Colorectal Cancer in Inflammatory Bowel Diseases: A Population-Based Study in Utah

BACKGROUND AND AIMS

The molecular, endoscopic, and histological features of IBD-associated CRC differ from sporadic CRC. The objective of this study was to describe the prevalence, clinical features, and prognosis of IBD-associated CRC compared to patients with sporadic CRC in a US statewide population-based cohort.

METHODS

All newly diagnosed cases of CRC between 1996 and 2011 were obtained from Utah Cancer Registry. IBD was identified using a previously validated algorithm, from statewide databases of Intermountain Healthcare, University of Utah Health Sciences, and the Utah Population Database. Logistic regression was performed to identify risk factors associated with IBD-associated cancer and Cox regression for differences in survival.

RESULTS

Among 12,578 patients diagnosed with CRC, 101 (0.8%) had a prior history of IBD (61 ulcerative colitis and 40 Crohn's disease). The mean age at CRC diagnosis was greater for patients without IBD than those with IBD (67.1 vs 52.8 years, P < 0.001). Individuals with IBD-associated CRC were more likely to be men (odds ratio [OR] 1.90, 95% CI 1.23-2.92), aged less than 65 years (OR 6.77, 95% CI 4.06-11.27), and have CRC located in the proximal colon (OR 2.79, 95% CI 1.85-4.20) than those with sporadic CRC. Nearly 20% of the IBD-associated CRCs had evidence of primary sclerosing cholangitis. After adjustment for age, gender, and stage at diagnosis, the excess hazard of death after CRC diagnosis was 1.7 times higher in IBD than in non-IBD patients (95% CI 1.27-2.33).

CONCLUSIONS

The features of patients with CRC and IBD differ significantly from those without IBD and may be associated with increased mortality.

Abstract 2706: KRT16 germline mutation associated with familial syndrome of tylosis with esophageal cancer (TOC)

Tylosis (palmoplantar keratoderma) with esophageal cancer (TOC) also known as Howel-Evans syndrome has been associated with pathogenic mutations in RHBDF2. A potential TOC family was referred for clinical evaluation at the Family Cancer Assessment Clinic (FCAC) at Huntsman Cancer Institute, Salt Lake City, Utah. Multiple relatives of the proband had hyperkeratosis on the areas of skin associated with pressure and friction, especially the feet, as well as oral leukoplakia. The proband’s father, paternal aunt, paternal grandfather, and paternal great grandfather had been diagnosed with esophageal cancer. Clinical testing was unable to identify a germline mutation in RHBDFR2 that explained the observed phenotype and inheritance pattern. As part of Heritage 1K Project (University of Utah), Pediatric & Adult Cancer Section, we performed whole genome sequencing (WGS) on 5 family members, 4 that were affected with the hyperkeratosis, and 1 unaffected family member, to identify other potential genetic causes for the observed TOC phenotype. We prioritized variants via VAAST (Variant Annotation, Analysis and Search Tool). Reducing our genes of interest to those involved in palmoplantar keratoderma with PHEVOR (Phenotype Driven Variant Ontological Re-ranking Tool), we identified a pathogenic mutation: KRT16 c.379C&gt;T p.Arg127Cys. This mutation is reported in a large palmoplantar keratoderma family (without esophageal cancer) and is listed as pathogenic in Clinvar (www.ncbi.nlm.nih.gov/clinvar). KRT16 c.379C&gt;T p.Arg127Cys was present in each of the affected family members, but not in the unaffected relative. Our analysis is the first of its kind to suggest carriers of pathogenic variants in KRT16 are at-risk for esophageal cancer, and may benefit from esophageal surveillance. Additionally, patients presenting with a family history of esophageal cancer should be considered for germline testing for KRT16 mutations along with RHBDF2 mutations.

Citation Format: Erin L. Young, Lance Pflieger, Luke Maese, Trent Fowler, Kinley Garfield, N. Jewel Samadder, Bella Johnson, Clinton C. Mason, Barry Moore, Shawn Ryanearson, Mark Yandell, Wendy Kohlmann, Joshua D. Schiffman. KRT16 germline mutation associated with familial syndrome of tylosis with esophageal cancer (TOC) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 2706. doi:10.1158/1538-7445.AM2017-2706

Improvements in Colorectal Cancer Incidence Not Experienced by Nonmetropolitan Women: A Population-Based Study From Utah

PURPOSE

Little is known about disparities in colorectal cancer (CRC) incidence and mortality by community-level factors such as metropolitan status.

METHODS

This analysis utilized data from the Surveillance, Epidemiology, and End Results (SEER) program from Utah. We included patients diagnosed with CRC from 1991 to 2010. To determine whether associations existed between metropolitan/nonmetropolitan county of residence and CRC incidence, Poisson regression models were used. CRC mortality was assessed using multivariable Cox regression models.

FINDINGS

CRC incidence rates did not differ between metropolitan and nonmetropolitan counties by gender (males: 46.2 per 100,000 vs 45.1 per 100,000, P = .87; females: 34.4 per 100,000 vs 36.1 per 100,000, P = .70). However, CRC incidence between the years of 2006 and 2010 in nonmetropolitan counties was significantly higher in females (metropolitan: 30.4 vs nonmetropolitan: 37.0 per 100,000, P = .002). As compared to metropolitan counties, the incidence of unstaged CRC in nonmetropolitan counties was significantly higher in both males (1.7 vs 2.8 per 100,000, P = .003) and females (1.4 vs 1.6 per 100,000, P = .002). Among patients who were diagnosed between 2006 and 2010, metropolitan counties were found to have significantly increased survival among males and females, but nonmetropolitan counties showed increased survival only for males.

CONCLUSIONS

While we observed a decreasing incidence of CRC among men and women in Utah, this effect was not seen in women in nonmetropolitan areas nor among those with unstaged disease. Further studies should evaluate factors that may account for these differences. This analysis can inform interventions with a focus on women in nonmetropolitan areas.

