The document discusses updates in colorectal cancer screening, including different pathways and precursors of colorectal cancer, optimal terminology for classifying serrated lesions, variability in detection rates among endoscopists, importance of adequate bowel preparation and withdrawal technique, and technical solutions such as chromoendoscopy to help improve adenoma detection.
Colon cancer screening recommendationsPennMedicine
Colon cancer screening recommendation presentation from Dr. Tracy d'Entremont, Director of Oncology Services at the Abramson Cancer Center at Valley Forge.
A multidisciplinary approach that includes surgery, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer
Tried to summarise all landmark trials in carcinoma breast in radiation oncology,medical oncology as well in surgical oncology.
References taken from Devita Book,Breast Disease book from Springer,journals like NEJM,JAMA,LANCET,ANNL ONCOLOGY etc,internet,Perez book,Practical Clinical Oncology by Hanna etc textbooks.
Thanks.
In Depth review of the Surgical management of esophageal carcinoma including management overview, endoscopic management, Type of surgeries, Open, and minimally invasive, Extent of lymphadenectomy. Literature review of evidence for type of surgery and complications
Colon cancer screening recommendationsPennMedicine
Colon cancer screening recommendation presentation from Dr. Tracy d'Entremont, Director of Oncology Services at the Abramson Cancer Center at Valley Forge.
A multidisciplinary approach that includes surgery, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer
Tried to summarise all landmark trials in carcinoma breast in radiation oncology,medical oncology as well in surgical oncology.
References taken from Devita Book,Breast Disease book from Springer,journals like NEJM,JAMA,LANCET,ANNL ONCOLOGY etc,internet,Perez book,Practical Clinical Oncology by Hanna etc textbooks.
Thanks.
In Depth review of the Surgical management of esophageal carcinoma including management overview, endoscopic management, Type of surgeries, Open, and minimally invasive, Extent of lymphadenectomy. Literature review of evidence for type of surgery and complications
This is very important topic for Laparoscopic surgeons,as bile injury is not uncommon,how to approach such biliary injuries is prime to know for evolving surgeons.This slide would also helpful for surgery residents.
Dr. Murphy presents slides discussing general screening trends in the US, including how the US compares to other countries, different screening modalities, and differences in screening by:
-Age
-Gender
-Geography
-Race/Ethnicity
Colorectal Cancer Screening - What does the evidence really say?Jarrod Lee
Colorectal cancer is one of the most common cancers around the world. Screening has been proven to detect cancers in early curable stages, and to even prevent them. Yet, few topics are as controversial as colorectal cancer screening in medicine today. We take an evidence based approach to examine what the science truly says about the different modalities of cancer screening.
Understanding the Screening Options from the new USPSTF Colorectal Cancer Scr...Ryan Kerr
The Colorectal Cancer Task Force is a subcommittee within the Colorado Cancer Coalition.
Our goal is to improve colorectal cancer outcomes in the state of Colorado.
This presentation gives a high-level overview of each of the colorectal cancer screening options mentioned in the new United States Preventive Services Task Force (USPSTF) screening guidelines (released June 2016).
This is very important topic for Laparoscopic surgeons,as bile injury is not uncommon,how to approach such biliary injuries is prime to know for evolving surgeons.This slide would also helpful for surgery residents.
Dr. Murphy presents slides discussing general screening trends in the US, including how the US compares to other countries, different screening modalities, and differences in screening by:
-Age
-Gender
-Geography
-Race/Ethnicity
Colorectal Cancer Screening - What does the evidence really say?Jarrod Lee
Colorectal cancer is one of the most common cancers around the world. Screening has been proven to detect cancers in early curable stages, and to even prevent them. Yet, few topics are as controversial as colorectal cancer screening in medicine today. We take an evidence based approach to examine what the science truly says about the different modalities of cancer screening.
Understanding the Screening Options from the new USPSTF Colorectal Cancer Scr...Ryan Kerr
The Colorectal Cancer Task Force is a subcommittee within the Colorado Cancer Coalition.
Our goal is to improve colorectal cancer outcomes in the state of Colorado.
This presentation gives a high-level overview of each of the colorectal cancer screening options mentioned in the new United States Preventive Services Task Force (USPSTF) screening guidelines (released June 2016).
We are all part of the effort in reducing bowel cancer. Apart from screening and early detection, risk can be actively reduced by making healthy lifestyle changes. There are more effective treatments being explored through research. Continual improvement in services for people affected by bowel cancer will also increase their chances of longer-term survival.
