Colorectal Cancer

Bruce D. Greenwald, MD
Associate Professor of Medicine
University of Maryland
School of Medicine
 Outline
Where is the colon and what does it do?
Why is colon cancer important?
How many cases/year?
Who gets it?
Who dies from it?
How does colon cancer develop?
How is colon cancer treated?
Is colon cancer preventable?
 2003 Estimated US Cancer Cases*
Men
Men Women
Prostate 222,849 675,300 658,800
675,300 210,816 Breast
Lung/bronchus 94,542 79,056 Lung/bronchus
Colon/rectum 74,283 72,468 Colon & rectum
Urinary bladder 40,518 39,528 Uterine corpus
Melanoma of 27,012 26,352 Ovary
skin
26,352 Non-Hodgkin
Non-Hodgkin 27,012 lymphoma
lymphoma
19,764 Melanoma of
Kidney 20,259 skin
Oral cavity 20,259 19,764 Thyroid
Leukemia 20,259 13,176 Pancreas
Pancreas 13,506 13,176 Urinary bladder
All other sites 114,801 62,238 All other sites
ONS=Other nervous system.
*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.
Source: American Cancer Society, 2003.
 2003 Estimated US Cancer Deaths*
Men Women
Lung/bronchus 88,629 67,650 Lung/bronchus
285,900 270,600
Prostate 28,590 40,590 Breast
Colon & rectum 28,590 29,766 Colon & rectum
Pancreas 14,295 16,236 Pancreas
Non-Hodgkin 11,436 13,530 Ovary
lymphoma
10,824 Non-Hodgkin
Leukemia 11,436 lymphoma
Esophagus 11,436 10,824 Leukemia
Liver/intrahepatic 8,577 8,118 Uterine corpus
bile duct
5,412 Brain/ONS
Urinary bladder 8,577
5,412 Multiple myeloma
Kidney 8,577
62,238 All other sites
All other sites 62,898
ONS=Other nervous system.
*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.
Source: American Cancer Society, 2003.
 Ethnic/Gender Differences
Incidence per 100,000 Survival (%)

40 100

35
80
30
63
53
25 60

20

15 40

10
20
5

0 0
Women Men

African-American White

Source: Surveillance, Epidemiology, and End Results Program, 1973-1999, Division of Cancer Control
and
Population Sciences, National Cancer Institute, 2002.
 Colon cancer rates for Baltimore City
and Maryland, 1994-1998
70

60 Baltimore
City
50 Maryland

40

30

20

10

0
Overall Men Women African- White
American

Source: Maryland Department of Health and Mental Hygience. Annual Cancer Report. September, 2001.
Age-adjusted incidence per 100,000 population
How Does Colorectal Cancer Develop?

Janne PA, Mayer RJ. N Engl J Med 2000;342:1960.

Colon Polyp
Colon Cancer
How Does Colorectal Cancer Develop?

Janne PA, Mayer RJ. N Engl J Med 2000;342:1960.

 Symptoms of Colorectal Cancer

Time Course Symptoms Findings

Early None None
Occult blood in stool
Mid Rectal bleeding Rectal mass
Change in bowel Blood in stool
habits
Late Fatigue Weight loss
Anemia Abdominal mass
Abdominal pain Bowel obstruction
Staging of Colorectal Cancer
Frequency of Colorectal Cancer by
Dukes Stage
Survival by Dukes Stage
Treatment of Colorectal Cancer
by Stage
 Is Colorectal Cancer Preventable?

YES!

Screening

Chemoprevention
 Screening Techniques for Colorectal
Cancer
Fecal occult blood test (FOBT) every year, or

Flexible sigmoidoscopy every 5 years,or

A fecal occult blood test every year plus flexible

sigmoidoscopy every 5 years (recommended by the
American Cancer Society), or

Double-contrast barium enema every 5 to 10 years, or

Colonoscopy every 10 years (recommended by the

American College of Gastroenterology).
 Screening For Colon Cancer
SAVES LIVES!!!
Mortality
Test Reduction
Fecal occult blood testing 33%
Flexible sigmoidoscopy 66%
(in portion of colon examined)

FOBT + flexible sigmoidoscopy 43%

(compared to sigmoidoscopy alone)

Colonoscopy ~76-90%
(after initial screening and polypectomy)
 Colorectal cancer screening
First assess RISK

