NordICC Controversies: Practice Differences in Europe and the US

Mark A. Lewis, MD, discusses salient differences between the Northern European practices that were studied in NordICC and the American population.
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-- TRANSCRIPT --
Hello, Medscape. This is Mark Lewis. I'm coming to you from my office in the month of March. Now, you may be watching this at a later date, but the reason I wanted to apply that time stamp is because March is Colon and Rectal Cancer Awareness Month.
This month has felt different to me because it's happening on the heels of the NordICC trial, which attempted to establish the mortality benefit of screening colonoscopy, and in its wake has caused a large amount of controversy and, frankly, questions to be asked - rightly - as we enter this month and really grapple with this as a public health problem.
The first thing I would say is it's crucial that we continue to distinguish screening and diagnosis. The diagnostic part is key. If you are having a problem - say, blood in the stool - and you are under the traditional age of screening, that is a diagnostic dilemma, and frankly, none of this language around screening should apply to you.
Obviously, the pretest probability there is substantially higher that something is wrong. Now, that could turn out to be something entirely benign and, say, hemorrhoidal. We can't keep presuming that in all of these young people who appear in our offices with advanced-stage colorectal cancer. I've often said, and I'll repeat it now, that a medical oncologist is the last type of physician that should be encountering these patients.
When we talk about prevention, "prevention" is an interesting word. I sometimes worry that it's an absolute, like, if we did everything right and if the patients did everything right, whatever that means, there would be no colorectal cancer.
I think what we're looking at instead is risk mitigation, in trying to incur a stage-down migration whereby when we do diagnose diseases, we're finding them earlier. In some instances, that can obviate the need for a medical oncologist like myself. I think that's a very important observation.
The second thing I wanted to say is that it is crucial to examine some of the salient differences between the Northern European practices that were studied in NordICC and the American population that many of you listening to this will be caring for.
One of the things that was interesting is this was a study looking at what was the uptake of invitation to screening colonoscopy. Many words have been written, both the initial paper and in subsequent responses and correspondence in The New England Journal of Medicine, about this invitation.
In fairness to investigators, they actually budgeted for this, or, I should say, accounted for this in their statistical design. They had estimated that half, 50%, of the invitees would follow through on screening colonoscopy, and the absolute number was 42%. It was very interesting because one of the critiques that came through The New England Journal of Medicine - I'll read it to you - said, "This cannot examine the 58% of patients who could benefit from screening colonoscopy." I think that's a fair point.
The other thing that I think is slightly technical, and had to be explained to me by a gastroenterologist, is this whole notion of adenoma detection rate (ADR). Again, there's been a large amount of back-and-forth about what's reasonable to expect of a gastroenterologist, and what's reasonable to expect of a gastroenterologist in the United States vs in Europe.
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