Colon Cancer Screening- Knowing The Guidelines

- Getting It Done!

Richard C. Wender, MDAlumni Professor and Chair

Department of Family & Community Medicine

Thomas Jefferson University

Philadelphia, PA

Past President, American Cancer Society

Colorectal Cancer – 2010 Update From CA

• Estimated new cases – 142,570

• Estimated deaths – 51,370

47.547.2

45.5

43.6

4241.4

41.140.540.6

46.546.9

48.4

50.1

51.251.5

52

53.1

53.9

40

42

44

46

48

50

52

54

56

2005-20072004-20062003-20052002-20042001-20032000-20021999-20011998-20001997-1999

Perc

ent

Percent of Colon and Rectal Cancer IncidenceEarly and Late Stage, 1997-1999 to 2005-2007

Early Stage

Late Stage

Where We Are: CRC Screening in PA & US( Age 50 and over; BRFSS, CDC)

2002 2008

PA | US PA | US

Stool Tests (2 yrs) 29% 30% 19% 21%

Endoscopy* (ever) 38% 48.6% 62%

62.5%

*Endoscopy=Colonoscopy or Sigmoidoscopy

PA (‘98) PA (‘08)

Total Population 23.4 18

By Race/ethnicity

Asian or Pacific Islander

NA 14.5

Black or African American

29 21.9

White 23 18

Hispanic or Latino 15.5 6.4

Decline in PA CRC Death Rate & U.S. Target

U.S. 2010/2020 Target: 13.9 deaths per 100,000 population

Where we want to be:PA CRC Screening Goals

• Increase the percentage of CRC Screening in the Pennsylvania adult population age 50 and above to 80% by 2014.

• Decrease the incidence of late-stage CRC diagnoses among Pennsylvania adults age 50 and above to 44% by 2014.

Question 1:

Which approach most accurately describes your current approach to colon cancer screening?

1. Colonoscopy for all – no specific back-up plan2. Colonoscopy for all – digital rectal FOBT as a back-up

plan3. Colonoscopy for all – FOBT at home OR in-office as a

back-up4. Colonoscopy for all – home FOBT as back-up5. FOBT/FIT or Colonoscopy offered - patient chooses6. FOBT/FIT is primary screening approach7. Other

Reaching Our Goal?

Understanding the Guidelines

CRC Screening Guidelines: New Concepts

• A 50% sensitivity threshold for cancer

• 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

• Annual gFOBT with at least 50% test sensitivity for cancer, or…

• Annual FIT with at least 50% test sensitivity for cancer, or…

• sDNA at uncertain screening interval

What Is A Highly Sensitive Stool Blood Test?

ACS defined “Sensitive” FOBT/FIT as one that has >50% sensitivity for cancer on one time testing.

Exceeds 50% Under 50%Hemoccult Sensa Hemoccult IIFIT’s (multiple brands)

Fecal Immunochemical Tests (FIT’s) May Replace Guiac FOBT

• FIT’s

–Demonstrate superior sensitivity and specificity

–Are specific for colon blood and are unaffected by diet or medications

–Some can be developed by automated readers

–Some improve patient participation in screening

Allison JE, et.al. J Natl Cancer Inst. 2007; 191:1-9Cole SR, et.al. J Med Screen. 2003; 10:117-122

FIT’s available in the US

Name Manufacturer

InSure Enterix, Quest Company

Hemoccult-ICT Breckman-Coulter

Instant-View Alpha Scientific Designs

MonoHaem Chemicon International

Clearview Ultra-FOB Wampole Laboratory

Auto Micro 80 Polymedco

Hemosure One Step WHPM, Inc.

Magstream Hem Sp Fujirebio, Inc.

Take home lesson:

Know which stool test you’re using

…And consider switching from guiac-FOBT to Fecal Immunochemical Testing (FIT)

Tests That Detect Adenomatous Polyps and Cancer

• Flexible sigmoidoscopy every 5 years, or…

• Colonoscopy every 10 years, or…

• Double-contrast barium enema every 5 years, or…

• CT colonography every 5 years

ACS Screening Guideline Versus USPSTF Guideline – Key Differences

ACS – Multi-society Task Force

USPSTF

Recommends a preferred test:

Yes – structural exams with higher sensitivity for polyps

No

C-T colonography:

Yes No

DCBE: Yes No

Fecal DNA: Yes (but at unknown interval)

