1. Colorectal Cancer Screening 101
Patient Education
December 2014

2. Colon Anatomy, Polys, Colorectal Cancer (CRC) & Colorectal Cancer Screening Exams

3. What is the colon? Also called the large intestine or large bowel
Part of the digestive system
About five (5) feet long
Absorbs water and nutrients from food you eat
Removes waste (feces) from your body
Explain what the colon is to the patient
“The colon, also called the large intestine or large bowel, is a part of the digestive system. It is about five feet long and it’s purpose is to absorb nutrients and water from the food we eat and also remove waste from our bodies.”

4. Colon Anatomy Anus Rectum Sigmoid Descending Transverse Ascending
Cecum
Explain the anatomy of the colon to the patient
“The colon has several parts. It begins at the cecum, which connects to the small intestine. The next part, the ascending colon, travels up the right side of the abdomen. Next, there is the transverse colon which runs across the abdomen. Then, the descending colon travels down the left side of the abdomen. Finally you have the sigmoid colon which is the short ‘s’ shaped lower portion that leads to the rectum and then the anus.”
“Polyps can occur throughout the entire colon and rectum but most often they are found in the descending colon, sigmoid colon or rectum.”
Cecum

5. Colon Polyps
Noncancerous or cancerous growths in the lining of the colon
Vary in size
May have a stalk or may be flat
Common in adults
Unknown what causes them
Lifestyle factors: High-fat, low-fiber diet, obesity, sedentary lifestyle, etc.
Genetic factors
Polyps must be removed to determine if the polyp is cancerous or noncancerous
Biggest risk of developing polyps
is being over 50 years
Describe polyps to the patient
“Polyps are growths in the lining of the colon. They can be cancerous or noncancerous and vary in size and the way they look. It is not clearly known what causes polyps but lifestyle factors and family history may play a part. Polyps must be removed to determine if they are cancerous. The biggest risk factor to getting polyps is being over 50 years old.”

6. Common Terms re: Polyps
Hyperplastic
Common, abnormal noncancerous growths
Do not cause any symptoms
Adenomatous
Pre-cancerous polyps
May cause symptoms
Sessile
Polyps that grow in a flat, broad-based structure
Serrated
Polyps that have a saw tooth like appearance
Dysplasia
Describes how much the polyp looks like cancer
Low-grade: mild or moderate; does not look much like cancer
High-grade: severe; has characteristics of cancer
Explain the different types of polyps to patients
“There are many types of polyps and all should be removed during the colonoscopy procedure, which we will discuss in detail later. You may see these words in your colonoscopy or pathology reports after you have you screening exam. Hyperplastic polyps are not of concern really and do not cause symptoms. Adenomatous polyps, also called adenomas, are pre-cancerous growths and may cause symptoms. Sessile polyps have a flat, broad-based structure while serrated polyps have a saw tooth appearance. Dysplasia describes how much your polyp looks like cancer. You may see low-grade or high-grade dysplasia in the report which describes how much your polyp looks like cancer.”

7. Adenomatous Polyps
Have various growth patterns that help decide when you will need your next colonoscopy
Tubular – small, lower risk of cancer developing
Tubulovillous – some tubular and some villous qualities
Villous – large, higher risk of cancer developing
Dysplasia
How much your polyp looks like cancer
All adenomas are dysplastic
High-grade dysplasia, higher risk of cancer developing
“The size of your adenoma matters. It helps determine your risk of developing cancer as well as tells you when you need to have your next colonoscopy. All adenomas have characteristics of cancer but some look more like cancer than others. However, all adenomas must be removed so they do not turn into cancer.”
Normal Colon
Adenoma
Colon Cancer

8. What is Colorectal Cancer (CRC)?
Second leading cause of death because of cancer in the U.S.
Third most common cancer diagnosed in men and women in the U.S.
It is expected that over 50,000 people will die from colorectal cancer in the U.S. in 2014
The risk of developing colorectal cancer in your lifetime is about 1 in every 20 people
Explain colorectal cancer to the patient
“Colorectal cancer is the 2nd leading cause of cancer death in the US and the 3rd most common diagnosed in both men and women. It’s expected that over 50,000 people will die from colorectal cancer this year in the US. Your lifetime risk of developing colorectal cancer is 1 out of every 20 people. This is why colorectal cancer screening is so very important.”
American Cancer Society. Colon/Rectum Cancer: Detailed Guide (revised 1/31/2014).

