1. Colon Cancer Sreening Recommendations
Jose M Nieto DO FACP FACG AGAF FASGE
Borland Groover Clinic

2. No financial disclosures

3. Outline 1. Review SCREENING recommendations 2. Colon Polyps
A. Non-neoplastic polyps
B. Neoplastic polyps
i. Serrated polyps
ii. Adenomatous polyps
3. SURVEILLANCE recommendations
A. Low-risk adenomas
B. High-risk adenomas
C. Serrated polyps
4. Quality indicators for Colonoscopy
5. Emerging technologies
A. Stool DNA testing
B. CT Colonography
6. Summary

4. Colorectal Cancer COMMON PROBLEM: GOOD NEWS:
3rd incident cancer (150,000/yr)
2nd cancer mortality (50,000/yr)
Lifetime incidence 5%
GOOD NEWS:
Incidence & Mortality is declining
53% reduction due to screening (Edwards BK, Cancer 2010)
: ¼ - ½ million cases prevented (Yang DX, Cancer 2014)
Other reasons:
decreased exposure to risk factors
improved therapy

5. CRC Screening
GOAL:
Decrease mortality by decreasingn incidence of advanced disease
5-yr survival (%)
LOCALIZED (bowel wall) 90
REGIONAL (LNs) 68
DISTANT (metastases) 10
EARLY DETECTION:
PREVENTION:
Detection / removal adenomas

6. CRC Screening Guidelines
American Cancer Society (1st in 1980)
USPSTF
ACR
USMSTF (2012 SURVEILLANCE)
ACS-USMSTF-ACR (2008 SCREENING)
ACG
NCCN
ACP stetements
Council of European Union

7. CRC Screening Guidelines 2008 ACS-MSTF-ACR
Primary goal: PREVENTION
Sensitive point in time preferred over repeated testing
Start age 50
Stop when life expectancy <10 yrs
STOOL BASED TESTING:
gFOBT, iFOBT, sDNA
STRUCTURAL TESTING:
RADIOLOGICAL:
DCBE
CTC
ENDOSCOPIC:
Flexible Sigmoidoscopy
Colonoscopy

8. CRC Screening Guidelines 2008 ACS-MSTF-ACR
Early Detection / Prevention:
Colonoscopy
CTC
FSIG
DCBE
Early Detection:
gFOBT
iFOBT
sDNA
q10 yrs
q5 yrs (Colonoscopy if >6 mm)
q5 yrs
q1 yr q?
2008 USPSTF:
FOBT q1 yr
FSIG q5 yrs + FOBT q3 yrs
Colonoscopy q10 yrs

9. Colon Polyps Non-Neoplastic Polyps Neoplastic Polyps
Hyperplastic
Mucosal
Inflammatory pseudopolyps
Submucosal (lipomas, fibromas, GIST)
Hamartomatous
Juvenile polyposis
Peutz-Jeghers
Cronkhite-Canada syndrome
Neoplastic Polyps
Serrated Polyps
Adenomatous Polyps
Colon Cancer-Post Curative surgery

10. Non-Neoplastic Polyps
1. Hyperplastic polyp
2. Inflammatory pseudopolyps
3. Submucosal (lipomas, fibromas, GIST)

11. Non-Neoplastic Polyps
HAMARTOMAS
Juvenile Polyposis Syndrome
Peutz-Jeghers Syndrome
Cronkhite-Canada Syndrome

12. Neoplastic Polyps
Serrated Polyps
Adenomatous/Tubulovillous Polyps

13. Serrated Polyps Hyperplastic Polyps (non-neoplastic)
Typically <5mm in RS
No increase in CRC
No increase in proximal neoplasia
If large > 10mm or proximal
precursor to SSA/P & progression to CRC
increased risk of synchronous advanced adenoma & multiple small adenomas
increased risk of metachronous adenomas
Serrated Polyposis Syndrome (SPS)
WHO Criteria:
> 5 serrated proximal colon (> > 10mm)
> 1 serrated proximal colon + FH of SPS
> 20 serrated polyps
Annual colonoscopy recommended (increased risk CRC)

