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

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

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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

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Feburary 24, 2015

  • Dr. Keith A. Wied

Southeast Texas Gastroenterology

Who, What, When, Where, Why and How of Colorectal Cancer Screening

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Colorectal Cancer

  • Colorectal cancer is the 3rd 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

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Who?

  • Who needs

screening

  • You!
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What?

  • A screening

exam

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Definitions

  • Screening
  • Surveillance
  • Diagnostic
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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
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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

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Survelliance

  • A process of following patients with:

– Known history of polyps – History of Colorectal Cancer (CRC) – High risk factors

  • Family History
  • Other associated diseases
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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

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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)

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Where?

  • Accredited facility
  • Board Certified
  • High Volume
  • High Quality Colonoscopy

– Cecal Intubation – Withdrawal time of >6 minutes – APD rate

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Southeast Texas Gastroenterology Associates

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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
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How?

  • Best screening test is any valid test the

patient has access to and is willing to take

  • NOT screening is NOT an option!
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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
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Screening Options

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

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

  • 2 Histologic Types

– Adenomas (2/3)

  • Tubular
  • Tubulovillous
  • Villous

– Hyperplastic (1/3)

  • Serrated Adenomas
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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)
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Adenoma – Carcinoma Sequence

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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

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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

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Effects of Screening

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

  • Under Utilization

– Lack of insurance – Lower socioeconomic class – Education, Racial, Ethnic factors – Lack of PCP knowledge of guidelines and recommendations

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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

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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%

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Risk of Colorectal Cancer (CRC)

20 40 60 80 100

General population Family history of colorectal neoplasia Inflammatory bowel disease HNPCC mutation FAP

5% 15%–20% 15%–40% 70%–80% >95% Lifetime risk (%)

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Risk Factors

Adapted from Burt RW et al. Prevention and Early Detection of CRC, 1996

Sporadic (65%–85%) Familial (10%–30%) Hereditary nonpolyposis colorectal cancer (HNPCC) (5%) Familial adenomatous polyposis (FAP) (1%) Rare CRC syndromes (<0.1%)

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Environmental Factors Associated with Increased and Decreased Risk of CRC

Increased risk:

  • Sedentary lifestyle
  • Red meat in diet
  • Obesity
  • Smoking
  • Alcohol
  • Bacterial Biofilm

Decreased risk:

  • Consumption of fruits

and vegetables

  • Chemoprevention –

Calcium, folate, NSAIDS, ASA

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Colonoscopy Preps

  • Multiple
  • No pill preps
  • 4 liter and 2 liter preps
  • Split dose preps preferred
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Over the past two decades Colorectal Cancer incidence and mortality has declined secondary to screening and early detection

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Screen It Like You Mean It!

  • Screening saves lives
  • March is Colorectal Cancer Awareness

Month

  • March 6th is “Dress in Blue Day”
  • Spread the Word
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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

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Another Reason to Have a Colonoscopy!