Current Controversies in Oncology
The Controversy: CT Colonography for Colorectal Cancer Screening vs. Optical Colonoscopy
Al B. Benson III , MD
Robert H. Lurie Comprehensive Cancer Center
Northwestern University

This interesting, in-depth study from ASCO looked closely at the Medicare and Medicaid’s recent decision not to pay for optical colonoscopy screening. However, it did not address the other, larger controversy associated with colorectal screening: That the cost and risk of using the procedure doesn’t justify early, invasive screening. This conclusion rose from two recent studies showing colorectal screening did not statistically extend a patient’s life. Here is part of the introduction and conclusion from the ASCO panel:

Colorectal cancer is a leading cause of cancer death that is also a potentially preventable disease by applying screening strategies. The subject of colorectal cancer screening has been one of significant interest with extensive efforts undertaken to improve not only the rate of screening, but also to explore alternative methods of screening.

Recent literature has emerged evaluating the optimal role of two important technologies, optical colonoscopy and computed tomographic (CT) colonography. Although the Centers for Medicare & Medicaid Services (CMS ) will reimburse optical colonoscopy for the purposes of colorectal cancer screening, CMS denied reimbursement for CT colonography in its February 2009 Proposed Decision Memorandum.1 CMS stated that the evidence was inadequate to justify the use of this screening modality, expressing concerns that it is not yet possible to generalize study results to support its use in an older population of patients. In addition, the U.S. Preventative Services Task Force has not endorsed CT colonography screening. The CMS decision has raised significant concerns prompting the mailing of letters to the CMS Acting Administrator from Members of Congress, including the Congressional Black Caucus.

In conclusion, CTC represents an important technological advance but in order to make a significant contribution to the average-risk screening armamentarium, there are several critical issues that still need to be resolved. Thus, at this juncture, we believe that CTC’s numerous important limitations, especially the lack of therapeutic ability, preclude its designation as a preferred CRC screening strategy. We, therefore, concur with the decisions not to endorse CTC by the U.S. Preventive Services Task Force (being particularly concerned about the potential harms associated with “incidentalomas”)18 and the Centers for Medicare & Medicaid Services.19 As the technology and clinical paradigms mature, CTC may have a role in screening a subgroup of patients, including those with multiple comorbidities, those refusing colonoscopy, and possibly patients at lowest risk of CRC.20 However, at present, we believe that the evidence strongly supports colonoscopy as the dominant CRC screening strategy.

Here is a link to the entire study and panel discussion from ASCO: CT Colonography for Colorectal Cancer Screening vs. Optical Colonoscopy

Feel good and keep smiling! Pat

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