Transcript General Medicine Conference - Texas Tech University Health

General Medicine Subspecialty
Conference
Colon Cancer Screening
Selim Krim, MD
Assistant Professor
Texas Tech University Health Sciences Center
U.S. Burden of Colorectal Cancer
153,760 new cases diagnosed in the
United States in 2007
52,180 deaths in 2007
Second leading cause of cancer deaths in
the United States
About 6% of Americans are expected to
develop the disease within their lifetime
Why is screening important?
Adenoma to Carcinoma Pathway
Regular screening for and removal of polyps can reduce a
person's risk of developing colorectal cancer by up to 90 percent.
Early detection of cancers that are already present in the colon
increases the chances of successful treatment and decreases the
chance of dying as a result of the cancer.
How and when should physicians start screening?
Colon Cancer Screening
Screening programs should begin by classifying the individual
patient’s level of risk based on personal, family, and medical history,
which will determine the appropriate approach to screening in that
person.
Men and women at average risk should be offered screening for
colorectal cancer and adenomatous polyps beginning at age 50
years.
Case 1
A 50-year-old man comes for an annual health maintenance visit. He feels
well, and medical history is unremarkable. There is no family history of
colorectal cancer. Physical examination and routine laboratory studies are
normal. Which of the following is the most appropriate recommendation for
colorectal cancer screening for this patient?
Fecal occult blood testing now; repeat every 2 to 3 years
Flexible sigmoidoscopy now; repeat every 2 to 3 years
Barium enema examination now; repeat every 2 to 3 years
Colonoscopy now; repeat every 10 years
Virtual colonoscopy (CT colonography) now; repeat every 10 years
ACS/USPSTF Recommendations
Men and women at average risk should be offered screening with
one of the following options beginning at age 50 years;
Offer yearly screening with fecal occult blood test (FOBT) using a
guaiac-based test with dietary restriction or an immunochemical
test without dietary restriction.
Offer flexible sigmoidoscopy every 5 years.
Offer screening with FOBT every year combined with flexible
sigmoidoscopy every 5 years. When both tests are performed, the
FOBT should be done first.
Offer colonoscopy every 10 years.
Case 2
A 50-year-old man comes for a general physical examination. He feels well
and is asymptomatic. Medical history is significant only for hypertension
treated with atenolol. He takes no other medications or over-the-counter
drugs. Family history is unremarkable. Physical examination is normal.
Results of routine laboratory studies are also normal, including a
hemoglobin level of 14.8 g/dL (148 g/L). One of three stool sample
submitted for fecal occult blood testing is positive. Which of the following is
the most appropriate next step in evaluating this patient?
Repeat fecal occult blood test
Flexible sigmoidoscopy
Repeat fecal occult blood test and flexible sigmoidoscopy
Double-contrast barium enema examination
Colonoscopy
ACS/USPSTF Recommendations
If the result of a screening test is abnormal, physicians should
recommend a complete structural examination of the colon and
rectum by colonoscopy (or flexible sigmoidoscopy and double
contrast barium enema if colonoscopy is not available).
Offer yearly screening with fecal occult blood test (FOBT) using a
guaiac-based test with dietary restriction or an immunochemical
test without dietary restriction. Two samples from each of 3
consecutive stools should be examined without rehydration.
Patients with a positive test on any specimen should be followed
up with colonoscopy.
Case 3
A 32-year-old man comes for an annual health maintenance visit. His
mother was diagnosed with colorectal cancer at 65 years of age. The
patient reports no rectal bleeding or other symptoms. Medical history is
noncontributory except for hypercholesterolemia. Physical examination is
normal. When should this patient first undergo colorectal cancer screening?
Now, then every 5 years
At age 40 years, then every 10 years
At age 40 years, then every 5 years
At age 45 years
At age 50 years, then every 5 years
ACS/AGA Recommendations
People with a first-degree relative with colon cancer or
adenomatous polyp diagnosed at age >60 years or 2 seconddegree relatives with colorectal cancer should be advised to be
screened as average risk persons, but beginning at age 40 years.
People with 1 second-degree relative (grandparent, aunt, or uncle)
or third-degree relative (great-grandparent or cousin) with
colorectal cancer should be advised to be screened as average
risk persons.
Case 4
A 32-year-old man comes for an annual health maintenance visit. His
mother was diagnosed with colorectal cancer at 55 years of age. The
patient reports no rectal bleeding or other symptoms. Medical history is
noncontributory except for hypercholesterolemia. Physical examination is
normal. When should this patient first undergo colorectal cancer screening?
