Colorectal Cancer and Screening Cancer Screening Programs January 2013 This presentation will take 30-60 minutes if you use all the slides. Not all of the slides need to be used, though. This is the main message: Men and women age 50 and over should get regular screening for colorectal cancer. There are 2 brochures that can be given out for this presentation: Frequently Asked Questions, and Home Stool Test Instructions

How much do you know about colorectal cancer? How common is colorectal cancer in Alberta? (i.e. 1 in X men and 1 in X women)? How many cases of colorectal cancer can be treated successfully if found early (i.e. X out of 10)? Does a diet rich in fruits and vegetables help reduce risk of colorectal cancer? What is a home stool test checking for? Is it a reliable way to detect signs of colorectal cancer? 1 in 14 men and 1 in 17 women will be diagnosed with colorectal cancer in their lifetime. It is the second most commonly diagnosed cancer in men and the third most commonly diagnosed cancer in women. 9 out of 10 cases of colorectal cancer can be treated successfully if found early. Early detection improves your changes of beating colorectal cancer significantly. A diet rich in fruits and vegetables can help reduce risk of colorectal cancer. Easting a healthy diet is a good way to reduce your risk. A home stool test checks for the presence of hidden blood in the stool that may be a sign of colorectal cancer. Yes- it is a reliable way to detect signs of colorectal cancer and is the recommended test for anyone who has no personal family history of the disease or inflammatory bowel disease.

What is Colorectal Cancer? Cancer that develops on the inner wall of the colon and rectum (large bowel or large intestine) As cancers of the colon and rectum are very similar, they are referred to as “Colorectal Cancer”

What are Polyps? Pre-cancerous polyps are small growths that may be found on the inner wall of the colon & rectum Polyps can develop and exist over long periods of time without any signs or symptoms before becoming cancer This image shows what a polyp looks like compared to a normal intestinal fold.

Colorectal Cancer Facts In 2012, 1930 new cases of colorectal cancer were expected in Alberta Colorectal cancer will develop in 1 in 14 men and 1 in 17 women throughout their lifetime In Alberta: it is the 2nd most commonly diagnosed cancer in men and 3rd most commonly diagnosed cancer in women To explain the 2nd bullet point with more detail: If there are 14 men in the room - it doesn't necessarily mean that 1 in 14 of them will develop colorectal cancer. It means, that if all 14 of those men live until at least 85 years old, then 1 out of 14 will develop colorectal cancer. Reference: Canadian Cancer Society’s Steering Committee on Cancer Statistics. Canadian Cancer Statistics 2012. Toronto, ON: Canadian Cancer Society; 2012.

More Colorectal Cancer Facts In 2012, 720 colorectal cancer deaths were expected in Alberta Colorectal cancer is the 2nd leading cause of death from cancer in Alberta for both men and women combined The leading cause of cancer deaths in Alberta men is lung cancer. Next is prostate, followed by colorectal cancer. For Alberta women, the leading cause of cancer deaths is lung cancer. Next is breast, followed by colorectal cancer. So, colorectal cancer is the 2nd leading cause of cancer deaths when data from both men and women are combined. Reference: Canadian Cancer Society’s Steering Committee on Cancer Statistics. Canadian Cancer Statistics 2012. Toronto, ON: Canadian Cancer Society; 2012.

Risk Factors You Can’t Change Age Family history Ethnicity Personal cancer history Inflammatory Bowel Disease Age – approximately 90% of cases are in adults 50 and over Family history includes – colorectal cancer, Familial Adenomatous Polyposis (FAP), Hereditary Non-Polyposis Colorectal Cancer (HNPCC). The more relatives affected, the higher the risk. Ethnicity – African Americans have been found to have a higher incidence and mortality of colorectal cancer than other racial groups in the U.S. and the reason for this is not yet understood. Jews of Eastern European descent (Ashkenazi Jews) have one of the highest risks of colorectal cancer and several gene mutations have been found to increase their risk of colorectal cancer. Personal cancer history includes – colorectal, small bowels/intestines, uterus, ovaries or breast Inflammatory Bowel Disease includes ulcerative colitis and Crohn’s disease

Risk Factors You Can Change Food Choices Physical activity Body Weight Smoking There are some things we can do to lower our risk of colorectal cancer. Many of these things we can do also help prevent or decrease our risk for other chronic diseases (heart disease, diabetes, osteoporosis, etc).