No

But ACS & USPSTF Guidelines Agree on All Key Components

• All adults over 50 y.o. must be screened

• The screening options on both lists are:

– Colonoscopy every 10 years

– High Sensitivity FOBT or FIT annually

– Flexible sigmoidoscopy every 5 years

– Flex sig plus FOBT/FIT

• Screening with FOBT at time of digital rectal IS NOT recommended

If a patient happened to have a C-T colonography, or, less commonly now, double contrast barium enema, they should be considered to be successfully screened

CRC Screening and Aging

• The USPSTF recommends routine screening up until age 75

• From 76 to 85 y.o. – Do not screen routinely

• Ages 86 and over – Do not screen

Post Polypectomy Surveillance

Finding Next Colonoscopy

Small hyperplastic polyps 10 years

Only one or two tubular adenomas <1cm with only low-grade dysplasia

5-10 years

Three to ten adenomas OR any adenoma >1cm OR any with villous features or high grade dysplasia

3 years

>10 adenomas Less than 3 yearsBrooks DD, et.al. Am Fam Phys. Apr 1, 2008

Practically speaking, all CRC guidelines are telling us to do the same thing:

Be prepared to offer screening colonoscopy and a high sensitivity stool blood test

Colonoscopy – Is It Truly a Gold Standard?

• Distal vs. proximal colon cancer

–Colonoscopy confers only 12-33% protection against proximal colon cancer; 80% against distal

–Distal colon cancer in the US is declining. Proximal colon cancer rates are flat

Bressler B, et.al. Gastroenterology 2004; 127:452-456

Why Has Colonoscopy Been Disappointing For Right-Sided Cancers?

• Quality of colonoscopy

• Right-sided cancers may more likely derive from flat polyps

• Right-sided cancers may grow faster

• Timing of prep may not be ideal

Colonoscopy is the Best Screening Test for Colon Cancer

…. isn’t it?

Maybe Not!

Evaluating Test Strategies for Colorectal Cancer Screening

Zauber and her team conducted a decision analysis using microsimulation models

Zauber AG et.al. Ann of Int Med. 2008, 149; 659-669

• Number of life-years gained is essentially identical regardless of screening strategy used:

–Sensitive guiac FOBT annually

–Fecal Immunochemical Test (FIT) annually

–Flexible sigmoidoscopy every 5 years with midinterval sensitive FOBT

–Colonoscopy every 10 years

ASSUMING 100% ADHERENCE

Less Effective Strategies

Flexible sigmoidoscopy every 5 years

or

Low sensitivity FOBT annually

The Key Determinant of Effectiveness of Colon Cancer Screening

Getting it done!

Barriers to Physician Recommendation of CRCS

• Patient

–Comorbidity

–Patients who previously refused screening

–Language barriers

–Distrustful patients

–Patient already under the care of a GI specialist

–Perceived lack of patient acceptability

Guerra, CE et al. Barriers to Physician Recommendation of Colorectal Cancer Screening. J Gen Intern Med. 2007;22(12):1681-8.

Barriers to Physician Recommendation of CRCS

• Physician

–Forgetfulness

–Outdated knowledge of guidelines

–Fatigue

Barriers to Physician Recommendation of CRCS

• System–Acute care visits

• Due to lack of time, higher acuity and de-prioritization of screening

–Lack of time• Too many active issues and/or patient concerns

–Lack of reminder systems–Absence of reliable test tracking system–Lack of insurance coverage–Delays in colonoscopy scheduling

Barriers to Recommending CRCS

• All eligible patients do not consistently receive a provider recommendation for CRCS

• Interventions are needed to address the multiple barriers to address patient, physician and system level barriers

Guerra, CE et al. Barriers to Physician Recommendation of Colorectal Cancer Screening. J Gen Intern Med. 2007;22(12):1681-8.

The Biggest Barrier Of All

• Lack of payment to support outreach to entire enrolled population of patients

The Journal Article

• Sarfaty M, Wender R. How to increase colorectal cancer screening rates in practice. Ca Cancer J Clin 2007;57:354-366

• This article is available online at http://CAonline.AmCancerSoc.org

• Free CME credit for successfully completing the online quiz http://CME.AmCancerSoc.org

Interactive Web-based Toolboxhttp://www.cancer.org/aspx/pcmanual/default.aspx

Toolbox

• Your recommendation

• Office policy

• Reminder system

• Communication strategies

Essential 1: Physician Recommendation

• Physician recommendation is the most effective intervention for encouraging patients to be screened

• 74-90% of patients who have not had CRCS report they would schedule CRCS if their physician recommended the test

Lewis SF, et al.; Guerra CE, et al.

