General Medicine Subspecialty Conference Colon Cancer Screening General Medicine Subspecialty Conference Colon Cancer Screening Selim Krim, MD Assistant

General Medicine Subspecialty General Medicine Subspecialty ConferenceConference

Colon Cancer Screening Colon Cancer Screening

Selim Krim, MDSelim Krim, MDAssistant ProfessorAssistant Professor

Texas Tech University Health Sciences CenterTexas Tech University Health Sciences Center

U.S. Burden of Colorectal CancerU.S. Burden of Colorectal Cancer

153,760 new cases diagnosed in the 153,760 new cases diagnosed in the United States in 2007 United States in 2007

52,180 deaths in 200752,180 deaths in 2007

Second leading cause of cancer deaths in Second leading cause of cancer deaths in the United States the United States

About 6% of Americans are expected to About 6% of Americans are expected to develop the disease within their lifetime develop the disease within their lifetime

Why is screening important?Why is screening important?

Adenoma to Carcinoma PathwayAdenoma to Carcinoma Pathway

Regular screening for and removal of polyps can reduce a Regular screening for and removal of polyps can reduce a person's risk of developing colorectal cancer by person's risk of developing colorectal cancer by up to 90 percentup to 90 percent. .

Early detection of cancersEarly detection of cancers that are already present in the colon that are already present in the colon increases the chances of increases the chances of successful treatmentsuccessful treatment and decreases the and decreases the chance chance of dyingof dying as a result of the cancer. as a result of the cancer.

How and when should physicians start screening?How and when should physicians start screening?

Colon Cancer ScreeningColon Cancer Screening

Screening programs should begin by classifying the individual Screening programs should begin by classifying the individual patient’s level of risk based on personal, family, and medical history, patient’s level of risk based on personal, family, and medical history, which will determine the appropriate approach to screening in that which will determine the appropriate approach to screening in that person.person.

Men and women at average risk should be offered screening for Men and women at average risk should be offered screening for colorectal cancer and adenomatous polyps beginning at age 50 colorectal cancer and adenomatous polyps beginning at age 50 years.years.

Case 1Case 1

A 50-year-old man comes for an annual health maintenance visit. He feels A 50-year-old man comes for an annual health maintenance visit. He feels well, and medical history is unremarkable. There is no family history of well, and medical history is unremarkable. There is no family history of colorectal cancer. Physical examination and routine laboratory studies are colorectal cancer. Physical examination and routine laboratory studies are normal. Which of the following is the most appropriate recommendation for normal. Which of the following is the most appropriate recommendation for colorectal cancer screening for this patient? colorectal cancer screening for this patient?

Fecal occult blood testing now; repeat every 2 to 3 years Fecal occult blood testing now; repeat every 2 to 3 years

Flexible sigmoidoscopy now; repeat every 2 to 3 years Flexible sigmoidoscopy now; repeat every 2 to 3 years

Barium enema examination now; repeat every 2 to 3 years Barium enema examination now; repeat every 2 to 3 years

Colonoscopy now; repeat every 10 years Colonoscopy now; repeat every 10 years

Virtual colonoscopy (CT colonography) now; repeat every 10 yearsVirtual colonoscopy (CT colonography) now; repeat every 10 years

ACS/USPSTF RecommendationsACS/USPSTF Recommendations

Men and women at average risk should be offered screening with Men and women at average risk should be offered screening with one of the following options beginning at age 50 years;one of the following options beginning at age 50 years;

Offer yearly screening with fecal occult blood test (FOBT) using a Offer yearly screening with fecal occult blood test (FOBT) using a guaiac-based test with dietary restriction or an immunochemical guaiac-based test with dietary restriction or an immunochemical test without dietary restriction. test without dietary restriction.

Offer flexible sigmoidoscopy every 5 years.Offer flexible sigmoidoscopy every 5 years.

Offer screening with FOBT every year combined with flexible Offer screening with FOBT every year combined with flexible sigmoidoscopy every 5 years. When both tests are performed, the sigmoidoscopy every 5 years. When both tests are performed, the FOBT should be done first.FOBT should be done first.

Offer colonoscopy every 10 years.Offer colonoscopy every 10 years.

