This is a detailed presentation about colon cancer- clinical presentation and preventive strategy .

1. March - CRC Awareness Month

2. Colorectal Cancer
Prevention & Early Detection
Vijay Arya M.D.,F.A.C.P.,F.A.C.G.,A.G.A.F.
Clinical Asst. Prof. of Medicine at Northwell.
Director,Endoscopy Unit, WHMC.
March - CRC Awareness Month

3. • Third most common cancer in USA
- 131,607 new cases/year (2012) 67,700
men, 63907 women
• Second Leading cause of cancer
death in men and women
- 51,690 deaths (2012)
• Average patient CRC death
- Losses 13 years of life
• A person at age of 50 has about
- 5 % lifetime risk
- 2.5% CRC death rate
CRC Facts

5. CRC Etiology
• Environmental
– Stress
– Activity
– Diet
• Genetic – Sporadic 85-90% Avg risk
• - HCCS 5-10% High risk

6. Consumption of red meat and
Saturated fat
Refined carbohydrates
Alcohol
Lack of regular physical activity.
Low fruit and vegetable intake.
A low-fiber and high-fat diet.
Overweight and obesity.
Tobacco use.
INCREASED RISK
Dietary factors implicated in colorectal
carcinogenesis

8. North America has highest rate of Obesity-
related cancers
•Colon
•Rectum
•Pancreas
•Esophagus
•Others

9. Dietary fiber
Vegetables
Fruits
Antioxidant/ vitamins
Calcium
folate (B Vitamin)
DECREASED RISK
Dietary factors implicated in colorectal
carcinogenesis

10. LIFESTYLE MODIFICATION
• 35% of all cancers are attributable to
diet
• 50%-75% of CRC in the US may be
preventable through dietary
modifications
• You are what you EAT
• When, what ,where, how, how much to
eat ?
• You can,t change your genetic makeup

11. Chemo-Prevention
• Above age 50 ,Healthy ,without risk of GI
Bleeding
• Aspirin 75 , 80 , 100 mg / day
• Many years before benefit
• High risk of bleeding- Hx of PUD, NSAID,S
• Antiplatelet meds
• Steroids
• Age >65

12. Genetic Model of Colorectal Cancer
Bat-26
(HNPCC)
APC
Mutation
Normal
Epithelium
K-ras
Adenoma
Bat-26
(Sporadic)
p53
Late
Adenoma
Early Late
Cancer Cancer
Dwell Time: Many decades 2-5 years 2-5 years
Optimum phase for
early detection
Courtesy of Barry M. Berger. MD, FCAP EXACT Sciences

13. Janne and Mayer 2000
ADENOMA-CARCINOMA SEQUENCE (1993)

14. • AGE: 90% of cases occur at age 50 and
above
Average Risk Factors for Colorectal CancerAverage Risk Factors for Colorectal Cancer

15. Average Risk Factors for Colorectal CancerAverage Risk Factors for Colorectal Cancer
• Male > Female

16. • Asymptomatic
Average Risk Factors for Colorectal CancerAverage Risk Factors for Colorectal Cancer

17. Age/ Gender/ Ethnicity
• >80% of CRC diagnosed > 55 yrs
• Life time risk 5.7% M v/s 5.1% F
• Mortality for F lag behind by 10 yrs
• Increased age, male sex, black race- Higher
incidence
• African American screening start age 45
• USPSTF- recommends screening Age 50-75
• >Age 76 , individual basis

18. COLONOSCOPY
• Excellent prep up to cecum/ withdrawal time
at least 6 minutes/ No polyps- 10 yrs
• 1-3 Adenomas ( <1 cm) – 5 yrs
• 3-10 Adenomas – 3 yrs
• Poor prep ( unable to detect 5 mm polyp)- Rpt
colonoscopy with better prep
• PCPs & Patients are requesting for rpt
colonoscopy sooner than required
• New patients need to get screened

19. –First Degree Relative with colon cancer
–Hx of ureterosigmoidostomy
–Personal history of Adenomas
–Inflammatory Bowel Disease / with PSC
–Type 2 Diabetes
–Acromegaly
–Bacteremia – strep bovis, clos
septicum,strep agalactiae
–Familail breast ca- BRCA 1 or 2 mutation pos
High Risk Factors for Colorectal Cancer?High Risk Factors for Colorectal Cancer?

