Colorectal Cancer Screening Saves Lives – and You Can Help!

1. Colorectal Cancer Screening Saves Lives – and You Can Help! Arkansas Foundation for Medical Care March 15, 2013 Durado Brooks, MD, MPH Director, Prostate and Colorectal Cancers

2. Colorectal Cancer • The third most common cancer in U.S. and the second deadliest • 141,000 new cases expected this year • More than 49,000 deaths nationwide • 1.1 million Americans living with colorectal cancer • Death rates have fallen steadily over the past 20 years

3. Trends in Colorectal Cancer Death Rates* by Race/Ethnicity and Sex, US, 1975-2003 Males African Americans Females African Americans 43% Whites Rate per 100,000 46% Whites *Age-adjusted to the 2000 US standard population. Data Source: Surveillance, Epidemiology, and End Results (SEER) Program, 1975-2003, Division of Cancer Control and Population Sciences, National Cancer Institute, 2006.

4. Trends in CRC incidence and mortality CRC incidence and mortality have fallen steadily over the past 2 decades. Research suggests that observed declines in incidence and mortality are due in large part to: • CRC treatment advances • Screening  detecting cancers at earlier, more treatable stages • Screening and polyp removal, preventing progression of polyps to invasive cancers • NEJM study Feb 2012 showed polyp removal associated with 53% lower risk of CRC death

5. Risk Factors

6. Non-Modifiable Risk Factors • Increased risk with: • Personal history of inflammatory bowel disease, adenomatous polyps or colon cancer • Family history of adenomatous polyps, colon cancer, other conditions • Individuals with these risk factors may require earlier and more intensive screening The remainder of this presentation will focus on the average risk population.

7. Pop Quiz: #1 Risk Factor?

8. Non-Modifiable Risk Factors • Age • 90% of cases occur in people 50 and older • Gender • slight male predominance, but common in both men and women • Race/Ethnicity – higher rates among • African Americans • Native Americans (esp. Northern Plains Tribes) • Alaska Natives • Ashkenazi Jews

9. Colorectal Cancer Risk Factors Modifiable Risk Factors • Diet • Tobacco • Alcohol • Physical Activity • Obesity

10. Risk Factor - Polyps Types of polyps: • Hyperplastic • minimal cancer potential • Adenomatous • approximately 90% of colon and rectal cancers arise from adenomas

11. Normal to Adenoma to Carcinoma Human colon carcinogenesis progresses by the dysplasia/adenoma to carcinoma pathway

12. Screening

13. Benefits of Screening • Cancer Prevention • Removal of pre-cancerous polyps prevent cancer (unique aspect of colon cancer screening) • Cost-effective • Cost of CRC screening compares favorably to many other common interventions (i.e. mammograms) • Treatment costs for advanced disease have risen greatly in recent years • Improved survival • Early detection markedly improves chances of long term survival

14. Benefits of Screening *1996 - 2003

15. Trends in Recent* CRC Screening Prevalence (%), by Educational Attainment and Health Insurance Status, Adults 50-75 Years, US, 2000-2010 Source: Klabunde et al, Cancer Epidemiol Biomarkers Prev2011;20:1611-1621 National Health Interview Survey Public Use Data File 2010, National Center for Health Statistics, Centers for Disease Control and Prevention, 2011. American Cancer Society, Surveillance Research, 2011 .

16. Trends in Recent* CRC Screening Prevalence (%), by Educational Attainment and Health Insurance Status, Adults 50-75 Years, US, 2000-2010 Source: Klabunde et al, Cancer Epidemiol Biomarkers Prev2011;20:1611-1621 National Health Interview Survey Public Use Data File 2010, National Center for Health Statistics, Centers for Disease Control and Prevention, 2011. American Cancer Society, Surveillance Research, 2011 .

17. Lower use of colorectal screening examinations in minority populations

18. 5-Year Relative Survival Rates – CRC 67% 56% 50% 45%

19. Screening Tests

20. ACS Screening Guidelines

21. Recommended Screening Tests ACS and USPSTF • High Sensitivity Fecal Occult Blood Testing • Guaiac • Immunochemical • Colonoscopy • Flexible Sigmoidoscopy (FSIG) • Recent studies support efficacy

22. Pop Quiz: Which test(s) do patients prefer?

23. Patient Preferences Inadomi, Arch Intern Med 2012

24. Colonoscopy Colonoscopy allows doctor to directly see inside entire bowel

25. Why Colonoscopy is NOT gold standard • Evidence does not support “best test” or “gold standard” • Colonoscopy misses ~ 10% of significant lesions in expert settings • Higher potential for patient injury than other tests • More costly on a one-time basis • Measurable outcomes vary widely (i.e. test performance is highly operator dependent) • Greater patient requirements for successful completion • Requires a bowel prep and facility visit, and often a pre-procedure specialty office visit • Access • Limited by insurance status, local resources • Patient preference • Many individuals don’t want an invasive test or a test that requires a bowel prep

26. Stool Test: Guaiac • Most common type in U.S. • Best evidence (3 RCT’s) • Need specimens from 3 bowel movements • Non-specific • Results influenced by foods and medications • Older forms (Hemoccult II) have unacceptably low sensitivity • Better sensitivity with newer versions (HemoccultSensa)

