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 Crohn’s 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%) < 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)

10. 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%)

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 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

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 (< 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;142:86-94 • Smith RA, et al. CA Cancer J Clin 2001:51:38-75

13. Fecal Immunochemical Test (FIT) • Mono/polyclonal antibody detect intact globin protein portion of human Hgb • Specific for globin in LGI tract since globin 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 used Levin B, et al. CA Cancer J Clin 2003;53:44-55 Smith A, et al. Cancer 2007;107:2152-2159

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 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!

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 • 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

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 • <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 judgment Winawer SJ, et al. CA Cancer J Clin 2006;56:143-159

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 2001:51:38-75

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 >$400/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”