Colorectal Cancer ScreeningColorectal Cancer Screening

VT SGNA ConferenceVT SGNA Conference

October 24, 2015October 24, 2015

Lynn Butterly, MDLynn Butterly, MD

Director, Colorectal Cancer ScreeningDirector, Colorectal Cancer Screening

Dartmouth-Hitchcock Medical CenterDartmouth-Hitchcock Medical Center

Rationale for ScreeningRationale for Screening

Second most common cause of Second most common cause of death from cancer in the U.S.death from cancer in the U.S.

PreventionPrevention as well as Early as well as Early DetectionDetection

Almost all CRC begins as a polypAlmost all CRC begins as a polyp

Prevention vs. Early Prevention vs. Early DetectionDetection

Comparison to mammographyComparison to mammography

Prevention Focus: Incidence of Prevention Focus: Incidence of colorectal cancer at screening colorectal cancer at screening colonoscopies is extremely smallcolonoscopies is extremely small

Incidence of polyps is Incidence of polyps is at leastat least 40%40%

CRC Screening TestsCRC Screening Tests

Fecal Occult Blood Testing (gFOBT/ FIT)Fecal Occult Blood Testing (gFOBT/ FIT) Stool DNA (Cologuard)Stool DNA (Cologuard) Flexible Sigmoidoscopy (average risk pts.)Flexible Sigmoidoscopy (average risk pts.) (Air Contrast Barium Enema)(Air Contrast Barium Enema) ColonoscopyColonoscopy Virtual Colonoscopy (CTC) Virtual Colonoscopy (CTC) (PillCam for incomplete colonoscopy)(PillCam for incomplete colonoscopy)

Hemoccult TestingHemoccult Testing

Large, worldwide trials have shown that Large, worldwide trials have shown that Hemoccult testing can reduce mortality Hemoccult testing can reduce mortality from colorectal cancerfrom colorectal cancer

Ease of use: can do at home, inexpensiveEase of use: can do at home, inexpensive

Not within 5-10 years after colonoscopy Not within 5-10 years after colonoscopy

(Positive is always considered positive)(Positive is always considered positive)

Fecal Occult Blood Fecal Occult Blood TestingTesting

High sensitivity test recommendedHigh sensitivity test recommended

Colonoscopy is recommended for any Colonoscopy is recommended for any positive FOBT (both guaiac and FIT)positive FOBT (both guaiac and FIT)

In-office DRE FOBT is not appropriate In-office DRE FOBT is not appropriate for CRC screening (and is no longer for CRC screening (and is no longer reimbursable by CMS for screening)reimbursable by CMS for screening)

Problems with HemoccultsProblems with Hemoccults

Not specific for Not specific for humanhuman hemoglobin hemoglobin– For example, a rare steak can interfereFor example, a rare steak can interfere

Certain foods and drugs can interfereCertain foods and drugs can interfere Even if it detects true blood loss, Even if it detects true blood loss,

does not differentiate the source of does not differentiate the source of bleedingbleeding

Fecal Occult Blood Tests - Fecal Occult Blood Tests - FITFIT

Fecal Immunochemical Fecal Immunochemical TestingTesting

FECAL IMMUNOCHEMICAL TESTING FECAL IMMUNOCHEMICAL TESTING (FIT)(FIT)

FITs use antibodies to human globin and are FITs use antibodies to human globin and are therefore therefore specific for bleedingspecific for bleeding vs. diet or vs. diet or medication effect (avoids some g-FOBT medication effect (avoids some g-FOBT pitfalls)pitfalls)

FIT has FIT has better sensitivity better sensitivity than guaiac testing; than guaiac testing; still has ease of use for patientsstill has ease of use for patients

FITs have been FITs have been widely used and testedwidely used and tested throughout the world. Some studies show throughout the world. Some studies show higher detection rates for both advanced higher detection rates for both advanced adenomas and cancer than g-FOBTadenomas and cancer than g-FOBT

FIT is FIT is reimbursablereimbursable by CMS at $22/test or by CMS at $22/test or more more

CRC Screening TestsCRC Screening Tests

Fecal Occult Blood Testing (FOBT/ FIT)Fecal Occult Blood Testing (FOBT/ FIT) Stool DNA (Cologuard)Stool DNA (Cologuard) Flexible Sigmoidoscopy (average risk pts.)Flexible Sigmoidoscopy (average risk pts.) (Air Contrast Barium Enema)(Air Contrast Barium Enema) ColonoscopyColonoscopy Virtual Colonoscopy (CTC) Virtual Colonoscopy (CTC) (PillCam for incomplete colonoscopy)(PillCam for incomplete colonoscopy)

CologuardCologuard

Approved by FDA for average risk Approved by FDA for average risk screeningscreening

Approved by CMSApproved by CMS Greater sensitivity than FIT for CRC:Greater sensitivity than FIT for CRC:

– CRC: 92% (DNA) vs. 74% (FIT)CRC: 92% (DNA) vs. 74% (FIT)– Advanced polyps: 42% (DNA) vs. 24% (FIT)Advanced polyps: 42% (DNA) vs. 24% (FIT)– SSP > 1cm: 42% (DNA) vs. 5% (FIT)SSP > 1cm: 42% (DNA) vs. 5% (FIT)

Multi-target stool DNAMulti-target stool DNA Current recommended use is every 3 yearsCurrent recommended use is every 3 years Cost is high compared to FOBTCost is high compared to FOBT

