1. Colorectal Cancer:
Putting Prevention into Practice
Durado Brooks, MD, MPH
Director, Prostate and Colorectal Cancers

2. Colorectal Cancer
 The third most common cancer in U.S. and the
second deadliest
 141,000 new cases expected this year
 More than 49,000 deaths nationwide
 1.1 million Americans living with colorectal
cancer
 Death rates have fallen steadily over the past 20
years

3. Trends in CRC
CRC incidence and mortality have fallen steadily
over the past 2 decades.
Research suggests that observed declines in
incidence and mortality are due in large part to:
 Screening and polyp removal, preventing progression
of polyps to invasive cancers
 NEJM study Feb 2012 showed polyp removal associated
with 53% lower risk of CRC death
 Screening  detecting cancers at earlier, more
treatable stages
 CRC treatment advances

4. Risk Factors

5. Colorectal Cancer Risk Factors
 Age
 90% of cases occur in people 50 and older
 Gender
 slight male predominance, but common in both men
and women
 Race/Ethnicity
 Increased rates documented in African Americans,
Alaska Natives, some American Indian tribes,
Ashkenazi Jews

6. Colorectal Cancer Risk Factors
Modifiable Risk Factors
 Diet
 Obesity
 Physical Activity
 Tobacco
 Alcohol

7. Non-Modifiable Risk Factors
 Increased risk with:
 Personal history of inflammatory bowel disease,
adenomatous polyps or colon cancer
 Family history of adenomatous polyps, colon cancer,
other conditions
 Individuals with these risk factors may require
earlier and more intensive screening
The remainder of this presentation will focus
on the average risk population.

8. Colorectal Cancer
Sporadic (average
risk) (65%–85%)
Family
history
(10%–30%)
Rare
syndrome
s (<0.1%) Hereditary
nonpolyposis
colorectal cancer
Familial (HNPCC) (5%)
adenomatous
polyposis (FAP)
(1%)
CENTERS FOR DISEASE CONTROL
AND PREVENTION

9. Risk Factor - Polyps
Types of polyps:
 Hyperplastic
 minimal cancer
potential
 Adenomatous
 approximately 90%
of colon and rectal
cancers arise from
adenomas

10. Normal to Adenoma to
Carcinoma
Human colon carcinogenesis
progresses by the dysplasia/adenoma
to carcinoma pathway

11. Screening

12. Benefits of Screening
 Cancer Prevention
 Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
 Cost-effective
 Cost of CRC screening compares favorably to many
other common interventions (i.e. mammograms)
 Treatment costs for advanced disease have risen
greatly in recent years
 Improved survival
 Early detection markedly improves chances
of long term survival

13. Benefits of Screening
Survival Rates by Disease Stage*
100 89.8%
90
80 67.7%
70
5-yr 60
50
Survival 40
30
20 10.3%
10
0
Lo cal Reg io n al Distan t
St age of Det ect ion
*1996 - 2003

14. Trends in Recent* CRC Screening Prevalence (%), by
Educational Attainment and Health Insurance Status,
Adults 50-75 Years, US, 2000-2010
Source: Klabunde et al, Cancer Epidemiol Biomarkers Prev 2011;20:1611-1621
National Health Interview Survey Public Use Data File 2010, National Center for Health Statistics, Centers for Disease Control
and Prevention, 2011.
American Cancer Society, Surveillance Research, 2011
.

15. Lower use of colorectal screening
examinations in minority populations

16. Screening Tests

17. ACS Screening Guidelines
Options for Average risk adults age 50 and older:
Tests That Detect Adenomatous Polyps and Cancer
Colonoscopy every 10 years, or
Flexible sigmoidoscopy (FSIG) every 5 years, or
Double contrast barium enema (DCBE) every 5 years, or
CT colonography (CTC) every 5 years
Tests That Primarily Detect Cancer
Guaiac-based fecal occult blood test (gFOBT) with high test
sensitivity for cancer, or
Fecal immunochemical test (FIT) with high test sensitivity for
cancer, or
Stool DNA test (sDNA), with high sensitivity for cancer

