Colon cancer presentation by Dr. Lindsay Strader

1. Colon Cancer: You Have TheColon Cancer: You Have The
Power!Power!
Lindsay Strader, D. O.Lindsay Strader, D. O.
May 19, 2016May 19, 2016

2. DisclosuresDisclosures
• No financial disclosuresNo financial disclosures

3. You’re a colorectal surgeon?You’re a colorectal surgeon?
WHY???WHY???
• 30 multi-specialty surgical30 multi-specialty surgical
practicepractice
• 1 of 5 colorectal surgeons in1 of 5 colorectal surgeons in
WichitaWichita
• The ONLY female colorectalThe ONLY female colorectal
surgeon in the regionsurgeon in the region
• There was a need I could fill inThere was a need I could fill in
my hometown.my hometown.
• There is no better fulfillmentThere is no better fulfillment
than curing someone of cancerthan curing someone of cancer

4. ObjectivesObjectives
• To inspire you to take action in preventingTo inspire you to take action in preventing
colon cancer by learningcolon cancer by learning
• Who gets colon cancer?Who gets colon cancer?
• What is colon cancer?What is colon cancer?
• What risk factors increase colon cancer?What risk factors increase colon cancer?
• What can we do to prevent colon cancer?What can we do to prevent colon cancer?
• What happens after a diagnosis of colonWhat happens after a diagnosis of colon
cancer?cancer?
• What power do you have to prevent colonWhat power do you have to prevent colon
cancer?cancer?

5. Who gets colon cancer?Who gets colon cancer?
• 3rd most common cancer3rd most common cancer
in USin US
• Lifetime risk of 1 in 20 (5%)Lifetime risk of 1 in 20 (5%)
• In 2015, ~93,000 new colonIn 2015, ~93,000 new colon
cancers and ~40,000 newcancers and ~40,000 new
rectal cancers wererectal cancers were
diagnoseddiagnosed
• ColoRectal Cancer is oftenColoRectal Cancer is often
abbreviated as CRCabbreviated as CRC
Men
675,300
Women
658,800

6. Who gets CRC?Who gets CRC?
• Mortality rates for colorectal cancer have beenMortality rates for colorectal cancer have been
dropping for 20 yearsdropping for 20 years
• There are approximately 1 million survivors ofThere are approximately 1 million survivors of
colorectal cancer living in the United Statescolorectal cancer living in the United States

7. What is CRC?What is CRC?

8. What is CRC?What is CRC?
• CRC is the abnormalCRC is the abnormal
growth of cells thatgrowth of cells that
develop on the inner liningdevelop on the inner lining
of the colonof the colon
• This can lead to cells thatThis can lead to cells that
invade into and eveninvade into and even
through the colon.through the colon.
• These cells can alsoThese cells can also
spread to other areas ofspread to other areas of
the body called metastasis.the body called metastasis.

9. What causes CRC?What causes CRC?
• Most CRC start as polypsMost CRC start as polyps
• Polyps form because ofPolyps form because of
damage to the DNA celldamage to the DNA cell
cyclecycle
• Some risks factors forSome risks factors for
polyp formation can bepolyp formation can be
modifiable; others are notmodifiable; others are not

10. Risk Factors for CRCRisk Factors for CRC
• AGEAGE
• 90% of all CRC occur in90% of all CRC occur in
people 50+people 50+
• Basis for colon cancerBasis for colon cancer
screening starting at age 50screening starting at age 50

11. Age is just a number!!!Age is just a number!!!
• Although age is not a modifiable risk fact, you haveAlthough age is not a modifiable risk fact, you have
the POWER to be healthy at any age!the POWER to be healthy at any age!

