Colorectal Cancer Screening

Jesse Samuel Moore, MDa,*, Tess Hannah Aulet, MDb

 Introduction
Colorectal cancer (CRC) is common in the United
States.
It is the third leading cause of cancer death in men and
women.
Nearly all CRCs begin as small adenomatous polyps, so
it is a disease in which screening, particularly with
colonoscopy.
The rates of screening for patients 50 to 75 years old
from 2002 to 2010 increased from 52% to 65%,3 and
the annual incidence of new colon cancers in the same
time period declined by 2% to 4%.
 Introduction
It is important for surgeons to understand the
rationale for screening, cancer risk
stratification, available screening procedures,
current guidelines, and the outcomes of
screening.
This understanding allows careful counseling
of patients and their families.
Cancers found during screening are typically
earlier stage and more likely to be curable.
 CAUSE AND PATHOPHYSIOLOGY
Risk Factors:
Age is the most significant risk factor in developing
CRC
Race and ethnicity
Hereditary factors (HNPCC and FAP)
Diets high in processed and red meats
Alcohol use
Smoking
Obesity
 CAUSE AND PATHOPHYSIOLOGY
Protective Factors:
A healthy body weight and routine physical
activity
Aspirin (acetylsalicylic acid [ASA]) and NSAIDs
Dietary supplementation with vitamins A, C, E,
and D; folate; and fiber
Calcium supplementation
 CAUSE AND PATHOPHYSIOLOGY
Adenoma-Carcinoma Sequence
Adenomatous polyps are precursors for most CRCs
it takes approximately 10 years for an adenoma to
transform into a carcinoma
 SCREENING RATIONALE
Symptoms for CRC often develop late in the
natural course of the disease.
Precursor or early lesions rarely cause symptoms,
which is why early detection with screening is
important.
The detection of adenomas and removal with
screening disrupts the adenoma-carcinoma
sequence.
Once a patient is diagnosed with adenomas or
CRC, they are no longer in the screening category
and are placed in a surveillance program.
Defining Patients Risk
 SCREENING PROCEDURES
There are several options for CRC screening:
Stool-based tests : Guaiac Fecal Occult Blood Test
(gFOBT), Fecal Immunochemical Test (FITS),
combination FITS-DNA
Radiographic test: Computed Tomography
Colonography (CTC), double-contrast barium
enema (DCBE)
Endoscopic test:
Has diagnostic and therapeutic capabilities
Sigmoidocscopy (FSIG), Colonoscopy
 STOOL-BASED TESTS
Guaiac fecal occult blood testing (gFOBT)
detects heme via a peroxidase reaction.
Restrictive diet is no longer recommended.
High doses of vitamin C can cause a false-
positive and should be avoided before testing.
Patients apply stool to a guaiac card from 3
consecutive bowel movements.
A positive gFOBT requires follow-up
colonoscopy.
 STOOL-BASED TESTS
Fecal immunochemical tests (FITs) use antibodies
that are specific to the globin moiety of hemoglobin.
No pretesting dietary changes are needed, Only a
single stool card is needed.
FIT tests are specific to blood that is colonic in origin,
Its Sensitivity is similar to the sensitivity of gFOBT.
 STOOL-BASED TESTS
The most recent testing: FIT + DNA testing: higher single-
test sensitivity than FIT alone, the specificity is lower than
that of FIT alone.
Stool-based tests have some advantages compared with
radiographic or endoscopic techniques.
Stoolbased testing is unable to detect most polyps because
most polyps do not bleed.
Any abnormal stool-based test requires subsequent
colonoscopy and a small number of these are false-
positives.
The annual (gFOBT, FIT) or every-3-year (fecal DNA) interval
may be more frequent than some patients wish to endure.
 Radiographic Tests
Protocols for Computed tomography colonography (CTC) remain variable
across studies.
Most studies and guidelines include a full mechanical bowel prep before
CTC, but other studies have been performed on unprepped colons.
In addition, the number of scanner detectors, the reconstruction
techniques, and the slice thickness have not been standardized.
There is agreement that lesions larger than 10 mm need to be referred for
colonoscopy.
For lesions between 6 and 9 mm there is less consensus. Some guidelines
recommend follow-up CTC in 3 years, whereas the ACR recommends
colonoscopy.
Whether there is a real increase in lifetime cancer risk as a result of
episodic radiation exposure from radiographic studies is debated.
 ENDOSCOPIC SCREENING
Endoscopic screening can be performed with
either sigmoidoscopy or colonoscopy; offer the
advantage of both diagnostic and therapeutic
capabilities
With this technique, direct visualization of the
large intestinal mucosa is possible with the goal
of identifying early or precancerous lesions.
Removal of adenomas has served as the primary
prevention of CRC.
These procedures are invasive procedures and
involve risk.
