Transcript Slide 1

Colorectal Cancer Awareness in TN:
Risk Factors, Screening, Outreach
Keith D. Gray, M.D.
Assistant Professor of Surgery
Division of Surgical Oncology
The University of Tennessee Medical Center
CRC Facts
• 2008, 150K new cases and
50K deaths
• Lifetime risk of developing
colon cancer is 1 in 19
• 2nd leading cause of cancer
death among men and
women combined
• Death rate has been
decreasing over last 20
years, due to earlier
screening and better imaging
and treatment
Uncontrollable Risk Factors for
Developing Colorectal Cancer
• Age – 50 or older
• Family history of cancer of the colon or rectum
• Personal history of cancer of the colon, rectum,
ovary, endometrium or breast
• History of polyps of the colon
• Inflammatory bowel disease – ulcerative colitis or
Crohn’s disease
• Hereditary conditions
Controllable Risk Factors for
Developing Colorectal Cancer
• Obesity
• Physical inactivity
• Cigarette smoking
• Diet high in red or processed meat
• Heavy alcohol consumption
• Inadequate screening
•50-75% of cancers can be prevented by
lifestyle and dietary changes
CRC Burden in TN
TN = 52.3 (50.5, 54.2)
CRC Burden in TN
TN = 18.9 (17.8 -20)
Disparate CRC Outcomes
TN Risk Profile (2007)
• 13.5% (12.4%) below poverty – 15th
– Median per capita income = $13,282 in Central Appalachia,
lowest in the nation
• 24.1% (19.6%) < HS education – 7th
– 9.6% < 9th grade education (5th)
• 31.5% sedentary – 2nd
• 67.4% obese (BMI>25) – 4th
– High fat diets, physical inactivity
• 26.4% (16.3% - 32.5%) consume 5+ fruits/veges per day
• 24.3% currently smoke (5th)
TN Screening Report (2006)
• FOBT (>50)
– Last 2yrs: 25.6% (12.1 – 26.6%)
– Last 1yr: 15.7% (6.6 – 22.5%)
• Colonoscopy (>50)
– Ever: 56.2% (49.8 – 69.2%)
– <10yrs: 53.4% (46.6 – 66.4%)
– <5yrs: 49.9% (40.6 – 60.9%)
Establishment of CRC Screening
Guidelines
• ACS established CRC early detection guidelines in 1980
– 1997 – 1st update
– 2000 – 2nd update
• 1995-2000 Medline data
• Colorectal Cancer Advisory Committee
– 2003 - technology update
• Immunochemical FOBT (iFOBT) added as acceptable screening method
– 2006 - ACS and US Multi-Society Task Force issued a joint guideline
update for postpolypectomy and postcolorectal cancer resection
surveillance
• Follow-up intervals were often too short, increasing cost and potential patient
risk
– 2008 - Virtual Colonoscopy accepted as screening tool
Eddy D. CA Cancer J Clin 1980;30:193-240
Smith RA, et al. CA Cancer J Clin 2001:51:38-75
Mysliwiec PA, et al. Ann Intern Med 2004;141:264-271
Ko CW, et al. Gastrointest Endosc 2007;65:648-56
CRC Screening Methods
•
Fecal Occult Blood Test (FOBT)
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2 samples from each of 3 consecutive stool samples at home
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Avoid NSAIDS (7d), Vit C sources (3d), red meat (3d)
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Stool sample from DRE is inadequate!
•
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Low sensitivity (< 5%) as bleeding often intermittent and blood may not be
present in entire stool
Sole method of FOBT in up to 33% of PCP’s Nadel MR, et al. Ann Intern Med 2005;142:8694
–
Advantages
•
•
Cheap, private, no bowel prep
Clinical trials show 33% reduction in CRC mortality with proper use; these
results may not be realized in community settings because common use
of in-office tests and inappropriate follow-up of positive results
Nadel MR, et al. Ann Intern Med 2005;142:86-94
Smith RA, et al. CA Cancer J Clin 2001:51:38-75
Fecal Immunochemical Test
(FIT)
• Mono/polyclonal antibody detect intact globin protein portion of
human Hgb
– Specific for globin in LGI tract since globin won’t survive passage
through UGI tract
• No cross-reactivity with non-human Hgb or foods
• Smith A, et al (Cancer 2006) demonstrated sensitivity of 87% for
cancer and 43% for high risk adenomas in 2000+ patients
– Similar findings by InSure
• ACS statement: “in comparison with guaiac-based test for the
detection of occult blood, immunochemical test are more
patient-friendly, and are likely to be equal or better in sensitivity
and specificity.”
• Less commonly used
Levin B, et al. CA Cancer J Clin 2003;53:44-55
Smith A, et al. Cancer 2007;107:2152-2159
Endoscopy v. DCBE
• DCBE
– Instilling of barium and air to define colonic mucosa
– Less sensitive for subcentimeter lesions
– Often used with near-obstructing lesions
• Flexible Sigmoidoscopy
– Veterans Affairs Cooperative Study Group; 3121 patients
• Exam to splenic flexure detects majority of CRC’s but misses >50% of
proximal colon cancers Lieberman DA, NEJM 2000;20-162-168
– No need for sedation
– Best is combined with FOBT/FIT
• Colonoscopy
– Gold standard when cecum is reached
– Risk of perforation
– All Roads Lead to Colonoscopy!
