CRC Screening

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CRC Screening

  1. 1. CRC Screening Colorectal Cancer Screening
  2. 2. <ul><li>“Colorectal cancer commands the attention of [us all] because it is one of the most lethal diseases that we deal with, it occurs frequently (and silently), and it is a disease for which we have the greatest ability to intervene and alter the natural history in a dramatic way.” </li></ul><ul><li>C. Richard Boland, MD </li></ul>
  3. 3. How lethal is CRC? <ul><li>CRC is the third most common internal cancers in men & women </li></ul><ul><li>CRC is the second leading cause of cancer death </li></ul><ul><li>CRC is the leading cancer death in men and women who do not smoke </li></ul><ul><li>We each have a 1 in 18 chance of developing the disease </li></ul>
  4. 4. Deaths in USA <ul><li>150,000 new cases of CRC each year </li></ul><ul><li>57,000 people died from CRC yearly </li></ul><ul><ul><li>½ are women </li></ul></ul><ul><ul><li>Typically affects people 50 yrs and older </li></ul></ul><ul><ul><li>Men have > risk of CRC but more women die of CRC because they live longer </li></ul></ul><ul><ul><li>Relative risk highest amongst African-American </li></ul></ul><ul><ul><li>CRC can be heredity </li></ul></ul><ul><ul><ul><li>Familial Adenomatous Polyposis [FAP], 1% </li></ul></ul></ul><ul><ul><ul><li>Hereditary nonpolyposis CRC, [HNPCC] 5% </li></ul></ul></ul><ul><ul><ul><li>Family Hx of CRC or adenomas, 18-23% </li></ul></ul></ul><ul><ul><ul><li>Personal Hx of prior colon cancer, long standing IBS, Crohn’s, ovarian, endometrial and probably breast cancer </li></ul></ul></ul><ul><ul><ul><li>Most cases are sporadic in average risk patients, 65-85% </li></ul></ul></ul>
  5. 5. Deaths World Wide <ul><li>CRC is the 4 th most common cancer world wide </li></ul><ul><li>New cases yearly </li></ul><ul><ul><li>400,000 in men </li></ul></ul><ul><ul><li>380,000 in women </li></ul></ul><ul><li>Almost 400,000 deaths yearly </li></ul><ul><ul><li>CRC is the 1st most common cause of cancer in the European Union (1) </li></ul></ul>
  6. 6. What else do we know about CRC? <ul><li>Through screening, CRC is the most preventable visceral cancer. </li></ul>
  7. 7. Currently there is a low level of CRC screening. This is due to: Physician, then patient attitudes about current screening methods.
  8. 8. <ul><li>In order to “beat” a problem, it is wise to learn everything about it you possibly can. </li></ul><ul><li>SO….. </li></ul>
  9. 9. What are the contributors to CRC? <ul><li>Older Age </li></ul><ul><li>Ethnicity </li></ul><ul><li>Personal/Family history of CRC </li></ul><ul><li>Polyps </li></ul><ul><ul><li>Present in 10-30% of population by age 50 yo </li></ul></ul><ul><ul><li>Present in 30-60% of population by age 70-75 yo </li></ul></ul><ul><ul><li>Reduced incidence of CRC when polyps are removed </li></ul></ul><ul><li>Diet high in meat, fat, protein, or alcohol & low in fiber, calcium, selenium, or folate are associated with increase in CRC </li></ul>
  10. 10. What are the distracters to CRC? <ul><li>Young Age/However occurs 7% in people <50 </li></ul><ul><li>Ethnicity </li></ul><ul><li>No Personal/Family history of CRC/However 80% occurs in people without history </li></ul><ul><li>Diet low in meat, fat, protein, or alcohol & high in fiber, calcium, selenium, or folate are associated with decrease in CRC </li></ul><ul><li>HRT decreases CRC </li></ul><ul><li>ASA & NSAIDS may reduce CRC </li></ul><ul><li>Lifestyle can affect risk, decreasing CRC with exercise & healthy eating. </li></ul><ul><li>BUT in particular…screening for CRC, decreases CRC. </li></ul>
  11. 11. Screening Facts <ul><li>60% of Americans over 50 have NEVER been screened for CRC </li></ul><ul><li>ALL FORMS OF SCREENING REDUCES MORTALITY </li></ul><ul><li>Screening detects and removes pre-cancerous polyps </li></ul><ul><li>Screening is cost-effective </li></ul>
  12. 12. According to Vogelstein @ John Hopkins.. Normal Adenoma Advanced Adenoma Early Carcinoma Colonic epithelium Benign neoplasia Lasting many decades Benign, 2 -5 years Malignant neoplasm Late Carcinoma 2 -5 years Benign neoplasia … we may have decades plus/minus 10 years to find CRC!
