What’s New in Colon Cancer Screening?

1. What’s New in Colon Cancer Screening? Raj Putcha, M.D. Gastroenterologist, Texas Digestive Disease Consultants North Texas SGNA November 15, 2009

2. Why is Colorectal Cancer a Big Deal? • 3rd most common cause of death (overall) • Men (AMI, lung CA) • Women (AMI, breast CA) • 2nd most common cause of death (cancer related) • Men • Women

3. Colon Cancer Statistics • 150,000 new cases each year • 110,000 colon • 40,000 rectum • 50,000 die each year

4. Colon Cancer: Who is At Risk? • Age • Environmental • Alcohol • Smoking • Diabetes • Genetic (family history) • IBD

5. Increasing Incidence CRC with Age Age (years)

6. Who should get screened? • Age >= 50 (male/female) • African american >= 45 • Family history CRC/adenomatous polyp <60 1st degree relative • 2 1st degree relatives any age • Age 40 or 10y rule • Every 5y if negative • Family history CRC/adenomatous polyp >60 1st degree relative • 2 or more 2nd degree relatives • Age 40 • Every 10y if negative

7. Colon Cancer Screening: Lowering the Risk • Colonoscopy (>90% risk reduction) • Other screening methods • Guaiac FOBT • iFOBT (aka FIT) • Stool DNA • Virtual/CT Colonoscopy • (Flex Sig) • (ACBE)

8. Virtual CT (CT colonography)

9. Virtual CT (CT colonography) “Non invasive” • Perforation risk • Prep? • Radiation exposure • Cancer risk 0.14% • Incidentalomas • Cost $$$

10. Virtual CT (CT colonography)

11. Virtual CT (CT colonography) • Sensitivity • >10mm polyp (92%) • <10mm polyp (55-85%) • Surveillance interval? (5y) • Interpretation ability • Reimbursement • (+) --> colonoscopy another day!

12. iFOBT (FIT) • More specific than gFOBT • Selectively detects human globin (part of Hgb) • Colonic globin blood loss • Degradation of globin upper GI bleedingMore specific than gFOBT • Less stool samples (1)

13. Stool DNA • Colorectal neoplasm shed DNA • PregGen-Plus • commercially available DNA stool kit • Panel of DNA markers • Not all genetic abnormalities included • False negatives & false positives • Sn 62-100% Sp 82-100% • Expensive • 5 y interval for (-)

14. Guaiac FOBT • Detect Hgb • peroxidase reaction • Hemoccult-SENSA most Sn • Special diet before • Avoid red meat/hi fiber • Avoid NSAIDs • iron ok • High false (+) • DRE specimen NOT useful

15. Colonoscopy • Risks • Sedation (cardiac, pulmonary) • Conscious • Anesthesiologist (propofol) • Bleeding • Perforation • Diagnostic 1/6000 • Therapeutic 1/1000 • Infection (HCV, HIV, HBV, bacterial pathogens) • Cleaning scopes

16. Colonoscopy • The Prep • NO more Go-Lytely (4L) • NO more Fleets Soda • New PEG 2L • More palatable • Less side effects • ?split dose prep

17. Colonoscopy: new horizons • HD/NBI • ?results • Colon PILLCAM • Recent study NEJM • Aer-O-Scope • Self propelling/self navigating

18. Colon Cancer: Lowering the Risk (what else) • High fiber diet • Low red meat diet • Regular physical activity • HRT post menopausal • Aspirin daily • Calcium

19. Is Colon Cancer Screening Effective? • Decreasing incidence rates • Increasing incidence rate • right sided (ascending/cecum) • Bias? • Improved 5 year survival • Mortality • Except: right sided

20. Who should be doing screening CRC? • GI • CRS • Family practioners/IM • General surgeons

21. Are People Getting Screened? • Couric effect (year 2000) • 20% increase • 40% adults >50 • Insured • Higher education • Non hispanic • Regular medical care

22. Are People Getting Screened?

23. Why Don’t People Get Screened for CRC? • Fear • “you can’t handle the truth” • Prep • Cost $$ • Time off from work • Embarrassing • Complication(s) • perforation

24. Colon Cancer: Staging & Prognosis

25. What Can You Do? • Frontline of medicine • Get yourself screened • Get your family screened • Get your friends screened • Understand CRC stats & screening methods

26. Summary • CRC is common • CRC is preventable • Get screened • Age >= 50 • Family history >= 40 • Getting screened NOT big deal • Risks • Prep