Transcript Final Provider Presentation, Short Version This project actually

Prevention and Early Detection
of Colorectal Cancer
America’s
#2
Cancer
Killer
A presentation sponsored by
Iowa Colorectal Cancer Screening Task Force
American Cancer Society
Prevention and Early Detection
of Colorectal Cancer
America’s
#2
Cancer
Killer
Message: You Can Stop this Killer by
Integrating Screening Into Your Practice!
Prevention
• Environmental factors can be modified to
prevent or reduce the occurrence of CRC
– Increase exercise
– Reduce obesity
– Calcium
– Vitamin D
– NSAIDs
• May be a very important strategy in future
Outline of Talk
• Epidemiology and natural history
• The case for screening
• Recommended screening tests
– Fecal occult blood tests (FOBT)
– Flexible sigmoidoscopy
– Double contrast barium enema (DCBE)
– Colonoscopy
• New tests on the horizon-virtual colonoscopy,
genetic testing, stool DNA
• Summary/Conclusions
Colorectal Cancer: Epidemiology
(The bad news):
•Incidence: (in 2006)
•148,610 new cases will be diagnosed in U.S.
•Lifetime risk is 6% (1 in 18)
•Deadly:
•Second leading cause of cancer deaths
•55,170 deaths/yr; 5-year mortality 33%
•Expensive:
•The most costly cancer to treat
Colorectal Cancer: Epidemiology
(The good news)
• If detected early, 91% 5-year relative
survival rate (adjusted for normal life
expectancy)
• The most preventable form of
visceral cancer if screening is
performed
Natural History: Polyp to Cancer
Normal
Adenoma
Carcinoma
Ten years allows time to intervene
Risk Factors for Colorectal Cancer
Average Risk
>50 years old, asymptomatic High-Risk Cases
High Risk
FAP
HNPCC
IBD
Personal or 10 relative
with CRC or Adenomas
25%
75%
Average-Risk Cases
American Cancer Society. Cancer Facts & Figures 2002. Atlanta, GA: American
Cancer Society; 2002:20 27.
Colorectal Cancer Screening
• Compelling rationale
– Early detection and treatment proven to
decrease in cancer-related mortality
• Suitable and effective tests
– Are widely available
• Favorable cost-effectiveness
– Removal of polyps prevents invasive
cancer and saves money
• So, what’s the problem?
The U.S. population is not being
screened!
• Only 26% of the eligible population have
had a FOBT in the past 3 years
• Only 33% have ever had a FOBT
• Approximately 60% of the eligible US
population are never screened for CRC
2004 Behavior Risk Factor Surveillance System {database}
Atlanta Centers for Disease Control and Prevention; 2004
U.S. CRC Screening Rates
How is Iowa Doing?
Iowa is not the best or worst, but we can do better
2004 Behavior Risk Factor Surveillance System {database}
Atlanta Centers for Disease Control and Prevention; 2004
Early Detection Saves Lives
5-Year Relative Survival Rates* for Iowa Patients
Diagnosis With CRC Between 1995-2001
100% 96%
100
75
84%
100
75
50
50
25
0
Stage 0 Stage I Stage II
25
0
(Dukes’ A) (Dukes’ B)
Early Diagnosis:
60% of
Patients
65%
8%
Stage III Stage IV
(Dukes’ C) (Dukes’ D)
Late Diagnosis:
40% of
Patients
SEER*Stat -- Version 6.2.4
* Adjusted for normal life expectancy
Why aren’t patients screened?
• The most common reasons • “My doctor never told me I should be screened.”
• “I’m embarrassed!”
• “The screening tests cost too much!”
• “I don’t think that insurance covers screening.”
• “I don’t have a family history of colorectal cancer.”
• “I don’t have any symptoms of colorectal cancer.”
• Therefore, we must recommend screening and
help our patients dispel the limitations of
understanding, fear and embarrassment
2004 Iowa Behavior Risk Factor Surveillance System {database}
Iowa Department of Public Health; 2004
Age Distribution of Colorectal Cancer (In Situ and Malignant),
Males and Females Combined, Iowa, 2000-2003
(N=8,509)
Number
4000
8,029 (94%) Cancers
diagnosed after Age 50+
3000
2000
25% have
Polyps @ 50
1000
74% after
Age 65+
t
10 o 9
to
14
15
-1
9
20
-2
25 4
-2
30 9
-3
4
35
-3
40 9
-4
4
45
-4
50 9
-5
4
55
-5
60 9
-6
65 4
-6
9
70
-7
75 4
-7
9
80
-8
4
85
+
5
<
5
0
Age at Diagnosis
Recommended CRC Screening Strategies:
Average risk (ACS, AGA, ACG Guidelines)
Options beginning at age 50 years:
 Annual fecal occult blood testing (FOBT) or
 Flexible sigmoidoscopy (FS) every 5 years, or
 Annual FOBT + FS every 5 years or
 Double -contrast barium enema every 5 yrs.,
 Colonoscopy every 10 yrs.
