Colon Cancer Surveillance & Evaluation

Colon CancerSurveillance & Evaluation Lorna Thorpe, Ph.D. NYC DOHMH – Division of Epidemiology CDC - Nat’l Center for Chronic Disease Prevention and Health Promotion

Objectives • Review cancer surveillance goals • Identify measurable indicators related to colorectal cancer • Summarize national and local surveillance findings • Discuss strengths and weaknesses of available indicators • Lead group discussion on local surveillance opportunities

Cancer Surveillance Goals • Identify and track trends • Strengthen cancer prevention and control activities • Prioritize use of resources

Where are the Measurable Indicators for Tracking Colorectal Cancer? Monitor Prevalence of Risk Factors Cancer-related death occurs Cancer develops Polyp(s) develop

Where are the Measurable Indicators for Tracking Colorectal Cancer? Monitor Prevalence of Risk Factors Measure Use of Cancer Screening Tests Cancer-related death occurs Cancer develops Polyp(s) develop

Where are the Measurable Indicators for Tracking Colorectal Cancer? Monitor Prevalence of Risk Factors Measure Use of Cancer Screening Tests Track Incidence Of New Cancer Diagnoses Cancer-related death occurs Cancer develops Polyp(s) develop

Where are the Measurable Indicators for Tracking Colorectal Cancer? Monitor Prevalence of Risk Factors Measure Use of Cancer Screening Tests Track Incidence Of New Cancer Diagnoses Assess Cancer- Related Mortality Rates Cancer-related death occurs Cancer develops Polyp(s) develop

Individual Risk Factors for Colorectal Cancer • An unlikely set of indicators for tracking disease trends • Most behavioral risk factors are non-specific to colorectal cancer • Attributable fraction of highest risk groups is small • Highest risk groups may be adequately educated and/or screened

Risk Factors for Colorectal Cancer • Age • Diet • Physical activity • History of polyps (familial polyposis) • Personal medical history • Family medical history

Percent of Colorectal Cancer Burden due to Medical Risk Factors Source: CDC

Monitoring Colorectal Cancer Screening Strengths • Highly effective primary and secondary prevention approach • Long lead time (polyp  cancer, cancer  death) • Reduces mortality • Relatively cost-effective • Discrete, measurable event • Can set measurable, attainable, short-tem targets

Colorectal Cancer Screening Weaknesses • Not routinely captured in existing data sources • Not yet a HEDIS measure for health insurance • Not routinely assessed by PROs in Medicare • Not a reportable procedure • Reliant on self-reported prevalence estimates • Complicated screening recommendations menu makes for difficult prevalence assessment

Screening Rates in NYC • Large randomized telephone survey of adults (n=10,000) • Able to look at multiple subgroups • Very timely • Expensive • Difficult to validate • Asked about “ever” sigmoidoscopy or colonoscopy

Age-Adjusted Prevalence of Ever Colonoscopy or Sigmoidoscopy Screen, by Neighborhood -- NYC 2002

Low Screening Rates Among Groups at Higher Risk for Colorectal Cancer • No groups are being screened enough • Groups at higher risk have lower screening rates • Physically inactive • Smokers

Black and Hispanic New Yorkers Have Lower Rates of Screening than Whites

Screening Questions Planned for 2003 Survey • Ever had sigmoidoscopy or colonoscopy? • Which type, or both? • Time since last colonoscopy/sigmoidoscopy • Ever had a blood stool test (FOBT)? • Time since last FOBT

Other Data Sources for Tracking Screening Trends • Medicaid Managed Care Enrollees (MEDS) • Covers only a small proportion of >65 population • Unstable coverage for many enrollees • 678,000 enrollees, but only 62,000 age 45 and older

Colonoscopy Procedure Rates in NYC Medicaid MCO enrollees, between Jan-June 2002 Age MCO Enrollee Colonoscopies Rate per Pop performed 100,000 pop* 45-64 56,210 943 3355.3 65+ 5,193 112 4313.5 3436.3 = 3.4 per 100 MCO recipients age 45 or older * Annualized rate Source: NYC DOHMH

Other Data Sources for Tracking Screening Trends • Medicaid Managed Care Enrollees (MEDS) • Covers only a small proportion of >65 population • Unstable coverage for many enrollees • 678,000 enrollees, but only 62,000 age 45 and older • Colonoscopy provider surveys

Other Data Sources for Tracking Screening Trends • Medicaid Managed Care Enrollees (MEDS) • Covers only a small proportion of >65 population • Unstable coverage for many enrollees • 678,000 enrollees, but only 62,000 age 45 and older • Colonoscopy provider surveys • SPARCS Ambulatory procedures dataset

Tracking New Diagnoses of Colorectal Cancer (Incidence) Strengths • New York State Cancer Registry • Gold standard quality for completeness and accuracy • Includes incidence, stage at diagnosis, treatment regimen, mortality • National incidence trends, SEER and NPCR • High quality, complete, detailed follow-up

Tracking New Diagnoses of Colorectal Cancer (Incidence) Weaknesses • New York State Cancer Registry • Confidentiality concerns limit the timeliness and accessibility of NYC-specific data • Currently, grouped 1995-1999 data are available • National incidence trends, SEER and NPCR • No local specificity

Avg. Annual Age-Specific Incidence and Mortality Rates by Gender, U.S. 1995-1999

Avg Annual Age-Adjusted Colorectal Cancer Incidence Rates, By Borough and Gender – NYC, 1995-1999

Assessing Colorectal Cancer Mortality Rates Strengths • New York City Vital Statistics • Local control allows for timely internal analyses that can inform programs • Currently, 2001 mortality is available • Substantial demographic information

Assessing Colorectal Cancer Mortality Rates Weaknesses • New York City Vital Statistics • No information on medical or behavioral risk factors, stage at diagnosis, or treatment modality • Deaths reflect screening patterns and risk behaviors several years ago • Not rapidly sensitive to interventions

Age-Adjusted Colorectal Cancer Mortality Rates, by Neighborhood – NYC 2001

Colorectal Cancer Death Rates are Highest Among African Americans

Conclusions – Risk Factors • Not appropriate as indicators to track and evaluate impact of interventions

Conclusions - Screening • Timely, population-based measures of screening prevalence in NYC are now available • DOHMH is improving quality of measures as a first-line evaluation measure for screening promotion • Objective measures of screening exams performed are desired

Conclusions - Incidence • Need to improve access to data yet ensure confidentiality • Timeliness • Local specificity • Access to qualitative measures (i.e. stage at diagnosis)

Conclusions - Mortality • Important and ultimate end-point to impact • Reflects a combination of incidence, access to care, and quality of treatment • Not useful for short-term evaluatory purposes

Points for Discussion • What combinations of indicators are best for evaluating media awareness campaigns? • Are there untapped sources of information? • What are some attainable screening targets? • Should different risk groups have different targets?

Colon Cancer Surveillance & Evaluation