Which is the best test for colorectal cancer screening? Giovanna da - PowerPoint PPT Presentation

Which is the best test for colorectal cancer screening? Giovanna da Silva, MD, FACS, FASCRS Staff, Department of Colorectal Surgery Director of Clinical Research Cleveland Clinic Florida

Disclosures • None

Colorectal Cancer (CRC) Siegeel. R et al, Ca Cancer J CLIN 2017

National Goal Percentage of U.S. Adults Age 50-75 years Up-to-Date with CRC Screening, Behavioral Risk Factor Surveillance System 1/3 Americans > 50 years of age do not follow recommended screening American Cancer Society

Colon cancer screening guidelines US Preventive Services Task Force Guidelines (USPSTF) American Cancer Society ( ACS) TESTS USPSTF ACS Frequency 2016 2018 Every Stool-Based Tests gFOBT (HS) Yes Yes 1 y FIT Yes Yes 1 y FIT DNA Yes Yes 3 y ? Direct Visualization Tests Colonoscopy Yes Yes 10 y CT Colonography Yes Yes 5 y Flex sig Yes Yes 5 y Flex sig with FIT Yes No Flex sig 10y FIT 1 y

Stool-Based Tests Cons Pros • Less sensitive for • Noninvasive advanced lesions and • Can be done at home cancer • No bowel prep • Frequency • No medical restrictions • Low compliance • Colonoscopy if • Lower cost abnormal test • Suitable for mass • Don’t prevent screening programs CRC/advanced lesions

Fecal Occult Blood Test (gFOBT) • Guaiac FOBT (gFOBT) - Guaiac resin + Hb + H2O2 -- Blue - Need to avoid certain foods and meds - 3 stool samples • RCT: reduces CRC death by 15-30% when done every 1-2 years • 1-time sensitivity for CRC: 13-50% • High-sensitivity gFOBT: Hemoccult SENSA Shaukat A, NEJM 2013 Mandel jS, NEJM 2000

Fecal Immunochemical Test ( FIT) Antibody detects human Hb • - No need of dietary restriction - Single sample - Better sensitivity and specificity than gFOBT • Different cutoff values available in the US • Recommended every year • Meta-analysis - 1-time cancer detection: 50-79%; overall accuracy: 95% - Better patient compliance than gFOBT Mousavinezhad M et al, MJIRI, 2016 Lee J K et al. Ann Int Med, 2014

Polyp-Cancer Pathway Calderwood AH

FIT-DNA Cologuard • Combination of FIT and markers for abnormal DNA • Detect high-risk lesions: adenoma ≥10 mm, sessile serrated polyp, villous or tubulovillous adenoma, adenoma with high grade dysplasia • 1-time sensitivity for CRC: 92% • Cost $ 500 vs. $ 20 (FIT) • Recommended every 3 years

Stool-Based tests CRC detection Sensitivity Specificity FOBT Hemoccult SENSA 62-79% 87-96% FIT Light (10μg Hb/g) 79-88% 91-93% FIT Chek (20μg Hb/g) 73-75% 91-95% FIT DNA 92% 84% USPSTF JAMA 2016

FIT-DNA vs. FIT Sensitivity n=9989 Cancer Advanced (n=65) Neoplasia (n=757) FIT-DNA 92.3% 42.4% FIT 73.8% 23.8% Imperiale TF et al, NEJM, 2014

FIT DNA vs. FIT Specificity n=9989 Negative for Entirely non advanced negative lesions colonoscopy FIT-DNA 86.6% 89.9% FIT 94.9% 96.4% FIT DNA: more false positives extra colonoscopy Imperiale TF et al, NEJM, 2014

Direct Visualization Tests Colonoscopy/Flexible sigmoidoscopy • High sensitivity for cancer and all pre cancerous lesions • Single-session diagnosis and treatment • Longer interval between examination

Direct visualization Tests Colonoscopy/Flexible sigmoidoscopy • Need of bowel prep • Need of sedation • Operator dependent • Costs Lower for flex sig • Risks - Perforation – 4/10.000 - Bleeding 8/10.000 Lin JS, USPSTF. 2016

Colonoscopy& Flex sig Meta-analysis & Systematic review • Flexible sigmoidoscopy (4 RCT) - Reduction in CRC incidence and/or mortality of 29-76%- less for distal CRC • Colonoscopy (10 obs studies) - Reduction in CRC incidence and mortality of 80% distal colon and 40-60% in the proximal colon Brenner H et al, BMJ 2014 Rex DK, Am J Gastroenterology, 2014

Robertson DJ

• 9167 patients with adenoma removed at baseline/no cancer • Median FU 47.2 months • 58 (0.6%) diagnosed with cancer Gut.2014

Colonoscopy Quality benchmarks • Adenoma detection rate: 25% • Cecal Intubation: 90% • Photo documentation • Withdrawal time: 6-9 min • Bowel preparation: 85% adequate - Inadequate bowel prep should be repeated within 1 year Anderson JC, Clinical And translational Gastroenterology, 2015

CT Colonography • Patients who refuses, can’t undergo or had incomplete c-scope • Sensitivity 67-94% for adenomas > 1 cm • 40-70% incidentalomas- potential harm • Radiation exposure • Recommended every 5 years • Insurance coverage might be challenging

CT Colonography vs.Colonoscopy Meta-analysis • 3163 Colonoscopy (OC) • 3120 CT colonography (CTC) - 246 (7.9%) referred to OC (polyp > 6 mm) • No statistical difference - Cancer CTC 0.4% vs. OC 0.1% - Advanced lesions: CTC 3.2% vs. OC 3.4% • OC: 0.2% colonic perforation Kim DH et al NEJM 2007

Colorectal cancer screening Which is the best test?

Choice can improve adherence RCT n=997 Inadomi JA et al Arch Intern Med. 2012

U.S Multi-Society Task Force Colorectal Cancer ( MSTF) Ranking • Tier1 - Colonoscopy every 10 years - Annual fecal immunochemical test • Tier 2 - CT colonography every 5 years - FIT DNA every 3 years - Flexible sigmoidoscopy every 5-10 years • Tier 2 - Capsule colonoscopy every 5 years

Colorectal cancer screening Which is the best test? “The best colorectal cancer screening test is the one that gets done” Richard Wender , MD

Thank you!