updates in colorectal cancer screening & prevention€¦ · updates in colorectal cancer...

Updates in Colorectal Cancer Screening & Prevention

Swati G. Patel, MD MSAssistant Professor of Medicine

Division of Gastroenterology & HepatologyGastrointestinal Cancer Risk and Prevention ClinicUniversity of Colorado Anschutz Medical Center

Disclosures

• None

Objectives

• Review colorectal cancer epidemiology

• Understand colorectal cancer screening options and recommendations

• Understand risk of colorectal cancer based on family history

A few patients…

• I am healthy! I have no symptoms or problems. I don’t think I could have colon cancer.

• I don’t ever want a colonoscopy. Is there another test I can do instead?

• Colonoscopy is too risky for me!!

Colorectal Cancer Incidence & Mortality

Colorectal Cancer Symptoms

•Change in bowel habits/stool caliber

•Blood in stool

•Unintentional weight loss

•Fatigue

•Iron deficiency anemia

•Abdominal pain

NONE!!

•Change in bowel habits/stool caliber

•Blood in stool

•Unintentional weight loss

•Fatigue

•Iron deficiency anemia

•Abdominal pain

NONE!!

Colorectal Cancer Pathogenesis

10-15 years

Importance of Screening

Who Should Get Screened for CRC?

Colorectal Cancer Screening

Colorectal Cancer Screening Options

Stool-based tests

Fecal occult blood testing (FOBT)

Fecal Immunochemical Testing (FIT)

Stool DNA (Cologuard)

Structural Tests

CT Colonography

Barium Enema

Flexible Sigmoidoscopy

Colonoscopy

Colorectal Cancer Screening & Prevention

Structural Test

Stool-Based Test

Colorectal Cancer Screening Options

Stool-based tests

Fecal occult blood testing (FOBT)

Fecal Immunochemical Testing (FIT)

Stool DNA (Cologuard)

Structural Tests

CT Colonography

Barium Enema

Flexible Sigmoidoscopy

Colonoscopy

Stool-Based Tests

• Detect microscopic blood in the stool

• Performed annually

• If positive colonoscopy

• FOBT– Non-specific (human vs non-human

hemoglobin; location in GIT)– Dietary (red meat, poultry, fish, raw

vegetables) & medication restriction (NSAIDs)

– Three successive smears

• FIT– Human globin– No restrictions– Single sample

Stool-Based Testing Performance

Sensitivity CRC

SensitivityAdenoma

Cost Compliance

Hemoccult II 13% - 50% 8% - 20%

Hemoccult SENSA 50% - 79% 21% - 35% $13 49.5%

FIT 75 % - 80% 15% - 44% $28 61.5%

Stool-Based Testing EfficacyTrial Screening Follow-up

(years)N CRC Incidence CRC Mortality All-Cause

Mortality

Nottingham Scholefield et al. 2002

Biennial 11.7 152,303

1.51 vs 1.53/1000 person yr NS 0.87 (0.78-0.97, p=0.010) 1.01 (0.96-1.05) NS

Funen Kronborg et al. 2004

Biennial 17 61,939 1.02 (0.93-1.12) NS 0.84 (0.73-0.96, p<0.05) 0.99 (0.97-1.02) NS

Goteborg Lindholm et al. 2008

Biennial 15.75 23,916 0.96 (0.86-1.06) NS 0.84 (0.71-0.99, p<0.05) 1.02 (0.99-1.06) NS

Minnesota Mandel et al. 1999, 2000

Annual (A) & Biennial (B)

18 46,551 A: 0.8 (0.73-0.94, p<0.001)

B: 0.83 (0.73-0.94, p=0.002)

A: 0.67 (0.51-0.83, p<0.05)

B: 0.79 (0.62-0.97, p<0.05)

342 (334-350)A: 340 (333-348)B: 343 (336-351)NS

Stool-Based Tests

Disadvantages

• Not designed to detect

pre-cancerous lesions

• Requires annual testing

• High false positive rates

• TWO STEP TEST

Advantages

• Low risk, non-invasive

• No bowel preparation

• Home testing

• Inexpensive

Colorectal Cancer Screening Options

Stool-based tests

Fecal occult blood testing (FOBT)

Fecal Immunochemical Testing (FIT)

Stool DNA (Cologuard)

Structural Tests

CT Colonography

Barium Enema

Flexible Sigmoidoscopy

Colonoscopy

Colonoscopy

• Insertion of a flexible scope to visualize the entire rectum and colon

• Can diagnose cancer and perform biopsies

• Can detect and remove potentially pre-cancerous polyps

• Requires a bowel preparation to cleanse the colon– Clear liquids day before procedure– Bowel preparation evening before and day of

procedure (split dose)

