Our next speaker is Dr. Jennifer Christie, who is a professor of medicine at Emory. She's a clinical director at the Emory Clinic, and she's the current vice president of the American Society for Gastrointestinal Endoscopy. Her presentation pertains to screening and surveillance for colon cancer in 2021 and beyond. Thank you, Jennifer. Okay. Good morning, everyone. It is really a pleasure to be here in person with all of you. I don't know about you, but it's my first meeting in person in almost two years. So congratulations to the course directors and the course organizers and ACG as well as ASGE for putting this together. So these are my disclosures, mostly related to my research support. So our four major objectives in the next 20 minutes are number one, to understand the current state of colorectal cancer incidence and mortality in the United States today. Number two, discuss some of the racial and ethnic disparities in screening and outcomes. And then three, to discuss the effectiveness of the various screening modalities that we have available to us. And then lastly, to review some of the current guidelines and rationale for starting and stopping screening for colorectal cancer, specifically in average risk individuals. So fortunately, colorectal cancer incidence and mortality has been on the decline in recent years. And this is largely due to the work that our primary care doctors are doing and certainly to you for all the work that you're doing to get these patients screened. However, colorectal cancer is still the third leading cause of cancer-related deaths in the United States. And unfortunately, about 150,000 people will be diagnosed with colon cancer this year. And approximately 53,000 people will die from colorectal cancer in 2021. And the alarming fact is that 10.5% of these patients will be younger than the age of 50. And that represents a 15% increase from 2002 to 2016. So as mentioned, the overall rates are declining. However, there are differences as it relates to race and ethnicity. And Dr. May eloquently outlined to us many of the barriers that could be responsible for this. African-Americans or blacks, as well as American Indian and Alaskan Natives have the highest incidence as well as death from colorectal cancer. And Hispanic populations actually have the lowest incidence and death rate, and certainly the lower screening rates as well. And we really need to figure out how to improve the screening rates in all groups. So the overall recommendations for colon cancer screening for average risk individuals have changed over recent years. And several society and task force guidelines have outlined some of these changes. In 2018, the American Cancer Society used some modeling data to suggest that we should start to screen people starting at age 45 through 75 for colon cancer. And again, that's because of some of the epidemiological trends that we're seeing in terms of early onset colorectal cancer. As far as individuals age 76 to 85, it's a maybe. And it's going to determine, be determined by some of the patient preferences, comorbidities, and we'll discuss some of the data around that in a little bit. And certainly for individuals after the age of 85, there is a minimal to no benefit, but rather increased risk. And so we really should stop screening average risk individuals who are asymptomatic after the age of 85. And then very recently, these recommendations came out in May of 2021. The USPSTF also recommended that we start screening average risk individuals at age 45. And this was based on a large systematic review from multiple studies that they reviewed. And they concluded with moderate certainty that starting screening at age 45 has a modest benefit. And so that came with a grade B recommendation. And then of course, for individuals age 50 to 75, they concluded with high certainty that screening these individuals has a substantial benefit. And so that comes with a grade A recommendation. For patients age 76 to 85, it showed that it may have a small benefit, again, depending on preferences, comorbidities, and any prior screening history, that it may have a very small benefit and it's really going to be variable. And so what does that mean? We've got A, B, C, D, E, and F. Bottom line is that if someone comes into your office age 45 and wants to be screened, has access to screening, then certainly I think we would all agree that we would just do it. And I don't know about you, I'm starting to see more of these individuals coming into the endoscopy suite, which really I'm quite delighted about. And people are starting to get the message and starting to heed it. But certainly in patients age 76 to 85, it may be a little bit more nuanced. And so we have to have these conversations with our patients. So the American Cancer Society recommendations, if you go on their website, you'll see that they suggest many different options for patients to obtain screening. And as was mentioned, it's divided into stool-based tests as well as the visual tests. The stool-based tests tend to be less costly, easier to do. They can do it at home. But of course, it comes with some downside in that if it comes back positive, that patient will have to have a colonoscopy. As far as how do we approach these patients with all of these options, that can get a little bit tricky. But in 2017, I thought it was a very important recommendation that the US Multi-Society Task Force recommended thinking about either using a multiple option approach in which you give patients at least two options for screening. And then this may increase their likelihood to do at least one of them. So there's some data to support that the multi-option approach actually does improve the uptake of screening. But some data does not support that. So it's variable. The second approach is the preferred approach in which you give a patient an option to have a colonoscopy. But if he or