Colorectal Cancer

#2
Cancer
Killer

SCREENING SAVES LIVES

1

This presentation is about colorectal cancer and how screening for it can keep
this type of cancer from killing you and those you care about.

Colorectal cancer is cancer which is located in the colon or large intestine and
rectum.

Screening involves taking one of several tests which can detect this cancer early.

1
 The Bad News: Frequency
Average risk - 1 out of 18 chance per lifetime

High risk – 1 out of 5 chance per lifetime

•Colorectal cancer is bad news for Iowans.

•Most Iowans have a 1 in 18 chance of developing this type of cancer and some
have a 1 in 5 chance.
•In 2006, it was estimated that 2,040 Iowans will develop colorectal cancer.
This represents 13% of all the cases of cancer which will develop in Iowa each
year.
•The number of people who develop this cancer is high for both men and
women. Colorectal cancer is NOT a man’s disease.
•Further colorectal cancer affects people of all races.
•How do you know whether you have an average or high risk? This will be
explained later in the presentation.

2
 The Bad News: Deadly

1. Lung Cancer
2. Colorectal Cancer

•While lung cancer is the most deadly type of cancer, colorectal cancer is the
second most deadly for both men and women.
•It was estimated that 660 Iowans died from colorectal cancer in 2006. This
represents about 10% of all cancer-related deaths.

3
 The Bad News: Expensive

•Colorectal cancer also an expensive disease. The annual treatment costs are
estimated to be over $6.5 billion per year. The only cancer which is more
expensive to treat is breast cancer.

4
 Assessing your individual risk
You have a higher risk if you have any of the
following risk factors:

• Personal history of colorectal cancer or polyps

• Personal history of inflammatory bowel disease
• Family history of colorectal cancer or polyps
• Certain inherited cancer syndromes

Even without symptoms, people with these risk

factors need earlier and more frequent screening

•Iowans who have a 1 in 18 chance of developing colorectal cancer are called

“average risk” persons. Iowans who have a 1 in 5 chance of developing this
type if cancer are called “high risk” persons.
•So, how do you determine whether your risk is average or high? To decide if
you are at “average” or “high” risk for this cancer, one needs to determine if you
have certain risk factors or symptoms.
•The risk factors for “high” risk persons are:
a personal history of colorectal cancer or precancerous tissue
called polyps, or inflammatory bowel disease OR
a family history of colorectal cancer or polyps, OR
certain inherited cancer syndromes
Individuals with these risk factors need to take screening tests earlier and more
frequently

5
 Assessing your individual risk
Also, you have a higher risk if you have
one or more of the following symptoms:
– Rectal bleeding
– Iron deficiency anemia
– Change in bowel habits; constipation or diarrhea
– Persistent abdominal pain
If you have these symptoms, you should
seek evaluation immediately.

•The symptoms which indicate more than average risk are:

rectal bleeding
iron deficiency anemia
change in bowel habits
persistent abdominal pain
•Persons with these symptoms should seek medical evaluation immediately.

6
 AVERAGE RISK
If you don’t have these risk factors or
symptoms, you are considered to have
average risk for developing colorectal
cancer.

Without any of these risk factors or symptoms you are considered to have an
average risk for developing colorectal cancer.

7
 IMPORTANCE OF AGE 50

•Average risk Iowans should begin routine screening for colorectal cancer at age
50 because, it is much more common after this age. For average risk people,
94% of the cases occur after age 50.

8
 ATTENTION AVERAGE RISK
IOWANS

High-Risk Cases:
25%

75Average-Risk Cases:
75%%

American Cancer Society. Cancer Facts & Figures 2002. Atlanta, GA: American Cancer 9
Society; 2002:20–27.

TAKE NOTE. Even if you are only at average risk, 75% of the cases of
colorectal cancer occur among people who are at average risk. Average risk
individuals need to get serious about screening for this cancer beginning at age
50.

