1. Overview of Colorectal Cancer and CRC Screening Program
CDC CRC Control Program
DHMH—Baltimore City
March 29, 2010

2. Colorectal Cancer Development and Prevention
Exposures (life style, occupation, and environment)
Acquired (not inherited) genetic changes
Inherited
cancer
susceptibility
genes
Asymptomatic Clinical
Disease Disease
Advanced
Disease
Convalescence
or Death
Birth
Age
Primary Prevention
- Risk Factor reduction
Colonoscopy with
adenoma removal
Secondary Prevention
- Screening, early detection and diagnosis
Tertiary Prevention
Medical care

3. CRC Incidence and Mortality

4. Annual age-adjusted cancer incidence rates, US, 1975-2004
CA Cancer J Clin Jemal et al. 58 (2): (2008).

5. Annual age-adjusted cancer death rates--Males, US, 1930-2004
CA Cancer J Clin Jemal et al. 58 (2): (2008).

6. Annual age-adjusted cancer death rates--Females, US, 1930-2004
CA Cancer J Clin Jemal et al. 58 (2): (2008).

7. CRC Screening

8. Colorectal Cancer Screening Status of People Age 50 Years and Older Maryland Cancer Surveys,

9. Provider Recommendation is KEY to Screening
80% of people 50+ in Maryland reported having a provider recommend endoscopy…..
of those, 88% got screened
Percent Screened
with Endoscopy
Of the 20% who did NOT report a provider recommendation….only 24% got screened
Source: Maryland Cancer Survey, 2008

10. Source: Maryland Cancer Survey, 2008

11. Source: Maryland Cancer Survey, 2008

12. Patient:
Family and personal history
Past screening
Symptoms
Primary Doctor:
Referral
Case
Management and
Communication
Colonoscopist:
Risk history
Medication changes
Prep instructions
Post colonoscopy instructions
Colonoscopy report
Findings
Recommendations
Pathologist:
Pathology report

13. Who needs CRC screening?

14. Colorectal Cancer Rates by Age and Sex Cancers of the Colon and Rectum: Average Annual Age-Specific SEER Incidence and U.S. Mortality Rates by Gender,
Incidence Men
Incidence
Women
Age recommended to start screening
Mortality
Men
Mortality
Women
Source: SEER Cancer Statistics Review Colon and Rectum Cancer, SEER Incidence and U.S. Death Rates, Age-Adjusted and Age-Specific Rates, By Race and Sex (Rates based on SEER 17 areas)

15. Colorectal Cancer Mortality Rates by Race and Sex in Maryland, 1998-2005
Age-adjusted rate per 100,000 population
Black men
Black women
White men
White women
Source: NCHS Compressed Mortality File in CDC Wonder

16. Colorectal Cancer Cases by Risk History
Sporadic
(average risk) (65%–85%)
(84, ,670 cases/yr.)
We are rapidly gaining knowledge about who develops colorectal cancer.
The majority of colorectal cancers, 65% to 85%, occur in people with no known cause (i.e., they are considered sporadic).
10% to 30% of cases of colorectal cancer occur in people who have a family member who has had a polyp or colorectal cancer.
A small percentage of colorectal cancers occur as part of an inherited syndrome. Approximately 5% are associated with hereditary nonpolyposis colorectal cancers (HNPCC) and 1% are associated with familial adenomatous polyposis (FAP).
Less than 0.1% are rare colorectal cancer syndromes.
Family
history (10%–30%)
Rare syndromes (<0.1%)
Hereditary nonpolyposis colorectal cancer (HNPCC) (5%)
Familial adenomatous polyposis (FAP) (1%)

17. Approx. lifetime risk of CRC
Group
Approx. lifetime risk of CRC
General Population
5-6%
One first degree relative (FDR) with CRC
2--3-fold increased over general population
Two First Degree Relatives (FDR)s with CRC
3--4-fold increased
FDR with CRC diagnosed < 50
One second or third degree relative
About 1.5-fold increased
Two second degree relatives
About 2--3-fold increased
One FDR with adenoma
About 2-fold increased
Inflammatory Bowel Disease (ulcerative colitis and Crohn colitis)
[7-10% have CRC after having ulcerative colitis for 20 years; then ~1%/year]
Familial Adenomatous Polyposis
Hereditary Non-polyposis Colorectal Cancer
~100%
~80+%
Burt. Gastroenterology 2000;119:837-53
Winawer et al. Gastroenterology 203;124:

