kill the cancer do screening now! daniel m. kruss, m.d

D. M. Kruss MDD. M. Kruss MD

Kill the CancerDo Screening now!

Daniel M. Kruss, M.D.

Kill the CancerDo Screening now!



Colon Cancer Screening







•130,200 new cases expected this year •93% are over age 50 •20% diagnosed at emergency surgery •4th most common cancer • 2nd cause of cancer death

•130,200 new cases expected this year •93% are over age 50 •20% diagnosed at emergency surgery •4th most common cancer • 2nd cause of cancer death




• 56,300 deaths expected this year

• 6% Lifetime Risk

• 62% Five-year survival 53% in African Americans

• 56,300 deaths expected this year

• 6% Lifetime Risk

• 62% Five-year survival 53% in African Americans




Because of these large numbers, even a small improvement in survivalwill save many lives!

Because of these large numbers, even a small improvement in survivalwill save many lives!



Colon Cancer ScreeningWhat is cancer?

•abnormal growth of abnormal cells

•growth out of control cells multiply too quickly cells form masses called tumors tumors invade other organs

•malignant tumors spread distantly (metastasize)

What is cancer?

•abnormal growth of abnormal cells

•growth out of control cells multiply too quickly cells form masses called tumors tumors invade other organs

•malignant tumors spread distantly (metastasize)




Symptoms occur only late in the course of the disease

Survival is related to the amount of spread at the time of surgery

Goal: Detect the cancer, or pre-cancerous polyp before it spreads

Symptoms occur only late in the course of the disease

Survival is related to the amount of spread at the time of surgery

Goal: Detect the cancer, or pre-cancerous polyp before it spreads



What do we know What do we know about colon cancer?about colon cancer?



Colon Cancer ScreeningThe cause of colon cancer is

partly genetic. It is more common in certain settings:

1. Family history of colon cancer

2. Familial Polyposis syndromes

3. Ulcerative Colitis and Crohn's Disease patients

4. Cancer of breast, ovarian, uterus

The cause of colon cancer is partly genetic. It is more common in certain settings:

1. Family history of colon cancer

2. Familial Polyposis syndromes

3. Ulcerative Colitis and Crohn's Disease patients

4. Cancer of breast, ovarian, uterus


Colon Cancer Screening Familial RiskFamilial Risk

General PopulationGeneral Population 6%6%

One 1st-degree RelativeOne 1st-degree Relative 2 to 3X2 to 3X

Two 1st-degree RelativeTwo 1st-degree Relative 3 to 6X3 to 6X

1st-degree Relative <50 Yrs1st-degree Relative <50 Yrs 3 to 6X3 to 6X

One 2nd- or 3rd-degree RelativeOne 2nd- or 3rd-degree Relative 1.5X1.5X

One 1st-degree Relative & Polyp One 1st-degree Relative & Polyp 2X2X




colon cancer may also haveenvironmental triggers such as diet, geography, ???

colon cancer may also haveenvironmental triggers such as diet, geography, ???




Over 90% of colorectal carcinomas develop from an adenomatous polyp.

Over 90% of colorectal carcinomas develop from an adenomatous polyp.



Colon Cancer ScreeningEpidemiologic studies

suggest:

• 1 of every 5 persons is at risk to develop adenomatous polyps

• 5% of these may progress to colorectal cancer

• Screening for polyps at a stage when they can be colonoscopically removed is shown to decrease colorectal cancer mortality

Epidemiologic studies suggest:

• 1 of every 5 persons is at risk to develop adenomatous polyps

• 5% of these may progress to colorectal cancer

• Screening for polyps at a stage when they can be colonoscopically removed is shown to decrease colorectal cancer mortality




This guides our present strategy:This guides our present strategy:

• • find polypsfind polyps

• • remove polypsremove polyps

• • prevent 90% of colon prevent 90% of colon cancerscancers

The other 10% awaits new The other 10% awaits new genetic tests for blood and/or genetic tests for blood and/or stoolstool



How can we detectHow can we detectColon cancer?Colon cancer?