  13. 13. EARLY DETECTION IS THE KEY! <ul><li>Even if we don’t get CRC in the adenoma stage, localized CRC 5-yr survival rate is 90% compared to 5% with metastasizes. </li></ul>
  14. 14. Who do you screen? <ul><li>The Average Risk Person [ARP] = is 50 yo or older without other risk factors for CRC = 75-80% of the at risk population </li></ul><ul><li>Other high risk patients should be screened earlier = 25-20% of the at risk population </li></ul><ul><li>Lowest screened: </li></ul><ul><ul><li>People aged 50-54 (31%) </li></ul></ul><ul><ul><li>Hispanics (31%) </li></ul></ul><ul><ul><li>Asian/Pacific Islanders (35%) </li></ul></ul><ul><ul><li>People < 9 th grade education (34%) </li></ul></ul><ul><ul><li>No Health Care (20%) </li></ul></ul><ul><ul><li>Medicaid Coverage (29%) </li></ul></ul><ul><ul><li>No medical care during last year (20%) </li></ul></ul><ul><ul><li>Daily smokers (32%) </li></ul></ul><ul><ul><li>More screening in New England / Mid-Atlantic </li></ul></ul><ul><ul><li>Less screening in Gulf/South </li></ul></ul>
  15. 15. High Risk People = 20-25% of population <ul><li>People with HNPCC diagnosis </li></ul><ul><ul><li>These people get CRC at 45 yo instead of the common age of 63 yo </li></ul></ul><ul><ul><li>Also increased in people with endometrial, ovarian, breast cancer </li></ul></ul><ul><ul><li>Begin screening at 20 -30 yo </li></ul></ul><ul><ul><li>High suspicion when they follow the “Rule of 3-2-1” [Amsterdam II criteria] </li></ul></ul><ul><ul><ul><li>3 relatives with CRC/at least one is first degree relative of the other two </li></ul></ul></ul><ul><ul><ul><li>2 successive generations </li></ul></ul></ul><ul><ul><ul><li>1 diagnosis before the age of 50 </li></ul></ul></ul><ul><ul><li>Mutation in the hMSH2 & hMLH1 genes [signaling proteins responsible for gene repair] that increases microsatelitte instability [MSI] = Hallmark of HNPCC </li></ul></ul>
  16. 16. More High Risk <ul><li>People with Familial Adenomatous Polyposis, FAP </li></ul><ul><ul><li>50% have polyps in teens </li></ul></ul><ul><ul><li>95% have polyps by 35 yo </li></ul></ul><ul><ul><li>100% have CRC by 40 yo unless their colon is removed </li></ul></ul><ul><ul><li>Mutation in the APC [adenomatous polyposis coli] gene responsible for tumor suppression </li></ul></ul><ul><li>Ashkenazi Jews </li></ul><ul><ul><li>6% population has double the risk of CRC </li></ul></ul><ul><ul><li>Mutation in APC tumor suppressor gene </li></ul></ul><ul><li>African American men & women </li></ul><ul><ul><li>Develop CRC more commonly on the right side of the colon. May be missed depending on screening modality. </li></ul></ul>
  17. 17. Fact! <ul><li>Every man and woman 50 years or older is at risk for the development of CRC. </li></ul>
  18. 18. CRC Screening Options for Patients Presented in 1997 by AGA* <ul><li>Annual Fecal Occult Blood Testing [FOBT] </li></ul><ul><li>Flexible sigmoidoscopy every 5 yrs </li></ul><ul><li>Annual FOBT plus flexible sigmoidoscopy every 5 yrs </li></ul><ul><li>Double-contrast barium enema every 5 yrs </li></ul><ul><li>Colonoscopy every 10 yrs </li></ul><ul><li>* American Gastroenterological Association </li></ul>
  19. 19. Patient Selection of Options <ul><li>Almost noninvasive </li></ul><ul><ul><li>31% chose FOBT only </li></ul></ul><ul><li>Invasive procedures: </li></ul><ul><ul><li>38% chose colonoscopy, most preferred invasive option </li></ul></ul><ul><ul><li>14% preferred barium enema </li></ul></ul><ul><ul><li>13% preferred flexible sigmoidoscopy </li></ul></ul><ul><li>71% chose to repeat colonoscopy </li></ul><ul><ul><li>36% chose to repeat FOBT </li></ul></ul>
  20. 20. Why patients don’t participate….. <ul><li>Fear of pain, embarrassment, distaste </li></ul><ul><li>Lack of perceived need </li></ul><ul><li>Fear of the results </li></ul><ul><li>Fatalism [belief nothing can be done] </li></ul><ul><li>Too busy, not willing to take time off for screening </li></ul><ul><li>Inadequate transportation and telephone service </li></ul><ul><li>Deference to authority </li></ul><ul><li>Lack of screening coverage by health plan or no insurance </li></ul>
