Colorectal Cancer 101- Research Advocacy Training Webinar
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Colorectal Cancer 101- Research Advocacy Training Webinar
- 1. Colorectal Cancer 101 Research Advocacy Training and Support Program Our webinar will begin shortly. WELCOME!
- 2. • Speaker(s): Dennis Ahnen, MD • Archived Webinars: FightColorectalCancer.org/Webinars • AFTER THE WEBINAR: Expect an email with links to the material & a survey. If you fill it out, we’ll send you a Blue Star pin. • Ask a question in the panel on the RIGHT SIDE of your screen • Follow along via Twitter – use the hashtag #CRCWebinar Today’s Webinar:
- 3. What is a RESEARCH ADVOCATE? A research advocate brings a patient viewpoint to the research process and communicates a collective patient perspective Fight CRC’s Research Advocacy Training and Support (RATS) Program: • Goal is to improve the ability of research advocates to effectively participate in the research process. • In person meetings, online trainings, and webinars. • Continued education and ongoing training and support Brought to you by RATS:
- 4. Resources:
- 5. Disclaimer: The information and services provided by Fight Colorectal Cancer are for general informational purposes only. The information and services are not intended to be substitutes for professional medical advice, diagnoses or treatment. If you are ill, or suspect that you are ill, see a doctor immediately. In an emergency, call 911 or go to the nearest emergency room. Fight Colorectal Cancer never recommends or endorses any specific physicians, products or treatments for any condition.
- 6. Speaker: Dennis Ahnen, MD is an active clinician and investigator. He is the Co-Director of the University of Colorado Hereditary Cancer Clinic and Director of the Genetics Clinic at Gastroenterology of the Rockies; he provides consultative service to GI cancer families along with a genetic councilor in both clinics. Dr. Ahnen’s clinical and research interests are in understanding the process of colorectal cancer and its prevention. After over 30 years, Dr. Ahnen retired from his Staff Physician position at the Department of Veterans Affairs in Oct of 2014. He maintains an appointment as Professor of Medicine at the University of Colorado School of Medicine and has a part time appointment at Gastroenterology of the Rockies. Disclosures- Dr. Ahnen is on the Scientific Advisory boards of EXACT Sciences and Cancer Prevention Pharmaceuticals
- 7. Colorectal Cancer 101 Dennis J. Ahnen MD Director, Genetics Clinic Gastroenterology of the Rockies Professor of Medicine, University of Colorado School of Medicine
- 8. • What is colorectal cancer (CRC)? • Clinically • Biologically/Molecularly • Who is at risk for CRC and what is the risk? • How can CRC be prevented? • Lifestyle, nutritional, and chemoprevention • Screening • Staging and Treatment of CRC Colorectal Cancer 101
- 9. What is Colorectal Cancer?
