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The International Digestive Cancer Alliance

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                The International Digestive Cancer Alliance
  Digestive Cancers and their pre-
  dominance in various regions of
  the world provide a real challenge
  for national gastroenterological
  societies, patient groups and related
  organisations. How does one raise
  the awareness of this growing                 IDCA Fact Sheet
  problem? There are several success-
  ful national campaigns achieving           Digestive cancers are the most common cancers worldwide,
  excellent results and there are some       with 3 million new cases each year.
  areas which have yet to tackle this
  problem. The recently founded Inter-       Digestive cancers cause more than 2 million deaths worldwide
  national Digestive Cancer Alliance         each year.




                                                                                                                    SPECIAL SECTION: IDCA
  is an umbrella organisation which
  aims to pool existing resources,           Digestive cancer sites include: colon and rectum, esophagus
  increase awareness and assist those        and stomach, liver, pancreas.
  who wish to initiate their own diges-
  tive cancer campaigns. s                   Most of these cancers can be prevented or cured.

                                             The mission of the International Digestive Cancer Alliance
                                             (IDCA) mission is to promote screening, early detection, and
                                             primary prevention of digestive cancers worldwide.

                                             The Alliance will collaborate with a wide range of interested
                                             groups, including: professional societies, public advocacy
                                             groups, legislators, industry, and the media in order to reduce
                                             the burden of this group of cancers worldwide.

                                             Founding organizations are: OMGE, OMED, UEGF, ESGE, CRPFA,
                                             UICC*

                                             Meetings of the IDCA have been held in San Francisco, Rome,
                                             Geneva, Frankfurt, New York and Washington, DC.

                                             H.H. Pope John Paul II has offered patronage to the IDCA.

                                            * Organisation Mondiale de Gastro-Entérologie/World Organization of
                                              Gastroenterology (OMGE);
                                              Organisation Mondiale d’Endoscopie Digestive/World Organization of
                                              Digestive Endoscopy (OMED);
                                              United European Gastroenterology Federation (UEGF);
                                              European Society of Gastrointestinal Endoscopy (ESGE);
                                              Cancer Research and Prevention Foundation of America (CRPFA); Union
  Sidney Winawer, M.D. (top) and Meinhard     Internationale Contre le Cancer/International Union against Cancer
  Classen, M.D., co-chairmen of the IDCA.     (UICC).




                                                     23
                             IDCA                                      IDCA Global Program
                         Executive                             The International Alliance will consist of a core group that will facili-
                         Committee                             tate and coordinate and help support national programs of digestive
                                                               cancer prevention initiated by national member societies.
                         Chairmen                                 The Alliance will provide:
                         Sidney Winawer (USA)                  • A forum for interaction among national societies through web sites,
                         Meinhard Classen (Germany)               meetings, and communications, for those with established pro-
                                                                  grams and for those with emerging programs.
                         Council                               • Guidance in initiating national prevention programs.
                         Carolyn R. Aldigé (USA)               • Data from international surveys.
                         Anthony Axon (United King-            • Epidemiological and statistical data.
                             dom)                              • Experts for consultation, speaking, organization.
                         Rikiya Fujita (Japan)                 • Materials that can be adopted nationally (educational, logistic, com-
                         Bernard Levin (USA)                      munications, etc.)
                         Christa Maar (Germany)                • Models for effective interactive meetings.
                         Alberto Montori (Italy)               • Recognition for member societies in global campaigns, media
                         Paul Rozen (Israel)                      reports, and conferences.
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                         Robert Smith (USA)                    • Mentoring by national programs for emerging programs.
                         Graeme Young (Australia)

                         Treasurer
                         Joseph Geenen (USA)
                                                                       Background
                         Organization & Contact                Several organizations in the field of gastroenterology (listed in the
                         Medconnect                            IDCA Fact Sheet, p.23) have joined forces to form the International
                         Bruennsteinstr. 10                    Digestive Cancer Alliance (IDCA) in order to raise global awareness of
                         81541 Munich, Germany                 digestive cancers.
                         Tel: +49-89-4141 92 40                   Digestive cancers account for the highest number of cancers each
                         Fax: +49-89-4141 92 45                year worldwide. This year, there will be approximately 3 million new
                         E-mail: idca@medc.de                  cases of digestive cancers globally, with 2.2 million deaths. Colorectal
                                                               cancer is the most common of the digestive cancers – it is expected
                                                               that half a million people will die of colorectal cancer this year. In
                                                               a meeting held at the Vatican in 2002, senior experts from medical




                        Incidence and deaths:                                   Incidence and deaths:
                        all cancers worldwide                                   digestive cancers worldwide
                        (men and women)           Incidence       Deaths           (men and women)           Incidence       Deaths

                        Digestive cancers          3 000 000      2 200 000        Colorectal                   950 000        500 000
                        Lung                       1 250 000      1 100 000        Stomach                      875 000        650 000
                        Breast                     1 000 000        400 000        Liver                        560 000        550 000
                        Genitourinary              1 000 000        450 000        Esophagus                    400 000        330 000
                        Gynecological                850 000        400 000        Pancreas                     200 000        200 000
                        Leukemia, lymphoma           700 000        450 000

                        Total (all cancers)       10 000 000      6 200 000        Total (digestive cancers) 3 000 000       2 200 000



                                                                              24
 organizations in more than 50                   IDCA Mission Statement
 countries discussed the world-
 wide scale of the problem and           The mission of the International Digestive Cancer Alliance is to pro-
 how to alleviate it. The meet-          mote the screening, early detection, and primary prevention of diges-
 ing included an audience with           tive cancers worldwide through an international alliance of organiza-
 H.H. Pope John Paul II, who             tions that share the same goal.
 is lending his support to the
 campaign. Future IDCA cam-              IDCA membership:
 paigns will focus on cancers of         • Medical/professional
 the stomach, esophagus, liver,          • Public/advocacy
 and pancreas.                           • Political/insurers
     This first meeting focused           • Media
 on the prevention of colorectal         • Industry
 cancer. Many of these cancers
 can be prevented by screening           Colorectal cancer campaign goals:
 and modification of lifestyle.           • Promote guidelines
 Unfortunately, most people              • Increase awareness
 are not aware of these cancers          • Increase access




                                                                                                                   SPECIAL SECTION: IDCA
 and the potential for prevent-          • Increase screening
 ing them. Greater awareness             • Modify lifestyle
 of these cancers could alert
 people with symptoms to seek            Colorectal cancer campaign targets:
 medical advice, and could pro-          • 2005 World Congress of Gastroenterology
 mote earlier detection. Screen-           —75% people aware of colorectal cancer screening
 ing for these cancers increases           —50% screened
 the likelihood of detecting             • 2009 World Congress of Gastroenterology
 potential problems before can-            —Reduce incidence by 50%
 cer develops, thereby increas-            —Reduce mortality by 50%
 ing treatment success rates.




New cancers worldwide – colon/rectum
      Female, all ages                       Male, all ages                           North America
      New cancers: 380 832                   New cancers: 401 715.
                                                                                      Western Europe
              1%                                       1%                             Eastern Europe
             2%                                     3%
                                                                                      Southern Europe
           2%
                                                  6%              19%
                           21%                                                        Northern Europe
     14%
                                          16%                                         Asia except China

                                                                                     China
                                                                        12%
 18%
                                   15%                                                South, Central America and
                                                                                      Caribbean
                                                                                      Continental Africa
                                            20%                      10%
        6%              14%
             7%                                          6%    7%                     Australia, New Zealand and
                                                                                      South Pacific



                                                       25
                                IDCA Action Plan for 2003–4                                                   Beginning in March 2000,
                                                                                                          the Foundation joined forces
                        In their report on page 7 of this issue of WGN, Professor Meinhard                with the American Society for
                        Classen and Professor Sidney Winawer outline the main activities of               Gastrointestinal Endoscopy,
                        the IDCA over the next few years. We encourage you to read this as                the Foundation for Digestive
                        it gives readers insight into the highlights of the campaign which will           Health and Nutrition and the
                        involve national gastroenterological societies around the world.                  National Colorectal Cancer
                                                                                                          Roundtable to launch a cam-
                        Introducing the Founding Organisations of the IDCA                                paign designating March as
                        World Organisation of Gastroenterology (OMGE)                                     National Colorectal Cancer
                        World Organisation of Digestive Endoscopy (OMED)                                  Awareness Month. Now head-
                        United European Gastroenterology Foundation (UEGF)                                ing into its fourth year, the
                        European Society of Gastrointestinal Endoscopy (ESGE)                             goal of National Colorectal
                        Cancer Research and Prevention Foundation (CRPF)                                  Cancer Awareness Month is to
                        International Union against Cancer (UICC)                                         generate widespread aware-
                           Over the next issues of WGN, we will be introducing you to the                 ness about colorectal cancer
                        founding organisations of IDCA and in this issue, we begin with:                  and to encourage people
                                                                                                          to learn more about how to
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                                       The Cancer Research and Prevention Foundation                      reduce their risk of the dis-
                                       The Cancer Research and Prevention Foundation, for-                ease through regular screen-
                                       merly the Cancer Research Foundation of America, was               ing and a healthy lifestyle.
                                       started in 1985 when Founder and President Carolyn                     One feature of the Foun-
                        Aldigé first understood the power of prevention to defeat cancer –                 dation’s successful colorectal
                        and recognized that too few of the country’s resources were used to               cancer campaign is its annual
                        promote cancer prevention research or education. Today, it is one of              Dialogue for Action educa-
                        the nation’s leading health organisations and has catapulted cancer               tional conferences. These
                        prevention into prominence. Since its inception the Foundation has                programs are innovative,
                        provided more than $57 million in research and education funding                  creative forums for initiating
                        to more than 250 scientists from more than 150 of America’s most                  both local and national change
                        prestigious academic medical centers and has been pivotal in devel-               to increase colorectal cancer
                        oping a body of knowledge that is the basis for important cancer pre-             screening rates in a country
                        vention and early detection strategies. The foundation is a founding              or region (see DDW Orlando
                        organisation of the IDCA.                                                         Meeting programme on p. 31).




                        Extract from the Pope’s Speech
                        Papal Audience for Participants Attending the
                        IDCA Launch Meeting, March 2002
                        “Ladies and gentlemen, it gives me pleasure to               the Scientific Committee, the delegates, moderators,
                        greet all of you who are taking part in this congress        speakers, scholars and all those who are commit-
                        aimed at awakening public opinion to the impor-              ted to fighting the disease to which you direct your
                        tance of the prevention of cancer of the digestive           attention.
                        tract, especially cancer of the colon.                          One cannot fail to be pleased in noting the
                           I would also like to express my great esteem for          increasing availability of technological and phar-
                        the organizers of this conference, the members of            macological resources that, in most cases, permit




                                                                                26
                        early detection of cancer             style and undergo periodical check-ups. I congratu-
                        symptoms, conducive to                late you for this public service and I hope that your
                        prompter and more effective           profession, while following its governing ethical
                        treatment.                            code, will always draw inspiration from those time-
                            I urge you not to stop at         less ethical values that form its firm foundations.
                        the results you have already             Informing people respectfully and truthfully,
                        achieved but to continue,             especially when they are critically ill, is a mission
                        with confidence and deter-             of those involved in public health. Your congress
                        mination, in research and             intends to make a contribution in this respect and
                        treatments, availing your-            I wish it every success. I also sincerely hope that
                        selves of the latest scientific        there will be a widespread response to the mes-
resources. May young doctors follow your example              sage you plan to launch so as to involve mass
and may they, with your help, learn to follow the             media in a fruitful awareness campaign.
same path that will be of benefit to everyone’s                   I will gladly pray for you and, as I commend
health.                                                       your work to God, I give you my heartfelt blessing,
   Ladies and gentlemen, thanks to the cooperation            which I gladly extend to your loved ones and to all
of so many collaborators and volunteers, you are              those who work with you in this noble humanitar-
making a great effort to inform the public that they          ian mission.”




                                                                                                                      SPECIAL SECTION: IDCA
can enjoy better health if they follow a regular life-                                    H.H. Pope John Paul II




Letter from
Senator Hillary Rodham Clinton



                                                                   March 23, 2002
Dear Friends,

   I am pleased to have this opportunity to send              This disease is highly preventable through exami-
greetings to each of you gathered for the launch              nation and education. I commend your efforts to
of the first global campaign to target prevention of           focus worldwide attention on the prevention of this
digestive cancers.                                            and other digestive cancers. It is my hope that in
   This year in the United States alone more than             the future young persons will have to turn to the
148 000 new cases of colorectal cancer will be                history books to learn about the diseases called
diagnosed and 56 000 people will die from this                cancer.
disease. Colorectal cancer is the second leading                 You have my best wishes for every success in
cause of cancer-related deaths in the United States.          this endeavor.

                                                                                Sincerely yours,




                                                                                Hillary Rodham Clinton
                                                                                United States Senator



                                                         27
                          IDCA and WHO                           ing attention to the worldwide             ogy Week (UEGW) meeting held
                                                                 problem of cancer and the need for         in Geneva in November 2002 with
                          The World Health Organization          greater emphasis on prevention.            Dr. Andreas Ullrich, Medical Officer
                          has had a long-standing com-           The IDCA responded to this chal-           of the WHO Cancer Control Pro-
                          mitment to cancer control. On          lenge in two ways: firstly, a letter        gram. Dr. Ullrich expressed great
                          the occasion of the recent pub-        (reprinted below) was drafted and          interest in working closely with the
                          lication of the second edition         sent directly to Ms. Gro Harlem            IDCA, and a number of potential
                          of its book on National Cancer         Brundtland, Director-General of the        collaborative activities were con-
                          Control Programmes: Policies           WHO. Secondly, the IDCA held very          sidered. The WHO press release
                          and Managerial Guidelines, the         productive joint meetings at the           and the IDCA letter are presented
                          WHO issued a press release call-       United European Gastroenterol-             below.




