COLON CANCERIntervention for Prevention

Marigo Werner

OBJECTIVES Define colon cancer Discuss pathophysiology of colon cancer Discuss morbidity and mortality statistics Discuss detailed plan for intervention Discuss evaluation methods Discuss implementation of intervention plan

DEFINITIONS*A tumor is abnormal tissue and can be benign (not cancer) or malignant (cancer).*A polyp is a benign (non-cancerous) tumor.*Adenomatous polyps (adenomas) are polyps that can change into cancer.*Hyperplastic polyps and inflammatory polyps, in general are not pre-cancerous.*Dysplasia is an area in the lining of the colon or rectum where the cells look abnormal (but not like true cancer cells) when viewed under the microscope.(American Cancer Society, 2012).

TYPES OF CANCER IN COLON AND RECTUM

Adenocarcinomas are a type of colorectal cancer. They make up 95% of colon cancers.

Carcinoid tumors start from specialized hormone producing cells in the intestine.

Gastrointestinal stromal tumors start from interstitial cells of cajal.

(American Cancer Society, 2012)

TYPES OF CANCER IN COLON AND RECTUM (CONTINUED) Lymphomas are cancers of the immune

system cells that typically start in lymph nodes.

Sarcomas start in blood vessels as well as in muscle and connective tissue in the wall of the colon and rectum. Sarcomas of colon and rectum are rare.

(American Cancer Society, 2012).

CLINICAL MANIFESTATIONS Tumors of the right (ascending) and left

(descending) colon include pain, a palpable mass in the lower right quadrant, anemia, and dark red or mahogany-colored blood mixed with the stool.

(Huether, 2010, p. 1501)

CLINICAL MANIFESTATIONS Manifestations of tumors of the left, or

descending colon include progressive abdominal distention, pain, vomiting, constipation, need for laxatives, cramps and bright red blood on the surface of the stool (Huether, 2010, p.1051).

COLON CANCER STATISTICS Approximately 150,000 new cases of

colorectal cancer are diagnosed each year and nearly 50,000 people die from this disease each year. Colorectal cancer accounts for 10% of all cancer deaths in the U.S.

Colon cancer is a significant health problem in Kentucky-it is the second leading cause of cancer death in Kentucky (“Kentucky Colon”, 2012).

COLORECTAL CANCER STATISTICS

SEER Incidence

From 2005-2009, the median age at diagnosis for cancer of the colon and rectum was 69 years of age3. Approximately 0.1% were diagnosed under age 20; 1.1% between 20 and 34; 4.0% between 35 and 44; 13.4% between 45 and 54; 20.4% between 55 and 64; 24.0% between 65 and 74; 25.0% between 75 and 84; and 12.0% 85+ years of age.

The age-adjusted incidence rate was 46.3 per 100,000 men and women per year. These rates are based on cases diagnosed in 2005-2009 from 18 SEER geographic areas.

Incidence Rates by Race

Race/Ethnicity Male Female

All Races 54.0 per 100,000 men 40.2 per 100,000 women

White 53.1 per 100,000 men 39.2 per 100,000 women

Black 66.9 per 100,000 men 50.3 per 100,000 women

Asian/Pacific Islander 44.9 per 100,000 men 34.2 per 100,000 women

American Indian/Alaska Native a 45.2 per 100,000 men 38.0 per 100,000 women

Hispanic b 45.2 per 100,000 men 31.5 per 100,000 women

(National Cancer Institute, 2012)

COLORECTAL CANCER STATISTICS

United States Cancer Statistics (USCS)

Cancers By State and Region

2008 Cancer Types Grouped by State and Region

Colon and Rectum. Age-Adjusted Invasive Cancer Incidence Rates and 95% Confidence Intervals by U.S. Census Region and Division, State and Metropolitan Area, and Race and Ethnicity, United States (Table 2.4.1.1M) *†‡

Rates are per 100,000 persons and are age-adjusted to the 2000 U.S. standard population (19 age groups - Census P25-1130).

Geographic Area All Races White Black Hispanic §||

United States 51.6 50.2 63.5 45.9

South 51.9 50.0 64.1 48.2

East South Central 60.3 57.9 73.0 39.6

Kentucky 64.0 63.9 67.4 – (Table 2.4.1.1M) Colon and Rectum. Age-Adjusted Invasive Cancer Incidence Rates and 95% Confidence Intervals by U.S. Census Region and Division, State and Metropolitan Area, and Race and Ethnicity, United States *†‡ Footnotes

* Rates are per 100,000 persons and are age-adjusted to the 2000 U.S. standard population (19 age groups – Census P25–1130).