she says, nope, not doing that, doc, don't have the time, can't get off work, again, some of the things we talked about earlier, then you offer them another test that may be less invasive. And they may be likely to go with that particular test. And then, of course, you have the risk stratified approach in which you try to predict whether a patient has a high likelihood of having a high-risk lesion, either an advanced polyp or colorectal cancer, and you want to offer colonoscopy in those patients. And then patients who have a low risk, you may want to offer another test. However, this is difficult to make those predictions, because I'm sure we've all seen this, that you've had a patient, you think it's going to be a routine screening exam, and then boom, you see a colon cancer in the rectum or in the distal colon in a 47-year-old, and that could be quite alarming. But these are different approaches in which you can address this. But what is most important is that the patient, nonetheless, has the information. Not only the patient, but also the primary care providers who are oftentimes sending these patients to us and having these conversations before we're able to do so. And so this data reflects the review done by Asma Shoukat and her team, their recent ACG recommendations as it relates to colon cancer screening, as well as data from the Kaiser group. They did a systematic review as well, which helped to inform the USPSTF guidelines. And what I want to highlight for you is that for the multi-targeted stool DNA test, the sensitivity is pretty good. And however, we don't have information as it relates to any impact on CRC incidence or mortality. Same thing for CT colonoscopy. It's very good to detect colorectal cancer, not so good to detect flat lesions or sessile serrated adenomas that we know are advanced lesions that could lead to colon cancer. So that may be a particular downside for this test. And also, we don't have the information as it relates to overall CRC incidence and mortality. As far as this serum septin-9 test, this is the first blood-based screening test for colorectal cancer that has been approved by the FDA. As you can see, the sensitivity is about 48%, although there's some differing or improved iterations of this test that has raised that sensitivity, but that data is still out. And then also, we just need more long-term and comparative effectiveness data to really be able to understand how it compares to colonoscopy. As far as colonoscopy, this data is based on two large cohort studies, and we know that the performance for colorectal cancer is really good, somewhere between 90% and 100%. And then colonoscopy with polypectomy, we know that it decreases the overall CRC incidence by 53%, so very effective. It also has been shown to decrease mortality. So we have to have a conversation about what are the harms of the various screening modalities. So of course, with the stool-based tests, they're not invasive, they tend to be less costly. However, there may be a certain degree of anxiety that comes with them. So if you have a patient that has a positive stool-based test, that patient, as I mentioned, does have to follow up with colonoscopy. And then if that colonoscopy is negative, what do we do? Do we do an upper endoscopy? Do we do a CT scan? Do we do another colonoscopy in a year? Well, most of the recommendations in the USPSTF guidelines say don't do any of that. They just continue to follow the patient, particularly if they're asymptomatic. But that is something that we have to be concerned about, and then patients are asking questions about that as well. Colonoscopy, again, highly sensitive, highly specific. But because of its invasiveness, it does come with potential complications. Bleeding an 8 out of 10,000, particularly with polypectomy, and perforation, 4 out of 10,000, that goes up a little higher in our older population, which we'll talk about in a little bit. And then also the bowel prep. These patients have to make sure that we give the right prep to the right patient because of the risk of electrolyte abnormalities, nephropathy, and other things that can happen as a complication of the bowel prep. And then the day off from work. Dr. May talked about that earlier. Not everyone can do that. And oftentimes their escort or their ride has to do the same, so that can be a disadvantage. As far as CT colonography, not invasive, but there is radiation exposure. The technology is improving, so we think that radiation risk is decreasing, but nonetheless, still the radiation exposure. And then you have what happens when you find, you know, a little benign cyst, you know, on the adrenal glands, or, you know, what do you do? And then the patient's anxious. How far do you go to work that up? So it can lead to additional costs. It can lead to additional tests and complications from those tests. So these are all things to consider with our patients and with the referring physician. So why does the USPSTF, say, start to screen at 45? Well, we know still the majority of patients diagnosed with colon cancer are over the age of 60, but we are starting to see trends where younger patients are developing early onset colorectal cancer. Again, it's not quite clear why that's happening, but we think that there's this birth cohort effect. So there's data to suggest that patients born around 1990 are actually twice as likely to have colon cancer than individuals born around the 1950s. So, you know, age is good in many ways. And four times as likely to have rectal cancer. And again, we're thinking that maybe obesity and Western diet may be playing a role. We're seeing that because many other countries and cultures around the world who may be adopting that Western diet are starting to see those increases as well. So to further support that downward shift in terms of when to begin screening, the epidemiologists at the American Cancer Society