d. m. kruss md kill the cancer do screening now! daniel m. kruss, m.d. kill the cancer do screening...
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D. M. Kruss MDD. M. Kruss MD
Kill the CancerDo Screening now!
Daniel M. Kruss, M.D.
Kill the CancerDo Screening now!
Daniel M. Kruss, M.D.
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Daniel M. Kruss, M.D.
Colon Cancer Screening
Daniel M. Kruss, M.D.
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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
•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
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
• 56,300 deaths expected this year
• 6% Lifetime Risk
• 62% Five-year survival 53% in African Americans
• 56,300 deaths expected this year
• 6% Lifetime Risk
• 62% Five-year survival 53% in African Americans
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
Because of these large numbers, even a small improvement in survivalwill save many lives!
Because of these large numbers, even a small improvement in survivalwill save many lives!
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer ScreeningWhat 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)
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)
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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
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
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
What do we know What do we know about colon cancer?about colon cancer?
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer ScreeningThe 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
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
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening Familial RiskFamilial Risk
General PopulationGeneral Population 6%6%
One 1st-degree RelativeOne 1st-degree Relative 2 to 3X2 to 3X
Two 1st-degree RelativeTwo 1st-degree Relative 3 to 6X3 to 6X
1st-degree Relative <50 Yrs1st-degree Relative <50 Yrs 3 to 6X3 to 6X
One 2nd- or 3rd-degree RelativeOne 2nd- or 3rd-degree Relative 1.5X1.5X
One 1st-degree Relative & Polyp One 1st-degree Relative & Polyp 2X2X
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
colon cancer may also haveenvironmental triggers such as diet, geography, ???
colon cancer may also haveenvironmental triggers such as diet, geography, ???
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
Over 90% of colorectal carcinomas develop from an adenomatous polyp.
Over 90% of colorectal carcinomas develop from an adenomatous polyp.
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer ScreeningEpidemiologic 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
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
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
This guides our present strategy:This guides our present strategy:
• • find polypsfind polyps
• • remove polypsremove polyps
• • prevent 90% of colon prevent 90% of colon cancerscancers
The other 10% awaits new The other 10% awaits new genetic tests for blood and/or genetic tests for blood and/or stoolstool
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
How can we detectHow can we detectColon cancer?Colon cancer?
1. Fecal Occult Blood1. Fecal Occult Blood
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer ScreeningWhat 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
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
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Fecal Occult Blood Testing
Colon Cancer Screening
Fecal Occult Blood TestingThree Prospective Randomized TrialsThree Prospective Randomized Trials
Site No. ofSubjects
Duration(Years)
MortalityReduction
Minn. 46,551 13 33%
U.K. 152,650 7.8 15%
Denmark 140,000 10 18%
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer ScreeningA polyp or a cancer in the
colonmay bleed, slowly, and causetiny amounts of OB in the stool.
Large studies show us that only1/3 of polyps and 1/2 of cancersbleed, however!!
Depending on the method used,between 1.5-8% of 'healthy'persons will have OB in the stool!!
A polyp or a cancer in the colonmay bleed, slowly, and causetiny amounts of OB in the stool.
Large studies show us that only1/3 of polyps and 1/2 of cancersbleed, however!!
Depending on the method used,between 1.5-8% of 'healthy'persons will have OB in the stool!!
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer ScreeningIf we make our OB tests too
sensitive, we may find a fewmore cancers, but will detecta lot more false positives.
There is no harm in finding afalse positive, except in theobligation (cost?) of examiningeach one to see if there is a cancer.
If we make our OB tests toosensitive, we may find a fewmore cancers, but will detecta lot more false positives.
There is no harm in finding afalse positive, except in theobligation (cost?) of examiningeach one to see if there is a cancer.
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer ScreeningIf 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.
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.
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
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.
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.
Colon Cancer ScreeningColon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer ScreeningFecal 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!
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!
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer ScreeningIt must be clearly understood that
the OB test is only one of severalmethods of screening and thatit is, at best, 50% predictive.
Then why do it?
It must be clearly understood thatthe OB test is only one of severalmethods of screening and thatit is, at best, 50% predictive.
Then why do it?
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
Early detection is stillthe only methodto prevent deaths from colon cancer
Early detection is stillthe only methodto prevent deaths from colon cancer
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
How can we detectHow can we detectColon cancer?Colon cancer?
2. Sigmoidoscopy2. Sigmoidoscopy
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer ScreeningThe American Cancer Society
previously recommended:
Sigmoidoscopy this was based on data suggestingthat half of the cancers will beseen in this area, and anypatients who have polyps seen,will receive full colonoscopy
The American Cancer Society previously recommended:
Sigmoidoscopy this was based on data suggestingthat half of the cancers will beseen in this area, and anypatients who have polyps seen,will receive full colonoscopy
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
How can we detectHow can we detectColon cancer?Colon cancer?
3. Colonoscopy3. Colonoscopy
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer ScreeningThe 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
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
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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
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
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer ScreeningIf a polyp is found,
what is needed?
1. Annual colonoscopy until the colon is 'clear'
2. then re-examine every 3-5 years
If a polyp is found, what is needed?
1. Annual colonoscopy until the colon is 'clear'
2. then re-examine every 3-5 years
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
What are the risks of colonoscopy?
bleeding and/or perforationoccur in less than 1/500 patients
When properly indicated, theprocedure is very safe andvery efficient
What are the risks of colonoscopy?
bleeding and/or perforationoccur in less than 1/500 patients
When properly indicated, theprocedure is very safe andvery efficient
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
What should I do now?What should I do now?
