Colorectal Cancer Screening Payam Afshar, MS, MD Kaiser Permanente, San Diego Objectives Colorectal cancer background Colorectal cancer screening populations Colorectal cancer screening modalities Colonoscopy surveillance program Colorectal cancer screening pearls Definitions Screening = asymptomatic patient with no prior history of colon polyps or cancer Diagnostic testing = symptomatic patient, such as iron deficiency anemia, rectal bleeding, abnormal CT imaging, etc. Surveillance = prior history of polyps or cancer based on prior endoscopic evaluation 1
Background 2nd cause of cancer death in U.S. (Lung cancer is 1st) 1 US Cancer Statistics Working Group. 2014 1 US Cancer Statistics Working Group. 2014 Background 2nd cause of cancer death in U.S. (Lung cancer is 1st) 1 in 20 average Americans will have colorectal cancer 1/3 of patients with CRC will mortality associated with it 3-10% of Americans have a 1st degree relative with CRC 1 Incidence: - 90% of CRC > 50 years old - 10% of CRC < 50 years old - 80% of CRC are sporadic - 20% have genetic/hereditary factors 2 1. Henrikson NB, et al. Family history and natural history of colorectal cancer: a systematic review. Genet Med. 2015; 17 (9): 702-712. 2. Lin JS, et al. Screening for Colorectal Cancer: A Systematic Review for the USPSTF; 2016. AHRQ publication 2
Background Early colorectal cancer diagnosis = good prognosis Incidence of CRC in U.S. has decreased 3% per year in past decade for those > 50 years of age due to screening 1 1 US Cancer Statistics Working Group. 2014 Medicare coverage for CRC began January 1998 1 US Cancer Statistics Working Group. 2014 Background Early colorectal cancer diagnosis = good prognosis Incidence of CRC in U.S. has decreased 3% per year in past decade for those > 50 years of age due to screening 1 Incidence of CRC in U.S. has increased for those < 50 years of age in last decade Environmental factors can help control risk of CRC - Obesity - Diet (processed meats, red meats) - Exercise - Tobacco smoking 1 US Cancer Statistics Working Group. 2014 3
Colorectal cancer screening Case #1 75 year old female with maternal grandmother with colorectal cancer had colonoscopy 1 year ago with removal of 3 sigmoid colon polyps. Pathology in the records show all as hyperplastic polyps. Patient is inquiring about next colorectal cancer screening. Your recommendations are: A. Repeat colonoscopy in 2 years due to prior polyps B. Repeat colonoscopy in 2 years due to family history of colon cancer C. Repeat colonoscopy in 9 years D. No future colorectal cancer screening is needed Case #2 48 year old female with paternal grandfather with colorectal cancer is seeing you for non-gi related clinic visit. Patient is inquiring about her first colorectal cancer screening based on her family history of colon cancer. Your recommendations are: A. Start colonoscopy now as she is overdue B. Offer any CRC screening modality now C. Start colonoscopy in 2 years D. Offer any CRC screening modality in 2 years E. Perform rectal exam with guaiac in office today 4
Screening populations: Average Risk 50-75 years old (Grade A recommendation)* 76-80 years old (Grade C recommendation)** > 85 years old (Grade D recommendation)*** Appropriately screened population: Patient is healthy enough to undergo treatment if CRC detected Patient does not have co-morbid conditions and estimated life expectancy < 10 years * Grade A = recommend service; high certainty that net benefit is substantial ** Grade C = selectively offer or provide service; moderate certainty that net benefit is small (USPSTF recommendations are 76-85 years old) *** Grade D = discourage the use of the this service USPSTF - Colorectal cancer screening. JAMA 2016; 315 (23); 2564-2575 Screening populations: Increased Risk Family history of CRC: Family history Recommendations - CRC or advanced adenomas* in first-degree relative at age < 60, OR - Two or more first-degree relatives with CRC at any age (not genetic syndrome) - CRC or advanced adenomas* in first-degree relative at age > 60 *Advanced adenoma = polyp > 1 cm in size, villous features, high-grade dysplasia Colonoscopy every 5 years starting at age 40, or 10 years before youngest case in the family was diagnosed, whichever comes first Start screening at age 40 with any test; repeat testing as average risk or based on findings Recommendations on family history are being updated in very near future 1. Rex, D, et al. Colorectal Cancer Screening: Recommendations for Physicians and Patients From the U.S. Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2017 Jul;153(1):307-323. CRC screening in African-Americans Medical Societies - US Preventive Service Task Force (USPSTF) - American Cancer Society (ACS) - Multi-Society Task Force on CRC (MSTF) - American College of Radiology (ACR) Age of onset - American College of Gastroenterology (ACG) - American Society for Gastrointestinal Endoscopy (ASGE) 45 - American College of Physicians (ACP) 40 50 Conclusion: start CRC screening for African-Americans at 50 years of age 5
CRC screening in average risk patients < 50 years old 6.3 6.1 3.9 4.3 3.6 4.1 1970-2014: 250,000 cancer deaths identified in government-based study in 20-54 years olds (median age 49 y/o) All race mortality on the rise since 2005 (1.0% per year) White race mortality on the rise since 2005 (1.4 % per year) Research Letter. JAMA 2017; 318 (6):572-574. Screening populations: High Risk History of inflammatory bowel disease - Ulcerative colitis (NOT ulcerative proctitis) - Crohn s colitis Screening populations: Highest risk 1. Lynch syndrome (hereditary non-polyposis colorectal cancer). Completely fulfills following criteria: A. 3 relatives with Lynch syndrome-associated cancers (small bowel, large bowel, upper GU tract, and endometrial) B. 2 successive generations are involved C. 1 first degree relative affected < 50 years old 2. Familial Adenomatous Polyposis (FAP) - > 10 adenomas (attenuated FAP) or > 100 adenomas (classic FAP) Conclusion: refer for genetic counseling for testing OR gastroenterology 6
Clinical practice Assessment for risk of CRC Questions to start asking patients around 30 years of age: 1. Do you have a history of Inflammatory Bowel Disease? 2. Do you have any family members with history of colon polyps or colon/rectal cancer? A. First degree relative? B. Age at time of diagnosis? C. Number and type of polyps (if known)? Case #1 75 year old female with maternal grandmother with colorectal cancer had colonoscopy 1 year ago with removal of 3 sigmoid colon polyps. Pathology in the records show all as hyperplastic polyps. Patient is inquiring about next colorectal cancer screening. Your recommendations are: A. Repeat colonoscopy in 2 years due to prior polyps B. Repeat colonoscopy in 2 years due to family history of colon cancer C. Repeat colonoscopy in 9 years D. No future colorectal cancer screening is needed Case #1 75 year old female with maternal grandmother with colorectal cancer had colonoscopy 1 year ago with removal of 3 sigmoid colon polyps. Pathology in the records show all as hyperplastic polyps. Patient is inquiring about next colorectal cancer screening. Your recommendations are: A. Repeat colonoscopy in 2 years due to prior polyps B. Repeat colonoscopy in 2 years due to family history of colon cancer C. Repeat colonoscopy in 9 years D. No future colorectal cancer screening is needed 7
Case #2 48 year old female with paternal grandfather with colorectal cancer is seeing you for non-gi related clinic visit. Patient is inquiring about her first colorectal cancer screening based on her family history of colon cancer. Your recommendations are: A. Start colonoscopy now as she is overdue B. Offer any CRC screening modality now C. Start colonoscopy in 2 years D. Offer any CRC screening modality in 2 years E. Perform rectal exam with guaiac in office today Case #2 48 year old female with paternal grandfather with colorectal cancer is seeing you for non-gi related clinic visit. Patient is inquiring about her first colorectal cancer screening based on her family history of colon cancer. Your recommendations are: A. Start colonoscopy now as she is overdue B. Offer any CRC screening modality now C. Start colonoscopy in 2 years D. Offer any CRC screening