                        World Health Organization Press Release
                        National Cancer Control Programmes
                        Policies and Managerial Guidelines
                        Second Edition
SPECIAL SECTION: IDCA




                        Each year, cancer affects more than 10 million people            siders possibilities for prevention, early detection, cure,
                        worldwide, and kills 6 million. Without effective control        and care. It discusses the appropriateness of particular
                        of the disease, these figures will increase significantly,         technologies, and describes how to manage national
                        with the most marked rise occurring in the develop-              programs tailored to different resource settings.
                        ing countries. Although much remains to be learned
                        about the etiology of cancer, enough is now known                From the report:
                        about the causes of cancer and means of control for              “While many Member States recognize the need to
                        suitable interventions to have a significant impact. At           develop national cancer control programs, few in the
                        least one-third of cases are preventable by such means           industrialized world and even fewer in developing
                        as controlling tobacco and alcohol use, moderating               countries have yet done so. As a result many people
                        diet, and immunizing against viral hepatitis B. Early            die from preventable cancers and suffer unnecessarily
                        detection, and therefore prompt treatment, of a further          from pain and anguish at the end of their lives … This
                        one-third of cases is possible where resources allow.            edition provides the information needed to guide the
                        Effective techniques for pain relief are sufficiently well        development of feasible, equitable, sustainable, and
                        established to permit comprehensive palliative care for          effective national cancer control programs.”
                        the remaining, more advanced, cases. The establish-
                        ment of a national cancer control program, tailored to           Dr. Gro Harlem Brundtland,
                        the socio-economic and cultural context, should allow            WHO Director-General
                        countries to effectively and efficiently translate the
                        present knowledge into action. Implementation of the             National Cancer Control Programmes. Policies and
                        necessary measures requires the formulation of evi-              Managerial Guidelines. Second Edition. Geneva: WHO,
                        dence-based policies, the mobilization and appropriate           2002. (ISBN 924154557-7.)
                        allocation of resources, the active participation of all
                        stakeholders and – above all – government commit-                Copies of the book can be ordered from the WHO:
                        ment to legislation, education, and national and inter-          WHO Marketing & Dissemination,
                        national collaboration in support of cancer control.             1211 Geneva 27
                           This monograph provides guidance for policy-mak-              Switzerland
                        ers and others on the establishment of national cancer           Tel.: +41 22 791 24 76
                        control programs. It outlines the scientific basis of             Fax: +41 22 791 48 57
                        feasible approaches to the control of cancer, and con-           E-mail: publications@who.int


                                                                                    28
        IDCA Letter to the WHO

                                      To Ms. Gro Harlem Brundtland, Director-General, World Health Organization
  Dear Director-General,

    The recently-released second edition of National            most countries. Among the findings:
Cancer Control Programmes: Policies and Managerial              • 67% of responding physicians sought help for
Guidelines states that millions of lives can be saved               developing educational materials.
each year by implementing cancer prevention pro-                • 64% wanted greater distribution of educational
grams. We agree wholeheartedly, and nowhere is this                 material.
more pertinent than in digestive cancers. Digestive             • 57% were interested in hearing expert speakers on
cancers as a group (esophagus, stomach, pancreas,                   CRC screening.
liver, colon) are the most common form of cancer                • 54% sought additional training in CRC screening.
worldwide, with an incidence of approximately 3 mil-                There is now strong evidence that colorectal screen-
lion new cases and a mortality of 2.2 million people            ing is effective in reducing the incidence and mortality
each year. Among these cancers, colorectal cancer               from this disease. Guidelines have provided several
(CRC) has the highest incidence.                                options for screening. The challenge now is to imple-
    We launched a worldwide campaign for CRC pre-               ment screening worldwide, especially in countries at




                                                                                                                           SPECIAL SECTION: IDCA
vention at the Vatican in Rome in March 2002, as the            high risk for the disease. This will require overcom-
first focus of the new International Digestive Cancer            ing the low level of awareness of both the public
Alliance, sponsored by several international medical            and every physician regarding the importance of CRC
societies and supported by H.H. Pope John Paul II.              screening.
Medical representatives from more than 50 countries,                It appears from this survey that some physicians
as well as the media, health-care officials, and industry        do recommend colorectal cancer screening, but that
representatives participated in the meeting.                    approaches vary widely in terms of screening options
    We plan to help raise awareness and encourage               offered, at what age screening should start and the
preventive approaches globally through the national             interval between screens, especially screening colonos-
member societies of the Alliance, and through                   copy.
www.gastro-pro.org, a new e-learning tool for gas-                  Many countries do not have established CRC guide-
troenterologists and other health workers in remote             lines for health-care providers. It also appears that
locations and underserved countries, which will soon            resources are not adequate to support screening and
publish an instructional module on simple CRC screen-           diagnosis in many countries, especially the low-risk
ing techniques. We also plan to initiate campaigns that         countries. We hope that the International Digestive
will focus on the prevention of other digestive cancers.        Cancer Alliance can help overcome some of these bar-
    CRC was chosen as the first campaign because of              riers and stimulate national organized programs.
its high incidence worldwide and the tremendous                     Colorectal cancer is a major worldwide medical bur-
potential for prevention. A worldwide survey reported           den, especially in Western and westernized countries.
at the meeting in Rome, demonstrated the low rate               We now have an understanding of the natural history
of promotion of CRC screening, especially in develop-           of colorectal cancer. We also have the tools to inter-
ing countries. The results of the survey were based on          vene in that natural history and substantially reduce
158 responses from 59 countries. They showed there              CRC incidence and mortality. There is a consensus
was a higher level of physician awareness in high-risk          that screening is effective and should be promoted
countries of the importance of CRC screening than in            and there are many guidelines available that can help
low-risk countries, and higher awareness for familial           health-care providers.
high-risk people, but there was a substantial lack of               However, awareness must be raised, resources
awareness in all countries, regardless of the familial          strengthened, guidelines developed that are specific
risk.                                                           for each country if they are not available, a national
    The survey uncovered many barriers to screening,            program developed, and efforts made to reduce the
including lack of public awareness and inadequate               financial barriers. We now have a unique opportu-
financial support and resources on a national basis in           nity to dramatically reduce the numbers of men and


                                                           29
                        women who are destined to be afflicted by and die of
                        this major cancer. Our goal is the same as WHO’s: sav-
                                                                                       The Colorectal
                        ing lives through strategies that are available today.
                           We welcome an active collaboration with WHO in
                                                                                       Cancer
                        this critical worldwide disease, the control of which
                        we all share. This can be organized in several ways.
                                                                                       Campaign
                        WHO could make its resources available to the Inter-
                        national Digestive Cancer Alliance as one of the found-
                                                                                       in Italy
                        ing organizations, or designate the Alliance as a WHO          Massimo Crespi, M.D.
                        Collaborating Center for the Prevention of Digestive
                        Cancers, or in some other way as is appropriate. We            Thanks to the initiative of the Italian Federation of Diges-
                        would be pleased to meet at the time of the European           tive Diseases representing the three Italian societies
                        Digestive Disease Week to be held in Geneva during             involved in gastroenterology and endoscopy – Associ-
                        the week of October 20th to discuss further how we             azione Italiana Gastroenterologi ed Endoscopisti Diges-
                        can work together. We are responding to the challenge          tivi Ospedalieri (AIGO), Società Italiana di Endoscopia
                        presented by WHO.                                              Digestiva (SIED), and Società Italiana di Gastroentero-
                                                                                       logia (SIGE) – an alliance was formed in 2002 with
                          Yours sincerely,                                             the Italian League against Cancer and the Cancer Insti-
                                                                                       tutes for the promotion of an awareness campaign for
                                                                                       colorectal cancer prevention and screening. The official
SPECIAL SECTION: IDCA




                                                                                       launch of the campaign in March 2002 took place at
                                                                                       the Italian Parliament, with extensive participation from
                                                                                       politicians, health authorities, and media representa-
                        Professor Sidney J. Winawer, M.D., USA
                                                                                       tives. The logo with the apple and the simple, straight-
                        Chairman: International Digestive Cancer Alliance
                                                                                       forward message “preventing colorectal cancer may
                                                                                       save your life” was created by the public relations firm
                                                                                       Weber Shandwick Italy, which is in charge of the global
                                                                                       campaign on behalf of the sponsoring organizations.
                        Professor Meinhard Classen, M.D., Germany                          A major grant by the Johnson & Johnson Foundation
                        Chairman: International Digestive Cancer Alliance              allowed a countrywide campaign, which has carried out
                                                                                       the following activities up to the beginning of 2003:
                                                                                       • Production and distribution of a “white book” on
                                                                                           the burden of colorectal cancer (CRC) in Italy,
                                                                                           aimed at health authorities and the press, as well as
                          IDCA and Gastro-Pro                                              potential sponsors.
                          Gastro-Pro (http://www.gastro-pro.org/) now                  • Distribution of 10 000 posters and 500 000 leaflets
                          has a GI cancer section, with Meinhard Classen                   to the 260 gastroenterology services in Italy, to the
                          and Sidney Winawer, co-chairs of IDCA, as its co-                provincial sections of the League, and to general
                          chairs. Together, they have been reviewing the                   practitioners to provide the public with information
                          first contribution to this section, which is a superb             about CRC screening and risk factors. A toll-free
                          series on colorectal cancer being developed by                   number has been activated and is receiving thou-
                          Paul Rozen. The co-editors are also preparing an                 sands of calls; the operators direct inquirers to the
                          overview of this section which will focus on the                 nearest participating GE Service. Screening colonos-
                          scale of digestive cancers worldwide and opportu-                copy has been free of charge in Italy since January
                          nities for prevention, both primary and secondary.               2002, thanks to a campaign directed towards the
                          Some of these statistics appear in this issue of                 Parliament by the gastroenterological societies.
                          WGN. In addition, the IDCA will provide the read-            • A press briefing held in Milan in October 2002,
                          ers of WGN with information on new develop-                      which resulted in related articles in 13 of the major
                          ments, interesting perspectives, viewpoints, and                 lay newspapers and magazines, with a total cover-
                          controversial issues in the area of digestive cancer             age of 35 377 000 potential readers.
                          in a special features section.                               • A top-circulation magazine, Famiglia Cristiana,
                                                                                           agreed to insert the campaign leaflet in the


                                                                                  30
    680 000 copies sold at newsstands, in addition to                      We would suggest that the logo with the apple
    the issues sent to subscribers.                                    could serve as a unifying symbol for the CRC cam-
• A 20-second TV spot based on the logo (the apple)                    paign, at least in Europe. We would also propose that
    was aired for 45 times free of charge on the three                 the information and recommendations included in our
    Mediaset television channels, at different times dur-              leaflet, agreed after lengthy discussions by a group
    ing the day, reaching a total potential audience of                of experts and tested on a trial basis on a population
    69 890 000.                                                        sample, could become a widespread multilingual mes-
Many other initiatives are still in the planning phase.                sage for the real start of the campaign supported by
We believe that the Italian awareness campaign could                   the UEGF and the IDCA – avoiding overlapping initia-
serve as a good model at the national level for similar                tives that might only confuse the target audience.
initiatives in other countries, within the framework of
the actions planned by the International Digestive Can-                 Prof. Massimo Crespi, MD
cer Alliance (IDCA) and the Public Affairs Committee                    “Regina Elena” National Cancer Institute
of the United European Gastroenterology Federation                      Viale Regina Elena, 291, 00161 Rome, Italy
                                                                        E-mail: mcrespi@uni.net
(UEGF).



  DDW Orlando Meeting | S U N D AY ,                              M AY 18 , 2 0 0 3
                                                                                           Orlando II Room, Peabody Hotel




                                                                                                                                     SPECIAL SECTION: IDCA
  OMED Screening Committee Meeting                                                 International Digestive Cancer Alliance
  (in collaboration with the International Digestive                               (in collaboration with the OMED
  Cancer Alliance)                                                                 Screening Committee)
  07:55–08:00 Introduction – P. Rozen                                  13:00–14:30 International Activities
                                                                                   (Chair: S. Winawer, M. Classen)
  08:00–09:00 Colonoscopy Screening Programs –
                                                                                   Reports by founding members of IDCA and the
              Performance & Quality Control
                                                                                   World Health Organisation:
              Chair: J. Bond
                                                                                   s IDCA (S. Winawer/M. Classen)
              s D. Rex - U.S.
                                                                                   s OMED (P. Rozen)
              s M. Crespi – Italy
                                                                                   s CRPF (C. Aldigé)
              s W. Schmiegel – Germany
                                                                                   s UICC (R. Smith/B. Levin)
              s J. Regula – Poland
                                                                                   s UEGF (M. Crespi)
              Comments invited from Drs. G. Hoff & M. Pignone
                                                                                   s ESGE (A. Nowak, L. Aabakken)

  09:00–09:45 Update on Non-invasive Screening Tests for                           s WHO (TBC)

              Colorectal Cancer
                                                                       14:30–15:00 Break
              Chair: P. Rozen
              s Central laboratory development of                      15:00–15:20 The CRPF Dialogue for Action Educational
              immunochemical FOBTs as compared to office                            Model
              developed guaiac tests – G.P. Young                                  (J. Blanchard, K. Peterson)
              s Stool DNA tests - New technical & clinical data
                                                                       15:20–15:30 Background Presentation: Common Barriers to
              – M. Ross
                                                                                   and Facilitators of Colorectal Cancer Screening
              Comments invited from R. Schoengold, G.P. Young
                                                                                   (Background Presenter: M. Classen,
              & D. Ransohoff
                                                                                   Key Discussant: P. Rozen)
  09:45–10:00 Break
                                                                       15:30–16:30 Facilitated Conversation: Conditions Existing
  10:00–12:00 National Screening & Associated Research                             in Various Countries that Hinder or Encourage
              Programs                                                             Colorectal Cancer Screening
              Chair: S. Winawer & A. Axon                                          (Facilitator: S. Winawer)
              G.P. Young (Australia), M. Korman (Australia),
                                                                       16:30–16:45 Recorder Summary and Discussant/Participant
              G. Hoff (Norway), H. Gutierrez-Galiana (Uruguay),
                                                                                   Comments
              M. Zavoral (Czech Republic), J. Spicak (Czech
                                                                                   (Recorder Summation: G. Young)
              Republic), B. Wong (Hong Kong/China), Y. Sano
              (Japan ), Y. Tatsumi (Japan), R.Melcher (Germany)        16:45–17:00 Observations and Next Steps
              Comments invited from W. Atkin, O. Kronborg,                         (S. Winawer, M. Classen)
              J. Mandel & A. Sonnenberg



                                                                  31
SPECIAL SECTION: IDCA
  The International Digestive Cancer Alliance – IDCA

  Future Events:
  Colon Cancer Awareness Campaign in Moscow
  next June
  Sidney Winawer and Meinhard Classen