Now, then every 10 years
At age 40 years, then every 5 years
At age 40 years, then every 10 years
At age 45 years, then every 5 years
At age 50 years, then every 5 years
ACS/AGA Recommendations
People with a first-degree relative (parent, sibling, or child) with
colon cancer or adenomatous polyps diagnosed at age <60 years
or 2 first-degree relatives diagnosed with colorectal cancer at any
age should be advised to have screening colonoscopy starting at
age 40 years or 10 years younger than the earliest diagnosis in
their family, whichever comes first, and repeated every 5 years.
Case 5
A 65-year-old woman underwent initial colonoscopy 1 month ago for
colorectal cancer screening. A 6-mm tubular adenoma of the sigmoid colon
was found and removed during the examination. The patient has no family
history of colorectal cancer. Which of the following is the most appropriate
recommendation for colorectal cancer surveillance for this patient?
Repeat colonoscopy in 1 year
Repeat colonoscopy in 3 years
Repeat colonoscopy in 5 years
Flexible sigmoidoscopy in 5 years
Virtual colonoscopy (CT colonography) in 5 years
ACS/AGA Recommendations
Patients who have had 1 or more adenomatous polyps removed at
colonoscopy should be managed according to the findings on that
colonoscopy.
Patients who have had numerous adenomas, a malignant
adenoma (with invasive cancer), a large sessile adenoma, or an
incomplete colonoscopy should have a short interval follow-up
colonoscopy based on clinical judgment. Patients who have
advanced or multiple adenomas (>3) should have their first followup colonoscopy in 3 years. Patients who have 1 or 2 small (<1 cm)
tubular adenomas should have their first follow-up colonoscopy at
5 years.
Case 6
A 45-year-old woman is undergoing evaluation to determine the cause of
iron deficiency anemia. The patient is otherwise healthy, and family history
is unremarkable. Colonoscopy shows a 2-cm villous adenoma in the
sigmoid colon; the adenoma is removed during the procedure. In addition to
counseling regarding screening of family members, which of the following is
most appropriate at this time?
Repeat colonoscopy in 6 months
Repeat colonoscopy in 3 years
Repeat colonoscopy in 10 years
Repeat colonoscopy in 5 years
Annual fecal occult blood testing
Referral for left hemicolectomy
ACS Recommendations
Patients with 3-10 adenomas, any adenoma >1 cm, any adenoma
with villous features, or high-grade dysplasia should have their
next follow-up colonoscopy within 3 years.
Case 7
A 35-year-old man with a 10-year history of ulcerative colitis involving the
entire colon comes for a follow-up office visit. A small bowel follow-through
radiographic series obtained at the time of diagnosis was normal. The
patient is doing well on mesalamine maintenance therapy. He has only
occasional diarrhea and bleeding and has rarely required corticosteroids. A
colonoscopic examination with biopsies 1 month ago showed changes of
chronic ulcerative colitis but no signs of dysplasia. Which of the following
surveillance options is most appropriate for this patient?
Repeat colonoscopy with biopsies starting at age 50; then repeat
examination every 5 years
Repeat colonoscopy with biopsies now; then repeat examination every 5
years
Repeat colonoscopy with biopsies now; then repeat examination every 1 to
2 years
Colonoscopy with biopsies only if the patient has symptoms refractory to
medical therapy
Barium enema examination or virtual colonoscopy (CT colonography) now;
repeat studies every 1 to 2 years
ACS/USPSTF Recommendations
In patients with inflammatory bowel disease ( UC or Crohn’s),
cancer risk begins to be significant 8 years after the onset of
pancolitis, or 12-15 years after the onset of left-sided colitis
Colonoscopy with biopsies for dysplasia. Every 1-2 years. These
patients are best referred to a center with experience in the
surveillance and management of inflammatory bowel disease
Case 8
A 24 year old woman comes for a general physical examination.
She feels well and is asymptomatic. Medical history is significant
only for tonsillectomy at the age of 12. She takes no medications or
over-the-counter drugs. 10 years ago, her father was diagnosed with
familial adenomatous polyposis. Physical examination is normal.
Results of routine laboratory studies are also normal. Which of the
following is the most appropriate next step in managing this patient?
Colonoscopy every year starting at age 50
Colonoscopy every year starting at age 20-25
Colonoscopy every 2-3 years starting at age 20-25
Yearly stools for occult blood and flexible sigmoidoscopy (beginning
at puberty)
Refer for colectomy
ACS/USPSTF Recommendations
People who have a genetic diagnosis of familial adenomatous polyposis
(FAP), or are at risk of having FAP but genetic testing has not been
performed or is not feasible, should have annual sigmoidoscopy,
beginning at age 10-12 years, to determine if they are expressing the
genetic abnormality. Genetic testing should be considered in patients with
FAP who have relatives at risk. Genetic counseling should guide genetic
testing and considerations of colectomy.
