Screening for colorectal cancer with fecal occult blood testing and sigmoidoscopy.

BACKGROUND: The high incidence of and mortality from colorectal cancer (160,000 new cases and 60,000 deaths in the United States each year) are compelling public health concerns. Following the evolution of effective surgery for this disease since the 1960s, the focus has been on improving methods of detection and integrating them into effective screening programs. PURPOSE: This was the first study to evaluate the effectiveness, in a setting of comprehensive medical examinations, of using the fecal occult blood test in conjunction with sigmoidoscopy, rather than sigmoidoscopy alone, to screen for colorectal cancer. Our end points were extent of compliance with fecal occult blood test and sigmoidoscopy, numbers of cancers detected, and mortality rate. METHODS: From 1975 through 1979, a total of 21,756 patients (aged 40 and older) who presented at the Preventive Medicine Institute-Strang Clinic for routine medical examinations were enrolled by calendar period into study and control groups. Study patients were offered annually both rigid sigmoidoscopy examinations and fecal occult blood tests requiring two stool specimens per day for 3 days, while control patients were offered only annual sigmoidoscopy. The majority of fecal occult blood test cards were not rehydrated before assay. Patients with positive tests were referred for double-contrast barium enema and colonoscopy. Two distinct trials were carried out. Trial I was primarily a demonstration of feasibility of using the fecal occult blood test as a supplemental screening method. Of the 9277 participants, 7168 (77%) were assigned to the study group and offered the fecal occult blood test. In trial II, approximately half of the 12,479 patients were assigned to each group. Patients in both trials had follow-up through 1984. RESULTS: Compliance with the fecal occult blood test was initially high in both trials, but diminished such that only 56% of study patients in trial I and 20% of those in trial II returned for second tests. On the initial (prevalence) screen, a substantial number of early-stage cancers were detected by the fecal occult blood test, primarily in trial II. In trial II, survival probability was significantly greater (P < .001) in the study group than in the controls (70% versus 48%), and colorectal cancer mortality was lower (0.36 versus 0.63) with borderline significance (P = .053, one-sided). CONCLUSIONS AND IMPLICATIONS: The screening of average-risk individuals (aged 50 and older) for colorectal cancer through use of the fecal occult blood test in conjunction with sigmoidoscopy can increase the likelihood of early detection of this disease. This practice, coupled with prompt diagnostic work-up following positive tests, will result in treatment of earlier stage cancers and increased survival after treatment.

Reduced capacity for DNA repair synthesis in patients with or genetically predisposed to colorectal cancer.

Peripheral resting mononuclear leukocytes were compared for their capacities to repair DNA lesions induced by a 1-hour exposure to a standardized 10-microM dose of N-acetoxy-N-2-fluorenylacetamide (N-AcO-2-FAA). Leukocytes from the following 3 groups were studied: 39 control subjects, 40 patients after colonic resection because of colorectal cancer (disease-free at the time of this study), and 28 individuals with a hereditary predisposition to colorectal cancer. Although the level of N-AcO-2-FAA that bound to mononuclear leukocyte DNA was the same for the various population groups, the level of N-AcO-2-FAA-induced unscheduled DNA synthesis (UDS) was significantly reduced in the mononuclear leukocytes of individuals who had had colorectal cancer or a genetic predisposition for the disease. These findings indicate that a deficiency in mononuclear leukocyte DNA repair synthesis is associated with the development of colorectal cancer in these populations. Our observation of this nonspecific UDS deficiency (relating to colorectal cancer) was not explained by experimental variations among the sampled groups with regard to individual differences in lymphocyte heterogeneity, age, sex, smoking habits, or blood pressure.

Colonic epithelial cell proliferation in responders and nonresponders to supplemental dietary calcium.

Supplemental dietary calcium decreased and normalized hyperproliferation of colonic epithelial cells in individuals in familial colon cancer kindreds, measured by rates and patterns of [3H]thymidine labeling of epithelial cells in colonic crypts. In whole colonic crypts hyperproliferation was decreased to lower levels in over one-half of the subjects individually studied during the course of the calcium supplementation regimen. The remaining familial colon cancer subjects did not show reductions in cell proliferation measured over the whole crypt. However, when their cell-labeling data were analyzed in regions of the colonic crypt, the size of the proliferative compartment decreased and contracted towards the crypt base after calcium, a pattern typical of individuals at decreased risk for colonic cancer. This contraction of the proliferative region of the crypts occurred through decreased cell labeling in the two crypt compartments closest to the luminal surface and increased cell labeling in the second crypt compartment nearest to the base of the crypt. Following in vitro exposure of colonic epithelial cells to increasing physiological amounts of calcium, cell proliferation in familial colon cancer subjects decreased uniformly and greater heterogeneity in responsiveness was observed in cells from individuals with familial polyposis.

