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Colorectal Cancer Screening The Basics

Colorectal Cancer Screening The Basics. Barbara G. Lloyd MD FACS Medical Consultant Montana Cancer Control Programs Sep 4, 2009. Take Home Points. Why emphasize CRC screening Incidence Mortality Risk factors Benefits Current status Screening barriers CRC screening guidelines 2008

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Colorectal Cancer Screening The Basics

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  1. Colorectal Cancer Screening The Basics Barbara G. Lloyd MD FACS Medical Consultant Montana Cancer Control Programs Sep 4, 2009

  2. Take Home Points • Why emphasize CRC screening • Incidence • Mortality • Risk factors • Benefits • Current status • Screening barriers • CRC screening guidelines 2008 • CRC Screening Tests

  3. Why: United States 3rd most common cancer 146,970 new cases expected in 2009 The 2nd deadliest cancer ≈ 50,000 deaths nationwide annually  1 million living with CRC

  4. WHY: Montana “There are three kinds of lies: lies, damned lies and statistics.” (Benjamin Disraeli) • 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

  5. Cancer Burden • Montana Central Tumor Registry, 8/2009 • Montana Office of Vital Statistics, 2/2009

  6. Cancer Burden • Montana Central Tumor Registry, 9/2009 • Montana Office of Vital Statistics, 2/2009

  7. CRC Risk Factors Lifestyle-related factors: • Smoking • Obesity • Diet • red or processed meats, high-fat • frying, broiling, or grilling meat • Low fruit and vegetable, low fiber • Physical inactivity • Heavy alcohol use • Type 2 diabetes

  8. CRC Risk Factors • Age • Gender • Race/Ethnicity

  9. CRC Risk Factors Race in Montana Rates are per 100,000 age-adjusted to 2000 census standard Source: Cancer Among American Indian Residents of Montana 2002-2006, August 2008

  10. 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%)

  11. CRC Risk Factors May need earlier & more intensive screening: • Personal history • inflammatory bowel disease • adenomatous polyps • colorectal cancer • Family history • adenomatous polyps • colorectal cancer • genetic syndromes (HNPCC, FAP,…)

  12. Risk Categories ACS & US Multi-Society Task Force on Colorectal Cancer • Average • Increased • Personal hx colon polyps • Personal hx colon cancer (cured) • 1st degree Family hx colon polyps or CRC <60yo or ≥2 of any age • Highest • FAP or HNPCC • IBD

  13. Risk Categories USPSTF Patient Population under Consideration: • adults ≥50 years of age • those with 1st degreerelatives who have had colorectal adenomas • those with 1st degreerelatives who have had colorectal cancer • all ethnicand racial groups Excluded: • those with specific inherited syndromes • those with inflammatorybowel disease

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

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

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

  17. Changing Mortality Rates

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

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

  20. Benefits of Screening Ries et al; www.seer.cancer.gov/csr/1975_2004/,2007

  21. Benefits of Screening

  22. Montana CRCFive- Year Survival

  23. Montana CRCStage at Diagnosis § Small number of cases of invasive cervical cancer

  24. Montana CRCStage at Diagnosis

  25. Benefits of CRC Screening USPSTF Benefit: • Convincing evidence for the 3 tests for adults age 50-75 • Adequate evidence benefits decline >75 UPSTF Harm: • Use of invasive procedures initially or as follow-up • Preparation, sedation or procedure itself

  26. Benefits of CRC Screening USPSTF Life-years gained per 1000 screened: • Colonoscopy = 271 • SENSA = 259 • Flexible Sigmoidoscopy/SENSA = 257 • FIT = 256 • Hemoccult II = 218 • Flexible Sigmoidoscopy = 199

  27. Cancer Screening Costs Screening costs per year of life saved: • Colorectal cancer = $11,890 to $29,725 • Mammography every 2 years for women aged 65 or older = $36,924

  28. Cancer TX Cost Source: National Cancer Institute Cancer Trends Progress Report – 2005 Update http://progressreport.cancer.gov

  29. Screening CRCHow are we doing? 'To me the only way you achieve a summit is to come back alive. The job is half done if you don't get down again.' John Mallory

  30. CRC Screening Rates: US • Only 40% of CRC detected at the earliest stage • ≈ 1/2 ≥ 50yo report having had recent CRC screening • Slow but steady improvement over the past decade • Still disparity by education, income, insurance status and race/ethnicity

  31. Endoscopy by Educational Attainment and Health Insurance Status Adults 50 Years and Older, US, 1997-2004 Source: Behavioral Risk Factor Surveillance System CD-ROM (1996-1997, 1999) and Public Use Data Tape (2001, 2002, 2004), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention and Prevention, 1999, 2000, 2002, 2003, 2005.

  32. FOBT by Educational Attainment and Health Insurance Status Adults 50 Years and Older, US, 1997-2004 Source: same as previous slide

  33. Colonoscopy/Sigmoidoscopy BRFSS 2006 < 50% 50-59% >/= 60% 36

  34. MT Cancer Screening BRFSS

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

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

  37. Cancer Control Opportunity The American Cancer Society estimates that 90 % of CRC in the US Cases&Deaths could be prevented ACS: Colorectal cancer facts and figures sp ed 2005

  38. Why emphasize CRC screening: • Incidence • Mortality • Risk factors • Benefits • Current screening status ?’s Photo by Drake Barton Montana-moods@hughes.net

  39. Screening Barriers In God we trust. All others must bring DATA. —Robert W. Hayden (dates unknown)

  40. WHY NOT: United States • Low awareness of CRC as a personal health threat • Lack of knowledge of screening benefits • Fear, embarrassment, discomfort • Time • Cost • Access • “My doctor never talked to me about it!”

  41. 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

  42. 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

  43. Why Not: Montana

  44. Why Not: Montana

  45. Why Not: Montana American Indian Barriers * p < .05, *** p< .001

  46. Colonoscopy Capacity MT

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