Testimony

Statement by
George A. Mensah, M.D.
Acting Director
National Center for Chronic Disease Prevention
and Health Promotion
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services

on
Colorectal Cancer Screening
before
The Cancer Coalition, United States Senate

March 16, 2005

Good Morning. I am Dr. George Mensah, the Acting Director of the National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention (CDC), and also a board certified internist and cardiologist. I am pleased to discuss CDC's efforts in promoting colorectal cancer screening and prevention.

Disease Burden/Screening

Colorectal cancer is the second leading cause of cancer-related death in the nation, after lung cancer. In 2005, it is estimated that 56,300 Americans will die from colorectal cancer and approximately 145,300 new cases will be diagnosed. Colorectal cancer incidence increases with age, and over 90 percent of colorectal cancers occur in adults aged 50 or older. Screening has been shown to reduce both incidence and mortality from colorectal cancer. Through regular screening, precancerous polyps can be identified and removed, there by preventing the development of colorectal cancer. Colorectal cancers can also be detected early, leading to more effective treatment. Fifty to 60 percent of deaths from colorectal cancer could be prevented if everyone aged 50 or older were screened regularly.

The U.S. Preventive Services Task Force and several scientific organizations recommend regular screening for all adults aged 50 years or older. Specifically, screening with one, or a combination, of the following tests is recommended for average-risk men and women aged 50 years or older:

  1. Fecal occult blood test (FOBT) performed at-home (annually)
  2. Flexible sigmoidoscopy (every 5 years)
  3. Colonoscopy (every 10 years)
  4. Double contrast barium enema (every 5 years)

It should be noted that persons at higher risk should begin screening at a younger age and may need to be tested more frequently. Persons at increased risk for colorectal cancer are those with a personal or family history of colorectal cancer or polyps, Inflammatory Bowel Disease or certain hereditary disorders such as Hereditary Non-Polyposis Colorectal Cancer.

Despite evidence demonstrating the effectiveness of colorectal cancer screening tests, colorectal cancer screening lags far behind screening for other cancers, such as breast and cervical cancers. Based upon CDC's 2000 National Health Interview Survey (NHIS) published in Cancer, only 42.5 percent of adults 50 years or older (45 percent of men and 41 percent of women) had been screened according to guidelines, (sigmoidoscopy or colonoscopy within the previous 10 years or a fecal occult blood test (FOBT) home test kit within the preceding year).

Our colleagues at the National Cancer Institute (NCI) and the Food and Drug Administration (FDA) continue to explore and approve new technologies for colorectal cancer. For example, virtual colonoscopy, stool DNA testing, and the camera pill are new technologies that may be widely used in the future. Virtual colonoscopy and stool DNA testing are already in use in some health care settings; however, data are not yet sufficient to support these tests for wide-spread colorectal cancer screening. Until these new technologies are deemed safe and more effective for the public, we need to focus on promoting broader use of the currently recommended screening tests for colorectal cancer.

The key health benefits of colorectal cancer screening are to find and remove colorectal polyps before they become colorectal cancer, thereby preventing the development of the cancer altogether, and to identify early cancers when the disease is at a more treatable stage. Overall, survival is greatly enhanced when colorectal cancers are detected and treated early.

The Department of Health and Human Services has established a goal through the Healthy People 2010 objectives to reduce the colorectal cancer death rate to 16.5 per 100,000 by 2010. To help achieve this very important public health goal, CDC has implemented a series of colorectal cancer initiatives designed to provide national leadership in support of colorectal cancer prevention and early detection. These cancer prevention and control efforts cover four main areas - intervention research, health promotion, public health program, and partnerships.

Intervention Research

We have learned much about colorectal cancer. Most colorectal cancers develop from precancerous polyps in a slow, predictable fashion, allowing time to intervene and halt that progression with screening tests. Regular screening will reduce new colorectal cancer cases and deaths from colorectal cancer. CDC recently published several studies related to colorectal cancer screening. One study, published in January 2005 in the Annals of Internal Medicine, highlights information from "A National Survey of Primary Care Physicians' Methods for Screening for Fecal Occult Blood study." This study was a collaborative effort between CDC, the NCI, and the Centers for Medicare & Medicaid Services (CMS) that examined how colorectal cancer screening and follow-up are conducted in community practice. The study found that some physicians might not be following the recommended national guidelines for performing the fecal occult blood test (FOBT) when they screen patients for colorectal cancer. The study concluded that FOBT is often not performed, or if it is, follow-up is not pursued as recommended; therefore, fewer lives may be saved than are potentially possible. CDC plans to address topics such as this one with a new training and education effort designed to reach practicing clinicians with disease prevention and health promotion messages.

