1. What Everyone Should Know About Colon Cancer Prevention Maria T. Abreu, MD Chief, Division of Gastroenterology Professor of Medicine

2. Outline  Colon Cancer Facts  Getting Tested  Preventive Strategies

3. What is colon cancer? Begins in the colon or rectum ( colorectal cancer ) Usually develops from pre-cancerous changes or growths in the lining of these organs These growths are called polyps Begins in the colon or rectum ( colorectal cancer ) Usually develops from pre-cancerous changes or growths in the lining of these organs These growths are called polyps

4. Colon Polyp to Cancer takes about 10-15 years

5. Types of Colon Cancer

6. Why talk about it? 2 nd leading cause of cancer deaths 3 rd most common cancer in men and women Florida: 10,200 new cases 3,900 deaths Nationwide:147,500 new cases 57,100 deaths 2 nd leading cause of cancer deaths 3 rd most common cancer in men and women Florida: 10,200 new cases 3,900 deaths Nationwide:147,500 new cases 57,100 deaths 2003 Cancer Death Estimates One of the most preventable cancers! Data represents 2003 colorectal cancer estimates

7. Why don’t we talk about it? Uncomfortable topic Unaware of risk factors Avoidance of doctor check-ups Fear of getting tested Perceived as “man’s disease” No symptoms, no problem Uncomfortable topic Unaware of risk factors Avoidance of doctor check-ups Fear of getting tested Perceived as “man’s disease” No symptoms, no problem Embarrassment or fear worth losing your life?

8. Women’s Issues: Women are…  Diagnosed with colon cancer equally as men  Less likely to get screening than men  Prefer female endoscopists (>50%)

9. Risk Factors Nearly 90% of colon cancer patients are over the age of 50. Other risk factors include: family or personal history of colon cancer or polyps chronic inflammatory bowel disease hereditary colorectal syndromes use of cigarettes and other tobacco products high-fat/low fiber diet physical inactivity Nearly 90% of colon cancer patients are over the age of 50. Other risk factors include: family or personal history of colon cancer or polyps chronic inflammatory bowel disease hereditary colorectal syndromes use of cigarettes and other tobacco products high-fat/low fiber diet physical inactivity Risk increases with age

10. Symptoms Signs and symptoms typically occur only in advanced colon cancer. Symptoms may include: Change in bowel habits lasting more than a few days Bleeding from the rectum Blood in the stool Cramping or gnawing stomach pains Weakness and fatigue Jaundice (yellow-green color of the skin & white part of the eye) Signs and symptoms typically occur only in advanced colon cancer. Symptoms may include: Change in bowel habits lasting more than a few days Bleeding from the rectum Blood in the stool Cramping or gnawing stomach pains Weakness and fatigue Jaundice (yellow-green color of the skin & white part of the eye) Early colon cancer usually has no symptoms

11. Why get tested? Testing can help detect pre-cancerous polyps Removing the polyp early may prevent it from becoming cancer Testing can help detect pre-cancerous polyps Removing the polyp early may prevent it from becoming cancer Get the test. Get the polyp. Get the cure. Since some colon cancers can not be prevented, finding them early is the best way to improve the chance of a cure. 90% survival rate if caught early

12. Benefits of Screening Five-Year Relative Survival Rates for Colorectal Cancer by Stage at Diagnosis, 1995-2000

13. Who should get tested? American Cancer Society recommends that all average risk women and men begin regular colon cancer early detection testing at age 50.

14. Colon Cancer Tests Fecal occult blood testing (FOBT) Barium enema Flexible sigmoidoscopy Colonoscopy Virtual Colonoscopy Get the test. Get the polyp. Get the cure.

15. Colonoscopy

16. Colonoscopy Advantages  Detects >90% polyps and cancer  Provides diagnosis and therapy  Medicare covers average-risk Limitations  Risks  Availability  Cost  Compliance Get the polyp. Get the cure.

