Colorectal Cancer Screening: The Basics

1. Colorectal Cancer Screening: The Basics July 21, 2010

2. Take Home Points • Colorectal Cancer • Overview • Screening Guidelines • Screening Participation • Screening Barriers • CRC Screening Tests • CRC Screening Algorithm

3. Colorectal Cancer • 3rd most common • 475 incidence cases (avg/yr 2002-06) • 3rd deadliest cancer • 170 deaths in MT (avg/yr 2003-07) • Screening for CRC is effective • CRC screening rates could be better

4. CRC Risk Factors • Age • Gender • Race/Ethnicity • No racial/ethnic differences in MT

5. CENTERS FOR DISEASE CONTROL AND PREVENTION Colorectal Cancer Sporadic (average risk) (65%–85%) Family history(10%–30%) Rare syndromes (<0.1%) Hereditary nonpolyposis colorectal cancer (HNPCC) (5%) Familial adenomatouspolyposis (FAP) (1%)

6. CRC Screening Guidelines2008 The American College of Obstetricians and Gynecologists The American Collegeof Physicians, American Academy of Family Physicians, AmericanCollege of Preventive Medicine, and Centers for Disease Controland Prevention USPSTF Joint Guideline: ACS, U. S. Multi-Society Task Force on Colorectal Cancer, American College of Radiology 6

7. Cancer Screening U.S. Preventive Services Task Force: • Sufficient Evidence • Breast • Cervical • Colorectal • Not Sufficient Evidence • Lung • Prostate • All Others

8. CRC Screening Guidelines2008 USPSTF CRC screening recommendation: • Age 50-75: screening using • Annual high-sensitivity FOBT • Sigmoidoscopy every 5 yrs combined with high-sensitivity FOBT every 3 yrs • Colonoscopy at intervals of 10 yrs • Age 76-85: against routine screening, considerations may support screening in individuals • Age >85: against screening 8

9. CRC Screening Tests Tests recommended USPSTF: • Colonoscopy • Sigmoidoscopy • Fecal Occult Blood Testing (FOBT) • Guaiac • Immunochemical 9

10. Colonoscopy/Sigmoidoscopy BRFSS 2006 < 50% 50-59% >/= 60% 10

11. MT Cancer Screening BRFSS

12. MT Cancer Screening by Race * p < .05, ** p< .01

13. MT Cancer Screening2008 BRFSS • Approximately 20% had both • < 60% had FOBT or endoscopy or both 13

14. Why Not: Montana BRFSS Cancer Screening Questions: • Have you ever had a • Mammogram • Pap smear • PSA test • DRE • Colonoscopy or sigmoidoscopy • FOBT • If yes, when was your last one

15. Why Not: Montana Added for Mammogram & Endoscopy: • Has provider ever recommended that you have… • Have you had…(endoscopy ever / mammogram within 2 years) • If never screened or not up to date, Why not? • What is main reason you have not… Use responses to infer barriers

16. Why Not: Montana

17. Why Not: Montana

18. Colonoscopy Capacity Survey 2008 41 hospitals perform colonoscopy 40 returned surveys Info from M.D. for nonresponding hospital 3 ambulatory centers Affiliated with large hospitals All returned surveys

19. Colonoscopy Capacity Survey 2008 13 Urban 15,000 screens per year Total capacity ~21,000 7 week wait 25% of screen capacity unused 31 Rural 4,000 screens per year Total capacity ~22,000 2 week wait 80% of screen capacity unused

20. Why emphasize CRC screening: • Incidence • Mortality • Risk factors • Benefits • Current screening status • Questions?

21. Colorectal Cancer Screening 2008

23. Colonoscopy Sensitivity for CRC =95% Estimate: $800 - $1600

24. Risk Factor - Polyps Different types: • Hyperplastic • minimal cancer potential • Adenomatous • approximately 90% of colon and rectal cancers arise from adenomas 24

25. Flat Lesions Soetikno, JAMA 2008 Caveats • Most lesions not truly flat 25

26. Human colon carcinogenesis Normal Polyp Cancer Normal to Adenoma to Carcinoma 26

27. Benefits of CRC Screening Benefits: • Cancer Prevention: Removal of pre-cancerous polyps • Long-term survival: Improved by early detection 27

28. Colonoscopy Colonoscopy – Pros • Can usually view entire colon • Can biopsy and remove polyps • Done every 10 years • Can diagnose other diseases

29. Colonoscopy  Colonoscopy – Cons • Can miss small polyps • Full bowel preparation needed • More expensive on a one-time basis • Sedation of some kind is usually needed • Will need someone else to drive home • May require a missed day of work

30. Colonoscopy  Colonoscopy – Cons • Risk of serious Complications 25/10,000 • Bleeding 12.3/10,000 • Tear or perforations 3.8/10,000 • Infection or diverticulities • Cardiovascular events • Severe abdominal pain • Serious complication consequence: • Hospital admission • Surgery • Death 0.6/10,000 procedures reported

31. Guaiac Fecal Occult Blood Test Sensitivity for CRC =varies (64% for Hemoccult SENSA) Estimate:$10 - $25

32. FOBT Fecal Occult Blood Test – Pros • No direct risk to the colon • No bowel preparation • Sampling done at home • Inexpensive

33. FOBT Fecal Occult Blood Test – Cons • May miss many polyps and some cancers • May produce false-positive test results • May have pre-test dietary limitations • Should be done annually • Organized system needed for follow-up • Colonoscopy needed if abnormal

34. In-Office FOBT • Single sample, in-office CRC sensitivity = 9.5 % • Hemoccult II 3 card, take-home sensitivity = 43.9 % • In-office FOBT not a CRC screening tool • Nearly 30% of physicians reported using for screening colorectal cancer Nadel et al, Annals of Int Med Jan 2005

35. Fecal Immunochemical Test Sensitivity for CRC =varies (66% for Magstream FIT) Estimate: $28

36. FIT Fecal Immunochemical Test – Pros • No direct risk to the colon • No bowel preparation • No pre-test dietary restrictions • Sampling done at home • Fairly inexpensive

37. FIT Fecal Immunochemical Test – Cons • May miss many polyps and some cancers • May produce false-positive test results • Should be done annually • Colonoscopy needed if abnormal

38. Colorectal cancer symptoms Blood in or on the stool Stomach pains, aches, or cramps that are persistent Unexplained weight loss Change in bowel habits

39. 39

40. Resources Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline: http://caonline.amcancersoc.org/cgi/content/full/CA.2007.0018v1 USPSTF CRC screening 2008 update: http://www.ahrq.gov/CLINIC/uspstf/uspscolo.htm MDPHHS Cancer Control webpage: www.cancer.mt.gov Email questions on cancer control: cancerinfo@mt.gov The Community Guide: www.thecommunityguide.org How to Increase Colorectal Cancer Screening Rates in Practice: A Primary Care Clinician's Evidence-Based Toolbox and Guide: http://www.cancer.org/docroot/PRO/content/PRO_4_1x_ColonMD_Clinicians_Manual.pdf.asp Ballew, Lloyd, and Miller. 2009. Capacity for Colorectal Cancer Screening by Colonoscopy, Montana, 2008. American Journal of Preventive Medicine 36:329-332.