21. Higher than Avg risk
• Pt,s 53 yr old brother had an adenoma
• Start screening at age 40 or 10 yrs prior to
diagnosis of affected relative,whichever
comes first.
• Hx of CRC <55, Adenoma <60 – special efforts
to screen first degree relatives

22. Higher than Avg Risk
• Large adenoma >1 cm
• Multiple adenomas >2
• Villous adenoma or High grade dysplasia
• F hx of CRC
• RPT Colonoscopy should be done in 3 yrs

23. Malignant polyp
• Favorable criterion
• Complete excision
• Not poorly differentiated
• No vascular/ lymphatic invasion
• f/u colonoscopy in 3 months to check for
residual tissue at polypectomy site if neg rpt
at 1 yr

24. Malignant plyp
• Unfavorable signs
• Incomplete excision
• Less than 2 mm margin from polypectomy
• Undifferentiated
• Vascular/ lymphatic invasion
• Hemicolectomy should be done

25. HCCS- CLUES
• CRC/ Polyps Age < 50
• >10 Adenoma
• Syn/ Meta cancers
• Numerous relatives with cancers
• Accurate personal /3 generation fhx
• 3-2-1 rule
• Age at diagnosis/ death
• All- AD except MYH asso polyposis( MAP)

26. SHARE THE INFO
• 5-10% of CRC
• Identify pts- counseling /genetic testing of at
risk
• Risk reducing management
• Syn specific surveillance
• Not at risk- avg risk CRC
SAVE THE

27. HCCS
• A- non-polyposis-
• HNPCC
• LS
• Lynch like syn
• Familial crc type x
• B- polyposis syn-
• FAP/ MAP/JPS/PJ/Hamartoma ts/ SPS

28. HCCS- 3 Q TOOL
• Personal hx of polyp/ CRC < age 50
• First degree relative < age 50 with CRC,
uterine, ovarian, gastric, small bowel, kidney,
ureter, bladder, biliary, pancreas, or brain
• >2 FDR or SDR with CRC ,any age
• One in Five ( 20%) LS Missed
• Universal molecular testing of all
CRC/Adenoma

29. HCCS
• LS – germline mutation in MMR gene & MSI-H
• MMR defi in Tumor can be detected by IHC
• Histological clues to MSI-H
• Poorly diff, mucinous & signet cell
• Tumor infiltration by lymphocytes
• Crohn’s like lymphocyte reaction

30. HCCS
• Mutation in ¼ MMR gene
• MLH1,MSH2,MSH6,PMS2
• Large deletion in EPCAM /hyper MSH2
• Microsatellites are areas of short DNA rpts
• Cacacaca– prone to errors in replication
normally corrected by MMR gene
• Can be studied in tumor/ nl tissue/blood
• >2 MSI-H , 1 MSI-L ,0 MSS

31. HCCS – S/S Colonoscopy
• Colonoscopy 1-2 yrs beginning age 20-25
• Pelvic exam –annual
• Transvaginal us/ endometrial sampling
• EGD 2-3 yrs with HP testing -age 30-35
• Colectomy with ileo-anal anastomosis
• Aspirin –chemoprevention
• Hysterectomy/ bilat sal- age 40 / finished
child-bearing

32. HCCS- Case
• 37 yr old pt,s 62 yr old mother with colon ca
• Maternal uncle –colon ca
• Maternal grand-mother- endometrial ca
• Suspect HCCS
• Genetic counselling
• Mother,s tumor tissue for –MSI
• If pos – blood test for germ line mutation in
mmr gene
• Neg blood test does not exclude the dx

33. FAP/MAP
• About 1% each with pheno overlap
• <100 adenoma – attenuated FAP- late teenage
• 100-1000- classic -preteenage
• >1000 profuse -preteenage
• 100% gastric/duod fundic gland polyps
• 100% risk of CRC around age 40
• Bx nl papilla to r/o adenoma( 2 nd cancer)
• Thyroid/ brain/hepatoblastoma
• Cong hyp of retinal pigment

35. High Risk-Sporadic
• 15% Sporadic CRC ,MSI-H
• Pos MLH1 gene
• Pos BRAF mutation
• Sporadic CRC ( 85-90%)- genetic alt in single
cell- chromosomal instability with MSS

37. Symptoms associated with CRC
Weight loss
Loss of appetite
Night sweats
Fever
Rectal bleeding
Change in bowel habits
Obstruction
Abdominal pain & mass
Iron-deficiency anemia

