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Colorectal Cancer Screening: The Basics. July 21, 2010. Take Home Points. Colorectal Cancer Overview Screening Guidelines Screening Participation Screening Barriers CRC Screening Tests CRC Screening Algorithm. Colorectal Cancer . 3 rd most common 475 incidence cases (avg/yr 2002-06)

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Colorectal cancer screening the basics l.jpg

Colorectal Cancer Screening: The Basics

July 21, 2010


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Take Home Points

  • Colorectal Cancer

    • Overview

    • Screening Guidelines

    • Screening Participation

    • Screening Barriers

  • CRC Screening Tests

  • CRC Screening Algorithm


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Colorectal Cancer

  • 3rd most common

    • 475 incidence cases (avg/yr 2002-06)

  • 3rd deadliest cancer

    • 170 deaths in MT (avg/yr 2003-07)

  • Screening for CRC is effective

  • CRC screening rates could be better


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    CRC Risk Factors

    • Age

    • Gender

    • Race/Ethnicity

    • No racial/ethnic differences in MT


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    CENTERS FOR DISEASE CONTROL

    AND PREVENTION

    Colorectal Cancer

    Sporadic (average risk) (65%–85%)

    Family

    history(10%–30%)

    Rare syndromes (<0.1%)

    Hereditary nonpolyposis colorectal cancer (HNPCC) (5%)

    Familial adenomatouspolyposis (FAP) (1%)


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    CRC Screening Guidelines2008

    The American College of Obstetricians and Gynecologists

    The American Collegeof Physicians, American Academy of Family Physicians, AmericanCollege of Preventive Medicine, and Centers for Disease Controland Prevention

    USPSTF

    Joint Guideline: ACS, U. S. Multi-Society Task Force on Colorectal Cancer, American College of Radiology

    6


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    Cancer Screening

    U.S. Preventive Services Task Force:

    • Sufficient Evidence

      • Breast

      • Cervical

      • Colorectal

    • Not Sufficient Evidence

      • Lung

      • Prostate

      • All Others


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    CRC Screening Guidelines2008

    USPSTF CRC screening recommendation:

    • Age 50-75: screening using

      • Annual high-sensitivity FOBT

      • Sigmoidoscopy every 5 yrs combined with high-sensitivity FOBT every 3 yrs

      • Colonoscopy at intervals of 10 yrs

    • Age 76-85: against routine screening, considerations may support screening in individuals

    • Age >85: against screening

    8


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    CRC Screening Tests

    Tests recommended USPSTF:

    • Colonoscopy

    • Sigmoidoscopy

    • Fecal Occult Blood Testing (FOBT)

      • Guaiac

      • Immunochemical

    9


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    Colonoscopy/Sigmoidoscopy BRFSS 2006

    < 50%

    50-59%

    >/= 60%

    10


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    MT Cancer Screening

    BRFSS


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    MT Cancer Screening by Race

    * p < .05, ** p< .01


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    MT Cancer Screening2008 BRFSS

    • Approximately 20% had both

    • < 60% had FOBT or endoscopy or both

    13


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    Why Not: Montana

    BRFSS Cancer Screening Questions:

    • Have you ever had a

      • Mammogram

      • Pap smear

      • PSA test

      • DRE

      • Colonoscopy or sigmoidoscopy

      • FOBT

    • If yes, when was your last one


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    Why Not: Montana

    Added for Mammogram & Endoscopy:

    • Has provider ever recommended that you have…

    • Have you had…(endoscopy ever / mammogram within 2 years)

    • If never screened or not up to date,

      Why not?

    • What is main reason you have not…

      Use responses to infer barriers


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    Why Not: Montana


    Why not montana17 l.jpg

    Why Not: Montana


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    Colonoscopy Capacity Survey 2008

    41 hospitals perform colonoscopy

    40 returned surveys

    Info from M.D. for nonresponding hospital

    3 ambulatory centers

    Affiliated with large hospitals

    All returned surveys


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    Colonoscopy Capacity Survey 2008

    13 Urban

    15,000 screens per year

    Total capacity ~21,000

    7 week wait

    25% of screen capacity unused

    31 Rural

    4,000 screens per year

    Total capacity ~22,000

    2 week wait

    80% of screen capacity unused


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    • Why emphasize CRC screening:

      • Incidence

      • Mortality

      • Risk factors

      • Benefits

      • Current screening status

  • Questions?


