Colon-Rectal Cancer Didactics

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Hi. This is Dr. Keith Bradley from NARAP, The National Alliance of Research Associates Programs. Welcome to this presentation about Colon-Rectal Cancer as preparation for your work as a Research Associate in NARAP’s national, multi-center study on facilitating screening for patients and their visitors in the emergency department. This material will give you a background about why you are doing the work you will do as a RA with this study. We hope it will help you to see the importance of your efforts for study participants as well as provide a reference for you to go back to review about the study.

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Colon-Rectal Cancer is the 2nd leading cause of cancer in the United States.

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While cancer can be found in any part of the gastrointestinal tract, it is most commonly found in the colon, the large bowel, leading to the rectum

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Colon-rectal cancer is the gradual, progressive growth of a tumor that encroaches on the lumen of the bowel causing: obstruction to the movement of feces

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bleeding perforation of the bowel wall metastases of the cancer to other parts of the body

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The risk factors can be categorized as inherited and acquired

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The older we get, the greater the risk we have of getting colon-rectal cancer. This is a risk factor we just have to accept as the price of hopefully living to a ripe, old age. If you have had colon-rectal cancer once, the chances are greater that you will get it again. Inflammatory bowel diseases like ulcerative colitis and Crohn’s disease increase your risk of colon-rectal cancer. A history of colon-rectal cancer in your family, the people you share common genetics with, makes it more likely you too will get colon-rectal cancer, particularly if they had adenomas, polyps , at a relatively early age. And if polyps run in your family, there is a higher chance that these precursors of colon-rectal cancer will be found in your bowel.

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There appear to be things we do during our lives that can increase our chances of getting colon-rectal cancer. A diet high in saturated fat, protein, calories, meat and alcohol raises the risk. So that burger, fries and a beer may come back to bite you in the form of colon-rectal cancer. A diet low in calcium and folate, also raises the risk. When your Mommy told you to drink your skim milk and eat your beans and green, leafy vegetables, she was helping you prevent colon-rectal cancer. A sedentary lifestyle is associated with all kinds of health problems, including colon-rectal cancer. And, of course, tobacco use raises the risk for a whole host of diseases, with many cancers leading the list.

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To decrease your risk of colon-rectal cancer, eat a low-fat, high fiber diet There is some evidence that the use of non-steroidal, anti-inflammatory drugs, such as aspirin and post menopausal hormone therapy, may be protective. But the factor we are most interested in for this study is the early identification and removal of polyps, the precursors to colon-rectal cancer.

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The number of new cases and deaths due to colon-rectal cancer has been decreasing. We can hypothesize that lifestyle changes, particularly fewer people smoking, may be having an effect on the rates of colon-rectal cancer. But, the inclusion of colon-rectal cancer screening in routine primary preventive care has certainly had a major impact on decreasing the deaths from this all too common and potentially fatal illness.

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There are three ways to screen for colon-rectal cancer: fecal occult blood testing sigmoidoscopy and colonoscopy There are advantages and disadvantages for each of these testing modalities . It is up to the patient and their doctor as to what the best strategy is.

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The patient takes samples of their stool, smears them on a card, seals it and sends it off to be tested for the presence of blood, even in amounts that are too small to see.

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The specimens are then tested and if blood is found, the patient can be advised by their doctor about what further testing needs to be done to see if they have colon-rectal cancer, hopefully at an early stage that can be successfully treated.

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The flexible sigmoidoscope has a camera with a light source at the end that allows the rectum, sigmoid and descending colon to be directly visualized. If a suspicious lesion is seen, instruments can be passed along the interior of the scope and the lesion removed or biopsied.

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This is what we are looking to find with screening: This is a small polyp on the wall of the colon. This lesion has the potential to turn into colon-rectal cancer.

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But, through the scope a snare is passed and the polyp removed. It will be biopsied to see if there is evidence of cancer and further treatment needed. But if the biopsy is negative, the polyp with the potential to turn into colon-rectal cancer has been taken out and tragedy down the road averted.

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This is what you don’t want to see in the scope. This is colon-rectal cancer. You can see the areas of bleeding. Maybe the patient already had symptoms, like tiredness from anemia, low hemoglobin, or some vague abdominal pain. Biopsy of this lesion showed it was cancer.

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The patient underwent a removal of a large section of bowel, a major operation. You can see the large cancer in the middle of the photograph.

