New Trends in Colorectal Cancer Screening & Surveillance
This content discusses the importance of colorectal cancer screening and surveillance, outlining updated guidelines and recommendations from various medical organizations. It covers key statistics, screening methods, incidence rates based on heritage/race, and more. The focus is on advancing strategies for early detection and prevention of colorectal cancer.
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Colorectal Cancer Screening & Surveillance: Anything New? Timothy C. Hoops, M.D.
Case A 53-year-old male presents to the office with a history of greater than 15 years of esophageal reflux symptoms including heartburn, regurgitation and episodes of hoarseness. He has been treated with omeprazole 20 mg once daily but has breakthrough symptoms at times for which he takes a 2nddose. He denies dysphagia. He has no family history of colon cancer His physical exam is unremarkable. What might you recommend?
Screening for Colon Cancer ACS estimates that in the US in 2014: 136,830 new CRC diagnoses 50,310 CRC deaths Lifetime risk for CRC: Men 5% Women 4.7% 3rd leading cause of death in both men and women
Screening for Colon Cancer Ideal screening study Prevalent disease Effective High sensitivity and specificity Safe Available Convenient Cheap
Incidence/Mortality - Heritage/Race Siegel, CA Cancer J Clin 2014;64:104
Screening Guidelines USPSTF 2008 Screening for CRC beginning age 50 to age 75 FOBT Sigmoidoscopy Colonoscopy Insufficient evidence for stool DNA & CT colonography Recommend screening in 75-85 y/o based on individual considerations Recommend against screening > age 85 Ann Intern Med. 2008; 149: 627
Screening Guidelines ACS, US Multisociety Task force and American College of Radiology 2008 Tests that detect adenomatous polyps and cancer (detect and prevent cancer) Flexible Sigmoidoscopy every 5 years, or Colonoscopy every 10 years, or Double Contrast Barium Enema every 5 years, or CT Colonography every 5 years Gastroenterology 2008; 134:1570
Screening Guidelines ACS, US Multisociety Task force and American College of Radiology 2008 Tests that primarily detect cancer Annual gFOBT with high test sensitivity for cancer, or Annual FIT with high test sensitivity for cancer, or sDNA, with high sensitivity for cancer, interval uncertain Gastroenterology 2008; 134:1570
Screening Guidelines American College of Gastroenterology Cancer Prevention tests offered first Beginning age 50; age 45 in AA Colonoscopy every 10 years Alternatives: Sigmoidoscopy CT colonography Family Hx CRC > age 60 as per average risk < age 60 start age 40 and Q 5 years Rex; Am J Gastroenterol 2009; 104:739
Screening Guidelines Cancer Detection tests for those declining prevention tests Fecal immunochemical test annual Alternatives Hemoccult Sensa Fecal DNA Rex; Am J Gastroenterol 2009; 104:739
Screening In 1980 s and 1990 s, most screening was FOBT and sigmoidoscopy Since about 2000, most CRC screening in the US has been with colonoscopy No published randomized controlled trial of colonoscopy to date Has it been effective?
CRC Trends Siegel, CA Cancer J Clin 2014;64:104
Polypectomy CRC Mortality Zauber AG et al. N Engl J Med 2012;366:687-696.
Colon Cancer and Screening Rates Yang, DX. Cancer 2014; 10:1002
Colon Cancer and Screening Rates Estimated number of cancers prevented over 3 decades: 236,000 to 550,000 Yang, DX. Cancer 2014; 10:1002
So what is wrong with colonoscopy as a screening study?
