Colonoscopy Screening

Sarah Jameson FNP-CSusan VanZandt FNP-C

Disclosure

1. Advisory board member Shire/Takeda2. Potential conflicts of interest have been resolved

Learning objectives

● Review current colorectal (CRC) screening guidelines● Compare screening modalities and indications for each● Understand surveillance recommendations● Understand procedures associated with GI

Why do we screen?

Colorectal cancer is the second leading cause of cancer for men and women in the US

There will be an estimated 140,000 new cases of CRC diagnosed in 2019

1 in 20 will be diagnosed with CRC in their lifetime

1 in 3 people are NOT up to date on their CRC screening

60% of CRC could have been prevented with screening

National Cancer Institute, 2019Centers for Disease Control, 2019

When do we start screening?

● Non-African Americans as average risk start screening at age 50

● African Americans start at age 45● Adults with bleeding symptoms to determine cause is not

screening (diagnostic)

Rex, DK, et al Gastroenterology 2017

When do we stop screening?

● Is this patient UTD with screening?● Has previous screenings been negative, specifically the

colonoscopy?● Is the patient >75?● Does this patient have a

Screening case study

1. 45 yo caucasian female with FH of colon cancer in maternal grandmother and maternal aunt. Denies any abdominal pain, change in bowel pattern, hematochezia, or weight loss. Does she need a colonoscopy screening?

2. 30 yo african american male with FH of colon cancer in father at age 40. Denies any abdominal pain, change in bowel pattern, hematochezia, or weight loss. Does he need a colonoscopy screening?

Case Study

1. 45 yo caucasian female with FH of colon cancer in maternal grandmother and maternal aunt. Denies any abdominal pain, reports change in bowel pattern, with hematochezia, but denies weight loss. Does she need a colonoscopy screening?

2. 30 yo african american male with FH of colon cancer in father at age 50. Reports abdominal pain, change in bowel pattern, hematochezia, and weight loss. Does he need a colonoscopy screening?

MSTF tiers of screening

Tier I: Colonoscopy every 10 yrs and/or annual FIT

Tier II: CT colonography every 5 yrs, FIT-fecal DNA every 3 yrs, or Flex-Sigmoidoscopy every 5-10 yrs

Tier III: Capsule endoscopy every 5 yrs

Rex, DK, et al Gastroenterology 2017

Colonoscopy

Mayo Clinic, 2019

FIT Testing

● Detects blood from heme● Sensitivity 61-91%● Specificity 87.5-97%● Pros: cheap, no prep, non-invasive, no dietary restrictions, only

one sample needed● Cons: test characteristics

Guaiac based fecal occult testing

● Detects blood from heme or hemoglobin● Sensitivity 37.1-79.4%● Specificity 86.7-97.7%● Pros: cheap, no prep, non-invasive● Cons: test characteristics, dietary restrictions, multiple samples

needed

Cologuard

● Detects DNA changes from exfoliated cells PLUS FIT● Sensitivity 92%● Specificity 87%● Pros: Higher sensitivity detects right sided-serrated lesions● Cons: Expensive

Stool screening test was positive, now what?

Stool screening test was positive, now what?

● It does not mean the patient has cancer● Refer to GI● GI will evaluate for colonoscopy vs Barium Enema vs wait

○ CV disease, particularly recent stents or MI○ Recent CVA○ COPD with home O2 use○ End Stage Liver Disease

Colonoscopy

● The gold standard. Allows for diagnosis of cancer and removal of precancerous adenomas.

● Pros: This is the only method that can reduce incidence of and mortality from distal and proximal colorectal cancers

● Cons: 0.1% risk of bleeding, 0.1 % risk of perforation (risk increases with age)

(NEJM, 2016)

American Society of CRS

The Procedure

Type of polyps

● Not all polyps become cancer● It generally takes many years for a polyp to turn into cancer● 3 categories

○ Benign (hyperplastic)○ Precancerous (TA, SSP)○ Cancerous (evolving adenocarcinoma)

● Size matters!○ < 1cm, generally easy to remove, usually benign

Cleveland Clinic, 2018

We think it takes about 10 years for a CR polyp with a gene mutation to turn into colon cancer

Cleveland Clinic, 2018

When to re-screen or follow up...

When to re-screen or follow up

10 YEARS 5 YEARS 3 YEARS 1 YEAR

No polyps, No FH 1-2,

Case Study 1: “Classic Case”

CC: 63 year old female referred to GSI for IDA

HPI: Reports she was feeling “tired”, no overt signs of GI bleeding. PCP found hemoglobin to be 5.0, went to ER, received 2 units, d/c with hemoglobin of 9.2. Reports daily epigastric abdominal pain. On Meloxicam and excedrin for joint arthralgias. Reports daily BM, no changes in stool, no weight loss.

FH: No FH of CRC. Has never had a colonoscopy.

PMH: includes HTN, HLD, anxiety, arthritis.

Case Study 1: “Classic Case” cont.● The plan

○ EGD: r/o NSAID induced PUD○ COL: r/o IBD vs malignancy vs other

● EGD was unremarkable● COL

○ Frond-like non-obstructing mass in cecum, partially circumferential○ Initially colonoscopy biopsies said TVA, underwent lap R hemicolectomy--revealed stage II (T3

N0 M0) moderately differentiated adenocarcinoma without lymphovascular invasion

Case Study 2: “Atypical”

CC: 35 year old male who presented to ED with anemia and hematochezia. Hemoglobin 8.0 on admission, hemoccult +.

HPI: Reported month long history of umbilical abdominal pain that was cramping in quality. Pain worsened, he presented to ED. Reported he typically has a BM daily, now BM once every other day. Reports a 10 pound weight loss, cannot quantify timeframe.

FH: No FH of CC.

PMH: Only PMH is tobacco abuse.

Case Study 2: “Atypical” cont.

● The plan○ EGD: r/o PUD vs gastritis○ COL: r/o IBD vs malignancy vs other

● EGD was unremarkable● COL

○ Frond-like villous infiltrative polypoid and partially obstructing large mass in transverse colon--unable to mass beyond

○ Pathology revealed differentiated adenocarcinoma

○ Pt underwent L hemicolectomy○ Margins and lymph nodes negative

Case Study 3: The Gold Standard

CC: 51 year old male who presented to GSI for initial colonoscopy screening.

HPI: Denies abdominal pain, overt GI bleeding, change in bowel habits.

FH: Father diagnosed with CC in 60s.

PMH: Obesity

Case Study 3: The Gold Standard

● The Plan: Colonoscopy: ● Results: 3 sessile polyps 2-3 mm in size found in transverse and ascending colon, 3

mm polyp in rectosigmoid colon, 8 mm polyp in rectum. ● Path: 2-3 mm polyps were TA, 8 mm polyp was moderately differentiated mucinous

adenocarcinoma arising from TA

Hemorrhoids

Colonoscopy revealed IH, negative for malignancy. Pt still complaining of hematochezia.

● Ensure pt is drinking plenty of water and getting enough fiber○ Straining worsens hemorrhoids○ Consider adding miralax○ Sitz baths

● Anusol 2.5% cream● Non-surgical treatment with rubber band ligation (done at office)● Refer to CRS

Final Thoughts

1. Colon cancer is the second leading cause of cancer for men and women in the US2. Colon cancer is preventable with colonoscopy

○ Stool tests should be offered if pt declines scope as they have numerous false positives and false negatives

3. A person with increased risk should never have a stool test○ i.e. FH CC, personal history of polyps, are currently bleeding

4. Repeat colonoscopy depends on FH, size, pathology, and number of polyps

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