Case 2Case 2

A 50-year-old man comes for a general physical examination. He feels well A 50-year-old man comes for a general physical examination. He feels well and is asymptomatic. Medical history is significant only for hypertension and is asymptomatic. Medical history is significant only for hypertension treated with atenolol. He takes no other medications or over-the-counter treated with atenolol. He takes no other medications or over-the-counter drugs. Family history is unremarkable. Physical examination is normal. drugs. Family history is unremarkable. Physical examination is normal. Results of routine laboratory studies are also normal, including a Results of routine laboratory studies are also normal, including a hemoglobin level of 14.8 g/dL (148 g/L). One of three stool sample hemoglobin level of 14.8 g/dL (148 g/L). One of three stool sample submitted for fecal occult blood testing is positive. Which of the following is submitted for fecal occult blood testing is positive. Which of the following is the most appropriate next step in evaluating this patient? the most appropriate next step in evaluating this patient?

Repeat fecal occult blood test Repeat fecal occult blood test

Flexible sigmoidoscopy Flexible sigmoidoscopy

Repeat fecal occult blood test and flexible sigmoidoscopy Repeat fecal occult blood test and flexible sigmoidoscopy

Double-contrast barium enema examination Double-contrast barium enema examination

ColonoscopyColonoscopy


If the result of a screening test is abnormalIf the result of a screening test is abnormal, physicians should , physicians should recommend a complete structural examination of the colon and recommend a complete structural examination of the colon and rectum by rectum by colonoscopy colonoscopy (or flexible sigmoidoscopy and double (or flexible sigmoidoscopy and double contrast barium enema if colonoscopy is not available).contrast barium enema if colonoscopy is not available).

Offer yearly screening with fecal occult blood test (FOBT) using a Offer yearly screening with fecal occult blood test (FOBT) using a guaiac-based test with dietary restriction or an immunochemical guaiac-based test with dietary restriction or an immunochemical test without dietary restriction. Two samples from each of 3 test without dietary restriction. Two samples from each of 3 consecutive stools should be examined without rehydration. consecutive stools should be examined without rehydration. Patients with a positive test on any specimen should be followed Patients with a positive test on any specimen should be followed

up with colonoscopyup with colonoscopy..

Case 3Case 3

A 32-year-old man comes for an annual health maintenance visit. His A 32-year-old man comes for an annual health maintenance visit. His mother was diagnosed with colorectal cancer at 65 years of age. The mother was diagnosed with colorectal cancer at 65 years of age. The patient reports no rectal bleeding or other symptoms. Medical history is patient reports no rectal bleeding or other symptoms. Medical history is noncontributory except for hypercholesterolemia. Physical examination is noncontributory except for hypercholesterolemia. Physical examination is normal. When should this patient first undergo colorectal cancer screening? normal. When should this patient first undergo colorectal cancer screening?

Now, then every 5 years Now, then every 5 years

At age 40 years, then every 10 yearsAt age 40 years, then every 10 years

At age 40 years, then every 5 years At age 40 years, then every 5 years

At age 45 years At age 45 years


ACS/AGA RecommendationsACS/AGA Recommendations

People with a first-degree relativePeople with a first-degree relative with colon cancer or with colon cancer or adenomatous polyp diagnosed at adenomatous polyp diagnosed at age age >>60 years60 years or 2 second- or 2 second-degree relatives with colorectal cancer should be advised to be degree relatives with colorectal cancer should be advised to be screened as average risk persons, screened as average risk persons, but beginning at age 40 years.but beginning at age 40 years.

People with 1 second-degree relative (grandparent, aunt, or People with 1 second-degree relative (grandparent, aunt, or uncle) or third-degree relative (great-grandparent or cousin) with uncle) or third-degree relative (great-grandparent or cousin) with colorectal cancer should be advised to be screened as average colorectal cancer should be advised to be screened as average risk persons.risk persons.

Case 4Case 4

A 32-year-old man comes for an annual health maintenance visit. His A 32-year-old man comes for an annual health maintenance visit. His mother was diagnosed with colorectal cancer at 55 years of age. The mother was diagnosed with colorectal cancer at 55 years of age. The patient reports no rectal bleeding or other symptoms. Medical history is patient reports no rectal bleeding or other symptoms. Medical history is noncontributory except for hypercholesterolemia. Physical examination is noncontributory except for hypercholesterolemia. Physical examination is normal. When should this patient first undergo colorectal cancer screening? normal. When should this patient first undergo colorectal cancer screening?

