1. Colorectal Cancer (CRC)
Hyo Jong Kim
Division of Gastroenterology
Department of Internal Medicine
Kyung Hee University Medical Center

3. CRC in Korea

4. CRC in Korea
2004년 사망원인통계연보, 통계청

5. CRC in Korea

6. CRC in Korea 100 Colon cancer 80 60 Lung cancer Stomach cancer 40
Liver cancer 20
1995
2000
2005
2010
2015

7. Adenoma-Carcinoma Sequence

8. Adenoma-Carcinoma Sequence
and Polypectomy
10 yrs X

9. CRC: A Preventable Disease
Common and lethal
Long presymptomatic dwell time
High cure rate with early detection
Safe, accurate diagnostic tests

10. Prevent the Preventable Disease!

11. The Case of George W. Bush

12. Bush Transferred Presidential Power
                                                                                                      
The New York Times June 30, 2002

13. Bush Returns to Activities

14. Cheney? No More!
CNN. Tuesday, November

15. Cheney Gets to be President for 2 hours

16. The Case of George W. Bush
1998
Screening
Colonoscopy
Polypectomy for benign polyp
1st Follow-up
Colonoscopy
1999
Polypectomy for benign polyp
2002
2nd Follow-up
Colonoscopy
propofol, 20 mins
1.5 ounces of Fleet's phosphosoda, Propofol, 20 mins

17. The Case of George W. Bush
1998
Screening
Colonoscopy
Polypectomy for benign polyp
1st Follow-up
Colonoscopy
1999
Polypectomy for benign polyp
2002
2nd Follow-up
Colonoscopy
Negative
;1.5 ounces of Fleet's phosphosoda, Propofol, 20 mins

18. Cumulative Incidence of CRC in the National Polyp Study Cohort
Incidence Reduction
90%
88%
76%
*; P<0.001 SEER; The Surveillance, Epidemiology, and End Results
Winawer SJ. The National Polyp Study Workgroup. N Engl J Med 1993; 329:

19. CRC Screening Options Fecal occult blood test (FOBT) annually
Flexible sigmoidoscopy q 5 yrs
FOBT + sigmoidoscopy q 5 yrs
Double Contrast Barium enema (DCBE) q 5 yrs
Colonoscopy q 10 yrs

20. Evidence for CRC Screening
Strategy Mortality Incidence
Reduction Reduction
FOBT %-33% %
Sigmoidoscopy %
FOBT + sigmoidoscopy %
DCBE unknown
Colonoscopy RR %-60%
USPSTF. Ann Intern Med 2002;137:132

21. Colonoscopy versus Sigmoidoscopy

22. Colonoscopy versus Sigmoidoscopy

23. The Michelangelo Code
Michelangelo's "Night"

24. The Michelangelo Code
Breast Cancer in Michelangelo's "Night"

25. The Michelangelo Code
Breast Cancer in Michelangelo's "Night"

26. Sigmoidoscopy =? Single Mammography
Breast Cancer in Michelangelo's "Night"

27. Screening Test Efficacy for CRC
One-Time Testing Detection Rate of
Advanced Neoplasia (%)
FOBT alone
Sigmoidoscopy alone
Combined FOBT and sigmoidoscopy
DCBE
Colonoscopy

28. Recommended Tests and Screening Intervals
Test USPSTF GC ACG ACS KNCC
Year of
recommendation
Sigmoidoscopy recommended q 5 yr q 5 yr q 5 yr
interval ?
Colonoscopy insufficient q 10 yr q 10 yr † q 10 yr q 5-10 yr
evidence
*: Persons at average risk for CRC, screening should begin at the age of 50 years, † : preferred strategy
USPSTF: US Preventive Services Task Force, GC: Gastrointestimal Consortium, ACG: American College of Gastroenterology
ACS: American Cancer Society, KNCC: Korean National Cancer Institute

29. Korean National Guideline†
All persons ≥ 50 y shoud begin regular screening
colonoscopy q 5-10yr (preferred)
DCBE + sigmoidoscopy q 5-10 yr
†;Korean Society of Coloproctology and National Cancer Center, 2001

30. Cost, Resources, and Capacity
Screening

31. Surveillance
N Engl J Med 2006;355:2551

32. Korean Population Structure
2002
2020
26.7%
41.7%
Male
Female
Male
Female
Thousand persons
Statistical Handblook of Korea 2002, Korean National Statistical Office.

