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CRC Incidence, Mortality, and Survival in U.S.

Colorectal Cancer Screening Update 2009 Maryland Dept. of Health and Mental Hygiene Center for Cancer Surveillance and Control Cigarette Restitution Fund Programs Unit. CRC Incidence, Mortality, and Survival in U.S. Annual age-adjusted cancer incidence rates, US, 1975-2004.

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CRC Incidence, Mortality, and Survival in U.S.

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  1. Colorectal Cancer ScreeningUpdate 2009Maryland Dept. of Health and Mental HygieneCenter for Cancer Surveillance and ControlCigarette Restitution Fund Programs Unit

  2. CRC Incidence, Mortality, and Survival in U.S.

  3. Annual age-adjusted cancer incidence rates, US, 1975-2004 CA Cancer J Clin Jemal et al. 58 (2): 71-96 (2008).

  4. Annual age-adjusted cancer death rates--Males, US, 1930-2004 CA Cancer J Clin Jemal et al. 58 (2): 71-96 (2008).

  5. Annual age-adjusted cancer death rates--Females, US, 1930-2004 CA Cancer J Clin Jemal et al. 58 (2): 71-96 (2008).

  6. Source: SEER Cancer Statistics Review, 1975-2005. (Rates are from SEER 9 areas.)

  7. CRC Screening

  8. Colorectal Cancer Screening Status of People Age 50 Years and OlderMaryland Cancer Surveys, 2002-2008

  9. Provider Recommendation is KEY to Screening Percent Screened with Endoscopy 80% of people 50+ in Maryland reported having a provider recommend endoscopy….. of those, 88% got screened Of the 20% who did NOT report a provider recommendation….only 24% got screened Source: Maryland Cancer Survey, 2008

  10. Source: Maryland Cancer Survey, 2008

  11. Source: Maryland Cancer Survey, 2008

  12. Patient: Family and personal history Past screening Symptoms Primary Doctor: Referral Case Management and Communication • Colonoscopist: • Risk history • Medication changes • Prep instructions • Post colonoscopy instructions • Colonoscopy report • Findings • Recommendations Pathologist: Pathology report

  13. Who needs screening?

  14. Colorectal Cancer Rates by Age and SexCancers of the Colon and Rectum:Average Annual Age-Specific SEER Incidenceand U.S. Mortality Rates by Gender, 2001-2005 Incidence Men Incidence Women Age recommended to start screening Mortality Men Mortality Women Source: SEER Cancer Statistics Review 1975-2005. Colon and Rectum Cancer, SEER Incidence and U.S. Death Rates, Age-Adjusted and Age-Specific Rates, By Race and Sex (Rates based on SEER 17 areas)

  15. Colorectal Cancer Mortality Rates by Race and Sex in Maryland, 1998-2005 Age-adjusted rate per 100,000 population Black men Black women White men White women Source: NCHS Compressed Mortality File in CDC Wonder

  16. Colorectal Cancer Cases by Risk History (84,600-110,670 cases/yr.) Sporadic (average risk) (65%–85%) Family history(10%–30%) Rare syndromes (<0.1%) Hereditary nonpolyposis colorectal cancer (HNPCC) (5%) Familial adenomatous polyposis (FAP) (1%)

  17. Risk of CRC Burt. Gastroenterology 2000;119:837-53 Winawer et al. Gastroenterology 203;124:544-560

  18. Colonoscopy, every 10 years or FOBT annually, plus Flex sig., every 5 years FOBT if refuse endoscopy Colonoscopy (interval for repeat depends on risk, history, and prior results) Average Risk Increased Risk Maryland Screening Recommendations: Medical Advisory Committee on CRC

  19. New Guidelines Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline from the American Cancer Society, the US Multi-Society Task Force on CRC, and the American College of Radiology CA Cancer J Clin 58: 130-160 (May 2008)

  20. Bernard Levin, David A. Lieberman, Beth McFarland, Robert A. Smith, Durado Brooks, Kimberly S. Andrews, Chiranjeev Dash, Francis M. Giardiello, Seth Glick, Theodore R. Levin, Perry Pickhardt, Douglas K. Rex, Alan Thorson, Sidney J. Winawer, for the American Cancer Society Colorectal Cancer Advisory Group, the US Multi-Society Task Force, and the American College of Radiology Colon Cancer Committee

  21. 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 New Guidelines American Cancer Society, May 2008

  22. Tests that Primarily Find Cancer • Guaiac-based fecal occult blood testing (gFOBT) every year  • Fecal immunochemical test (FIT) every year  • Stool DNA test (unclear how often this is needed) New Guidelines American Cancer Society, May 2008

  23. New CRC Screening Guidelines American Cancer Society, May 2008 • Beginning at age 50, men and women at average risk for CRC should use one of the screening tests • The tests that are designed to find both early cancer and polyps are preferred if these tests are available to you and you are willing to have one of these more invasive tests. • Talk to your doctor about which test is best for you.

