colon cancer awareness
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March - CRC Awareness Month
Colorectal Cancer Prevention & Early Detection
Vijay Arya M.D.,F.A.C.P.,F.A.C.G.,A.G.A.F. Clinical Asst. Prof. of Medicine at Northwell.
Director,Endoscopy Unit, WHMC.
March - CRC Awareness Month
• Third most common cancer in USA- 131,607 new cases/year (2012) 67,700
men, 63907 women• Second Leading cause of cancer
death in men and women- 51,690 deaths (2012)
• Average patient CRC death- Losses 13 years of life
• A person at age of 50 has about - 5 % lifetime risk- 2.5% CRC death rate
CRC Facts
CRC Etiology • Environmental
– Stress– Activity– Diet
• Genetic – Sporadic 85-90% Avg risk• - HCCS 5-10% High risk
Consumption of red meat and
Saturated fat
Refined carbohydrates
Alcohol
Lack of regular physical activity.
Low fruit and vegetable intake.
A low-fiber and high-fat diet.
Overweight and obesity.
Tobacco use.
INCREASED RISK
Dietary factors implicated in colorectal carcinogenesis
North America has highest rate of Obesity-related cancers
•Colon
•Rectum
•Pancreas
•Esophagus
•Others
Dietary fiber
Vegetables
Fruits
Antioxidant/ vitamins
Calcium
folate (B Vitamin)
DECREASED RISK
Dietary factors implicated in colorectal carcinogenesis
LIFESTYLE MODIFICATION
• 35% of all cancers are attributable to diet
• 50%-75% of CRC in the US may be preventable through dietary modifications
• You are what you EAT• When, what ,where, how, how much to
eat ?• You can,t change your genetic makeup
Chemo-Prevention
• Above age 50 ,Healthy ,without risk of GI Bleeding
• Aspirin 75 , 80 , 100 mg / day • Many years before benefit • High risk of bleeding- Hx of PUD, NSAID,S• Antiplatelet meds • Steroids • Age >65
Genetic Model of Colorectal Cancer
Bat-26(HNPCC)
APC
Mutation
NormalEpithelium
K-ras
Adenoma
Bat-26(Sporadic)
p53
LateAdenoma
Early LateCancer Cancer
Dwell Time: Many decades 2-5 years 2-5 years
Optimum phase forearly detection
Courtesy of Barry M. Berger. MD, FCAP EXACT Sciences
Janne and Mayer 2000
ADENOMA-CARCINOMA SEQUENCE (1993)
• AGE: 90% of cases occur at age 50 and above
Average Risk Factors for Colorectal CancerAverage Risk Factors for Colorectal Cancer
Average Risk Factors for Colorectal CancerAverage Risk Factors for Colorectal Cancer
• Male > Female
• Asymptomatic
Average Risk Factors for Colorectal CancerAverage Risk Factors for Colorectal Cancer
Age/ Gender/ Ethnicity• >80% of CRC diagnosed > 55 yrs• Life time risk 5.7% M v/s 5.1% F• Mortality for F lag behind by 10 yrs • Increased age, male sex, black race- Higher
incidence• African American screening start age 45 • USPSTF- recommends screening Age 50-75• >Age 76 , individual basis
COLONOSCOPY
• Excellent prep up to cecum/ withdrawal time at least 6 minutes/ No polyps- 10 yrs
• 1-3 Adenomas ( <1 cm) – 5 yrs• 3-10 Adenomas – 3 yrs• Poor prep ( unable to detect 5 mm polyp)- Rpt
colonoscopy with better prep • PCPs & Patients are requesting for rpt
colonoscopy sooner than required• New patients need to get screened
– First Degree Relative with colon cancer– Hx of ureterosigmoidostomy– Personal history of Adenomas– Inflammatory Bowel Disease / with PSC– Type 2 Diabetes– Acromegaly– Bacteremia – strep bovis, clos septicum,strep
agalactiae– Familail breast ca- BRCA 1 or 2 mutation pos
High Risk Factors for Colorectal Cancer?High Risk Factors for Colorectal Cancer?
