Colorectal%20cancer Management

Colorectal Cancer (CRC) Screening

• Primary goals are CRC prevention and early detection
• Substantially reduces mortality rates in individuals between the age of 50 to 70 year 
• May either be done among high-risk groups (eg those with IBD or with adenomatous polyps) or to the general population
• No single screening test is 100% sensitive
• Screening IBD patients helps detect CRC at an earlier stage but does not reduce mortality from CRC

Screening for the General Population

• Colonoscopy
  • Best screening modality for high-risk patients and best follow-up strategy for evaluating patients with positive gFOBT
  • Only screening test shown to reduce the incidence of CRC among screened individuals
  • Advantages include its wide availability, it allows single-session diagnosis and treatment, ability to examine entire colon, comfortable when done with sedation, and is the only test recommended at 10-year intervals
  • Interval for colonoscopy depends on factors such as family history of CRC (especially in 1st-degree relatives <50 years old), age at colitis diagnosis, presence of primary sclerosing cholangitis (PSC) and severity of inflammation

• Flexible sigmoidoscopy
  • Recommended direct visualization test used for the detection of adenomatous polyps and carcinoma
  • Studies have shown that this test helps reduce mortality risk from CRC
  • Advantages: Requires less preparation and no sedation
  • Disadvantage for this procedure includes colonic perforation, bleeding and examination is limited only to the distal colon

• Carcinoembryonic antigen (CEA)
  • May be considered as a screening tool for CRC although some medical societies do not recommend this due to its low sensitivity (46%) and specificity (89%)
  • Also used in monitoring of treatment response and cancer recurrence

• Chromoendoscopy with dye-spraying/image-enhanced endoscopy (IEE)
  • Yields higher results in detecting dysplasia compared with standard white-light endoscopy
  • Use of indigo carmine dye, although more costly, is preferred over methylene blue (as the former does not induce DNA damage)

• Computed Tomography Colonography (Virtual Colonoscopy/CTC)
  • A non-invasive technique that may be used to detect polyps or carcinomas >10 mm in size
  • Not suitable for detecting lateral spread and polyps measuring <1 cm
  • Advantages: Does not require sedation, is noninvasive, cost-effective and with very low test-related complications

• Capsule colonoscopy (PillCam^TM Colon 2)
  • Approved imaging test for screening of proximal colon for individuals at high risk for CRC who have undergone colonoscopy but were not able to complete the procedure, and have contraindications to colonoscopy, CT colonography, and sedation
  • Advantages: Non-invasive imaging tool with lesser risk for complications compared to colonoscopy
  • Disadvantages: Needed bowel preparations are more extensive compared to colonoscopy

• Guaiac-based fecal occult blood testing (gFOBT)
  • Shown by several studies to reduce mortality from CRC 
  • A negative result does not ensure that patient is free from CRC
  • Disadvantages: Possibility to miss tumors that is not bleeding or only slightly bleeding and high false-positive rates due to reaction from non-heme in food or blood in the upper gastrointestinal tract

• Fecal immunochemical testing (FIT)
  • Has higher detection rates for advanced adenomas and cancer compared to gFOBT
  • No diet restriction necessary for the test and a single test is sufficient

• Fecal immunochemical testing-Deoxyribonucleic Acid (FIT-DNA)
  • An emerging screening test that uses FIT to detect DNA biomarkers in stool samples
  • Recommended screening test for average-risk individuals because of its high sensitivity compared to FIT

• Blood-based screening test
  • Methylated Septin 9 (mSEPT9) DNA blood test is another new modality used for CRC screening
  • Circulating mSEPT9 DNA in plasma is a biomarker for minimally invasive CRC
  • Alternative test for individuals refusing to undergo other screening procedures
  • Disadvantage: Sensitivity in detecting CRC and advanced adenomas is low compared to other screening modalities

Screening Based on Risk Stratification

• Individuals at average risk
  • Recommended at age ≥45 years
  • Colonoscopy is the preferred screening modality and may be done every 10 years
  • If colonoscopy is incomplete, repeat colonoscopy within 1 year or other screening methods (eg double-contrast barium enema) should be considered
  • Other recommended screening tests include annual fecal-based tests (ie gFOBT, FIT) or FIT-DNA every 3 years, flexible sigmoidoscopy every 5 years

• Individuals at increased risk
  • Following screening colonoscopy and complete polypectomy:
    • Low-risk adenomas (≤2 tubular adenomas measuring <1 cm): 1st follow-up colonoscopy within 5 years, if normal, repeat every 5-10 years
    • Low-risk SSP (≤2 polyps or measuring <1 cm without dysplasia): 1st follow-up colonoscopy within 5 years, if normal repeat every 10 years
    • Advanced/multiple adenomas (3-10 polyps measuring ≥10 mm and with any villous features or high-grade dysplasia): Repeat colonoscopy within 3 years; subsequent colonoscopies within 5 years, or depending on findings
    • Pedunculated polyps without disease recurrence: Follow-up colonoscopy in 3 years
  • For patients with large colorectal polyps, recommended timing of follow-up colonoscopy after receiving complete resection are as follows:
    • For patients without high-risk features, invasive cancer and unfavorable risk factors for recurrence receiving complete resection: 1 to 3 years
    • Patients without recurrence after 1st surveillance colonoscopy: Every 3 years
    • Patients with risk factors: Within 6 months
    • Patients with history of complete resection and no disease recurrence: Within 1 year and every 3 years subsequently; repeat endoscopic therapy if with disease recurrence

