Is it worth to do screening for colorectal cancer in Hong Kong?

1. Is it worth to do screening for colorectal cancer in Hong Kong? Dr WONG Kiu Fung North District Hospital

2. Why screening colorectal cancer in Hong Kong Is colorectal cancer common in HK? Can screening able to improve mortality? Any good screening tools? Any evidence to support screening?

3. Colorectal Cancer (CRC) Commonest cancer in Hong Kong (16.5% of all new cancer cases in 2013) 2nd leading cause of cancer deaths in HK. (2,073 people died of the CRC, 14.5% of all cancer deaths in 2015. ) 3rd most prevalent cancer worldwide (1million new cases and ½ million death per year)

4. Prevention is better than Cure

5. In Hong Kong Insufficient local evidence to support a population-based colorectal cancer screening programme.

6. Effectiveness of screening to reduce colorectal cancer mortality: Flexible sigmoidoscopy

7. Effectiveness of screening to reduce colorectal cancer mortality: Faecal occult blood test (FOBT)

8. Benefit of screening and Early Intervention US Preventive Services Task Force (USPSTF) 2016 Recommendation Statement: Screening for colorectal cancer in adults (average risk) aged 50-75years reduced CRC mortality and potential CRC incidence.

9. What screening tool is the best No head-to-head studies demonstrating which strategies is the most effective. Different screening methods have their own strengths and limitations

10. Faecal Immunochemical Test (FIT) • FOBT screening effectively reduces CRC mortality by 15-33% • FIT is more superior than previous guaiac FOBT • Used in many population based screening: • Sensitive, Simple to use, safe, cheap, reproducible result

11. Prospective Diagnostic Accuracy Studies of FIT Tests (with or without stool DNA Test) Using Colonoscopy Reference Standard

12. Visualization Tests

13. Harms of Screening Harm of Colonoscopy Screening

14. Potential barriers to population based endoscopic screening Insufficient endoscopic staff Possible complications Government financial burden Lack of established colonoscopy quality indicators

15. Diagnostic Accuracy of Screening CT Colonography (CTC) Detect adenoma CTC with bowel prep has sensitivity to detect adenoma 6mm and larger comparable with colonoscopy.

16. Harms of CTC Screening • Harm of CT Colonography • Little to no risk of serious adverse events • Estimated radiation dose: 4.5-7mSv • Extra-colonic findings were common (27-69%)

17. Benefits of Colorectal Screening Strategies Over a Lifetime 90% life-years gained compare with CLN Life Years Gained

18. Colorectal cancer screening recommendations for guaiac-based fecal occult blood test, fecal immunochemical test and colonoscopy among asymptomatic average-risk adults USPSTF: US Preventive Service Task Force CTFPHC: Canadian Task Force on Preventative Health Care CAG: Canadian Association of Gastroenterology ACG: American College of Gastroenterology

19. In Hong Kong In 2010, Cancer Expert Working Group on Cancer Prevention and Screening (CEWG) recommends individuals aged 50 to 75 to discuss with their doctor and consider screening for colorectal cancer (CRC).

20. In 2016, Population-based colorectal cancer screening pilot program

21. Target Age group: 61-70 years old

22. Two Tier Approach *The assumption is based on the findings of the 5-year CRC screening project conducted by CUHK from May 2008 to Oct 2012.

23. Workload Estimation(based on 2016 population estimate)3-year biennial FIT for eligible persons Remarks: *Each participation will receive 2FIT. For each participant with negative result, he will have next FIT 2 years later. # The assumption is based on the findings of the 5-yr CRC screening project conducted by CUHK from May 2008 - Oct 2012 ^ The assumption is based on the survey findings on 456 community dwelling elderly aged 66-75 conducted by DH in July 2013

24. Take Home Message Screeningfor colorectal cancer in adults (average risk) aged 50-75years reduced CRC mortality. Many types of screening methods. Goal: adequate participationamong eligible population and maintain adherence over time. It is worth to promote colorectal cancer screening in Hong Kong

