DIGEST DIAGNOSIS THROUGH INVESTIGATION OF GASTROESOPHAGEAL SYMPTOMS COLORECTAL CANCER LEARNING PROGRAM [COPY] Colorectal Cancer [LOGO] RX&D Takeda STEERING COMMITTEE Alan Barkun, MD, CM, FRCPC, FACP, FACG, AGAF, MSc (Clinical Epidemiology) Chairholder, Douglas G. Kinnear Chair in Gastroenterology and Professor of Medicine, Director of Digestive Endoscopy (adult section), Division of Gastroenterology, Chief Quality Officer, Division of Gastroenterology, McGill University and the McGill University Health Centre Marc Bradette, MD, FRCP, CSPQ Gastroenterologist and chief of service, Pavillon Htel-Dieu de Qubec, Centre Hospitalier Universitaire de Qubec, Clinical Professor, Universit Laval Brian Bressler, MD, MS, FRCPC Clinical Assistant Professor of Medicine Division of Gastroenterology, University of British Columbia Christian Dallaire, MD Gastroenterologist, Hpital St-Franois dAssise du Centre Hospitalier Universitaire de Qubec, Assistant Professor, Universit Laval James C. Gregor, MD, FRCPC Professor of Medicine, University of Western Ontario STEERING COMMITTEE Desmond Leddin, MB, FRCPC, FRCPI Professor of Medicine (Gastroenterology) Dalhousie University, Canada, Director of Training Centers, World Gastroenterology Organisation Louis W.C. Liu, MEng, PhD, MD, FRCPC Assistant Professor, University of Toronto Division of Gastroenterology, Department of Medicine Co-Director, Metabolism Nutrition Unit, Undergraduate MD Program Director, Clinical Motility Investigation Unit, University Health Network Par Nijhawan, MD, FRCPC, AGAF Gastroenterologist Mackenzie Health Hospital, Medical Director, Digestive Health Clinic Clarence K.W. Wong, MD, FRCPC Associate Professor of Medicine, University of Alberta, Medical Lead, Alberta Colorectal Cancer Screening Program Bruno Nicoletti, MD, CCFP Associate Professor of Medicine, University of Ottawa, Family Physician Rideau Valley Health Services (FHO) Objectives Review the incidence and prevalence of colorectal cancer in Canada Understand the rationale for population- based screening Learn about the types of colorectal cancer screening tests available Identify the risk category and screening intervals for your patients based on personal and family histories Meet your patient Jane Age: 51 Ive always been good about getting regular Pap smears and mammograms. Now that Im in my fifties, I am wondering if there are any other types of cancer I should be screened for. Fictitious patient. May not represent all patients. LEADING TYPES OF NEW CANCER CASES Leading types of estimated new cancer cases in men in Non-melanoma skin cancers (42,700 cases) 2.Prostate (23,600 cases) 3.Colorectal (13,500 cases) 4.Lung (13,400 cases) Leading types of estimated new cancer cases in women in Non-melanoma skin cancers (33,400) 2.Breast (24,400 cases) 3.Lung (12,700 cases) 4.Colorectal (10,800 cases) 1. Canadian Cancer Statistics Canadian Cancer Society. 2. Leddin DJ, et al. Can J Gastroenterology 2010;24: JANE SHOULD ALSO BE SCREENED FOR COLORECTAL CANCER. 2 LEADING CAUSES OF DEATH FROM CANCER Leading causes of estimated death from cancer in men 1 1.Lung (27%) 2.Colorectal (12.8%) 3.Prostate (10%) Leading causes of estimated death from cancer in women 1 1.Lung (26.5%) 2.Breast (13.8%) 3.Colorectal (11.5%) 1. Canadian Cancer Statistics Canadian Cancer Society. 2. Leddin DJ, et al. Can J Gastroenterology 2010;24: Jane should also be screened for colorectal cancer. JANE SHOULD ALSO BE SCREENED FOR COLORECTAL CANCER. 2 EPIDEMIOLOGY OF COLORECTAL CANCER 1. Canadian Cancer Statistics Canadian Cancer Society. PRECANCEROUS POLYPS One of the most common precancerous conditions of the colon is adenomatous polyps Adenomas take an average of 10 years to develop into an invasive colorectal cancer Most adenomatous polyps do not have any symptoms. They are usually discovered during colorectal screening tests or investigation of unrelated conditions. If symptoms do exist, they can include: Rectal bleeding (may cause anemia) Bloody stools Diarrhea or constipation Decreased amount of stool expelled Abdominal pain Prolapse of the polyp through the anus Bowel obstruction from a large adenoma 1 1. Precancerous conditions of the colon and rectum. Canadian Cancer Society. SCREENING OPTIONS To reduce mortality from colon cancer in the population, a screening program should: Provide screening tests of adequate sensitivity to detect early colon cancers and advanced adenomas Be acceptable to the target population 1 1. Leddin DJ, et al. Can J Gastroenterology 2010;24: Screening for colorectal cancer. Canadian Cancer Society. Screening methodIntervalNotes Stool test screening (fecal occult blood testing [FOBT] or fecal immunochemical testing [FIT]) Every 2 years for people age 50 and over 2 FIT is the test preferred by the Canadian Association of Gastroenterology 1 Flexible sigmoidoscopy10 years or longer 1 Should be offered for colon cancer screening to all average- risk individuals 1 ColonoscopyNot recommended for population screening 1 Required to