Updates in Colorectal Cancer Screening & Prevention

Updates in Colorectal Cancer Screening & Prevention Swati G. Patel, MD MS Assistant Professor of Medicine Division of Gastroenterology & Hepatology Gastrointestinal Cancer Risk and Prevention Clinic University of Colorado Anschutz Medical Center

None Disclosures

Objectives Review colorectal cancer epidemiology Understand colorectal cancer screening options and recommendations Understand risk of colorectal cancer based on family history

A few patients I am healthy! I have no symptoms or problems. I don t think I could have colon cancer. I don t ever want a colonoscopy. Is there another test I can do instead? Colonoscopy is too risky for me!!

Colorectal Cancer Incidence & Mortality

Colorectal Cancer Symptoms Change in bowel habits/stool caliber Blood in stool Unintentional weight loss Fatigue Iron deficiency anemia Abdominal pain NONE!! Change in bowel habits/stool caliber Blood in stool Unintentional weight loss Fatigue Iron deficiency anemia Abdominal pain NONE!!

Colorectal Cancer Pathogenesis 10-15 years

Importance of Screening

Who Should Get Screened for CRC?

Colorectal Cancer Screening

Colorectal Cancer Screening Options Stool-based tests Structural Tests Fecal occult blood testing (FOBT) Fecal Immunochemical Testing (FIT) Stool DNA (Cologuard) CT Colonography Barium Enema Flexible Sigmoidoscopy Colonoscopy

Colorectal Cancer Screening & Prevention Structural Test Stool-Based Test

Stool-Based Tests Detect microscopic blood in the stool Performed annually If positive colonoscopy FOBT Non-specific (human vs non-human hemoglobin; location in GIT) Dietary (red meat, poultry, fish, raw vegetables) & medication restriction (NSAIDs) Three successive smears FIT Human globin No restrictions Single sample

Stool-Based Testing Performance Sensitivity CRC Sensitivity Adenoma Hemoccult II 13% - 50% 8% - 20% Cost Compliance Hemoccult SENSA 50% - 79% 21% - 35% $13 49.5% FIT 75 % - 80% 15% - 44% $28 61.5%

Stool-Based Testing Efficacy Trial Screening Follow-up (years) N CRC Incidence CRC Mortality All-Cause Mortality Nottingham Scholefield et al. 2002 Biennial 11.7 152,30 3 1.51 vs 1.53/1000 person yr NS 0.87 (0.78-0.97, p=0.010) 1.01 (0.96-1.05) NS Funen Kronborg et al. 2004 Biennial 17 61,939 1.02 (0.93-1.12) NS 0.84 (0.73-0.96, p<0.05) 0.99 (0.97-1.02) NS Goteborg Lindholm et al. 2008 Biennial 15.75 23,916 0.96 (0.86-1.06) NS 0.84 (0.71-0.99, p<0.05) 1.02 (0.99-1.06) NS Minnesota Mandel et al. 1999, 2000 Annual (A) & Biennial (B) 18 46,551 A: 0.8 (0.73-0.94, p<0.001) B: 0.83 (0.73-0.94, p=0.002) A: 0.67 (0.51-0.83, p<0.05) B: 0.79 (0.62-0.97, p<0.05) 342 (334-350) A: 340 (333-348) B: 343 (336-351) NS

Stool-Based Tests Advantages Low risk, non-invasive No bowel preparation Home testing Inexpensive Disadvantages Not designed to detect pre-cancerous lesions Requires annual testing High false positive rates TWO STEP TEST

Colonoscopy Insertion of a flexible scope to visualize the entire rectum and colon Can diagnose cancer and perform biopsies Can detect and remove potentially precancerous polyps Requires a bowel preparation to cleanse the colon Clear liquids day before procedure Bowel preparation evening before and day of procedure (split dose) Sedation given during the procedure Requires day off life/work Requires escorted transportation

Colonoscopic Polypectomy

Colonoscopy Performance Considered the gold standard Not perfect 2-12% of large polyps are missed May not be as protective of cancer on the right side of the colon OR 0.58 (CI 0.53-0.64) OR 0.24 (CI 0.21-0.27)

Colonoscopy Quality Specialty/Training Personality (vigilance, conscientiousness) Procedural/motor skills Knowledge base Endoscopist Factors Patient factors Bowel preparation Tumor biology System factors Technical factors Financial Organizational High-definition scopes Image enhancement Devices (cap, endocuff) Chromoendoscopy

Colonoscopy Quality

Colonoscopy Efficacy No randomized controlled trials to date Indirect evidence: National Polyp Study: 76-90% reduction in CRC incidence after polypectomy VA study: lower endoscopy within past 6 years associated with 60% reduction in CRC mortality FOBT & Flexible Sigmoidoscopy trials Current trials underway: VA CONFIRM (Colonoscopy vs FIT) Spanish trial (Colonoscopy vs FIT) Nordic-European Initiative (Colonoscopy vs no screening)

Colonoscopy Risks Perforation 0.5/1,000 Bleeding 2.6/1,000 Death 2.9/100,000

Colonoscopy Advantages Can visualize the entire colon Diagnose and remove lesions Performed every 10 years Minimal patient discomfort SINGLE STEP TEST Disadvantages Invasive, procedural risks Sedation required Time consuming, expensive Full bowel preparation Operator, preparation dependent

What is the best screening test?

ACS-MSTF-ACR-AGA > 50: FS every 5 years +/- FOBT every year -Or- High Sensitivity FOBT/FIT every year -Or- Colonoscopy every 10 years -Or- CT Colonography every 5 years -Or- Fecal DNA every 3 years USPSTF 50-75: FS every 5 years with interval High Sensitivity FOBT/FIT -Or- High Sensitivity FOBT/FIT every year -Or- Colonoscopy every 10 years

Family history and CRC

Increased Risk Group Definition Modality Starting Age/ Interval ACS/MSTF/ ACR 1 FDR > 60 CRC/Adenoma Any 40/Average risk intervals 2 SDR CRC any age ASGE 1 FDR > 60 CRC/Adenoma ACG 1 FDR > 60 CRC/Adenoma Colonoscopy Colonoscopy Preferred 40/Average risk intervals 50/ Average risk intervals NCCN 1 FDR > 60 CRC Colonoscopy 50/ q 5-10 yrs 1 SDR < 50 CRC 1 FDR Adv Adenoma

CRC Risk Categories Based on Family History Average Risk Increased Risk High Risk Hereditary Risk No Personal or family history of colon polyps or colorectal cancer (CRC) One first-degree relative with CRC/Adenoma over the age of 60 Two second degree relatives with CRC any age One first-degree relative with CRC/Adenoma younger than age 60 Two or more first degree relatives with CRC/Adenoma, any age Three or more family members with colorectal cancer Multiple other cancer types in the family Young ages of onset of cancers (less than 50) Age 50, any screening test Age 40-50, colonoscopy every 5-10 years Age 40, colonoscopy every 5 years Referral to Genetics Expert

Take home points Colon cancer is common and lethal Colon cancer is preventable! There are a menu of stool-based and structural CRC screening options The best option is the one your patient will commit to! Family history of CRC may increase a patient s risk

Thank you for your attention!