Now, then every 10 years Now, then every 10 years






People with a first-degree relative (parent, sibling, or child) with colon cancer or adenomatous polyps diagnosed at age <60 years or 2 first-degree relatives diagnosed with colorectal cancer at any age should be advised to have screening colonoscopy starting at age 40 years or 10 years younger than the earliest diagnosis in their family, whichever comes first, and repeated every 5 years.

Case 5Case 5

A 65-year-old woman underwent initial colonoscopy 1 month ago for A 65-year-old woman underwent initial colonoscopy 1 month ago for colorectal cancer screening. A 6-mm tubular adenoma of the sigmoid colon colorectal cancer screening. A 6-mm tubular adenoma of the sigmoid colon was found and removed during the examination. The patient has no family was found and removed during the examination. The patient has no family history of colorectal cancer. Which of the following is the most appropriate history of colorectal cancer. Which of the following is the most appropriate recommendation for colorectal cancer surveillance for this patient?recommendation for colorectal cancer surveillance for this patient?

Repeat colonoscopy in 1 year Repeat colonoscopy in 1 year

Repeat colonoscopy in 3 years Repeat colonoscopy in 3 years


Flexible sigmoidoscopy in 5 years Flexible sigmoidoscopy in 5 years

Virtual colonoscopy (CT colonography) in 5 yearsVirtual colonoscopy (CT colonography) in 5 years


Patients who have had 1 or more adenomatous polyps removed Patients who have had 1 or more adenomatous polyps removed at colonoscopy should be managed according to the findings on at colonoscopy should be managed according to the findings on that colonoscopy.that colonoscopy.

Patients who have had numerous adenomas, a malignant Patients who have had numerous adenomas, a malignant adenoma (with invasive cancer), a large sessile adenoma, or an adenoma (with invasive cancer), a large sessile adenoma, or an incomplete colonoscopy should have a short interval follow-up incomplete colonoscopy should have a short interval follow-up colonoscopy based on clinical judgment. Patients who have colonoscopy based on clinical judgment. Patients who have advanced or multiple adenomas (advanced or multiple adenomas (>>3) should have their first follow-3) should have their first follow-up colonoscopy in 3 years. up colonoscopy in 3 years. Patients who have 1 or 2 small (<1 Patients who have 1 or 2 small (<1 cm) tubular adenomas should have their first follow-up cm) tubular adenomas should have their first follow-up colonoscopy at 5 years. colonoscopy at 5 years.

Case 6Case 6

A 45-year-old woman is undergoing evaluation to determine the cause of A 45-year-old woman is undergoing evaluation to determine the cause of iron deficiency anemia. The patient is otherwise healthy, and family history iron deficiency anemia. The patient is otherwise healthy, and family history is unremarkable. Colonoscopy shows a 2-cm villous adenoma in the is unremarkable. Colonoscopy shows a 2-cm villous adenoma in the sigmoid colon; the adenoma is removed during the procedure. In addition to sigmoid colon; the adenoma is removed during the procedure. In addition to counseling regarding screening of family members, which of the following is counseling regarding screening of family members, which of the following is most appropriate at this time? most appropriate at this time?

Repeat colonoscopy in 6 months Repeat colonoscopy in 6 months



Repeat colonoscopy in 5 yearsRepeat colonoscopy in 5 years

Annual fecal occult blood testing Annual fecal occult blood testing

Referral for left hemicolectomyReferral for left hemicolectomy

ACS RecommendationsACS Recommendations

Patients with 3-10 adenomas, any Patients with 3-10 adenomas, any adenoma adenoma >>1 cm1 cm, any adenoma , any adenoma with with villous featuresvillous features, or high-grade dysplasia should have their , or high-grade dysplasia should have their next next follow-up colonoscopy within 3 yearsfollow-up colonoscopy within 3 years. .

