Colon Cancer: You Have Colon Cancer: You Have The Power!The Power!

Lindsay Strader, D. O.Lindsay Strader, D. O.May 19, 2016May 19, 2016

DisclosuresDisclosures• No financial disclosuresNo financial disclosures

You’re a colorectal You’re a colorectal surgeon? WHY???surgeon? WHY???

• 30 multi-specialty surgical 30 multi-specialty surgical practicepractice

• 1 of 5 colorectal surgeons in 1 of 5 colorectal surgeons in WichitaWichita

• The ONLY female colorectal The ONLY female colorectal surgeon in the regionsurgeon in the region

• There was a need I could fill in There was a need I could fill in my hometown.my hometown.

• There is no better fulfillment There is no better fulfillment than curing someone of cancerthan curing someone of cancer

ObjectivesObjectives• To inspire you to take action in preventing To inspire you to take action in preventing

colon cancer by learningcolon cancer by learning

• Who gets colon cancer?Who gets colon cancer?

• What is colon cancer?What is colon cancer?

• What risk factors increase colon cancer?What risk factors increase colon cancer?

• What can we do to prevent colon cancer?What can we do to prevent colon cancer?

• What happens after a diagnosis of colon What happens after a diagnosis of colon cancer?cancer?

• What power do you have to prevent What power do you have to prevent colon cancer?colon cancer?

Who gets colon cancer?Who gets colon cancer?• 3rd most common cancer 3rd most common cancer

in USin US

• Lifetime risk of 1 in 20 Lifetime risk of 1 in 20 (5%)(5%)

• In 2015, ~93,000 new In 2015, ~93,000 new colon cancers and colon cancers and ~40,000 new rectal ~40,000 new rectal cancers were diagnosedcancers were diagnosed

• ColoRectal Cancer is often ColoRectal Cancer is often abbreviated as CRCabbreviated as CRC

Men675,300

Women658,800

Who gets CRC?Who gets CRC?

• Mortality rates for colorectal cancer have been Mortality rates for colorectal cancer have been dropping for 20 yearsdropping for 20 years

• There are approximately 1 million survivors of There are approximately 1 million survivors of colorectal cancer living in the United Statescolorectal cancer living in the United States

What is CRC?What is CRC?

What is CRC?What is CRC?• CRC is the abnormal CRC is the abnormal

growth of cells that growth of cells that develop on the inner develop on the inner lining of the colonlining of the colon

• This can lead to cells that This can lead to cells that invade into and even invade into and even through the colon.through the colon.

• These cells can also These cells can also spread to other areas of spread to other areas of the body called the body called metastasis.metastasis.

What causes CRC?What causes CRC?• Most CRC start as Most CRC start as

polypspolyps

• Polyps form because of Polyps form because of damage to the DNA cell damage to the DNA cell cyclecycle

• Some risks factors for Some risks factors for polyp formation can be polyp formation can be modifiable; others are modifiable; others are notnot

Risk Factors for CRCRisk Factors for CRC• AGEAGE

• 90% of all CRC occur in 90% of all CRC occur in people 50+people 50+

• Basis for colon cancer Basis for colon cancer screening starting at age 50screening starting at age 50

Age is just a number!!!Age is just a number!!!• Although age is not a modifiable risk fact, you Although age is not a modifiable risk fact, you

have the POWER to be healthy at any age!have the POWER to be healthy at any age!

Risk FactorsRisk Factors• Race/EthnicityRace/Ethnicity

• Lowest in Asian/Pacific IslanderLowest in Asian/Pacific Islander

• Highest in African AmericanHighest in African American

• Geographical LocationGeographical Location

• Lowest in NortheastLowest in Northeast

• Highest in MidwestHighest in Midwest

• Nightshift WorkersNightshift Workers

• >3 nights/week for 15 years >3 nights/week for 15 years increased rates in womenincreased rates in women

Modifiable Risk FactorsModifiable Risk Factors• Diet rich in red meat and Diet rich in red meat and

processed foodsprocessed foods

• Obesity/Inactive LifestyleObesity/Inactive Lifestyle

• Tobacco UseTobacco Use

• Alcohol UseAlcohol Use

Increased RiskIncreased Risk• History of colon History of colon

polyps or cancerpolyps or cancer

• Inflammatory Inflammatory Bowel Disease Bowel Disease (Crohn’s Disease, (Crohn’s Disease, Ulcerative Colitis)Ulcerative Colitis)

Inherited Family Inherited Family SyndromesSyndromes

• Polyposis syndromes Polyposis syndromes (FAP, MAP)(FAP, MAP)

• Lynch Syndrome (HNPCC)Lynch Syndrome (HNPCC)

Familial/Inherited CRCFamilial/Inherited CRC

Screening for CRCScreening for CRC• Screening is the act of finding a Screening is the act of finding a

disease that has no symptomsdisease that has no symptoms

• Screening allows us to:Screening allows us to:

• Remove polyps, therefore Remove polyps, therefore preventing colon cancer from preventing colon cancer from developingdeveloping

• Remove early cancer, Remove early cancer, therefore preventing colon therefore preventing colon cancer surgerycancer surgery

• Diagnose colon cancer, Diagnose colon cancer, allowing us to remove that allowing us to remove that part of the colon during part of the colon during surgerysurgery

Why screen for CRC?Why screen for CRC?

