Colorectal Cancer Prevention Quantity and Quality Count Ernesto Drelichman, MD Gastrointestinal Surgery & Endoscopy Providence Hospital
Key Messages Colorectal cancer can be prevented Screening reduces mortality from CRC All persons aged 50 years or older should be screened High-risk individuals should begin screening earlier Several effective screening options are available; not screening is no longer an option
Key Messages Quality Risk Assessment Consent Screening Study with quality indicators Pathology Communication Computerized Registry Follow up
Colon & Rectal Cancer 2 nd leading cause of cancer death 3rd most common cancer overall 147,500 new cases annually 57,100 deaths annually
Why Screen?...the primary strategy for preventing colorectal cancer deaths is to detect and remove precancerous polyps or to detect and treat cancer in its earliest stages CDC 2/99
Colorectal Carcinogenesis Normal Mucosa Aberrant Crypt Foci Adenoma Cancer T(0) T(10)
Staging and Prognosis Stage TNM Grouping 5-Yr. Survival 0 Tis; N0; M0 100% I T1-2; N0; M0 90-95% II T3-4; N0 M0 75-80% III Any T; N1-3; M0 40% IV Any T; Any N; M1 5%
Colorectal Adenocarcinoma Flat Raised Ulcerated Infiltrating
Stage IV Colon Cancer
Diagnosis vs Screening People with symptoms or signs that suggest the presence of colorectal cancer or polyps fall outside the domain of screening and should be offered an appropriate diagnostic evaluation.
Presentation Proximal (R-side) Ill-defined abd. pain Weight loss Occult bleeding Distal (L-side) Altered bowel habits Dec. stool caliber BRBPR
Screening vs Surveillance Screening = Detection of asymptomatic disease in healthy individuals at average risk (e.g. no identifiable risk factors other than age) Surveillance = Search for asymptomatic disease among higher risk individuals (e.g. personal history of polyps or cancer, etc.)
Screening Compliance CRC Overall 53% Breast Cancer 77% Behavioral Risk Factor Surveillance System, 2001
Barriers to Screening Patient Lack of information Low perceived risk Inconvenience Discomfort Expense Provider Lack of information Competing priorities Too many options Access concerns Petersen GM - Gastroenterol Clin North Am 2002;31:1061-8 Vernon SW - J Natl Cancer Inst 1997;89:1406-22
Katie s first colonoscopy "It really didn't hurt"
Screening Options Interval Fecal occult blood test (FOBT) 1 year Flexible sigmoidoscopy 5 years FOBT/Flex. Sig. 1 year/5 years Barium enema (DCBE) 5 years Colonoscopy 10 years Choice of screening tests should be suited to the situation.
IDEAL SCREENING TEST Detect all curable cancers Detect and allows excision adenomas Available, acceptable, safe Affordable and cost effective Providers must tailor to patients
FOBT Detect the pseudoperoxidase activity of heme Sensitivity neoplasms = 15% to 30% Poor specificity and high false positives
A better FIT Noninvasiveness No prep No diet restrictions Sensitivities of 66% for detecting cancer and 27% for detecting advanced polyps and a specificity of 95% Cost $18 and $30 Medicare reimbursed Morikawa T et al Gastroenterology. 2005;129:422-8
DNA Detect gene mutations in tumor cells sloughed into stool Noninvasiveness No prep No diet restrictions
DNA The DNA panel Sensitivity for invasive cancers = 40.8% Hemoccult P<0.001 = 14.1 percent Expensive Imeriale et al. N Engl J Med. 2004;351:2704-14
Barium Enema Screening No sedation required Reasonable sensitivity for cancer (83%) 1 1 Rex, et al. - Gastroenterology 1997;112:17-23; 2 Winawer, et al. - N Engl J Med 2000 Jun 15;342(24):1766-72
Barium Enema Screening Low Specificity - frequent need for repeat bowel prep and colonoscopy Lipoma Large fold Residual stool Poor sensitivity for polyps > 10 mm (48%) 2 1 Rex, et al. - Gastroenterology 1997;112:17-23; 2 Winawer, et al. - N Engl J Med 2000 Jun 15;342(24):1766-72
Virtual Colonoscopy Lack of consensus about its role in screening. Sensitivity 60% for cancer detection
SCREENING COLONOSCOPY If the result of a screening test is abnormal, physicians should recommend a complete colonic Evaluation: Colonoscopy Ko, Hyman Dis Colon Rectum 2006; 49: 1 3
COLONOSCOPY SCREENING IN THE U.S. Recommended as an option in 1997 Proposed as the preferred method of screening by ACG in 2000 Reimbursement by Medicare in 2001
Advantages Colonoscopy Gold Standard for Quality Highest sensitivity and specificity Entire colorectum assessed Neoplasms can be biopsied and/or removed during the screening exam (no follow-up testing required)
How to bend light?
