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Colon Cancer Screening - Knowing The Guidelines - Getting It Done!

Colon Cancer Screening - Knowing The Guidelines - Getting It Done!. Richard C. Wender, MD Alumni Professor and Chair Department of Family & Community Medicine Thomas Jefferson University Philadelphia, PA Past President, American Cancer Society. Colorectal Cancer – 2010 Update From CA.

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Colon Cancer Screening - Knowing The Guidelines - Getting It Done!

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  1. Colon Cancer Screening- Knowing The Guidelines- Getting It Done! Richard C. Wender, MD Alumni Professor and Chair Department of Family & Community Medicine Thomas Jefferson University Philadelphia, PA Past President, American Cancer Society

  2. Colorectal Cancer – 2010 Update From CA • Estimated new cases – 142,570 • Estimated deaths – 51,370

  3. Where We Are: CRC Screening in PA & US( Age 50 and over; BRFSS, CDC) 20022008 PA | US PA | US Stool Tests (2 yrs) 29% 30% 19% 21% Endoscopy* (ever) 38% 48.6% 62% 62.5% *Endoscopy=Colonoscopy or Sigmoidoscopy

  4. Decline in PA CRC Death Rate & U.S. Target U.S. 2010/2020 Target:13.9 deaths per 100,000 population

  5. Where we want to be:PA CRC Screening Goals Increase the percentage of CRC Screening in the Pennsylvania adult population age 50 and above to 80% by 2014. Decrease the incidence of late-stage CRC diagnoses among Pennsylvania adults age 50 and above to 44% by 2014.

  6. Question 1:Which approach most accurately describes your current approach to colon cancer screening? • Colonoscopy for all – no specific back-up plan • Colonoscopy for all – digital rectal FOBT as a back-up plan • Colonoscopy for all – FOBT at home OR in-office as a back-up • Colonoscopy for all – home FOBT as back-up • FOBT/FIT or Colonoscopy offered - patient chooses • FOBT/FIT is primary screening approach • Other

  7. Reaching Our Goal? Understanding the Guidelines

  8. CRC Screening Guidelines: New Concepts • A 50% sensitivity threshold for cancer • Tests that predominantly target prevention versus tests that predominantly target cancer

  9. “It is the strong opinion of this expert panel that colon cancer prevention should be the primary goal of CRC screening” Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008

  10. Tests That Primarily Detect Cancer • Annual gFOBT with at least 50% test sensitivity for cancer, or… • Annual FIT with at least 50% test sensitivity for cancer, or… • sDNA at uncertain screening interval

  11. What Is A Highly Sensitive Stool Blood Test? ACS defined “Sensitive” FOBT/FIT as one that has >50% sensitivity for cancer on one time testing. Exceeds 50%Under 50% Hemoccult Sensa Hemoccult II FIT’s (multiple brands)

  12. Fecal Immunochemical Tests (FIT’s) May Replace Guiac FOBT • FIT’s • Demonstrate superior sensitivity and specificity • Are specific for colon blood and are unaffected by diet or medications • Some can be developed by automated readers • Some improve patient participation in screening Allison JE, et.al. J Natl Cancer Inst. 2007; 191:1-9 Cole SR, et.al. J Med Screen. 2003; 10:117-122

  13. FIT’s available in the US

  14. Take home lesson: Know which stool test you’re using

  15. …And consider switching from guiac-FOBT to Fecal Immunochemical Testing (FIT)

  16. Tests That Detect Adenomatous Polyps and Cancer • Flexible sigmoidoscopy every 5 years, or… • Colonoscopy every 10 years, or… • Double-contrast barium enema every 5 years, or… • CT colonography every 5 years

  17. ACS Screening Guideline Versus USPSTF Guideline – Key Differences

  18. But ACS & USPSTF Guidelines Agree on All Key Components • All adults over 50 y.o. must be screened • The screening options on both lists are: • Colonoscopy every 10 years • High Sensitivity FOBT or FIT annually • Flexible sigmoidoscopy every 5 years • Flex sig plus FOBT/FIT • Screening with FOBT at time of digital rectal IS NOT recommended

  19. If a patient happened to have a C-T colonography, or, less commonly now, double contrast barium enema, they should be considered to be successfully screened

  20. CRC Screening and Aging • The USPSTF recommends routine screening up until age 75 • From 76 to 85 y.o. – Do not screen routinely • Ages 86 and over – Do not screen

  21. Post Polypectomy Surveillance Brooks DD, et.al. Am Fam Phys. Apr 1, 2008

  22. Practically speaking, all CRC guidelines are telling us to do the same thing: Be prepared to offer screening colonoscopy and a high sensitivity stool blood test

