Overview of Colorectal Cancer and CRC Screening Program

CDC CRC Control ProgramDHMH—Baltimore City

March 29, 2010

Birth

Inheritedcancer susceptibilitygenes

Age

Asymptomatic ClinicalDisease Disease

AdvancedDisease

Exposures (life style, occupation, and environment)

Acquired (not inherited) genetic changes

Primary Prevention- Risk Factor reduction-Colonoscopy with adenoma removal

Secondary Prevention- Screening, early detection and diagnosis

Convalescenceor Death

Tertiary Prevention-Medical care

Colorectal Cancer Development and Prevention

CRC Incidence and Mortality

Annual age-adjusted cancer incidence rates, US, 1975-2004

CA Cancer J Clin Jemal et al. 58 (2): 71-96 (2008).

Annual age-adjusted cancer death rates--Males, US, 1930-2004

CA Cancer J Clin Jemal et al. 58 (2): 71-96 (2008).

Annual age-adjusted cancer death rates--Females, US, 1930-2004

CA Cancer J Clin Jemal et al. 58 (2): 71-96 (2008).

CRC Screening

Colorectal Cancer Screening Status of People Age 50 Years and Older

Maryland Cancer Surveys, 2002-2008

22.616.9

10.111.0

19.8

25.9

10.3

41.2

22.8

50.3

10.5

58.7

8.6

7.1

17.7

66.6

0 10 20 30 40 50 60 70

Up-to-date with colonoscopy

Up-to-date with FOBT and/orsigmoidoscopy

Tested but not up-to-date*

Never tested

Percent

2002 2004 2006 2008

80% of people 50+ in 80% of people 50+ in Maryland reported having a Maryland reported having a provider provider recommend recommend endoscopy…..

of those, 88% got screened

88%

24%

0%

25%

50%

75%

100%

Providerrecommended

No providerrecommended

Percent Screened with Endoscopy

Source: Maryland Cancer Survey, 2008

Provider Recommendation is KEY to Screening

Of the 20% who did NOT report a provider recommendation….only 24% got screened

Colorectal Cancer Colonoscopy or Sig.

(50+ years)

Never screenedwith col. or sig.

25%

Ever screened with col. or sig.

Source: Maryland Cancer Survey, 2008

Colorectal Cancer Colonoscopy or Sig.

(50+ years)

Never screenedwith col. or sig.

25%

Ever screened with col. or sig.

85% 85% have been to doctor have been to doctor

for “routine checkup”for “routine checkup” in past 2 yearsin past 2 years

Only 15%have NOT had checkup

Source: Maryland Cancer Survey, 2008

Patient:Family and personal historyPast screeningSymptoms

Primary Doctor:Referral

Pathologist:Pathology report

Case Management and Communication

Colonoscopist:Risk historyMedication changesPrep instructionsPost colonoscopy instructionsColonoscopy report

FindingsRecommendations

Who needs CRC screening?Who needs CRC screening?

Colorectal Cancer Rates by Age and SexCancers of the Colon and Rectum:

Average Annual Age-Specific SEER Incidenceand U.S. Mortality Rates by Gender, 2001-2005

Source: SEER Cancer Statistics Review 1975-2005. Colon and Rectum Cancer, SEER Incidence and U.S. Death Rates, Age-Adjusted and Age-Specific Rates, By Race and Sex (Rates based on SEER 17 areas)

0

100

200

300

400

500

30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Age Group

Nu

mb

er

pe

r 1

00

,00

0

Incidence Men

Incidence Women

MortalityMen

MortalityWomen

Age recommended to start screening

Colorectal Cancer Mortality Rates by Race and Sex in Maryland, 1998-2005

Age-adjusted rate per 100,000 population

Source: NCHS Compressed Mortality File in CDC Wonder

0

10

20

30

40

50

1998 1999 2000 2001 2002 2003 2004 2005

White men

Black women

White women

Black men

Colorectal Cancer Cases by Risk History

Sporadic Sporadic (average risk) (65%–85%)(average risk) (65%–85%)

FamilyFamilyhistoryhistory(10%–30%)(10%–30%)

Hereditary nonpolyposis Hereditary nonpolyposis colorectal cancer colorectal cancer

(HNPCC) (5%)(HNPCC) (5%)Familial adenomatous Familial adenomatous polyposis (FAP) (1%)polyposis (FAP) (1%)

Rare Rare syndromes syndromes

(<0.1%)(<0.1%)

(84,600-110,670 cases/yr.)(84,600-110,670 cases/yr.)