Abstract IA11: Chemoprevention in hereditary GI cancer syndromes

Chemoprevention offers an attractive option to prevent the occurrence of cancer in high risk cancer syndromes, such as familial adenomatous polyposis (FAP) and Lynch syndrome. However, data, especially from clinical trials, is sparse. This presentation will review the state of art concepts of chemoprevention in regards to these hereditary GI cancer syndromes.

Lynch Syndrome: In the randomized CAPP2 trial, 861 participants with Lynch syndrome took either daily aspirin (600 mg) or placebo for up to 4 years; the primary endpoint was the development of CRC (1). After a mean follow-up of 55.7 months, participants taking daily aspirin for at least 2 years had a 63% reduction in the incidence of CRC (incidence rate ratio [IRR], 0.37; 95% CI, 0.18–0.78; P = .008). These participants also saw a reduced risk from all Lynch syndrome cancers (IRR, 0.42; 95% CI, 0.25–0.72; P = .001). Risk of colorectal neoplasia was unaffected, and there was no protection seen for participants who completed &lt;2 years of the intervention. Subgroup analyses from this trial showed that the association between obesity and CRC in patients with Lynch syndrome may be attenuated by taking daily aspirin (2). However, limitations of the CAPP2 trial highlight the need for larger and long-term randomized trials in this area (3, 4). Similar findings have been reported in an observational study from the Colon Cancer Family Registry. In 1,858 patients who have Lynch syndrome, aspirin use was associated with reduced risk of CRC, for both patients who took aspirin for 5 or more years (HR, 0.25; 95% CI, 0.10—0.62; P = .003) and between 1 month and 4.9 years (HR, 0.49; 95% CI, 0.27—0.90; P = .02), compared to those who took aspirin for less than 1 month (5)

Based on the limited evidence above, we suggest that aspirin may be used to prevent cancer in patients with Lynch syndrome, but it is emphasized that the optimal dose is currently unknown. This is consistent with the stance of the American Gastroenterological Association (6). In contrast, the American College of Gastroenterology does not recommend standard use of aspirin for chemoprevention (7). Many expert clinics advise their patients with LS to use either 81 mg or 300 mg per day of Aspirin, which may provide a chemopreventive benefit while reducing the likelihood of side effects (ie. peptic ulcer disease, gastrointestinal bleeding, hemorrhagic stroke)—but again this dosing has yet to be shown to be effective in clinical trials. The CAPP3 trial which is currently enrolling participants in Europe will involve a double blind dose non-inferiority trial comparing 100, 300 or 600 mg daily in 3,000 Lynch syndrome gene carriers and will provide much needed clarity, however not for at least 5 years.

Familial Adenomatous Polyposis: FAP has always been first and foremost a surgical disease, whose treatment with colectomy has long been known to reduce the risk of premature death. Because prophylactic colectomy carries appreciable short and long-term complications, there has always been a desire to reduce polyp burden and potentially delay surgical intervention through the use of medication. However, most of the clinical trials efforts to date have dealt with patients who have already undergone prophylactic colectomy and in whom recurrent adenomas in the retained rectum are being managed. Nonsteroidal anti-inflammatory agents have been the most commonly employed chemopreventive agents, with sulindac being the most extensively studied and clinically used. Review of all the historical clinical trials is beyond the scope of this paper but we will selectively highlight the most significant. The most influential and often cited study supporting the use of sulindac is a relatively small but controlled trial by Giardiello et al. 22 FAP patients (18 of whom had not yet undergone colectomy) were treated for 9 months with sulindac at a dose of 150 mg twice a day and assessed at intervals of 3 months (8). A 56% reduction in adenoma count and 65% reduction in average adenoma diameter were observed. However, no complete adenoma regression was observed and regrowth occurred by 3 months following discontinuation of sulindac, implying the need for continuous therapy. Similar findings have been shown in a number of other studies, varying the dose of the sulindac or route of delivery and length of follow-up (9-11). There is concern that sulindac therapy changes the morphology of adenomas from protruding to flat lesions and that such lesions continue to serve as precursors for CRC development but are more difficult to visualize and remove with optic colonoscopy (12, 13). Celecoxib, a selective Cox-2 inhibitor which potentially has the advantage of reduced gastrointestinal side effects, was found to have an adenoma regression effect only at higher doses of 400 mg twice a day. However, the Food and Drug Administration indication of FAP for Celebrex was withdrawn recently due to a failure to perform a postmarketing study intended to verify clinical benefit.

Sulindac, though not available in all countries, is used in the US at a dose of 150 mg twice daily primarily for the control of polyposis in the retained rectum of patients with FAP who have already undergone a colectomy with an IRA or an IPAA with a rectal cuff. It is imperative that these patients continue to undergo annual surveillance due to the risk of subsequent cancers.

Patients with FAP are also at greatly increased risk for duodenal neoplasia, with duodenal adenomas eventually forming in &gt;50% of patients and duodenal adenocarcinoma occurring in up to 12% (14, 15). Following colectomy, duodenal adenocarcinoma is the leading cause of cancer death in these patients, and prevention of duodenal adenocarcinomas by endoscopic surveillance with polyp resection, duodenectomy, Whipple surgical procedure, and ampullectomy are often challenging and suboptimal (16). NSAIDs have much less efficacy in duodenal adenomas (17, 18). A recent trial involving 92 FAP patients randomized to therapy with dual COX and epidermal growth factor receptor (EGFR) inhibition, with sulindac 150 mg twice daily and erlotinib 75 mg daily respectively, reported a 71% decrease in duodenal polyp burden after 6 months of therapy (19). However, the frequency of side effects, primarily an acne-like rash, may limit the use of these medications at the doses used in this study. Follow-up clinical trials with EGFR inhibition are now underway to explore reduced dosing options to mitigate these side effects while retaining chemopreventive efficacy.

