Colorectal Cancer Screening:Colorectal Cancer Screening: Considerations and Controversies Considerations and Controversies

David W. Hamilton, RN, MSN, CS, ACNP-BCDavid W. Hamilton, RN, MSN, CS, ACNP-BCSan Francisco General Hospital and Trauma CenterSan Francisco General Hospital and Trauma Center

Division of GastroenterologyDivision of GastroenterologyApril 22, 2010April 22, 2010

Learning ObjectivesLearning Objectives

List & describe available CRC screening testsList & describe available CRC screening tests List 2 advantages & disadvantages of each testList 2 advantages & disadvantages of each test Understand recommended guidelines for CRC Understand recommended guidelines for CRC

screeningscreening Identify those individuals at high risk for CRCIdentify those individuals at high risk for CRC Recognize indications & intervals for surveillanceRecognize indications & intervals for surveillance

What CRC screening test and interval would you What CRC screening test and interval would you

recommend for a 37-year-old male whose father was recommend for a 37-year-old male whose father was

diagnosed with CRC at age 52 ?diagnosed with CRC at age 52 ?

A.A. FOBT annuallyFOBT annually

B.B. Flexible sigmoidoscopy q 5 yearsFlexible sigmoidoscopy q 5 years

C.C. Colonoscopy now, then annuallyColonoscopy now, then annually

D.D. Colonoscopy at age 40 and q 5 years Colonoscopy at age 40 and q 5 years

E.E. Colonoscopy at age 50, then q 5-10 yearsColonoscopy at age 50, then q 5-10 years

Margaret – age 60Margaret – age 60 F/u with PMD after completing a screening colonoscopyF/u with PMD after completing a screening colonoscopy PMH: HTN, Hyperlipidemia, ObesityPMH: HTN, Hyperlipidemia, Obesity FH: Mother (HTN); Father (CAD); No GI malignancy.FH: Mother (HTN); Father (CAD); No GI malignancy. Findings: -Hemorrhoids (grade 1)Findings: -Hemorrhoids (grade 1)

-Diverticulosis-Diverticulosis -Hemi-circumferential descending colon -Hemi-circumferential descending colon

malignancy requiring a left malignancy requiring a left hemicolectomyhemicolectomy

No post-operative complicationsNo post-operative complications

What surveillance interval will Margaret need to follow?What surveillance interval will Margaret need to follow?A.A. Colonoscopy annuallyColonoscopy annuallyB.B. Colonoscopy at 1 yr, then 3 yrs, then 5 yrsColonoscopy at 1 yr, then 3 yrs, then 5 yrsC.C. Colonoscopy every 5 yearsColonoscopy every 5 years

At what age, if any, would you stop performing At what age, if any, would you stop performing CRC screening?CRC screening?

A.A. 6868

B.B. 7373

C.C. 8181

D.D. 8383

E.E. 8686

F.F. No age limit for CRC screeningNo age limit for CRC screening

Colorectal Cancer (CRC)Colorectal Cancer (CRC) In the U.S. - 149,000 cases annually; ~50,000 deathsIn the U.S. - 149,000 cases annually; ~50,000 deaths Life-time cumulative incidence of ~ 5% Life-time cumulative incidence of ~ 5% 33rdrd most common cancer most common cancer 22ndnd leading cause of cancer-related death (men and women) leading cause of cancer-related death (men and women) 90% - occur in adults > 50 years of age90% - occur in adults > 50 years of age 5-year survival 5-year survival

*90% with localized disease *90% with localized disease *68% with lymph node involvement*68% with lymph node involvement*10% with distant metastasis*10% with distant metastasis

Only 39% are detected in early stageOnly 39% are detected in early stage Disparities among racial and ethnic groupsDisparities among racial and ethnic groups Alarm symptoms: change in bowel habit, tenesmus, change in Alarm symptoms: change in bowel habit, tenesmus, change in

stool caliber, hematochezia, melena, chronic bleeding, weight stool caliber, hematochezia, melena, chronic bleeding, weight loss, abdominal pain.loss, abdominal pain.

