CRC Screening

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CRC Screening

• Colorectal Cancer Screening

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• 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

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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

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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 gt 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, Crohns, ovarian, endometrial and probably
  breast cancer
• Most cases are sporadic in average risk patients,
  65-85

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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)

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What else do we know about CRC?

• Through screening, CRC is the most preventable
  visceral cancer.

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Currently there is a low level of CRC screening.
This is due to Physician, then patient
attitudes about current screening methods.
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• In order to beat a problem, it is wise to learn
  everything about it you possibly can.
• SO..

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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

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What are the distracters to CRC?

• Young Age/However occurs 7 in people lt50
• 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 particularscreening for CRC, decreases
  CRC.

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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

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According to Vogelstein _at_ 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
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EARLY DETECTION IS THE KEY!

• Even if we dont get CRC in the adenoma stage,
  localized CRC 5-yr survival rate is 90 compared
  to 5 with metastasizes.

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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 lt 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

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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

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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.

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Fact!

• Every man and woman 50 years or older is at risk
  for the development of CRC.

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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

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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

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Why patients dont 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

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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

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How to get patient cooperation

• physicians must first OFFER patients a
  controlled screening choice.

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• 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.

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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

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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

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2004s 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

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Testing Options
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Clinical Decisions in CRC Screening

• Patient considerations
• Patient finances
• Patient risk
• Patient compliance
• Initial
• Repeat
• Screening considerations
• Testing effectiveness

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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

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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

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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?

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Colon Chemoprevention

• The substances being investigated are
• A FDA approved statin
• A novel nutritional agent that contains inulin
• NSAIDS
• To learn more about Mayos Chemoprevention
  Clinical Trials, contact Paul Limburg, MD, MPH,
  at 507-266-4338

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SO.

• 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!

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Resources
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References

• 1.http//www.foodingredientsfirst.com/newsmaker_ar
  ticle.asp?idNewsMaker83fSiteE0D45nwhd

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Preventive HealthCare

• Women
• Pap
• Traditional
• ThinPrep
• SureCell
• Pelvic Exams
• Breast Screening
• Mammograms
• Thermograms
• BSE-Breast SelfExam
• Bone Density
• CRC Screening
• Lipid Screening

• Men
• Prostate Screening
• CRC Screening
• Lipid Screening
• Bone Density