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Colorectal Cancer
A Preventable Burden
Citywide Colorectal Cancer Control
Coalition
Ambassador Program
NYC Coalition Mission
“To increase awareness & screening
for colorectal cancer & adenomatous
polyps in NYC men and women in
order to reduce the incidence &
mortality of this disease”
C5 Ambassadors
Program:
Goals
To educate health care providers:
1. CRC as a public health problem
2. Effectiveness of CRC screening
3. What are the current guidelines
4. Recommendations of the NYC
DOHMH
U.S. Burden of Colorectal Cancer
Procrastination
•
•
•
•
•
•
•
147,500 new cases in 2005
57,100 deaths in 2005
150 deaths/day
11% of all cancer deaths
758,000 person-years of life lost
Lifetime risk of developing CRC = 5%
Cost of treatment  $6 billion
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There Are Major Health Disparities
of Colorectal Cancer in the U.S
Incidence
Rate*
Mortality
Rate*
African American
58.3
27.7
Caucasian
52.7
21.3
Hispanic-American
35.7
13.1
African-American
45.2
19.9
Caucasian
36.6
14.3
Hispanic-American
23.6
8.3
Men
Women
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* Rates per 100,000
Colorectal Cancer Risk Groups
IBD
1%
FAPFAP
1%
HNPCC
5%
5%
FH 15%-20%
Sporadic
(Average Risk)
~75%
HNPCC-Hereditary Non-Polyposis Colorectal Cancer
Winawer, Schottenfeld, Flehinger, JNCI 1991: 83:243-253.
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Hereditary Non-Polyposis
Colorectal Cancer (HNPCC)
Normal
cecum
3/95
Cecal
cecum
5/96
Amsterdam Criteria
• Three or more relatives with Hereditary
Non-Polyposis Colorectal Cancers
– One a first degree relative of the other two
• Two or more generations
• One with cancer < age 50
Vasen et al. GE 1999; 116 (6): 1453
Lifetime Risks Of Colorectal
Cancer
Population risk of CRC
1 first-degree relative
1 FDR & 1 second-degree relative
1 relative aged under 45
2 first-degree relatives
Autosomal dominant pedigree
1 in 20
1 in 17
1 in 12
1 in 10
1 in 6
1 in 2
Colorectal Cancer
“The most preventable, but least
prevented, cancer”
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The Best Screening Test
Is
THE ONE THAT GETS DONE.
Low Screening Rates
90
• CRC has far lower
screening rates than
breast or cervical
cancer
80
70
60
50
CRC
Breast
Cervical
40
30
20
10
0
% Screened
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Why Screen for Colon Cancer?
•
•
•
•
•
Proven effectiveness of screening
Highly preventable cancer
Well defined pre-malignant phase (adenoma)
Adenomas take 5-10 years to become cancer
Molecular basis of carcinogenesis is the best
understood of all solid tumors (molecular
diagnostics)
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Barriers to CRC Screening
•Lack of physician •Negative attitudes •Practical issues
recommendation
about the test:
–Poor Patient
Adherence
–FOBT:
•Lack of
embarrassing,
–Conflicts with
worrisome
distasteful
work/family
symptoms
commitments
–Sigmoidoscopy /
•Fear of the results
Colonoscopy:
–Inconvenience
pain, discomfort,
(need for further
–Lack of interest
injury
testing)
–Cost
% Mortality Reduction Using
Different Screening Methods
1000
Annual
FOBT
33%*
Colonoscopy
Sigmoidoscopy
Every 5-10 years Every 10 †years
90%
30%*
*Observed
†Estimated
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Effectiveness of FOBT
Prospective, randomized, controlled trials
Mandel
Duration
Subjects (n)
Frequency
F/U duration (yrs)
CRC mortality
Reduction
Hardcastle
(USA)
(UK)
1975-92
1981-95
46,551
152,850
annual/biennial biennial
13
7.8
33%/21%
15%
Kronborg
(Denmark)
1985-95
140,000
biennial
10
18%
Colorectal Cancer Mortality
Reduction By Sigmoidoscopy
Colorectal
Cancer Mortality
Reduction
Study
Design
Kaiser
Permanente,
USA
Retrospective,
Case Control
30%
Selby, NEJM
1992
Univ.