- 10. Normal epithelium Abnormal epithelium Small adenoma Large adenoma Colon carcinoma 10-15 Years The Adenoma Carcinoma Sequence
- 11. Molecular Pathways to CRC Normal Epithelium Colon Carcinoma Chromosomal Instability- Mutations, LOH, Aneuploidy- 70% Microsatellite Instability- Lynch Syndrome- <5% CIMP Pathway- Serrated/Epigenetic- 25%
- 12. Lung CRC 49,700 BreastProstate Lung CRC 132,700 Other Other Prostate Breast Pancreas New Cases- 1,658,370 Deaths- 577,190 Who is at Risk for CRC? CRC Incidence and Mortality- U.S. 2015
- 13. Cancer Mortality Time Trends Men Women
- 15. CRC Mortality Women Men CRC Incidence and Mortality (Women) Incidence Mortality
- 16. Who is at CRC risk? • Identifiable Risk Factors • Demographic • Family History • Lifestyle • Diet • Those who don’t get screened
- 17. Risk Factors Demographic • Country of origin • Age • Sex • Race/Ethnicity • SES • Family History Lifestyle • Obesity • Low Physical Activity • Smoking • Alcohol Diet • High Red/Processed Meat • Low Fiber Containing foods •Fruits and Vegetables
- 19. Colorectal Cancer Incidence and Mortality Men Women Men > Women
- 20. CRC Incidence-Age and Sex Lifetime risk 5-6% 5-6%
- 21. Cumulative CRC Mortality by Race
- 22. Risk Factors Demographic • Country of origin • Age • Sex • Race/Ethnicity • SES • Family History Lifestyle • Obesity • Low Physical Activity • Smoking • Alcohol Diet • High Red/Processed Meat • Low Fiber Containing foods •Fruits and Vegetables
- 23. Familial Colorectal Cancer Adapted from Burt RW et al. Prevention and Early Detection of CRC, 1996 Sporadic (≈ 70%) Familial (≈ 25%) Lynch Syndrome (≈ 3%) (HNPCC) Familial Adenomatous Polyposis (<1%) Rare CRC Syndromes
- 24. Familial Adenomatous Polyposis • Rare • Autosomal Dominant • High CRC risk ≈100% • Early Onset • Easily recognized • Genetic testing or screening at around age 12 • Surveillance annually
- 25. Lynch Syndrome • Autosomal Dominant – 3% of CRCs • High CRC risk- up to 50% • Early onset- 44 yrs • Proximal location- 65% • Other cancers • Under-recognized • Screening works • Annual colonoscopy • Start at age 25 or 10 years younger than earliest Lynch cancer in the family
- 26. Familial Colorectal Cancer Adapted from Burt RW et al. Prevention and Early Detection of CRC, 1996 Sporadic (≈ 70%) Familial (≈ 25%) Lynch Syndrome (2-3%) (HNPCC) Familial Adenomatous Polyposis (<1%) Rare CRC Syndromes
- 27. Family History of CRC Increases Risk FoldRisk Lifetime Risk 5% Screening Intensity
- 28. Family History of CRC Increases Risk Fuchs et al NEJM 1994
- 29. Risk Factors Demographic • Country of origin • Age • Sex • Race/Ethnicity • SES • Family History Lifestyle • Obesity • Low Physical Activity • Smoking • Alcohol Diet • High Red/Processed Meat • Low Fiber Containing foods •Low Fruit and Vegetable Protective Factors • Screened • Aspirin for selected groups
- 30. Normal epithelium Abnormal epithelium Small adenoma Large adenoma Colon carcinoma 40% 20% 30% 40%Adenoma Incidence Metachronous Adenoma Incidence CRC Mortality 35% CRC Incidence CRC Survival 20% ASA and the Ad-Carc Sequence Lynch CRCs 50%
- 31. Normal epithelium Abnormal epithelium Small adenoma Large adenoma Colon carcinoma ASA Prevents Why not use it in everyone? Benefit is small Lifetime CRC risk- 5% 3% Lifetime CRC Mortality- 2.5% 1.6% Additive with surveillance? Risks of ASA 2-6 X GI Bleed Intracraneal Hemorrhage Aspirin Chemoprevention
- 32. ASA Chemoprevention Should Be Considered In…. • High CRC risk • History of CRC or Advanced Adenoma • Lynch Syndrome • Strong FH • High CVD Risk • Established CAD • Metabolic syndrome • CVD risk >10-15% • Low GI Bleeding Risk • No PUD/GI Bleed • No ASA Intolerance • No H. pylori/on PPI • Low IC Bleed Risk • No Uncontrolled Hypertension An adjunct to high quality CRC screening