18. Maryland Screening Recommendations: Medical Advisory Committee on CRC
Colonoscopy, every 10 years or
FOBT annually, plus
Flex sig., every 5 years
FOBT if refuse endoscopy
Colonoscopy
(interval for repeat depends
on risk, history, and
prior results)
Average Risk
Increased Risk
Maryland Screening Recommendations:
Medical Advisory Committee on CRC

19. Risk Category Age to Begin Screening
Average risk, asymptomatic
50 years
Increased risk
Family history CRC or adenoma (1 FDR <60 or 2 FDR any age)
Colonoscopy at 40 years old or 10 years before the youngest case in the FDRs
Family history CRC or adenoma in 1 FDR >= 60
Start screening (any method) at 40 years old
Genetic syndrome:
FAP
HNPCC
Puberty
21 years old
Inflammatory bowel disease
8 years after start of pancolitis;
12-15 years after start of left sided colitis

20. See Program Manual 1A, Attachment 1

22. Colonoscopy
or other
screening test

23. CA Cancer J Clin 58: 130-160 (May 2008)
New Guidelines
Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008:
A Joint Guideline from the
American Cancer Society,
the US Multi-Society Task Force on CRC, and
the American College of Radiology
CA Cancer J Clin 58: (May 2008)

24. for the American Cancer Society Colorectal Cancer Advisory Group,
Bernard Levin,
David A. Lieberman,
Beth McFarland,
Robert A. Smith,
Durado Brooks,
Kimberly S. Andrews,
Chiranjeev Dash,
Francis M. Giardiello,
Seth Glick,
Theodore R. Levin,
Perry Pickhardt,
Douglas K. Rex,
Alan Thorson,
Sidney J. Winawer,
for the American Cancer Society Colorectal Cancer Advisory Group,
the US Multi-Society Task Force, and
the American College of Radiology Colon Cancer Committee

25. Tests that Find Both Polyps and Cancer
Flexible sigmoidoscopy every 5 years 
Colonoscopy every 10 years 
Double contrast barium enema every 5 years 
CT colonography (virtual colonoscopy) every 5 years
New Guidelines American Cancer Society, May 2008

26. Tests that Primarily Find Cancer
Guaiac-based fecal occult blood testing (gFOBT) every year 
Fecal immunochemical test (FIT) every year 
Stool DNA test (unclear how often this is needed)
New Guidelines American Cancer Society, May 2008

27. New CRC Screening Guidelines American Cancer Society, May 2008
Beginning at age 50, men and women at average risk for CRC should use one of the screening tests
The tests that are designed to find both early cancer and polyps are preferred if these tests are available to you and you are willing to have one of these more invasive tests.
Talk to your doctor about which test is best for you.

28. CRC Screening Program in Maryland

32. Colonoscopy Equipment

34. Long Handle Polypectomy Snare

35. Polyp Snare

36. Reusable Biopsy Forceps

37. Hot Biopsy Forceps

38. Disposable Retriever

39. Prong Retriever

40. Brush Biopsy

41. Injection

42. Colonoscopy Findings: Pathology

45. Different types of polyps
Sessile polyp
Tubulovillous adenoma
Sessile polyp
Hyperplastic polyp

46. Different types of polyps
Sessile polyp
Tubular adenoma
Sessile polyp
Tubulovillous adenoma
Pedunculated polyp

47. Different types of polyps
Pedunculated polyp
Tubular adenoma
Pedunculated polyp
Tubular adenoma

49. Copyright
Mediamed art
Milan (Italy)

50. Wall of the colon under a low power microscope
Inside of the intestine (feces touch this surface)
Atlas of Human Histology. Di Fiore.
1974, Lea& Febiger
Mucosa
Submucosa
Muscularis
Serosa

51. Robbins Pathologic
Basis of Disease, 6th Ed. Cotran, Kumar, and Collins WB Saunders
p. 827

53. Pedunculated adenoma HEAD OF POLYP SUBMUCOSA STALK RESECTION LINE
INTESTINAL
WALL
Muscularis

54. Pedunculated adenoma HEAD OF POLYP SUBMUCOSA (lymphatics, arteries)
STALK
RESECTION LINE
INTESTINAL
WALL
Muscularis

55. Polyp with no evidence of invasive carcinoma2 1 3
Polyp with no evidence of invasive carcinoma
SUBMUCOSA
Low grade dysplasia
Severe dysplasia
Carcinoma in-situ, intramucosal carcinoma
“High grade
dysplasia”

56. Polyp with invasive carcinoma
SUBMUCOSA
INVASIVE CARCINOMA
(invasion in submucosa
which contains lymphatics, and arteries = potential for metastases)

57. Polyp with invasive carcinoma: Pertinent pathology information
Tumor differentiation
Lymphatic/vascular invasion
Distance from resection line
RESECTION LINE

58. Sessile Polyps Usually submitted in several pieces
Difficult to determine the orientation of the specimen
(“is the margin free of tumor?”)
Other issues—type of polyp?

