Colorectal Cancer Awareness in TN: Risk Factors, Screening, Outreach

1
Colorectal Cancer Awareness in TN Risk Factors,
Screening, Outreach

• Keith D. Gray, M.D.
• Assistant Professor of Surgery
• Division of Surgical Oncology
• The University of Tennessee Medical Center

2
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

3
Uncontrollable Risk Factors for Developing
Colorectal Cancer

• Age 50 or older
• Family history of cancer of the colon or rectum
• Personal history of cancer of the colon, rectum,
  ovary, endometrium or breast
• History of polyps of the colon
• Inflammatory bowel disease ulcerative colitis
  or Crohns disease
• Hereditary conditions

4
Controllable Risk Factors for Developing
Colorectal Cancer

• Obesity
• Physical inactivity
• Cigarette smoking
• Diet high in red or processed meat
• Heavy alcohol consumption
• Inadequate screening

5

• 50-75 of cancers can be prevented by lifestyle
  and dietary changes

6
CRC Burden in TN
TN 52.3 (50.5, 54.2)
7
CRC Burden in TN
TN 18.9 (17.8 -20)
8
Disparate CRC Outcomes
9
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) lt HS education 7th
• 9.6 lt 9th grade education (5th)
• 31.5 sedentary 2nd
• 67.4 obese (BMIgt25) 4th
• High fat diets, physical inactivity
• 26.4 (16.3 - 32.5) consume 5 fruits/veges per
  day
• 24.3 currently smoke (5th)

10
TN Screening Report (2006)

• FOBT (gt50)
• Last 2yrs 25.6 (12.1 26.6)
• Last 1yr 15.7 (6.6 22.5)
• Colonoscopy (gt50)
• Ever 56.2 (49.8 69.2)
• lt10yrs 53.4 (46.6 66.4)
• lt5yrs 49.9 (40.6 60.9)

11
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
  tool

Eddy D. CA Cancer J Clin 198030193-240 Smith
RA, et al. CA Cancer J Clin 20015138-75 Mysliwi
ec PA, et al. Ann Intern Med 2004141264-271 Ko
CW, et al. Gastrointest Endosc 200765648-56
12
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 (lt 5) as bleeding often
  intermittent and blood may not be present in
  entire stool
• Sole method of FOBT in up to 33 of PCPs Nadel
  MR, et al. Ann Intern Med 200514286-94
• 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
200514286-94 Smith RA, et al. CA Cancer J Clin
20015138-75
13
Fecal Immunochemical Test (FIT)

• Mono/polyclonal antibody detect intact globin
  protein portion of human Hgb
• Specific for globin in LGI tract since globin
  wont 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 used

Levin B, et al. CA Cancer J Clin
20035344-55 Smith A, et al. Cancer
20071072152-2159
14
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 CRCs
  but misses gt50 of proximal colon cancers
  Lieberman DA, NEJM 200020-162-168
• 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!

15
ACS recommendations for CRC screening in
average-risk, asymptomatic people
All positive test should be followed up with
colonoscopy. DCBE /- Flex sig is a suitable
alternative.
16
Individuals at increased risk of developing CRC

• 2x average risk in this population accounts for
  15-20 of colon cancers
• Whos at increased risk?
• h/o of AP/CRC in any 1st degree relative lt60, or
• gt2 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

17
Postpolypectomy Surveillance Colonoscopy
Recommendations - 2006 Update

• Small rectal hyperplastic polyps
• nl colonoscopy, 10-year f/u
• Hyperplastic polyposis syndrome should be
  screened more frequently
• lt2 small tubular adenomas with LGD
• 5-10 years
• 3-10 adenomas, any gt1cm, any with villous
  features or HGD
• 3 year f/u if completely removed
• Subsequent 5 year f/u if nl or above
• gt 10 adenomas
• f/u lt3 years and consider familial syndrome
• Piecemeal removal of sessile adenomas
• Repeat endoscopy in 2-6 months
• After complete removal confirmed, subsequent
  surveillance based on judgment

Winawer SJ, et al. CA Cancer J Clin
200656143-159
18
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

19
ACS recommendations for CRC screening among
people at high risk
Adapted from Smith RA, et al. CA Cancer J Clin
20015138-75
20
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 gt400/test additional markers
  increases cost

21
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

22
Key Points

• Colon cancer is common in the U.S.
• Prevention and early detection save lives.
• Everyone over 50 should undergo colon cancer
  screening as part of annual exam.
• Education improves screening.

23
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

24
(No Transcript)
25
(No Transcript)