“They say that time changes things, but you’re the one that needs to change them.”– Andy Warhol

1. Place photo here Colorectal Cancer: Moving Forward with Organized Cancer Screening Kimberly Rogers, Program ManagerWyoming Department of HealthComprehensive Cancer Control Program “They say that time changes things, but you’re the one that needs to change them.”– Andy Warhol

2. Colorectal Cancer in Wyoming: A look at incidence and mortality (WCSP, 2003) • In 2003, 243 cases were reported, and in that same year, 106 Wyoming people died as a result of colorectal cancer. • Although the incidence rates for men and women in Wyoming are similar, the incidence rate for Wyoming females is higher than the national rate. • There is a dramatic incline in cases among Wyoming people ages 60-64 years old. • There are higher incidence rates among those living in Park, Big Horn, Washakie, and Hot Springs Counties. • There are higher mortality rates among those living in Carbon, Albany, Platte, and Goshen Counties.

3. 2000-2003 Colorectal Cancer Incidence & Mortality Trend Data Rate per 100,000 population

4. Colorectal Cancer Screening in Wyoming • Less than ½ (43.9%) of Wyoming residents age 50 and older report having had a FOBT home kit, sigmoidoscopy, or colonoscopy within the past 5 years (2004 BRFSS). • Adults ages 50-59, those in the lowest density counties, and those who were uninsured were least likely to have had a sigmoidoscopy or colonoscopy. Counties with lower CRC screening rates Counties with higher CRC screening rates * This includes Flexible Sigmoidoscopy and Colonoscopy Only

5. A Little Humiliation Never Helps…

6. What Do We Want to Accomplish for Wyoming People Impacted by Colorectal Cancer? GOAL #1: • Decrease the number of men and women dying of colorectal cancer in Wyoming. Objective I: • By 2010, increase the percentage of men and women age 50 and older who have had a sigmoidoscopy or colonoscopy to 60%. Baseline: 50.9% of Wyoming respondents ages 50 and over reported they had received a sigmoidoscopy or colonoscopy. (BRFSS, 2003) Objective II: • By 2010, increase the percentage of men and women age 50 and older who have had fecal occult blood stool (FOBT) testing to 35%. Baseline: Only about one in five Wyoming adults age 50 and older (18.5%) reported having a blood stool test in the past 2 years. (BRFSS, 2003) * Taken from the 2006-2010 Wyoming Cancer Control Plan

7. Strategies to Decrease the Burden of Colorectal Cancer in Wyoming • Provide culturally appropriate colorectal cancer education and information to Wyoming adults, families, communities, and interested healthcare providers; • Promote colon screening services available in Wyoming through education and information dissemination; • Promote advocacy group initiatives surrounding colorectal cancer; • Provide education and information about colon cancer statewide, including the use of a marketing campaign utilizing evidence-based strategies to promote colon cancer screening; • Increase access to screening for un-insured and under-insured Wyoming residents; • Educate policymakers on screening coverage and treatment costs pertaining to colorectal cancer; • Promote physician/client discussion about colorectal cancer, including the importance of colorectal cancer screening; and • Educate patients to request tests relating to colon cancer.

8. Screening:Fecal Occult Blood Testing (FOBT) • A fecal occult blood test detects blood in the stool. • Blood in the stool may be the only symptom of colon cancer. However, not all blood in the stool is caused by cancer. • Although fecal occult blood testing may be used to screen for colorectal cancer, it is never used to diagnose this disease. • Checking for hidden (occult) blood in the stool can be done at home.

9. Screening:Flexible Sigmoidoscopy • Enables the physician to view inside the the large intestine from the rectum through the last part of the colon, called the sigmoid or descending colon. • Observe any bleeding, inflammation, abnormal growths, and ulcers in the descending colon and rectum. • Not sufficient to detect polyps or cancer in the ascending or transverse colon (two-thirds of the colon). • If anything unusual is in your rectum or colon, like a polyp or inflamed tissue, the physician can remove a piece of it using instruments inserted into the scope.

10. Screening:Colonoscopy • In a conventional colonoscopy, the doctor inserts a colonoscope—a long, flexible, lighted tube—into the patient's rectum and slowly guides it up through the colon. • Pain medication and a mild sedative help the patient stay relaxed and comfortable during the 30- to 60-minute procedure. • A tiny camera in the scope transmits an image of the lining of the colon, so the doctor can examine it on a video monitor. • If an abnormality is detected, the doctor can remove it or take tissue samples using tiny instruments passed through the scope.

