Colorectal Cancer and Screening Cancer Screening Programs September 2013
Update on Colorectal Cancer Screening · 2018. 11. 19. · 1 Update on Colorectal Cancer Screening...
Transcript of Update on Colorectal Cancer Screening · 2018. 11. 19. · 1 Update on Colorectal Cancer Screening...
-
1
Update on Colorectal Cancer Screening
What every clinician should know
Ilche T. Nonevski, MD, MBAAssistant Clinical Professor, UIC-Rockford
Rockford Gastroenterology Associates May 6, 2016
Outline Primer on Colorectal Cancer Screening
CRC: The numbers National numbers Local success stories
CRC: the science Screening and Prevention Approaches
Guideline based approach Pros and cons Emphasis on quality
Take home points Questions and discussion
-
2
RGA Background Founded in 1976 National leaders in GI quality
National Committee members New England Journal of Medicine article (2006)
Comprehensive GI Care 15 Physicians 8 Nurse Practitioners
Colorectal Cancer 2016 ACS Estimates: 134,490 cases
95,270 new cases of colon cancer 39,220 new cases of rectal cancer 49,190 deaths
2nd leading cause of cancer related death Lifetime risk for colorectal cancer
1 in 20 (5%)
Infamous Cancer in Famous People
Pope John Paul II72
President Ronald Reagan 74
Vince Lombardi57
Justice Ginsburg66
Darryl Strawberry36
Sharon Osbourne49
-
3
CRC: Overall Incidence
Screening comparisons Colon Cancer Mortality reduction 70-90%
Colonoscopy: 61-89% reduction in CRC1 In GETTING colon cancer, NOT dying from it
Mammogram (50-69 year olds) 2 Death is 40% preventable PSA for prostate screening 3 Relative risk reduction for death is 21%
1. Am J Gastroenterol. 2016 Jan 12.2. N Engl J Med 2015; 372:2353-23583. Cochrane Database Syst Rev. 2013
CRC: The Numbers Incidence of colon cancer 2000-20101
Decreased by 30%!!! 50-80 year olds
Parallels widespread use of colonoscopy Detection CRC at early stage is surgically
curable Success!!
What about in Rockford?
1. CA Cancer J Clin 2015;65:5-29
-
4
CRC: The Numbers Incidence of colon cancer 2000-20101
Decreased by 30%!!! 50-80 year olds
Parallels widespread use of colonoscopy Detection CRC at early stage is surgically
curable Success!!
What about in Rockford?
1. CA Cancer J Clin 2015;65:5-29
Rockford: CRC Prevention is working!1 of only 6 counties in Illinois with below
average rates
Source: Illinois Department of Health
CRC Screening Success!! Not so fast
23,000,000 eligible patients are NOT getting screened Access, cost, reluctance
“My doctor didn’t mention it!!” #2 reason given by age-eligible adults who are not up-to-date with
CRC screening1
-
5
CRC Screening Success!! Not so fast
Incidence of colon cancer in patients
-
6
CRC Risk Factors Dietary
High red meat/processed meat Low vegetables and fiber
Physical inactivity Obesity Type II Diabetes Smoking Heavy alcohol use
Source: American Cancer Society
Un-Modifiable CRC Risk Factors Age
Racial & ethnic background Personal history of CRC/adenomas Personal history of IBD
UC & Crohn’s colitis > 8 years Family history of CRC/adenomas Inherited syndromes
Familial Adenomatous Polyposis (FAP) Lynch Syndrome (HNPCC)
Source: American Cancer Society
Why is CRC easier to screenand prevent?
Johns Hopkins Online
Adenoma to Carcinoma Sequence
Fewer than 10% of all adenomas become cancerous. However, more than 95% of colorectal cancers develop from adenomas
-
7
Adenoma to Carcinoma Sequence
CMS.gov
Stage of Diagnosis Predicts Survival
Stage of Diagnosis Predicts Survival
-
8
Average Risk CRC Screening
Am Fam Physician. 2015 Jan 15;91(2):93-100.
