Colorectal Malignancy Counteractive action and Early Discovery : Redesign 2008.

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Individual history of incendiary entrail infection, adenomatous polyps or colon ca. Family history of adenomatous polyps, colon growth, different conditions ...
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Colorectal Cancer Prevention & Early Detection : Update 2008 Nadim G. Haddad,M.D. Partner Professor Director of GI Fellowship

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Colorectal Cancer The third most normal tumor in U.S. 148,810 new cases expected in 2008 The second deadliest growth 49,960 passings across the nation More than 1 million Americans living with colorectal tumor

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Colorectal Cancer Risk Factors Age 90% of cases happen in individuals 50 and more seasoned Gender slight male transcendence, yet basic in both men and ladies Race/Ethnicity African Americans have most astounding rate and death rate of all gatherings in U.S., Hispanics the least (with significant variety relying upon nation of birthplace) Increased rates likewise recorded in Alaska Natives, some American Indian tribes, Ashkenazi Jews

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Risk Factors (proceeded with) Increased danger with: Personal history of provocative entrail ailment, adenomatous polyps or colon ca Family history of adenomatous polyps, colon malignancy, different conditions *Individuals with these danger elements may require prior and more serious screening

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CENTERS FOR DISEASE CONTROL AND PREVENTION Colorectal Cancer Sporadic (normal danger) (65%–85%) Family history (10%–30%) Rare disorders (<0.1%) Hereditary nonpolyposis colorectal tumor (HNPCC) (5%) Familial adenomatous polyposis (FAP) (1%)

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Risk Factor - Polyps Different sorts: Hyperplastic negligible tumor potential Adenomatous around 90% of colon and rectal diseases emerge from adenomas

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Normal to Adenoma to Carcinoma Human colon carcinogenesis advances by the dysplasia/adenoma to carcinoma pathway

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Benefits of Screening Cancer Prevention Removal of pre-destructive polyps anticipate growth (remarkable part of colon tumor screening) Improved survival Early recognition especially enhances odds of long haul survival

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Benefits of Screening *1996 - 2003

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Colorectal Screening Rates Just 40% of colorectal malignancies are distinguished at the soonest organize. Somewhat more than half * of Americans over age 50 report having had a late colorectal growth screening test Slow however enduring change in these numbers over the previous decade (yet all are not profiting to the same degree) *varies in light of information source

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Colorectal Screening Rates Source: MMWR March 2008

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Trends in Recent* Endoscopy Prevalence (%), by Educational Attainment and Health Insurance Status, Adults 50 Years and Older, US, 1997-2004 *A adaptable sigmoidoscopy or colonoscopy inside the previous five years. Note: Data from taking an interest states and the District of Columbia were collected to speak to the United States. Source: Behavioral Risk Factor Surveillance System CD-ROM (1996-1997, 1999) and Public Use Data Tape (2001, 2002, 2004), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention and Prevention, 1999, 2000, 2002, 2003, 2005.

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Colorectal Screening Rates Low: Reasons (as indicated by Patients) Low familiarity with CRC as an individual wellbeing risk Lack of learning of screening advantages Fear, shame, uneasiness Time Cost Access "My specialist never conversed with me about it!"

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Colorectal Cancer Screening 2008

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ACS 2003 CRC Prevention and Early Detection Recommendations Fecal Occult Blood Testing (FOBT) Guaiac Immunochemical Flexible Sigmoidoscopy (FSIG) FSIG + FOBT Colonoscopy Double Contrast Barium Enema (DCBE)

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The 2008 CRC Guidelines Update was a Joint Effort of 5 Organizations American Cancer Society U. S. Multi-Society Task Force on Colorectal Cancer American Gastroenterological Association American College of Gastroenterology American Society of Gastrointestinal Endoscopists American College of Radiology

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2008 CRC Screening Guidelines: Process Expert board investigated and pondered on accessible proof amid two eye to eye gatherings and a progression of phone calls Literature distributed between January 2002 and January 2008, and in addition unpublished edited compositions and original copies, were looked into by board

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2008 CRC Guidelines Update: Evidence Criteria and Limitations Current confirmation has various confinements: Prospective studies are unprecedented Sample sizes have a tendency to be little Study members frequently incorporate higher danger, symptomatic patients and/or screening populaces (extent of predisposition dubious) Priority set on planned investigations of asymptomatic grown-ups, with all subjects experiencing colonoscopy Because adherence to standard screening is low, we are thinking about setting a test affectability edge for test acknowledgment