Identification of Barrett’s esophagus patients at higher risk for adenocarcin...Ivor Kovic
Final presentation given by Ileana Lulic and Ivor Kovic at the end of Scientific research in gastro-intestinal & liver diseases
Sunday, July 8 - Friday, August 3, 2007
Amsterdam, Academisch Medisch Centrum
Identification of Barrett’s esophagus patients at higher risk for adenocarcin...ilulic
Final presentation given by Ileana Lulic and Ivor Kovic at the end of Scientific research in gastro-intestinal & liver diseases
Sunday, July 8 - Friday, August 3, 2007
Amsterdam, Academisch Medisch Centrum
Gastroenterologist Dr. Patricia Raymond takes medicine seriously, and herself lightly. As a female gastroenterologist, she is, in fact, a “Chick who checks cheeks”. Dr. Raymond’s mission is to decrease the fright and ‘ick’ that keep about 50% of Americans from getting their screening colonoscopy at age 50—using laughter and knowledge to combat the fear. You can enjoy some of that humor at her website ColonJoke.com. And you can watch her music parody videos on YouTube at www.ButtMeddler.com. Please give a warm welcome to Dr. Pat Raymond’s alter ego, the divine….Ms Butt Meddler!
CARCINOMA ESOPHAGUS - DR ZAHID IQBAL MIR
Dr. Zahid Iqbal Mir, MBBS MS (General Surgery), DNB (General Surgery) has done his MBBS and masters in General Surgery from the prestigious Govt Medical College Jammu and DNB in General Surgery from NBEMS New Delhi. He is a passionate surgeon, earlier practising at Government Medical College, Jammu as Registrar in Department of General Surgery. Nowadays working as Senior Resident in Department of General Surgery, Government Medical College & Hospital, Sector 32, Chandigarh and a rising name in field of surgery.
He is an enthusiastic, enigmatic and dedicated teacher as well. He is not just a resolute learner, but also an awe inspiring guiding light for his juniors, which makes him the most loveable and respected senior.
Currently he is running “LOVE FOR SCALPEL” for PGMEE aspirants on most of the social platforms, which is gaining immense popularity among residents, medical graduates and undergraduates.
Familial Adenomatous Polyposis affects 1 in 10,000 to 30,000 Americans who experience 100% risk of colon cancer, and FAP doesn't end with a total colectomy for removal of their hundreds of polyps.
Follow this journey of two real FAP patients through pancreatitis from symptomatic ampulla polyps, surgical resection of giant small bowel polyps, bowel obstruction from abdominal desmoid tumors, and Wilm's tumor of the kidney. How do we diagnose, monitor and support our FAP patients? Can pharmacotherapy reduce risk of polyp growth in FAP? What are the extracolonic manifestations of the APC gene mutation? Our responsibility doesn't end when the colon does.
1. Update in Colorectal Cancer
Screening
Douglas K. Rex, M.D.
Indiana University
Medical Center
Indianapolis, IN
2. Colorectal Cancer – Molecular Basis
Pathway Frequency Genes MSI Precursor Speed
CIN 65-70% APC No Adenoma Slow
K-ras
p53
Lynch 3% MLH1 Yes Adenoma Fast
MLH2
MLH6
PMS2
CIMP 30-35% BRAF Sometimes Serrated Can be fast
3. Minimal Terminology of Serrated
Lesions (WHO)
§
Hyperplastic polyp (HP)
§
Sessile serrated adenoma/polyp (SSA/P)
–
With cytological dysplasia
–
Without cytological dysplasia
§
Traditional serrated adenoma (TSA)
4. Therefore
§
The WHO recommends that the term
“serrated adenoma” always be preceded
by a qualifier:
–
Sessile serrated adenoma/polyp (SSA/P)
–
Traditional serrated adenoma (TSA)
5. Features of major categories
of serrated lesions
WHO Prevalence Shape Distribution Malignant
classification potential
Hyperplastic Very Sessile/flat Mostly distal Very low
polyp common
Sessile Common Sessile/flat 80% proximal Significant
serrated
adenoma/
polyp
Traditional Rare Sessile/ Mostly distal Significant
serrated pedunculated
adenoma
7. SSA/P without and with
cytological dysplasia
§
SSA/P without §
SSA/P with
dysplasia dysplasia
8. 2416 SSA/Ps
mean age
§
SSA/P 61y
§
SSA/P with LGD 66y
§
SSA/P with HGD 72y
§
SSA/P with cancer 76y
• Lash J Clin Pathol 2010;63:681-6
9. The serrated pathway
Hyperplastic polyp
?↓?