  24. CRC Screening Program in Maryland

  25. Summary of Cigarette Restitution FundColorectal Cancer Screening in Maryland As of December 31, 2008: 16,737 People have had one or more screening procedures ______________________________________ 8,328 FOBTs (all income levels) 148Sigmoidoscopies 13,552 Colonoscopies Source: DHMH, CCSC, Client Database (CDB), C-CoPD, C-CoP, as of 2/11/2009

  26. Summary of Cigarette Restitution FundColorectal Cancer Screening________ County, Maryland 2000-2008: XX Individuals screened for CRC by one or more method+ ____________________________________________________________ XX FOBTs* XX Colonoscopies* ____________________________________________________________ X Cancers* X High grade dysplasia* XX Adenoma(s)* Obtain numbers for your jurisdiction from the chart presented at the teleconference 2/18/2009 CCSC HO Memo 09-08, Attachment 5, or call Lorraine Underwood 410-767-0791 +Source: DHMH, CCSC, Client Database (CDB), C-CoPD, as of 2/11/2009 *Source: DHMH, CCSC, Client Database (CDB), C-CoP, as of 2/11/2009

  27. Gender of 17,035 Screened* for CRC Maryland 2000-December 2008 Men 5,332 (31%) Women 11,673 (68%) *Of clients screened with one or more of the following: FOBT, Flex sig, colonoscopy, DCBE Source: DHMH, CCSC, Client Database (CDB), C-CoP, as of 1/14/2009

  28. Minority Status of 16,711 New People Screened* for CRC, Maryland 2000-December 2008 Non-minority 8,539 (51%) Minority 8,172 (49%) *Of clients screened with one or more of the following: FOBT, Flex sig, colonoscopy, DCBE Source: DHMH, CCSC, Client Database (CDB), C-CoPD, as of 1/14/2009

  29. Results* of 13,507 Colonoscopies Maryland Cigarette Restitution Fund ProgramMaryland 2000-December 2008 * Most “advanced” finding on colonoscopy Source: DHMH, CCSC, Client Database (CDB), C-CoP, as of 1/12/2009

  30. Recommended screening afterinitial screening--rescreening or surveillance colonoscopy “Recall Interval”

  31. After first colonoscopy, then what? • Interval between colonoscopies will depend on: • findings, • risk history, and • symptoms

  32. Interval between colonoscopies IF Findings on colonoscopy were negative: • No CRC; • No adenomas; and • No or only a few hyperplastic polyps, Average risk, and No CRC symptoms • Interval will usually be 10 years • See guidelines for recommended interval

  33. Interval between colonoscopies– based on findings IF Findings showed: • Inadequate colonoscopy • didn’t reached cecum • inadequate bowel preparation • Cancer • Adenomatous polyp(s)—need to know: • Number • Size • Histology • Completeness of removal • Many hyperplastic polyps indicating Hyperplastic Polyposis Syndrome • Interval will usually be LESS THAN 10 years • See guidelines for recommended interval

  34. Interval between colonoscopies– based on risk history IFfirst colonoscopy was negative BUT person is at increased risk because of family history: • Interval may be LESS THAN 10 years • See guidelines for recommended interval

  35. Example • 53 year old patient had a colonoscopy: “several adenomas were found” What is the recommended recall interval? What else do you need to know to determine the interval? Who will tell the patient? Will anyone remind the patient when the next colonoscopy is needed?

  36. Answer: You need to know more about the Risk and Colonoscopy Results before you can set the right recall interval: • Was the bowel preparation adequate? • Was the cecum reached? • How many adenomas were found? • How big were the adenomas? • Were they completely removed? • What was the pathology? • What is the family and personal risk history of the patient?

  37. http://caonline.amcancersoc.org/ Guidelines for Colonoscopy Surveillance after polypectomy--Winawer et al. CA--A Cancer Journal for Clinicians 56 (3) 143. (2006)

  38. Keys to the right recall • Colonoscopy Report • Pathology Report • Recommendation based on guidelines • Communication

  39. Date and Time Procedure  Patient description  Risk factors- ASA class  Indications Consent signed  Sedation   Colonoscope  Bowel Prep  Reached cecum  Colonoscopy withdrawal time  Findings Specimen(s) to path lab  Impression  Complications  Pathology  Recommendations, Follow-up Plan/Recall  Other  Standards for Colonoscopy Reports--CoRADS* * Standardized colonoscopy reporting and data system (CoRADS): report of the Quality Assurance Task Group of the National Colorectal Cancer Roundtable, Lieberman et al., Gastrointestinal Endoscopy 2007; 65: 757-766

  40. Adequacy of First ColonoscopyAmong 10,328* Cycle 1 ColonoscopiesMaryland 2000-December 2008 *10,328 of the 11,421 first colonoscopies had information on “adequacy” of the col. Source: DHMH, CCSC, Client Database (CDB), Ad-hoc report, 1/12/2009

  41. Reporting on Colonoscopy Findings: • Number of masses, polyps, other lesions • (try to give actual or estimated number rather than “several” or “multiple”) • Findings: for EACH mass/polyp/lesion-- • location • size • description • tattoo • biopsy(ies) taken • method of each biopsy • whether lesion completely removed or not • whether there was piecemeal removal • whether specimens retrieved • whether saline lift used • number of specimens sent to pathology

  42. How will your patients be reminded about their next colonoscopy?

  43. Patient: Family and personal history Past screening Symptoms Primary Doctor: Referral Case Management and Communication • Colonoscopist: • Risk history • Medication changes • Prep instructions • Post colonoscopy instructions • Colonoscopy report • Findings • Recommendations Pathologist: Pathology report

  44. Acknowledgements • -Funding from the Maryland Cigarette Restitution Fund • -Staff and partners of Local Public Health Department Programs in MD and their contracted providers • -- DHMH Center for Cancer Surveillance and Control (CCSC) • Database and Quality assurance • Surveillance and Epidemiology Unit • University of Maryland at Baltimore • Ciber, Inc. • - CCSC CRF Programs Unit • - DHMH FHA, Information Technology • -- Minority Outreach Technical Assistance Partners

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