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Physician Assistant Cancer Education

CANCER

COL O R E C TA L

Case-Based Series in Population-Oriented Prevention

Supported by a Grant Number 1 R25 CA10974301A2/05 from the National Cancer Institute

SCHOOL OF ALLIED HEALTH SCIENCES


ii BCM School of Allied Health Sciences - Physician Assistant Program

PACE Project Personnel J. David Holcomb, EdD, Principal Investigator Laurel R. Spence, MS, PA-C, Co-investigator Carl E. Fasser, PA, Project Coordinator Robert McLaughlin, PhD, Consulting Psychologist Module Authorship Laurel R. Spence, MS, PA-C Carl E. Fasser, PA

Funding Source This project was supported by a Grant Number 1 R25 CA109743-01A2/05 from the National Cancer Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute of the National Institutes of Health. Copyright Statement The following copyright information applies to the PACE project during all phases of curricula development and dissemination. Materials that remain under development, as well as curricula in the dissemination phase of the project are subject to copyright protection, as outlined below. The material in this curriculum may be used for educational purposes without restriction or permission. Electronic or print redistribu­tion for all non-profit purposes is permitted, provided this notice is attached in its entirety. Unauthorized, for-profit redistribution is prohibited. The BCM School of Allied Health Sciences requests that attribution of source be made when the material is used. Š School of Allied Health Sciences, Baylor College of Medicine, 2009.


Physician Assistant Cancer Education iii

PACE Diffusion Steering Committee Frank Ambriz, PA-C, Associate Professor and Director, Physician Assistant Program, University of the Texas-Pan American, Edinburg, Texas Carl Fasser, PA, Professor and Director, Physician Assistant Program, School of Allied Health Sciences, Baylor College of Medicine, Houston, Texas Venetia Orcutt, MBA, PA-C, Associate Professor and Director, Physician Assistant Program, University of Texas Southwestern Medical Center, Dallas, Texas Henry Lemke, M.M.S., PA-C, Professor and Director, Physician Assistant Program, University of North Texas Health Science Center, Fort Worth, Texas Edward Maxwell, PA-C, Associate Professor and Director, Physician Assistant Program, Texas Tech University Health Science Center, Midland, Texas Richard Rahr, EdD, Professor and Director, Physician Assistant Program, University of Texas Medical Branch at Galveston, Galveston, Texas Dennis Blessing, PhD, PA-C, Professor and Director, Physician Assistant Program, University of Texas Health Science Center in San Antonio, San Antonio, Texas James Somers, PhD, PA-C, Professor and Director, Physician Assistant Program, University of Nebraska Medical Center, Omaha, Nebraska

Physician Assistant Cancer Education Project Cancer Instructional Content Committee Maria Jibaja, EdD, Associate Professor, Baylor College of Medicine, Family & Community Medicine, Houston, Texas – Chair Robert Evans, PA-C, Physician Assistant, Department of Urology at MD Anderson Cancer Center, Houston, Texas Gilad Amiel, MD, Assistant Professor, Department of Urology, Baylor College of Medicine, Houston, Texas Cathy Montoya, MLS, Director, Education Resource Center, Baylor College of Medicine, Houston, Texas Maura Polansky, MS, PA-C, Director, PA Postgraduate Program on Oncology at MD Anderson Cancer Center, Houston, Texas Lorraine Potocki, MD, Associate Professor, Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas Lynn Yeoman, PhD, Professor, Department of Pharmacology, Baylor College of Medicine, Houston, Texas J. David Holcomb, EdD, Senior Vice President and Dean, School of Allied Health Sciences, Baylor College of Medicine, Houston, Texas (ex-officio)


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Table of Contents Section I: Frequently Asked Questions....................................................... 2 Why screen for colorectal cancer?.....................................................................................................................2 What are the risk factors for colorectal cancer?.............................................................................................2 How do adenomatous polyps progress to colorectal cancer?......................................................................3 What are the common symptoms of colorectal cancer? . ............................................................................3

Section II: Clinical Prevention and Epidemiologic Concepts......................... 3 Texas Cancer Plan.................................................................................................................................................3 Epidemiologic concepts.......................................................................................................................................4

Section III: Colorectal Cancer Screening Programs...................................... 5 What methods are utilized for colorectal cancer screening?.................................................5 Who issues colorectal cancer screening guidelines?.....................................................................................7 What are the current screening guidelines for colorectal cancer?..............................................................7

Section IV: National and Statewide Statistics............................................. 7 How successfully are colorectal cancer prevention guidelines translated into standard medical practice?..............................................................................................................................7 Texas Cancer Registry........................................................................................................................................10

Section V: Case Studies............................................................................ 11 Case 1: Increasing Joint Pain of One Week’s Duration and Hypertension ............................................11 Case 2: Prior Removal of Adenomatous Polyps . .........................................................................................11 Case 3: Insurance Physical Examination in Otherwise Healthy Adult....................................................12

Section VI: Counseling Patients Regarding Screening Outcomes............... 14 Assessing colorectal cancer risk.......................................................................................................................14 Referral and the next step..................................................................................................................................14

Section VII: Integration/Clinical Correlation............................................. 15 Section VIII: References........................................................................... 24


Physician Assistant Cancer Education 1

COLORECTAL CANCER MODULE

Case-based Series in Population-Oriented Prevention (CPOP)

Recommended Reading: 1. American Cancer Society. Detailed Guide: Colon and Rectum Cancer. What are the risk factors for colorectal cancer? American Cancer Society. March 7, 2006. Available at: http://www.cancer.org/docroot/CRI/content/CRI_2_4_2X_What_are_the_risk_ factors_for_colon_and_rectum_cancer.asp?sitearea= 2. American Cancer Society. Guidelines on screening and surveillance for the early detection of adenomatous polyps and colorectal cancer. American Cancer Society. 2001. Available at: http://www.cancer.org/docroot/PRO/content/PRO_1_1_ Colorectal_Cancer_Screening_Guidelines_2001.asp 3. U.S. Preventive Services Task Force (USPSTF). Recommendations and Rationale: Screening for Colorectal Cancer. U.S. Preventive Services Task Force. July 2002. Available at: http://www.ahrq.gov/clinic/3rduspstf/colorectal/colorr.htm

Objectives: Knowledge Competencies 1. Explain the importance of screening for colorectal cancer 2. Discuss the incidence, prevalence and mortality for colorectal cancer 3. Identify the importance of family history as a risk factor for colorectal cancer 4. List known diseases or conditions associated with increased incidence of colorectal cancer 5. Describe the procedures for conducting colorectal cancer screening 6. Discuss the role of epidemiologic factors in the development of cancer 7. Explain epidemiological terms and concepts utilized to evaluate screening tests and programs; to include: primary, secondary and tertiary prevention, incidence and prevalence of disease, reliability, accuracy, sensitivity, specificity, positive predictive value and negative predictive value of testing methods Skill Competencies 1. Elicit risk factors for colorectal cancer during interview 2. Perform a fecal occult blood test 3. Refer for colorectal screening based upon age and other risk factors 4. Make appropriate referrals for patients requiring specialized screening programs 5. Perform colorectal cancer risk assessment as part of routine medical practice 6. Counsel patients regarding the importance of screening to detect colorectal cancer 7. Advise patients regarding lifestyle behaviors that help prevent colorectal cancer 8. Identify the early symptoms of colorectal cancer


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Section I: Frequently Asked Questions Why screen for colorectal cancer? Cancer is the second leading cause of death both in the state of Texas and in the United States (U.S.), where the number of cancer-related deaths are only exceeded by deaths related to heart disease. An estimated 1.5 million new cancer cases are diagnosed in the U.S. on an annual basis. As the third most common cancer diagnosed in both men and women in the U.S., colorectal cancer is responsible for approximately 10% of cancer deaths annually. Notably, incidence rates of colorectal cancer have consistently decreased during the past twenty years due to improved screening procedures, protocols and improved adherence to such guidelines.1 In order to further reduce colorectal cancer incidence, morbidity and mortality rates, it is essential to further utilize and improve screening methods to successfully identify and remove adenomas, which are potential precursors to the disease. It is also essential to detect colorectal cancer at an early, localized stage, when the five-year survival rate is 90%. Nonetheless, only 39% of CRC cases are currently diagnosed while in the localized stage.1-4 These statistics support the assertion that “[t]he most powerful tool in the fight against cancer is prevention…”5