18. Recommended Screening Tests
ACS and USPSTF
 High Sensitivity Fecal Occult Blood Testing
 Guaiac
 Immunochemical
 Colonoscopy
 Flexible Sigmoidoscopy (FSIG)
 Recent studies support efficacy

19. Colonoscopy
Colonoscopy
allows doctor to
directly see inside
entire bowel

20. Why Not Colonoscopy for All?
 Screening rates remain disappointingly low
 Evidence does not support “best test” or “gold standard”
 Colonoscopy misses ~ 10% of significant lesions in expert settings
 Higher potential for patient injury than other tests
 Test performance is highly operator dependent
 Greater patient requirements for successful completion
of tests that detect both polyps and cancers
 Requires a bowel prep and facility visit, and often a pre-
procedure specialty office visit (all with associated costs)
 Patient preference
 Many individuals don’t want an invasive test or a test that
requires a bowel prep
 Some may not have access to the invasive tests due to lack
of coverage or local resources

21. Patient Preferences
Inadomi, Arch Intern Med 2012

22. Stool Test: Guaiac
 Most common type in U.S.
 Best evidence (3 RCT’s)
 Need specimens from 3
bowel movements
 Non-specific
 Results influenced by foods
and medications
 Older forms (Hemoccult II)
have unacceptably low
sensitivity
 Better sensitivity with newer
versions (Hemoccult Sensa)

23. Stool Test: Immunochemical (FIT)
 Specific for human blood and for
lower GI bleeding
 Results not influenced by foods
or medications
 Some types require only 1 or 2
stool specimens
 Higher sensitivity than older
forms of guaiac-based FOBT
 Slightly more costly than guaiac
tests
FIT use in the US will likely increase due to recent elimination
of guiaic- based testing by LabCorp and Quest Labs

24. FOBT Quality Issues
Sensitivity of Take Home vs. In-Office
FOBT
Sensitivity
FOBT method All Advanced Cancer
(Hemoccult II) Lesions
3 card, take-home 23.9 % 43.9 %
Single sample, in-
office 4.9 % 9.5 %
Collins et al, Annals of Int Med Jan 2005

25. Stool Testing Quality Issues
 CRC screening by FOBT should be performed with
high-sensitivity FOBT - either FIT or a highly sensitive
gFOBT (such as Hemoccult SENSA).
 Older, less sensitive guiaic tests (such as
Hemoccult II) should not be used for CRC
screening.
 Annual testing
 In-office FOBT is essentially worthless as a screening
tool for CRC and must be strongly discouraged.
 All positive screening tests should be evaluated by
colonoscopy

26. High Quality Stool Testing
Clinicians Reference: FOBT
One page document designed
to educate clinicians about
important elements of colorectal
cancer screening using fecal
occult blood tests (FOBT).
Provides state-of-the-science
information about guaiac and
immunochemical FOBT, test
performance and characteristics
of high quality screening
programs.
Available at
www.cancer.org/colonmd

27. How Can We Improve
Screening Rates?

28. Sub-Optimal Screening Rates
Reasons (according to Patients)
• Low awareness of CRC as a personal health threat
• Lack of knowledge of screening benefits
• Fear, embarrassment, discomfort
• Time
• Cost
• Access
• Structural issues (lack of systems in most settings)
• “My doctor never talked to me about it!”

29. Opportunistic vs. Organized
Preventive Care
 Most preventive care for adults in the U.S. is opportunistic, i.e.
occurs incidentally during encounters with healthcare
professionals
 Opportunistic care depends on a coincidence of encounters,
circumstances, and interests between patient and provider
 This means some adults get some preventive care on some
occasions and at some interval
 Few adults receive the full package, or even the majority of
recommended preventive services

31. “Action Plan” Toolkit Version
 Eight page guide introduces
clinicians and staff to concepts
and tools provided in the full
Toolkit
 Contains links to the full Toolkit,
tools and resources
 Not colorectal-specific; practical,
action-oriented assistance that
can be used in the office to
improve screening rates for
multiple cancer sites (colorectal,
breast and cervical)
Available at
http://nccrt.org/about/provider-
education/crc-clinician-guide/

32. Communication

33. #1: Make a Recommendation
Determine the screening
Essential messages you and your
#1: staff will share with
patients.
Explore how your
Essential practice will assess a
#1: patient’s risk status and
receptivity to screening.

