Colorectal Cancer: Putting Prevention into Practice

Durado Brooks, MD, MPHDirector, Prostate and Colorectal Cancers

Colorectal Cancer

The third most common cancer in U.S. and the second deadliest 141,000 new cases expected this year More than 49,000 deaths nationwide

1.1 million Americans living with colorectal cancer Death rates have fallen steadily over the past 20

years

Trends in CRC

CRC incidence and mortality have fallen steadily over the past 2 decades.Research suggests that observed declines in incidence and mortality are due in large part to: Screening and polyp removal, preventing progression

of polyps to invasive cancers NEJM study Feb 2012 showed polyp removal associated

with 53% lower risk of CRC death Screening detecting cancers at earlier, more

treatable stages CRC treatment advances

Risk Factors

Colorectal Cancer Risk Factors Age

90% of cases occur in people 50 and older Gender

slight male predominance, but common in both men and women

Race/Ethnicity Increased rates documented in African Americans,

Alaska Natives, some American Indian tribes, Ashkenazi Jews

Colorectal Cancer Risk Factors

Modifiable Risk Factors Diet Obesity Physical Activity Tobacco Alcohol

Non-Modifiable Risk Factors

Increased risk with: Personal history of inflammatory bowel disease,

adenomatous polyps or colon cancer Family history of adenomatous polyps, colon cancer,

other conditions Individuals with these risk factors may require

earlier and more intensive screening

The remainder of this presentation will focus on the average risk population.

Colorectal CancerSporadic (average risk) (65%–85%)

Familyhistory(10%–30%)

Hereditary nonpolyposis

colorectal cancer (HNPCC) (5%)Familial

adenomatous polyposis (FAP)

(1%)

Rare syndrom

es (<0.1%)

CENTERS FOR DISEASE CONTROLAND PREVENTION

Risk Factor - Polyps

Types of polyps: Hyperplastic

minimal cancer potential

Adenomatous approximately 90%

of colon and rectal cancers arise from adenomas

Normal to Adenoma toCarcinoma

Normal to Adenoma toCarcinoma

Human colon carcinogenesis progresses by the dysplasia/adenoma

to carcinoma pathway

Screening

Benefits of Screening

Cancer Prevention Removal of pre-cancerous polyps prevent cancer

(unique aspect of colon cancer screening)

Cost-effective Cost of CRC screening compares favorably to many

other common interventions (i.e. mammograms) Treatment costs for advanced disease have risen

greatly in recent years

Improved survival Early detection markedly improves chances

of long term survival

Benefits of Screening

Survival Rates by Disease Stage*

89.8%

67.7%

10.3%

0102030405060708090

100

Local Regional Distant

Stage of Detection

5-yrSurvival

*1996 - 2003

Trends in Recent* CRC Screening Prevalence (%), by

Educational Attainment and Health Insurance Status, Adults 50-75 Years, US, 2000-2010

Source: Klabunde et al, Cancer Epidemiol Biomarkers Prev 2011;20:1611-1621

National Health Interview Survey Public Use Data File 2010, National Center for Health Statistics, Centers for Disease Control and Prevention, 2011.

American Cancer Society, Surveillance Research, 2011.

Lower use of colorectal screening examinations in minority populations

Screening Tests

Options for Average risk adults age 50 and older:

Tests That Detect Adenomatous Polyps and Cancer

Colonoscopy every 10 years, or

Flexible sigmoidoscopy (FSIG) every 5 years, or

Double contrast barium enema (DCBE) every 5 years, or

CT colonography (CTC) every 5 years

Tests That Primarily Detect Cancer

Guaiac-based fecal occult blood test (gFOBT) with high test sensitivity for cancer, or

Fecal immunochemical test (FIT) with high test sensitivity for cancer, or

Stool DNA test (sDNA), with high sensitivity for cancer

ACS Screening Guidelines

Recommended Screening Tests ACS and USPSTF

High Sensitivity Fecal Occult Blood Testing Guaiac

Immunochemical

Colonoscopy

Flexible Sigmoidoscopy (FSIG) Recent studies support efficacy

Colonoscopy

Colonoscopy allows doctor to directly see inside entire bowel

Why Not Colonoscopy for All?