What are the risk factors for colorectal cancer? Several factors have shown themselves to be related to an increased risk of colorectal cancer. These factors include age, race, ethnic background, lifestyle, family history, inflammatory bowel disease, heredity, colorectal polyps, and previous colorectal cancer. • Previous colorectal cancer or adenomatous colorectal polyps - The chance of colorectal cancer recurrence is higher in patients whose initial colorectal cancer was diagnosed prior to age 60.6 Five categories of colorectal polyps have been identified. “Of these, the adenomatous polyp is the major precursor of colorectal cancer. The only type not directly related to the subsequent development of carcinoma is the purely hyperplastic polyp.”7 Therefore, adenomatous polyps are removed when found during endoscopy, especially if larger than 1 cm in size.3, 7-10 • Age - Over 90% of colorectal cancer cases are diagnosed in patients older than age 50.6 The prevalence of adenomatous polyps at age 50 is between 20% and 25%. The prevalence of adenomatous polyps increase to 50% between 75 and 80 years of age.3

• Inflammatory bowel disease (IBD) - IBD includes Crohn’s disease and ulcerative colitis. Patients with chronic IBD are at an increased risk of developing colorectal cancer, as precancerous changes may occur with chronic inflammation of the intestinal mucosa. “The risk of developing colorectal cancer is inversely correlated with the age of onset of the colitis but is directly correlated to the extent and duration of active disease.”11 When IBD affects a large extent of the colorectum (pancolitis), the risk for colorectal cancer increases approximately 8 years following the onset of symptoms. Patients with localized IBD (left-sided colitis) are at an increased risk for colorectal cancer between 12 and 15 years after onset of disease. 3, 6, 9-11 • Family history - Although the majority of colo­ rectal cancer cases occur in average risk patients, 20 to 30% of cases occur among patients with a family history of colorectal cancer in a first-degree relative.6, 12 A positive family history of colorectal cancer includes any first-degree relative with colorectal cancer detected prior to age 60 and/ or two or more first- or second-degree relatives (related to each other) with colorectal cancer. Most guidelines advocate screening patients with a positive family history of colorectal cancer beginning at either age 40 or ten years prior to the age of the earliest colorectal cancer diagnosis within the immediate family. 3, 6, 12, 13 • Hereditary syndromes - Two hereditary syndromes are responsible for 6% of colorectal cancer; Familial Adenomatous Polyposis (FAP) and Hereditary Non-polyposis Colorectal Cancer (HNPCC). 1. Familial adenomatous polyposis (FAP) due to the growth of hundreds of polyps in the colorectal area between the ages of 5 and 40 years of age in affected patients. FAP accounts for 1% of colorectal cancer (desmoid tumors).6, 14 Proliferative disorders in a patient with FAP may also include papillary carcinoma of the thyroid, epidermal cysts and mandibular osteomas.15 2. Hereditary non-polyposis colorectal cancer (HNPCC) is an inherited condition (also known as “Lynch Syndrome”) that leads to increased risk for colorectal cancer development at a young age. As the name of this syndrome suggests, these patients do not have extensive polyp development in the colon, unlike patients with FAP. In addition


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to a personal and familial increase in the incidence of colorectal cancer (accounts for 3 to 5% of all colorectal cancer cases), cancers of the endometrium, ovary, stomach, small bowel, kidney, ureters, pancreas and bile duct occur with a higher prevalence among those with HNPCC.6, 16, 17 •

Ethnic background: Ashkenazi Jews have the highest colorectal cancer risk of any ethnic group in the world. Several genetic mutations have been isolated within this group, although they only partially explain such increased colorectal cancer risk.6 Race: For reasons not yet understood, colorectal cancer case incidence and mortality rates are the highest among African Americans as compared with other racial groups within the U.S.6 Lifestyle factors: Physical inactivity and a diet high in animal fat and low in food from plant sources (such as fruits, vegetables, grains) may increase colorectal cancer risk. Patients who are overweight, have diabetes and/or are smokers may be at an increased of dying from colorectal cancer. Some sources have associated heavy alcohol use with colorectal cancer.6

How do adenomatous polyps progress to colorectal cancer? Adenomatous polyps are dysplastic lesions arising from normal colonic mucosa. These precancerous lesions may progress from low grade to high grade dysplasia.3, 8-10, 18 Once adenomatous polyps traverse the basement membrane and invade the submucosa of the colon, they are labeled as “invasive adenocarcinoma.” Increasing adenoma size, presence of a villous component within the adenoma and an increased patient age may be correlated with higher grade dysplasia and an increased risk for colorectal cancer.18-20

What are the common symptoms of colorectal cancer? As many cases of colorectal cancer remain asymp­to­ matic until the disease has progressed to an advanced stage, the screening of asymptomatic patients according to evidence-based guidelines for colorectal cancer is of vital importance. Although the clinical presentation of colorectal cancer may be quite variable, the following symptoms may indicate colorectal cancer:16, 17, 21-23 • Diarrhea, constipation, or other change in bowel habits • Blood in the stool (melena or hematochezia)

• Unexplained anemia • Abdominal pain and tenderness in the lower • • • • • •

abdomen Intestinal obstruction Unexplained/unintentional weight loss Narrow stools Mucous discharge Sensation of a lump in the rectum Feeling that the bowel is not completely emptied after a bowel movement

Section II: Clinical Prevention and Epidemiologic Concepts Texas Cancer Plan Established in 1985, the Texas Cancer Council is charged with the responsibility for developing and implementing the Texas Cancer Plan, a “statewide blueprint for cancer prevention and control in Texas… [that] provides a planned, evidence-based approach to reducing the impact of cancer on Texans.” Significant among the five comprehensive goals are: 1) Prevention information and services; 2) Early detection and treatment; and 3) Professional education and practice. The concepts of primary, secondary and tertiary prevention form the basis for the first two goals of the Texas Cancer Plan, which may be accessed online at http://www.tcc.state. tx.us/pdfs/texascancerplan2005.pdf.24 Primary prevention focuses upon the reduction, or control, of the known modifiable risk factors for a targeted disease process (Table 1). This prevention strategy is the most cost-effective form of health care. TABLE 1. Primary Prevention for Colorectal Cancer21 Healthy Diet 1. Restrict caloric intake (men: <2500 kcal/day; women: <2000 kcal/day) 2. Reduce dietary fat (<25% of total calories as fat) 3. Eat ≥ five servings of vegetables and fruit per day 4. Consume poorly soluble cereal fiber (e.g. wheat bran), especially if at high risk for CRC 5. Ensure a dietary calcium intake of 1000–1200 mg per day Healthy Lifestyle 1. Participate in regular physical activity 2. Restrict alcohol intake 3. Do not smoke


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The goals of primary prevention are to avoid the suffering, cost and burden associated with disease, prior to its occurrence.21, 22, 24-30

TABLE 2. Epidemiologic Concepts [derived from30]

Disease Present

Disease Absent

Predictive Value

a

b

PPV

(True Positive)

(False Positive)

[a ÷ (a + b) x 100]

c

d

NPV

(False Negative)

(True Negative)

[d ÷ (c + d) x 100]

Sensitivity

Specificity

[a ÷ (a + c) x 100]

[d ÷ (b + d) x 100]

Positive Test Result

Secondary prevention methods screen the asymptomatic popu­ Negative lation to identify individuals Test Result who: 1) Are at an increased risk for developing disease; 2) Have precursor lesions that may progress to the disease state when untreated; 3) Have evidence of early disease. Thus, evidence-based screening recommendations and programs are secondary prevention strategies.21, 22, 24-30

Tertiary prevention involves the treatment and support of patients who are symptomatic for disease, such as cancer, to minimize disease-related complications and to promote rehabilitation.21, 22, 24-30 As cancer care moves more from the acute care realm to the chronic care medical model, tertiary prevention is increasingly relevant. Approximately 10.5 million Americans reported a personal history of cancer when surveyed in January 2003.1 Furthermore, some estimates state, “…one of every six people over [age] 65 is a cancer survivor.”25, 26

Epidemiologic concepts As the focus of this learning module is risk assessment and management, additional relevant terminology must be defined.

• Accuracy of a testing method may be described

by its sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Sensitivity and specificity are independent of the disease prevalence within the population screened by the test; whereas the terms positive predictive value (PPV) and negative predictive value (NPV) are dependent upon the disease prevalence within the population screened by the test.30

• Sensitivity - A test is considered sensitive when it identifies more true positives than false negatives. In other words, out of the pool of patients screened for a particular disease, more patients with disease will test positive for the disease (true positives) as compared with patients who have disease and test negative for the disease (false negatives). Using Table 2 below, the sensitivity of a test may be calculated utilizing the equation [a ÷ (a + c) x 100].30

• Incidence is the number of times over a specified

• Specificity - A test with high specificity will correctly identify patients without disease as negative for the disease (true negative) rather than identifying patients who do not have disease as positive for the disease (false positive). Specificity may be determined by the equation [d ÷ (b + d) x 100], utilizing Table 2.30

• Prevalence refers to the number of disease cases

• Positive predictive value (PPV) is determined by the proportion of patients who test positive that actually have the disease. PPV allows a practitioner to determine the probability of patients that test positive on screening tests that do have the disease (true positives) versus patients testing positive on the test who do not have the disease (false positive). PPV may be calculated using Table 2 and the equation [a ÷ (a + b) x 100].30

time period that a disease occurs within a given population.30 This term applies to new disease cases. For example, the number of new colorectal cancer cases diagnosed within the year 2006 in the U.S. would be appropriately referred to as the 2006 incidence of colorectal cancer in the U.S. present within a population at a specific point in time.30 This term refers to total CRC cases, both newly diagnosed and formerly diagnosed cases, within the time frame utilized. In other words, the approxi­mate number of individuals with colorectal cancer within the U.S. during the year 2006 is the prevalence of colorectal cancer in the U.S. during 2006.