CRC Screening Options High sensitivity FOBT (FIT)
30-50% reduction in mortality No impact on preventing colon cancer
Sigmoidoscopy plus FOBT Effective for left-sided CRC Misses right colon polyps
Including sessile serrated adenomas
CT colonography Cologuard Stool DNA testing Colonoscopy
CT Colonography
-
9
CT Colonography 90% sensitivity for polyps & cancer >10mm Can miss flat sessile adenomas in right colon
Higher risk for malignancy Requires colon prep
Colonoscopy slot scheduled afterward Radiation exposure (likely overstated) Management of extra-colonic findings
Incidental findings Potentially added costs for workup Increased anxiety for patients
CT Colonography Ideal for:
Incomplete colonoscopy due to anatomy (not poor prep)
Patients reluctant to have colonoscopy But willing to have colonoscopy if polyp found
Willing to undergo prep and potentially 2 procedures
Willing to repeat every 5 years regardless of findings
Willing to drive to Madison or Chicago
Cologuard
-
10
Cologuard Stool DNA
Detects 2 different types of mutations common in colorectal cancer (CRC) and advanced adenomas (AA) and occult bleeding
FDA approved CMS approved
Average risk colon cancer screening (ages 50-85) Expected to pay for test every 3 years Cost is $600 per test
CRC Screening Comparisons
Test SensitivityColorectal
Cancer
SensitivityAdvancedAdenoma
False Positives FalseNegatives
(Miss Rate)
Cologuard 92% 42% 13% 8%For CRC
Fit Testing 74% 24% 10 mm
Cologuard—Take Home Points Very effective for detecting colon cancer Not effective for detecting advanced
adenomas (pre-cancerous) Does not prevent colon cancer Higher false positives (compared to FIT) More expensive than colonoscopy (Medicare
data) Ideal for average risk patients reluctant to have
colonoscopy
-
11
High Risk CRC Screening
Am Fam Physician. 2015 Jan 15;91(2):93-100.Consider 40 for family history of ANY polyp if
pathology results are not available
CRC Prevention Options Colonoscopy is the gold standard
Only test that can prevent cancer over entire colon 60-90 % reduction in new cancers Up to 68 % reduction in deaths
Colonoscopy is the most cost-effective screening tool Through reduction in mortality
Sonnenberg, Ann Int Med, 2000
Old data
Goal of Colonoscopy Perform the safest, highest quality procedure Remove precancerous polyps
Completely Polyp types
Hyperplastic: nearly universally benign Tubular Adenoma: most common precancerous
polyp Tubulovillous adenoma: Villous adenoma (more aggressive) Sessile serrated adenomas (small but aggressive)
-
12
Colonoscopy
Villous adenoma
-
13
Serrated Adenoma
Serrated Adenoma
Colon Cancer
-
14
Colon Cancer
Colon Cancer
CRC Screening-Summary
CRC screening is effective CRC prevention is preferred Colonoscopy is the gold standard
Only test that can prevent colorectal cancer over the entire colon
-
15
Quality Measures for Colonoscopy
Cecal intubation rate for Avg Risk Screening Acceptable standard > 95%
RGA 98% Adenoma Detection Rate (ADR)
Standards: Males >30% Females >20%
RGA Males 55% Females 37%
Reasons for Patient Reluctanceto have Colonoscopy
Invasive Concern for intolerance of prep Concern for safety of procedures
Joan Rivers Self-conscious of body image Logistics
Day off work plus driver Costs
High deductible co-pays
Colonoscopy Risks Major complications for average risk screening ASGE Guidelines 2011 Cardiopulmonary
0.9% Perforation (0.3-0.07%)
1 in 2,000 is considered standard of care (0.05%) RGA: 1 in 14,000 or 0.01%
Source: ASGE Guidelines 2011
-
16
Colonoscopy Risks Post-polypectomy bleeding
Standard of care: 1 in 100 (1%) Medicare data 2 in 1,000 (0.2%) RGA 2 in 1,000 (0.2%)
Take out larger, more complicated polyps Can have up to 10 % bleeding rate
Death directly attributable to colonoscopy 19 in 284,000, or 0.007%
Source: ASGE Guidelines 2011
Risk In Perspective
Medicare Reimbursement for CRC Screening
Screening horizon: 10 years
Colonoscopy (no intervention) $588 National average (private) cost $1,200
CT colonography Every 5 years ($600 x 2) $1200
Cologuard Every 3 years ($600 x3) $1800
FIT testing Every 1 year ($25 x 10) $250
-
17
Cost of Screening: Perspective 81 % of all American Households: HDTVs1
52% have multiple HDTVs 68% of households with income < $50,000
Average cost 32” HDTV (2012) 2 Decreasing $435 Yet, average cost paid increasing $1224
Average replacement cycle 2 6 years Average life span of HDTV 7-9 years1. Source: Leichtman Research Group 2014, 20152. IHS Technology. Com survey 2012
But wait! Too much of a good thing? The impact of over-screening
1 in 4 colonoscopies Potentially inappropriate
1 in 5 colonoscopies1 Probably inappropriate
GI recommendations Inconsistent with guidelines 60% of time2
1. JAMA Intern Med. 2013;173(7):542-550.2. Am J Prev Med. 2007;33(6):471-478.
Appropriate Utilization 94 %
80 %
Source: GI Quic national database
-
18
Impact of over-screening
Higher risk of complications Minimal impact on CRC rates Negative impact on patient outcomes
“Break a hip on the way to the bathroom” Life expectancy
-
19
Take Home Points Colon cancer is prevalent Colon cancer is deadly Colon cancer rates are rising for younger
patients Colon cancer and death is nearly entirely
preventable 23 million eligible patients are not screened ANY SCREENING IS BETTER THAN
NO SCREENING
Take Home Points Colonoscopy remains the gold standard and
the only test that prevents cancer of entire colon—start at age 50 Preferred test for average risk screening Only recommended test for high risk population
FIT testing is most cost effective option For patients reluctant to have colonoscopy
Do NOT recheck if negative colonoscopy < 5 years
CT colonography and Cologuard are alternative options Have diagnostic limitations and drawbacks
Take Home Points Ask family history of colon polyps as well as
cancer in every patient Recommend colonoscopy at age 40 in
patients with family history of any polyp if pathology not available to confirm hyperplastic Or 10 years before age advanced adenoma was
detected Identify patients with multiple cancers and
family members Think hereditary cancer syndromes
-
20
Take Home Points Colonoscopy is safe
Think lifetime risk of dying from car accident Colonoscopy is cost effective
Think cost of cancer treatment Think HDTV life cycle
Demand high quality colonoscopy with: High cecal intubation rates High adenoma detection rates Low complication rates Proper adherence to national guidelines
Take Home Points Know when to stop screening
75-80 years old depending on age, family history co-morbidities
Discuss CRC prevention and screening at every visit
Help prevent colon cancer!!
-
21
Thank you Contact info
Phone 815.397.7340 Email: [email protected]
Reach out anytime with any GI questions