Higher than Avg risk• Pt,s 53 yr old brother had an adenoma
• Start screening at age 40 or 10 yrs prior to diagnosis of affected relative,whichever comes first.
• Hx of CRC <55, Adenoma <60 – special efforts to screen first degree relatives
Higher than Avg Risk• Large adenoma >1 cm
• Multiple adenomas >2
• Villous adenoma or High grade dysplasia
• F hx of CRC
• RPT Colonoscopy should be done in 3 yrs
Malignant polyp
• Favorable criterion• Complete excision• Not poorly differentiated• No vascular/ lymphatic invasion• f/u colonoscopy in 3 months to check for
residual tissue at polypectomy site if neg rpt at 1 yr
Malignant plyp • Unfavorable signs• Incomplete excision• Less than 2 mm margin from polypectomy• Undifferentiated • Vascular/ lymphatic invasion• Hemicolectomy should be done
HCCS- CLUES• CRC/ Polyps Age < 50 • >10 Adenoma• Syn/ Meta cancers• Numerous relatives with cancers• Accurate personal /3 generation fhx• 3-2-1 rule• Age at diagnosis/ death• All- AD except MYH asso polyposis( MAP)
SHARE THE INFO
• 5-10% of CRC• Identify pts- counseling /genetic testing of at
risk • Risk reducing management • Syn specific surveillance• Not at risk- avg risk CRC
SAVE THE FAMILY
HCCS• A- non-polyposis-• HNPCC• LS• Lynch like syn• Familial crc type x
• B- polyposis syn-• FAP/ MAP/JPS/PJ/Hamartoma ts/ SPS
HCCS- 3 Q TOOL• Personal hx of polyp/ CRC < age 50• First degree relative < age 50 with CRC,
uterine, ovarian, gastric, small bowel, kidney, ureter, bladder, biliary, pancreas, or brain
• >2 FDR or SDR with CRC ,any age• One in Five ( 20%) LS Missed • Universal molecular testing of all
CRC/Adenoma
HCCS
• LS – germline mutation in MMR gene & MSI-H • MMR defi in Tumor can be detected by IHC• Histological clues to MSI-H• Poorly diff, mucinous & signet cell• Tumor infiltration by lymphocytes• Crohn’s like lymphocyte reaction
HCCS• Mutation in ¼ MMR gene• MLH1,MSH2,MSH6,PMS2• Large deletion in EPCAM /hyper MSH2• Microsatellites are areas of short DNA rpts• Cacacaca– prone to errors in replication
normally corrected by MMR gene• Can be studied in tumor/ nl tissue/blood• >2 MSI-H , 1 MSI-L ,0 MSS
HCCS – S/S Colonoscopy• Colonoscopy 1-2 yrs beginning age 20-25• Pelvic exam –annual• Transvaginal us/ endometrial sampling• EGD 2-3 yrs with HP testing -age 30-35 • Colectomy with ileo-anal anastomosis• Aspirin –chemoprevention• Hysterectomy/ bilat sal- age 40 / finished
child-bearing
HCCS- Case• 37 yr old pt,s 62 yr old mother with colon ca• Maternal uncle –colon ca• Maternal grand-mother- endometrial ca• Suspect HCCS• Genetic counselling• Mother,s tumor tissue for –MSI• If pos – blood test for germ line mutation in mmr
gene• Neg blood test does not exclude the dx
FAP/MAP• About 1% each with pheno overlap• <100 adenoma – attenuated FAP- late teenage• 100-1000- classic -preteenage• >1000 profuse -preteenage• 100% gastric/duod fundic gland polyps• 100% risk of CRC around age 40 • Bx nl papilla to r/o adenoma( 2 nd cancer)• Thyroid/ brain/hepatoblastoma• Cong hyp of retinal pigment
High Risk-Sporadic• 15% Sporadic CRC ,MSI-H • Pos MLH1 gene • Pos BRAF mutation
• Sporadic CRC ( 85-90%)- genetic alt in single cell- chromosomal instability with MSS
Symptoms associated with CRC
Weight loss
Loss of appetite
Night sweats
Fever
Rectal bleeding
Change in bowel habits
Obstruction
Abdominal pain & mass
Iron-deficiency anemia
• Offer Early Detection / Primarily Cancer• High-Sensitivity FOBT -Annual ( FIT ,Stool
DNA based Tests, (DCBE,CTC – every 5 yrs)
• Offer Detection of polyp/cancer &Prevention
• Flexible Sigmoidoscopy – Every 5 year• Colonoscopy- Every 10 year
Types of Screening
Benefits of Screening
Cancer Prevention• Removal of pre-cancerous polyps to prevent cancer(unique aspect of colon cancer screening)
Improved survival• Early detection markedly improves chancesof long-term survival
Largest reduction in mortality during the 10 yrs after screeningComes from detection and removal of early stage cancer
Annual FOBT reduces CRC mortality and incidence by 30%FS has also shown the same benefit
Colonoscopy reduces mortality by 60-70% ( RCTs Awaiting)
100% Adherence to same regimen is equally effective
Benefits of Screening
Survival Rates by Disease Stage*
5-yrSurvival
*1996 - 2003
100908070605040302010
0
89.8%
67.7%
10.3%
Local Regional Distant
Stage of Detection
Colorectal Screening Rates
Just 40% of colorectal cancers are detectedat the earliest stage.
