27th Annual Winter CME Conference February 8-11, 2017 1/3/2017

Colorectal Cancer Screening - a review and update Sean E. McGarr D.O., FACG Therapeutic Endoscopist Director Gastrointestinal Oncology Services, HACCC MaineGeneral Gastroenterology 1/3/2017

Outline The goal of this talk: What are colon polyps? Colorectal cancer (CRC) statistics Screening guidelines 1/3/2017

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Colonic polyps Protuberance into the normally flat colonic mucosa Asymptomatic Classified as sessile pedunculated 1/3/2017

Colonic polyps Hyperplastic polyps Adenomatous polyps common (rectum) indistinguishable from adenomatous polyps Adenomatous polyps nearly all colorectal cancers arise from adenomas only minority of adenomas progress to cancer (1 in 20 or less) 1/3/2017

Serrated polyps The term serrated has slightly different features seen with the microscope. Both types need to be removed from your colon. These types of polyps are not cancer, but are precancerous and therefore, you have some increased risk of subsequently developing cancer of the colon. 1/3/2017

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Distribution of colon polyps 15% 10% 25% 50% 1/3/2017

Genetics of colon cancer Colon cancer arises as a series of histopathologic & molecular changes: Normal epithelial cells Small adenomatous polyp Large adenomatous polyp Colorectal carcinoma 1/3/2017 1 Janne, NEJM 2000;342:1960 2 Fearon, Cell1990;61:759

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CRC epidemiology U.S. statistics in 2012 143,460 new cases 51,690 deaths 3rd/2nd most frequent diagnosed cancer in men and women 3rd/2nd leading cause of cancer death Maine statistics in 2012 750 new cases 260 deaths (preliminary) 74 cases with 21 deaths MGMC in 2011 1/3/2017

For average risk individual 6% lifetime risk for being diagnosed with colorectal cancer 2.5% chance of dying from it Results in premature death Average loss: 13 years of life >90% of cases occur in patients > 50 1/3/2017

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Rational for screening CRC does not develop overnight More than 80% of CRC arise from adenomatous polyp Polyps < 1cm is size <1% risk from cancer Polyps > 1cm in size 10% risk for developing into cancer in 10 years Removal of polyps 70 to 90% risk reduction for CRC 1/3/2017

Defining CRC risk groups Average risk group >50 years of age No personal of family history of CRC No history of inflammatory bowel disease 80% of CRC arises in this group High risk group Personal and/or family history of CRC or polyp Long standing colitis Genetic predisposition 1/3/2017

Screening guidelines for the average risk group Begin screening at age 50 Asymptomatic Annual Fecal Occult Blood Test (FOBT) 15-43% reduction in CRC mortality 3 consecutive stool samples annually Can detect up to 92% of all cancers when repeated annually Dietary restrictions 1/3/2017

Limitations of FOBT Sensitivity limitations Specificity limitations Relatively insensitive detecting polyps compared to CRC Specificity limitations False positive rate Necessitates additional procedures Endoscopy Stool DNA 1/3/2017

*Colonoscopy is the screening method that MaineHealth providers recommend for their patients. Other Types of Screening Include: Flexible Sigmoidoscopy Fecal Occult Blood Test (FOBT) Physician’s Guidelines Fecal DNA Fecal Immunoassay (FIT test) Double Contrast Barium Enema CT Colonography (Virtual Colonoscopy) Digital Rectal Exam is NOT considered beneficial in CRC screening and not recommended as a preferred screening choice 1/3/2017

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Colonoscopy Benefits Most sensitive and specific screening tool Definitive treatment If polyps detected then proceed with polypectomy Almost eliminates risk for progression to CRC Lowers the risk for CRC development Lowers the risk for CRC related death 1/3/2017

Colonoscopy Disadvantages “My rule of thousands” Complications (perforation, bleeding, polypectomy syndrome, infection) Overall routine risk 0.35% Polypectomy risk 2.3% Lifetime risk of CRC 6% High costs Bowel preparation Public health capacity limitations 1/3/2017

Virtual Colonoscopy Reconstructed spiral CT images Non-invasive No sedation Allows visualization of the entire colon Still require preparation Uncomfortable VC CC 1/3/2017

Roberta Rietti: CT Colonography Master Thesis - YouTube 1/3/2017

Fecal immunochemical test (FIT) The fecal immunochemical test (FIT) is a screening test for colon cancer It tests for blood in the stool FIT only detects human blood from the lower intestines Medicines and food do not interfere with the test, so it tends to be more accurate and have fewer false positive results than other tests 1/3/2017

FIT vs. FOBT Monoclonal/poly Ab to detect globin proteins which do not survive passage from the UGI FIT true-positive CRC 87% vs. 54% Polyps >10mm 45% vs. 23% No need to modify diet or ASA Cost $75 vs $5 1/3/2017

After considering public comments and consulting with appropriate organizations, the Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is sufficient to cover CologuardTM – A multitarget stool DNA test – A colorectal cancer screening test for asymptomatic, average risk beneficiaries, aged 50 to 85 years. Therefore, Medicare Part B will cover the CologuardTM test once every three years for beneficiaries who meet all of the following criteria: Age 50 to 85 years Asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test). At average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer). 1/3/2017

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Surveillance colonoscopy CRC screening FOBT Sigmoidoscopy Colonoscopy Virtual colon Fecal markers Colonoscopy Surveillance colonoscopy 1/3/2017

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High risk group 1 to 2 first-degree relatives with CRC or adenomas 1st degree relative with CRC <40 years of age Hereditary CRC syndromes Initial screening 40 or 10 years less 1/3/2017

High risk surveillance National polyp study 15 to 25% probability of missed polyp High risk for advanced polyp at follow up 3 or more polyps at initial colonoscopy >60 years of age and family history CRC Repeat exam at 3-5 years Low risk for advanced polyp at follow up Repeat exam at 5 years 1/3/2017

High risk surveillance After complete removal of adenoma with invasive cancer (malignant polyp) Repeat examination in 3 to 6 months Repeat at 1 year Extend to 3 – 5 years 1/3/2017

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