investigate positive results from other screening methods 1 SCREENING OPTIONS To reduce mortality from colon cancer in the population, a screening program should: Provide screening tests of adequate sensitivity to detect early colon cancers and advanced adenomas Be acceptable to the target population 1 1. Leddin DJ, et al. Can J Gastroenterology 2010;24: Screening for colorectal cancer. Canadian Cancer Society. Screening methodIntervalNotes Stool test screening (fecal occult blood testing [FOBT] or fecal immunochemical testing [FIT]) Every 2 years for people age 50 and over 2 FIT is the test preferred by the Canadian Association of Gastroenterology 1 Flexible sigmoidoscopy10 years or longer 1 Should be offered for colon cancer screening to all average- risk individuals 1 ColonoscopyNot recommended for population screening 1 Required to investigate positive results from other screening methods 1 FROM PROFILE TO PRACTICE: Which screening method should you choose to screen Jane? FROM PROFILE TO PRACTICE: Which screening method should you choose to screen Jane? STOOL TESTS (FOBT OR FIT) Performed every 2 years (average risk) 1 Should not be used for diagnostic testing 1 No direct risk to the colon 2 No bowel preparation 2 Samples can be collected at home 2 May miss some polyps/cancers 2 Colonoscopy needed if the test indicates an abnormality 2 1. Screening for colorectal cancer. Canadian Cancer Society. 2. Colon cancer: Catching it early. American Cancer Society. FLEXIBLE SIGMOIDOSCOPY Performed every 10 years or longer (average risk) 1 Fairly quick 2 Sedation not usually used 2 Does not require a specialist 2 Doesnt view upper part of colon 2 Cant see or remove all polyps 2 Colonoscopy needed if abnormal 2 1. Leddin DJ, et al. Can J Gastroenterology 2010;24: Colon cancer: Catching it early. American Cancer Society. COLONOSCOPY Not recommended for population-based screening 2 Full bowel preparation is necessary 1 Allows full view of rectum and entire colon and polyp biopsy and removal if necessary 1 Some patients may develop interval cancers (colorectal cancer within 3-5 years of colonoscopy and polypectomy) 3 Complications such as bleeding and/or tearing or perforation can occur 1 One study found that the rates of colonoscopy-related bleeding and perforation were 1.64/1000 and 0.85/1000, respectively 4 Older age was associated with increased odds of bleeding or perforation 3 1. Colon cancer: Catching it early. American Cancer Society. 2. Leddin DJ, et al. Can J Gastroenterology 2010;24: Lieberman DA, et al. Gastroenterology 2012;143: Rabeneck L, et al. Gastroenterology 2008;135: PATIENTS WITH FAMILY HISTORY RelativesScreening recommendation Family history of colon cancer or polyps First degree One 60 years Colonoscopy every 5 years Start at age 40, or 10 years before the age of onset of the youngest affected relative, whichever came first Average-risk screening, starting at age 40 Second degree One Two or more Average-risk screening, starting at age 50 Average-risk screening, starting at age 40 Third degree OneAverage-risk screening, starting at age 50 1.Canadian Association of Gastroenterology Guidelines on Colon Cancer Screening. PATIENTS WITH FAMILY HISTORY RelativesScreening recommendation Family history of colon cancer or polyps First degree One 60 years Colonoscopy every 5 years Start at age 40, or 10 years before the age of onset of the youngest affected relative, whichever came first Average-risk screening, starting at age 40 Second degree One Two or more Average-risk screening, starting at age 50 Average-risk screening, starting at age 40 Third degree OneAverage-risk screening, starting at age 50 1.Canadian Association of Gastroenterology Guidelines on Colon Cancer Screening. FROM PROFILE TO PRACTICE: Suppose Janes mother was diagnosed with colorectal cancer at 55. When should screening start or have started? How often should she be screened? With which test method should you screen Jane? FROM PROFILE TO PRACTICE: Suppose Janes mother was diagnosed with colorectal cancer at 55. When should screening start or have started? How often should she be screened? With which test method should you screen Jane? PATIENTS WITH FAMILY HISTORY RelativesScreening recommendation Family history of colon cancer or polyps First degree One 60 years Colonoscopy every 5 years Start at age 40, or 10 years before the age of onset of the youngest affected relative, whichever came first Average-risk screening, starting at age 40 Second degree One Two or more Average-risk screening, starting at age 50 Average-risk screening, starting at age 40 Third degree OneAverage-risk screening, starting at age 50 1.Canadian Association of Gastroenterology Guidelines on Colon Cancer Screening. FROM PROFILE TO PRACTICE: Suppose Janes mother was diagnosed with colorectal cancer at 55. When should screening start or have started? How often should she be screened? With which test method should you screen Jane? FROM PROFILE TO PRACTICE: Suppose Janes mother was diagnosed with