Factors Affecting CRC RiskFactors Affecting CRC Risk

Multiple factors, especiallyMultiple factors, especially::-Age (primary RF)-Age (primary RF)-Race-Race-Gender-Gender-Family history of CRC-Family history of CRC-Family history of adenomatous polyps-Family history of adenomatous polyps

High-Risk IndividualsHigh-Risk Individuals-1 FDR with cancer at age <50-1 FDR with cancer at age <50-2 FDR with CRC at any age-2 FDR with CRC at any age-FH of hereditary nonpolyposis colorectal cancer (HNPCC)-FH of hereditary nonpolyposis colorectal cancer (HNPCC)-FH of familial adenomatous polyposis (FAP)-FH of familial adenomatous polyposis (FAP)

-Smoking-Smoking-Diet-Diet

CRC Screening TestsCRC Screening Tests

CRC Screening TestsCRC Screening Tests

Early Cancer DetectionEarly Cancer Detection Fecal Occult Blood Test (FOBT) Fecal Occult Blood Test (FOBT)

**Hemoccult II/ Hemoccult SensaHemoccult II/ Hemoccult Sensa Fecal Immunochemical Test (FIT)Fecal Immunochemical Test (FIT) Stool DNA (sDNA)Stool DNA (sDNA)

Early Cancer Detection and Cancer PreventionEarly Cancer Detection and Cancer Prevention Flexible Sigmoidoscopy (FS)Flexible Sigmoidoscopy (FS) Barium Enema (DCBE)Barium Enema (DCBE) Colonoscopy (CSPY)Colonoscopy (CSPY) CT Colonography (CTC/virtual colonoscopy)CT Colonography (CTC/virtual colonoscopy)

Fecal Occult Blood TestFecal Occult Blood Test (FOBT) (FOBT)

Detects pseudoperoxidase activity of heme as intact hgb or free heme. Detects pseudoperoxidase activity of heme as intact hgb or free heme. Sensitivity ~38%; Specificity ~97% (Hemoccult II) Sensitivity ~38%; Specificity ~97% (Hemoccult II) Sensitivity ~75%; Specificity~87% (Hemoccult Sensa)Sensitivity ~75%; Specificity~87% (Hemoccult Sensa)

AdvantagesAdvantages-Non invasive – 3 stool samples-Non invasive – 3 stool samples-Inexpensive (Costs $5 - $10)-Inexpensive (Costs $5 - $10)-Only test w/ evidence of efficacy (reduced mortality 16% in RCT) w/ annual testing-Only test w/ evidence of efficacy (reduced mortality 16% in RCT) w/ annual testing

DisadvantagesDisadvantages-Low sensitivity (Hemoccult II)-Low sensitivity (Hemoccult II)-Not selective for lower GI bleeding-Not selective for lower GI bleeding-Not specific for human hgb.-Not specific for human hgb.-Interference by plant peroxidase activity = false +-Interference by plant peroxidase activity = false +-Dietary restrictions (radishes, turnips, red meat, fish, ASA/NSAIDs)-Dietary restrictions (radishes, turnips, red meat, fish, ASA/NSAIDs)-Antioxidants (Vitamin C) = false --Antioxidants (Vitamin C) = false --Poor adherence - because requires -Poor adherence - because requires annualannual testing testing-Positive test -Positive test → → colonoscopy colonoscopy

Fecal Immunochemical TestFecal Immunochemical Test (FIT) (FIT)

Detection of globin via specific antibodies for human hemoglobinDetection of globin via specific antibodies for human hemoglobin Not a “guaiac” reaction (any blood)Not a “guaiac” reaction (any blood) Sensitivity ~81%; Specificity~97%Sensitivity ~81%; Specificity~97%

AdvantagesAdvantages-Globin (protein component of Hgb) degraded by digestive enzymes in UGI tract -Globin (protein component of Hgb) degraded by digestive enzymes in UGI tract

