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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. CRC Facts. 2008, 150K new cases and 50K deaths

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colorectal cancer awareness in tn risk factors screening outreach
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

crc facts
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
uncontrollable risk factors for developing colorectal cancer
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
controllable risk factors for developing colorectal cancer
Controllable Risk Factors for Developing Colorectal Cancer
  • Obesity
  • Physical inactivity
  • Cigarette smoking
  • Diet high in red or processed meat
  • Heavy alcohol consumption
  • Inadequate screening
crc burden in tn
CRC Burden in TN

TN = 52.3 (50.5, 54.2)

crc burden in tn7
CRC Burden in TN

TN = 18.9 (17.8 -20)

tn risk profile 2007
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)
tn screening report 2006
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%)
establishment of crc screening guidelines
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

crc screening methods
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
fecal immunochemical test fit
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

endoscopy v dcbe
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!
acs recommendations for crc screening in average risk asymptomatic people
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.

individuals at increased risk of developing crc
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
postpolypectomy surveillance colonoscopy recommendations 2006 update
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

postcancer resection surveillance colonoscopy recommendations 2006 update
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
acs recommendations for crc screening among people at high risk
ACS recommendations for CRC screening among people at “high risk”
  • Adapted from Smith RA, et al. CA Cancer J Clin 2001:51:38-75
emerging technology
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
outreach efforts crc
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
key points
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.
improving crc outcomes
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”