Colorectal cancer: primary and secondary prevention - PowerPoint Presentation

1. Colorectal cancer: primary and secondary prevention8th October 2022Anne MurphyAdvanced Nurse PractitionerColorectal DiseaseCork University Hospital

2. Cork University HospitalCUH serves population of over 1.1 million.40 different specialties.Tertiary referral centre Currently employs 3,488Teaching hospital affiliated with University College Cork

3. Cancer CentreRapid access clinicsMDT- Oncologists/Surgeons/Radio-oncologists/Nurses/dieticiansTertiary referral Bowel cancer screeningRobot / interventional radiology/5 colorectal surgeons2 Clinical Nurse Specialists (CNS)1 Advanced Nurse Practitioner1 cANP

4. Qualifications and experienceRegistered General Nurse -1998Registered Midwife -1991Certificate in Counselling -1999 Certificate –Colorectal nursing to include endoscopy -2001MSc Nursing Science -2005MSc Advanced Nurse Practice -2007Medicine prescribing -2007Radiology Prescribing -2008Set-up Nurse Led services; Rapid Access clinic for patients with red flag Symptoms – 20001st accredited Nurse Endoscopist in Ireland 2002Clinical work expansion Functional bowel disorders; Posterior Tibial Nerve stimulation anal manometry and Endoanal U/S Clinical Nurse lead on National Steering/Advisory Group for guidelines; Bowel screen Ireland program 2007/ Fm Hx / Polyp surveillance 2008/Advocate for Advanced Nurse Practitioner role politically and education support UCD and UCCResearch; Currently participating in “Prehabilitation project” and “surgical site infection study”

5. Remember You can ask questions at any time

6. Colorectal cancer: primary and secondary preventionPrimary prevention; action taken to decrease the chance of getting a disease or condition.Secondary Prevention; the identification and treatment of precursor conditions or early stage disease in the asymptomatic population. population screening programs

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9. Family History

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16. Changes in the gut microbiome may be influencing the increasing rates of colorectal cancer in adults under 50.Credit: Journal of Translational Medicine. April 2017. doi: 10.1186/s12967-017-1175-y. CC BY 4.0.Why Is Colorectal Cancer Rising Rapidly among Young Adults. November 5, 2020, by NCI

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19. The Cost??

20. Chemicals in the EnvironmentAir and water pollution, chemicals in soil and food, and pesticide use. 18 chemicals identified that cause cancer in the intestines of mice or rats, by damaging DNA, potentially leading to harmful mutations in cells of the colon and rectum. Indirect effects. For example, mixtures of certain environmental chemicals (sometimes called endocrine disrupters and obesogens) can disrupt the bodies metabolism leading to obesity Chemicals that are now banned, their use in earlier decades could have effects later in life for people who were born back then, In addition, some environmental chemicals may have harmful effects on the complex bacteria in the gut.Consider all individual’s environmental exposures over the course of their life, including exposures in the womb. How those chemicals interact with a person’s genetic make-up.

21. Screening The presumptive identification of unrecognised disease by application of tests, examinations or other procedures which can be applied rapidly, to sort out apparently well persons who probably have a disease from those who probably do not A screening test is not intended to be diagnostic. Persons with positive or suspicious findings must be referred for diagnosis and necessary treatmentWhen can screening be useful? When primary prevention – taking away the causes of the disease – is not possible or limited in its effect When the criteria of Wilson and Jungner are met

22. The Criteria of Wilson & JungnerThe disease must be a serious health problem There must be a pre-clinical phase which can be detected The natural history of the disease must be known The test must be; sensitive and specific Simple and cheap Safe and acceptable for the target group Reliable Diagnosis and treatment Adequate facilities for diagnosis and treatment must be in placeAn effective, acceptable and safe treatment must be present Cost-effectiveness*Wilson JMG, Jungner G. The principles and practice of screening for disease, Public Health Papers 34, WHO 1968

23. Bowel Cancer Screening

24. Benefits of Screening

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27. Translational OncologyVolume 14, Issue 10, October 2021, 101174 Global colorectal cancer burden in 2020 and projections to 2040Author; YueXiPengfeiXuPhD

28. Colorectal cancerForty-three studies reported trends in the incidence of colorectal cancer in patients aged under 50 years Four of them examined international databases and described an increase in incidence in this age group in a wide range of wealthy countries worldwide, often accompanied by a decreasing incidence in those aged 50 and overIncidence trends for twelve cancers in younger adults—a rapid reviewErica di Martino, Lesley Smith, Stephen H. Bradley, et al. British Journal of Cancer. volume 126, pages1374–1386 (2022)

29. Younger patient’s with Cancer

30. Younger patients with cancerGrowing evidence suggests that younger patients are more likely to experience a diagnostic delay. Younger patients are more likely than older people to have consulted with a doctor three or more time before referral Even when referred, younger patients may be referred through a less urgent route compared to older onesA delay in diagnosis may result in cancer progressing to a less curable stage. Some studies suggest that for some younger cancers patients have more advanced disease at diagnosis compared to older patients.Incidence trends for twelve cancers in younger adults—a rapid review. r; Erica di Martino, Lesley Smith, Stephen H. Bradley, et al. British Journal of Cancer. volume 126, pages1374–1386 (2022)

31. Younger patients with cancerYounger colorectal cancer patients often present with more aggressive diseaseThe recent increase in incidence in younger patients is driven by more invasive cancers For example, one study reported that the proportion of patients under 50 presenting with Stage 4 colorectal cancer in the Republic of Ireland has doubled in recent years, from 11% in 1994 to 23% in 2012.Incidence trends for twelve cancers in younger adults—a rapid review. r; Erica di Martino, Lesley Smith, Stephen H. Bradley, et al. British Journal of Cancer. volume 126, pages1374–1386 (2022)Ullah MF, Fleming CA, Mealy K. Changing trends in age and stage of colorectal cancer presentation in Ireland—from the nineties to noughties and beyond. Surgeon. 2018;16:350–4

