Colorectal Cancer A Preventable Burden

1. Colorectal Cancer A Preventable Burden Citywide Colorectal Cancer Control Coalition Ambassador Program

2. NYC Coalition Mission “To increase awareness & screening for colorectal cancer & adenomatous polyps in NYC men and women in order to reduce the incidence & mortality of this disease”

3. C5 Ambassadors Program:Goals To educate health care providers: • CRC as a public health problem • Effectiveness of CRC screening • What are the current guidelines • Recommendations of the NYC DOHMH

10. There Are Major Health Disparities of Colorectal Cancer in the U.S * Rates per 100,000 U

11. Colorectal Cancer Risk Groups FAP 5% HNPCC-Hereditary Non-Polyposis Colorectal Cancer Winawer, Schottenfeld, Flehinger, JNCI 1991: 83:243-253. U

15. Normalcecum3/95 Cecalcecum5/96 Hereditary Non-Polyposis Colorectal Cancer (HNPCC)

16. Amsterdam Criteria • Three or more relatives with Hereditary Non-Polyposis Colorectal Cancers • One a first degree relative of the other two • Two or more generations • One with cancer < age 50 Vasen et al. GE 1999; 116 (6): 1453

22. Population risk of CRC 1 in 20 1 first-degree relative 1 in 17 1 FDR & 1 second-degree relative 1 in 12 1 relative aged under 45 1 in 10 2 first-degree relatives 1 in 6 Autosomal dominant pedigree 1 in 2 Lifetime Risks Of Colorectal Cancer

24. Colorectal Cancer “The most preventable, but least prevented, cancer” U

25. The Best Screening Test Is THE ONE THAT GETS DONE.

28. Low Screening Rates • CRC has far lower screening rates than breast or cervical cancer U

29. Why Screen for Colon Cancer? • Proven effectiveness of screening • Highly preventable cancer • Well defined pre-malignant phase (adenoma) • Adenomas take 5-10 years to become cancer • Molecular basis of carcinogenesis is the best understood of all solid tumors (molecular diagnostics) U

30. Barriers to CRC Screening

34. % Mortality Reduction Using Different Screening Methods 1000 Colonoscopy Every 10 years 90%† Annual FOBT 33%* Sigmoidoscopy Every 5-10 years 30%* *Observed †Estimated U

35. Prospective, randomized, controlled trials Mandel Hardcastle Kronborg (USA) (UK) (Denmark) Duration 1975-92 1981-95 1985-95 Subjects (n) 46,551 152,850 140,000 Frequency annual/ biennial biennial biennial F/U duration (yrs) 13 7.8 10 CRC mortality 33%/21% 15% 18% Reduction Effectiveness of FOBT

36. Colorectal Cancer Mortality Study Design Reduction Published Kaiser Retrospective, 30% Selby, NEJMPermanente, Case Control 1992USA Univ. Retrospective, 40% Newcomb,Wisconsin, Case Control JNCI 1992USA Colorectal Cancer Mortality Reduction By Sigmoidoscopy Reviewed in Colorectal Cancer Screening: Clinical Guidelines and Rationale. Winawer, Fletcher, et al., Gastroenterology, Feb. 1997.

37. Lieberman1 Imperiale2 Setting VA; Multi-center Eli Lilly co No. Of subjects 3,121 1,994 Male 96.8% 58.9% Age (mean) 62.9 yrs 59.8 yrs Cancer 1.0% 0.6% Adenoma (any) 37.0% -- Adenoma >1 cm 7.9% -- Adenoma w/ HGD 1.6% -- What Do You Find If You Perform Screening Colonoscopy on Average-risk Subjects? 1N Engl J med 343:162, 2000 2N Engl J med 343:169, 2000 U

38. 15-22 cancers are prevented or detected early per 1,000 screening colonoscopies 1,000 average-risk asymptomatic men and women aged 50 and older COLONOSCOPY 5% - 6% will have advanced adenomas ►50-60 advanced adenomas detected by screening 0.5% - 1% will have cancer ► 5-10 cancers detected early by screening 20% (10-12) would have developed cancer over 20 years

39. Cost Effectiveness of Colon Cancer Screening vs. Other Measures Cost ($) per added year of life (x 1000) Colon Hypertension Mammography Cholesterol Screening* *Any colon screening The cost varies with the model used; this is a ballpark number Lieberman 2003.

41. Randomized trial Surveillance intervals Surveillance methods Colorectal Cancer incidence Adenoma-carcinoma model 7 clinical centers Memorial Sloan Kettering Coord. Center National Polyp Study

42. Colorectal Cancer Incidence in NPS Following Colonoscopic Polypectomy (1418 pts ; 8401 person yrs)

48. Resources Less Intensive Surveillance Increased Resources for Screening

49. Alternative and Future Colorectal Cancer Screening Methods