References

1. Burn J, Mathers JC, Bishop DT. Chemoprevention in Lynch syndrome. Familial cancer. 2013;12(4):707-18. Epub 2013/07/25.

2. Movahedi M, Bishop DT, Macrae F, Mecklin JP, Moeslein G, Olschwang S, et al. Obesity, Aspirin, and Risk of Colorectal Cancer in Carriers of Hereditary Colorectal Cancer: A Prospective Investigation in the CAPP2 Study. J Clin Oncol. 2015. Epub 2015/08/19.

3. Cleland JG. Does aspirin really reduce the risk of colon cancer? Lancet. 2012;379(9826):1586; author reply 7. Epub 2012/05/01.

4. Jankowski J, Barr H, Moayyedi P. Does aspirin really reduce the risk of colon cancer? Lancet. 2012;379(9826):1586-7; author reply 7. Epub 2012/05/01.

5. Ait Ouakrim D, Dashti SG, Chau R, Buchanan DD, Clendenning M, Rosty C, et al. Aspirin, Ibuprofen, and the Risk of Colorectal Cancer in Lynch Syndrome. Journal of the National Cancer Institute. 2015;107(9). Epub 2015/06/26.

6. Rubenstein JH, Enns R, Heidelbaugh J, Barkun A. American Gastroenterological Association Institute Guideline on the Diagnosis and Management of Lynch Syndrome. Gastroenterology. 2015;149(3):777-82; quiz e16-7. Epub 2015/08/01.

7. Syngal S, Brand RE, Church JM, Giardiello FM, Hampel HL, Burt RW. ACG clinical guideline: Genetic testing and management of hereditary gastrointestinal cancer syndromes. Am J Gastroenterol. 2015;110(2):223-62; quiz 63. Epub 2015/02/04.

8. Giardiello FM, Hamilton SR, Krush AJ, Piantadosi S, Hylind LM, Celano P, et al. Treatment of colonic and rectal adenomas with sulindac in familial adenomatous polyposis. The New England journal of medicine. 1993;328(18):1313-6.

9. Winde G, Gumbinger HG, Osswald H, Kemper F, Bunte H. The NSAID sulindac reverses rectal adenomas in colectomized patients with familial adenomatous polyposis: clinical results of a dose-finding study on rectal sulindac administration. International journal of colorectal disease. 1993;8(1):13-7. Epub 1993/03/01.

10. Winde G, Schmid KW, Schlegel W, Fischer R, Osswald H, Bunte H. Complete reversion and prevention of rectal adenomas in colectomized patients with familial adenomatous polyposis by rectal low-dose sulindac maintenance treatment. Advantages of a low-dose nonsteroidal anti-inflammatory drug regimen in reversing adenomas exceeding 33 months. Diseases of the colon and rectum. 1995;38(8):813-30. Epub 1995/08/01.

11. Cruz-Correa M, Hylind LM, Romans KE, Booker SV, Giardiello FM. Long-term treatment with sulindac in familial adenomatous polyposis: a prospective cohort study. Gastroenterology. 2002;122(3):641-5. Epub 2002/03/05.

12. Lynch HT, Thorson AG, Smyrk T. Rectal cancer after prolonged sulindac chemoprevention. A case report. Cancer. 1995;75(4):936-8. Epub 1995/02/15.

13. Matsumoto T, Nakamura S, Esaki M, Yao T, Iida M. Effect of the non-steroidal anti-inflammatory drug sulindac on colorectal adenomas of uncolectomized familial adenomatous polyposis. Journal of gastroenterology and hepatology. 2006;21(1 Pt 2):251-7. Epub 2006/02/08.

14. Jasperson KW, Tuohy TM, Neklason DW, Burt RW. Hereditary and familial colon cancer. Gastroenterology. 2010;138(6):2044-58. Epub 2010/04/28.

15. Biasco G, Pantaleo MA, Di Febo G, Calabrese C, Brandi G, Bulow S. Risk of duodenal cancer in patients with familial adenomatous polyposis. Gut. 2004;53(10):1547; author reply Epub 2004/09/14.

16. Conio M, Gostout CJ. Management of duodenal adenomas in 98 patients with familial adenomatous polyposis. Gastrointestinal endoscopy. 2001;53(2):265-6. Epub 2001/03/30.

17. Debinski HS, Trojan J, Nugent KP, Spigelman AD, Phillips RK. Effect of sulindac on small polyps in familial adenomatous polyposis. Lancet. 1995;345(8953):855-6. Epub 1995/04/01.

18. Nugent KP, Farmer KC, Spigelman AD, Williams CB, Phillips RK. Randomized controlled trial of the effect of sulindac on duodenal and rectal polyposis and cell proliferation in patients with familial adenomatous polyposis. The British journal of surgery. 1993;80(12):1618-9. Epub 1993/12/01.

19. Samadder NJ, Neklason DW, Boucher KM, Byrne KR, Kanth P, Samowitz W, et al. Effect of Sulindac and Erlotinib vs Placebo on Duodenal Neoplasia in Familial Adenomatous Polyposis: A Randomized Clinical Trial. JAMA : the journal of the American Medical Association. 2016;315(12):1266-75. Epub 2016/03/24.

Citation Format: N. Jewel Samadder. Chemoprevention in hereditary GI cancer syndromes. [abstract]. In: Proceedings of the AACR Special Conference on Colorectal Cancer: From Initiation to Outcomes; 2016 Sep 17-20; Tampa, FL. Philadelphia (PA): AACR; Cancer Res 2017;77(3 Suppl):Abstract nr IA11.

