Colon Cancer Screening and Surveillance. Louis V. Antignano, M.D. Wilson Gastroenterology October 11, 2011

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1 Colon Cancer Screening and Surveillance Louis V. Antignano, M.D. Wilson Gastroenterology October 11, 2011

2 Colorectal Cancer Preventable cancer Number 2 cancer killer in the USA Often curable if detected early

3 Colorectal Cancer Lifetime risk is roughly equal in men and women Most common after 50 years of age Can affect those younger than 50 y/o Risk of CRC increases with age

4 Screening and Surveillance Screening for average risk individuals Surveillance for individuals of higher risk

5 Who is considered average risk? 50 years of age No prior history of colorectal cancer or of adenomatous (i.e., precancerous) polyps No family history of colon cancer Which affected relatives, and their age at diagnosis, is important in risk assessment No history of inflammatory colitis (i.e., ulcerative colitis or Crohn s colitis)

6 Who is considered high risk? Personal history of colorectal cancer or of adenomatous (i.e., precancerous) colorectal polyps Strong family history of colon cancer Inherited forms of CRC special situations Predisposing GI diseases Crohn s disease of the colon Chronic ulcerative colitis

7 Colorectal Cancer - Symptoms Most early colorectal cancers produce no symptoms. This is why screening for colorectal cancer is so important. CRC is often curable if found before symptoms develop. Removal of colon polyps, the precursor of most colon cancers, can prevent death from colon cancer.

8 Colorectal Cancer - Symptoms New onset of abdominal pain Blood in or on the stool or a change in stool caliber or shape A change in typical bowel habits, constipation, diarrhea

9 Colorectal Cancer - Symptoms While these symptoms do not always indicate the presence of colorectal cancer, the new onset of these symptoms should prompt a visit with your physician and further evaluation.

10 What is Colonoscopy? Colonoscopy is the careful examination of the large intestine using a lighted, flexible fiber optic/electronic instrument called a colonoscope. The procedure allows a gastroenterologist a well trained specialist to look inside the entire colon to check for abnormal or inflamed tissue.

11 What is Colonoscopy? Colonoscopy has emerged over the last two decades as the preferred method to screen people for abnormal precancerous growths called polyps or colon cancer. Colonoscopy is among the most powerful tools in use in clinical medicine It has the extraordinary potential to both identify and permit removal of precancerous colorectal polyps before they turn into cancer.

12 Colon Polyp Precursor of Colorectal cancer

13 Colon Cancer Screening Average risk individuals Most colorectal cancers develop from polyp. If polyps grow unnoticed and are not removed, they may become cancerous. Screening tests can find pre-cancerous polyps so they can be removed before they turn into cancer.

14 Colon Cancer Screening The development of more than percent of colorectal cancer can be avoided through early detection and removal of pre-cancerous polyps

15 CRC Prevention v CRC Detection The 2009 ACG colorectal cancer screening guideline divides the options into cancer prevention tests and cancer detection tests. Cancer prevention tests are preferred over detection tests.

16 Colon Cancer Prevention Colonoscopy: the preferred colorectal cancer prevention test Colonoscopy every 10 years is the preferred colorectal cancer prevention test for individuals with average risk of CRC For normal risk individuals, the American College of Gastroenterology recommends colonoscopy every beginning at age 50, and age 45 for African Americans.

17 Colon Cancer Prevention Alternative CRC prevention test: flexible sigmoidoscopy every 5 to 10 years Coupled with annual tests for fecal occult blood Examines only the lower half of the colon 50% of all colon polyps, and many cancers, lie beyond the reach of flexible sigmoidoscopy Not all polyps and cancers bleed and tests for blood in the stool may be falsely negative

18 Colon Cancer Detection Preferred Cancer Detection Test: Fecal Immunochemical Test (FIT) Annual fecal immunochemical testing is the preferred colorectal cancer detection test. FIT is a relatively new test that detects hidden blood in the stool. If results are positive, a colonoscopy is performed.

19 Colon Cancer Detection Alternative Cancer Detection Test: CT Colonography every 5 years CT Colonography or virtual colonoscopy is an X-ray designed to look for colon polyps and cancers. CTC is an alternative to colonoscopy every 10 years for patients who decline colonoscopy. If polyps are detected, a regular colonoscopy is required to remove these pre-cancerous growths.

