Optimal Colorectal Cancer Prevention Targets and Barriers

1
Optimal Colorectal Cancer PreventionTargets and
Barriers

• John I Allen, MD, MBA
• Minnesota Gastroenterology
• ICSI

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American Cancer Society 2015 Challenge Goals

• Reduce aged-adjusted cancer mortality by 50
• Reduce age-adjusted cancer incidence by 25
• Improve quality of life for cancer survivors

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The Problem The Target

• 2500 develop CRC 1875
• 850 people die 425
• 60 get screened 75
• 80 of CRC deaths - gt 65

Minnesota Cancer Facts and Figures 2009.
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CRC Develops over 10 years
Normal
Polyp
Cancer
10 years
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Genetic CRC Syndromes
Increased Risk Screening
Average Risk Screening

• Barriers
• Management Strategies
• Impact
• Priority

Surveillance
Cancer Treatment
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CRC Genetic Syndromes

• Lynch Syndrome 3-5
• 20-40s
• Multiple organs at risk (colon, ovary, uterus)
• Known genetic mutations
• FAP 1-2
• Teens-30
• Multiple Organs (colon, upper intestine)
• Known genetic mutation

Hendricks YMC et al. Diagnosis approach and
management of Lynch Syndrome A guide for
clinicians. Ca Cancer J Clin 56213-225. 2006
Updated 2008
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CRC Genetic Syndromes

• Barriers
• Knowledge
• Patients
• Providers
• Specialists
• Coordination of Care (registries)
• Reimbursement for cancer genetic counselors
• Fear

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Increased Risk GroupsScreening lt 50 yrs

• Familial
• 1-2 close relatives with CRC 20
• Racial/Ethnic
• African-American
• Native American
• Inflammatory Bowel Disease
• Usually in specialty care

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Average Risk People

• Barriers to screening and ways to increase rates
• Screening options
• Quality of Colonoscopy

Klabunde C et al. Improving colorectal cancer
screening thru research in primary care. Medical
Care 46 Supplement 9. 2008 Patlak M et al.
Implementing colorectal cancer screening Workshop
Summary. IOM Workshop. National Academy
Press www.nap.edu/catalog/12239.html Whitlock EP
et al. AIM 149638-658. 2008 USPSTF Screening
Recommendations.
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Quality in Colonoscopy

• If all screening modalities lead to colonoscopy
• What if the colon exam was sub-standard?
• Operator dependent
• High Quality Studies
• National Polyp Study. NEJM 3291977-1981, 1993
• Imperiale et al. N Engl J Med 20083591218-24.
• Miss rate in community practice is alarming!
• Association of Colonoscopy and Death From
  Colorectal Cancer. Baxter et al. Ann Intern Med.
  20091501-8.
• Complete colonoscopy was strongly associated with
  fewer deaths from left-sided, but not from
  right-sided CRC

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238 102 per MD
Benchmark gt 25
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Colonoscopy - Overuse

• Only 35 of endoscopists follow National
  Guidelines when recommending follow up exams
  after initial colonoscopy
• Guidelines are available why are we paying for
  overuse?
• Gastroenterology 200613018721885
• 2009 PQRI Colonoscopy overuse measure

Mysliwiec PA et al. Are physicians doing too much
colonoscopy? A national survey of colorectal
surveillance after polypectomy. Ann Intern Med
2004 Aug 17 141264-71.
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How do we

• Identify and screen people at high risk?
• Systematically address geographic and other types
  of disparity?
• Reduce overuse of colonoscopy and ensure
  consistent quality?
• Motivate average risk people to get screened?