1. Fecal Occult Blood1. Fecal Occult Blood



Colon Cancer ScreeningWhat is fecal Occult Blood?

• OB is blood mixed in stool which you cannot see

• It may come from sources anywhere along the gut from mouth to rectum

• It may be an early warning signal that a polyp or tumor is present

What is fecal Occult Blood?

• OB is blood mixed in stool which you cannot see

• It may come from sources anywhere along the gut from mouth to rectum

• It may be an early warning signal that a polyp or tumor is present



Fecal Occult Blood Testing


Fecal Occult Blood TestingThree Prospective Randomized TrialsThree Prospective Randomized Trials

Site No. ofSubjects

Duration(Years)

MortalityReduction

Minn. 46,551 13 33%

U.K. 152,650 7.8 15%

Denmark 140,000 10 18%



Colon Cancer ScreeningA polyp or a cancer in the

colonmay bleed, slowly, and causetiny amounts of OB in the stool.

Large studies show us that only1/3 of polyps and 1/2 of cancersbleed, however!!

Depending on the method used,between 1.5-8% of 'healthy'persons will have OB in the stool!!

A polyp or a cancer in the colonmay bleed, slowly, and causetiny amounts of OB in the stool.

Large studies show us that only1/3 of polyps and 1/2 of cancersbleed, however!!

Depending on the method used,between 1.5-8% of 'healthy'persons will have OB in the stool!!



Colon Cancer ScreeningIf we make our OB tests too

sensitive, we may find a fewmore cancers, but will detecta lot more false positives.

There is no harm in finding afalse positive, except in theobligation (cost?) of examiningeach one to see if there is a cancer.

If we make our OB tests toosensitive, we may find a fewmore cancers, but will detecta lot more false positives.

There is no harm in finding afalse positive, except in theobligation (cost?) of examiningeach one to see if there is a cancer.



Colon Cancer ScreeningIf we make our OB tests less

sensitive, we will have fewer false positives, but will miss a few real cancers.

We can improve OB specificity by avoiding red meats, vitamin C, aspirin and arthritis medicines, and many fresh fruits and vegetables for three days before and during three days of stool collection.

If we make our OB tests less sensitive, we will have fewer false positives, but will miss a few real cancers.

We can improve OB specificity by avoiding red meats, vitamin C, aspirin and arthritis medicines, and many fresh fruits and vegetables for three days before and during three days of stool collection.


There is a trade-off between compliance and false-positives.

Screening does not change the incidence of new colon cancers, but affects the stage at which they are discovered.

The mortality was reduced from 8.33 to 5.88 per 1000 in the Minnesota study of stool OB.

There is a trade-off between compliance and false-positives.

Screening does not change the incidence of new colon cancers, but affects the stage at which they are discovered.

The mortality was reduced from 8.33 to 5.88 per 1000 in the Minnesota study of stool OB.

Colon Cancer ScreeningColon Cancer Screening



Colon Cancer ScreeningFecal Occult blood testing

performed as part of an in-office digital rectal exam failed to detect potentially cancerous colon growths 95 percent of the time!

Fecal Occult blood testing performed as part of an in-office digital rectal exam failed to detect potentially cancerous colon growths 95 percent of the time!



Colon Cancer ScreeningIt must be clearly understood that

the OB test is only one of severalmethods of screening and thatit is, at best, 50% predictive.

Then why do it?

It must be clearly understood thatthe OB test is only one of severalmethods of screening and thatit is, at best, 50% predictive.

Then why do it?




