9/13/2019 Goals • CRC/Screening Facts • Available CRC Screening Tests • Tools To Help you Talk About CRC Screening (in a 20 minute clinic visit) • When to Stop Screening • Risk Factors / Prevention • Increasing Incidence of CRC in Young Colorectal Cancer Screening and Prevention Cynthia M. Yoshida, MD, AGAF North American Menopause Society Annual Meeting September 2019 University of Virginia Health System Colorectal Cancer – The Facts CRC Screening Prevalence (%) By State 1:24 Women diagnosed with CRC • (1:22 Men) • 3rd most common cancer death in U.S. • 2018: ~140,000 new cases, ~50,000 deaths • Direct costs ‐ ~$70,000 per CRC patient • 67.3% age 50 ‐ 75 y up ‐ to ‐ date with CRC Adults age ≥ age 50 screening (2016) FOBT in past year • FS in past 5 yrs • CY in past 10 yrs • cdc.gov/cancer/colorectal/statistics; coloncancerpreventionproject.org Colorectal Cancer Facts and Figures 2017 ‐ 2019, American Cancer Society 1
9/13/2019 CRC Screening Saves Lives CRC Screening Prevention of CRC and Early Detection Progression of pre ‐ malignant adenomas or sessile serrated polyps invasive CRC • Before 2000: risk factors (e.g., smoking) and the uptake of CRC screening • After 2000: 2 ‐ 3% per year ‐ due to screening ‐ detection/removal of precancerous polyps Kumar et al: Robbins and Cotran Pathologic Basis of Disease, 8 th Edition 2009 Colorectal Cancer Facts and Figures 2017 ‐ 2019, American Cancer Society U.S Preventive Services Task Force U.S. Multi ‐ Society Task Force on CRC 2017 Recommendations 2016 AGA/ACG/ASGE Start at age 50 y (Grade A) • Screening tests to detect early ‐ stage CRC • o stool ‐ based tests: gFOBT, FIT, FIT ‐ DNA o direct visualization tests: flexible sigmoidoscopy FIT; colonoscopy; CT colonography) o serology tests: SEPT9 DNA test No head ‐ to ‐ head studies demonstrate that any of these screening strategies are more • effective than others, although they have varying levels of evidence supporting their effectiveness, as well as different strengths/limitations Adults aged 76 to 85 y: decision to screen for CRC is an individual one (Grade C) • JAMA . 2016;315(23):2564 ‐ 2575; uspreventiveservicestaskforce.org. Am J Gastroenterol 2017;112(7):1016 ‐ 1030 2
9/13/2019 American Cancer Society CRC Screening Tests Recommendations 2018 Stool – Based Tests Frequency Test Type FIT 1 year Detection FIT DNA (Cologuard ) 3 years Detection Direct Visualization Tests Frequency Test Type Colonoscopy 10 years Preventive CT Colonography (CTC) 5 years Detection Flexible Sigmoidoscopy +/ ‐ FIT FS 5 ‐ 10 yr, annual FIT Detection Wolf AMD, et al. CA: Cancer J Clin 2018;68:250 ‐ 281 JAMA. 2016;315(23):2564 ‐ 2575. Am J Gastroenterol . 2009 Mar;104(3):739 ‐ 50 Stool ‐ Based Tests: FIT and DNA/FIT DeeP ‐ C Trial ‐ FIT vs sDNA/FIT FIT Stool DNA/FIT Advanced Antibody test for AB test for human Hgb + Adenoma/SSP Colon Cancer Specificity human hemoglobin Amplification /detection of ≥ 1 cm DNA biomarkers Detects blood from lower GI tract FIT 23.8% 73.8% 94.9% Simple, private, non ‐ invasive FIT DNA 42.4% 92.3% 86.6% Stool sample collected at home, mailed to lab No dietary restrictions 13.4% False Positives Preferred CRC No bowel prep especially in elderly detection test = more colonoscopy Methylated target DNA (NDRG4, BMP3), KRAS mutations Imperiale TF, et al. N Engl J Med. 2014:370(14):1287 3
9/13/2019 CT Colonography Findings on CTC Score Description • Bowel prep, oral contrast ‐ stool tagging C0 inadequate study Inadequate prep/insufflation • Colon insufflation (rectal tube – No polyp 6mm; recommend routine screening with CTC air/CO 2 ) C1 normal colon or benign lesion or colonoscopy in 5 yrs • Image acquisition (supine/side, ~15 min, no sedation) Polyps 6 ‐ 9 mm, <3 in number; recommend repeat CTC C2 indeterminate polyp polyp surveillance or colonoscopy with polypectomy Polyps 10 mm, 3 polyp each 6 ‐ 9 mm; recommend C3 polyp, possibly advanced adenoma colonoscopy with polypectomy Lesion compromises bowel lumen, shows extracolonic C4 colorectal mass, likely malignant invasion, recommend surgical consultation • 2D/3D Image processing • Extracolonic abnormalities JACR 2016:13(8): 931–935 ausrad.com/ct ‐ colonography/researchgate.net/publication/221919190_Virtual_Colonoscopy Colonoscopy All Roads Lead to Colonoscopy (and polypectomy) FIT/high sensitivity FOBT Flex sig + FIT Preferred CRC PREVENTION test • detects and removes polyps Stool FIT/DNA Requires prep Often requires sedation • day off work, another adult driver Invasive Sept9 Blood Test CT Colonography 4
