Colorectal Cancer Screening Paul Traficanti DO, FACOEP

Transcription

1 Health Partners Plans Colorectal Cancer Screening Paul Traficanti DO, FACOEP

2 Colorectal Cancer Centers for Disease Control (CDC) Of cancers that affect both men and women, colorectal cancer is the second leading cause of cancer- related deaths in the United States Third most common cancer overall Early detecbon has a significant posibve impact on these stabsbcs and can extend and save countless lives 2

3 Colorectal Cancer Health Partners Plans: recognize the impact early detecbon and screening has on colorectal cancer outcomes Providers: educate pabents to the risks they face and what screening methods are available to them 3

4 HEDIS/Stars CMS - repeatedly used as a Stars measure. Ø Stars data collected from HEDIS measures Ø The average industry performance (3 Star RaBng) corresponds to a 63 71% compliance rate among the eligible populabon. 4

5 Agenda StaBsBcs Risk Factors Screening Summary 5

6 StaBsBcs American Cancer Society Ø In 2015, approximately 132,700 men and women will be diagnosed with colorectal cancer (CRC), and approximately 49,000 will die from it. Ø RelaBve 5- year survival rate is 90% for colorectal cancer (CRC) pabents diagnosed at an early, localized stage; however, only 40% of cases are diagnosed with this stage. (American Cancer Society Cancer PrevenBon and Early DetecBon Facts and Figures ) 6

7 StaBsBcs American Cancer Society Colorectal cancer screening is a major priority because exisbng knowledge has the potenbal to prevent cancer, diminish suffering and save lives. (American Cancer Society Colorectal Cancer Facts and Figures ) 7

8 Future Screening Goals NaBonal Campaign American Cancer Society/PA Dept. of Health Screening 80% of eligible populabon by

9 CRC in Pennsylvania, Incidence Mortality High Low Mapping can contribute to seeing the BIG PICTURE What explains county level incidence and mortality?

10 CRC Risk Factors Hereditary and Family GeneBc Personal History Behavioral (American Cancer Society Colorectal Cancer Facts and Figures ) 10

11 Risk - Hereditary and Family History Ø First degree relabve with a history of CRC Risk increased 2-3 Bmes Ø If more than one relabve has a history of CRC Risk increased to 3-6 Bmes Ø About 20% of CRC pabents have a close relabve with diagnosis of CRC Increased survival Becer awareness? (American Cancer Society Colorectal Cancer Facts and Figures ) 11

12 Risk - GeneBc PredisposiBon About 5% of pabents diagnosed with CRC have a known genebc syndrome that is presumed to cause the disease. Lynch Syndrome is most common Among Lynch Syndrome pabents in one study, lifebme risk was 66% in men and 43% in women Familial adenomatous polyposis (FAP) is the second most common predisposing genebc risk factor Without intervenbon, the lifebme risk of CRC approaches 100% by age 40 (American Cancer Society Colorectal Cancer Facts and Figures ) 12

13 Risk - Personal Medical History Prior colorectal cancer History of adenomatous polyps Chronic inflammatory bowel disease, parbcularly ulcerabve colibs Diabetes poorer survival rates (American Cancer Society Colorectal Cancer Facts and Figures ) 13

14 Risk - Behavioral Factors Physical AcSvity Physically acbve people have a 25% lower risk of CRC PaBents who are less acbve have a much higher risk of death due to CRC Overweight and Obesity Although associated with higher risk in both men and women, it is more consistently appreciated in men Independent of physical acbvity Abdominal obesity (waist circumference) appears to be a more important predictor (American Cancer Society Colorectal Cancer Facts and Figures ) 14

15 Risk - Behavioral Factors Dietary Influences Increased Risk High consumpbon of red and/or processed meats - WHO Decreased Risk Dietary fiber, cereal fiber, whole grains Moderate daily fruit and vegetable intake Dairy Products (milk and calcium) Vitamin D Dietary Folate (American Cancer Society Colorectal Cancer Facts and Figures ) 15

16 Risk - Behavioral Factors Smoking Alcohol moderate to heavy use vs light consumpbon MedicaSons Some medicabons when used chronically may actually reduce the risk of CRC 1. ASA, NSAIDS, post- menopausal hormones 2. The American Cancer Society does not recommend the use of any medicabon for CRC prevenbon (American Cancer Society Colorectal Cancer Facts and Figures ) 16

17 Screening for CRC Joint guidelines largely adopted nasonally in 2008 American Cancer Society - US MulB- Society Task Force on Colorectal Cancer (ACS MSTF) The American College of Gastroenterology (ACG) Preferred Approach vs Menu of OpBons US PrevenBve Services Task Force (USPSTF) 17

18 American Cancer Society Ø Incidence and death rates for colorectal cancer increase with age 90% of new cases and 93% of deaths occurring in people 50 years and older (American Cancer Society Colorectal Cancer Facts and Figures ) 18

