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Colorectal Cancer Screening

M3 Teaching Session

Why do we screen?
Early detection of colorectal cancer
Improved survival at earlier stages

Prevention of colorectal cancer

Removal of premalignant lesions Size, Histology, Number of polyps

Staging and Survival, US 1999-2005

Jemal, 2010

Methods of Screening
FOBT (gFOBT, FIT) sDNA (stool)

Flexible sigmoidoscopy Colonoscopy DCBE double contrast barium enema CTC CT colonography


Identify fecal blood or genetic mutations Collection Storage Frequency Detection but not Intervention

Flexible Sigmoidoscopy and Colonoscopy

Require bowel prep Sedation vs non-sedated Ability to intervene on premalignant (polypectomy) or malignant (biopsies) abnormalities Operator dependent Low invasive procedure

Colonoscopy and Polypectomy

Case 1
40 yo AA M presents for HTN recheck
Takes HCTZ Otherwise healthy, asymptomatic

Family history
Mother died of colon cancer Sister and Aunt had breast cancer

Case 2
53 yo F presents for routine f/u
Takes Pentasa History of Ulcerative Colitis Takes Urosdiol Recently diagnosed with PSC

Case 3
55 yo M presents with cough
Does not see a doctor regularly Not interested in screening procedures

Who to screen and when

Average risk, asymptomatic pts Pts with inflammatory bowel disease Pts with family history of colon cancer Pts with family history of colon polyps Pts with personal history of polyps

Average risk, asymptomatic patients

Start at age 50

Patients with inflammatory bowel disease

Start 8 years after onset of disease

Patients with PSC

Start at time of PSC diagnosis

Patients with family history

First degree relative age 60 or older
Start at age 40

First degree relative age 59 or younger

Start at age 40 or 10 yrs earlier than youngest case in immediate family

Patients with FAP

Start at age 10, MANY polyps APC gene mutation

Patients with HNPCC (lynch syndrome)

Start at age 20 or 10 yrs earlier than youngest case in immediate family Error in mismatch repair -> accumulation of mutations
More prevalent in rapidly dividing tissues

Risk factors
Obesity Lack of physical activity Diabetes Diet (red / processed meats) Smoking Excessive alcohol

Family history of colon cancer Inflammatory bowel disease Diabetes Race

The bottom line

Identify risk factors
Family history, Race, Inflammatory bowel ds, PSC

Which test to use

Discuss with patients

Get your patients screened!!!

Reference Materials
Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline from the ACS, USMSTF, ACR ACG Guidelines for Colorectal Cancer Screening 2008 NCCN Clinical Practice Guidelines for Colorectal Cancer Screening