= more specific for lower GI bleed= more specific for lower GI bleed-B/C more specific for human blood, reduces false + rate by 30%-B/C more specific for human blood, reduces false + rate by 30%-Non invasive-Non invasive-No dietary/drug interference-No dietary/drug interference-One stool sample-One stool sample

DisadvantagesDisadvantages-Processed in laboratory-Processed in laboratory-More expensive than FOBT ($18 - $30)-More expensive than FOBT ($18 - $30)-Positive test -Positive test →→ colonoscopy colonoscopy

Stool DNAStool DNA

Detects altered DNA from epithelial cells in stool shed by neoplasmsDetects altered DNA from epithelial cells in stool shed by neoplasms

AdvantagesAdvantages-Sensitivity 91% & Specificity 93% - 1 pilot study-Sensitivity 91% & Specificity 93% - 1 pilot study-Non invasive-Non invasive

DisadvantagesDisadvantages-Not all genetic abnormalities for CRC can be isolated-Not all genetic abnormalities for CRC can be isolated-Evolving. No test widely used. Only results from small studies-Evolving. No test widely used. Only results from small studies-High monetary cost-High monetary cost-A study found no better sensitivity than FIT-A study found no better sensitivity than FIT-Requires entire stool (30+ grams) – shipped with ice pack-Requires entire stool (30+ grams) – shipped with ice pack-Positive test -Positive test →→ colonoscopy colonoscopy

Flexible SigmoidoscopyFlexible Sigmoidoscopy Examines only distal colon. Must reach 40 cm to be acceptable for screeningExamines only distal colon. Must reach 40 cm to be acceptable for screening Sensitivity ~70%Sensitivity ~70% 2 Case- control studies evaluated use in screening2 Case- control studies evaluated use in screening

*59% reduction in CRC mortality within reach of scope*59% reduction in CRC mortality within reach of scopeAdvantagesAdvantages-Simple bowel prep (Mag Citrate/Fleet’s enema)-Simple bowel prep (Mag Citrate/Fleet’s enema)-No sedation. Mild discomfort.-No sedation. Mild discomfort.-Relatively quick exam (5-10 minutes); No recovery-Relatively quick exam (5-10 minutes); No recovery-Performed in diverse settings (PCP office; rural clinics)-Performed in diverse settings (PCP office; rural clinics)

DisadvantagesDisadvantages-Requires well trained endoscopist-Requires well trained endoscopist-Cannot detect lesions beyond length of sigmoidoscope (60cm) -Cannot detect lesions beyond length of sigmoidoscope (60cm) -Complications: perforation (1 in 20,000), bleeding, infection-Complications: perforation (1 in 20,000), bleeding, infection-Low reimbursement rates-Low reimbursement rates-Polyps detected -Polyps detected →→ colonoscopy colonoscopy

Double Contrast Barium EnemaDouble Contrast Barium Enema Radiologic exam uses barium and air to evaluate the entire colonRadiologic exam uses barium and air to evaluate the entire colon No randomized, controlled trials evaluating efficacy as primary screeningNo randomized, controlled trials evaluating efficacy as primary screening Sensitivity ~80%; Specificity ~92%Sensitivity ~80%; Specificity ~92% Being replaced by other screening tests, i.e. CT colonography; colonoscopyBeing replaced by other screening tests, i.e. CT colonography; colonoscopy

AdvantagesAdvantages-Examines entire colon. Detects most polyps/cancers.-Examines entire colon. Detects most polyps/cancers.-Performed when incomplete/failed colonoscopy -Performed when incomplete/failed colonoscopy -No sedation/rapid exam (20-40 mins)/return to work-No sedation/rapid exam (20-40 mins)/return to work

DisadvantagesDisadvantages-Requires well-trained radiologist-Requires well-trained radiologist-Questionable polyp vs. stool -Questionable polyp vs. stool → → colonoscopycolonoscopy-Radiation exposure - multiple radiographs -Radiation exposure - multiple radiographs -Bowel prep – dietary and laxative. Suboptimal prep reduce sensitivity/specificity-Bowel prep – dietary and laxative. Suboptimal prep reduce sensitivity/specificity-Uncomfortable: Rectal tube for air/contrast-Uncomfortable: Rectal tube for air/contrast-Complications: perforation (1 in 25,000)-Complications: perforation (1 in 25,000)-Positive exam (polyp/mass) -Positive exam (polyp/mass) → → colonoscopycolonoscopy

