Is virtual colonoscopy (CT colonography, or CTC) being unfairly held to a higher standard for a screening test for colorectal cancer than other screening tests?

I may not be the best person to answer this question since some of the main researchers in this field are my coworkers and friends. However, I do think they received unfair, tough treatment when the Centers for Medicare and Medicaid Services (CMS) decided whether or not to cover the test (they ultimately decided not to).

Now, someone else agrees with me! An editorial was published on this topic in this week's Annals of Internal Medicine. (Aside from this: I love how the journal has a section entitled "Key Summary Points", by the way. Very useful to a time-strapped clinician). This article goes point by point through the concerns raised by Medicare (via the U.S. Preventive Services Task Force in their last review of colorectal screening modalities), specifically the dose of radiation needed with each virtual colonoscopy, the false-negative rate for small polyps, extracolonic findings and the variations in reliability of virtual colonoscopy. No one is claiming that virtual colonoscopy is perfect, but it is a good test and merits serious consideration. I find it hard to believe that it is not as good as a stool guaiac test. So also conclude the authors who note, "it seems that CTC is being held to a new and higher standard" prior to CMS approval.

Among the many posters I walked past at this past week's Gastrointestinal Cancer Symposium, one in particular caught my eye: Suicide in patients with pancreatic cancer.

The researchers found, using the SEER database, that the standardized mortality ratio was 10.8 among patients with pancreatic cancer compared to the general population. Further analysis identified that single men with potentially surgically resectable pancreatic cancer are at particularly high risk (OR: 2.5). What is not clear in the abstract was how death from suicide was determined. Thus, with a little online searching, I was able to discover that the risk for suicide is also higher in men recently diagnosed with prostate cancer (at least in Sweden).

During 2008, the Journal of Clinical Oncology ran several articles about the higher rate of suicide in cancer patients, particularly in patients with gastric, lung and head and neck cancers, as well as older, male cancer patients. A further study at Dana-Farber Cancer Institute identified that nearly 6% of patients with a thoracic malignancy (chiefly lung and esophageal cancers) have suicidal ideations and a whopping 30% met criteria for an anxiety and/or depression disorder.

For me, this research in total serves as an important reminder to check in with patients about ther emotional state, particularly after a new diagnosis of cancer and particularly for those who are unmarried, older-aged or male. This research also reinforces the crucial role that cancer psychology serves for our patients. I am so grateful that their services are available to me and to the patients and families I see.

I just got back from the Gastrointestinal Cancer Symposium (which many informally call ASCO GI) in Orlando, Florida this week. Not too many "big splash" practice-changing results were presented this year. A few results did catch my attention though, including the negative study from Dr. Okita and colleagues out of Asia involving the use of sorafenib or placebo after transarterial chemoembolism (TACE) for hepatocellular carcinoma. (HemOnc Today has a nice short summary of the oral presentation here).

This was for Childs Pugh Class A patients with a large burden of cancer (at least 10 lesions, or lesions at least 7 cm in size) who had had at least a partial response to TACE prior to enrollment. To the investigators credit, more than 450 patients were enrolled (all from Japan and Korea). Additionally, the majority of patients had hepatitis B or hepatitis C as their underlying risk for hepatoma. Although sorafenib did not extend progression free survival, the treatment was only for a few months after TACE (with a median of 17 weeks on sorafenib and 20 weeks on placebo), and the average sorafenib dose was roughly 200 mg twice a day, which is not the protocol specified 400 mg twice a day, suggesting a lot of adverse events requiring dose modification.

These important exceptions tell me that it may not be that sorafenib is totally ineffective, but that after TACE patients with a high tumor burden may not be able to tolerate much of the drug. The subgroup analysis was interesting as well — Korean patients did substantially better on sorafenib than placebo, unlike the Japanese patients. The reason for this is not clear to me — some single nucleotide polymophism or other gene present only in one population that affects tolerabiliity, metabolism or effectiveness of sorafenib?

Also interestingly, there was a substantial difference between the investigators' assessment of response and the central review, with their being a benefit for sorafenib over placebo seen in the investigator assessments only, which reinforce for me the importance of blinding and central review to eliminate possible biases.