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
If you are over 55: screening for OB every year, colonoscopy (or sigmoidoscopy)
If you have polyps, tell your bloodrelatives to have screening andbe sure you have regular tests
If relatives had colon polyps or colon cancer, get your colonoscopy now!
If you are over 55: screening for OB every year, colonoscopy (or sigmoidoscopy)
If you have polyps, tell your bloodrelatives to have screening andbe sure you have regular tests
If relatives had colon polyps or colon cancer, get your colonoscopy now!
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Familial Risk Screening
Colon Cancer Screening
Familial Risk Screening Any Family HistoryAny Family History Same as Average Risk Screening,Same as Average Risk Screening, begin at age 55begin at age 55
Strong Family History -Definition:Strong Family History -Definition: 2 Affected First-degree Relatives 2 Affected First-degree Relatives or or 1 First-degree Relative Diagnosed <601 First-degree Relative Diagnosed <60Colonoscopy every 5 years, Colonoscopy every 5 years, Start at age 40 YearsStart at age 40 Years
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer ScreeningScreening 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%
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%
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Fewer than half of patients Fewer than half of patients diagnosed with colorectal cancer diagnosed with colorectal cancer had received a screening had received a screening procedure at least six months procedure at least six months prior to their diagnosisprior to their diagnosis
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
94 percent of colorectal cancer 94 percent of colorectal cancer patients had either not undergone patients had either not undergone a colonoscopy at all, or not until a colonoscopy at all, or not until having the procedure that led to having the procedure that led to their diagnosistheir diagnosis
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
The prognosis of colon cancer
is directly related to the
extent of disease when first
diagnosed!!
The prognosis of colon cancer
is directly related to the
extent of disease when first
diagnosed!!
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
There are no signs or symptoms
of colon cancer until late in the course!
There are no signs or symptoms
of colon cancer until late in the course!
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
LateLate signs include: signs include:
• change in bowel habitchange in bowel habit• rectal bleeding (red or occult)rectal bleeding (red or occult)• anemia (weakness, fatigue)anemia (weakness, fatigue)• cramping abdominal pain orcramping abdominal pain or• pelvic/rectal pain or strainingpelvic/rectal pain or straining
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer ScreeningGood News!Good News!
Now Medicare Now Medicare covers covers
Screening colonoscopy!Screening colonoscopy!
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer ScreeningMedicare pays for:Medicare pays for:
Fecal Occult Blood Tests - every Fecal Occult Blood Tests - every yearyear
Flexible Sigmoidoscopy - every 4 Flexible Sigmoidoscopy - every 4 years*years*
Screening Colonoscopy Screening Colonoscopy Every 10 years for average risk*Every 10 years for average risk*Every 2 years for high riskEvery 2 years for high risk
*if no exam of the colon in the past 4 years
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer ScreeningMEDICARE PAYS FOR COLONOSCOPYMEDICARE PAYS FOR COLONOSCOPY
Every 2 years for high risk:Every 2 years for high risk:close relative with colon ca close relative with colon ca
close relative with adenomatous polypsclose relative with adenomatous polypsfamilial adenomatous polyposisfamilial adenomatous polyposisprior polyps or colorectal cancerprior polyps or colorectal cancerInflammatory bowel disease (UC, Crohn’s)Inflammatory bowel disease (UC, Crohn’s)
Every 10 years for average risk*Every 10 years for average risk*
*if no exam of the colon in the past 4 years
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Let’s review Let’s review our strategy . . .our strategy . . .
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
What else can we do?What else can we do?
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
Lifestyle modifications may be useful:Lifestyle modifications may be useful:
• • Low-dose aspirin or NSAID’s dailyLow-dose aspirin or NSAID’s daily
• • Reduce animal fat Reduce animal fat
• • Increase fiber, calcium, magnesiumIncrease fiber, calcium, magnesium
? (fruits, vegetables) no proof!? (fruits, vegetables) no proof!
Lifestyle modifications may be useful:Lifestyle modifications may be useful:
• • Low-dose aspirin or NSAID’s dailyLow-dose aspirin or NSAID’s daily
• • Reduce animal fat Reduce animal fat
• • Increase fiber, calcium, magnesiumIncrease fiber, calcium, magnesium
? (fruits, vegetables) no proof!? (fruits, vegetables) no proof!
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Lifestyle modifications,Lifestyle modifications,and diet,and diet,What we know. . .What we know. . .
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
How can we detectHow can we detectColon cancer?Colon cancer?
4. Future Methods4. Future Methods
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Inherited Syndrome Screening
Colon Cancer Screening
Inherited Syndrome ScreeningFAPFAPSigmoidoscopySigmoidoscopy
Every one to two years, starting age Every one to two years, starting age 10 to 12 years10 to 12 years
HNPCCHNPCCColonoscopyColonoscopy
Every 1 to 2 years, starting age 25 Every 1 to 2 years, starting age 25 yearsyears
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
REFERRAL TO GASTROENTEROLOGIST
Colon Cancer Screening
REFERRAL TO GASTROENTEROLOGISTPositive screening testsPositive screening tests
Questions about appropriate screeningQuestions about appropriate screening
When colonoscopy is needed When colonoscopy is needed
Diagnosis and/or management of the Diagnosis and/or management of the known inherited syndromes of colon known inherited syndromes of colon cancercancer
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
Your survival --
--is up to you!!
Your survival --
--is up to you!!
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer ScreeningIf you won’t do it for If you won’t do it for
yourself. . .yourself. . .
Do it for the ones who Do it for the ones who love you!love you!
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Does a test need to be Does a test need to be ‘cost effective’ to be ‘cost effective’ to be recommended?recommended?
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening
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D. M. Kruss MDD. M. Kruss MD
Colon Cancer Screening