Colo s in Amsterdam. Chris Mulder, Jochim Terhaar sive Droste. VU Medisch Centrum Afdeling MDL

Transcription

1 Colo s in Amsterdam Chris Mulder, Jochim Terhaar sive Droste VU Medisch Centrum Afdeling MDL

2 Open access colo Threshold low in CRC-family Open access 0 5% CM: scientific evaluation 0,0 KWF/MLDS: basic research

3 Endoscopy Amsterdam 2004 Total number: Total number colo/sigmo: CM: CRC data unknown??

4 Peppen ZonMW 2005 Screening information Breast cancer screening Sensitivity: 70% If you have breast cancer the chance that it will be found is 70% Two cancers detected, one missed What about FOBT, acceptable?

5 Habbema ZonMW 2005 Are the effect estimates of FOBT screening favorable and robust? 3 RCT s (Nottingham, Fünen, Minnesota) all lead to the same effect estimate: 15-20% mortality reduction of colorectal cancer after years of screening. CM: 80-85% 85% gaat toch dood

6 September 2004 CM: FOBT - mortality reduction is only 10% - will patients accept this

7 FOB ZonMW Habbema ZonMW 2005 What is known about various cost aspects? Costs per unit: Invitation: 3 Screening: 3,5 Colonoscopy diagnostic: 160 Colonoscopy therapeutic: 250 Treatment stage I-III: 8500; stage IV: 800 Follow-up per year: 250 Palliative treatment per CRC death: Regional organization costs (9 centres): 2,6 mln National organization: 1,8 mln. CM: FOB too cheap? Palliative treatment too cheap?

8 Current colonoscopies in the Netherlands a b b b Habbema ZonMW 2005 a Based on: Nauta JA, Ottes L van Rijen AJG, Deel II, Zorgconsumptie vergeleken, in: Met het oog op gepaste zorg, Zoetermeer 2004 b From: Prismant, Landelijke Medische Registratie, informatie verrichtingen CM: even more gross-assumptions

9 1999: Nederland endoscopies Kolkman Magma 2001 Colo: > Gastro: > ERCP: > CM: which data are reliable?

10 Obstacle: colonoscopic capacity Colonoscopy: bottleneck to be resolved extra colonoscopies yearly strategy: 2 yearly Habbema ZonMW 2005 CM: is only 10% extra

11 Colo-capaciteit 2009 MDL 264 retirement 16 + trainees 51 = 300 gastroenterologists + trainees 60 ++:after 2009 CM: Manpower gross-assumption assumption

12 Marilyn or expensive drugs?

13 Kleibeuker ZonMW 2005 CRC treatment: palliative Endoscopic debulking, stenting Surgical resection Rectal cancer: radiotherapy Colon and rectal cancer: chemotherapy, biologicals Liver/lung metastases: radiofrequency ablation CRC prevention cheaper??

14 Avastin (bevacizumab) NL: 2 February 2005 first line treatment Avastin / 5-FU / LV +/- Irinotecan ,- (20 months) CM: metastatic disease will become too expensive?

15 FU + Leucovorin 500,- ; 4,5 months Survival months FU / Leucovorin / Irinotecan / Avastin $ ,- ; 20 months Survival >> 20 months CM: to treat 1 patient: 750 x coloscopie

16 Concern CRC screening 1. Is FOBT good enough? 2. What are the prospects for alternative tests? 3. Can colonoscopy-capacity needs be met? 4. Will attendance be high enough? 5. Should we and can we- reorganize all cancer screening? Peppen ZonMW 2005 CM: 1) no 2)?? 3) yes 4) yes/?

17 Verweij ZonMW 2005 Respect for autonomy Persons should not be forced to screening They must be well-informed They should be empowered to make a reasonable choice of their own They should have the possibility to avoid the offer of screening CM: we don t force anyone

18 Screening & follow-up Fockens ZonMW 2005 Consensus on follow-up? Yes! Follow-up after removal of adenomatous polyps: CBO 2001 (Nagengast, NTvG 2001) 1st FU after 3 yrs ( 3 polyps) of 6 yrs (1-2 polyps) Stop FU: 1 adenoma 65 yrs; 2 ad. 75 yrs; 3 ad. cont. FAP & HNPCC: special FU-scheme CM: Dutch GE can manage this

19 Conclusion: approximately one in 4 deviates significantly from the recommended frequency of screening Advise 1: reduce discomfort and embarrassment at endoscopy Advise 2: use reminder letters CM: What about low-riskers?

20 High risk categories Increased familial risk Population 1:25 1 f.d. relative CRC 1:17 1 f.d. + 1 s.d. CRC 1:12 Kleibeuker ZonMW f.d. < 50 yrs 1:10 } 2 f.d. CRC 1: 6 national guidelines Dominant pedigree 1: 2 CM: do we scope enough?

21 Enquete onder HA en MDL artsen respons MDL / GE HLK (N=420) 84% Huisarts A dam (N=400) 40% Gemiddelde leeftijd Voor CRC screening Voor persoonlijke screening 48 (range 25-71) 92% 95% 50 (range 34-71) 54% 41%

22 Methode populatie screening MDL / GE HLK Huisarts FOBT/ Sigmo Colo anders Geen mening 12% 72% 16% 0% 44% 32% 13% 11%

23 CRC in NL Incidence: 9000 / year metastatics 5000 Palliative treatment chemotherapy 2500

24 CRC metastatic therapy x = million per year CM: mass-coloscreening cheaper

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26 Methode persoonlijke screening MDL / GE HLK Huisarts FOBT Sigmo % 14% Colo anders 97% - 32% 15% Geen mening - 15%

27 Persoonlijke screening vanaf.. 50 jaar 55 jaar 60 jaar Anders/geen mening MDL / GE HLK 37% 42% 21% - Huisarts 22% 28% 22% 28%

28 Familiaire belasting / hoog risico MDL / GE HLK Huisarts 1e / 2e graads familielid CRC / poliepen 4% 38% Hoog risico CRC 2% 11%

29 Verweij ZonMW 2005 Persons should not be forced Not a fundamental problem FOBT procedure requires that they take action themselves Forgoing screening can be easy and not very costly

30 Verweij ZonMW 2005 Is avoiding the offer of screening possible? Inviting people to screening already affect their lives and outlook (worries, medicalization) Preference of not being troubled by all kinds of health risks is made impossible by proactive screening offers People should have at least been given the possibility to cancel further invitations

31 Fockens ZonMW 2005 Secondary screening & Follow-up Who will guide formulation of best practice procedure? Dutch Society of Gastroenterologists (NGMDL) in conjunction with Governement (ZonMW) Health care insurance companies Dutch Cancer Society

32 The challenge of colorectal cancer Prostate/ testis 9% Hem atologic 8% Female reprod 8% Head & neck 6% Lung 16% Bladder 5% GI 7% Other 5% Breast 14% Kidney 3% Stom ach 6% CRC 14% ~ 200,000 cases each year in Western Europe Accounts for ~ 100,000 deaths annually in W estern Europe About 25% present with m etastatic disease 40 50% of newly diagnosed patients eventually develop m etastatic disease 5-year survival rate of patients w ith m etastatic disease is ~ 3% Ferlay et al GLOBOCAN 2000: All of Europe

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34 Chemotherapy of Metastatic Colorectal Cancer 5-Fluorouracil (+ leucovorin) Oral fluoropyrimidines Capecitabine UFT (+ leucovorin) Irinotecan Oxaliplatin Cetuximab (Anti-EGFR Ab) Bevacizumab (Anti-VEGF Ab)