An Evidence-Based Approach to Colorectal Cancer (CRC) Screening in Average-Risk, Asymptomatic Adults

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Zachary Jarou, MD Candidate, Class of 2014
Family Medicine Clerkship, Spring 2013
Michigan State University
College of Human Medicine

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  • An Evidence-Based Approach to Colorectal Cancer (CRC) Screening in Average-Risk, Asymptomatic Adults

    1. 1. Prevalence Reduction in Morbidity/Mortality Sensitivity, Specificity, Reliability Reasonable Cost Low Risk from Screening Test
    2. 2. ~140k new cases each year ~50k yearly deaths Lifetime risk of CRC diagnosis in US is 5% (1 in 20)
    3. 3. 10% ⅓ 96% adenomas progress to colorectal cancer of colorectal cancers develop from adenomatous polyps over a period of 10-15 years of adults develop ≥ 1 polyps by age 50, this increases with age Early detection & removal of polyps eliminates the possibility they become cancerous. Routine screening could save ~19,000 lives per year
    4. 4. • Sensitivity (Sn) – Hemoccult II < FIT ≤ Hemoccult SENSA <FSIG < colonoscopy • Specificity (Sp) – Hemoccult SENSA < FIT ≈ Hemoccult II <FSIG = colonoscopy • Reliability – FSIG, CTC, colonoscopy = operator-dependent (better training/more experience improve Sn) – quality standards/minimum volume requirements USPSTF (2008)
    5. 5. • Colonoscopy has superior single-test accuracy compared to other screening modalities – FS+FOBT failed to identify 24% of advanced colonic neoplasia in one study – CTC or DCBE missed 2.1% 10+ mm polyps and miss rate as high as 26% for smaller polyps • Single FOBT by DRE will miss 95% of CRC – Patients should take home 3 testing cards with 2 windows each, use one card per day – Cochrane review = 16% reduction in mortality (RR = 0.84, 95% CI = 0.78-0.90) – NNS = 1,176; 10k persons completing FOBT annually will prevent 8.5 deaths over 10 years AFP (2008)
    6. 6. Regardless of screening method, the cost per life-year saved ($10-25k) compares favorably with other commonly endorsed preventive health care interventions Pignone et al. (2002), AFP (2008) Median cost of colonoscopy is $1,736
    7. 7. • Bowel Perforation – CTC = 0-6 per 10,000 – DCBE = 1 per 25,000 – FSIG = 1 per 25,000-50,000 – Colonoscopy = 1 per 2,000-3,000 (65% are sigmoid) • Serious Complications – deathor event requiring hospitalization (perforation, major bleeding, diverticulitis, severe abdominal pain, and cardiovascular events) – FSIG = 3.4 per 10,000 procedures – Colonoscopy = 25 per 10,000 procedures
    8. 8. • Conscious Sedation – FSIG = most performed without (some discomfort) – Colonoscopy = most performed with (cardiopulmonary complications are ~½ of all adverse events); patients will also miss a day of work and need a chaperone for transportation • Bowel Prep – FSIG = less intensive (complete or partial) – Colonoscopy = more intensive (complete required) – DCBE/CTC* = complete required, if same day colonoscopy not available a second bowel prep will be required
    9. 9. • False Reassurance from False-Negative Results (gFOBT/FIT) • Unnecessary Invasive Tests Due to False- Positive Results (CTC) – 10% of first-time CTcolonographiesfound to have extracolonic abnormalities which may or may not be clinically significant; potential for both benefit & harm
    10. 10. • Radiation Exposure (CTC) – radiation exposure reported to be 10 mSv perCTC – at this level of exposure, 1 additional individual per 1000 would develop cancer in his or her lifetime – cumulative radiation risk should be considered in the context of the growinguse of other diagnostic and screening tests that involve radiation exposure. – improvements in CT colonography technology and practice are lowering this radiation dose
