Colorectal Cancer

1. Colorectal Cancer Paula M. Rechner M.D. War Memorial Hospital October 13, 2005

2. Goals • Identify Colorectal Cancer as a serious health problem in the US • Provide current guidelines • Outline present day insurance coverage • Identify targets for prevention • Provide a rural surgeon’s perspective on colorectal cancer

3. American Cancer SocietyColorectal Cancer Facts & Figures – Special Edition 2005 • 145,290 new diagnoses expected in 2005 • Colon: 104,950 • Rectum: 40,3410

4. American Cancer SocietyColorectal Cancer Facts & Figures – Special Edition 2005 • 56,290 predicted deaths • 5 year localized survival rate: 90% • Only 39% CRC found at this stage due to low screening rates • 5 year survival with metastatic disease: 10% • 5 year overall survival rate: 63%

5. American Cancer SocietyColorectal Cancer Facts & Figures – Special Edition 2005 • 5.6% OF Americans will develop CRC in their lives

6. American Cancer SocietyColorectal Cancer Facts & Figures – Special Edition 2005 • Third most common type of cancer • Second most common cause of cancer death • When men and women are considered separately CRC is the third most common cause of death in each sex

7. American Cancer SocietyColorectal Cancer Facts & Figures – Special Edition 2005 • THE LEADING CAUSE OF CANCER DEATH AMONG NONSMOKING AMERICANS

8. U.S. Colorectal Cancer Incidence

9. U.S. Colorectal Cancer Mortality

10. Colorectal Cancer Risk Factors

11. MayoClinic.comRisk Factors for Colorectal Cancer • Age: 90% are age > 50 • Inflammatory Bowel Disease

12. MayoClinic.comRisk Factors for Colorectal Cancer • Family History • Hereditary • Shared environmental exposure to a carcinogen, diet or lifestyle • Familial Adenomatous Polyposis (FAP) • Cancer by age 40!!! • Hereditary Nonpolyposis Colorectal Cancer (HNPCC) • Ashkenazi Jews (Fewer than 10% of CRC are caused by inherited gene mutations)

13. MayoClinic.com (continued) • Diet • Low fiber • High Fat • High Calories • Sedentary Lifestyle • Increased transit time • Prolonged colonic exposure to carcinogens • Diabetes • 40% increased risk of developing colorectal cancer

14. MayoClinic.com (continued) • Smoking • 1 in 10 fatal colon cancers may be caused by smoking • Once diagnosed with colorectal cancer, smokers face a 30 to 40 percent increased risk of dying of the disease • Alcohol • 1 drink per day for women • 2 drinks per day for males • Personal History of Colorectal Cancer or Polyps

15. American Cancer Society

16. Colorectal Cancer Diagnosis and Screening

17. MayoClinic.com Screening and Diagnostic Procedures • Digital Rectal Exam • Limited exam • Likely to miss small polyps • Fecal Occult Blood Test • False Positive • False Negative • Flexible Sigmoidoscopy • Limited Exam • Minimal perforation risk

18. MayoClinic.com Screening and Diagnostic Procedures (continued) • Barium Enema • “significantly high rate of missing important lesions…especially in the lower bowel and rectum” • Flexible sigmoidoscopy may be done in addition to BE • Colonoscopy • “most sensitive test for colon cancer, rectal cancer and polyps”

19. MayoClinic.com Screening and Diagnostic Procedures (continued) • New Technologies • Virtual colonoscopy • 2 minute CT scan • No prep – potential in the future • Less accurate than colonoscopy • Diagnostic not therapeutic • Not widely available

20. American Cancer SocietyScreening and Surveillance • At Age 50 for men and women at average risk • FOBT or FIT every year-take home kit not DRE • 6 samples from 3 consecutive BM’s • Flexible Sigmoidoscopy every 5 years • FOBT or FIT every year + Flex Sig every 5 years • Double-contrast barium enema every 5 years • Colonoscopy every 10 years

21. American Cancer SocietyScreening and Surveillance • FOBT • Reduces risk of death from CRC by 15-33% • FOBT reduces incidence of CRC by 20% • Detection of polyps • Early removal of polyps found thus preventing CRC • Flexible Sigmoidoscopy (FS) • Reduces CRC mortality by 60% for cancers within reach of the instrument • FS followed by Colonoscopy if a polyp is found identifies 70-80% of individuals with CRC

22. American Cancer SocietyScreening and Surveillance • FOBT and Flexible Sigmoidoscopy • One test would compensate for the limitations and may improve early detection • Colonoscopy • National Polyp Study • 76-90% CRC Prevention • Most sensitive test for CRC and Polyps • Gold Standard for Screening • Screening, Diagnostic and Therapeutic

23. American Cancer SocietyScreening and Surveillance • Barium Enema with Air Contrast • Less sensitive than colonoscopy • Colonoscopy is required if a polyp is found • DNA based fecal screening and Virtual Colonoscopy • Are not recommended at this time

24. Screening and Surveillance for Increased Risk Patients

25. Screening and Surveillance for High Risk Patients

26. COST

27. American Cancer SocietyScreening and Surveillance

28. Insurance Coverage

29. Medicare • CRC screening covered since 1998 • All recommended screening options covered since 2001 • An initial preventative health care visit for all Medicare beneficiaries within 6 months of enrolling in Medicare covered since January 2005!

