Financial Disclosers

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1 Slide 1 Colorectal Cancer Screening Jason Hemming, MD NESGNA November 15, 2014 Slide 2 Bio Slide 3 Financial Disclosers I have no actual or potential conflict of interest relation to this presentation No discussion of off-label medication or product/device uses

2 Slide 4 Outline Review colon cancer epidemiology and screen options Discuss most recent 2008/2009 CRC screenin guidelines Discuss Colonoscopy related Quality Measure with CRC screening Slide 5 Epidemiology & Clinical Consequence CRC is the 3rd most common form of cancer diagnosed in men and women in the US (148,0 cases / year) CRC is the 2nd leading cause of cancer deaths the US (56,000 deaths / year) Average CRC death results in 13years of lost l 5% lifetime risk and 2.5% CRC related death Slide 6 Couric Effect CRC Awareness is Increasing Medicare funding for screening State laws mandating insurance coverage Widespread guideline endorsements ACG, ASGE, AGA ACS, ASCRS, ACR, AAFP US Preventive Services Task Force

3 Slide 7 US Adherence Rates Cancer Screening Breast CA 69% * Cervical CA 86% * Prostate CA 75% * Colorectal CA 42% & 63% ** * Cancer 2002; 95: ** JAMA 2003; 289: 1414 Slide 8 National Adherence (2006 < 50% 50-59% >/= 60 Slide 9 Colon Cancer Risk Group Sporadic (average (65% 85%) Rare syndromes (<0.1%) Familial adenomatous polyposis (FAP) (1%) Family history (10% 30%) Hereditary nonpolyposis colorectal cancer (HNPCC) (5%)

4 Slide 10 Criteria for Medical Screening Acceptable sensitivity, specificity and predictive value Valid and reliable Identify disease early and lead to treatment that impedes disease progression Further testing and management of the disease must be available, accessible and acceptable Benefits must outweigh costs Surveillance : monitoring of premalignant conditions (IBD history of adenomas/cancer Slide 11 Adenoma Carcinoma Sequence Normal Epithelium Tubular Adenoma (TA) Tubulovillous Adenoma (TVA) Villous Adenoma (VA) Invasive Adenocarcinoma (CA) Muto T. Cancer 1975; 3 Slide 12 Adenoma Carcinoma Sequence

5 Slide 13 U.S. CRC Screening Guidelines : Prior to 1997 No consensus FOBT Flex Sig BE Slide Guidlines Addition of Colonoscopy Adenoma - Carcinoma Sequence Selby NEJM 1992 : protection from Flex-SIG National Polyp Study (Winnawer 1993) : Decreased CRC mortality following polypectom Slide 15 Evolution of U.S. CRC Screening Guidelines Prior to 1997 No consensus FOBT, Flex Sig, BE consensus CSPY q10yr 2002 Screening : grade A 2003 Included FIT, FOBT 2008 Prevention vs Early Detection

6 Slide 16 Invasive vs Non-Invasiv Adenoma vs Cancer detecti One Step vs Two Step Slide 17 Invasive Screening Colonoscopy Flex Sig AC-BE CT-Colon Non-Invasive Screening FOBT/FIT? Colon Capsule Slide 18 Assumptions: Non-Invasive Screening Less likely to prevent cancer Repeated at regular intervals to be effective If abnormal -> needs invasive testing Not recommended for those not willing to have repeated testing and CSPY if abnormal

7 Slide 19 Adenoma Detection Colonoscopy Flex Sig Barium Enema Virtual Colon Colon Capsule Cancer Detection FOBT/FIT Stool DNA Slide 20 Adenoma Detection Colonoscopy Flex Sig Barium Enema Virtual Colon Colon Capsule Cancer Detection FOBT/FIT Stool DNA ONE ST Slide 21 Primarily Detect Cancer Guaiac-Based FOBT heme or hemoglobin Fecal Immunochemical Test (FIT) human globin Stool DNA (sdna)

8 Slide 22 FOBT Decreased Mortality 15-33% Cancer Sensitivity 50-75% Digital FOBT sensitivity 5% Needs annual compliance Dietary restrictions Slide 23 Fecal Immunochemical Tes (FIT) Greater sensitivity / specificity Cancer sensitivity of 82-87% More specific for LGI sources of bleeding Better adherence no dietary restrictions Blood in Stool = non-specific finding Slide 24 ACS/MSTF Guidelines : FOBT/FIT Acceptable option if: annual & high sensitivity test Any (+) followed up by colonoscopy Not recommended during DRE / Pelvic exam

9 Slide 25 ACG Guidelines FIT is preferred annual testing Superior performance adherence doubles detection of advanced lesions little loss of PPV Slide 26 Fecal DNA Testing Adenomas and Carcinomas shed cells with altered DN Requires high sensitivity multi-target assay ACS/MSTF - acceptable option interval uncertain (5yr rec) CRC sensitivity 65% (1.0) -> 87% (1.1) Advanced adenoma sensitivity 20% FIT still preferred - costs, better data Slide 27 Invasive Screening Tests Flex sigmoidoscopy Colonoscopy Air Contrast Barium Enema CT Colography (virtual colon)

10 Slide 28 Barium Enema Slide 29 ACS/MSTF : Barium Enema DCBE q5years acceptable option Availability of highly trained radiologist decreased volume = inexperienced radiologists ACG (2009) : not recommended as alt screening te low volumes less effective than CT-COLON Slide 30 Virtual Colonoscopy

11 Slide 31 CT-Colography ACRIN Trial (NEJM 2008) detected 90% of adenomas or cancers (>10mm) in ASX patients detected 78% of lesions >6mm NPV 95% for polyps >5mm Pooled data Sens polyps >1cm 48-93% (mean 63%) Spec polyps >1cm 96-97% Slide 32 CT-Colography ACRIN Trial (NEJM 2008) detected 90% of adenomas or cancers (>10mm) in ASX patients detected 78% of lesions >6mm 14% referral for colonoscopy NPV 95% for Years polyps 0, 5, >5mm 10 = 42% colonoscopy + CT-COLON but Neg Colonoscopy (PPV23%) Pooled data Sens polyps >1cm 48-93% (mean 63%) Spec polyps >1cm 96-97% Slide 33 Virtual Colonoscopy Still needs prep Air insufflation Radiation Extra-Colonic Findings Colonoscopy was found to be less unpleasant than expected in 87% as opposed to only 67% with CT-COLO

12 Slide 34 Invasive CRC screening te Flexible sigmoidoscopy Colonoscopy Air Contrast Barium Enema CT Colography (virtual colon) Slide 35 Flexible Sigmoidoscop 2012 Meta-Analysis : 32% CRC incidence reduction and 50% Mortality reduction Norwegen RCT - 76% Mortality reduction Missed rate of 30% for advanced adenomas Preferred with Annual FOBT Slide 36 ACS/MSTF - Flex Sig Guidelines Acceptable option provided beyond 40cm Adenomas are used as indication for full colonosco Appropriate interval remains uncertain every 5years in most clinical setting concerns about quality / completeness Flex-SIG q5yr + FIT yearly

13 Slide 37 Colonoscopy Advanced Adenomas 5-10% Cancer <1% Incidence reduction 50-70% Mortality reduction 30-65% Missed advanc adenomas 2-1 Interval Cance 0.1% Complications 0.4% Slide 38 USPSTF Regular screening beginning at age 50 FOBT (high-sens) q1yr Flex Sigmoidoscopy q5yr (FOBT q3yr) Colonoscopy q10yr individualized > 85 against Slide 39

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