Heterogeneous responses of human colon carcinomas to hexamethylene bisacetamide.

Primary cultures of resected human colon carcinoma were used to study differentiation agents directly on the biologically relevant cancer cells rather than on highly selected established cell lines. To achieve primary cultures which remained viable and replicating for several days, carcinomas were partly digested to epithelial organoids, which were selectively plated with high efficiency on collagen I-bovine serum albumin films in specially formulated serum-free medium. A monoclonal antibody, 29-15, was identified which binds to a cell surface epitope expressed on 16 of 21 invasive colon carcinomas of the Dukes' B2, C, or D histopathology classes, but not expressed on any of 11 noninvasive benign tumors (adenomas) at identical antibody titer. Noncytotoxic concentrations of the differentiation agent, hexamethylene bisacetamide (HMBA), induced the loss of the 29-15 epitope from HT29 colon carcinoma cells. HMBA also induced HT29 cells to lose the capacity for anchorage-independent growth with a similar dose-response curve and time course to the loss of 29-15 epitope. Twelve primary cultured human colon carcinomas exhibited differential responses when exposed to 1 to 7 mM HMBA for 7 days. Four moderately to well-differentiated carcinomas lost expression of the 29-15 epitope at each HMBA concentration. The tumor growth fraction was decreased in each tumor, with a mean decrease of 76% at 5 mM HMBA. A dose-dependent induction of nonproliferating tumor colonies, lacking [3H]thymidine labeling, occurred in three of the four carcinomas. In six other tumors, including those at less differentiated stages, HMBA induced the opposite effect: a two- to threefold increase in the tumor growth fraction at the optimal value of 5 mM HMBA, an increase in mean colony size, and no loss of the 29-15 malignancy epitope. No effects were observed in the two other carcinomas tested. Thus HMBA was able to induce growth arrest and loss of the malignancy epitope 29-15 in those carcinomas already at an advanced stage of differentiation, and to exert a growth stimulating effect on those carcinomas apparently at more immature stages.

New chemotherapeutic drug sensitivity assay for colon carcinomas in monolayer culture.

Ten previously untreated colon carcinomas were tested for chemotherapeutic drug sensitivity in primary monolayer culture. Colon carcinomas were partly digested to groups of epithelial cells which plated with a mean efficiency of 42 +/- 9% (SE) on a collagen I-bovine serum albumin substrate in serum-free medium, producing patches of tightly adherent epithelial cells. The cultured cells were judged epithelial by the presence of cytokeratins, an epithelial cell surface epitope, junctional complexes, and brush borders. Each carcinoma was plated in 40 to 60 Petri dishes (35 mm), yielding a mean of 28 +/- 8 (SE) colonies per dish (6832 +/- 1952 cells). Drugs tested in duplicate plates were mitomycin C, cisplatin, streptozotocin, and 5-fluorouracil at 0.1, 1, 10, and 100 micrograms/ml, and at 0.1, 1, and 2x the peak tolerated drug concentration in serum. Twenty-four h after plating, any nonadherent cells were removed, and the adherent tumor cells were continuously exposed to the drugs for 3 days. Each drug induced colony lysis in a dose-dependent manner in responsive tumors. Drug-resistant, cycling cells were identified by [3H]thymidine incorporation in colonies which were not lysed by drug treatment. Each of the ten carcinomas exhibited inherent resistance to one or more chemotherapy drugs within the concentration ranges clinically achievable.

Unscheduled DNA synthesis in mononuclear leukocytes from patients with colorectal polyps.

The mononuclear leukocytes from peripheral blood samples of individuals with (n = 30) and without (n = 48) colonic polyps were examined for their abilities to carry out unscheduled DNA synthesis (UDS) induced by N-acetoxy-N-2-fluorenylacetamide (N-AcO-2-FAA). Individuals with polyps had significantly reduced UDS values compared to the nonpolyp group (P less than 0.01). Furthermore, in a more comprehensive study, patients with hyperplastic polyps had N-AcO-2-FAA-induced UDS values not significantly different from control individuals who were asymptomatic and free from colonic disease as judged by complete colonoscopy. However, patients who had had adenomatous polyps in their large bowel had significantly reduced levels of N-AcO-2-FAA-induced UDS in their mononuclear leukocytes (P less than 0.005). When N-AcO-2-FAA binding to DNA determinations were made in parallel and DNA repair proficiency indices were calculated (i.e., N-AcO-2-FAA-induced UDS/N-AcO-2-FAA binding to DNA), the patients with adenomatous polyps were still shown to be deficient in carrying out DNA repair synthesis. Since adenomatous polyps of the large bowel are considered the premalignant lesion for colorectal cancer, we postulate that reduced UDS may be a genetically sensitive marker that is useful in studying the mechanisms of genetic predisposition to colorectal cancer.

