Colorectal cancer in adults under Colorectal cancer in adults under age 50, age 50 and older; How age 50, age 50 and older; How many and which risk factors are many and which risk factors are

exhibited? exhibited?

• Mary C. Lemp, NP, DNP (c)Mary C. Lemp, NP, DNP (c)

• North Shore University HospitalNorth Shore University Hospital

• Manhasset, NYManhasset, NY

• I wish to gratefully acknowledge the I wish to gratefully acknowledge the assistance and support from my assistance and support from my committee and instructors at Case committee and instructors at Case Western Reserve University.Western Reserve University.

• Committee chair: Dr. Lynn LotasCommittee chair: Dr. Lynn Lotas

• Committee: Dr. Amy ZhangCommittee: Dr. Amy Zhang

Dr. Stephen Marrone Dr. Stephen Marrone

IntroductionIntroduction

• Public health policy recommends Public health policy recommends colonoscopy screening beginning at age colonoscopy screening beginning at age 50.50.

• Nationally, 10% of adults diagnosed with Nationally, 10% of adults diagnosed with colorectal cancer are under age 50.colorectal cancer are under age 50.

• Is there an increase in the incidence of Is there an increase in the incidence of colorectal cancer in adults under age 50?colorectal cancer in adults under age 50?

Purposes of the studyPurposes of the study

• Identify adults who have been Identify adults who have been diagnosed with colorectal cancer diagnosed with colorectal cancer under age 50.under age 50.

• Identify adults who have been Identify adults who have been diagnosed with colorectal cancer age diagnosed with colorectal cancer age 50 and older.50 and older.

• Evaluate the common risk factors Evaluate the common risk factors that each group exhibits.that each group exhibits.

• Evaluate the number of risk factors Evaluate the number of risk factors exhibited by each group (<50, 50 exhibited by each group (<50, 50 and>).and>).

• Compare/contrast the risk factors Compare/contrast the risk factors exhibited by each group.exhibited by each group.

RQ 1RQ 1

• How many adults under age 50 will How many adults under age 50 will be diagnosed with colorectal cancer, be diagnosed with colorectal cancer, in this sample?in this sample?

RQ 2RQ 2

• What are the common risk factors What are the common risk factors and the number that are exhibited by and the number that are exhibited by adults under age 50 and age 50 and adults under age 50 and age 50 and older who are diagnosed with older who are diagnosed with colorectal cancer?colorectal cancer?

RQ 3RQ 3

• What are the similarities and What are the similarities and differences between adults under differences between adults under age 50 and age 50 and older in risk age 50 and age 50 and older in risk factors that are exhibited?factors that are exhibited?

Background and Background and SignificanceSignificance

• Colorectal cancer is the 4th most Colorectal cancer is the 4th most common cancer diagnosis in the U.S.common cancer diagnosis in the U.S.

• 155,000 new cases annually155,000 new cases annually

• 55,000 deaths annually55,000 deaths annually

• 10% of adults diagnosed with 10% of adults diagnosed with colorectal cancer are under age 50.colorectal cancer are under age 50.

• Known risk factors are: a prior history Known risk factors are: a prior history of cancer, a family or personal of cancer, a family or personal history of colorectal cancer, a history history of colorectal cancer, a history of IBD, age and adenomatous polyps. of IBD, age and adenomatous polyps.

Theoretical frameworkTheoretical framework

• Theory guiding the research is the Theory guiding the research is the Health Promotion Model, developed Health Promotion Model, developed by Nola Pender.by Nola Pender.

• Advocacy of shared partnerships Advocacy of shared partnerships among nurses, physicians and the among nurses, physicians and the community.community.

• Health is not simply the absence of Health is not simply the absence of illness.illness.

Nursing professional needs best information

Adult chooses to undergo colonoscopy

Adult seeks health information

Theory of planned behavior: adult seeks health Theory of planned behavior: adult seeks health information.information.

Theory of reasoned action: adult discusses Theory of reasoned action: adult discusses options with nursing professional, who needs options with nursing professional, who needs to present the best information available.to present the best information available.

Social cognitive theory: adult discusses risks Social cognitive theory: adult discusses risks and benefits with health care provider and and benefits with health care provider and chooses to undergo colonoscopy. (Healthy chooses to undergo colonoscopy. (Healthy behavior).behavior).

Operational DefinitionOperational Definition

• The Data Collection Instrument (DCI) The Data Collection Instrument (DCI) developed to gather data such as: developed to gather data such as: geography, age at diagnosis, geography, age at diagnosis, personal/family history of any personal/family history of any cancer, BMI, gender, history of IBD, cancer, BMI, gender, history of IBD, history of polyps, stage at diagnosis history of polyps, stage at diagnosis and site of colorectal cancer (rectum, and site of colorectal cancer (rectum, sigmoid, transverse or right colon).sigmoid, transverse or right colon).

AssumptionsAssumptions

• The medical record is a reasonable The medical record is a reasonable source of individuals health source of individuals health information.information.

