CRC Screening Colorectal Cancer Screening
“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.” C. Richard Boland, MD
How lethal is CRC? • CRC is the third most common internal cancers in men & women • CRC is the second leading cause of cancer death • CRC is the leading cancer death in men and women who do not smoke • We each have a 1 in 18 chance of developing the disease
Deaths in USA • 150,000 new cases of CRC each year • 57,000 people died from CRC yearly • ½ are women • Typically affects people 50 yrs and older • Men have > risk of CRC but more women die of CRC because they live longer • Relative risk highest amongst African-American • CRC can be heredity • Familial Adenomatous Polyposis [FAP], 1% • Hereditary nonpolyposis CRC, [HNPCC] 5% • Family Hx of CRC or adenomas, 18-23% • Personal Hx of prior colon cancer, long standing IBS, Crohn’s, ovarian, endometrial and probably breast cancer • Most cases are sporadic in average risk patients, 65-85%
Deaths World Wide • CRC is the 4th most common cancer world wide • New cases yearly • 400,000 in men • 380,000 in women • Almost 400,000 deaths yearly • CRC is the 1st most common cause of cancer in the European Union (1)
What else do we know about CRC? • Through screening, CRC is the most preventable visceral cancer.
Currently there is a low level of CRC screening. This is due to: Physician, then patient attitudes about current screening methods.
In order to “beat” a problem, it is wise to learn everything about it you possibly can. SO…..
What are the contributors to CRC? • Older Age • Ethnicity • Personal/Family history of CRC • Polyps • Present in 10-30% of population by age 50 yo • Present in 30-60% of population by age 70-75 yo • Reduced incidence of CRC when polyps are removed • Diet high in meat, fat, protein, or alcohol & low in fiber, calcium, selenium, or folate are associated with increase in CRC
What are the distracters to CRC? • Young Age/However occurs 7% in people <50 • Ethnicity • No Personal/Family history of CRC/However 80% occurs in people without history • Diet low in meat, fat, protein, or alcohol & high in fiber, calcium, selenium, or folate are associated with decrease in CRC • HRT decreases CRC • ASA & NSAIDS may reduce CRC • Lifestyle can affect risk, decreasing CRC with exercise & healthy eating. • BUT in particular…screening for CRC, decreases CRC.
Screening Facts • 60% of Americans over 50 have NEVER been screened for CRC • ALL FORMS OF SCREENING REDUCES MORTALITY • Screening detects and removes pre-cancerous polyps • Screening is cost-effective
According to Vogelstein @ John Hopkins.. …we may have decades plus/minus 10 years to find CRC! Benign neoplasia Malignant neoplasm Early Carcinoma Adenoma Advanced Adenoma Normal Colonic epithelium Benign neoplasia Lasting many decades Benign, 2 -5 years 2 -5 years Late Carcinoma
EARLY DETECTION IS THE KEY! Even if we don’t get CRC in the adenoma stage, localized CRC 5-yr survival rate is 90% compared to 5% with metastasizes.
Who do you screen? • The Average Risk Person [ARP] = is 50 yo or older without other risk factors for CRC = 75-80% of the at risk population • Other high risk patients should be screened earlier = 25-20% of the at risk population • Lowest screened: • People aged 50-54 (31%) • Hispanics (31%) • Asian/Pacific Islanders (35%) • People < 9th grade education (34%) • No Health Care (20%) • Medicaid Coverage (29%) • No medical care during last year (20%) • Daily smokers (32%) • More screening in New England / Mid-Atlantic • Less screening in Gulf/South
High Risk People = 20-25% of population • People with HNPCC diagnosis • These people get CRC at 45 yo instead of the common age of 63 yo • Also increased in people with endometrial, ovarian, breast cancer • Begin screening at 20 -30 yo • High suspicion when they follow the “Rule of 3-2-1” [Amsterdam II criteria] • 3 relatives with CRC/at least one is first degree relative of the other two • 2 successive generations • 1 diagnosis before the age of 50 • Mutation in the hMSH2 & hMLH1 genes [signaling proteins responsible for gene repair] that increases microsatelitte instability [MSI] = Hallmark of HNPCC
More High Risk • People with Familial Adenomatous Polyposis, FAP • 50% have polyps in teens • 95% have polyps by 35 yo • 100% have CRC by 40 yo unless their colon is removed • Mutation in the APC [adenomatous polyposis coli] gene responsible for tumor suppression • Ashkenazi Jews • 6% population has double the risk of CRC • Mutation in APC tumor suppressor gene • African American men & women • Develop CRC more commonly on the right side of the colon. May be missed depending on screening modality.