Screening for Patients with Inflammatory Bowel Disease

• Colonoscopy should be done in all ulcerative colitis and Crohn’s colitis patients every 1-2 years and should be started 8-10 years after onset of symptoms or when in remission
  • In the presence of primary sclerosing cholangitis (PSC), surveillance colonoscopy must be done annually independent of the onset of symptoms
  • Colonoscopy with chromoendoscopy is recommended if standard-definition white light endoscopy (SD-WLE) is used
• Strictures (especially in ulcerative colitis) should be assessed thoroughly through biopsy and brush cytology
• When deemed appropriate, chromoendoscopy with biopsies of surrounding mucosa are done to check for dysplasia

Screening for Patients with Personal History of Colorectal Cancer

• Colonoscopy 1 year post-operatively (within 3-6 months if preoperative colonoscopy is incomplete)
  • If normal, this is repeated in 2-3 years then every 5 years
  • If sessile serrated polyps (SSP) or adenomas are found, colonoscopy is done in 1-3 years
  • Subsequent colonoscopic intervals will vary among patients but should not exceed 5 years

• Screening for Lynch syndrome with routine tumor testing at the time of diagnosis is recommended
  • Immunohistochemical and/or MSI testing may be used as the primary approach for tumor testing 
• For patients with rectal cancer treated with transanal local excision, proctoscopy with endorectal ultrasound (EUS) or MRI of the rectal anastomosis should be done
  • Repeat every 3-6 months for the 1st 2 years, then every 6 months until 5 years

Screening for Individuals with Positive Family History of Colorectal Cancer

• Individuals with ≥1st-degree relative with CRC at any age: Colonoscopy beginning 10 years before the earliest diagnosis in the family or at age 40 and repeated every 5 years; if positive, may repeat according to colonoscopy results
• Individuals with 2nd- to 3rd-degree relative with CRC diagnosed at any age: Colonoscopy beginning at age 45 and repeated every 10 years; if positive, may repeat according to colonoscopy results
• Individuals with 1st-degree relative with advanced adenomas: Colonoscopy beginning at relative’s age of onset of adenoma or at age 40 years and repeated every 5-10 years or according to findings

Screening for Patients After Surgical/Endoscopic Removal of Adenomatous Polyps or Sessile Serrated Polyps (SSP)

• Surveillance colonoscopy is recommended for adults age 45-75 years 
• Surveillance colonoscopy between 75-85 years of age should be individualized 
• Risk of CRC is increased in patients with ≥3 adenomas or SSP measuring ≥1 cm at 1st colonoscopy, those with villous or tubulovillous histology, or high-grade dysplastic component
• Low-risk patients are those with ≤2 adenomas or SSP <1 cm without villous or high-grade dysplastic features and may not require colonoscopic surveillance
  • However, colonoscopy may be performed at 7-10 years for those with adenomas or 5 years for those with SSPs if other factors are present (eg family history)

• Patients with either one adenoma measuring >1 cm in size or 3-4 small adenomas <1 cm are considered intermediate risk and surveillance colonoscopy is recommended every 3 years

Screening for Special Population

• Obese people
  • Screening should be initiated as early as 45 years of age

• Smokers
  • Based on various studies, screening is recommended among active smokers and those with >20 pack-years of smoking
  • Screen as early as 45 years of age, especially for those with >20 pack-years of smoking

Diet

• Regarded as the most important acquired factor in colorectal cancer (CRC)
• Diets rich in fruits and vegetables may help reduce the risk for CRC
• Calcium salts and calcium-rich foods may have protective role in CRC since they decrease colon cell turnover and reduce the cancer-promoting effects of fatty acids and bile acids
• Consumption of red meat should be limited to <500 g (18 oz) per week but processed food should be avoided

Weight Management

• Maintain body mass index (BMI) near the lower limit of the normal range

Physical Activity

• Adults should aim to have at least 2.5 hours of moderate intensity exercise (eg brisk walking) a week or 30 minutes on at least 5 days a week

Alcohol

• Should be limited to no more than 2 drinks per day (30 g of ethanol or 4 units) for men and 1 drink per day (15 g of ethanol or 2 units) for women

Smoking

• Patients should be discouraged from smoking or, for smokers, encouraged to quit smoking

Aspirin

• Intake of low-dose Aspirin of at least 5-10 years duration may have a protective effect against CRC development in patients 45-59 years old

• Detecting relapse in advance is the main goal
  • Rise in carcinoembryonic antigen (CEA) level is usually the first signal of recurrence and is most effective in patients with elevation preoperatively

• Surveillance recommendations for rectal cancer include:
  • Digital rectal exam (DRE) and prostoscopy every 3-4 months for 2 years, then every 6 months for a total of 5 years
  • Rectal MRI every 6 months for at least 3 years
• Colorectal cancer (CRC) surveillance include:
  • History, physical examination every 3-6 months for 2 years, then every 6 months for a total of 5 years
  • CEA test at baseline, then every 3-6 months for 2 years, then every 6 months for a total of 5 years if cancer is potentially resectable for isolated metastases
  • Colonoscopy at 1 year post-resection or every 3-6 months after resection if not done preoperatively due to an obstructing lesion
    • If follow-up colonoscopy reveals advanced adenoma, repeat colonoscopy in 1 year
    • If no advanced adenoma seen, repeat at 3 years, then every 5 years thereafter
    • More frequently done if CRC presented before 50 years of age
    • Important also in identifying and removing metachronous polyps, especially in the first 2 years after resection
  • CT scan of the chest, abdomen and pelvis every 3-6 months for 2 years then every 6-12 months for 5 years among stage IV patients and every 6-12 months for 5 years among stage II at high risk of recurrence and III patients
    • Important in monitoring potentially resectable metastases
  • Endoscopic surveillance for patients who underwent endoscopic removal of polyps with invasive cancer should be individualized
  • Proctoscopy with endoscopic ultrasound or MRI with contrast is recommended every 3-6 months for the 1st 2 years then every 6 months for a total of 5 years in patients with rectal CA who underwent transanal local excision only