59. Stage 1 Stage 2 Invasive carcinoma: Colon cancer staging
Pathology, Second Edition. Rubin and Farber. 1994:

60. Cancer in the regional lymph nodes
Stage 3
Cancer in the regional lymph nodes
Stage 4
Invasive carcinoma: Colon cancer staging
Pathology, Second Edition. Rubin and Farber. 1994:

61. Colonoscopy Findings: Adequacy of the Exam

62. Adequacy of Colonoscopy
Cecum

63. Adequate Colonoscopy? Reached the cecum? Adequate bowel prep?
Reached and explored?
Reached and intubated the terminal ileum?
Peeked into the cecum but couldn’t get in
Adequate bowel prep?
“Adequate to visualize any lesion >5mm”
“Adequate enough”
“Adequate”
“Fair”
“Excellent”

64. Is the bowel prep “adequate”?

65. Adequate
prep?

66. How can I dictate a picture of what I’m seeing here?

67. What to think about if prep was inadequate:
Can you figure out why this patient might have had inadequate prep?
Is there anything that could have been done differently?
By the provider
By your program
By the patient
Are there lessons learned for future clients and for this client’s next colonoscopy?
Different instructions, different prep
Discussion with the provider(s)
Other

68. Case Management

69. Roles before Colonoscopy
Administrative Case Manager (nurse or other case manager in program)
Obtain information for enrollment
Schedule appointment and colonoscopy
Instruct about bowel prep and procedures
Solve any barriers (transportation, accompaniment home)
Medical Case Manager
Do an exam and clear the patient for colonoscopy
Give instructions about medication changes if needed
Instruct on bowel prep and procedures
Schedule specifics about the colonoscopy

70. Roles after Colonoscopy
Medical Case Manager (doctor who did the endoscopy)
Give you a report of the colonoscopy
Give you the recall interval
Give the client the results
Administrative Case Manager
Obtain colonoscopy and pathology reports
Review recall recommendation—is it correct per program standards?
Enter data in computer
Notify client of their results (verbal; written)
Ask about complications
Inform the primary care provider

71. “Recall Interval”
Recommended screening after initial screening-- rescreening or surveillance colonoscopy

72. Keys to the right recall
Colonoscopy Report
Pathology Report
Recommendation based on guidelines
Communication

73. After first colonoscopy, then what?
Recall interval between colonoscopies will depend on:
findings,
risk history, and
symptoms

74. Interval between colonoscopies
IF Findings on colonoscopy were negative:
No CRC;
No adenomas; and
No or only a few hyperplastic polyps,
Average risk, and
No CRC symptoms
Recall interval will usually be 10 years
See guidelines for recommended interval

75. Interval between colonoscopies– based on findings
IF Findings showed:
Inadequate colonoscopy
didn’t reached cecum
inadequate bowel preparation
Cancer
Adenomatous polyp(s)—need to know:
Number
Size
Histology
Completeness of removal
Many hyperplastic polyps indicating Hyperplastic Polyposis Syndrome
Recall interval will usually be LESS THAN 10 years
See guidelines for recommended interval

76. Interval between colonoscopies– based on risk history
IF first colonoscopy was negative BUT person is at increased risk because of family history:
Interval may be LESS THAN 10 years
See guidelines for recommended interval

77. “several adenomas were found”
Example
53 year old patient had
a colonoscopy:
“several adenomas were found”
What is the recommended recall interval?
What else do you need to know to determine the interval?
Who will tell the patient?
Will anyone remind the patient when the next colonoscopy is needed?

78. Answer:
You need to know more about the Risk and Colonoscopy Results before you can set the right recall interval:
Was the bowel preparation adequate?
Was the cecum reached?
How many adenomas were found?
How big were the adenomas?
Were they completely removed?
What was the pathology?
What is the family and personal risk history of the patient?

