1. DR Jameel Tariq Miro

2.  Lifetime incidence 5%  90% of cases occur after age 50  One-third of patients with colorectal cancer die from the disease  Only approximately 50 % of patients are screened for colorectal cancer  Colorectal cancer is a preventable disease

7.  Two-thirds of polyps are adenomas (dysplasia)  Adenoma prevalence 25% at age 50 and 50% by age 70  Risk of cancer increases with polyp size, number, and histology  The polyp examined is representative of the individual’s propensity to form polyps and cancer

8.  Average risk – begin at age 50  Family risk factors  Primary degree relative doubles risk  Begin screening at age 40 or 10 years earlier than diagnosis of relative  Colon cancer syndromes (5-10% of colon CA)  Hereditary non-polyposis colorectal cancer (HNPCC)* ▪ Colonoscopy every 1-2 years beginning at age 20-25  Familial Adenomatous Polyposis (FAP)

9. GI Consortium  Annual FOBT  Flex sig every 5 yrs  Combination of above  DCBE every 5 years  Colonoscopy every 10 years (preferred option – ACG) American Cancer Society  Recommendations now identical to the GI consortium

11.  Improved detection of hemoglobin as compared to guaic based FOBT tests  Immunochemical FOBT testing uses antibodies to human globin expressed in colorectal bleeding.  94 % sensitivity for cancers and 67 % for advanced adenomas with approximate 90% sensitivity in high risk individuals  Has not yet been tested in asymptomatic average risk patients

15.  20-30 % of proximal advanced adenomas are missed with sigmoidoscopy  Sigmoidoscopy particularly poor in women missing 65 % of advanced polyps as opposed to colonoscopy (NEJM 2005)  Would you ever mammogram one breast ?

17.  Two large cohort studies (Winawer, et al, NEJM 1993 and Citarda, et al Gut 2001) have demonstrated significant reductions in colon cancer incidence if colonoscopy with polypectomy are performed  FOBT and sigmoidoscopy that lead to colonoscopy with polypectomy have been shown to significantly reduce colorectal cancer mortality

20.  Combines the most complete examination of the colon with the direct therapy of removing dysplastic polyps  The role of polyps as a precursor to cancer provides the rationale for endoscopic screening illustrated by the benefit of adenoma removal by polypectomy at the time of colonoscopy

21.  CT colonography/Virtual colonoscopy  Fecal DNA analysis  Capsule endoscopy

22.  Computed tomography procedure that uses helical, multiple thin section images along with specialized computer programming to provide three-dimensional and two- dimensional images of the colon

26.  Colorectal cancer is a disease in which many DNA mutations associated with carcinogenesis have been characterized  Stool DNA is stable, shed continuously and through amplification tests can be detected in minute amounts  Most studied stool test for DNA mutations is a multicomponent test that targets point mutations at 15 “hot spots” on K-ras, APC, p53, Bat-26, and long DNA

27.  Alquist, et al. Gastroenterology 2000 studied patients with colon cancers, large adenomas, and normal colons  Sensitivity of 91% for colon cancer, 82% for large adenomas and a specificity of 93%  Imperiale, et al. NEJM 2004 studied patients in a screening population  Poor sensitivity for invasive cancers (52%) and advanced polyps (15%)

28. M2A captures images at 2 fps More than 50,000 images are taken Field of view: 140º Min. detectable object: Less than 0.1 mm

29. Teeth Epiglottis Small Intestine Ileocecal valve Wall of right colon Multiple telangiectasia on a gastric fold

30. FOBT, barium enema, sigmoidoscopy  All recommended but all with significant weaknesses  Will iFOBT make a come back ?  Screening Colonoscopy  Standard of care – Diagnosis along with therapy  CT colonography  Here today – Further verification using one technology in multicenter study and more importantly how CT colongraphy will work with standard colonoscopy  Fecal DNA analysis and Capsule Endoscopy  Here tomorrow – Further refinement and technical improvements needed

31. THANK YOU JTMIRO@UQU.EDU.SA