Screening for colorectal cancers What ’ s new?. Screening Routine examination of asymptomatic population of a disease Routine examination of asymptomatic

Screening for colorectal Screening for colorectal cancerscancers

WhatWhat’’s new?s new?

Colorectal CancerColorectal Cancer

Suitable for screeningSuitable for screening High incidence among both male and femaleHigh incidence among both male and female 2nd most commonly diagnosed cancer and 2nd most commonly diagnosed cancer and

2nd most common cause for cancer death in 2nd most common cause for cancer death in Hong Kong*Hong Kong*

Benign adenomatous polyps as premalignant Benign adenomatous polyps as premalignant stagestage

Removal of polyps can prevent development Removal of polyps can prevent development into invasive cancerinto invasive cancer

Treatment for invasive cancer well Treatment for invasive cancer well establishedestablished *HK cancer registry 2006

WhatWhat’’s new?s new?

When not to screen?When not to screen? New screening toolsNew screening tools New guidelinesNew guidelines

Who to screen?Who to screen?

Asymptomatic people > 50 yearsAsymptomatic people > 50 years

Start screening earlier for known Start screening earlier for known high risk groupshigh risk groups Personal history of CRCPersonal history of CRC Family history of CRCFamily history of CRC Known inheritance of genetic Known inheritance of genetic

cancer syndromescancer syndromes Inflammatory bowel diseaseInflammatory bowel disease

When not to screen?When not to screen? When harm of screening rises When harm of screening rises

significantly to outweigh the potential significantly to outweigh the potential benefits benefits

First seen in recommendations in year First seen in recommendations in year 20082008

Consider screening for age 76-85 years Consider screening for age 76-85 years for special cases only for special cases only Cat C recommendation*Cat C recommendation*

Do not consider in any case > 85 yearsDo not consider in any case > 85 years Cat D recommendation*Cat D recommendation** Screening for colorectal cancer: US precventive services task force recommendation statement* Screening for colorectal cancer: US precventive services task force recommendation statement

Which screening test to Which screening test to use?use?

USPSTF recommedations 08USPSTF recommedations 08 Screening tests recommended (Cat A)Screening tests recommended (Cat A)

Colonoscopy every 10 yearsColonoscopy every 10 years Annual sensitive FOBT/ FITAnnual sensitive FOBT/ FIT Flexible sigmoidoscopy every 5 years with a mid-Flexible sigmoidoscopy every 5 years with a mid-

interval sensitive FOBT/ FITinterval sensitive FOBT/ FIT Consider stop screening by 75 years old Consider stop screening by 75 years old

(Cat C/D)(Cat C/D) Evidence inadequate to assess benefits and Evidence inadequate to assess benefits and

harms of CT colonography and fecal DNA harms of CT colonography and fecal DNA testingtesting

Ann G. Zauber, Iris Lansdorp-Vogelaar, Amy B. Knudsen, Janneke Wilschut, Marjolein van Ballegooijen, andKaren M. Kuntz Evaluating Test Strategies for Colorectal Cancer Screening: A Decision Analysis for the U.S. Preventive Services Task Force Ann Intern Med. 2008;149:659-669.

Ann G. Zauber, Iris Lansdorp-Vogelaar, Amy B. Knudsen, Janneke Wilschut, Marjolein van Ballegooijen, andKaren M. Kuntz Evaluating Test Strategies for Colorectal Cancer Screening: A Decision Analysis for the U.S. Preventive Services Task Force Ann Intern Med. 2008;149:659-669.

Which screening test to Which screening test to use?use?

ACS-MSTF ACS-MSTF recommendations 08recommendations 08 For detecting polyps + cancerFor detecting polyps + cancer

Colonoscopy 10 yearlyColonoscopy 10 yearly Flexible sigmoidoscopy 5 yearlyFlexible sigmoidoscopy 5 yearly DCBE 5 yearlyDCBE 5 yearly CT colonographyCT colonography

For primarily detecting cancerFor primarily detecting cancer Annual high sensitivity gFOBT/ FITAnnual high sensitivity gFOBT/ FIT Stool DNA test ? IntervalStool DNA test ? Interval

(any positive test would warrant a colonoscopy)(any positive test would warrant a colonoscopy)

* Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology CA Cancer J Clin 2008

* Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology CA Cancer J Clin 2008

Which screening test to use?Which screening test to use?Asia Pacific consensus 2008Asia Pacific consensus 2008

Screening should start at 50 Screening should start at 50 yearsyears

Male sex, smoking, obesity and Male sex, smoking, obesity and family history are risks factorsfamily history are risks factors

Recommended testsRecommended tests FOBT (gFOBT or FIT)FOBT (gFOBT or FIT) Flexible sigmoidoscopyFlexible sigmoidoscopy ColonoscopyColonoscopy

DCBE and CT colonography not DCBE and CT colonography not preferredpreferred

* Asia Pacific Consensus Recommendations for Colorectal cancer screening Gut2008;57:1166-76

What new tools in the What new tools in the current update?current update?