9. CRC in Colorado
About 1,720 people will get colorectal cancer in Colorado in 2014
About 44 out of 100,000 men will get CRC
About 34 out of 100,000 women will get CRC
About 670 people will die from colorectal cancer in Colorado in 2014
About 17 men out of 100,000 will die
from CRC
About 12 women out of 100,000 will die
“Specifically here in Colorado about 1700 people will get CRC this year and 670 people will die from it.”
American Cancer Society, Cancer Facts & Figures 2014

10. CRC Risk Factors Risks you cannot change Risks you can change Age
Family history
Personal history
Race
Genetics
Risks you can change
Diet high in red meat/processed
meat consumption
Sedentary lifestyle
Obesity
Cigarette smoking
Alcohol consumption
Describe risks, you can and cannot control, to the patient
“There are several things you can do to lower your chances of getting CRC but there are also things that are out of your control. For instance, you can’t change how old you are, what your sex is or your race. You also can’t change if you’ve had adenomas or CRC before or if someone in your family has. But you can watch your diet, be active and get regular exercise, lose weight, don’t smoke or don’t drink alcohol.”
American Cancer Society. Colon/Rectum Cancer: Detailed Guide (revised 1/31/2014).

11. Can you prevent CRC?
Screening is the best way to prevent colorectal cancer
Screening looks for cancer or pre-cancerous polyps in people who do not have symptoms
If polyps are found they can be removed before they turn into cancer, preventing colorectal cancer altogether
Explain why CRC screening is important
“Screening is the best way to prevent CRC. If polyps are found, they can be removed before they turn into cancer.”
American Cancer Society. Colon/Rectum Cancer: Detailed Guide (revised 1/31/2014).

13. Choosing the Right CRC Screening Test for You
Colonoscopy
Flex Sig
Virtual Colonoscopy
PillCam
Stool Testing

14. CRC Screening Methods Detect Polyps and Cancer
Flexible Sigmoidoscopy
Colonoscopy
Computed Tomographic Colonography (virtual colonoscopy)
Detect Polyps/Abnormalities
Video capsule (PillCam)
Detect Cancer
High sensitivity FOBT/FIT
Stool/Fecal DNA test
Tailor this slide to your clinic specifically. What screening methods are available at your clinic?
“There are so many ways to get screened for colorectal cancer. There are tests that specifically look for polyps and tests that specifically look for cancer.”
“At this clinic, the options for testing are ***list the screening methods available at your clinic and only go over those options with the patient***

15. Bowel Preparation Many CRC screening methods require bowel preparation
Flexible Sigmoidoscopy
Colonoscopy
Computed Tomographic Colonography
Video Capsule
Necessary in order to be able to see the colon and find abnormalities and/or polyps
Requires diet and/or fluid restrictions but will vary according to your doctor’s instructions
Explain the bowel preparation process to the patient
Tailor your discussion with the patient to the bowel prep your provider(s) uses
“With most screening methods the bowel preparation is the worst part of the CRC screening process but extremely important. The flexible sigmoidoscopy, colonoscopy, virtual colonoscopy and video capsule require a bowel preparation. This is necessary in order for the doctor to clearly see the colon and find any abnormalities or polyps. It does require diet and fluid restrictions and we will go over the specific bowel prep process now.”
***explain the bowel preparation process specific to your provider instructions***

17. What is a flexible sigmoidoscopy (FSG)?
An internal exam of the lower portion of the colon, from the rectum to the sigmoid colon (sometimes through the descending colon noted by the green line) using an instrument called a sigmoidoscope
Sedation may or may not be used. Ask your doctor.
Describe the flex sig only if this method is done at your clinic
“The flexible sigmoidoscopy is an internal exam that only exams the lower portion of the colon using a sigmoidoscope. This scope is a thin, flexible tube with a small camera used to see inside your colon. Sedation is generally not used but confirm this with your doctor. This exam takes about minutes. You will lie on your side with your knees drawn up toward your chest. The scope will be inserted through your anus and gently advanced through the lower portion of your colon. Air will also be inserted through the scope so the doctor will have a better view of your colon. Tissue samples or polyps may be removed during the procedure. You may feel pressure and slight cramping during the exam. Although risks from this procedure are rare, following the exam if you experience abdominal pain, fever, chills or rectal bleeding contact your navigator or doctor immediately or go to the nearest emergency room.”
“The flex sig is not sufficient too detect polyps or cancer in the upper portions of the colon and therefore you may be advised to complete a colonoscopy.”
Descending colon