33. Cost, Resources, and Capacity
Screening
Surveillance

34. Diagnostic Yield of Flexible Sigmoidoscopy in Men
Veterans Affairs Cooperative Study Group 380
17,732 (men=96.8%)
N Engl J Med 2001;345:55

35. Diagnostic Yield of Flexible Sigmoidoscopy in Men and Women
Tandem study to Veterans Affairs Cooperative Study Group 380
1,463 women
N Engl J Med 2005;352:2061

36. Sex, Independent Predictor
N Engl J Med 2006;358:1863

37. Number Needed to Screen
N Engl J Med 2006;358:1863

38. Polypectomy

39. Is it too big to remove endoscopically?

40. Endoscopic Submucosal Dissection(ESD) for Rectosigmoid Epithelial Neoplasm

41. Endoscopic Management of ECC†
† ECC: Early Colorectal Cancer

42. ESD for Early Sigmoid Cancer

43. ESD for Early Sigmoid Cancer

44. ESD for Early Sigmoid Cancer

45. ESD for Early Sigmoid Cancer

46. Emerging Screening Tests
CT Colonoscopy
Stool DNA testing

47. CT Colonoscopy
N Engl J Med 2003;349:2191

48. CT Colonoscopy; Endoview

49. CT Colonoscopy; Filet view

50. Screening CT Colonoscopy
CT colonoscopy and Opitical Colonoscopy for the Detection of Adenomas
N Engl J Med 2003;349:2191

51. CT Colonoscopy: Clinical Application
obstructing sigmoid cancer

52. CT Colonoscopy in Unsuccessful Colonoscopy

53. CT Colonoscopy in Unsuccessful Colonoscopy

54. CT Colonoscopy in Unsuccessful Colonoscopy

55. Laparoscopically Assisted Colectomy

56. A Comparison of Laparoscopically Assisted and
Open Colectomy for Colon Cancer
n=872
median follow-up; 4.4 yrs
P=0.32
P=0.50
Cumulative Incidence of Recurrence
Overall Survival
N Egnl J Med 2004;350:2050

57. Normal Cell Growth and Carcinogenesis
Inactivation of Tumor Suppressor Genes promotion of cell growth, inhibition of cell death
nomal epithelium
dysplastic
ACF
mild
dysplasia
severe
dysplasia
invasive
tumor
Activation of Proto-oncogenes stimulation of cell proliferation

58. Colorectal neoplasia is….

59. …. a Genetic Disease RAS mutation APC mutation and loss p53 mutation
SMAD2/4
DCC
loss

60. Molecular Markers in a Single Test
10 mutations in APC
3 muations in K-ras
8 muations in p53
1 microsatellite instability marker, BAT-26
1 long DNA marker

61. Fecal DNA Panel and Occult-Blood Test
Most advanced finding at colonoscopy
Group that could be evaluated
(N=4404)
Analyzed subgroup
(N=2507)
Positive Fecal DNA Panel
Postive occult-blood test
Adenocarcinoma 31 31
16/31 (51.6)
4/31 (12.9)
Adenocarcinoma + high-grade dysplasia 72 71
29/71 (40.8)
10/71 (14.1)
Advanced adenoma
426
403
61/403 (15.1)
43/403 (10.7)
Minor polyps
1627
648
49/648 (7.6)
31/648 (4.8)
No polyps on colonoscopy
2318
1423
79/1423 (5.6)
68/1423 (4.8)
N Engl J Med. 2005;352:1384.

62. Bush’s Note at the 2005 World Summit
“I think I may NEED A BATHROOM BREAK?
Is this possible?”
U.S. President George W. Bush writes a note to Secretary of State Condoleezza Rice during a Security Council meeting
at the 2005 World Summit and 60th General Assembly of the United Nations in New York September 14,

63. Bush’s Fecal DNA Test

64. Low screening rates 38.7% 29.9% 23.5% 19.4%
Among appropriate populations that receive screening tests
CDC’s Behavioral Risk Factor Surveillnace System (BRFSS),U.S.,2001

65. Among appropriate populations that receive screening tests
Compliance %
100
Pap Test * 80
PSA Test†
Mammography * 60
FOBT &/or Endoscopy *
75%
81%
Endoscopy*
70% 40
FOBT*
42% 20
40%
17%
Selected Tests
Among appropriate populations that receive screening tests
†;JAMA. 2003;289:1414, *; CDC’s Naional Health Intervew Survey (NHIS) 2000

66. The Case of Katie Couric

67. “Katie Couric Effect”
March, 2000

68. Public Awareness
Katie Couric, the screening role for colonoscopy

69. ``Katie Couric Procedure''
March, 2002

70. Obstacles To Screening Compliance
Public acceptance of screening tests
Public awareness
Physician awareness of screening

71. Physician Awareness of Screening
1998 Gallup poll (U.S.)
<50% of all Americans ≥ 50 yrs have ever had any type of screening
88% of of nonscreened patients said health care provider had not discussed screening
by the National Colorectal Cancer Roundtable (NCCR)

72. patient care organization succesful screening programs
physician
insurer
patient care organization
succesful screening programs