Early detection is stillthe only methodto prevent deaths from colon cancer

Early detection is stillthe only methodto prevent deaths from colon cancer




2. Sigmoidoscopy2. Sigmoidoscopy



Colon Cancer ScreeningThe American Cancer Society

previously recommended:

Sigmoidoscopy this was based on data suggestingthat half of the cancers will beseen in this area, and anypatients who have polyps seen,will receive full colonoscopy

The American Cancer Society previously recommended:

Sigmoidoscopy this was based on data suggestingthat half of the cancers will beseen in this area, and anypatients who have polyps seen,will receive full colonoscopy




3. Colonoscopy3. Colonoscopy



Colon Cancer ScreeningThe case for screening colonoscopy*

Involves greater risk and inconvenience however

•few significant lesions are missed

•entire colon is examined

•screening interval of 10 years

(few polyps become cancer in less time)

*or virtual colonoscopy when available or air contrast barium enema and sigmoidoscopy

The case for screening colonoscopy*

Involves greater risk and inconvenience however

•few significant lesions are missed

•entire colon is examined

•screening interval of 10 years

(few polyps become cancer in less time)

*or virtual colonoscopy when available or air contrast barium enema and sigmoidoscopy




If you are positive on OB screening, what is needed?

colonoscopy (full colon exam)

if positive findings, act on them

if negative, consider searching the remainder of the GI tract

If you are positive on OB screening, what is needed?

colonoscopy (full colon exam)

if positive findings, act on them

if negative, consider searching the remainder of the GI tract



Colon Cancer ScreeningIf a polyp is found,

what is needed?

1. Annual colonoscopy until the colon is 'clear'

2. then re-examine every 3-5 years

If a polyp is found, what is needed?

1. Annual colonoscopy until the colon is 'clear'

2. then re-examine every 3-5 years




What are the risks of colonoscopy?

bleeding and/or perforationoccur in less than 1/500 patients

When properly indicated, theprocedure is very safe andvery efficient

What are the risks of colonoscopy?

bleeding and/or perforationoccur in less than 1/500 patients

When properly indicated, theprocedure is very safe andvery efficient



What should I do now?What should I do now?




If you are over 55: screening for OB every year, colonoscopy (or sigmoidoscopy)

If you have polyps, tell your bloodrelatives to have screening andbe sure you have regular tests

If relatives had colon polyps or colon cancer, get your colonoscopy now!

If you are over 55: screening for OB every year, colonoscopy (or sigmoidoscopy)

If you have polyps, tell your bloodrelatives to have screening andbe sure you have regular tests

If relatives had colon polyps or colon cancer, get your colonoscopy now!



Familial Risk Screening


Familial Risk Screening Any Family HistoryAny Family History Same as Average Risk Screening,Same as Average Risk Screening, begin at age 55begin at age 55

Strong Family History -Definition:Strong Family History -Definition: 2 Affected First-degree Relatives 2 Affected First-degree Relatives or or 1 First-degree Relative Diagnosed <601 First-degree Relative Diagnosed <60Colonoscopy every 5 years, Colonoscopy every 5 years, Start at age 40 YearsStart at age 40 Years



Colon Cancer ScreeningScreening is optional...

Without screening a 50 year old at average risk, has 530/10,000 chance of invasive colon cancer and 250/10,000 risk of dying from it.

Screening between ages 50-75 reduces this risk by 10-75%

Screening is optional...

Without screening a 50 year old at average risk, has 530/10,000 chance of invasive colon cancer and 250/10,000 risk of dying from it.

Screening between ages 50-75 reduces this risk by 10-75%



Fewer than half of patients Fewer than half of patients diagnosed with colorectal cancer diagnosed with colorectal cancer had received a screening had received a screening procedure at least six months procedure at least six months prior to their diagnosisprior to their diagnosis



94 percent of colorectal cancer 94 percent of colorectal cancer patients had either not undergone patients had either not undergone a colonoscopy at all, or not until a colonoscopy at all, or not until having the procedure that led to having the procedure that led to their diagnosistheir diagnosis




The prognosis of colon cancer

is directly related to the

extent of disease when first

diagnosed!!

The prognosis of colon cancer

is directly related to the

extent of disease when first

diagnosed!!