18. What to expect: FSG The procedure takes about 10 – 20 minutes
You will lie on your side with knees drawn up toward your chest
The sigmoidoscope is inserted through the anus and gently advanced
Air will be inserted through the scope to provide a better view of the colon
Careful examination is done during the insertion and withdrawal of the scope

19. FSG Procedure
Tissue samples may be taken or polyps may be removed during the procedure
You may feel pressure and slight cramping during the exam
If you experience abdominal pain, fever and chills or rectal bleeding following the exam contact your navigator or doctor immediately
FSG is not sufficient to detect polyps or cancer in the remaining portion of the colon and you may be advised to complete a colonoscopy

20. What is a colonoscopy?
An internal exam of the entire length of the colon using an instrument called a colonoscope
Describe the colonoscopy procedure to the patient
“The colonoscopy is an internal exam that views the entire colon using a colonoscope. The colonoscope is a long, thin, flexible tube with a small camera attached that views the colon as the tube is inserted into and withdrawn from the colon. The procedure takes between 30 and 60 minutes. You will be sedated to make the exam more comfortable. You will lie on your side with your knees drawn up toward your chest. The colonoscope will be inserted through your anus and gently advanced through your colon. Air will be inserted through the scope to provide a better view of your colon for the doctor. Suction may also be used to remove any secretions also allowing for a better view of the colon. Tissue samples or polyps may be taken with tiny forceps inserted through the scope.”
“Because you will be sedated during the colonoscopy, you will need to have someone drive you to and from your appointment. Also, something happening during this procedure is very rare, we must talk about some of the risks that could happen. During the procedure the colon or rectum wall could tear. This is called a perforation. You could experience bleeding from a site where they removed a tissue sample or a polyp. Again, risks are rare when having a colonoscopy but it is important to understand that if you feel intense pain, have bleeding, a fever or some other unexplained symptom following the procedure contact your doctor or patient navigator or go to the nearest emergency room.”

21. What to expect: Colonoscopy
The procedure takes about 30 – 60 minutes
You will lie on your side with knees drawn up toward your chest
Sedation is provided to the patient
After being given the sedative, the colonoscope is inserted through the anus and gently advanced

22. The Colonoscopy
Air will be inserted through the scope to provide a better view of the colon
Suction may be used to remove any secretions in the colon
Better views are seen during withdrawal of the colonoscope so a more careful examination is done during withdrawal of the scope
Tissue samples and/or polyps may be taken with tiny forceps inserted through the scope

23. The Colonoscopy
You must have someone bring you to the exam. You will not be able to drive because sedation is used
Risk of complications is low but could include
Tear in the colon/rectum wall (perforation)
Bleeding from the site where a tissue sample or polyp was removed from the colon/rectum wall
Adverse event related to sedation (e.g. breathing problems)

25. What is a computed tomographic (CT) colonography?
Procedure that uses low dose radiation CT scanning to get a view of the inside of the colon
Also referred to as a virtual colonoscopy
Describe the CT colonography
“CT colonography is an exam that uses low dose radiation CT scanning to get a view of the inside of your colon. It takes about 15 minutes. You will lay on your back on the CT exam table. A small tube will be inserted into your rectum to allow air to be pumped into the colon to help get rid of folds and wrinkles in the colon that could hide polyps. You could have feelings of fullness or a need to pass gas as a result. Pain and discomfort are uncommon however. The table will move through the scanner to get images. The risks with this procedure are low but include exposure to radiation and a risk of the colon being injured or torn due to air being inflated. Also, depending on the findings of your CT colonography, you may be asked to have a follow up colonoscopy.”
Image from a CT colonography

26. What to expect: CT Colonograpy?
The procedure takes about 15 minutes
You will be positioned on the CT exam table lying on your back
A small tube will be inserted into the rectum to allow air to be pumped into the colon to help eliminate folds/wrinkles that may hide polyps
The table will move through the scanner to obtain the images

27. What to expect: CT Colonograpy?
You may experience a feeling of fullness or a need to pass gas
Pain and discomfort are uncommon
Risk of complications is low but may include
Inflation of the colon could injure or perforate the bowel
Exposure to radiation
You may be asked to follow up with a colonoscopy