  21. 21. Why patients do participate….. <ul><li>Clinician advise </li></ul><ul><li>Perceived benefit [test as effective] </li></ul><ul><li>Family member who has had the test </li></ul><ul><li>Continuing relationship with the practitioner </li></ul><ul><li>Higher socioeconomic status </li></ul><ul><li>More personal experience of illness </li></ul><ul><li>Regular preventive health behavior [dentist, use of seatbelts] </li></ul><ul><li>Family history of CRC </li></ul><ul><li>Age under 75 yrs </li></ul><ul><li>Being married </li></ul><ul><li>Belief that CRC is curable </li></ul><ul><li>Other GI symptoms [stomach symptoms, haemorrhoids] </li></ul>
  22. 22. How to get patient cooperation… <ul><li>… physicians must first OFFER patients a controlled screening choice. </li></ul>
  23. 23. <ul><li>To date, all choices of CRC screening have been based on an understanding of disease that originated 30 years ago. A time when many of our current medical physicians were beginning their careers. These classifications were based on morphological differences; tumors were grouped according to levels of differentiation, gland formation, etc, but gave little insight into clinical management according to biological type. </li></ul>
  24. 24. Today….. <ul><li>….we are beginning to understand the biological concepts of CRC </li></ul><ul><li>To access additional information on the biological types of CRC, click on the below link. </li></ul><ul><li>Biological concepts of Colorectal cancer </li></ul>
  25. 25. Thus in 2003 two more modalities were added to our current screening procedures. <ul><ul><li>One, a marketing venture called “Virtual Colonoscopy” Known as CT Colonography in the medical world. </li></ul></ul><ul><ul><li>Two, a biological “hands-off” testing that relies on the current understanding that CRC is the end result of a heterogeneous group of processes that alter the biological characteristics of colorectal epithelium </li></ul></ul>
  26. 26. 2004’s Available Screening Modalities <ul><li>FOBT-Fecal Occult Blood Testing </li></ul><ul><ul><li>Digital Rectal Exam [DRE] - is NOT a screening Test for CRC </li></ul></ul><ul><li>Flexible Sigmoidoscopy </li></ul><ul><li>Double Contrast Barium Enema </li></ul><ul><li>Colonoscopy [Screening & Diagnostic] </li></ul><ul><li>Stool-based DNA Testing </li></ul><ul><li>Virtual Colonoscopy </li></ul>
  27. 27. Testing Options Most expensive diagnostic test / No direct evidence of effectiveness Projected sensitivity less than colonoscopy Only test that is screening, diagnostic and therapeutic during a single procedure Not preferred if other screens are available Not firmly effective, must be used with FOBT. ^40% reduction CRC ^^30% reduction Effective $800 Every 3 to 5 yrs. Interval not clearly determined. High compliance expected. Expected to be high 65-70% decrease in CRC mortality Noninvasive/ Testing is representative of entire colon Patient, No direct stool handling Stool-based DNA Testing $2000-$3000 Longest interval protection/ every 10 yrs as screening tool Bowel Prep/ Anesthesia, thus variable / Perforation risk 1:500 to 1:4000 Highest sensitivity may prevent 76 to 90% cancers Invasive Qualified Physicians Colonoscopy “ Gold Standard” Every 5 to 10 years No studies show effectiveness Every 5 yrs. Less likely to repeat due to discomfort. ^Annually,rehydration ^^Biennial Timed Intervals Qualified Physicians Qualified Physicians Physician, PA, N P Patient, Must handle stool Performed by $500-$1000 Bowel Prep is uncomfortable, procedure is not. Variable >10mm lesions same as Colonoscopy <5mm&flat lesions mixed to poor Minimally Invasive Virtual Colonoscopy [CT Colonography] $200 Bowel Prep/ Uncomfortable/Perforation 1/25,000. Low sensitivity Invasive Double Contrast Barium Enema $180 - $350 Bowel prep / No anesthesia, may be uncomfortable/ Perforation [1:10,000] 50-70% but misses lesions proximal to the scope. [With FOBT inc to 76%] Invasive Sigmoidoscopy $5 - $7 Variable 50% Not diagnostic Low 30-50% Noninvasive FOBT 3 samples Cost Compliance [Risks] Test Sensitivity Invasiveness Test