Case 7Case 7 A 35-year-old man with a 10-year history of ulcerative colitis involving the A 35-year-old man with a 10-year history of ulcerative colitis involving the

entire colon comes for a follow-up office visit. A small bowel follow-through entire colon comes for a follow-up office visit. A small bowel follow-through radiographic series obtained at the time of diagnosis was normal. The radiographic series obtained at the time of diagnosis was normal. The patient is doing well on mesalamine maintenance therapy. He has only patient is doing well on mesalamine maintenance therapy. He has only occasional diarrhea and bleeding and has rarely required corticosteroids. A occasional diarrhea and bleeding and has rarely required corticosteroids. A colonoscopic examination with biopsies 1 month ago showed changes of colonoscopic examination with biopsies 1 month ago showed changes of chronic ulcerative colitis but no signs of dysplasia. Which of the following chronic ulcerative colitis but no signs of dysplasia. Which of the following surveillance options is most appropriate for this patient? surveillance options is most appropriate for this patient?

Repeat colonoscopy with biopsies starting at age 50; then repeat Repeat colonoscopy with biopsies starting at age 50; then repeat examination every 5 years examination every 5 years Repeat colonoscopy with biopsies now; then repeat examination every 5 Repeat colonoscopy with biopsies now; then repeat examination every 5 years years Repeat colonoscopy with biopsies now; then repeat examination every 1 to Repeat colonoscopy with biopsies now; then repeat examination every 1 to 2 years 2 years Colonoscopy with biopsies only if the patient has symptoms refractory to Colonoscopy with biopsies only if the patient has symptoms refractory to medical therapy medical therapy Barium enema examination or virtual colonoscopy (CT colonography) now; Barium enema examination or virtual colonoscopy (CT colonography) now; repeat studies every 1 to 2 yearsrepeat studies every 1 to 2 years


In patients with inflammatory bowel disease ( UC or Crohn’s), cancer risk begins to be significant 8 years after the onset of pancolitis, or 12-15 years after the onset of left-sided colitis

Colonoscopy with biopsies for dysplasia. Every 1-2 years. These patients are best referred to a center with experience in the surveillance and management of inflammatory bowel disease

Case 8Case 8

A 24 year old woman comes for a general physical examination. A 24 year old woman comes for a general physical examination. She feels well and is asymptomatic. Medical history is significant She feels well and is asymptomatic. Medical history is significant only for tonsillectomy at the age of 12. She takes no medications or only for tonsillectomy at the age of 12. She takes no medications or over-the-counter drugs. 10 years ago, her father was diagnosed over-the-counter drugs. 10 years ago, her father was diagnosed with familial adenomatous polyposis. Physical examination is with familial adenomatous polyposis. Physical examination is normal. Results of routine laboratory studies are also normal. Which normal. Results of routine laboratory studies are also normal. Which of the following is the most appropriate next step in managing this of the following is the most appropriate next step in managing this patient? patient?

Colonoscopy every year starting at age 50 Colonoscopy every year starting at age 50 Colonoscopy every year starting at age 20-25Colonoscopy every year starting at age 20-25Colonoscopy every 2-3 years starting at age 20-25 Colonoscopy every 2-3 years starting at age 20-25 Yearly stools for occult blood and flexible sigmoidoscopy (beginning Yearly stools for occult blood and flexible sigmoidoscopy (beginning at puberty)at puberty)Refer for colectomyRefer for colectomy


People who have a genetic diagnosis of familial adenomatous polyposis People who have a genetic diagnosis of familial adenomatous polyposis (FAP), or are at risk of having FAP but genetic testing has not been (FAP), or are at risk of having FAP but genetic testing has not been performed or is not feasible, performed or is not feasible, should have annual sigmoidoscopy, should have annual sigmoidoscopy, beginning at age 10-12 yearsbeginning at age 10-12 years, to determine if they are expressing the , to determine if they are expressing the genetic abnormality. Genetic testing should be considered in patients with genetic abnormality. Genetic testing should be considered in patients with FAP who have relatives at risk. Genetic counseling should guide genetic FAP who have relatives at risk. Genetic counseling should guide genetic testing and considerations of colectomy.testing and considerations of colectomy.

Case 9Case 9

32-year-old man comes for an annual health maintenance visit. 32-year-old man comes for an annual health maintenance visit. Family history is positive for hereditary nonpolyposis colorectal Family history is positive for hereditary nonpolyposis colorectal cancer. The patient reports no rectal bleeding or other symptoms. cancer. The patient reports no rectal bleeding or other symptoms. Medical history is noncontributory except for hypercholesterolemia. Medical history is noncontributory except for hypercholesterolemia. Physical examination is normal. When should this patient first Physical examination is normal. When should this patient first undergo colorectal cancer screening?undergo colorectal cancer screening?