9/13/2019 WHO GETS Which Test? Which CRC Screening Test is Best? { Average Risk FIT/gFOBT annual FIT/DNA q 3 yr • M/F CTC q 5 yr “ The best test is the one that gets • Age 50 ‐ 75 FS q 5 yr annual FIT done, and that gets done well.” Colonoscopy q 10 yr Increased Risk • Family History CRC Sid Winawer ‐ 2012 • FH Advanced Polyps Colonoscopy • Personal History CRC/APs • Personal History IBD American Cancer Society National Colorectal Cancer Round Table Conversation Cards Understand the toll CRC can take on your patients. • Make sure your knowledge is up to date about the • recommended screening options. Educate your patients and staff on the various options. Understand the power of the physician recommendation. • Track CRC screening rates in your practice along with • breast and cervical cancer screening rates. More screening doesn’t have to mean more work for you. • Make sure patients/staff understand that most insurance • companies are required to cover CRC screening. https://nccrt.org/resource/can ‐ womens ‐ health ‐ providers ‐ advance ‐ 80 ‐ 2018 / https://www.cancer.org/health ‐ care ‐ professionals/colon ‐ md.html#materials 5
9/13/2019 Risk Factors for CRC When To Stop CRC Screening Hereditary/Medical History Relative Risk Age USPSTF Recommendations Grade FH CRC one first degree relative 2.2 The decision…should be an individual one, taking into account the patient’s overall health and prior screening history. More than one relative 4 Age Adults who have never been screened are more likely to benefit. Relative with CRC < age 45 3.9 • 76 ‐ 85 C Adults who 1) are healthy enough to undergo treatment if CRC is detected Median age ‐ 68 M, 72 F • Inflammatory bowel disease 1.7 • and 2) do not have comorbid conditions that would significantly limit their Diabetes 1.3 Sex life expectancy Behavioral Factors Male • ETOH 2 ‐ 3 drinks/day 1.2 Race American College of Physicians ‐ Stop CRC screening in adults > age 75 years ETOH > 3 drinks/day 1.4 AA, Asian • OR if life expectancy < 10 years Obesity BMI >30 1.3 Red meat consumption (100 gm/d) 1.2 ** No recommendations on when to stop colonoscopy in patients with a h/o adenomatous or sessile Processed meat consumption (50 serrated polyps – e.g. surveillance colonoscopy ** 1.2 gm/d) Smoking 1.2 USPSTF recommendations on screening for colorectal cancer. JAMA. 2016;315(23):2564 ‐ 2575; Qaseem A, et al. Ann Intern Med. 2012;156(5):378 ‐ 386 . Colorectal Cancer Facts and Figures 2017 ‐ 2019, American Cancer Society Incidence of CRC Foods, Metabolic Syndrome Additives, Obesity Preservatives Gen X and Millennials CRC in Age <50 yo ‐ Causes Not Fully Understood ~35 ‐ 40% FH CRC or genetic mutation Is the biology of CRC different in younger adults? 60% are sporadic distinct pathological/molecular features Possible risk factors: obesity, type 2 diabetes, • more advanced at Dx sedentary lifestyle, red meat/processed • meat/fat/processed food consumption , aggressive CA • microbiome (societal overuse of antibiotics), poorer prognosis • smoking, alcohol, other? Microbiome Antibiotics Inflammation Lieberman D. Clin Gastroenterol and Hepatol. Nov 2018; 16(11):1705 ‐ 1707 JNCI 2017:109(8); ruesch.georgetown.edu/youngadultcrc 6
9/13/2019 Summary • CRC is common. Screening saves lives (You can save lives) • High Risk (IBD/FH CRC/Advanced Polyps ) Colonoscopy • Average Risk Best screening test is the one that is consistently done • Start screening at age 45 ‐ 50 y • CRC is increasing among young age <50 Age <50 with rectal bleeding Colonoscopy o • Prevention – keep up with screening; control DM, obesity, smoking, ETOH, red/processed meat 7
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