Colorectal Cancer Guide for Family Physicians

Colorectal cancer is a leading cause of morbidity and mortality in the United States. Family physicians play an integral role in educating patients about the current screening recommendations and modalities of available screening to improve early detection and allow treatment at its earliest stages. Family physicians must have the tools to minimize barriers to screening, alleviate patient concerns about screening modalities available, and educate patients on lifestyle modifications that have the potential to significantly lower the risk of developing colorectal cancer. Osteopathic physicians should consider the five osteopathic treatment models when developing an individualized plan for each patient.

Endoscopic colorectal cancer screening—can supply meet demand?

Colorectal Cancer Screening and Early Detection

Carcinogenesis is a multiyear, multistep, multipath disease of progressive genetic alterations and associated tissue damage. Chemoprevention is the use of drugs or other agents to inhibit, delay, or reverse this process. Despite the enormous population at risk of cancer who would benefit, drug

Rates of New or Missed Colorectal Cancers After Colonoscopy and Their Risk Factors: A Population-Based Analysis

Colorectal cancer (CRC) remains a frequently addressed topic in primary care. Recent studies have been published detailing modifiable risk factors for CRC, as well as preventative measures. Providers must be up to date on screening recommendations and modalities. Colonoscopy is the preferred method of screening for CRC, and the screening recommendations in the United States were recently updated in 2020. It is also common for the practitioner to encounter patients who refuse colonoscopy but are willing to undergo alternative methods of testing. The COVID pandemic has also placed a burden on hospital resources, and colonoscopy may not be logistically feasible in some healthcare settings. Therefore, awareness of the guidelines for the various alternative modalities, along with their respective guidelines for frequency of screening is critical. This article provides a brief review of the risk factors associated with colon cancer, the screening modalities (including colonoscopy, sigmoidoscopy, CT colonography, fecal immunohistochemical testing (FIT), guaiac-based fecal occult blood testing (gFOBT), multi target stool DNA testing (MTs-DNA), and others) and the most recent screening recommendations for the general population.

Comparing Risks and Benefits of Colorectal Cancer Screening in Elderly Patients

This Month in Gastroenterology

Introduction: Hepatitis C (HCV) is a significant burden within the United States, with the Center for Disease Control and Prevention (CDC) estimating 3.2 million individuals chronically infected. Newer therapies for HCV have brought hope for a significant percentage of these patients with rates of cure over 90% among approved regimens. In 2012, the CDC set forth guidelines for screening for HCV. We sought to identify understanding of CDC recommendations amongst primary care residents in the United States. Methods: A web-based survey was used to gauge understanding of current CDC screening recommendations. The survey included basic demographic data such as gender, residency in internal medicine or family medicine, and current level of training. The survey was sent to all primary care residents within the Henry Ford Health System and to Internal Medicine residency program directors throughout the United States through the ACGME list-server with request to be distributed to their residents. Results: 186 responses were received. 58.8 were male and 98.2% were internal medicine residents. Level of training was evenly split, with 34.6% PGY1, 33.3% PGY2, and 30.9% PGY3. 59.8% of respondents have received formal education regarding screening guidelines in their residency program. 69.5% of respondents stated they screened every patient born from 1945-65 at least once for HCV. Amongst the groups currently recommended for screening, 95.7% of residents recognized the role for screening in history of injected drug use, 70.6% in long-term hemodialysis patients, 92% in patients with HIV, and 95.7% in healthcare workers after sharps exposure or mucosal exposure to HCV-positive blood. There was a broad spread of understanding of current cure rates for HCV, with 13.9% of respondents believing the cure rate was 90%. Limited provider time was the most significant obstacle to screening patients born between 1945 and 1965 for HCV (68.7%). Conclusion: Our findings indicate good understanding of current CDC recommendations for HCV screening. There is room for improvement in follow-through with actual screening. There is poor understanding of the efficacy of current available therapies for HCV. This may reflect a lack of formal education in regards to HCV screening and treatment. Our study is limited by low response rate, especially among family medicine residents.

Colon Cancer: An Update and Future Directions

Prospective Clinical Validation of an Assay for Methylated SEPT9 DNA in Human Plasma as a Colorectal Cancer Screening Tool in Average Risk Men and Women ≥50 Years

