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Colorectal Cancer ScreeningColorectal Cancer Screening
VT SGNA ConferenceVT SGNA Conference
October 24, 2015October 24, 2015
Lynn Butterly, MDLynn Butterly, MD
Director, Colorectal Cancer ScreeningDirector, Colorectal Cancer Screening
Dartmouth-Hitchcock Medical CenterDartmouth-Hitchcock Medical Center
Rationale for ScreeningRationale for Screening
Second most common cause of Second most common cause of death from cancer in the U.S.death from cancer in the U.S.
PreventionPrevention as well as Early as well as Early DetectionDetection
Almost all CRC begins as a polypAlmost all CRC begins as a polyp
Prevention vs. Early Prevention vs. Early DetectionDetection
Comparison to mammographyComparison to mammography
Prevention Focus: Incidence of Prevention Focus: Incidence of colorectal cancer at screening colorectal cancer at screening colonoscopies is extremely smallcolonoscopies is extremely small
Incidence of polyps is Incidence of polyps is at leastat least 40%40%
CRC Screening TestsCRC Screening Tests
Fecal Occult Blood Testing (gFOBT/ FIT)Fecal Occult Blood Testing (gFOBT/ FIT) Stool DNA (Cologuard)Stool DNA (Cologuard) Flexible Sigmoidoscopy (average risk pts.)Flexible Sigmoidoscopy (average risk pts.) (Air Contrast Barium Enema)(Air Contrast Barium Enema) ColonoscopyColonoscopy Virtual Colonoscopy (CTC) Virtual Colonoscopy (CTC) (PillCam for incomplete colonoscopy)(PillCam for incomplete colonoscopy)
Hemoccult TestingHemoccult Testing
Large, worldwide trials have shown that Large, worldwide trials have shown that Hemoccult testing can reduce mortality Hemoccult testing can reduce mortality from colorectal cancerfrom colorectal cancer
Ease of use: can do at home, inexpensiveEase of use: can do at home, inexpensive
Not within 5-10 years after colonoscopy Not within 5-10 years after colonoscopy
(Positive is always considered positive)(Positive is always considered positive)
Fecal Occult Blood Fecal Occult Blood TestingTesting
High sensitivity test recommendedHigh sensitivity test recommended
Colonoscopy is recommended for any Colonoscopy is recommended for any positive FOBT (both guaiac and FIT)positive FOBT (both guaiac and FIT)
In-office DRE FOBT is not appropriate In-office DRE FOBT is not appropriate for CRC screening (and is no longer for CRC screening (and is no longer reimbursable by CMS for screening)reimbursable by CMS for screening)
Problems with HemoccultsProblems with Hemoccults
Not specific for Not specific for humanhuman hemoglobin hemoglobin– For example, a rare steak can interfereFor example, a rare steak can interfere
Certain foods and drugs can interfereCertain foods and drugs can interfere Even if it detects true blood loss, Even if it detects true blood loss,
does not differentiate the source of does not differentiate the source of bleedingbleeding
Fecal Occult Blood Tests - Fecal Occult Blood Tests - FITFIT
Fecal Immunochemical Fecal Immunochemical TestingTesting
FECAL IMMUNOCHEMICAL TESTING FECAL IMMUNOCHEMICAL TESTING (FIT)(FIT)
FITs use antibodies to human globin and are FITs use antibodies to human globin and are therefore therefore specific for bleedingspecific for bleeding vs. diet or vs. diet or medication effect (avoids some g-FOBT medication effect (avoids some g-FOBT pitfalls)pitfalls)
FIT has FIT has better sensitivity better sensitivity than guaiac testing; than guaiac testing; still has ease of use for patientsstill has ease of use for patients
FITs have been FITs have been widely used and testedwidely used and tested throughout the world. Some studies show throughout the world. Some studies show higher detection rates for both advanced higher detection rates for both advanced adenomas and cancer than g-FOBTadenomas and cancer than g-FOBT
FIT is FIT is reimbursablereimbursable by CMS at $22/test or by CMS at $22/test or more more
CRC Screening TestsCRC Screening Tests
Fecal Occult Blood Testing (FOBT/ FIT)Fecal Occult Blood Testing (FOBT/ FIT) Stool DNA (Cologuard)Stool DNA (Cologuard) Flexible Sigmoidoscopy (average risk pts.)Flexible Sigmoidoscopy (average risk pts.) (Air Contrast Barium Enema)(Air Contrast Barium Enema) ColonoscopyColonoscopy Virtual Colonoscopy (CTC) Virtual Colonoscopy (CTC) (PillCam for incomplete colonoscopy)(PillCam for incomplete colonoscopy)
CologuardCologuard
Approved by FDA for average risk Approved by FDA for average risk screeningscreening
Approved by CMSApproved by CMS Greater sensitivity than FIT for CRC:Greater sensitivity than FIT for CRC:
– CRC: 92% (DNA) vs. 74% (FIT)CRC: 92% (DNA) vs. 74% (FIT)– Advanced polyps: 42% (DNA) vs. 24% (FIT)Advanced polyps: 42% (DNA) vs. 24% (FIT)– SSP > 1cm: 42% (DNA) vs. 5% (FIT)SSP > 1cm: 42% (DNA) vs. 5% (FIT)
Multi-target stool DNAMulti-target stool DNA Current recommended use is every 3 yearsCurrent recommended use is every 3 years Cost is high compared to FOBTCost is high compared to FOBT
CRC Screening TestsCRC Screening Tests
Fecal Occult Blood Testing (FOBT/ FIT)Fecal Occult Blood Testing (FOBT/ FIT) Stool DNA (Cologuard)Stool DNA (Cologuard) Flexible Sigmoidoscopy (average risk pts.)Flexible Sigmoidoscopy (average risk pts.) (Air Contrast Barium Enema)(Air Contrast Barium Enema) ColonoscopyColonoscopy Virtual Colonoscopy (CTC) Virtual Colonoscopy (CTC) (PillCam for incomplete colonoscopy)(PillCam for incomplete colonoscopy)