14. Serrated Polyps Sessile Serrated Adenoma/Polyp (SSA/P)
Typically in proximal colon
Typically lack classic dysplasia
Foci of classic DYSPLASIA & foci CANCER can occur
Traditional Serrated Adenoma (TSA)
Typically in rectosigmoid
Diffuse but mild DYSPLASIA
SSA/Ps & TSAs = Significant malignant potential
Manage like adenomas
Sessile w indistinct borders (must ensure complete excision)
Thought to disproportionately cause INTERVAL CANCERS

15. Adenomatous Polyps ⅔ of all polyps
>95% CRC arises from adenomas; <5% adenomas lead to CRC
Prevalence:
30% at baseline (30-50% will have synchronous)
4% Advanced adenoma at baseline (8% > age 65)
Advanced Adenomas: > 10 mm / HGD / Villous features
FOCAL CANCER RISK:
Villous histology
Polyp size
HGD
METACHRONOUS ADENOMA RISK:
# of polyps (> 3 )
Lifetime polyps
Polyp size (20% when > 20 mm)

16. Surveillance Guidelines
2012 USMSTF (Endorsed by AGA, ASGE, ACG, ACS, & ACR)
Risk Stratification
LRAs:
1-2 TA <10mm
HRAs:
Villous histology
HGD
Adenoma >10 mm
>3 small adenomas

17. Baseline: NO POLYPS 2012 USMSTF
RECOMMENDATION:
10 yrs
QUALITY of EVIDENCE:
Moderate
STUDY n
5 yr AA (%)
2007 VA Co-Op
291
2.4
2008 Imperiale
1256
1.3
2009 Leung
370
1.4
2010 Brenner
115
4.4
2010 US Vets 86 7
2011 Korean
1242 2
2009 PLCOC
318
5.3 yrs)
Advanced yrs: % (baseline 4-10%)
CAVEAT: FDR w CRC <age yr interval
Concern for 10yr interval:
3 Canadian population studies:
9% of CRC are INTERVAL cancers
most occur 1-5 yrs from baseline exam
Importance of HIGH QUALITY examination

18. Baseline: Distal HPs <10mm 2012 USMSTF
RECOMMENDATION:
10 yrs
QUALITY of EVIDENCE:
Moderate
HPs are very common:
benign lesions
no increased synchronous / metachronous adenomas
Polyp Size (mm)
% HPs
1-5 50
6-9
27.9
>10 mm
13.7

19. Baseline: 1-2 Adenomas <10mm 2012 USMSTF
RECOMMENDATION:
5-10 yrs
QUALITY of EVIDENCE:
Moderate
STUDY n
5yr AA (%)
2007 VA Co-Op
291
4.6
2008 PPT
1905 5
2010 US Vets 86
5.2
2011 Korean
1242
2.4
2009 PLCOC
318
5.3 yrs)
Baseline AA: 4-10%
Best to do 5-year interval

20. Baseline: 3-10 Adenomas <10mm 2012 USMSTF
RECOMMENDATION:
3 yrs
QUALITY of EVIDENCE:
Moderate
2009 NCI Pooling Study
# Polyps

21. Surveillance Guidelines 2012 USMSTF
Risk Stratification
LRAs:
1-2 TA <10mm
HRAs:
Villous histology
HGD
Adenoma >10 mm
>3 small adenomas
2010 British Gastro Society:
LRAs
1-2 TA <10mm
IRAs
Adenoma >10 mm
3-4 small adenomas
HRAs
>5 small adenomas
>3 adenomas w 1 >10mm

22. Baseline: >10 Adenomas <10mm 2012 USMSTF
RECOMMENDATION:
<3 yrs
QUALITY of EVIDENCE:
Moderate
Consider 1yr colonoscopy
Consider HEREDITARY syndromes

23. High (size) / Mod (histo)
Baseline: >1 Adenoma >10mm, or Adenoma w villous features, or HGD
2012 USMSTF
RECOMMENDATION:
3 yrs
QUALITY of EVIDENCE:
High (size) / Mod (histo)
STUDY
Feature
Surveillance AA (%)
2009 NCI Pooling Study (3-5 yrs)
10-19 mm
15.9
>20 mm
19.3
2007 VA Co-Op (5 yrs)
>10 mm
15.5
TVA
16.8
16.1
LARGE POLYPS:
If complete excision is questioned...early f/u recommended
Risk of HGD does not appear independent:
Size &
Histology

