This document summarizes a webinar on polyps and colorectal cancer screening. The webinar discusses how colon cancer develops from polyps, screening guidelines based on age and risk factors, and various screening options including colonoscopy and fecal immunochemical tests. It emphasizes that screening is effective at detecting cancer early by finding and removing polyps, but that uptake remains low, with factors at the patient, provider and systems levels influencing screening rates. Modifying diet and lifestyle, such as increasing fiber intake and physical activity, can also help to lower colon cancer risk.

1. Polyps and Prevention: The Importance of
Screening for Colorectal Cancer

2. TODAY’S WEBINAR
 SPEAKER(S)
 Folasade May, M.D., Ph.D., M.Phil.
 QUESTIONS
 Ask a question in the panel on the RIGHT SIDE of your
screen
 WEBINAR ARCHIVE
 FightCRC.org/webinar
 TWEET ALONG
 Follow along via Twitter – use the hashtag #CRCWebinar

3. RESOURCES
TABOO-TY PODCAST MINI MAGAZINES CLINICAL TRIAL FINDER

4. FIGHTCOLORECTALCANCERDISCLAIMER
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.

5. Dr.FolaMay Dr. May graduated cum laude from Yale University with a degree in molecular,
cellular, and developmental biology. After college, she attended the University
of Cambridge to study epidemiology and international health, earning a
master’s of philosophy before returning to the States to attend Harvard Medical
School.
Dr. May came to UCLA in 2011 to begin her gastroenterology fellowship. As a
fellow in the UCLA Specialty Training and Advanced Research (STAR) program,
she earned a PhD in health policy and management from the UCLA Fielding
School of Public Health. Her doctoral dissertation addressed black-white
disparities in colorectal cancer incidence, screening, and outcomes.
Dr. May joined the digestive diseases faculty at UCLA as a clinical instructor of
medicine in 2015. She is a member of the UCLA Jonsson Comprehensive Cancer
Center (JCCC) and research collaborator at the UCLA Center for Cancer
Prevention Control Research (CPCR). Her research focuses on eliminating
patient, provider, and system-level barriers to colorectal cancer screening in
Federally Qualified Health Centers and in the Veterans Health Administration.
She is also faculty at the UCLA Center for World Health as co-director for the
Global Health Education Program in the David Geffen School of Medicine. She
has participated in global health programs in Costa Rica, Nigeria, South Africa,
Uganda, Malawi and Tanzania.

6. drfolamay
Polyps and Prevention:
The Importance of Screening for Colorectal Cancer
Fola May, MD, PhD
Vatche &Tamar Manoukian Division of Digestive Diseases at UCLA
Greater Los AngelesVeterans Health Affairs
UCLA Cancer Prevention Control Research

7. drfolamay
Colon cancer is common
American Cancer Society, Inc., 2018.
#3 cause of cancer in men and women in the United States

8. drfolamay
Colon cancer is deadly
#2 cause of cancer-related deaths in the United States
American Cancer Society, Inc., 2018.

9. What we will cover today
• How does colon cancer start?
• What is a colon polyp?
• How do we prevent colon cancer?
• When should I start screening?
• What are my screening test options?
• How do I become a champion for colon cancer screening?
• What is the role of diet and lifestyle in colon cancer risk?
drfolamay

10. drfolamay
“Colon Cancer”
=“Colorectal Cancer”
=Cancer that develops in the colon
and/or rectum

11. drfolamay

12. drfolamay
What’s the colon for anyway?
The colon and rectum:
• Large intestine or large bowel
• Last parts of the digestive system
The colon functions to:
• Absorb water and salt from food
• Form stool
The rectum functions to:
• Store stool until ready to pass

13. drfolamay
What is a polyp?
A Polyp is a lump or growth of abnormal
cells

14. drfolamay
How does colon cancer develop?
Normal Colon Polyp Colon Cancer
Colon cancer develops when the cells in polyps
begin to grow uncontrollably.
years & years & years

15. drfolamay
Many types of colon polyps
Not pre-cancerous
Mucosal polyps
Inflammatory Pseudopolyps
Submucosal polyps
Hamartomatous polyps
May be pre-cancerous
Sessile serrated polyps
Sessile serrated adenomas
Traditional sessile adenoma
Tubular adenomas

16. drfolamay
Adenomatous polyps
• Source of the majority of colon cancers
• ≤ 5% will progress to CRC (over ~7 to 10 years)
• Require more frequent screening if considered ”advanced”:
• ≥ 1 centimeter in diameter
• Microscope exam reveals “tubulo-villous” features or “high grade
dysplasia”

17. drfolamay
• Red or black blood
• Change in stool shape
• Cramping or discomfort
• Urge to have a bowel
movement
• New constipation or
diarrhea
• Decreased appetite
• Unintentional weight loss
But by the time these
symptoms occur, the cancer
can be advanced
Precancerous polyps and early colon cancer do not cause symptoms.
As a polyp grows, it can bleed into the stool or cause a blockage in the intestine, which may
cause symptoms of colon cancer:
Do not wait for symptoms

18. So how do we prevent polyps from
becoming cancer?
drfolamay

19. drfolamay
Colon cancer screening
• Screening tests allow us to detect and
remove colon polyps before they become
cancer.
• Screening tests also detect colon cancers
early and before they cause symptoms.

