Xavier Llor, MD, PhD, American Gastroenterological Association education committee chair, and medical director of the New Haven, Conn.-based Yale University's colorectal cancer prevention program, spoke to Becker's ASC Review about CRC screening guidelines and what physicians can do to raise screening rates in their communities.
Note: These responses were edited for style.
Question: When the American Cancer Society first made its recommendation, it seemed like it sent waves through gastroenterology world, how did you perceive the guideline?
Xavier Llor: The initial concern was how we were going to screen 9 million more Americans if we are already struggling to screen many of the 50 and older individuals. The very positive aspect of that is these recommendations generated an important debate. Through this we have recognized many of the gaps in knowledge that would be better informed if this screening age decrease would eventually have its intended effects.
Q: Now with the Canadian Association of Gastroenterology partially advising for starting screening at 45, do you believe this is a trend that will continue?
XL: What fostered reaching this conclusion by the ACS and the Canadian Association is the very rapid increase in colorectal cancer incidence in younger individuals, opposed to the steady decline of CRC in the 50 year and older population. Subsequent microsimulation modeling also suggested an important gain in life-years when [a patient] started screening at 45
Q: Do you believe this is the beginning of a larger trend, as early-onset CRC cases continue to increase?
XL: Certainly if the trend continues, it is more likely earlier screening can gather more enthusiasm. There are though important considerations. Among others, in spite of this trend, the burden of disease in the 45- to 49-year-old population is still much lower in magnitude than in the 50 year and older population. It is also unclear if the commonly used screening methods will be as effective for this group. We are not clear if the biology of these tumors differs and if cancer development in these cases is faster or not different than that of older patients. Another important aspect many are concerned about is if this will result in negative effects if we shift resources from populations at higher risk (those over 50) to lower risk groups.
Q: Could you share some insight into your committee's thought process on CRC screening?
XL: The AGA does have its mechanisms outside our committee to deal with guidelines and recommendations. The AGA officially does support the ACS recommendations of starting screening at 45 years, but at the same time will continue reviewing evidence and make adjust recommendations according to new knowledge.
Q: Is there anything GI physicians can do to increase CRC screening rates in their individual communities?
XL: We can help educate not only the community but also other providers on screening importance of screening. We need to help establish organized screening programs that reach out to the more challenged individuals. We need to facilitate screening for the underserved that are often in situations with limited options. We need to advocate for everyone in our community because we want everyone to be colon cancer-free, no matter who they are or how many resources they have.