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    Colorectal Cancer Screening 2008


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    Colonoscopy

    Sensitivity for CRC =95%

    Estimate: $800 - $1600


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    Risk Factor - Polyps

    Different types:

    • Hyperplastic

      • minimal cancer

        potential

    • Adenomatous

      • approximately 90% of colon and rectal cancers arise from adenomas

    24


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    Flat Lesions

    Soetikno, JAMA 2008

    Caveats

    • Most lesions not

      truly flat

    25


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    Human colon carcinogenesis

    Normal Polyp Cancer

    Normal toAdenomatoCarcinoma

    26


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    Benefits of CRC Screening

    Benefits:

    • Cancer Prevention: Removal of pre-cancerous polyps

    • Long-term survival: Improved by early detection

    27


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    Colonoscopy

    Colonoscopy – Pros

    • Can usually view entire colon

    • Can biopsy and remove polyps

    • Done every 10 years

    • Can diagnose other diseases


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    Colonoscopy

     Colonoscopy – Cons

    • Can miss small polyps

    • Full bowel preparation needed

    • More expensive on a one-time basis

    • Sedation of some kind is usually needed

    • Will need someone else to drive home

    • May require a missed day of work


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    Colonoscopy

     Colonoscopy – Cons

    • Risk of serious Complications 25/10,000

      • Bleeding 12.3/10,000

      • Tear or perforations 3.8/10,000

      • Infection or diverticulities

      • Cardiovascular events

      • Severe abdominal pain

    • Serious complication consequence:

      • Hospital admission

      • Surgery

      • Death 0.6/10,000 procedures reported


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    Guaiac Fecal Occult Blood Test

    Sensitivity for CRC =varies (64% for Hemoccult SENSA)

    Estimate:$10 - $25


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    FOBT

    Fecal Occult Blood Test – Pros

    • No direct risk to the colon

    • No bowel preparation

    • Sampling done at home

    • Inexpensive


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    FOBT

    Fecal Occult Blood Test – Cons

    • May miss many polyps and some cancers

    • May produce false-positive test results

    • May have pre-test dietary limitations

    • Should be done annually

    • Organized system needed for follow-up

    • Colonoscopy needed if abnormal


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    In-Office FOBT

    • Single sample, in-office CRC sensitivity = 9.5 %

    • Hemoccult II 3 card, take-home sensitivity = 43.9 %

    • In-office FOBT not a CRC screening tool

    • Nearly 30% of physicians reported using for screening colorectal cancer

    Nadel et al, Annals of Int Med Jan 2005


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    Fecal Immunochemical Test

    Sensitivity for CRC =varies (66% for Magstream FIT)

    Estimate: $28


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    FIT

    Fecal Immunochemical Test – Pros

    • No direct risk to the colon

    • No bowel preparation

    • No pre-test dietary restrictions

    • Sampling done at home

    • Fairly inexpensive


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    FIT

    Fecal Immunochemical Test – Cons

    • May miss many polyps and some cancers

    • May produce false-positive test results

    • Should be done annually

    • Colonoscopy needed if abnormal


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    Colorectal cancer symptoms

    Blood in or on the stool

    Stomach pains, aches, or cramps that are persistent

    Unexplained weight loss

    Change in bowel habits


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    39


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    Resources

    Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline:

    http://caonline.amcancersoc.org/cgi/content/full/CA.2007.0018v1

    USPSTF CRC screening 2008 update: http://www.ahrq.gov/CLINIC/uspstf/uspscolo.htm

    MDPHHS Cancer Control webpage: www.cancer.mt.gov

    Email questions on cancer control: [email protected]

    The Community Guide: www.thecommunityguide.org

    How to Increase Colorectal Cancer Screening Rates in Practice: A Primary Care Clinician's Evidence-Based Toolbox and Guide: http://www.cancer.org/docroot/PRO/content/PRO_4_1x_ColonMD_Clinicians_Manual.pdf.asp

    Ballew, Lloyd, and Miller. 2009. Capacity for Colorectal Cancer Screening by Colonoscopy, Montana, 2008. American Journal of Preventive Medicine 36:329-332.


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