Two articles published in the December 2004 issue of Gastroenterology provide information on the nation's ability to screen the U.S. population for colorectal cancer. The study found that of the 70.1 million persons aged 50 years or older in the U.S. at average risk for colorectal cancer, only 28.3 million have been screened appropriately for colorectal cancer, leaving 41.8 million persons not screened appropriately for colorectal cancer. Approximately three million flexible sigmoidoscopies and 14 million colonoscopies were performed in 2002, but these procedure numbers could be increased by 30 to 60 percent. Lastly, the study further showed that the health care system currently has the capacity to screen the U.S. population using FOBT with colonoscopy for follow-up of positive tests. Widespread screening with flexible sigmoidoscopy or colonoscopy may take up to 10 years, depending on the proportion of available capacity used for colorectal cancer screening. Additional data from this study, soon to be published, shows that in 2002, waiting times for these endoscopic procedures were up to six months, longer in urban than rural areas. The results of these studies provide baseline information to address nationwide planning for colorectal screening and follow-up examination. Data from two CDC surveillance systems, the Behavioral Risk Factor Surveillance System (BRFSS) and the National Health Interview Survey (NHIS), were used for these studies. This week, CDC's Morbidity and Mortality Weekly Report will highlight some of these studies.

CDC is in the process of planning a new screening initiative directed at gaining critical knowledge about colorectal cancer and screening. Based upon recently published CDC survey data (NHIS), we know that persons who are uninsured or have lower incomes are less likely to be screened for colorectal cancer. Through a series of demonstration programs, CDC will assess the feasibility and cost of implementing organized community-based colorectal cancer screening in health care settings that include low-income, uninsured, or underinsured persons. CDC will fund three sites over a three-year project period to perform colorectal cancer screening services and diagnostic follow-up, and to evaluate the provision of those services. The project sites will be announced after a program announcement has been issued and selections made in the summer of 2005. We hope to learn critical information from these demonstration programs that will allow us to better address future widespread colorectal cancer screening.

Health Promotion

In addition to colorectal cancer research efforts, CDC and CMS created the Screen for Life: National Colorectal Cancer Action Campaign to reach the American public in 1999. Screen for Life (SFL), a multimedia health promotion campaign, is designed to educate men and women aged 50 years or older about colorectal cancer and the importance of having regular colorectal cancer screening tests. English and Spanish language campaign materials explain colorectal cancer screening and encourage health consumers to speak with their doctors about getting screened. SFL also provides resources, such as A Call to Action, a Web-based educational Power-Point slide set designed to provide health care professionals with an overview on the benefits of colorectal cancer screening and encourage them to recommend screening to their patients aged 50 years or older.

This year, CDC is partnering with television personality Katie Couric and her organization, the National Colorectal Cancer Research Alliance (NCCRA), and the Entertainment Industry Foundation (EIF) to broaden the reach and appeal of the SFL campaign. Together, CDC, NCCRA and EIF have developed and produced new public service advertisements (PSAs), which debuted on the "Today Show" March 14, 2005. These new materials were released by CDC Director Dr. Julie Gerberding, and included a poster, print ad and airport diorama featuring Katie Couric, as well as television PSAs featuring Academy Award-winning actor Morgan Freeman.

Public Health Programs

CDC also works through its National Comprehensive Cancer Control Program to integrate prevention and control activities across the continuum of care for all cancers, including colorectal cancer. The objectives are to use resources as efficiently as possible, improve community-based education and health promotion, share expertise, and effectively address at-risk populations. CDC works directly with state health departments, tribes, and territories to accomplish these objectives. Through the comprehensive cancer control program, CDC funds 16 state programs - Alabama, Colorado, Georgia, Iowa, Kentucky, Louisiana, Maine, Massachusetts, Michigan, New Mexico, New York, North Carolina, Rhode Island, Utah, Washington and West Virginia - to implement specific colorectal cancer strategies within their statewide cancer control plans. These programs can serve as models for other states.

Partnerships

CDC works with both federal and non-governmental organizations, including NCI, CMS and the American Cancer Society (ACS). Since 1997, CDC and ACS have led the National Colorectal Cancer Roundtable, a network of over 60 public and private organizations that promote colorectal cancer awareness and screening on the national level. CDC and its partners look to provide coordination and collaboration to reduce the national burden of colorectal cancer. The success of CDC's efforts hinge on getting all adults aged 50 or older screened for colorectal cancer. CDC will continue to advance colorectal cancer prevention and control efforts by promoting colorectal cancer screening to save more lives.

We know that in the future with continued research, new tests may be added to our current list of recommended screening tests. CDC encourages the use of proven safe and effective screening tests to reduce colorectal cancer cases and deaths. CDC is committed to working with our partners to explore the feasibility and efficacy for safe new technologies for screening.

Thank you for your interest and support of colorectal cancer screening. I would be happy to answer any questions you may have.

Last Revised: March 16, 2005