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![Page 1: Colorectal Cancer Awareness in TN: Risk Factors, Screening, Outreach Keith D. Gray, M.D. Assistant Professor of Surgery Division of Surgical Oncology The.](https://reader035.fdocuments.us/reader035/viewer/2022062619/551562fc550346a1418b4b99/html5/thumbnails/1.jpg)
Colorectal Cancer Awareness in TN: Risk Factors, Screening, Outreach
Keith D. Gray, M.D.Assistant Professor of SurgeryDivision of Surgical Oncology
The University of Tennessee Medical Center
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CRC Facts
• 2008, 150K new cases and 50K deaths
• Lifetime risk of developing colon cancer is 1 in 19
• 2nd leading cause of cancer death among men and women combined
• Death rate has been decreasing over last 20 years, due to earlier screening and better imaging and treatment
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Uncontrollable Risk Factors for Uncontrollable Risk Factors for Developing Colorectal CancerDeveloping Colorectal Cancer
• Age – 50 or olderAge – 50 or older
• Family history of cancer of the colon or rectumFamily history of cancer of the colon or rectum
• Personal history of cancer of the colon, rectum, ovary, Personal history of cancer of the colon, rectum, ovary, endometrium or breastendometrium or breast
• History of polyps of the colonHistory of polyps of the colon
• Inflammatory bowel disease – ulcerative colitis or Inflammatory bowel disease – ulcerative colitis or Crohn’s diseaseCrohn’s disease
• Hereditary conditionsHereditary conditions
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Controllable Risk Factors for Controllable Risk Factors for Developing Colorectal CancerDeveloping Colorectal Cancer
• ObesityObesity
• Physical inactivityPhysical inactivity
• Cigarette smokingCigarette smoking
• Diet high in red or processed meatDiet high in red or processed meat
• Heavy alcohol consumptionHeavy alcohol consumption
• Inadequate screeningInadequate screening
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•50-75% of cancers can be prevented by lifestyle and dietary changes
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CRC Burden in TN
TN = 52.3 (50.5, 54.2)
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CRC Burden in TN
TN = 18.9 (17.8 -20)
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Disparate CRC Outcomes
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TN Risk Profile (2007)
• 13.5% (12.4%) below poverty – 15th
– Median per capita income = $13,282 in Central Appalachia, lowest in the nation
• 24.1% (19.6%) < HS education – 7th
– 9.6% < 9th grade education (5th)
• 31.5% sedentary – 2nd
• 67.4% obese (BMI>25) – 4th
– High fat diets, physical inactivity
• 26.4% (16.3% - 32.5%) consume 5+ fruits/veges per day
• 24.3% currently smoke (5th)
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TN Screening Report (2006)
• FOBT (>50)
– Last 2yrs: 25.6% (12.1 – 26.6%)
– Last 1yr: 15.7% (6.6 – 22.5%)
• Colonoscopy (>50)
– Ever: 56.2% (49.8 – 69.2%)
– <10yrs: 53.4% (46.6 – 66.4%)
– <5yrs: 49.9% (40.6 – 60.9%)
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Establishment of CRC Screening Guidelines
• ACS established CRC early detection guidelines in 1980
– 1997 – 1st update
– 2000 – 2nd update • 1995-2000 Medline data• Colorectal Cancer Advisory Committee
– 2003 - technology update• Immunochemical FOBT (iFOBT) added as acceptable screening method
– 2006 - ACS and US Multi-Society Task Force issued a joint guideline update for postpolypectomy and postcolorectal cancer resection surveillance
• Follow-up intervals were often too short, increasing cost and potential patient risk
– 2008 - Virtual Colonoscopy accepted as screening toolEddy D. CA Cancer J Clin 1980;30:193-240
Smith RA, et al. CA Cancer J Clin 2001:51:38-75
Mysliwiec PA, et al. Ann Intern Med 2004;141:264-271
Ko CW, et al. Gastrointest Endosc 2007;65:648-56
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CRC Screening Methods
• Fecal Occult Blood Test (FOBT)
– 2 samples from each of 3 consecutive stool samples at home
– Avoid NSAIDS (7d), Vit C sources (3d), red meat (3d)
– Stool sample from DRE is inadequate!• Low sensitivity (< 5%) as bleeding often intermittent and blood may not be
present in entire stool• Sole method of FOBT in up to 33% of PCP’s Nadel MR, et al. Ann Intern Med 2005;142:86-
94
– Advantages• Cheap, private, no bowel prep• Clinical trials show 33% reduction in CRC mortality with proper use; these
results may not be realized in community settings because common use of in-office tests and inappropriate follow-up of positive results
Nadel MR, et al. Ann Intern Med 2005;142:86-94Smith RA, et al. CA Cancer J Clin 2001:51:38-75
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Fecal Immunochemical Test (FIT)
• Mono/polyclonal antibody detect intact globin protein portion of human Hgb– Specific for globin in LGI tract since globin won’t survive passage
through UGI tract
• No cross-reactivity with non-human Hgb or foods
• Smith A, et al (Cancer 2006) demonstrated sensitivity of 87% for cancer and 43% for high risk adenomas in 2000+ patients– Similar findings by InSure
• ACS statement: “in comparison with guaiac-based test for the detection of occult blood, immunochemical test are more patient-friendly, and are likely to be equal or better in sensitivity and specificity.”