Understanding the contribution of family history to colorectal cancer risk and its clinical implications: A state-of-the-science review

Persons with a family history (FH) of colorectal cancer (CRC) or adenomas that are not due to known hereditary syndromes have an increased risk for CRC. An understanding of these risks, screening recommendations, and screening behaviors can inform strategies for reducing the CRC burden in these families. A comprehensive review of the literature published within the past 10 years has been performed to assess what is known about cancer risk, screening guidelines, adherence and barriers to screening, and effective interventions in persons with an FH of CRC and to identify FH tools used to identify these individuals and inform care. Existing data show that having 1 affected first-degree relative (FDR) increases the CRC risk 2-fold, and the risk increases with multiple affected FDRs and a younger age at diagnosis. There is variability in screening recommendations across consensus guidelines. Screening adherence is <50% and is lower in persons under the age of 50 years. A provider's recommendation, multiple affected relatives, and family encouragement facilitate screening; insufficient collection of FH, low knowledge of guidelines, and poor family communication are important barriers. Effective interventions incorporate strategies for overcoming barriers, but these have not been broadly tested in clinical settings. Four strategies for reducing CRC in persons with familial risk are suggested: 1) improving the collection and utilization of the FH of cancer, 2) establishing a consensus for screening guidelines by FH, 3) enhancing provider-patient knowledge of guidelines and communication about CRC risk, and 4) encouraging survivors to promote screening within their families and partnering with existing screening programs to expand their reach to high-risk groups. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2633-2645. © 2016 American Cancer Society.

Efficacy and safety of eflornithine (CPP-1X)/sulindac combination therapy versus each as monotherapy in patients with familial adenomatous polyposis (FAP): design and rationale of a randomized, double-blind, Phase III trial

Background

Molecular studies suggest inhibition of colorectal mucosal polyamines (PAs) may be a promising approach to prevent colorectal cancer (CRC). Inhibition of ornithine decarboxylase (ODC) using low-dose eflornithine (DFMO, CPP-1X), combined with maximal PA export using low-dose sulindac, results in greatly reduced levels of normal mucosal PAs. In a clinical trial, this combination (compared with placebo) reduced the 3-year incidence of subsequent high-risk adenomas by >90 %. Familial Adenomatous Polyposis (FAP) is characterized by marked up-regulation of ODC in normal intestinal epithelial and adenoma tissue, and therefore PA reduction might be a potential strategy to control progression of FAP-related intestinal polyposis. CPP FAP-310, a randomized, double-blind, Phase III trial was designed to examine the safety and efficacy of sulindac and DFMO (alone or in combination) for preventing a clinically relevant FAP-related progression event in individuals with FAP.

Methods

Eligible adults with FAP will be randomized to: CPP-1X 750 mg and sulindac 150 mg, CPP-1X placebo and sulindac 150 mg, or CPP-1X 750 mg and sulindac placebo once daily for 24 months. Patients will be stratified based on time-to-event prognosis into one of the three treatment arms: best (ie, longest time to first FAP-related event [rectal/pouch polyposis]), intermediate (duodenal polyposis) and worst (pre-colectomy). Stage-specific, “delayed time to” FAP-related events are the primary endpoints. Change in polyp burden (upper and/or lower intestine) is a key secondary endpoint.

Discussion

The trial is ongoing. As of February 1, 2016, 214 individuals have been screened; 138 eligible subjects have been randomized to three treatment groups at 15 North American sites and 6 European sites. By disease strata, 26, 80 and 32 patients are included for assessment of polyp burden in the rectum/pouch, duodenal polyposis and pre-colectomy groups, respectively. Median age is 40 years; 59 % are men. The most common reasons for screening failure include minimal polyp burden (n = 22), withdrawal of consent (n = 9) and extensive polyposis requiring immediate surgical intervention (n = 9). Enrollment is ongoing.

Trial registration

This trial is registered at ClinicalTrials.gov (NCT01483144; November 21, 2011) and the EU Clinical Trials Register(EudraCT 2012-000427-41; May 15, 2014).

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-016-0494-4) contains supplementary material, which is available to authorized users.

Familial Risk in Patients With Carcinoma of Unknown Primary

IMPORTANCE

Carcinoma of unknown primary (CUP) accounts for 3% to 5% of all cancers and is associated with poor prognosis. Familial clustering of different cancer sites with CUP is unknown and may provide information regarding etiology, as well as elevated cancer risks in relatives.

OBJECTIVE

To quantify the risk of cancer by site in first- and second-degree relatives and first cousins of individuals with CUP.

DESIGN, SETTING, AND PARTICIPANTS

Nested case-control study of patients who received a diagnosis of CUP between 1980 and 2010 identified from the Utah Cancer Registry. Population controls with no CUP diagnosis were sex and age matched 10:1 to patients with CUP. Data about relatives were drawn from the Utah Population Database.

MAIN OUTCOMES AND MEASURES

Familial aggregation of cancer risk in relatives of cases compared with controls using Cox regression analysis.

RESULTS

For the 4160 index patients (median [interquartile range] age, 72 [62-81] years; 47.6% male) who had received a diagnosis of CUP, first-degree relatives were at an elevated risk of CUP themselves (hazard ratio [HR], 1.35 [95% CI, 1.07-1.70]), as well as lung (HR, 1.37 [95% CI, 1.22-1.54]), pancreatic (HR, 1.28 [95% CI, 1.06-1.54]), myeloma (HR, 1.28 [95% CI, 1.01-1.62]), and non-Hodgkin lymphoma (HR, 1.16 [95% CI, >1.00-1.35]) cancers compared with controls without CUP. When the analysis was restricted to relatives of cancer-free controls, additional increased risks for colon (HR, 1.19 [95% CI, 1.06-1.33]) and bladder (HR, 1.18 [95% CI, >1.00-1.38]) cancers were observed. Second-degree relatives of patients with CUP were at a slight increased risk of lung (HR, 1.14 [95% CI, 1.03-1.26]), pancreatic (HR, 1.17 [95% CI, 1.01-1.37]), breast (HR, 1.09 [95% CI, 1.02-1.16]), melanoma (HR, 1.09 [95% CI, >1.00-1.19]), and ovarian (HR, 1.19 [95% CI, 1.02-1.39]) cancers.