20. Age to start screening

21. drfolamay
Those with a family history
Family History American Cancer
Society
American College
of
Gastroenterology
First degree relative
with colon cancer or
colon polyps
(mother, father, sister,
brother)
Colonoscopy at age 40
Repeat every 5 years
Colonoscopy at age 40
-OR-
10 years younger than
diagnosis age of the
youngest affected relative
Repeat every 5 years

22. drfolamay
Higher risk groups
Crohn’s disease
Ulcerative colitis
Familial polyposis syndromes
Hereditary colon cancer
Screen early (age varies);
Often repeated annually
African-Americans*
Begin screening at age 45
(Screen with colonoscopy)
*American College of Gastroenterology recommendation

23. drfolamay
“Average risk” individuals
U.S. Preventive Task
Force
American Cancer
Society
Start at age 50
Screen until at least age 75
(Consider screening till age 85)
Start at age 45
Screen until age 75

24. drfolamay
Ahnen et al. Mayo Clin Proc, 2014.
Age > 50 Age < 50
45 or 50?

25. drfolamay
Pros and cons for screening at 45
Motivations
• Rising incidence in age <50
• No current efforts in age < 50
• May boost screening overall
Potential Shortcomings
• No strong data to support
• Possible diversion of resources
• Additional 21 million to screen
between age 45-49
• May widen inequities in screening
• Cost
• Insurance coverage
Liang et al, Gastro, 2018.
Imperiale et al, CGH, 2018.

26. Screening modalities

27. drfolamay
gFOBT
CT Colonography
Fecal Immunochemical
Test (FIT)
FIT-DNA
(Cologuard)
Stool-based strategies
Direct-visualization techniques
Flexible Sigmoidoscopy Colonoscopy
Screening tests
Serology
Capsule

28. drfolamay
Colonoscopy
• Performed in a hospital or medical clinic
• Requires bowel preparation
• Gastroenterologist uses a “colonoscope,” a long flexible tube
with a light at the end
• Requires conscious sedation or monitored anesthesia care
• Examines the walls of the colon (20-30 minutes)
• Risks are very small (1:1000) and include bleeding, infection,
and colon injury
• Considered the gold standard for finding colon cancer or
precancerous polyps
• If normal, repeated every 10 years

29. drfolamay
A proper colon prep is key!

30. drfolamay
Polyps can be hard to see

31. drfolamay
Barriers to screening colonoscopy
Embarrassment
Fear of discomfort
Time off Work
Insurance
Concerns about Prep
Access to endoscopist
Fear of Sedation
Out of pocket costs
Need for escort

32. drfolamay
Fecal immunochemical test (FIT)
• Second most common screening test
• Stool-based test that can be performed at home
• Tests the stool for small amounts of human blood
which may be a sign of colon cancer
• Low-risk screening option
• Performed yearly to be effective
• Two-step screening process

33. drfolamay
Abnormal follow-up after positive FIT
Positive FIT
Result
Must have
colonoscopy

34. drfolamay
Abnormal follow-up after positive FIT
Up to 1 in 3 with abnormal FIT have a large
polyp or colon cancer.
Up to 1 in 10 with abnormal FIT have colon
cancer.

35. drfolamay
gFOBT
CT Colonography
Fecal Immunochemical
Test (FIT)
FIT-DNA
(Cologuard)
Flexible Sigmoidoscopy Colonoscopy
Serology
Capsule

36. drfolamay
• Tests stool for 11 pre-cancer and cancer biomarkers
• Includes test for human hemoglobin (i.e. DNA+FIT)
• 3-year screening interval (proposed)
• Limitations:
• Very few studies
• No data to support 3-year interval
• High false positive rate
• High failure to complete rate
• Not always covered by insurance
Multitarget stool DNA (Cologuard)

37. drfolamay
gFOBT
CT Colonography
Fecal Immunochemical
Test (FIT)
FIT-DNA
(Cologuard)
Flexible Sigmoidoscopy Colonoscopy
Serology
Capsule

38. drfolamay
gFOBT
CT Colonography
Fecal Immunochemical
Test (FIT)
FIT-DNA
(Cologuard)
Flexible Sigmoidoscopy Colonoscopy
Serology
Capsule

39. drfolamay
CT Colonography
• CT or “CAT Scan” that provides a 2-D and 3-D image of the colon.
• Requires a bowel preparation and insufflation with air or carbon
dioxide.
• Requires colonoscopy if polyps are found
• Does not detect small polyps well
• May result in further unnecessary testing and costs due to
unexpected findings (25%-80% cases).