12. Risk FactorsRisk Factors
• Race/EthnicityRace/Ethnicity
• Lowest in Asian/Pacific IslanderLowest in Asian/Pacific Islander
• Highest in African AmericanHighest in African American
• Geographical LocationGeographical Location
• Lowest in NortheastLowest in Northeast
• Highest in MidwestHighest in Midwest
• Nightshift WorkersNightshift Workers
• >3 nights/week for 15 years>3 nights/week for 15 years
increased rates in womenincreased rates in women

13. Modifiable Risk FactorsModifiable Risk Factors
• Diet rich in red meat andDiet rich in red meat and
processed foodsprocessed foods
• Obesity/Inactive LifestyleObesity/Inactive Lifestyle
• Tobacco UseTobacco Use
• Alcohol UseAlcohol Use

14. Increased RiskIncreased Risk
• History of colonHistory of colon
polyps or cancerpolyps or cancer
• InflammatoryInflammatory
Bowel DiseaseBowel Disease
(Crohn’s Disease,(Crohn’s Disease,
Ulcerative Colitis)Ulcerative Colitis)

15. Inherited Family SyndromesInherited Family Syndromes
• Polyposis syndromes (FAP,Polyposis syndromes (FAP,
MAP)MAP)
• Lynch Syndrome (HNPCC)Lynch Syndrome (HNPCC)

16. Familial/Inherited CRCFamilial/Inherited CRC

17. Screening for CRCScreening for CRC
• Screening is the act of finding aScreening is the act of finding a
disease that has no symptomsdisease that has no symptoms
• Screening allows us to:Screening allows us to:
• Remove polyps, thereforeRemove polyps, therefore
preventing colon cancer frompreventing colon cancer from
developingdeveloping
• Remove early cancer, thereforeRemove early cancer, therefore
preventing colon cancerpreventing colon cancer
surgerysurgery
• Diagnose colon cancer,Diagnose colon cancer,
allowing us to remove that partallowing us to remove that part
of the colon during surgeryof the colon during surgery

18. Why screen for CRC?Why screen for CRC?

19. Screening optionsScreening options
Stool TestsStool Tests
Fecal Occult Blood Test (FOBT)Fecal Occult Blood Test (FOBT)
Fecal Immunochemical Test (FIT)Fecal Immunochemical Test (FIT)
Stool DNA Test (Cologard)Stool DNA Test (Cologard)
Imaging TestsImaging Tests
Barium EnemaBarium Enema
CT Colonography (CTC)CT Colonography (CTC)
ProceduresProcedures
Flexible SigmoidoscopyFlexible Sigmoidoscopy
ColonoscopyColonoscopy

20. Stool TestsStool Tests
• Fecal Occult Blood Tests/FecalFecal Occult Blood Tests/Fecal
Immunohistochemical TestsImmunohistochemical Tests
(FOBT/FIT)(FOBT/FIT)
• Guaiac based testing that detectsGuaiac based testing that detects
occult bloodoccult blood
• Must test 1-3 consecutive bowelMust test 1-3 consecutive bowel
movements (not accurate on digitalmovements (not accurate on digital
rectal exam)rectal exam)
• Tests can be affected by diet orTests can be affected by diet or
other sources of bleedingother sources of bleeding
• Misses most polyps because ofMisses most polyps because of
non-/intermittent-bleedingnon-/intermittent-bleeding

21. Stool TestsStool Tests
• Cologuard DNA testCologuard DNA test
• Detects 11 biomarkersDetects 11 biomarkers
including bloodincluding blood
• Study of 10,000 patientsStudy of 10,000 patients
• Sensitivity to detect CRC:Sensitivity to detect CRC:
Cologuard 94%, FIT 74%Cologuard 94%, FIT 74%
• Sensitivity to detect pre-Sensitivity to detect pre-
cancerous polyps:cancerous polyps:
Cologuard 42%, FIT 24%Cologuard 42%, FIT 24%

22. Screening with Stool testsScreening with Stool tests
• Advantages include relatively easy test,Advantages include relatively easy test,
no invasive procedure or sedationno invasive procedure or sedation
involved, and inexpensive.involved, and inexpensive.
• Disadvantages include false positiveDisadvantages include false positive
results and misses 95% of polypsresults and misses 95% of polyps
found on colonoscopy.found on colonoscopy.
• If test is positive, need to undergoIf test is positive, need to undergo
colonoscopycolonoscopy
• Regular annual use of FOBT/FIT testsRegular annual use of FOBT/FIT tests
decrease CRC death by 30% and CRCdecrease CRC death by 30% and CRC
incidence by 20% by detecting largeincidence by 20% by detecting large
pre-cancerous polyps.pre-cancerous polyps.