27. Stool Test: Immunochemical (FIT) • Specific for human blood and for lower GI bleeding • Results not influenced by foods or medications • Some types require only 1 or 2 stool specimens • Higher sensitivity than older forms of guaiac-based FOBT • Slightly more costly than guaiac tests FIT use in the US will likely increase due to recent elimination of guiaic- based testing by LabCorp and Quest Labs

28. Sensitivity of Take Home vs. In-Office FOBT FOBT Quality Issues Collins et al, Annals of Int Med Jan 2005

29. Stool Testing Quality Issues • In-office FOBT is essentially worthless as a screening tool for CRC and should never be used. • CRC screening by FOBT should be performed with high-sensitivity FOBT - either FIT or a highly sensitive gFOBT (such as Hemoccult SENSA). • Older, less sensitive guiaic tests (such as Hemoccult II) should not be used for CRC screening. • Annual testing • All positive screening tests should be evaluated by colonoscopy

30. High Quality Stool Testing Clinicians Reference: FOBTOne page document designed to educate clinicians about important elements of colorectal cancer screening using fecal occult blood tests (FOBT). Provides state-of-the-science information about guaiac and immunochemical FOBT, test performance and characteristics of high quality screening programs. Available at www.cancer.org/colonmd

31. Improving Screening Rates

32. Why are Screening Rates Low?(according to patients) Low awareness of CRC as a personal health threat Lack of knowledge of screening benefits Fear, embarrassment, discomfort Time Cost Access Structural issues (lack of systems in most settings)

33. Pop Quiz: #1 Reason for not getting screened?

34. Sub-Optimal Screening RatesReasons (according to Patients) “My doctor never talked to me about it!”

35. Is a Doctor’s Recommendation Really That Useful? Gastroenterology Dept Adapted from Jack Tippit, Saturday Evening Post

36. Yes. Unequivocally! A clinician’s recommendation is the most consistently influential factor in cancer screening

37. Opportunistic vs. Organized Preventive Care • Most preventive care for adults in the U.S. is opportunistic, i.e. occurs incidentally during encounters with healthcare professionals • Opportunistic care depends on a coincidence of encounters, circumstances, and interests between patient and provider • This means some adults get some preventive care on some occasions and at some interval • Few adults receive the full package, or even the majority of recommended preventive services

39. “Action Plan” Toolkit Version Eight page guide introduces clinicians and staff to concepts and tools provided in the full Toolkit Contains links to the full Toolkit, tools and resources Not colorectal-specific; practical, action-oriented assistance that can be used in the office to improve screening rates for multiple cancer sites (colorectal, breast and cervical) Available at http://nccrt.org/about/provider-education/crc-clinician-guide/

40. Communication

41. #1: Make a Recommendation • Determine the screening messages you and your staff will share with patients. Essential #1: Explore how your practice will assess a patient’s risk status and receptivity to screening. Essential #1:

42. #2 Develop a Screening Policy Create a standard course of action for screenings, document it, and share it. Essential #2: Compile a list of screening resources and determine the screening capacity available in your community. Essential #2:

43. Pop Quiz: What kind of stool test is used in your practice?

44. Office Screening Policy • Individual Risk Level (“risk stratification”) • Medical resources (e.g. location and accessibility of endoscopy facilities) • Patient preference • State and federal program policies and processes (CDC program,…) • Insurance (deductible? copay? resources for uninsured?) • Impact of Affordable Care Act on preventive services Factors to Consider in Your Office Policy

45. Patient Protection and Affordable Care Act Cancer Screening: • No co-pays and coverage for cancer screening with an “A” or “B” recommendation from USPSTF. • Waiver of deductible for colorectal cancer screening tests regardless of coding, subsequent diagnosis, or ancillary tissue. • “Loophole” led to co-pays for some when polyp found during screening exam .

46. For more information Published: March 2013 Affordable Care Act Implementation FAQs Q5: If a colonoscopy is scheduled and performed as a screening procedure pursuant to the USPSTF recommendation, is it permissible for a plan or issuer to impose cost-sharing for the cost of a polyp removal during the colonoscopy? No. Based on clinical practice and comments received from the American College of Gastroenterology, American Gastroenterological Association, American Society of Gastrointestinal Endoscopy, and the Society for Gastroenterology Nurses and Associates, polyp removal is an integral part of a colonoscopy. Accordingly, the plan or issuer may not impose cost-sharing with respect to a polyp removal during a colonoscopy performed as a screening procedure. On the other hand, a plan or issuer may impose cost-sharing for a treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service.

47. #3 Be Persistent with Reminders Determine how your practice will notify patient and physician when screening and follow up is due. Essential #3: Ensure that your system tracks test results and uses reminder prompts for patients and providers. Essential #3:

48. Patient Reminders • Two types 1. Cues to action 2. Education

49. Patient Education Get Tested For ColonCancer: Here's How."An 7-minute video reviewing options for colorectal cancer screening tests, including test preparation.Available as DVD, or you can refer patients to the URL to view from their personal computer.

50. Clinician Reminder Types • Chart Prompts • Problem lists • Screening schedules • Integrated summaries • Alerts – “Flags” placed in chart • Follow-Up Reminders • Tickler System • Logs and Tracking • Electronic Reminder Systems