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evidence based answers to critical
questions on cancer screening
and prevention
86IN HPV ELIMINATION OF CERVICAL CANCER: THE NOVEL
OPTIONS IN VACCINATION AND SCREENING
J. Cuzick
Centre for Cancer Prevention, Queen Mary University of London, London,
UNITED KINGDOM
The recognition that infection with certain human papillomavirus (HPV) types
is a necessary cause of cervical cancer has opened new fronts for the prevention
of this disease. Primary prevention is now possible via immunization and
secondary prevention has gained impetus with the availability of HPV DNA
testing. Although universal vaccination of teenagers and young women is a
desirable policy, even with high uptake a substantial reduction in the burden of
cervical cancer is unlikely for at least 10–15 years. To achieve cost-effective
reductions, screening and immunization must be considered as integrated
approaches. Several novel options are possible. If the nonavalent vaccine proves
to be effective, a screen and vaccine strategy in older women is attractive, and
raises the possibility of virtually eliminating cervix cancer in 5-10 years. New
approaches for triage following primary HPV-based screening are also being
developed and promise to substantially reduce referrals for non-progressive
infections. These include HPV typing, p16 and methylation of viral and human
genes. Lastly, the use of self sampling is likely to increase in vaccinated women
with less frequent HPV-based tests. New collection devices and transport media
will be needed to facilitate this.
Disclosure: J. Cuzick: Advisory boards for Abbott, Becton-Dickinson, Roche,
GenProbe, Qiagen, Glaxo Smith Kline, Merck.
87IN PROSTATE CANCER: WHAT ARE THE PROSPECTS AND
GUIDELINES FOR SCREENING AND PREVENTION?
H. De Koning
Public Health, Erasmus MC, Rotterdam, NETHERLANDS
The European Randomized Study of Screening for Prostate Cancer (ERSPC)
showed a significant prostate cancer mortality reduction in the screening group of
21% after a median follow-up of 11 years, and of 29% in screened men when
adjusted for selection bias. However, PSA screening is associated with considerable
unfavorable effects. In the ERSPC screening group, cumulative incidence of
prostate cancer was 7.4%, versus 5.1% in the control group. A proportion of the
screen-detected tumors (10-56%) would never have led to clinical symptoms but
these over-diagnosed cancers are frequently treated with associated risks of adverse
effects. Furthermore, because of a long lead-time, estimated 5-12 years, men have
to live longer with those effects. Two specific studies on quality of life after
prostate cancer treatment have been performed for men participating in
Rotterdam and Sweden. Pre-operatively 1-2% of the men were incontinent and
31-40% impotent. After 18-52 months 6-16% of the radical prostatectomy patients
and 3% of the radiation therapy patients were incontinent. Six to 52 months after
radical prostatectomy, 83-88% of pre-operatively potent men became impotent,
compared with 42-66% of the men receiving radiation therapy. In this lecture the
effects of screening strategies on prostate cancer mortality and quality of life will
be quantified, using the well-validated MISCAN-model, developed by our institute,
and hereby using results from the ERSPC. The implications of our results are that
the benefit of PSA screening is diminished by loss of QALYs, that is dependent
primarily on post-diagnosis long-term utility assumptions. Longer follow-up data
from both the ERSPC and quality of life and cost-effectiveness analyses are
essential for making universal recommendations regarding screening, but it is
possible that limited testing of middle-aged men with relatively long intervals is a
cost-effective public health policy.
Disclosure: The author has declared no conflicts of interest.
Annals of Oncology 23 (Supplement 9): ix53, 2012
doi:10.1093/annonc/mds387
88IN SCREENING FOR COLORECTAL CANCER: EUROPEAN
GUIDELINES
N. Segnan 1 , J. Patnick 2 , L. von Karsa 3
1 Head, Department of Cancer Screening and Unit of Cancer Epidemiology, CPO
Piemonte and S.Giovanni University Hospital, Turin, ITALY, 2 Nhs Breast
Screening Programme, Oxford University, Sheffield, UNITED KINGDOM, 3 Quality
Assurance Group, International Agency for Research on Cancer, Lyon Cedex,
FRANCE
Screening for colorectal cancer: European guidelines for quality assurance According
to the most recent estimates by the International Agency for Research on Cancer
(IARC) colorectal cancer (CRC) is the most common cancer in Europe and it is one
of the most causes of cancer death in Europe. Worldwide CRC ranks third in
incidence and fourth in mortality with an estimated 1.2 million cases and 0.6 million
deaths annually. In the 27 Member States of the European Union (EU), CRC ranks
first in incidence and second in mortality in both sexes, with approximately 334 000
new cases and 149 000 deaths estimated for men and women combined in 2008.