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Negative predictive value (NPV) is essentially the opposite of PPV. NPV is determined by the proportion of patients who test negative that truly do not have the disease. Therefore, NPV is based upon the probability of patients that test negative on screening tests do not have the disease (true negatives) versus patients testing negative on the test who actually do have the disease (false positive). NPV may be determined by the equation [d ÷ (c + d) x 100] using Table 2.30

TABLE 3. Criteria for Evaluating a Screening Test27, 28 Considerations about the disease for which to be screened 1. The disease must have an asymptomatic state and progress to a symptomatic state 2. The disease must be sufficiently prevalent in the population 3. The disease must cause significant morbidity and mortality 4. Treatments must be available that will beneficially affect morbidity and mortality Considerations about the tests for the disease 1. The screening test must be a “good” test (Determined by sensitivity, specificity, positive and negative predictive value of the test) 2. The evaluation of the screening program must avoid the common significant biases 3. The screening test must be cost-effective Considerations about the patient(s) to be screened 1. The screening test must be acceptable to the patient 2. The patient must have sufficient life expectancy to derive benefit from the potential life gained by the screening program

SECTION III: Colorectal Cancer Screening Programs What methods are utilized for colorectal cancer screening? 8, 9, 31-39 Colorectal cancer screening methods include fecal occult blood (FOBT), flexible sigmoidoscopy (Flex Sig), colonoscopy, and double contrast barium enema (DCBE). Other diagnostic studies include virtual colonoscopy using CT and stool DNA testing.

• Fecal occult blood testing (FOBT)8, 9, 32, 34 – Procedure: The patient collects six stool samples total (two samples from each of three consecutive stools at home) and returns cards for either guaic (most common) or immunochemical (less common, must be processed in lab) testing for blood in the stool. This test may be combined with sigmoidoscopy (every five years) – see agency recommendations. The information below refers to FOBT alone. – Frequency of testing: Every one to two years, depending upon the protocol.7-8 – Adenoma detection: Sensitivity: 4-89%; specificity: 62-98% – CRC detection: Sensitivity: 20-100%; specificity: 63-100% – Approximate cost: $10-$25 – Advantage/Benefits: This process is more sensitive than a single “in office” test obtained by a digital rectal examination (DRE) for multiple reasons: 1) Colonic neoplasms often bleed intermittently; 2) Blood is often not present throughout the entire stool; 3) Blood may be attributed to hemorrhoids and/or trauma imposed by the practitioner during a DRE. – Disadvantage/Risks: Dietary restrictions are required: 1) Avoid non-steroidal antiinflammatory drugs (NSAIDS) for seven days prior to testing; 2) Avoid vitamin C from supplements or citrus fruits and juices for three days prior to testing; 3) Avoid red meats for three days prior to testing. – Follow-up: A positive home-FOBT result (1 or more test windows positive) requires a diagnostic examination with colonoscopy. If a positive FOBT is followed by a negative colonoscopy, FOBT can be suspended for at least 5 years. • Flexible sigmoidoscopy (flex sig)8, 9, 32, 34, 35 – Procedure: The provider uses a flexible 60cm endoscope to directly visualize the distal portion of the colorectum to the splenic flexure. – Frequency of testing: Every 5 years – Adenoma detection: Within reach of the sigmoidocope - sensitivity: 33-78%; specificity: 84% – CRC detection: Within reach of the sigmoid­ ocope - sensitivity: 67-90%, specificity: 85-95%


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– Approximate cost: $150-$400 (lower cost for screening sigmoidoscopy only; higher cost for sigmoidoscopy with polypectomy) Advantage/Benefits: Does not require sedation – Disadvantage/Risks: 1) Bowel cleansing (via enema(s) the morning of the test) is required of the descending and sigmoid colon and rectum; 2) Visualizes the distal portion of the colorectum only—may miss lesions in the proximal colon (estimated to occur in 1-2 % of patients; 3) Risk of bowel perforation. – Follow-up: If a screening examination detects cancer, large adenomatous polyps (greater than 1 cm), sessile polyps, or carcinoma in situ, a colonoscopy is then performed. If no polyps are found, the sigmoidoscopy is repeated in 5 years. • Combination FOBT/flex sig8, 9, 32, 34, 36 – Procedure: (See individual descriptions above) – Frequency of testing: Annual FOBT combined with a flex sig every 5 years – Adenoma detection: Perhaps a 5% improvement in sensitivity when FOBT is combined with flex sig over the use of Flex Sig alone – CRC detection – Unclear whether the combined protocol significantly improves the detection of proximal colonic lesions – Approximate cost: $200-$525 (five-year estimate; derived by combining estimates for each testing method alone) – Advantage/Benefits: Does not require sedation – Disadvantage/Risks: 1) Bowel cleansing (via enema(s) the morning of the test) is required of the descending and sigmoid colon and rectum; 2) Visualizes the distal portion of the colorectum only—questionable whether addition of FOBT improves the detection of lesions within the proximal colon; 3) Risk of bowel perforation. – Follow-up: Either a positive home-FOBT result, or visual detection of cancer, large adenomatous polyps (greater than 1 cm), sessile polyps, or carcinoma in situ during sigmoidoscopy, leads to follow up examination with colonoscopy. • Colonoscopy8, 9, 31-38 – Procedure: The provider directly visualizes the entire colorectum (to the cecum) using a colonoscope. Procedure lasts 20 to 40 minutes. – Frequency of testing: Every 5 to 10 years depending upon patient risk factors and screening protocol.

– Adenoma detection: Sensitivity: 75-100%; Specificity: 90-98% – CRC detection: Sensitivity: 79-100%; Specificity: 90-96% – Approximate cost: $600-$1600 (lower cost for screening colonoscopy only; higher cost for colonoscopy with polypectomy) – Advantage/Benefits: Most sensitive of the screening methods. Considered the “gold standard.”38 Allows for the biopsy and removal of polyps at the time of the screening examination. – Disadvantage/Risks: Typically performed with conscious sedation and a full bowel prep (requiring that patients drink several liters of nonabsorbable laxative the night before the test or use a powerful laxative). Patients need to have someone accompany them to the examination and drive them home. They are unable to return to work the same day, and some may miss a second day of work.37 – Follow-up: Determined by findings during screening and by the pathology results from any polyps removed. If cancer is detected, further assessment and treatment can be pursued. If negative, may repeat colonoscopy in 5 to 10 years depending upon protocol. • Double Contrast Barium Enema (DCBE)2, 8, 9, 32, 34, 39 – Procedure: A radiologic examination of the entire colorectum by instilling barium and air to define contours of the colorectal mucosa.39 The examination takes 20 to 40 minutes. – Frequency of testing: Every 5 years. – Adenoma detection: Sensitivity: 48-100%; specificity: 67-100% – CRC detection: Sensitivity: 62-100%; specificity: 90-100% – Approximate cost: $250-$500 – Advantage/Benefits: No sedation is used. A relatively non-invasive procedure. – Disadvantage/Risks: Less sensitive than colonoscopy for visualizing adenomas and neoplasms smaller than 1 cm.2 Bowel prep involves a laxative the night before the examination, a clear liquid diet, and 1 or 2 enemas the morning of the test. – Follow-up: If the test is positive, a colonoscopy is performed; if it is negative, it is repeated in 5 years.


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Additional (“investigational”) testing methods32 1. Virtual colonoscopy: Images from a spiral CT are arranged to create “3-D” simulated images of the lumen of the colon and rectum. Bowel prep, as prescribed for colonoscopy utilizing an endoscope, is necessary for a virtual colonoscopy examination, as well. In addition to the considerable expense of this procedure, a colonoscopy must be completed for removal of any polyps detected by virtual colonoscopy. More research is needed regarding the use of this technology. 2. Stool DNA testing: This process involves the isolation of human DNA from stool and performing an assay to identify a number of potential mutational targets that may be associated with malignancy. The utility and acceptability of this testing is still under investigation. The stool DNA testing currently available is expensive (approximately $800) and requires the patient to collect an entire bowel movement, rather than sampling bowel movements on FOBT cards.

