勞工大腸癌採樣及防治講習 怡仁綜合醫院 胃腸科 黃文豪

Age-standardized incidence of colon cancer per 100,000 population in various populations for men (A) and women (B). Age-standardized incidence of colon cancer per 100,000 population in various populations for men (A) and women (B).

結腸癌發生人數按年齡及性別分類 台灣癌症登記資料庫 98年

結腸癌發生人數按臨床、病理分類 台灣癌症登記資料庫 98年

直腸癌發生人數按年齡及性別分類 台灣癌症登記資料庫 98年

直腸癌發生人數按臨床、病理分類 台灣癌症登記資料庫 98年

Factors that may influence carcinogenesis in the colon and rectum Probably causative High-fat and low-fiber diet (adjusted for energy intake) Red meat consumption Possibly causative Beer and alc. Consumpion( esp. for rectal ca.) Cigarette smoking Diabetes mellitus Enviromental carcinogens and mutagens Heterocyclic amines ( from charbroiled and fried meat and fish) Low dietary selenium Propably protective Aspirin, NSAID, and cyclooxygenase-2 inhibitors Calcium Hormone replacement therapy (estrogen) Low body mass Physical activity Possible protective Carotene-rich foods High-fiber diet Vitamins C and E Vitamin D Yellow-green cruciferous vegetable

Risk factors for colorectal cancer Age≧ 50 years High-fat, low-fiber diet Personal history of Colorectal adenomas (synchronous or metachronous) Colorectal carcinoma Family history of a polyposis syndrome: Familial adenomatous polyposis Turcost’s syndrome Muir-Torre syndrome Peutz-Jeghers syndrome Familial huvenile polyposis Hereditary nonpolyposis colorectal cancer First-degree relative with colorectal cancer Inflammatory disease Ulcerative colitis Chrohn’s disease

大腸直腸癌的形成過程

Colon polyps Two-thirds of polyps are adenomas (dysplasia) Adenoma prevalence 25% at age 50 and 50% by age 70 Risk of cancer increases with polyp size, number, and histology The polyp examined is representative of the individual’s propensity to form polyps and cancer

Colorectal Cancer (CRC) RCF-10 CRC Slides Section A 二○一七年三月十八日 Sporadic (average risk) (75-80%) Family history (10-15%) Rare syndromes (<0.1%) Hereditary non-polyposis colorectal cancer (HNPCC) (3-5%) Familial adenomatous polyposis (FAP) (1-2%) 14

5-Year Survival for CRC by Stage RCF-10 CRC Slides Section A 二○一七年三月十八日 100 70-90% 80 25-70% 65% % of patients 60 40 5-Year Survival for CRC by Stage The 5-year survival rate for patients with CRC is ~65%. This is dependent on the stage of disease at presentation. While only 37% of all patients with CRC are identified with localized stage I or II disease, 5-year survival for these patients is ~92%. Five-year survival rates drop to ~70% with involvement of adjacent organs or lymph nodes in stage III disease. Five-year survival is as low as ~10% in patients with stage IV disease with both nodal and metastatic involvement. The changing landscape of first- and second-line therapies for metastatic disease offers increased potential for prolongation of survival in such patients. With newer and more sophisticated diagnostic/imaging techniques in CRC, the number of patients diagnosed with early CRC may improve the overall 5-year survival rates for these patients. 20 5-10% All Stages Localized (Stage I and II) Regional Stage III Distant (Stage IV) SEER Cancer Statistics Review, 1975-2003. At: http://seer.cancer.gov/csr/1975_2003/results_merged/sect_06_colon_rectum.pdf. Accessed May 2006. 15

Screening = Prevention & Early Detection RCF-10 CRC Slides Section A 二○一七年三月十八日 Prevention = polyp removal Decreased Incidence Early Detection Decreased Mortality 16

*The U.S. Preventive Services Task Force recommends screening for adults of ages 50 to 75 years. Screening for adults of ages 76 to 85 years is not routinely recommended, and for adults older than 85 years, screening is not recommended. †Testing options are divided into those that detect adenomatous polyps and cancer (flexible sigmoidoscopy, colonoscopy, double-contrast barium enema, computed tomography colonography), and those that primarily detect cancer (FOBT, stool DNA testing). Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps 2008: a joint guideline from the American Cancer Society, the U.S. Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin 2008; 58:130-60. FOBT, fecal occult blood test. U.S. Preventive Services Task Force. Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Int Med 2008; 149:627-637. The U.S. Preventive Services Task Force recommends screening for adults of ages 50 to 75 years. Screening for adults of ages 76 to 85 years is not routinely recommended,and for adults older than 85 years, screening is not recommended. †Testing options are divided into those that detect adenomatous polyps and cancer (flexible sigmoidoscopy, colonoscopy, double-contrast barium enema, computed tomography colonography), and those that primarily detect cancer (FOBT, stool DNA testing).