CONCLUSIONS AND RELEVANCE

Relatives of patients with CUP are at increased risk of CUP and several other malignant neoplasms, including lung, pancreatic, and colon cancer. The present data may suggest sites of origin for CUP and provide cancer risk information for relatives of patients with CUP that can lead to effective intervention. Relatives of patients with CUP should be aware of the elevated risks for lung, pancreatic, and colon cancer and encouraged to modify risk factors and adhere to site-specific population cancer screening.

Abstract LB-074: Regression of duodenal neoplasia in familial adenomatous polyposis patients using COX and EGFR inhibition: A randomized placebo-controlled trial

The objective of this trial was to test the effect of a combination of COX and EGFR inhibition on duodenal adenoma progression in patients with familial adenomatous polyposis (FAP). FAP is caused by mutations in the APC gene and is characterized by the development of hundreds of colorectal adenomas and colorectal cancer. FAP patients are also at increased risk for duodenal neoplasia with a ∼10% lifetime risk of duodenal carcinoma. Surgical and endoscopic management of duodenal neoplasia is difficult and chemoprevention has not been successful. Preclinical data has illustrated that a combination of cyclooxygenase (COX) and epidermal growth factor (EGFR) inhibition diminishes small intestinal adenoma development by 87% in mice with germline Apc mutations. Therefore, we conducted a double blind, randomized, placebo-controlled trial in which FAP patients received combination therapy with 150 mg sulindac twice per day and 75 mg erlotinib daily or placebo for 6 months (NCT01187901). The total number and diameter of polyps in a 10cm segment of the proximal duodenum were mapped at baseline and 6 months. The primary outcome was change in total polyp burden, calculated as the sum of the diameters of polyps. We also evaluated RNA expression in duodenal tissue and polyps at endpoint from 10 patients on drug and 10 patients on placebo by RNA sequencing. Seventy-three randomized patients were included in the intention to treat analysis. Over six months, the median change in total duodenal polyp burden was an increase of 8.0 mm from baseline burden in the placebo group (23.0 to 31.0 mm) and the median change in the sulindac-erlotinib group was a decrease of 8.5 mm (29.0 to 19.5 mm). The estimated net difference in change between the two groups was -19.0 mm (95% CI: -32.0, -10.9; P&lt;0.001). Grade 1 and 2 adverse events were more common in the sulindac-erlotinib group, with an acne-like rash observed in 87% of patients receiving treatment and 20% of patients receiving placebo (P&lt;0.001). We identified ∼ 750 differentially expressed genes (fold ≥ 2, false discovery rate &lt; 0.05) in polyps from patients on placebo as compared with patient-matched normal duodenum which were unchanged in polyps from patients on drug. These differentially expressed genes suggested increased EGFR, prostaglandin E2 (PGE2 or COX2) and WNT signaling in duodenal polyps from patients on placebo but not on drug. In duodenal tissue from patients on drug when compared to tissue from patients on placebo, we identified differentially expressed genes suggestive of a reactivated immune response including interferon gamma and interleukin 12 signaling; a possible mechanism for the regression of duodenal polyps observed in drug treated patients. In conclusion, combined chemoprevention with sulindac and erlotinib in FAP patients is effective to lower duodenal polyp burden, block COX2 and EGFR activity, and may reactivate immune surveillance. At the doses tested, however, frequent adverse events may limit the use of these medications.

Part of this abstract was presented as part of a preliminary presentation.

Citation Format: Deborah W. Neklason, Don A. Delker, Kenneth M. Boucher, Priyanka Kanth, Kathryn Byrne, Philip Bernard, Wade Samowitz, Michelle W. Done, Therese Berry, Lisa Pappas, Laurel Smith, Danielle Sample, Rian Davis, Matthew K. Topham, Randall W. Burt, Scott K. Kuwada, N Jewel Samadder. Regression of duodenal neoplasia in familial adenomatous polyposis patients using COX and EGFR inhibition: A randomized placebo-controlled trial. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr LB-074.

Effect of Sulindac and Erlotinib vs Placebo on Duodenal Neoplasia in Familial Adenomatous Polyposis: A Randomized Clinical Trial

IMPORTANCE

Patients with familial adenomatous polyposis (FAP) are at markedly increased risk for duodenal polyps and cancer. Surgical and endoscopic management of duodenal neoplasia is difficult and chemoprevention has not been successful.

OBJECTIVE

To evaluate the effect of a combination of sulindac and erlotinib on duodenal adenoma regression in patients with FAP.

DESIGN, SETTING, AND PARTICIPANTS

Double-blind, randomized, placebo-controlled trial, enrolling 92 participants with FAP, conducted from July 2010 through June 2014 at Huntsman Cancer Institute in Salt Lake City, Utah.

INTERVENTIONS

Participants with FAP were randomized to sulindac (150 mg) twice daily and erlotinib (75 mg) daily (n = 46) vs placebo (n = 46) for 6 months.

MAIN OUTCOMES AND MEASURES

The total number and diameter of polyps in the proximal duodenum were mapped at baseline and 6 months. The primary outcome was change in total polyp burden at 6 months. Polyp burden was calculated as the sum of the diameters of polyps. The secondary outcomes were change in total duodenal polyp count, change in duodenal polyp burden or count stratified by genotype and initial polyp burden, and percentage of change from baseline in duodenal polyp burden.

RESULTS

Ninety-two participants (mean age, 41 years [range, 24-55]; women, 56 [61%]) were randomized when the trial was stopped by the external data and safety monitoring board because the second preplanned interim analysis met the prespecified stopping rule for superiority. Grade 1 and 2 adverse events were more common in the sulindac-erlotinib group, with an acne-like rash observed in 87% of participants receiving treatment and 20% of participants receiving placebo (P < .001). Only 2 participants experienced grade 3 adverse events. [table: see text].