Risk of CRCGroup Approx. lifetime risk of CRC

General Population 5-6%

One first degree relative (FDR) with CRC 2--3-fold increased over general population

Two First Degree Relatives (FDR)s with CRC 3--4-fold increased

FDR with CRC diagnosed < 50 3--4-fold increased

One second or third degree relative About 1.5-fold increased

Two second degree relatives About 2--3-fold increased

One FDR with adenoma About 2-fold increased

Inflammatory Bowel Disease (ulcerative colitis and Crohn colitis)

[7-10% have CRC after having ulcerative colitis for 20 years; then ~1%/year]

Familial Adenomatous Polyposis

Hereditary Non-polyposis Colorectal Cancer

~100%

~80+%

Burt. Gastroenterology 2000;119:837-53 Winawer et al. Gastroenterology 203;124:544-560

Average Risk

Increased Risk

Colonoscopy, every 10 years orFOBT annually, plus Flex sig., every 5 years

FOBT if refuse endoscopy

Colonoscopy(interval for repeat depends on risk, history, and prior results)

Maryland Screening Recommendations:Medical Advisory Committee on CRC

Risk Category Age to Begin ScreeningAverage risk, asymptomatic 50 years

Increased risk

Family history CRC or adenoma (1 FDR <60 or 2 FDR any age)

Colonoscopy at 40 years old or 10 years before the youngest case in the FDRs

Family history CRC or adenoma in 1 FDR >= 60

Start screening (any method) at 40 years old

Genetic syndrome:

FAP

HNPCC

Puberty

21 years old

Inflammatory bowel disease 8 years after start of pancolitis;

12-15 years after start of left sided colitis

See Program Manual 1A, Attachment 1

Colonoscopy or other

screening test

New Guidelines

Screening and Surveillance for the Early Detection of Colorectal Cancer and

Adenomatous Polyps, 2008:

A Joint Guideline from the American Cancer Society,

the US Multi-Society Task Force on CRC, and the American College of Radiology

CA Cancer J Clin 58: 130-160 (May 2008)

Tests that Find Both Polyps and Cancer

Flexible sigmoidoscopy every 5 years 

Colonoscopy every 10 years 

Double contrast barium enema every 5 years 

CT colonography (virtual colonoscopy) every 5 years

New Guidelines American Cancer Society, May 2008

Tests that Primarily Find Cancer

Guaiac-based fecal occult blood testing (gFOBT) every year 

Fecal immunochemical test (FIT) every year 

Stool DNA test (unclear how often this is needed)

New Guidelines American Cancer Society, May 2008

New CRC Screening Guidelines American Cancer Society, May 2008

• Beginning at age 50, men and women at average risk for CRC should use one of the screening tests

• The tests that are designed to find both early cancer and polyps are preferred if these tests are available to you and you are willing to have one of these more invasive tests.

• Talk to your doctor about which test is best for you.

CRC Screening Program in Maryland

Colonoscopy Equipment

Long Handle Polypectomy Snare

Polyp Snare

Reusable Biopsy Forceps

Hot Biopsy Forceps

Disposable Retriever

Prong Retriever

Brush Biopsy

Injection

Colonoscopy Findings: Pathology

Different types of polyps

Sessile polyp

Hyperplastic polyp

Sessile polyp

Tubulovillous adenoma

Different types of polyps

Sessile polyp

Tubular adenoma

Sessile polyp

Tubulovillous adenoma

Pedunculated polyp

Different types of polyps

Pedunculated polyp

Tubular adenoma

Pedunculated polyp

Tubular adenoma

CopyrightMediamed artMilan (Italy)

Wall of the colon under a low power microscope

Mucosa

Submucosa

Muscularis

Serosa

Atlas of Human Histology. Di Fiore. 1974, Lea& Febiger

Inside of the intestine (feces touch this surface)

Robbins Pathologic Basis of Disease, 6th Ed. Cotran, Kumar, and Collins. 1999. WB Saundersp. 827

RESECTION LINE

SUBMUCOSA

HEAD OFPOLYP

STALK

INTESTINALWALL Muscularis

Pedunculated adenoma

RESECTION LINE

SUBMUCOSA

HEAD OFPOLYP

STALK

INTESTINALWALL

(lymphatics, arteries)

Pedunculated adenoma

Muscularis

1

2

3

SUBMUCOSA1 Low grade dysplasia

2 Severe dysplasia

3 Carcinoma in-situ, intramucosal carcinoma

Polyp with no evidence of invasive carcinoma

“High gradedysplasia”

SUBMUCOSA

INVASIVE CARCINOMA(invasion in submucosa which contains lymphatics, and arteries = potential for metastases)

Polyp with invasive carcinoma

Polyp with invasive carcinoma: Pertinent pathology information

•Tumor differentiation

•Lymphatic/vascular invasion

•Distance from resection line

RESECTION LINE

Sessile Polyps

• Usually submitted in several pieces• Difficult to determine the orientation of the specimen

(“is the margin free of tumor?”)• Other issues—type of polyp?

Invasive carcinoma: Colon cancer stagingPathology, Second Edition. Rubin and Farber. 1994: 684-94

Stage 1

Stage 2

Invasive carcinoma: Colon cancer stagingPathology, Second Edition. Rubin and Farber. 1994: 684-94

Stage 3

Stage 4

Cancer in the regional lymph nodes

Colonoscopy Findings:Adequacy of the Exam

Adequacy of Colonoscopy

http://www.cht.nhs.uk/services/clinical-services-a-z/surgery-anaesthetics/endoscopy/

Cecum

Adequate Colonoscopy?