Expansion of the epithelial cell proliferative compartment and frequency of adenomatous polyps in the colon correlate with the strength of family history of colorectal cancer.

Expansion of the proliferative compartment of epithelial cells in colonic crypts and colonic adenomas have been described as phenotypic precursors to colon cancer in individuals affected with hereditary or sporadic colon cancer. This study measured the size of the proliferative compartment in colonic crypts and the frequency of adenomas in asymptomatic members of families having sporadic colorectal cancer. The subjects were divided into 2 groups according to the frequency of colorectal cancer in their families. A shift of the compartment of proliferating epithelial cells toward the lumenal surface of colonic crypts was seen in the group of subjects with a stronger family history of colorectal cancer, with significant differences in the numbers of proliferative cells in the upper and the lower crypt compartments (P < 0.05) and in the fraction of proliferative cells at the highest compartment at the lumenal surface of the crypts (P < 0.05). Cell proliferation patterns in normal-appearing mucosa of the 2 groups revealed no difference in whole crypt [3H]thymidine labeling index. Colonoscopic examination of the 56 subjects revealed an overall prevalence of adenomas of 21%; when stratified by frequency of colorectal cancer in their families, 3 of 22 subjects (14%) with a weaker family history had adenomas, while 9 of 34 (26%) with a stronger family history had adenomas. Thus, parallel abnormalities of colonic epithelial cell proliferation and neoplasia were seen in individuals with a family history of colorectal cancer, both of which were more pronounced with increasing strength of family history. This observation provides further evidence of relationships among these factors in the etiology of "sporadic" colorectal cancer.

Beneficial effect of human growth hormone on stress ulcers.

Human growth hormone was effective in healing erosions and controlling hemorrhage in six of eight patients with stress ulcers. This approach was based on known beneficial effects of growth hormone on nucleic acid and protein synthesis, demonstration of deleterious effects of stress on nucleic acid and protein synthesis, and demonstrated protective effects of growth hormone on animals subjected to stress. Bleeding cessation within 24 hours of its administration in two patients suggests the possible role of additional mechanisms involved in hemostasis. In a comparable group of eight patients with stress ulcer hemorrhage not treated with this agent, six died with continued bleeding. This high mortality represented the usual outcome in our patients with stress ulcer hemorrhage. These observations need to be extended to additional patients with stress ulcers in a larger randomized study.

Diagnosis and prevention of gastrointestinal malignancies.

The consistently high mortality rates associated with gastrointestinal cancer result in large part from malignancies that progress undetected to an advanced stage of disease when treatment is usually less effective. In response to this fact, increasing attention has been directed toward developing methods of both primary and secondary prevention of malignancies. Advances in primary prevention have resulted in a better understanding of various etiologic factors in the environment that are related to carcinogenesis and how they can be corrected or eliminated. Advances in secondary prevention have improved efforts to identify and eradicate the premalignant stages of gastrointestinal cancer before lethal consequences can develop. Refinements in screening methods and improvements in diagnostic procedures, such as the introduction of endoscopic ultrasound, will allow physicians to detect gastrointestinal cancers and their premalignant forerunners at an earlier stage in an effort to render treatment strategies more effective.

Screening diagnosis and staging of esophageal cancer.

In geographic areas where there is a high risk of esophageal cancer, analysis of cells obtained from the esophagus has been used effectively to detect early lesions. This has been demonstrated on a large scale in studies from China. Using abrasive balloon cytology techniques, 75% of the cancers detected were early lesions, where the 5-year survival after resection was in the range of 90%. Endoscopic followup studies indicate that dysplastic changes in the esophageal mucosa are a common precursor to malignancy. In many cases, the time course from dysplasia to carcinoma in situ to early invasive cancer may take place over many years, allowing a reasonable amount of time for screening. In low-incidence areas, such as the United States, most esophageal cancers are related to the excessive use of tobacco and alcohol. These factors are too common and the incidence of the disease too low, however, to justify screening on this basis. There are smaller groups at higher risk where selective screening by endoscopy with cytology and biopsy is recommended, usually every 1 to 3 years. These include patients with longstanding achalasia, lye strictures, and Plummer- Vinson syndrome. Patients with cancers of the head and neck region and patients with celiac disease may also be considered to be at increased risk. Tylosis is a rare inherited disease with a very high risk of esophageal cancer. There is an increased incidence of adenocarcinoma of the esophagus with Barrett's epithelium, and once identified such patients should be kept under endoscopic surveillance. The finding of severe dysplasia in any of these groups would indicate a shorter screening interval. Most patients with symptoms referable to the esophagus are first tested by barium esophagram. If negative, with persistent symptoms or if a suspicious lesion is identified, endoscopy with cytology and biopsy is recommended. Staging of the cancer is based on the size of the cancer both longitudinally and circumferentially and the presence of extraesophageal spread. At the present time, CT is the best noninvasive method for judging the extent of the cancer. Performance and nutritional status are also determinants of prognosis and should be considered in planning treatment.