Non-invasive testing for Colorectal carcinoma Stool test: Fecal occult blood test (FOBT) Chemical (guaiac-based FOBT) Immunochemical (iFOBT) Stool DNA test Serum test Tumor marker (CEA)?? Proteomics: analyze global pattern of protein expression (not available)

化學法 1.自西元1965年Okamoto等學者報告以來已有近50年的歷史 2.主要是利用紅血球中的過氧化酵素產生氧化還原反應，改變試劑顏色來判別。 3.臨床上常用的試劑依不同化學性質可分為兩種，一種是具有致癌性的O-Toluidine或 B e n z i d i n e ； 另一種是不具致癌性的 Guaiaconic acid(零陵香)。 4.每日糞便中血液若超過6-20克，就會有陽性反應。 5.三種試劑的敏感度以O-Toluidine 最高， 其次是B e n z i d i n e ， 再次為 Guaiaconic acid，但是敏感度越高越易受食物干擾，例如攝取含有動物血液或含鐵的食物，或是有嘴破、腸胃道發炎、出血、痔瘡等情況

化學法篩檢大腸直腸癌的檢查前準備建議 -美國癌症協會 (AMEICAN CACER SOCIETY) 檢查前三天禁止食用富含血色素及鐵質之食物， 例如紅肉、內臟、豬血等，此外例如甘藍、瓜類、花椰等蔬菜因富含過氧化酶也應禁食，以預防氧化還原反應造成偽陽性。 勿服用會造成胃部發炎的藥物，例如阿斯匹靈(Aspirin)或非類固醇類抗發炎藥物(NSAID)，因上消化道出血也會使判讀呈現陽性。 勿服用維他命C及抗氧化劑，避免因抑制氧化還原反應造成偽陰性。 連續三次糞便檢體，每次檢體做兩次檢查。 檢體採集至檢驗室檢查時間不超過六天，以免呈現偽陰性。 試劑片不能加水(re-hydration)，曾有研究指出加水可提高敏感度，但也因此降低了特異性。 單一陽性抹片，應被視為陽性檢查結果，甚至在未做飲食限制時。

免疫法 以單株抗原抗體檢測糞便中是否有人類紅血球的存在。 只與人類血紅素反應，專一性最高，不會誤認飲食裡其他動物的血液成份為出血，而且只與血紅素反應，如果出血來源是上消化道，血紅素在腸胃道近端就已被消化酵素代謝故不會顯現陽性，對下消化道出血有較高的專一性， 為篩檢大腸直腸癌的最佳檢查方法。 需有較嚴格的採檢時間(採檢後立即裝入特殊容器)以及送檢時間限制(建議於四十八小時內送至檢驗單位)

免疫法篩檢應注意的事項 受檢者不須特別限制食物，但有痔瘡便秘出血、血尿或月經期間不適合做此檢驗。 酒精及一些藥物如Aspirin, NSAIDs, 類固醇等藥物, 可能在有些病人身上造成腸胃刺激出血。這類物質應於受檢日前兩天起停用。 免疫法糞便潛血試驗所需之檢體為新鮮糞便，且應使用特定採便容器於糞便排出後立即採集，以採集棒碰觸穿刺採集3-6處不同部位的糞便檢體，採便容器內應有定量的保存劑。 非特定採便容器所採集之糞便檢體不可用於免疫法糞便潛血試驗，因沒有保存液的糞便，其中的血色素將快速被破壞而喪失抗原性。

糞便潛血檢驗方法比較

Stool DNA test

Tumor marker (CEA)

Disease Patients with Elevated CEA(％) Carcinoma of entodermal origin(colon,stomach,pancreas,lung) 60-75 Colon cancer Overall 63 Dukes Stage A 20 Dukes Stage B 58 Dukes Stage C 68 Lung cancer Small cell carcinoma About33 Non-small cell carcinoma About67 Carcinoma of entodermal origin(e.g,head and neck,ovary,thyroid) 50 Breast cancer Metastatic disease ≧50 Localized disease About25 Acute nonmalgnant inflammatory disease,especially gastrointestinal tract(e.g,ulcerative colitis,regional enteritis,diverticulitis,peptic ulcers,chronic pancreatitis) Variable Liver disease(alcoholic cirrhosis,chronic active hepatitis,obstructive jaundice) Renal failure,fibrocystic breast disease,hypothyrcidism) Healthy persons Nonsmokers 3 Smokers 19 Former Smokers 7

謝謝聆聽~