should be referred. We identified ‘high probability' and ‘moderate probability' groups for having a genetic susceptibility. The proportion of patients diagnosed with cancer in Australia who have a high probability of having a genetic predisposition and who should be referred for genetic assessment is 1%. If the moderate probability group is also assessed this proportion increases to 6%. This model has identified the proportion of new patients diagnosed with cancer who should be referred for genetic assessment. This data is the first step in determining the resources required for provision of an adequate cancer genetic service

Colorectal cancer risk assessment and screening recommendation: a community survey of healthcare providers' practice from a patient perspective

<p>Abstract</p> <p>Background</p> <p>Family history is a common risk factor for colorectal cancer (CRC), yet it is often underused to guide risk assessment and the provision of risk-appropriate CRC screening recommendation. The aim of this study was to identify from a patient perspective health care providers' current practice relating to: (i) assessment of family history of CRC; (ii) notification of "increased risk" to patients at "moderately/potentially high" familial risk; and (iii) recommendation that patients undertake CRC screening.</p> <p>Methods</p> <p>1592 persons aged 56-88 years randomly selected from the Hunter Community Study (HCS), New South Wales, Australia were mailed a questionnaire. 1117 participants (70%) returned a questionnaire.</p> <p>Results</p> <p>Thirty eight percent of respondents reported ever being asked about their family history of CRC. Ever discussing family history of CRC with a health care provider was significantly more likely to occur for persons with a higher level of education, who had ever received screening advice and with a lower physical component summary score. Fifty one percent of persons at "moderately/potentially high risk" were notified of their "increased risk" of developing CRC. Thirty one percent of persons across each level of risk had ever received CRC screening advice from a health care provider. Screening advice provision was significantly more likely to occur for persons who had ever discussed their family history of CRC with a health care provider and who were at "moderately/potentially high risk".</p> <p>Conclusions</p> <p>Effective interventions that integrate both the assessment and notification of familial risk of CRC to the wider population are needed. Systematic and cost-effective mechanisms that facilitate family history collection, risk assessment and provision of screening advice within the primary health care setting are required.</p

Trends in colon and rectal cancer incidence in Australia from 1982 to 2014: Analysis of data on over 375,000 cases

Background: Incidence of pancreatic cancer is higher in African Americans than in U.S. whites. We hypothesized that poor oral health, disproportionately common in African Americans and associated with increased risk of pancreatic cancer in several studies of predominantly white populations, may play a role in this disparity. Methods: We examined the relation of self-reported measures of oral health (periodontal disease and adult tooth loss) in relation to pancreatic cancer incidence in the prospective Black Women's Health Study (BWHS). Cox proportional hazard analyses were used to calculate HRs of pancreatic cancer for women with periodontal disease, tooth loss, or both, relative to women who reported neither. Multivariable models adjusted for age, cigarette smoking, body mass index (BMI), type 2 diabetes, and alcohol consumption. Results: Participants aged 33 to 81 were followed for an average of 9.85 years from 2007 through 2016, with occurrence of 78 incidence cases of pancreatic cancer. Multivariable HRs for pancreatic cancer incidence were 1.77 [95% confidence interval (CI) 0.57–5.49] for periodontal disease with no tooth loss, 2.05 (95% CI, 1.08–3.88) for tooth loss without report of periodontal disease, and 1.58 (95% CI, 0.70–3.57) for both tooth loss and periodontal disease. The HR for loss of at least five teeth, regardless of whether periodontal disease was reported, was 2.20 (95% CI, 1.11–4.33). Conclusions: The poor oral health experienced by many African Americans may contribute to their higher incidence of pancreatic cancer. Impact: Future research will assess associations between the oral microbiome and pancreatic cancer risk in this population