Transcript Colon Cancer

Colon Cancer Screening for
Primary Care Physicians
Richard C. Wender, MD
Alumni Professor and Chair
Department of Family & Community Medicine
Thomas Jefferson University
Past President, American Cancer Society
What We’ll Cover
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Epidemiology
Screening Trends
New Guidelines
Improving preventive practice
– Organizing your office
– Improving quality and screening rates
Colon Cancer: Epidemiology
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108,070 cases predicted in 2008
49,960 deaths expected
Death rates declining by 4.7% per year
from 2002-2004
Cancer Facts and Figures, 2008. American Cancer Society
CRC Screening: Rates Are Rising . . . Probably
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NHIS data based on self report
– Screening exceeding 60% in many
states
– 70% in Connecticut
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HEDIS data based on claims and chart
reviews
– 55% in commercial and rising
– 53% in Medicare and flat
Understanding Screening Rate Trends
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With shift to colonoscopy as
predominant modality, shouldn’t all
rates be going up?
– Perhaps abandonment of FOBT and
FIT is negatively impacting rates
• Hard to reach everyone with
colonoscopy
Understanding Screening Rate Trends
Annual FOBT/FIT:
People coming in and out of being “up
to date” every year
Colonoscopy:
Key driver of gradual increase in “up to
date” status
Colon Cancer Screening –
Understanding The New Guidelines
New Guideline Methodology
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Guidelines were developed by a consensus
group representing:
– American Cancer Society
– American College of Radiology
– Multi-Society GI Task Force
• American College of Gastroenterology
• American Gastroenterological Association
• American Society for Gastrointestinal
Endoscopy
CRC Screening Guidelines: New Concepts
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A 50% sensitivity threshold for cancer
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Tests that predominantly target prevention
versus tests that predominantly target
cancer
“It is the strong opinion of this
expert panel that colon cancer
prevention should be the primary
goal of CRC screening”
Screening and Surveillance for the Early Detection of Colorectal
Cancer and Adenomatous Polyps, 2008
Tests That Primarily Detect Cancer
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Annual gFOBT with at least 50% test
sensitivity for cancer, or…
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Annual FIT with at least 50% test
sensitivity for cancer, or…
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sDNA at uncertain screening interval
U.S.P.S.T.F. Guidelines
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Do not include DNA or C-T Colonography
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Medicare has decided NOT to cover
colography
Tests That Detect
Adenomatous Polyps and Cancer
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Flexible sigmoidoscopy every 5 years,
or…
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Colonoscopy every 10 years, or…
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CT colonography every 5 years
Double-contrast barium enema every 5
years, or…
Key Questions in Colon
Cancer Screening
Colorectal Cancer Screening And Prevention
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Do we still need a menu of options?
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Should colonoscopy be the preferred
testing option?
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What screening options might be dropped
from the menu?
What new tests might be added to the
menu?
CRC Screening: Issue 1
Do we still need a menu of screening
options?
A Screening Menu
• We cannot yet abandon the menu
– No one clearly superior test for all people
– No one structural test that is available to all
– No one test that will be accepted by all
CRC Screening: Issue 2
What new tests are added to the
screening menu?
Fecal DNA Testing (PreGen-Plus)
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Advantages:
– Passes the 50% sensitivity threshold
– DNA shedding unlikely to be intermittent
– Doesn’t require stool handling
– May not be necessary annually
Fecal DNA Testing
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Disadvantages:
– Sensitivity may be less than sensitive
stool blood tests, particularly FIT
– Requires mailing of a whole stool sample
– Safe interval is not known
– Expense: >$250 per test
• 10 times more than FIT
• Close to 100 times more than guiac FOBT
Fecal DNA Tests – An Update
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Pre Gen Plus is up to its third generation of
refined testing – Performance is reportedly
better, but as yet unproven
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Cost is coming down and may be as low as
$300
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Testing interval reported by the company is 5
years
Data supporting this interval is
inadequate
DNA For Colon Cancer – Blood Tests
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Several blood tests in clinical trials
Fecal DNA
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A promising technology
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BUT, some FIT studies have showed better
sensitivity for cancer at far less cost. And the
testing interval of 5 years seems long. 3 years or
fewer may make more sense, but significantly
increases the cost
Lots of studies demonstrating the ability to find
abnormal DNA that is associated with cancer
C-T Colonography Issues
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It’s NOT a virtual experience
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Cost is high
AND colonoscopy is required for abnormal
findings
To be an option, sensitivity and specificity must
be outstanding
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– Requires a prep
– Requires air insufflation of the colon
Will CT Colonography Become The Preferred
First Line Screening for Colon Cancer?
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Cheaper
Safer
Visualizes the whole colon
Requires the same prep
BUT is it accurate?