Screening optionsScreening optionsStool TestsStool Tests

Fecal Occult Blood Test (FOBT)Fecal Occult Blood Test (FOBT)Fecal Immunochemical Test (FIT)Fecal Immunochemical Test (FIT)Stool DNA Test (Cologard)Stool DNA Test (Cologard)

Imaging TestsImaging TestsBarium EnemaBarium EnemaCT Colonography (CTC)CT Colonography (CTC)

ProceduresProceduresFlexible SigmoidoscopyFlexible SigmoidoscopyColonoscopyColonoscopy

Stool TestsStool Tests• Fecal Occult Blood Tests/Fecal Fecal Occult Blood Tests/Fecal

Immunohistochemical Tests Immunohistochemical Tests (FOBT/FIT)(FOBT/FIT)

• Guaiac based testing that detects Guaiac based testing that detects occult bloodoccult blood

• Must test 1-3 consecutive bowel Must test 1-3 consecutive bowel movements (not accurate on movements (not accurate on digital rectal exam)digital rectal exam)

• Tests can be affected by diet or Tests can be affected by diet or other sources of bleedingother sources of bleeding

• Misses most polyps because of Misses most polyps because of non-/intermittent-bleedingnon-/intermittent-bleeding

Stool TestsStool Tests• Cologuard DNA testCologuard DNA test

• Detects 11 biomarkers Detects 11 biomarkers including bloodincluding blood

• Study of 10,000 patientsStudy of 10,000 patients

• Sensitivity to detect Sensitivity to detect CRC: Cologuard 94%, FIT CRC: Cologuard 94%, FIT 74%74%

• Sensitivity to detect pre-Sensitivity to detect pre-cancerous polyps: cancerous polyps: Cologuard 42%, FIT 24%Cologuard 42%, FIT 24%

Screening with Stool Screening with Stool teststests

• Advantages include relatively easy Advantages include relatively easy test, no invasive procedure or test, no invasive procedure or sedation involved, and inexpensive.sedation involved, and inexpensive.

• Disadvantages include false positive Disadvantages include false positive results and misses 95% of polyps results and misses 95% of polyps found on colonoscopy.found on colonoscopy.

• If test is positive, need to undergo If test is positive, need to undergo colonoscopycolonoscopy

• Regular annual use of FOBT/FIT tests Regular annual use of FOBT/FIT tests decrease CRC death by 30% and CRC decrease CRC death by 30% and CRC incidence by 20% by detecting large incidence by 20% by detecting large pre-cancerous polyps.pre-cancerous polyps.

Imaging TestsImaging Tests• Double Contrast Barium EnemaDouble Contrast Barium Enema

• Barium sulfate introduced by Barium sulfate introduced by enema followed by air to expand enema followed by air to expand the colonthe colon

• Similar sensitivity for polyps as Similar sensitivity for polyps as colonoscopycolonoscopy

• Requires bowel prep but no Requires bowel prep but no sedationsedation

• Positive result requires Positive result requires colonoscopy for biopsy/removalcolonoscopy for biopsy/removal

• Imaging test of choice for Imaging test of choice for incomplete colonoscopyincomplete colonoscopy

Imaging TestsImaging Tests• CT ColonographyCT Colonography

• Rectal tube inserted for air contrast, Rectal tube inserted for air contrast, then undergo CT scanthen undergo CT scan

• Similar sensitivity to barium enema Similar sensitivity to barium enema with much higher radiation with much higher radiation exposureexposure

• Requires bowel prep but no Requires bowel prep but no sedationsedation

• Positive results require colonoscopy Positive results require colonoscopy for biopsy/removalfor biopsy/removal

• More expensive than colonoscopy More expensive than colonoscopy and no longer covered by insuranceand no longer covered by insurance

Screening with Imaging Screening with Imaging TestsTests

• Advantages include non-Advantages include non-invasive and no sedation invasive and no sedation required.required.