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Likely, the patient had a colostomy constructed where the remaining large bowel is attached to the abdominal wall and feces is diverted into a bag. Depending on clinical factors, chemotherapy and radiation treatments might be needed hopefully to stem the progression of this colon-rectal cancer toward a fatal outcome.

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This is what you really don’t want to see when looking through the scope. This is an advanced colon-rectal tumor. This patient would be very symptomatic, with signs of obstruction: constipation, severe abdominal pain, a distended abdomen.

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At operation, this is a very extensive, invasive colon-rectal cancer. Chances are very high that this cancer has already spread. This patient would have very little chance for long-term survival. If this had been found when it was a polyp, when the patient had no symptoms and was just being screened such a horrible outcome could have been avoided

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Unfortunately, many people who should have colon-rectal cancer screening, do not get it done.

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While there are many reasons for this, certainly one of them is fear of the procedure or of the results that might be found.

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Getting screened for colon-rectal cancer can be life-saving. The U.S. Preventive Services Task Force has recommended that people 50-75 years old have one of three options: annual screening with a sensitive FOBT flexible sigmoidoscopy every 5 years with a mid-interval sensitive FOBT colonoscopy every 10 years As Research Associates, you will be an integral part of the research seeing how we can facilitate colon-rectal cancer screening among patients and their visitors in the emergency department. You will be part of a national, multi-center study that has the potential to save lives for participants in the research and to change how we help people get the screening they need in the future. I hope you are as excited as we at NARAP and at your Affiliate hospital are for your work with us . Without you and our Research Associates around the country, none of this vital work would be possible. Now, please go to the Test and Evaluation section to complete this portion of your on-line training.

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Colon-Rectal Cancer Keith Bradley, MD National Alliance of Research Associates Programs NARAP

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Colon-Rectal Cancer 2nd leading cause of cancer deaths in U.S.

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Colon-Rectal Cancer 2nd leading cause of cancer deaths in U.S. complex interactions between inherited susceptibility and environmental risk factors

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Risk Factors Inherited Acquired

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Inherited Risk Factors age > 40 personal hx of colon-rectal cancer Ulcerative colitis or Crohn’s disease family (parents or siblings) hx of colon-rectal cancer or adenomas before age 60 Familial polyposis

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Acquired Risk Factors diet high in low in saturated fat - calcium protein - folate calories meat (both red and white) alcohol sedentary lifestyle smoking cigarettes

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Decreased Risk low-fat, high-fiber diet nonsteroidal anti-inflammatory drugs post menopausal female hormone use polyp removal

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Colon-Rectal Cancer 2nd leading cause of cancer deaths in U.S. complex interactions between inherited susceptibility and environmental risk factors number of new cases and deaths due to colon-rectal cancer has been decreasing

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Screening fecal occult blood test flexible sigmoidoscopy colonoscopy

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Fecal Occult Blood Test special cards are coated with a stool sample and returned to the physician or lab

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Fecal Occult Blood Test special cards are coated with a stool sample and returned to the physician or lab fecal occult blood test performed every 1 or 2 years in people between the ages of 50-80 years decreases deaths due to colorectal cancer by 20 – 40%

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Flexible Sigmoidoscopy a thin, lighted tube (sigmoidoscope) into rectum and only the descending colon most often done in a doctor’s office or clinic by a family practitioner (FP) or general internist patient remembers the procedure polyps or other abnormal tissue  removed and biopsied combined with FOBT every 3 years

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Colonoscopy a thin, lighted tube (colonoscope) into rectum and through the entire colon most often done in a hospital or specialized setting by a gastroenterologist (but possibly a FP) under conscious sedation polyps or other abnormal tissue  removed and biopsied

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Polyps ademomas = precursors for vast majority of colorectal cancer most of these adenomas are polypoid

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Colon-Rectal Cancer Screening Fewer than 50% over age 50 get screened

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Colon-Rectal Cancer Screening Fewer than 50% over age 50 get screened In a survey, respondents who had never had a colonoscopy said they would rather give up three months of life than have the test.

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United States Preventive Services Task Force (USPSTF) Recommendations Adults, beginning at age 50 years and continuing until age 75 years Options annual screening with a sensitive FOBT flexible sigmoidoscopy every 5 years with a mid-interval sensitive FOBT colonoscopy every 10 years

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