20 Colon Cancer Detection Alternative Cancer Detection Tests: Fecal DNA Testing every three years or Annual Hemoccult Sensa

21 CRC Screening in African Americans Screening for African Americans Should Begin Earlier African-Americans diagnosed with colorectal cancer at younger age than other ethnic groups. African- Americans with colorectal cancer have decreased survival compared with other ethnic groups. The American College of Gastroenterology in 2009 issued new guidelines recommending colorectal cancer screening in African-Americans starting at age 45 rather than age 50.

22 CRC Screening in African Americans Colonoscopy is the preferred method of screening for colorectal cancer in all ethnic groups. Data support the recommendation that African-Americans should begin screening at a younger age because Higher incidence of colorectal cancer Greater prevalence of proximal or right-sided polyps and cancer in African Americans The guidelines published in the March 2009 issue of The American Journal of Gastroenterology.

23 Bowel Preparation A clean colon results in the best test. The cleaner the colon, the more accurate will be colonoscopy The cleanest colon gives the best results adequate cleansing is absolutely necessary for a safe and reliable colonoscopy No, an inadequately colon can not be adequately cleaned during the colonoscopy examination.

24 Bowel Preparation Many patients claim the prep is the toughest part of the exam. A good prep is essential, so it is vitally important to follow your doctor s bowel preparation instructions exactly. Split-dosing of the prep taking one-half the night before and the remainder to finish about 2-3 hours prior to colonoscopy gives the best results and leads to the most accurate examination

25 Colonoscopy Many avoid colonoscopy because of anxiety about possible discomfort during the procedure Medication given IV provides for relaxation, analgesia, amnesia

26 Colonoscopy Sedation-analgesia fentanyl + midazolam Provides relaxation Provides analgesia Provides amnesia Deep sedation - propofol Requires presence of an anesthesia professional (anesthesiologist or CRNA) Close to anesthesia-type loss of pain sensation, with relaxation and amnesia Cost of anesthesia professional sometimes exceeds the cost of the colonoscopist Some insurance companies do not pay for anesthesia professional unless there is a medically valid reason to use deep sedation

27 Colonoscopy You Will Be Treated Carefully & Gently The doctor then slowly inserts a thin flexible lighted tube, the colonoscope into the rectum and maneuvers it gently through the inside of the entire colon. The scope transmits an image of the colon onto a video screen so the doctor can check for any abnormalities. If any pre cancerous polyps are found, they are removed during the examination through tools that the doctor can pass through the colonoscope. This results in the prevention of development of colon cancer in a single procedure.

28 Colonoscopy Colonoscopy is Simple The colonoscopy procedure itself typically takes about 15 to 30 minutes You should expect to be at the endoscopy suite for about 2 to 3 hours on the day of your colonoscopy.

29 Colonoscopy Colonoscopy is Safe Colonoscopy is a safe procedure. Potential complications are rare but can occur Bleeding (1/1000) Infection reaction to drugs used for sedation rupture of spleen (1/45,000) colon perforation (1/1000) that usually requires emergency surgery to repair

30 Colonoscopy Your doctor will review these possible problems with you and you should have the chance to ask questions if you have concerns. SPEAK UP! ASK QUESTIONS!

31 Colonoscopy

32 Colonoscopy Follow-up When is your next colonoscopy? Average risk 10 years One adenoma > 1 cm 3 years Villus adenoma any size 3 years Three or more adenomas any size 3 years Two or fewer adenomas < 1 cm 5 to 10 years Hyperplastic polyps (< 6) 10 years

33 Colonoscopy Follow-up When is does a family history of colon polyps or colon cancer matter? Single first degree relative (parent, sibling, child) who develop CRC or colon adenoma younger than 60 y/o colonoscopy every 5 years Personal history of colon adenoma and FDR w/crc or adenoma, any age 5 years

34 Colonoscopy Follow-up Colon cancer syndromes multiple (3 or more) FDR with colon cancer or colon polyps are special situations Hereditary non-polyposis colon cancer Cancer of ovary, uterus, kidney, small intestine, gall bladder, basal cell skin cancer, brain tumor, stomach, pancreas Familial Adenomatous Polyposis (FAP)

35 Colonoscopy Follow-up Once colonoscopy has been done and the prevention colonoscopy interval established, routine testing of stool for blood is not indicated Falsely positive results lead to unnecessary procedures and unnecessary procedure risk Routine testing of stool for blood during office rectal or gynecological examination to assess CRC risk is not recommended after the prevention colonoscopy interval established

36 Colon Cancer Screening Two screening tests have been shown unequivocally to prolong life: Pap smears Colonoscopy

37 Colon Cancer Screening and Surveillance Wilson Medical Center American College of Gastroenterology American Gastroenterological Association American Society GI Endoscopy CDC NIH

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