Joint Screening Guidelines: Will NYCDOHMHs recommendation to NYCs doctors change

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Joint Screening GuidelinesWill NYCDOHMHs
recommendation to NYCs doctors change?

• Lynn D. Silver, MD, MPH
• Assistant Commissioner
• Bureau of Chronic Disease Control Prevention
• New York City Department of Health Mental
  Hygiene

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Colonoscopies are here to stay at
least for now

• NYCDOHMH will not be changing its key
  recommendation to doctors at this time

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Why?

• Even with the new guidelines there are
  outstanding issues re CT Colonography that need
  to be addressed before DOHMH will consider a
  change in recommendation
• Optimal strategies for effectiveness
• Capacity for the procedure in the city
• Reimbursement Policies

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Other Tests

• Little reason to promote flexible sigmoidoscopy,
  double contrast barium enema or guiac fecal
  occult blood tests at this time, given far better
  alternatives in each class

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One Change should be madeBack Up Tests Move
to High Sensitivity

• Specify that if FOBT or FIT is used,
  high-sensitivity tests should be employed

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Colonoscopy vs. Colonography

• BOTH tests have similar prep
• Full cathartic predation clear liquid diet
• CT Colonography no sedation necessary, less
  invasive
• Colonoscopy still needs to be performed
  (if polyps are detected) usually double prep!
• Potential loss of patients between both
  procedures
• Impact of alternative strategies for smaller
  polyps is still under study
• Detection of sessile/flat lesions
• Impact of frequency and models for surveillance
• Need for quality assurance for both

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FOCUS ON PREVENTION

• NYCDOHMH has always focused on the prevention of
  colon cancers
• Colonoscopies provide the ability to treat
  pre-cancerous polyps therefore prevent cancer
• As more information on CT Colonography best
  practices becomes available NYCDOHMH will
  reassess its screening recommendation
  accordingly.
• Insurers should begin to cover CT Colonography as
  an effective alternative

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CRC Screening Methods Costs and Benefits
CTC OC FOBT
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The role of colonoscopy in preventing colon cancer
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CT Colonography

• Of 1000 patients
• If any polyp criteria is used to refer 500
  patients 50 would be referred to CS
  (Pickhardt)
• If using any polyp 6mm to refer to CS
  approximately 129 patients would be referred (Kim
  et al)
• Potentially decreases need for optical
  colonoscopy by over 85

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Key Issues to Explore

• Optimal Screening Interval
• Colonoscopy 10 years?
• Colonography 5 years?
• Incidental Screening Findings
• CTC shown to detect extracolonic cancer
  abdominal aortic aneurysm (AAA)

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CT Colonography Capacity in NYC

• Do New York Citys hospitals have capacity in
  hardware, software and specifically trained
  radiologists?
• Original NYC recommendation for colonoscopy
  preceded by assessment of capacity

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COST!

• Will Medicare insurance companies cover CT
  Colonography Screening? And if so by how much and
  how often?
• Currently Medicare has no reimbursement
• Insurance coverage not extensive

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Clarity of Message

• We have successfully shifted NYC screening
  patterns to a highly effective preventative test
• Tripled screening of uninsured
• Eliminated health disparities
• Greatly increased overall screening rates to 62
• Developed funding bases for uninsured patients
  for colonoscopies
• Any change in recommendation
  should be cautious

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Open IssuesColonography vs. Colonoscopy

• Need to determine optimal strategies for when
  polyp removal needed after CTC vs. surveillance
  to maximize cancer prevention and minimize
  iatrogenesis
• Need insurance coverage
• Need to strengthen quality assurance systems for
  both colonoscopy and colonography
• Where CTC is used, develop systems for same day
  CS to avoid double prep