joint session with acofp and cancer treatment …...colorectal cancer screening guidelines...
TRANSCRIPT
Joint Session with ACOFP and Cancer
Treatment Centers of America (CTCA):
Cancer Screening:
Consensus & Controversies
Ashish Sangal, M.D.
9/13/2016
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Cancer Screening: Consensus & Controversies
Ashish Sangal, MD
Director, Medical Education
Medical/Thoracic Oncology
Cancer Treatment Centers of America
OMED 2016
Anaheim, California
September 20, 2016
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Lung Cancer Screening:CT Screening Current Status
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Disclosures
No conflict of interest!
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Lung Cancer Facts
4 CA Cancer J Clin. 2013 Jan;63(1):11-30
Cause of cancer-related deathin the United States
Only 15% of lung cancer patients are diagnosed at an early, localized stage
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Lung Cancer Facts
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Lung Cancer Facts
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- 228,190 cases yearly in the US- 13.7% of all new cancer cases- 27.5% of all cancer deaths- Estimated deaths: 159,480
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Screening for Lung Cancer
The ideal screening test:
• Scientifically validated
• Relative safety
• Accessible
• Reproducible
• Low cost
• Improve outcome
7 NCCN Guidelines Version 1.2016
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Screening for Lung CancerHistorical Review: Chest X-ray/Sputum Cytology
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Northwest London Mass Radiography Service[55k male ; bi-annual CXR for 3 yr]
Memorial-Sloan Kettering study
The Johns Hopkins study
Czechoslovakian study
[6364 males ; bi-annual CXR + sputum cytology for 3 yrs]
Mayo Lung Project
[10,993 male ; CXR + sputum cytology every 4 mon up to 20 yr]
The Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial[154,942 M+F; annual CXR for 3 yr]
N=20k; annual CXR + sputum cytology
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Screening for Lung CancerHistorical Review: Chest X-ray/Sputum Cytology
None of the randomized trial shown mortality benefit !!!
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Screening with Chest CTNational Lung Screening Trial (NLST)
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20% fewer lung cancer deaths among 53,000 participants screened with
low-dose helical (spiral) CT compared to those screened with chest X-rays.
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Downside with CT Screening
• High false positive rate
• False negative
• Radiation risk
• Risk to patient with workup
• Cost of screening per life saved?
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United States Preventive Task Force (USPSTF) Recommendation
• Age 55-80
• Able and willing to receive treatment
• Smokers and formal smokers who have not quit in the past 15 yrs
• > 30 pack yr smoking history
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National Cancer Comprehensive Network (NCCN) GuidelinesWho should be screened?
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Lung CT Scan Follow Up:Next steps if no nodules
• Next LDCT in 1 yr
• At least for 2 yrs
• After 2 yrs clinician may continue yrly screening
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Lung CT Scan Follow Up:Next steps if solid or part solid nodule
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Lung CT Scan Follow Up:Timing of 2nd Screening Test
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Fleischner Society Guidelines
19 MacMahon H, Austin JH, Gamsu G et al.
Radiology 2005; 237:395-400
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Caveats
• Surveillance after lung cancer surgery
• Not in Europe
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Lung Screening ProgramsRequirements
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Lung Screening ProgramsBenefits vs. Dangers
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Summary
• Lung cancer screening involves a multidisciplinary approach and includes several specialties
• Management of downstream testing and follow-up requires administrative processes
• Individuals at high risk of lung cancer should participate in an informed and shared decision making process
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Colorectal Cancer Screening2015 Updated Guidelines
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Colorectal Cancer Screening Guidelines
• Updated December 2015
• American Cancer Society (ACS), US Multi-Society Task Force on Colorectal Cancer, and American College of Radiology
• American College of Physicians (ACP)
• American College of Gastroenterology (ACG)
• National Comprehensive Cancer Network (NCCN)
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Colorectal Cancer Screening Guidelines
• All guidelines recommend routine screening for colorectal cancer and adenomatous polyps in asymptomatic adults
• Start at age 50
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American Cancer Society (ACS), US Multi-Society Task Force on Colorectal Cancer, and American College of Radiology
• Screening begins at age 50 years for asymptomatic men and women
• Screening begins at 40 years for asymptomatic African American men and women
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High risk patients
• Earlier age
• Family history of colorectal cancer or polyps
• Family history of a hereditary colorectal cancer syndrome such as familial adenomatous polyposis (FAP) or hereditary non-polyposis colon cancer (HNPCC)
• Personal history of colorectal cancer
• Personal history of inflammatory bowel disease (UC or Crohn’s disease)
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American Cancer Society (ACS), US Multi-Society Task Force on Colorectal Cancer, and American College of Radiology
• Screening options for average risk adults consist of tests that detect adenomatous polyps and cancer.