CONCLUSIONS AND RELEVANCE

Among participants with FAP, the use of sulindac and erlotinib compared with placebo resulted in a lower duodenal polyp burden after 6 months. Adverse events may limit the use of these medications at the doses used in this study. Further research is necessary to evaluate these preliminary findings in a larger study population with longer follow-up to determine whether the observed effects will result in improved clinical outcomes.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT 01187901.

Risk of Incident Colorectal Cancer and Death After Colonoscopy: A Population-based Study in Utah

BACKGROUND & AIMS

Colonoscopy is widely recommended for colorectal (CRC) screening in the United States, but evidence of effectiveness is limited. We examined whether exposure to colonoscopy decreases the odds of incident CRC and death from CRC in Utah.

METHODS

We performed a case-control study of Utah residents, 54 to 90 years old, who received a CRC diagnosis from 2000 through 2010 (cases). Age- and sex-matched controls with no history of CRC (controls) were selected for each case. We determined receipt of colonoscopy 6 months to 10 years before the reference date for each case and control through administrative claims data. Colonoscopy exposure was compared by using conditional logistic regression.

RESULTS

We identified 5128 cases and 20,512 controls; 741 cases (14%) and 5715 controls (28%) received a colonoscopy. Exposure to colonoscopy reduced the odds for a diagnosis of CRC; the odds ratios (ORs) were 0.41 for any CRC (95% confidence interval [CI], 0.38-0.44), 0.58 for proximal colon cancer (95% CI, 0.51-0.65), and 0.29 for distal colon or rectal cancer (95% CI, 0.25-0.33). This finding was consistent among sexes, age groups, and cancer stages. Similarly, in a subgroup analysis, colonoscopy was associated with decreased odds of death from CRC (OR, 0.33; 95% CI, 0.28-0.39) in both the proximal colon (OR, 0.43; 95% CI, 0.34-0.55) and distal colon or rectum (OR, 0.23; 95% CI, 0.18-0.30).

CONCLUSIONS

In the population of Utah, colonoscopy is associated with a large reduction in risk of new-onset CRC and death from CRC. This reduction in risk for CRC was greatest for the distal colon and rectum, with a more modest reduction for proximal colon cancer.

Outcomes of Next-Day Versus Non-next-Day Colonoscopy After an Initial Inadequate Bowel Preparation

BACKGROUND

Inadequate bowel preparation is the most common cause of failed colonoscopy, and repeat failure occurs in more than 20 % of follow-up attempts. Limited data suggest that next-day follow-up may reduce the risk for repeat inadequate preparation.

OBJECTIVE

Evaluate differences in prep quality with next-day follow-up after initial inadequate preparation.

DESIGN

Retrospective study.

SETTING

Academic center.

PATIENTS

Outpatient screening and surveillance colonoscopies between 7/2002 and 6/2007.

INTERVENTION

Comparison of next-day versus any other day ("non-next-day") repeat colonoscopy outcomes.

MAIN OUTCOME MEASUREMENTS

Aronchick scale, polyp and adenoma detection rates.

RESULTS

Of 20,798 initial colonoscopies, 857 (4.1 %) had inadequate preparation. 460 (54 %) were lost to follow-up. One hundred and fourteen (13 %) had next-day and 283 (33 %) had non-next-day colonoscopy with mean follow-up of 8.8 months. On follow-up examination, 29.8 % of next-day and 23.3 % of non-next-day colonoscopies had inadequate bowel preparation (p = 0.48). The adenoma detection rate for the next-day group improved from 3.5 to 38.6 % on follow-up, compared to 20.5 and 36.8 % in the non-next-day group. There was no significant difference between groups in detection of total adenoma (p = 0.73) or advanced adenomas (p = 0.20) on follow-up examinations.

LIMITATIONS

Retrospective design, differences in baseline colonoscopy characteristics.

CONCLUSION

The results confirm the need for repeat examination after a colonoscopy with inadequate bowel prep, as there was substantial increase in adenoma detection on follow-up. There were no differences in outcomes between next-day versus non-next-day colonoscopy. These data support repeating after inadequate colonoscopy within 1 year as convenient for patient and physician.

Increased Risk of Colorectal Cancer Among Family Members of All Ages, Regardless of Age of Index Case at Diagnosis

BACKGROUND & AIMS

It is not clear whether familial risk of colorectal cancer (CRC) varies with age of index CRC patients or their relatives. We quantified the risk of CRC in first-degree relatives (FDRs), second-degree relatives, and first-cousin relatives of individuals with CRC, stratified by ages and sexes of index patients and ages of relatives.

METHODS

CRCs diagnosed between 1980 and 2010 were identified from the Utah Cancer Registry and linked to pedigrees from the Utah Population Database. Age- and sex-matched CRC-free individuals were selected to form the comparison group. CRC risk in relatives was determined by Cox regression analysis.

RESULTS

Of 18,208 index patients diagnosed with CRC, the highest familial risk was observed in FDRs of index CRC patients who were diagnosed at an age younger than 40 years (hazard ratio [HR], 2.53; 95% confidence interval [CI], 1.7-3.79). However, familial risk was increased in FDRs even when the index case was diagnosed with cancer at an advanced age (>80 years; HR, 1.76; 95% CI, 1.59-1.94). Ages of relatives and ages of index cases of CRC each affected familial cancer risk; the highest risk was found in young relatives (<50 years) of individuals with early-onset CRC (<40 years; HR, 7.0; 95% CI, 2.86-17.09).

CONCLUSIONS

All relatives of individuals with CRC are at increased risk for this cancer, regardless of the age of diagnosis of the index patient. Although risk is greatest among young relatives of early-onset CRC cases, relatives of patients diagnosed at advanced ages also have an increased risk.