23. Imaging TestsImaging Tests
• Double Contrast Barium EnemaDouble Contrast Barium Enema
• Barium sulfate introduced byBarium sulfate introduced by
enema followed by air to expandenema followed by air to expand
the colonthe colon
• Similar sensitivity for polyps asSimilar sensitivity for polyps as
colonoscopycolonoscopy
• Requires bowel prep but noRequires bowel prep but no
sedationsedation
• Positive result requiresPositive result requires
colonoscopy for biopsy/removalcolonoscopy for biopsy/removal
• Imaging test of choice forImaging test of choice for
incomplete colonoscopyincomplete colonoscopy

24. Imaging TestsImaging Tests
• CT ColonographyCT Colonography
• Rectal tube inserted for air contrast,Rectal tube inserted for air contrast,
then undergo CT scanthen undergo CT scan
• Similar sensitivity to barium enemaSimilar sensitivity to barium enema
with much higher radiation exposurewith much higher radiation exposure
• Requires bowel prep but no sedationRequires bowel prep but no sedation
• Positive results require colonoscopyPositive results require colonoscopy
for biopsy/removalfor biopsy/removal
• More expensive than colonoscopyMore expensive than colonoscopy
and no longer covered by insuranceand no longer covered by insurance

25. Screening with ImagingScreening with Imaging
TestsTests
• Advantages include non-Advantages include non-
invasive and no sedationinvasive and no sedation
required.required.
• Disadvantages includeDisadvantages include
exposure to radiation and CTexposure to radiation and CT
Colonography not covered byColonography not covered by
insurance or performed ininsurance or performed in
WichitaWichita
• Any abnormalities requireAny abnormalities require
follow-up colonoscopyfollow-up colonoscopy
“optimally on the same day to“optimally on the same day to
avoid repeat bowel prep”.avoid repeat bowel prep”.

26. ProceduresProcedures
• Flexible sigmoidoscopyFlexible sigmoidoscopy
• Lighted flexible camera that evaluates the rectumLighted flexible camera that evaluates the rectum
and sigmoid colonand sigmoid colon
• Requires enemas but no bowel prep or sedationRequires enemas but no bowel prep or sedation
• If polyps are found, formal bowel prep andIf polyps are found, formal bowel prep and
colonoscopy is requiredcolonoscopy is required
• Decrease in CRC incidence by 33% and CRCDecrease in CRC incidence by 33% and CRC
death by 43%death by 43%
• However, 40% of cancers arise in the area notHowever, 40% of cancers arise in the area not
evaluated by flex sigevaluated by flex sig
• 75% of cancers and 50% of polyps have no75% of cancers and 50% of polyps have no
polyps in the area evaluated by flex sigpolyps in the area evaluated by flex sig

27. ProceduresProcedures
• ColonoscopyColonoscopy
• Gold Standard for CRC screeningGold Standard for CRC screening
• Requires full bowel prep andRequires full bowel prep and
sedation and typically one day ofsedation and typically one day of
work absencework absence
• Most sensitive method ofMost sensitive method of
detecting polyps/cancerdetecting polyps/cancer
• Miss rate for 1 cm polyps is 5%,Miss rate for 1 cm polyps is 5%,
and polyps <5 mm is 25%and polyps <5 mm is 25%
• Able to biopsy and remove polypsAble to biopsy and remove polyps
and potentially cancerand potentially cancer

28. ColonoscopyColonoscopy

29. Relax!!! It’s easier now!Relax!!! It’s easier now!

30. Excuses, Excuses, Excuses!!!Excuses, Excuses, Excuses!!!

31. I don’t have time!!!I don’t have time!!!
• Do you have time forDo you have time for
colon cancercolon cancer
treatment? Becausetreatment? Because
that will take a lot morethat will take a lot more
time off of work than atime off of work than a
colonoscopy!colonoscopy!

