Colorectal Cancer Screening in Europe: Guidelines, Implementation, and Future Directions

1. National Centre for Screening Monitoring andItalian Colorectal Cancer Screening GroupEuropean Guidelines WorkshopColorectal Cancer Screening in Europe Lawrence von KarsaQuality Assurance GroupSection of Early Detection and Prevention

2. Overview topics • Collaborative effort in developing the EU CRC screening Guidelines • CRC screening programmes in Europe • Future directions in colorectal cancer screening in Europe and worldwide.

3. THE COUNCIL OF THE EUROPEAN UNIONRecommendation on Cancer Screening of2 December 2003 1. Implementation of cancer screening programmes • 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;

4. 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

5. EU CRC Screening GuidelinesItalian 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 Giordano Reviewer: (Ch 6) Guido Costamagna

6. Colorectal Cancer Screening Programmes in the EU 1/2011 Population-based FOBT-based Belgium * Cyprus Denmark* Finland France* Hungary Ireland* Italy Lithuania* Malta* Netherlands* Portugal* Romania Slovenia* Spain* Sweden* UK* BulgariaFranceFinlandHungaryIrelandLatviaLithuania MaltaNetherlands PortugalRomaniaSloveniaSpainSwedenUK FOBT/CS-based AustriaBelgiumCyprusCzech Rep.DenmarkGermanyGreeceSlovak Rep. Non population-based Austria Bulgaria Czech Rep.* Germany Greece Latvia Poland Slovak Rep. FOBT/FS-based Italy CS-based 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 Poland No programme No programme Estonia Luxembourg Estonia Luxembourg

7. THE COUNCIL OF THE EUROPEAN UNIONRecommendation on Cancer Screening of2 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.

8. 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

9. 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)

10. 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

11. 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

12. Sequence of Steps in Quality-controlledImplementation 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

13. 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

14. Thank you for your attention