Carol A. Burke, MD, FACG

Transcription

1 Updated Guidelines for CRC C Screening and Surveillance Carol A. Burke MD, FACG, FASGE, FACP Cleveland Clinic, Cleveland, OH Gastroenterology t 2012;143: Gut 2010;59:666 1

2 Caveat for all Recommendations Quality Colonoscopy Complete exam High polypectomy rate/adr Adequate bowel preparation Excellent technical approach Complete polyp resection Interval Cancers Occur in < 9% with colonoscopy in past 3 yrs Proximal Microsatellite Instability-High CpG Island Methylation (CIMP) Baxter N, Gastroenterology 2011;140:

3 Interval CRC Completion rate: > 95% vs 80% OR, 0.72 (95% CI, ) Polypectomy rate: 30% versus 10% OR, 061(95%CI 0.61 CI, ) Proximal only ADR: > 20% vs % 19.9% HR, 12.5 (95% CI, ) ) Baxter N, Gastroenterology 2011;140:65 72 Kaminski MF, NEJM 2010;362: Adequate Bowel Preparation Sufficient to detect polyps > 5 mm Guideline: Split dose (at least 1/2 prep on day of exam) If bowel prep poor, repeat exam < 1 year If bowel prep fair but adequate, ate and <10 mm tubular adenomas detected, FU at 5 years Gastroenterology 2012;143:844 3

4 Adenoma Miss Rate Suboptimal Prep N=216, Repeat < 3 yrs N=133, average risk, by patient Adenomas Miss Rate (95% CI) < 5 mm 6-9 mm > 10 mm All sizes CRC 48% (35-49) 43% (39-57) 27% (29-59) 42% (35-49) 0% Feature 1 Adenoma (31% normal BL ) High Risk State (25% normal BL) Miss Rate Interval, days 34% % 271 Lebwohl B, et al GIE 2011;73:1207 Chokshi R, et al GIE 2012;75:1197 Colonoscopy Technique Matters 11 gastroenterologists Grouped by ADR Low: < 21% Moderate: 21-42% High: > 42% Comparison of WD time and technique on ADR Blinded video review Technique Scored Points: 0 (worst) -5 (best) Looking behind folds, adequate cleansing, adequate distension 5 colon locations (cecum, asc, transverse, desc, r-s) Lee R, et al. GIE 2011;74:128 4

5 Technique Trumps WD Time Lee R, et al. GIE 2011;74:128 Polypectomy Technique Size, mm Incomplete Resection Rate (RR, 95% CI) 6% (ref) 9% (1.66, ) 13% (1.95, ) 23% (3.21, ) Adenoma SSP En bloc 8% Piecemeal 7% 31% (3.74, ) 20% (1.41, ) Pohl H, et al. Gastroenterology 2013:144;74 5

6 Incomplete Resection % 10 5 Incomplete Resection Rate 0 MD 1 MD 2 MD 3 MD 4 MD 5 Pohl H, et al. Gastroenterology 2013:144;74 USMTF Colonoscopy Surveillance Recommendations Risk Factor Interval Comment Normal Examination 10 yrs Adequate Preparation Lieberman, et al. Gastroenterology 2012;143;844 6

7 CRC after Negative Colonoscopy Evidence for 10 yr interval Yrs FU Singh 2006 (N=35,975) Lakoff 2008 (N=110,402) 0.66 ( ) 1.28 ( ) 0.59 ( ) 0.80 ( ) 0.55 ( ) 0.56 ( ) Brenner (N=1,692) ( ) 0 ( ) ( ) 0.45 ( ) Singh H, et al. JAMA 2006;295:2366 Lakoff J, et al. Clin Gastro Hep 2008;6;1117 Brenner H, et al. JCO 2011;29:3761 Surveillance Colonoscopy and CRC Mortality 53% Reduction Zauber A, et al. NEJM 2012;366:687 7

8 USMTF Colonoscopy Surveillance Recommendations Risk Factor Interval Comment (yrs) 1-2, < 1cm, TA 5-10 Base on other risk factors 3-10, or > 1 cm, or TVA/VA/HGD 3 If normal or 1-2 TA, repeat 5 yrs > 10 adenomas 1 exam < 3 Consider genetic syndrome Lieberman, et al. Gastroenterology 2012;143;844 Yield of Surveillance Colonoscopy 9127 patients FU interval: 47 months Any Adenoma Adv. Adenoma > 10 mm TVA/VA HGD CRC Characteristic on FU Martinez et al, GASTROENTEROLOGY 2009;136:

9 Baseline Characteristics Predict Advanced Neoplasia Recurrence Polyp Characteristic Advanced Neoplasia OR (95% CI) Number of Adenomas 1.32 ( ) Large Adenoma 1.56 ( ) Villous Histology 1.40 ( ) HGD 1.08 ( ) Proximal Location 1.68 ( ) Risk Status at Baseline Advanced Adenoma CRC Low Risk 6.9% 0.5% High Risk 15.5 % 0.8% Martinez et al, GASTROENTEROLOGY 2009;136: Numerous Adenomas Predict Advanced Neoplasia Recurrence No. Adenomas OR (95% CI) ( ) ( ) ( ) > 5 387( ( ) Martinez et al, GASTROENTEROLOGY 2009;136:

10 MYH Associated Polyposis (MAP) MYH base excision repair gene Repair of oxidative DNA damage Bi-allelic mutations result in Attenuated polyposis or early onset CRC Frequency of carrier state is 2% Church et al. Dis Colon Rectum 2012; 55: Prevalence of Mutations N= 7225 [4 vs 2] [5 vs 4] [10 vs 7] [56 vs 7] [80 vs 2] Grover S, et al. JAMA 2012;308:485 10

11 Predicting Advanced Neoplasia on 3 rd Colonoscopy Low Risk High Risk Findings@ 1 st exam: Low High Low High Low High Findings@ 2 nd exam: Normal Low Risk High Risk Robertson & Burke, Ann Intern Med. 2009;151: USMTF Surveillance Recommendations Risk Factor Serrated Lesions Interval Yrs < 10 mm, recto-sigmoid hyperplastic polyps 10 SSP < 10 mm 5 SSP > 10 mm or SSP with dysplasia or TSA 3 Serrated Polyposis Syndrome 1 SPS: > 5 serrated polyps proximal sigmoid with > 2 being > 10 mm Any serrated polyp proximal sigmoid with FHX SPS > 20 serrated polyps throughout the colon Lieberman D, et al. Gastro 2012;143:844 11

12 Interval FOBT If baseline colonoscopy adequate and colonoscopy surveillance planned, DO NOT PERFORM FOBT Lieberman D, et al. Gastro 2012;143:844 When should screening stop? US Preventive Services Task Force Age Group Recommendation yrs Do not Screen (Individualize) > 85 yrs Do not Screen Grade C D USPSTF Statement. Ann Intern Med 2008, 149:

13 When should surveillance stop? US Multi-Society Task Force on CRC Discontinue surveillance/screening when risk > benefit Surveillance decisions Individualize Ages yrs Potential benefit of surveillance > screening Ages > 85 yrs HRA pts at higher risk for metachronous advanced neoplasia vs average-riskrisk Consider continued surveillance 13