Colorectal Cancer A Preventable Burden
-
Upload
eve-alford -
Category
Documents
-
view
41 -
download
0
description
Transcript of Colorectal Cancer A Preventable Burden
![Page 1: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/1.jpg)
Colorectal Cancer A Preventable Burden
Citywide Colorectal Cancer Control Coalition
Ambassador Program
![Page 2: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/2.jpg)
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”
![Page 3: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/3.jpg)
C5 Ambassadors Program:
GoalsTo educate health care providers:
1. CRC as a public health problem
2. Effectiveness of CRC screening
3. What are the current guidelines
4. Recommendations of the NYC DOHMH
![Page 4: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/4.jpg)
![Page 5: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/5.jpg)
U.S. Burden of Colorectal CancerU.S. Burden of Colorectal CancerProcrastinationProcrastination
• 147,500 new cases in 2005
• 57,100 deaths in 2005
• 150 deaths/day
• 11% of all cancer deaths
• 758,000 person-years of life lost
• Lifetime risk of developing CRC = 5%
• Cost of treatment $6 billion
U
![Page 6: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/6.jpg)
![Page 7: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/7.jpg)
![Page 8: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/8.jpg)
![Page 9: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/9.jpg)
![Page 10: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/10.jpg)
Incidence Rate*
Mortality Rate*
Men
African American 58.358.3 27.7
CaucasianCaucasian 52.7 21.3
Hispanic-AmericanHispanic-American 35.7 13.1
Women
African-AmericanAfrican-American 45.2 19.9
CaucasianCaucasian 36.6 14.3
Hispanic-AmericanHispanic-American 23.6 8.3
There Are Major Health Disparities of Colorectal Cancer in the U.S
* Rates per 100,000U
![Page 11: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/11.jpg)
IBD1%
FAP1%
HNPCC5%
FH 15%-20%
Sporadic(Average Risk)
~75%
Colorectal Cancer Risk Groups
Winawer, Schottenfeld, Flehinger, JNCI 1991: 83:243-253.
FAP
5%
HNPCC-Hereditary Non-Polyposis Colorectal Cancer
U
![Page 12: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/12.jpg)
![Page 13: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/13.jpg)
![Page 14: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/14.jpg)
![Page 15: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/15.jpg)
Normalcecum3/95
Cecalcecum5/96
Hereditary Non-Polyposis Colorectal Cancer (HNPCC)
![Page 16: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/16.jpg)
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 < age 50
Vasen et al. GE 1999; 116 (6): 1453
![Page 17: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/17.jpg)
![Page 18: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/18.jpg)
![Page 19: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/19.jpg)
![Page 20: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/20.jpg)
![Page 21: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/21.jpg)
![Page 22: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/22.jpg)
Lifetime Risks Of Colorectal Cancer
Population risk of CRCPopulation risk of CRC 1 in 201 in 20
1 first-degree relative1 first-degree relative 1 in 171 in 17
1 FDR & 1 second-degree relative 1 FDR & 1 second-degree relative 1 in 12 1 in 12
1 relative aged under 451 relative aged under 45 1 in 101 in 10
2 first-degree relatives2 first-degree relatives 1 in 6 1 in 6
Autosomal dominant pedigreeAutosomal dominant pedigree 1 in 21 in 2
![Page 23: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/23.jpg)
![Page 24: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/24.jpg)
Colorectal Cancer
“The most preventable, but least prevented, cancer”
U
![Page 25: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/25.jpg)
The Best Screening Test Is
THE ONE THAT GETS DONE.
![Page 26: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/26.jpg)
![Page 27: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/27.jpg)
![Page 28: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/28.jpg)
Low Screening Rates
• CRC has far lower screening rates than breast or cervical cancer
0
10
20
30
40
50
60
70
80
90
% Screened
CRCBreastCervical
U
![Page 29: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/29.jpg)
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)
U
![Page 30: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/30.jpg)
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
![Page 31: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/31.jpg)
![Page 32: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/32.jpg)
![Page 33: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/33.jpg)
![Page 34: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/34.jpg)
% Mortality Reduction Using Different Screening Methods
1000
AnnualFOBT33%*
SigmoidoscopyEvery 5-10 years
30%*
ColonoscopyEvery 10 years
90%†
*Observed†Estimated
U
![Page 35: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/35.jpg)
Effectiveness of FOBTProspective, randomized, controlled trialsProspective, randomized, controlled trials
MandelMandel HardcastleHardcastle KronborgKronborg
((USA)USA) ((UK)UK) ((Denmark)Denmark)
DurationDuration 1975-921975-92 1981-951981-95 1985-951985-95
Subjects (n) Subjects (n) 46,55146,551 152,850152,850 140,000140,000
FrequencyFrequency annual/annual/biennial biennialbiennial biennial biennialbiennial
F/U duration (yrs) F/U duration (yrs) 13 13 7.8 7.8 10 10
CRC mortalityCRC mortality 33%/21%33%/21% 15% 15% 18% 18%
ReductionReduction
![Page 36: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/36.jpg)
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.