  Colorectal cancer is the most         pean Society of Gastrointestinal        2004 to participate in this event.
  common form of carcinoma of the       Endoscopy (ESGE) and the Euro-          Professor Vladimir Ivashkin, Presi-
  digestive tract in the Russian Fed-   pean Association for Gastroenter-       dent of the RGA, expects approxi-
  eration – a country about 1.8 times   ology and Endoscopy (EAGE) are          mately 1000 participants to attend.
  the size of the USA, occupying the    planning to hold an endoscopy           Prominent personalities from Rus-
  vast area between Europe and          postgraduate course in Moscow at        sian public life will assist in improv-
  the northern Pacific Ocean, cover-     the same time and in collabora-         ing awareness of colorectal cancer
  ing an area of 10 672 000 square      tion with the IDCA. This project will   and raising public awareness of the
  miles (17 075 200 km2) and with       unite colleagues from the entire        enormous potential for prevention




                                                                                                                          SPECIAL SECTION: IDCA
  a population of almost 150 million    Russian Federation and neighbor-        of the disease. s
  people.                               ing countries – in particular, gas-
     The Russian Gastroenterological    troenterologists from Central Asia,
  Association (RGA) requested assis-    who will have an opportunity to
  tance from the IDCA in running        come together on June 24 and 25,
  a campaign aimed at increasing
  public awareness of this disease.
  The campaign will be launched in
  Moscow in June 2004. The Euro-




                                                         19
An Overview of the Epidemiology and
Prevention of Digestive Cancer
René Lambert, in collaboration with the IDCA


W    orldwide, 10 million new                  women as annual                                             cer registries has pro-
cases of cancer occurred in 2002               incidence or mortal-                                        gressively increased;
and 6.2 million people died of                 ity rates for 100 000                                       the most recent data
cancer that same year. Digestive               persons; these are                                          are available in the
cancers account for the high-                  crude rates. Com-                                           eighth volume of
est incidence and mortality of                 parisons over a                                             Cancer Incidence in
cancer worldwide, with 3 million               period of time in the                                       Five Continents (IARC
new cases and 2.2 million deaths               same population,                                            Press, 2003).
annually (colorectal, esophageal               and comparisons                                                The United Nations
and stomach, liver and pancreas).              between different                                           make a distinc-
Lung cancer is the second most                 populations, are                                            tion between more
frequent cause of death from can-              based on age-stan-                  René Lambert            developed regions,
cer (1.25 million). National health            dardized rates.                                             which comprise North
policy in every country in the world               The relative 5-year survival is          America, Japan, Europe (including




                                                                                                                                     SPECIAL SECTION: IDCA
should be concerned with the pre-              a global prognostic index of the             Russia) and Australia/New Zealand
vention of digestive cancers. This             disease; the term “relative” means           – with a population estimated
is the first article in World Gastro-           that the figure takes into account            at 1188 million in 2000; and less
enterology News of a series to be              the lifespan of the average popula-          developed regions, consisting of
published under the auspices of                tion. Data on survival are found in          all regions of Africa, Latin America,
the International Digestive Cancer             the Surveillance Epidemiology and            and the Caribbean, Asia (excluding
Alliance (IDCA). The series will dis-          End Results (SEER) registry in the           Japan) and Melanesia, Micronesia
cuss the prevalence, detection, and            USA (10% of the population), in the          and Polynesia, with a population
prevention of cancers throughout               Eurocare II study (IARC database,            of 6284 million. Digestive cancer
the entire digestive tract.                    1999) in Europe, in the World Can-           occurs in all regions of the world,
                                               cer Report (IARC Press, 2003) and            but the burden is distributed
The Scale of Digestive Cancer                  in Cancer Survival in Developing             unequally in the more developed
The annual numbers of new                      Countries (IARC Press, 1998).                and the less developed countries.
(incident) cases and deaths from                   The accuracy of the data and the         Populations in less developed
cancer are expressed for men and               coverage of the populations in can-          countries are more vulnerable to
                                                                                            cancers in which infectious agents
                                                                                            play a significant role; this includes
Table 1. The three most frequent cancers in various regions of the world. The figures in     cancers of the stomach, liver, and
brackets represent the age-standardized incidence per 100 000 persons in the respective     possibly esophagus. In the large
region (from World Cancer Report, Lyons: IARC, 2003).                                       bowel and pancreas, differences in
                                                                                            lifestyle play the major role. Table 1
  Region          1                      2                        3                         shows the age-standardized inci-
  Asia                                                                                      dence for the three most frequent
    Eastern       Stomach (42)           Lung (39)                Liver (35)                cancer sites in various regions of
  America                                                                                   the world. A diges-
    North         Prostate (102)         Lung (58)                Large bowel (40)          tive cancer (either
    South         Prostate (29)          Lung (25)                Stomach (21)              stomach, liver,
  Europe                                                                                    or large bowel)
    West          Prostate (55)          Lung (53)                Large bowel (42)          is always pres-
    East          Lung (70)              Large bowel (33)         Stomach (34)              ent among the
    North         Prostate (45)          Lung (44)                Large bowel (34)          three top-ranking
    South         Lung (59)              Large bowel (33)         Stomach (19)
                                                                                            lesions.


                                                               21
                        Table 2. The burden of cancer (both sexes) in the more developed countries. Estimates in 2000 and expected cases in 2020 (from
                        Globocan 2000, Lyons: IARC, 2001).

                                                  Estimates in 2000                                                         Expected cases in 2020

                                                  Cases                    Deaths                    Ratio of
                                                  (n)                      (n)                       cases : deaths

                         Large bowel                610591                 301648                    2.02                     806176
                         Stomach                    334011                 229939                    1.45                     439842
                         Pancreas                   127416                 128730                    0.98                     168453
                         Liver                      106950                 105649                    1.01                     142836
                         Esophagus                   71163                  63938                    1.11                      94251

                         Total                    1250131                  829904                    1.50                   1651558



                        Table 3. The burden of cancer (both sexes) in less developed countries. Estimates in 2000 and expected cases in 2020 (from Globocan
                        2000, Lyons: IARC, 2001).

                                                  Estimates in 2000                                                          Expected cases in 2020

                                                  Cases                     Deaths                   Ratio of
                                                  (n)                       (n)                      cases : deaths
SPECIAL SECTION: IDCA




                         Stomach                    543026                   416614                  1.30                     983414
                         Liver                      457406                   442916                  1.03                     801685
                         Esophagus                  341163                   273560                  1.24                     624574
                         Large bowel                334123                   190761                  1.75                     592146
                         Pancreas                    88969                    84734                  1.05                     162401

                         Total                    1764687                   1408585                  1.25                    3164220



                            The Globocan 2000 database                Time Trends in Incidence and                  1975–79 and for 1992–96 (SEER
                        (IARC Press, 2001) gives an estimate          Mortality from Digestive Cancers              registry). During the first period,
                        of the burden of cancer in each               Significant variations in inci-                the incidence increased while
                        country for the year 2000, with a             dences and mortality rates can                the mortality decreased slightly
                        projection of trends in subsequent            occur within a relatively short               (improved treatment); during the
                        decades, based on demographic                 period. The incidence of adeno-               second period, the incidence and
                        statistics. For the most frequent             carcinoma in Barrett’s esophagus              mortality decreased together. The
                        digestive cancers, the estimates              and at the esophagogastric junc-              reduction in the incidence may be
                        of incident cases and number of               tion is increasing. The incidence             attributable to endoscopic removal
                        deaths occurring in the more and              of noncardiac stomach cancer is               of adenomatous polyps.
                        in the less developed countries               decreasing worldwide; however,                    Data on stomach cancer in
                        are summarized in Tables 2 and 3.             crude numbers of cases will still             Japan (from the Osaka Cancer Reg-
                        Digestive cancers (with the excep-            increase in less developed coun-              istry) are shown in Table 5. During
                        tion of colorectal cancer in select           tries (demographic pressure and               the period 1973–89, when the
                        populations) have a poor prognosis            aging population). The increas-               national screening policy was fully
                        and deserve increased attention in            ing incidence of colorectal cancer            effective, there was a reduction
                                             order to achieve         in North America and Europe is                in the incidence and mortality of
                                             prevention. The          tending to stabilize, but there has           stomach cancer. The change in inci-
                                             tables also show         been a recent increase in Japan.              dence has been attributed to spon-
                                             the number of            A reduction in cancer mortality               taneous changes in lifestyle that
                                             cases expected in        has also resulted from treatment              occurred at a much earlier period.
                                             2020, based on           of the disease. Table 4 shows                 Mortality decreased more than
                                             the demographics         the incidence and mortality from              incidence, because the screening
                                             of the population.       colorectal cancer in the USA for              improved the survival of patients in


                                                                                         22
whom cases were detected at the                 step), secondary prevention (early          able by interventions at the level of
preclinical stage.                              detection and treatment at the              the causative factors. Helicobacter
                                                preclinical stage), and multimodal          pylori infection is responsible for
A Worldwide Strategy for Cancer                 therapy (for advanced cancer).              approximately 50% of gastric can-
Prevention                                                                                  cer cases, in conjunction with a
In the USA, the National Cancer                 Strategy for Prevention of                  diet poor in fruit and antioxidants
Act (1971) aimed to achieve a                   Digestive Cancers                           and rich in salt. Nitrosamines are
50% reduction in cancer mortal-                 Causal factors. The preventive              potent carcinogens that develop
ity by 2000. The objective was not              approach to cancer should focus             in foods containing nitrates and
reached, but during those three                 on the multiple causal factors              nitrites and salt-preserved fishes,
decades, basic knowledge about                  which have been delineated in the           or in the achlorhydric stomach. For
cancer expanded exponentially. In               etiology of digestive cancer. Diet          colorectal cancer, prevention aims
2003, Dr. von Eschenbach, director              and nutrition (quantitative and             at a healthy diet, with less fat, less
of the U.S. National Cancer Institute,          qualitative), rank first; carcinogens        meat, more fruit and vegetables,
is offering a new target to scientists          may contaminate food or develop             and daily physical exercise. For
and health-care providers: eliminat-            during its preparation. Infectious          hepatocellular carcinoma, preven-
ing suffering and death due to can-             agents also play a role, particularly       tion is based on immunization
cer by 2015, so that people can live            in less developed countries.                against hepatitis B virus and on the
with, rather than die of, cancer. The               For esophageal squamous-cell            conservation of ground nuts in hot
objective is to bring cancer under              cancer the responsible agents in            and humid countries. Worldwide,




                                                                                                                                      SPECIAL SECTION: IDCA
control as a chronic manageable                 the more developed countries are            it is estimated that 25% of cases
disease: “preemption” of cancer                 alcohol and tobacco consumption,            are caused by hepatitis C virus
instead of prevention of cancer. This           acting in synergy; in less developed        and 60% by hepatitis B virus. In
means slowing, delaying, or stop-               countries, scalding hot beverages,          sub-Saharan Africa and South-East
ping the progression so that the                oral consumption of opioids, and            Asia, food contaminants are also a
lethal phenotype is not reached.                possibly infectious agents (papillo-        causal factor. Aflatoxins, products
The strategy includes primary                   mavirus) play a role. Gastric cancer        of Aspergillus fungi, accumulate
prevention (at the transformation               is a disease that is largely prevent-       in traditional diets based on maize
                                                                                            and ground nuts. In other coun-
Table 4. Variation in the age-standardized incidence and mortality rates per 100 000        tries, alcohol is the causal factor for
for colorectal cancer (standardization versus the American population) during two           hepatocellular carcinoma. For chol-
distinct periods in the SEER Registry. The incidence increased during the first period and   angiocarcinoma, in Asia (Thailand)
decreased during the second.                                                                the consumption of raw and con-
                                                                                            taminated fish is the source of the
                               1973–79                       1992–96
                                                                                            liver flukes (Opisthorchis viverrini)
 Incidence rate                                                                             that responsible for the develop-
   Males                       +3.9                          –9.0                           ment of the disease, while in West-
   Females                     +0.7                          –2.9                           ern countries cholangiocarcinoma
 Mortality rate                                                                             occurs in connection with chronic
  Males                        +1.1                          –6.1                           inflammatory bowel disease.
  Females                      –2.1                          –5.0
                                                                                                Genetic susceptibility. The
                                                                                            prevention of digestive cancer by
Table 5. Age-standardized incidence and mortality rates per 100 000 for stomach cancer      intervention at the level of envi-
(standardization versus the Japanese population) in the Osaka Cancer Registry.              ronmental factors affects sporadic
                                                                                            cancer, which
                       1963–65           1987–89            Ratio 1989 : 1963
                                                                                            accounts for most
 Incidence rate                                                                             of the burden.
   Males               150.1             96.7               0.64                            With inherited
   Females              71.5             41.5               0.58                            cancer syndromes,
 Mortality rate                                                                             molecular biology
  Males                117.8             59.8               0.05                            is becoming the
  Females               57.3             26.7               0.46                            tool of choice and


                                                                    23
is being added to conventional             flat, or slightly depressed. They can         The physicians can also play a
screening methods. Specific proto-          be precisely analyzed with the help      role in the primary prevention of
cols for chemoprevention or surgi-         of chromoscopy and easily treated        cancer in cooperation with other
cal resection are also available.          during endoscopy. An optical zoom        health-care providers and payers.
Inherited colorectal cancer mainly         can display the magnified archi-          The specialist must also be an
concerns the familial adenoma-             tecture of the mucosa and predict        active partner in the campaign to
tous polyposis (FAP) and heredity          the histology (optical biopsy) with      increase awareness of risk factors
nonpolyposis colorectal cancer             some reliability. The significance of     and prevention. Finally, the gastro-
(HNPCC) syndromes, and a small             flat adenomas is not yet completely       enterologist needs to be integrated
fraction of the cases of gastric           understood.                              into a multidisciplinary community
cancer. In addition, genetic poly-             Digestive specialists and the        of oncologists, surgeons, patient
morphism may increase suscepti-            prevention strategy. The gastroen-       advocates, providers, and every
bility to cancer. The best example         terologist (primary care physician,      other group of people who share
is the frequency of the inactive           endoscopist, surgeon, oncologist)        the goal of reducing the incidence,
form of the aldehyde dehydroge-            has a major role in the prevention       mortality, and morbidity of diges-
nase enzyme in Asian individu-             of digestive cancer. The most criti-     tive cancers. s
als, explaining the poor tolerance         cal role is in endoscopic detection
for alcohol and increased risk for         of asymptomatic disease in the
                                                                                     René Lambert, M.D.
esophageal squamous-cell cancer.           esophagus, stomach, and colon.            International Agency for Research
    Detection at the preclinical           In regions with a high prevalence            on Cancer




