Transcript Slide 1

Breast and Colorectal Cancer
Screening in Family Care Clinic
and their Outcomes
Presented by
Liana Poghosyan, MD
Ne Moe, MD
May 19, 2008
Introduction
Epidemiology and Clinical Consequences
Breast cancer is the most common non-skin malignancy among women in
the United States and second only to lung cancer as a cause of cancerrelated death
In 2001, an estimated 192,200 new cases of breast cancer were
diagnosed in American women, and 40,200 women died of the disease
The risk for developing breast cancer increases with age beginning in the
fourth decade of life
The probability of developing invasive breast cancer over the next 10
years is 0.4 percent for women aged 30-39, 1.5 percent for women aged
40-49, 2.8 percent for women aged 50-59, and 3.6 percent for women
aged 60-69
Individual factors other than age that increase the risk for developing
breast cancer include family history or a personal history of breast cancer,
biopsy-confirmed atypical hyperplasia, and having a first child after age
30.
Epidemiology and Clinical
Consequences
Colorectal cancer is the fourth most
common cancer in the United States and
the third leading cause of cancer death
A person at age 50 has about a 5 percent
lifetime risk of being diagnosed with
colorectal cancer and a 2.5 percent chance
of dying form it, the average patient dying
of colorectal cancer loses 13 years of life
Background
Fortunately, we can detect these fatal disease in
pre-cancerous stage, these cancers are
preventable. Therefore, cancer screenings are
extremely important in all population
In order to know the performance of FCC in
screening those two preventable cancers, we
reviewed a total of 200 charts. According to
exclusion criteria, we needed to exclude 47
patients, therefore our data is based on 153
patients who came to our FCC within 5 years
back
Material and Method
Out of 153, there were 116 women and 37 men
Among 116 women, 30 were under 50
No colorectal screening were done under 50
years of age on both genders
All females were older than 40, and we reviewed
for Breast cancer screening
Both for female and male older than 50, we
reviewed only for Colorectal cancer screening
Exclusion criteria:
Younger than 40 for female and 50
for male
Less than 3 visits
More than 5 years
Inclusion criteria:
Female over 40
Male over 50
More than 2 visits
Seen last 5 years
Reviewed both Attendings and Residents
charts
Cont Materials and Methods
We reviewed: age, sex, medical records, date of
birth, and screening tests
In the screening tests: for breast cancer, we
reviewed for mammogram, results, follow up,
outcome
For Colorectal cancer, we reviewed for FOBT,
DCBE, Flex Sig, Colonoscopy, and their results,
follow up, and outcomes
The time frame is 5 years back
The study is retrospective
Results
All females reviewed were older than
40 years old
Mammogram srceening tests were
done on 104 patients out of 116
which is 90% compliance rate
Result
For female Breast cancer screening under 50,
mammography was done on 22 patients out of 30 which is
73%
None of them found mass or calcification
For female breast cancer screening older than 50,
mammography was done on 82 patients out of 86, which is
95% compliance rate
Out of these 82 patients who got mammogram, 22 patients
which is 27% of female older than 50 have found to have
mass or calcification
18 patients (82%) got follow up mammo, spot compression
mammo, ultrasound, or stereotatic biopsy
None of them has breast cancer
Result
Among 153 patients, there were 123
patients (80%) eligible to be sreened for
colorectal cancer in both male and female
83 patients (67%) were screened for
colorectal cancer
Out of 123 combined male and female, 37
(27%) were male and 86 (73%) were
female
Result
For female colorectal cancer screening, there
were total of 86 females older than 50 who were
eligible to be screened for Colorectal cancer
Among them, 51 patients were screened for
colorectal cancer that is 60% of eligible patients
Several screening methods were used: FOBT,
DCBE, Flex Sig, Colonoscopy
FOBT 38 (75%) is the most commonly screening
tool, Flexible sigmoidoscopy 2 (4%) is the least
method to used. Others are: Colonoscopy 8
(16%), double contrast barium enema 3 (6%)
Result
Out of 153 patient population, we reviewed 37
male patients
Among them, 32 patients were older than 50
years and eligible to screen for colorectal cancer
22 patients were screened for colorectal cancer
which is 68.8% of patient population who are
eligible to be screened
FOBT is the most common screening method, 18
out of 22 (82%) and second most common
method is Colonoscopy: 4 out of 22 (18%)
There were no double contrast barium enema or
