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