Colorectal Cancer Screening 101

Patient Education

December 2014

Colon Anatomy, Polys, Colorectal Cancer (CRC) & Colorectal Cancer Screening Exams

What is the colon?

• • • • • Also called the large intestine or large bowel Part of the digestive system About five (5) feet long Absorbs water and nutrients from food you eat Removes waste (feces) from your body http://www.aboutcancer.com/colon_and_rectal_anatomy.htm

Colon Anatomy

• • • • • • •

Anus Rectum Sigmoid Descending Transverse Ascending Cecum

Cecum http://en.wikipedia.org/wiki/Large_intestine

Colon Polyps

• Noncancerous or cancerous growths in the lining of the colon o Vary in size o o o May have a stalk or may be flat Common in adults Unknown what causes them  Lifestyle factors: High-fat, low-fiber diet, obesity, sedentary lifestyle, etc.

 Genetic factors • Polyps must be removed to determine if the polyp is cancerous or noncancerous • Biggest risk of developing polyps is being over 50 years http://www.colon-cleanse-information.com/colon-polyps.html

Common Terms re: Polyps

• • • • • Hyperplastic o o Common, abnormal noncancerous growths Do not cause any symptoms Adenomatous o o Pre-cancerous polyps May cause symptoms Sessile o Polyps that grow in a flat, broad-based structure Serrated o Polyps that have a saw tooth like appearance Dysplasia o Describes how much the polyp looks like cancer • Low-grade: mild or moderate; does not look much like cancer • High-grade: severe; has characteristics of cancer

Adenomatous Polyps

• • Have various growth patterns that help decide when you will need your next colonoscopy o Tubular – small, lower risk of cancer developing o o Tubulovillous – some tubular and some villous qualities Villous – large, higher risk of cancer developing Dysplasia o o o How much your polyp looks like cancer All adenomas are dysplastic High-grade dysplasia, higher risk of cancer developing Normal Colon Adenoma Colon Cancer http://www.kolumbus.fi/hans/gastrolab/feb17.jpg

http://www.gastrolab.fi/iamp4/105/002.jpg

http://www.kolumbus.fi/hans/hires/hi0060.jpg

What is Colorectal Cancer (CRC) ?

• Second leading cause of death because of cancer in the U.S.

• Third most common cancer diagnosed in men and women in the U.S.

• It is expected that over 50,000 people will die from colorectal cancer in the U.S. in 2014 • The risk of developing colorectal cancer in your lifetime is about 1 in every 20 people American Cancer Society. Colon/Rectum Cancer: Detailed Guide. 2013 (revised 1/31/2014). http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/index

CRC in Colorado

• About 1,720 people will get colorectal cancer in Colorado in 2014 o o About 44 out of 100,000 men will get CRC About 34 out of 100,000 women will get CRC • About 670 people will die from colorectal cancer in Colorado in 2014 o o About 17 men out of 100,000 will die from CRC About 12 women out of 100,000 will die from CRC American Cancer Society, Cancer Facts & Figures 2014 http://www.cancer.org/acs/groups/content/@research/documents/webcontent/acspc-042151.pdf

CRC Risk Factors

• • Risks you

cannot

o o o o o Age Family history Personal history Race Genetics change Risks you

can

o o o o o change Diet high in red meat/processed meat consumption Sedentary lifestyle Obesity Cigarette smoking Alcohol consumption American Cancer Society. Colon/Rectum Cancer: Detailed Guide. 2013 (revised 1/31/2014). http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/index

Can you prevent CRC?

• Screening is the best way to prevent colorectal cancer • Screening looks for cancer or pre-cancerous polyps in people who do not have symptoms • If polyps are found they can be removed before they turn into cancer, preventing colorectal cancer altogether American Cancer Society. Colon/Rectum Cancer: Detailed Guide. 2013 (revised 1/31/2014). http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/index

Choosing the Right CRC Screening Test for You

Colonoscopy Stool Testing Flex Sig PillCam Virtual Colonoscopy

CRC Screening Methods

• Detect Polyps and Cancer o Flexible Sigmoidoscopy o o Colonoscopy Computed Tomographic Colonography (virtual colonoscopy) • Detect Polyps/Abnormalities o Video capsule (PillCam) • Detect Cancer o o High sensitivity FOBT/FIT Stool/Fecal DNA test

Bowel Preparation

• Many CRC screening methods require bowel preparation o Flexible Sigmoidoscopy o o o Colonoscopy Computed Tomographic Colonography Video Capsule • Necessary in order to be able to see the colon and find abnormalities and/or polyps • Requires diet and/or fluid restrictions but will vary according to your doctor’s instructions

What is a flexible sigmoidoscopy (FSG)?

• • An internal exam of the lower portion of the colon, from the rectum to the sigmoid colon (sometimes through the descending colon noted by the green line) using an instrument called a sigmoidoscope Sedation may or may not be used. Ask your doctor.

