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Colorectal Cancer   Bruce D. Greenwald, MDAssociate Professor of Medicine    University of Maryland      School of Medicine
Outline•   Where is the colon and what does it do?•   Why is colon cancer important?     • How many cases/year?     • Who ...
2003 Estimated US Cancer Cases*                                            Men                                            ...
2003 Estimated US Cancer Deaths*                                               Men              WomenLung/bronchus        ...
Ethnic/Gender Differences            Incidence per 100,000                                                 Survival (%)  4...
Colon cancer rates for Baltimore City             and Maryland, 1994-1998 70 60                                           ...
How Does Colorectal Cancer Develop?Janne PA, Mayer RJ. N Engl J Med 2000;342:1960.
Colon Polyp
Colon Cancer
How Does Colorectal Cancer Develop?Janne PA, Mayer RJ. N Engl J Med 2000;342:1960.
Symptoms of Colorectal CancerTime Course     Symptoms          FindingsEarly           None              None             ...
Staging of Colorectal Cancer
Frequency of Colorectal Cancer by          Dukes Stage
Survival by Dukes Stage
Treatment of Colorectal Cancer           by Stage
Is Colorectal Cancer Preventable?                  YES!•   Screening•   Chemoprevention
Screening Techniques for Colorectal                 Cancer   Fecal occult blood test (FOBT) every year, or   Flexible si...
Screening For Colon Cancer             SAVES LIVES!!!                                            MortalityTest            ...
Colorectal cancer screening          First assess RISKAVERAGE RISK INDIVIDUAL• All patients age 50 years and older, the  a...
Why aren’t more people screened for                colon cancer?     Reasons for refusal of fecal occult blood testing    ...
Fecal Occult Blood Testing•   Examination of stool for occult (“hidden”)    blood•   Can detect one teaspoon or less of bl...
FOBT improves survival   Years after diagnosis
Trends in FOBT, 1997-2001                    30                    25                    20                               ...
Double-contrast Barium Enema
Double-contrast Barium Enema•   Pros    • Examines entire colon    • Relatively low cost•   Cons    • Never studied as a s...
Sigmoidoscopy/Colonoscopy
Site Distribution
Flexible sigmoidoscopy  •    Pros        • May be done in office        • Inexpensive, cost-effective        • Reduces dea...
Colonoscopy•   Pros     • Examines entire colon     • Removal of polyps performed at time of exam     • Well-tolerated wit...
Colonoscopy
Chemopreventive agentsFiber                      Not effectiveAspirin                    May be effectiveNSAIDs (ibuprofen...
Future techniques for colorectal           cancer screening•   Stool DNA testing•   Capsule endoscopy (Givens capsule)•   ...
Fecal Testing for Gene Mutations
Fecal Testing for Gene Mutations•   Pros     • No sedation or preparation necessary     • Home-based (sample mailed to phy...
Videocapsule
VideocapsuleLymphoma
CT ColographyColon Polyp
CT ColographyColon Polyp
CT Colography Colon Cancer
CT Colography•   Pros     • No sedation necessary     • 20 min procedure vs. 25 min for colonoscopy     • Low risk     • E...
Summary•   Colorectal cancer is the third most common    cancer and cause of cancer death in the U.S.•   Chemopreventive a...
Rectal CA pp
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  1. 1. Colorectal Cancer Bruce D. Greenwald, MDAssociate Professor of Medicine University of Maryland School of Medicine
  2. 2. Outline• Where is the colon and what does it do?• Why is colon cancer important? • How many cases/year? • Who gets it? • Who dies from it?• How does colon cancer develop?• How is colon cancer treated?• Is colon cancer preventable?
  3. 3. 2003 Estimated US Cancer Cases* Men Men WomenProstate 222,849 210,816 Breast 675,300 675,300 658,800Lung/bronchus 94,542 79,056 Lung/bronchusColon/rectum 74,283 72,468 Colon & rectumUrinary bladder 40,518 39,528 Uterine corpusMelanoma of 27,012 26,352 Ovary skin 26,352 Non-HodgkinNon-Hodgkin 27,012 lymphoma lymphoma 19,764 Melanoma ofKidney 20,259 skinOral cavity 20,259 19,764 ThyroidLeukemia 20,259 13,176 PancreasPancreas 13,506 13,176 Urinary bladderAll other sites 114,801 62,238 All other sites ONS=Other nervous system. *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: American Cancer Society, 2003.