  28. 28. Clinical Decisions in CRC Screening <ul><li>Patient considerations: </li></ul><ul><ul><ul><li>Patient finances </li></ul></ul></ul><ul><ul><ul><li>Patient risk </li></ul></ul></ul><ul><ul><ul><li>Patient compliance </li></ul></ul></ul><ul><ul><ul><ul><li>Initial </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Repeat </li></ul></ul></ul></ul><ul><li>Screening considerations </li></ul><ul><ul><ul><li>Testing effectiveness </li></ul></ul></ul>
  29. 29. Knowing that “all asymptomatic people 50 yr old and older should be screened for CRC,” what is your choice? <ul><li>FOBT, annually with colonoscopy if positive </li></ul><ul><li>FOBT, annually with sigmoidoscopy every 5 yrs starting at 50 </li></ul><ul><li>Double Contrast Barium Enema </li></ul><ul><ul><li>[Not preferred if other screens are available] </li></ul></ul><ul><li>Virtual Colonoscopy every 5 to 10 yrs </li></ul><ul><li>Colonoscopy every 10 yrs </li></ul><ul><li>DNA Testing every 3 to 5 years </li></ul><ul><li>DNA Testing every 10 yrs with Colonoscopy every 5 yrs spaced between the colonoscopies </li></ul>
  30. 30. What is the BEST Screening Plan for the Average Risk Patient? <ul><li>The plan that is followed through on!!! </li></ul><ul><li>Otherwise…. </li></ul><ul><li>Colonoscopy every 10 yrs with DNA testing every 5 yrs spaced between the Colonoscopy beginning at an earlier age than 50 yo for the high risk patients </li></ul>
  31. 31. Recently due to scientific studies…… <ul><li>… doctors are realizing colon cancer is an ubiquitous disease with many paths and many “reactive treatments” when the disease is diagnosed. [ie,surgery, chemotherapy, radiation] </li></ul><ul><li>Because of this, and the desire to find more cost-effective therapies, the concept of chemoprevention has evolved….high risk patients take some drug or nutritional substance long term to help lower their risk of CRC. </li></ul><ul><li>Sound like Functional Medicine? </li></ul>
  32. 32. Colon Chemoprevention <ul><li>The substances being investigated are: </li></ul><ul><ul><li>A FDA approved statin </li></ul></ul><ul><ul><li>A novel nutritional agent that contains inulin </li></ul></ul><ul><ul><li>NSAIDS </li></ul></ul><ul><li>To learn more about Mayo’s Chemoprevention Clinical Trials, contact Paul Limburg, MD, MPH, at 507-266-4338 </li></ul>
  33. 33. SO………. <ul><li>Click on this link and fill out the consent form. </li></ul><ul><li>Make a choice to NOT become a Colorectal Cancer statistic! </li></ul><ul><li>THANK-YOU and your loved ones thank-you too! </li></ul>
  34. 34. Resources http://www.oncolink.upenn.edu Oncolink http://cancernet.nci.nih.gov http://rex.nci.nih.gov National Cancer Institute http://www.cdc.org Centers for Disease Control and Prevention http://www.hsph.harvard.edu/cancer Harvard Center for Cancer Prevention http://www.colorectal-cancer.net Colorectal Cancer Network http://www.ccalliance.org Colon Cancer Alliance http://www.nccra.org National http://www.preventcancer.org Cancer Research Foundation of America http://www.cancerfacts.org Cancer Facts http://www.cancercare.org Cancer Care http://www.asge.org American Society of Gastrointestinal Endoscopy http://www.fascrs.org American Society of Colon and Rectal Surgeons http://www.gastro.org American Gastroenterology Association http://www.aafp.org American Academy of Family Physicians http://www.acg.gi.org American College of Gastroenterology http://www.cancer.org American Cancer Society
  35. 35. References <ul><li>1.http://www.foodingredientsfirst.com/newsmaker_article.asp?idNewsMaker=83&fSite=E0D45&nw=hd </li></ul>
  36. 36. Preventive HealthCare <ul><li>Women </li></ul><ul><ul><li>Pap </li></ul></ul><ul><ul><ul><li>Traditional </li></ul></ul></ul><ul><ul><ul><li>ThinPrep </li></ul></ul></ul><ul><ul><ul><li>SureCell </li></ul></ul></ul><ul><ul><li>Pelvic Exams </li></ul></ul><ul><ul><li>Breast Screening </li></ul></ul><ul><ul><ul><li>Mammograms </li></ul></ul></ul><ul><ul><ul><li>Thermograms </li></ul></ul></ul><ul><ul><ul><li>BSE-Breast SelfExam </li></ul></ul></ul><ul><ul><li>Bone Density </li></ul></ul><ul><ul><li>CRC Screening </li></ul></ul><ul><ul><li>Lipid Screening </li></ul></ul><ul><li>Men </li></ul><ul><ul><li>Prostate Screening </li></ul></ul><ul><ul><li>CRC Screening </li></ul></ul><ul><ul><li>Lipid Screening </li></ul></ul><ul><ul><li>Bone Density </li></ul></ul>

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