  23. Colonoscopy – Is It Truly a Gold Standard? • Distal vs. proximal colon cancer • Colonoscopy confers only 12-33% protection against proximal colon cancer; 80% against distal • Distal colon cancer in the US is declining. Proximal colon cancer rates are flat Bressler B, et.al. Gastroenterology 2004; 127:452-456

  24. Why Has Colonoscopy Been Disappointing For Right-Sided Cancers? • Quality of colonoscopy • Right-sided cancers may more likely derive from flat polyps • Right-sided cancers may grow faster • Timing of prep may not be ideal

  25. Colonoscopy is the Best Screening Test for Colon Cancer …. isn’t it?

  26. Maybe Not!

  27. Evaluating Test Strategies for Colorectal Cancer Screening Zauber and her team conducted a decision analysis using microsimulation models Zauber AG et.al. Ann of Int Med. 2008, 149; 659-669

  28. Number of life-years gained is essentially identical regardless of screening strategy used: • Sensitive guiac FOBT annually • Fecal Immunochemical Test (FIT) annually • Flexible sigmoidoscopy every 5 years with midinterval sensitive FOBT • Colonoscopy every 10 years ASSUMING 100% ADHERENCE

  29. Less Effective Strategies Flexible sigmoidoscopy every 5 years or Low sensitivity FOBT annually

  30. The Key Determinant of Effectiveness of Colon Cancer Screening Getting it done!

  31. Barriers to Physician Recommendation of CRCS Patient Comorbidity Patients who previously refused screening Language barriers Distrustful patients Patient already under the care of a GI specialist Perceived lack of patient acceptability • Guerra, CE et al. Barriers to Physician Recommendation of Colorectal Cancer Screening. J Gen Intern Med. 2007;22(12):1681-8.

  32. Barriers to Physician Recommendation of CRCS Physician Forgetfulness Outdated knowledge of guidelines Fatigue

  33. Barriers to Physician Recommendation of CRCS System Acute care visits Due to lack of time, higher acuity and de-prioritization of screening Lack of time Too many active issues and/or patient concerns Lack of reminder systems Absence of reliable test tracking system Lack of insurance coverage Delays in colonoscopy scheduling

  34. Barriers to Recommending CRCS All eligible patients do not consistently receive a provider recommendation for CRCS Interventions are needed to address the multiple barriers to address patient, physician and system level barriers Guerra, CE et al. Barriers to Physician Recommendation of Colorectal Cancer Screening. J Gen Intern Med. 2007;22(12):1681-8.

  35. The Biggest Barrier Of All • Lack of payment to support outreach to entire enrolled population of patients

  36. The Journal Article Sarfaty M, Wender R. How to increase colorectal cancer screening rates in practice. Ca Cancer J Clin 2007;57:354-366 This article is available online at http://CAonline.AmCancerSoc.org Free CME credit for successfully completing the online quiz http://CME.AmCancerSoc.org

  37. Interactive Web-based Toolbox http://www.cancer.org/aspx/pcmanual/default.aspx

  38. Toolbox Your recommendation Office policy Reminder system Communication strategies

  39. Essential 1: Physician Recommendation Physician recommendation is the most effective intervention for encouraging patients to be screened 74-90% of patients who have not had CRCS report they would schedule CRCS if their physician recommended the test Lewis SF, et al.; Guerra CE, et al.

  40. Impact of Physician Recommendation Lack of physician recommendation of CRCS is strongly associated with NOT undergoing CRCS Harewood GC et al.; Guerra CE, et al.; Klabunde CN et al. Conversely, physician recommendation of CRCS is one of the most important facilitators of adherence to CRCS Subramanian S, et al.; Teng EJ, et al.; Zapka JG et al.; Myers RE, et al.; Mandelson MT, et al; Bejes C, et al; Holt WS Jr, et al.

  41. Goal Every eligible patient enrolled in your practice should receive a recommendation to undergo CRCS

  42. Essential 2: An Office Policy Takes into account patient risk level: average, increased, high local medical resources insurance coverage patient preferences

  43. Office Policy: Determining Patient Risk Have you or any members of your family had CRC? Have you or any members of your family had an adenomatous polyp? Has any member of your family had a CRC or adenomatous polyp when they were under the age of 50? (If yes, consider a hereditary syndrome) Do you have a history of Crohn’s disease or ulcerative colitis (for more than 8 years)? Do you or any members of your family have a history of cancer of the endometrium, small bowel, ureter, or renal pelvis? (If yes, consider HNPCC)

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