                                                                                                                           SPECIAL SECTION: IDCA
stage. Detecting cancer at the pre-        of the disease, this also applies to      150, cours Albert Thomas
clinical stage is the objective of indi-   early detection of hepatocellular         Lyon 69008, France
                                                                                     E-mail : lambert@iarc.fr
vidual screening. Mass screening           carcinoma using ultrasonography.
protocols are cost-effective when
there is a significant prevalence of
the disease, when there is an ade-
quate screening test (sensitivity and      Joint OMED and IDCA Meeting
specificity criteria), and when the
disease can be completely cured at         on Screening for Colorectal
this stage. Mass screening protocols
are valid for stomach                      Cancer (Orlando, 2003)
cancer in Japan (photo-
fluorography), hepato-                                     OMED Morning Session
carcinoma in Asia and in
some African countries                                    Paul Rozen
(ultrasound), and for
colorectal cancer in                                      T  he first Joint Scien-   tion (CRPF) of Washington.
more developed coun-                                      tific Meeting of the           The first session (chaired by
tries (fecal occult blood                                 OMED (World Orga-         Dr. Bond) reviewed international
testing and/or sigmoid-                                   nization for Digestive    colonoscopy screening programs,
oscopy or colonoscopy).                    Endoscopy) Screening Committee           their performance and quality con-
    In recent years, endoscopy has         and the International Digestive          trol. The key address was given by
been acknowledged as the gold              Cancer Alliance (IDCA) was held          Dr. Rex (USA), who reviewed the
standard in the detection of the           in Orlando, Florida, preceding the       potential technical pitfalls associ-
early stages of cancer in the esoph-       Digestive Disease Week (DDW)             ated with screening colonoscopy,
agus, stomach, and large bowel.            scientific sessions. This provided an     the need for nonpunitive, volun-
The most recent models of video            opportunity to address colorectal        tary, continuous quality improve-
endoscopes have opened up a new            cancer screening methodology,            ment including patient satisfac-
field in the detection of neoplasia         receive reports of international         tion, and identifying targets to be
at a preclinical stage. Nonpolypoid        programs, introduce IDCA activi-         reached. Dr. Crespi reported that
lesions – known as “flat lesions” –         ties, and interact with the Cancer       screening colonoscopy, introduced
can be slightly elevated, completely       Research and Prevention Founda-          in Italy in 2002, includes 260 endo-


                                                              25
                        scopic units and is provided at         formed by the EXACT Company. The          a lack of national health insurance
                        no cost. A nationwide awareness         overall sensitivity using a panel of      and recognition of CRC as a major
                        campaign supports screening and         DNA markers was around 70% for            health problem. Dr. Sano (Japan) is
                        recommends annual fecal occult          invasive CRC, with a specificity of        evaluating the timing of the second
                        blood testing (FOBT) or optional        about 97%. In 2003, a more com-           follow-up examination in a colo-
                        colonoscopy. Dr. Regula (Poland)        plete evaluation will be available        noscopy screening program includ-
                        reported on 17 000 examina-             from a multicenter, colonoscopy-          ing 5300 average-risk persons. The
                        tions on asymptomatic volunteers,       controlled study of 5500 persons.         initial conclusions are that the colo-
                        reaching the cecum in 85%, with            The third session, co-chaired by       noscopy should be repeated within
                        another 14 000 planned for 2003.        Dr. Winawer and Dr. Axon, reviewed        3 years if there are no polyps, or
                        Most of the examinations are            a number of national screening            only polyps < 5 mm, otherwise in
                        performed without sedation, and         projects. Dr. Young described the         1 year. They emphasized the impor-
                        polyps >10 mm are referred for          National CRC Screening program in         tance of recognizing flat adenomas.
                        repeated examination and polypec-       Australia; pilot studies in three sites   Dr. Gutierrez-Galina from Uruguay
                        tomy. An external monitoring com-       will include 70 000 participants.         described the high incidence and
                        pany that audits quality assurance      This will be based on a comparative       mortality from CRC there. A screen-
                        found that serious complications        evaluation of two types of central        ing study, performed in collabora-
                        occurred in 0.016% of cases. Dr.        laboratory-developed immuno-              tion with a Japanese government
                        Classen presented an overview of        chemical FOBTs. Other screening           agency, is using an immunochemi-
                        the German colonoscopy program,         methodologies are being evaluated         cal FOBT. They had a surprisingly
SPECIAL SECTION: IDCA




                        initiated in 2002. One issue there      in smaller studies. Dr. Korman from       high level (13.8%) of positivity in
                        is that screening colonoscopy is        Australia summarized a 200-person         3500 screenees, with a positive pre-
                        not allowed at public hospitals, but    survey of satisfaction with screen-       dictive value of 40% for colorectal
                        only by private endoscopists, mak-      ing sigmoidoscopy or colonoscopy,         neoplasia. Dr. Rabeneck (Ontario)
                        ing it difficult to obtain an audit of   which found that both were well           evaluated the use of screening in
                        results. Dr. Hoff (Norway) recom-       accepted by the screenees and             the fully-insured Ontario population
                        mended that a colonoscope should        that endoscopy was not an impedi-         and found that only < 20% had had
                        be used routinely for unsedated,        ment to compliance. Dr. Hoff from         some form of colon test performed
                        extended flexible sigmoidoscopy.         Norway updated the data from              for either screening or diagnostic
                        Dr. Tatsumi from Japan commented        a 13 000-person pilot screening           evaluation. They are now evaluating
                        that annual FOBT was used after         sigmoidoscopy program, with inter-        the compliance of 120 000 persons
                        colonoscopy in 6000 patients and        mediate recommendations to use            in a pilot study of FOBT screening.
                        that endoscopy was repeated if the      CO2 for insufflation, training endos-      Dr. Tatsumi from Japan described
                        FOBT was positive. They are evalu-      copists to perform painless exami-        how the large industrial company,
                        ating the timing of a second exami-     nations, and to use a 140-cm colo-        Matsushita, provides total health
                        nation in order to maintain quality     noscope for deeper insertion. Dr.         care, including CRC screening, to its
                        control of its performance.             Zavoral (Czech Republic) described        71 300 employees. They use immu-
                            In the second session, chaired      their national biennial FOBT pro-         nochemical FOBT, with 5% positiv-
                        by Dr. Rozen, Dr. Young (Australia)     gram, based on general practitio-         ity; compliance for follow-up in
                        emphasized the better quality con-      ners, and given to 110 000 asymp-         unsedated colonoscopy is very high.
                        trol and standardization of central     tomatic screenees in 2001. They           Almost all CRCs detected are early
                        laboratory automated immuno-            aim at 50% population compliance          cancer. Dr. Melcher from Germany
                        chemical FOBTs as compared to the       with 5% FOBT positivity and are just      illustrated how biological research
                        guaiac test. The screenees showed       seeing the results of the colonos-        can be added to a screening pro-
                        better acceptance of the use of a       copy follow-up. Dr. Benjamin Wong         gram. In their study, they perform
                        long-handled brush to collect the       from Hong Kong described their            MIS and karyotype the cancers. Dr.
                        specimen than with the standard         high incidence of CRC. A pilot study      Atkin (UK) commented that they
                        spatula. The immunochemical test        comparing guaiac to immunochem-           have completed enrollment in a
                        (Insure) was found to have better       ical FOBT demonstrated the poor           screening sigmoidoscopy study and
                        sensitivity, but the same specificity    specificity of the former, due to the      in the UK have initiated a pilot bien-
                        as FlexSure. Dr. Ross, USA, updated     high levels of peroxidase in the Chi-     nial FOBT study of 300 000 persons
                        the fecal DNA studies being per-        nese diet. Their major problems are       in two geographic areas. Dr. Son-


                                                                                 26
nenberg reminded us that reducing       pilto and organized local screening    colorectal cancer and to encourage
CRC mortality by screening has not      programs. These will be the themes     people to learn more about how
been proven to decrease all-cause       for future, interactive meetings and   to reduce their risk of the disease
mortality. Dr. Mandel agreed that       intersted persons can contact the      through regular screening and
there was no certain prolongation       undersign. s                           a healthy lifestyle. Ms. Duncan
of life as a result of screening, but                                          described the Colossal Colon Tour,
that there will be a decrease in         Dr. Paul Rozen                        a 20-city American tour launched as
                                         Chairman, OMED Colorectal Cancer
CRC mortality and obviously death                                              part of NCRCAM 2003. The Colossal
                                             Screening Committee
from other causes. In conclusion,        Tel Aviv Medical Center               Colon (picture below) is a 12-meter
the meeting addressed new and            Dept. of Gastroenterology             long, 1.2-meter high replica of a
evolving non-invasive screening          6 Weizmann Str.                       human colon that shows healthy
methodologies and the promo-             64239 Tel Aviv, Israel
                                                                               tissue, Crohn’s disease, diverticu-
                                         E-mail: rozen@tasmc.health.gov.il
tion and performance of national                                               losis, ulcerative colitis, polyps and
                                                                               various stages of colon cancer.
                                                                                   Ms. Blanchard and Dr. Peter-
                                                                               son briefly discussed the essential
                  IDCA Afternoon Session                                       components of the Dialogue for
                                                                               Action educational conference – an
                  Sidney Winawer and Meinhard Classen                          annual feature of their national
                                                                               awareness month – which focuses
                  Dr. Winawer,




                                                                                                                       SPECIAL SECTION: IDCA
                                        IDCA has extended membership to        on implementing colorectal cancer
                    Co-Chair of IDCA,   about 60 national societies and is     screening as part of a compre-
                    presented an        cooperating with WHO. It has des-      hensive and coordinated cancer
                    overview of IDCA    ignated March as Digestive Cancer      prevention strategy. The CRPF
which was launched in 2002 at           Awareness Month and is helping to      Dialogue for Action team works
the Vatican in Rome. The mission        plan scientific meetings.               closely with a region or organiza-
of the IDCA is to promote screen-           Following the IDCA background      tion to assist them in starting or
ing, early detection, and primary       presentations, Ms. Judie Blanchard,    extending a program for change in
prevention of digestive cancers         Ms. Shanna
worldwide through an interna-           Duncan and Dr.
tional alliance of organizations that   Karen Peterson,
share the same goal. The IDCA           of the Cancer
will include broad participation of     Research and
medical and professional groups,        Prevention
patient and public advocacy             Foundation
groups, health-care authorities,        (CRPF), reported
the media, and industry. The first       on the current
campaign is focusing on colorectal      work of their
cancer, with the goals of promoting     Foundation.
guidelines, increasing awareness,       March has
screening, and modifying lifestyle.     already been the
The IDCA also initiated a campaign      CPRF’s National
on cancer of the esophagus and          Colorectal
stomach at the OMED spring meet-        Cancer Aware-
ing held in Rome in May 2003.           ness Month
IDCA will provide a forum for inter-    (NCRCAM) for
national interaction, offering assis-   the past 4 years.
tance with initiating programs, and     The goal of
will provide models for interactive     NCRCAM is to
meetings and offer recognition to       generate wide-
member societies and founding           spread aware-
organizations. Since its inception,     ness about


                                                        27
                        the health of a community, a state,      population level. There was a gen-       is useless if colonoscopy facilities
                        or a country. (For inquiries about       eral feeling that those who need         cannot respond to the demand.
                        a Dialogue for Action program in         screening most seek it least. In this    Very few countries felt that they had
                        your country, contact Dr. Karen          respect, health system strategies        enough colonoscopy resources to
                        Peterson: karen.peterson@preven          to engage minority groups and the        undertake colonoscopic screening.
                        tcancer.org or +1-703-837-3680.          socio-economically disadvantaged             While some countries have
                        For more information about CRPF,         need development. Few countries          been raising public awareness of
                        National Colorectal Cancer Aware-        seem to be proactive in this regard.     the problems posed by CRC, defi-
                        ness Month, or the Colossal Colon,       Screening can only be effective          cient knowledge seemed universal.
                        go to www.preventcancer.org).            and reach a sizable proportion of        Health-care professionals need to
                           Attendees of the IDCA meeting         the population if it is inexpensive      work together to make screening
                        at DDW were able to experience           or adequately reimbursed. There is       more feasible and simple. Cost is
                        a “mini” Dialogue for Action. Dr.        enormous variation between coun-         also a determinant of accessibility.
                        Sidney Winawer facilitated the con-      tries, and even within countries,            When it comes to screening,
                        versation and Drs. Rozen and Clas-       with regard to the way in which          without participation there is no
                        sen presented background issues          costs are managed. For CRC screen-       detection and hence the best test is
                        in barriers to screening. Dr. Young      ing to be provided at a manageable       the one that gets done. What gets
                        provided the following summary           cost to the individual, health-care      done depends not on the doctor,
                        which summarizes the require-            providers need to consider screen-       but on the individual in the popula-
                        ments of a successful screening          ing for CRC as a priority. The ways in   tion. For any country or region, the
SPECIAL SECTION: IDCA




                        program:                                 which advocates of screening have        steps toward implementing screen-
                        • Identification of the target group      involved health-care funding bodies      ing in the face of the many patient
                        • Effective participation of those       in recognizing the priorities differ     and system barriers are:
                           targeted                              greatly between countries.               • Determine whether CRC is of
                        • Quality application of screening           For screening to be endorsed             sufficient magnitude to warrant
                           tests                                 and supported by health funders,             screening
                        • Appropriate, timely, and effective     there are three areas of profes-         • Define the screening process
                           diagnostic follow-up                  sional activity that require careful         options and match these to the
                        • Appropriate, timely, and effective     attention. The screening tool (fecal         existing health-care system.
                           treatment                             occult blood test, fecal immuno-             Ensure acceptability and feasibil-
                           It was apparent from the discus-      chemical tests, fecal DNA tests, sig-        ity
                        sion that the barriers to screening      moidoscopy, colonoscopy, CT colo-        • Provide professional evidence-
                        were common to all countries, but        nography, etc.) needs to be used             based guidelines and make
                        that the relative magnitude of the       appropriately, with reliable quality         attempts to achieve adherence
                        barriers varied considerably. The        assurance programs in place. Poor            to these
                        health-care system is important.         quality would bring screening into       • Establish public education and
                        In countries in which health-care        disrepute. To aid quality and appro-         advocacy
                        strategies tend to be ad hoc and         priate decision-making, evidence-        • Interact with public health pol-
                        individualized, especially when          based best-practice guidelines for           icy-makers
                        reimbursement is based on indi-          professionals in all aspects of pre-     • Track screening outcomes and
                        vidual contact, the system reacts        vention of CRC need to be devel-             monitor quality
                        to the individual and may not be         oped and promulgated, and adher-             The way forward depends on
                        designed to maximize population          ence to the must be monitored.           five barrier-breaking principles:
                        outcomes. In countries in which          Professionals need to participate        1 Focus on the screening process
                                           there is a central-   in developing these. Countries in            and its implementation within a
                                           ized approach to      which such guidelines are in place           health-care system, not the indi-
                                           public health pol-    seem to be proceeding at a faster            vidual at a single point of care.
                                           icy and screening,    rate. If there is to be a measurable     2 There needs to be a desire on
                                           resources may be      population impact, then access               the part of everyone (public,
                                           more focused on       to all elements of the screening             professionals, and politicians)
                                           the public health     program is necessary. For instance,          to screen – the policy has to be
                                           problem at the        implementation of FOBT testing               embraced.


