International Agency for Research on Cancer

Lyon, France

National Centre for Screening Monitoring andItalian Colorectal Cancer Screening Group

European Guidelines Workshop

Colorectal Cancer Screening in Europe

Lawrence von KarsaQuality Assurance Group

Section of Early Detection and Prevention

Overview topics

1. Collaborative effort in developing the EU CRC screening Guidelines

2. CRC screening programmes in Europe

3. Future directions in colorectal cancer screening in Europe and worldwide.

THE COUNCIL OF THE EUROPEAN UNIONRecommendation on Cancer Screening of

2 December 2003

1. Implementation of cancer screening programmes

(a) Offer evidence-based cancer screening through a systematic population-based approach with quality assurance at all appropriate levels. The tests which should be considered in this context are listed in the Annex;

(b) Implement screening programmes in accordance with European guidelines on best practice where they exist and facilitate the further development of best practice for high quality cancer screening programmes on a national and, where appropriate, regional level;

EU CRC Screening GuidelinesLiterature group leadChapter lead authors

Silvia Minozzi Literature Group

Iris Vogelaar Introduction

Nea Mallila Organisation

Sue Moss Evaluation

Stephen HalloranFaecal occult blood testing

Roland Valori Endoscopy

Phil Quirke Pathology

Wendy Atkin Surveillance

Joan Austoker Communication

Robert Steele Training and management of lesions detected in screening

EU CRC Screening Guidelines

Italian experts

Editor (Methodology, Public Health, Chs 1-3, 10): Nereo Segnan

Literature group: Silvia Minozzi, Paola Armaroli, Rita Banzi,Cristina Bellisario Carlo Senore, Luca Vignatelli, Nereo Segnan

Authors: (Ch 2) Carlo Senore, Paola Armaroli (Ch 4) Marco Zappa, (Ch 5) Carlo Senore, Giorgio Minoli (Ch7) Mauro Risio (Ch 8) Giorgio Minoli (Ch 9) Carlo Senore, Nereo Segnan (Ch 10) Livia GiordanoLivia Giordano

Reviewer: (Ch 6) Guido Costamagna

Colorectal Cancer Screening Programmes in the EU 1/2011

Population-based

FOBT/FS-based

FOBT/CS-based

CS-basedItaly

Poland

AustriaBelgiumCyprusCzech Rep.DenmarkGermanyGreeceSlovak Rep.

BulgariaFranceFinlandHungaryIrelandLatviaLithuania MaltaNetherlands PortugalRomaniaSloveniaSpainSwedenUK

No programme

FOBT-based

Non population-based

EstoniaLuxembourg

Belgium *CyprusDenmark*FinlandFrance*HungaryIreland*ItalyLithuania*Malta*Netherlands* Portugal*RomaniaSlovenia*Spain*Sweden*UK*

AustriaBulgariaCzech Rep.*GermanyGreeceLatviaPolandSlovak Rep.

No programmeEstoniaLuxembourg

Sources:Karsa, Anttila, Ronco et al. 2008,European Commission, IARC, ECN and EUNICE;IDCA/IARC/UEGF Survey 11/2009-2011

Financial supportof EU Public Health Programme

THE COUNCIL OF THE EUROPEAN UNIONRecommendation on Cancer Screening of

2 December 2003

HEREBY INVITES THE COMMISSION:7. To report on the implementation of cancer screening

programmes, on the basis of the information provided by Member States, not later than the end of the fourth year after the date of adoption of this Recommendation, to consider the extent to which the proposed measures are working effectively, and to consider the need for further action.

ANNEX:• pap smear screening for cervical cancer precursors starting

not before the age of 20 and not later than the age of 30;• mammography screening for breast cancer in women aged

50 to 69 in accordance with European guidelines on quality assurance in mammography;

• faecal occult blood screening for colorectal cancer in men and women aged 50 to 74.

Future directions in colorectal cancer screening

Implementing the EU Guidelines

• Technical and scientific support

Regional funds

European Schools of Screening Management

External QA schemes

• Pan-European collaboration in

Monitoring and evaluation

Accreditation

Future directions in colorectal cancer screening

Systematic updating of the EU Guidelines and the annex of recommended evidence-based screening tests in the Council Recommendation with special attention to:

• Screening by flexible sigmoidoscopy

• CT colonography in assessment

• Nurse practitioners

• Family risk (evidence)

Research Agenda Evaluation of screening protocols with different

testing options (eg FOBT and/or FS or CS; newer technologies, etc.)

Linkage of screening data and cancer registry data in routine monitoring

Impact of screening on symptomatic care

Testing surveillance protocols for CRC screening

Integrating effective primary and secondary prevention interventions control of colorectal cancer

Improving the process of programme implementation

Economic impact of population-based screening

Estimated proportion of breast, cervix and colorectal cancer deaths worldwide (left) and in the EU-27

(right) in 2008.

Source: Ferlay J et al. (2010), GLOBOCAN 2008, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 10 [Internet]. IARC, Lyon,France

Sequence of Steps in Quality-controlled

Implementation of Screening Programmes*

1. Comprehensive planning of screening process: feasibility of screening models, professional performance, organisation and financing, quality assurance (QA)

2. Preparation of all components of screening process to perform at requisite high level (including feasibility testing)

3. Expert verification of adequacy of preparations

 4.  Piloting and modification, if necessary, of all screening systems and components, including QA, in routine settings

5.  Expert verification of adequacy of pilot performance

6. Transition of pilot to service screening and geographicallyphased programme rollout in other regions of the country

7. Intensive monitoring of programme rollout for early detectionand correction of quality problems *Source: L. von Karsa, Quality Assurance

Group, Prevention and Early Detection Section, International Agency for Research on Cancer

Programme implementation - Key requirements

Involvement of civil society• Engagement in discussion of benefits and harm of

screening Cancer registration

• Accurate assessment of cancer burden for effective monitoring and evaluation

Good governance• Long-term political commitment• Adequate, sustainable resources• Competent oversight (standards)

Autonomous programme management• Coordination of numerous stakeholders and activities• Organisational development• Control of resources (dedicated budget and staff)

International collaboration*Source: L. von Karsa, Quality Assurance Group, Prevention and Early Detection Section, International Agency for Research on Cancer

Thank you for your attention