Colorectal Cancer A Preventable Burden

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Colorectal Cancer A Preventable Burden

• Citywide Colorectal Cancer Control Coalition
• Ambassador Program

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NYC Coalition Mission

• To increase awareness screening for colorectal
  cancer adenomatous polyps in NYC men and women
  in order to reduce the incidence mortality of
  this disease

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C5 Ambassadors Program Goals

• To educate health care providers
• CRC as a public health problem
• Effectiveness of CRC screening
• What are the current guidelines
• Recommendations of the NYC DOHMH

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There Are Major Health Disparities of Colorectal
Cancer in the U.S
Incidence Rate Mortality Rate
Men
African American 58.3 27.7
Caucasian 52.7 21.3
Hispanic-American 35.7 13.1
Women
African-American 45.2 19.9
Caucasian 36.6 14.3
Hispanic-American 23.6 8.3
Rates per 100,000
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Colorectal Cancer Risk Groups
FAP
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HNPCC-Hereditary Non-Polyposis Colorectal Cancer
Winawer, Schottenfeld, Flehinger, JNCI 1991
83243-253.
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Hereditary Non-Polyposis Colorectal Cancer (HNPCC)
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Amsterdam Criteria

• Three or more relatives with Hereditary
  Non-Polyposis Colorectal Cancers
• One a first degree relative of the other two
• Two or more generations
• One with cancer lt age 50

Vasen et al. GE 1999 116 (6) 1453
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Lifetime Risks Of Colorectal Cancer

• Population risk of CRC 1 in 20
• 1 first-degree relative 1 in 17
• 1 FDR 1 second-degree relative 1 in
  12
• 1 relative aged under 45 1 in 10
• 2 first-degree relatives 1 in 6
• Autosomal dominant pedigree 1 in 2

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Colorectal Cancer

• The most preventable, but least prevented,
  cancer

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The Best Screening Test Is
THE ONE THAT GETS DONE.
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Low Screening Rates

• CRC has far lower screening rates than breast or
  cervical cancer

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Why Screen for Colon Cancer?

• Proven effectiveness of screening
• Highly preventable cancer
• Well defined pre-malignant phase (adenoma)
• Adenomas take 5-10 years to become cancer
• Molecular basis of carcinogenesis is the best
  understood of all solid tumors (molecular
  diagnostics)

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Barriers to CRC Screening
Lack of physician recommendation Lack of worrisome symptoms Fear of the results (need for further testing) Negative attitudes about the test FOBT embarrassing, distasteful Sigmoidoscopy / Colonoscopy pain, discomfort, injury Practical issues Poor Patient Adherence Conflicts with work/family commitments Inconvenience Lack of interest Cost
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Mortality Reduction Using Different Screening
Methods
1000
Colonoscopy Every 10 years 90
Annual FOBT 33
Sigmoidoscopy Every 5-10 years 30
Observed Estimated
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Effectiveness of FOBT

• Prospective, randomized, controlled trials
• Mandel Hardcastle Kronborg
• (USA) (UK) (Denmark)
• Duration 1975-92 1981-95 1985-95
• Subjects (n) 46,551 152,850 140,000
• Frequency annual/ biennial biennial biennial
• F/U duration (yrs) 13 7.8 10
• CRC mortality 33/21 15 18
• Reduction

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Colorectal Cancer Mortality Reduction By
Sigmoidoscopy

• Colorectal Cancer Mortality
  Study Design Reduction Published
• Kaiser Retrospective, 30 Selby,
  NEJMPermanente, Case Control 1992USA
• Univ. Retrospective, 40 Newcomb,Wisconsin, Case
  Control JNCI 1992USA

Reviewed in Colorectal Cancer Screening Clinical
Guidelines and Rationale. Winawer, Fletcher, et
al., Gastroenterology, Feb. 1997.
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What Do You Find If You Perform Screening
Colonoscopy on Average-risk Subjects?

• Lieberman1 Imperiale2
• Setting VA Multi-center Eli Lilly co
• No. Of subjects 3,121 1,994
• Male 96.8 58.9
• Age (mean) 62.9 yrs 59.8 yrs
• Cancer 1.0 0.6
• Adenoma (any) 37.0 --
• Adenoma gt1 cm 7.9 --
• Adenoma w/ HGD 1.6 --

1 N Engl J med 343162, 2000 2 N Engl J med
343169, 2000
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15-22 cancers are prevented or detected early per
1,000 screening colonoscopies

1,000 average-risk asymptomatic men and women
aged 50 and older
COLONOSCOPY
5 - 6 will have advanced adenomas ?50-60
advanced adenomas detected by screening
0.5 - 1 will have cancer ? 5-10 cancers
detected early by screening
20 (10-12) would have developed cancer over 20
years
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Cost Effectiveness of Colon Cancer Screening vs.
Other Measures
Cost () per added year of life (x 1000)
Colon Hypertension Mammography
Cholesterol Screening
Any colon screening The cost varies with the
model used this is a ballpark number
Lieberman 2003.
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National Polyp Study

• Randomized trial
• Surveillance intervals
• Surveillance methods
• Colorectal Cancer incidence

• Adenoma-carcinoma model
• 7 clinical centers
• Memorial Sloan Kettering Coord. Center

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Colorectal Cancer Incidence in NPS Following
Colonoscopic Polypectomy (1418 pts 8401 person
yrs)
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Resources

• Less Intensive Surveillance
• Increased Resources for Screening

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Alternative and Future Colorectal Cancer
Screening Methods
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Virtual Colonoscopy
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Virtual Colonoscopy

• Prep Needed

• Air Discomfort

• No Biopsy

• No Polypectomy

• 5060 Need Real Time Colonoscopy

• Miss rate of small adenomas?

• Radiation

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Stool DNA Testing
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Stool DNA Testing
Tail
Pail
Mail
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Stool DNA Testing

• Advanced
• Cancer adenomas specificity
• 1. 20/22 (91) 9/11 (82) 26/28 (93)
• 2. 33/52 (64) 16/28 (57) 204/212 (96)

1. Ahlquist et al. Gastroenterology 2000 2.
Tagore et al. Clin colorectal cancer 2003
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Breaking Down Barriers
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Successful Strategies in New York City

• Systematic referral of all outpatients over age
  50
• Electronic medical record prompts, preventive
  flow sheets, chartstickers or postcards to all
  patients over the age of 50
• Patient navigators
• Direct endoscopy referral (DERs) to simplify
  process for increasing screening

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NYC Colorectal Cancer Screening Advisory
PanelRationale

• About 1,500 NYC residents die annually from
  colorectal cancer
• Most deaths are preventable
• Colonoscopy preferred
• Examines entire colon
• Sensitive Specific for adenomas and cancer
• Provides screening, diagnosis, treatment
• Sufficient Capacity in N.Y.C.
• Preferred recommendation may reduce confusion
• Other options are available (National Guidelines)

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The Best Screening Test Is
THE ONE THAT GETS DONE.
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Adenomatous Polyp
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Adenoma to Carcinoma Pathway
Adenoma
Normal
Cancer
APC loss
K-ras mutation
Chrom 18 loss
p53 loss
Normal Epithelium
Early Adenoma
Cancer
Hyper- proliferation
Intermediate Adenoma
Late Adenoma
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US Rates of Colorectal Cancer Incidence (age 50)
SEER 1993-1997
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