Fact! Every man and woman 50 years or older is at risk for the development of CRC.
CRC Screening Options for PatientsPresented in 1997 by AGA* • Annual Fecal Occult Blood Testing [FOBT] • Flexible sigmoidoscopy every 5 yrs • Annual FOBT plus flexible sigmoidoscopy every 5 yrs • Double-contrast barium enema every 5 yrs • Colonoscopy every 10 yrs *American Gastroenterological Association
Patient Selection of Options • Almost noninvasive • 31% chose FOBT only • Invasive procedures: • 38% chose colonoscopy, most preferred invasive option • 14% preferred barium enema • 13% preferred flexible sigmoidoscopy • 71% chose to repeat colonoscopy • 36% chose to repeat FOBT
Why patients don’t participate….. • Fear of pain, embarrassment, distaste • Lack of perceived need • Fear of the results • Fatalism [belief nothing can be done] • Too busy, not willing to take time off for screening • Inadequate transportation and telephone service • Deference to authority • Lack of screening coverage by health plan or no insurance
Why patients do participate….. • Clinician advise • Perceived benefit [test as effective] • Family member who has had the test • Continuing relationship with the practitioner • Higher socioeconomic status • More personal experience of illness • Regular preventive health behavior [dentist, use of seatbelts] • Family history of CRC • Age under 75 yrs • Being married • Belief that CRC is curable • Other GI symptoms [stomach symptoms, haemorrhoids]
How to get patient cooperation… … physicians must first OFFER patients acontrolled screening choice.
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.
Today….. • ….we are beginning to understand the biological concepts of CRC To access additional information on the biological types of CRC, click on the below link. Biological concepts of Colorectal cancer
Thus in 2003 two more modalities were added to our current screening procedures. • One, a marketing venture called “Virtual Colonoscopy” Known as CT Colonography in the medical world. • 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
2004’s Available Screening Modalities • FOBT-Fecal Occult Blood Testing • Digital Rectal Exam [DRE] - is NOT a screening Test for CRC • Flexible Sigmoidoscopy • Double Contrast Barium Enema • Colonoscopy [Screening & Diagnostic] • Stool-based DNA Testing • Virtual Colonoscopy
Clinical Decisions in CRC Screening • Patient considerations: • Patient finances • Patient risk • Patient compliance • Initial • Repeat • Screening considerations • Testing effectiveness
Knowing that “all asymptomatic people 50 yr old and older should be screened for CRC,” what is your choice? • FOBT, annually with colonoscopy if positive • FOBT, annually with sigmoidoscopy every 5 yrs starting at 50 • Double Contrast Barium Enema • [Not preferred if other screens are available] • Virtual Colonoscopy every 5 to 10 yrs • Colonoscopy every 10 yrs • DNA Testing every 3 to 5 years • DNA Testing every 10 yrs with Colonoscopy every 5 yrs spaced between the colonoscopies
What is the BEST Screening Plan for the Average Risk Patient? The plan that is followed through on!!! Otherwise…. 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
Recently due to scientific studies…… …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] • 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. Sound like Functional Medicine?
Colon Chemoprevention • The substances being investigated are: • A FDA approved statin • A novel nutritional agent that contains inulin • NSAIDS • To learn more about Mayo’s Chemoprevention Clinical Trials, contact Paul Limburg, MD, MPH, at 507-266-4338
Click on this link and fill out the consent form. Make a choice to NOT become a Colorectal Cancer statistic! THANK-YOU and your loved ones thank-you too! SO……….
References • 1.http://www.foodingredientsfirst.com/newsmaker_article.asp?idNewsMaker=83&fSite=E0D45&nw=hd