Hereditary and common familial colorectal cancer: evidence for colorectal screening

Colorectal cancer (CRC) is the fourth most common cancer among men and women. Between 3 and 6% of all CRCs are attributed to well-defined inherited syndromes, including Lynch syndrome, familial adenomatous polyposis, MUTYH-associated polyposis and several hamartomatous conditions. Up to 30% of CRC cases exhibit common familial risk, likely related to a combination of inherited factors and environment. Identification of these patients through family history and appropriate genetic testing can provide estimates of cancer risk that inform appropriate cancer screening, surveillance and/or preventative interventions. This article examines the colon cancer syndromes, their genetic basis, clinical management and evidence supporting colorectal screening. It also deals with the category of common (non-syndromic) familial risk including risk determination and screening guidelines.

Familial colorectal cancer risk by subsite of primary cancer: a population-based study in Utah

BACKGROUND

Familial occurrence is common in colorectal cancer (CRC), but whether this increased familial risk differs by colonic subsite of the index patients CRC is not well understood.

AIM

To quantify the risk of CRC in first-degree (FDR), second-degree (SDR) and first cousin (FC) relatives of individuals with CRC, stratified by subsite in the colorectum and age at diagnosis.

METHODS

Colorectal cancers diagnosed between 1980 and 2010 were identified from the Utah Cancer Registry and linked to pedigrees from the Utah Population Database. Age and gender-matched CRC-free controls were selected to form the comparison group for determining CRC risk in relatives using Cox regression analysis.

RESULTS

Of the 18,208 index patients diagnosed with CRC, 6584 (36.2%) were located in the proximal colon, 5986 (32.9%) in the distal colon and 5638 (31%) in the rectum. The elevated risk of CRC in relatives was similar in analysis stratified for CRC colorectal subsites in the index cases. FDR had similarly elevated risk of all site CRC, whether the index patient had cancer in the proximal colon [hazards ratio (HR): 1.85; 95% CI: 1.70-2.02], distal colon (HR: 1.90; 95% CI: 1.73-2.08) or rectum (HR: 1.83; 95% CI: 1.66-2.02) compared to relatives of controls. This risk was consistently greater for FDR when cases developed CRC below the age of 60 years.

CONCLUSIONS

Relatives of CRC patients have a similarly elevated risk of CRC regardless of colonic tumour subsite in the index patient, and it is greatest for relatives of younger age index cases.

Epidemiology and familial risk of synchronous and metachronous colorectal cancer: a population-based study in Utah

BACKGROUND & AIMS

Patients diagnosed with colorectal cancer (CRC) are at risk for synchronous and metachronous lesions at the time of diagnosis or during follow-up evaluation. We performed a population-based study to evaluate the rate, predictors, and familial risk for synchronous and metachronous CRC in Utah.

METHODS

All newly diagnosed cases of CRC between 1980 and 2010 were obtained from the Utah Cancer Registry and linked to pedigrees from the Utah Population Database.

RESULTS

Of the 18,782 patients diagnosed with CRC, 134 were diagnosed with synchronous CRC (0.71%) and 300 were diagnosed with metachronous CRC (1.60%). The risk for synchronous CRC was significantly higher in men (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.02-2.06) and in patients aged 65 years or older (OR, 1.50; 95% CI, 1.02-2.21). Synchronous CRCs were located more often in the proximal colon (OR, 1.70; 95% CI, 1.20-2.41). First-degree relatives of cases with synchronous (OR, 1.86; 95% CI, 1.37-2.53), metachronous (OR, 2.34; 95% CI, 1.62-3.36), or solitary CRC (OR, 1.75; 95% CI, 1.63-1.88) were at increased risk for developing CRC, compared with relatives of CRC-free individuals. Four percent of first-degree relatives of patients with synchronous or metachronous cancer developed CRC at younger ages than the age recommended for initiating CRC screening (based on familial risk), and therefore would not have been screened.

CONCLUSIONS

Of patients diagnosed with CRC, 2.3% are found to have synchronous lesions or develop metachronous CRC during follow-up evaluation. Relatives of these patients have a greater risk of CRC than those without a family history of CRC. These results highlight the importance of obtaining a thorough family history and adhering strictly to surveillance guidelines during management of high-risk patients.

Increased risk of colorectal neoplasia among family members of patients with colorectal cancer: a population-based study in Utah

BACKGROUND & AIMS

Colorectal cancer (CRC) frequently develops in multiple members of the same families, but more data are needed to prepare effective screening guidelines. We quantified the risk of CRC and adenomas in first-degree relatives (FDRs) and second-degree relatives and first cousins of individuals with CRC, and stratified risk based on age at cancer diagnosis.

METHODS

We performed a case-control study of Utah residents, 50-80 years old, who underwent colonoscopy from 1995 through 2009. Index cases (exposed to colonoscopy) were colonoscopy patients with a CRC diagnosis. Age- and sex-matched individuals, unexposed to colonoscopy (controls) were selected to form the comparison groups for determining risk in relatives. Colonoscopy results were linked to cancer and pedigree information from the Utah Population Database to investigate familial aggregation of colorectal neoplasia using Cox regression analysis.

RESULTS

Of 126,936 patients who underwent a colonoscopy, 3804 were diagnosed with CRC and defined the index cases. FDRs had an increased risk of CRC (hazard rate ratio [HRR], 1.79; 95% confidence interval [CI],1.59-2.03), as did second-degree relatives (HRR, 1.32; 95% CI, 1.19-1.47) and first cousins (HRR, 1.15; 95% CI, 1.07-1.25), compared with relatives of controls. This risk was greater for FDRs when index patients developed CRC at younger than age 60 years (HRR, 2.11; 95% CI, 1.70-2.63), compared with older than age 60 years (HRR, 1.77; 95% CI, 1.58-1.99). The risk of adenomas (HRR, 1.82; 95% CI, 1.66-2.00) and adenomas with villous histology (HRR, 2.43; 95% CI, 1.96-3.01) also were increased in FDRs. Three percent of CRCs in FDRs would have been missed if the current guidelines, which stratify screening recommendations by the age of the proband, were strictly followed.