Ways to Decrease Your Risk Get screened regularly! Eat more fibre (whole grains, beans, lentils, peas, bran) and less saturated fats (red meat, whole milk dairy products) Eat lots of vegetables and fruit It is important to be screened regularly. Talk to your doctor or nurse about what type of colorectal cancer screening is best for you. There is a strong link between diet and colorectal cancer risk. Good sources of fibre include wholegrain products, fruit, vegetables, nuts/seeds, and legumes. Examples include: Wholegrain products: oats, rye, barley, bran, quinoa, wholemeal bread, wholewheat pasta, wholegrain breakfast cereals (porridge oats, All-Bran, Weetabix, etc) Fruit: oranges, prunes, berries, bananas, apples, pears, avocado Vegetable: broccoli, carrots, sweet potatoes, green beans Nuts/Seeds: flax seed, almond, pecans, pistacios Legumes (also called pulses): beans, lentils, and peas A diet high in red meats (beef, lamb, liver, etc) and processed meats (hot dogs, deli meats, etc) can increase your risk of colorectal cancer. Limit intake of red meat (a main source of saturated fats) to no more than 18 ounces a week (about 3 small steaks). This is a touchy subject for Albertans! Meats are an important source of protein and vitamin B12. But studies show that people who eat a lot of red meat tend to eat less plant-based food and therefore have less protection against cancer. Include 7 – 10 servings of vegetables and fruit in your daily diet. Eat at least one dark green and one orange vegetable each day. Examples include broccoli, romaine lettuce, spinach, carrots, sweet potatoes, pumpkins/squash, turnips, garlic, oranges and berries.

More Ways to Reduce Your Risk Lower alcohol intake Add exercise into your daily life Stay at a healthy body weight Consider quitting smoking and snuff/chew and avoiding second hand smoke Lower alcohol consumption to moderate or low levels. If alcohol is consumed, amount should be limited to no more than two drinks a day for men and one a day for women. Pregnant women should not consume any alcohol. Try incorporating regular physical activity into your daily life. It is recommended that you aim for 2 and a ½ hours of moderate to vigorous activity per week. Moderate exercise can mean anything from a brisk walk to playing outside with grandchildren. Body Mass Index (BMI) gives a rough measure of body fatness by measuring weight relative to height. BMI calculation: 1) Multiply your weight in pounds x 703 2) Multiply your height x your height (in inches) 3) Divide #1 number by #2 number to get your BMI Adults should stay within the lower end of their normal BMI range, especially avoiding increases in waist circumference. 50% of Albertans are overweight or obese! A study by the American Cancer Society researchers (published in Dec 2009 in Cancer Epidemiology, Biomarkers, and Prevention) shows that long term smoking increases the risk of colorectal cancer Tobacco also comes in smokeless (spit) form that is placed inside the mouth and is also harmful: Snuff – ground-up moist tobacco usually placed between the bottom lip and gum (also known as “dipping”). Chew – shredded tobacco leaves placed between gum and cheek (also called “a wad”). Plug – shredded tobacco leaves pressed into a hard block and placed between gum and cheek.

What about Symptoms? Approximately 90% of people who get colorectal cancer are 50 and over with no symptoms If symptoms do occur see your doctor or nurse right away! Symptoms may include: Changes in bowel movements (constipation, diarrhea) Narrow or bloody stools Abdominal cramps Unexplained weight loss Constant tiredness/weakness Colorectal cancer in the early stages usually does not have any symptoms. When found early, 90% of cases can be prevented or treated successfully. If there are symptoms present, usually the colorectal cancer is in a later stage. Important Message: Do not wait for symptoms to appear before talking to your healthcare provider about colorectal cancer and screening. Everyone 50 and over should be screened regularly for colorectal cancer.

Why is Finding Colorectal Cancer Early Important? If found early through regular screening, the success rate for treatment is greater than 90% If found at a later stage when there are symptoms, only about 10% of people survive (to 5 years) Screening can also prevent colorectal cancer by removing pre-cancerous polyps Screening can help detect polyps, which are pre-cancerous cells. Polyps sometimes bleed into the colon – traces of blood may be found in the stool, but are invisible to the naked eye. The most common screening tests in Alberta are: Home stool test – this can help detect blood in the stool that is not visible. Colonoscopy – this can be the primary screening test and is also the follow-up test for an abnormal home stool test result. If polyps are found during a colonoscopy, they can be removed. More details about the different screening tests will come in later slides.