40. drfolamay
gFOBT
CT Colonography
Fecal Immunochemical
Test (FIT)
FIT-DNA
(Cologuard)
Flexible Sigmoidoscopy Colonoscopy
Serology
Capsule

41. drfolamay
“First Tier” tests
Colonoscopy
Every 10 years
Fecal Immunochemical
Test (FIT) annually
MSTF. 2018.

42. drfolamay
Despite strong evidence for screening and
guidelines,
one in three Americans is unscreened

43. drfolamay
Behavioral Risk Factor
Surveillance System
(BRFSS), 2012.
Screening* (%) Among US Adults Age 50-75
Colorectal cancer screening uptake
PercentPopulationScreened
Year
37.1%
55.0%
64.5%
65.1%
66.2%
67.3%

44. Patient-Level Factors
Knowledge
Beliefs
Health Literacy
Education
Income
Insurance
Access to care
Comorbidity
Cancer fatalism
Fear
Provider-Level Factors
Health care setting
Knowledge of guidelines
Practices
Recommendation to screen
System-Level Factors
Reminder systems
Access to providers
Colonoscopy capacity
Care coordination Smedley et al. IOM, 2003.
So why is screening so difficult?
drfolamay

45. National campaign to increase screening
• National Colorectal Cancer Roundtable campaign
• In 2014, established goal of ”80% by 2018”
• Endorsed by over 700 organizations & institutions
• Renewed in 2018 as “80% in every community”
• Targeted efforts and funding to improve screening in low participation
populations
drfolamay

46. Rates decreasing over time
Surveillance, Epidemiology, and End
Results Program 9; 1975-2013.
drfolamay

47. Improving from here
• Increase participation in screening
• Know your family history
• “Surveillance” for individuals with polyps
• Follow screening intervals
• Survivors need to continue colonoscopies
• Year 1  Year 4  Year 9
drfolamay

48. Colonoscopy for survivors
Kahi et al. AJG. 2016.
Colorectal
cancer
diagnosis
Colonoscopy before
surgery
(or 3-6 mo post)
Colonoscopy at 1
year
Surgical
resection
Colonoscopy 3
years later
Colonoscopy
every 5 years
*If rectal cancer: May need rectal ultrasound every 3-6
months as well (2-3 years)
drfolamay

49. drfolamay
And are there additional ways to
minimize risk?

50. drfolamay
Colon cancer risk factors
Risk Factors You Can Change
• Diet
• Physical inactivity
• Obesity
• Type 2 diabetes
• Tobacco use
• Heavy alcohol use
Risk Factors You Can Not Change
• Age
• Male gender
• Race (African-Americans)
• Personal history of polyps
• Family history of polyps or cancer
• Inflammatory bowel disease (IBD)
• Inherited polyp syndromes

51. drfolamay
Modifying your diet
• Minimize processed meats:
• Ham, bacon, hot dogs, raw sausages (salami), bologna,
blood sausage, pate, meat spreads, cold cuts, canned
meats, corned beef
• Minimize red meats:
• Beef, pork, lamb, goat
• Increase intake of:
• Whole grains, fiber, fruit, non-starchy vegetables, vitamin
C-rich foods, fish, vitamin D
Slide credit: UCLA Digestive Health
Nutrition Program

52. drfolamay
Other lifestyle changes
• Increase physical activity
• Drink alcohol in moderation
• Maximum of 2 drinks/day for men; 1 drink/day for women
• Maximum 14 units/week for men and women
• Avoid tobacco

53. In summary
• Screening for colon cancer is effective
• Screening works by removing polyps and finding cancers early
• There are many effective screening options so pick the one that is
best for you
• We can all help educate family and loved ones about colon cancer
risk and screening
drfolamay

54. drfolamay
Thank You!

56. Q
&
A
SNAP A #STRONGARMSELFIE
In 2018, up to $55,000 will be donated thanks to our
sponsors: Bayer, Fujifilm, Myriad Genetics and Taiho
Oncology!
Flex a “strong arm” & post it to Twitter or Instagram using the
hashtag #StrongArmSelfie

57. CONTACT US
CALL TOLL FREE
1.877.427.2111