Transcript 28_Darwin_Colon Pancreas Cancer_USE_less MB

Screening and Prevention of
Cancers of the Colon and
Pancreas
Peter E. Darwin, MD, FACP, FASGE
Professor
Department of Medicine
U.S. Mortality From
Colorectal Cancer
Adenoma-Carcinoma
Sequence With Molecular
Correlate
Colon Polyp
Colon Cancer
Who gets colon polyps?
• Anyone can get colon polyps, but certain
people are more likely to get them than
others. You may have a greater chance if:
– 50 years of age or older
– Had polyps before
– Someone in your family has had polyps or
colon cancer
– Uterine or ovarian cancer
Who gets colon polyps?
• You may also be more likely to get colon
polyps if you:
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–
–
–
Eat a lot of fatty foods
Smoke
Drink alcohol
Don’t exercise
What are the symptoms of colon
polyps?
• Most people do not have symptoms
• Some symptoms may include:
– Bleeding from the anus. You might notice
blood on your underwear or toilet paper
– Constipation or diarrhea
– Blood in the stool (pitch black or red streaks)
(familial adenomatous polyposis syndrome)
Colorectal Cancer Screening
Average risk
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Fecal occult blood testing (FOBT)
Flexible sigmoidoscopy
Barium enema
Colonoscopy
CT colography
Colorectal Cancer Screening:
Double-Contrast Barium Enema
Colon Cancer
CT Colography/Virtual Colonoscopy
Solitary 16-mm
Pedunculated Cecal
Polyp in a 55-Year-Old
Man at Average Risk for
Colorectal Neoplasia
Pickhardt et al. N Engl J Med
2003;349:2191-2200
Endoscopic Screening Rates are Low
CDC Behavioral Risk Factor Surveillance System
Percentage of eligible adults undergoing
screening lower endoscopy within 5 years
50
38.7
per cent
40
29.9
33.3
30
20
10
0
1997
1999
MMWR Morb Mortal Wkly Rep 2003 Mar 14;52(10):193-6.
2001
Racial Disparities in Colon Cancer
Colorectal cancer incidence per 100,000 in SC
Lloyd et al. Cancer 2007;109(2):378-385
Racial Disparities in Colon Cancer
Colorectal cancer mortality per 100,000 in SC
Lloyd et al. Cancer 2007;109(2):378-385
Colon Cancer Screening: Outcomes
• FOBT Testing
– 3 prospective randomized clinical trials have
demonstrated significant reductions in colon
cancer mortality ranging from 15-33%
• Flexible Sigmoidoscopy
– 2 case-controlled studies associated with a 6080% reduction in colon cancer mortality for
lesions within reach of the sigmoidoscope
Levin et al. Gastroenterology 2008;134:1570.
Colon Cancer Screening: Outcomes
• Colonoscopy
– Case-control study of 32,702 VA patients
– 50% reduction in colon cancer mortality
associated with colonoscopy in symptomatic
patients
Muller et al, Ann Intern Med 1995;123:904
How can you prevent colon polyps?
• Eat more fruits and vegetables and less fatty
foods
• Don’t smoke
• Avoid alcohol
• Exercise most days of the week
• Lose weight if you are overweight
• Calcium may lower your risk
– Milk, cheese, yogurt, broccoli
Colorectal Cancer Screening
 Fecal occult blood test (FOBT) every year, or
 Flexible sigmoidoscopy every 5 years, or
 A fecal occult blood test every year plus flexible
sigmoidoscopy every 5 years (recommended by the
American Cancer Society), or
 Double-contrast barium enema every 5 to 10 years, or
 Colonoscopy every 10 years (recommended by the
American College of Gastroenterology).
Pancreas Cancer Background
• More than 32,000 cases per year in the US
and almost all are expected to die
• Second only to colon cancer in GI related
cancer mortality
• 20% have resectable disease at presentation
• Median survival is 8 to 12 months for
locally advanced and 3 to 6 months for
metastatic disease
Risk Factors for Pancreas Cancer
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Chronic pancreatitis/inflammation
Diabetes mellitus
Smoking
Family history
Obesity
History
• Dark urine, pale stools, and yellow skin and
eyes from jaundice
• Pain in the upper part of your belly
• Pain in the middle part of your back that
doesn’t go away when you shift your
position
• Nausea and vomiting
• Stools that float in the toilet
History
• Presentation depends on location
• Weight loss – anorexia, diarrhea, early
satiety
• Jaundice – scleral icterus, acholic stools,
dark urine, pruritus
• New onset diabetes, blood clots, depression,
pancreatitis
Staging
• Staging is a careful attempt to find out the
following:
– The size of the tumor in the pancreas
– Whether the tumor has invaded nearby tissues
– Whether the cancer has spread, and if so, to
what parts of the body
M1
TNM Classification
N1
T4
T1
T2
T3
CT scan
• An x-ray machine linked to a computer
takes a series of detailed pictures of the
pancreas and surrounding organs
• Used to evaluate ductal dilation, mass lesion
within the pancreas and spread
MRI
• A large machine uses a strong magnet and a
computer to make an image of your
pancreas and organs
• Requires:
– Compliant patient
– No metal
Endoscopic Ultrasound
• A thin, lighted tube (endoscope) is passed
into the small intestine
• Sound waves make a pattern of echoes that
create a picture of the pancreas
• Needle biopsy can remove a sample of
tissue
UM-130
UC-30P
7.5 / 12 MHz.
7.5 MHz.
EUS-FNA – Pancreatic Mass
EUS-FNA: Pancreatic
Adenocarcinoma
ERCP
• A thin, lighted tube (endoscope) is passed
into the small intestine
• A smaller tube is then inserted into the bile
and pancreatic duct and dye is injected
• Therapy can be performed such as brush
cytology or stent placement
ERCP for Diagnosis
Treatment
• Surgical removal if possible (resection of
the pancreatic head is termed a Whipple
procedure)
• If locally advanced, radiation and chemo
therapy
• If spread (metastasized), chemotherapy
Prevention
• If you smoke, stop smoking
• Eat a diet high in fruits, vegetables and
whole grains
• Exercise regularly
• Possible screening in high risk families
(more than 2 first degree relatives)