29. What is capsule endoscopy?
A noninvasive procedure that uses a wireless camera, small enough to fit inside a vitamin-sized disposable capsule, that you swallow
Allows physician to view the entire colon to detect polyps without sedation or radiation
Describe the PillCam
“This is a newer and less invasive exam. You swallow a vitamin-sized, disposable pill that allows the doctor to see the entire colon and detect the presence of polyps or abnormalities without the use of sedation or radiation like some of the other screening methods. You will be given a belt to place around you waist that has sensors and a data recorder which allows the capsule to wirelessly show pictures of your colon. You will have to complete a bowel prep but you can go about your day as scheduled once you swallow the pill. About 10 hours later, you will return the belt to your doctor’s office and they will follow up with you regarding your results. You may be asked to complete a follow up colonoscopy. The pill will usually pass with a bowel movement within 24 hours and it does not have to be retrieved. You should not experience any discomfort during this process.”

30. What to expect: Capsule Endoscopy
A belt with sensors and a data recorder will be placed around your waist
Allows the capsule to wirelessly transmit images of your colon
You will swallow the capsule with a glass of water
You will drink about 2 cups of bowel prep solution shortly after
You are free to go about your regularly scheduled day

31. What to expect: Capsule Endoscopy
Approximately 10 hours later you will return the belt to your doctor’s office
The capsule usually naturally passes with a bowel movement within 24 hours
The capsule is disposable and does not need to be retrieved
There should be no discomfort when swallowing the capsule, it traveling through your colon or eliminating it during a bowel movement
You may be asked to follow up with a colonoscopy

32. What are Stool-based Screening Tests?
Noninvasive, take home tests that look for signs of colorectal cancer in stool (feces)
You collect stool specimens in the comfort of your home
A positive result will require follow up with a colonoscopy
Describe only the methods used at your clinic
“There are three types of stool-based screening tests for colorectal cancer screening. They are all take home tests that look for signs of CRC in your feces. You have to collect the stool sample at home. And if you have a positive result you have to have a colonoscopy. “

33. What to expect: Fecal Occult Blood Test (FOBT)?
Looks for hidden (occult) blood in the stool
Cannot determine if blood is from the colon or other parts of the digestive tract
Not specific to human hemoglobin
Must collect an actual stool sample
Requires multiple samples from different bowel movements
Involves dietary restrictions
Positive test requires a colonoscopy
Must be done annually to provide adequate screening
Explain the specifics of the FOBT your clinic uses

34. What to expect: Fecal Immunochemical Test (FIT)?
Looks for hemoglobin protein found in red blood cells
Specific for human hemoglobin
Less likely to react to bleeding from upper digestive tract
No dietary restrictions
No actual stool collected
Brush stool surface or, if loose stool, stir the water around the stool
Requires multiple samples from different bowel movements
Positive test requires a colonoscopy
Must be completed annually to provide adequate screening
Explain the specifics of the FIT used in your clinic

35. What to expect: DNA Stool Test
Looks for abnormal sections of DNA from cancer or polyps
Tests for blood in the stool
Requires no dietary restrictions and one bowel movement
Must handle and collect stool sample according to the manufacturer’s instructions
Positive test requires a colonoscopy
Interval testing is every 3 years
Describe DNA stool test

36. How Do You Pay For Screening?
Preventive services, to include CRC screening, are covered by Medicaid, Medicare and private insurance
Check with your insurance to see if a co-payment is required if:
A polyp is removed during a colonoscopy
You have a colonoscopy following a positive stool test
You have a colonoscopy following a FSG, virtual colonoscopy or PillCam
CCSP will cover the cost of endoscopic screening (FSG and colonoscopy) for individuals uninsured or underinsured who meet further criteria through June 30, 2015.
Encourage patients to contact their insurance provider to determine if they will have co-payments if a polyp is removed during the colonoscopy.
“Preventive services are now covered by health insurance since the start of the Affordable Care Act. This means that CRC screening is covered by Medicaid, Medicare and private insurance. However, it is extremely important that you contact your insurance to see if you will be charged a co-pay if a polyp is removed during your colonoscopy, if you have a colonoscopy because you have a positive stool test or if you need a colonoscopy because you had a flex sig, virtual colonoscopy or the PillCam and had a suspicious exam that requires further screening with a colonoscopy. “

37. Questions?
“So what do you think? Are you ready to schedule your screening exam? Do you have any questions or concerns?”