9
 Good News

A series of changes in the cells lining the colon takes

10 years to progress from normal to colon cancer.

10
10
years

Normal Polyp Cancer

There is time to intervene 10

•One piece of good news about this type of cancer is that it generally takes a
long time for the tissue to change from normal into cancer. It usually takes 10 -
15 years for the tissue to progress from normal, to polyp, to cancer. Polyps are
tissues which are more likely to become cancerous, especially if they are large.

•This long lead time presents an excellent window of opportunity for screening
and intervention.

•Even though not all polyps develop into cancer, and even though the
progression is slow, this 10 year lag time does not mean you can wait until you
are 60 to begin getting screened. It is important to begin screening at 50. It is
estimated that by age 50, 1 out of four Iowans has the type of polyp which
COULD develop into cancer.

10
 More Good News

Alive at diagnosis Alive 5 years later

1 year 2 year 3 year 4 year 5 year

• The most preventable form of digestive

tract cancer if screening is performed 11

Another item of good news about colorectal cancer is that screening for it is very
effective at preventing death. This is true because screening can identify this
type of cancer early and, if treatment is begun early, a very large percent of
people can avoid dying from this type of cancer. If detected early, the relative
survival rate (adjusted for normal life expectancy) is 91%. This is not true for
most other types of cancer. If screening is performed, colorectal cancer is the
most preventable form of cancers affecting the digestive tract.

11
 And More Good News:

FOBT Flex Sig

Double
Contrast
Colonoscopy Barium
Enema
12

More good news is that there are several effective screening tests for colorectal
cancer. The American Cancer Society, the Centers for Disease Control and
Prevention, and the Iowa Department of Public Health all support these tests.

FOBT = fecal occult blood test

Flex Sig = flexible sigmoidoscopy

12
 So What’s the Problem?

13

•The problem is that about half of the population is not being screened for
colorectal cancer screening.

13
 Late Detection
Five year survival rates
100% 96%
100 84% 100 65%
75 75
50 50
25 25 8%
0 0
Stage 0 Stage I Stage II Stage III Stage IV
Only 60% of patients 40% of patients
are diagnosed early are diagnosed late

SEER*Stat -- Version 6.2.4 14

This slide shows how likely it is that one will be alive 5 years after being
diagnosed with colorectal cancer. This likelihood ranges from 8% to 100%
depending on how early the cancer is diagnosed. There are five stages of
diagnosis, from 0-IV.
Stage 0: No cancer present
Stage I: The cancer is confined to the lining of the colon
Stage II: The cancer has penetrated the colon wall
Stage III: The cancer has spread to the lymph nodes
Stage IV: The cancer has spread to other organs
If the cancer is detected early, at Stages 0, I, or II, the cancer has been diagnosed
early and the person has a much higher chance of being alive 5 years after the
diagnosis.
The larger the number of people who don’t get screened, the smaller the number
of people whose cancer can be detected early. Only 60% of those who have
colorectal cancer are diagnosed early, which is the point in time when treatment
has the greatest likelihood of preventing death.

14
 Why aren’t Iowans screened?
• The most common reasons -
• “My doctor never told me I should be screened.”
• “I’m embarrassed!”
• “The screening tests cost too much!”
• “I don’t think that insurance covers screening.”
• “I don’t have a family history of colorectal cancer.”
• “I don’t have any symptoms of colorectal cancer.”

15

So why don’t more Iowans get screened for this cancer?

Sometimes Iowans indicate that their physician never recommended these tests.
Another reason is that Iowans have misunderstandings, fear and embarrassment
about these tests.
Some Iowans are not screened because of the cost of these tests.
Many Iowans are not screened because they do not have symptoms or risk
factors which indicate that they may develop colorectal cancer. This is a
dangerous approach as early stages of colorectal cancer are usually WITHOUT
any symptoms.
BRFSS data suggests people do not seek screening due to low education level,
very low income, and because only around 5% believe that colorectal cancer is a
high problem.

