Early Detection for Colorectal Cancer Resource-Stratified Guideline

An interview with Dr. Marcia Cruz-Correa from the University of Puerto Rico and MD Anderson Cancer Center on the ASCO Resource Stratified Guideline on early detection for colorectal cancer.

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Hello, and welcome to the ASCO Guidelines Podcast series. My name is Shannon McKernin. And today, I'm interviewing Dr. Marcia Cruz-Correa from the University of Puerto Rico and MD Anderson Cancer Center, senior author on "Early Detection for Colorectal Cance: ASCO Resource-Stratified Guideline." Thank you for being here today, Dr. Cruz-Correa.

Well, thank you very much for the opportunity to speak with you today.

So first, can you give us a general overview of what this guideline covers?

Absolutely, Shannon. Well, we are very excited to review the content of the guideline. And we put together a summary of the current guidelines out there for patients that are undergoing colorectal cancer screening.
With these particular resource, a certified guideline takes, for the first time, into account the place where the colorectal cancer screening is being delivered, which is different from when you read any other colorectal cancer screening guidelines, where normally we assume that all available methodologies are equally distributed regardless of the country or the setting. So in our particular guideline, we really emphasize the fact that, depending on where our clinicians are, they might have differing technologies available. And that's why it's called resource-stratified-guidelines, to help our clinicians and our practicing physicians to understand what would be the best method to be able to implement screening in their own settings.

So what are the key recommendations of this guideline?

I think that the most important recommendation is that colorectal cancer is a prevalent disease, not only affecting very highly developed countries, but a disease that we're seeing more and more in low-to-middle-income countries. As ASCO is an organization that has members from around the world, being cognizant of the fact that colorectal cancer affects many individuals across different settings, and countries, and continents, for that matter, allows us to provide the most important information which is to consider colorectal cancer screening across the different settings, so not only in the industrialized well-developed first-world country, but also in the low-to-middle-income, or those that are becoming more and more industrialized.
So our main recommendation-- it's number one-- that we need consider colorectal cancer screening even in settings where, for many years, the burden of disease was really focused in infectious-driven diseases. Nowadays, we're seeing more and more low-to-middle-income countries where the number one cause of death, it's not an infectious-driven disease, but rather a cancer. And colorectal cancer, it's one of the top cancers that we're seeing in many of the settings. So our number one recommendation is to be cognizant about that so that different countries and different settings, the practitioners consider screening.
And our second and most important recommendation is that, the important thing is to consider what you have available in your setting, in your clinical practice. And depending on what you have available, then you can offer the method that could be given to your patient. So it's almost like thinking differently. It's not a one size fits all, but rather it's more or less of a personalized recommendation based on your setting, based on your clinical practice methods available to you.

So why is this guideline so important? And how will it change practice?

We believe that it's very important, because when you look at guidelines in any published article out there, we read it. And it looks as if everyone had every resource available. And when you're practicing in a low-to-middle-income country, or a place-- it could be a rural area where you have more basic settings or more limited settings-- you might not have that new machine or that new equipment.
So then, as a practitioner, you feel that you're not equipped to be able to provide the best care to your patients. So this guideline, it's mirrored after a previous guideline that was put together by the ASCO Clinical Practice Group, where we stratify the type of practice for our-- where our practitioners are providing care. There are four main practice settings.
The first one is what we call the basic setting, which is where you have the minimal necessary facilities to be able to evaluate patients and provide first primary care services. The second tier, it's called the limited setting, where you have more clinical facilities, but yet you don't have all the elements, like imaging, for instance, or the specialized surgeon, or the third- or fourth-level specialized technology.
Then you have something, the next level would be the enhanced, where you, again, you see more methods and more availability of more clinical instrumentation and facilities. And then final one, which is the fourth level, will be the maximal setting. So in a maximal setting is when you go to a city, a cancer center, for instance, where you have all the specialists, all the imaging, all the endoscopy, and experts that are able to use those equipments and provide the best care.
So using that four-level approach, from basic-- and think about, when you think about basic, it's in a rural community maybe in-a-low-to-middle income or developing country, places where you have a general surgeon. And you may have a primary physician. You may have nurse practitioners or nurses that actually provide that first care, first-level care. And then you keep going from there all the way to the maximal setting. So depending where you are, these resource-stratified guidelines will provide the physician and the clinical practitioner with methods that they can implement now.
So to give you an example, when you think about colorectal cancer screening, you think about individuals that come to see you because they have no symptoms or they might have some symptoms. Most of the time, they would be asymptomatic individuals that come for a general screening, general visit. So this resource-stratified allows the physician that is practicing at a basic or a limited setting to provide, for the case of colorectal cancer, screening to provide fecal or cold-blood testing. This is a test that has been shown to be effective, that when used in the adequate setting for a patient that is 50 years of age or older, will provide enough sensitivity to diagnose an individual that might have either colorectal cancer or advanced colonic polyps so that that patient can then undergo a confirmatory test such as a barium enema, if you are in a basic setting.
Very different, Shannon, when you are in a setting where you have all the instrumentation there-- you as a physician, you could either do a fecal immunological testing to look for, or cold blood. Or you could decide to refer a patient to a colonoscopy. And I think, when you practice in the US, I mean, large or industrialized places like Europe or Australia, you think that everyone has access to endoscopy.
And believe it or not, one of the things that we realized when we were looking at all these data, is that in basic settings, setups for colonoscopy for removal of polyps with polypectomy during a colonoscopy are not available. So we took all those factors of clinical facilities, and availability of equipment, and expert physicians to be able to provide adequate care for the patients that are receiving care by our practitioners in the different settings, from basic all the way to enhanced and maximal settings.

And finally, how will these guideline recommendations affect the patients?

You have asked the most important question. The reason that we put guidelines out there is to guide our physicians, our practitioners to provide the best care that they can regardless of where they are. By providing this information, the ultimate and most important beneficiary of these guidelines is the patients.
Right now, in many settings, especially in low-to-middle-income or developing countries, they are not receiving screening or preventive testing. In fact, there are many countries that do not have standardized or institutionalized programs for colorectal cancer screening. So if you don't have a program in place, you can imagine that then a patient would not even be considered for preventive care.
So the ultimate and most important beneficiary of this resource-stratified colorectal cancer screening guideline is the patients that we serve. So as countries continue to evolve, and even in a country that is industrialized but where you have limited resources, only access to a basic laboratory, there we can still provide screening.
And then the guidelines are written in a way that you can identify the type of practice where you're at. And you can choose between the different methods. And then it guides you as to decide when to refer a patient to a higher level with regards to clinical facilities.
So if you're in a basic setting and you get a positive screening test, what do you do with that patient? Are you able to refer to the second level, which will be the limited? Or do you have to refer it all the way to enhanced? So it's almost like it's a guideline, but it's very practical in nature.
So our hope is that this will allow our practitioners to feel empowered, to understand that this is a disease that will be affecting their population, the patients that they are taking care of, but furthermore, that they feel empowered to provide the best care, because that's why we practice medicine. And that's the bottom line, the most important reason why this was put together.

Great, thank you so much for your work on this important guideline. And thank you for your time today, Dr. Cruz-Correa.

Thank you very much for the opportunity, Shannon. And you know, hopefully we'll get many comments from across the different members of the organization across the globe.

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