Who issues the colorectal cancer screening guidelines? Many agencies publish prevention and screening guidelines, the specific details of which may vary and, perhaps, contradict each other. As a result, healthcare providers and organizations must decide which guidelines to follow. In addition to the agencies listed below, various specialty organizations have put forth recommendations regarding colorectal cancer screening in both average and high risk patients (such as the American Society for Gastrointestinal Endoscopy (ASGE), the American Gastroenterology Association (AGA) and the American College of Gastroenterology (ACG)). The United States Prevention Task Force (USPSTF), sponsored by the Agency for Healthcare Research and Quality (AHRQ), is an “independent panel of private-sector experts in prevention and primary care…” that reviews and evaluates epidemiologic data and guidelines from other agencies and organizations within the U.S. to reach a consensus regarding the “preventive services [that] should be incorporated routinely into primary medical care.” The panel uses a population-based model as the basis for its prevention recommendations.8, 9, 40 The American Cancer Society (ACS) is “a nationwide, community-based voluntary health organization

dedicated to eliminating cancer as a major health problem by preventing cancer, saving lives, and diminishing suffering from cancer, through research, education, advocacy, and service…In addition to cancer prevention, the Society focuses on a variety of early detection programs and encourages regular medical checkups and recommended cancer screenings.”41 The National Comprehensive Cancer Network (NCCN) is “a not-for-profit alliance of 20 of the world’s leading cancer centers…dedicated to improving the quality and effectiveness of care provided to patients with cancer…[that] promotes the importance of continuous quality improvement and recognizes the significance of creating clinical practice guidelines appropriate for use by patients, clinicians, and other health care decision-makers.”42 The National Health and Medical Research Council (NHMRC) is an Australian group that recently instituted a national colorectal cancer populationbased screening initiative for the entire Australian population.22 NHMRC recommendations are included as a comparison to those issued within the U.S.

What are the current screening guidelines for colorectal cancer? The tables below summarize the recommendations for colorectal cancer screening and surveillance from USPSTF8, 9, ACS41, NCCN42 and NHMRC22. Table 4 reviews screening guidelines for average risk patients, while Table 5 focuses upon CRC surveillance guidelines for high risk patients. Further details may be found in the publications of each organization.8, 9, 22, 41, 42

Section IV: Nationwide Statistics How successfully are colorectal cancer prevention guidelines translated into standard medical practice? According to national screening trends and reports on the status of cancer prevention within the U.S., “the extent to which screening programs are adopted by the population” and to which established screening modalities are disseminated and integrated into clinical and community practice “influences incidence, survival and mortality.”43, 44 Healthcare providers must possess a working knowledge of the most current recommendations to promote early detection and treatment of premalignant and malignant lesions of the colon and rectum as an advocate for patient health.


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TABLE 4. CRC Screening Recommendations for AVERAGE RISK Patients • Age ≥ 50 years of age • Negative family history of CRC • Negative personal history of adenoma and IBD USPSTF8,9 ACS41 NCCN42 Preferred No method No method Colonoscopy screening method preferred preferred q 10 yrs

NHMRC42 FOBT + Flex Sig FOBT q two yrs/flex sig q 5 yrs

Other options and recommendations

Colonoscopy q 10 yrs for symptomatic patients

FOBT q 1 yr Flex Sig q 5 yrs (± FOBT) Colonoscopy q 10 yrs DCBE q 5 yrs

FOBT + Flex Sig FOBT q 1yr/flex sig q 5 yrs Colonoscopy q 10 yrs DCBE q 5 yrs

FOBT + Flex Sig FOBT q 1yr/flex sig q 5 yrs DCBE q 5 yrs

KEY: USPSTF, United States Preventive Services Task Force; ACS, American Cancer Society; NCCN, National Comprehensive Cancer Network (U.S.); NHMRC, National Health and Medical Research Council (Australia); FOBT, Fecal Occult Blood Testing; Flex Sig, Flexible Sigmoidoscopy; DCBE, Double Contrast Barium Enema; IBD, Inflammatory Bowel Disease; CRC, Colorectal Cancer

TABLE 5. CRC Screening Recommendations for HIGH RISK Patients • Family history of CRC • Hereditary syndrome (FAP or HNPCC) • Personal history of adenoma/CRC, endometrial/ovarian cancer (< 60 yrs) and IBD Family history CRC

ACS (41) Colonoscopy q 5 to 10 yrs beginning at 40 yrs OR 10 yrs prior to earliest family diagnosis

NCCN (42) Colonoscopy** q 1 to 5 yrs beginning at 40 yrs OR 10 yrs prior to earliest family diagnosis

NHMRC (22) Colonoscopy q 5 yrs beginning at 50 yrs OR 10 yrs prior to earliest family diagnosis

Hereditary Endoscopy beginning at Endoscopy + syndrome: FAP puberty + genetic testing; polypectomy q 1 yr beginning total colectomy in teens + genetic testing; total colectomy Hereditary Colonoscopy q 1 to 2 yrs Colonoscopy q 1 to 2 yrs syndrome: beginning at age 21; q 1 yr beginning at age 20 to 25 yrs HNPCC beginning ≥ age 40 years + OR 10 yrs prior to earliest genetic testing family diagnosis; screen for assoc. malignancy

Endoscopy + polypectomy beginning age 12 to 15 + genetic testing; total colectomy

Prior CRC or Colonoscopy 1 yr after adenoma resection (if applies), then removal q 3 to 5 yrs Endometrial or No recommendations given ovarian cancer < 60 yrs

Colonoscopy** 1 yr after resection (if applies), then q 3 to 5 yrs

No recommendations given

Colonoscopy** q 5 yrs beginning at 40 yrs OR at diagnosis

No recommendations given

IBD Colonoscopy + biopsy q 1 to 2 yrs

Colonoscopy** q 1 to 2 yrs No recommendations given beginning 8 to 10 yrs following symptom onset

Colonoscopy q 1 to 2 yrs beginning at age 25 OR 5 yrs prior to earliest family diagnosis + genetic testing; screen for assoc. malignancy

NOTE: ** indicates preferred method, per agency; USPSTF defers to ACS guidelines for high risk patients, as USPSTF only considers average risk population screening KEY: USPSTF, United States Preventive Services Task Force; ACS, American Cancer Society; NCCN, National Comprehensive Cancer Network (U.S.); NHMRC, National Health and Medical Research Council (Australia); FOBT, Fecal Occult Blood Testing; Flex Sig, Flexible Sigmoidoscopy; DCBE, Double Contrast Barium Enema; CRC, Colorectal Cancer; FAP, Familial Adenomatous Polyposis; HNPCC, Hereditary NonPolyposis Colorectal Cancer Syndrome; IBD, Inflammatory Bowel Disease; CRC, Colorectal Cancer


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TABLE 6. 2006 NHIS Colorectal Cancer Screening Prevalence Rates Among US Adults (≥ 50 Years) Screening Test Flex Sig -OR Colonoscopy (prior 10 years)

FOBT (prior year)

Age Group All Aged Aged 50-64 Years Aged 65+ 50+ Years Years Insured Uninsured Insured

Race and Ethnicity White, Black, Other Non- Non- Race, Hispanic Hispanic Non- Hispanic

Hispanic (Latino)

56%

53%

25%

61%

58%

54%

49%

43%

16%

14%

8%

20%

17%

17%

17%

13%

54%

47%

FOBT (prior year) 60% 57% 29% 65% 62% 58% -OR Endoscopy (prior 10 years) KEY: NHIS, National Health Interview Survey; FOBT, Fecal Occult Blood Testing; Flex Sig, Flexible Sigmoidoscopy. Modified from Smith et al.43

Preventive medicine guideline updates are available in a variety of formats to allow healthcare providers to remain current with screening recommendations. Furthermore, the general public requires a basic awareness and acceptance of the concept that routine preventive healthcare visits are an essential component to preserving ones overall health and wellness. Media campaigns and public health initiatives have emphasized the need for routine colorectal cancer screening and have, thus, increased the collective understanding regarding the disease and the importance of early detection.43, 44 Despite efforts to increase cancer screening among average risk patients, preventive services and cancer screening remain underutilized within the U.S. According to recent reports, “…access to health care remains an important barrier to cancer control and influences cancer prevention, treatment and survival outcomes.” While numerous factors contribute to this issue, patients with “structural supports” in place, such as those with health insurance and those with an established relationship with a primary healthcare provider, obtain screening at higher rates compared with those who do not have such support.43 Barriers to routine cancer screening appear to vary among racial, ethnic, cultural and socioeconomic groups within the U.S.45 For over fifty years, the

