C:\Fakepath\Screening For Crc2

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C:\Fakepath\Screening For Crc2

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

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