• Disadvantages include Disadvantages include exposure to radiation and CT exposure to radiation and CT Colonography not covered by Colonography not covered by insurance or performed in insurance or performed in WichitaWichita

• Any abnormalities require Any abnormalities require follow-up colonoscopy follow-up colonoscopy “optimally on the same day to “optimally on the same day to avoid repeat bowel prep”.avoid repeat bowel prep”.

ProceduresProcedures• Flexible sigmoidoscopyFlexible sigmoidoscopy

• Lighted flexible camera that evaluates the Lighted flexible camera that evaluates the rectum and sigmoid colonrectum and sigmoid colon

• Requires enemas but no bowel prep or Requires enemas but no bowel prep or sedationsedation

• If polyps are found, formal bowel prep and If polyps are found, formal bowel prep and colonoscopy is requiredcolonoscopy is required

• Decrease in CRC incidence by 33% and CRC Decrease in CRC incidence by 33% and CRC death by 43%death by 43%

• However, 40% of cancers arise in the area not However, 40% of cancers arise in the area not evaluated by flex sigevaluated by flex sig

• 75% of cancers and 50% of polyps have no 75% of cancers and 50% of polyps have no polyps in the area evaluated by flex sigpolyps in the area evaluated by flex sig

ProceduresProcedures• ColonoscopyColonoscopy

• Gold Standard for CRC screeningGold Standard for CRC screening

• Requires full bowel prep and Requires full bowel prep and sedation and typically one day sedation and typically one day of work absenceof work absence

• Most sensitive method of Most sensitive method of detecting polyps/cancerdetecting polyps/cancer

• Miss rate for 1 cm polyps is 5%, Miss rate for 1 cm polyps is 5%, and polyps <5 mm is 25%and polyps <5 mm is 25%

• Able to biopsy and remove Able to biopsy and remove polyps and potentially cancerpolyps and potentially cancer

ColonoscopyColonoscopy

Relax!!! It’s easier now!Relax!!! It’s easier now!

Excuses, Excuses, Excuses, Excuses, Excuses!!!Excuses!!!

I don’t have time!!!I don’t have time!!!

• Do you have time for Do you have time for colon cancer colon cancer treatment? Because treatment? Because that will take a lot that will take a lot more time off of work more time off of work than a colonoscopy!than a colonoscopy!

I heard the prep is I heard the prep is terrible!!!terrible!!!

I’m afraid it will hurt.I’m afraid it will hurt.• Moving towards using CO2 Moving towards using CO2

for insufflationfor insufflation

• Significantly less abdominal Significantly less abdominal pain and bowel distensionpain and bowel distension

• Absorbed 13 times faster Absorbed 13 times faster than oxygen and 160 times than oxygen and 160 times faster than nitrogenfaster than nitrogen

• CO2 typically resorbs in 20 CO2 typically resorbs in 20 minutes for much less gas minutes for much less gas painpain

I don’t want to be I don’t want to be awake!awake!

• Conscious sedation versus Conscious sedation versus anesthesia-directed propofolanesthesia-directed propofol

• Faster recovery, improved Faster recovery, improved sedation and greater sedation and greater efficiency with propofolefficiency with propofol

• Higher cost with anesthesia Higher cost with anesthesia providersproviders

• Regardless, if you briefly Regardless, if you briefly wake up, more medication wake up, more medication will be given to complete the will be given to complete the exam.exam.

I don’t have any I don’t have any symptoms!symptoms!

• Many CRC/polyps are Many CRC/polyps are asymptomatic.asymptomatic.

• Symptoms of CRC Symptoms of CRC include:include:

• Rectal bleedingRectal bleeding

• Abdominal painAbdominal pain

• Change in bowel Change in bowel habitshabits

• AnemiaAnemia

No excusesNo excuses

ComplicationsComplications• Although colonoscopy Although colonoscopy

has the highest has the highest complication rate of all complication rate of all the screening the screening procedures, it is still low.procedures, it is still low.

• Depending on Depending on interventionintervention• Bleeding 0.3-5%Bleeding 0.3-5%• Perforation 0.01-6%Perforation 0.01-6%

Colonoscopy benefitsColonoscopy benefits

Screening guidelinesScreening guidelines• FIT test annually*FIT test annually*

• Flexible Sigmoidoscopy Flexible Sigmoidoscopy every 5 years +/- FIT test every 5 years +/- FIT test annually*annually*

• Barium enema every 5 Barium enema every 5 years*years*

• Colonoscopy every 10 Colonoscopy every 10 yearsyears

• *Positive results require *Positive results require follow-up colonoscopyfollow-up colonoscopy

High-risk screening High-risk screening guidelinesguidelines

• If you have a first degree relative with CRC/polyps diagnosed < 60 years If you have a first degree relative with CRC/polyps diagnosed < 60 years old OR if you have 2 first degree relatives with CRC/polyps diagnosed at old OR if you have 2 first degree relatives with CRC/polyps diagnosed at any ageany age