National Center for Health Statistics has conducted a nationwide household interview survey focused upon a variety of health conditions, the National Health Interview Survey (NHIS), in an attempt to estimate the overall health status of Americans, to track preventive screening trends, and to determine access to healthcare among the various populations and regions of the country.43 According to researchers, the “actual prevalence of [cancer screening] tests is most likely lower than reported by [the] survey,” as it is limited by the self-report of participants.”44 Another limitation of the NHIS survey is that data was initially stratified into two broadly defined race/ethnic groups, “Black” and “White,” until approximately ten years ago when “Hispanic” was added as a race/ethnic classification. As such, the most current NHIS results are estimated for non-Hispanic Whites, non-Hispanic Blacks, Hispanics, and “other race, non-Hispanic.” Furthermore, an “insufficient sample size precludes the estimation of reliable cancer screening estimates for other ethnic groups.”43 See Table 6 above for 2006 NHIS data for colorectal cancer screening. The Hispanic population has traditionally been less likely to receive colorectal cancer screening as compared with non-Hispanic race/ethnic groups. However, recent NHIS data have revealed an improvement in cancer screening rates among Hispanic groups. Many advocate for further


10 BCM School of Allied Health Sciences - Physician Assistant Program

stratification of race/ethnic groups when comparing variables among groups. Broad groupings of race/ ethnicity may “be obscuring important differences in more specific populations.” For example, “Hispanic/ Latinos in the US are a heterogenous population with different countries of origin and immigration histories…”, and Hispanic subgroups differ on cultural, socioeconomic, and health-related systems barriers that influence their receipt of preventive services, including cancer screening.”43, 44

Texas Cancer Registry47 Colorectal cancer screening, incidence and mortality rates vary across states. Such differences “may be attributable to factors such as demographic characteristics [age, urbanization, race and ethnicity], risk factor prevalence, and variations in cancer registration operations…”44 Therefore, it is important for healthcare providers to be familiar with cancer statistics for the state, region and county in which he or she practices preventive medicine. The mission of the Texas Cancer Registry is “to contribute significantly to the knowledge of cancer for use in reducing the cancer burden in Texas.” The

three primary goals of the Texas Cancer Registry (TCR) are to: 1) Collect cancer data and maintain a quality statewide population-based cancer registry with complete, timely and accurate data; 2) Achieve and maintain recognition as a nationally certified cancer registry; 3) Meet the data needs of Texas healthcare practitioners, cancer researchers, health planners, the public and other state and national entities. The TCR offers online access to select cancer incidence and mortality data for the state of Texas, for Texas counties with a population of at least 100,000, and for the eleven “Health Service Regions” located in Texas. (http://www.dshs.state.tx.us/tcr/default.shtm) Selected Cancer Fact Sheets47 to review include: 1. The State of Texas (2 pages) http://www.dshs.state.tx.us/tcr/publications/ files/2007fact-Texas.pdf 2. Harris County (2 pages) http://www.dshs.state. tx.us/tcr/publications/files/CountyFactsSheets/200 7/2007ctyfact-Harris.pdf 3. Texas Health Service Region 6 (2 pages) http:// www.dshs.state.tx.us/tcr/publications/files/ RegionalFactsSheets/2007regfact-HSR06.pdf


Physician Assistant Cancer Education 11

SECTION V: Case Studies CP, a 53-year-old Asian man with a history of hypertension, presents complaining of “increasing join pain” for one-week in duration. The patient CASE #1 denies change in bowel habits, denies a change in stool size/color/consistency, denies hematochezia, melena, hemorrhoids, abdominal pain and food intolerance; no prior colorectal cancer screening. BMI is 22 (ht 5’7”/wt. 140), diet consists of fruits, vegetables, fish and occasional red meat; daily exercise of walking 30-45 minutes daily. Denies history of smoking, alcohol abuse and illicit drug use. Family history is positive for hypertension, coronary artery disease, diabetes mellitus and prostate cancer. Family history is negative for colorectal cancer or inflammatory bowel disease. Select the letter corresponding to your answer for the following multiple-choice questions, based upon your current risk assessment practice standards and understanding of current cancer screening guidelines. 1. Classify this patient’s risk for colorectal cancer: A. Average risk B. High risk C. Insufficient information 2. Which variables below increase this patient’s risk for colorectal cancer? (select all that apply) A. Adherence to screening guidelines B. Adenomatous colorectal polyps C. Alcohol and tobacco use history D. Body mass index E. Diet/exercise habits F. Education level G. Ethnicity/race H. Family history I. Gender J. Inflammatory bowel disease K. Patient age L. Religious beliefs M. Socioeconomic status

3. Which screening test(s), if any, would you recommend for this patient? (select all that apply) A. Colonoscopy B. Fecal occult blood test C. Sigmoidoscopy D. None indicated at this time 4. Would you refer this patient for genetic counseling and testing? A. Yes B. No C. Unsure DL, a 65-year-old Hispanic woman with a personal history of ovarian cancer 8 years ago, status post bilateral salpingo-ophorectomy and CASE #2 chemotherapy, depression and anxiety, irritable bowel syndrome, migraine headache, and obesity [BMI 33 (ht. 5’4”/wt. 192)] who was recently diagnosed with diabetes mellitus, presents for a follow-up appointment to assess diabetes control. The patient’s last colorectal cancer screening was at age 55 years via colonoscopy, when several adenomatous polyps were removed. Following a lengthy discussion regarding the patient’s glucose control and medication adherence, the patient mentions that she has noticed bright red blood per rectum intermittently during the past two weeks. Family history is significant for diabetes mellitus, depression, hypertension, lung cancer (father) and endometrial cancer (sister and mother). Select the letter corresponding to your answer for the following multiple-choice questions, based upon your current risk assessment practice standards and understanding of current cancer screening guidelines. 1. Classify this patient’s risk for colorectal cancer: A. Average risk B. High risk C. Insufficient information


12 BCM School of Allied Health Sciences - Physician Assistant Program

2. Which variables below increase this patient’s risk for colorectal cancer? (select all that apply) A. Adherence to screening guidelines B. Adenomatous colorectal polyps C. Alcohol and tobacco use history D. Body mass index E. Diet/exercise habits F. Education level G. Ethnicity/race H. Family history I. Gender J. Inflammatory bowel disease K. Patient age L. Religious beliefs M. Socioeconomic status 3. Which screening test(s), if any, would you recommend for this patient? (select all that apply) A. Colonoscopy B. Fecal occult blood test C. Sigmoidoscopy D. None indicated at this time 4. Would you refer this patient for genetic counseling and testing? A. Yes B. No C. Unsure CB, a healthy 42-year-old African American man without significant medical problems or complaints, presents as a new patient seeking CASE #3 a full physical examination for documentation on a life insurance application. BMI is 24.5 (ht. 6’1”/wt. 186), diet consists of red meat, lean chicken, fish and vegetables, exercises 3-5 times weekly, is a former smoker (6 pack years), moderately consumes alcoholic beverages and denies illicit drug use. Family history is significant for hypertension, inflammatory bowel disease, colorectal cancer (father, deceased at age 51 years; 3 uncles, deceased at ages 56, 62 and 64 years), lung cancer (paternal grandmother, deceased at 89 years) and non-Hodgkin lymphoma (mother, deceased at age 72). The patient

expresses concern over his significant family history of colorectal cancer and states that he was screened annually for colorectal cancer via FOBT by his family physician in his former hometown. All FOBT screenings had been negative. Select the letter corresponding to your answer for the following multiple-choice questions, based upon your current risk assessment practice standards and understanding of current cancer screening guidelines. 1. Classify this patient’s risk for colorectal cancer: A. Average risk B. High risk C. Insufficient information 2. Which variables below increase this patient’s risk for colorectal cancer? (select all that apply) A. Adherence to screening guidelines B. Adenomatous colorectal polyps C. Alcohol and tobacco use history D. Body mass index E. Diet/exercise habits F. Education level G. Ethnicity/race H. Family history I. Gender J. Inflammatory bowel disease K. Patient age L. Religious beliefs M. Socioeconomic status 3. Which screening test(s), if any, would you recommend for this patient? (select all that apply) A. Colonoscopy B. Fecal occult blood test C. Sigmoidoscopy D. None indicated at this time 4. Would you refer this patient for genetic counseling and testing? A. Yes B. No C. Unsure


Physician Assistant Cancer Education 13

SECTION V: Case Studies: Answers Colorectal Case Study 1: 1. A. Average risk 2. A. Adherence to screening guidelines K. Patient age 3. A. Colonoscopy, B. Fecal occult blood test and C. Sigmoidoscopy (all correct) 4. B. No Colorectal Case Study 2: 1. B. High risk 2. A. Adherence to screening guidelines B. Adenomatous colorectal polyps D. Body mass index E. Diet/exercise habits K. Patient age 3. A. Colonoscopy 4. B. No Colorectal Case Study 3: 1. B. High risk 2. H. Family history I. Alcohol and tobacco use history 3. A. Colonoscopy 4. A. Yes

SECTION V: Case Studies: Optional Exercise Question: What screening tests might you recommend for yourself and/or a family member with the same profile as the patients in these case studies? Would you recommend anything different than you recommended for your patients? Why, or why not? This is an interesting question to ponder, as the data in Table 7 on the following page demonstrates. During 2006, Australia initiated a nationwide, universal screening for colorectal cancer with an annual FOBT for patients 55 years and older. Just prior to implementation of this screening program, a survey of Western Australian General Practitionerâ&#x20AC;&#x2122;s colorectal screening recommendations and attitudes revealed that the type of screening test recommended for patients differed than the screening test he/she would prefer ordered for themselves. Over half of the GPs would reportedly follow the proposed screening guidelines and recommend a FOBT for patients, while over half indicated that they preferred a colonoscopy for their own colorectal screening.


