1. Colorectal Cancer The Race to Cancer Prevention
Meredith L. Cashdollar PA-C
Chambersburg Gastroenterology Assoc., LTD

2. Colorectal Anatomy
The term “colorectal” refers to the lower gastrointestinal tract, which is divided into:
1. cecum
2. ascending (right colon)
3. transverse colon
4. descending (left colon)
5. sigmoid colon
6. rectum
Large Intestine (Colon) is approximately 5 to 6 feet in length and one to two inches in width
Primary role: salt & water absorption

3. Colorectal Anatomy
The rectum is located within the pelvis and is not a true intra-abdominal structure
The diameter of the rectum is larger than that of the colon
Primary purpose of the rectum: storage reservoir for stool

4. Colorectal Cancer Awareness March is colon cancer awareness month!
Common
Lethal
Preventable
Third most common cancer
Second leading cause of cancer related death

5. Epidemiology United States (+)145,000 new cases each year
-105,000 = colon cancer
-40,000 = rectal cancer
56,000 Americans will die of CRC/year

6. Incidence Worldwide
Worldwide: 500,000 lives will be lost

7. 50 yrs of age is the Golden Age for Colorectal Cancer prevention
How many of you have parents, grandparents and relatives over the age of 50?
50 yrs of age is the Golden Age for Colorectal Cancer prevention

8. Incidence Age is a major risk factor Lifetime risk is about 5-6%
CRC increases after the age of 50
90% of cases occur after the age of 50
Rare to occur before age 40 (not unheard of)
Lifetime risk is about 5-6%
American Cancer Society recommends screening starting at age 50 for average-risk adults

9. Known Risk Factors Personal history of adenomatous polyps
Personal/Family History of IBD
Crohn’s Disease & Ulcerative Colitis
Increasing Age
Genetic Predisposition
Family history of CRC/Adenomatous polyps
Familial Adenomatous Polyposis (FAP)
100% chance of CRC by 30yrs.
Hereditary Nonpolyposis Colorectal Cancer

10. Probable Risk Factors Dietary – Environmental - Lifestyle
-Diets high in fat & cholesterol
-Diets low in fiber
Alcohol consumption
Cigarette smoking
Sedentary lifestyle/physical inactivity
Obesity
-Specifically red meat (greater than 1 pound/week)

11. Questionable Risk Factors
Diabetes mellitus
Pelvic radiation
Breast cancer

12. Protective Factors Diet rich in fiber: fruits, vegetables, grains
Regular physical activity
Maintaining a healthy body weight
Regular use of aspirin
Diet high in calcium
Vitamin B6
Folic acid
Omega-3 fatty acids

13. “Red Flag” Signs/Symptoms
50% of patients present with abdominal pain
35% present with altered bowels
30% present with occult-bleeding
15% present with intestinal obstruction
-fever of unknown origin
-unintentional weight loss
-fatigue
-abdominal tenderness
-abdominal distention
-ascites

14. Colorectal Polyps
A colorectal polyp is a growth that sticks out of the lining of the colon or rectum
Polyps of the colon and rectum are usually benign and produce no symptoms, but they may cause painless rectal bleeding
There may be single or multiple polyps and they become more common as people age.
Over time, certain types of polyps, called adenomatous polyps, may develop into cancer
Another common type of polyp found in the colon is called a hyperplastic polyp, which is generally not at risk for developing into colon cancer

15. Colorectal Polyps

16. Colorectal Polyps -Precursors for Screening-
Polyps are the precursor for determining how often we screen a patient for colorectal cancer: it is also based on the (1) size (2) amount/number (3) histology
Histology: Characteristic features under the microscope (Biopsy report proves)

17. Colon Cancer Where Does It Begin?
Adenoma-carcinoma Sequence
Most colorectal cancers arise from polyps:
Adenomatous polyps
Adenomas progress  Dysplasia
Dysplasia progress  Cancer
Majority of colorectal cancers are adenocarcinomas
*Takes approximately 7-10 years to occur
-The vast majority of colorectal cancers are adenocarcinomas, which arise from pre-existing adenomatous polyps that develop in the normal colonic mucosa
-Dysplasia: abnormal growth or development of cells, tissue, bone, or an organ

18. Histological Transition from normal colon mucosa to adenomatous polyps to dysplasia which subsequently results into colorectal cancer

19. Progression of Colorectal Cancer

20. -Right-sided colon cancers: larger and more likely to bleed
-Left-sided colon cancers: smaller and more likely to obstruct

21. Screening Two opportunities to prevent cancer and cancer related death
Finding and removing polyps
Removing early cancers to improve prognosis
Available tests
FOBTs (Fecal Occult Blood Test)
Flexible sigmoidoscopy
Double contrast barium enema
Colonoscopy
Virtual Colonoscopy

22. FOBTs Fecal occult blood test Simple test
Colorectal cancers/polyps often bleed
FOBT detect microscopic amounts of blood in the stool
Simple test
Chemically coated cards
Place small amount of stool (2 samples) from 3 consecutive stools
Reduces the risk of cancer related death by up to one-third
Detect hidden blood

23. Sigmoidoscopy
Allows direct visualization of the lining of the lower half of the colon
Area were half of all cancers occur
Approximately the first 60cm of the colon
Procedure
Thin maneuverable tube with a light and camera is advanced along the rectum and left-sided colon

