new york society for gastrointestinal endoscopy the 39th ... sidn… · sidney j. winawer, md,...
TRANSCRIPT
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New York Society for Gastrointestinal Endoscopy
The 39th Annual New York Course Issues in Colorectal Cancer Screening
Sidney J. Winawer, MD, Fellow NYSGE
Memorial Sloan Kettering Cancer Center
New York, NY
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NYSGE 1976 Yale Club
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The New York Society
For Gastrointestinal Endoscopy
Presents:
A Day In
The Colon
Colonoscopy, Indications, Contraindications, Limitations
Co-sponsor: American Society for Gastrointestinal Endoscopy
Supported in part by grant from The American Cancer Society
1976 MSKCC
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Colorectal Cancer in U.S. (1975–2011)
46% mortality reduction
Attributed primarily to screening
Report to Nation. Edwards, Cancer 2010; Kohler, JNCI 2015
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New USPSTF Guidelines – 2015
CRC screening – Grade A
Tests not graded
Recommended tests
Colonoscopy q 10 yrs
FOBT q 1 yr
FS / FIT q 10 yrs / q 1 yr
Alternatives
sDNA q 3 yrs
CTC q 5 yrs
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Issues in Colorectal Cancer Screening
Screening CO interval
Effectiveness of Screening CO
Interval Cancers
CO vs. FOBT
sDNA, blood tests
Single vs. multiple options
Disparities
Medico-Legal
Other
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Screening Colonoscopy
1997 Guidelines: CO q 10 yrs
Adenoma – Carcinoma Sequence
Selby, NEJM 1992 – 10-yr protection from SIG
Colonoscopy Intervention – NPS
Winawer et al. Gastro 1997.
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Effectiveness of Screening
Colonoscopy
Est. Incid. 67% − 77%
Est. Mortality 65%
Prox. / Distal Incid. 56% / 84%
Brenner, Ann Int Med 2011
Singh, JAMA / Gastro 2010
Kahi, Rex, Clin Gastro Hep 2009
Lakoff, Clin Gastro Hep 2008
Brenner, GUT, 2006
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Impact of Screening Colonoscopy on Colorectal
Cancer Incidence and Mortality
RCT’s
Nordic/European Trial *
CO vs Usual Care
Spanish Trial
CO vs FIT
U.S. Trials (2)
CO vs FIT / gFOBT
Bretthauer et al., NEJM 2011
Quintero, Castells, et al., NEJM 2012
*Biostatistics – A. Zauber
*Scientific Support – IDCA: Winawer, Classen Co-Chairs
WEO Working Party
S. Winawer, A. Zauber
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Interval Cancers
Normal Screening Colonoscopy 1/1000
Post Polypectomy 1/200
Kaminski. NEJM 2010
Robertson. GUT 2013
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Reasons for Interval Cancers (Pooled data from 8 centers; 9,167 patients;
Mean follow-up: 47 months)
Missed Cancers 52%
Incomplete Polypectomy 19%
New Cancers 24%
Robertson: Gastro 2008 (A), Paper submitted
71%
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Serrated Polyp Pathway CpG Island Methylation (CIMP)
BRAF, MSI
Non-
dysplastic
Serrated
Polyp
Lieberman, Rex, Winawer et al., Gastroenterology 2012
Legget, Gastroenterology 2010
Huang, Am Jn Gastroenterology 2004
Modified from D. Rex
Large
Hyperplastic
Polyp
Dysplastic
Serrated
Polyp
Serrated
Carcinoma
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Serrated Polyp Identified
on Colonoscopy
Serrated Polyps 10%
Large (>1cm) or Dysplastic Serrated Polyps 1−3%
Risk of Synchronous AA/CRC 3−5X
Risk of Metachronous AA/CRC 3X
Proximal
Flat
Hiraoka. Gastro 2010
Schoen. Gastro 2010
Li. AJG 2009
Lee. Digestion 2008
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Advances in Colonoscopy
High-resolution-magnification endoscopy
Autofluorescence (optical biopsy with laser fiber)
Spectral modulation: narrow band imaging, i-scan
Confocal laser endomicroscopy
Endosonography and targeted tissue sampling
Modified from G. Tytgat
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Interval Cancers ADR and CRC Risk and CRC Deaths
Screening Colonoscopy Study
314.872 Colonoscopies
136 Gastroenterologists
Interval CRC’s
Advanced Stage CRC
CRC Deaths
Corley. NEJM 2014
Inversely
Associated
with ADR
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Screening Issues
gFOBT / FIT CO
Main Effect Early Detection Prevention
Adv ADN sens 16 − 38% 88 − 94%
Screening adherence 48 − 60% (annual / decade) (single exam)
Dx w/u adherence 80% − 96% N /A
Initial cost Low (C/E) Higher (C/E)
Complications Low (single round) Low (screening)
Cai, Ca Prev Res 2011
Khaled-de Bakker, Ca Prev Res 2011
Murff, Ann Int Med 2010
Morikama, Gastro 2005
Hol, Gut 2010
Van Rossum, Gastro 2008
Van Roon, Gut 2012
Grotta, Clin Gastro Hep 2012
Pickhardt, NEJM 2003
Brenner, Ann Int Med 2011
Brenner, Gastro 2010
Kahi, Gastro Hep 2009
Imperiale, NEJM, 2008
Rex, Gastro 1997
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Effectiveness as a Function
of Adherence to FIT: Age 50-75 LY
G p
er
10
00
FIT
Percent Adherence
Zauber, et al. Ann Int Med 2008
100 80 50
250
0
50
100
150
200
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Colorectal Cancer Screening Strategies
Population
Colonoscopy
I
Colonoscopy
II
gFOBT / FIT
Stool DNA
Flex. Sig.
CTC
NCS
Bio-repository
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“Menu” vs. Single Test
Recommendation
↑ Participation from choice
vs.
↓ Participation from confusion
Segnan JNCI 2005 Senore Gut 2013 Inadomi Arch Int Med 2012
Jones CEBP 2010 Redetmeler JAMA 1995
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Elimination of Screening Colonoscopy Disparities NYC Coalition (C5)
Richards, Kerker, Thorpe, Olson, Krauskopf, Weber, Winawer, Am.Jn.Gastroenterology., 2011
Scre
en
ing
Co
lon
osco
py R
ate
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Interval CRC Litigation
Procedure
Informed Consent
Complete CO — Ce / TI / Retroflexion
Adequate Prep
Photodocumentation
Biology
Proximal Location
Serrated / Flat CRC
FH
IHC
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Other Issues in Surveillance
U.S. Multi-Society Task Force
Stopping Age? No! (USPSTF Stop? @75; Stop! @85)
Individualized based on assessment of benefit, risk,
co-morbidities . . .
Poor Prep? (Inadequate, suboptimal, fair) Repeat within a year
+ FOBT (Avoid!) after colonoscopy? Repeat colonoscopy
New significant rectal bleeding after colonoscopy? Re-evaluate for repeat colonoscopy
Lifestyle factors: race, gender, ethnicity? No change in surveillance
Lieberman. Gastro 2012
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‘Wrap-Up’
Colorectal Cancer Mortality ↓
Primarily from screening
65% men + women screened in U.S.
80% by 2018 campaign launched
Effectiveness depends on high quality
colonoscopy and complete polypectomy
Many screening tests available
*NCCRT / CDC / GISoc.
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THE BEST SCREENING TEST
IS
THE ONE THAT GETS DONE.