38. • Offer Early Detection / Primarily Cancer
• High-Sensitivity FOBT -Annual ( FIT ,Stool
DNA based Tests, (DCBE,CTC – every 5 yrs)
• Offer Detection of polyp/cancer
&Prevention
• Flexible Sigmoidoscopy – Every 5 year
• Colonoscopy- Every 10 year
Types of Screening

40. Benefits of Screening
 Cancer Prevention
• Removal of pre-cancerous polyps to prevent cancer
(unique aspect of colon cancer screening)
 Improved survival
• Early detection markedly improves chances
of long-term survival
Largest reduction in mortality during the 10 yrs after screening
Comes from detection and removal of early stage cancer
Annual FOBT reduces CRC mortality and incidence by 30%
FS has also shown the same benefit
Colonoscopy reduces mortality by 60-70% ( RCTs Awaiting)
100% Adherence to same regimen is equally effective

41. Benefits of Screening
Survival Rates by Disease Stage*
5-yr
Survival
*1996 - 2003
100
90
80
70
60
50
40
30
20
10
0
89.8%
67.7%
10.3%
Local Regional Distant
Stage of Detection

42. Colorectal Screening Rates
 Just 40% of colorectal cancers are detected
at the earliest stage.
 A little more than half * of Americans over
age 50 report having had a recent colorectal
cancer screening test
Slow but steady improvement in these numbers
over the past decade (but all are not benefiting
to the same degree)
*varies based on data source

43. Colorectal Screening Rates Low:
Reasons (according to Patients)
 Low awareness of CRC as a personal health threat
 Lack of knowledge of screening benefits
 Fear, embarrassment, discomfort
 Time
 Cost
 Access
 “My doctor never talked to me about it!”
22 million people not up-to-date with screening

44. CT Colonography (CTC)
CTC Image Optical Colonoscopy
*AKA “Virtual Colonoscopy”
Images courtesy of Beth McFarland, MD

45. CT Colonography
Rationale
 Allows detailed evaluation of the entire colon
 A number of studies have demonstrated a high
level of sensitivity for cancer and large polyps
 Minimally invasive (rectal tube for air insufflation)
 No sedation required

46. CT Colonography
Limitations
 Requires full bowel prep (which most patients find
to be the most distressing part of colonoscopy)
 Colonoscopy is required if abnormalities are detected,
sometimes necessitating a second bowel prep
 Steep learning curve for radiologists
 Limited availability to high quality exams in many
parts of the country
 Most insurers do not currently cover CTC as
a screening modality

47. CT Colonography
Limitations
 Extra-colonic findings can lead to additional testing
(may have both positive and negative connotations)
 Questions regarding:
 Significance of radiation exposure
 Management of small polyps

48. Sigmoidoscopy is Incomplete
Equivalent to
“left breast mammogram”

49. Colonoscopy
Colonoscopy is considered the gold standard for colorectal cancer screening

51. Beth Israel Medical Center
1
Sivak et al., 2004, 2
Winawer et al., 1993
Dr Hiromi Shinya1
and Dr William Wolf
 1971 - First colonoscopic polypectomy
COLONOSCOPY

52. • Available best option:
– Screening Colonoscopy/polypectomy
Polyp to Cancer Progression
CRC is Preventable / Curable

53. DISCOVERY OF THE CENTURY
Polypectomy snare

54. Quality Colonoscopy
• An effort to make Colonoscopy less variable
through a process of measurement, education
& performance enhancement
• Adenoma Detection Rate( ADR)
• Withdrawal time
• Cecal Intubation Rate ( CIR)
• Adherence to screening / surveillance intervals
• Prep quality to see polyp 6 mm & >

55. ADR
• 1% increase in ADR = 3 % reduction in CRC
incidence / 5% reduction in mortality
• Simple act of measurement improved ADR
• ASGE-maintain passport
• ADR= protection against CRC
• Education
• Withdrawal technique
• Technical advances and devices

56. ADR
• High ADR= Better cleared at first
colonoscopy=Shorter interval ( double
protection)
• Low ADR= Not effectively cleared= Longer
interval ( double lack of protection)
• 3 or > Adenoma( 1 cm/ >) ,f/u exam at 1 yr
• Future--Incentive to achieve high ADR/ allow
longer interval = Improve cost-effectiveness

57. CIR
• TI intubation is gold standard
• IC valve, Appendiceal orifice, Taenia coli
• Medial wall of cecum
• Documentation with Photographs
• Low CIR = Higher rate of interval CRC