Wisconsin,
USA
Retrospective,
Case Control
40%
Newcomb,
JNCI 1992
Reviewed in Colorectal Cancer Screening: Clinical Guidelines and Rationale.
Winawer, Fletcher, et al., Gastroenterology, Feb. 1997.
Published
What Do You Find If You Perform
Screening Colonoscopy on
Average-risk Subjects?
Lieberman1
Setting
VA; Multi-center
No. Of subjects
3,121
Male
96.8%
Age (mean)
62.9 yrs
Cancer
1.0%
Adenoma (any)
37.0%
Adenoma >1 cm
7.9%
Adenoma w/ HGD 1.6%
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Imperiale2
Eli Lilly co
1,994
58.9%
59.8 yrs
0.6%
---1
2
N Engl J med 343:162, 2000
N Engl J med 343:169, 2000
15-22 cancers are prevented or detected
early per 1,000 screening colonoscopies
1,000 average-risk
asymptomatic men and women
aged 50 and older
COLONOSCOPY
5% - 6% will have advanced adenomas
►50-60 advanced adenomas
detected by screening
20% (10-12) would have developed
cancer over 20 years
0.5% - 1% will have cancer
► 5-10 cancers
detected early by screening
Cost Effectiveness of
Colon Cancer Screening vs. Other
Measures
40
Cost ($)
per
added
year
of life
(x 1000)
35
30
25
20
15
10
5
0
Colon
Hypertension
Screening*
Mammography
Cholesterol
*Any colon screening
The cost varies with the model used; this is a ballpark number
Lieberman 2003.
National Polyp Study
•
•
•
•
Randomized trial
Surveillance intervals
Surveillance methods
Colorectal Cancer
incidence
• Adenoma-carcinoma
model
• 7 clinical centers
• Memorial Sloan
Kettering Coord.
Center
Colorectal Cancer Incidence in NPS Following
Colonoscopic Polypectomy
(1418 pts ; 8401 person yrs)
Resources
Less Intensive Surveillance
Increased Resources for Screening
Alternative and Future
Colorectal Cancer Screening
Methods
Virtual Colonoscopy
Virtual Colonoscopy
 Prep Needed
 Air Discomfort
 No Biopsy
 No Polypectomy
 50–60% Need “Real Time” Colonoscopy
 Miss rate of small adenomas?
 Radiation
Stool DNA Testing
Stool DNA Testing
Tail
Pail
Mail
Stool DNA Testing
Cancer
1. 20/22 (91%)
2. 33/52 (64%)
Advanced
adenomas
9/11 (82%)
16/28 (57%)
specificity:
26/28 (93%)
204/212 (96%)
1. Ahlquist et al. Gastroenterology 2000
2. Tagore et al. Clin colorectal cancer 2003
Breaking Down Barriers
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Successful Strategies in New
York City
• Systematic referral of all outpatients over age 50
• Electronic medical record prompts, preventive
flow sheets, chartstickers or postcards to all
patients over the age of 50
• Patient navigators
• Direct endoscopy referral (DERs) to simplify
process for increasing screening
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NYC Colorectal Cancer Screening
Advisory Panel:
Rationale
• About 1,500 NYC residents die annually from colorectal
cancer
• Most deaths are preventable
• Colonoscopy preferred
• Examines entire colon
• Sensitive & Specific for adenomas and cancer
• Provides screening, diagnosis, treatment
• Sufficient Capacity in N.Y.C.
• Preferred recommendation may reduce confusion
• Other options are available (National Guidelines)
The Best Screening Test
Is
THE ONE THAT GETS DONE.
Adenomatous Polyp
Adenoma to Carcinoma
Pathway
Normal
APC
loss
Adenoma
K-ras
mutation
Chrom 18
loss
Cancer
p53
loss
Normal
HyperEarly Intermediate Late
Cancer
Epithelium proliferation Adenoma Adenoma Adenoma
US Rates of Colorectal Cancer
Incidence (age 50+)
500
Rate Per 100,000
400
300
200
100
0
20-24
30-34
40-44
50-54
60-64
70-74
80-84
Age (years)
Incidence Rate
Mortality Rate
SEER: 1993-1997
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