of Epigenomics, a molecular diagnostics company
developing products for the screening and diagnosis
of cancer, reviews the progress made in this field both
in the United States and Europe. The genetics of colon
cancer that we have learned so well in the previous
articles are again of paramount importance in the
development of these blood-based tests. So far, the
value of these blood-based tests has been with invasive
cancer. The use for detection of advanced adenomas
is not yet ready for prime time but there is hope and
Despite poor compliance rates, our discussions of
screening and colon cancer prevention should not imply
that everything is rosy when screening is instituted.
Flexible sigmoidoscopy, fecal occult blood testing, and
radiological techniques alone or combined all have their
drawback. In many areas of the world, colonoscopy is
deemed to be the most effective method for screening
and is particularly attractive as it incorporates cancer
prevention through the removal of adenomatous polyps.
Recent data on risk reduction however has questioned
this concept, particularly for lesions located in the right
side of the colon that may be flat and easily missed. The
article by Drs. Coe and Wallace from the Mayo Clinic in
Jacksonville, FL is a good review of flat colonic lesions,
their pathology and clinical significance. The important
concerns of how to minimize the risk of missed lesions
treat the lesions when found, and provide appropriate
follow-up are addressed.
The risk of right colon lesions as well as the entire
concern about screening and removal of colon polyps
is placed into perspective in the next provocative
article by Drs. Allison and Meijer. To effect balance,
the authors suggest that options other than colonoscopy
for screening, such as FIT, could be a better option for
mortality reduction from colorectal cancer. It seems
that the net balance from these discussions leaves the
responsibility to the physician that confronts the patient.
Compliance with, risks, availability and quality of
performance, must all enter into the decision process.
The World Endoscopy Organization’s (WEO)
prestigious Colorectal Cancer Screening Committee
is chaired by Professor Graeme Young of Flinders
University in Adelaide, Australia. The final article
in this series comes from Dr. Young who has been a
valuable contributor to the many issues of this series.
Under his leadership the WEO committee has addressed
these and many of the other important issues related
to the diagnosis and treatment of colorectal cancer.
His article in this series is a report of the Committee’s
Workshop that was held in 2011 as they relate to the
issues discussed in this series. The ongoing progress
in the development of new molecular markers and
how these might impact of the right colon lesion
problem is presented. Additional areas addressed by
this Committee are the choice of screening test, how
many and what kind of tests, and follow-up algorithms.
This Committee, under the auspices of the WEO has
developed a list of issues that will be considered for
Working Parties to address. The issues considered are:
1. The challenge of right-sided lesions
2. Surveillance intervals
3. Reporting standards for FIT tests
4. Comparing new tests
5. Comparative effectiveness screening
trials of different strategies
6. Sample stability and quality
7. Cost effectiveness including age
8. Improving population engagement
9. Quality assurance for organized
10. The adenoma as a target lesion
The WEO Committee indicates that significant
changes are expected in how screening will be performed
in the future. We look forward to future issues of this
Colorectal Cancer Series in Practical Gastroenterology
under the direction of Dr. James Disario. n
1. Levin, B: Colorectal Cancer: Genetic factors of practical importance. Practical Gastroenterol. 1992, XVI, No1: 16G-16H.
2. Jasperson, K, Kohlmann, W, Burt, B; Inherited risk for colorectal cancer: practical approaches for identification, referral and
management. Practical Gastroenterol. 2007, 31,9: 37-48.
3. Lynch,HT, Boland, CR, Rodriguez-Bigas, MA, et. al.: Who
should be sent for genetic testing in hereditary colorectal cancer
syndromes? J. Clin. Oncol. 2007, 25; 3534-3542.
4. Winawer SJ, Zauber AG, O’Brien MJ, et. al.: Randomized
comparison of surveillance intervals after colonoscopic removal
of newly diagnosed adenomatous polyps. N Engl J Med. 1993,
5. Winawer SJ: The achievements, impact and future of the
National Polyp Study. Gastrointest Endosc 2006, 64: 975-978.
6. Winawer SJ, Zauber AG, O’Brien MJ, et. al.:Colonoscopic
Polypectomy and Long-Term Prevention of Colorectal Cancer
Deaths. N Engl J Med. 2012, 366: 687-96.
7. Allison, JE: The role of fecal occult blood testing in screening
for colorectal cancer. Practical Gastroenterol. 2007, 31,6: 20-32.
8. Ransohoff D: Developing molecular biomarkers for cancer.