Screening of colorectal cancer Yearly 4000 lives could be saved in - - PowerPoint PPT Presentation

Screening of colorectal cancer

Yearly 4000 lives could be saved in Hungary

György Bodoky Unified Saint István and Saint László Hospital Department of Oncology

1.000.000 new cases yearly Over 400.000 death Out of 18 people 1 is at risk 10-15% of total cancer-related death cases (2nd most frequent cancer) Treatment cost is several billion Euro per year Occurence of colorectal cancer

Occurence of colorectal cancer

In Hungary

• 10 000 new cases yearly, increasing trend
• Most frequent onset between age 50 and 75
• Under age 40 it occurs mainly due to genetic predisposition

Colorectal cancer mortality

• CRC is the 2nd most frequent cancer in both gender
• CRC is the 2nd most frequent cause of cancer-related death
• CRC is the most frequent cause of cancer-related death

among non-smoking men and women

• all of us have a 1:18 chance to have the disease

Risk factors

• < age 40 family anamnesis
• Inheritance (FAP, Gardner syndrome, Peutz-Jeugers syndrome,

Lynch- syndrome)

• Eating habits: high consumption of meat, fat, protein and alcohol,

low intake of fiber, calcium, selen and foliate

• Inflammatory bowel diseases: frequency is 20% after 10 years

30% after 20 years

• Polypus colorectalis : occurence at age 50 is 10 - 30%

at age 70 - 75 it is 30 - 60%

• Colorectal cancer in anamnesis

Hajlamosító tényezők

• Young age – however 7% of CRC occurs under age 50
• Ethnics
• Lack of own- or family anamnesis– however 80% of CRC
• ccurs without anamnesis
• Low comsumption of meat, fat and alcohol and high intake of

fiber, calcium, selen and foliate reduce the risk of CRC

• Hormone Replacement Therapy (HRT) reduces CRC risk
• Aspirin, NSAID and vitamin D might reduce CRC risk
• Healthy lifestyle – exercise, healthy food reduce the risk
• BUT it is CRC-screening which is the most significant factor in

reducing CRC-risk

Which are the inhibiting factors of colorectal cancer ?

Stage I 15%-20% Stage II 20%–35% Stage III 25%–30% Stage IV 20%–25% CRC stage at the time of diagnosis

Screening of colorectal cancer

What else do we know about CRC screening? By screening colorectal carcinoma is the most preventable type of visceral cancer

Development of CRC according to Vogelstein...

Normal Adenoma

Advanced Adenoma

Early Carcinoma

Colon epithelium Benignus neoplasia which persist for many decades Benignus, during 2 -5 years

Malignant neoplasia Advanced Carcinoma

2 -5 years

Benignus neoplasia

There is a 10 years period for the diagnosis of CRC !

CRC sreening

The aim of the screening is to detect and remove adenomas and the cancer that has already been formed in patients with asymptomatic disease and then the follow-up of the patient The method

• f

screening has a number

• f

recommendations around the world taking into account the country's epidemiological, economic, health and cultural situation

Early diagnosis is the key

Even if CRC is not diagnosed in the status of adenoma in case of localized CRC 90% 5-years survival can be expected in case of metastatic CRC

• nly 5% 5-years survival can be expected

Facts about CRC screening

• ALL METHODS OF SCREENING REDUCE

MORTALITY

• Pre-carcinoma polypus can be diagnosed and

removed by screening

• Screening is cost-effective

Who to screen?

Average risk patient: over age 50, without CRC risk-factors 75-80% of the effected population High-risk patients should be screened earlier 20-25% of the population is under high- risk

High risk population= 20-25 % of total population

• Herediter nonpolyposis colorectal carcinoma (HNPCC)

– These people at the age of 45 develop CRC instead of the average age of 63

• Endometrium-, ovarian- and breast cancer

– Screeing has to be started at age 20-30

• Special attention to the “3-2-1 rule” ( Amsterdam II criteria)

– 3 family members with CRC, out of them at least one is a first- degree relative of the other two – In 2 successive generations – 1 of the diagnosis happened before age 50

• Mutation in hMSH2 & hMLH1 genes

Even higher risk

• Familial Adenomatous Polyposis, FAP

– 50% has polypus at adolescence age – 95% has polypus before the age 35 – 100% will develop CRC by the age 40 unless they had colectomy – Mutation in the APC [adenomatous polyposis coli] gene which is responsible for tumor-supression