CRC Screening TestsCRC Screening Tests

Fecal Occult Blood Testing (FOBT/ FIT)Fecal Occult Blood Testing (FOBT/ FIT) Stool DNA (Cologuard)Stool DNA (Cologuard) Flexible Sigmoidoscopy (average risk pts.)Flexible Sigmoidoscopy (average risk pts.) (Air Contrast Barium Enema)(Air Contrast Barium Enema) ColonoscopyColonoscopy Virtual Colonoscopy (CTC) Virtual Colonoscopy (CTC) (PillCam for incomplete colonoscopy)(PillCam for incomplete colonoscopy)

ColonoscopyColonoscopy

Interrupt the Polyp to Cancer SequenceInterrupt the Polyp to Cancer Sequence

Efficacy of all screening tests for CRC Efficacy of all screening tests for CRC preventionprevention is derived from is derived from polypectomypolypectomy

CRC Screening TestsCRC Screening Tests

Fecal Occult Blood TestingFecal Occult Blood Testing Stool DNAStool DNA Flexible Sigmoidoscopy (average risk pts.)Flexible Sigmoidoscopy (average risk pts.) (Air Contrast Barium Enema)(Air Contrast Barium Enema) ColonoscopyColonoscopy Virtual Colonoscopy (CTC)Virtual Colonoscopy (CTC) Pill Cam for incomplete colonoscopy Pill Cam for incomplete colonoscopy

CRC SCREENING TESTSCRC SCREENING TESTS

“ “VIRTUAL COLONOSCOPY”VIRTUAL COLONOSCOPY”

CComputed omputed TTomographic omographic CColonographyolonography

CTCCTC

CTC ConsiderationsCTC Considerations

First described in 1994 – over 20 years agoFirst described in 1994 – over 20 years ago Included in recent ACS screening recommendationsIncluded in recent ACS screening recommendations Some issues remain to be clarified (CMS decision)Some issues remain to be clarified (CMS decision)

Sensitivity for detecting lesions Sensitivity for detecting lesions Comfort Comfort Cost-effectivenessCost-effectiveness Radiation exposureRadiation exposure

CTC ConsiderationsCTC Considerations

Sensitivity for detecting lesionsSensitivity for detecting lesions Comfort Comfort Cost-effectivenessCost-effectiveness Radiation exposureRadiation exposure

CTC IssuesCTC Issues

Sensitivity for detecting lesionsSensitivity for detecting lesions Comfort Comfort Cost-effectivenessCost-effectiveness

– Need for polypectomyNeed for polypectomy– Extracolonic lesionsExtracolonic lesions

Radiation from repeated CTRadiation from repeated CT

Colorectal CancerColorectal Cancer

RISK FACTORSRISK FACTORS

Screening vs. Screening vs. SurveillanceSurveillance

Risk Factors for Colon Cancer Risk Factors for Colon Cancer Will Will Determine Appropriate Testing Determine Appropriate Testing OptionsOptions

Average RiskAverage Risk:: age over 50, no other hx age over 50, no other hx

Increased RiskIncreased Risk:: Personal History of Colorectal CancerPersonal History of Colorectal Cancer Personal History of Pre-cancerous PolypsPersonal History of Pre-cancerous Polyps Family History Family History of Colorectal Cancer or of Colorectal Cancer or

PolypsPolyps IBDIBD Hereditary Syndromes (FAP, HNPCC)Hereditary Syndromes (FAP, HNPCC)

Family History of Colon Family History of Colon CancerCancer

IMPORTANT FACTORS:IMPORTANT FACTORS:

- - RelationshipRelationship of affected relatives of affected relatives

First Degree: First Degree: parents, siblings, parents, siblings, childrenchildren

- - AgesAges of relatives at time of diagnosis of relatives at time of diagnosis

- - NumberNumber of affected relatives of affected relatives

Increased Risk CRC Increased Risk CRC ScreeningScreening

At what age should we begin At what age should we begin screening a person with a first degree screening a person with a first degree relative diagnosed with CRC at age relative diagnosed with CRC at age 65?65?

A. Age 50A. Age 50

B. Age 55B. Age 55

C. Age 40C. Age 40

D. Age 45D. Age 45

Colorectal Cancer Screening Colorectal Cancer Screening

GUIDELINEGUIDELINE

RECOMMENDATIONSRECOMMENDATIONS

Screening Recommendations for Screening Recommendations for

Average RiskAverage Risk Patients Patients Begin screening at age 50 Begin screening at age 50

Flexible sigmoidoscopy every 5 years withFlexible sigmoidoscopy every 5 years with FOBT every 3 yearsFOBT every 3 years oror FOBT annuallyFOBT annually oror Colonoscopy every 10 years if normal testColonoscopy every 10 years if normal test (or)(or) CTC every 5 years or Stool DNA every 3 yearsCTC every 5 years or Stool DNA every 3 years

CRC Screening and CRC Screening and SurveillanceSurveillance

Increased Risk Increased Risk Recommendations Recommendations

Recommendations for Recommendations for Increased RiskIncreased Risk Patients Patients

FHx: Begin screening at age 40 or 10 FHx: Begin screening at age 40 or 10 years younger than age of relative at years younger than age of relative at diagnosis, diagnosis, whichever comes firstwhichever comes first

(unless hereditary syndrome in family)(unless hereditary syndrome in family) Test of choice is colonoscopy unless Test of choice is colonoscopy unless

there are medical contraindicationsthere are medical contraindications Hereditary syndromes Hereditary syndromes managed by managed by

specialist with much earlier testingspecialist with much earlier testing

Compelling case for CRC Compelling case for CRC ScreeningScreening

Preventable diseasePreventable disease Decrease in incidence over last Decrease in incidence over last

decade shows that screening worksdecade shows that screening works Spend $14 billion/year in US on Spend $14 billion/year in US on

treatment for CRCtreatment for CRC 80% by 2018 Initiative: Decrease 80% by 2018 Initiative: Decrease

CRC and improve public healthCRC and improve public health