flexible sigmoidoscopy in male population in FCC
Analysis
Total: 200
Data Pool: 153
Male: Female ratio – 37 (24.2%):
116 (75.8%)
Analysis
Female above 40 years old mammo
compliance rate: 90%
Both gender colorectal screening
older than 50 years old: 67%
Gender Ratio
Gender Distribution
120
Female, 116
100
80
Male
Female
Numbers 60
40
Male, 37
20
0
1
Gender
Female Mammogram
FCC Compliance
Mammo, 104
1
Mammo
Total Female, 116
98
100
102
104
106
Total Female
108
110
1
Mammo
104
Total Female
116
112
114
116
FCC Colorectal Screening
140
120
100
123
Series1
80
83
(67%)
60
40
20
0
Total Eligible
Colorectal sreening
Discussion
By knowing about our performance
and compliance in FCC, we can find
out the barriers for these screening
tests and ways to overcome these
barriers so that we can improve the
quality of care for our patient
population we are serving
Discussion
Adding ultrasonography to mammography may improve breast cancer
detection, research suggests
USA Today (5/14, 7D, Szabo) reports, "Screening women with
both ultrasounds and mammograms allows doctors to find more
breast cancers than if they rely on mammograms alone,"
according to a study published in the May 14 issue of the Journal
of the American Medical Association. But, "the combination also
leads to many more unnecessary biopsies, and experts don't
recommend it to most patients."
For the study, "almost 3,000 women recruited from 21
centers" were randomized "to receive either mammography alone,
or mammography plus ultrasound performed by a physician,"
HealthDay (5/13, Gordon) added. The results revealed that the
diagnostic yield for mammography was "7.6 cancers" per 1,000
women screened. Mammogram plus ultrasound "found 31 of the
cancers," which produces a yield of "11.8 cancers" per 1,000
women. This finding suggests that ultrasonography increased the
yield by 4.2 per 1,000 over mammography alone
Discussion
MedPage Today (5/13, Bankhead) noted, "Mammography alone
had a diagnostic accuracy (area under the curve) of 0.78, which
increased to 0.91 with supplemental ultrasound (P=0.003)." In
addition, "[t]he positive predictive value of biopsy
recommendation after complete diagnostic workup was 22.6
percent for mammography (19 of 84), 8.9 percent for ultrasound
(21 of 235), and 11.2 percent for combined imaging (31 of 276)."
But, the "number of false-positive diagnoses increased from 116
(for mammography alone), to 275 (for the combined use of
mammography and ultrasound)
In an accompanying editorial, Christiane Kuhl, M.D., of the
University of Bonn, wrote that "the issue of false positives, while
troubling, is less of an issue with ultrasound than with
mammography, because biopsies can often be performed during
the screening with ultrasound-guided biopsy," WebMD (5/13,
Boyles) reported. This week's JAMA Report video features the
study.
Discussion
Virtual Colonoscopy
Virtual colonoscopy is a procedure that uses a series of xrays called computed tomography to make a series of
pictures of the colon
A computer puts the pictures together to create detailed
images that may show polyps and anything else that seems
unusual on the inside surface of the colon. This test is also
called colonography or CT colonography
Clinical trials are comparing virtual colonoscopy with
commonly used colorectal cancer screening tests. Other
clinical trials are testing whether drinking a contrast
material that coats the stool, instead of using laxatives to
clear the colon, shows polyps clearly
Advantages of CTC
Accurate detection of 4 mm or larger polyps
Non-invasive with virtually no risk
Significantly less expensive
Cost: $475
Time efficient exam: Can work the same day
Flexible viewing and analysis
Record: 3D electronic model
Sensitivity: 93.8% for polys >1 cm vs
87.5% with colonoscopy
Specificity: 96%
Discussion
DNA stool test
This test checks DNA in stool cells for
genetic changes that may be a sign
of colorectal cancer
Sensitivity: 89%
Specificity: 86%
4 times more sensitive than FOBT
Cost: $150
Conclusion
In our FCC, the compliance rate for Breast cancer is 90% and
colorectal cancer is 67%
While there is room to improve in breast cancer screening, FCC
performance in colorectal screening needs to improve significantly
to meet the standard of care
Should consider not only FOBT, needs to schedule more for Flex
Sig in FCC
Should also encourage administration to make other test options
available such as Virtual Colonoscopy and DNA tool test
There should be a system in place to schedule an appointment for
a patient just exclusively to discuss, evaluate and order screening
tests for disease prevention and health promotion at least once a
year