                                                                                  28
3 The test must be accessible and       sen), OMED (Dr. Rozen), UEGF (Dr.      Brazil, and China, collaboration
   the cost acceptable – funders        Crespi), ESGE (Dr. Nowak), the         with patient and public advocacy
   must be prepared to pay.             Burda Foundation (Dr. Maar), and       groups, the Montreal WCOG Colos-
4 People need to participate            the UICC (Dr. Levin and Dr. Smith).    sal Colon public and scientific
   – behavioral and educational         Each of the founding organiza-         events, and international assistance
   issues need to be comprehen-         tions will be featured individually    with implementation of the CRPF
   sively and effectively addressed.    in future issues of WGN. The CRPF      meeting model. s
5 Interventions carried out (screen-    was described in the previous
   ing, diagnostic, and therapeutic)    issue, and the UEGF is featured         Sidney Winawer
   need to be effective and of suffi-    in the current issue, providing         Meinhard Classen
                                                                                Co-Chairmen, IDCA
   cient quality – quality assurance    their perspective on digestive
                                                                                IDCA Executive Secretariat
   programs are essential.              cancer.                                 Medconnect
The meeting then turned to an               The meeting closed with a brief     Bruennstein Str. 10
overview of activities by each of the   presentation of future IDCA activi-     81541 Munich,
founding organizations of IDCA:         ties, including assistance in plan-     Germany
                                                                                E-mail: idca@medc.de
OMGE (Dr. Winawer and Dr. Clas-         ning scientific meetings in Russia,




                       5                  UNITED EUROPEAN




                                                                                                                      SPECIAL SECTION: IDCA
                 5       5
                   55
               5
                 5
                     5                   GASTROENTEROLOGY
             5
        5                               FEDERATION

Public Affairs Committee of the
United European Gastroenterology Federation
Massimo Crespi (on behalf of the UEGF Public Affairs Committee)

T he United European Gastroenter-       ESGE, and ESPGHAN) and several         • UEGF must be seen to be
ology Federation (UEGF) is a found-     associate members. These societies       involved, not just in treating
ing member of the International         represent all the national societies     patients and administering
Digestive Cancer Alliance (IDCA).       in their disciplines.                    expensive medications and
The main aims of the UEGF are:                                                   operations, but also in prevent-
• To organize an annual confer-         Broader Aims of the UEGF’s               ing disease and promoting
    ence (United European Gas-          Public Affairs Committee                 health.
    troenterology Week, UEGW)           UEGF has the potential to become       • The UEGF should have a role
    encompassing all the different      involved in the European politi-         as a support organization for
    branches of the discipline of       cal agenda on health care, and it        patient groups throughout
    gastroenterology.                   therefore needs to be perceived          Europe. This will help promote
• Beyond the process of orga-           as a truly representative body for       gastroenterol-
    nizing the annual UEGW, to          gastroenterology in Europe. To           ogy as a spe-
    enhance the profile of gastroen-     achieve this aim, the Public Affairs     cialty.
    terology in Europe.                 Committee (PAC) was set up under       • UEGF must be
    The UEGF’s membership con-          the chairmanship of Professor M.         seen to be a
sists of the seven major gastro-        Keighley to enhance the UEGF’s           body that is
enterology societies in Europe          profile on the basis of the following     engaged in
(ASNEMGE, CICD, EAGE, EASL, EPC,        considerations:                          educating the


                                                        29
                            public on the prevention of             lished and can be ordered from:        embarrassing; only half of the pop-
                            disease by health measures, life-       Ms. V. Warner, Director, Public        ulation sample knew that there are
                            style and awareness campaigns,          Affairs Project, United European       screening tests available, but they
                            and with screening recommen-            Gastroenterology Federation,           were willing to undergo screening
                            dations, if appropriate.                c/o Dept. of Surgery, Queen            if it was free of charge.
                        •   In order to take the message            Elizabeth Hospital, Birmingham              The intense work of the PAC
                            forward, UEGF will need to be           B15 2TH, United Kingdom (tel./         and the outcomes of the different
                            engaged in a media operation            fax: +44-121-414 7918; e-mail:         campaigns will be presented at
                            that will identify news affecting       v.warner@bham.ac.uk).                  the forthcoming UEGW meeting
                            gastrointestinal disease and pro-     • Producing a document on food           in Madrid and submitted for the
                            viding bulletins for press outlets.     and health and implementing            attention of the Commissioner of
                        •   The UEGF must also be seen to           an educational project amongst         Health of the European Union, who
                            be an organization engaged in           schoolchildren in Europe. A pilot      has confirmed that he will attend
                            training standards that are com-        phase has been completed and           UEGW. s
                            parable throughout Europe. This         a set of “ten commandments”
                            is particularly important in the        on healthy behavior has been            Massimo Crespi, M.D.
                                                                                                            Regina Elena
                            field of endoscopy and surgery.          produced.
                                                                                                               National Cancer Institute
                        •   The UEGF should also be pro-          • Possibly organizing a public            Viale Regina Elena, 291
                            ducing guidelines on best prac-         event at each UEGW, with                00161 Roma, Italy
                            tice.                                   involvement of European and             E-mail: mcrespi@uni.net
SPECIAL SECTION: IDCA




                        •   The UEGF should produce a               national health authorities, the
                            dynamic educational web site in         public, and the media.
                            different languages for the pro-
                            fession and for the public.           PAC Campaigns for Colorectal
                                                                  Cancer Prevention
                        The PAC’s Ongoing and Planned             In order to focus action on colorec-
                        Projects                                  tal cancer prevention and screening
                        • Gathering information on public         – nowadays considered a priority
                           awareness of certain gastroen-         in most European countries – an
                           terological diseases by the pub-       “ad hoc” sub-committee has been
                           lic and exploring GPs’ attitudes.      established to prepare simple,
                           A questionnaire on awareness           straightforward lobbying messages
                           of colorectal cancer and screen-       for the public and GPs as a basis
                           ing amongst the asymptomatic           for implementing specific actions
                           healthy public, exploring the          by the national societies. The initial
                           reasons for lack of compliance         data from the survey of general
                           with existing guidelines, has          public awareness on preven-
                           been completed with a repre-           tion, risk factors, and screening of
                           sentative sample of population         colorectal cancer in 21 European
                           in 21 European countries.              countries are extremely interest-
                        • A survey of the impact of gastro-       ing. There are large differences
                           intestinal diseases on the citi-       in awareness levels from country
                           zens of Europe has already been        to country; there is very limited
                           completed, with input from             knowledge of risk factors such as
                                           the associated         family history and age; lifestyle is
                                           national societ-       considered important, but physical
                                           ies. A booklet         exercise is mostly not recognized
                                           with a detailed        as a protective factor. In addition,
                                           analysis of gas-       the majority of those surveyed
                                           trointestinal can-     (with wide variations between
                                           cers in Europe         countries) state that discussing
                                           has been pub-          bowel symptoms with a doctor is


                                                                                   30
DIGESTIVE CANCER AWARENESS CAMPAIGN



               The International Digestive Cancer Alliance


  Prevention of Colorectal Cancer
  Robert Sandler

  Colorectal cancer is a prevent-        patients did not show                                       cancer. The mecha-
  able disease. When people migrate      that fiber prevented                                         nism for protection
  from low-incidence countries, such     new adenomas dur-                                           by calcium is not
  as Japan or Africa, to a high-inci-    ing the 3-year study                                        known.
  dence country such as the United       period.                                                         Selenium. Trace
  States, the rates of disease among         Fruits and vegeta-                                      metals such as
  their offspring increase to those of   bles. There are a large                                     selenium, zinc, iron,
  their adopted country. This indi-      number of studies of                                        and fluoride may




                                                                                                                             SPECIAL SECTION: IDCA
  cates that there is something in the   fruits and vegetables                                       be capable of influ-
  environment that is responsible. If    in connection with                                          encing the risk of
  we could identify and modify these     colorectal cancer, and                                      colorectal cancer.
  environmental factors, we could        virtually all of them           Robert Sandler             A large randomized
  prevent colorectal cancer.             demonstrate a mod-                                         trial of selenium
                                         erate protective effect. One excep-       administration to prevent skin
  Diet                                   tion is a report from the Nurses’         cancer found that colorectal cancer
  There have been a large number         Health Study, which did not find a         deaths were 60% less frequent in
  of studies of diet and colon cancer.   protective effect against colon or        individuals who were assigned to
  Unfortunately, it has been difficult    rectal cancer. While the mechanism        the selenium group. These results
  to draw firm conclusions about          for protection by vegetables is not       are quite surprising and need to be
  the association between diet and       known, there are a large number of        confirmed.
  colorectal cancer.                     chemicals from the plant kingdom              Micronutrients. Because fruits
      Red meat. The majority of stud-    that have been found to be anticar-       and vegetables are associated with
  ies have shown an increased risk of    cinogenic or antimutagenic in test        a lower risk of colorectal cancer,
  colorectal cancer with high intakes    systems. These chemicals operate          one might speculate that the pro-
  of red meat. Heterocyclic amines       at a number of different sites in the     tective effect might be due to vita-
  and polyaromatic hydrocarbons          carcinogenic pathway.                     mins, particularly the antioxidant
  are produced when red meat is              Calcium. A large randomized           vitamins A, C, and E. Antioxidants
  cooked at high temperature. These      controlled trial has shown that           can inhibit free-radical reactions
  compounds may be carcinogenic.         1200 mg per day of calcium, in            and thereby prevent oxidative
      Fiber. Burkett advanced the        the form of calcium carbonate,            damage to DNA. Unexpectedly,
  hypothesis that fiber prevents          resulted in a 19% reduction in            clinical trials of antioxidant vita-
  colorectal cancer almost 40 years      the development of new adeno-             mins have not shown an effect
  ago. Although the hypothesis is        mas and a 24% reduction in the            against colonic
  appealing, recent studies indicate     number of new adenomas in com-            neoplasms. In
  that it may not be correct. A large,   parison with a placebo. The end           the large Nurses’
  carefully conducted cohort study       point in the study was adenomas,          Cohort, women
  found no protective effect of fiber     rather than cancer, but because           who took mul-
  from any source – cereals, fruits,     virtually all cancers are thought to      tivitamins that
  or vegetables. Two randomized          arise from adenomas, the protec-          contained folic
  trials of fiber in post-polypectomy     tive effect is thought to extend to       acid for at least


                                                          33
                        15 years were about 75% less             stances in feces. However, neither      study showed that hormone
                        likely to develop colon cancer than      constipation nor the use of laxa-       replacement reduces the overall
                        women who never took multivita-          tives appears to be an important        risk of colon cancer.
                        mins. Protection required vitamin        risk factor for colorectal cancer.
                        use for 15 years or more; a shorter          NSAIDs. Aspirin and nonste-         Practical recommendations
                        duration of use conferred no pro-        roidal anti-inflammatory drugs           Sensible modifications in diet and
                        tection. The protective effect seen      appear to be protective against         lifestyle could have a favorable
                        in the Nurses’ study was primarily       colorectal neoplasia, based on          impact on the development of
                        due to the folic acid component of       evidence from a variety of different    colorectal cancer. At the same time,
                        the multivitamins, rather than the       types of studies. In a randomized       it is important to recognize that the
                        antioxidant vitamins.                    trial of polyposis patients, sulindac   benefits of screening for colorectal
                            Smoking and alcohol. The             has been shown to result in polyp       cancer completely overshadow
                        majority of studies demonstrate          regression. The mechanism is not        the effects of primary prevention.
                        an increased risk of colorectal can-     known, but it could be related to       In discussing strategies for cancer
                        cer and adenomas with cigarette          increased apoptosis in transformed      prevention with our patients, it
                        smoking.                                 mucosa. There has been specula-         is very important to make it clear
                            Alcohol has been linked with an      tion that the effect could be due to    that the most important strategy is
                        increased risk for both adenomas         inhibition of the cyclooxygenase-2      screening.
                        and cancer. The data are more            pathway to prostaglandin produc-            Practical, evidence-based rec-
                        consistent for adenomas, but the         tion, since Cox-2 is up-regulated       ommendations for primary preven-
SPECIAL SECTION: IDCA




                        majority of studies also support an      in colon tumors. Celecoxib has          tion might include the following:
                        association between alcohol and          been shown to decrease the              • Eat a sensible diet, high in
                        cancer. The effect of alcohol may        numbers of polyps in polyposis              vegetables and fruits; limit red
                        relate to its antagonism of methyl       patients. Three recent randomized           meat (less than two servings per
                        group metabolism, and the effects        controlled trials have shown that           week).
                        appear to be increased by low            daily aspirin can decrease the risk     • Avoid obesity (body mass index
                        levels of the folic acid, a methyl       of recurrent colorectal adenomas.           < 26 kg/m2).
                        donor.                                   Taken together, the three studies,      • Take regular exercise – 30 min/
                            Physical activity. Physical activ-   along with extensive observa-               day, moderate or vigorous.
                        ity has consistently been shown to       tional studies, show that aspirin       • Consider supplements with cal-
                        protect against colorectal cancer.       is an effective chemopreventive             cium (1200 mg/day) and folic
                        Both leisure-time and occupational       agent.                                      acid (1 mg).
                        activities appear to be important.           Despite the compelling evi-         • Limit alcohol consumption;
                            Obesity. The amount of food,         dence of a protective effect of             don’t smoke.
                        rather than the type, may be             aspirin and conventional NSAIDs,        • Participate in regular screening.
                        important. Obesity has been linked       these drugs have well-known             • Avoid health claims and fads
                        to colon cancer in both men and          adverse effects. Drugs in this class        based on weak data. s
                        women. Recent cohort studies             can increase the risk of hemor-
                        have shown that obese women              rhagic strokes and gastrointestinal      Note: This paper was presented at
                        were 50% more likely to develop          bleeding. Because of an unfavor-         Digestive Disease Week, Orlando,
                        colon cancer, and obese men 80%          able cost–benefit ratio, these drugs      Florida, 2003.
                        more likely.                             should not be recommended for
                            Constipation. There has long         routine prevention in low-risk indi-     Robert S. Sandler, MD, MPH
                        been speculation that constipa-          viduals.                                 Professor of Medicine and
                                            tion might be            Hormone use. Postmenopausal            Epidemiology,
                                            responsible for      hormones have been shown to be           Chief, Division of Gastroenterology
                                                                                                            and Hepatology,
                                            large-bowel          associated with a decreased risk of
                                                                                                          CB#7555, 4111 Bioinformatics
                                            cancer, due to       colorectal cancer. A meta-analysis         Building,
                                            more prolonged       has shown that postmenopausal            University of North Carolina,
                                            contact with         women who had taken hormone              Chapel Hill, NC 27599-7555, USA
                                                                                                          E-mail:
                                            the mucosa by        replacement were 20% less likely
                                                                                                            robert_sandler@med.unc.edu
                                            carcinogenic sub-    to develop colon cancer. A recent


                                                                                  34
Letter in Support of IDCA from
His Holiness John Paul II



  SECRETARIAT OF STATE
  FIRST SECTION . GENERAL AFFAIRS




  Prot. No. 552172                                              From the Vatican, 17 January 2004




           The Holy Father is pleased to have been informed of the International Colorectal Cancer
  awareness month being promoted for March this year. He sends prayerful best wishes and
  heartfelt encouragement to all those participating his initiative.




