Screening of colorectal cancer Yearly 4000 lives could be saved in - PowerPoint PPT Presentation

Screening of colorectal cancer Yearly 4000 lives could be saved in Hungary György Bodoky Unified Saint István and Saint László Hospital Department of Oncology

Occurence of colorectal cancer 1.000.000 new cases yearly Over 400.000 death Out of 18 people 1 is at risk 10-15% of total cancer-related death cases (2nd most frequent cancer) Treatment cost is several billion Euro per year

Occurence of colorectal cancer In Hungary • 10 000 new cases yearly, increasing trend • Most frequent onset between age 50 and 75 • Under age 40 it occurs mainly due to genetic predisposition

Colorectal cancer mortality • CRC is the 2nd most frequent cancer in both gender • CRC is the 2nd most frequent cause of cancer-related death • CRC is the most frequent cause of cancer-related death among non-smoking men and women • all of us have a 1:18 chance to have the disease

Risk factors • < age 40 family anamnesis • Inheritance (FAP, Gardner syndrome, Peutz-Jeugers syndrome, Lynch- syndrome) • Eating habits: high consumption of meat, fat, protein and alcohol, low intake of fiber, calcium, selen and foliate • Inflammatory bowel diseases: frequency is 20% after 10 years 30% after 20 years • Polypus colorectalis : occurence at age 50 is 10 - 30% at age 70 - 75 it is 30 - 60% • Colorectal cancer in anamnesis

Hajlamosító tényez ő k Which are the inhibiting factors of colorectal cancer ? • Young age – however 7% of CRC occurs under age 50 • Ethnics • Lack of own- or family anamnesis– however 80% of CRC occurs without anamnesis • Low comsumption of meat, fat and alcohol and high intake of fiber, calcium, selen and foliate reduce the risk of CRC • Hormone Replacement Therapy (HRT) reduces CRC risk • Aspirin, NSAID and vitamin D might reduce CRC risk • Healthy lifestyle – exercise, healthy food reduce the risk • BUT it is CRC-screening which is the most significant factor in reducing CRC-risk

CRC stage at the time of diagnosis Stage I 15%-20% Stage II 20%–35% Stage III 25%–30% Stage IV 20%–25%

Screening of colorectal cancer

What else do we know about CRC screening? By screening colorectal carcinoma is the most preventable type of visceral cancer

Development of CRC according to Vogelstein... There is a 10 years period for the diagnosis of CRC ! Benignus Malignant neoplasia neoplasia Early Advanced Adenoma Carcinoma Normal Adenoma Colon Benignus neoplasia Benignus, 2 -5 years epithelium which persist for during 2 -5 many decades years Advanced Carcinoma

CRC sreening The aim of the screening is to detect and remove adenomas and the cancer that has already been formed in patients with asymptomatic disease and then the follow-up of the patient The method of screening has a number of recommendations around the world taking into account the country's epidemiological, economic, health and cultural situation

Early diagnosis is the key Even if CRC is not diagnosed in the status of adenoma in case of localized CRC 90% 5-years survival can be expected in case of metastatic CRC only 5% 5-years survival can be expected

Facts about CRC screening • ALL METHODS OF SCREENING REDUCE MORTALITY • Pre-carcinoma polypus can be diagnosed and removed by screening • Screening is cost-effective

Who to screen? Average risk patient: over age 50, without CRC risk-factors 75-80% of the effected population High-risk patients should be screened earlier 20-25% of the population is under high- risk

High risk population= 20-25 % of total population • Herediter nonpolyposis colorectal carcinoma (HNPCC) – These people at the age of 45 develop CRC instead of the average age of 63 • Endometrium-, ovarian- and breast cancer – Screeing has to be started at age 20-30 • Special attention to the “3-2-1 rule” ( Amsterdam II criteria) – 3 family members with CRC, out of them at least one is a first- degree relative of the other two – In 2 successive generations – 1 of the diagnosis happened before age 50 • Mutation in hMSH2 & hMLH1 genes

Even higher risk • Familial Adenomatous Polyposis, FAP – 50% has polypus at adolescence age – 95% has polypus before the age 35 – 100% will develop CRC by the age 40 unless they had colectomy – Mutation in the APC [adenomatous polyposis coli] gene which is responsible for tumor-supression • Ashkenaz jewish – 6% of them has double or triple risk for CRC – Mutation in the APC tumor supressor gene