Screening and surveillance for colorectal cancer.

Colorectal cancer is the second most common cause of cancer death among American men and woman. Currently available screening and surveillance techniques are effective in detecting early-stage colorectal cancer and its premalignant precursor lesion, the adenomatous polyp (adenoma). Removal of adenomas by colonoscopic polypectomy significantly reduces the incidence of colorectal cancer. Appropriate screening and surveillance recommendations should be based on the individual's colorectal cancer risk stratification. High-risk groups, such as patients with hereditary nonpolyposis colorectal cancer (HNPCC) and familial adenomatous polyposis (FAP), should be offered genetic counseling and specialized screening recommendations for colorectal and associated extracolonic malignancies.

Natural history of colorectal cancer.

Colorectal cancer arises from a precursor lesion, the adenomatous polyp, which forms in a field of epithelial cell hyperproliferation and crypt dysplasia. Progression from this precursor lesion to colorectal cancer is a multistep process, accompanied by alterations in several suppressor genes that result in abnormalities of cell regulation, and has a natural history of 10-15 years. Environmental factors and inherited susceptibility play major roles in this sequence of events. As a result of familial and genetic studies, we now have a better understanding of various high-risk groups and the application of screening methods to these individuals and to people at average risk. In the future, further identification of genetically predisposed individuals and colonoscopic screening of the general population may provide new opportunities for control of colorectal cancer through secondary prevention, and a better understanding of lifestyle factors and their modification will lead to improved strategies for primary prevention.

Tritiated-thymidine labeling of rectal epithelial cells in 'non-prep' biopsies of individuals at increased risk for colonic neoplasia.

Recent measurements have shown increased proliferation of colonic epithelial cells in individuals at heightened risk for cancer of the large intestine. This biomarker has facilitated measurements of the effects of nutritional intervention in studies that are attempting to inhibit tumor development in high-risk individuals. In this study, further measurements were made of the proliferation of rectal epithelial cells, when biopsies were removed from mucosa that had not previously been disturbed by any tapwater or other enema preparations. Progressive increases were found in the numbers of [3H]dThd-labeled epithelial cells in rectal crypts, and in labeling index profiles, in patients having previous sporadic adenomas or colon cancer, compared to individuals who had not developed colonic neoplasms. The most quiescent proliferative equilibrium was found in individuals without previous colonic disease. Findings indicated that 'non-prep' rectal biopsies obtained from the most accessible region of the large intestine, show modifications in the biomarker of cell proliferation paralleling colon cancer risk.

Screening and surveillance for colorectal carcinoma.

Screening and surveillance examinations are effective in lowering colorectal cancer risk. Screening tests have been demonstrated to reduce colorectal cancer mortality. Colonoscopic removal of adenomatous polyps has been determined to reduce colorectal cancer incidence. High-risk individuals and their family members should be identified and offered more aggressive recommendations for appropriate screening and surveillance guidelines. Colorectal cancer screening strategies are in an acceptable range of cost effectiveness.

Recurrent deletions involving chromosomes 1, 5, 17, and 18 in colorectal carcinoma: possible role in biological and clinical behavior of tumors.