                                                                                                       SPECIAL SECTION: IDCA
            His Holiness is appreciative of the work of the International Digestive Cancer Alliance,
  which steadfastly seeks to promote screening for the early detection and primary prevention
  of digestive cancers throughout the world. The Church is always open to genuine scientific and
  technological progress, and she values the efforts and sacrifices of those who, with dedication
  and professionalism, help to improve quality of service rendered to the sick, and who seek to
  reduce factors which adversely affect human life and health (cf. No. 4 Message for the World Day
  of the Sick, 2003). The Holy Father reminds the members of the international medical community
  of the increasingly urgent need to close the unacceptable gap that separates the developing world
  from the developed in terms of preventive health care education and treatment. In this regard
  he is confident that they will address the question of access to the health care programmes and
  structures, lacking in many parts of our world.

          Entrusting the activities of the International Colorectal Cancer awareness month to the
  guidance of Mary, Seat of Wisdom, His Holiness invokes God´s abundant blessings upon all
  those involved and he cordially imparts his Apostolic Blessing.




  With every good wish, I am

                                                               Yours sincerely,




                                                               Leonardo Sandri
                                                               Substitute




                                                 35
                        Results of an OMGE International Survey
                        The Role of the Gastroenterologist in the
                        Management of Patients with Digestive Cancers
                        Position Paper from an OMGE Working Party*, chaired by Sidney J. Winawer


                        Digestive cancers as a group have the highest inci-               (94%), and follow-up of gastro-
                        dence of all cancers worldwide. More than 3 million               intestinal cancer patients (91%),
                        new cases occur each year, with 2.2 million deaths. A             and least often trained in surgical
                        Working Party was organized by OMGE to evaluate the               oncology (51%), radiation oncol-
                        role of the gastroenterologist in the overall manage-             ogy (20%), and alternative medi-
                        ment of patients with digestive cancers and to make               cine (14%).
                        recommendations for improving the management and                • The top five topics that respon-
                        continuity of care of these patients.                             dents believe should be pre-
                           A survey was developed and sent to OMGE’s mem-                 sented at postgraduate courses
                        ber organizations. The survey asked questions in four             and clinical symposia are: new
                        main areas: practice directly related to these patients,          therapeutic approaches (97%),
                        including prevention, treatment, follow-up, and                   chemoprevention (90%), screen-            Sidney J. Winawer
SPECIAL SECTION: IDCA




                        administration of chemotherapy; training of fellows in            ing (88%), palliative care (85%),
                        gastrointestinal programs in the area of digestive can-           and the biology of gastrointestinal cancer (84%).
                        cer; postgraduate education in digestive cancer; and              Low scores were given for alternative medicine
                        society interactions in digestive cancer. Ninety surveys          (48%) and lifestyle and cancer (75%).
                        were distributed to leaders of member societies of              • Ninety-one percent of respondents believed there
                        OMGE worldwide.                                                   should be more interactions between gastrointesti-
                                                                                          nal and oncology societies.
                        Results
                        Of the 90 surveys, 47 responses were received from 47           Discussion
                        countries. Collated responses to the survey are listed               The management of patients with cancer has
                        below.                                                          become exceedingly complex. Patients with digestive
                        • Gastroenterologists administer chemotherapy often/            cancers are faced with an enormous increase in the
                           occasionally (30%) or rarely/never (69%).                    range of options available for diagnosis and treatment.
                        • Gastrointestinal cancer treatment is administered by          This usually works to the patient’s advantage, provid-
                           a multidisciplinary team of medical oncologists, gas-        ing a benefit that has strikingly reduced the likelihood
                           troenterologists, radiation oncologists, and surgeons        of deaths from cancer. However, patients may become
                           often/occasionally (57%) or rarely/never (40%).              lost in the maze of specialty medicine without a doctor
                        • Gastrointestinal cancer treatment is planned by a             who provides continuity of care throughout their ill-
                           multidisciplinary team of medical oncologists, gas-          ness. This can be disconcerting to the patient and fam-
                           troenterologists, radiation oncologists and surgeons         ily, and counterproductive for the specialists involved
                           often/occasionally (71%) or rarely/never (27%).              in the case. It was this perception that led OMGE to
                        • Gastrointestinal cancer prevention programs are               organize a working party to evaluate the role of the
                           organized by gastroenterologists occasionally/often          gastroenterologist in the management of patients with
                           (68%) or rarely/never (30%).                                 digestive cancers. The gastroenterologist is often the
                        • The top two components of cancer prevention pro-              first physician to see the patient and make the diagno-
                           grams are educational lectures for a medical audi-           sis, and refer the patient for treatment. Often, however,
                           ence and cancer screening guidelines, regardless             the gastroenterologist does not remain involved during
                           of whether gastroenterologists or other individuals          a long course of treatment, but may be called back to
                           organize the programs.                                       help in diagnosis or palliation at a later stage.
                        • Among respondents with a gastrointestinal training                 The purpose of the international survey reported in
                           program, fellows are trained most often in screen-           this paper is to evaluate the gastroenterologists’ role,
                           ing (94%), pathology of gastrointestinal cancer              and serve as a basis for making recommendations to


                                                                                   36
OMGE. The recommendations that this working party             *OMGE Working Party:
has made to OMGE are listed below. Others have also           S. Winawer, Chair (USA); J.R. Armengol-Miró (Spain);
                                                              D.K. Bhargava (India); M. Bushey (USA);
addressed this issue. A dialogue with other interested
                                                              M. Classen (Germany); M. Crespi (Italy);
societies regarding this issue would be a good begin-         E.V. Cutsem (Belgium); W. Fleig (Germany);
ning, with a matrix provided by the newly formed              R. Fujita (Japan); J. Geenen (USA); S.J. Konturek (Poland);
International Digestive Cancer Alliance, whose mission        A. Kulakowski (Poland); S. Labib (Egypt); B. Levin (USA);
is to raise awareness of digestive cancers worldwide.         P. Rougier (France); P. Rozen (Israel);
                                                              W. Schmiegel (Germany); B. Wong (China);
                                                              S.-D. Xiao (China); G. Young (Australia); A. Zauber (USA)
OMGE Working Party Recommendations
• More interaction among physicians in the manage-             Note: The full-length version of this working party report
  ment of patients                                             is available at www.worldgastroenterology.org. Readers
• Gastroenterologists should be part of a digestive            are encouraged to refer to this full publication, which
                                                               also contains suggested reading.
  cancer team
• Gastroenterologists should be involved with
                                                               Corresponding author
  patients throughout their management                         Prof. Sidney J. Winawer, MD
• Fellowship training should include the full range of         Memorial Sloan-Kettering Cancer Center,
  cancer management                                            1275 York Avenue,
                                                               New York, NY 10021, USA
• Postgraduate meetings should include multidisci-
                                                               E-mail: winawers@mskcc.org
  plinary sessions on digestive cancers s




                                                                                                                            SPECIAL SECTION: IDCA
First National Working Party Conference on
Colorectal Cancer Screening (Berlin, Germany)
Meinhard Classen

G   ermany is the first country          committees:                                    The working party is now busy
to offer its population an early        • Information and motivation in            compiling the results of this confer-
detection program for colorectal           the healing professions                 ence, which will be published as
cancer that includes colonoscopy        • The informed patient                     a position paper to be presented
(available since 1 October 2002).       • Colorectal cancer screening in           to authorities, government bod-
Although the number of screening           large corporations                      ies, and organizations concerned
colonoscopies increased by 500%         • Model projects in neighboring            with colorectal cancer, as well as
over the past year, the compliance         countries                               any other interested parties. The
rate remains low. The first National     • Identification of relatives in            workshop participants are expected
Working Party on Colorectal Cancer         high-risk groups                        to commit themselves to the imple-
(meeting on 25 and 26 Febru-            The conference was hosted and              mentation of the decisions taken
ary 2004) brought together 120          organized by German Cancer Aid             at this conference, and these will
representatives from 100 profes-        (Deutsche Krebshilfe) and the              be reported on in more detail in
sional fields for one and a half days’   Network against Colorectal Cancer          the next issue of World Gastro-
intensive discussion and consensus      (Netzwerk gegen Darmkrebs).                enterology News. We are convinced
searching. Politicians, doctors from    The conference’s patrons were the          that all of these measures will lead
various disciplines, epidemiologists,   President of the Cancer Research           to increased participation in colorec-
naturopathic and homeopathic            and Prevention Foundation (CRPF),          tal cancer screening programs. s
doctors, corporations, union repre-     Ms. Carolyn Aldigé from the USA,
                                                                                     Prof. Meinhard Classen, MD
sentatives, press and media – and,      and the International Digestive
                                                                                     Dept. of Medicine,
last but by no means least, colorec-    Cancer Alliance (IDCA) represented           Technical University of Munich,
tal cancer patients – took part in      by Prof. S. Winawer. The CRPF’s              Ismaninger Strasse 22,
this interactive meeting.               Dialogue for Action program                  81675 Munich, Germany
                                                                                     E-mail: Meinhard.Classen@
    The following topics were dealt     provided the inspiration for this
                                                                                      lrz.tu-muenchen.de
with simultaneously by five sub-         national conference.


                                                         37
DIGESTIVE CANCER AWARENESS CAMPAIGN



                The International Digestive Cancer Alliance

  Digestive Cancer Series (Co-Editors: Sidney Winawer and Meinhard Classen)
  Taxonomy for
  Neoplastic Lesions of the Digestive Mucosa
  René Lambert


  Taxonomy: “the systematic               Table 1. Macroscopic classification of neoplasia in the gastrointestinal mucosa (Paris
  distinguishing, ordering, and naming    Consensus Classification).
  of type groups within a subject field”
                                           Superficial cancer
  (Merriam–Webster 3rd Unabridged
                                           Type 0        Superficial protruding or nonprotruding lesions
  Dictionary, 2003).
                                           Advanced cancer
                                           Type 1        Protruding carcinoma, attached with a wide base
                                           Type 2        Ulcerated carcinoma with sharp and raised margins
  S  uperficial versus Advanced             Type 3        Ulcerated carcinoma without definite limits
  Neoplastic Lesions                       Type 4        Nonulcerated, diffusely infiltrating carcinoma
      In digestive endoscopy neoplas-      Type 5        Unclassifiable advanced carcinoma
  tic lesions are called superficial
  when their appearance suggests
  that the depth is restricted to the     affects the choice of treatment                    Large neoplasms are readily
  mucosa of the submucosa or              between three options: doing                   identified by endoscopy, but the
  advanced when involvement of            nothing, for a nonneoplastic lesion;           most important aspect of cancer
  the mucularis propria is suspected.     carrying out endoscopic mucosec-               prevention is the observation and
  The classification as superficial or      tomy; or referring the patient for             classification of superficial lesions.
  advanced will be confirmed (or           radical surgery.                                   Endoscopy can discover “super-
  eventually unconfirmed) by the                                                          ficial” neoplastic lesions by identify-
  pathologist.                            The Paris Classification of Gross               ing a slight elevation or depression,
                                          Morphology                                     discolored areas, or irregularities in
  The Relevance of Classifications            In 1926, Borrmann classified                 the vascular network. Various dyes
     The secondary prevention of          the gross morphology of gastric                can be applied to the lesions to
  gastrointestinal cancer relies on       cancer into types 1, 2, 3, and 4               enhance their surface characteris-
  detecting superficial neoplasia at       relative to protrusion, excavation,            tics, and endoscopic magnification
  a presymptomatic stage. At this         or infiltration. The same categories            is opening up new perspectives
  stage, the probability of a complete    were later adopted in Japan for                for analyzing the surface (e.g., the
  cure is very high. Endoscopy is the     the esophagus and the large intes-             pit pattern in the large intestine)
  gold standard for detection: pro-       tine, and a type 5 was added for               and the capillary network, as seen
  truding or excavated lesions are        unclassifiable advanced cancer. The             through the trans-
  easily found, because they alter the    Japanese experts also added type               lucent unstained
  surface contours. Nonprotruding         0 for the endoscopic description of            epithelium.
  lesions may be suspected on the         superficial lesions – i.e., the precur-             The endo-
  basis of changes in color or in the     sors of advanced cancer (Table 1).             scopic description
  network of superficial capillaries.      Based on these descriptions, a                 of “superficial”
     The endoscopic appearance or         consensus Paris classification was              neoplastic lesions
  morphology of superficial lesions        published in December 2003.                    (type 0) is based


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D I G E ST I V E C A N C E R AWA R E N E S S C A M PA I G N