C-T vs. Colonoscopy: Sensitivities for All Polyps
Polyp Size
>10mm
>8mm
>6mm
C-T
92.2%
92.6%
85.7%
Colonoscopy
88.2%
89.5%
90.0%
What Percent of Patients Would Require
Colonoscopy If C-T Were Done First?
Polyp Size
Threshold
% Requiring
Colonoscopy
10mm
7.5
8mm
13.5
6mm
29.7
Virtual colonoscopy identified 55 polyps not
seen on initial colonoscopy
•21 were adenomatous
•One 11mm malignant polyp
Non-Colonic Findings
• 5 asymptomatic cancers
• Aortic aneurysms
• Renal and gall bladder calculi
Next Big C-T Colonograhy Study
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Published in JAMA
Results were far less good than seen in
the Pickardt study. Key factors were
Experience of the center
Time devoted to reading
Use of digital subtraction and flythrough technology
And The Next Big CT Study
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The ACRIN study is a multi-center
study with each site using the new
technology
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First results will be reported within 6
months
ACRIN Results – First Report
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15 center trial
2,531 asymptomatic patients
– Either 2D or 3D
– Multiple manufacturers
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Almost all had colonoscopy
ACRIN Results
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547 polyps detected in 390 patients
– 2/3 were adenomas
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Mean size was 8.9 mm
128 polyps > 1 cm
7 cancers detected
2-Dimensional Primary Reading
Virtual Colonoscopy “Fly Through”
ACRIN Results
Sensitivity =
Sensitivity
Specificity
Adenomas > 1 cm
90%
86%
Polyps 6-9 mm
84%
86-89%
Will C-T Colonography Become A Mainstream
Option?
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Reasons to think that it will
– Cheaper than colonoscopy as a single,
one-time test
– Excellent performance characteristics in
experienced centers
– Safer than colonoscopy
Will C-T Colonography Become A Mainstream
Option?
Reasons to think it will not:
– Time consuming for radiologist
– Few experienced centers exist today
• Requires extensive training
– Small polyps are ignored
• Requiring shorter screening interval (every 5 years)
• This impacts cost and capacity
– If all polyps >6cm lead to colonoscopy, 3 to 5
CTC’s will lead to 1 colonoscopy
Should Colonoscopy Be The Preferred
Screening Test?
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Colonoscopy utilization is increasing
dramatically
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Sigmoidoscopy utilization is decreasing
and barium enema is rarely utilized
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Clinicians are still utilizing FOBT and
FIT
– Requires annual testing and rates of
repeat testing are very low
Colonoscopy Preferred?
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Colonoscopy is not a gold standard
– Complications in 1/1000 exams
– Misses from 5 to 10% of important lesions
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But the key advantages are accuracy and
ability to screen as infrequently as every 10
years
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Our practice has decided to recommend
colonoscopy as preferred strategy with a FIT
test as a back-up
Colonoscopy Preferred?
Hype May Exceed Reality
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Annual FIT screening may be as effective
as colonoscopy every 10 years
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Hard to find evidence that mortality from
right sided diseases is declining
What Tests Might Be Dropped From The
Guidelines?
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Lower sensitivity FOBT’s , such as
Hemoccult II do not meet the 50%
threshold and should be dropped from
the guideline
Pearls In Cancer Screening: Colon Cancer
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The FOBT done at the time of a digital rectal must
be stopped
– A negative result offers ZERO reassurance…or,
even worse, false reassurance
– A major national campaign is underway to stop this
– Medicare will no longer pay
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Few people do FOBT or FIT every year
– A test that can be done less frequently is preferred
for most
Bringing Quality To A Colonoscopy
Screening Program
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Characteristics of a high-quality screening
program
– Patient registry
– Appointment made by PCC office staff, not the
patient
– Short wait time
– Navigation through prep & reminder of date
– High quality colonoscopy with standard
reporting
– Call-back reminder
Why focus on primary care practice?
What can we do about it?
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We have it in our power to improve the
screening rate. ‘This is our sphere of
influence.’
80-90% of people >age 50 saw 1°MD last
year
(BRFSS, CDC)
Few practices currently have mechanisms
to assure that every eligible patient gets a
recommendation for screening.
A physician’s recommendation
is the most influential factor
in cancer screening!
How Can We Increase CRC Screening Rates
in Practice?
4 Essentials:
#1 A Screening Recommendation
for every eligible patient
#2 An Office Policy
known to all who work in the office
#3 A Reminder System
#4 An Effective Communication System
Essential #1:
Screening Recommendation
The Goal:
A recommendation to every eligible
patient
• Requires a system that doesn’t depend
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on the doctor alone.