Sessile serrated adenoma/polyp
↓ probably slow
SSA/P with cytologic dysplasia
↓ sometimes fast
CIMP colon cancer
10. So……….
§
SSA/P is the main precursor of CIMP-high CRC
§
No reliable way to distinguish HP from SSA/P
endoscopically
• Kimura et al AJG 2012: “Type O” pit
§
Agreement for pathologists distinguishing HP
from SSA/P is moderate
§
Most large serrated lesions in the proximal colon
are SSA/P
§
SSA/P with cytological dysplasia is a dangerous
lesion
11. Clinical associations of serrated
polyps with CIMP-high CRCs
§
SSA/P histology (vs hyperplastic)
§
Proximal location (vs distal) of serrated
lesions
§
Size (big vs small) of serrated lesions
§
Number (more vs fewer) of serrated
lesions
12. Can screening tests detect
serrated lesion ?
Sensitivity for serrated lesions
Colonoscopy highly variable
FIT ?
Fecal DNA ?
CT colonography ?
Flex sig ?
Capsule colonoscopy ?
Serum assays ?
13. Colorectal Cancer Screening
Tests
§
Non-invasive tests §
Imaging tests
§
gFOBT √ §
Colonoscopy √
§
FIT √
§
Flex sig (seldom
§
Fecal DNA used)
§
Serum tests §
CT colonography
(seldom used)
§
Capsule
14. How do we achieve
excellence in screening?
§
Utilize high quality colonoscopists
–
Should be able to quote ADR
–
Should see split dose preparations
–
Should see consistent photographic
documentation of cecal intubation
–
Should see appropriate use of follow up
exams
§
Switch from gFOBT to FIT
–
Avoid exams on digital rectals
15. RCT of FIT vs g-FOBT
§
20,623 screenees
§
RCT of FIT (OC-
Sensor) vs g-FOBT
(HII)
§
Adherence 59.6%
vs 46.9% (HII)
§
Positivity 5.5% vs
2.4% (HII)
Van Rossum; GASTRO 2008;135:82
18. Septin 9 performance
§
7000 patient sceening trial: manuscript still
not published
§
62% sensitivity for cancer
–
Sensitivity lower for early stage cancer
§
No sensitivity for adenomas
§
88% specificity
19. Fecal DNA testing vs Septin 9
Ahlquist CGH 2012;10:272
Fecal DNA test Septin 9
Sensitivity for cancer 91% 50%
Stage I-III
Sensitivity for cancer 75% 88%
Stage IV
Sensitivity for large 82% 14%
adenomas
specificity 93% 73%
20. CT colonography
§
Not approved by the USPSTF
–
Radiation risk
–
Extracolonic findings
§
Not approved by CMS
–
Insufficient data in the elderly
–
Less cost-effective than colonoscopy
21. First RCT of Colonoscopy vs CTC
Netherlands (abstract 353;DDW 2011)
§
Colonoscopy: 5,924 §
CTC: 2,920 invited
§ invited 21%
Adherence: §
Adherence: 32%
§
Advanced adenomas per §
Advanced adenomas per
100 participants: 100 participants:
–
8.4 –
5.2
§
Advanced adenomas per §
Advanced adenomas per
100 invitees: 100 invitees:
–
1.7 –
1.7
28. Pre-cancerous lesions in the
colo-rectum: the basics
Lesion Paris shape Distribution Prevalence Pathology
Traditional 1p Left Low Mostly LGD
adenomatous
polyps 1s Throughout Common Mostly LGD
Flat 2a Greater to Common Mostly LGD
adenomas right
(lesions)
Sessile 1s or 2a Right colon Common Distinction
serrated from HP may
adenoma not be reliable
(polyp)
TSA 1s or 1p Left colon rare Uncertain
Depressed 2c Greater to rare ↑↑HGD and
(adenomas) 2a + 2c right invasive CA
2c+ 2a
30. Associations with interval
cancers
§
Serrated §
Other associations
§ associationsinterval
Features of §
Colonoscopy by
cancers non-GI doctors
–
Proximal location §
Doctors with low
–
MSI positive ADRs
–
CIMP positive §
Low cecal
intubation rates
§
Low polypectomy
rates
§
Indication of FOBT
31. The Adenoma Detection Rate
§
% of persons age ≥ 50 undergoing
screening colonoscopy with ≥ 1 adenoma
detected and removed
–
Rex et al (USMSTF) 2002
• AJG 2002;97:1296
–
Rex et al (ACG/ASGE Task Force on
Quality) 2006
• GIE 2006;63:S16
32. Operator dependence – cancer
prevention
Kaminski et al NEJM2010;362:1795-803
Adenoma Hazard ratio
detection rate
(ADR)
< 11% 10.94
11.0 14.9% 10.75
15.0-19.9% 12.50
46. Bowel Preparation and Polyp
Detection Rates
Europe (N=5,832)
Adequate
Inadequate
Completion (%) 90.4 71.1*
Time to cecum (min) 11.9 16.1*
Withdrawal time (min) 9.8 11.3*
Any adenoma 29.4 23.9*
Adenoma >1 cm (%) 6.4 4.3*
*P<0.05 for all measures.
