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Project aims to reduce burden of colon cancer

There was an enthusiastic flurry of activity at the medical school during the first annual meeting of the Colorectal Cancer Interdisciplinary Health Research Team June 24-26, 2002. This is the first time the entire team, from Memorial University and the University of Toronto, met face-to-face to discuss the progress of the past year. About 20 people from the Toronto group met with their counterparts in Newfoundland to discuss progress and strategies for the upcoming year.

It was an exciting and productive meeting for the 45 people involved. From the amount of work already accomplished, itís hard to believe that it was just over a year ago that the Canadian Institutes of Health Research approved $5 million to finance the five-year study of colorectal cancer.

"The team in both Ontario and Newfoundland has made tremendous progress," said Dr. John McLaughlin, the principal investigator for the study at the University of Toronto. "In one year all parts of a very complex and multi-faceted study are well underway."

At Memorial, the principal investigators for the Colorectal Cancer Study are Dr. Pat Parfrey, clinical epidemiologist and nephrologist, and Dr. Ban Younghusband, molecular geneticist. "The aim is to reduce the overall burden of colon cancer in Newfoundland, Ontario and the world," said Dr. Younghusband.

"We want to reduce the incidence of this type of cancer, reduce anxiety about risk and screening through social science, and develop better screening to identify cancers earlier."

People at high risk of colorectal cancer can be identified through molecular testing or family history. "Then itís a matter of getting them into screening programs which will remove polyps before they are cancerous," he said.

Dr. Younghusbandís particular role in the project is molecular research. "Based on molecular characteristics of the tumour, we should be able to identify cancers that are hereditary. The importance of this is that in places like Toronto, even in St. Johnís, nuclear families increasingly donít know a lot about the medical history of their ancestors. If you have two parents and one child, and one of the parents has colon cancer, how do you identify if itís hereditary or not? By being able to test the tumour, we can tell if itís hereditary and if it is, the child and their children should be put into an intensive screening program."

Fiona Curtis, supervised by Drs. Parfrey and Jane Green, and Angela Hyde, a student in Dr. Younghusbandís laboratory, are doing a pilot project on 200 cancers from the Avalon region. "Weíre fairly confident we can identify the majority of cancers as hereditary or non-hereditary," said Dr. Younghusband. "Weíre going to do a larger study over five years covering the whole provincial population to see if our results pan out. This will also allow us to follow families over a longer period of time to see if those who have hereditary colon cancers do better or worse than those with sporadic cancers."

Elizabeth Dicks is the nurse-coordinator for the project and she said over the past year it has grown by leaps and bounds. "We keep being approached by students and investigators who are interested in different aspects of colon cancer ó for example, diet. Because of the number of different components and the variability of the study, thereís always someone who finds something they want to do. There is tremendous potential for mentoring and teaching."

Another part of the Colorectal Cancer Study is looking at ways to reduce anxiety leading up to the screening process of colonoscopy and encourage more people to have this procedure. In Ontario, a study has already been completed on what encourages people to have a colonoscopy. "The results show that the best incentive is a really unambiguous recommendation from a family doctor," said Dr. McLaughlin. "This is important for high risk families because this screening can prevent colon cancer from developing."

Part of the Newfoundland share of the funding, which is over $2 million, includes an allocation to enhance the ability of the cancer registry at the Newfoundland Cancer Treatment and Research Foundation to rapidly collect information about newly diagnosed cancer. "The registry will help us keep track of families who are at higher risk, and identify families at higher risk," said Dr. Younghusband. "Then they can be put in screening programs and thereby reduce the burden of cancer in those people."

Improvements are being made in the speed at which new cancers are registered. Until now itís been a matter of coding paper records and there can be a long delay before cancers are registered. "Part of the experiment weíre doing is to install a rapid case ascertainment system whereby pathology reports are forwarded electronically as they are typed, and once a week any pathology report that includes cancer is sent to the registry," explained Dr. Younghusband.

Ms. Dicks said a major focus of the project now is obtaining names to start a Newfoundland familial colorectal cancer database. To do this, information from the Newfoundland Cancer Treatment and Research Foundation is reviewed by a pathologist on the team to make sure it deals with the specific type of cancer being studied. Then the doctor who treated the patient is asked to send a letter to the patient to introduce the study; the patient can then follow up by calling their own doctor or contacting the study through a toll-free number (1-888-908-4988).

"We explain to the patient that they will receive a package of information and after we receive the family history, we draw a family tree and assess risk according to an established protocol," said Ms. Dicks. "If the person is at intermediate or high risk, they are offered genetic counseling for the family and a screening protocol."

Dr. Younghusband and Dr. McLaughlin are equally enthusiastic about the progress of the project. "This is a novel way of mounting new science and doing it in an interdisciplinary way," said Dr. McLaughlin. "Thereís good basic science such as in the molecular genetics labs, and good clinical science through clinical genetics. Then weíre looking at issues related to survival in colon cancer patients and prevention through screening, communications, and working with family physicians."

Dr. Younghusband is quick to credit the Canadian Institutes of Health Research (CIHR) for funding such a large project. "Many of our studies may not have been fundable on their own, but as a package they make this an incredibly valuable study. Itís important that the public realize how valuable team research is."

Dr. McLaughlin also credits the initiative and vision of the CIHR. "Itís quite remarkable that these multi-faceted projects, including psycho-social studies, can be contemplated Ė a number of years ago they wouldnít have been funded. Itís the vision of the CIHR thatís made this possible."

With four years to go on the project, interest remains high and expectations of progress even higher. "After a year, there is great enthusiasm for the program," said Dr. McLaughlin. "Everyone is very pleased with the progress thatís been made. In particular, Memorial has accomplished a huge amount in a short time."

Ms. Dicks said the Newfoundland team works really well together and she is enthusiastic about the cooperation of the principal investigators, who make themselves available for frequent meetings and consultations. "If I have any complaint, itís that we just donít have the space we need. Other than that, the project is going really wellópeople are motivated and keen."

For more information on the Colorectal Cancer Interdisciplinary Health Research Team, visit www.mshri.on.ca/colorectalcancer.

{Memorial University of Newfoundland}