  4. 4. 2003 Estimated US Cancer Deaths* Men WomenLung/bronchus 88,629 67,650 Lung/bronchus 285,900 270,600Prostate 28,590 40,590 BreastColon & rectum 28,590 29,766 Colon & rectumPancreas 14,295 16,236 PancreasNon-Hodgkin 11,436 13,530 Ovary lymphoma 10,824 Non-HodgkinLeukemia 11,436 lymphomaEsophagus 11,436 10,824 LeukemiaLiver/intrahepatic 8,577 8,118 Uterine corpus bile duct 5,412 Brain/ONSUrinary bladder 8,577 5,412 Multiple myelomaKidney 8,577 62,238 All other sitesAll other sites 62,898 ONS=Other nervous system. *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: American Cancer Society, 2003.
  5. 5. Ethnic/Gender Differences Incidence per 100,000 Survival (%) 40 100 35 80 30 63 53 25 60 20 15 40 10 20 5 0 0 Women Men African-American WhiteSource: Surveillance, Epidemiology, and End Results Program, 1973-1999, Division of Cancer Controland Population Sciences, National Cancer Institute, 2002.
  6. 6. Colon cancer rates for Baltimore City and Maryland, 1994-1998 70 60 Baltimore City 50 Maryland 40 30 20 10 0 Overall Men Women African- White AmericanSource: Maryland Department of Health and Mental Hygience. Annual Cancer Report. September, 2001. Age-adjusted incidence per 100,000 population
  7. 7. How Does Colorectal Cancer Develop?Janne PA, Mayer RJ. N Engl J Med 2000;342:1960.
  8. 8. Colon Polyp
  9. 9. Colon Cancer
  10. 10. How Does Colorectal Cancer Develop?Janne PA, Mayer RJ. N Engl J Med 2000;342:1960.
  11. 11. Symptoms of Colorectal CancerTime Course Symptoms FindingsEarly None None Occult blood in stoolMid Rectal bleeding Rectal mass Change in bowel Blood in stool habitsLate Fatigue Weight loss Anemia Abdominal mass Abdominal pain Bowel obstruction
  12. 12. Staging of Colorectal Cancer
  13. 13. Frequency of Colorectal Cancer by Dukes Stage
  14. 14. Survival by Dukes Stage
  15. 15. Treatment of Colorectal Cancer by Stage
  16. 16. Is Colorectal Cancer Preventable? YES!• Screening• Chemoprevention
  17. 17. Screening Techniques for Colorectal Cancer Fecal occult blood test (FOBT) every year, or Flexible sigmoidoscopy every 5 years,or A fecal occult blood test every year plus flexible sigmoidoscopy every 5 years (recommended by the American Cancer Society), or Double-contrast barium enema every 5 to 10 years, or Colonoscopy every 10 years (recommended by the American College of Gastroenterology).
  18. 18. Screening For Colon Cancer SAVES LIVES!!! MortalityTest ReductionFecal occult blood testing 33%Flexible sigmoidoscopy 66%(in portion of colon examined)FOBT + flexible sigmoidoscopy 43%(compared to sigmoidoscopy alone)Colonoscopy ~76-90%(after initial screening and polypectomy)
  19. 19. Colorectal cancer screening First assess RISKAVERAGE RISK INDIVIDUAL• All patients age 50 years and older, the asymptomatic general populationHIGH RISK• Personal history – polyp or cancer• Family history – polyp or cancer in first degree relatives
  20. 20. Why aren’t more people screened for colon cancer? Reasons for refusal of fecal occult blood testing • Fear of further testing and surgery • Feeling well • Unpleasantness of stool collection procedure But: • Strongest predictor of whether a patient will be screened = physician encouragementHynam et al. J Epidemiol Comm Health 1995;49:84Mandelson et al. Am J Prevent Med 2000;19:149
  21. 21. Fecal Occult Blood Testing• Examination of stool for occult (“hidden”) blood• Can detect one teaspoon or less of blood in a bowel movement• Uses chemical reaction between blood and reagent
  22. 22. FOBT improves survival Years after diagnosis
  23. 23. Trends in FOBT, 1997-2001 30 25 20 1997 Prevalence (%) 15 1999 10 2001 5 0 Total Men Women Less than High High School Some college School graduate or greaterSource: Behavioral Risk Factor Surveillance System, 1996-1997, 1999, 2001, National Center for Chronic DiseasePrevention and Health Promotion, Centers for Disease Control and Prevention and Prevention, 1999, 2000, 2002.
