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Lawrence von Karsa
Lecture Abstract
The Main Features of the New European Guidelines for Colorectal Cancer Screening
Lawrence von Karsa, European Cancer Screening Network; Quality Assurance Group, Early Detection and Prevention Section, International Agency for Research on Cancer, Lyon, France;
Introduction: Colorectal cancer (CRC) is the second most frequent cancer and the second most frequent cause of cancer deaths in the European Union. According to 2006 estimates of the International Agency for Research on Cancer (IARC) over 300,000 new cases and over 140,000 deaths due to CRC were reported in the EU [1]. Regular, systematic examination of predominantly asymptomatic individuals of average risk and of appropriate age using an evidence-based screening test followed by appropriate treatment has the potential to prevent many deaths due to CRC and thereby significantly reduce the burden of disease in the population. In 2003 the Council of the European Union unanimously adopted a recommendation on cancer screening [2] in which the EU Member States are unanimously invited to implement national screening programmes for breast, cervical and colorectal cancer with a population-based approach and with appropriate quality assurance at all levels, taking into account European quality assurance guidelines for cancer screening, where they exist. Updated and expanded EU guidelines for breast and cervical cancer screening have been published by the European Commission [3, 4]. Although CRC screening programmes are currently running or being established in 19 of the 27 EU member states, comprehensive guidelines for quality assurance of colorectal cancer screening which are suitable for implementation throughout the 27 EU Member States are currently being developed in a project which is coordinated by IARC and co-funded by the EU Health Programme [5]. The other partners in the project are the Cancer Prevention Unit in Turin, the European Cancer Patient Coalition in Brussels, the Public Association for Healthy People in Budapest and the University of Oxford in the UK.
Methods: The EU guidelines for quality assurance in colorectal cancer screening are being developed in a pan-European network of over 100 experts involved in screening programme implementation and research as well as relevant scientific and professional societies, client and patient groups, governmental and other public institutions from all of the 27 EU Member States and two EU applicant countries. A similar sprectrum of experts from countries outside the EU is encouraged to participate in the consensus and review process. The draft outline and content of the guidelines is being prepared in a collaborative, interative process by approximately 50 experts in multidisciplinary editorial, writing, review and literature groups. Using an adapted PICOS format (population, intervention, comparison, outcome, study) the clinically relevant questions for the guidelines are identified in workshops. The literature group conducts systematic searches and data analysis based on a protocol agreed by the expert groups, reports the summary results to the authors and editors, and participates in the final review process of the guideline. Preliminary results have been presented at international and pan-European meetings dealing with colorectal cancer screening in 2008 in Budapest, Copenhagen, Oxford and Vienna and at a transatlantic symposium in 2009 in New York.
Results: An outline of a comprehensive, evidence-based, best practice guideline was developed in 2007 and has been subsequently repeatedly revised and expanded. The evidence collected and analysed to date has been documented in approximately 400 tables, each dealing with a separate publication. The evidence tables have been used to draft and revise 10 chapters dealing with: introduction and epidemiology, organisation, monitoring and evaluation, fecal occult blood testing (FOBT), endoscopy (in screening and in assessment), management of lesions detected in screening, pathology, training and communication. Additional topics will be covered in annexes. The final recommendations will be presented with a supplementary, short, user-friendly format. Although the Council of the EU currently only recommends FOBT for CRC screening, endoscopic screening programmes are currently underway or are being planned or piloted in at least seven EU member states. The EU quality assurance guidelines therefore also deal with quality assurance of endoscopy in screening. In the available space key principles on which the guidelines are based will be presented. The most fundamental principle being that screening should be implemented in the context of an organized, population-based programme following comprehensive quality assurance guidelines. Adequate attention needs to be paid to planning and training, identification and information of the target population, multidisciplinary management of detected lesions, as well as to coordination, monitoring and evaluation. Organized programmes are recommended because they include an administrative structure responsible for implementtation, quality assurance and evaluation. Overall screening outcome and quality depend on the performance at each step in the screening process. Population-based programmes generally require a high degree of organisation in order to identify and personally invite each individual in the eligible target population. The population-based approach to programme implementation is recommended because it provides an organisational framework conducive to effective management and continuous improvement of the screening process such as through linkage with population and cancer registries for optimisation of invitation to screening and for evaluation of screening. And it is essential to making screening available to all those in the target population who may benefit from early detection and improved treatment.
Conclusions: The problems facing health care systems on both sides of the Atlantic are increasingly similar. The underlying principles of quality assurance of colorectal cancer screening apply irrespective of the health care system and the target population. Increased exchange of experience, and cooperation and collaboration in development and implementation of quality assurance for CRC screening has the potential to improve control of this important cause of suffering and death and to provide a model for improvement of control of other chronic disease.
References
1 Ferlay J, Autier P, Boniol M, Heanue M, Colombet M, Boyle P (2007) Estimates of the cancer incidence and mortality in Europe in 2006. Ann Oncol 18: 581-592
2 Council of the European Union 2003 Council of the European Union. Council Recommendation of 2 December 2003 on cancer screening (2003/878/EC). Off J Eur Union 2003; L 327/34-38.
3 European Commission. European Guidelines for Quality Assurance in Breast Cancer Screening and Diagnosis. Fourth edition Perry N, Broeders M, de Wolf C, Törnberg S, Holland R, von Karsa L, Puthaar E (eds). Office for Official Publications of the European Communities, Luxembourg, 2006
4 European Commission. European Guidelines for Quality Assurance in Cervical Cancer Screening. Second edition. Arbyn M, Anttila A, Jordan J, Schenck U, Ronco G, Segnan N, Wiener H, Herbert A, Daniel J, von Karsa L (eds) Office for Official Publications of the European Communities, Luxembourg, 2008
5 Karsa L von, Anttila A, Ronco G, Ponti A, Malila N, Arbyn M, Segnan N, Castillo-Beltran M, Boniol M, Ferlay J, Hety C, Sauvaget C, Voti L, Autier P. Cancer screening in the European Union. Report on the implementation of the Council Recommendation on cancer screening, First report. European Communities, Luxembourg 2008.
