D. M. Kruss MD Colon Cancer How to nip it in the bud! Daniel M. Kruss, M.D. Colon Cancer How to nip it in the bud! Daniel M. Kruss, M.D.

D. M. Kruss MD Colon Cancer Screening Daniel M. Kruss, M.D. Colon Cancer Screening Daniel M. Kruss, M.D.

D. M. Kruss MD Colon Cancer Screening 130,200 new cases expected this year 93% are over age 50 20% diagnosed at emergency surgery 4th most common cancer 2nd cause of cancer death 130,200 new cases expected this year 93% are over age 50 20% diagnosed at emergency surgery 4th most common cancer 2nd cause of cancer death

D. M. Kruss MD Colon Cancer Screening 56,300 deaths expected this year 6% Lifetime Risk 62% Five-year survival 53% in African Americans 56,300 deaths expected this year 6% Lifetime Risk 62% Five-year survival 53% in African Americans

D. M. Kruss MD Colon Cancer Screening Because of these large numbers, even a small improvement in survival will save many lives! Because of these large numbers, even a small improvement in survival will save many lives!

D. M. Kruss MD Colon Cancer Screening What is cancer? abnormal growth of abnormal cells growth out of control cells multiply too quickly cells form masses called tumors tumors invade other organs malignant tumors spread distantly (metastasize) What is cancer? abnormal growth of abnormal cells growth out of control cells multiply too quickly cells form masses called tumors tumors invade other organs malignant tumors spread distantly (metastasize)

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening Symptoms occur only late in the course of the disease Survival is related to the amount of spread at the time of surgery Goal: Detect the cancer, or pre-cancerous polyp before it spreads Symptoms occur only late in the course of the disease Survival is related to the amount of spread at the time of surgery Goal: Detect the cancer, or pre-cancerous polyp before it spreads

D. M. Kruss MD Colon Cancer Screening What do we know about colon cancer?

D. M. Kruss MD Colon Cancer Screening The cause of colon cancer is partly genetic. It is more common in certain settings: 1. Family history of colon cancer 2. Familial Polyposis syndromes 3. Ulcerative Colitis and Crohn's Disease patients 4. Cancer of ovary, uterus, (breast?) The cause of colon cancer is partly genetic. It is more common in certain settings: 1. Family history of colon cancer 2. Familial Polyposis syndromes 3. Ulcerative Colitis and Crohn's Disease patients 4. Cancer of ovary, uterus, (breast?)

D. M. Kruss MD Colon Cancer Screening Familial Risk General Population 6% One 1st-degree Relative 2-3X Two 1st-degree Relative 3-6X 1st-degree Relative <50 Yrs 3-6X One 2nd- or 3rd-degree Relative 1.5X One 1st-degree Relative & Polyp 2X

D. M. Kruss MD Colon Cancer Screening colon cancer may also have environmental or behavioral triggers: Increasing age, male, cigarette smoking, obesity, African- American, gyne cancers at early age, ??? colon cancer may also have environmental or behavioral triggers: Increasing age, male, cigarette smoking, obesity, African- American, gyne cancers at early age, ???

D. M. Kruss MD Colon Cancer Screening Over 90% of colorectal carcinomas develop from an adenomatous polyp

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening Epidemiologic studies suggest: 1 of every 5 persons is at risk to develop adenomatous polyps 1 of every 5 persons is at risk to develop adenomatous polyps 5% of these may progress to colorectal cancer 5% of these may progress to colorectal cancer Screening for polyps at a stage when they can be colonoscopically removed is shown to decrease colorectal cancer mortality Screening for polyps at a stage when they can be colonoscopically removed is shown to decrease colorectal cancer mortality Epidemiologic studies suggest: 1 of every 5 persons is at risk to develop adenomatous polyps 1 of every 5 persons is at risk to develop adenomatous polyps 5% of these may progress to colorectal cancer 5% of these may progress to colorectal cancer Screening for polyps at a stage when they can be colonoscopically removed is shown to decrease colorectal cancer mortality Screening for polyps at a stage when they can be colonoscopically removed is shown to decrease colorectal cancer mortality

D. M. Kruss MD Colon Cancer Screening This guides our present strategy: find polyps find polyps remove polyps remove polyps prevent 90% of colon cancers prevent 90% of colon cancers The other 10% awaits new genetic tests for blood and/or stool

D. M. Kruss MD Colon Cancer Screening How can we detect Colon cancer? 1. Fecal Occult Blood

D. M. Kruss MD Colon Cancer Screening What is fecal Occult Blood? OB is blood mixed in stool which you cannot see It may come from sources anywhere along the gut from mouth to rectum It may be an early warning signal that a polyp or tumor is present What is fecal Occult Blood? OB is blood mixed in stool which you cannot see It may come from sources anywhere along the gut from mouth to rectum It may be an early warning signal that a polyp or tumor is present

D. M. Kruss MD Colon Cancer Screening Fecal Occult Blood Testing Three Prospective Randomized Trials

D. M. Kruss MD Colon Cancer Screening A polyp or a cancer in the colon may bleed, slowly, and cause tiny amounts of OB in the stool. Large studies show us that only 1/3 of polyps and 1/2 of cancers bleed, however!! Depending on the method used, between 1.5-8% of 'healthy' persons will have OB in the stool!! A polyp or a cancer in the colon may bleed, slowly, and cause tiny amounts of OB in the stool. Large studies show us that only 1/3 of polyps and 1/2 of cancers bleed, however!! Depending on the method used, between 1.5-8% of 'healthy' persons will have OB in the stool!!