Screening for Colon Cancer Ideal screening study Prevalent disease Effective High sensitivity and specificity Safe Available Convenient Cheap - $$$
Screening Rates Colorectal Cancer Screening Among Adults Aged 50 Years or Older, United States, 2010Z CHARACTERISTIC FOBTa Sex Men 9.0 Women 8.6 Age, years 50-64 8.0 65+ 9.7 Race/ethnicity White (non-Hispanic) 9.2 Black (non-Hispanic) 8.4 Asiand 6.9 American Indian/Alaska Nativee Hispanic/Latino 5.6 Education, years 11 5.8 12 6.8 13 to 15 11.0 16+ 10.4 ENDOSCOPYb EITHER FOBT or ENDOSCOPYc 57.4 55.6 60.2 58.3 52.3 61.2 55.2 63.7 58.5 53.0 44.5 61.5 55.5 45.9 6.1 46.5 48.1 45.3 47.0 42.1 51.9 59.5 66.7 43.9 54.2 63.1 69.2 Health insurance coverage Yes 9.2 59.4 62.2 No 1.6 17.8 18.8
Effectiveness of Colonoscopy Reduction of cancers more in left colon than in right Biological differences Quality issues Cecal intubation rates Adenoma detection rates Prep quality Split dose preps
CT Colonography CT colonography Colonoscopy Global Sensitivity Specificity Subgroup analysis Lesions between 5 and 7 mm Sensitivity Specificity Lesions between 8 and 10 mm Sensitivity Specificity Lesions > 10 mm Sensitivity Specificity 66.8% (62.7 70.8%) 80.3% (77.7 82.8%) 92.5% (89.0 95.2%) 73.2% (67.7 78.1%) 77.1% (73.3 80.5%) 87.4% (86.3 88.4%) 86.7% (81.3 91.0%) 98.0 (97.1 98.6%) 86.7% (81.7 90.7%) 90.0% (89.1 91.0%) 88.5% (81.5 93.6%) 99.2% (98.6 99.5%) 91.2% (86.5 94.6%) 87.3% (86.2 88.3%) 92.9% (86.0 97.1%) 91.3% (89.9 92.5%) Martin-Lopez, Colorectal Disease 2013; 16:O82
CT Colonography Pooled sensitivity/specificity for advanced neoplasia and cancer CT colonography Global Sensitivity 96.8% (89.0-99.6%) Specificity 99.0% (98.7-99.2%) Colonoscopy 91.2% (80.7-97.1%) 100% (99.9-100%) Martin-Lopez, Colorectal Disease 2013; 16:O82
CT Colonography Advantages: Rapid No sedation Lower procedural risk Extracolonic findings Disadvantages Same prep as for colonoscopy (? prep-less procedures) Discomfort with insufflation Radiation Contrast allergy Need for a colonoscopy for positive findings
FIT Antibody to human globin Doesn t cross react with dietary meats No need to avoid foods with peroxidase activity Measures colonic blood upper GI globin is digested Fewer samples needed than FOBT Increased sensitivity and specificity compared to FOBT
Pooled sensitivity/specificity for FIT 68.45% 98.50% Lee, Annals of Internal Medicine. 160(3):171-181, February 4, 2014.
FIT Relatively cheap Good sensitivity and specificity profile Higher participation rates than colonoscopy Not good for detecting polyps
Stool DNA Testing Multiple studies with numerous DNA markers Target shed DNA from shed cells Look for DNA markers present in malignancies Aberrantly methylated BMP3 and NDRG4 promoter regions Mutant KRAS actin FIT
Methylated Sept9 Sept9 encodes the protein Septin 9, part of a protein complex active in mitotic cell division Colon cancer has increased levels of mSEPT9 Initial studies showed increased serum levels of mSept9 in patients with colon cancer Initial retrospective case-control studies Sensitivity 52% to 72% Specificity 90 to 95%
mSept9 Prospective trial in screening population 7941 patients , 53 CRC cases, 3025 adenomas Sensitivity CRC (all) 48.2% (32.4-63.6%) 91.5% (89.7-99.5%) Stage I 35.05% Stage II 63.05% Stage III 46.0% Stage IV 77.4% Adv Aden 11.2% Specificity Church, TR. Gut 2014; 63:317
Colon Cancer Screening So which test should be done?
The Best Test Is The One That Gets Done