19 Screening for CRC American College of Gastroenterology preferred model replaces menu of opbons simplifies and shortens discussions with pabents RecommendaBons divided into Ø Cancer prevenbons Ø Cancer detecbon Rex DK, Johnson DA, Anderson JC et al. American College of Gastroenterology Guidelines for Colorectal Cancer Screening 2008, The American Journal of Gastroenterology 2009; 104:

20 PrevenBon vs DetecBon Cancer PrevenBon: has the ability to image both cancer and polyps e.g., Colonoscopy, Flex Sig, CT Colonography Cancer DetecBon: slightly lower sensibvity for detecbng cancer and low sensibvity for detecbng polyps, e.g., Fecal Immunochemical TesSng (FIT), Hemoccult, Fecal DNA 20

21 Preferred PrevenBon The preferred CRC prevenson test is colonoscopy every 10 years Should be offered first Beginning at age 50 Beginning at age 45 for African Americans Rex DK, Johnson DA, Anderson JC et al. American College of Gastroenterology Guidelines for Colorectal Cancer Screening 2008, The American Journal of Gastroenterology 2009; 104: United States PrevenKve Services Task Force (USPSTF) 21

22 Preferred PrevenBon Cons- Not always desirable Availability Operator dependent Quality of prep Cumbersome healthcare process 22

23 Preferred DetecBon The preferred CRC detecson test is a yearly FIT Offered to pabents who decline colonoscopy or other prevenbve test When colonoscopy is not a viable opbon Superior performance compared with older guaiac- based Hemoccult cards no dietary concerns 10-12% gains in adherence/compliance Rex DK, Johnson DA, Anderson JC et al. American College of Gastroenterology Guidelines for Colorectal Cancer Screening 2008, The American Journal of Gastroenterology 2009; 104:

24 FIT Fecal Immunochemical Test 80% SensiBvity FOBT/Hemoccult II sensibvity about 5% following single digital rectal exam Completed in privacy of own home NaBonally prevents 22 deaths/1000 persons vs. 4 deaths/1000 persons for colonoscopy 24

25 Ø Average risk person Screening begins at age 50 Ø African Americans Screening begins at age 45 Ø Gender Currently no adjustment conflicbng evidence Rex DK, Johnson DA, Anderson JC et al. American College of Gastroenterology Guidelines for Colorectal Cancer Screening 2008, The American Journal of Gastroenterology 2009; 104:

26 Summary Ø Colonoscopy PrevenSon every 10 years beginning at age 50 (age 45 for African Americans) Rex DK, Johnson DA, Anderson JC et al. American College of Gastroenterology Guidelines for Colorectal Cancer Screening 2008, The American Journal of Gastroenterology 2009; 104:

27 Summary Ø FIT DetecSon yearly beginning at age 50 (age 45 for African Americans) Rex DK, Johnson DA, Anderson JC et al. American College of Gastroenterology Guidelines for Colorectal Cancer Screening 2008, The American Journal of Gastroenterology 2009; 104:

28 Screening 80% by 2018 Flu/FIT Reminders/Birthday Cards/Telephonic/Text Direct outreach (HPP FIT IniBaBve) Pay for Performance Models (QCP) 28

29 Advanced Age The benefits of early detecbon and intervenbon decline aner 75 years For those 75 to 85 years old, screening on an individual basis Benefits are small Risk is high - - perforabon, bleeding Recommends against screening for those > 85 years or life expectancy < 10 years Harms outweigh the benefits United States PrevenBve Services Task Force (USPSTF) 29

30 AlternaBves CT Colonography Every 5 years Risk vs Benefit? Extra- colonic findings and cost of workup Misses some polyp types Considerable radiabon exposure Flexible Sigmoidoscopy Every 5 years United States PrevenBve Services Task Force (USPSTF) 30

31 AlternaBves Double Contrast BE Falling out of favor Fecal DNA tesbng Efficacy not established 31

32 HEDIS/Stars HEDIS Successful screening acributed to one of the following: (applies to y/o Medicare or Commercial) 1. Fecal Occult Blood Test (FOBT) or FIT completed and reported during measurement year 2. Colonoscopy completed and reported during last 10 years 3. Flex Sig completed and reported during the last 5 years Importance of DocumentaBon 32

33 ConsideraBon for Early Screening Certain populabons at increased risk may benefit from early screening or more frequent intervals First degree relabve with colorectal cancer or adenomatous polyps: begin at age 40 and every 5 years. Inflammatory bowel disease especially UC Familial adenomatous polyposis (FAP) Hereditary non- polyposis colorectal cancer (Lynch Syndrome) United States PrevenBve Services Task Force (USPSTF) 33

34 What is the best screening test for colorectal cancer? 34

35 The one you get! 35

36 QuesSons? Dr. Paul TraficanS Medical Director 36