D. M. Kruss MD Colon Cancer Screening If we make our OB tests too sensitive, we may find a few more cancers, but will detect a lot more false positives. There is no harm in finding a false positive, except in the obligation (cost?) of examining each one to see if there is a cancer. If we make our OB tests too sensitive, we may find a few more cancers, but will detect a lot more false positives. There is no harm in finding a false positive, except in the obligation (cost?) of examining each one to see if there is a cancer.

D. M. Kruss MD Colon Cancer Screening If we make our OB tests less sensitive, we will have fewer false positives, but will miss a few real cancers. We can improve OB specificity by avoiding red meats, vitamin C, aspirin and arthritis medicines, and many fresh fruits and vegetables for three days before and during three days of stool collection. If we make our OB tests less sensitive, we will have fewer false positives, but will miss a few real cancers. We can improve OB specificity by avoiding red meats, vitamin C, aspirin and arthritis medicines, and many fresh fruits and vegetables for three days before and during three days of stool collection.

D. M. Kruss MD There is a trade-off between compliance and false-positives. Screening does not change the incidence of new colon cancers, but affects the stage at which they are discovered. The mortality was reduced from 8.33 to 5.88 per 1000 in the Minnesota study of stool OB. There is a trade-off between compliance and false-positives. Screening does not change the incidence of new colon cancers, but affects the stage at which they are discovered. The mortality was reduced from 8.33 to 5.88 per 1000 in the Minnesota study of stool OB. Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening Fecal Occult blood testing performed as part of an in-office digital rectal exam failed to detect potentially cancerous colon growths 95 percent of the time!

D. M. Kruss MD Colon Cancer Screening It must be clearly understood that the OB test is only one of several methods of screening and that it is, at best, 50% predictive. Then why do it? It must be clearly understood that the OB test is only one of several methods of screening and that it is, at best, 50% predictive. Then why do it?

D. M. Kruss MD Colon Cancer Screening Early detection is still the only method to prevent deaths from colon cancer Early detection is still the only method to prevent deaths from colon cancer

D. M. Kruss MD Colon Cancer Screening How can we detect Colon cancer? 2. Sigmoidoscopy

D. M. Kruss MD Colon Cancer Screening The American Cancer Society previously recommended: Sigmoidoscopy this was based on data suggesting that half of the cancers will be seen in this area, and any patients who have polyps seen, will receive full colonoscopy The American Cancer Society previously recommended: Sigmoidoscopy this was based on data suggesting that half of the cancers will be seen in this area, and any patients who have polyps seen, will receive full colonoscopy

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening How can we detect Colon cancer? 3. Colonoscopy

D. M. Kruss MD Colon Cancer Screening The case for screening colonoscopy* Involves greater risk and inconvenience however few significant lesions are missed entire colon is examined screening interval of 10 years (few polyps become cancer in less time) *or virtual colonoscopy when available or air contrast barium enema and sigmoidoscopy The case for screening colonoscopy* Involves greater risk and inconvenience however few significant lesions are missed entire colon is examined screening interval of 10 years (few polyps become cancer in less time) *or virtual colonoscopy when available or air contrast barium enema and sigmoidoscopy

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening If you are positive on OB screening, what is needed? colonoscopy (full colon exam) if positive findings, act on them if negative, consider searching the remainder of the GI tract If you are positive on OB screening, what is needed? colonoscopy (full colon exam) if positive findings, act on them if negative, consider searching the remainder of the GI tract

D. M. Kruss MD Colon Cancer Screening If a polyp is found, what is needed? 1. Annual colonoscopy until the colon is 'clear' 2. then re-examine every 3-5 years If a polyp is found, what is needed? 1. Annual colonoscopy until the colon is 'clear' 2. then re-examine every 3-5 years

D. M. Kruss MD Colon Cancer Screening What are the risks of colonoscopy? bleeding and/or perforation occur in less than 1/500 patients When properly indicated, the procedure is very safe and very efficient What are the risks of colonoscopy? bleeding and/or perforation occur in less than 1/500 patients When properly indicated, the procedure is very safe and very efficient

D. M. Kruss MD Colon Cancer Screening What should I do now?

D. M. Kruss MD Colon Cancer Screening If you are over 55: screening for OB every year, colonoscopy (or sigmoidoscopy) If you have polyps, tell your blood relatives to have screening and be sure you have regular tests If relatives had colon polyps or colon cancer, get your colonoscopy now! If you are over 55: screening for OB every year, colonoscopy (or sigmoidoscopy) If you have polyps, tell your blood relatives to have screening and be sure you have regular tests If relatives had colon polyps or colon cancer, get your colonoscopy now!

