Colorectal Cancer: Putting Prevention into Practice
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  • 1. Colorectal Cancer:Putting Prevention into Practice Durado Brooks, MD, MPH Director, Prostate and Colorectal Cancers
  • 2. Colorectal Cancer The third most common cancer in U.S. and the second deadliest  141,000 new cases expected this year  More than 49,000 deaths nationwide 1.1 million Americans living with colorectal cancer Death rates have fallen steadily over the past 20 years
  • 3. Trends in CRCCRC incidence and mortality have fallen steadilyover the past 2 decades.Research suggests that observed declines inincidence and mortality are due in large part to: Screening and polyp removal, preventing progression of polyps to invasive cancers  NEJM study Feb 2012 showed polyp removal associated with 53% lower risk of CRC death Screening  detecting cancers at earlier, more treatable stages CRC treatment advances
  • 4. Risk Factors
  • 5. Colorectal Cancer Risk Factors Age  90% of cases occur in people 50 and older Gender  slight male predominance, but common in both men and women Race/Ethnicity  Increased rates documented in African Americans, Alaska Natives, some American Indian tribes, Ashkenazi Jews
  • 6. Colorectal Cancer Risk FactorsModifiable Risk Factors Diet Obesity Physical Activity Tobacco Alcohol
  • 7. Non-Modifiable Risk Factors Increased risk with:  Personal history of inflammatory bowel disease, adenomatous polyps or colon cancer  Family history of adenomatous polyps, colon cancer, other conditions Individuals with these risk factors may require earlier and more intensive screening The remainder of this presentation will focus on the average risk population.
  • 8. Colorectal Cancer Sporadic (average risk) (65%–85%) Family history (10%–30%) Raresyndrome s (<0.1%) Hereditary nonpolyposis colorectal cancer Familial (HNPCC) (5%) adenomatous polyposis (FAP) (1%) CENTERS FOR DISEASE CONTROL AND PREVENTION
  • 9. Risk Factor - PolypsTypes of polyps: Hyperplastic  minimal cancer potential Adenomatous  approximately 90% of colon and rectal cancers arise from adenomas
  • 10. Normal to Adenoma to Carcinoma Human colon carcinogenesisprogresses by the dysplasia/adenoma to carcinoma pathway
  • 11. Screening
  • 12. Benefits of Screening Cancer Prevention  Removal of pre-cancerous polyps prevent cancer (unique aspect of colon cancer screening) Cost-effective  Cost of CRC screening compares favorably to many other common interventions (i.e. mammograms)  Treatment costs for advanced disease have risen greatly in recent years Improved survival  Early detection markedly improves chances of long term survival
  • 13. Benefits of Screening Survival Rates by Disease Stage* 100 89.8% 90 80 67.7% 70 5-yr 60 50Survival 40 30 20 10.3% 10 0 Lo cal Reg io n al Distan t St age of Det ect ion*1996 - 2003
  • 14. Trends in Recent* CRC Screening Prevalence (%), by Educational Attainment and Health Insurance Status, Adults 50-75 Years, US, 2000-2010Source: Klabunde et al, Cancer Epidemiol Biomarkers Prev 2011;20:1611-1621National Health Interview Survey Public Use Data File 2010, National Center for Health Statistics, Centers for Disease Controland Prevention, 2011.American Cancer Society, Surveillance Research, 2011 .
  • 15. Lower use of colorectal screeningexaminations in minority populations
  • 16. Screening Tests
  • 17. ACS Screening GuidelinesOptions for Average risk adults age 50 and older:Tests That Detect Adenomatous Polyps and Cancer Colonoscopy every 10 years, or Flexible sigmoidoscopy (FSIG) every 5 years, or Double contrast barium enema (DCBE) every 5 years, or CT colonography (CTC) every 5 yearsTests That Primarily Detect Cancer Guaiac-based fecal occult blood test (gFOBT) with high test sensitivity for cancer, or Fecal immunochemical test (FIT) with high test sensitivity for cancer, or Stool DNA test (sDNA), with high sensitivity for cancer
  • 18. Recommended Screening Tests ACS and USPSTF High Sensitivity Fecal Occult Blood Testing  Guaiac  Immunochemical Colonoscopy Flexible Sigmoidoscopy (FSIG)  Recent studies support efficacy
  • 19. ColonoscopyColonoscopyallows doctor todirectly see insideentire bowel
  • 20. Why Not Colonoscopy for All? Screening rates remain disappointingly low Evidence does not support “best test” or “gold standard”  Colonoscopy misses ~ 10% of significant lesions in expert settings  Higher potential for patient injury than other tests  Test performance is highly operator dependent Greater patient requirements for successful completion of tests that detect both polyps and cancers  Requires a bowel prep and facility visit, and often a pre- procedure specialty office visit (all with associated costs) Patient preference  Many individuals don’t want an invasive test or a test that requires a bowel prep  Some may not have access to the invasive tests due to lack of coverage or local resources
  • 21. Patient PreferencesInadomi, Arch Intern Med 2012
  • 22. Stool Test: Guaiac Most common type in U.S. Best evidence (3 RCT’s) Need specimens from 3 bowel movements Non-specific Results influenced by foods and medications Older forms (Hemoccult II) have unacceptably low sensitivity Better sensitivity with newer versions (Hemoccult Sensa)
  • 23. Stool Test: Immunochemical (FIT) Specific for human blood and for lower GI bleeding Results not influenced by foods or medications Some types require only 1 or 2 stool specimens Higher sensitivity than older forms of guaiac-based FOBT Slightly more costly than guaiac testsFIT use in the US will likely increase due to recent eliminationof guiaic- based testing by LabCorp and Quest Labs
  • 24. FOBT Quality Issues Sensitivity of Take Home vs. In-Office FOBT Sensitivity FOBT method All Advanced Cancer (Hemoccult II) Lesions 3 card, take-home 23.9 % 43.9 % Single sample, in- office 4.9 % 9.5 %Collins et al, Annals of Int Med Jan 2005
  • 25. Stool Testing Quality Issues CRC screening by FOBT should be performed with high-sensitivity FOBT - either FIT or a highly sensitive gFOBT (such as Hemoccult SENSA).  Older, less sensitive guiaic tests (such as Hemoccult II) should not be used for CRC screening. Annual testing In-office FOBT is essentially worthless as a screening tool for CRC and must be strongly discouraged. All positive screening tests should be evaluated by colonoscopy
  • 26. High Quality Stool Testing Clinicians Reference: FOBT One page document designed to educate clinicians about important elements of colorectal cancer screening using fecal occult blood tests (FOBT). Provides state-of-the-science information about guaiac and immunochemical FOBT, test performance and characteristics of high quality screening programs. Available at www.cancer.org/colonmd
  • 27. How Can We Improve Screening Rates?