15
 How do you screen
for colorectal cancer?
Beginning at age 50:
• Fecal occult blood test (FOBT) every year or
• Flexible sigmoidoscopy (FS) every 5 years,
or
• FOBT annually + FS every 5 years or
• Colonoscopy every 10 yrs or
• Double -contrast barium enema every 5 yrs.

16

•Professional and government experts recommend that adults 50 and older use
one of four tests.
•Fecal occult blood test or FOBT every year.
•Flexible sigmoidoscopy every five years
•A combination of FOBT every year AND flexible sigmoidoscopy every five
years
•Colonoscopy every 10 years
•Double-contrast barium enema every 5 years

16
 Fecal Occult Blood Test (FOBT)

17

•The first screening strategy is the fecal occult blood test.

•The patient is given cards like these pictured in the slide and asked to provide
stool samples from three consecutive bowel movements. The cards with the
three small stool samples are mailed to a laboratory which observes the reaction
between a chemical on the card and an enzyme from blood and some foods
which may be in the stool sample. When these enzymes are present, the
chemical turns blue.
•This test is the cheapest one and not invasive but it is not as accurate as other
tests.

17
 Flexible Sigmoidoscopy

18

•Flexible sigmoidoscopy screening involves inserting a slender lighted tube,

about the thickness of your index finger, in the rectum. This allows the physician
to look inside the rectum and about half of the colon for cancer or polyps. This
test may be somewhat uncomfortable but it should not be painful. The exam
lasts only 10-20 minutes and the patient can return to work.
•This test is the second most expensive. It is accurate for the portion of the
intestine which it can reach, but it does not reach as far as the tube used for a
colonoscopy with is another screening test for colorectal cancer.

18
 Location of polyps/cancer

Right side Left side

10% 15%
30% 25%
20%

19

This is a diagram of the gastrointestinal tract. As seen in the picture the large
pink tube is the colon or large intestine with the rectum at the bottom. The
numbers reflect the percent of cancer which occurs in the various sections of the
large intestine. 40% of the cancers occur on the right side which is beyond the
reach of the screening equipment used during one of the screening tests called
flexibile sigmoidoscopy.

19
 FOBT AND FS
• FOBT detects larger, bleeding polyps, but is
less accurate for smaller, non-bleeding polyps
• Flexible sigmoidoscopy detects left-sided
lesions, but misses 30-40% of all polyps and
cancers that are right-sided
• The combination of both tests largely corrects
the limitations of performing either test alone.
FS + FOBT=75%

20

•Each of the last two tests has some limitations. Combining the two tests
provides a more thorough screening strategy.
•When used in combination, flexible sigmoidoscopy and fecal occult blood tests
can catch nearly 3 out of 4 polyps and cancerous cells.

20
 Colonoscopy

examines removes biopsies

entire colon polyps cancer
21

•Let’s talk about colonoscopy. This test involves preparation the day before which may include
taking enemas and drinking a powerful laxative. People frequently find the preparation worse
than the test. The physician that performs the test is usually a specialist, such as a surgeon or
gatroenterologist, to whom you are referred by your family doctor. On the day of the test
patients are generally placed under sedation. The physician inserts a long flexible tube (as shown
in the first picture on this slide) which is linked to a video display through the rectum into the
colon. This screening strategy enables the specialist to see the entire colon. During the
procedure, patients may feel some pushing and may experience some discomfort, but the
discomfort should be minimal. Also, the sensation of discomfort is reduced by the medications
used to sedate you during the procedure. The medication has an amnesic effect and most
patients do not remember the exam or having an unpleasant experience. The images of the
tissues lining the colon are displayed on a monitor. The exam lasts 30-45 minutes. During
recovery, some patients report discomfort similar to gas pain. The patient requires a ride home
and needs to take the day off from work but should feel back to normal within an hour.
•The images on the monitor enable the specialist to not only detect cancerous and precancerous
tissue, but also to remove precancerous tissue or polyps (as shown in the second picture) and
obtain a biopsy of cancerous tissue (as shown in third picture) within the same procedure.
• While this is the most expensive test, it is the most accurate because the physician can see the
entire colon. Further it is the only test which can prevent precancerous tissue from developing
into cancer by removing the polyps. Finally, this is the test which needs to be done least
frequently.