Even in those Member States in the lower range of age-standardised rates of CRC,
the burden of disease is significant compared to other regions of the world. CRC is
therefore an important health problem across the EU. Screening is an important tool
in cancer control in countries with a significant burden of CRC, provided the
screening services are of high quality. The EU recommends population-based
screening for breast, cervical and colorectal cancer using evidence-based tests with
quality assurance of the entire screening process including diagnosis and
management of patients with screen-detected lesions. In this context,
multidisciplinary evidence-based guidelines for quality assurance in colorectal cancer
screening and diagnosis have been developed by experts in a project coordinated by
the IARC. The full guideline document covers the entire process of population-based
screening. It consists of 10 chapters and over 250 recommendations, graded
according to the strength of the recommendation and the supporting evidence. The
450-page guidelines and the extensive evidence base have been published by the
European Commission. The content of the executive summary is presented here to
promote international discussion and collaboration by making the principles and
standards recommended in the new EU Guidelines known to a wider professional
and scientific community. Following these recommendations has the potential to
enhance the control of colorectal cancer through improvement in the quality and
effectiveness of screening programmes and services.
Disclosure: All authors have declared no conflicts of interest.
89IN CANCER REGISTRIES IN SUPPORT OF PLANNING AND
ASSESSING POPULATION BASED ONCOLOGY OUTCOMES
J.W. Coebergh
Department of Public Health, Erasmus MC, Rotterdam AND Comprehensive
Cancer South (IKZ) Eindhoven, NETHERLANDS
The about 200 population-based cancer registries in Europe are currently in an
upswing thanks to an ERA-net FP7 project named EUROCOURSE www.eurocourse.
org that aims to strengthen their infrastructure in order to better serve the clinical
oncology and public health communities and policymakers to solidify & improve
prevention (primary and through mass screening), cure (including quality of care)
and care (both survivorship and palliative) in various ways: - clarifying widely
diverging governance and budgets, despite uniform operational methodology and
training needs of both data collectors and data analysts, which warrants valid,
neutral, safe and integer data gathering and timely information ‘production’ on all
aspects of incidence and prognosis of the cancers ‘that be’ both through on-line and
peer-reviewed reporting and with a new European dataportal at IARC - promoting
enrichment by linkages with other data sources, e.g. vital statistics and research, e.g.
EPIC-study, and occupational, screening and clinical cohorts, with due attention to,
traditionally very well kept, data protection (alas hampered by unwarranted obstacles
in certain memberstates (a sequel from an unfortunate dictatorial past + incorrect
interpretation of EU directive 95/46). - allowing registries to be sampling frame for
in-depth studies of quality of care (adherence to guidelines/best practice?) both
process and outcome carried out with more speed/urgency than usual because also
needed in areas/parts of Europe without registry coverage, i.e. in or within more than
50% of the EU, especially in larger memberstates) not only of first line treatments
due to increasing application of targeted drugs and survivorship in the various
phases of the disease - allowing depth via strategic collaborations with clinical,
etiological, screening databases (stakeholders), promoting the cost-effectiveness of a
rich infrastructure serving many users (Nordic ‘model’) versus the current threat of
fragmentation by tumourspecific clinical databases (at risk for becoming data
cemetaries) With the tree as metaphor a landscape of registries is shown, remaining
close to its clinical roots. Major European references Comment: Lancet Oncology
2005;6:193-5 Trends: Eur J Cancer 2008;44:1345-89 Recent data: Eur J Cancer
2010;46:765-81.
Disclosure: The author has declared no conflicts of interest.
© European Society for Medical Oncology 2012. Published by Oxford University Press on behalf of the European Society for Medical Oncology.
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