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TABLE 7. CRC Screening Methods: Western Australian General Practitioners’ (GP) Recommendations and Attitudes48

Test recommended by GP for patients

GPs’ perception of patients’ choice of test

GPs’ preferred test for their own screening

Fecal occult blood testing (FOBT)

430 (53.7%)

396 (49.4%)

236 (29.5%)*

Colonoscopy

285 (35.6%)

278 (34.7%)

479 (59.8%)*

Flexible sigmoidoscopy

37 (4.6%)

20 (2.5%)

20 (2.5%)

Computed tomography (CT)

18 (2.2%)

69 (8.6%)

32 (4.0%)

Double Contrast Barium Enema (DCBE)

0 (0.0%)

2 (0.25%)

3 (0.4%)

* p = 0.004 (χ2) Modified from Turner et al.48

SECTION VI: Counseling Patients Regarding Screening Outcomes Assessing colorectal cancer risk The first step in counseling patients regarding screening test results is to offer a brief message about the results and whether the testing changed the patient’s risk status for colorectal cancer. Sample messages follow. • Average risk - “Based upon the results of your screening tests, there is no current evidence that you are at an increased risk for colorectal cancer. It will be important for you to repeat this screening test “X” years from now [depending upon the testing completed or recommended]. If you should develop any new symptoms, such as rectal bleeding, during this period of time you need to let me know promptly.” • High risk - “Based upon the results of your colorectal screening tests, a diagnosis of early stage colorectal cancer is likely. These results need to be followed up with additional testing by a specialist as soon as possible. We can arrange the referral today and our office can contact your insurance plan regarding coverage for the specialist.”

Referral and the next steps The patient may not “hear” or register much of the information you offer following the word “cancer.” Be sensitive to this fact and offer either written material to your patient or arrange for a follow-up appointment

as soon as possible to discuss further details regarding the referral process. It is important to discuss logistical details with your patient regarding expectations during and following the referral process, to include followup with you, the primary care/referring provider, and with the cancer treatment center/provider.49 A sample message follows. • Referral -“The next step of your evaluation will determine the extent of cancer cells present within your body. Additional testing will investigate whether the cancer is confined, or localized, within the colorectal area, or whether it has spread to another location in your body. These details are necessary for a proper diagnosis, to “stage” the disease and decide on which of the available treatment options are best for you at this time. The treatment options may include chemotherapy medications, radiation therapy and/or surgical removal of the CRC. The specialist to whom I am referring you will be able to provide much more information. This specialist and I will communicate with each other to keep each other informed about your health and decisions that affect your health. You will continue to see me periodically so I can continue to provide care for “X.” [this part varies depending upon the patients other health conditions and depending upon the distance the patient will be traveling for treatment by the oncologist].


Physician Assistant Cancer Education 15

SECTION VII: Integration/Clinical Correlation

THE OFFICE VISIT This simulated office visit is designed to take you through the process of the steps that are necessary to implement colorectal cancer screening, to make recommendations for your individual patient based upon the evidence-based guidelines, to counsel your patient appropriately according to risk factors, test results and to suggest appropriate follow-up evaluation, which may include a referral to another healthcare provider.

Patient Intake Process Chief Complaint (CC): DM is a 51-year-old woman presenting to your family practice as a new patient without complaints. Next Steps: DM fills out the standard intake forms. She is then escorted to the examination room by the medical assistant who confirms the reason for the patient visit, takes vital signs and prepares DM to been seen by the provider.


16 BCM School of Allied Health Sciences - Physician Assistant Program

PATIENT INTERVIEW 1.

What specific elements of the past medical history are pertinent? (select all that apply) A. Childhood illnesses B. Adult illnesses C. Obstetric/gynecologic D. Accidents/injuries E. Surgeries/hospitalizations F. Medications/allergies

2.

What specific elements of the family history are pertinent? (select all that apply) A. Parental illnesses B. Sibling illnesses C. Children illnesses D. Cause/age of death-1st degree relatives E. Cancer-related history F. Psychiatric history

3.

What specific elements of the prevention history are pertinent? (select all that apply) A. Diet and exercise B. Tobacco, alcohol and illicit drug use C. Sexual history D. Sunscreen usage E. Environmental exposures F. Screening tests G. Immunization

4.

Which components of the review of systems are pertinent? (select all that apply) A. General B. Skin, Hair, Nails C. Head, Eyes, Ears, Nose/Sinuses, Mouth/Throat D. Neck E. Breast F. Cardiovascular G. Respiratory H. Gastrointestinal I. Genitourinary J. Musculoskeletal K. Neurological L. Psychiatric M. Endocrine


Physician Assistant Cancer Education 17

ADDITIONAL HISTORICAL INFORMATION PMH: Adult illnesses: DM was diagnosed with cervical cancer at age 39 and was treated with a Loop Electrosurgical Excision Procedure (LEEP) with cone biopsy. She denies any abnormal pap smears since treatment. She was diagnosed with herpes simplex virus (HSV) at age 27 and denies recent outbreaks. She has a history of seasonal allergies (since age 20), depression and anxiety with h/o panic attacks and nocturnal awakening (since age 48), and irritable bowel syndrome (IBS – since age 46). PSH/Hospitalizations: Liposuction/Tummy Tuck – 9 years ago; LEEP/Cone biopsy – 12 years ago; Tubal ligation – 16 years ago after last delivery. (4 vaginal deliveries – 16, 19, 21, and 24 years ago) Medications: DM takes Xanax as needed (prn) for anxiety, Ambien prn sleep disturbance, Zelnorm daily for IBS, Zyrtec daily (during the fall and spring) for seasonal allergies, Zoloft daily for depression and anxiety, a daily multivitamin, and herbal supplements ginko biloba, black cohosh and soy for menopausal symptoms. Allergies: No known drug allergies (NKDA)

Prevention: Screening tests – Last physical examination was three years ago. Last mammogram and last Pap test were also three years ago. She has never had a colorectal screening. ROS: Gen - Fatigue, loss of appetite, difficulty sleeping CV - Denies chest pain, fainting, shortness of breath, lower extremity edema Resp - Denies cough, shortness of breath, excessive sputum, wheezing, pleurisy GI - Occasional gas/bloating and indigestion/ heartburn, nausea, diarrhea, constipation, change in bowel habits, and abdominal pain. Denies vomiting, melena, hematochezia, jaundice, pain with swallowing. GU - Occasional nocturia, urinary incontinence, urinary frequency and decreased libido. Reports irregular menses for past two years with occasional hot flashes. Denies dysuria, hematuria, vaginal discharge or genital lesions.

FH: Breast CA - sister (diagnosed 6 months ago at age 52, currently undergoing treatment), maternal grandmother (age of diagnosis unknown, deceased at age 64), Ovarian CA – mother (diagnosed age 74, deceased at age 76), Colorectal CA – maternal grandfather (age of diagnosis unknown, deceased at age 53).

Musculoskeletal - Denies stiffness, back pain, joint pain, joint swelling, weakness, cramps.

Social/Habits: Lives with boyfriend, son (age 19) and daughter (age 16). Works at home as a writer and homemaker. She is a non-smoker (never smoked), drinks between 2-3 alcoholic servings a week and exercises by walking twice a week for 30 minutes at a moderate pace.

Psychiatric - Admits history of depression and anxiety. Denies memory loss, suicidal or homicidal ideation, delusions, hallucinations.

Neurological - Frequent headache – relieved with ibuprofen or acetaminophen and rest. Denies history of migraine, tremors, vertigo, numbness, seizures, weakness.

Endocrine - Admits cold intolerance, polydipsia and weight gain. Denies polyphagia, heat intolerance or polyuria.


