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    C:\Fakepath\Screening For Crc2 C:\Fakepath\Screening For Crc2 Presentation Transcript

    • SCREENING FOR COLORECTAL CANCER UNIVERSITY OF ILLINOIS CHICAGO JUNE 02, 2006 PREPARED BY RAMON GARCIA, MD, FACP GARCIA MEDICAL CENTERS
    • Garcia Medical & Endoscopy Center
    • RATIONALE
      • The earlier the detection of localized lesions in asymptomatic individuals, the greater will be the surgical cure rate.
      • Particularly IMPORTANT in:
        • Individuals with a FH of the disease.
        • These have 1.7 times the risk.
        • Risk > if FH occurs before age 60.
    • Basics of Colon Cancer
      • CRC is the 2 nd or 3 rd leading cause of cancer death in the USA.
      • 150,000 cases diagnosed every year
      • 56,000 die
      • CRC is preventable
      • Most of the time, it starts as a polyp.
      • And…precancerous polyps present themselves years before they become malignant.
    • THE BAD GUYS: POLYPS
      • Hamartomas,Hyperplastic or Adenomatous
      • Adenomatous polyps:
        • Tubular
        • Villous
        • Tubulovillous
      • Polyps are either Pedunculated or Sessile.
      • Sessile more dangerous than pedunculated.
      • Villous more dangerous than the others.
      • Size is important: > 2.5 cms 8-30% of malignancy
      • 1% of Adenomatous polyps become malignant.
      • Found in 30% of autopsies.
    • MOLECULAR PATHOGENESIS
      • DNA mutations in polyps
        • Loss of Tumor Suppressor Gene
          • Allelic Loss: Chromosomes 5 and 18
          • APC Tumor Suppressor Gene, p-53
          • B-catenin ( Stomach, cell adhesion)
          • Tcf-4 (Transcription protein)
        • Activation: Oncogene
          • c-MYC Oncogene
      • Relevance: Tests being developed.
        • Analysis of stool for mutations in the APC (Adenomatous Polyposis Coli) tumor suppressor gene.
    • THE PROBLEM
      • Overall mortality decreased slightly between 1992-2000.
      • Rates for Hispanics remained the same.
        • Likely attributable to lower screening rates.
        • And thus, less likely to be diagnosed at an earlier stage.
      • Education,Income and Health Insurance affect the rate of screening for all groups.
      • Northeastern States have a higher percentage of screening as well as a smaller disparity of screening between groups than do the Southwestern States.
      • Regardless of ethnicity CRC screening is low in all groups.
      • Factors beyond health care access prevent Hispanic men and women from receiving CRC tests.
    • Geographical Differences
      • .
    • ETIOLOGY AND RISK FACTORS
      • DIET
        • Animal Fats (colonic anaerobe count)
        • Insulin Resistance (IGF-1)
        • Fiber ?
      • HEREDITY
        • Polyposis Coli
        • HNPCC (Lynch) Hereditary Non-polyposis colon cancer
        • 25% of CRC patients have a FH
      • IBD
        • Incidence small in the first 10 years
        • Rises to 8-30% after 25 years of active disease
        • Prophylactic colectomy ?
      • URETEROSIGMOSDOSTOMY
      • BACTEREMIA
      • TOBACCO
    • PRIMARY PREVENTION
      • ASA
        • Cyclo-oxygenase
      • FA
      • CALCIUM
      • Estrogen Replacement
        • Bile acids
        • IGF-1
    • CDC Guidelines
      • FOBT – FIT every year
        • Pros:
          • Cheap, Easy, Part of PE
          • Statistical reduction in mortality in individuals with annual screening.
        • Cons:
          • Interference from: Diet, vitamins, etc.
          • High False (+): Less than 10% will have CRC
          • High False (-): More than 50% of CRC will be Heme (-)
      • Flexible Sigmoidoscopy every 5 years
        • Pros: Relatively simple
        • Cons:
          • Incidence of CRC moving to the Right Side of the Colon.
          • Invasive
          • Misses half of the lesions
      • Double contrast BE every 5 years
    • CDC GUIDELINES (Cont.)
      • Colonoscopy every 10 years
        • Pros:
          • Higher sensitivity than any of the above in detecting villous adenomas.
        • Cons:
          • Expensive
          • Invasive
          • Cost effectiveness remains to be determined.
        • Being considered to replace the others:
          • Every 10 years after 50.
      • Screening rates are so bad that the best one is the one you get.
    • Tubular Adenoma
    • Rectal CA