Requires an opportunistic approach*
i.e. don’t limit efforts to “check-ups”
*N.B. An opportunistic approach does not justify an in-office FOBT.
This has NO evidence base. #170
Essential #2:
An Office Policy
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States the intent of the practice.
– tangible, maintains consistency,
– prerequisite for reliable, reproducible
practice
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Algorithms easiest policies to follow.
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Beware: one size does not fit all patients!
Beware: one size does not fit all
practices!
Essential #3: A Reminder System
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Two types:
– Physician Reminders
– Patient Reminders
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There is evidence for effectiveness of both
Evidence on physician reminders is from
two meta-analysis
Essential #4: An Effective Communication System
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Better communication has many benefits. So
how can we improve it?
– Staff involvement
– Decision aids
– Theory-based approaches
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Theory-based communication has
documented has greater impact.
The Ecology of Primary Care Practices
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Typical practice consists of
– 2-5 clinicians
– Fewer than 3 non-clinician nursing and
clerical staff for each clinician
• Most practices have a hierarchical
management structure
– Physician owners and office manager
provide oversight
Stange KC et al, J of Fam Pract 46(1998):377-89
Primary Care Practices:
Culture and Financial Reality
“Climates permeated with stress and overwork”
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Most work on margins of financial viability
– Little time for self-reflection
– Little or no training in quality improvement and
organizational management
Crabtree BF. Healthcare Manage Rev, Vol 281(2003):279-83
Grumbach K and Bodenheimer J. JAMA (2002):889-93
Primary Care and CRC Screening
Primary care clinicians virtually
all recommend CRC screening
Virtually no primary care clinicians
are successfully screening all
eligible, enrolled patients
No Single Model To Absorb These Costs
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PCC offices are complex, non-linear
systems
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Organizational principles can be used
to describe PCC settings
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Generally speaking, high performing
practices share some key
characteristics
Crabtree BF, et al. Primary Practice Organizations and
Preventive Services Delivery: A Qualitative Analysis. J of
Fam Pract 46(5):403-409 1998, May
Clinical Preventive Service Delivery In
Primary Care
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Study of 18 family medicine offices
Practices use individualized approaches
– No one approach used successfully across
all practices
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Preventive service delivery was identified as
a priority
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Factors included competing demands, a
physician champion, and economic concerns
Crabtree BF, et al. Annals of Fam Med 3(5):430-5, 2005
Characteristics of High Performing Practice
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Leadership
A culture of improvement
Greater staff involvement
Higher investment in people
– Greater investment in technology has not,
yet, been demonstrated to promote
prevention, including CRC screening
Orzano AJ, et al. Improving outcomes for high risk
diabetes using information systems. J Am B of Fam
Med 20(3) 295-51 2007 May-Jun
Improving Quality: Characteristics of High
Performing Practices
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Involving staff in decision making
– Higher staff retention
– Higher productivity
– Practice satisfaction
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Staff meetings do not correlate with
improved participation and outcomes
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Soliciting staff feedback through every day
discussions works better
Hung Y et al. Medical Care Vol.44 (10): 946-51 Oct 2006
Prescription For Health: RWJ Funded Pilot
Programs To Improve Quality Care Delivery
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17 PBRN’s funded in round 1
Lessons from prescription for health
– Health behavior change resources are
enthusiastically received by all
– Patients prefer personal contact methods
– Practice extenders require extensive
training and careful case management
and support
Prescription For Health: cont’d
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Lessons from prescription for health
– Integrating tools requires practice change,
use of a practice change model and
specialized expertise
– Even simple interventions require change
and a change model
Ann of Fam Med 3 Suppl 2:512-19, 2005 Jul-Aug
Electronic Health Records Do Not Invariably
Improve Care Quality
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Analysis of 50 practices in a practice
improvement study
– 37 practices not using an EMR were more
likely to meet diabetes outcomes than 13
practices utilizing an EMR
Crosson JC, et al. Annals of Fam Med 5(3):209-15. 2007
A New Model To Enhance Prevention and
Chronic Disease Management
- The Patient Centered
Medical Home
The Physician Practice Connection:
Patient-Centered Medical Home
Joint Principles of PPC-PCMH:
– Personal physician
– Physician directed medical practice
– Whole person orientation
– Care is coordinated or integrated
– Quality and safety are hallmarks
– Enhanced access
– Payment recognizes value
www.NCQA.org
PPC-PCMH Content and Scoring
Standards:
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Access and communication
Patient tracking and registry functions
Care management
Patient self-management support
Electronic prescribing
Test tracking
Referral tracking
Performance reporting and improvement
Advanced electronic communications
The Four Essentials: A Review
• A recommendation to every eligible
patient
• An office policy
• A reminder system
• An effective communication system