24. Baseline: SERRATED POLYPS 2012 USMSTF
RECOMMENDATION:
3-5 yrs
QUALITY of EVIDENCE:
Low
RISK FACTORS:
SIZE: >10mm
HISTO:
Sessile serrated > HP
SSA/P w dysplasia > SSA/P w/o dysplasia
Location: Prox SC > distal SC
Recommendations:
SSA/P > 10mm
SSA/P w dysplasia
Traditional serrated adenomas
SSA/P <10mm w/o dysplasia
HRA-like: 3 yrs
LRA-like: 5 yrs

25. 2nd Surveillance Guidelines 2012 USMSTF
Baseline
Surveillance
1st
2nd
LRA
Neg
10 yrs **
5 yrs
HRA
3 yrs **
Baseline
Neg 1st colon
% 3-5 yrs
Consider 5yr surveillance rather than 10

26. Colonoscopy Quality Indicators
Adenoma detection rate
Avg. risk: 30.2% (22-58%) Heitman SJ, Clin Gastro Hep 2009
40% w High Definition Colonoscopes
Cecal intubation rate
(Adherence to surveillance guidelines)
Overutilization
Underutilization
Monitoring of bowel preparation
Inadequate -----> 35% adenoma & 36% AA miss rate at 1 yr
USMSTF:
Inadequate: repeat < 1yr
Fair but adequate: repeat 5 yrs (OK to detect >5 mm)

27. Colonoscopy: Imperfect Gold Std
Back-to-back colonoscopy in 183 patients
Rex DK, Gastroenterol 1997
Polyp Size (mm)
Miss Rate (%)
< 5 27
6-9 13
>10 mm 6
CTC trials: Segmental Unblinding
Polyp Size (mm)
Miss Rate (%)
>10 mm
12-17

28. Interval Cancers Majority due to missed lesions
Directly related to quality of exam
Incomplete polyp resection
19-27% occur in same colon segment
polyps >20 mm ---> 18% residual adenoma
Biologically different
More proximal
Increased microsatellite instability (mismatch repair)
CIMP +ve (CpG Island Methylator Phenotype)
? significant role from SSA/P

29. Stool DNA Testing Approved 2014 Earlier test withdrawn from mrkt
Immunochemical assay (iFOBT) added
Molecular assay for DNA mutations & methylation biomarkers
COLOGUARD
Detects 92% of CRC
Detects 42% adenomas
Contraindications:
Hx of ADENOMAS, CRC
FHx of CRC
Diarrhea, hemorrhoids, fissures
2014 FIT v sDNA v Colonoscopy
NNTT (find 1 CRC):
FIT
sDNA
Colonoscopy

30. Ideal test for patients fearful of colonoscopy!
Stool DNA Testing
“Patients with a negative Gologuard test result should be advised to continue participating in a colorectal cancer screening program with another recommended screening method”
Cologuard +ve ---> COLONOSCOPY
Cologuard -ve ---> COLONOSCOPY
Ideal test for patients fearful of colonoscopy!

31. CT Colonography Major Disadvantages:
Nearly as sensitive as colonoscopy
Still need bowel preparation
Fecal tagging techniques being developed
Need colonoscopy if positive
Extracolonic findings can lead to futile work-up
Major Disadvantages:
Requires radiation for a screening test
Not covered by insurance

32. Surveillance for Post Curative Surgery Colon Cancer 2012 USMSTF
RECOMMENDATION:
1 year
QUALITY of EVIDENCE:
Moderate
Colonoscopy 1 yr, 3 yrs, 5 yrs post surgery
Rectal Cancer: EUS with Sigmoidoscopy 1 yr, 3 yrs, 5 yrs post surgery

33. Summary 10 yr colonoscopy 5 yr colonoscopy 3 yr colonoscopy
NEGATIVE x2 (including distal HPs)
Age w NEGATIVE colon for other cause
5 yr colonoscopy
NEGATIVE x1
NEGATIVE x2 w FDR age <60
1-2 small adenomas
SSA/P < 10 mm w/o dyspl
3 yr colonoscopy
3-5 small adenomas
HRAs (adenoma > 10mm, HGD, Villous features)
SSA/P > 10 mm, SSA/P w dyspl, TSAs
1 yr colonoscopy
> 5 small adenomas
> 3 adenomas w > 10 mm+
Malignant polyp
< 1 yr colonoscopy
Inadequate preparation
Large flat adenomas w HGD
Large flat adenoma or SSA/P w incomplete resection