Screening methods Test Implementer How invasive Sensitivity Compliance Time interval Effectiveness Stool blood Patient handles Noninvasive Non-diagnostic Varied ^Yearly with ^40% dicrease in CRC stool rehydration 3 samples Low 50% ^^30% dicrease ^^Bi-annually 30-50% Sígmoidoscopy Physician Invasive 50-70% but Bowel preparation/ In every 5 years. Not effective enough. laesions proximal Low repeat rate Must be combined with No anesthaesia/, to sko are invisable due to discomfort stool blood can be [Concommittant discomfortable/ with stool blood it is Perforation 76%] [1:10,000] Barium enema Experienced Invasive Low sensibility Bowel preparation/ Effectivity is not Not preferred if other with double physician confirmed by trial methods are available Discomfort/ contrast Perforation 1/25,000. Colonoscopy Experienced Invasive Highest sensitivity, Bowel preparation/ Longest The only method which physician Anesthaesia is protection is suitable for screening, “Gold Standard” 80- 90% of cancer feasible diagnostic and cases can be For screening in therapeutic intervention prevented Risk of perforation every 10 years as well 1:500 - 1:4000 Stool DNA test Patient handles Noninvasive/ 65-70% dicrease in High compliance In every 3-5 Lower sensitivity stool Represents the CRC mortality can be expected year. compared to entire colon colonoscopy Virtual Experienced Minimal In laesions >10mm Bowel preparation In every 5-10 Most expensive, no Colonoscopy physician invasive comperable to is uncomfortable, years evidence about the colonoscopy the intervention is effectiveness [CT not Colonography] In flat, <5mm laesions it is weak

Screening from stool blood • Occult blood test – Sensitivity is only 50 % at the first occasion, it is 90 % on long- term if the test is repeated in every 1-2 years – High false-negative ratio,resulting in false sense of security – Majority of positive tests are false positive resulting in redundant colonoscopy – Effective only in case of long-term good patient compliance – In case of using immunochemical test for haemoglobin detection dietary restictions are needed Stool DNA test FDA registration: Aug.11, 2014. – Detects abnormal DNA from the stool – It is important to select the right molecular markers – Sensitivity 52-70%, specificity cc 95%

Screening with endoscopy • Colonoscopy – The whole colon can be overviewed, polypus can be removed and biopsy can be performed – High sensitivity 80%, specificity 95% – Ratio of false negative results is 15-25% in adenomas smaller than 5 mm, 0-6% in adenomas larger than 10 mm – Decreases CRC incidence and mortality by 90% – Each patient detected as positive by any other screening method has to be referred to colonoscopy – Severe complications occurring in 1-2 / 1000 cases GOLD STANDARD FOR CRC SCREENING

Effectiveness of screening methods method prevented cc. prevented death (%) (%) 22,5 47,0 stool blood 37,5 52 sigmoidoscopy 50,0 66,0 Stool blood + sigmoidoscopy 70,0 90,0 colonoscopy Lieberman D.: Gastroenterology

Effectiveness of CRC screening The incidence of colorectal cancer in the US dropped by 30% between 2000 and 2010 among adults ages 50 and older, according to a recent report (CA, A Cancer Journal for Clinicians 2014; 64: 104-117), a decline attributed primarily to widespread screening. A new effort aims to further reduce incidence of the disease by screening 80% of adults according to current guidelines by 2018. CA Cancer J Clin 2014;64:104-117.

Csurgó Population: 5129

Tokaj Population: 4639

Pancho Arena April 21. 2014 4500 paying viewer

Cost-effectiveness of CRC screening • All CRC sreening methods are cost-effective • As cost-effective as mammography screening • More cost-effective than eg. cholesterine or high blood pressure screenings • Colonoscopic screening of patients above the age 40 with CRC anamnesis in their straigh line family members is economically profitable

Which is the best screening method for an average-risk patient? Colonoscopy in every 10 years from age 50, for high- risk patients additional stool DNS test at each 5th year between two colonoscopy But in case we do not perform these.. Any method we consistently go through!