• Ashkenaz jewish

– 6% of them has double or triple risk for CRC – Mutation in the APC tumor supressor gene

Test Implementer How invasive Sensitivity Compliance Time interval Effectiveness Stool blood 3 samples Patient handles stool Noninvasive Non-diagnostic Low 30-50% Varied 50% ^Yearly with rehydration ^^Bi-annually ^40% dicrease in CRC ^^30% dicrease Sígmoidoscopy Physician Invasive 50-70% but laesions proximal to sko are invisable [Concommittant with stool blood it is 76%] Bowel preparation/ No anesthaesia/, can be discomfortable/ Perforation [1:10,000] In every 5 years. Low repeat rate due to discomfort Not effective enough. Must be combined with stool blood Barium enema with double contrast Experienced physician Invasive Low sensibility Bowel preparation/ Discomfort/ Perforation 1/25,000. Effectivity is not confirmed by trial Not preferred if other methods are available Colonoscopy “Gold Standard” Experienced physician Invasive Highest sensitivity, 80- 90% of cancer cases can be prevented Bowel preparation/ Anesthaesia is feasible Risk of perforation 1:500 - 1:4000 Longest protection For screening in every 10 years The only method which is suitable for screening, diagnostic and therapeutic intervention as well Stool DNA test Patient handles stool Noninvasive/ Represents the entire colon 65-70% dicrease in CRC mortality High compliance can be expected In every 3-5 year. Lower sensitivity compared to colonoscopy Virtual Colonoscopy [CT Colonography] Experienced physician Minimal invasive In laesions >10mm comperable to colonoscopy In flat, <5mm laesions it is weak Bowel preparation is uncomfortable, the intervention is not In every 5-10 years Most expensive, no evidence about the effectiveness

Screening methods

Screening from stool blood

• Occult blood test

– Sensitivity is only 50 % at the first occasion, it is 90 % on long- term if the test is repeated in every 1-2 years – High false-negative ratio,resulting in false sense of security – Majority of positive tests are false positive resulting in redundant colonoscopy – Effective only in case of long-term good patient compliance – In case of using immunochemical test for haemoglobin detection dietary restictions are needed

Stool DNA test FDA registration: Aug.11, 2014.

– Detects abnormal DNA from the stool – It is important to select the right molecular markers – Sensitivity 52-70%, specificity cc 95%

Screening with endoscopy

• Colonoscopy

– The whole colon can be overviewed, polypus can be removed and biopsy can be performed – High sensitivity 80%, specificity 95% – Ratio of false negative results is 15-25% in adenomas smaller than 5 mm, 0-6% in adenomas larger than 10 mm – Decreases CRC incidence and mortality by 90% – Each patient detected as positive by any other screening method has to be referred to colonoscopy – Severe complications occurring in 1-2 / 1000 cases

GOLD STANDARD FOR CRC SCREENING

method prevented cc. (%) prevented death (%) stool blood 22,5 47,0 sigmoidoscopy 37,5 52 Stool blood + sigmoidoscopy 50,0 66,0 colonoscopy 70,0 90,0

Lieberman D.: Gastroenterology

Effectiveness of screening methods

Effectiveness of CRC screening

The incidence of colorectal cancer in the US dropped by 30% between 2000 and 2010 among adults ages 50 and older, according to a recent report (CA, A Cancer Journal for Clinicians 2014; 64: 104-117), a decline attributed primarily to widespread screening. A new effort aims to further reduce incidence

• f

the disease by screening 80%

• f

adults according to current guidelines by 2018.

CA Cancer J Clin 2014;64:104-117.

Csurgó

Population: 5129

Tokaj

Population: 4639

Pancho Arena

April 21. 2014

4500 paying viewer

• All CRC sreening methods are cost-effective
• As cost-effective as mammography screening
• More cost-effective than eg. cholesterine or high blood

pressure screenings

• Colonoscopic screening of patients above the age 40

with CRC anamnesis in their straigh line family members is economically profitable

Cost-effectiveness of CRC screening

Colonoscopy in every 10 years from age 50, for high- risk patients additional stool DNS test at each 5th year between two colonoscopy

But in case we do not perform these..

Any method we consistently go through!

Which is the best screening method for an average-risk patient?