(National Cancer Institute, 2012)

INCIDENCE RATES OF COLORECTAL CANCER

Rates of Getting Colorectal Cancer by StateThe number of people who get colorectal cancer is called the colorectal cancer incidence. In the United States, the risk of getting colorectal cancer varies from state to state.Colorectal Cancer Incidence Rates,* by State, 2008† (National Cancer Institute, 2012)

RATES OF COLON CANCER IN KENTUCKY2003-2007

(Kentucky Cancer Registry, 2012)

COLON CANCER DEATH RATES, BY STATE, 2008

Deaths from Colorectal Cancer by State Rates of dying from colorectal cancer also vary from state to state.

Colorectal Cancer Death Rates,* by State, 2008†

(National Cancer Institute, 2012)

CANCER MORTALITY RATES IN KENTUCKY (Kentucky Cancer

(Kentucky Cancer Registry, 2012)

RISK FACTORS FOR COLORECTAL CANCER Age-more than 9 out of 10 people

diagnosed with colon cancer are at least 50 years old.

Personal history of colorectal polyps or colorectal cancer.

Colorectal cancer removed-more likely to develop new cancers in other areas of the colon and rectum (American Cancer Society, 2012).

RISK FACTORS FOR COLORECTAL CANCER(CONTINUED) Personal history of inflammatory bowel

disease. Inflammatory bowel disease includes ulcerative colitis and Crohn’s disease, which are conditions in which the colon is inflamed over a long period of time. People who have had IB for many years often develop dysplasia.

Family history of colorectal cancer . 1 in 5 people who develop colorectal cancer have other family members who have been affected by this disease(American Cancer Society, 2012).

RISK FACTORS FOR COLORECTAL CANCER (CONTINUED) Inherited syndromes-about 5% to 10%

of people who develop colorectal cancer have inherited gene defects (mutations) that cause the disease.

Two of the most common inherited syndromes linked with colorectal cancer are familial adenomatous polyposis (FAP) and hereditary non-polyposis colorectal cancer (HNPCC) (American Cancer Society, 2012).

RISK FACTORS FOR COLORECTAL CANCER (CONTINUED) Diet high in red meat (beef, lamb, or

liver), processed meat (hot dogs and some luncheon meats).

Cooking at high temperature (frying, broiling, or grilling)

Obesity Smoking (American Cancer Society,

2012).

COLON CANCER SCREENING Colon cancer prevention and early

detection should be the primary goal of CRC screening.

Screening an average-risk individual can reduce CRC mortality by detecting cancer at an early curable stage and by detecting and removing adenomas. It has also been shown to be cost-effective compared to other screening programs (NCCN guidelines, 2012).

COLON CANCER SCREENING Colon cancer screening for the average

risk person should begin at age 50. Colonoscopy every 10 years Flexible sigmoidoscopy every 5 years CT colonography every 5 years (NCCN

guidelines, 2012)

COLON CANCER SCREENING Screening modalities that primarily

detect cancer are stool-based screening. Guiac-based testing annually (requires 3

successive stool specimens). Immunochemical based testing annually Stool DNA test with high sensitivity

(NCCN guidelines, 2012).

COLON CANCER SCREENING Intensive surveillance program should

be initiated for high risk patients. Colonoscopy is recommended rather

than flexible sigmoidoscopy because of the predominant proximal location of cancer. It should be offered every one to two years, beginning between the age of 20 to 25 years

(American Cancer Society, 2012).

INTERVENTION PLAN Raise awareness in the community about

colon cancer and the importance of colon cancer screening. Screening an average-risk individual can reduce CRC mortality (NCCN guidelines, 2012).

Form a task for composed of members from the local hospital, local cancer center, health department, Kentucky Cancer Program, American Cancer Society Representative, local school board, civic organizations, churches, representative from local medical society, representative from local nurse practitioners, and volunteers.

INTERVENTION PLAN Task force will develop a publicity

campaign. Educational spots will be played on the

radio Ads will be placed in The Medical Leader Speakers will give presentations at local

churches and civic organizations Literature on colon cancer will be

passed out at local business such as Wal-Mart and Food City

INTERVENTION PLAN Task force will give presentation at local

medical society meeting to promote colon cancer screening.

Instruction sheet for FOBT will be developed and provided for local family practice physicians to give to patients who are doing the FOBT.

INTERVENTION PLAN This is a hyperlink that shows a sample

instruction sheet for collection of specimen for FOBT.

Fecal Occult Blood Test Instructions.docx

INTERVENTION PLAN A comprehensive family history is one

important way to identify at-risk individuals. Correctly recognizing Lynch Syndrome is essential for the application of appropriate screening and surveillance measures (Jang & Chung, 2010, p. 151).

