1. Colorectal Cancer Proposal of a Screening Program for Developing Countries with Emphasis on Costs

2. Presentator: Alessandro L. Loiola, MD Atendant of Coloproctology at the Specialties´ Regional Referral Center, Vitoria / ES - Brazil Developer of Health Contents for Boasaude.com.br E-mail: alpl@escelsanet.com.br

3. Objectives Create a consciousness of the problem for third-world countries Access some relevant features in the diagnosis of Colorretal Cancer Sugest steps for a screening program

4. Recommended articles BOND JH. Screning for colorectal cancer. Hosp Prac, Jan 15:59-74, 1997. SELBY JV et alii. Effect of fecal occult blood testing on mortality from colorectal cancer. Am Col Phys, 118:1-6, 1993.

5. Recommended websites: Colorectal Cancer Homepage at http://home.swipnet.se/crc/ http://home.swipnet.se/crc/ Colorectal Forum at www.colorectal-forum.org/ www.colorectal-forum.org/ NCI CancerNet Database at www.meb.uni-bonn.de/cancernet/ www.meb.uni-bonn.de/cancernet/

6. Creating a Consciouness for screening: did you know that... Colorectal cancer kills more than AIDS and Diabetes ? In some countries (Brazil included) colorectal cancer causes more deaths per year than ovarian, uterine, prostate or even lung cancer ?

7. Relevant Features of Colorectal Cancer  Special Risk Factors  Decade of ocurrance  Clinical manifestations  Pathology

8. Relevant Features of Colorectal Cancer: 1 - Special risk factors Diet habits Inflamatory bowel diseases Familial adenomatous polyposis syndrome Strong incidence of cancer in the family

9. Relevant Features of Colorectal Cancer: 2 - Decade of occurrance

10. Relevant Features of Colorectal Cancer: 3 - Clinical manifestations Low intestinal bleeding Altered bowel habits Unexplained weight loss

11. Relevant Features of Colorectal Cancer: 4 - Pathology 90% of Colorectal malignant tumors are Carcinomas 60-70% of the lesions are located in the last 1/3 part of large bowel 30% of all lesions can be reached by digital exam only

12. Steps of the Colorectal Cancer Screening Program

13. Colorectal Cancer Screening Program - Step 1 Faecal-occult-blood test (FOBT) in people after age 50 and/or with known risk factors and/or physical evidences suggesting colorretal cancer

14. Colorectal Cancer Screening Program - Step 1a Patients with negative FOBT, without evidences at physical examination and/or without risk factors: repeat FOBT every year

15. Colorectal Cancer Screening Program - Step 1b Patients with negative FOBT but with sustained clinical suspicion and/or with risk factors: go to Step 2

16. Colorectal Cancer Screening Program - Step 1c Patients with positive FOBT: go to Step 2 (sigmoidoscopy)

17. Colorectal Cancer Screening Program - Step 2 Sigmoidoscopy (flexible if possible)

18. Colorectal Cancer Screening Program Step 2a - Negative Sigmoidoscopy Patients without clinical suspicion and any risk factor: follow up with FOBT every year, one sigmoidoscopy each 3-5 years and one colonoscopy each 10 years.

19. Colorectal Cancer Screening Program Step 2b - Negative Sigmoidoscopy Patients with sustained clinical suspicion and/or any risk factor: consider Barium enema. One can choose promptly performing a Colonoscopy (Step 3) If all negative: follow up as Step 2a.

20. Colorectal Cancer Screening Program Step 2c - Positive Sigmoidoscopy Go to Step 3 (Colonoscopy), after collecting samples.

21. Colorectal Cancer Screening Program Step 3 - Colonoscopy To further exam the extention of a particular lesion and to identify more lesions Patients with negative colonoscopy: follow up as Step 2a.

22. Colorectal Cancer Screening Program Hole of Barium Enema Detect other lesions Can be replace (with restrictions) colonoscopy where this exame is not obtainable