• Reached the cecum?– Reached and explored?– Reached and intubated the terminal ileum?– Peeked into the cecum but couldn’t get in

• Adequate bowel prep?– “Adequate to visualize any lesion >5mm”– “Adequate enough”– “Adequate”– “Fair”– “Excellent”

Is the bowel prep “adequate”?

http://www.webmm.ahrq.gov/case.aspx?caseID=67&searchStr=cancer

Adequate prep?

How can I dictate a picture of what I’m seeing here?

What to think about if prep was inadequate:

• Can you figure out why this patient might have had inadequate prep?

• Is there anything that could have been done differently?– By the provider– By your program– By the patient

• Are there lessons learned for future clients and for this client’s next colonoscopy?– Different instructions, different prep– Discussion with the provider(s)– Other

Case Management

Roles before Colonoscopy

• Administrative Case Manager (nurse or other case manager in program)– Obtain information for enrollment– Schedule appointment and colonoscopy– Instruct about bowel prep and procedures– Solve any barriers (transportation, accompaniment home)

• Medical Case Manager – Do an exam and clear the patient for colonoscopy– Give instructions about medication changes if needed– Instruct on bowel prep and procedures– Schedule specifics about the colonoscopy

Roles after Colonoscopy

• Medical Case Manager (doctor who did the endoscopy)– Give you a report of the colonoscopy– Give you the recall interval– Give the client the results

• Administrative Case Manager – Obtain colonoscopy and pathology reports– Review recall recommendation—is it correct per program

standards?– Enter data in computer– Notify client of their results (verbal; written)– Ask about complications– Inform the primary care provider

Recommended screening afterafter initial screening--

rescreening or surveillance colonoscopy

“Recall Interval”

Keys to the right recall

1. Colonoscopy Report

2. Pathology Report

3. Recommendation based on guidelines

4. Communication

After first colonoscopy, then whatthen what?

• Recall interval between colonoscopies will depend on:

– findings,

– risk history, and

– symptoms

Interval between colonoscopies

IF IF Findings on colonoscopy were negative:– No CRC;

– No adenomas; and

– No or only a few hyperplastic polyps,

Average risk, and

No CRC symptoms

• Recall interval will usually be 10 years • See guidelines for recommended interval

See Program Manual 1A, Attachment 1

Recall Interval Based on Finding of First Colonoscopy

Finding Interval

“Inadequate” bowel prep

(How inadequate was it?)

Repeat right away or do other screening (e.g., DCBE)

Didn’t reach or view cecum Repeat right away or do other screening to check cecum

“Two adenomas” Need to know histology and size

Any villous histology (villous, tubulovillous) or high grade dysplasia

If completely removed, repeat in 3 years

One or more adenomas >1 cm in size

Repeat in 3 years

Incomplete removal of adenomas Consider short recall interval (2-6 months)

1-2 tubular adenomas, <1 cm size Repeat in 5-10 years

Recall Interval Based on Finding of First Colonoscopy

Finding Interval

“Inadequate” bowel prep

(How inadequate was it?)

Repeat right away or do other screening (e.g., DCBE)

Didn’t reach or view cecum Repeat right away or do other screening to check cecum

“Two adenomas” Need to know histology and size

Any villous histology (villous, tubulovillous) or high grade dysplasia

If completely removed, repeat in 3 years

One or more adenomas >1 cm in size

Repeat in 3 years

Incomplete removal of adenomas Consider short recall interval (2-6 months)

1-2 tubular adenomas, <1 cm size Repeat in 5-10 years

Standards for Colonoscopy Reports--CoRADS*

• Date and Time Procedure 

• Patient description • Risk factors-• ASA class • Indications• Consent signed • Sedation  • Colonoscope • Bowel Prep • Reached cecum 

• Colonoscopy withdrawal time 

• Findings• Specimen(s) to path lab • Impression • Complications • Pathology • Recommendations, • Follow-up Plan/Recall • Other 

* Standardized colonoscopy reporting and data system (CoRADS): report of the Quality Assurance Task Group of the National Colorectal Cancer Roundtable, Lieberman et al., Gastrointestinal Endoscopy 2007; 65: 757-766

Patient:Family and personal historyPast screeningSymptoms

Primary Doctor:Referral

Pathologist:Pathology report

Case Management and

Communication

Colonoscopist:Risk historyMedication changesPrep instructionsPost colonoscopy instructionsColonoscopy report

FindingsRecommendations

Indicator Type, Number and Description CDC Benchmark

Screening Priority Population

1 Percent of new clients screened who are at average risk for CRC

≥ 75%

2 Percent of average risk new clients screened who are aged 50 years and older

≥ 95%

Completeness of Clinical Follow-up

3 Percent of abnormal test results with diagnostic follow-up completed

≥ 90%

4 Percent of diagnosed cancers with treatment initiated

≥ 90%

Timeliness of Clinical Follow-up

5 Percent of positive tests (FOBT/FIT, sigmoidoscopy, or DCBE) followed-up with colonoscopy within 90 days

≥ 80%

6 Percent of cancers diagnosed with treatment initiated within 60 days

≥ 80%

CDC Benchmarks for CRC Screening