Who, What, When, Where, Why and How of Colorectal Cancer Screening - PowerPoint PPT Presentation

Who, What, When, Where, Why and How of Colorectal Cancer Screening Dr. Keith A. Wied Southeast Texas Gastroenterology Feburary 24, 2015

Colorectal Cancer • Colorectal cancer is the 3 rd most commonly diagnosed cancer • Third leading cause of death in US • Approximately 136,830 people diagnosed with colon cancer in 2014 – 50,310 died of colon cancer • Majority of these cancers can be prevented by screening

Who? • Who needs screening • You!

What? • A screening exam

Definitions • Screening • Surveillance • Diagnostic

Screening • The examination of a group of asymptomatic individuals to detect those with a high probability of having or developing a given disease. (Stedmans Medical Dictionary) • Mammography, Pap smears, PSA

Screening for CRC • The process of looking for cancerous or pre-cancerous lesions in a patient without symptoms • The goal is to avert or diagnose at an early curable stage

Survelliance • A process of following patients with: – Known history of polyps – History of Colorectal Cancer (CRC) – High risk factors • Family History • Other associated diseases

Diagnostic • Proceeding with an exam to define a symptom, abnormal lab values, or abnormal imaging study – Abdominal pain, change in BM’s or blood in the stool – Iron deficiency anemia – Mass found on imaging study

When? • Starting at age 50 – Majority of CRC diagnosed between 50-75 years of age • Starting at age 45 for African Americans • Before age 50 if there are other risk factors – Family History of polyps/CRC – IBD – Genetics (HNPCC, FAP)

Where? • Accredited facility • Board Certified • High Volume • High Quality Colonoscopy – Cecal Intubation – Withdrawal time of >6 minutes – APD rate

Southeast Texas Gastroenterology Associates

Why? • Early staged colorectal cancer has no symptoms thus screening is important • It saves lives • Colon cancer can only be found if looked for • It can only be cured if found early

How? • Best screening test is any valid test the patient has access to and is willing to take • NOT screening is NOT an option!

Factors to Consider in Screening • The disease is a major problem • Effective therapy is available • Sensitive and specific screening tests are available • Screening tests are cost effective

Screening Options • FOBT/FIT/Stool DNA • Flexible Sigmoidoscopy • FOBT and Flex Sig • Flex Sig and ACBE • Virtual Colonoscopy • Colonoscopy

Fecal Occult Blood Test (FOBT) • Guaiac Based • Done at home annually • Sensitive, not very specific • Medication and dietary restriction • May produce false positive • Can miss polyps and colon cancer • If positive, colonoscopy is needed

Fecal Immunochemical Test (FIT) • Done at home annually • No pre-test, dietary, or medication restrictions • Higher sensitivity • May produce false positive • Can miss polyps and colon cancer • If positive, colonoscopy is needed

Stool DNA Test (Cologuard) • Qualitative detection of colorectal neoplasia associated DNA markers and for the presence of occult blood • Done at home • No medication or dietary restrictions • More sensitive and specific than others

Stool DNA Test (Continued) • Fewer false positives and false negatives • FDA and CMS approved • If negative, repeat every 3 years • If positive, colonoscopy is needed

Flexible Sigmoidoscopy • Enema prep • No sedation (discomfort?) • Views approximately 1/3 of colon • Can miss pathology • Polyps not removed • Recommended every 5 years • If abnormal, colonoscopy needed

Air Contrast Barium Enema • Requires prep • No sedation (discomfort?) • Usually defines the entire colon • Can miss small polyps • Polyps not removed • High number of false positives • Recommended every 5 years • If abnormal, colonoscopy needed

Virtual Colonoscopy (CT Colonography) • Requires prep • No sedation (discomfort?) • Usually defines the entire colon • Can miss small polyps • Polyps not removed • Recommended every 5 years • If abnormal, colonoscopy needed

Colonoscopy • Requires prep • Done with sedation • Views entire colon • Able to remove polyps/tissue • Can miss small polyps • Invasive • Recommended every 10 years

Got Polyps? • 2 Histologic Types – Adenomas (2/3) • Tubular • Tubulovillous • Villous – Hyperplastic (1/3) • Serrated Adenomas

Got Polyps? • Less than 10% of all polyps will advance to cancer • 95% of all colorectal cancers begin as a polyp • Adenoma – Carcinoma sequence • Variable (10-20 years)

Adenoma – Carcinoma Sequence

Colorectal Cancer Basic Facts • Colorectal cancer develops slowly over years • Most begin as noncancerous growth called adenoma arising from colonic mucosa • An estimated one-third to one-half of all individuals will develop at lease one adenoma

CRC Screening is Increasing • Medicare funding • Insurance companies mandated to pay for screening • National campaign to inform about benefits of CRC • Endorsed by – United States Preventative Services Task Force, American Cancer Society and all National Gastroenterology Associations

Effects of Screening • Have seen increased screening rates • Pre 2001 – 25% • Post 2001 – 55% • Goal – 80% by 2018

Screening Trends • Under Utilization – Lack of insurance – Lower socioeconomic class – Education, Racial, Ethnic factors – Lack of PCP knowledge of guidelines and recommendations

Screening Trends (Continued) • Over Utilization – Screening patients over 80 years of age – Screening patients with severe comorbidities and limited life expectancy – Too frequent surveillance exams

Screening Trends (Continued) • Lifetime Risk (average risk) – 5% or 1 in 20 • Risk increases with family history of CRC/polyps – 10% to 20% • Other diseases and genetics – 10% to 95%

Risk of Colorectal Cancer (CRC) 5% General population Family history of 15%–20% colorectal neoplasia Inflammatory 15%–40% bowel disease 70%–80% HNPCC mutation >95% FAP 0 20 40 60 80 100 Lifetime risk (%)

Risk Factors Sporadic (65 %– 85%) Familial (10 %– 30%) Rare CRC Hereditary syndromes nonpolyposis colorectal (<0.1%) cancer (HNPCC) (5%) Familial adenomatous polyposis (FAP) (1%) Adapted from Burt RW et al. Prevention and Early Detection of CRC , 1996

Environmental Factors Associated with Increased and Decreased Risk of CRC Increased risk: Decreased risk: • Sedentary lifestyle • Consumption of fruits • Red meat in diet and vegetables • Obesity • Chemoprevention – • Smoking Calcium, folate, • Alcohol NSAIDS, ASA • Bacterial Biofilm

Colonoscopy Preps • Multiple • No pill preps • 4 liter and 2 liter preps • Split dose preps preferred

Over the past two decades Colorectal Cancer incidence and mortality has declined secondary to screening and early detection

Screen It Like You Mean It! • Screening saves lives • March is Colorectal Cancer Awareness Month • March 6 th is “Dress in Blue Day” • Spread the Word

Take Home Message • Incidence and death rates are declining • Eat right, exercise and avoid smoking • Screening saves lives • Most people get screened because their doctor told them to • Advances in treatment have led to improved survival • Advances in molecular profiling of cancers has led to personalized treatments

Another Reason to Have a Colonoscopy!