Colorectal Cancer Challenges and Opportunities

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Colorectal CancerChallenges and Opportunities

• 2006

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Colorectal Cancer

• The third most common cancer in U.S.
• 148,610 new cases in 2006
• The second deadliest cancer
• 55,170 deaths nationwide
• More than 1.2 million Americans living with
  colorectal cancer

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Risk Factors

• Age
• 90 of cases occur in people 50 and older
• Gender
• slight male predominance, but common in both men
  and women
• Family and personal history
• Race
• African Americans have highest incidence and
  mortality rate of all groups in U.S.

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Behavioral Risk Factors

• Tobacco
• Alcohol
• Physical inactivity
• Obesity
• High fat diet (esp. red meats)

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Protective Factors

• Exercise
• Folic acid, in long term daily multivitamin
• Calcium
• Estrogen therapy
• Problematic due to other negative effects

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Protective Factors

• Aspirin/NSAIDs
• Statin Drugs?
• Vitamin E? Selenium?
• Some supportive evidence currently under study

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Whos At Risk?

• Average Risk
  All adults 50 years and older
• Increased Risk
  Personal history of inflammatory bowel
  disease, adenomatous polyps or colon cancer
• Family history of adenomatous polyps, colon
  cancer, other conditions

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Colorectal Cancer
Sporadic (average risk) (6585)
Family history(1030)
Rare syndromes (Hereditary nonpolyposis colorectal cancer (HNPCC)
(5)
Familial adenomatous polyposis (FAP) (1)
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Benefits of Screening

• Cancer Prevention
• Removal of pre-cancerous polyps prevent cancer
  (unique aspect of colon cancer screening)
• Improved survival
• Early detection markedly improves chances of long
  term survival

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Benefits of Screening
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Colorectal Screening Rates are Low

• Just 38 of colorectal cancers are detected at
  the earliest stage.
• Less than half of Americans over age 50 report
  having had a recent colorectal cancer screening
  test.

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Colorectal Cancer Screening Rates
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CRC Screening Methods

• Fecal Occult Blood Testing (FOBT)
  Guaiac
  Immunochemical
• Flexible Sigmoidoscopy (FSIG)
• FOBT FSIG
• Colonoscopy
• Double Contrast Barium Enema (DCBE)
• All of the above methods have evidence to
  support their use

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Fecal Occult Blood Test (FOBT)
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Fecal Occult Blood Test (FOBT)

• Detects blood in the stool
• Cancers tend to bleed
• Large polyps also may bleed (but are less likely
  to bleed compared with cancers)

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Evidence for CRC Screening

• Fecal Occult Blood Testing
• Randomized controlled trials in U.S., U.K. and
  Denmark
• Survival benefit 15 to 33 with annual or
  biennial screening
• Incidence decreased 18 in U.S. study (evidence
  of prevention)
• All studies showing benefit of FOBT utilized 3
  card, take home, guaiac-based testing with
  colonoscopic evaluation of all positives

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Sensitivity of Take Home In-Office FOBT
Collins et al, Annals of Int Med Jan 2005
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Fecal Occult Blood Test

• Bleeding from cancers and polyps usually
  intermittent
• In-office FOBT is essentially worthless as a
  screening tool for CRC and must be strongly
  discouraged
• However
• In a recent national survey, nearly 30 of
  physicians reported using single-sample,
  in-office FOBT at the time of rectal exam as
  their primary method of screening for colorectal
  cancer
• Nadel et al, Annals of Int Med Jan 2005

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Fecal Occult Blood Test

• Inadequate follow up of positive FOBT
• Approximately 30 of patients who were told they
  had a positive FOBT reported that this test was
  either followed up with a repeat FOBT, or no
  diagnostic work up.
• Nadel et al, Annals of Int Med Jan 2005

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Fecal Immunochemical Tests (FIT)

• Based on the immunochemical detection of
  human hemoglobin (Hb) as an indicator of blood in
  the stool.
• Does not react to non-human blood (i.e. from
  recently consumed red meat
• Use a monoclonal or polyclonal antibody that
  reacts with the intact globin protein portion of
  human hemoglobin.
• Because globin breaks down during passage from
  upper to lower GI tract, a positive fecal
  immunochemical test is specific for lower GI
  (i.e. colon or rectal) bleeding
• Some FITs require only 2 samples, and no
  smearing
• Higher patient acceptance shown in a few studies

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Flexible Sigmoidoscopy (FSIG)

• FSIG allows doctor to directly see inside lower
  portion of bowel

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Diagram of the Colon and Rectum
Splenic flexure
Reach of Flexible Sigmoidoscopy
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Flexible Sigmoidoscopy (FSIG)