24. Sigmoidoscopy Effectiveness Risks and Disadvantages
Reduces cancer related death by 66% when done every 5 years
Risks and Disadvantages
Perforation occurs in about 2 per every 10,000 procedures
Does not exam the entire colon
Right-sided cancers/polyps can be missed

25. Flexible Sigmoidoscope

26. Provides a x-ray picture of the rectum and entire colon
Barium Enema
Provides a x-ray picture of the rectum and entire colon
Procedure: Liquid barium coats the entire inside of the colon
Reveals structural abnormalities such as polyps and cancers
Preparation is a laxative
Does not require sedation
Utilized in patients that are high risk for a procedure
Those that could not tolerate a sedation/procedure

27. Barium Enema Effectiveness Risks and disadvantages:
Detects about half of large polyps & 40% of all polyps in the colon/rectum
Risks and disadvantages:
Relatively safe
Helps to reduce the risk of cancer related deaths but not definitively proven
If an abnormality is found, further testing is required

28. Colonoscopy

29. Colonoscopy

30. Colonoscopy
Allows direct visualization of the lining of the rectum and entire colon
Procedure
Thin maneuverable tube with a light and camera is guided throughout the entire colon
Preparation is laxative
Requires sedation in most instances

31. Colonoscopy Effectiveness Risks and Disadvantages
Detects most small polyps and almost all large polyps and cancers
Polyps and some cancers can be removed at the time of the procedure
Risks and Disadvantages
Bleeding or perforation could occur in about 1 in 1,000 people
Requires sedation
Diagnostic & Therapeutic

32. Endoscopy

33. Polypectomy

34. Hidden Disease Processes of the Colon

35. Diverticulosis Diverticulosis:
Saclike herniations of the mucosal layer of the colon through the muscular wall
Common among older persons (50%/50yr.)
Usually producing no symptoms except occasional rectal bleeding

36. Diverticulosis

37. Diverticular Bleed
Can be a cause for anemia of unknown origin

38. IBD: Ulcerative Colitis

39. IBD: Ulcerative Colitis

40. Clostridium Difficile Colitis
These are pseudomembranes
*Antibiotics – is the major cause of C. diff (iatrogenic)
*Major antibiotic: Clindamycin – which causes C. diff
*Flagyl  antibiotics (treatment for C. diff)
*Vancomycin (PO) is the second choice (expensive, and you don’t want to develop vancomycin resistant strains)

41. Pedunculated Polyp with Cancer
Friable
Non-mobile
This patient most likely had rectal bleeding or at least occult + stool

42. Colorectal Carcinoma

44. Surgical Intervention

45. Wireless Capsule Endoscopy "The Camera in a Pill"
Capsule Endoscopy is a term used to describe a miniature capsule used to record images through the digestive tract for use in medical purposes
It is an imaging device for the detection of gastrointestinal diseases and has been hailed as a major breakthrough in medical technology. Many improvements in the product are enabling the Camera Capsule to see areas not possible with current endoscopic equipment.

46. Emerging Tests Virtual colonoscopy Fecal genetics
CT scan of the bowel allows for visualization of the entire colon lining
Fecal genetics
PreGen-Plus
Detects presence of abnormalities associated with pathogenesis of colorectal cancer
DNA from colorectal cancers is shed in the stool and can be isolated

47. Virtual Colonoscopy Procedure Effectiveness
CT scan is completed after air insufflation of the colon
Preparation is a laxative
Sedation is not required
Effectiveness
Conflicting results in studies to date

48. Virtual Colonoscopy

49. Virtual Colonoscopy Risks and Disadvantages Relatively safe
Uncomfortable
Lack of widespread availability
If abnormality is found, conventional colonoscopy is recommended
Size of polyp that should lead to optical colonoscopy has not been agreed upon

50. Fecal Genetics Procedure Effectiveness Risks and Disadvantages
Complete bowel movement must be collected and shipped in ice to specialized lab
Effectiveness
More effective than FOBTs for advanced cancers in one study to date
Risks and Disadvantages
Not widely available
Complex and expensive

51. Screening Average Risk Increased Risk Begin at age 50
American College of Gastroenterology recommends colonoscopy
Discuss with your doctor a screening plan that is best for you
Increased Risk
Begin screening at age 40 or 10 years younger than the earliest diagnosis in your family, whichever comes first

52. Screening Personal history of IBD
Depends on severity and duration of the disease
Screening begins about 8 years after diagnosis of the disease if entire colon is involved (pan-colonic)
Screening begins 15 years after diagnosis of disease if limited to left colon
Repeated every one to two years thereafter

53. Colorectal cancer is about 90% curable if caught in the early stages
Benefits of Screening
Colorectal cancer is about 90% curable if caught in the early stages

54. Summary http://www.chgastro.com/about.html
Colorectal cancer is highly lethal, fortunately it is greatly preventable!
Proper Diet and Lifestyle modifications are important for the health of your colon
Colorectal cancer is the 3rd most common cancer risk and 2nd deadliest cancer for both men & women
Colorectal cancer screening for average-risk patients begins at age 50!
Colonoscopy remains the gold standard for colorectal cancer screening

55. Happy St. Patrick’s Day!
Now you can make a Difference Educate your family and friends about the importance of Colorectal Cancer Screening!