INTRODUCTION: Colorectal cancer (CRC) is the third most common cancer diagnosed in both men and women in the United States (U.S). Over the past 10 years, the incidence and mortality rates of CRC in the U.S has steadily declined however, reductions have been significantly slower amongst African Americans (AA) who continue to have the highest rate of mortality amongst other racial groups. Several meta-analysis studies evaluated FIT to other modalities for detection of asymptomatic CRC. Pooled analysis revealed FIT sensitivity 79% and specificity 94%. In a study by Quintero et. al authors in 2012 NEJM compared one-time colonoscopy (26503) with FIT (26599) every 2 years. More compliance was noted with FIT group compared to colonoscopy group. Given AA are disproportionately affected by CRC and data on the utilization of FIT testing amongst AA population is scanty and poorly studied, we aim to study the utilization of FIT testing amongst AA. METHODS: We retrieved electronic medical records from a large safety net hospital between January 2010 and January 2019. We identified average risk patients who received screening for CRC using FIT, colonoscopy or sigmoidoscopy or either. Data regarding screening modalities for CRC were obtained. We utilized ICD-9 and ICD-10 procedure codes for FIT, colonoscopy and sigmoidoscopy. MS excel and STAT software were used for data management and analyses. Two-sided P-value <0.05 was considered statistically significant. RESULTS: Our study revealed that over all utilization of FIT was less compared to colonoscopy with 21.5 % vs 70.23% respectively at our institution. Similarly, the percentage of AA patients who received only FIT as a screening from total AA population for CRC was about 20.7% only and colonoscopy was about 70.9%. Table 1.0 summarizes total demographics and percentages of each screening modality. Table 3.0 summarizes trends of CRC screening trends in AA pts. CONCLUSION: Multiple screening tests such as colonoscopy, FIT, sigmoidoscopy, Fecal Occult Blood Test (FOBT) and FIT DNA are available to detect CRC. But FIT is most specific (96.4%) compared to other screening modalities. Our study reveals that only 20.7 % of AA patients received FIT as a screening tool for CRC compared to 70.9% who received traditional colonoscopy. More multi center studies are needed to analyze the barriers in utilization of FIT especially amongst AA patients. One potential barrier could be the awareness of FIT as a screening modality for CRC amongst primary care physicians.Table 1.: Summarizes demographics and utilization of CRC screening modality in total patientsTable 2.: Summarizes radical trends of utilization of CRC screening methodsTable 3.: Summarizes radical trends of utilization of CRC screening in African American population

Pancreatic cancer (PC) is an exceptionally lethal malignancy with increasing incidence and mortality worldwide. One of the principal challenges in the treatment of PC is that the diagnosis is usually made at a late stage when potentially curative surgical resection is no longer an option. General clinicians including internists and family physicians are well positioned to identify high-risk individuals and refer them to centers with expertise in PC screening and treatment where screening modalities can be employed. Here, we provide an up-to-date review of PC precursor lesions, epidemiology, and risk factors to empower the general clinician to recognize high-risk patients and employ risk reduction strategies. We also review current screening guidelines and modalities and preview progress that is being made to improve screening tests and biomarkers. It is our hope that this review article will empower the general clinician to understand which patients need to be screened for PC, strategies that may be used to reduce PC risk, and which screening modalities are available in order to diminish the lethality of PC.

Purpose: Colorectal cancer (CRC) is the second most common cause of cancer mortality in men and woman in the United States. It is accepted that screening for CRC has an impact on disease specific mortality. There are no available data on effects of screening on overall mortality. However, it is uncertain what the optimum screening algorithm should be for the greatest effect on these outcomes. We present results of a prospective study to determine the association between the use of a single screening modality (colonoscopy, flexible sigmoidoscopy, barium enema, FOBT) versus multimodality screening on overall mortality in a cohort of VA patients. We aimed to identify the screening modality that was most statistically associated with a patient still being alive at the end of the study follow-up period. Methods: Eligible patients with an increased risk of CRC were identified in an out-patient setting at a single VA hospital. Patients were followed from enrollment to November 2012, a maximum time period of 16 years, or death. Using the VA computerized medical records, CRC screening modalities, co-morbidities, demographic information, patient medical utilization, and mortality were recorded. We analyzed for healthy user bias by comparing utilization of health care testing (PSA and flu shots in males, Pap smear and mammogram in females) in the screened and non-screened patients. Results: Data of 2,127 patients were analyzed. Ages were 21-89. Participants were followed for a maximum time period of 16 years with a mean follow-up of 8.22 ± 3.36 years. Overall mortality was 25.2%. 72% of patients underwent some modality of CRC screening. The most represented screening modality was FOBT alone (n = 323). The modality that offered the most significant association of survival was FOBT plus colonoscopy (30% living; 16% dead, p < .0001). Patients with no screening modalities had a significant mortality (25% living; 35% dead, p < .0001). Regarding healthy user bias analysis, 32% of patients who underwent any CRC screening modality fulfilled criteria for being a health care utilizer. In contrast, only 18% of those not receiving any modality qualified (p < .0003). Conclusion: In this prospective cohort study, use of any screening modality including FOBT alone offered a statistically significant increased odds of being alive at the end of the study period as compared to no screening at all. However, the subgroup analysis is strongly indicative of an existent healthy user bias. In the absence of a randomized controlled trial of exposure to CRC screening modalities and mortality outcome, this study is suggestive of a decrease in all cause mortality with CRC screening tempered by the presence of bias.

Prospects for the worldwide control of colorectal cancer through screening