• Lesions can be biopsied as part of the procedure
• Opportunity to find not only cancer, but also
  adenomatous polyps (prevention)
• Abnormalities in the lower part of the bowel are
  associated with a high probability of growths in
  other parts of the bowel

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Distribution of Colorectal Lesions
Transverse 15
Ascending 25 Cecum
Descending 5
Sigmoid 25
Rectum 20
Rectosigmoid 10
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Flexible Sigmoidoscopy
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Evidence for CRC Screening

• Flexible Sigmoidoscopy
• Case-control studies
• 60 decrease in mortality from cancers within
  the reach of the scope
• No decrease in deaths from cancers in parts of
  the colon not reached by the sigmoidoscope (i.e.
  cancers in the transverse and ascending colon)

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Evidence for CRC Screening

• FOBT Flexible Sigmoidoscopy
• Single case-control study suggesting benefit
  over FSIG alone
• FOBT may help detect cancers located beyond
  reach of sigmoidoscope

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Evidence for CRC Screening
Kaiser Northern California

• Age-adjusted incidence of distal CRC following
  normal screening Flexible Sigmoidoscopy

(rate per 100,00)
Doria-Rose et al, Gastroenterology Sept 2004
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Evidence for CRC Screening

• Flexible Sigmoidoscopy
• Declining use and interest
• 
  Medicare

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Double Contrast Barium Enema

• Double Contrast barium enema relies on barium to
  reveal filling defects, and air to reveal lesions
  after most of barium has been removed.

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Evidence for CRC Screening

• Double Contrast Barium Enema
• No direct evidence for use in screening
• Some evidence as surveillance method

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Colonoscopy

• Colonoscopy allows doctor to directly see inside
  entire bowel

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Diagram of the Colon and Rectum
Splenic flexure
Reach of Colonoscopy
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Colonoscopy

• Provides opportunity to find not only cancer, but
  also adenomatous polyps
• Growths can be biopsied as part of the procedure,
  and polyps can be completely removed

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Evidence for CRC Screening

• Colonoscopy
• Studies as screening modality currently underway
• Best method for diagnostic evaluation after
  abnormalities identified by other screening
  techniques
• Proven superior to FSIG and DCBE for
  surveillance after polypectomy

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Colonoscopy

• Limitations
• Expense
• Limited access in some settings
• Logistics (time off work, need driver,)
• Prep
• Complications (sedation, bleeding,
  perforation,)
• Misses approximately 10 of significant lesions

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ACS 2001 Guidelines for Screening and Early
Detection of CRC in Average Risk Individuals

• FOBT annually FSIG every 5 years
• (preferred compared with FOBT or FSIG alone)
• FSIG every 5 years
• FOBT annually
• Colonoscopy every 10 years
• DCBE every 5 years
• All positive tests should be followed up with
  colonoscopy

FOBT guaiac-based or immunochemical
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CRC Screening Recommendations Various
Organizations
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CRC Screening Methods

• Guidelines emphasize options because
• Individuals differ in their preferences among
  these choices
• Physicians vary in their ability or readiness to
  refer patients to all options equally
• Access is uneven geographically, and in terms of
  insurance coverage
• There still is considerable uncertainty about
  program performance in terms of benefits, harms,
  and costs

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Colorectal Screening Rates Low2001 Survey of
50,000 Adults
Source Behavioral Risk Factor Surveillance
System, 2001
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Colorectal Screening Rates LowReasons
(according to Physicians)

• Believe that patients dont want screening
• Unclear about guidelines
• Low awareness of screening benefits
• Lack of skills to perform screening
• Structural issues (lack of practice systems)
• Low reimbursement
• Context of visit
• Time

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Colorectal Screening Rates LowReasons
(according to Patients)

• Low awareness of CRC as a personal health threat
• Lack of knowledge of screening benefits
• Fear, embarrassment, discomfort
• Time
• Cost
• Access

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Consumers Lack Concern About Colon Cancer
Over two thirds of the target audience knows that
there are things they can do to prevent colon
cancer, but only 26 is concerned about getting
colon cancer.

• Target Audience - Women 50-64 who have never had
  a CRC test or have not had them in the correct
  time frame, but who have seen a primary care
  doctor at least once in the past year.
• Tested Women - Women 50-64 who have had one of
  the CRC tests in the correct time frame

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Knowledge of Colorectal Cancer Risk Factors Among
the General Population Age 50 Years, Michigan
2001-2002
Special Cancer Behavioral Risk Factor Survey,
2001-2002
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Colorectal Screening Rates LowReasons
(according to Patients)

• My doctor never talked to me about it !