      Table 2. Subtypes of type 0 superficial    the risk of invasion is greater and is          are slightly elevated (IIa), with a
      neoplastic lesions (Paris Consensus       relatively independent of the size. A           very low risk of progression to can-
      Classification).                           suspicion of deep invasion can be               cer. On the other hand, depressed
                                                further confirmed if the lesion fails            (IIc) lesions are significant precur-
        Protruding
                                                to lift after injection of saline into          sors of advanced cancer, in spite of
        Pedunculated                Ip
                                                the submucosa. Types that com-                  being rare (no more than 5% of all
        Sessile                     Is
                                                bine the IIa and IIc patterns share             superficial neoplastic lesions).
        Nonprotruding
                                                the same prognosis as depressed
        Slightly elevated           IIa
        Completely flat              IIb         lesions.                                        The Vienna Histopathological
        Slightly depressed          IIc             There are wide variations                   Classification
        Elevated and depressed      IIa + IIc   along the gastrointestinal tract in                There is worldwide agreement
                                    IIc + IIa   the relative proportions of each                among pathologists in the inter-
        Excavated                               subtype of superficial neoplastic                pretation (diagnosis, histological
        Ulcer                       III         lesion that are observed. Overall,              pattern, grading of differentiation)
                                                the nonprotruding subtypes are                  of invasive gastrointestinal cancer.
                                                more frequent, reaching 84% in                  On the other hand, there has been
       on three criteria: size; morphology      the esophagus (squamous epithe-                 wide variation in the classification
       (Table 2); and location in the gas-      lium), 97% in the distal stomach,               of superficial neoplastic lesions:
       trointestinal tract. Type 0 is divided   and 50% in the large intestine.                 in Western countries, a polypoid
       into categories: protruding lesions      Depressed (IIc) lesions are fre-                neoplastic lesion of the columnar
       are termed 0-I and divided into          quent in the squamous epithelium                epithelium in the gastrointestinal
       two subtypes, pedunculated (Ip)          of the esophagus (45%), but rela-               tract is called “adenoma,” and a
       or sessile (Is). Nonprotruding and       tively rare in Barrett’s esophagus              flat neoplastic area is called “dys-
       nonexcavated lesions are termed          or at the esophagogastric junction,             plasia.” In Asian countries, these
       0-II, and these are divided into         and are very frequent (78%) in the              lesions are referred to as polypoid,
       three subtypes: slightly elevated        distal stomach. In the large intes-             flat, and depressed adenomas.
       (IIa), completely flat (IIb), or          tine, most nonprotruding lesions                Similarly, noninvasive lesions with
       slightly depressed (IIc). The distinc-
       tion between small sessile protrud-
       ing lesions (Is) and slightly ele-       Table 3. Histological classification of superficial neoplastic lesions in the esophagus,
                                                stomach, and large intestine (revised Vienna Classification).
       vated nonprotruding lesions (IIa)
       can be made more easily by plac-          Group 1         Negative for intramucosal (or intraepithelial) neoplasia
       ing a closed forceps biopsy device        Group 2         Indefinite for intramucosal (or intraepithelial) neoplasia
       (2.5 mm in diameter) next to the          Group 3         Low-grade intramucosal (or intraepithelial) neoplasia
       lesion and using it as a calibrating                      (this is equivalent to adenoma or dysplasia)
       gauge. The lesion is called IIa when      Group 4         High-grade intramucosal neoplasia
       its elevation is less than the diam-            4-1       Adenoma/dysplasia
       eter of the forceps (< 2.5 mm)                  4-2       Noninvasive carcinoma
       and Is when it is more elevated                 4-3       Suspicious for invasive carcinoma
       than the forceps. Excavated lesions             4-4       Intramucosal carcinoma with invasion of the lamina propria
       (ulcers) are classified as 0-III.          Group 5         Submucosal carcinoma
           The morphologic classification
       of superficial lesions has a prog-
                                                Table 4. Staging of superficial tumors in the TNM classification.
       nostic value at all sites, and the
                            risk of invasion     Esophagus                                   Stage 0                Tis N0 M0
                            into the submu-      Squamous-cell cancer                        Stage I                T1 N0 M0
                            cosa varies with     Adenocarcinoma                              Stage IIb              T1 N1 M0
                            the subtype.         Stomach                                     Stage 0                Tis N0 M0
                            Depressed 0-IIc      Carcinoma                                   Stage IA               T1 N0 M0
                            lesions deserve                                                  Stage IB               T1 N1 M0
                            special atten-       Colon and rectum                            Stage 0                Tis N0 M0
                            tion, because        Carcinoma                                   Stage I                T1 N0 M0


                                                                    34
                                                     D I G E ST I V E C A N C E R AWA R E N E S S C A M PA I G N



high-grade intraepithelial neopla-     sion into the lamina propria. In the      behavior of the tumor (2 for benign,
sia have been called intramucosal      esophagus and stomach, intramu-           3 for malignant). An adenocarci-
carcinoma in Japan, but high-grade     cosal lesions are Tis (noninvasive)       noma in the esophagus, stomach,
dysplasia in Western countries.        or T1m (invasive). In the large           or large intestine would be classi-
    Most of the divergence in          intestine, all intramucosal lesions       fied with the code 81140/3.
semantics has now disappeared          (invasive or noninvasive) are Tis,
with the adoption of the Vienna        because there is no risk of lym-          An Inseparable Couple: the
consensus classification, which         phatic propagation.                       Clinician and the Pathologist
applies to both squamous and               Superficial malignant lesions              Assessment of invasion into the
columnar epithelium. In the Vienna     are classified into stages I or II, but    submucosa based on surgical speci-
classification (Table 3), the term      Tis lesions are always classified          mens is easy, as the full thickness of
“intraepithelial neoplasia” replaces   as stage 0. Advanced tumors are           the gastrointestinal wall is available
both of the terms “adenoma” and        classified into stages I to IV. When       for examination. A semiquantitative
“dysplasia.” Noninvasive neoplastic    the tumor is staged clinically, each      evaluation into superficial invasion
lesions are classified as low-grade     component has to be defined as             (sm1) or deep invasion (sm2) is
or high-grade intraepithelial neo-     clinical or pathological. For exam-       frequently used. In specimens from
plasia. Noninvasive intramucosal       ple, after an endoscopic mucosec-         endoscopic mucosectomy, the
carcinoma, also called “carcinoma      tomy, pT1, cN0, cM0 means that            submucosa is not complete, and a
in situ,” is in group 4-2; invasive    the primary tumor is confirmed at          quantitative micrometric measure
intramucosal carcinoma is in group     histology and that positive lymph         of the depth of invasion from the
4-4. Lesions termed “intramucosal      nodes and metastases were absent          lower limit of the muscularis muco-
carcinoma” in the East and “high-      clinically. When the classification is     sae is preferred. Japanese patholo-
grade dysplasia” in the West have      based on postoperative findings,           gists have established empirical
therefore now become subdivi-          it is called pTNM. The TNM classi-        cut-off limits for the legitimacy of
sions of the same group. Carci-        fication used in cancer registries is      endoscope treatment: 200 µ in the
noma invading the submucosa            also used for clinical trials in cancer   esophagus, 500 µ in the stomach
is in group 5 of the classification.    treatment.                                and 1000 µ in the large bowel.
Confirmed superficial neoplastic                                                   This micrometric measure actually
lesions are therefore classified into   The WHO Classification of                  deserves generalization for compar-
groups 3, 4, or 5.                     Neoplastic Lesions                        ing outcomes after either surgical or
                                           The WHO International Classifi-        endoscopic treatment. Assessment
The TNM Classification                  cation of Diseases (ICD) includes a       of the completeness of a resec-
    Tumor staging for cancer reg-      specific classification for oncology        tion often requires input from the
istries uses the TNM classification     (ICD-0). The double coding system,        clinician, which can be combined
(Table 4). The TNM applies only to     for topography and morphology, is         with the microscopic view from the
cases that have been microscopi-       also used in tumor registries, and it     pathologist.
cally confirmed as malignant and        describes premalignant and malig-            s
combines categories selected in        nant lesions.
the T (tumor), N (nodes), and M            The coding for topography is          René Lambert, MD
(metastases) components in all         based on four alphanumeric sym-           International Agency for Research on
stages.                                bols – the first three refer to the          Cancer,
                                                                                 150, cours Albert Thomas,
    Advanced carcinomas are clas-      viscera (C15, esophagus; C16,
                                                                                 69372 Lyon cedex 08,
sified as T2 (invasion of the mus-      stomach; C18, colon; C20, rectum),        France
cularis propria), T3 (invasion of      and the fourth is for the subsite. An     E-mail: Lambert@iarc.fr
the serosa), or T4 (invasion into      adenocarcinoma is coded C15.5 in
adjacent structures). Superficial       the lower third of esophagus, C16.3
malignant lesions are classified as     in the gastric antrum, and C18.7 in
T1m or T1sm. For carcinomas, an        the sigmoid, with the fourth digit
“in situ” category (Tis) is used for   indicating the visceral sector.
high-grade intramucosal neoplasia          The coding for histology has six
when there is no invasion of the       numbers – the first five for the type
basal membrane – i.e., no inva-        of carcinoma, and the sixth for the


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D I G E ST I V E C A N C E R AWA R E N E S S C A M PA I G N




       International Digestive Cancer Alliance Meeting
       during Digestive Disease Week 2004
       Sidney J. Winawer, Meinhard Classen, Paul Rozen


       In the four years since the launching of the Interna-              Presentations of various pilot and screening pro-
       tional Digestive Cancer Alliance (IDCA) in Rome in             grams on CRC already established were made by
       May 2000, many meetings have been held around the              professors Finlay Macrae (Australia); Benjamin Wong
       world and others are being planned. A tradition has            (Hong Kong); Robert J.C. Steele (United Kingdom);
       been established of holding an annual meeting dur-             Julius Spicak (Czech Republic); Dai Ming Fan (China);
       ing the Digestive Disease Week (DDW) conference in             Roque Sáenz (Chile); and Urs Marbet (Switzerland).
       the United States, taking advantage of the presence of         CRC is on the rise in Australia, where pilot programs
       many American and international members. The IDCA              using immunochemical tests have been initiated. To
       meeting held during Digestive Disease Week (DDW)               date, 38 228 people have taken part in these, and
       in New Orleans (Sunday 16 May 2004) was opened                 95% of those with positive findings (8.7–12.5% of
       by a brief review of the evolution of IDCA and its mis-        those screened), have been referred for colonoscopy.
       sion and activities since inception. The meeting was           In Hong Kong, CRC is also on the increase, but so
       especially exciting; being attended by 97 invited IDCA         far the government has not been willing to initiate
       members from 36 countries and representation of                a screening program. The IDCA has agreed to help
       Industry.                                                      develop a prevention model with outcomes that will
                                                                      help make a positive case for prevention to the health
       National Colorectal Cancer Screening Programs:                 authorities there. Large-scale pilot studies have already
       Successful Strategies for Unique Challenges and                been started in the United Kingdom, using guaiac-
       Barriers – Key Lessons                                         based fecal occult blood testing (FOBT) to detect
          The aims of the meeting were: firstly, to present            early-stage cancer, but several issues still need to be
       successful strategies and key lessons from several             clarified in connection with compliance, improve-
       national programs; secondly, to communicate infor-             ments in the test, pathology, and surgery. Eastern
       mation to members about expertise, outcome models,             Europe has many programs in progress, almost all
       and the resources available to assist national screen-         using FOBT, except for Poland, where a large colonos-
       ing programs; thirdly, to review the relative benefits          copy screening trial is in progress involving approxi-
       of primary and secondary colorectal cancer (CRC)               mately 40 centers throughout the country. China has
       prevention; and fourthly, to initiate a discussion on          been studying various approaches to CRC screening,
       gastric cancer, its epidemiology and potential for             including guaiac-based FOBT immunochemical test-
       prevention.                                                    ing and exfoliative cytology. The incidence of CRC
                                                                      has been rising very rapidly in Chile, doubling in the
                                                                      last 5 years and rising 83% in the last 20 years. There
                                                                      are many problems there in attempting to initiate a
                                                                      screening program, including costs and colonoscopy
                                                                      capacity. There is currently no national screening
                                                                      program in Switzerland, although they are studying
                                                                      population preferences for flexible sigmoidoscopy,
                                                                      FOBT, and colonoscopy, as well as the quality of the
                                                                      examinations, acceptance, and the outcome of each
                                                                      examination.