58. Bowel Preparation
• Dreaded more than procedure itself
• Patient perspective
High volume
Unpalatable
Dietary restriction
Complex instructions
Day before v/s split dose
Impact on work or daily activity
Tolerability (side effects)

59. Bowel Prep
• Inadequate bowel prep -20-40%
• Rpt procedures- Cost
• Missed lesions-both small and large
• Commonly used preps- PEG
• 2 L V/S 4 L
• Day of , Day before, Split
• Adjuvant - Dietary restrictions/ NPO

60. TYPE OF PREPARATION

61. PREP COMPARISON

62. Bowel Prep Scale
• Overall -Poor, Fair, Good , Excellent
• Segmental scores
• BBPS – R, T, L 0-1,2,3 Max 9 , Adequate 5
• ABPS- C, A,T,D,S,R Max 24 , Adequate 13
• Total score doesn’t guarantee adequate prep
in all segments

63. Complications
•Miss rate :
- 5% of Colorectal Cancer
- 2% - 12% Polyp 1cm or larger
- >20% Polyp 6mm or larger
•Bleeding (2 -6 per 1000 examination)
•Bowel Perforation ( approx 1 per 1000 examination)
•Infection (approx 4% )
•Mortality (0.03%)
•Abdominal Pain & discomfort (5% - 11%)

64. Source: National Endoscopy Database/Clinical Outcomes Research Initiative
COLONOSCOPY – ALL AGES

65. Mortality
Person years of life lost
COLORECTAL CANCER

66. Trends
 Incidence and deaths rates have fallen steadily for the past
20 yrs
U.S. Colorectal Cancer Mortality 1975-2005
40.0
35.0
30.0
25.0 Blalck Male
WhiteMale
20.0
Black Female
15.0 White Female
10.0
5.0
0.0

67. Research suggests that these declines are due in large
part to:
•Screening and polyp removal, preventing progression of
polyps to invasive cancers
•Screening detecting cancers at earlier, more treatable
Stages
•CRC treatment advances

68. CRC is third leading cause of death in USA
Early stages are detectable/ curable
Screening can prevent CRC
Katie Couric: http://www.nccra.com/about/videos.htm
SUMMARY

69. POLYPECTOMY

70. S

72. Endoscopic Removal of Large Colon Polyps
Endoscopic Mucosal Resection (EMR)
Endoscopic Submucosal dissection (ESD)
- ESD is a variant of EMR in which a specialized
needle knife is used to dissect lesions from the
submucosa. The advantage of ESD is that it often
permits removal of large sessile polyps en bloc (eg. in
one piece), whereas EMR often removes the polyp
piecemeal.

73. Polypectomy Risks
Removal of large colon polyps during endoscopy is
associated with various risk, including:
- Perforation
- Bleeding
- Post Polypectomy Syndrome
- Inadequate Polypectomy

74. Non Invasive Polyp
Large polyps may contain cancer that is completely contained within the polyp.
In these cases, polypectomy is considered curative, provided:
- The cancer is completely contained within the resected tissue
- No lymphovascular invasion
- Resection margins are free of cancer

75. Invasive polyps features that suggest the presence of malignancy include:
- Friability
- Induration
- Ulceration
- Smooth velvety surface (e.g. non-granular laterally spreading tumor in the Rt colon)
- Non lifting sign
Invasive Polyp

76. Endoscopic Ultrasound Role (EUS)
EUS can be used to assess invasive polyps features, especially sessile lesions in
the rectum, such as:
- Sub-mucosal invasion
- Enlarged Lymph nodes
Conventional EUS vs High frequency Mini-probes through the biopsy channel of the
colonoscope to visualize the entire colon

77. Polyp size and location
- Unusually large polyps ( >10 cm or with circumferential growth ) are not a
contraindication for endoscopic polypectomy.
- Such polyps may require multiple sessions for removal and subsequent
surveillance is mandatory
- These considerations should be explained to the patient prior to embarking on a
course of endoscopic resection

80. Patient Preparation
- The preparation for endoscopic removal of large colon polyps
is the same as that for routine colonoscopy and includes
dietary changes and consumption of a bowel preparation.
- Polypectomy is a high-risk procedure with regard to bleeding
- Patient taking antiplatelets and anticoagulants will need to
stop the medication
- Antibiotic prophylaxis is not recommended for polypectomy

81. Equipment
In addition to the standard endoscopic equipment, additional equipment that may
be used for the removal of large colon polyps includes:
●Polypectomy snares
●Electrosurgical generators
●Injection needles
●Saline or hyaluronic acid
●Methylene blue or indigo carminedye for staining
●India ink or other dye for tattooing
●Retrieval nets
●Hemoclips
●Nylon loops
●Argon plasma coagulation probes
●Argon gas
●Needle knives
All of the devices used can pass through the working channel of a standard
endoscope.