There are no signs or symptoms

of colon cancer until late in the course!

There are no signs or symptoms

of colon cancer until late in the course!




LateLate signs include: signs include:

• change in bowel habitchange in bowel habit• rectal bleeding (red or occult)rectal bleeding (red or occult)• anemia (weakness, fatigue)anemia (weakness, fatigue)• cramping abdominal pain orcramping abdominal pain or• pelvic/rectal pain or strainingpelvic/rectal pain or straining



Colon Cancer ScreeningGood News!Good News!

Now Medicare Now Medicare covers covers

Screening colonoscopy!Screening colonoscopy!



Colon Cancer ScreeningMedicare pays for:Medicare pays for:

Fecal Occult Blood Tests - every Fecal Occult Blood Tests - every yearyear

Flexible Sigmoidoscopy - every 4 Flexible Sigmoidoscopy - every 4 years*years*

Screening Colonoscopy Screening Colonoscopy Every 10 years for average risk*Every 10 years for average risk*Every 2 years for high riskEvery 2 years for high risk

*if no exam of the colon in the past 4 years



Colon Cancer ScreeningMEDICARE PAYS FOR COLONOSCOPYMEDICARE PAYS FOR COLONOSCOPY

Every 2 years for high risk:Every 2 years for high risk:close relative with colon ca close relative with colon ca

close relative with adenomatous polypsclose relative with adenomatous polypsfamilial adenomatous polyposisfamilial adenomatous polyposisprior polyps or colorectal cancerprior polyps or colorectal cancerInflammatory bowel disease (UC, Crohn’s)Inflammatory bowel disease (UC, Crohn’s)

Every 10 years for average risk*Every 10 years for average risk*

*if no exam of the colon in the past 4 years



Let’s review Let’s review our strategy . . .our strategy . . .



What else can we do?What else can we do?




Lifestyle modifications may be useful:Lifestyle modifications may be useful:

• • Low-dose aspirin or NSAID’s dailyLow-dose aspirin or NSAID’s daily

• • Reduce animal fat Reduce animal fat

• • Increase fiber, calcium, magnesiumIncrease fiber, calcium, magnesium

? (fruits, vegetables) no proof!? (fruits, vegetables) no proof!

Lifestyle modifications may be useful:Lifestyle modifications may be useful:

• • Low-dose aspirin or NSAID’s dailyLow-dose aspirin or NSAID’s daily

• • Reduce animal fat Reduce animal fat

• • Increase fiber, calcium, magnesiumIncrease fiber, calcium, magnesium

? (fruits, vegetables) no proof!? (fruits, vegetables) no proof!



Lifestyle modifications,Lifestyle modifications,and diet,and diet,What we know. . .What we know. . .




4. Future Methods4. Future Methods



Inherited Syndrome Screening


Inherited Syndrome ScreeningFAPFAPSigmoidoscopySigmoidoscopy

Every one to two years, starting age Every one to two years, starting age 10 to 12 years10 to 12 years

HNPCCHNPCCColonoscopyColonoscopy

Every 1 to 2 years, starting age 25 Every 1 to 2 years, starting age 25 yearsyears



REFERRAL TO GASTROENTEROLOGIST


REFERRAL TO GASTROENTEROLOGISTPositive screening testsPositive screening tests

Questions about appropriate screeningQuestions about appropriate screening

When colonoscopy is needed When colonoscopy is needed

Diagnosis and/or management of the Diagnosis and/or management of the known inherited syndromes of colon known inherited syndromes of colon cancercancer




Your survival --

--is up to you!!

Your survival --

--is up to you!!



Colon Cancer ScreeningIf you won’t do it for If you won’t do it for

yourself. . .yourself. . .

Do it for the ones who Do it for the ones who love you!love you!



Does a test need to be Does a test need to be ‘cost effective’ to be ‘cost effective’ to be recommended?recommended?

kill the cancer do screening now! daniel m. kruss, m.d

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