32. I heard the prep is terrible!!!I heard the prep is terrible!!!

33. I’m afraid it will hurt.I’m afraid it will hurt.
• Moving towards using CO2 forMoving towards using CO2 for
insufflationinsufflation
• Significantly less abdominalSignificantly less abdominal
pain and bowel distensionpain and bowel distension
• Absorbed 13 times faster thanAbsorbed 13 times faster than
oxygen and 160 times fasteroxygen and 160 times faster
than nitrogenthan nitrogen
• CO2 typically resorbs in 20CO2 typically resorbs in 20
minutes for much less gasminutes for much less gas
painpain

34. I don’t want to be awake!I don’t want to be awake!
• Conscious sedation versusConscious sedation versus
anesthesia-directed propofolanesthesia-directed propofol
• Faster recovery, improvedFaster recovery, improved
sedation and greatersedation and greater
efficiency with propofolefficiency with propofol
• Higher cost with anesthesiaHigher cost with anesthesia
providersproviders
• Regardless, if you brieflyRegardless, if you briefly
wake up, more medicationwake up, more medication
will be given to complete thewill be given to complete the
exam.exam.

35. I don’t have any symptoms!I don’t have any symptoms!
• Many CRC/polyps areMany CRC/polyps are
asymptomatic.asymptomatic.
• Symptoms of CRCSymptoms of CRC
include:include:
• Rectal bleedingRectal bleeding
• Abdominal painAbdominal pain
• Change in bowel habitsChange in bowel habits
• AnemiaAnemia

36. No excusesNo excuses

37. ComplicationsComplications
• Although colonoscopyAlthough colonoscopy
has the highesthas the highest
complication rate of allcomplication rate of all
the screening procedures,the screening procedures,
it is still low.it is still low.
• Depending onDepending on
interventionintervention
• Bleeding 0.3-5%Bleeding 0.3-5%
• Perforation 0.01-6%Perforation 0.01-6%

38. Colonoscopy benefitsColonoscopy benefits

39. Screening guidelinesScreening guidelines
• FIT test annually*FIT test annually*
• Flexible SigmoidoscopyFlexible Sigmoidoscopy
every 5 years +/- FIT testevery 5 years +/- FIT test
annually*annually*
• Barium enema every 5Barium enema every 5
years*years*
• Colonoscopy every 10 yearsColonoscopy every 10 years
• *Positive results require*Positive results require
follow-up colonoscopyfollow-up colonoscopy

40. High-risk screeningHigh-risk screening
guidelinesguidelines
• If you have a first degree relative with CRC/polyps diagnosed < 60 years oldIf you have a first degree relative with CRC/polyps diagnosed < 60 years old
OR if you have 2 first degree relatives with CRC/polyps diagnosed at anyOR if you have 2 first degree relatives with CRC/polyps diagnosed at any
ageage
• Start screening at age 40 or 10 years before the first diagnosis, whichStart screening at age 40 or 10 years before the first diagnosis, which
ever comes firstever comes first
• Repeat screening every 5 yearsRepeat screening every 5 years
• If you have a first-degree relative with CRC/polyps diagnosed >60 years oldIf you have a first-degree relative with CRC/polyps diagnosed >60 years old
OR if you have 2 second-degree relatives with CRC/polyps diagnosed at anyOR if you have 2 second-degree relatives with CRC/polyps diagnosed at any
ageage
• Start screening at age 40 or 10 years before the first diagnosis, whichStart screening at age 40 or 10 years before the first diagnosis, which
ever comes firstever comes first
• Repeat screening every 10 yearsRepeat screening every 10 years

41. • If you have a family history of colon cancer or polyps,If you have a family history of colon cancer or polyps,
you should see your doctor for recommendations onyou should see your doctor for recommendations on
when to start your colon cancer screening.when to start your colon cancer screening.