Descending colon

What to expect: FSG

• The procedure takes about 10 – 20 minutes • You will lie on your side with knees drawn up toward your chest • The sigmoidoscope is inserted through the anus and gently advanced • Air will be inserted through the scope to provide a better view of the colon • Careful examination is done during the insertion and withdrawal of the scope

FSG Procedure

• Tissue samples may be taken or polyps may be removed during the procedure • You may feel pressure and slight cramping during the exam • If you experience abdominal pain, fever and chills or rectal bleeding following the exam contact your navigator or doctor immediately • FSG is not sufficient to detect polyps or cancer in the remaining portion of the colon and you may be advised to complete a colonoscopy

What is a colonoscopy?

• An internal exam of the entire length of the colon using an instrument called a colonoscope

What to expect: Colonoscopy

• The procedure takes about 30 – 60 minutes • You will lie on your side with knees drawn up toward your chest • Sedation is provided to the patient • After being given the sedative, the colonoscope is inserted through the anus and gently advanced

The Colonoscopy

• Air will be inserted through the scope to provide a better view of the colon • Suction may be used to remove any secretions in the colon • Better views are seen during withdrawal of the colonoscope so a more careful examination is done during withdrawal of the scope • Tissue samples and/or polyps may be taken with tiny forceps inserted through the scope

•

The Colonoscopy

You must have someone bring you to the exam. You will not be able to drive because sedation is used • Risk of complications is low but could include o Tear in the colon/rectum wall (perforation) o o Bleeding from the site where a tissue sample or polyp was removed from the colon/rectum wall Adverse event related to sedation (e.g. breathing problems)

What is a computed tomographic (CT) colonography?

• • Procedure that uses low dose radiation CT scanning to get a view of the inside of the colon Also referred to as a virtual colonoscopy

Image from a CT colonography http://www.massgeneral.org/imaging/services/procedure.aspx?id=2254

What to expect: CT Colonograpy?

• The procedure takes about 15 minutes • You will be positioned on the CT exam table lying on your back • A small tube will be inserted into the rectum to allow air to be pumped into the colon to help eliminate folds/wrinkles that may hide polyps • The table will move through the scanner to obtain the images

What to expect: CT Colonograpy?

• You may experience a feeling of fullness or a need to pass gas • Pain and discomfort are uncommon • Risk of complications is low but may include o Inflation of the colon could injure or perforate the bowel o Exposure to radiation • You may be asked to follow up with a colonoscopy

What is capsule endoscopy?

• • A noninvasive procedure that uses a wireless camera, small enough to fit inside a vitamin-sized disposable capsule, that you swallow Allows physician to view the entire colon to detect polyps without sedation or radiation http://thefutureofthings.com/5306-the-pillcam-colon-video-capsule/

What to expect: Capsule Endoscopy

• A belt with sensors and a data recorder will be placed around your waist o Allows the capsule to wirelessly transmit images of your colon • You will swallow the capsule with a glass of water o You will drink about 2 cups of bowel prep solution shortly after • You are free to go about your regularly scheduled day

What to expect: Capsule Endoscopy

• • • • Approximately 10 hours later you will return the belt to your doctor’s office The capsule usually naturally passes with a bowel movement within 24 hours o The capsule is disposable and does not need to be retrieved There should be no discomfort when swallowing the capsule, it traveling through your colon or eliminating it during a bowel movement You may be asked to follow up with a colonoscopy

What are Stool-based Screening Tests?

• • • Noninvasive, take home tests that look for signs of colorectal cancer in stool (feces) You collect stool specimens in the comfort of your home A positive result will require follow up with a colonoscopy http://www.mountainside-medical.com/hemoccult-sensa-single-slide-tests.html

http://fightcolorectalcancer.org/research-treatment/medicare-now-covers-stool-dna-screening-test-cologuard/ http://seekingalpha.com/article/1575652-exact-sciences-line-your-pockets-not-your-toilet-bowl-3-of-5

What to expect: Fecal Occult Blood Test (FOBT)?

• • • • • Looks for hidden (occult) blood in the stool o o Cannot determine if blood is from the colon or other parts of the digestive tract Not specific to human hemoglobin Must collect an actual stool sample o Requires multiple samples from different bowel movements Involves dietary restrictions Positive test requires a colonoscopy Must be done annually to provide adequate screening

What to expect: Fecal Immunochemical Test (FIT)?

• • • • • Looks for hemoglobin protein found in red blood cells o Specific for human hemoglobin o Less likely to react to bleeding from upper digestive tract No dietary restrictions No actual stool collected o o Brush stool surface or, if loose stool, stir the water around the stool Requires multiple samples from different bowel movements Positive test requires a colonoscopy Must be completed annually to provide adequate screening

What to expect: DNA Stool Test

• • • • • • Looks for abnormal sections of DNA from cancer or polyps Tests for blood in the stool Requires no dietary restrictions and one bowel movement Must handle and collect stool sample according to the manufacturer’s instructions Positive test requires a colonoscopy Interval testing is every 3 years

How Do You Pay For Screening?

• Preventive services, to include CRC screening, are covered by Medicaid, Medicare and private insurance • Check with your insurance to see if a co-payment is required if: o o o A polyp is removed during a colonoscopy You have a colonoscopy following a positive stool test You have a colonoscopy following a FSG, virtual colonoscopy or PillCam • CCSP will cover the cost of endoscopic screening (FSG and colonoscopy) for individuals uninsured or underinsured who meet further criteria through June 30, 2015.

Questions?