This fact about family history will be reviewed with the medical society to encourage this practice.

INTERVENTION PLAN Life size colon will be displayed at

annual Hillbilly Days Festival. This display allows people to walk through the inside of a colon and see polyps and tumors. This will be done in conjunction with the Kentucky Cancer Program.

Volunteers will be present at the display to answer questions and provide education material (Kentucky Cancer Program, 2012).

INTERVENTION PLAN An educational program will be developed

with the local hospital employee education department that will be made available to healthcare provider.

A form letter will be developed and provided for family practice physicians to send to patients who have FOBT ordered .

Community Preventive Services Task Force recommends use client reminders to improve compliance with FOBT (2012).

INTERVENTION PLAN FOBT will be available through the local

health department. A free colon cancer screening will be

provided by the local cancer center in conjunction with local general surgeons.

According to the Community Preventive Service Task force, the team found sufficient strong evidence that interventions using one-on-one education, client reminders, provider assessment and feedback and reducing structural barriers are effective in promoting colorectal cancer screening with FOBT. (2012).

INTERVENTION PLAN Colon Cancer education material will

placed in family practice physicians’ offices.

Researchers concluded: “Low-cost education materials have the potential to contribute to public engagement with health promotion and disease prevention” (“New Findings”, 2007).

EVALUATION OF INTERVENTION PLAN The intervention plan will be evaluated

by having family practice physicians or designated staff member keep a log of patients who have FOBT ordered.

This log will be collected monthly for six months and reviewed by the task to determine the amount of testing being done.

EVALUATION OF INTERVENTION PLAN A log of patients who undergo FOBT will

also be kept by the health department, which will be collected and reviewed.

A log will be kept at the free colon cancer screening to determine the number of participants.

EVALUATION OF INTERVENTION PLAN The ultimate measure of success in a

screening program is a demonstrable reduction in mortality in the screened population. However, this needs large numbers of individuals, and at least 10 years of assessment for most cancers (Siakora, 2011).

EVALUATION OF INTERVENTION PLAN It will take time to reveal the ultimate

effectiveness of the intervention plan (Siakora, 2011).

This campaign to increase community awareness about colon cancer and encourage participation in FOBT will be launched in March which is National Colon Cancer Awareness Month.

REFERENCESAmerican Cancer Society. (2012). American cancer society recommendations for colorectal cancer early detection. Retrieved from http://www.cancer.org/ cancer/colonandrectumColon cancer prevention; New findings from university college in the area of colon cancer prevention described. (2007, January). Clinical Oncology Week, 28, 282. Retrieved from http://proquest.umi.compqdlink?did=1188666061&Fmt

REFERENCESCommunity Preventive Services Task Force. (2012). Task force recommendations and findings. Retrieved from http://www.thecommunityguide.org/cancer/screen

Department of Health and Human Services Centers for Disease Control and Prevention. (2012). Cancer data by state. Retrieved from http://apps.nccd.gov/usc

REFERENCEGlittens, C. (2008, November). Limitations for colon cancer screening. Oncology Nursing News, 2(7), 24. Retrieved from http://rx9vhehy4rserialssolutions.comHuether, S. E., (2010). Pathophysiology the biologic basis for disease in adults and children. Alterations of digestive function (pp. 1452-1515).

REFERENCESJang, E., & Chung, D. C. (2010). Hereditary colon cancer: Lynch syndrome. Gut and Liver, 4(2), pp.151-160. doi: 10.5009/gnl. 2010.4.2.151Kentucky Cancer Registry. (Cartographer). (2012). Cancer Mortality Rates in Kentucky [Demographic map]. Retrieved from http://cancer_rates.info/common/new.html

REFERENCESKentucky Cancer Registry. (Cartographer). (2012). Cancer Incidence Rates in Kentucky [Demographic map]. Retrieved from http://cancer_rates.info/ky/index.phpNational Cancer Institute. (Cartographer). (2012). Surveillance epidemiology and end results [Demographic chart]. Retrieved from http://seer.cancer.gov/statistics

REFERENCESNational Comprehensive Cancer Network Version 2012. (2012). Colorectal cancer screening. Retrieved from http://www.nccn.org/professionals/physicians_gls/

Screening for Colorectal Cancer: U.S. Preventive Services Task Force Recommendation Statement. (2008, November). Annals of Internal Medicine, 149(9), 627-637. Retrieved from http://rx9vh3hy4r.search.serialssolutions.com

REFERENCES Sikora, K. (2011). Cancer screening.

Medicine, 40(1), pp. 24-28. Retrieved from http://liberty.summon.serialssolutions.com.ez