colorectal cancer at 55. When should screening start or have started? How often should she be screened? With which test method should you screen Jane? PATIENTS WITH FAMILY HISTORY RelativesScreening recommendation Family history of colon cancer or polyps First degree One 60 years Colonoscopy every 5 years Start at age 40, or 10 years before the age of onset of the youngest affected relative, whichever came first Average-risk screening, starting at age 40 Second degree One Two or more Average-risk screening, starting at age 50 Average-risk screening, starting at age 40 Third degree OneAverage-risk screening, starting at age 50 1.Canadian Association of Gastroenterology Guidelines on Colon Cancer Screening. FROM PROFILE TO PRACTICE: Suppose Janes mother was diagnosed with colorectal cancer at 55. When should screening start or have started? How often should she be screened? With which test method should you screen Jane? FROM PROFILE TO PRACTICE: Suppose Janes mother was diagnosed with colorectal cancer at 55. When should screening start or have started? How often should she be screened? With which test method should you screen Jane? PATIENTS WITH FAMILY HISTORY RelativesScreening recommendation Family history of colon cancer or polyps First degree One 60 years Colonoscopy every 5 years Start at age 40, or 10 years before the age of onset of the youngest affected relative, whichever came first Average-risk screening, starting at age 40 Second degree One Two or more Average-risk screening, starting at age 50 Average-risk screening, starting at age 40 Third degree OneAverage-risk screening, starting at age 50 1.Canadian Association of Gastroenterology Guidelines on Colon Cancer Screening. FROM PROFILE TO PRACTICE: Suppose Janes paternal aunt was diagnosed with colorectal cancer at 75, and her maternal grandmother was diagnosed at age 55. When should screening start or have started? How often should she be screened? With which test method should you screen Jane? FROM PROFILE TO PRACTICE: Suppose Janes paternal aunt was diagnosed with colorectal cancer at 75, and her maternal grandmother was diagnosed at age 55. When should screening start or have started? How often should she be screened? With which test method should you screen Jane? PATIENTS WITH FAMILY HISTORY RelativesScreening recommendation Family history of colon cancer or polyps First degree One 60 years Colonoscopy every 5 years Start at age 40, or 10 years before the age of onset of the youngest affected relative, whichever came first Average-risk screening, starting at age 40 Second degree One Two or more Average-risk screening, starting at age 50 Average-risk screening, starting at age 40 Third degree OneAverage-risk screening, starting at age 50 1.Canadian Association of Gastroenterology Guidelines on Colon Cancer Screening. FROM PROFILE TO PRACTICE: Suppose Janes paternal aunt was diagnosed with colorectal cancer at 75, and her maternal grandmother was diagnosed at age 55. When should screening start or have started? How often should she be screened? With which test method should you screen Jane? FROM PROFILE TO PRACTICE: Suppose Janes paternal aunt was diagnosed with colorectal cancer at 75, and her maternal grandmother was diagnosed at age 55. When should screening start or have started? How often should she be screened? With which test method should you screen Jane? PATIENTS WITH FAMILY HISTORY RelativesScreening recommendation Family history of colon cancer or polyps First degree One 60 years Colonoscopy every 5 years Start at age 40, or 10 years before the age of onset of the youngest affected relative, whichever came first Average-risk screening, starting at age 40 Second degree One Two or more Average-risk screening, starting at age 50 Average-risk screening, starting at age 40 Third degree OneAverage-risk screening, starting at age 50 1.Canadian Association of Gastroenterology Guidelines on Colon Cancer Screening. FROM PROFILE TO PRACTICE: Suppose Janes paternal aunt was diagnosed with colorectal cancer at 75, and her maternal grandmother was diagnosed at age 55. When should screening start or have started? How often should she be screened? With which test method should you screen Jane? FROM PROFILE TO PRACTICE: Suppose Janes paternal aunt was diagnosed with colorectal cancer at 75, and her maternal grandmother was diagnosed at age 55. When should screening start or have started? How often should she be screened? With which test method should you screen Jane? Janes results Family history shows that Jane is of average risk FIT was negative Jane should be retested in 2 years 1 Fictitious patient. May not represent all patients. 1. Screening for colorectal cancer. Canadian Cancer Society. Management and follow-up Management algorithms for colorectal cancer are complicated and are best handled by a specialist EVEN IF PATIENTS ARE BEING SCREENED REGULARLY, NEW SYMPTOMS (E.G., BLOOD IN STOOL) SHOULD BE INVESTIGATED Tips on talking to your doctor. Canadian Cancer Society.