Colonoscopy; Surveillance Indications

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Colonoscopy Surveillance Indications

• SR Brown
• Colorectal Surgeon
• Sheffield Teaching Hospitals

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Colorectal cancer screening in high risk groups

• Gut 200251(Suppl V)

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Screening vs Surveillance

• Screening
• Asymptomatic population
• Surveillance
• Previous symptoms/high risk

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High risk groups

• Previous colorectal cancer
• Acromegaly
• Ureterosigmoidostomy
• Hereditary and Familial bowel cancer
• IBD
• Previous polyps

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Aims

• To discuss salient aspects of guidelines
• To highlight recent developments in colonoscopic
  surveillance

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Colorectal cancer surveillance
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Colorectal cancer surveillance aims

• Detect recurrence
• Diagnose and treat metachronous neoplasia
• Evaluate anastomosis

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Colorectal cancer surveillance

• Incidence metachronous tumours 5-10
• Metachronous cancers
• approx. 2
• Cochrane review 1.3 (18/1342)
• Metachronous adenomas
• 22 (425/1923)

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Colorectal cancer surveillance

• Synchronous/early metachronous cancers
• 4
• 0.6 missed due to incomplete colon exam

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Familial cancer surveillance
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Familial Cancer Summary
Family group Screening procedure Age at initial screen Screening procedure and interval
2 FDR with CRC Colonoscopy At 1st consult or age 35-40 years (whichever later) If initial clear repeat at age 55
1 FDRlt45 yr with CRC Colonoscopy At 1st consult or age 35-40 years (whichever later) If initial clear repeat at age 55
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Lifetime risk of colorectal cancer
Risk Group Risk (of dying)
General population 150
Any family history 117
One affected relative lt45 years 110
Two affected relatives 16
Houlston et al. 1970
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Familial Cancer Summary
Family group Screening procedure Age at initial screen Screening procedure and interval
2 FDR with CRC Colonoscopy At 1st consult or age 35-40 years (whichever later) If initial clear repeat at age 55
1 FDRlt45 yr with CRC Colonoscopy At 1st consult or age 35-40 years (whichever later) If initial clear repeat at age 55
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Chances of preventing death with screening
colonoscopy35 year old with FDRlt45 years

• 1 in 25,000 people aged 30-39 develop colorectal
  cancer per year
• Relative risk 5
• Risk of cancer 1 in 5000 in per year
• Assume asymptomatic cancer dwell time of 3 years
• Chance of detecting cancer 1 in 1660

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Familial Cancer Summary
Family group Screening procedure Age at initial screen Screening procedure and interval
2 FDR with CRC Colonoscopy At 1st consult or age 35-40 years (whichever later) If initial clear repeat at age 55
1 FDRlt45 yr with CRC Colonoscopy At 1st consult or age 35-40 years (whichever later) If initial clear repeat at age 55
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Chances of preventing death with screening
colonoscopy55 year old with FDRlt45 years

• 1 in 1,630 people aged 50-59 develop colorectal
  cancer per year
• Relative risk 3
• Risk of cancer 1 in 543 per year
• Assume asymptomatic cancer dwell time of 3 years
• Chance of detecting cancer 1 in 181

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Hereditary cancer surveillance
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Hereditary Cancer Summary
Family group Screening procedure Age at initial screen Screening procedure and interval
FAP Genetic testing Flexi sigOGD Puberty Flexi sig yearly Colectomy if ve
HNPCC Colonoscopy /- OGD 25 yrs or 5 yrs before earliest CRC in family 2 yearly colonoscopy and OGD
Juvenile polyposis Peutz-Jegher Genetic testing Colonoscopy OGD Puberty Flexi sig yearly Colectomy if ve
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IBD surveillance
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IBD Summary
Disease group Screening procedure Age at initial screen Screening procedure and interval
UC or Crohns coloitis Colonoscopy biopsies every 10cm After 8 years for pan colitis, 15 years for left sided colitis 3 yrly 2nd decade, 2yrly 3rd decade, yrly thereafter
UC PSC Colonoscopy At diagnosis PSC Annually
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Controversies

• ? Survival advantage (Cochrane review 2004)
• No clear evidence
• May allow earlier detection of cancer
• ?lead-time bias

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Controversies

• Ongoing inflammation increases risk
• Dysplasia as a marker for cancer
• Reliability
• Detection
• Histological interpretation

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Controversiesdetection

• Pan-chromoscopy and targeted biopsy (Rutter 2004)
• Back-to-back colonoscopy
• Conventional then dye-spray
• Conventional no dysplasia in 2904 random biopsies
• Targeted 157 biopsies 7 patients with dysplasia

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Ileo-anal pouch surveillance
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Pouch cancer

• 15 case reports
• 10 residual rectal mucosa
• 5 ??pouch mucosa
• All pre-existing dysplasia
• 8 had cancer in original resection
• 9 had mucosectomy

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Surveillance recommendations

• Pouchoscopy
• 1st year then 2-3 yearly
• Increased surveillance (yearly) if
• Pre-existing dysplasia/cancer
• PSC
• Mucosectomy if high risk

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Polyp surveillance
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Summary

• Read guidelines!!