    11. 11. Detect both adenomatous polyps and cancers.
    12. 12. Detect primarily cancer.
    13. 13. • American Cancer Society/US Multi-society Task Force on Colorectal Cancer/American College of Radiology (ACS/USMSTF/ACR) • Kaiser Permanente Care Management Institute (KPCMI) • US Preventive Services Task Force (USPSTF)
    14. 14. • •
    15. 15. Modality USPSTF KPCMI ACS/USMSTF/ACR Standard gFOBT ✗ ✗ ✗ HS-gFOBT/FIT ✔ ✔ ✔ FSIG ✔ ✔ ✔ Colonoscopy ✔ ✔ ✔ CTC ✗ ✗ ✔ sDNA ✗ ✗ ✔ DCBE ✗ ✔
    16. 16. Modality USPSTF Recommended? Standard gFOBT ✗ HS- gFOBT/FIT ✔ FSIG ✔ Colonoscopy ✔ CTC ✗ sDNA ✗  between ages 50-75 years old, all are equally effective in life-years gained (assuming 100% adherence)  against routine screening in adults 76-85 years old  strategies differ in total number of colonoscopies required to gain similar numbers of life-years
    17. 17. Modality KPCMI Recommended? Standard gFOBT ✗ HS- gFOBT/FIT ✔ FSIG ✔ Colonoscopy ✔ CTC ✗ sDNA ✗ DCBE ✗ with history of routine screening, discontinue at 75 without history of routine screening, discontinue at 80 this study also includes screening recommendations for those at increased risk of CRC
    18. 18. Modality ACS/USMSTF/ACR Recommended? Standard gFOBT ✗ HS- gFOBT/FIT ✔ FSIG ✔ Colonoscopy ✔ CTC ✔ ✔ do not specify age to discontinue screening if colonoscopy is contraindicated due to life-limiting co- morbidity neither CTC nor any other screening tests are appropriate
    19. 19. Modality USPSTF KPCMI ACS/USMSTF/ACR Standard gFOBT ✗ ✗ ✗ HS-gFOBT/FIT ✔ ✔ ✔ FSIG ✔ ✔ ✔ Colonoscopy ✔ ✔ ✔ CTC ✗ ✗ ✔ sDNA ✗ ✗ ✔ DCBE ✗ ✔
    20. 20. Follow the USPSTF Guidelines.
    21. 21. African Americans have 20% higher incidence and 45% higher mortality from CRC than whites
    22. 22. Effect of Affordable Care Act on Colorectal Cancer Screening All new private health plans are required to cover CRC screening tests with “A”/“B” USPSTF ratings (effective beginning 2011) Medicare preventive services will have no out-of-pocket costs & are exempt from deductibles, even with polypectomy (effective October 2010)
    23. 23. • Information from Your Family Doctor: Colon Cancer Screening (2008). http://www.aafp.org/afp/2008/1215/p1393.h tml • National Cancer Institute. Colorectal Cancer Screening (PDQ). http://www.cancer.gov/cancertopics/pdq/scre ening/colorectal/Patient
    24. 24. • American Cancer Society/US Multisociety Task Force on Colorectal Cancer/American College of Radiology (ACS/USMSTF/ACR). Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin 2008 May-Jun;58(3):130-60. • Kaiser Permanente Care Management Institute (KPCMI). Colorectal cancer screening clinical practice guideline. Oakland (CA): Kaiser Permanente Care Management Institute; 2008 Dec. 190 p. • US Preventive Services Task Force (USPSTF). Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008 Nov 4;149(9):627-37.
    25. 25. • American Cancer Society. Colorectal Cancer Facts & Figures 2011-2013. • Pignoneet al (2002). Cost-effectiveness Analyses of Colorectal Cancer Screening: A Systematic Review for the U.S. Preventive Services Task Force. AHRQ Pub. No. 03-519 • Wilkins T and ReynoldsPL (2008). Colorectal Cancer: A Summary of the Evidence for Screening and Prevention. American Family Physician. http://www.aafp.org/afp/2008/1215/p1385.html

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