How Do I Get Screened? If you are 50 and over, talk to your doctor or nurse about getting screened regularly for colorectal cancer About 30% of Albertans aged 50 to 74 get screened for colorectal cancer – leaving 70% unscreened! To find a doctor call Health Link Alberta: 1-866-408-LINK (5465) visit: www.informalberta.ca Encourage people in your group to talk to their healthcare provider about colorectal cancer screening. You may want to start a discussion about colorectal cancer and screening with the following sample questions: Why do you think so few Albertans 50 to 74 get screened for colorectal cancer? Can this be changed? Do you think it’s important for Albertans 50 to 74 to be screened for colorectal cancer? Why or why not? Feel free to create your own questions to encourage discussion and interaction. 13

Colorectal Cancer Screening Tests The Alberta Colorectal Cancer Screening Program recommends a Home Stool Test every year for everyone 50 to 74 Other screening tests are available – talk to your doctor or nurse about what is right for you There are a number of different colorectal cancer screening tests available in Alberta, including: Home Stool Test (Fecal Occult Blood Test/FOBT) Colonoscopy Flexible Sigmoidoscopy Double Contrast Barium Enema The first 2 tests are the most common in Alberta. For more information about the different tests, please refer to the Healthcare Worker resources (Colorectal Cancer Screening Clinical Practice Guidelines, Chart and Wheel) The Alberta Colorectal Cancer Screening Program recommends a Home Stool Test every year because the evidence shows that this test is most effective for populations. Colonoscopy is also commonly recommended by doctors, but in some areas of the province there is a long wait list and it is a higher risk procedure compared to the Home Stool Test (chance of perforating (puncturing/piercing) the colon, reaction to the anesthetic, etc.)

Home Stool Test Also called Fecal Occult Blood Test (FOBT) Finds blood in the stool that is not visible to the eye Picked up from your doctor or from the lab (with a form from your healthcare provider) Can also use the Home Stool Test (FOBT) sample provided in the kit to show what it looks like.

A Home Stool Test Every Year Small samples of stool are smeared onto test cards, which are then returned to the lab NO diet restrictions except Vitamin C supplements Refer to the brochure Colorectal Cancer Screening: Home Stool Test Instructions for step-by-step instructions on how to do the test. Vitamin C supplements can cause false positive test results (abnormal test result when it shouldn’t be). In the past, there use to be many diet restrictions over several days (no red meat, spinach, etc.). However, these have been removed because the evidence shows that the only thing that causes false positive test results are Vitamin C in large quantities. There may be members of your community who have done this test in the past and remember all the food restrictions. This is no longer the case and the only thing they need to avoid is Vitamin C supplements 3 days before and during the testing days.

What does an abnormal result mean? If test result is abnormal, means blood was found in the stool samples This does not necessarily mean you have cancer Additional testing is needed to determine the source and cause of bleeding An abnormal test may also be due to pre-cancerous polyps, certain diets or other conditions such as hemorrhoids (piles) If the test result is normal, no follow-up is needed. But remember: it is important to do the Home Stool Test every year. The follow-up test for an abnormal home stool test result is a colonoscopy to determine the cause of blood in the stool.

Colonoscopy When a FOBT is abnormal, colonoscopy is the recommended follow-up test A thin flexible tube is placed into the rectum and colon for the doctor to examine the areas. General colonoscopy procedure: Powerful laxatives are given ahead of time to clear the bowel of stool A long flexible tube with a small camera is inserted through the anus A special doctor examines the lining of the entire colon and rectum for polyps or cancer Biopsies and removal of polyps can be performed during the procedure If cancer is found, the doctor will speak with you about the next steps and treatment choices Discuss with your doctor the rare risks of this procedure and whether you would prefer to be awake during the procedure or given a light anesthetic If the results from a colonoscopy are normal, then no further screening tests are required for the next 10 years. Please refer to the Healthcare worker resources in the kit for more information about the Alberta Colorectal Cancer Screening Clinical Practice Guidelines and recommendations for individuals at different levels of risk. This test can also be done every 10 years as a screening test

Alberta Colorectal Cancer Screening Program (ACRCSP) An organized provincial colorectal cancer screening program Coordinated by the Alberta Health Services – Screening Programs Encourages men and women aged 50 to 74 to get screened Sends letters to clients about abnormal home stool test results in some areas of Alberta In partnership with healthcare providers www.screeningforlife.ca/colorectal Visit the website for more information and downloadable resources or to contact the program. The website also contains information on other cancer screening programs (breast and cervical cancer screening)

Resources Free to order (visit www.screeningforlife.ca) Brochures, information sheets Posters and flyers Clinical Practice Guidelines Professional and Educator – clinical/program information Resources most pertinent to the public are the brochures and information sheets.

Thank you! Questions? www.screeningforlife.ca 1-866-727-3926