ccpc13 20 att2 crc slides providers
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Colorectal Cancer Updatefor Healthcare Providers
May 2013
Maryland Department of Health and Mental Hygiene
Prevention and Health Promotion Administration
Cigarette Restitution Fund ProgramCenter for Cancer Prevention and Control
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Prevention and Health Promotion AdministrationMay 20132
CRC Incidence, Mortality, and
Survival in the U.S.
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Colorectal Cancer
Third most commonly diagnosed cancerin Maryland among both men andwomenSecond leading cause of cancer-relatedmortality
Incidence and mortality have beendecreasing in recent years
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Colorectal Cancer Incidence and Mortality Ratesby Year of Diagnosis or Death, Maryland,
2002-2008
Maryland Cancer Registry (incidence rates)NCHS Compressed Mortality File in CDC WONDER (mortality rates)
51.554.6
48.646.3
41.3 41.6 42.5
20.9 19.6 19.2 18.8 18.6 17.7 16.7
0
10
20
30
40
50
60
70
2002 2003 2004 2005 2006 2007 2008
A g e - a
d j u s
t e d r a
t e
p e r
1 0 0
, 0 0 0 p
o p u
l a t i o n
Year of Diagnosis or Death
Incidence Mortality
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Source: SEER 9 areas. SEER
Program, National Cancer Institute.
5-year CRC survivalhas improved over
the past 30 years inthe U.S.
Colorectal Cancer
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Prevention and Health Promotion AdministrationMay 20136
CRC Screening
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Colorectal Cancer Screening Status of PeopleAge 50 Years and Older
Maryland Cancer Surveys and BRFSS, 2002-2010
2317
1011
41
10
26
50
2320
59
11
67
18
7
98
66
5
22
0 10 20 30 40 50 60 70
Up-to-date withcolonoscopy
Up-to-date withFOBT and/or
sigmoidoscopy
Tested but not up-to-date*
Never tested
Percent
2002 2004 2006 2008 2010
Maryland Cancer Survey, 2002-2008BRFSS, 2010
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80% of people 50+ inMaryland reported having aprovider r e c o m m e n dendoscopy..
of those, 88% got screened
88%
24%
0%
25%
50%
75%
100%
Provider recommended
No provider recommended
P e r c e n
t S c r e e n e
d
w i t h E n
d o s c o p y
Maryland Cancer Survey, 2008
Provider Recommendation is KEY to Screening
Of the 20% who did NOTreport a providerrecommendation.only24% got screened
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Prevention and Health Promotion AdministrationMay 20139
Colorectal Cancer Screeningwith
colonoscopy orsigmoidoscopy?
(50+ years)
Never screened withcolonoscopy or
sigmoidoscopy25%
Ever screened withcolonoscopy or
Sigmoidoscopy75%
Maryland Cancer Survey, 2008
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Colorectal CancerScreening
with colonoscopy or
sigmoidoscopy?(50+ years)
Never screenedwith colonoscopy or
sigmoidoscopy25%
Ever screened withcolonoscopy orSigmoidoscopy
75%
85%have been to doctor
for routine checkup in past 2 years
Only 15%have NOT had checkup
Maryland Cancer Survey, 2008
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Patient:Family and personal historyPast screeningSymptoms
Primary Doctor:Referral
Pathologist:Pathology report
Case
Management andCommunication
Colonoscopist:
Risk historyMedication changesPrep instructionsPost colonoscopy instructionsColonoscopy report
Findings
Recommendations
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Who needs screening?