AVERAGE RISK INDIVIDUAL

All patients age 50 years and older, the
asymptomatic general population

HIGH RISK
Personal history polyp or cancer
Family history polyp or cancer in first
degree relatives
 Why arent more people screened for
colon cancer?
Reasons for refusal of fecal occult blood testing
Fear of further testing and surgery
Feeling well
Unpleasantness of stool collection procedure

But:
Strongest predictor of whether a patient will be
screened = physician encouragement

Hynam et al. J Epidemiol Comm Health 1995;49:84

Mandelson et al. Am J Prevent Med 2000;19:149
 Fecal Occult Blood Testing
Examination of stool for occult (hidden)
blood
Can detect one teaspoon or less of blood in a
bowel movement
Uses chemical reaction between blood and
reagent
FOBT improves survival

Years after diagnosis

 Trends in FOBT, 1997-2001
30
25
20
1997
Prevalence(%)

15
1999
10
2001
5
0
Total Men Women Less than High High School Some college
School graduate or greater

Source: Behavioral Risk Factor Surveillance System, 1996-1997, 1999, 2001, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease Control and Prevention and Prevention, 1999, 2000, 2002.
Double-contrast Barium Enema
 Double-contrast Barium Enema
Pros
Examines entire colon
Relatively low cost
Cons
Never studied as a screening test
Missed 50% of polyps > 1cm in one study
Detects 50-75% of cancers in those with
positive FOBT
Interval between exams unknown

Winawer et al. Gastroenterology 1997; 112:599

Rex, Endoscopy 1995; 27:200
Lieberman et al. N Engl J Med 2000; 343:163
Sigmoidoscopy/Colonoscopy
Site Distribution
 Flexible sigmoidoscopy
Pros
May be done in office
Inexpensive, cost-effective
Reduces deaths from rectal cancer
Easier bowel preparation, usually done without
sedation
Cons
Detects only half of polyps
Misses 40-50% of cancers located beyond the view
of the sigmoidoscope
Often limited by discomfort, poor bowel preparation

Selby et al N Engl J Med 1992; 336:653 Stewart et al Aust NZ J Surg 1999; 69:2
Newcomb et al. JNCI 1992; 84:1572 Painter et al Endoscopy 1999; 3:269
Rex et al. Gastrointest Endosc 1999; 99:727
 Colonoscopy
Pros
Examines entire colon
Removal of polyps performed at time of exam
Well-tolerated with sedation
Easier bowel preparation, usually done without
sedation
Cons
Expensive
Risk of perforation, bleeding low but not negligible
Requires high level of training to perform
Miss rate of polyps < 1 cm ~25%, > 1 cm ~5%

Rex et al. Gastroenterology 1997; 112:24-8

Postic et al. Am J Gastroenterol 2002; 97:3182-5
Colonoscopy
 Chemopreventive agents
Fiber Not effective

Aspirin May be effective

NSAIDs (ibuprofen, etc) Probably effective
Vitamin E, vitamin C, beta Not effective
carotene
Folate Effective if obtained in diet

Calcium Effective
Estrogen Effective, but has other
problems
 Future techniques for colorectal
cancer screening
Stool DNA testing

Capsule endoscopy (Givens capsule)

CT colography (virtual colonoscopy)

Fecal Testing for Gene Mutations
 Fecal Testing for Gene Mutations
Pros
No sedation or preparation necessary
Home-based (sample mailed to physician)
No risk
Cons
Current tests not very good (~50% of cancers
missed)
Cost
Frequency of exam unknown
Not therapeutic
Not covered by insurance
Videocapsule
 Videocapsule
Lymphoma
CT Colography

Colon Polyp
CT Colography

Colon Polyp
CT Colography

Colon Cancer
 CT Colography
Pros
No sedation necessary
20 min procedure vs. 25 min for colonoscopy
Low risk
Extracolonic lesions may be detected

Cons
Preparation (residual fluid cannot be aspirated)
Air insufflation
Cost (? need for more frequent exams)
Radiation dose (similar to barium enema)
Not therapeutic
Not covered by insurance
 Summary

Colorectal cancer is the third most common

cancer and cause of cancer death in the U.S.

Chemopreventive agents have modest

benefit in average risk individuals

Screening for colorectal cancer saves lives!

Patient and physician compliance with

screening is poor