A little more than half * of Americans overage 50 report having had a recent colorectalcancer screening testSlow but steady improvement in these numbersover the past decade (but all are not benefitingto the same degree)
*varies based on data source
Colorectal Screening Rates Low:Reasons (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear, embarrassment, discomfort
Time
Cost
Access
“My doctor never talked to me about it!”
22 million people not up-to-date with screening
CT Colonography (CTC)
CTC Image Optical Colonoscopy
*AKA “Virtual Colonoscopy”
Images courtesy of Beth McFarland, MD
CT Colonography
Rationale Allows detailed evaluation of the entire colon
A number of studies have demonstrated a highlevel of sensitivity for cancer and large polyps
Minimally invasive (rectal tube for air insufflation)
No sedation required
CT Colonography
Limitations
Requires full bowel prep (which most patients findto be the most distressing part of colonoscopy)
Colonoscopy is required if abnormalities are detected,sometimes necessitating a second bowel prep
Steep learning curve for radiologists
Limited availability to high quality exams in manyparts of the country
Most insurers do not currently cover CTC asa screening modality
CT Colonography
Limitations
Extra-colonic findings can lead to additional testing(may have both positive and negative connotations)
Questions regarding:
Significance of radiation exposure
Management of small polyps
Sigmoidoscopy is IncompleteEquivalent to“left breast mammogram”
Colonoscopy
Colonoscopy is considered the gold standard for colorectal cancer screening
Beth Israel Medical Center
1 Sivak et al., 2004, 2Winawer et al., 1993
Dr Hiromi Shinya1 and Dr William Wolf
1971 - First colonoscopic polypectomy
COLONOSCOPY
• Available best option:– Screening Colonoscopy/polypectomy
Polyp to Cancer Progression
CRC is Preventable / Curable
DISCOVERY OF THE CENTURY
Polypectomy snare
Quality Colonoscopy • An effort to make Colonoscopy less variable
through a process of measurement, education & performance enhancement
• Adenoma Detection Rate( ADR)• Withdrawal time• Cecal Intubation Rate ( CIR)• Adherence to screening / surveillance intervals• Prep quality to see polyp 6 mm & >
ADR• 1% increase in ADR = 3 % reduction in CRC
incidence / 5% reduction in mortality• Simple act of measurement improved ADR• ASGE-maintain passport• ADR= protection against CRC• Education• Withdrawal technique• Technical advances and devices
ADR • High ADR= Better cleared at first
colonoscopy=Shorter interval ( double protection)
• Low ADR= Not effectively cleared= Longer interval ( double lack of protection)
• 3 or > Adenoma( 1 cm/ >) ,f/u exam at 1 yr• Future--Incentive to achieve high ADR/ allow
longer interval = Improve cost-effectiveness
CIR• TI intubation is gold standard• IC valve, Appendiceal orifice, Taenia coli• Medial wall of cecum • Documentation with Photographs• Low CIR = Higher rate of interval CRC
Bowel Preparation
• Dreaded more than procedure itself • Patient perspective
High volume
Unpalatable
Dietary restriction
Complex instructions
Day before v/s split dose
Impact on work or daily activity
Tolerability (side effects)
Bowel Prep• Inadequate bowel prep -20-40%• Rpt procedures- Cost• Missed lesions-both small and large• Commonly used preps- PEG• 2 L V/S 4 L• Day of , Day before, Split • Adjuvant - Dietary restrictions/ NPO