Case 9
32-year-old man comes for an annual health maintenance visit.
Family history is positive for hereditary nonpolyposis colorectal
cancer. The patient reports no rectal bleeding or other symptoms.
Medical history is noncontributory except for hypercholesterolemia.
Physical examination is normal. When should this patient first
undergo colorectal cancer screening?
Now
At age 35
At age 40 years
At age 45 years
At age 50 years
ACS/USPSTF Recommendations
People with a genetic or clinical diagnosis of hereditary
nonpolyposis colorectal cancer (HNPCC) or who are at increased
risk for HNPCC should have colonoscopy every 1-2 years
beginning at age 20-25 years, or 10 years earlier than the
youngest age of colon cancer diagnosis in the family--whichever
comes first. Genetic testing for HNPCC should be offered to firstdegree relatives of persons with a known inherited mismatch
repair (MMR) gene mutation.
Case 10
Three months ago, a 62-year-old man underwent segmental sigmoid colon
resection for a near-obstructing colorectal cancer found on flexible
sigmoidoscopy. Surgery was considered curative, and the patient did not
require postoperative chemotherapy or radiation therapy. He has no
personal or family history of colorectal cancer or polyps. On a follow-up visit
today, he feels well. Physical examination is normal. Which of the following
is the most appropriate colorectal cancer surveillance procedure for this
patient?
Colonoscopy now
Colonoscopy in 3 months
Colonoscopy in 1 year
Colonoscopy in 3 years
CT scan of the abdomen now
CT scan of the abdomen in 3 years
ACS/USPSTF Recommendations
Patients with a colon cancer that has been resected with curative
intent should have a colonoscopy around the time of initial
diagnosis to rule out synchronous neoplasms. If the colon is
obstructed preoperatively, colonoscopy can be performed
approximately 6 months after surgery. If this or a complete
preoperative examination is normal, subsequent colonoscopy
should be offered after 3 years, and then, if normal, every 5 years.
Case 11
A 67-year-old man undergoes diagnostic colonoscopy after he has a
positive fecal occult blood test. A sigmoid colon cancer is found. The
remainder of the colonoscopic examination is normal, and a CT scan of the
abdomen shows no findings suggestive of metastatic disease. The serum
carcinoembryonic antigen (CEA) level is slightly elevated. The patient
undergoes resection of the sigmoid colon with good results. Postoperative
recommendations include follow-up office visits every 3 months for 3 years,
CEA measurement, and surveillance colonoscopy. When should the first
surveillance colonoscopy be performed?
In 1 year
In 3 years
In 5 years
Only if the CEA level increases
ACS/USPSTF Recommendations
Patients with a colon cancer that has been resected with curative
intent should have a colonoscopy around the time of initial
diagnosis to rule out synchronous neoplasms. If the colon is
obstructed preoperatively, colonoscopy can be performed
approximately 6 months after surgery. If this or a complete
preoperative examination is normal, subsequent colonoscopy
should be offered after 3 years, and then, if normal, every 5 years.
Case 12
A 47-year-old woman is evaluated for abdominal discomfort of 3 months'
duration accompanied by a change in stool caliber. Her medical history is
otherwise noncontributory, and her family history is unremarkable. Physical
examination, including rectal examination, is normal. Results of fecal occult
blood testing are positive. Colonoscopy reveals a 3-cm sigmoid tumor
confirmed as adenocarcinoma on biopsy. On resection of the mass, tumor
invasion of the muscularis propria is identified, in addition to metastases in
one regional lymph node. The postoperative recovery is uneventful, and the
patient presents for a follow-up office visit. Which of the following is the
most appropriate next step in management?
Adjuvant chemotherapy
Radiation therapy
Observation
Immunohistochemical staining of tumor
Colon Cancer Classification
Stage
Extent
Adjuvant
chemotherapy
indicated
5 year survival
Stage 0
Intramucosal
No
100%
Stage 1
Submucosa/Musc
ularis mucosae
No
95%
Stage 2A
Subserosa
No
85%
Stage 2B
Perforation
No
75%
Stage 3
Lymph nodes
(LN)
Yes
65% for up to
3+LN, 45%
FOR>4LN
Stage 4
Distant disease
Yes
5%
Adjuvant chemotherapy after surgery
Adjuvant systemic chemotherapy after resection of node positive
colon cancer is associated with 30% reduction in the risk of disease
recurrence, and 22 to 32% reduction in mortality.
Remember for colon cancer only in stage 3 disease – adjuvant
chemotherapy with oxaliplatin plus 5-FU and leucovorin.
For rectal cancer: stage 2 and 3 disease : adjuvant chemotherapy +
radiation
Questions ?
Thank you