Tristan Rogers Message Board

Many colon cancer patients aren't getting the screenings recommended after surgery to make sure the disease hasn't returned, new research shows.

Only about 40 percent of the 4,426 older patients in the study got all the doctor visits, blood tests and the colonoscopy advised in the three years after cancer surgery, according to the results released Monday by the journal Cancer.

While nearly all made the doctor visits and almost three-quarters got a colonoscopy, many didn't get the blood tests that can signal a return of colon cancer, according to the researchers at University Hospitals Case Medical Center in Cleveland.

Whether doctors didn't offer the tests or patients failed to get them isn't known, said Dr. Gregory Cooper, who led the study. He said perhaps the follow-up care was being provided by doctors who aren't specialists and who aren't familiar with the guidelines.

"I would probably put most of the blame on the providers," said Cooper, a gastroenterologist at the hospital.

About 149,000 Americans are expected to be diagnosed with colorectal cancer this year. Survival after five years varies from 90 percent for cancer that hasn't spread to 10 percent for advanced cases.

Cooper and his colleagues used a federal database of cancer cases and Medicare records for patients to see if the guidelines were being followed. They focused on those 66 and older with less advanced cancer who had surgery that could cure them.

Patients were tracked for three years, beginning six months after surgery. When the study began in 2000, the minimum guidelines called for at least two doctor visits a year, twice yearly blood tests for two years and a colonoscopy within three years. Cooper said a colonoscopy is now recommended in the first year.

Overall, 60 percent of the patients didn't meet the guidelines. Of those who did, more than half actually got advanced medical scans like CT scans and PET scans that are not recommended for routine screening. The scans could have been done because of signs or symptoms of a recurrence but the researchers said they suspect they were done for routine follow-up.

There was less screening among older age groups, African-Americans and those with other health problems.

"Quite honestly, I'm sorry to say, I'm not surprised about the findings," said Dr. Len Lichtenfeld, deputy chief medical officer for the American Cancer Society, which funded the study. Despite advanced medical technology, "our ability to deliver the recommended care to patients has left something to be desired."

With the information resources available today, he said patients can take an active role in their follow-up care and make sure that they are getting the screenings they need.

___

On the Net:

American Cancer Society: http://www.cancer.org/

News Link

Nearly two-thirds of hospitals fail to check colon cancer patients well enough for signs that their tumor is spreading, says a study that advises patients to ask about this mark of quality care before surgery.

National guidelines say when colon cancer is removed, doctors should check at least 12 lymph nodes for signs of spread. Checking fewer than 12 isn't considered enough to be sure the cancer is contained.

But a study of nearly 1,300 hospitals found that overall, just 38 percent fully comply with the guideline, Northwestern University researchers report Tuesday in the Journal of the National Cancer Institute.

"It's a fairly simple thing we can do to try to improve care for our patients," said lead author Dr. Kyle Bilimoria, of Northwestern and the American College of Surgeons.

Colorectal cancer is the nation's second leading cancer killer, set to claim almost 50,000 lives this year.

Some 148,000 Americans are diagnosed annually. For many, the node check can be crucial. Whether cancer has entered these doorways to the rest of the body is an important factor in long-term survival — and thus helps doctors decide who gets chemotherapy after surgery and who can skip it.

"Patients who could benefit from additional chemotherapy may not be getting complete treatment and have a higher chance of relapse," said Dr. Durado Brooks of the American Cancer Society, who wasn't involved with the study. "It is something that consumers need to begin asking. ... Frankly, that is most likely to change medical practice."

To check enough nodes, surgeons must remove enough of the fat tissue by the colon where they hide, and pathologists must painstakingly dissect that tissue to find the tiny nodes.

Surgeons frequently tell of getting a pathology report of four clean nodes and asking the pathologist to find more, "and lo and behold, one of those additional nodes turns out to be positive," Bilimoria said.

Previous studies have estimated that up to half of colon cancer patients have at least 12 nodes checked. Bilimoria's study is the first look at which hospitals are most likely to follow the guideline — and will report the rates directly to each institution. His team examined a national cancer database for records showing which hospitals checked 12 or more lymph nodes in at least 75 percent of eligible patients in 2004 and 2005, the latest data available.