11. Screening:Virtual Colonoscopy • Virtual colonoscopy (VC) uses x rays and computers to produce two- and three-dimensional images of the colon (large intestine) from the lowest part, the rectum, all the way to the lower end of the small intestine and display them on a screen. The procedure is used to diagnose colon and bowel disease, including polyps, diverticulosis, and cancer. • VC is more comfortable than conventional colonoscopy for some people because it does not use a colonoscope. As a result, no sedation is needed, and you can return to your usual activities or go home after the procedure without the aid of another person. • The doctor cannot take tissue samples or remove polyps during VC, so a conventional colonoscopy must be performed if abnormalities are found.

12. Colorectal Cancer Screening Recommendations • The USPSTF strongly recommends that clinicians screen men and women 50 years of age or older for colorectal cancer. • The USPSTF found fair to good evidence that several screening methods are effective in reducing mortality from colorectal cancer. • FOBT (Yearly after age 50)* • Colonoscopy (Every 10 Years beginning at age 50)* * If you are high risk for CRC or have family who have had CRC your physician may request you begin screening at an earlier age. • The USPSTF concluded that the benefits from screening substantially outweigh potential harms, but the quality of evidence, magnitude of benefit, and potential harms vary with each method.

13. What are the benefits to organized colorectal cancer screening? • Early screening and diagnosis = less aggressive treatment; • Reduces colorectal cancer mortality for adults over age 50 at average risk of colorectal cancer; • Reduces health-related disparities to underserved populations who would not normally have the resources for ongoing screening; • Cost effective (controversial) • Cost of screening vs. cost of treatment

14. Wyoming Colorectal Cancer Early Detection Reimbursement Program: A look at the possibilities • Wyoming Colorectal Cancer Task Force would research and select a CRC screening strategy for organized screening in Wyoming; • Determine a reimbursement method (billing vs. voucher program); • Determine eligibility requirements for the program; • Begin educating the public and providers about CRC screening; • Obtain funding to provide CRC screening to eligible program applicants; • Begin contracting with providers for medical screening services and treatment, and • Begin screening Wyoming men and women who meet eligibility requirements.

15. Is Organized colorectal cancer screening cost-effective? • Screening for colorectal cancer appears cost-effective compared with no screening. • Cost-effectiveness analyses have come to disparate conclusions depending on the estimated compliance rates, procedural costs, complication rates, and sensitivity and specificity of screening tests. • Yearly FOBT with flexible sigmoidoscopy every 5 years to be the most cost-effective strategy for screening of the general population. Frazier et al. • In contrast, colonoscopy every 10 years was the most cost-effective primary screening strategy. Sonnenberg et al. • Double contrast barium enema every 5 years to be superior to colonoscopy, with an incremental cost-effectiveness ratio of $55,600 per year of life saved versus more than $100,000 per year of life saved. McMahon et al.

16. How much would it cost to adequately screen Wyoming men and women who are un-insured or underinsured? • According to the Census Bureau, 135,661 men and women over the age of 50 live in Wyoming (2000). • According to this data, 52,000 Wyoming men and women in this age group are below the 250% FPL. • Of that population, 5,000 (approximately 10%) report no health insurance to aid in screening. • If 20% of the eligible men and women in Wyoming took advantage of this program, it is estimated that the program could provide services to 1,000 Wyoming men and women each year. Therefore, the annual cost of the program is calculated as follows:

17. Proposed Yearly Colorectal Cancer Screening Budget

18. Colorectal Cancer Reimbursement Program Budget* Treatment Option In 2003, 234 Wyoming citizens were diagnosed with colorectal cancer. Based on the same criteria (approximately 10%), it is estimated that roughly 23 patients would need treatment services each year. Therefore, the annual cost of treatment for colorectal cancer is calculated as follows.

19. Proposed Treatment Budget

20. Next Steps • Continued education and awareness about issues pertaining to colorectal screening; • Join the WCCCC for the January working meeting • Join the CRC Task Force; • Spearhead CRC marketing and education initiatives; • Provide education and recommendations for screening policy and funding to Wyoming policymakers; and

21. Questions?