• Start screening at age 40 or 10 years before the first diagnosis, which Start screening at age 40 or 10 years before the first diagnosis, which ever comes firstever comes first

• Repeat screening every 5 yearsRepeat screening every 5 years

• If you have a first-degree relative with CRC/polyps diagnosed >60 years If you have a first-degree relative with CRC/polyps diagnosed >60 years old OR if you have 2 second-degree relatives with CRC/polyps diagnosed old OR if you have 2 second-degree relatives with CRC/polyps diagnosed at any ageat any age

• Start screening at age 40 or 10 years before the first diagnosis, which Start screening at age 40 or 10 years before the first diagnosis, which ever comes firstever comes first

• Repeat screening every 10 yearsRepeat screening every 10 years

• If you have a family history of colon cancer or If you have a family history of colon cancer or polyps, you should see your doctor for polyps, you should see your doctor for recommendations on when to start your colon recommendations on when to start your colon cancer screening.cancer screening.

How are we doing???How are we doing???• 50% of Americans 50% of Americans

are up-to-date with are up-to-date with screening screening recommendationsrecommendations

• 65% in Kansas65% in Kansas

• 5 fold increase in 5 fold increase in colonoscopy colonoscopy screenings over the screenings over the last 5 yearslast 5 years

• Pink-ribbon Pink-ribbon syndromesyndrome

Why the big push to Why the big push to screen?screen?

Why the big push to Why the big push to screen?screen?

What happens after CRC What happens after CRC diagnosis?diagnosis?

• Pathology diagnosis of Pathology diagnosis of CRCCRC

• CT scan of body and blood CT scan of body and blood test to check for disease test to check for disease spread (metastasis)spread (metastasis)

• Meet/Discuss options with Meet/Discuss options with colorectal surgeoncolorectal surgeon

• Consider colonoscopy to Consider colonoscopy to “tattoo” the lesion“tattoo” the lesion

Surgeon DiscussionSurgeon Discussion• Most common question: Most common question:

Will I have to have a bag?Will I have to have a bag?

• Usually ostomy is NOT Usually ostomy is NOT requiredrequired

• Usually ostomy is Usually ostomy is temporarytemporary

• You probably know You probably know someone with an someone with an ostomy…ostomy…

Surgeon DiscussionSurgeon Discussion• Open versus Minimally-InvasiveOpen versus Minimally-Invasive

• Risks and Benefits of surgeryRisks and Benefits of surgery

After SurgeryAfter Surgery• Once pathology returned, will know staging of Once pathology returned, will know staging of

cancercancer

TreatmentTreatment• Treatment based on cancer stageTreatment based on cancer stage

• Stage 1- Surgery aloneStage 1- Surgery alone

• Stage 2- Surgery +/- ChemotherapyStage 2- Surgery +/- Chemotherapy

• Stage 3- Surgery + ChemotherapyStage 3- Surgery + Chemotherapy

• Stage 4- Chemotherapy alone, Stage 4- Chemotherapy alone, possible surgerypossible surgery

• Rectal cancer may have indications for Rectal cancer may have indications for radiationradiation

You have the power to You have the power to stop colon cancer!!!stop colon cancer!!!

You Have The Power!!!You Have The Power!!!• Get informed about your Get informed about your

familyfamily

• Find out what cancers Find out what cancers run in your familyrun in your family

• Inform your children Inform your children about your family historyabout your family history

• Talk with your doctor Talk with your doctor about the right time to about the right time to start screening for you start screening for you and your familyand your family

You Have The Power!!!You Have The Power!!!• Schedule your colon Schedule your colon

cancer screening cancer screening today!!!today!!!• stool test, barium stool test, barium

enema or enema or colonoscopycolonoscopy

• Keep up to date on Keep up to date on when your next test when your next test should beshould be

You Have The Power!!!You Have The Power!!!• Modify your risk factorsModify your risk factors

• Stop smokingStop smoking

• Limit alcohol, red meat, and Limit alcohol, red meat, and processed foodsprocessed foods

• Enjoy an active lifestyle and Enjoy an active lifestyle and keep a healthy weightkeep a healthy weight

GET YOUR REAR IN GET YOUR REAR IN GEAR!!!GEAR!!!

• 5K run/walk and 1 5K run/walk and 1 mile fun runmile fun run

• Sunday, May 29, Sunday, May 29, 7:30pm7:30pm

• Farm and Art Market Farm and Art Market 1st and Mosley1st and Mosley

• Sign up at Sign up at getyourrearingear.cgetyourrearingear.comom

Questions?Questions?