 SIGMOIDOSCOPY FLEXIBLE
SIGMOIDOSCOPY (FSIG)
FSIG allows endoscopic examination of the rectum,
sigmoid, and descending colon.
If a lesion is identified, it may be removed or biopsied.
Data on the sensitivity of this procedure are limited
FSIG is 60% to 70% as sensitive for detecting CRC and
advanced adenomas as colonoscopy.
The sensitivity of this screening modality may vary with
age, gender, and race because some studies have
shown variability in the prevalence of proximal
adenomas based on these factors
 SIGMOIDOSCOPY FLEXIBLE
SIGMOIDOSCOPY (FSIG)
This procedure typically takes less time than a
colonoscopy.
There is a potential to miss as many as one-third of
adenomas and CRCs.
Effectiveness of FSIG depends on the endoscopists
ability.
If a sigmoidoscopy is abnormal, patients may be
referred for a full endoscopic examination with
colonoscopy.
The rate of referral to a colonoscopy after a screening
FSIG is variable because of the lack of standard referral
criteria, and ranges from 5% to 33%
 SIGMOIDOSCOPY
The most common risks associated with sigmoidoscopy
include bleeding and perforation.
The risk of perforation is 1 in every 10,000 procedures.
Risk for major bleeding events is estimated to be 2 in
10,000 procedures.
However, screening sigmoidoscopy may lead to referral for
colonoscopy and additional risk for perforation and
bleeding may occur.
There is variability in the screening interval
recommendations for FSIG.
In general, FSIG should be performed every 5 years after a
normal examination and may be combined with fecal-
based studies to increase sensitivity.
SCREENING RECOMMENDATIONS
Recommendations for Average Risk
Recommendations for Personal History
of Colorectal Cancer or Adenoma
The NCCN has stated that individuals with a
history of adenomatous polyps should be placed
in a surveillance program.
In patients with prior adenoma removal,
screening interval recommendation depends on
size, histology, degree of removal, and quantity.
Individuals with advanced adenomas (>10 mm,
villous features, or high-grade dysplasia) should
undergo colonoscopy every 3 years.
Patients who undergo resection for CRC should
have colonoscopy at 1 year for surveillance.
 Recommendations for Family History
The USMSTF along with the American Cancer Society (ACS) and ACR
published joint guidelines in 2008, which stated that individuals
with a family history of either CRC or adenomatous polyp in a first-
degree relative should initiate screening with colonoscopy at 40
years of age or 10 years before first diagnosis.
If adenoma or CRC is diagnosed in a first-degree relative before the
age of 60 years, the screening interval should be 5 years; otherwise
they follow the interval of average-risk individuals.
NCCN guidelines differ in that, if a first-degree relative with CRC is
more than 60 years of age, they recommend initiating screening at
age 50 years.
Both the USMSTF and NCCN state that an individual with 2 first-
degree relatives with CRC at any age should initiate screening at age
40 years or 10 years before earliest diagnosis of CRC and undergo 5-
year interval screening.
Recommendations for Lynch Syndrome and
Familial Adenomatous Polyposis
Screening was recommended to be every 1 to 2 years
starting at age 20 to 25 years or 10 years before the
earliest diagnosis of CRC in a first-degree relative.
For patients with diagnosed or suspected FAP, initiating
screening with FSIG annually starting at age 10 to 12
years is recommended.
This approach allows for assessment of gene
expression.
Colonoscopy can also be performed as a screening
method.
For both HNPCC and FAP, counseling on genetic testing
is recommended
 Recommendations for Inflammatory
Bowel Disease
The USPSTF/ACS/ACR guidelines from 2008
recommend initiating screening colonoscopy
with biopsies for dysplasia every 1 to 2 years,
8 years after a diagnosis of pancolitis or 12 to
15 years after diagnosis of left-sided colitis.
The NCCN recommends initiation of
surveillance with colonoscopy 8 to 10 years
after the onset of symptoms for both patients
with UC and patients with Crohns disease.
 Recommendations for the Elderly
After the age of 75 years, the benefit of early detection
and intervention from screening declines.
Screening CRC for Patients aged 76 to 85 years should
be individualized.
Factors such as presence of comorbidities that may
limit life expectancy or preclude treatment if cancer is
detected, as well as prior screening history, are
important to include when counseling these patients.
Patients in this age group who have never been
screened are more likely to benefit from screening.
The USPSTF does not recommend screening in
individuals more than 86 years old.
 SUMMARY
Screening and early intervention of CRC reduces
mortality.
It is important to understand basic screening rationale
and how to risk stratify patients, and to have a familiarity
with the recommendations in order to make the
appropriate recommendations based on the individuals
risk of CRC.
Colonoscopy remains the screening tool with the highest
sensitivity for cancer and precancerous polyps, and it is
also the only modality to allow therapeutic interventions
for the entire colon.
Thank You