Double Contrast Barium EnemaDouble Contrast Barium Enema

ColonoscopyColonoscopy

Insertion of a flexible camera to view entire colon (160 cm) Insertion of a flexible camera to view entire colon (160 cm) Sensitivity ~97.5%Sensitivity ~97.5% Studies - incidence of CRC reduced by 76% - 90%Studies - incidence of CRC reduced by 76% - 90%

- 59% reduction in mortality w/ therapeutic interventions- 59% reduction in mortality w/ therapeutic interventions

AdvantagesAdvantages

-Greatest advantage = direct inspection and therapeutic intervention-Greatest advantage = direct inspection and therapeutic intervention

-Can detect flat polyps-Can detect flat polyps

-Regarded as the “gold standard” for diagnosis of polyps/CRC-Regarded as the “gold standard” for diagnosis of polyps/CRC

…….continued.continuedDisadvantagesDisadvantages-Invasive procedure. Expensive.-Invasive procedure. Expensive.-Dietary and bowel cleansing (considered most unpleasant)-Dietary and bowel cleansing (considered most unpleasant)-Sedation and chaperone home-Sedation and chaperone home-Skilled endoscopist. No quality assurance programs exist.-Skilled endoscopist. No quality assurance programs exist.-Carries most risks/complications: post-polypectomy -Carries most risks/complications: post-polypectomy

bleeding (most common), perforation (1:1000), bleeding (most common), perforation (1:1000), cardiopulmonary, infection, missed lesions (polyps = cardiopulmonary, infection, missed lesions (polyps = 6%-15%; cancer ~5%).6%-15%; cancer ~5%).

-Possible incomplete polypectomy -Possible incomplete polypectomy *A factor in up to 25% of interval cancers.*A factor in up to 25% of interval cancers.

Not perfect, but still the best test for cancer preventionNot perfect, but still the best test for cancer prevention

Colon Polyps/MassColon Polyps/Mass

Colon mass (Adenocarcinoma)Colon mass (Adenocarcinoma)

PedunculatedPedunculated SessileSessile FlatFlat

Colonoscopy for SurveillanceColonoscopy for Surveillance

Surveillance interval is based on:Surveillance interval is based on:

A.A. Number Number

B.B. Size Size

C.C. HistologyHistology

Post-polypectomyPost-polypectomy

HyperplasticHyperplastic

1-2 tubular adenomas <1 cm1-2 tubular adenomas <1 cm

3-10 adenomas; villous features; 3-10 adenomas; villous features; ≥1cm; HGD≥1cm; HGD

>10 adenomas>10 adenomas

Large sessile adenoma removed piecemealLarge sessile adenoma removed piecemeal

Post surgical resection of colorectal cancerPost surgical resection of colorectal cancer

Interval/InterventionInterval/Intervention

10 years10 years

5-10 years5-10 years

3 years3 years

< 3 years< 3 years

2-6 months2-6 months

1/3/5 years post resection1/3/5 years post resection

Larry – age 51Larry – age 51 Screening colonoscopy last yearScreening colonoscopy last year Findings: 4 polypsFindings: 4 polyps

-5mm, 7mm, 3mm, 4mm -5mm, 7mm, 3mm, 4mm -Histology: Tubular -Histology: Tubular

adenoma (all) adenoma (all) When is Larry due for his next When is Larry due for his next

colonoscopy?colonoscopy?A.A. 1 year 1 year B.B. 3 years3 yearsC.C. 5 years5 yearsD.D. 10 years10 years

CT Colonography CT Colonography (CTC/Virtual Colonoscopy)(CTC/Virtual Colonoscopy)

CT ColonographyCT Colonography

A low radiation dose CT used to detect colon mass/polypsA low radiation dose CT used to detect colon mass/polyps

