1. Screening and Prevention of Cancers of the Colon and Pancreas Peter E. Darwin, MD, FACP, FASGE Professor Department of Medicine

4. U.S. Mortality From Colorectal Cancer

5. Adenoma-Carcinoma Sequence With Molecular Correlate

6. Colon Polyp

7. Colon Cancer

8. Who gets colon polyps? Anyone can get colon polyps, but certain people are more likely to get them than others. You may have a greater chance if: –50 years of age or older –Had polyps before –Someone in your family has had polyps or colon cancer –Uterine or ovarian cancer

9. Who gets colon polyps? You may also be more likely to get colon polyps if you: –Eat a lot of fatty foods –Smoke –Drink alcohol –Don’t exercise

10. What are the symptoms of colon polyps? Most people do not have symptoms Some symptoms may include: –Bleeding from the anus. You might notice blood on your underwear or toilet paper –Constipation or diarrhea –Blood in the stool (pitch black or red streaks)

12. (familial adenomatous polyposis syndrome) (hereditary non-polyposis colorectal cancer syn.)

13. Colorectal Cancer Screening Fecal occult blood testing (FOBT) Flexible sigmoidoscopy Barium enema Colonoscopy CT colography Average risk

14. Colorectal Cancer Screening: Double-Contrast Barium Enema Colon Cancer

17. CT Colography/Virtual Colonoscopy Pickhardt et al. N Engl J Med 2003;349:2191-2200 Solitary 16-mm Pedunculated Cecal Polyp in a 55-Year-Old Man at Average Risk for Colorectal Neoplasia

18. Endoscopic Screening Rates are Low MMWR Morb Mortal Wkly Rep 2003 Mar 14;52(10):193-6. CDC Behavioral Risk Factor Surveillance System

19. Racial Disparities in Colon Cancer Colorectal cancer incidence per 100,000 in SC Lloyd et al. Cancer 2007;109(2):378-385

20. Racial Disparities in Colon Cancer Colorectal cancer mortality per 100,000 in SC Lloyd et al. Cancer 2007;109(2):378-385

21. Colon Cancer Screening: Outcomes FOBT Testing –3 prospective randomized clinical trials have demonstrated significant reductions in colon cancer mortality ranging from 15-33% Flexible Sigmoidoscopy –2 case-controlled studies associated with a 60- 80% reduction in colon cancer mortality for lesions within reach of the sigmoidoscope Levin et al. Gastroenterology 2008;134:1570.

22. Colon Cancer Screening: Outcomes Colonoscopy –Case-control study of 32,702 VA patients –50% reduction in colon cancer mortality associated with colonoscopy in symptomatic patients Muller et al, Ann Intern Med 1995;123:904

23. How can you prevent colon polyps? Eat more fruits and vegetables and less fatty foods Don’t smoke Avoid alcohol Exercise most days of the week Lose weight if you are overweight Calcium may lower your risk –Milk, cheese, yogurt, broccoli

24. Colorectal Cancer Screening  Fecal occult blood test (FOBT) every year, or  Flexible sigmoidoscopy every 5 years, or  A fecal occult blood test every year plus flexible sigmoidoscopy every 5 years (recommended by the American Cancer Society), or  Double-contrast barium enema every 5 to 10 years, or  Colonoscopy every 10 years (recommended by the American College of Gastroenterology).

26. Pancreas Cancer Background More than 32,000 cases per year in the US and almost all are expected to die Second only to colon cancer in GI related cancer mortality 20% have resectable disease at presentation Median survival is 8 to 12 months for locally advanced and 3 to 6 months for metastatic disease

27. Risk Factors for Pancreas Cancer Chronic pancreatitis/inflammation Diabetes mellitus Smoking Family history Obesity

28. History Dark urine, pale stools, and yellow skin and eyes from jaundicejaundice Pain in the upper part of your belly Pain in the middle part of your back that doesn’t go away when you shift your position Nausea and vomiting Stools that float in the toilet

29. History Presentation depends on location Weight loss – anorexia, diarrhea, early satiety Jaundice – scleral icterus, acholic stools, dark urine, pruritus New onset diabetes, blood clots, depression, pancreatitis

30. Staging Staging is a careful attempt to find out the following: –The size of the tumor in the pancreas –Whether the tumor has invaded nearby tissues –Whether the cancer has spread, and if so, to what parts of the body

31. TNM Classification T1T2 T4 N1 M1 T3

32. CT scan An x-ray machine linked to a computer takes a series of detailed pictures of the pancreas and surrounding organs Used to evaluate ductal dilation, mass lesion within the pancreas and spread

33. MRI A large machine uses a strong magnet and a computer to make an image of your pancreas and organs Requires: –Compliant patient –No metal

35. Endoscopic Ultrasound A thin, lighted tube (endoscope) is passed into the small intestine Sound waves make a pattern of echoes that create a picture of the pancreas Needle biopsy can remove a sample of tissue

36. 7.5 / 12 MHz. 7.5 MHz. UC-30P UM-130

37. EUS-FNA – Pancreatic Mass

38. EUS-FNA: Pancreatic Adenocarcinoma

39. ERCP A thin, lighted tube (endoscope) is passed into the small intestine A smaller tube is then inserted into the bile and pancreatic duct and dye is injected Therapy can be performed such as brush cytology or stent placement

40. ERCP for Diagnosis

41. Treatment Surgical removal if possible (resection of the pancreatic head is termed a Whipple procedure) If locally advanced, radiation and chemo therapy If spread (metastasized), chemotherapy

42. Prevention If you smoke, stop smoking Eat a diet high in fruits, vegetables and whole grains Exercise regularly Possible screening in high risk families (more than 2 first degree relatives)