TYPE OF PREPARATION
PREP COMPARISON
Bowel Prep Scale• Overall -Poor, Fair, Good , Excellent • Segmental scores• BBPS – R, T, L 0-1,2,3 Max 9 , Adequate 5• ABPS- C, A,T,D,S,R Max 24 , Adequate 13• Total score doesn’t guarantee adequate prep in
all segments
Complications
•Miss rate :
- 5% of Colorectal Cancer
- 2% - 12% Polyp 1cm or larger
- >20% Polyp 6mm or larger
•Bleeding (2 -6 per 1000 examination)
•Bowel Perforation ( approx 1 per 1000 examination)
•Infection (approx 4% )
•Mortality (0.03%)
•Abdominal Pain & discomfort (5% - 11%)
Source: National Endoscopy Database/Clinical Outcomes Research Initiative
COLONOSCOPY – ALL AGES
MortalityPerson years of life lost
COLORECTAL CANCER
Trends
Incidence and deaths rates have fallen steadily for the past20 yrs
U.S. Colorectal Cancer Mortality 1975-2005
40.0
35.0
30.0
25.0 Blalck Male
WhiteMale20.0
Black Female
15.0 White Female
10.0
5.0
0.0
Research suggests that these declines are due in large part to:
•Screening and polyp removal, preventing progression of polyps to invasive cancers
•Screening detecting cancers at earlier, more treatable Stages
•CRC treatment advances
CRC is third leading cause of death in USA
Early stages are detectable/ curable
Screening can prevent CRC
Katie Couric: http://www.nccra.com/about/videos.htm
SUMMARY
POLYPECTOMY
S
Endoscopic Removal of Large Colon Polyps
Endoscopic Mucosal Resection (EMR)
Endoscopic Submucosal dissection (ESD)
- ESD is a variant of EMR in which a specialized needle knife is used to dissect lesions from the submucosa. The advantage of ESD is that it often permits removal of large sessile polyps en bloc (eg. in one piece), whereas EMR often removes the polyp piecemeal.
Polypectomy Risks
Removal of large colon polyps during endoscopy is associated with various risk, including:
- Perforation- Bleeding- Post Polypectomy Syndrome- Inadequate Polypectomy
Non Invasive PolypLarge polyps may contain cancer that is completely contained within the polyp.In these cases, polypectomy is considered curative, provided:
- The cancer is completely contained within the resected tissue - No lymphovascular invasion- Resection margins are free of cancer
Invasive polyps features that suggest the presence of malignancy include:
- Friability- Induration- Ulceration- Smooth velvety surface (e.g. non-granular laterally spreading tumor in the Rt colon)- Non lifting sign
Invasive Polyp
Endoscopic Ultrasound Role (EUS)
EUS can be used to assess invasive polyps features, especially sessile lesions in the rectum, such as:
- Sub-mucosal invasion- Enlarged Lymph nodes
Conventional EUS vs High frequency Mini-probes through the biopsy channel of the colonoscope to visualize the entire colon
Polyp size and location- Unusually large polyps ( >10 cm or with circumferential growth ) are not a contraindication for endoscopic polypectomy.
- Such polyps may require multiple sessions for removal and subsequent surveillance is mandatory
- These considerations should be explained to the patient prior to embarking on a course of endoscopic resection
Patient Preparation
- The preparation for endoscopic removal of large colon polyps is the same as that for routine colonoscopy and includes dietary changes and consumption of a bowel preparation.
