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Colorectal Cancer Update for Healthcare Providers May 2013

Colorectal Cancer Update for Healthcare Providers May 2013 Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Cigarette Restitution Fund Program Center for Cancer Prevention and Control. CRC Incidence, Mortality, and Survival in the U.S.

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Colorectal Cancer Update for Healthcare Providers May 2013

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  1. Colorectal Cancer Update for Healthcare Providers May 2013 Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Cigarette Restitution Fund Program Center for Cancer Prevention and Control

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

  3. Colorectal Cancer • Third most commonly diagnosed cancer in Maryland among both men and women • Second leading cause of cancer-related mortality • Incidence and mortality have been decreasing in recent years

  4. 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)

  5. Source: SEER 9 areas. SEER Program, National Cancer Institute. Colorectal Cancer 5-year CRC survival has improved over the past 30 years in the U.S.

  6. CRC Screening

  7. Colorectal Cancer Screening Status of People Age 50 Years and OlderMaryland Cancer Surveys and BRFSS, 2002-2010 Maryland Cancer Survey, 2002-2008 BRFSS, 2010

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

  9. Colorectal Cancer Screening with colonoscopy or sigmoidoscopy? (50+ years) Never screened with colonoscopy or sigmoidoscopy 25% Ever screened with colonoscopy or Sigmoidoscopy 75% Maryland Cancer Survey, 2008

  10. Colorectal Cancer Screening with colonoscopy or sigmoidoscopy? (50+ years) Never screened with colonoscopy or sigmoidoscopy 25% Ever screened with colonoscopy or Sigmoidoscopy 75% 85% have been to doctor for “routine checkup” in past 2 years Only 15% have NOT had checkup Maryland Cancer Survey, 2008

  11. 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

  12. Who needs screening?

  13. Colorectal Cancer Cases by Risk History Sporadic (average risk) (65%–85%) Family history(10%–30%) Rare syndromes (<0.1%) Hereditary nonpolyposis colorectal cancer (HNPCC, 2-3%) Familial adenomatous polyposis (FAP) (<1%) http://www.cancer.gov/cancertopics/pdq/genetics/colorectal/HealthProfessional

  14. Risk of CRC Burt RW. Gastroenterology 2000;119:837-53 Winawer S, et al. Gastroenterology 2003;124:544-560

  15. Maryland Screening Recommendations: Medical Advisory Committee on CRC Colonoscopy, every 10 years or FOBT or FIT annually if refuse endoscopy or Flexible sigmoidoscopy, every 5 years with a high sensitivity fecal occult blood test* (FOBT), every 3 years Colonoscopy (interval for repeat depends on risk, history, and prior colonoscopy results) Average Risk Increased Risk * Hemoccult SENSA or fecal immunochemical test (FIT)

  16. Age to Begin Screening by Risk Category Rex DK, et al. Am J Gastroenterol 2009:104;739-750 American Cancer Society, 2012 http://www.cancer.org/Cancer/ColonandRectumCancer/MoreInformation/ColonandRectumCancerEarlyDetection/colorectal-cancer-early-detection-acs-recommendations

  17. 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, and the American College of Radiology CA Cancer J Clin 58: 130-160 (May 2008)

  18. 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 2012 http://www.cancer.org/Cancer/ColonandRectumCancer/MoreInformation/ColonandRectumCancerEarlyDetection/colorectal-cancer-early-detection-screening-tests-used

  19. 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, 2012 http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/colorectal-cancer-detection-recommendations United States Preventive Services Task Force http://www.uspreventiveservicestaskforce.org/uspstf08/colocancer/coloartzaub.htm#results

  20. CRC Screening Guidelines American Cancer Society, June 2012 • 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 the patient and the patient is willing to have one of these more invasive tests. • Talk to your doctor about which test is best for you.

  21. CRC Screening under the Cigarette Restitution Fund Program (CRFP) in Maryland

  22. Summary of Cigarette Restitution FundColorectal Cancer Screening in Maryland As of December 31, 2012: 23,203 People have had one or more screening procedures ______________________________________ 8,356 FOBTs (all income levels) 181Sigmoidoscopies 21,355 Colonoscopies DHMH, CCPC, Client Database, C-CoPD, as of 2/25/2013

  23. Summary of Cigarette Restitution FundColorectal Cancer Screening________ County, Maryland 2000-20XX: 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 Client Database, C-CoPD and C-CoP reports, or call Lorraine Underwood 410-767-0791 DHMH, CCPC, Client Database, C-CoPD, as of xx/xx/xxxx DHMH, CCPC, Client Database, C-CoP, as of xx/xx/xxxx

  24. Gender of 23,173 Screened* for CRC Maryland, 2000-December 2012 Men 7,587 (33%) Women 15,586 (67%) *Of clients with known gender screened with one or more of the following: FOBT, flexible sigmoidoscopy, colonoscopy, imaging DHMH, CCPC, Client Database, C-CoPD, as of 2/26/2013

  25. Minority Status of 23,203 New People Screened* for CRC, Maryland, 2000-December 2012 Non-minority or Unknown 11,110 (48%) Minority 12,093 (52%) *Of clients screened with one or more of the following: FOBT, flexible sigmoidoscopy, colonoscopy, imaging DHMH, CCPC, Client Database, C-CoPD, as of 2/26/2013

  26. Results* of 21,356 Colonoscopies Maryland Cigarette Restitution Fund ProgramMaryland, 2000-December 2012 * Most “advanced” finding on colonoscopy DHMH, CCPC, Client Database, C-CoP, as of 2/27/2013

  27. “Recall Interval” Recommended screening after initial screening--rescreening or surveillance colonoscopy

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

  29. 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)

  30. Guidelines for Recall Intervals Following Colonoscopy • Lieberman DA, Rex DK, Winawer SJ, Giardiello FM, Johnson DA, Levin TR. Guidelines for Colonoscopy Surveillance After Screening and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology, 2012;143:844–857 • Rex DK, Ahnen DJ, Baron JA, Batts KP, Burke CA, et al. Serrated lesions of the colorectum: Review and recommendations from an expert panel. Am J Gastroenterol. 2012:109;1315-29.

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

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

  33. Adequacy of First ColonoscopyAmong 16,813* First Cycle ColonoscopiesMaryland, 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

  34. 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

  35. How will your patients be reminded about their nextcolonoscopy?

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

  37. Acknowledgements • Funding from the Maryland Cigarette Restitution Fund (CRF) • Staff and partners of Local Public Health Department Programs 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

  38. PREVENTION AND HEALTH PROMOTION ADMINISTRATION

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