The only unacceptable option is NOT to screen
Digital rectal exam is not an appropriate screening method
Winawer S et al. Gastroenterology 2003: 124:544-560
Coverage for average risk
Medicare patients
 Screening with annual FOBT and
sigmoidoscopy are allowed every 4 yrs
 Direct colonoscopic screening is allowed
every 10 yrs
 Barium enema may be used as an
alternative to either sigmoidoscopy or
colonoscopy and is allowed every 5 yrs
(since July 1, 2001)
Fecal Occult Blood Testing
Winawer 2001
CRC Mortality/10 yr. (%)
Control
Screened
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
But
Only
About
10-20%
England
Denmark
Minnesota
Pros and Cons of FOBT
Pros:
Cons:
• Evidenced based,
finds most cancers,
reduces mortality
• Non-invasive
• No bowel prep
• Easy to perform,
widely available
• Cost-effectiveness
is established
• Limited effectiveness
• Requires annual testing
• Patient role may be
considered distasteful
• Dietary restrictions used
• High rate of false
negatives and positives
• Requires proper response
by PCP, investigate (+) !
Rex DK Rev Gastroenterol Disord. 2002
Flexible Sigmoidoscopy
Flexible sigmoidoscopy
Pros:
• Office based
• Easy prep
• Primary care MD’s
PA’s & RN’s can do
• No sedation
• Very cost effective
• (can have same day
colonoscopy)
• 50-80% reduction of
left-sided CRC’s
•
•
•
•
Cons:
No sedation = discomfort
Limited insertion to L colon
Miss rates are higher than
BE/colonoscopy, especially
right side
• Finding polyps requires followup colonoscopy for removal
• 40% of CRC in R colon
Double Contrast Barium Enema
“Apple Core”
Lesion
Double Contrast BE
Pros:
• Safe
• Low cost
• Cost effective
• Full colon exam
• High rate of
reimbursement
• Readily available,
seldom used, no
randomized trials
Cons:
• Requires bowel prep
• Not studied adequately
• Missed 50% adenomas <
1cm, better if > 1cm
• Sensitivity for pts. with
(+)FOBT is 50-70%
• Tolerance/expertise decr.
• Colonoscopy must be
done if a polyp is found
Combination
Double contrast barium enema
plus flexible sigmoidoscopy is
a reasonably good alternative
when colonoscopy is not available
Colonoscopy
The most effective weapon
against colon cancer currently available
Benefits of Colonoscopy
Can examine Can remove
entire colon adenomas
Can biopsy
carcinomas
Colonoscopy
Pros:
• Highest accuracy
• Diagnostic and
therapeutic
• Sedation leads to
willingness to repeat
• Cost effective in
comparison to other
tests.
Cons:
• Requires bowel prep
• Highest up front costs
• Not always available
• Highest risk of all tests
(complications 1:2000)
• How feasible as a
national strategy?
Do we have the Capacity?
• 14.2 million colonoscopies performed in 2002
• Direct colonoscopy screening of those over age
50 would require up to 2.6 million more
procedures per year -Total - 16.8 million
• Surveys in Iowa suggest that we have adequate
resources
Rex and Lieberman, 2001
Seeff, Richards, Shapito, Nadel, Manninen, Given, et al., 2004
Colonoscopy: Modify Indications
To Increase Availability
25
(Reduce frequency)
BRBPR
(FS acceptable)
20
Polyp surveillance
Pain
(Low yield)
15
(Do More)
Constipation
(+)FOBT
Diarrhea
10
5
Screen
0
(+)FHx
Anemia
FS/BE IBD
Cancer
.
Surveillance CORI: National Endoscopic Database, 2000-2001
If There is a Family History of CRC,
The Screening Strategy is Different!
15-20 %
5%
Lynch et al. Cancer 2004
How to Reduce Deaths due to
Colon Cancer
Screening for CRC:
What should be done?
The present
Benefit is proven:
•
•
•
•
•
•
FOBT
FS
FOBT + FS
DCBE
FS + DCBE
Colonoscopy
The future
Data dependent:
• Virtual colonoscopy
• Stool DNA testing
• Genetic testing
• Effective
Chemoprevention
What the Physician Considers
Test
Sensitivity Specificity Cost
Invasive
FOBT
Low
Low
(Low)
No
Flex sig
Mod
Mod
Mod
Yes
DCBE
Mod
Low
Mod
Yes
Colonoscopy
High
High
High
Yes
Virtual C’
High
Low
High
No
Stool DNA
Mod
Mod
High
No
Ahlquist ‘2001
What The Patient Considers
• Which test is most accurate?
• Which test is most convenient?
• Which causes the least discomfort, fear
or embarrassment?
• Cost-insurance, Medicare coverage?
• What do other people say about it?
• What does my doctor recommend?
What the Insurer Considers
Screening Test
Estimated Charge
FOBT
$10-30
FS
$150-300
DCBE
$250-500
Stool-based DNA test
$600-800
CT colonography
$800-1000
Video colonoscopy
$600-1500
The Cost of NOT Screening
–
–
–
–
Expense of cancer care
Emotional costs for patients
Missed opportunity for prevention
Legal consequences for providers
The End
You can prevent colorectal cancer
by screening!
Acknowledgements
•
•
•
•
•
American Cancer Society
Centers for Disease Control & Prevention
Exact Sciences
John Bond, MD, Univ. of Minnesota
Douglas Rex, MD, Univ. of Indiana
Prepared by
Robert W. Summers, MD, Univ. of Iowa
Colorectal Cancer Web Links
www.cancer.org
www.ccalliance.org
www.preventcancer.org/colorectal
www.hopkinskimmelcancercenter.org
www.colorectal-cancer.net
www.cdc.gov/cancer/screenforlife/index.htm