Now Now At age 35 At age 35 At age 40 years At age 40 years At age 45 years At age 45 years At age 50 yearsAt age 50 years


People with a genetic or clinical diagnosis of hereditary People with a genetic or clinical diagnosis of hereditary nonpolyposis colorectal cancer (HNPCC) or nonpolyposis colorectal cancer (HNPCC) or who are at increased who are at increased risk for HNPCC should have colonoscopy every 1-2 years risk for HNPCC should have colonoscopy every 1-2 years beginning at age 20-25 years, or 10 years earlier than the beginning at age 20-25 years, or 10 years earlier than the youngest age of colon cancer diagnosis in the family--whichever youngest age of colon cancer diagnosis in the family--whichever comes firstcomes first. Genetic testing for HNPCC should be offered to first-. Genetic testing for HNPCC should be offered to first-degree relatives of persons with a known inherited mismatch degree relatives of persons with a known inherited mismatch repair (MMR) gene mutation. repair (MMR) gene mutation.

Case 10Case 10

Three months ago, a 62-year-old man underwent segmental sigmoid colon Three months ago, a 62-year-old man underwent segmental sigmoid colon resection for a near-obstructing colorectal cancer found on flexible resection for a near-obstructing colorectal cancer found on flexible sigmoidoscopy. Surgery was considered curative, and the patient did not sigmoidoscopy. Surgery was considered curative, and the patient did not require postoperative chemotherapy or radiation therapy. He has no require postoperative chemotherapy or radiation therapy. He has no personal or family history of colorectal cancer or polyps. On a follow-up visit personal or family history of colorectal cancer or polyps. On a follow-up visit today, he feels well. Physical examination is normal. Which of the following today, he feels well. Physical examination is normal. Which of the following is the most appropriate colorectal cancer surveillance procedure for this is the most appropriate colorectal cancer surveillance procedure for this patient? patient?

Colonoscopy now Colonoscopy now Colonoscopy in 3 monthsColonoscopy in 3 monthsColonoscopy in 1 year Colonoscopy in 1 year Colonoscopy in 3 years Colonoscopy in 3 years CT scan of the abdomen now CT scan of the abdomen now CT scan of the abdomen in 3 yearsCT scan of the abdomen in 3 years


Patients with a colon cancer that has been resected with curative Patients with a colon cancer that has been resected with curative intent should have a colonoscopy around the time of initial intent should have a colonoscopy around the time of initial diagnosis to rule out synchronous neoplasms. diagnosis to rule out synchronous neoplasms. If the colon is If the colon is obstructed preoperatively, colonoscopy can be performed obstructed preoperatively, colonoscopy can be performed approximately 6 months after surgeryapproximately 6 months after surgery. If this or a complete . If this or a complete preoperative examination is normal, subsequent colonoscopy preoperative examination is normal, subsequent colonoscopy should be offered after 3 years, and then, if normal, every 5 years.should be offered after 3 years, and then, if normal, every 5 years.

Case 11Case 11

A 67-year-old man undergoes diagnostic colonoscopy after he has a A 67-year-old man undergoes diagnostic colonoscopy after he has a positive fecal occult blood test. A sigmoid colon cancer is found. The positive fecal occult blood test. A sigmoid colon cancer is found. The remainder of the colonoscopic examination is normal, and a CT scan of the remainder of the colonoscopic examination is normal, and a CT scan of the abdomen shows no findings suggestive of metastatic disease. The serum abdomen shows no findings suggestive of metastatic disease. The serum carcinoembryonic antigen (CEA) level is slightly elevated. The patient carcinoembryonic antigen (CEA) level is slightly elevated. The patient undergoes resection of the sigmoid colon with good results. Postoperative undergoes resection of the sigmoid colon with good results. Postoperative recommendations include follow-up office visits every 3 months for 3 years, recommendations include follow-up office visits every 3 months for 3 years, CEA measurement, and surveillance colonoscopy. When should the first CEA measurement, and surveillance colonoscopy. When should the first surveillance colonoscopy be performed? surveillance colonoscopy be performed?