CONCLUSIONS

FDRs, second-degree relatives, and first cousins of patients who undergo colonoscopy and are found to have CRC have a significant increase in the risk of colorectal neoplasia. These data should be considered when establishing CRC screening guidelines for individuals and families.

Characteristics of missed or interval colorectal cancer and patient survival: a population-based study

BACKGROUND & AIMS

Colorectal cancers (CRCs) diagnosed within a few years after an index colonoscopy can arise from missed lesions or the development of a new tumor. We investigated the proportion, characteristics, and factors that predict interval CRCs that develop within 6-60 months of colonoscopy.

METHODS

We performed a population-based cohort study of Utah residents who underwent colonoscopy examinations from 1995 through 2009 at Intermountain Healthcare or the University of Utah Health System, which provide care to more than 85% of state residents. Colonoscopy results were linked with cancer histories from the Utah Population Database to identify patients who underwent colonoscopy 6-60 months before a diagnosis of CRC (interval cancer). Logistic regression was performed to identify risk factors associated with interval cancers.

RESULTS

Of 126,851 patients who underwent colonoscopies, 2659 were diagnosed with CRC; 6% of these CRCs (159 of 2659) developed within 6 to 60 months of a colonoscopy. Sex and age were not associated with interval CRCs. A higher percentage of patients with interval CRC were found to have adenomas at their index colonoscopy (57.2%), compared with patients found to have CRC detected at colonoscopy (36%) or patients who did not develop cancer (26%) (P < .001). Interval CRCs tended to be earlier-stage tumors than those detected at index colonoscopy, and to be proximally located (odds ratio, 2.24; P < .001). Patients with interval CRC were more likely to have a family history of CRC (odds ratio, 2.27; P = .008) and had a lower risk of death than patients found to have CRC at their index colonoscopy (hazard ratio, 0.63; P < .001).

CONCLUSIONS

In a population-based study in Utah, 6% of all patients with CRC had interval cancers (cancer that developed within 6 to 60 months of a colonoscopy). Interval CRCs were associated with the proximal colon, earlier-stage cancer, lower risk of death, higher rate of adenoma, and family history of CRC. These findings indicate that interval colorectal tumors may arise as the result of distinct biologic features and/or suboptimal management of polyps at colonoscopy.

Associations between cigarette smoking, hormone therapy, and folate intake with incident colorectal cancer by TP53 protein expression level in a population-based cohort of older women

Cigarette smoking (CS), hormone therapy (HT), and folate intake (FI) are each thought to influence colorectal cancer risk, but the underlying molecular mechanisms remain incompletely defined. The TP53 (p53) protein, encoded by the TP53 tumor-suppressor gene that is commonly mutated in colorectal cancer, can be readily assessed to differentiate biologically distinct colorectal cancer subtypes. In this prospective cohort study, we examined CS-, HT-, and FI-associated colorectal cancer risks by TP53 protein expression level among Iowa Women's Health Study (IWHS) participants. The IWHS recruited 41,836 randomly selected Iowa women, ages 55 to 69 years, with a valid driver's license at study entry in 1986. Self-reported exposure variables were assessed at baseline. Incident colorectal cancer cases were ascertained by annual linkage with the Iowa Cancer Registry. Archived, paraffin-embedded tissue specimens were collected and evaluated for TP53 protein expression by immunohistochemistry. Multivariate Cox regression models were fit to estimate relative risks (RR) and 95% confidence intervals (CI) for associations between CS, HT, or FI and TP53-defined colorectal cancer subtypes. Informative environmental exposure and protein expression data were available for 492 incident colorectal cancer cases: 222 (45.1%) TP53 negative, 72 (14.6%) TP53 low, and 198 (40.2%) TP53 high. Longer duration (>5 years) of HT was inversely associated with TP53 high colorectal cancers (RR, 0.50; 95% CI, 0.27-0.94). No other statistically significant associations were observed. These data support possible heterogeneous effects from HT on TP53-related pathways of colorectal carcinogenesis in older women.

Risk of colorectal cancer and adenomas in the families of patients with adenomas: a population-based study in Utah

BACKGROUND

Guidelines recommend that individuals with a first-degree relative (FDR) diagnosed with colorectal cancer (CRC) or advanced adenoma before age 60 years should undergo colonoscopy starting at age 40 years. The authors quantified the risk of adenomas and CRC in FDRs, second-degree relatives (SDRs), and third-degree relatives (TDRs) of patients diagnosed with adenomas and advanced adenomas.

METHODS

A population-based, retrospective, case-control study was performed of residents of the state of Utah aged 50 years to 80 years who underwent colonoscopy between 1995 and 2009 at Intermountain Healthcare or the University of Utah. Controls were selected from the population of colonoscopy patients who were free of adenomas or CRC and matched to each case based on sex and birth year. Colonoscopy results were linked with cancer and pedigree information from the Utah Population Database to investigate the familial aggregation of adenomas and CRC using Cox regression analysis. The unit of analysis was the relatives of cases and controls.

RESULTS

Of 126,936 patients who underwent colonoscopy, 43,189 had adenomas and 5563 had advanced adenomas and defined the case population. An elevated risk of CRC was found in FDRs (relative risk [RR], 1.35; 95% confidence interval [95% CI], 1.25-1.46), SDRs (RR, 1.15; 95% CI, 1.07-1.23) of adenoma cases, and in FDRs of advanced adenoma cases (RR, 1.68; 95% CI, 1.29-2.18) compared with controls. Approximately 10% of CRCs diagnosed in relatives would have been missed if the current screening guidelines were strictly adhered to.

CONCLUSIONS

Relatives of colonoscopy patients with adenomas and advanced adenomas appear to have a significantly elevated risk of developing colorectal neoplasia. These data should be considered when establishing CRC screening guidelines for individuals and their families.