D. M. Kruss MD Colon Cancer Screening Familial Risk Screening Any Family History Same as Average Risk Screening, Same as Average Risk Screening, begin at age 55 begin at age 55 Strong Family History -Definition: 2 Affected First-degree Relatives 2 Affected First-degree Relativesor 1 First-degree Relative Diagnosed <60 Colonoscopy every 5 years, Start at age 40 Years

D. M. Kruss MD Colon Cancer Screening Screening is optional... Without screening a 50 year old at average risk, has 530/10,000 chance of invasive colon cancer and 250/10,000 risk of dying from it. Screening between ages reduces this risk by 10-75% Screening is optional... Without screening a 50 year old at average risk, has 530/10,000 chance of invasive colon cancer and 250/10,000 risk of dying from it. Screening between ages reduces this risk by 10-75%

D. M. Kruss MD Colon Cancer Screening 94 percent of colorectal cancer patients had either not undergone a colonoscopy at all, or not until having the procedure that led to their diagnosis

D. M. Kruss MD Colon Cancer Screening The prognosis of colon cancer is directly related to the extent of disease when first diagnosed!! The prognosis of colon cancer is directly related to the extent of disease when first diagnosed!!

D. M. Kruss MD Colon Cancer Screening There are no signs or symptoms of colon cancer until late in the course! There are no signs or symptoms of colon cancer until late in the course!

D. M. Kruss MD Colon Cancer Screening Late signs include: change in bowel habitchange in bowel habit rectal bleeding (red or occult)rectal bleeding (red or occult) anemia (weakness, fatigue)anemia (weakness, fatigue) cramping abdominal pain orcramping abdominal pain or pelvic/rectal pain or strainingpelvic/rectal pain or straining

D. M. Kruss MD Colon Cancer Screening Good News! Medicare covers Screening colonoscopy!

D. M. Kruss MD Colon Cancer Screening Medicare pays for: Fecal Occult Blood Tests - every year Fecal Occult Blood Tests - every year Flexible Sigmoidoscopy - every 4 years* Flexible Sigmoidoscopy - every 4 years* Screening Colonoscopy Screening Colonoscopy Every 10 years for average risk* Every 2 years for high risk *if no exam of the colon in the past 4 years

D. M. Kruss MD Colon Cancer Screening MEDICARE PAYS FOR COLONOSCOPY Every 2 years for high risk: close relative with colon ca close relative with adenomatous polyps close relative with adenomatous polyps familial adenomatous polyposis prior polyps or colorectal cancer Inflammatory bowel disease (UC, Crohn’s) Every 10 years for average risk* *if no exam of the colon in the past 4 years

D. M. Kruss MD Colon Cancer Screening What else can we do?

D. M. Kruss MD Colon Cancer Screening Lifestyle modifications may be useful: Low-dose aspirin or NSAID’s daily Low-dose aspirin or NSAID’s daily Reduce animal fat Reduce animal fat Increase fiber, calcium, magnesium Increase fiber, calcium, magnesium ? (fruits, vegetables) no proof! ? (fruits, vegetables) no proof! Lifestyle modifications may be useful: Low-dose aspirin or NSAID’s daily Low-dose aspirin or NSAID’s daily Reduce animal fat Reduce animal fat Increase fiber, calcium, magnesium Increase fiber, calcium, magnesium ? (fruits, vegetables) no proof! ? (fruits, vegetables) no proof!

D. M. Kruss MD Colon Cancer Screening How can we detect Colon cancer? 4. Future Methods

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening REFERRAL TO GASTROENTEROLOGIST Positive screening tests Questions about appropriate screening When colonoscopy is needed Diagnosis and/or management of the known inherited syndromes of colon cancer

D. M. Kruss MD Colon Cancer Screening Your survival -- --is up to you!! Your survival -- --is up to you!!

D. M. Kruss MD Colon Cancer Screening If you won’t do it for yourself... Do it for the ones who love you!

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening Let’s review our strategy... our strategy...

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening Does a test need to be ‘cost effective’ to be recommended?

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Kill the Cancer Do Screening now! Daniel M. Kruss, M.D. Kill the Cancer Do Screening now! Daniel M. Kruss, M.D.

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening Lifestyle modifications, and diet, What we know...

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening Inherited Syndrome Screening FAPSigmoidoscopy Every one to two years, starting age 10 to 12 years HNPCCColonoscopy Every 1 to 2 years, starting age 25 years

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening

D. M. Kruss MD Colon Cancer Screening Fewer than half of patients diagnosed with colorectal cancer had received a screening procedure at least six months prior to their diagnosis