Transcript Colon Cancer Screening

Kill the Cancer
Do Screening now!
Daniel M. Kruss, M.D.
D. M. Kruss MD
Colon Cancer
Screening
Daniel M. Kruss, M.D.
D. M. Kruss MD
Colon Cancer Screening
•130,200 new cases expected this year
•93% are over age 50
•20% diagnosed at emergency surgery
•4th most common cancer
• 2nd cause of cancer death
D. M. Kruss MD
Colon Cancer Screening
• 56,300 deaths expected this year
• 6% Lifetime Risk
• 62% Five-year survival
53% in African Americans
D. M. Kruss MD
Colon Cancer Screening
Because of these large
numbers, even a small
improvement in survival
will save many lives!
D. M. Kruss MD
Colon Cancer Screening
What is cancer?
•abnormal growth of abnormal cells
•growth out of control
cells multiply too quickly
cells form masses called tumors
tumors invade other organs
•malignant tumors spread distantly
(metastasize)
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
Symptoms occur only late in the
course of the disease
Survival is related to the amount
of spread at the time of surgery
Goal: Detect the cancer,
or pre-cancerous polyp
before it spreads
D. M. Kruss MD
Colon Cancer Screening
What do we know
about colon cancer?
D. M. Kruss MD
Colon Cancer Screening
The cause of colon cancer is partly
genetic. It is more common in
certain settings:
1. Family history of colon cancer
2. Familial Polyposis syndromes
3. Ulcerative Colitis and Crohn's
Disease patients
4. Cancer of breast, ovarian, uterus
D. M. Kruss MD
Colon Cancer Screening
Familial Risk
General Population
One 1st-degree Relative
Two 1st-degree Relative
1st-degree Relative <50 Yrs
One 2nd- or 3rd-degree Relative
One 1st-degree Relative & Polyp
6%
2 to 3X
3 to 6X
3 to 6X
1.5X
2X
D. M. Kruss MD
Colon Cancer Screening
colon cancer may also have
environmental triggers
such as diet, geography, ???
D. M. Kruss MD
Colon Cancer Screening
Over 90% of colorectal
carcinomas develop from
an adenomatous polyp.
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
Epidemiologic studies suggest:
• 1 of every 5 persons is at risk to
develop adenomatous polyps
• 5% of these may progress to
colorectal cancer
• Screening for polyps at a stage
when they can be colonoscopically
removed is shown to decrease
colorectal cancer mortality
D. M. Kruss MD
Colon Cancer Screening
This guides our present strategy:
• find polyps
• remove polyps
• prevent 90% of colon cancers
The other 10% awaits new genetic tests
for blood and/or stool
D. M. Kruss MD
Colon Cancer Screening
How can we detect
Colon cancer?
1. Fecal Occult Blood
D. M. Kruss MD
Colon Cancer Screening
What is fecal Occult Blood?
• OB is blood mixed in stool which
you cannot see
• It may come from sources
anywhere along the gut from
mouth to rectum
• It may be an early warning signal
that a polyp or tumor is present
D. M. Kruss MD
Colon Cancer Screening
Fecal Occult Blood Testing
Three Prospective Randomized Trials
Site
No. of
Subjects
Duration
(Years)
Mortality
Reduction
Minn.
46,551
13
33%
U.K.
152,650
7.8
15%
Denmark
140,000
10
18%
D. M. Kruss MD
Colon Cancer Screening
A polyp or a cancer in the colon
may bleed, slowly, and cause
tiny amounts of OB in the stool.
Large studies show us that only
1/3 of polyps and 1/2 of cancers
bleed, however!!
Depending on the method used,
between 1.5-8% of 'healthy'
persons will have OB in the stool!!
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
If we make our OB tests too
sensitive, we may find a few
more cancers, but will detect
a lot more false positives.
There is no harm in finding a
false positive, except in the
obligation (cost?) of examining
each one to see if there is a
cancer.
D. M. Kruss MD
Colon Cancer Screening
If we make our OB tests less
sensitive, we will have fewer false
positives, but will miss a few real
cancers.
We can improve OB specificity by
avoiding red meats, vitamin C,
aspirin and arthritis medicines, and
many fresh fruits and vegetables for
three days before and during three
days of stool collection.
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
There is a trade-off between
compliance and false-positives.
Screening does not change the
incidence of new colon cancers, but
affects the stage at which they are
discovered.
The mortality was reduced from 8.33
to 5.88 per 1000 in the Minnesota
study of stool OB.
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
Fecal Occult blood testing
performed as part of an in-office
digital rectal exam failed to detect
potentially cancerous colon
growths 95 percent of the time!
D. M. Kruss MD
Colon Cancer Screening
It must be clearly understood that
the OB test is only one of several
methods of screening and that
it is, at best, 50% predictive.
Then why do it?
D. M. Kruss MD
Colon Cancer Screening
Early detection is still
the only method
to prevent deaths from
colon cancer
D. M. Kruss MD
Colon Cancer Screening
How can we detect
Colon cancer?