82. Submucosal Injecion
-Injection of saline or an alternative substance into the submucosa below the polyp
raises the polyp on a cushion of fluid, facilitating endoscopic resection and
potentially decreasing the risk of perforation during subsequent snare excision
-A problem with saline injection is that it is rapidly absorbed. As a result, alternative
agents that are not as rapidly absorbed have been studied (with and without
epinephrine), including hyaluronic acid, dextrose solutions, succinylated gelatin,
and hydroxyethyl starch

83. COLONOSCOPES
RETRO-VIEW COLONOSCOPE
HIGH DEF. COLONOSCOPE

84. Technique
There are two primary goals of colonic polypectomy:
- Complete remove of all neoplastic tissue.
- Retrieval of all tissue sample
Only complete excision of the polyp permits accurate histologic diagnosis

87. High Def. Colonoscopy vs Chromoscopic
Colonoscopy

88. Chromoscopic Colonoscopy

89. Colonoscopy Report

90. Colonoscopy Report

91. Surgical Removal
HISTOLOGY (Invasive Polyp), SIZE, LOCATION
- Size: Polyp ≥2.0 cm in their greatest dimension, eg. large sessile polyp
- Difficult location, eg. Cecum
- Saddle polyp:
Figure: Supine double-contrast
barium enema spot image
shows a semiannular “saddle”
carcinoma. This lesion in the
transverse colon manifests as
two convex, barium-etched lines
(arrows) that represent the
edges of the lesion, which
straddles one-half of the
circumference of the bowel.

92. Surgical Removal
Surgery may be a better option for patients with:
- Polyps that occupy more than 1/3 of the circumference of the colon wall
- Presence of two cross haustral folds
- Polyps involving the base of the appendix
- Multiple large polyps in the right colon
- Patients with uncontrollable bleeding disorders

93. HOW IS COLORECTAL CANCER PREVENTED
•SHORT TERM
-Screening: A screening test is used to look for a
disease when a person is not
experiencing any symptoms.
•LONG TERM
-Life style modification

94. • Epidemiology
• Who is at Risk – Avg risk $ High risk
• How it can be prevented- short term/ long
term
• Short term – screening methods
• Long term – life style modification

95. Diagram of Colon and Rectum

96. TAKE THE QUIZ. GET THE TEST

97. Colorectal Cancer Screening
What is screening?
A screening test is used to look for a disease when a
person is not experiencing any symptoms.
Why is screening Important?
When Should I Begin to Get Screened?

98. Tests for Polyps and
Cancer

99. Anatomy and CRC Distribution
Transverse 15%
Ascending
25%
Cecum
Rectosigmoid
10%
Descending 5%
Sigmoid
25%
Rectum 20%

100. Colonoscopy
Colonoscopy
allows doctor
to directly see
inside entire
bowel

101. • Do I need to get a screening test for colorectal cancer?
• What screening test(s) do you recommend for me?
• How do I prepare?
• Do I need to change my diet or my usual medication schedule?
• What's involved in the test?
• Will it be uncomfortable or painful?
• Is there any risk involved?
• When and from whom will I get results?
If you're having a colonoscopy or sigmoidoscopy, you will want to know—
• Who will do the exam?
• Will I need someone with me?
Ask Your Doctor

102. 1. Can you use a brand new scope?
2. I have no problems why do I need a colonoscopy?
3. Can I use the pills for prep ?
4. Can I go for CTC instead of colonoscopy?
5. I do not have any one to accompany me
6. Can you schedule me in afternoon?
7. Can I go back to work after the procedure?
8. What is the age to stop screening ?
9. Can I have a DVD of my colonoscopy?
10.Is my risk lower if I am not born in USA?
FAQ

103. Prevention is better than Cure
Screening saves lives
Colon cancer is Curable if detected early
If you can’t do it for yourself, do it for your
family
Health is Wealth

104. Thank you