Froehlich et al. Gastrointest Endoscop. 2005;61:378-384.
47. Split-Dosing Provides More Satisfactory
Results
Than Traditional Dosing (cont)
60 Group A
Group A 90
Group B
Group B 76.5
50.7 80
50
44.1 70
39.7
40 56.2
60
32.4
Percent
Percent
50
43.8
30
40
19.1
20 30
23.5
20
10
5.5
4.1 4.4 10
0 0
Poor Fair Good Excellent Satisfactory Unsatisfactory
Group A = 4 L of PEG on the night before the procedure; Group B = 2 L of PEG on the
evening before and 2 L on the morning of the procedure.
47
Reprinted from Aoun et al. Gastrointest Endosc. 2005;62(2):213-218.
48. Efficacy of Suprep in 2
studies
§
Study 1 §
Study 2
OSS PEG-EA OSS PEG-EA
Success Success
82.4% 80.3% 97.2% 95.6%
Excellent Excellent
44.6% 37.3% 63.3% 52.5%
Good Good
37.8% 43.0% 33.9% 43.2%
Fair Fair
50. Arguments Against
Split-Dosing Regimens
§
Inconvenient to the patient
–
Unlikely to be a factor once the process is
explained to the patient
–
Patients not more likely to be incontinent en
route to the endoscopy unit
§
Anesthesiologists will not allow split-
dosing
–
Clear liquids allowed up until 2 hours prior
to sedation
50
51. How do we judge preps?
§
Efficacy
–
Split or same day dosing
§
Safety
–
Sodium phosphate use dramatically
decreased
–
Safe preps:
• PEG-ELS (Golytely etc) and SF-ELS (Nulytely)
• Sodium sulfate (SuPrep)
§
Tolerability
–
52. How to achieve effective
preparation
§
Split dose all preps
§
Low volume preps appropriate for routine
patients without severe constipation, on
anti-motility agents
§
Have fall back approach for patients with
clinical factors or proven track record of
being hard to prepare
§
Discuss importance of preparation in your
written instructions
53. What makes up good
detection?
§
Bowel preparation
§
Adequate time
§
Technique:
–
Looking behind folds
–
Cleaning up
–
Adequate distention
§
Central gaze in the monitor
§
Other factors:
–
Personality?
56. Are there technical solutions
to ADR & variable detection?
§
Flat lesions Effective?
–
Chromoendoscopy yes
–
NBI no
–
FICE no
–
iScan limited data
–
Autofluorescence mixed results
–
High definition mixed results
§
Hidden mucosa
–
Cap-fitted mixed results
–
Third-eye maybe
57. Conclusion regarding
technical solutions
§
Any gains in detection from technical
solutions are much smaller than the
variations in detection between examiners
using white light
§
More study in low detectors needed
58. Excellence in colonoscopy
§
Use effective bowel preparation regimens
§
Achieve high cecal intubation rates safely
and document with landmarks and
photography
§
Examine carefully; know the full spectrum
of precancerous lesions in the colon
–
Know your ADR
–
You should see proximal colon serrated
lesions on a regular basis
59. How do we achieve
excellence in screening?
§
Utilize high quality colonoscopists
–
Should be able to quote ADR
–
Should see split dose preparations
–
Should see consistent photographic
documentation of cecal intubation
–
Should see appropriate use of follow up
exams
§
Switch from gFOBT to FIT
–
Avoid exams on digital rectals