42. How are we doing???How are we doing???
• 50% of Americans are50% of Americans are
up-to-date withup-to-date with
screeningscreening
recommendationsrecommendations
• 65% in Kansas65% in Kansas
• 5 fold increase in5 fold increase in
colonoscopycolonoscopy
screenings over thescreenings over the
last 5 yearslast 5 years
• Pink-ribbonPink-ribbon
syndromesyndrome

43. Why the big push to screen?Why the big push to screen?

44. Why the big push to screen?Why the big push to screen?

45. What happens after CRCWhat happens after CRC
diagnosis?diagnosis?
• Pathology diagnosis ofPathology diagnosis of
CRCCRC
• CT scan of body and bloodCT scan of body and blood
test to check for diseasetest to check for disease
spread (metastasis)spread (metastasis)
• Meet/Discuss options withMeet/Discuss options with
colorectal surgeoncolorectal surgeon
• Consider colonoscopy toConsider colonoscopy to
“tattoo” the lesion“tattoo” the lesion

46. Surgeon DiscussionSurgeon Discussion
• Most common question:Most common question:
Will I have to have a bag?Will I have to have a bag?
• Usually ostomy is NOTUsually ostomy is NOT
requiredrequired
• Usually ostomy isUsually ostomy is
temporarytemporary
• You probably knowYou probably know
someone with ansomeone with an
ostomy…ostomy…

47. Surgeon DiscussionSurgeon Discussion
• Open versus Minimally-InvasiveOpen versus Minimally-Invasive
• Risks and Benefits of surgeryRisks and Benefits of surgery

50. After SurgeryAfter Surgery
• Once pathology returned, will know staging ofOnce pathology returned, will know staging of
cancercancer

51. TreatmentTreatment
• Treatment based on cancer stageTreatment based on cancer stage
• Stage 1- Surgery aloneStage 1- Surgery alone
• Stage 2- Surgery +/- ChemotherapyStage 2- Surgery +/- Chemotherapy
• Stage 3- Surgery + ChemotherapyStage 3- Surgery + Chemotherapy
• Stage 4- Chemotherapy alone, possibleStage 4- Chemotherapy alone, possible
surgerysurgery
• Rectal cancer may have indications forRectal cancer may have indications for
radiationradiation

52. You have the power to stopYou have the power to stop
colon cancer!!!colon cancer!!!

53. You Have The Power!!!You Have The Power!!!
• Get informed about yourGet informed about your
familyfamily
• Find out what cancers runFind out what cancers run
in your familyin your family
• Inform your children aboutInform your children about
your family historyyour family history
• Talk with your doctorTalk with your doctor
about the right time toabout the right time to
start screening for you andstart screening for you and
your familyyour family

54. You Have The Power!!!You Have The Power!!!
• Schedule your colonSchedule your colon
cancer screeningcancer screening
today!!!today!!!
• stool test, bariumstool test, barium
enema orenema or
colonoscopycolonoscopy
• Keep up to date onKeep up to date on
when your next testwhen your next test
should beshould be

55. You Have The Power!!!You Have The Power!!!
• Modify your risk factorsModify your risk factors
• Stop smokingStop smoking
• Limit alcohol, red meat, andLimit alcohol, red meat, and
processed foodsprocessed foods
• Enjoy an active lifestyle and keepEnjoy an active lifestyle and keep
a healthy weighta healthy weight

56. GET YOUR REAR IN GEAR!!!GET YOUR REAR IN GEAR!!!
• 5K run/walk and 15K run/walk and 1
mile fun runmile fun run
• Sunday, May 29,Sunday, May 29,
7:30pm7:30pm
• Farm and Art MarketFarm and Art Market
1st and Mosley1st and Mosley
• Sign up atSign up at
getyourrearingear.cogetyourrearingear.co
mm

57. Questions?Questions?