- 33. ScreeningRate(%) Incidence Mortality Overall Screening Lower Endoscopy 0 50 100 150 200 250 CRC Time Trends- US 17 75- 60- 45- 30-- 15- 0- CRCper100,000
- 34. Normal epithelium Abnormal epithelium Small adenoma Large adenoma Colon carcinoma The Adenoma Carcinoma Sequence Prevention- Risk Factors Endoscopic Polypectomy Early Detection Stool Tests
- 35. Screening Test USPSTF MSTF High Sens FOBT annual Yes Yes Flex Sig q 5 yr +/- interval FOBT Yes Yes Colonoscopy q 10 yr Yes Yes CT Colonography q 10 yr No Yes Stool DNA No Yes CRC Screening Tests
- 36. Fecal Occult Blood Test (FOBT)
- 37. High Sensitivity Fecal Occult Blood Test (FOBT)
- 41. HO FIT FS+FIT Colon HO FIT FS+FIT Colon Incidence Mortality Zauber et al Ann Int Med 2009 PercentReduction Effectiveness of CRC Screening
- 42. Screening Test USPSTF MSTF High Sens FOBT annual Yes Yes Flex Sig q 5 yr +/- interval FOBT Yes Yes Colonoscopy q 10 yr Yes Yes CT Colonography q 10 yr No Yes Stool DNA No Yes CRC Screening Tests
- 43. New Screening Technologies Stool DNA CT Colonography Colon Capsule
- 44. Multi-target Stool DNA/FIT vs FIT Trial Multi-target sDNA Performance FIT Performance P-Value Cancer 92.3% (83.0-97.5) 73.8% (61.5-84.0) 0.0018 Advanced Adenoma 42.4% (38.9-46.0) 23.8% (20.8-27.0) < 0.0001 Specificity 86.6% (85.9-87.2) 94.9% (94.4-95.3) < 0.0001 Specificity 89.8% (88.9-90.7) 96.4% (95.8-96.9) < 0.0001 Imperiale TF et al. N Engl J Med. 2014;370(14):1287-1297
- 45. CRC Screening- Risk Groups • Average risk • No personal or FH of colonic neoplasia or IBD • Start CRC screening at age 50, stop at age 75-85 • Options for screening (FIT, Endoscopy) • Increased risk- FDRs of patients with CRC • Start at age 40 or earlier depending on # and age of CRCs in family, colonoscopy is preferred • Hereditary Syndromes • Start much earlier (12-25), annual colonoscopy
- 46. CRC Screening- Risk Groups • Increased risk- FDRs of patients with CRC • 1 FDR > 60 years old- 10% population • Start screening at age 40 • Use any standard screening approach • 1 FDR <60 years or >1 FDR- 3% population • Start screening at age 40 or 10 yrs younger than earliest CRC in family • Use colonoscopy every 5 years
- 47. Colonoscopy Rates Are Improving In FDRs But….. 0 20 40 60 80 2005 2010 FDRs ≥50 Colonoscopy within 10 years Percent Non-FDRs ≥50 Tsai et al. Prev Chronic Dis 2015;12:140533
- 48. Colonoscopy Rates Are Improving In FDRs But….. 0 20 40 60 80 2005 2010 Percent Non-FDRs ≥50 FDRs ≥50 FDRs 40-49 Tsai et al. Prev Chronic Dis 2015;12:140533 Colonoscopy within 10 years
- 50. Stage and Survival Stage 5 Year Survival Stage I (T1 N0 M0) >90% Stage II (T2/3 N0 M0) 70-85% Stage III (Tx N1 M0) 35-65% Stage IV (Tx Nx M1) 5%
- 51. CRC- Treatment
- 52. Advances in Treatment of Metastatic CRC
- 53. • What is colorectal cancer (CRC)? • Common, lethal, preventable, molecularly diverse • Who is at risk for CRC and what is the risk? • Age >50, family history, genetically predisposed • How can CRC be prevented? • Screening most effective; lifestyle changes prudent • Aspirin chemoprevention in selected patients • Staging and Treatment of CRC • Surgery, adjuvant Rx, palliative chemotherapy • Molecularly tailored therapy Colorectal Cancer 101
- 54. Question & Answer: SNAP A #STRONGARMSELFIE Bayer HealthCare will donate $1 for every photo posted (up to $25,000). Flex a “strong arm” & post it to Twitter or Instagram! (Use the hashtag!)