ColonoscopyColonoscopy
Interrupt the Polyp to Cancer SequenceInterrupt the Polyp to Cancer Sequence
Efficacy of all screening tests for CRC Efficacy of all screening tests for CRC preventionprevention is derived from is derived from polypectomypolypectomy
CRC Screening TestsCRC Screening Tests
Fecal Occult Blood TestingFecal Occult Blood Testing Stool DNAStool DNA Flexible Sigmoidoscopy (average risk pts.)Flexible Sigmoidoscopy (average risk pts.) (Air Contrast Barium Enema)(Air Contrast Barium Enema) ColonoscopyColonoscopy Virtual Colonoscopy (CTC)Virtual Colonoscopy (CTC) Pill Cam for incomplete colonoscopy Pill Cam for incomplete colonoscopy
CRC SCREENING TESTSCRC SCREENING TESTS
“ “VIRTUAL COLONOSCOPY”VIRTUAL COLONOSCOPY”
CComputed omputed TTomographic omographic CColonographyolonography
CTCCTC
CTC ConsiderationsCTC Considerations
First described in 1994 – over 20 years agoFirst described in 1994 – over 20 years ago Included in recent ACS screening recommendationsIncluded in recent ACS screening recommendations Some issues remain to be clarified (CMS decision)Some issues remain to be clarified (CMS decision)
Sensitivity for detecting lesions Sensitivity for detecting lesions Comfort Comfort Cost-effectivenessCost-effectiveness Radiation exposureRadiation exposure
CTC ConsiderationsCTC Considerations
Sensitivity for detecting lesionsSensitivity for detecting lesions Comfort Comfort Cost-effectivenessCost-effectiveness Radiation exposureRadiation exposure
CTC IssuesCTC Issues
Sensitivity for detecting lesionsSensitivity for detecting lesions Comfort Comfort Cost-effectivenessCost-effectiveness
– Need for polypectomyNeed for polypectomy– Extracolonic lesionsExtracolonic lesions
Radiation from repeated CTRadiation from repeated CT
Colorectal CancerColorectal Cancer
RISK FACTORSRISK FACTORS
Screening vs. Screening vs. SurveillanceSurveillance
Risk Factors for Colon Cancer Risk Factors for Colon Cancer Will Will Determine Appropriate Testing Determine Appropriate Testing OptionsOptions
Average RiskAverage Risk:: age over 50, no other hx age over 50, no other hx
Increased RiskIncreased Risk:: Personal History of Colorectal CancerPersonal History of Colorectal Cancer Personal History of Pre-cancerous PolypsPersonal History of Pre-cancerous Polyps Family History Family History of Colorectal Cancer or of Colorectal Cancer or
PolypsPolyps IBDIBD Hereditary Syndromes (FAP, HNPCC)Hereditary Syndromes (FAP, HNPCC)
Family History of Colon Family History of Colon CancerCancer
IMPORTANT FACTORS:IMPORTANT FACTORS:
- - RelationshipRelationship of affected relatives of affected relatives
First Degree: First Degree: parents, siblings, parents, siblings, childrenchildren
- - AgesAges of relatives at time of diagnosis of relatives at time of diagnosis
- - NumberNumber of affected relatives of affected relatives
Increased Risk CRC Increased Risk CRC ScreeningScreening
At what age should we begin At what age should we begin screening a person with a first degree screening a person with a first degree relative diagnosed with CRC at age relative diagnosed with CRC at age 65?65?
A. Age 50A. Age 50
B. Age 55B. Age 55
C. Age 40C. Age 40
D. Age 45D. Age 45
Colorectal Cancer Screening Colorectal Cancer Screening
GUIDELINEGUIDELINE
RECOMMENDATIONSRECOMMENDATIONS
Screening Recommendations for Screening Recommendations for
Average RiskAverage Risk Patients Patients Begin screening at age 50 Begin screening at age 50
Flexible sigmoidoscopy every 5 years withFlexible sigmoidoscopy every 5 years with FOBT every 3 yearsFOBT every 3 years oror FOBT annuallyFOBT annually oror Colonoscopy every 10 years if normal testColonoscopy every 10 years if normal test (or)(or) CTC every 5 years or Stool DNA every 3 yearsCTC every 5 years or Stool DNA every 3 years
CRC Screening and CRC Screening and SurveillanceSurveillance
Increased Risk Increased Risk Recommendations Recommendations
Recommendations for Recommendations for Increased RiskIncreased Risk Patients Patients
FHx: Begin screening at age 40 or 10 FHx: Begin screening at age 40 or 10 years younger than age of relative at years younger than age of relative at diagnosis, diagnosis, whichever comes firstwhichever comes first
(unless hereditary syndrome in family)(unless hereditary syndrome in family) Test of choice is colonoscopy unless Test of choice is colonoscopy unless
there are medical contraindicationsthere are medical contraindications Hereditary syndromes Hereditary syndromes managed by managed by
specialist with much earlier testingspecialist with much earlier testing
Compelling case for CRC Compelling case for CRC ScreeningScreening
Preventable diseasePreventable disease Decrease in incidence over last Decrease in incidence over last
decade shows that screening worksdecade shows that screening works Spend $14 billion/year in US on Spend $14 billion/year in US on
treatment for CRCtreatment for CRC 80% by 2018 Initiative: Decrease 80% by 2018 Initiative: Decrease
CRC and improve public healthCRC and improve public health