25. Reference US Preventive Services Task Force. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2016 Jun 21;315(23):2564-75. doi: 10.1001/jama.2016.5989. Lin JS, Piper MA, Perdue LA, et al. Screening for Colorectal Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2016 Jun 21;315(23):2576-94. doi: 10.1001/jama.2016.3332. Duffy MJ, van Rossum LG, van Turenhout ST, et al. Use of faecal markers in screening for colorectal neoplasia: a European group on tumor markers position paper.Int J Cancer. 2011 Jan 1;128(1):3-11. doi: 10.1002/ijc.25654. Young GP, Symonds EL, Allison JE, et al. Advances in Fecal Occult Blood Tests: the FIT revolution. Dig Dis Sci. 2015 Mar;60(3):609-22. doi: 10.1007/s10620-014-3445-3. Epub 2014 Dec 10. Sano Y, Byeon JS, Li XB, et al. Colorectal cancer screening of the general population in East Asia. Dig Endosc. 2016 Apr;28(3):243-9. doi: 10.1111/den.12579. Epub 2016 Feb 4. Shahidi N, Cheung WY. Colorectal cancer screening: Opportunities to improve uptake, outcomes, and disparities. World J Gastrointest Endosc. 2016 Dec 16;8(20):733-740. doi: 10.4253/wjge.v8.i20.733. Huang JL, Chen P, Yuan X, et al. Tailoring choice between colonoscopy versus sigmoidoscopy for population-based colorectal cancer screening in Chinese patients: a prospective colonoscopy study. Lancet. 2016 Oct;388 Suppl 1:S87. doi: 10.1016/S0140-6736(16)32014-1. Lansdorp-Vogelaar I, Knudsen AB, Brenner H. Cost-effectiveness of colorectal cancer screening. Epidemiol Rev. 2011;33:88-100. doi: 10.1093/epirev/mxr004. Epub 2011 Jun 1. Wong JC, Lau JY, Suen BY, et al. Prevalence, distribution, and risk factor for colonic neoplasia in 1133 subjects aged 40-49 undergoing screening colonoscopy. J Gastroenterol Hepatol. 2017 Jan;32(1):92-97. doi: 10.1111/jgh.13450. Wong MC, Ching JY, Chan VC, et al. Colorectal Cancer Screening Based on Age and Gender: A Cost-Effectiveness Analysis. Medicine (Baltimore). 2016 Mar;95(10):e2739. doi: 10.1097/MD.0000000000002739. Wong MC, Ching JY, Chan VC, Sung JJ. The comparative cost-effectiveness of colorectal cancer screening using faecal immunochemical test vs. colonoscopy. Sci Rep. 2015 Sep 4;5:13568. doi: 10.1038/srep13568. John M. Inadomi. Screening for Colorectal Neoplasia. N Engl J Med 2017;376:149-56. Hong Kong Cancer Registry Website Department of Health (http://www.colonscreen.gov.hk/en/)

26. Some studies in HK tried to address the effectiveness of different screening tools and some suggested that colonoscopy is the most cost effectiveness. However, its application to a population based screening is very difficult.

31. Data Source: Hong Kong Population Projections published by the Census and Statistics Department of the Hong Kong Special Administrative Region in 2016 Around 1million Around 1.5 million Hong Kong’s ageing population is the combined result of rising life expectancy and declining fertility rate. As shown in the following diagrams, the increasing proportion of elderly people and declining proportion of younger people will result in an inverted population pyramid in 2040.

32. Singapore https://www.moh.gov.sg/content/moh_web/home/pressRoom/Parliamentary_QA/2014/crc-screening.html

34. Stool-Based Tests

35. Screening in younger age?

36. Why not start screening at earlier age Effectiveness of screening to reduce colorectal cancer mortality: Flexible sigmoidoscopy and Hemoccult II RCTs

37. Implementation strategies Remainder systems Media Reduce structural barriers to screening Allow feedback about screening test

38. USPSTF 2016 Recommendation highlight: Screening substantially reduces deaths from CRC among aged 50 to 75 years Inadequate participation of the eligible population is the key problem No preference among screening options

39. Groups and organizations recommending screening for colorectal neoplasia

40. USPSTF recommendation onScreening for Colorectal Cancer A systematic evidence review to update its 2008 recommendation on screening for CRC. A report from the Cancer Intervention and Surveillance Modeling Network (CISNET): Comparative modeling on optimal starting and stopping ages and screening intervalsacross the different available screening methods.

41. Effectiveness of screening to reduce colorectal cancer mortality: Flexible sigmoidoscopy and Hemoccult II RCTs

42. Prospective Diagnostic Accuracy Studies of FIT Tests (with or without stool DNA Test) Using Colonoscopy Reference Standard .

43. Prospective Diagnostic Accuracy Studies of Screening CT Colonography (CTC) Detect adenoma • CTC with bowel prep had sensitivity to detect adenoma 6mm and larger comparable with colonoscopy.

44. Targeted Age Group for Screening

45. Implementation Main goal: to maximize the total number of persons who are screened because that will have the largest effect on reducing CRC deaths. Engaging patients in informed decision making about the screening method that would most likely result in completion