Immunochemical FOBT (FIT)Immunochemical FOBT (FIT) Fecal DNA testingFecal DNA testing CT colonographyCT colonography

Immunochemical FOBT Immunochemical FOBT (FIT)(FIT)

Proposed advantageProposed advantage Detect human globinDetect human globin not subject to false not subject to false ––ve with high dose Vit ve with high dose Vit

CC Globin digested in upper GI tract, more Globin digested in upper GI tract, more

specific for lower GI tract bleedingspecific for lower GI tract bleeding Compare with high senstivity gFOBTCompare with high senstivity gFOBT

Similar in sensitivity and specificitySimilar in sensitivity and specificity*Allison JE, et al. Screening for colorectal neoplasms with new fecal occult blood tests: update on performance characteristics. J Natl Cancer Inst 2007;99:1462–1470 *Gopalswamy N et al. A comparative study of eight fecal occult blood tests and HemoQuant In patients in whom colonoscopy is indicated. Arch Fam Med 1994;3:1043–1048 *Greenberg PD, et al. A prospective multicenter evaluation of new fecal occult blood tests in patients undergoing colonoscopy. Am J Gastroenterol 2000;95:1331–1338 *Wong BC, et al. A sensitive guaiac faecal occult blood test is less useful than an immunochemical test for colorectal cancer screening in a Chinese population. Aliment Pharmacol Ther 2003;18:941–946 *Smith A, et al. Comparison of a brush-sampling fecal immunochemical test for hemoglobin with a sensitive guaiac-based fecal occult blood test in detection of colorectal neoplasia. Cancer 2006;107:2152–2159 *Levi Z, et al. A quantitative immunochemical fecal occult blood test for colorectal neoplasia. Ann Intern Med 2007;146:244–255

Fecal DNA testingFecal DNA testing Variable reported performanceVariable reported performance

sensitivity 52-91% , specificity 93-97%sensitivity 52-91% , specificity 93-97% Better than traditional gFOBTBetter than traditional gFOBT No conclusive difference with high No conclusive difference with high

sensitivity gFOBT/ FITsensitivity gFOBT/ FIT Issue of positive fDNA but Issue of positive fDNA but ––ve Ixve Ix

Newer version now available in marketNewer version now available in market not widely tested not widely tested ?any improvement of performance?any improvement of performance

Best test interval remained unknownBest test interval remained unknown Recommeded by manufacturer to be 5 yearlyRecommeded by manufacturer to be 5 yearly

*Imperiale TF, Ransohoff DF, Itzkowitz SH, et al. Fecal DNA versus fecal occult blood for colorectal-cancer screening in an average-risk population. N Engl J Med 2004;351:2704–2714

CT colonographyCT colonography

Radiological method to examine the colonRadiological method to examine the colon Multidetector CT scanners with 2D and 3D Multidetector CT scanners with 2D and 3D

reconstructionreconstruction Bowel preparation as for colonoscopyBowel preparation as for colonoscopy Stool and Fluid tagging to reduce false Stool and Fluid tagging to reduce false

positive ratespositive rates Colonic distension during scanColonic distension during scan Need training for radiologist for Need training for radiologist for

interpretationinterpretation

CT ColonographyCT Colonography

Preferred over barium enema Preferred over barium enema Colon proximal to an obstructing lesionColon proximal to an obstructing lesion incomplete colonoscopyincomplete colonoscopy

AccuracyAccuracy Similar to colonoscopy for lesions Similar to colonoscopy for lesions

>10mm>10mm (sensitivity 94% specificity 96% for (sensitivity 94% specificity 96% for

>10mm)*>10mm)* Inferior for smaller polyps and flat polypsInferior for smaller polyps and flat polyps

(sensitivity 89% specificity 90% for <6mm)*(sensitivity 89% specificity 90% for <6mm)*Pickhardt PJ, Choi JR, Hwang I, et al. Computed tomographic virtual colonoscopy to screenfor colorectal neoplasia in asymptomatic adults. N Engl J Med 2003;349:2191-200

CT ColonographyCT Colonography

Outstanding issuesOutstanding issues reporting of polyps 5 mm or smallerreporting of polyps 5 mm or smaller threshold polyp size for threshold polyp size for

colonoscopy referralcolonoscopy referral intervals for repeated examinationsintervals for repeated examinations radiation exposureradiation exposure extra-colonic findings and extra-colonic findings and

implicationsimplications Reported 7-15% of CT colonographiesReported 7-15% of CT colonographies- ASGE Techology Committee Update on CT colonography - ASGE Techology Committee Update on CT colonography

Gastrointestinal endoscopy 2009 Vol 69 No 3Gastrointestinal endoscopy 2009 Vol 69 No 3- USPSTF recommendation statement 2008- USPSTF recommendation statement 2008

- ASGE Techology Committee Update on CT colonography - ASGE Techology Committee Update on CT colonography Gastrointestinal endoscopy 2009 Vol 69 No 3Gastrointestinal endoscopy 2009 Vol 69 No 3- USPSTF recommendation statement 2008- USPSTF recommendation statement 2008

RecommendationsRecommendations

TestsTests ACSMSTACSMSTFF

USPSTFUSPSTF USPSTF USPSTF modelingmodeling

Other Other modelingmodeling

Asia Pacific Asia Pacific ConsensusConsensus

Traditional Traditional gFOBTgFOBT

NN YY suboptimalsuboptimal mixedmixed YY

Sensitive Sensitive gFOBT/FITgFOBT/FIT

YY YY YY YY YY

fDNA 5 fDNA 5 yearlyyearly

YY insufficieninsufficient t evidenceevidence

not not evaluatedevaluated

suboptimsuboptimalal


FS 5 yearlyFS 5 yearly YY YY suboptimalsuboptimal suboptimsuboptimalal

YY

CTC 5 CTC 5 yearlyyearly



YY not not preferredpreferred

CC’’scope 10 scope 10 yearlyyearly

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Take Home MessageTake Home Message

Different recommendations for Different recommendations for colorectal screeningcolorectal screening

Most consistently recommended Most consistently recommended for screening of colorectal cancerfor screening of colorectal cancer Colonoscopy 10 yearlyColonoscopy 10 yearly High sensitivity gFOBT/ FIT yearlyHigh sensitivity gFOBT/ FIT yearly

New technology coming upNew technology coming up Stool DNAStool DNA CT colonographyCT colonography

Documents

Screening for colorectal cancers What ’ s new?. Screening Routine examination of asymptomatic population of a disease Routine examination of asymptomatic