AdvantagesAdvantages-Imaging of entire colon with 2D & 3D display-Imaging of entire colon with 2D & 3D display-Used for incomplete colonoscopy (10%)-Used for incomplete colonoscopy (10%)-Rapid exam (~10 minutes); Minimally invasive -Rapid exam (~10 minutes); Minimally invasive -No sedation; no recovery-No sedation; no recovery-Detects polyps >1 cm/CA with high sensitivity -Detects polyps >1 cm/CA with high sensitivity 70% - 90% (adenomas); 95% (cancer) 70% - 90% (adenomas); 95% (cancer)

DisadvantagesDisadvantages-Reimbursement for-Reimbursement for screening screening limited limited-No RCT to demonstrate efficacy in reducing mortality from CRC-No RCT to demonstrate efficacy in reducing mortality from CRC-Imaging only; not therapeutic-Imaging only; not therapeutic-Bowel prep. Dietary restrictions (clear) + full cathartic-Bowel prep. Dietary restrictions (clear) + full cathartic-Discomfort (rectal tube, air insufflation); Risk of perforation-Discomfort (rectal tube, air insufflation); Risk of perforation-Controversy - radiation exposure; Pregnant women-Controversy - radiation exposure; Pregnant women-Incidental findings & false + lead to work-up = increased cost-Incidental findings & false + lead to work-up = increased cost-Difficult detecting flat polyps & those <6 mm-Difficult detecting flat polyps & those <6 mm-Consensus that 1 or more polyps >1 cm; 3 or more >6 mm -Consensus that 1 or more polyps >1 cm; 3 or more >6 mm → CSPY→ CSPY

*With <3 polyps <6 mm = controversial re: colonoscopy*With <3 polyps <6 mm = controversial re: colonoscopy-Positive findings (polyps/mass) -Positive findings (polyps/mass) → → colonoscopycolonoscopy

… ….continued.continued

CRC Screening for Average-RiskCRC Screening for Average-RiskScreening TestScreening Test ACS-USMSTF-ACRACS-USMSTF-ACR USPSTFUSPSTF IntervalInterval

Sensitive guaiac fecal Sensitive guaiac fecal occult blood testoccult blood test

Recommended if >50% sensitivity Recommended if >50% sensitivity for CRCfor CRC

RecommendedRecommended 1 year1 year

Fecal immunochemical Fecal immunochemical test test

Recommended if >50% sensitivity Recommended if >50% sensitivity for CRCfor CRC

Recommended, only if high Recommended, only if high sensitivity test usedsensitivity test used

1 year1 year

Stool DNA testStool DNA test Recommended if >50% sensitivity Recommended if >50% sensitivity for CRCfor CRC

Not recommended due to Not recommended due to insufficient evidence to asses insufficient evidence to asses sensitivity and specificity of sensitivity and specificity of fecal DNAfecal DNA

UncertainUncertain

Flexible SigmoidoscopyFlexible Sigmoidoscopy Recommended if sigmoidoscope is Recommended if sigmoidoscope is inserted to 40 cm or to the splenic inserted to 40 cm or to the splenic flexure flexure

Recommended with guaiac Recommended with guaiac fecal occult blood test every 3 fecal occult blood test every 3 yrsyrs

5 year5 year

Barium EnemaBarium Enema Recommended, but only if other Recommended, but only if other tests are not availabletests are not available

Not recommendedNot recommended 5 year5 year

CT ColonographyCT Colonography Recommended, with referral for Recommended, with referral for colonoscopy if polyps >6 mm are colonoscopy if polyps >6 mm are detecteddetected

Not recommendedNot recommended 5 year5 year

ColonoscopyColonoscopy RecommendedRecommended RecommendedRecommended 10 year10 year

Adapted from: Levin B, Lieberman DA, McFarland, et al. Adapted from: Levin B, Lieberman DA, McFarland, et al. CA Cancer J ClinCA Cancer J Clin. 2008; 58.. 2008; 58.Whitlock EP et al. Whitlock EP et al. Ann Intern MedAnn Intern Med. 2008; 149:638-658.. 2008; 149:638-658.Preventative Services Taskforce Preventative Services Taskforce Ann Intern MedAnn Intern Med. 2008; 149:627-637.. 2008; 149:627-637.