Impact of Physician Recommendation

• Lack of physician recommendation of CRCS is strongly associated with NOT undergoing CRCS

–Harewood GC et al.; Guerra CE, et al.; Klabunde CN et al.

• Conversely, physician recommendation of CRCS is one of the most important facilitators of adherence to CRCS

–Subramanian S, et al.; Teng EJ, et al.; Zapka JG et al.; Myers RE, et al.; Mandelson MT, et al; Bejes C, et al; Holt WS Jr, et al.

Goal

• Every eligible patient enrolled in your practice should receive a recommendation to undergo CRCS

Essential 2: An Office Policy

• Takes into account

–patient risk level: average, increased, high

–local medical resources

–insurance coverage

–patient preferences

Office Policy: Determining Patient Risk

1. Have you or any members of your family had CRC?2. Have you or any members of your family had an

adenomatous polyp?3. Has any member of your family had a CRC or

adenomatous polyp when they were under the age of 50? (If yes, consider a hereditary syndrome)

4. Do you have a history of Crohn’s disease or ulcerative colitis (for more than 8 years)?

5. Do you or any members of your family have a history of cancer of the endometrium, small bowel, ureter, or renal pelvis? (If yes, consider HNPCC)

Office Policy: Determining Patient Risk

• If an individual answers yes to any of these questions, that individual is at increased risk

Office Policy: Determining Patient Risk

• Increased Risk–Has a personal or family history of colorectal

polyps or CRC Or –Has a personal history of inflammatory bowel

disease for more than 8 years• 18-20% of population is at increased risk • Patients are not given options for screening• Colonoscopy is the preferred screening test• Screening should begin earlier (age 40 or

younger)

Office Policy: Determining Patient Risk

• High Risk (hereditary colorectal cancer syndromes)–Hereditary non-polyposis colorectal cancer

(HNPCC)

–Familial adenomatous polyposis (FAP)

–Attenuated FAP

Office Policy: Determining Patient Risk

• High Risk

–Suspect in someone with

• A family history of an adenomatous polyp or CRC in relative under age 50

• Two or more relatives with CRC

• Multiple colorectal adenomas (usually 10 or more) diagnosed over one or more exams

–Refer to local cancer genetic counselor www.nsgc.org• NOT eligible for this program

Office Policy: Determining Patient Risk

Assess Risk (Personal and Family hx) and Clinical Eligibility

Average Risk = no personal or family hx of CRC or adenomatous polyp, IBD,

symptoms

FIT

Positive

Refer to Patient Navigator Services

If + f/u with diagnostic

ColonoscopyRescreen in 1 yr

No Cancer -Surveillance Colonoscopy

In 3-5 yrs

YesRefer to PA DOH

endoscopist

Rescreen in 10 yrs

Neg

High risk = + family or personal hx of CRC or adenomatouspolyp, IBD > 8 yrs, HNPCC related ca,

FAP, aFAP

Colonoscopy

Polyp/Biopsy

No

Office Policy

• Once an office policy is created, the office staff must be engaged to actualize it

–Present office policy to staff and offer them the opportunity to ask questions

–Depict it using an algorithm

–Post it

–Disseminate it

–Build incentives around team goals

Examples of an Office Policy

1. Recommend colonoscopy for all patients. For those who hesitate, order Fecal Immunochemical Test (InSure)

– All positives undergo colonoscopy

2. Offer all patients the choice to have colonoscopy or a high sensitivity gFOBT (Hemoccult Sensa)

3. Recommend annual FIT for all

Essential 3: An Office Reminder System

• Reminders for patients–Passive

• Letters • Postcards• Prescriptions• Pamphlets• DVDs, videos• Websites• List of agencies that have available educational material included in

Toolbox–Active

• Telephone scripts• In-person• Electronic: For highly motivated patients:

www.myhealthtestreminder.com

Patient Reminder Letters

Patient Reminder Postcard

Telephone Scripts

www.MyHealthTestReminder.com

Patient Cues to Action

• Patient educational material

–DOH and ACS posters, brochures, videos can be ordered for free via the web: www.cancer.org/colonmd

American Cancer Society Patient Education Tools

This free brochure encourages your patients to talk with you about colorectal cancer screening and provides a list of questions to ask to help facilitate the conversation.