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0
50
100150
200
250
300
350
400
450
A g e - s p e c
i f i c r a
t e
p e r
1 0 0
, 0 0 0 p o p u
l a t i o n
Age Group
Colorectal Cancer Age-Specific Incidence Ratesby Gender, Maryland and U.S., 2004-2008
MD Male MD Female U.S. Male U.S. Female
Source: Maryland Cancer Registry
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Risk of CRC
Group Approx. lifetime risk of CRCGeneral Population 5-6%
One first degree relative (FDR) with CRC 2--3-fold increase over generalpopulation
Two FDRs with CRC 3--4-fold increase
FDR with CRC diagnosed < 50 3--4-fold increaseOne second or third degree relative About 1.5-fold increase
Two second degree relatives About 2--3-fold increase
Inflammatory Bowel Disease(ulcerative colitis and Crohns colitis)
7-10% have CRC after havingulcerative colitis for 20 years;then ~1%/year
Familial adenomatous polyposis (FAP)Hereditary non-polyposis colorectal cancer (HNPCC)
~100%~80+%
Burt RW. Gastroenterology 2000;119:837-53Winawer S, et al. Gastroenterology 2003;124:544-560
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Average Risk
Increased Risk
Colonoscopy, every 10 yearsor
FOBT or FIT annually if refuse endoscopyor
Flexible sigmoidoscopy, every 5 years
with a high sensitivity fecal occult bloodtest* (FOBT), every 3 years
Colonoscopy(interval for repeat dependson risk, history, andprior colonoscopy results)
Maryland Screening Recommendations:Medical Advisory Committee on CRC
* Hemoccult SENSA or fecal immunochemical test (FIT)
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Risk Category Age to Begin Screening
Average risk Age 50 years
Increased risk
Family HistoryColorectal cancer or adenomatous polyp(s)*in an FDR age 1 cm; villous
histology; or high grade dysplasia
Age 40 years, or 10 years before theyoungest case in the immediatefamily, whichever is earlier
Genetic syndrome:Familial adenomatous polyposis (FAP)
Hereditary non-polyposis colorectalcancer (HNPCC)
Age 10 to 12 years
Age 20 to 25 years, or 10 yearsbefore the youngest case in the
immediate family Inflammatory bowel disease Cancer risk begins to be significant 8
years after the onset of pancolitis(involvement of entire large intestine),or 12-15 years after the onset of left-sided colitis
Rex DK, et al. Am J Gastroenterol 2009:104;739-750 American Cancer Society, 2012http://www.cancer.org/Cancer/ColonandRectumCancer/MoreInformation/ColonandRectumCancer EarlyDetection/colorectal-cancer-early-detection-acs-recommendations
Age to Begin Screening by Risk Category
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Guidelines Screening and Surveillance for the Early Detection of Colorectal
Cancer and Adenomatous Polyps, 2008:
A Joint Guideline from the American Cancer Society,
the U.S. Multi-Society Task Force on CRC, andthe American College of Radiology
C A Cancer J Clin 58: 130-160 (May 2008)
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Tests that Find Both Polyps and Cancer
Flexible sigmoidoscopy every 5 years
Colonoscopy every 10 years
Double contrast barium enema every 5 years
CT colonography (virtual colonoscopy) every 5 years
Guidelines, American Cancer Society, June 2012http://www.cancer.org/Cancer/ColonandRectumCancer/MoreInformation/ColonandRectumCancerEarlyDetection/colorectal-cancer-early-detection-screening-tests-used
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Tests that Primarily Find Cancer
High sensitivity FOBT every year
Hemoccult SENSA or fecal immunochemical test (FIT)Stool DNA test (unclear how often this is needed,
not currently available commercially is U.S.)
Guidelines, American Cancer Society, 2012http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/colorectal-cancer-detection-recommendationsUnited States Preventive Services Task Force
http://www.uspreventiveservicestaskforce.org/uspstf08/colocancer/coloartzaub.htm#results
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CRC Screening Guidelines American Cancer Society, June 2012
Beginning at age 50, men and women at averagerisk for CRC should use one of the screening
tests.The tests that are designed to find both earlycancer and polyps are preferred if these tests areavailable to the patient and the patient is willingto have one of these more invasive tests.
Talk to your doctor about which test is best foryou.