National Cancer Institute-designated "Comprehensive Cancer Centers" did the best job, with 78 percent complying. Just under 34 percent of community hospitals, which are far more common and care for many more patients, complied. Just over half of other academic medical centers and Veterans Administration hospitals met the standard.

Improvement takes work from both surgeons and pathologists, Bilimoria said, noting that Northwestern went from about 50 percent compliance a decade ago to full compliance today.

But he expects more 12-node checks soon, saying the National Quality Forum recently listed the standard as a sign of quality care and that at least one insurance giant has begun requiring proof of 12-node checks before listing surgeons as preferred providers.

Meanwhile, he advises patients to ask about the 12-node check in choosing a surgeon and to check their pathology report to be sure it was done.

News Link

PHILADELPHIA – Most people over 75 should stop getting routine colon cancer tests, according to a government health task force that also rejected the latest X-ray screening technology.

The U.S. Preventive Services Task Force — in a break with other medical and cancer organizations — opted not to give its stamp of approval to the newest tests: CT colonography, an X-ray test known as virtual colonoscopy, and a stool DNA test. The panel said more research is needed.

The task force for the first time did endorse three tests and said everyone age 50 to 75 should get screened with one of them:

• a colonoscopy of the entire colon every 10 years

• a sigmoidoscopy of the lower colon every 5 years, combined with a stool blood test every three years

• a stool blood test every year

After reviewing research on the tests, the government-appointed panel of independent medical experts concluded that the benefits of detecting and treating colon cancer decline after age 75 and the risks rise. Colonoscopy complications can include infection, perforated colon and reactions to sedatives.

Doctors may decide to continue screening those between 76 and 85 because of the patient's medical history and risk factors but there's very little reason to routinely test anyone older than 85, according to the guidelines published in Tuesday's Annals of Internal Medicine.

"The risks of screening at that age are too great to justify any possible benefit," said Dr. Michael LeFevre, a task force member from the University of Missouri School of Medicine.

The new advice updates 2002 guidelines that did not give an age limit for screening. The task force in August said men over 75 should not be screened for prostate cancer; it didn't recommend for or against prostate screening of men under 75.

Colon cancer is the country's second leading cancer killer. Nearly 50,000 Americans are expected to die of colorectal cancer this year. Screening to spot early cancer or precancerous growths has resulted in fewer deaths over the last two decades.

Colonoscopy is considered the gold standard but it is not perfect. A long, thin tube with a small video camera is snaked through the large intestine to view the lining and any growths are removed.

The task force's stance on CT colonography and the stool DNA test is contrary to recent recommendations from the American Cancer Society, as well as radiology and gastroenterology groups that say the newer tests are effective and could encourage people scared of colonoscopies to get checked out. Only about half of those who need screening have it done.

The stool DNA test "has potential but it's an evolving technology," LeFevre said. "It's also likely to have a very high cost."

Also in Tuesday's journal are the results of a study that found a newer version of the DNA test was better than an older version or a stool blood test in finding cases of cancer.

For virtual colonoscopy, the task force expressed concerns about radiation exposure a patient would receive every five years from it, but acknowledged that the level is relatively low compared to other kinds of X-rays. They also worry that it will pick up blips inside and outside the colon that end up being nothing — but lead to more follow-up tests.

A member of the American College of Radiology Colon Cancer Committee said it was "surprising and unfortunate that such a well respected group would not come out and endorse CT colonography."

"The science is behind us that it works and it works well," said Dr. Judy Yee of the University of California, San Francisco, who has been involved in virtual colonoscopy research. "The goal is to get more Americans screened, and this is counterproductive to that goal."

The task force's guidelines could affect whether insurers and Medicare decide to pay for the test, Yee said. The cost of virtual colonoscopy can vary widely but it's generally much cheaper than a traditional colonoscopy, which can run several thousand dollars. If growths are found in a virtual colonoscopy, a traditional colonoscopy is need to remove them.

The task force will review its recommendations in five years and may make changes if more research emerges, LeFevre said.

___

On the Net:

Annals of Internal Medicine: http://www.annals.org/