30. Medicare Coverage • FOBT-Once every 12 months • Flexible Sigmoidoscopy-Once every 48 months • Screening Colonscopy • High Risk-Once every 24 months • Average risk-Once every 10 years, but not within 48 months of screening FS • Barium Enema-In place of FS only • High Risk-Every 24 months • Average Risk-Every 48 months

31. Medicare Coverage • You pay nothing for FOBT • You pay 20% of the Medicare-approved amount after the yearly Part B deductible, for all other tests • You pay 25% of the Medicare-approved amount after the yearly part deductible, if endoscopy is done in a hospital outpatient department

32. Blue Cross Blue Shield CoverageMI 2005 • Provider Type • M.D. or D.O. (otherwise not payable) • Payable under Preventive coverage • Age > 50 • 1 Per 10 Years unless “high risk”

33. “Average Risk” • 25% of “average risk” adults at age 50 will have adenomatous polyps • 70-80% of all Colorectal Cancers develop in “average risk” patients

34. > 40 years old V1005 V1006 V160 V1000 V7641 V7650 V7651 Any Appropriate Frequency Blue Cross Blue Shield High Risk Diagnosis • 25-40 years old • V1005 • V1006 • V160 • V1000 • V7641 • V7650 • V7651 • 1 per 2 years

35. V CODES • V1005-Personal history of malignant neoplasm of the large intestine • V1006-Personal history of malignant neoplasm of the rectum • V160-Family history of malignant neoplasm of the gastrointestinal tract • V1000-Personal history of malignant neoplasm of the gastrointestinal tract • V7641-Special screening for malignant neoplasms of the rectum • V7650-Special screening for malignant neoplasms of the intestine • V7651-Special screening for malignant neoplasms of the colon

36. State of MI PPO & GM Hourly and Salary Benefits for High Risk • 1 Per 10 years • Age >50

37. Colorectal Cancer Screening Statistics

38. American Cancer SocietyColorectal Cancer Facts & Figures – Special Edition 2005 • Less than 50% of people aged 50 or older have had a recent colonoscopy!!!!

39. American Cancer SocietyPopulations associated with even less screening • Age 50-64 • Non-white race • Fewer years of education • Lack of health insurance • Immigration to the US < 10 years

40. American Cancer Society

41. American Cancer SocietyMichigan Residents Age 50 and Older • White Non-Hispanic ~53% screened • Ranked 12th in the Nation • African American Non-Hispanic ~57% screened • Ranked 5th in the Nation

42. American Cancer SocietyBarriers to CRC Screening • Health Care Providers • Communication with patients • Several studies show patients are more likely to be screened if it is recommended to them • Attitudes and Beliefs • Effectiveness of screening • Familiarity with screening guidelines • Perception of patient preference and adherence • Lack of training to perform tests • Lack of adequate reminder systems within their practices

43. Barriers to CRC ScreeningAmerican Cancer Society • Health Insurance • If patient has any • If benefits include screening • Highly variable

44. Barriers to CRC ScreeningAmerican Cancer Society • Patients • “Too busy” • “Lack of physician recommendation” • “Inconvenience” • “Lack of interest” • “Cost” • “Embarrassment” • “unpleasantness of the test” • Unaware of benefits • Lack understanding of importance of screening

45. Strategies to Increase Utilization of CRC Screening • Physician office and health systems • Computer reminder systems • Identify eligible patients for screening • Organized support for referrals and follow up • Health Insurance • Only 9 of 29 states, where CRC screening is under 50%, have passed legislation to require CRC screening!!!!!! • 16 states and D.C. have such legislation • Education for Patients and Providers

46. MayoClinic.comPrevention • Eat 5 or more fruits and vegetables per day • Limit fat • < 30% Fat in daily calories • < 10% of saturated fats • Vitamins and Minerals that prevent CRC • Calcium • Pyridoxine (vitamin B-6) • Vitamin B-9 • Magnesium

47. Prevention of Colorectal Cancer

48. MayoClinic.comPrevention (continued) • Limit alcohol consumption • Stop smoking • Exercise 30 minutes per day • Hormone Replacement Therapy (HR) • May reduce risk of CRC • Women on HR who develop CRC may have a faster growing form of the disease • Consider taking statins for high cholesterol • NEJM (5/26/2005)– reduced risk in patients taking statins for five years or more

49. American Cancer Society • Aspirin and aspirin like drugs • May lower the risk of colorectal cancer • ACS does not encourage NSAIDs or Cox-2 inhibitors • Gastric side effects • Heart attack • Consult with physician

50. NCI Colorectal Cancer Research Investment