ACS recommendations for CRC screening in
average-risk, asymptomatic people
Test
Frequency
( starting at age 50)
FOBT or FIT*
Annually
Stool DNA Test
Interval uncertain
Flex Sig*
Q 5 years
FOBT + Flex Sig*
Annual FOBT/FIT and
Flex Sig q 5 years
DCBE*
q 5 years
CT colonography
q 5 years
Colonoscopy
q 10 years
*All positive test should be followed up with colonoscopy.
alternative.
DCBE +/- Flex sig is a suitable
Individuals at “increased risk” of
developing CRC
• 2x average risk in this population; accounts for
15-20% of colon cancers
• Who’s at increased risk?
– h/o of AP/CRC in any 1st degree relative <60, or
>2 1st degree relatives with h/o AP/CRC of any age (w/o
hereditary syndrome)
• Colonoscopy at age 40 or 10 years before youngest case
• Repeat q 5-10 years, pending findings
– h/o polypectomy and/or resection of CRC
Postpolypectomy Surveillance Colonoscopy
Recommendations - 2006 Update
•
Small rectal hyperplastic polyps
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–
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nl colonoscopy, 10-year f/u
Hyperplastic polyposis syndrome should be screened more frequently
<2 small tubular adenomas with LGD
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5-10 years
3-10 adenomas, any >1cm, any with villous features or HGD
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3 year f/u if completely removed
Subsequent 5 year f/u if nl or above
> 10 adenomas
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f/u <3 years and consider familial syndrome
Piecemeal removal of sessile adenomas
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Repeat endoscopy in 2-6 months
After complete removal confirmed, subsequent surveillance based on
judgment
Winawer SJ, et al. CA Cancer J Clin 2006;56:143-159
Postcancer Resection Surveillance Colonoscopy
Recommendations - 2006 Update
•
High quality perioperative colonoscopy
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Consider CT colonography or DCBE for obstructing lesions
•
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Consider colonoscopy 3-6 mo post-op to clear synchronous
lesions
Colonoscopy within 1 year of perioperative
clearance
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–
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3-year f/u if this exam nl, then 5 year f/u if 3-year exam nl
For abnormal findings, stratify by risk
Consider q3-6 month proctoscopy after LAR x 2-3
years
–
Independent of surveillance colonoscopies for
metachronous disease
ACS recommendations for CRC screening
among people at “high risk”
Risk Category
Age to Begin
Recommendation
Comment
FH of FAP
Puberty
Early endoscopic
surveillance
and genetic
counseling/testing
Colectomy for
(+) genetic
testing
FH of HNPCC
21
Colonoscopy &
genetic
counseling/testing
If genetics (+)
or unavailable,
colonoscopy;
q1-2 years
until 40, then
annually
Inflammatory
Bowel Disease
8 years after
pancolitis or 1215 years after
left colitis
Colonoscopy with
biopsies of
dysplasia q1-2
years
Prophylactic
colectomy for
persistent
dysplasia
Adapted from Smith RA, et al. CA Cancer J Clin 2001:51:38-75
Emerging Technology
•
CT (“virtual”) colonography
– May be used in cases of failed or incomplete colonoscopy or in cases of
obstructing cancer
– Accepted as a screening tool
– Medicare will not pay for it
– High rate of false positives
– Need colonoscopy if positive
•
Stool DNA mutation testing
– Uses multicomponent DNA-based stool assay targeting point mutations at hot
spots on colon oncogenes (i.e. K-ras, APC, and p53 genes)
– Single stool sample needed, DNA shed continuously
– Multicenter study by Colorectal Cancer Study Group in average risk patients:
• Fecal DNA panel v. FOBT
• Fecal DNA more sensitive in detecting adenomas and cancer, equal
specificity
– Not yet accepted as a screening tool
• Large stool collection kits; requires entire stool sample
• Expensive >$400/test; additional markers increases cost
Outreach Efforts (CRC)
• 2006 = 5, 2007 = 9; 2008 = 5; 2009 = 6
– CRC and skin outreach are least developed
programs
• Colonoscopies:
– 2006 = 4945; 2008 = 5756
• 225 new CRC diagnosed 2006 – 2008
– No change in stage distribution
Key Points
• Colon cancer is common in the U.S.
• Prevention and early detection save lives.
• Everyone over 50 should undergo colon
cancer screening as part of annual exam.
• Education improves screening.
Improving CRC Outcomes
• Be familiar with CRC screening guidelines
• Meet people where they are with outreach
• Target underserved areas
• Continue to advocate for CRC screening
legislation
• Emphasize prevention/healthy habits
• Use patient educators, “testimonials”