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CRC Screening Guidelines: What\'s New? CRC screening tests are assembled into two classifications: Tests that identify growth and precancerous polyps* Tests that principally recognize malignancy * It is the solid sentiment of the accord rules bunch that colon disease aversion ought to be the essential objective of CRC screening. Exams that are intended to recognize both early malignancy and precancerous polyps ought to be empowered if assets are accessible and patients will experience an obtrusive test If the full scope of screening tests are not accessible, doctors ought to try to offer no less than one test from every classification

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CRC Screening Guidelines: What Else is New? Two new tests suggested: stool DNA (sDNA) and electronic tomographic colonography (CTC) – some of the time alluded to as virtual colonoscopy The rules build up an affectability limit for prescribed tests The rules outline vital quality-related components for every type of testing The full article can be gotten to at:

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2008 CRC Screening Guidelines Beginning at age 50, both men and ladies at normal danger for creating colorectal tumor ought to utilize one of the screening tests underneath: * Colonoscopy ought to be done if test results are certain. ** For gFOBT or FIT utilized as a screening test, the bring home numerous example strategy ought to be utilized. gFOBT or FIT done amid an advanced rectal exam in the specialist\'s office is not sufficient for screening.

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2008 CRC Guidelines Continue to Emphasize Options Because: Evidence does not yet bolster any single test as "best" Uptake of screening remains disappointingly low Individuals contrast in their inclinations for some test Primary consideration doctors vary in their capacity to offer, clarify, or allude patients to all alternatives similarly Access is uneven geologically, and as far as test charges and protection scope Uncertainty exists about execution of various screening techniques with respect to advantages, damages, and expenses (particularly on automatic premise)

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Sensitivity of Take Home versus In-Office FOBT Sensitivity: Take Home versus In-Office Collins et al, Annals of Int Med Jan 2005

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In-Office FOBT ought to be deserted Conclusion In-office FOBT is basically useless as a screening apparatus for CRC and must be unequivocally debilitated However; In a late national study, almost 30% of doctors reported utilizing single-specimen, in-office FOBT as their essential technique for screening for colorectal tumor . Nadel et al, Annals of Int Med Jan 2005

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2008 CRC Screening Guidelines New Tests

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Stool DNA

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Stool DNA Test (sDNA) Rationale Fecal mysterious blood tests identify blood in the stool – which is irregular and non-particular Colon cells are shed consistently Polyps and malignancy cells contain strange DNA Stool DNA tests search for unusual DNA from cells that are passed in the stool* *All positive tests ought to be taken after with colonoscopy

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Normal Epithelium Late Adenoma Early Cancer Late Cancer Adenoma Genetic Model of Colorectal Cancer Bat-26 (Sporadic) p53 Bat-26 (HNPCC) K-ras APC Mutation Dwell Time: Many decades 2-5 years 2-5 years Optimum stage for early location Courtesy of Barry M. Berger. MD, FCAP EXACT Sciences

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sDNA - Sample Collection

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sDNA - Sample Collection pail embedded into section and introduced under can situate Patient supplies entire feces test; no eating regimen or medicine confinements Patient seals test in external compartment and cooler pack Patient seals holder and boats back to assigned lab (all pressing materials and names supplied)

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Performance Characteristics of Stool DNA in the Detection of CRC Three adaptations of the beforehand showcased sDNA test have been assessed Version 1 (K-ras, APC, p53,BAT-26, DIA) was assessed in the Imperiale trial Version 1.1 (K-ras, APC, P53), PreGen-Plus is the as of now advertised test Version 2 (Vimentin just, or Vimentin + DIA) is right now under assessment and is relied upon to enter the business sector in Fall 2008 Earlier and later tests were assessed in littler, blended populaces

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Performance Characteristics of Stool DNA in the Detection of CRC Testing assesses stool for the nearness of adjusted DNA in the adenoma-carcinoma grouping No dietary limitations No stool inspecting (uses the whole stool) Several studies recommending solid patient acknowledgment Testing interim questionable Uncertainty about the importance of false positives

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Stool DNA Limitations Misses a few malignancies Sensitivity for adenomas with ebb and flow business variant of test is low Technology (and test renditions) are experiencing significant change Costs a great deal more than different types of stool testing (around $300 - $400 per test) Not secured by most guarantors

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Stool DNA Limitations (cont.) Appropriate re-screening interim is not known Not clear how to oversee positive stool DNA test if colonoscopy is negative FDA issues Test accessibility

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CTC Image Optical Colonoscopy CT Colonography (CTC) Courtesy of Beth McFarland, MD

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CT Colonography Rationale Al

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