ACS: American Cancer SocietyACS: American Cancer SocietyUSMSTF: US Multi-Society Task Force on CRCUSMSTF: US Multi-Society Task Force on CRCACR: American College of RadiologyACR: American College of RadiologyUSPSTF: US Preventative Services Task ForceUSPSTF: US Preventative Services Task Force

Societal ConsensusSocietal Consensus

Agree Agree -Sensitive FOBT (Hemoccult Sensa) q 1 year-Sensitive FOBT (Hemoccult Sensa) q 1 year-FIT q 1 year-FIT q 1 year-Flex Sig (to 40cm or splenic flexure); q 5 years-Flex Sig (to 40cm or splenic flexure); q 5 years-Colonoscopy q 10 years-Colonoscopy q 10 years

DisagreeDisagree-Stool DNA-Stool DNA-Barium enema-Barium enema-CT Colonography-CT Colonography

QuestionQuestion Which methods of CRC screening are Which methods of CRC screening are

recommended by recommended by allall Societal guidelines? Societal guidelines?

A.A. Only colonoscopy and FOBT/FITOnly colonoscopy and FOBT/FIT

B.B. Colonoscopy, flexible sigmoidoscopy, Colonoscopy, flexible sigmoidoscopy, FOBT/FITFOBT/FIT

C.C. Colonoscopy, flexible sigmoidoscopy, Colonoscopy, flexible sigmoidoscopy, FOBT/FIT, fecal DNAFOBT/FIT, fecal DNA

CRC Screening Rates are Improving, but…CRC Screening Rates are Improving, but…

2006 Behavioral Risk Factor Surveillance System (BRFSS) Survey: 2006 Behavioral Risk Factor Surveillance System (BRFSS) Survey:

CharacteristicCharacteristic 2002 (%)2002 (%) 2006 (%)2006 (%)

Age ≥50 years who received Age ≥50 years who received FOBT within the past yr and/or FOBT within the past yr and/or FS/Colon within the past 10 yrsFS/Colon within the past 10 yrs

53.953.9 60.860.8

HispanicHispanic 43.943.9 47.247.2

Education less than a High Education less than a High School DiplomaSchool Diploma

41.041.0 45.545.5

$15,000 - $35,000 household $15,000 - $35,000 household incomeincome

49.149.1 53.953.9

Health InsuranceHealth Insurance

Lack of health insuranceLack of health insurance

55.955.9

33.133.1

63.063.0

36.736.7

CDC. CDC. MMWRMMWR. 2008; 57:253-258.. 2008; 57:253-258.

~40% ≥ 50 years of age are not being screened~40% ≥ 50 years of age are not being screened

The single most effective method toThe single most effective method to

increase CRC screening remains theincrease CRC screening remains the

recommendation for screening by therecommendation for screening by the

patient’s primary care provider.patient’s primary care provider.

Clinician Barriers to Clinician Barriers to Recommending CRC ScreeningRecommending CRC Screening

Not familiar with screening guidelinesNot familiar with screening guidelines Differences in guidelinesDifferences in guidelines Perceived patient anxiety regarding testingPerceived patient anxiety regarding testing Unfamiliarity with cost/insurance coverageUnfamiliarity with cost/insurance coverage Lack of reminders and/or available tracking systemsLack of reminders and/or available tracking systems TimeTime

Hannon PA Cancer Control. 2008 Apr; 15(2):174-181.Hannon PA Cancer Control. 2008 Apr; 15(2):174-181.Klabunde CN et al. Am J Prev Med. 2009 Jul; 37(1):8-16.Klabunde CN et al. Am J Prev Med. 2009 Jul; 37(1):8-16.Ling BS et al Med Care. 2008 Sep; 46 (9 Supp 1):S23-S29.Ling BS et al Med Care. 2008 Sep; 46 (9 Supp 1):S23-S29.