18 BCM School of Allied Health Sciences - Physician Assistant Program

Question: 5. Which 10 of the physical examination components and/or body systems should you focus upon during the physical examination? A. General H. Thorax/Lungs B. Vital Signs I. Abdominal C. Skin/Hair/Nails J. Pelvic D. Head/Eyes/Ears/Nose/Throat K. Rectovaginal E. Neck L. Musculoskeletal F. Breast M. Neurological G. Cardiovascular (CV)


Physician Assistant Cancer Education 19

PHYSICAL EXAMINATION FINDINGS GEN:

Well nourished, well developed female, no acute distress, appears stated age. Height 5’7”, weight 140 lb. (BMI 21.9)

VS: BP – 128/82, RR – 18, P – 76 Breast:

No palpable masses, no palpable lymph nodes, no nipple discharge, no color changes, no asymmetry, nontender

Neck:

Thyroid – normal size without masses, nontender, no palpable lymph nodes

CV: Regular rate and rhythm without murmurs, rubs, gallops TL:

Clear to auscultation bilaterally, no palpable lymph nodes

ABD:

Normal bowel sounds in all four quadrants, nontender, nondistended, no masses

Pelvic:

Vulva - without lesions Vagina - without lesions, no discharge, normal ruggae, grade II cystocoele Cervix - parous without lesions, no cervical motion tenderness Uterus - retroverted and retroflexed, six week sized, nontender, no palpable masses Adnexa - nontender without palpable masses

Rectovaginal: Soft stool in vault, no palpable masses, nontender, hemoccult positive with hemorrhoids NEURO:

Mini mental status examination 30/30, CN I-XII intact bilaterally, sensation intact throughout, finger-to-nose and rapid-alternating-movements accomplished with adequate precision, steady gait, negative Romberg, Babinski not present, reflexes intact


20 BCM School of Allied Health Sciences - Physician Assistant Program

CRC RISK ASSESSMENT AND STRATIFICATION Questions: 6. Classify this patientâ&#x20AC;&#x2122;s risk for colorectal cancer: A. Average risk B. High risk C. Insufficient information 7.

Which variables below increase this patientâ&#x20AC;&#x2122;s risk for colorectal cancer? (select all that apply) A. Adherence to screening guidelines B. Adenomatous colorectal polyps C. Alcohol and tobacco use history D. Body mass index E. Diet/exercise habits F. Education level G. Ethnicity/race H. Family history I. Gender J. Inflammatory bowel disease K. Patient age L. Religious beliefs M. Socioeconomic status

8.

Which screening test(s), if any, would you recommend for this patient? (select all that apply) A. Colonoscopy B. Fecal occult blood test C. Sigmoidoscopy D. None indicated at this time

9.

Would you refer this patient for genetic counseling and testing? A. Yes B. No C. Unsure


Physician Assistant Cancer Education 21

Flexible Sigmoidoscopy You give DM bowel prep instructions and schedule her for a flexible sigmoidoscopy in your office in 10 days. Procedure: Multiple polyps are found during the Flex Sig procedure; the majority of which were < 1 cm in size, although several of them were > 1 cm. All polyps were removed and sent to pathology. Pathology report arrives 4 days later Pathology Report47 Gross Description: “Polyp of sigmoid colon.” An ovoid, smooth-surfaced, firm, pale tan nodule, measuring 0.6 x 0.4 x 0.3 cm. Cassette ‘A’, all, bisected. Microscopic Examination: Specimen A: The sections show a polypoid structure consisting of a central fibrovascular core, surrounded by a mantle of mucosa showing an adenomatous architecture with a predominantly tubular pattern. The tubules are lined by tall columnar epithelium showing nuclear pseudostratification, hyperchromasia, increased mitotic activity, and loss of cytoplasmic mucin. There is no evidence of stromal invasion. Diagnosis: Colon, sigmoid, endoscopic biopsy: tubular adenoma (adenomatous polyp)

NOTE: A similar gross description, microscopic examination and diagnosis are listed for each specimen removed and submitted for pathology. Follow-up You call DM and schedule a follow-up appointment in your office the next day to discuss your follow-up evaluation recommendations. Question: 1. What follow-up evaluation do you recommend for DM? A. Colonoscopy B. Repeat fecal occult blood test and sigmoidoscopy in six months C. None indicated at this time


22 BCM School of Allied Health Sciences - Physician Assistant Program

Colonoscopy following Flexible Sigmoidoscopy Procedure: Additional polyps are removed in the proximal colon during colonoscopy. Most polyps were < 1 cm in size, although several of them were > 1 cm. All polyps were removed and sent to pathology. The pathology report is transmitted from the pathology laboratory to the GI office 4 days later. A copy of the report is also sent to your office. Pathology Report47 Gross Description: “Polyp of transverse colon.” An ovoid, smooth-surfaced, firm, pale tan nodule, measuring 1.8 x 1.4 x 1.3 cm. Cassette ‘A’, all. Microscopic Examination: Specimen A: The sections show a polypoid structure consisting of a central fibrovascular core, surrounded by a mantle of mucosa showing an adenomatous architecture with a predominantly tubular pattern. The tubules are lined by tall columnar epithelium showing nuclear pseudostratification, hyperchromasia, increased mitotic activity, and loss of cytoplasmic mucin. There is no evidence of stromal invasion. Diagnosis: Colon, sigmoid, endoscopic biopsy: tubular adenoma (adenomatous polyp)

NOTE: A similar gross description, microscopic examination and diagnosis are listed for each specimen removed and submitted for pathology. Follow-up DM returns to the GI office for a follow-up appointment. You call both the GI office and DM to discuss the next steps for surveillance of DM, in a collaborative effort to: 1) Reduce DM’s risk for developing colorectal cancer; 2) Detect malignancy at an early, localized stage, should colorectal cancer occur.


Physician Assistant Cancer Education 23

Integration/Clinical Correlation: Answers 1. B. Adult Illnesses E. Surgeries/Hospitalizations F. Medications/Allergies

2. A. Parental illnesses

B. Sibling illnesses D. Cause/age of death-1st degree relatives E. Cancer-related history

3. F. Screening tests 4.

A. General E. Breast F. Cardiovascular G. Respiratory H. Gastrointestinal I. Genitourinary K. Neurological L. Psychiatric M. Endocrine

5.

A. General B. Vital Signs E. Neck F. Breast G. Cardiovascular (CV) H. Thorax/Lungs I. Abdominal J. Pelvic K. Rectovaginal M. Neurological

6. A. Average risk 7.

C. D. E. G. K.

Alcohol and tobacco use history Body mass index Diet/exercise habits Family history Patient age

7. C. Sigmoidoscopy (A. Colonoscopy is acceptable) 8. B. No 9. A. Colonoscopy


24 BCM School of Allied Health Sciences - Physician Assistant Program

SECTION VIII: References 1. American Cancer Society. Cancer Facts & Figures 2007. [Online]. 2007 [cited 2007 Jan 4]. Available from: http://www.cancer.org/docroot/STT/ content/STT_1x_Cancer_Facts__Figures_2007. asp 2. Winawer S, Zauber A, Ho M. Prevention of colorectal cancer by colonoscopic polypectomy: The National Polyp Study Workgroup. N Engl J Med 1993;331:1977-1981. 3. Winawer SJ, Fletcher RH, Miller L, Godlee F, Stolar MH, Mulrow CD, et al. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology 1997;112(2):594-642. 4. Ries LAG, Eisner MP, Kosary CL, Hankey BF, Miller BA, Klegg L, et al. SEER Cancer Statistics Review, 1973-1997. Bethesda, MD: National Cancer Institute; 2000. 5. Minino AM, Arias E, Kochanek KD, Murphy SL, Smith BL. Deaths: Final Data for 2000: National Vital Statistics Reports 2002. 6. American Cancer Society. Detailed Guide: Colon and rectum cancer. What are the risk factors for colorectal cancer? [Online]. 2006 [cited 2006 Nov 20]. Available from: http://www.cancer.org/ docroot/CRI/content/CRI_2_4_2X_What_are_ the_risk_factors_for_colon_and_rectum_cancer. asp?sitearea= 7. Fenoglio-Preiser CM, Hutter RVP. Colorectal polyps: Pathologic diagnosis and clinical significance. CA Cancer J Clin [serial online] 1985 [cited 2007 Mar 7]; 35:322-344. Available from: http://caonline.amcancersoc.org/cgi/ reprint/35/6/322 8. U.S. Preventive Services Task Force (USPSTF). Recommendations and rationale: Screening for colorectal cancer. [Online]. 2002 [cited 2006 Dec 2]. Available from: http://www.ahrq.gov/ clinic/3rduspstf/colorectal/colorr.htm 9. Pignone M, Rich M, Teutsch SM, Berg AO, Lohr KN. Screening for colorectal cancer in adults at average risk: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137(2):132-141. 10. Eaden JA, Mayberry JF. Colorectal cancer complicating ulcerative colitis: a review. Am J Gastroenterol 2000;95:2710-2719.

