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Continued efforts needed to prevent rise in colon cancer
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ORLANDO — Evidence of successful efforts in colon cancer prevention exist; however, the increasing incidence among a younger population is alarming and continued efforts are needed to combat the incidence and mortality associated with this devastating disease, according to a lecturer at the World Congress of Gastroenterology at ACG 2017.
“Progress has been made — we have seen a real increase in colorectal screening rates from about 30% in 2000, when Katie Couric first went on the air as a public advocate and when the first roundtable was formed, to more than 70% in certain places across the United States,” Mark B. Pochapin, MD, FACG, of the NYU Langone Medical Center, said during The Emily Couric Memorial Lecture. “This is something that has given me the most gratification — knowing that our efforts are working. Of note, this is something that is relatively unique to the United States and is not happening in other areas of the world. We are doing a great job, but we have to do better. The focus now needs to be on the increasing incidence of colon cancer in younger adults. The focus needs to be aimed at increasing quality benchmarking and access, public advocacy and public outreach.”
In memoriam
Pochapin honored the passing of Virginia State Senator Emily Couric, for whom the lecture is named. Couric died of pancreatic cancer in 2001.
Senator Couric was a devoted advocate for health care issues, particularly in her instrumental work to pass the nation’s first legislation mandating health insurance coverage for colorectal cancer screening in the state of Virginia, according to Pochapin.
“I am grateful to present this talk, especially because I knew Emily and anyone who knew her and were lucky enough to know her experienced the incredible enthusiasm in everything she did,” Pochapin said. “Emily passed away from pancreatic cancer at the young age of 54, yet so much has happened in health care because of her. She mandated colorectal screening for everyone in the state of Virginia and also mandated that colonoscopy would be paid for by insurance companies. This was a big deal back then because insurance was giving everyone a hard time about coverage. What a great contribution for our patients.”
The Emily Couric Memorial Lecture was developed by the ACG, the Virginia Gastroenterological Society and the Old Dominion Society of Gastroenterology Nurses and Associates, to honor Couric’s energy, motivation and passion to make a difference for all.
Regarding public awareness of colon cancer, Pochapin said this is where the tragedy of Jay Monahan comes into play. Monahan, Katie Couric’s husband and Emily Couric’s brother-in-law, was diagnosed with colon cancer in 1997, a “pivotal year in colon cancer screening” because colonoscopy became part of the guidelines.
“Prior to this, a patient had to have blood in stool in order for us to perform a colonoscopy,” he said. “Now, we can do a colonoscopy for no other reason than they are age 50 years and the guidelines suggest it.”
That same year, the national CRC roundtable was formed and just 3 years later, Katie Couric had her on-air colonoscopy.
“When I diagnosed Jay Monahan, his disease was widely metastatic and he died only 6 months after diagnosis. Jay’s wife, Katie Couric, did not want others to suffer the same experience and she realized that she could do more to advocate for colorectal cancer screening than physicians could.”
Soon after her on-air test, there was a significant increase in monthly colonoscopy rates, now known as the ‘Katie Couric effect.’
“It was extraordinary how people literally ran to go get their colonoscopy after they saw her on-air test and heard about what happened to Couric’s husband. She became a public advocate,” he said.
Disparities remain
Although progress has been made, disparities in colon cancer remain, Pochapin said.
“It is important to know that there are key disparities in colon cancer incidence and mortality — blacks have a higher incidence than any other race,” he said. “We are additionally seeing people of a young age, between 20 and 44 years, with a higher incidence if they are black when compared with other races. There is higher mortality in this population and a younger-onset of disease. This is why the new multi-society recommendations were recently updated to include younger screening among blacks at age 45 years. The incidence of colon cancer in the young black population is skyrocketing.”
While the reason for this increase in incidence is not definitively known, Pochapin discussed some of hypotheses, including the potential change in the microbiome, overuse and misuse of antibiotics, a diet rich in meats, sugars, carbohydrates and fats, the increased obesity rate and decrease in physical exercise.
“The bottom line is that we need more research on this,” Pochapin said.
Diagnostic innovations
Colonoscopy innovations, such as food prep options and a novel irrigation bowel prep technology are on the horizon while development of new scope designs, including disposable (invendo) and attachments and the PillCam (Medtronic) enter the market regularly.
“While these new developments decrease the adenoma miss rate on first pass, they are still not detecting 100% of polyps,” Pochapin said. “We are still missing polyps with these technologies, thus, technology must not act as a substitute for quality.”
Pochapin additionally discussed innovations in blood tests and volatile organic compounds in screening for colon cancer.
Results of a phase 1 study assessing the Septin 9 Gene blood test, which encodes for a protein involved in cytokinesis and cytoskeletal remodeling, showed only a 48.2% sensitivity and 91.5% specificity. A later phase 2 prospective multi-center trial showed there was an improvement in the test’s sensitivity (73% vs. 68%) and a decrease in specificity (81% vs. 97%) compared with the fecal immunochemical test.
“A blood test for colon cancer screening is something that everyone wants. However, the Septin 9 Gene blood test is not yet recommended by the multi-society guidelines,” Pochapin said.
Perhaps more promising, according to Pochapin, is the potential for cancer detection with ‘man’s best friend.’
“We know about CAT scans and PET scans, but now we have DOG scans,” he said. “There are volatile organic compounds in breath and stool that are evaluated by a trained Labrador retriever and the dog can detect one out of five samples. VOCs are being picked up by dogs — dogs are clearly detecting cancer. By breath, there is a 91% sensitivity and by stool there is a 97% sensitivity. For specificity, there is a 99% with both breath and stool.”
He said the overall concept is that every disease has a ‘breath print’ and this can be isolated in the same way the microbiome or genome sequence is isolated.
“We may be able to isolate a certain type of disease. What is exciting in colon cancer is these isolates cluster in a way that seem distinct from any other — colorectal breath analyses have a distinct array of volatile organic compounds,” he said.
Looking ahead
Quality, access and education will move us forward in colon cancer, Pochapin said.
“An important practice of quality is being able to optimize what we do and I cannot stress enough how important the GIQuIC is in creating a repository of our procedures,” he said. “This is definitely something that is going to change the way we do things.”
He added that access to screening is also key and stressed the importance of ensuring that the underserved and uninsured are taken care of with discounted or free screening.
“We have to make sure that we have navigators and decrease ‘no-shows’ for these tests. We also have to know the importance of legislation, because when we legislate something, it becomes a priority. Finally, the public needs to be educated. The 80% by 2018 campaign currently has more than 1,500 pledges for colon cancer screening. If we can achieve 80% coverage of colonoscopies by 2018, we can prevent 277,000 cases of colorectal cancer and 203,000 colorectal cancer deaths by 2030. We are all a part of a team and the importance of each individual on this team is crucial in the prevention of colon cancer.” – by Jennifer Southall
Reference:
Church TR, et al. Gut. 2014; 63:317-325.
Johnson DA, et al. PLoS ONE. 2014;doi:10.1371/journal.pone.0098238.
Pochapin MB. Emily Couric Memorial Lecture. Presented at: World Congress of Gastroenterology at American College of Gastroenterology Annual Scientific Meeting; Oct. 13-18, 2017; Orlando, FL.
Disclosure: Pochapin reports serving on the advisory committee and being a board member for AcuamarkDx.