34. Q: Is a Doctor’s Recommendation
Really That Useful?
Gastroenterology Dept
Adapted from Jack Tippit, Saturday Evening Post
Aren’t we bucking human nature with this one?

36. #2 Develop a Screening Policy
Create a standard course
Essential of action for screenings,
#2: document it, and share it.
Compile a list of screening
Essential resources and determine
#2: the screening capacity
available in your
community.

37. Sample Screening Algorithm
Assess Risk: Personal
Sample Tools for Your Practice
& Family History
Average risk = Increased or high risk Increased or high risk
No family history of CRC based on personal
or adenomatous polyp based on family history
history
< 50 years > 50 years
Adenoma CRC IBD
High Risk: Adenoma or
Germline cancer
Do not
Screen Syndrome
screen
Surveillance HNPCC or FAP
Colonoscopy
If positive,
diagnosis by
colonoscopy
Screening Screen with
Options
Tests That Find Polyps and Cancer colonoscopy, genetic colonoscopy 10 years
Flexible sigmoidoscopy every 5 years, or testing, and other before youngest
cancer screening as relative or age 40
Colonoscopy every 10 years appropriate
Double-contrast barium enema every 5 years,
or *The multiple stool take-home test should be used. One test done by the doctor
CT colonography (virtual colonoscopy) every in the office is not adequate for testing.
5 years The tests that are designed to find both early cancer and polyps are preferred if
*This version of stage theory was adapted
Tests That Primarily Find Cancer these tests are available and the patientfrom the work have one of these more
is willing to of RE Myers.
Yearly fecal occult blood test (gFOBT) *, or invasive tests.

38. High Quality Stool Testing
Clinicians Reference: FOBT
One page document designed
to educate clinicians about
important elements of colorectal
cancer screening using fecal
occult blood tests (FOBT).
Provides state-of-the-science
information about guaiac and
immunochemical FOBT, test
performance and characteristics
of high quality screening
programs.
Available at
www.cancer.org/colonmd

39. #3 Be Persistent with Reminders
Determine how your
Essential practice will notify
#3: patient and physician when
screening and follow up is
due.
Ensure that your system
Essential tracks test results and
#3: uses reminder prompts
for patients and providers.

40. Reminder Fold-Over Postcard

41. Patient Education
Get Tested For Colon
Cancer: Here's How."
An 7-minute video reviewing
options for colorectal cancer
screening tests, including test
preparation.
Available as DVD, or you can
refer patients to the URL to
view from their personal
computer.

42. Office Wall Chart
 Screening guidelines
for Breast, Cervical,
Colon, Prostate and
other cancers
 General
lifestyle/prevention
 Tobacco
cessation
 Healthy diet
 Weight, etc
 English and Spanish

43. Clinician Reminder Types
 Chart Prompts
 Problem lists
 Screening schedules
 Integrated summaries
 Alerts – “Flags” placed in chart
 Follow-Up Reminders
 Tickler System
 Logs and Tracking
 Electronic Reminder Systems

44. #4 Measure Practice Progress
Discuss how your screening
Essential system is working during
#4: regular staff meetings and
make adjustments as
needed.
Have staff conduct a
Essential screening audit or contact
#4: a local company that can
perform such a service.

45. Saving Lives Through
Preventive
Cancer Screening
ADJUST PLAN
STUDY ACT

47. Communication

48. Health Card Kit

49. ACS Resources
Information and materials on colorectal cancer
for clinicians and patients are available at:
www.cancer.org/colonmd
Updated materials for other cancers are
available on a new webpage
www.cancer.org/professionals