• Less commonly usedLevin B, et al. CA Cancer J Clin 2003;53:44-55
Smith A, et al. Cancer 2007;107:2152-2159
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Endoscopy v. DCBE
• DCBE– Instilling of barium and air to define colonic mucosa– Less sensitive for subcentimeter lesions– Often used with near-obstructing lesions
• Flexible Sigmoidoscopy– Veterans Affairs Cooperative Study Group; 3121 patients
• Exam to splenic flexure detects majority of CRC’s but misses >50% of proximal colon cancers Lieberman DA, NEJM 2000;20-162-168
– No need for sedation– Best is combined with FOBT/FIT
• Colonoscopy– Gold standard when cecum is reached– Risk of perforation– All Roads Lead to Colonoscopy!
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ACS recommendations for CRC screening in average-risk, asymptomatic people
Test Frequency
( starting at age 50)
FOBT or FIT* Annually
Stool DNA Test Interval uncertain
Flex Sig* Q 5 years
FOBT + Flex Sig* Annual FOBT/FIT and Flex Sig q 5 years
DCBE* q 5 years
CT colonography q 5 years
Colonoscopy q 10 years
*All positive test should be followed up with colonoscopy. DCBE +/- Flex sig is a suitable alternative.
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Individuals at “increased risk” of developing CRC
• 2x average risk in this population; accounts for 15-20% of colon cancers
• Who’s at increased risk?– h/o of AP/CRC in any 1st degree relative <60, or>2 1st degree relatives with h/o AP/CRC of any age (w/o
hereditary syndrome)• Colonoscopy at age 40 or 10 years before youngest case• Repeat q 5-10 years, pending findings
– h/o polypectomy and/or resection of CRC
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Postpolypectomy Surveillance Colonoscopy Recommendations - 2006 Update
• Small rectal hyperplastic polyps– nl colonoscopy, 10-year f/u– Hyperplastic polyposis syndrome should be screened more frequently
• <2 small tubular adenomas with LGD– 5-10 years
• 3-10 adenomas, any >1cm, any with villous features or HGD– 3 year f/u if completely removed– Subsequent 5 year f/u if nl or above
• > 10 adenomas– f/u <3 years and consider familial syndrome
• Piecemeal removal of sessile adenomas– Repeat endoscopy in 2-6 months– After complete removal confirmed, subsequent surveillance based on
judgmentWinawer SJ, et al. CA Cancer J Clin 2006;56:143-159
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Postcancer Resection Surveillance Colonoscopy Recommendations - 2006 Update
• High quality perioperative colonoscopy– Consider CT colonography or DCBE for obstructing lesions
• Consider colonoscopy 3-6 mo post-op to clear synchronous lesions
• Colonoscopy within 1 year of perioperative clearance
– 3-year f/u if this exam nl, then 5 year f/u if 3-year exam nl– For abnormal findings, stratify by risk
• Consider q3-6 month proctoscopy after LAR x 2-3 years
– Independent of surveillance colonoscopies for metachronous disease
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ACS recommendations for CRC screening among people at “high risk”
Risk Category Age to Begin Recommendation Comment
FH of FAP Puberty Early endoscopic surveillance
and genetic counseling/testing
Colectomy for (+) genetic testing
FH of HNPCC 21 Colonoscopy & genetic counseling/testing
If genetics (+) or unavailable, colonoscopy; q1-2 years until 40, then annually
Inflammatory Bowel Disease
8 years after pancolitis or 12-15 years after left colitis
Colonoscopy with biopsies of dysplasia q1-2 years
Prophylactic colectomy for persistent dysplasia
Adapted from Smith RA, et al. CA Cancer J Clin 2001:51:38-75
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Emerging Technology
• CT (“virtual”) colonography– May be used in cases of failed or incomplete colonoscopy or in cases of
obstructing cancer– Accepted as a screening tool– Medicare will not pay for it– High rate of false positives– Need colonoscopy if positive
• Stool DNA mutation testing– Uses multicomponent DNA-based stool assay targeting point mutations at hot
spots on colon oncogenes (i.e. K-ras, APC, and p53 genes)
– Single stool sample needed, DNA shed continuously
– Multicenter study by Colorectal Cancer Study Group in average risk patients:• Fecal DNA panel v. FOBT• Fecal DNA more sensitive in detecting adenomas and cancer, equal
specificity
– Not yet accepted as a screening tool• Large stool collection kits; requires entire stool sample• Expensive >$400/test; additional markers increases cost
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Outreach Efforts (CRC)
• 2006 = 5, 2007 = 9; 2008 = 5; 2009 = 6– CRC and skin outreach are least developed
programs
• Colonoscopies:– 2006 = 4945; 2008 = 5756
• 225 new CRC diagnosed 2006 – 2008– No change in stage distribution
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Key Points
• Colon cancer is common in the U.S.Colon cancer is common in the U.S.
• Prevention and early detection save lives.Prevention and early detection save lives.
• Everyone over 50 should undergo colon Everyone over 50 should undergo colon cancer screening as part of annual exam.cancer screening as part of annual exam.
• Education improves screening.Education improves screening.
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Improving CRC Outcomes
• Be familiar with CRC screening guidelines
• Meet people where they are with outreach
• Target underserved areas
• Continue to advocate for CRC screening legislation
• Emphasize prevention/healthy habits
• Use patient educators, “testimonials”
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