  24. 24. Double-contrast Barium Enema
  25. 25. Double-contrast Barium Enema• Pros • Examines entire colon • Relatively low cost• Cons • Never studied as a screening test • Missed 50% of polyps > 1cm in one study • Detects 50-75% of cancers in those with positive FOBT • Interval between exams unknownWinawer et al. Gastroenterology 1997; 112:599Rex, Endoscopy 1995; 27:200Lieberman et al. N Engl J Med 2000; 343:163
  26. 26. Sigmoidoscopy/Colonoscopy
  27. 27. Site Distribution
  28. 28. Flexible sigmoidoscopy • Pros • May be done in office • Inexpensive, cost-effective • Reduces deaths from rectal cancer • Easier bowel preparation, usually done without sedation • Cons • Detects only half of polyps • Misses 40-50% of cancers located beyond the view of the sigmoidoscope • Often limited by discomfort, poor bowel preparationSelby et al N Engl J Med 1992; 336:653 Stewart et al Aust NZ J Surg 1999; 69:2Newcomb et al. JNCI 1992; 84:1572 Painter et al Endoscopy 1999; 3:269Rex et al. Gastrointest Endosc 1999; 99:727
  29. 29. Colonoscopy• Pros • Examines entire colon • Removal of polyps performed at time of exam • Well-tolerated with sedation • Easier bowel preparation, usually done without sedation• Cons • Expensive • Risk of perforation, bleeding low but not negligible • Requires high level of training to perform • Miss rate of polyps < 1 cm ~25%, > 1 cm ~5%Rex et al. Gastroenterology 1997; 112:24-8Postic et al. Am J Gastroenterol 2002; 97:3182-5
  30. 30. Colonoscopy
  31. 31. Chemopreventive agentsFiber Not effectiveAspirin May be effectiveNSAIDs (ibuprofen, etc) Probably effectiveVitamin E, vitamin C, beta Not effectivecaroteneFolate Effective if obtained in dietCalcium EffectiveEstrogen Effective, but has other problems
  32. 32. Future techniques for colorectal cancer screening• Stool DNA testing• Capsule endoscopy (Givens capsule)• CT colography (virtual colonoscopy)
  33. 33. Fecal Testing for Gene Mutations
  34. 34. Fecal Testing for Gene Mutations• Pros • No sedation or preparation necessary • Home-based (sample mailed to physician) • No risk• Cons • Current tests not very good (~50% of cancers missed) • Cost • Frequency of exam unknown • Not therapeutic • Not covered by insurance
  35. 35. Videocapsule
  36. 36. VideocapsuleLymphoma
  37. 37. CT ColographyColon Polyp
  38. 38. CT ColographyColon Polyp
  39. 39. CT Colography Colon Cancer
  40. 40. CT Colography• Pros • No sedation necessary • 20 min procedure vs. 25 min for colonoscopy • Low risk • Extracolonic lesions may be detected• Cons • Preparation (residual fluid cannot be aspirated) • Air insufflation • Cost (? need for more frequent exams) • Radiation dose (similar to barium enema) • Not therapeutic • Not covered by insurance
  41. 41. Summary• Colorectal cancer is the third most common cancer and cause of cancer death in the U.S.• Chemopreventive agents have modest benefit in average risk individuals• Screening for colorectal cancer saves lives!• Patient and physician compliance with screening is poor

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