modality in 2 years E. Perform rectal exam with guaiac in office today Case #3 54 year male with history of type 2 DM (Hgb A1c 10.2%), hypertension intermittently taking medications, and no family history of colorectal cancer is in your clinic based on the demands of his wife. You notice that the last visit to clinic was 2 years ago. The wife is aware that he is due for colorectal cancer screening and wants to know the best test to perform. You offer: A. Rectal exam with guaiac in your office that visit B. Fecal immunochemical test (FIT) at home and repeat annually C. Fecal DNA test at home D. Promote a colonoscopy 8
Case #4 64 year old male with normal colonoscopy 2 years ago presents with few days of rectal bleeding prior to day of visit. What is the appropriate management of this patient? A. Guaiac rectal exam, if negative, no work up needed B. Guaiac rectal exam; if positive, send patient to GI C. Rectal exam with anoscopy, if available D. Direct referral to GI Screening Tests: Stool-based Screening Methods Frequency Comments gfobt FIT FIT-DNA Annually Annually Every 1 or 3 yrs Home-based testing No bowel prep needed Requires dietary and medication adjustments Home-based testing No bowel prep needed More accurate than gfobt 75-80% sens, 90-95% spec Uncertain guidelines for follow up in positive tests after negative colonoscope Anxiety associated with (+) test 92% sens, 87% spec Guaiac-based testing is not considered as a valid screening modality based on most recent USPSTF guidelines (updated 2016) Screening Tets: Visualization-based Screening Methods Frequency Comments Colonoscopy CT colonography Flexible Sigmoidoscopy (+/- FIT) Every 10 years Every 5 years Every 5 years (every 10 years with annual FIT) Less frequent screening option Screening and diagnostic with potential of intervention Preferred test for (+)FH of CRC Sens, spec is operator dependent* Potential incidental findings 67-94% sens, 86-98% spec for adenomas > 10 mm No option for intervention Requires colonoscopy if (+) Not covered by Medicare Benefit of unsedated procedure Decreases small risks associated with colonoscopy Combines 2 screening modalities *Adenoma Detection Rate (ADR) 9
Life-years gained and CRC deaths averted / 1,000 patients screened similar among all screening modalities USPSTF - Colorectal cancer screening. JAMA 2016; 315 (23); 2564-2575 Risks of CRC screening Stool and serologic tests: Risks are related to colonoscopy and sedation Colonoscopy: Preparation risks - dehydration, electrolyte imbalances Sedation - cardiovascular events Procedure - bleeding (< 1 %), perforation (1/2500), infection, missed lesions, death USPSTF Screening CRC 2016 the screening tests are not presented in any preferred or ranked order direct comparison of screening methods to detect colorectal neoplasia in screening programs over time are limited. the best screening test is the one that gets done, and the USPSTF concludes that maximizing the total proportion of the eligible population that receives screening will result in the greatest reduction in colorectal cancer deaths. 10
Case #3 54 year male with history of type 2 DM (Hgb A1c 10.2%), hypertension intermittently taking medications, and no family history of colorectal cancer is in your clinic based on the demands of his wife. You notice that the last visit to clinic was 2 years ago. The wife is aware that he is due for colorectal cancer screening and wants to know the best test to perform. You offer: A. Rectal exam with guaiac in your office that visit B. Fecal immunochemical test (FIT) at home and repeat annually C. Fecal DNA test at home D. Promote a colonoscopy Case #3 54 year male with history of type 2 DM (Hgb A1c 10.2%), hypertension intermittently taking medications, and no family history of colorectal cancer is in your clinic based on the demands of his wife. You notice that the last visit to clinic was 2 years ago. The wife is aware that he is due for colorectal cancer screening and wants to know the best test to perform. You offer: A. Rectal exam with guaiac in your office that visit B. Fecal immunochemical test (FIT) at home and repeat annually C. Fecal DNA test at home D. Promote a colonoscopy 11