Prototype Fiberscope
Basil Hirschowitz, MD Emeritus Professor UAB
Basil Hirschowitz, M.D
Quality Screening Study Risk Assessment Uses and documents quality indicators in report Avoids potential complications of exam Makes correct recommendations in report Communicates to patients and referring physicians Registry to assure follow up
Perianal and DRE Photograph IC Valve appendiceal orifice Describe Prep Extraction time >6min Recommendations/risk Letter to referral Communicate to patient Computerized Registry Quality Indicators for Colonoscopy
A Quality exam starts here Perianal Exam and DRE
Terminal Ileum
Complete Study No cecal intubation Why and how was study completed what were the results Ileocolonic anastomosis Landmarks Appendiceal orifice Ileocecal valve Terminal ileum Transabdominal illumination*
Transillumination The Light at the End of the Tunnel
Diverticulosis Tics
Pedunculated Polyp Excision
Identification and removal of polyps prevents colorectal cancer
Piece-meal Polypectomy
Transanal Endoscopic Microsurgery
Direct Drive Endoscopy
Location, Location, Location Ink
Laparoscopic Colectomy
Informed Consent Perforation 1 of 1000 Major hemorrhage 3 of 1000 Respiratory depression 5 of 1000 Death from complication 3 of 10,000 Multiple series of prospective studies
Quality Perform a Safe Exam Good Risk Assessment Preop Appropriate study Cardiac and pulmonary monitors Complete hemostasis Avoid excessive looping Be aware of depth during polepectomy Admit high risk patient and obtain labs and dx studies
Know when to say Uncle Order BE to complete study
Know how to identify a complication
Know how to correct a complication Perforation
Know how to identify a Complication
Splenic injury
Key Messages Risk Assessment FAMILIAL RISK OF CRC Familial Setting Lifetime Risk General population in U.S. 6% 1 First degree relative CRC 2-3 x 2 first degree relative 3-4 x First degree CRC < 50 3-4 x AGA. Gastroent 2003; 124:544
High Risk Individuals Amsterdam Criteria (AC I,II) 3 relatives with CRC w 1 being a 1st degree relative of other 2 successive generations 1 CRC onset < 50 yrs of age AC II: substitute other HNPCC related CRC
Familial Colorectal Cancers HNPCC lifetime risk CRC 80-85% proximal to splenic flexure Extracolonic Cancers endometrial Ca- 60% ovarian Ca, UGI tumors GU cancers biliary and pancreatic tumors Risk of 2nd malignancy 50% in 15 years
Screening Recommendations Site Procedure Lower age limit Interval (years) (years) Colon Colonoscopy 20-25 2 Endometrium/ovaries GYN exam, CA-125 30-35 1-2 Transvaginal U/S Stomach Gastroscopy 30-35 1-2 Urinary tract U/S, urine cytology 30-35 1-2 Thorson AG Dis Colon Rectum 1999;42:1-9
Colon Cancer in HNPCC Surgeons Approach Surgical Options (+ Malignancy): 1. Total Colectomy with Ileorectal Anastomosis 2. Segmental Colectomy 3. Proctocolectomy +/- IPAA (+/- Prophylactic TAH, BSO) Cancer Prevention and Quality of Life
Polyposis Syndromes of the Colon Neoplastic Syndromes Familial Adenomatous Polyposis Attenuated Adenomatous Polyposis
FAP APC (5q21) 1 in 5,000 persons > 100 CR adenomas UGI polyps, osteomas, extra teeth Extracolonic cancers: - periampullary
FAP-Clinical Presentation
FAP - Colon
Gardner s Syndrome AD - subtype of FAP Additional features: - CHRPEs - desmoids, epidermoid cysts, fibromas, lipomas Extracolonic cancers: - thyroid, adrenal, HB Multifocal CHRPE Image courtesy of Dr. N. Lindor, Mayo Clinic Rochester
CT Scan Abdomen and Pelvis
Ulcerative Colitis and Crohn s Colitis
RISK OF COLORECTAL CANCER
Surveillance Colonoscopy should begin at 8-10 years duration of disease Then at 1-2 year intervals Exam full colonoscopy and 2-4 random biopsy samples at 10cm intervals along entire length of colon Eaden J et al. Gastrointestinal Endoscopy 2000
SURVEILLANCE BIOPSY PROTOCOL
PSEUDOPOLYPS
DALMS IN ULCERATIVE COLITIS
Risk of Cancer associated with Dysplasia Review of ten prospective studies Probability of cancer DALM 43% HGD 42% LGD 19% Bernstein et al. Lancet 1994
Surveillance Problems Questionnaire sent to GI (UK) Only 35% maintain a registry and only 49% of these were computerized Only 53% advised colectomy with HGD Only 4% for LGD Eaden J et al. Gastrointestinal Endoscopy 2000
Vosser
Vosser
SURGICAL OPTIONS IN ULCERATIVE COLITIS
Pathology Endo Path 24 hours What to do with results
Key Messages Communication recommendations Computerized Registry Follow up
nccn.org
Current Guidelines High Risk Average Risk Family Hx Personal Hx Age < 50 Age > 50 Heritable No Defined Syndrome Syndrome CRN IBD Screen Later Screen Now* Screen Early Screen Early Surveillance Colonoscopy Colonoscopy if Positive * Multiple options
Report Quality Indicators
Key Messages Colorectal cancer can be prevented Screening reduces mortality from CRC All persons aged 50 years or older should be screened High-risk individuals should begin screening earlier Several effective screening options are available; not screening is no longer an option
Key Messages Quality Study Risk Assessment Consent Safe Screening Study, dictated and photodocument Pathology and localization Communication Computerized Registry Follow up know what to do with results
GI Surgery and Endoscopy MISSION To Prevent colorectal cancer and its impact through education, risk assessment, screening and surveillance 248-849-ENDO (3636)