2. Sigmoidoscopy
D. M. Kruss MD
Colon Cancer Screening
The American Cancer Society
previously recommended:
Sigmoidoscopy
this was based on data suggesting
that half of the cancers will be
seen in this area, and any
patients who have polyps seen,
will receive full colonoscopy
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
How can we detect
Colon cancer?
3. Colonoscopy
D. M. Kruss MD
Colon Cancer Screening
The case for screening colonoscopy*
Involves greater risk and inconvenience
however
•few significant lesions are missed
•entire colon is examined
•screening interval of 10 years
(few polyps become cancer in less time)
*or virtual colonoscopy when available or
air contrast barium enema and sigmoidoscopy
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
If you are positive on OB screening,
what is needed?
colonoscopy (full colon exam)
if positive findings, act on them
if negative, consider searching
the remainder of the GI tract
D. M. Kruss MD
Colon Cancer Screening
If a polyp is found,
what is needed?
1. Annual colonoscopy until
the colon is 'clear'
2. then re-examine every 3-5
years
D. M. Kruss MD
Colon Cancer Screening
What are the risks of
colonoscopy?
bleeding and/or perforation
occur in less than 1/500
patients
When properly indicated, the
procedure is very safe and
very efficient
D. M. Kruss MD
Colon Cancer Screening
What should I do now?
D. M. Kruss MD
Colon Cancer Screening
If you are over 55:
screening for OB every year,
colonoscopy (or sigmoidoscopy)
If you have polyps, tell your blood
relatives to have screening and
be sure you have regular tests
If relatives had colon polyps or colon
cancer, get your colonoscopy now!
D. M. Kruss MD
Colon Cancer Screening
Familial Risk Screening
Any Family History
Same as Average Risk Screening,
begin at age 55
Strong Family History -Definition:
2 Affected First-degree Relatives
or
1 First-degree Relative Diagnosed <60
Colonoscopy every 5 years,
Start at age 40 Years
D. M. Kruss MD
Colon Cancer Screening
Screening is optional...
Without screening a 50 year old
at average risk, has 530/10,000
chance of invasive colon cancer
and 250/10,000 risk of dying
from it.
Screening between ages 50-75
reduces this risk by 10-75%
D. M. Kruss MD
Colon Cancer Screening
Fewer than half of patients
diagnosed with colorectal cancer
had received a screening
procedure at least six months
prior to their diagnosis
D. M. Kruss MD
Colon Cancer Screening
94 percent of colorectal cancer
patients had either not undergone
a colonoscopy at all, or not until
having the procedure that led to
their diagnosis
D. M. Kruss MD
Colon Cancer Screening
The prognosis of colon cancer
is directly related to the
extent of disease when first
diagnosed!!
D. M. Kruss MD
Colon Cancer Screening
There are no
signs or symptoms
of colon cancer until
late in the course!
D. M. Kruss MD
Colon Cancer Screening
Late signs include:
•
•
•
•
•
change in bowel habit
rectal bleeding (red or occult)
anemia (weakness, fatigue)
cramping abdominal pain or
pelvic/rectal pain or straining
D. M. Kruss MD
Colon Cancer Screening
Good News!
Now Medicare
covers
Screening colonoscopy!
D. M. Kruss MD
Colon Cancer Screening
Medicare pays for:
Fecal Occult Blood Tests - every year
Flexible Sigmoidoscopy - every 4 years*
Screening Colonoscopy
Every 10 years for average risk*
Every 2 years for high risk
*if no exam of the colon in the past 4 years
D. M. Kruss MD
Colon Cancer Screening
MEDICARE PAYS FOR COLONOSCOPY
Every 2 years for high risk:
close relative with colon ca
close relative with adenomatous polyps
familial adenomatous polyposis
prior polyps or colorectal cancer
Inflammatory bowel disease (UC, Crohn’s)
Every 10 years for average risk*
*if no exam of the colon in the past 4 years
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
Let’s review
our strategy . . .
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
What else can we do?
D. M. Kruss MD
Colon Cancer Screening
Lifestyle modifications may be useful:
• Low-dose aspirin or NSAID’s daily
• Reduce animal fat
• Increase fiber, calcium, magnesium
? (fruits, vegetables) no proof!
D. M. Kruss MD
Colon Cancer Screening
Lifestyle modifications,
and diet,
What we know. . .
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
How can we detect
Colon cancer?
4. Future Methods
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
Inherited Syndrome Screening
FAP
Sigmoidoscopy
Every one to two years, starting age 10 to
12 years
HNPCC
Colonoscopy
Every 1 to 2 years, starting age 25 years
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
REFERRAL TO GASTROENTEROLOGIST
Positive screening tests
Questions about appropriate screening
When colonoscopy is needed
Diagnosis and/or management of the known
inherited syndromes of colon cancer
D. M. Kruss MD
Colon Cancer Screening
Your survival ---is up to you!!
D. M. Kruss MD
Colon Cancer Screening
If you won’t do it for
yourself. . .
Do it for the ones who
love you!
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
Does a test need to be
‘cost effective’ to be
recommended?
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD
Colon Cancer Screening
D. M. Kruss MD