                                                                      International Assistance to National Screening
                                                                      Programs: Expertise, Outcome Models, Resources
                                                                         The second phase of the meeting provided a forum
                                                                      for presenting the resources available through inter-
                                                                      national organizations involved in the prevention of


                                                                 36
                                                      D I G E ST I V E C A N C E R AWA R E N E S S C A M PA I G N



                        colorectal cancer. Presentations         Screening Network that will focus on universal out-
                        were made by Professors René             come measures and quality indicators for screening
                        Lambert (International Agency            programs. An inaugural meeting was held in London
                        for Research on Cancer), Ann             in 2004.
                        Zauber (IDCA), Carolyn Aldigé               The European Society of Gastrointestinal Endos-
                        (Cancer Research and Preven-             copy (ESGE) has mounted several initiatives, includ-
                        tion Foundation), Robert Smith           ing meetings, journals, and training programs, and
                        (Union Internationale Contre             together with the United European Gastroenterology
                        le Cancer/American Cancer                Federation (UEGF) it has recently published a review
                        Society), Marion Nadel (Centers          of CRC screening (Endoscopy 2004; 36: 348–66). The
for Disease Control, USA), Anthony Axon (European                UEGF Public Affairs Committee has recently completed
Society of Gastrointestinal Endoscopy), Christa Maar             a European survey of colorectal cancer prevention
(Burda Foundation), Colm O’Morain (United European               practices. It was quite clear that both in Europe and
Gastroenterology Federation Public Affairs Commit-               the United States, the media and role models are criti-
tee), and Mark Pochapin (Weill Medical College, Cornell          cal for achieving increased public awareness. Many
University, Monahan Center, New York). It was clear              barriers to screening perceived by the public can
that considerable resources are available internationally        be broken down through active involvement by the
that can be helpful to the national programs. The Inter-         media, and screening awareness and screening activi-
national Agency for Research on Cancer (IARC), with              ties can be increased.
its new Director, Professor Peter Boyle, has a strong
interest in cancer prevention worldwide. The IARC                Relative Benefits of Primary and Secondary
has substantial resource materials available, includ-            Colorectal Cancer Prevention
ing the Globocan program (http://www-dep.iarc.fr/                    The IDCA meeting concluded with a review by Pro-
globocan/globocan.html), which provides the latest               fessor Graeme Young (Australia) of the relative bene-
data on cancer incidence, mortality, and other statistics        fits of primary and secondary prevention of CRC, and a
worldwide.                                                       review by Professor Richard Hunt (Canada) of the epi-
    The IDCA model is to use the Globocan data in its            demiology and potential for preventing gastric cancer.
mathematical model, as well as country-specific addi-             The IDCA considered it important to include these top-
tional data to help IDCA members in each country                 ics in the meeting, to emphasize both primary preven-
make the case for cancer prevention to health min-               tion and the importance of other cancers in addition to
isters, and then help organize awareness meetings,               CRC. The IDCA has a strong interest in primary preven-
followed by pilot campaigns. The Cancer Research                 tion as well as screening and has a broad interest in
and Prevention Foundation (CRPF) has developed a                 all types of digestive cancers in addition to colorectal
number of creative methods of increasing CRC aware-              cancer. The latter two aspects are to be included in
ness, including the “Dialogue for Action” meeting that           the next IDCA campaign, concerned with reducing the
was replicated recently in Berlin, “remember to be               burden of gastric cancer through Helicobacter pylori
screened” bracelets, the Colossal Colon model tour               eradication in a model project in China. A workgroup,
in U.S. cities, developing partner groups to promote             conference, and protocol are currently being planned
screening, and having the U.S. Congress designate                for October 2004 in China.
March as CRC Awareness Month. The American Can-                      The meeting closed with a brief summary of future
cer Society (ACS) has developed a round table that               IDCA activities, including active involvement in China,
brings together many disciplines from the profes-                meetings in Brazil and Rome, and the World Congress
sional and lay community to work together on CRC                 in Montreal in 2005.
prevention, and is working closely with the Union                   s
Internationale Contre le Cancer (UICC). A world con-
gress on cancer prevention is being planned. The                 Corresponding Author
Centers for Disease Control (CDC) have initiated                 Professor Sidney J. Winawer
several campaigns in the USA, including “Screen for              Co-Chair IDCA
Life” (http://www.cdc.gov/cancer/screenforlife)                  Memorial Sloan Kettering Cancer Center
                                                                 1275 York St.
and “Call to Action” (http://www.cdc.gov/cancer/
                                                                 NY 10021 New York
colorctl/calltoaction) and has recently supported,               USA
along with the ACS, an International Colorectal Cancer           E-mail: winawers@mskcc.org


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D I G E ST I V E C A N C E R AWA R E N E S S C A M PA I G N




       OMED Colorectal Cancer                                                           Session 3 (Chaired by Dr. M.
                                                                                        Classen, Germany, and Dr. M.

       Screening Committee Meeting                                                      Korman, Australia)
                                                                                            This session addressed endo-
       Paul Rozen, Sidney J. Winawer                                                    scopic screening programs. Dr.
                                                                                        R.S. Bresalier (USA) updated the
                                                                                        U.S. Flexible Sigmoidoscopy PLCO
       The annual meeting of the               specificity than office-developed          screening trial. Three to 5 years after
       Colorectal Cancer Screening             guaiac FOBTs. Dr. G. Castiglione         flexible sigmoidoscopy, 3.1% of the
       Committee of the Organisation           (Italy) uses the latex agglutination     patients had distal neoplasia after
       Mondiale d’Endoscopie Digestive/        test (OC-SENSOR). Biennial one-          a negative baseline examination.
       World Organization of Digestive         day testing increased screenee           Advanced distal adenoma, male
       Endoscopy (OMED/WGO) was held           compliance, the overall positivity       sex, and age over 70 were risk fac-
       jointly with the International Diges-   was 5%, and the predictive positive      tors for advanced proximal neopla-
       tive Cancer Alliance (IDCA) during      rate for significant neoplasia was        sia. Nonphysicians had performed
       Digestive Disease Week in New           29%. Dr. H. Saito (Japan) com-           70% of the 56 000 examinations.
       Orleans on 15 May 2004.                 pared HemSp with the automated           Dr. W. Schmiegal (Germany)
                                               MagStream Sp. The sensitivities of       addressed the issue of quality con-
       Session 1 (Chaired by Dr. M.            both tests were 90% for CRC, but         trol in Germany’s national colonos-
       Crespi, Italy, and Dr. J. Mandel,       MagStream’s specificity was signifi-       copy screening program, including
       USA)                                    cantly lower. The automated FOBT         320 000 examinations. Total colo-
           This session addressed colorec-     is convenient, but its specificity        noscopy was achieved in 98.8% of
       tal cancer (CRC) epidemiology and       needs improvement. Dr. G.P. Young        the examinations, 18% of which
       screening modeling. Dr. Mandel          (Australia) compared InSure (an          were without sedation. Adenomas
       reported a declining CRC incidence      automated immunochemical test)           were found in 30% of cases and
       and mortality in the white popula-      and the guaiac, office-developed          cancers (Dukes A and B) in 0.54%.
       tion in the United States. Dr. R.       HemoccultSensa test. InSure has          Dr. M. Crespi (Italy) noted that Italy
       Lambert (France) reviewed Interna-      simplified sample collection, which       provides free screening colonos-
       tional Agency for Research on Can-      improved compliance; predictive          copy, but there is no centralized
       cer (IARC) data on the high and ris-    positive rates and specificities          data management and because
       ing CRC incidence and mortality in      for neoplasia were similar. Two-         of low uptake, a public awareness
       “Westernizing” and “aging” coun-        day InSure, with 96% specificity,         campaign has now been initiated.
       tries. Dr. A. Zauber (USA) discussed    detected 100% of CRCs and 60–            Dr. J. Regula (Poland) stated that
       CRC screening modeling using the        70% of adenomas. Dr. D. Ahlquist         Poland now has a national single-
       MISCAN model, and reported that         (USA) reviewed fecal DNA test-           colonoscopy screening program
       flexible sigmoidoscopy with fecal        ing; this requires collection, rapid     with recruitment by general practi-
       occult blood testing (FOBT) saved       transfer to a central laboratory, and    tioners. A total of 30 000 persons
       more life-years with lowest costs.      freezing. A colonoscopy-controlled       participated, 77% without seda-
                                               comparison showed a sensitivity of       tion; 90% of the examinations
       Session 2 (Chaired by Dr. P.            51.6% and a specificity of 94.4%          were completed to the cecum, and
       Rozen, Israel, and Dr. J. Terdiman,     for invasive CRC, and a sensitivity      significant neoplasia was detected
       USA)                                    of 15.1% for advanced adenomas.          in 5.1% of cases. Dr. D. Lieberman
         This session considered nonen-        Dr. J.H. Bond (USA) reviewed com-        (USA) observed that the Medicare
       doscopic screening methodologies.       puted-tomographic colonography;          program allows screening colo-
                         Automated quan-       the best results were from an            noscopy every 10 years; quality
                         titative immuno-      experienced single institution. The      and resource availability is being
                         chemical FOBTs        limitations of this method are its       evaluated. Interval lesions occurred
                         for fecal hemo-       long learning curve, radiation expo-     3–5 years after baseline neoplasia,
                         globin, without       sure, costs, availability, a decreased   cancer in 0.7–1.1% of cases, and
                         dietary restric-      sensitivity for lesions smaller than     advanced neoplasia in 6–11%
                         tions, should         1 cm, and the inability to take          – underlining the importance of
                         provide better        biopsies or carry out polypectomy.       high-quality examinations.


                                                                38
                                                       D I G E ST I V E C A N C E R AWA R E N E S S C A M PA I G N



Session 4: Panel Discussions             able. In conclusion, it was agreed      is acceptable and is needed when
(Chaired by Dr. S.J. Winawer, USA)       that both population screening and      public health policy has not yet
    The first panel session               case-finding have their place.           included population CRC screening.
addressed the question of interval                                                   A full report is also to be pub-
neoplasia, occurring during surveil-     Conclusions                             lished and will be available from
lance of the colon. Dr. D.O. Faigel         This annual meeting allowed an       the authors or OMED.
(USA) noted that “new” findings           international exchange of experi-          s
could represent polyps that were         ence and ideas on how to perform
missed initially due to inadequate       and promote CRC screening. It           Corresponding Author
                                                                                 Prof. Paul Rozen, Chairman,
preparation and examination. Dr.         emphasized the development and
                                                                                   OMED Screening Committee
R. Lambert (France) stated that          promotion of high-quality screen-       Dept. of Gastroenterology,
with the low sensitivity of the          ing methodologies. Modeling will        Tel Aviv Medical Center,
guaiac test, biennial FOBTs can be       help decide on appropriate screen-      6 Weizmann Street,
false-negative for CRC, especially       ing policies for diverse settings.      Tel Aviv 64239,
                                                                                 Israel
as some CRCs start as flat adeno-         Population CRC screening should         Tel.: +972-3-6974869
mas. Dr. J. Mandel (USA) observed        be promoted and integrated into         Fax: +972-3-6974622
that FOBTs have to be prepared in        public health policy. Case-finding       E-mail: rozen@tasmc.health.gov.il
adequate numbers and repeatedly.
Dr. Y. Sano (Japan) reported that
after polypectomy, 7% of patients
were found to have advanced
                                         Ten Rules for Cancer
lesions at the follow-up examina-
tion; 34% were flat lesions and 5%
                                         Prevention
were depressed. The panel’s con-         Attilio Giacosa, Massimo Crespi (United European Gastroenterology
clusions were that the use of sensi-     Federation Public Affairs Committee)
tive FOBTs should be promoted, as
well as good bowel preparation,          Colorectal cancer (CRC) is the              Diets high in calories tend to
high-quality and complete colono-        leading cancer in nonsmokers            be high in fat (especially animal
scopic examinations, and follow-up       (of both sexes) in North America,       fat) and refined carbohydrates, but
adjusted to the quality of the initial   Australasia, and western Europe.        low in fiber and vegetable intake.
examination and findings.                 The major risk factors for CRC          The consequent glycemic overload
    The second panel session             are genetic and dietary. Evidence       produces a compensatory increase
focused on “population CRC               regarding genetic polymorphisms,        in blood insulin and insulin-like
screening and/or case-finding.” Dr.       which may influence the metabo-          growth factors, which in turn are
M. Crespi (Italy) stated that many       lism of nutrients, is thought to be     thought to stimulate colorectal cell
countries have no population CRC         important in the etiology of CRC        turnover and increase the suscepti-
screening, and case finding should        and colorectal adenomatous pol-         bility of cells to malignant transfor-
therefore be supported. Dr. R.J.         yps. At present, the strongest evi-     mation.
Steele (UK) reported that a United       dence of gene–nutrient interaction          Most vegetables are inversely
Kingdom national FOBT screening          in relation to CRC is for folate and    associated with CRC risk. A
program will probably be intro-          genetic variants associated with dif-   reduced risk has been particularly
duced, but he considered that this       ferences in metabolism of folate. In    associated with raw, green, and
did not negate case-finding. Dr. B.       European studies, significant trends     cruciferous vegetables, but less so
Wong (Hong Kong) observed that           have been found for increased CRC       for fruit consumption. Among mac-
there is a high incidence of CRC in      risk proportional to the intake of      ronutrients, a high
Hong Kong, but that screening is         bread and pasta, cakes and des-         intake of starch
not a public health priority, so that    serts, and refined sugar. Regard-        and saturated fat
case-finding is therefore encour-         less of the specific food source         appears to lead to
aged there. Dr. G.P. Young (Austra-      of calories, caloric excess and its     an increased risk.
lia) considered that a national CRC      consequences can be regarded as         High intakes of
screening program is best, but that      a well-established risk factor for      polyunsaturated
case finding should also be avail-        colorectal cancer.                      fatty acids (chiefly


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D I G E ST I V E C A N C E R AWA R E N E S S C A M PA I G N



       derived from olive oil and seed
       oils) show a marginal inverse asso-
       ciation with CRC. While fish con-
       sumption has been thought to be
       inversely associated with CRC risk,
       the correlation with meat intake is
       still debated.
           While excess weight is associ-
       ated with increased CRC risk (more
       so in men than women), physical
       exercise is inversely correlated to
       colon cancer. In addition, the body
       mass index (BMI) is directly associ-
       ated with colon adenomas (with a
       stronger association for larger ade-
       nomas). Analysis of the available
       observations shows that increasing
       levels of physical activity are associ-
       ated with an approximately 40%
       reduction in the risk of colon can-
       cer, independent of BMI.
           Taking all this into consideration,
       the Public Affairs Committee of the
       United European Gastroenterology
       Federation (UEGF) has developed
       “Ten Rules” on healthy diet and
       lifestyle for preventing colorectal
                                                 UEGF Ten Rules for Healthy Lifestyle
       cancer. These guidelines, which           and Cancer Prevention
       have been widely distributed
       through the national gastroenterol-
       ogy societies, also apply to other        q   Maintain a high level of physical exercise: at least 30 minutes a day
       types of cancer (e.g., prostate,              of vigorous activity are suggested (but the type of activity can vary
       breast) and degenerative diseases             with age).
       in general.                               q   Avoid excess weight, preferably by increasing physical activity.
          s                                      q   Eat plenty of fiber-rich food and whole grains and less food con-
                                                     taining sugars and products with white flour.
       Corresponding Author                      q   Aim to eat at least five portions a day of fruits and vegetables.
       Prof. Massimo Crespi                      q   Moderate the intake of animal fat (i.e., dairy fat and fatty meat) by
       “Regina Elena” National Cancer
        Institute                                    choosing light dairy products and removing visible fat from meat
       Viale Regina Elena 291                        and skin from chicken. Fat derived from “added fat” during cooking
       00161 Rome, Italy                             can be replaced by vegetable oils and possibly extra-virgin olive oil.
       E-mail: mcrespi@uni.net                   q   Remember that fish and beans are attractive alternatives to meat.
                                                     Fish oil is also good for preventing some other types of cancer
                                                     (such as breast cancer) and cardiovascular diseases.
                                                 q   Drink plenty of water. For alcoholic beverages, have less than two
                                                     glasses a day of wine or beer.
                                                 q   The selection and storage of food are very important: look mainly
                                                     for local and seasonal fresh or frozen food.
                                                 q   Healthy cooking requires lowering the amounts of added cooking
                                                     oils and fats, using low temperatures and short cooking times.
                                                 q   Whatever you do, do not smoke!



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