3. Latest international guidelines Nov 2019:
1. Screen average risk adults 50-75 years
2. Choose screening test after discussion:
• FIT or gFOBT every 2 years
• Colonoscopy every 10 years
3. Stop screening if > 75 years or life expectancy < 10 years
3
4. Stool Based Tests
• If positive, need colonoscopy
• Reduces CRC specific mortality: RR 0.82, NNT 377
• gFOBT: sensitivity 62-79%; specificity 87-96%
• FIT: sensitivity 73-88%; specificity 91-96%
• No difference between annual vs biannual
• Most RCT data from trials of 2 yearly tests
• Single large study of annual vs biannual showed no
difference through 30 years
4
8. Key changes from previous 2013 guidelines
• No surveillance (i.e. screening in 10 years) if:
• 1-4 adenomas < 1cm
• Serrated polyp < 1cm without dysplasia
• Surveillance at 3 years if high risk
• Adenoma > 1cm, high grade dysplasia or > 4 adenomas
• Serrated polyp > 1cm or with dysplasia
8
9. Low Risk Adenomas
Multiple studies since 2013 have confirmed the
indication for “no surveillance” in low risk adenomas
9
Lee SK et al, Gastroenterol 2020. Community study over 14 years with N=64,422.
10. > 2 Adenomas
10
• 3 large recent studies show no increased risk in CRC
incidence or mortality
Wieszczy et al, Gastroenterol 2020. Population cohort study with n=236,089
11. Presumptions
• Complete examination
• Good bowel preparation
• Competent endoscopist with satisfactory ADR
• Complete polyp resection as per guidelines
Quality matters, not Quantity!!
• Look for doctors and centres with quality assurance
programs
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17. Stomach Cancer Screening
• Controversial, even in areas with high incidence of
gastric cancer
• May contribute to earlier detection but no data to
show lower cancer related mortality
• Recommendations agree on following:
• No routine screening
• Consider in high risk populations: gastric intestinal
metaplasia (GIM), pernicious anemia, gastric adenomas,
familial cancer syndromes
17
18. 3 main recommendations if GIM found:
1. Test and treat H pylori
2. No endoscopic surveillance. Discuss only if high risk of
gastric cancer: extensive GIM, incomplete GIM, family
history
3. No routine short interval endoscopy for risk stratification
18
19. Gastric Intestinal Metaplasia (GIM)
• 10 year pooled cumulative gastric cancer rate 1.6%
• Annual cancer rate 0.16%; compared to 0.33% for BE
• 5 year progression to dysplasia: 15%
• Higher gastric cancer risk in:
• Incomplete GIM: RR 3.33
• Extensive GIM: RR 2.07
• Family history: RR 4.53
19
20. Risk Stratifying GIM
• Use Imaged Enhanced Endoscopy (IEE) after training
• WLE: 50-55% sensitivity for IM, 30-50% for dysplasia/ EGC
• IEE: 85-90% sensitivity for IM, 90-100% for dysplasia/ EGC
• Clearly photo document GIM extent
• Biopsies still recommended for confirmation
• Use validated staging biopsy
• If confirmed high risk GIM, consider endoscopic
surveillance 3-5 yearly
20 ESGE 2019, BSG 2019
28. • US PSTF guidelines, published JAMA Aug 2019
• Recommends against screening for pancreatic cancer
in asymptomatic adults
• No evidence that screening improves disease specific
morbidity or mortality
• Harms of screening outweigh its benefits
28
29. Screening tests
• No accurate validated biomarker or blood test
• No studies report the sensitivity of CT, MRI or EUS as
screening tests
• In cohort studies of high risk patients: yield of 15.6 cases
per 1000 persons
• Likely to be much lower PPV and high false positive in
average population
• Harms: complications related to EUS, ERCP and
surgery; unnecessary surgery
29
30. High Risk Population
• Consider in FDR with at least 2 affected genetically
related relatives
• Defined as persons with certain inherited genetic
syndomes (e.g. Peutz Jeghers syndrome, hereditary
pancreatitis, Lynch syndrome)
• Guidelines do not apply to this group
• Does not apply to those with risk factors like DM,
chronic pancreatitis, smoking, obesity
• High risk pancreatic cysts covered separately
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31. How to Screen
• Optimum strategy unknown
• Experts recommend (AGA 2020 expert review):
• Start at 50 years or 10 years younger than initial age of
familial onset
• Start at 40 years for CKDN2A and PRSS1 mutation carriers
in hereditary pancreatitis and 35 years for PJ syndrome
• Use MRI and EUS in combination or alternate years
• Do annually
• Stop when more likely to die from non pancreas causes
31
32. Future
• Liquid biopsy and molecular markers
• Artificial intelligence for detection
• Endocytoscopy for real time in vivo histology
32
34. Take Home Message
• Follow the guidelines!! (keeps changing)
• Quality matters: guidelines apply only if quality indicators met
• Colorectal cancer
• Stool tests 2 yearly
• Polyp surveillance intervals: changed; most will be less frequent;
check guidelines or expert
• Gastric cancer
• Don’t do; discuss only if high risk group
• GIM : needs proper assessment for high risk GIM
• Pancreatic cancer: Don’t do unless high risk group
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