Case #4 64 year old male with normal colonoscopy 2 years ago presents with few days of rectal bleeding prior to day of visit. What is the appropriate management of this patient? A. Guaiac rectal exam, if negative, no work up needed B. Guaiac rectal exam; if positive, send patient to GI C. Rectal exam with anoscopy, if available D. Direct referral to GI Case #4 64 year old male with normal colonoscopy 2 years ago presents with few days of rectal bleeding prior to day of visit. What is the appropriate management of this patient? A. Guaiac rectal exam, if negative, no work up needed B. Guaiac rectal exam; if positive, send patient to GI C. Rectal exam with anoscopy, if available D. Direct referral to GI Prognosis 5-year survival rates Local disease (stages < 2, confined to the wall) - 90% Regional disease with lymph nodes (stage 3) - 70% Widespread disease (stage 4) - 10% 12
Prognosis Efforts to raise screening rates should be enhanced. - The National Colorectal Cancer Roundtable proposed the goal of increasing screening rates to at least 80% by 2018 - More than 150 organizations have signed a pledge to achieve this goal Prognosis Detection and removal of pre-cancerous polyps Decreased incidence of CRC Decreased mortality from CRC Detection and treatment of early-stage CRC Decreased mortality from CRC SoCal Kaiser Data KP SoCal has been screening > 80% of eligible patients for CRC since 2013!!!!!! 13
SoCal Kaiser Data Screening for colorectal cancer is a healthcare system s responsibility SoCal Kaiser Data Colorectal Cancer Mortality Down Three-Year Averaged CRC Mortality Rate per 100,000 Person Year 14 13.8 Targeted 13 12 11 12.5 11.9 11.4 11.3 10 9 8 7 6 Baseline Year 1 Year 2 Year 3 Year 4 2009-2011 2010-2012 2011-2013 2012-2014 2013-2015 6.9 14
An approach that gets results February 2, 2018 Kaiser Permanente 2013. All Rights Reserved. Colonoscopy surveillance program Colonoscopy surveillance Surveillance = follow up testing in patient with increased risk of colorectal cancer based on prior history of polyps or colon cancer Colon polyps: - 2/3 of polyps are adenomas - 30% of men will have polyps at initial screening colonoscopy - 20% of women will have polyps at initial screening colonoscopy - Polyps increase with age and environmental risk factors 15
Colonoscopy surveillance Colon polyps increases risk of colon cancer based on: - Increased number of polyps - Increased size of polyp (> 10 mm) - Aggressive histology of polyp (villous features, highgrade dysplasia) Estimated polyp dwell time from small (< 1cm) polyp to an invasive cancer > 10 years in an average risk patient Polyp pathology Hyperplastic polyp (not pre-malignant) Tubular adenoma Tubulovillous adenoma +/- high grade dysplasia Sessile serrated polyp 16
Polyp pathology NOT PRE-MALIGNANT Hyperplastic polyp (not pre-malignant) PRE-MALIGNANT Tubular adenoma Tubulovillous adenoma +/- high grade dysplasia Sessile serrated polyp Colon cancer Surveillance recommendations Finding Colon polyp Frequency of colonoscopy - Small tubular adenomas (1-2) 5-10 years - Small tubular adenomas (3-10) 3 years - Small tubular adenomas (>10) < 3 years - Large tubular adenoma (> 10 mm) - any number 3 years - Villous adenoma - any number 3 years - Small sessile serrated polyp w/o dysplasia 5 years - Large sessile serrated polyp (> 10 mm) - Small sessile serrated polyps with dysplasia - Sessile serrated adenoma Colon cancer 3 years Follow up 1 year, 3 years, and every 5 years thereafter 17
Pearls for CRC screening 1. Start obtaining a family history for CRC before 40 years of age in your patients 2. Intention to order any stool-based colon study = intention to commit to colonoscopy 3. Family history of CRC is regarding only 1st degree relatives (unless there is a familial pattern of several family members) 4. The best colorectal screening modality for the average risk patient is the one that gets done. Consider colonoscopy for non-compliant medical patients. 5. Do not guaiac a rectal exam on your patients (not recommended as screening modality per USPSTF 2016 guidelines) 18