• Colonoscopies can prevent colorectal Colonoscopies can prevent colorectal cancer through polypectomy and/or cancer through polypectomy and/or early detection.early detection.

• Individuals can partner and be Individuals can partner and be guided by nursing professionals to guided by nursing professionals to adopt healthy behaviors.adopt healthy behaviors.

• Individuals often want to feel that Individuals often want to feel that they have control over their own they have control over their own behaviors.behaviors.

Limitations of the studyLimitations of the study

• A small sample from one hospital in a A small sample from one hospital in a suburb of New York state.suburb of New York state.

• The results are not generalizable to The results are not generalizable to the entire population.the entire population.

• The DCI has not been validated.The DCI has not been validated.

Review of the literatureReview of the literature

• Imperiale, et al evaluated 906 adults Imperiale, et al evaluated 906 adults aged 40-49. None of the asymptomatic aged 40-49. None of the asymptomatic participants were diagnosed with participants were diagnosed with colorectal cancer.colorectal cancer.

• Regula, et al evaluated 50,000 Regula, et al evaluated 50,000 participants in Poland: 3.4% of adults participants in Poland: 3.4% of adults aged 40-49 and 5.9% of adults aged 50-aged 40-49 and 5.9% of adults aged 50-66 were diagnosed with colorectal 66 were diagnosed with colorectal cancer.cancer.

• Lai, et al conducted an Lai, et al conducted an epidemiological study to determine epidemiological study to determine incidence rates and risk factors for incidence rates and risk factors for nine geographic areas of the U.S. The nine geographic areas of the U.S. The highest incidence of colorectal cancer highest incidence of colorectal cancer was confirmed to be the Northeast was confirmed to be the Northeast U.S. The lowest incidence was found U.S. The lowest incidence was found in the central mountain region.in the central mountain region.

• Loeve, et al, in a study from The Loeve, et al, in a study from The Netherlands, evaluated 553 patients who Netherlands, evaluated 553 patients who had undergone polypectomy for had undergone polypectomy for adenomatous polyps. None of the adenomatous polyps. None of the patients studied developed colorectal patients studied developed colorectal cancer. cancer.

• This can perhaps be explained by This can perhaps be explained by polypectomy removing the source of a polypectomy removing the source of a cancer and preventing development.cancer and preventing development.

• The CINAHL, PubMed, National The CINAHL, PubMed, National Cancer Institute (NCI), and Access Cancer Institute (NCI), and Access Medicine databases accessed. Medicine databases accessed.

• Keywords: colorectal cancer, Keywords: colorectal cancer, adenoma and adenocarcinoma.adenoma and adenocarcinoma.

MethodologyMethodology

• Retrospective chart review.Retrospective chart review.

• 257 charts of admitted patients, 257 charts of admitted patients, diagnosed with colorectal cancer diagnosed with colorectal cancer from 1/1/2007 through 12/31/2007.from 1/1/2007 through 12/31/2007.

DesignDesign

• Descriptive/evaluative retrospective Descriptive/evaluative retrospective chart review.chart review.

SettingSetting

• A large teaching hospital in a suburb A large teaching hospital in a suburb of L.I., N.Y.of L.I., N.Y.

SampleSample

• Adults admitted to this suburban Adults admitted to this suburban hospital, who have been diagnosed hospital, who have been diagnosed with colorectal cancer.with colorectal cancer.

• The charts requested, by colorectal The charts requested, by colorectal cancer diagnosis, from the Cancer cancer diagnosis, from the Cancer Registry.Registry.

• The charts accessed in the Medical The charts accessed in the Medical Records department. Records department.

ProcedureProcedure

• Obtained approval from the IRB’s @ Obtained approval from the IRB’s @ Case Western Reserve University and Case Western Reserve University and NSUH-Manhasset.NSUH-Manhasset.

• The DCI developed by the The DCI developed by the investigator and approved by the investigator and approved by the IRB’s.IRB’s.

• Requested the charts of individuals Requested the charts of individuals who had been admitted and who had been admitted and diagnosed with colorectal cancer.diagnosed with colorectal cancer.

• The individual charts were requested The individual charts were requested from the Cancer Registry, by the from the Cancer Registry, by the diagnosis of colorectal cancer.diagnosis of colorectal cancer.

• Employees of the Medical Records Employees of the Medical Records department obtained the charts.department obtained the charts.

• Data access was performed by the Data access was performed by the investigator, only.investigator, only.

• 257 individual charts were obtained.257 individual charts were obtained.

• Data entry onto the DCI was Data entry onto the DCI was performed by the investigator, only.performed by the investigator, only.

• The data collected was inputted into The data collected was inputted into SPSS version 15.SPSS version 15.

Inclusion criteriaInclusion criteria

• Adults aged 18 and over.Adults aged 18 and over.

• Diagnosis of colorectal cancer in Diagnosis of colorectal cancer in these adults.these adults.

• Patients admitted to NSUH-Patients admitted to NSUH-Manhasset during the calendar year Manhasset during the calendar year of 2007.of 2007.