![Page 37: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/37.jpg)
What Do You Find If You Perform Screening Colonoscopy on
Average-risk Subjects?LiebermanLieberman11 ImperialeImperiale22
SettingSetting VA; Multi-centerVA; Multi-center Eli Lilly coEli Lilly coNo. Of subjectsNo. Of subjects 3,121 3,121 1,9941,994MaleMale 96.8% 96.8% 58.9%58.9%Age (mean)Age (mean) 62.9 yrs 62.9 yrs 59.8 yrs59.8 yrsCancerCancer 1.0% 1.0% 0.6%0.6%Adenoma (any)Adenoma (any) 37.0% 37.0% ----Adenoma >1 cmAdenoma >1 cm 7.9% 7.9% ----Adenoma w/ HGD 1.6%Adenoma w/ HGD 1.6% ----
11 N Engl J medN Engl J med 343:162, 2000 343:162, 200022 N Engl J medN Engl J med 343:169, 2000 343:169, 2000
U
![Page 38: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/38.jpg)
1,000 average-risk asymptomatic men and women
aged 50 and older
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
COLONOSCOPY
15-22 cancers are prevented or detected early per 1,000 screening colonoscopies
![Page 39: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/39.jpg)
Cost Effectiveness of Colon Cancer Screening vs. Other
Measures
Lieberman 2003.
0
5
10
15
20
25
30
35
40
Cost ($)peraddedyear of life(x 1000)
Colon Hypertension Mammography CholesterolScreening*
*Any colon screeningThe cost varies with the model used; this is a ballpark number
![Page 40: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/40.jpg)
![Page 41: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/41.jpg)
National Polyp Study
• Randomized trial• Surveillance intervals• Surveillance methods• Colorectal Cancer
incidence
• Adenoma-carcinoma model
• 7 clinical centers• Memorial Sloan
Kettering Coord. Center
![Page 42: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/42.jpg)
Colorectal Cancer Incidence in NPS Following Colonoscopic Polypectomy (1418 pts ; 8401 person yrs)
![Page 43: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/43.jpg)
![Page 44: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/44.jpg)
![Page 45: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/45.jpg)
![Page 46: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/46.jpg)
![Page 47: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/47.jpg)
![Page 48: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/48.jpg)
Resources
Less Intensive Surveillance
Increased Resources for Screening
![Page 49: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/49.jpg)
Alternative and Future Colorectal Cancer Screening
Methods
![Page 50: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/50.jpg)
![Page 51: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/51.jpg)
Virtual Colonoscopy
![Page 52: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/52.jpg)
Virtual Colonoscopy
Prep Needed
Air Discomfort
No Biopsy
No Polypectomy
50–60% Need “Real Time” Colonoscopy
Miss rate of small adenomas?
Radiation
![Page 53: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/53.jpg)
Stool DNA Testing
![Page 54: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/54.jpg)
Stool DNA Testing
Tail
Pail
![Page 55: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/55.jpg)
Stool DNA Testing
AdvancedAdvanced CancerCancer adenomasadenomas specificity:specificity:1. 20/22 (91%)1. 20/22 (91%) 9/11 (82%)9/11 (82%) 26/28 (93%)26/28 (93%)2. 33/52 (64%)2. 33/52 (64%) 16/28 (57%)16/28 (57%) 204/212 (96%)204/212 (96%)
1. Ahlquist et al. 1. Ahlquist et al. GastroenterologyGastroenterology 2000 20002. Tagore et al. 2. Tagore et al. Clin colorectal cancerClin colorectal cancer 2003 2003
![Page 56: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/56.jpg)
Breaking Down Barriers
U
![Page 57: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/57.jpg)
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
U
![Page 58: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/58.jpg)
NYC Colorectal Cancer Screening Advisory Panel:
Rationale• 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)
![Page 59: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/59.jpg)
![Page 60: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/60.jpg)
![Page 61: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/61.jpg)
The Best Screening Test Is
THE ONE THAT GETS DONE.
![Page 62: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/62.jpg)
![Page 63: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/63.jpg)
Adenomatous Polyp
![Page 64: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/64.jpg)
![Page 65: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/65.jpg)
Adenoma to Carcinoma Pathway
APCloss
NormalEpithelium
EarlyAdenoma
CancerHyper-
proliferationIntermediate
AdenomaLate
Adenoma
K-rasmutation
Chrom 18loss
p53loss
AdenomaNormal Cancer
![Page 66: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/66.jpg)
![Page 67: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/67.jpg)
![Page 68: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/68.jpg)
![Page 69: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/69.jpg)
![Page 70: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/70.jpg)
US Rates of Colorectal Cancer Incidence (age 50+)
0
100
200
300
400
500
20-24 30-34 40-44 50-54 60-64 70-74 80-84
Age (years)
Rate
Per
100
,000
Incidence Rate Mortality RateSEER: 1993-1997SEER: 1993-1997
U
![Page 71: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/71.jpg)
![Page 72: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/72.jpg)
![Page 73: Colorectal Cancer A Preventable Burden](https://reader036.fdocuments.in/reader036/viewer/2022062718/56812be6550346895d9062e3/html5/thumbnails/73.jpg)