11. Coppola D, Karl RC. Pathology update: Pathology of early colonic neoplasia - Clinical and pathologic features of precursor lesions and minimal carcinomas. Cancer Control Journal [serial online] 1997 [cited 2007 Mar 7]; 4(2). Available from: http://www.moffitt.org/moffittapps/ccj//v4n2/ department4_5.html 12. Rustgi AK. Hereditary gastrointestinal polyposis and nonpolyposis syndromes. N Engl J Med 1994;331:1694-1702. 13. Winawer SJ, Zauber AG, Gerdes H, Oâ&#x20AC;&#x2122;Brien MJ, Gottlieb LS, Sternberg SS, et al. Risk of colorectal cancer in the families of patients with adenomatous polyps. N Engl J Med 1996;334(2):82-87. 14. Arvanitis ML, Jagelman DG, Fazio VW, Lavery IC, McGannon E. Mortality in patients with familial adenomatous polyposis. Dis Colon Rectum 1990;33:639-642. 15. Heyen F, Jagelman DG, Romania A, Zakov ZN, Lavery IC, Fazio VW, et al. Predictive value of congenital hypertrophy of the retinal pigment epithelium as a clinical marker for familial adenomatous polyposis. Dis Colon Rectum 1990;33(12):1003-1008. 16. Lynch HT, Smyrk T, Lynch JF. Overview of natural history, pathology, molecular genetics and management of HNPCC (Lynch Syndrome). Int J Cancer 1996;69(1):38-43. 17. Mecklin JP, Jarvinen HJ. Tumor spectrum in cancer family syndrome (hereditary nonpolyposis colorectal cancer). Cancer 1991;68:1109-1112. 18. Bond JH. Polyp guideline: Diagnosis, treatment, and surveillance for patients with colorectal polyps. Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol 2000;95(11):3053-63. 19. Fenoglio CM, Pascal RR. Colorectal adenomas and cancer: Pathologic relationships. Cancer 1982;50:2601-2608. 20. Oâ&#x20AC;&#x2122;Brien MJ, Winawer SJ, Zauber AG, Gottlieb LS, Sternberg SS, Diaz B, et al. The National Polyp Study: Patient and polyp characteristics associated with high-grade dysplasia in colorectal adenomas. Gastroenterol 1990;98(2):371-379. 21. McMurrick P. Bowel cancer: A guide for the GP. Aust Fam Physician 2006;35(4):192-197.


Physician Assistant Cancer Education 25

22. National Health and Medical Research Council (NHMRC). Australian Cancer Network Colorectal Cancer Guidelines Revision Committee. Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer. The Cancer Council Australia and Australian Cancer Network, Sydney 2005. 23. Nanda R. Colon cancer. MedlinePlus [Online] 2006 [cited 2007 Feb 20]. Available from: http:// www.nlm.nih.gov/medlineplus/print/ency/ article/000262.htm 24. Texas Cancer Council. Texas Cancer Plan 2005: A statewide blueprint for cancer prevention and control in Texas. [Online] 2005 [cited 2006 Nov 2]; 4th ed. Available from: http://www.tcc.state.tx.us/ pdfs/texascancerplan2005.pdf 25. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA 2004;291(10):1238-1246. 26. Fitzgerald MA. Certification column: Primary, secondary, and tertiary prevention: Important in certification and practice. Advance for Nurse Practitioners [serial online] 2000 [cited 2007 Jan 27]. Available from: http://www.fhea.com/ CertificationCols/level_prevention.htm 27. U.S. Preventive Services Task Force. Guide to clinical preventive services. Baltimore, MD: Wilkins & Wilkins; 1996. 28. Epling JW, Morrow CB, Cibula DA. A critical look at prevention: Colorectal cancer screening. Am J Prev Med 2003;24(4S): 139-142. 29. Department of Health and Human Services: Centers for Disease Control and Prevention. Cancer registries: The foundation for cancer prevention and control. [Online] 2005 [cited 2007 Feb 2]. Available from: http://www.cdc.gov/ cancer/npcr/npcrpdfs/about2004.pdf 30. Copeland J. An ounce of prevention: Common problems in primary care. Duke University School of Medicine [presentation online] 1997 [cited 2007 Feb 21]. Available from: http:// fmclerkship.mc.duke.edu/Course%20Documents/ Prevention0607.ppt

31. American Cancer Society. ACS guidelines on screening and surveillance for the early detection of adenomatous polyps and colorectal cancer. [Online] 2001 [cited 2006 Dec 8]. Available from: http://www.cancer.org/downloads/PRO/ ColorectalScreeningGuidelines.pdf 32. Lalani M, Schoen RE. Screening for colorectal cancer. In: Wildschut HIJ, Weiner CP, Peters TJ, editors. When to screen in obstetrics and gynecology. 2nd ed. Philadelphia, PA: Elsevier Ltd.; 2006. p. 649-657. 33. Screen for life: National Colorectal cancer action campaign, Department of Health and Human Services. Colorectal cancer: Facts on screening. [Online] 2006 [cited 2007 Feb 5]. Available from: http://www.cdc.gov/cancer/colorectal/pdf/fspatient.pdf 34. Institute of Medicine National Cancer Policy Board. Economic models of colorectal cancer screening in average-risk adults: A workshop. Washington D.C.; 2004. 35. Schoen RE. Prevalence of isolated advanced proximal neoplasia [comment]. J Natl Cancer Inst 2002;94:1763-1772. 36. Lieberman DA, Weiss DG. One-time screening for colorectal cancer with combined fecal occultblood testing and examination of the distal colon [see comments]. N Engl J Med 2001;345:555-560. 37. Newcomer MK, Shaw MJ, Williams DM, Jowell PS. Unplanned work absence following outpatient colonoscopy. J Clin Gastroenterology 1999;29:7678. 38. Rex DK, Johnson DA, Lieberman DA, Burt RW. Colorectal cancer prevention 2000: Screening recommendations of the American College of Gastroenterology. Am J Gastroenterol 2000;95:868-877. 39. Glick S, Wagner JL, Johnson CD. Cost effectiveness of double-contrast barium enema in screening for colorectal cancer. Am J Roentgenol 1998;170:629-636. 40. Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, et al. Current methods of the U.S. Preventive Services Task Force: A review of the process. Am J Prev Med 2001;20(3S):21-35.


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41. American Cancer Society. Guidelines on screening and surveillance for the early detection of adenomatous polyps and colorectal cancer. [Online]. 2001 [cited 2006 Nov 20]. Available from: http://www.cancer.org/docroot/PRO/ content/PRO_1_1_Colorectal_Cancer_Screening_ Guidelines_2001.asp

46. Holtby S, Zahnd E, Lordi N, McCain C, Chia YJ, Kurata JH. Health of Californiaâ&#x20AC;&#x2122;s adults, adolescents and children: Findings from CHIS 2003 and CHIS 2001. Los Angeles, CA: UCLA Center for Health Policy Research, 2006. [Accessed 27 July 2008]. Available from: www. healthpolicy.ucla.edu.

42. National Comprehensive Cancer Network (NCCN). Clinical practice guidelines in oncology: colorectal cancer screening. [Online]. 2006 [cited 2006 Dec 14]. Available from: http://www.nccn. org/professionals/physician_gls/PDF/colorectal_ screening.pdf

47. Texas Department of State Health Services: Texas Cancer Registry. [Online]. 2007 [cited 2008 July 29]. Available from: http://www.dshs.state.tx.us/ tcr/default.shtm

43. Smith RA, Cokkinides V, Brawley OW. Cancer screening in the United States, 2008: A review of current American Cancer Society guidelines and cancer screening issues. CA Cancer J Clin 2008;58:161-179. 44. Ries LA, Wingo PA, Miller DS, Howe HL, Weir HK, Rosenberg HM, Vernon SW, Cronin K, Edwards BK. The annual report to the nation on the status of cancer, 1973-1997, with a special section on colorectal cancer. Cancer 2000;88(10):2398-2424. 45. Coughlin SS, Costanza ME, Fernandez ME, et al. CDC-funded intervention research aimed at promoting colorectal cancer screening in communities. Cancer 2006;107(S5): 1196-1204.

48. Turner GB, Chin MW, Foster NM, Emery J, Forbes GM. Attitudes of Western Australian general practitioners to colorectal cancer screening [letters to the editor]. MJA 2006;185(4):237. 49. Questions to ask about a clinical trial. The University of Texas M. D. Anderson Cancer Center: Patient Education Office 2006. 50. New Patient Registration Form. Baylor College of Medicine: Dept. of Family and Community Medicine. [Online] 2005 [cited 2007 March 6]. Available from: https://bsm.bcm.edu/portal/ Forms/BFM_reg.pdf 51. Uthman EO. The Biopsy Report: A Patientâ&#x20AC;&#x2122;s Guide. CancerGuide [Online] 1994 [cited 2007 March 8]. Available from: http://cancerguide.org/ pathology.html


PACE Colorectal Cancer Module