Available at www.cancer.org/colonmd

Reminders for Clinicians

• Behavioral–Chart stickers

–Screening schedules/flow sheets

–Electronic reminders: Required in meaningful use

–Tracking databases: paper and electronic (COMMAND, PECS2)

• Cognitive: Audit and Feedback, Ticklers (provides national benchmarks and targets)

• System: Staff assignments

Preventive Service Schedule

http://www.ahrq.gov/ppip/timelinead.pdf

Flow Sheets

http://www.nyc.gov/html/doh/downloads/pdf/csi/hyperkit-clin-ptvcare-flowsht.pdf

http://www.aafp.org/fpm/20010200/preventivecareflowsheets.pdf

Sample Paper Tracking Template (“Tickler”)

MRN

Tel #

Name Sex Race/ Ethnicity

DOB RiskA/I/H FOBT distribution date

FOBT result

FS referral date

CS referral date

NeedsFOBT, FS, CS, none

Date reminder written/ Telephone contact

Test result and notification date

Comment

Electronic Medical Records

• Vista-Office Electronic Health Record (VOE) project. More information can be obtained at: http://www.worldvista.org/

• Free, online rating system for electronic medical records by the AC group based on the Institute of Medicine’s requirements for a computerized patient record at: www.acgroup.org/pages/396843/index.htm

Audit and Feedback

• Chart audit

–Review a prerequisite number of charts to document whether a certain elements are found on the chart

–Produces an 18.6% improvement in screening rates

–Can produce feedback for a provider or a practice

• A repeat audit may be conducted to assess the impact of an intervention

Essential 4: Effective Communication

• Stage-based communication –Based on the Transtheoretical Model (Prochaska

& DiClemente)

• Individuals who are candidates for making a health behavior change do so in different stages of readiness

Education

Examine patient barriers

Practical how-to information

Readdress screening at a later time

Select a screening option and provide motivational information

Patients that Previously Refused CRCS

• Stage-based communication theory suggests that individuals cycle in and out of stages

• Therefore, individuals who previously refused screening, may re-contemplate and ultimately consider screening

• Physicians should readdress CRCS even in patients who previously refused

The Toolkit: Short Version

• Available on-line in a few months

• Based on the “Five Basic Truths”

Five Basic Truths of Colon Cancer Screening

1. If you only recommend colonoscopy and are not prepared to offer FOBT/FIT, you can only achieve a 70% screening rate…at best!

Five Basic Truths of Colon Cancer Screening

2. If you only offer screening to patients who are coming to a primary care office, you can achieve very good but not spectacular screening rates

Population management is the central challenge confronting primary care practices

Unlike disease management, cancer screening can be addressed almost entirely by the team

Five Basic Truths of Colon Cancer Screening

3. If you give out FIT or FOBT tests but do not track whether the patient returns the test and prompt them to do so, return rates will be poor

This demands teamwork, technology and tenacity

You have to have a registry of all enrolled patients over age 50 and younger patients with risk factors

Five Basic Truths of Colon Cancer Screening

4. If you ask a patient to schedule their colonoscopy but do not schedule it before they leave the office, only about one half of them will call and schedule

Patient Quote from June 17, 2010

“If you had not made the call while I was here, I never would have done it”

Sit down with your colonoscopist and tell them what you expect

Five Basic Truths of Colon Cancer Screening

5. If you are “screening” patients with a stool blood test at the time of a rectal exam, it’s time to stop. This method doesn’t work.

Collins proved that digital rectal with Hemoccult II has a sensitivity under 5%

Collins JF et al. Ann Intern Med 2005;142:81-85

Summary

• Know who your patients are

• Figure out if they’re at increased risk

• Assign and implement an outreach program

• Have a team approach to screening

–The clinician may have to do nothing more than say ‘ “It’s time to be screened”

• Offer colonoscopy and a high sensitivity FOBT/FIT

–Provide patient navigation

How can we achieve an 80% colon cancer screening rate in Pennsylvania?

One Practice at a Time!

You and Your Team Can Make This Happen

Thank you!