looked at data from the SEER program from 2016, as well as data from the National Cancer Health Statistics. And what they found, and they looked at colon cancer incidence and mortality between 1975 and 2014. And what they found is as far as incidence, it was higher in men. Fortunately, there was a decrease in colorectal cancer of 1.4% per year in individuals age 50 to 64. And then also a 4% decrease per year in patients over the age of 65. However, in patients in the 20 to 49 cohort, which is in this panel here, you can see that there is that 22% increase over time. Again, many of these lesions are in the distal colon and the rectum. And they saw this across most, or it's not all racial and ethnic groups. Actually they saw it to occur more at higher rates in non-Hispanic whites. So as far as mortality, again, we see this decrease in patients younger than the age of 50 over this period of time, but we see the increase in adults under the age of 50. So again, further supporting that downward shift. Namesh Vakil and the team in Wisconsin, they wanted to look at what factors are associated with this early onset colorectal cancer. And they looked at their cohort of patients in their integrated healthcare system. And specifically looking at patients age 18 to 49, what they found is that, yes, there was an increase in that population over a period of time. There was no difference in terms of mortality based on race in this group. But they did find that, at least in their cohort, that there was a higher proportion of African-American and Hispanic patients. Certainly patients with a family history were at greater risk, obesity was more prevalent in the younger patient, rectal location. They had advanced disease, and so they oftentimes required multimodality treatment with chemo or radiation surgery. But they actually did quite well with higher mortality rates in the older group. So again, why does the USPSTF say start screening at age 45? They looked at, again, this modeling data from the Cancer Intervention and Surveillance Modeling Network. And what they found is with all of these screening modalities, they looked at life years gained if you start screening at 45 as opposed to 50. And what they found is with all of the screening modalities, there was at least on average about a 25 years life years gain, with the highest being in colonoscopy. Again, this is assuming that these tests are done at the recommended interval. So that's also important. And that the quality of these tests were the highest, colonoscopy included. So it's important not to just do it, but make sure it's high quality and make sure it's done in a timely fashion. So when do we stop screening? So as I mentioned, the ACS recommends to certainly stop at the age of 75, of 85, excuse me. And then in patients age 75 to 79, you can think about it. It's a green stop sign. And again, some of this is based on the data that has been looked at in the past. So Garcia, Albenix, and colleagues, they looked at 20% of patients from a random Medicare sample to determine what is the improvement in terms of CRC incidence and mortality in this group. And what they found was that in patients age 70 to 74, the absolute risk reduction of doing elective colonoscopies in these patients was modest, was 0.42%. And certainly patients older than that, 75 to 79, it was even smaller. So again, not very beneficial in this group. Grossberg and colleagues looked at the risk of elective colonoscopy in patients over the age of 75 in their cohort. They looked at, they retrospectively analyzed 30,000 colonoscopies over a period of time. And they looked at the outcomes, ED visits within seven days of the procedure, as well as hospitalizations. And as you can see, in patients in the 76 to 85 age range, there was a significant jump in ED visits within seven days, and also hospitalizations. So how do we determine per patient who should have it? So sometimes when I scope that 74-year-old, and the patient is clear, and they look good, and I say, you know, Mr. Smith, you really are a healthy person. I don't think we need to do this again, because it's not likely you're going to have anything. And it depends. Some patients are happy. They're like, great. I don't want to do this again. Other patients feel offended sometimes. So get your script together, okay. How are you going to communicate this in a way that they understand why you're making the recommendation you're making? So these life expectancy tools can be helpful also. And this particular one is from the cancerscreening.com website. They look at age, comorbidities, functional status. However, they don't look at prior screening history or cancer risk. That's the only downside. And if it's less than 10 years of their life expectancy, then CRC screening is not likely to benefit them or change mortality at all. So at the end of the day, patient preference and values are important. You want to talk to your patient about the different types of tests that we talked about, and then assess where they are, right. So we talked about fear being a major factor for many patients, costs, what are the comorbidities, family or personal history, so that it allows for this shared decision making. So lastly, I quickly want to share the resources that we have on the ASGE value of colonoscopy website and the campaign that was initiated by our president, Doug Rex, and now co-chaired by Jonathan Cohen and Joe Vacari. But there are a lot of physician resources for patients. Oh, who's that? That's our president, Doug Rex. I think he's in the room. But a lot of videos as it relates to screening and information for both physicians and patients, just so that they have a better understanding about this choice. And I want to thank you for your time, and happy to take questions afterwards. Thank you.

colon cancer

screening

surveillance

racial disparities

screening guidelines

shared decision-making