Colorectal Cancer

Proposal of a Screening Program for Developing Countries with Emphasis on Costs

Presentator: Alessandro L. Loiola, MD• Atendant of Coloproctology at

the Specialties´ Regional Referral Center, Vitoria / ES - Brazil

• Developer of Health Contents for Boasaude.com.br

• E-mail: alpl@escelsanet.com.br

Objectives• Create a consciousness of the problem for

third-world countries• Access some relevant features in the

diagnosis of Colorretal Cancer• Sugest steps for a screening program

Recommended articles

• BOND JH. Screning for colorectal cancer. Hosp Prac, Jan 15:59-74, 1997.• SELBY JV et alii. Effect of fecal

occult blood testing on mortality from colorectal cancer. Am Col Phys, 118:1-6, 1993.

Recommended websites:

•Colorectal Cancer Homepage at http://home.swipnet.se/crc/•Colorectal Forum at www.colorectal-forum.org/• NCI CancerNet Database at www.meb.uni-bonn.de/cancernet/

Creating a Consciouness for screening: did you

know that . . . • Colorectal cancer kills more than AIDS and

Diabetes ?• In some countries (Brazil included) colorectal

cancer causes more deaths per year than ovarian, uterine, prostate or even lung cancer ?

Relevant Features of Colorectal Cancer

Special Risk Factors Decade of ocurrance Clinical manifestations Pathology

Relevant Features of Colorectal Cancer:

1 - Special risk factors• Diet habits• Inflamatory bowel diseases• Familial adenomatous polyposis

syndrome • Strong incidence of cancer in the family

Relevant Features of Colorectal Cancer:

2 - Decade of occurrance

0100200300400500600700800900

1st 2nd 3rd 4th 5th 6th 7th 8th andover

Relevant Features of Colorectal Cancer:

3 - Clinical manifestations

• Low intestinal bleeding• Altered bowel habits• Unexplained weight loss

Relevant Features of Colorectal Cancer:

4 - Pathology • 90% of Colorectal malignant tumors are

Carcinomas• 60-70% of the lesions are located in the last 1/3 part

of large bowel• 30% of all lesions can be reached by digital exam

only

Steps of the Colorectal Cancer Screening Program

Barium EnemaConsider before going to step 3

Step 3Colonoscopy

Step 2Sigm oidoscopy

Step 1Faeccal-occult-blood test

Colorectal Cancer Screening Program - Step

1• Faecal-occult-blood test (FOBT) in people after age 50 and/or with known risk factors and/or physical evidences

suggesting colorretal cancer

Colorectal Cancer Screening Program - Step

1a• Patients with negative FOBT, without

evidences at physical examination and/or without risk factors: • repeat FOBT every year

Colorectal Cancer Screening Program - Step

1b

• Patients with negative FOBT but with sustained clinical suspicion

and/or with risk factors: go to Step 2

Colorectal Cancer Screening Program - Step

1c

• Patients with positive FOBT: go to Step 2 (sigmoidoscopy)

Colorectal Cancer Screening Program - Step

2

• Sigmoidoscopy (flexible if possible)

Colorectal Cancer Screening Program Step 2a - Negative

Sigmoidoscopy

• Patients without clinical suspicion and any risk factor: follow up with FOBT every year, one sigmoidoscopy each 3-5 years and one colonoscopy each 10 years.

Colorectal Cancer Screening Program Step 2b - Negative

Sigmoidoscopy• Patients with sustained clinical suspicion and/or

any risk factor: consider Barium enema. One can choose promptly performing a Colonoscopy (Step 3)• If all negative: follow up as Step 2a.

Colorectal Cancer Screening Program Step 2c - Positive Sigmoidoscopy

• Go to Step 3 (Colonoscopy), after collecting samples.

Colorectal Cancer Screening Program

Step 3 - Colonoscopy

• To further exam the extention of a particular lesion and to identify more lesions

• Patients with negative colonoscopy: follow up as Step 2a.

Colorectal Cancer Screening Program

Hole of Barium Enema

• Detect other lesions • Can be replace (with restrictions)

colonoscopy where this exame is not obtainable