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CRC Screening under theCigarette Restitution Fund
Program (CRFP) in Maryland
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Summary of Cigarette Restitution FundColorectal Cancer Screening in Maryland
As of December 31, 2012:
23,203 People have had one or morescreening procedures
______________________________________
8,356 FOBTs (all income levels)
181 Sigmoidoscopies21,355 Colonoscopies
DHMH, CCPC, Client Database, C-CoPD, as of 2/25/2013
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Summary of Cigarette Restitution FundColorectal Cancer Screening ________ County, Maryland
2000-20XX:
XX Individuals screened for CRCby one or more method +
____________________________________________________________
XX FOBTs*XX Colonoscopies*
____________________________________________________________
X Cancers*X High grade dysplasia*
XX Adenoma(s)*
DHMH, CCPC, Client Database, C-CoPD, as of xx/xx/xxxx
DHMH, CCPC, Client Database, C-CoP, as of xx/xx/xxxx
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Gender of 23,173 Screened* for CRCMaryland, 2000-December 2012
*Of clients with known gender screened with one or more of the following:FOBT, flexible sigmoidoscopy, colonoscopy, imaging
Women15,586(67%)
Men7,587(33%)
DHMH, CCPC, Client Database, C-CoPD, as of 2/26/2013
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Minority Status of 23,203 New People Screened* for CRC,Maryland, 2000-December 2012
*Of clients screened with one or more of the following:FOBT, flexible sigmoidoscopy, colonoscopy, imaging
Non-minority orUnknown11,110 (48%)
Minority12,093 (52%)
DHMH, CCPC, Client Database, C-CoPD, as of 2/26/2013
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Results* of 21,356 ColonoscopiesMaryland Cigarette Restitution Fund Program
Maryland, 2000-December 2012
* Most advanced finding on colonoscopy
DHMH, CCPC, Client Database, C-CoP, as of 2/27/2013
Cancer/SuspectCancer, 243, 1%
Adenoma High-Grade, 88, 0%
Adenomas, Other,5,074, 24%
Other poly ps,4,580, 22%
Other f indings,7,771, 36%
Negativ e, 3294,15%
Inadequate col butno f indings, 306,1%
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Recommended screeningafter initial screening--
rescreening or surveillancecolonoscopy
Recall Interval
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After first colonoscopy, then what ?
Interval between colonoscopies will dependon:
findings on last colonoscopy,
risk history, and symptoms
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For the recommended recall intervals,please see:DHMH Colorectal Cancer Minimal Elements
http://phpa.dhmh.maryland.gov/cancer/Shared%20Documents/ccpc13-24--att_CRCMinimalElements2013[1].pdf
(or http://phpa.dhmh.maryland.gov/cancer/ under Resources )
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Keys to the right recall
1. Colonoscopy Report2. Pathology Report
3. Recommendation based on guidelines4. Communication
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Standards for Colonoscopy Reports CO-RADS*
Colonoscopy report should include:
Date and Time - ProcedurePatient descriptionRisk factors
ASA classIndicationsConsent signedSedationColonoscope
Bowel prep adequacy
Whether cecum reachedColonoscopy withdrawal timeFindingsSpecimen(s) to path lab
ImpressionComplicationsPathologyRecommendationsFollow-up plan/RecallOther
*Standardized colonoscopy reporting and data system: report of the Quality AssuranceTask Group of the National Colorectal Cancer Roundtable, Lieberman et al.,Gastrointestinal Endoscopy 2007; 65: 757-766
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Adequacy of First Colonoscopy Among 16,813* First Cycle Colonoscopies
Maryland, 2000-December 2012
*16,813 of the 17,915 first colonoscopies had information on adequacy of the col in CRFP. DHMH, CCPC, Client Database, Data Download, 2/27/2013
Adequate15,258 (91%)
Not Adequate1,555 (9%)
(Inadequate prepOR didn't reach
cecum)
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Reporting onColonoscopy Findings:
Number of masses, polyps, other lesions(try to give actual or estimatednumber rather than several ormultiple )
Findings: for EACH mass/polyp/lesion
locationsizedescriptiontattoobiopsy(ies) takenmethod of each biopsywhether lesion completelyremoved or not
whether there was piecemeal removalwhether specimens retrievedwhether saline lift usednumber of specimens sent to pathology
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How will your patients be remindedabout their next colonoscopy?
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Patient:Family and personal historyPast screening
Symptoms
Primary Doctor:Referral
Pathologist:Pathology report
CaseManagement andCommunication
Colonoscopist:
Risk historyMedication changesPrep instructionsPost colonoscopy instructionsColonoscopy report
FindingsRecommendations
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Acknowledgements
Funding from the Maryland Cigarette Restitution Fund (CRF)
Staff and partners of Local Public Health DepartmentPrograms in MD and their contracted providers
DHMH Center for Cancer Prevention and Control (CCPC) Database and Quality assurance Surveillance and Evaluation Unit including
- University of Maryland at Baltimore- Ciber, Inc.
CCPC CRF Programs Unit Maryland Cancer Registry
Minority Outreach Technical Assistance Partners
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http://phpa.dhmh.maryland.gov
PREVENTION AND
HEALTH PROMOTIONADMINISTRATION