• Sedation given during the procedure– Requires day off life/work– Requires escorted transportation

Colonoscopic Polypectomy

Colonoscopy Performance

• Considered the “gold standard”

• Not perfect…– 2-12% of large polyps

are missed

– May not be as protective of cancer on the right side of the colon

OR 0.24 (CI 0.21-0.27)

OR 0.58 (CI 0.53-0.64)

Colonoscopy Quality

• High-definition scopes

• Image enhancement

• Devices (cap, endocuff)

• Chromoendoscopy

• Financial

• Organizational

• Bowel preparation

• Tumor biology

• Specialty/Training

• Personality (vigilance, conscientiousness)

• Procedural/motor skills

• Knowledge base

EndoscopistFactors

Patient factors

Technical factors

System factors

Colonoscopy Quality

Colonoscopy Efficacy

• No randomized controlled trials to date

• Indirect evidence:– National Polyp Study: 76-90% reduction in CRC incidence after

polypectomy– VA study: lower endoscopy within past 6 years associated with

60% reduction in CRC mortality– FOBT & Flexible Sigmoidoscopy trials

• Current trials underway:– VA CONFIRM (Colonoscopy vs FIT)– Spanish trial (Colonoscopy vs FIT)– Nordic-European Initiative (Colonoscopy vs no screening)

Colonoscopy Risks

• Perforation 0.5/1,000

• Bleeding 2.6/1,000

• Death 2.9/100,000

Colonoscopy

Disadvantages

• Invasive, procedural risks

• Sedation required

• Time consuming, expensive

• Full bowel preparation

• Operator, preparation dependent

Advantages

• Can visualize the entire colon

• Diagnose and remove lesions

• Performed every 10 years

• Minimal patient discomfort

• SINGLE STEP TEST

Colorectal Cancer Screening Options

Stool-based tests

Fecal occult blood testing (FOBT)

Fecal Immunochemical Testing (FIT)

Stool DNA (Cologuard)

Structural Tests

CT Colonography

Barium Enema

Flexible Sigmoidoscopy

Colonoscopy

What is the best screening test…?

ACS-MSTF-ACR-AGA

> 50:

FS every 5 years +/- FOBT

every year

-Or-

“High Sensitivity” FOBT/FIT

every year

-Or-

Colonoscopy every 10 years

-Or-

CT Colonography every 5

years

-Or-

Fecal DNA every 3 years

USPSTF50-75:

FS every 5 years with

interval “High Sensitivity”

FOBT/FIT

-Or-

“High Sensitivity”

FOBT/FIT every year

-Or-

Colonoscopy every 10

years

A few patients…

• I am healthy! I have no symptoms or problems. I don’t think I could have colon cancer.

• I don’t ever want a colonoscopy. Is there another test I can do instead?

• Colonoscopy is too risky for me!!

Family history and CRC

Increased Risk Group

Definition Modality Starting Age/ Interval

ACS/MSTF/

ACR

1 FDR > 60

CRC/Adenoma

2 SDR CRC any age

Any 40/Average risk intervals

ASGE 1 FDR > 60

CRC/Adenoma

Colonoscopy 40/Average risk intervals

ACG 1 FDR > 60

CRC/Adenoma

Colonoscopy

Preferred

50/ Average risk intervals

NCCN 1 FDR > 60 CRC

1 SDR < 50 CRC

1 FDR Adv Adenoma

Colonoscopy 50/ q 5-10 yrs

CRC Risk Categories Based on Family History

Average Risk

•No Personal or family history of colon polyps or colorectal cancer (CRC)

Increased Risk

•One first-degree relative with CRC/Adenoma over the age of 60

•Two second degree relatives with CRC any age

High Risk

•One first-degree relative with CRC/Adenoma younger than age 60

•Two or more first degree relatives with CRC/Adenoma, any age

Hereditary Risk

•Three or more family members with colorectal cancer

•Multiple other cancer types in the family

•Young ages of onset of cancers (less than 50)

Age 50, any screening test

Age 40-50, colonoscopy every 5-10 years

Age 40, colonoscopy every 5 years

Referral to Genetics Expert

Take home points

• Colon cancer is common and lethal

• Colon cancer is preventable!

• There are a menu of stool-based and structural CRC screening options– The best option is the one your patient will commit

to!

• Family history of CRC may increase a patient’s risk

Thank you for your attention!