– Tests that detect cancer and adenomatous polyps
– Flexible sigmoidoscopy every 5 years
– Colonoscopy every 10 years
– Double-contrast barium enema every 5 years
– Computed tomographic (CT) colonography every 5 years
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American Cancer Society (ACS), US Multi-Society Task Force on Colorectal Cancer, and American College of Radiology
• Tests that primarily detect cancer:
– Annual guaiac-based fecal occult blood test with high sensitivity for cancer
– Annual fecal immunochemical test (FIT) with high test sensitivity for cancer
– Stool DNA test with high sensitivity for cancer, interval uncertain
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American College of Gastroenterology (ACG)Prevention vs. Detection Screening Tests
• The ACG guidelines make a distinction between screening tests for cancer prevention and cancer detection
• Tests that prevent cancer are preferred over those that only detect cancer
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ACGPreferred screening options
• The preferred colorectal cancer prevention test is colonoscopy
– Every 10 years, beginning at age 50 years, but at age 45 years in African Americans
• For patients who decline colonoscopy or another cancer prevention test, the preferred cancer detection test is FIT annually
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ACGAlternative screening options
• Alternative cancer detection tests recommended in the ACG guidelines:
– Flexible sigmoidoscopy every 5-10 years
– CT colonography every 5 years, which replaces double contrast barium enema as the radiographic screening alternative for patients who decline colonoscopy
– Annual Hemoccult Sensa
– Fecal DNA testing every 3 years
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ACGFamily History impacts Screening Recommendation
• For patients with a single first-degree relative diagnosed with colorectal cancer or advanced adenoma before age 60 years, or those with two first-degree relatives with colorectal cancer or advanced adenoma, the guideline recommends colonoscopy every 5 years, beginning at age 40 years or at 10 years younger than the age at diagnosis of the youngest relative
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ACGAdditional information
• For screening purposes, patients with one first-degree relative diagnosed with colorectal cancer or advanced adenoma at age 60 years or older are considered at average risk
• The ACG recommends that all colorectal cancer patients be checked for Lynch syndromes, by testing for microsatellite instability (MSI)
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The National Comprehensive Cancer Network (NCCN) Guidelines
• Separate guidelines for average-risk and high-risk individuals
• For average individuals, the recommendations are nearly identical of those of the ACS, and the ACR
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NCCN High Risk Patients
• For high-risk individuals, the guidelines specify recommendations for each risk factor
– Lynch syndrome
– Familial adenomatous polyposis (FAP)
– Attenuated familial adenomatous polyposis (AFAP)
– MUTYH-associated polyposis (MAP)
– Peutz-Jeghers syndrome (PJS)
– Juvenile polyposis syndrome (JPS)
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Post polypectomy Surveillance
• The ACG has guidelines for surveillance of patients who have had adenomas detected and removed at colonoscopy
• Colonoscopy findings and recommended scheduling of follow-up colonoscopy are as follows:
– No polyps – 10 years
– Small (<10 mm) hyperplastic polyps in rectum or sigmoid – 10 years
– 1-2 small (<10 mm) tubular adenomas – 5 -10 years
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Post polypectomy Surveillance
• 3-10 tubular adenomas – 3 years
• 10 adenomas - < 3 years
• One or more tubular adenomas > or = to 10 mm – 3 years
• One or more villous adenomas – 3 years
• Adenoma with high grade dysplasia – 3 years
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Post polypectomy Surveillance
• For serrated lesions, the following recommendations are made:
– Sessile serrated polyp < 10 mm with no dysplasia –5 years
– Sessile serrated polyp > or = to 10 mm with no dysplasia – 3 years
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Post polypectomy Surveillance
• Sessile serrated poly with dysplasia – 1 year
• Traditional serrated adenoma – 1 year
• Serrated polyposis syndrome – 1 year
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Additional References:
• Levin B, Lieberman DA, McFarland B, Smith RA, Brooks D, Andrews KS, et al. J Clin. 2008 May-Jun. 58 (3):130-60.
• Rex DK, Johnson DA, Anderson JC, Schoenfeld PS, Burke CA, Inadomi JM, et al. Am J Gastroenterol. 2009 Mar. 104 (3):739-50.
• National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology: Colon Cancer Version 2.2015.
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Questions?
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