  • 28. Sub-Optimal Screening Rates Reasons (according to Patients)• Low awareness of CRC as a personal health threat• Lack of knowledge of screening benefits• Fear, embarrassment, discomfort• Time• Cost• Access• Structural issues (lack of systems in most settings)• “My doctor never talked to me about it!”
  • 29. Opportunistic vs. Organized Preventive Care Most preventive care for adults in the U.S. is opportunistic, i.e. occurs incidentally during encounters with healthcare professionals Opportunistic care depends on a coincidence of encounters, circumstances, and interests between patient and provider This means some adults get some preventive care on some occasions and at some interval Few adults receive the full package, or even the majority of recommended preventive services
  • 30. “Action Plan” Toolkit Version Eight page guide introduces clinicians and staff to concepts and tools provided in the full Toolkit Contains links to the full Toolkit, tools and resources Not colorectal-specific; practical, action-oriented assistance that can be used in the office to improve screening rates for multiple cancer sites (colorectal, breast and cervical) Available at http://nccrt.org/about/provider- education/crc-clinician-guide/
  • 31. Communication
  • 32. #1: Make a Recommendation Determine the screeningEssential messages you and your #1: staff will share with patients. Explore how yourEssential practice will assess a #1: patient’s risk status and receptivity to screening.
  • 33. Q: Is a Doctor’s Recommendation Really That Useful? Gastroenterology Dept Adapted from Jack Tippit, Saturday Evening PostAren’t we bucking human nature with this one?
  • 34. #2 Develop a Screening Policy Create a standard courseEssential of action for screenings, #2: document it, and share it. Compile a list of screeningEssential resources and determine #2: the screening capacity available in your community.
  • 35. Sample Screening Algorithm Assess Risk: Personal Sample Tools for Your Practice & Family History Average risk = Increased or high risk Increased or high risk No family history of CRC based on personal or adenomatous polyp based on family history history < 50 years > 50 years Adenoma CRC IBD High Risk: Adenoma or Germline cancer Do not Screen Syndrome screen Surveillance HNPCC or FAP Colonoscopy If positive, diagnosis by colonoscopy Screening Screen withOptionsTests That Find Polyps and Cancer colonoscopy, genetic colonoscopy 10 yearsFlexible sigmoidoscopy every 5 years, or testing, and other before youngest cancer screening as relative or age 40Colonoscopy every 10 years appropriateDouble-contrast barium enema every 5 years,or *The multiple stool take-home test should be used. One test done by the doctorCT colonography (virtual colonoscopy) every in the office is not adequate for testing.5 years The tests that are designed to find both early cancer and polyps are preferred if *This version of stage theory was adaptedTests That Primarily Find Cancer these tests are available and the patientfrom the work have one of these more is willing to of RE Myers.Yearly fecal occult blood test (gFOBT) *, or invasive tests.
  • 36. High Quality Stool Testing Clinicians Reference: FOBT One page document designed to educate clinicians about important elements of colorectal cancer screening using fecal occult blood tests (FOBT). Provides state-of-the-science information about guaiac and immunochemical FOBT, test performance and characteristics of high quality screening programs. Available at www.cancer.org/colonmd
  • 37. #3 Be Persistent with Reminders Determine how yourEssential practice will notify #3: patient and physician when screening and follow up is due. Ensure that your systemEssential tracks test results and #3: uses reminder prompts for patients and providers.
  • 38. Reminder Fold-Over Postcard
  • 39. Patient Education Get Tested For Colon Cancer: Heres How." An 7-minute video reviewing options for colorectal cancer screening tests, including test preparation. Available as DVD, or you can refer patients to the URL to view from their personal computer.
  • 40. Office Wall Chart  Screening guidelines for Breast, Cervical, Colon, Prostate and other cancers  General lifestyle/prevention  Tobacco cessation  Healthy diet  Weight, etc  English and Spanish
  • 41. Clinician Reminder Types Chart Prompts  Problem lists  Screening schedules  Integrated summaries Alerts – “Flags” placed in chart Follow-Up Reminders  Tickler System  Logs and Tracking Electronic Reminder Systems
  • 42. #4 Measure Practice Progress Discuss how your screeningEssential system is working during #4: regular staff meetings and make adjustments as needed. Have staff conduct aEssential screening audit or contact #4: a local company that can perform such a service.
  • 43. Saving Lives Through Preventive Cancer Screening ADJUST PLAN STUDY ACT
  • 44. Communication
  • 45. Health Card Kit
  • 46. ACS ResourcesInformation and materials on colorectal cancerfor clinicians and patients are available at:www.cancer.org/colonmdUpdated materials for other cancers areavailable on a new webpagewww.cancer.org/professionals