- Polypectomy is a high-risk procedure with regard to bleeding
- Patient taking antiplatelets and anticoagulants will need to stop the medication
- Antibiotic prophylaxis is not recommended for polypectomy
Equipment
In addition to the standard endoscopic equipment, additional equipment that may be used for the removal of large colon polyps includes:
●Polypectomy snares●Electrosurgical generators●Injection needles●Saline or hyaluronic acid●Methylene blue or indigo carminedye for staining●India ink or other dye for tattooing●Retrieval nets●Hemoclips●Nylon loops●Argon plasma coagulation probes●Argon gas●Needle knivesAll of the devices used can pass through the working channel of a standard endoscope.
Submucosal Injecion-Injection of saline or an alternative substance into the submucosa below the polyp raises the polyp on a cushion of fluid, facilitating endoscopic resection and potentially decreasing the risk of perforation during subsequent snare excision
-A problem with saline injection is that it is rapidly absorbed. As a result, alternative agents that are not as rapidly absorbed have been studied (with and without epinephrine), including hyaluronic acid, dextrose solutions, succinylated gelatin, and hydroxyethyl starch
COLONOSCOPES
RETRO-VIEW COLONOSCOPE
HIGH DEF. COLONOSCOPE
Technique
There are two primary goals of colonic polypectomy:
- Complete remove of all neoplastic tissue.
- Retrieval of all tissue sample
Only complete excision of the polyp permits accurate histologic diagnosis
High Def. Colonoscopy vs Chromoscopic Colonoscopy
Chromoscopic Colonoscopy
Colonoscopy Report
Colonoscopy Report
Surgical RemovalHISTOLOGY (Invasive Polyp), SIZE, LOCATION
- Size: Polyp ≥2.0 cm in their greatest dimension, eg. large sessile polyp
- Difficult location, eg. Cecum
- Saddle polyp:
Figure: Supine double-contrast barium enema spot image shows a semiannular “saddle” carcinoma. This lesion in the transverse colon manifests as two convex, barium-etched lines (arrows) that represent the edges of the lesion, which straddles one-half of the circumference of the bowel.
Surgical RemovalSurgery may be a better option for patients with:
- Polyps that occupy more than 1/3 of the circumference of the colon wall- Presence of two cross haustral folds- Polyps involving the base of the appendix- Multiple large polyps in the right colon - Patients with uncontrollable bleeding disorders
HOW IS COLORECTAL CANCER PREVENTED
•SHORT TERM -Screening: A screening test is used to look for a
disease when a person is not experiencing any symptoms.
•LONG TERM -Life style modification
• Epidemiology • Who is at Risk – Avg risk $ High risk• How it can be prevented- short term/ long
term• Short term – screening methods• Long term – life style modification
Diagram of Colon and Rectum
TAKE THE QUIZ. GET THE TEST
Colorectal Cancer Screening
What is screening?A screening test is used to look for a disease when a person is not experiencing any symptoms.Why is screening Important?When Should I Begin to Get Screened?
Tests for Polyps andCancer
Anatomy and CRC Distribution
Transverse 15%
Ascending
25%
Cecum
Rectosigmoid10%
Descending 5%
Sigmoid25%
Rectum 20%
Colonoscopy
Colonoscopyallows doctorto directly seeinside entirebowel
• Do I need to get a screening test for colorectal cancer?
• What screening test(s) do you recommend for me?
• How do I prepare?
• Do I need to change my diet or my usual medication schedule?
• What's involved in the test?
• Will it be uncomfortable or painful?
• Is there any risk involved?
• When and from whom will I get results?
If you're having a colonoscopy or sigmoidoscopy, you will want to know—
• Who will do the exam?
• Will I need someone with me?
Ask Your Doctor
1. Can you use a brand new scope?2. I have no problems why do I need a colonoscopy?3. Can I use the pills for prep ? 4. Can I go for CTC instead of colonoscopy?5. I do not have any one to accompany me6. Can you schedule me in afternoon?7. Can I go back to work after the procedure?8. What is the age to stop screening ?9. Can I have a DVD of my colonoscopy?10.Is my risk lower if I am not born in USA?
FAQ
Prevention is better than CureScreening saves lives
Colon cancer is Curable if detected earlyIf you can’t do it for yourself, do it for your family
Health is Wealth
Thank you
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