17. Polypectomy Technique

18. Colon Cancer Testing Is EFFECTIVE!!

19. The flat polyp  Techniques to improve detection –Narrow-band imaging –Chromoendoscopy –Endocytoscopy Soitenko et al. JAMA March 2008

20. Narrow Band Imaging

21. Left sided ulcerative colitis

22. Ulcerative colitis with extensive pseudopolyps

23. Testing rates remain far too low Are people getting tested?  Fewer than half of Americans over age 50 report having had a recent colorectal cancer screening test  Because of low testing rates, only 39% of colorectal cancers are detected at the earliest, most treatable stage

24. Is embarrassment or fear worth losing your life over? Why aren’t people getting tested? Uncomfortable topic Unaware of risk factors Not aware that colon cancer is a health threat Fear of getting tested Perceived as “man’s disease” No symptoms Some doctors don’t consistently offer to patients

25. Ethnic/Racial differences  Percentage who have never had screening colonoscopy –Hispanics - 67% –Black - 55.8% –White, non-Hispanic – 47% –Never married 60% –Education less than high school diploma 58% vs 52% completed high school vs 46% with some college education 2005 data, AHRQ

26. Don’t wait for your doctor Why aren’t people getting tested? The most common reason people give for not being tested is: “My doctor never talked to me about it !”

27. How is your state doing? UM

28. Colon Cancer Tests New Techniques Future Alternatives for Colon Cancer Screening

29. Virtual Colonoscopy

30.  Spiral CT to generate 3D images  Cleaning of bowel, distension with air  Non invasive, no complications  Not endorsed for CRC screening

31. Virtual Colonoscopy

32. Limitations Virtual Colonoscopy Limitations Virtual Colonoscopy  Variable results  No screening studies  No longitudinal studies  Cost  Does not allow for therapy

33. Stool DNA  Now recommended by ACS and USMSTF for average risk individuals  Multi-target DNA stool assay required to achieve adequate sensitivity and detect the various gene mutations K-ras APC P53 BAT-26 21 separate point mutations DIA

34. Video Capsule Colonoscopy  In the process of development –Battery life  No clinical data available  Anticipate to see clinical trials

35. Colon Cancer Tests Average Risk

36. Average Risk Individuals No Symptoms Age  50 No risk factors

37. Current Recommendations Average Risk *Preferred strategy by ACG TestInterval (years) FOBTYearly SigmoidoscopyEvery 5 FOBT + SigmoidoscopyYearly, every 5 ColonoscopyEvery 10* Barium enemaEvery 5

38. Approach to Colon Cancer Testing Asymptomatic Men and Women Age < 50 yr No family Hx No Screening HNPCC or FAP Genetic Counseling 1 first-degree  60 yrs Average-risk screening, starting age 40 YES family Hx 2 or more first-degree or 1 first-degree < 60 yrs Colonoscopy every 5 yrs, starting age 40 Age  50 yr NO family Hx Average Screening

39. Reduce Your Risk Reduce Your Risk Choices for good health Follow testing guidelines Know your family history Get regular exercise Do not smoke or use other tobacco products Avoid excessive alcohol consumption Follow testing guidelines Know your family history Get regular exercise Do not smoke or use other tobacco products Avoid excessive alcohol consumption

40. Reduce Your Risk Reduce Your Risk Choices for good health Eat 5 or more servings of fruits & vegetables a day Choose whole grain foods Limit your intake of red meat Maintain a healthy weight Eat 5 or more servings of fruits & vegetables a day Choose whole grain foods Limit your intake of red meat Maintain a healthy weight

41. Prevent Colon Cancer Prevent Colon Cancer Smart steps Talk to your doctor Get tested starting at age 50 Encourage your friends, family, and co-workers to get tested Maintain a healthy lifestyle Talk to your doctor Get tested starting at age 50 Encourage your friends, family, and co-workers to get tested Maintain a healthy lifestyle

42. It takes a village

46. Going to work is easy…they are all so good looking!

47. A great team

48. Call us (305) 243-UMGI 8644