79.
Guidelines for Colonoscopy Surveillance after polypectomy--Winawer et al. CA--A Cancer Journal for Clinicians 56 (3) 143. (2006)

80. See Program Manual 1A, Attachment 1

81. Recall Interval Based on Finding of First Colonoscopy
“Inadequate” bowel prep
(How inadequate was it?)
Repeat right away or do other screening (e.g., DCBE)
Didn’t reach or view cecum
Repeat right away or do other screening to check cecum
“Two adenomas”
Need to know histology and size
Any villous histology (villous, tubulovillous) or high grade dysplasia
If completely removed, repeat in 3 years
One or more adenomas >1 cm in size
Repeat in 3 years
Incomplete removal of adenomas
Consider short recall interval (2-6 months)
1-2 tubular adenomas, <1 cm size
Repeat in 5-10 years

82. Recall Interval Based on Finding of First Colonoscopy
“Inadequate” bowel prep
(How inadequate was it?)
Repeat right away or do other screening (e.g., DCBE)
Didn’t reach or view cecum
Repeat right away or do other screening to check cecum
“Two adenomas”
Need to know histology and size
Any villous histology (villous, tubulovillous) or high grade dysplasia
If completely removed, repeat in 3 years
One or more adenomas >1 cm in size
Repeat in 3 years
Incomplete removal of adenomas
Consider short recall interval (2-6 months)
1-2 tubular adenomas, <1 cm size
Repeat in 5-10 years

83. Standards for Colonoscopy Reports--CoRADS*
Colonoscopy withdrawal time 
Findings
Specimen(s) to path lab 
Impression 
Complications 
Pathology 
Recommendations,
Follow-up Plan/Recall 
Other 
Date and Time Procedure 
Patient description 
Risk factors-
ASA class 
Indications
Consent signed 
Sedation  
Colonoscope 
Bowel Prep 
Reached cecum 
* Standardized colonoscopy reporting and data system (CoRADS): report of the Quality Assurance Task Group of the National Colorectal Cancer Roundtable, Lieberman et al., Gastrointestinal Endoscopy 2007; 65:

84. Adequacy of First Colonoscopy Among 10,328
Adequacy of First Colonoscopy Among 10,328* Cycle 1 Colonoscopies Maryland 2000-December 2008
*10,328 of the 11,421 first colonoscopies had information on “adequacy” of the col.
Source: DHMH, CCSC, Client Database (CDB), Ad-hoc report, 1/12/2009

85. Colonoscopy Findings:
Reporting on
Colonoscopy Findings:
Number of masses, polyps, other lesions
(try to give actual or estimated number rather than “several” or “multiple”)
Findings: for EACH mass/polyp/lesion--
location
size
description
tattoo
biopsy(ies) taken
method of each biopsy
whether lesion completely removed or not
whether there was piecemeal removal
whether specimens retrieved
whether saline lift used
number of specimens sent to pathology

86. How will your patients be reminded about their next colonoscopy?

87. Communication Patient: Family and personal history Past screening
Symptoms
Primary Doctor:
Referral
Case
Management and
Communication
Colonoscopist:
Risk history
Medication changes
Prep instructions
Post colonoscopy instructions
Colonoscopy report
Findings
Recommendations
Pathologist:
Pathology report

88. Acknowledgements -Funding from the Maryland Cigarette Restitution Fund
-Staff and partners of Local Public Health Department Programs in MD and their contracted providers
-- DHMH Center for Cancer Surveillance and Control (CCSC)
Database and Quality assurance
Surveillance and Epidemiology Unit
University of Maryland at Baltimore
Ciber, Inc.
- CCSC Local PH Component
- DHMH FHA, Information Technology
-- Minority Outreach Technical Assistance Partners

89. CDC Benchmarks for CRC Screening Screening Priority Population
Indicator Type, Number and Description
CDC Benchmark
Screening Priority Population 1
Percent of new clients screened who are at average risk for CRC
≥ 75% 2
Percent of average risk new clients screened who are aged 50 years and older
≥ 95%
Completeness of Clinical Follow-up 3
Percent of abnormal test results with diagnostic follow-up completed
≥ 90% 4
Percent of diagnosed cancers with treatment initiated
Timeliness of Clinical Follow-up 5
Percent of positive tests (FOBT/FIT, sigmoidoscopy, or DCBE) followed-up with colonoscopy within 90 days
≥ 80% 6
Percent of cancers diagnosed with treatment initiated within 60 days