In 1 year In 1 year In 3 years In 3 years In 5 years In 5 years Only if the CEA level increasesOnly if the CEA level increases


Patients with a colon cancer that has been resected with curative Patients with a colon cancer that has been resected with curative intent should have a colonoscopy around the time of initial intent should have a colonoscopy around the time of initial diagnosis to rule out synchronous neoplasms. If the colon is diagnosis to rule out synchronous neoplasms. If the colon is obstructed preoperatively, colonoscopy can be performed obstructed preoperatively, colonoscopy can be performed approximately 6 months after surgery. approximately 6 months after surgery. If this or a complete If this or a complete preoperative examination is normal, subsequent colonoscopy preoperative examination is normal, subsequent colonoscopy should be offered after 3 yearsshould be offered after 3 years, and then, if normal, every 5 years., and then, if normal, every 5 years.

Case 12Case 12

A 47-year-old woman is evaluated for abdominal discomfort of 3 months' A 47-year-old woman is evaluated for abdominal discomfort of 3 months' duration accompanied by a change in stool caliber. Her medical history is duration accompanied by a change in stool caliber. Her medical history is otherwise noncontributory, and her family history is unremarkable. Physical otherwise noncontributory, and her family history is unremarkable. Physical examination, including rectal examination, is normal. Results of fecal occult examination, including rectal examination, is normal. Results of fecal occult blood testing are positive. Colonoscopy reveals a 3-cm sigmoid tumor blood testing are positive. Colonoscopy reveals a 3-cm sigmoid tumor confirmed as adenocarcinoma on biopsy. On resection of the mass, tumor confirmed as adenocarcinoma on biopsy. On resection of the mass, tumor invasion of the muscularis propria is identified, in addition to metastases in invasion of the muscularis propria is identified, in addition to metastases in one regional lymph node. The postoperative recovery is uneventful, and the one regional lymph node. The postoperative recovery is uneventful, and the patient presents for a follow-up office visit. Which of the following is the most patient presents for a follow-up office visit. Which of the following is the most appropriate next step in management? appropriate next step in management?

Adjuvant chemotherapy Adjuvant chemotherapy Radiation therapy Radiation therapy Observation Observation Immunohistochemical staining of tumorImmunohistochemical staining of tumor

Colon Cancer ClassificationColon Cancer Classification StageStage ExtentExtent Adjuvant Adjuvant

chemotherapy chemotherapy indicatedindicated

5 year survival5 year survival

Stage 0Stage 0 IntramucosalIntramucosal NoNo 100%100%

Stage 1Stage 1 Submucosa/Submucosa/Muscularis Muscularis mucosaemucosae

NoNo 95%95%

Stage 2AStage 2A SubserosaSubserosa NoNo 85% 85%

Stage 2BStage 2B PerforationPerforation NoNo 75% 75%

Stage 3Stage 3 Lymph nodesLymph nodes

(LN)(LN)

YesYes 65% for up to 65% for up to 3+LN, 45% 3+LN, 45% FOR>4LNFOR>4LN

Stage 4Stage 4 Distant diseaseDistant disease YesYes 5%5%

Adjuvant chemotherapy after surgeryAdjuvant chemotherapy after surgery

Adjuvant systemic chemotherapy after resection of node positive Adjuvant systemic chemotherapy after resection of node positive colon cancer is associated with 30% reduction in the risk of disease colon cancer is associated with 30% reduction in the risk of disease recurrence, and 22 to 32% reduction in mortality.recurrence, and 22 to 32% reduction in mortality.

Remember for Remember for colon cancer only in stage 3 disease – adjuvant colon cancer only in stage 3 disease – adjuvant chemotherapy with oxaliplatin plus 5-FU and leucovorin.chemotherapy with oxaliplatin plus 5-FU and leucovorin.

For rectal cancer: stage 2 and 3 diseaseFor rectal cancer: stage 2 and 3 disease : adjuvant chemotherapy + : adjuvant chemotherapy + radiation radiation

Questions ?Questions ?

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General Medicine Subspecialty Conference Colon Cancer Screening General Medicine Subspecialty Conference Colon Cancer Screening Selim Krim, MD Assistant