32. Younger patients with cancerin the US up to 5% of individuals aged 40–49 had received a colonoscopy Screening of asymptomatic individuals may result in ‘over-diagnosisThe increase in breast and colorectal cancer incidence is observed in individuals as young as 20–25-year old, It is consistently described across a number of high-income countries worldwide.A specific increase in invasive and late-stage disease in younger age groupsIncidence trends for twelve cancers in younger adults—a rapid review. r; Erica di Martino, Lesley Smith, Stephen H. Bradley, et al. British Journal of Cancer. volume 126, pages1374–1386 (2022)

33. Younger patients with cancerRe-evaluation of the age threshold for the referral of symptomatic patients. Lowering the minimum age for eligibility in colorectal cancer national screening programmes Lowering bowel cancer screening threshold to 45 may be cost-effective but would increase colonoscopy demand Notably, the US Preventative Services Taskforce recently lowered their age recommendations for bowel screening from 50 to 45 years.Incidence trends for twelve cancers in younger adults—a rapid review. r; Erica di Martino, Lesley Smith, Stephen H. Bradley, et al. British Journal of Cancer. volume 126, pages1374–1386 (2022)

34. Moving Toward A Human Vaccine?Dr Steven Lipkin, M.D., Ph.D., of Weill Cornell Medicine, reported that vaccine prevented the growth of colorectal tumours in a mouse model of Lynch syndrome and prolonged the mice’s survival compared with unvaccinated mice.If human trials of a cancer prevention vaccine do move forward, Dr. Lipkin noted, it will take several years to determine whether it works.Using the mouse model to better understand exactly how the vaccine works and ways that growing cancer cells can become resistant to its effects.Could a Vaccine Prevent Colorectal Cancer in People with Lynch Syndrome?April 19, 2019, by NCI Staff

35. Stress and CancerThe notion that stress and cancer are interlinked is talked about for decades. More recent animal studies indicate that stress can substantially facilitate cancer progression available clinical evidence is inconsistent,.Eckerling, A., Ricon-Becker, I., Sorski, L. et al. Stress and cancer: mechanisms, significance and future directions. Nat Rev Cancer 21, 767–785 (2021). https://doi.org/10.1038/s41568-021-00395-5

36. Stress and Cancer

37. Prevention…?Multi cancer early detection tests (MCED)Blood test;Biological signalsBiomarkersMore research..Screening for Many Cancers with One Test: Uncertainty Abounds. April 21, 2022, by Philip Castle, Ph.D., M.P.H.

38. Cancer prevention and aspirinSeveral trials have also shown that aspirin reduces the risk of developing precancerous colon polyps.Numerous studies have suggested that people who regularly take low doses of aspirin may have reduced risks of being diagnosed with or dying from cancer. Included among those trials were those in people with Lynch syndrome, a condition that greatly heightens the likelihood of developing some cancers, particularly colorectal cancer. In one such trial, people with Lynch syndrome who regularly took high-dose aspirin (600 mg) daily for at least 2 years cut their colorectal cancer risk by more than a thirdBut new findings from a randomized clinical trial, called ASPREE, suggest that the same may not hold true for older adults participants in the aspirin group had a 77% higher risk of dying from colorectal cancer than those in the placebo group Lancet. 2010 Nov 20;376(9754):1741-50. Long-term effect of aspirin on colorectal cancer incidence and mortality: 20-year follow-up of five randomised trials. Peter M Rothwell 1, Michelle Wilson, Carl-Eric Elwin, Bo Norrving, Ale Algra, Charles P Warlow, Tom W Meade JNCI: Journal of the National Cancer Institute, Volume 113, Issue 3, March 2021, Pages 258–265, https://doi.org/10.1093/jnci/djaa114Published: 11 August 2020Effect of Aspirin on Cancer Incidence and Mortality in Older Adults ; John J McNeil, MBBS, MSc, PhD, , *Peter Gibbs, MBBS, MD, Suzanne G Orchard, BSc(Hons), PhD, Jessica E Lockery, MBBS, Wendy B Bernstein, MD, Yin Cao, ScD, MPH, Leslie Ford, MD, Andrew Haydon, MBBS, PhD, Brenda Kirpach, CCRA, Finlay Macrae, MBBS, MD ...Regular Aspirin Use May Increase Older People’s Risk of Dying from Cancer. August 18, 2020, by NCI Staff

39. Cancer prevention with Aspirin and Lynch syndromeThe Lancet VOLUME 395, ISSUE 10240, P1855-1863, JUNE 13, 2020Cancer prevention with aspirin in hereditary colorectal cancer (Lynch syndrome), 10-year follow-up and registry-based 20-year data in the CAPP2 study: a double-blind, randomised, placebo-controlled trialProf John Burn, MD , Harsh Sheth, PhD †, Faye Elliott, MSc †Lynn Reed, Prof Finlay Macrae, MD, Jukka-Pekka Mecklin, MD, et al.

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41. What have we learned?Cancer remains a serious disease that many people will suffer and die fromScreening has an impact..Early referral especially of younger patients is importantFamily history is relevant to a subset of patientsLifestyle /environment is a major contributor to cancer incidenceCancer survivors are increasing and tertiary prevention requires vital resources to improve outcomes

42. What can we do?Public awareness campaignsPromote screening programsPromote healthy lifestyle choicesCommunity and GP awarenessRapid access symptomatic clinicsEasy access to specialists / investigations and treatments when diagnosed with cancer.Service improvements..ie..Pre-habilitation/ Surgical site infection /survivorship programs

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