Screening rates remain disappointingly low Evidence does not support “best test” or “gold standard”

Colonoscopy misses ~ 10% of significant lesions in expert settings Higher potential for patient injury than other tests Test performance is highly operator dependent

Greater patient requirements for successful completion of tests that detect both polyps and cancers Requires a bowel prep and facility visit, and often a pre-

procedure specialty office visit (all with associated costs)

Patient preference Many individuals don’t want an invasive test or a test that

requires a bowel prep Some may not have access to the invasive tests due to lack

of coverage or local resources

Patient Preferences

Inadomi, Arch Intern Med 2012

Stool Test: Guaiac

Most common type in U.S. Best evidence (3 RCT’s) Need specimens from 3

bowel movements Non-specific Results influenced by foods

and medications Older forms (Hemoccult II)

have unacceptably low sensitivity

Better sensitivity with newer versions (Hemoccult Sensa)

Stool Test: Immunochemical (FIT)

Specific for human blood and for lower GI bleeding

Results not influenced by foods or medications

Some types require only 1 or 2 stool specimens

Higher sensitivity than older forms of guaiac-based FOBT

Slightly more costly than guaiac tests

FIT use in the US will likely increase due to recent elimination of guiaic- based testing by LabCorp and Quest Labs

FOBT Quality Issues

Sensitivity of Take Home vs. In-Office FOBT

Sensitivity

FOBT method(Hemoccult II)

All Advanced Lesions

Cancer

3 card, take-home 23.9 % 43.9 %

Single sample, in-office 4.9 % 9.5 %

Collins et al, Annals of Int Med Jan 2005

Stool Testing Quality Issues

CRC screening by FOBT should be performed with high-sensitivity FOBT - either FIT or a highly sensitive gFOBT (such as Hemoccult SENSA). Older, less sensitive guiaic tests (such as

Hemoccult II) should not be used for CRC screening.

Annual testing In-office FOBT is essentially worthless as a screening

tool for CRC and must be strongly discouraged. All positive screening tests should be evaluated by

colonoscopy

Clinicians Reference: FOBTOne page document designed to educate clinicians about important elements of colorectal cancer screening using fecal occult blood tests (FOBT).

Provides state-of-the-science information about guaiac and immunochemical FOBT, test performance and characteristics of high quality screening programs.

Available at www.cancer.org/colonmd

High Quality Stool Testing

How Can We Improve Screening Rates?

Sub-Optimal Screening RatesReasons (according to Patients)

• Low awareness of CRC as a personal health threat• Lack of knowledge of screening benefits• Fear, embarrassment, discomfort• Time• Cost• Access• Structural issues (lack of systems in most settings)• “My doctor never talked to me about it!”

Opportunistic vs. Organized Preventive Care

Most preventive care for adults in the U.S. is opportunistic, i.e. occurs incidentally during encounters with healthcare professionals

Opportunistic care depends on a coincidence of encounters, circumstances, and interests between patient and provider

This means some adults get some preventive care on some occasions and at some interval

Few adults receive the full package, or even the majority of recommended preventive services

“Action Plan” Toolkit Version

Eight page guide introduces clinicians and staff to concepts and tools provided in the full Toolkit

Contains links to the full Toolkit, tools and resources

Not colorectal-specific; practical, action-oriented assistance that can be used in the office to improve screening rates for multiple cancer sites (colorectal, breast and cervical)

Available at http://nccrt.org/about/provider-education/c

rc-clinician-guide/

Communication

Essential #1:

Determine the screening messages you and your staff will share with patients.

#1: Make a Recommendation

Essential #1:

Explore how your practice will assess a patient’s risk status and receptivity to screening.