InstrumentationInstrumentation

• The DCI, developed by the investigator.The DCI, developed by the investigator.

• Evaluated: gender, age, geographic area of Evaluated: gender, age, geographic area of residence, site of cancer, stage at diagnosis, residence, site of cancer, stage at diagnosis, prior history of cancer, family history of prior history of cancer, family history of cancer, family history of colorectal cancer, cancer, family history of colorectal cancer, history of polyps, history of IBD, BMI, history history of polyps, history of IBD, BMI, history of tobacco smoking and current tobacco use.of tobacco smoking and current tobacco use.

• Answered Yes/No; or subscales numbered 1-Answered Yes/No; or subscales numbered 1-5; number 9 for missing data.5; number 9 for missing data.

Statistical AnalysisStatistical Analysis

• Descriptive statistics: frequencies, Descriptive statistics: frequencies, crosstabs and Chi square.crosstabs and Chi square.

• Crosstabs compared under age 50 to Crosstabs compared under age 50 to age 50 and older, in relation to the age 50 and older, in relation to the items on the DCI, that pertained to items on the DCI, that pertained to risk factors.risk factors.

FindingsFindings

• 10.5% of the sample was under age 50.10.5% of the sample was under age 50.

• Relatively evenly divided between male Relatively evenly divided between male (48.2%) and female (51.4%).(48.2%) and female (51.4%).

• 36.9% of the sample was aged 60-69.36.9% of the sample was aged 60-69.

• The most frequent sites of cancer were The most frequent sites of cancer were the right colon (36.3%) and the sigmoid the right colon (36.3%) and the sigmoid (left) colon (33.1%).(left) colon (33.1%).

• More than half the sample were More than half the sample were residents of L.I., N.Y. (59.1%).residents of L.I., N.Y. (59.1%).

• 22.6% of the sample had a prior 22.6% of the sample had a prior personal history of cancer.personal history of cancer.

• 36.6% of the sample had a family 36.6% of the sample had a family history of cancer.history of cancer.

• 10.5% of the sample reported a 10.5% of the sample reported a family history of colorectal cancer.family history of colorectal cancer.

• 49% of the sample reported a history 49% of the sample reported a history of smoking.of smoking.

• 35.6% of the sample had a BMI of 25-35.6% of the sample had a BMI of 25-29.9 (overweight).29.9 (overweight).

• 31.6% of the sample had a BMI of 30 31.6% of the sample had a BMI of 30 or > (obese).or > (obese).

Discussion of findingsDiscussion of findings

• Adults under age 50 exhibited three Adults under age 50 exhibited three common risk factors: a family history of common risk factors: a family history of cancer, a history of smoking and cancer, a history of smoking and obesity.obesity.

• Adults aged 50 and older exhibited five Adults aged 50 and older exhibited five common risk factors: a prior history of common risk factors: a prior history of cancer, a family history of cancer, a cancer, a family history of cancer, a family history of colorectal cancer, a family history of colorectal cancer, a history of smoking and obesity. history of smoking and obesity.

<50<50 50 and > 50 and >

Male: Male: 51.9% 48%51.9% 48%

Female:Female: 48.1% 48.1% 52% 52%

FHX-CRC:FHX-CRC: 7.7% 11.7% 7.7% 11.7%

FHX-CAN: 46.2% FHX-CAN: 46.2% 38.1% 38.1%

PHX-CAN: PHX-CAN: 7.4% 7.4% 24.6% 24.6%

H smoking: 37% 51.3%H smoking: 37% 51.3%

Obesity: Obesity: 46.2% 46.2% 38.5% 38.5%

• The common risk factors are: a The common risk factors are: a family history of cancer, a history of family history of cancer, a history of smoking and obesitysmoking and obesity

• Adults aged 50 and older additionally Adults aged 50 and older additionally reported a personal history of cancer reported a personal history of cancer and a family history of colorectal and a family history of colorectal cancer.cancer.

• This study evaluated a small sample This study evaluated a small sample (257).(257).

• One geographic area was One geographic area was represented.represented.

• The patients of one hospital were The patients of one hospital were evaluated.evaluated.

• There is no reason to recommend a There is no reason to recommend a change in public health policy. change in public health policy. Colonoscopy should still be Colonoscopy should still be recommended to adults beginning at recommended to adults beginning at age 50.age 50.

• Earlier screening should be Earlier screening should be recommended to adults under age 50, if recommended to adults under age 50, if risk factors or symptoms are exhibited.risk factors or symptoms are exhibited.

FutureFuture

• A multicenter study involving more A multicenter study involving more geographic regions of the U.S.geographic regions of the U.S.

• A larger sample, statistical A larger sample, statistical significance was not always achieved significance was not always achieved due to the small sample under age due to the small sample under age 50.50.

• Nursing professionals partnering with Nursing professionals partnering with the community to prevent the the community to prevent the development of colorectal cancer.development of colorectal cancer.