21
 Double Contrast Barium Enema
(DCBE)

22

•In this test, barium, a chalky substance given to the patient, partially fills the
colon and then air is added to expand it. Then x-ray films are taken. Because
barium blocks x-rays, any abnormal growths or areas will show up as grey areas
on the film. The film is read by a radiologist and the results are reported to the
patient’s personal physician. Patients experience moderate discomfort similar to
gas pain. The patient is also required to change positions, which may be
somewhat uncomfortable. The exam lasts 20-30 minutes. The patient can return
to work, but will have frequent barium stools (hard stools that contain residue
from the barium enema) or be constipated for several days following the exam.
During this time, the patient should drink lots of water and may need a stool
softener.
•While this test is not used often in Iowa, it is between flexible sigmoidoscopy
and colonoscopy in cost and less accurate than colonoscopy.
•However, when colonoscopy is not available, it may be a reasonable screening
option if it is combined with flexible sigmoidoscopy.
•The four tests mentioned so far have enough evidence for them to be
recommended for colorectal cancer screening.
.

22
 Other New Screening Tests

• Virtual colonoscopy

• Stool DNA test

23

•New tests are being developed all the time. Two tests which you may hear
about are virtual colonoscopy and the Stool DNA test.
•Both of these tests are safe enough to be used, but have not had enough
research to prove that they should be added to the list of recommended tests at
this time. Currently, neither test is covered by insurance.

23
 Virtual Colonoscopy

24

•Virtual colonoscopy is a recently developed technique that uses a computerized

axial tomography (CAT or CT) scanner and computer virtual reality software to
look inside the body.
•Preparation for this test is the same as the preparation for a colonoscopy. The
actual procedure begins by having a small flexible rubber tube placed in the
rectum, so that air can be introduced. A CAT scan is then performed while the
patient lies comfortably on his or her back and stomach. The scan generates a
three-dimensional (3D) image - length, width, and height - of the colon,
allowing the physician to look for tissue abnormalities associated with cancer.
•It is rarely used in Iowa, as there are not many locations that perform this kind
of test. In addition, virtual colonoscopy is a very expensive procedure in
locations that do provide this service.
.

24
 Stool DNA Test
Physician Patient Collects
Sends Stool DNA Analysis
Requisition Stool at Home Is Performed in
to Lab Lab
Physician

Lab Provides Patient Returns Physician

Collection and Specimen to Lab Communicates
Shipping Materials Results to Patient
to Patient DNA Alteration
Identified:
Perform colonoscopy
No DNA Alteration
Identified
Continue screening
25

•The Stool DNA test was made available commercially Aug 13, 2003.
•DNA, or deoxyribonucleic acid, is a type of molecule within each living cell
which stores the genetic code for all cells in the body. Sometimes the code is
altered or mutated. Some of these alternations lead to the development of
cancer. When human cells are shed into the stool, they include these DNA
components. If the DNA in the shed cells has changed, the DNA stool test can
detect changes which could indicate both a pre-cancerous or cancerous
condition.
•The sample collection for this test is done in the privacy of your home with no
advance preparation or dietary restrictions. The patient collects an entire stool
and it is sent in a special container via Fed Ex to a laboratory. The sample is then
analyzed for the evidence of pre-cancer and cancer from the DNA in the stool,
and if abnormalities are detected the physician recommends a colonoscopy.

