Which is the best test for colorectal cancer screening? Giovanna da - - PowerPoint PPT Presentation

Which is the best test for colorectal cancer screening?

Giovanna da Silva, MD, FACS, FASCRS

Staff, Department of Colorectal Surgery Director of Clinical Research Cleveland Clinic Florida

Disclosures

• None

Colorectal Cancer (CRC)

• Siegeel. R et al, Ca Cancer J CLIN 2017

National Goal

1/3 Americans > 50 years

• f age do not follow

recommended screening

American Cancer Society Percentage of U.S. Adults Age 50-75 years Up-to-Date with CRC Screening, Behavioral Risk Factor Surveillance System

Colon cancer screening guidelines

US Preventive Services Task Force Guidelines (USPSTF) American Cancer Society ( ACS)

TESTS USPSTF 2016 ACS 2018 Frequency Every Stool-Based Tests gFOBT (HS) Yes Yes 1 y FIT Yes Yes 1 y FIT DNA Yes Yes 3 y ? Direct Visualization Tests Colonoscopy Yes Yes 10 y CT Colonography Yes Yes 5 y Flex sig Yes Yes 5 y Flex sig with FIT Yes No Flex sig 10y FIT 1 y

Stool-Based Tests

Pros

• Noninvasive
• Can be done at home
• No bowel prep
• No medical restrictions
• Lower cost
• Suitable for mass

screening programs Cons

• Less sensitive for

advanced lesions and cancer

• Frequency
• Low compliance
• Colonoscopy if

abnormal test

• Don’t prevent

CRC/advanced lesions

Fecal Occult Blood Test

(gFOBT)

• Guaiac FOBT (gFOBT)
• Guaiac resin + Hb + H2O2 -- Blue
• Need to avoid certain foods and meds
• 3 stool samples
• RCT: reduces CRC death by 15-30% when done

every 1-2 years

• 1-time sensitivity for CRC: 13-50%
• High-sensitivity gFOBT: Hemoccult SENSA

Shaukat A, NEJM 2013 Mandel jS, NEJM 2000

Fecal Immunochemical Test

(FIT)

• Antibody detects human Hb
• No need of dietary restriction
• Single sample
• Better sensitivity and specificity than gFOBT
• Different cutoff values available in the US
• Recommended every year
• Meta-analysis
• 1-time cancer detection: 50-79%; overall accuracy: 95%
• Better patient compliance than gFOBT

Mousavinezhad M et al, MJIRI, 2016 Lee J K et al. Ann Int Med, 2014

Polyp-Cancer Pathway

Calderwood AH

FIT-DNA

Cologuard

• Combination of FIT and markers for

abnormal DNA

• Detect high-risk lesions: adenoma ≥10 mm,

sessile serrated polyp, villous or tubulovillous adenoma, adenoma with high grade dysplasia

• 1-time sensitivity for CRC: 92%
• Cost $ 500 vs. $ 20 (FIT)
• Recommended every 3 years

Stool-Based tests

CRC detection

Sensitivity Specificity FOBT Hemoccult SENSA 62-79% 87-96% FIT Light (10μg Hb/g) FIT Chek (20μg Hb/g) 79-88% 73-75% 91-93% 91-95% FIT DNA 92% 84%

USPSTF JAMA 2016

FIT-DNA vs. FIT

Sensitivity

n=9989

Imperiale TF et al, NEJM, 2014

Cancer (n=65) Advanced Neoplasia (n=757) FIT-DNA 92.3% 42.4% FIT 73.8% 23.8%

FIT DNA vs. FIT

Specificity

n=9989

Imperiale TF et al, NEJM, 2014

FIT DNA: more false positives extra colonoscopy

Negative for non advanced lesions Entirely negative colonoscopy FIT-DNA 86.6% 89.9% FIT 94.9% 96.4%

Direct Visualization Tests

Colonoscopy/Flexible sigmoidoscopy

• High sensitivity for cancer and all pre

cancerous lesions

• Single-session diagnosis and treatment
• Longer interval between examination

• Need of bowel prep
• Need of sedation
• Operator dependent
• Costs
• Risks
• Perforation – 4/10.000
• Bleeding 8/10.000

Lin JS, USPSTF. 2016

Direct visualization Tests

Colonoscopy/Flexible sigmoidoscopy

Lower for flex sig

Colonoscopy& Flex sig

Meta-analysis & Systematic review

• Flexible sigmoidoscopy (4 RCT)
• Reduction in CRC incidence and/or

mortality of 29-76%- less for distal CRC

• Colonoscopy (10 obs studies)
• Reduction in CRC incidence and mortality
• f 80% distal colon and 40-60% in the

proximal colon

Brenner H et al, BMJ 2014 Rex DK, Am J Gastroenterology, 2014

Robertson DJ

• 9167 patients with

adenoma removed at baseline/no cancer

• Median FU 47.2

months

• 58 (0.6%) diagnosed

with cancer

Gut.2014

Colonoscopy

Quality benchmarks

• Adenoma detection rate: 25%
• Cecal Intubation: 90%
• Photo documentation
• Withdrawal time: 6-9 min
• Bowel preparation: 85% adequate
• Inadequate bowel prep should be repeated within 1

year

Anderson JC, Clinical And translational Gastroenterology, 2015

CT Colonography

• Patients who refuses, can’t undergo or

had incomplete c-scope

• Sensitivity 67-94% for adenomas > 1 cm
• 40-70% incidentalomas- potential harm
• Radiation exposure
• Recommended every 5 years
• Insurance coverage might be challenging

CT Colonography vs.Colonoscopy

Meta-analysis

• 3163 Colonoscopy (OC)
• 3120 CT colonography (CTC)
• 246 (7.9%) referred to OC (polyp > 6 mm)
• No statistical difference
• Cancer CTC 0.4% vs. OC 0.1%
• Advanced lesions: CTC 3.2% vs. OC 3.4%
• OC: 0.2% colonic perforation

Kim DH et al NEJM 2007

Colorectal cancer screening Which is the best test?

Choice can improve adherence

Inadomi JA et al Arch Intern Med. 2012

RCT n=997

U.S Multi-Society Task Force Colorectal Cancer ( MSTF) Ranking

• Tier1
• Colonoscopy every 10 years
• Annual fecal immunochemical test
• Tier 2
• CT colonography every 5 years
• FIT DNA every 3 years
• Flexible sigmoidoscopy every 5-10 years
• Tier 2
• Capsule colonoscopy every 5 years

Colorectal cancer screening Which is the best test?

“The best colorectal cancer screening test is the one that gets done”

Richard Wender , MD

Thank you!