COMMENTARY

A Strategic Merger in Cancer Screening

David J. Kerr, CBE, MD, DSc, FRCP, FMedSci

Disclosures

October 18, 2017

Hello. I am David Kerr, professor of cancer medicine from the University of Oxford in Oxford, England. I want to talk about a lovely study by Dr Imperiale and colleagues[1] that has been published in the Journal of the National Cancer Institute. I am interested in the whole pathway of care for colorectal cancer and increasingly interested in screening. I am particularly keen to see whether we can use some of the genetic tests we have developed to select those patients for screening who may benefit most.

Imperiale and colleagues enrolled a cohort of almost 4500 patients who came for colonoscopic screening at their center in Indianapolis. They used the National Cancer Institute (NCI) forecasting tool that is widely available on the NCI website[2]; this is a multivariable model that predicts colorectal cancer risk depending on gender, weight, lifestyle factors, diet, and so on. It is a very useful, carefully worked-out tool.

Using the NCI tool, the investigators connected future risk to current risk in their screened population. They found a reasonable degree of concordance, suggesting a dual purpose for the NCI tool—not only to predict future risk for colorectal cancer but relating to current or actual risk. They reasonably suggest that this means that the NCI colorectal risk prediction tool may be used to streamline and improve the efficiency of screening. If we find people who come for screening and have a high risk score using the NCI tool, it may be better to focus more deliberately on increasing the intensity of screening. Rather more controversially, for those who have a lower risk, it may be possible to step back with a less intensive screening program.

More Efficient and Cost-Effective Screening

This study was carefully thought through and provides nice statistics; it's not a perfect degree of concordance, but it's an interesting use of the tool. I would argue that we could refine this further by using some of the genetic SNP (single nucleotide polymorphisms) tests that are becoming more available and will allow us to segregate risk not only by lifestyle but by genetics, too. If we merged these, I believe that we could improve the efficiency of screening.

Screening costs tens of billions of dollars in the United States every year, and although it is cost-effective, screening remains incredibly expensive and drains resources. I believe that we could improve that further by merging some of the genetic risk tests with the NCI colorectal cancer prediction test.

I have said this many times before, but as a cancer doctor who is getting older, it just becomes harder to treat patients with advanced disease. I would like to put more of my energy and what little is left of my intellect into thinking how we may better screen and use some of the modern precision medical tools and genetics to improve the chances for earlier diagnosis.

Thanks for listening. Let us look forward together to what I hope will continue to be an interesting year. As always, Medscapers, ahoy.

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