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Colorectal Screening Rates LowReasons
(according to Patients)

• According to a national survey, among men and
  women who had had a doctor visit in the past year
  but who had not had a recent fecal occult blood
  test, 94.6 reported that their doctor had not
  recommended the test in the past year

Coughlin and Thompson, 2005
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Colon Cancer Attitudes
 
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Physician Influence

• What the research tells us
• People are more likely to be screened for cancer
  if their primary care provider recommends or
  refers them for screening
• Provider commitment to recommending screening
  becomes proportionately stronger as providers
  understand how critical their recommendation is
• People who have a consistent source of care tend
  to adhere to screening recommendations

Seeff et al, 2004 Wei et al, 2005 Zapka et al,
2002 Lewis and Jensen, 1996
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Future Directions in CRC Screening

• Health Plan Employer Data and Information Set
  (HEDIS) measure on colorectal cancer screening
• Data collection by health plans
• First public reports made summer 2005

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Future Directions in CRC Screening

• Stool DNA tests
• Detects mutations on various genes and DNA
  segments that are associated with adenomas and
  colon cancer
• A recent comparison with standard FOBT
  demonstrated point sensitivity for cancer of 52
  (vs. 13 for FOBT), however other investigators
  found FOBT to be more sensitive for cancer
  detection
• Limitations
  
• Limited sensitivity (especially for adenomas)
• High cost (300 - 500)
• Appropriate screening interval not known
• Have to collect entire stool

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Future Directions in CRC Screening

• CT Colonography (Virtual Colonoscopy)

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Variable Sensitivity of CT Colonography in
Average Risk Patients, 50
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Future Directions in CRC Screening

• CT colonography Limitations
• Wide variation in results of published studies
• Absence of standards for performance and
  interpretation
• Skill of readers (radiologists) varies widely
• Full prep required
• Abnormal study requires colonoscopy
• Extracolonic findings
• Still a research tool in most settings

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• ACS Tools and Resources

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Patient Education Video
Get Tested For ColonCancer Here's How."An
7-minute video reviewing options for colorectal
cancer screening tests, including test
preparation.Available in DVD and VHS format, or
you can refer patients to the URL to view from
their personal computer.
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American Cancer Societys New Book for Patients
and Caregivers!

• American Cancer Societys Complete Guide to
  Colorectal Cancer
• Comprehensive, matter-of-fact
• Easy to read and assuring
• Helpful charts and illustrations, resources
  for patients, and a special section designed
  for caregivers
• Includes real-life stories from people with
  cancer and their loved ones and caregivers
• More than 400 pages on risk factors,
  prevention, testing, treatment choices, coping,
  and life after treatment
• Written by a team of world-class experts

1.800.ACS.2345 www.cancer.org/bookstore
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Physician Office Wall Chart

• Screening guidelines for Breast, Cervical, Colon,
  Prostate and Other
• General lifestyle/prevention
• Tobacco cessation
• Healthy diet
• Weight, etc
• English and Spanish

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Colorectal Cancer CME

• Continuing Medical Education Activity
• Colorectal Cancer Prevention and Early Detection
• For Internists, Family Physicians and Primary
  Healthcare Providers
• Available as DVD or online _at_

http//www.cancer.org/CME
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CRC Manual for Healthplans

• Tools and Strategies to Increase Colorectal
  Cancer Screening Rates A practical guide for
  health insurance plans.
• a collaborative effort between the Harvard Center
  for Cancer Prevention, the ACS New England
  Division and the ACS National Home Office

Full text and tools can be downloaded at
www.cancer.org/CRCmanual
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How to Increase Colorectal Cancer Screening Rates
in Practice A Primary Care Clinicians
Evidence-Based Toolbox and Guide

• Assists clinicians in reducing disparities in
  colorectal cancer by increasing prevention, early
  detection and treatment of the underserved and
  those at increased risk
• Downloadable in full or in individual
  chapters/sections from the National Colorectal
  Cancer Roundtables website (www.nccrt.org) in
  PDF format

Author Mona Sarfaty, MD Editor Richard
Wender, MD
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American Cancer Societys Get Your Tests!

• Interactive patient education/physician reminder
  tool explaining which cancer screening tests are
  recommended based on age and gender.
• Uses a simultaneous physician reminder chart card
  along with a patient prompt.
• Patient prompt is also available in Spanish.

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The Tools
American Cancer Societys Get Your Tests!

• Get Your Tests! Wheel
• Organized by age group
• Interactive
• User personalizes information

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The Tools
American Cancer Societys Get Your Tests!

• Get Your Tests! Card
• Memory jogger for patient chart
• Similar colors layout to Wheel -- helps link
  information

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• The barrier to reducing the number of deaths
  from colorectal cancer is not a lack of
  scientific data but a lack of organizational,
  financial, and societal commitment
• Daniel K. Podolsky, MD (NEJM 7/20/00)

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Thank you