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Stratégies de dépistage du cancer colorectal: endoscopie versus autres modes d’exploration

Screening strategies for CRC: endoscopy versus other modalities

  • Published:
Acta Endoscopica

Résumé

Le cancer colorectal, avec 36000 nouveaux cas et 16000 décès par an en France, est un problème majeur de santé publique. Il justifie le développement de stratégies de dépistage de masse de la population à risque moyen. En France ce dépistage est basé sur la recherche de saignement occulte dans les selles par le test Hémoccult II® répété tous les 2 ans dans 22 des 95 départements Français. D’autres pays développent des stratégies de dépistage endoscopiques. Il est important de comparer ces différentes stratégies en terme de réduction de mortalité, d’incidence du cancer colorectal et en terme de coût-efficacité.

Les études basées sur la réalisation d’un test hémoccult tous les 2 ans mettent en évidence une réduction de mortalité de 14 % après 10 ans de dépistage, moindre après 13 ans et nulle après 16 ans. L’incidence du cancer colorectal n’est pas significativement modifiée après 11 à 16 ans de dépistage.

Les études de dépistage basées sur l’endoscopie mettent en évidence dans les études cas-témoins une réduction de l’incidence du CCR de 45 à 80 % et une réduction de la mortalité de 56 à 75 % surtout au profit des CCR distaux. Les études avec contrôles «historiques» montrent une réduction d’incidence du CCR de 66 à 80 %. Plusieurs résultats d’études contrôlées de dépistage par rectosigmoidoscopie souple sont en attente en 2007–2008.

Les études combinant recherche de saignement occulte et endoscopie ne permettent pas d’augmenter le taux de détection du CCR et ne mettent en évidence qu’une réduction non significative du taux de mortalité.

Le dépistage par sigmoïdoscopie ne permet de détecter que 66% des hommes et 35% des femmes porteurs de CCR. Le risque relatif d’adénome proximal chez les patients porteurs d’adénome distal est de 2,8. Des scores visant à définir la population devant avoir une coloscopie totale après réalisation d’une sigmoïdoscopie ont été élaborés.

Les taux de complications des stratégies de dépistage endoscopiques sont bas, liéà une éventuelle polypectomie comme pour les endoscopies réalisées quelle que soit l’indication. L’acceptabilité du dépistage est meilleure pour le test hémoccult que pour la sigmoïdoscopie et que pour la coloscopie totale et ce quelle que soit les antécédents personnels ou familiaux de cancer colorectal ou d’adénome. La faisabilité du dépistage endoscopique se heurte au problème de la démographie médicale.

D’autres méthodes de dépistage sont décrites: recherche immunologique de sang dans les selles, détection d’ADN fécal, coloscopie virtuelle. Ces études ont prouvées la faisabilité de ces techniques en pratique, mais aucune n’a pour l’instant démontré un intérêt en terme de réduction d’incidence du cancer colorectal et de réduction de mortalité.

Summary

With 36 000 new cases per year and 16 000 deaths per year, colorectal cancer is a major health problem in France. This justifies the development of mass screening strategies for the average risk population. In France mass screening for colorectal cancer is based on fecal occult blood test with Hémoccult II® done every 2-year. This screening program is now applied in 22 of the 95 French administrative areas. Endoscopic screening programs are developed in other countries. It is of importance to compare those different screening program in term of decrease of the colorectal cancer incidence, mortality and in term of cost effectiveness.

Studies based on biennial hemoccult test showed a 16% decrease of colorectal mortality after 10 years of mass screening program. This mortality decrease was lower after 13 years of screening and very limited after 16 years of screening. The incidence of colorectal cancer was not significantly modified after 11 to 16 years of colorectal cancer screening with hemoccult.

Case-control endoscopic-based studies showed a 45 to 80% decrease of colorectal cancer incidence and a 56 to 75% decrease of colorectal cancer mortality, especially for distal colorectal cancers. Trials with historical controlled cohort showed a 66 to 80% decrease of colorectal cancer incidence, without decrease of mortality. Four randomized and controlled studies are now ongoing and results will be available between 2007 and 2008).

Studies with combination of fecal occult blood test and endoscopy didn’t increase the colorectal cancer detection rate and showed no significative decrease of colorectal mortality.

Screening programs based on rectosigmoidoscopy detected only 66% of men and 35% of women with colorectal cancer. The risk of proximal adenoma in the population of persons with distal adenoma detected on rectosigmoidoscopy is 2.8. An index is described to define the population who need a total colonoscopy after rectosigmoidoscopy.

Adverse events rates related on endoscopic screening programs are very low, similar to large endoscopic reports. Acceptability of screening programs is better for hemoccult than for rectosigmoidoscopy and total colonoscopy, even if there is personal or familial history of colorectal cancer or adenoma. Feasibility of endoscopic-based screening programs depends closely to the medical demography.

Others mass screening methods are described: immunological fecal occult blood test, fecal DNA detection, computed-tomography colonography. Those methods are feasible in practice but none have yet showed a decrease of colorectal incidence or mortality.

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  1. Service des Maladies de l’Appareil Digestif-SMAD, Centre d’Étude des Maladies Digestives de Rennes - CEMDR, CHU Pontchaillou, 35033, Rennes, France

    D. Heresbach, S. Manfredi & J. F. Bretagne

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Heresbach, D., Manfredi, S. & Bretagne, J.F. Stratégies de dépistage du cancer colorectal: endoscopie versus autres modes d’exploration. Acta Endosc 35, 621–648 (2005). https://doi.org/10.1007/BF03003921

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