Age to Stop Routine CRC Age to Stop Routine CRC ScreeningScreening

Purpose of screening = detect early CRC & extend life yearsPurpose of screening = detect early CRC & extend life years

If life expectancy <10 years, no utility in screening.If life expectancy <10 years, no utility in screening.

Studies: screening debilitated, terminally ill = little benefit.Studies: screening debilitated, terminally ill = little benefit.

U.S. Preventative Services Task ForceU.S. Preventative Services Task Force 50 – 75 yrs: CRC screening recommended50 – 75 yrs: CRC screening recommended 76 – 85 yrs: Do not routinely screen76 – 85 yrs: Do not routinely screen 86+: Do not screen86+: Do not screen

Only recommendations, use clinical judgment. Only recommendations, use clinical judgment.

What CRC screening test and interval would you What CRC screening test and interval would you

recommend for a 37-year-old male whose father was recommend for a 37-year-old male whose father was

diagnosed with CRC at age 52 ?diagnosed with CRC at age 52 ?

A.A. FOBT annuallyFOBT annually

B.B. Flexible sigmoidoscopy q 5 yearsFlexible sigmoidoscopy q 5 years

C.C. Colonoscopy now, then annuallyColonoscopy now, then annually

D.D. Colonoscopy at age 40 and q 5 years Colonoscopy at age 40 and q 5 years

E.E. Colonoscopy at age 50, then q 5-10 yearsColonoscopy at age 50, then q 5-10 years

Margaret – age 60Margaret – age 60 F/u with PMD after completing a screening colonoscopyF/u with PMD after completing a screening colonoscopy PMH: HTN, Hyperlipidemia, ObesityPMH: HTN, Hyperlipidemia, Obesity FH: Mother (HTN); Father (CAD); No GI malignancy.FH: Mother (HTN); Father (CAD); No GI malignancy. Findings: -Hemorrhoids (grade 1)Findings: -Hemorrhoids (grade 1)

-Diverticulosis-Diverticulosis -Hemi-circumferential descending colon -Hemi-circumferential descending colon

malignancy requiring a left malignancy requiring a left hemicolectomyhemicolectomy

No post-operative complicationsNo post-operative complications

What surveillance interval will Margaret need to follow?What surveillance interval will Margaret need to follow?A.A. Colonoscopy annuallyColonoscopy annuallyB.B. Colonoscopy at 1 yr, then 3 yrs, then 5 yrsColonoscopy at 1 yr, then 3 yrs, then 5 yrsC.C. Colonoscopy every 5 yearsColonoscopy every 5 years

At what age, if any, would you stop performing At what age, if any, would you stop performing CRC screening?CRC screening?

A.A. 6868

B.B. 7373

C.C. 8181

D.D. 8383

E.E. 8686

F.F. No age limit for CRC screeningNo age limit for CRC screening

CRC screening reduces cancer incidence & CRC screening reduces cancer incidence & mortality & saves lives.mortality & saves lives.

Decreased incidence & mortality attributed to Decreased incidence & mortality attributed to screening & improved treatment; however, the screening & improved treatment; however, the majority are not screened. majority are not screened.

Every year, CRC claims ~50,000 lives; many Every year, CRC claims ~50,000 lives; many preventable through early detection & trmt..preventable through early detection & trmt..

Clinician barriers or patients fears (lack of Clinician barriers or patients fears (lack of understanding/embarrassment) surrounding the understanding/embarrassment) surrounding the tests, the key is to raise awareness of CRC & tests, the key is to raise awareness of CRC & get patients screened.get patients screened.

There are several CRC screening tests There are several CRC screening tests available, each with it’s considerations and available, each with it’s considerations and controversies and no Societal consensus on controversies and no Societal consensus on one one “best” test. Despite this, we can all agree, “best” test. Despite this, we can all agree, the “best” test is the one the patient the “best” test is the one the patient understands, agrees with, and understands, agrees with, and completescompletes..

Questions and AnswersQuestions and Answers