Aren’t we bucking human nature with this one?

Q: Is a Doctor’s Recommendation Really That Useful?

Adapted from Jack Tippit, Saturday Evening Post

Gastroenterology Dept

Essential #2:

Create a standard course of action for screenings, document it, and share it.

#2 Develop a Screening Policy

Essential #2:

Compile a list of screening resources and determine the screening capacity available in your community.

Sample Tools for Your Practice

*This version of stage theory was adapted from the work of RE Myers.

Assess Risk: Personal & Family

History

Assess Risk: Personal & Family

History

Average risk =No family history of CRC or adenomatous

polyp

Average risk =No family history of CRC or adenomatous

polyp

< 50 years< 50 years

Increased or high risk based on personal

history

Increased or high risk based on personal

history

Increased or high risk based on family history Increased or high risk based on family history

> 50 years> 50 years

Do not screenDo not screen ScreenScreen

If positive, diagnosis by colonoscopy

If positive, diagnosis by colonoscopy

Adenoma

Adenoma

CRCCRC IBDIBD

SurveillanceColonoscopySurveillanceColonoscopy

High Risk:Germline Syndrome HNPCC or

FAP

High Risk:Germline Syndrome HNPCC or

FAP

Adenoma or cancer

Adenoma or cancer

Screening colonoscopy,

genetic testing, and other cancer screening as appropriate

Screening colonoscopy,

genetic testing, and other cancer screening as appropriate

Screen with colonoscopy 10

years before youngest relative or

age 40

Screen with colonoscopy 10

years before youngest relative or

age 40

OptionsTests That Find Polyps and CancerFlexible sigmoidoscopy every 5 years, or

Colonoscopy every 10 yearsDouble-contrast barium enema every 5 years, orCT colonography (virtual colonoscopy) every 5 yearsTests That Primarily Find CancerYearly fecal occult blood test (gFOBT) *, orYearly fecal immunochemical test (FIT) *, orStool DNA test (SDNA), interval uncertain

*The multiple stool take-home test should be used. One test done by the doctor in the office is not adequate for testing.The tests that are designed to find both early cancer and polyps are preferred if these tests are available and the patient is willing to have one of these more invasive tests.

Sample Screening Algorithm

Clinicians Reference: FOBTOne page document designed to educate clinicians about important elements of colorectal cancer screening using fecal occult blood tests (FOBT).

Provides state-of-the-science information about guaiac and immunochemical FOBT, test performance and characteristics of high quality screening programs.

Available at www.cancer.org/colonmd

High Quality Stool Testing

Essential #3:

Determine how your practice will notify patient and physician when screening and follow up is due.

#3 Be Persistent with Reminders

Essential #3:

Ensure that your system tracks test results and uses reminder prompts for patients and providers.

Reminder Fold-Over Postcard

Get Tested For ColonCancer: Here's How."An 7-minute video reviewing options for colorectal cancer screening tests, including test preparation.

Available as DVD, or you can refer patients to the URL to view from their personal computer.

Patient Education

Office Wall Chart

Screening guidelines for Breast, Cervical, Colon, Prostate and other cancers

General lifestyle/prevention Tobacco

cessation Healthy diet Weight, etc

English and Spanish

Clinician Reminder Types Chart Prompts

Problem lists Screening schedules Integrated summaries

Alerts – “Flags” placed in chart

Follow-Up Reminders Tickler System Logs and Tracking

Electronic Reminder Systems

Essential #4:

Discuss how your screening system is working during regular staff meetings and make adjustments as needed.

#4 Measure Practice Progress

Essential #4:

Have staff conduct a screening audit or contact a local company that can perform such a service.

Saving Lives Through Preventive

Cancer Screening

PLAN

ACTSTUDY

ADJUST

Communication

Health Card Kit

ACS Resources

Information and materials on colorectal cancer for clinicians and patients are available at: www.cancer.org/colonmd

Updated materials for other cancers are available on a new webpage www.cancer.org/professionals