25
 What Should You Consider in
Choosing a Screening Test
• What does my doctor recommend?
• Which test is most accurate?
• Which test is most convenient?
• Which causes the least discomfort, fear
embarrassment?
• Cost-insurance, Medicare coverage?
• What do other people say about it?
26

•So by now you see that this business of screening for colorectal cancer is a little
bit complicated. People have various degrees of risk for this problem and there
are several different tests available.
•In selecting the best screening strategy you need to consider the following:
which test does your physician recommend and how often
should it be conducted?
how important are test accuracy, convenience, comfort, and
cost for you?
what do other people say about these tests?

26
 Test cost

Screening Test Estimated

Charge
FOBT $10-30
FS $150-300
DCBE $250-500
Colonoscopy $600-1500

27

•Virtually all insurance providers pay for screening tests and for the follow-up
testing required to evaluate a positive result.
•Note that the cost of these tests ranges from $10-1500 dollars, depending on the
test and type and amount of insurance coverage. Consult your insurance plan or
provider to determine which tests are covered.

27
 Medicare Coverage for
Average Risk patients
• Blood stool test (FOBT) annually
• Sigmoidoscopy every 4 years
• Colonoscopy every 10 years
• Double contrast barium enema as an
alternative to either sigmoidoscopy or
colonoscopy every 5 yrs

(since July 1, 2001)

28

•Once one is 65, Medicare covers the following screening strategies for average
risk patients.
Blood stool test every year
Flexible sigmoidoscopy every 4 years
Colonoscopy every 10 years
Double contrast barium enema every 5 years if it is needed as
an alternative for either flexible sigmoidoscopy or a
colonoscopy

28
Don’t wait until 65 to be screened!
• Insurance covers most, if not all kinds of
screening. Consult your insurance plan
or provider to determine which tests are
covered.
• Screening should begin at age 50, not
at age 65, when Medicare coverage
begins.

29

29
 The Cost of NOT screening

– Individual early disability and death

– Emotional costs for patients and
family
– Treatment cost of colon cancer care

30

While some of these tests are expensive, the costs of not screening are even
greater.
Developing colorectal cancer will lead to
physical disability or even death for you and those you care
about
emotional problems for yourself and those around you, and
considerable financial cost. Treatment for those who are not
diagnosed early can be ~$60,000 over a 4-5 year period.

30
 So What?
• An average risk adult has a 1 in 18
chance of developing this cancer.

• A high risk adult has a 1 in 5 chance of

developing this cancer.

Can you afford to take this chance?

31

Whether you have a 1 in 18 or a 1 in 5 chance of developing this type of cancer,

can you afford to take this chance?

31
 You Can Reduce Deaths Due
to Colon Cancer
Screening!
Screening!
Any method of screening
is preferable to not
screening!
32

If you can’t afford to take this chance, GET SCREENED. Using any of the
screening tests mentioned in this program is better than not getting screened at
all.

32
 Have You and Your Loved Ones
Been Screened?

#2
Cancer
Killer

33

•If you see your physician regularly ask him or her about colorectal cancer
screening the next time you visit.
•If you don’t see your physician regularly, call and make an appointment today
to discuss your screening options.

33
This presentation was developed by the
Iowa Colorectal Cancer Task Force

34

34
 Acknowledgements
• American Cancer Society
• Centers for Disease Control and Prevention
• Exact Sciences
• Dr. John Bond, Univ. of Minnesota
• Dr. Douglas Rex, Univ. of Indiana
• Dr. Robert Summers, Univ. of Iowa
• Dr. Nancy Thompson, Univ. of Iowa
• Dr. Steven Wolfe, Univ. of Iowa
35

35
Colorectal Cancer Web Links
www.cancer.org
www.ccalliance.org
www.preventcancer.org/colorectal
www.hopkinskimmelcancercenter.org
www.colorectal-cancer.net
www.cdc.gov/cancer/screenforlife/index.htm
36

36