We have employed cytogenetic and restriction fragment length polymorphism (RFLP) analysis to identify a full spectrum of cytogenetic and molecular alterations associated with initiation and progression of "sporadic" colorectal cancer and also to correlate the alterations with biological and clinical behavior of the tumors. The study series included 63 colorectal cancers, 47 primary and 16 metastatic recurrences. Cytogenetic analysis was successful in 48 tumors (76%) of which 44 (91%) were abnormal. Of these 44 tumors, clonal abnormalities were identified in 43, whereas chromosomes from one tumor were unsuitable for complete analysis. Each of these abnormal tumors displayed heterogeneity with regard to extent and complexity of recurrent chromosomal abnormalities. Numerical losses of chromosomes 17 and 18 (20-34%) and gains of chromosome 7 (28%) were significantly higher. The four most frequent structural rearrangements on the other hand, involved specific regions of chromosomes 1p, 5q, 17p, and 18q. The shortest regions of overlap of these rearrangements or losses were located at 1p36, 5q21-22, 17p13 and 18q21- > ter. RFLP analysis directed at 1p, 5q, 17p and 18q identified allelic deletions of these regions in 39 tumors (64%) which included 17 normal and 11 cytogenetic failures. Of all the informative tumors, 32%, 37%, 31%, and 63% showed allelic losses at chromosomes 1p, 5q, 17p and 18q respectively. The two methods of analysis (cytogenetics and RFLP) employed to identify genetic alterations were complementary; probes for chromosome 1 and 18 showed the greatest degree of concordance, whereas probes for chromosomes 5 and 17 provided relatively higher rate of discordance with cytogenetic results. These differences could be attributed mainly to three reasons: 1) a limited number of probes used for RFLP analysis; 2) contamination of tumor cells with normal cells, and 3) either mutational inactivation or deletion of specific alleles not closely linked to the probes used. Regardless of these limitations, however, the combined use of cytogenetic and RFLP identified genetic alterations in a large number of tumors and help elucidate the role of hyperdiploidy and/or relative deficiency of a given chromosomal segment in expression of recessive mutations. In addition, alterations of either chromosomes 1 or 17 predicted poorer survival for the patients with primary colorectal cancer (p = 0.03).

Natural history and current management of colorectal polyps.

There are numerous histological types of colon polyps. The neoplastic polyp, the precursor to colon cancer, is called an adenoma. Adenomas vary in frequency throughout the world and are particularly prevalent in Western countries. The belief that after several years of development some adenomas will become cancers is termed the adenoma-carcinoma sequence. These adenomas occur in both males and females and their incidence increases with age. While small polyps were once considered unimportant, it is now recognized that adenomas may be small. The clinical importance of other small polyps, most often hyperplastic polyps, is still being investigated. When adenomas are found in the colon a full colonoscopy with removal of all polyps and review of their pathology should be performed.

Colorectal cytology in chronic ulcerative colitis.

During a period of ten years, 109 colorectal cytology specimens were obtained from 41 patients with chronic ulcerative colitis. There were 28 male and 13 female patients, whose average age was 45 years. All patients were symptomatic and had ulcerative colitis with repeated attacks of profuse diarrhea on the average for 12 years prior to their first cytologic examination. Eight cytology specimens were positive for malignant cells, 35 had atypia, 58 were negative and 8 were unsatisfactory. The malignant cells showed marked anisocytosis, pleomorphism and nuclear hyperchromasia and appeared in loosely cohesive clusters or in single forms in an inflammatory and necrotic background. Subsequent colectomy revealed invasive carcinoma in five patients and carcinoma in situ in two. Smears that were negative or showed atypia contained abundant chronic inflammatory cells. The atypical colonic epithelial cells contained prominent nuclei and formed cohesive clusters. Surgical biopsy and/or segmental resection revealed the presence of polyps, pseudopolyps, polypoid hyperplasia, mucosal atypia and crypt abscesses in patients with atypical and negative cytologic findings. It is concluded that cytologic examination of the colon can play an important role in the examination of patients with ulcerative colitis and allows for the detection of malignant transformation of the colonic mucosa.

Colon and rectal cancer: etiology and screening.

Our ultimate goal is primary prevention of colorectal cancer by delineating the etiologic factors in the pathogenesis of the disease and eliminating or modifying these factors. Further research is needed to accomplish this goal. In the meantime, early detection of colorectal cancer and its precursor lesions can be accomplished by methods currently available. Ultimately, a simple biochemical or immunologic test may become available which will identify individuals at high risk for colon cancer and may indicate that a very early lesion is present. This is the ultimate goal for secondary cancer prevention since the disease would then be discovered at a curable stage in almost all patients.

Hemorrhagic gastritis: current concepts.

Hemorrhagic gastritis is a common cause of upper GI hemorrhage, in which the clinical course may vary from a mild, self-limited illness when associated with gastric irritants, to lifethreatening massive hemorrhage when associated with stress in critically ill patients. Treatment is based upon early endoscopic diagnosis, withdrawal of offending gastric irritants, intensive organ system support, and reduction of gastric acidity. Angiographic techniques and surgery are restricted to patients who fail these supportive measures, often after blood replacement beyond the usual criteria for operative intervention, usually in patients with stress. Newer pharmacologic and endoscopic therapeutic modalities are under evaluation and may help improve survival among patients with massive hemorrhage from stress ulcer.