Achieving 80% by 2018: Working Together Can Get Us There. Zachary Gregg, MD Sentara Martha Jefferson April 18, 2016

Transcription

1 Achieving 80% by 2018: Working Together Can Get Us There Zachary Gregg, MD Sentara Martha Jefferson April 18,

2 Prostate 21% Lung & bronchus 14% Colon & rectum 8% Urinary bladder 7% Melanoma of skin 6% Non-Hodgkin 5% lymphoma Kidney & renal pelvis 5% Oral cavity & pharynx 4% Leukemia 4% Liver & intrahepatic 3% bile duct All other sites 23% Estimated new cancer cases in the US (2016) 1,685,210 Men 841,390 Women 843,820 Source: American Cancer Society. Cancer Facts & Figures Accessed at 29% Breast 13% Lung & bronchus 8% Colon & rectum 7% Uterine corpus 6% Thyroid 4% Non-Hodgkin lymphoma 3% Melanoma of skin 3% Leukemia 3% Pancreas 3% Kidney & renal pelvis 21% All other sites 43,190 new cancer cases in Virginia

3 Lung & bronchus 27% Prostate 8% Colon & rectum 8% Pancreas 7% Liver & intrahepatic 6% bile duct Leukemia 4% Esophagus 4% Urinary bladder 4% Non-Hodgkin 4% lymphoma Brain & other 3% nervous systems All other sites 25% Estimated cancer deaths in the US (2016) 595,690 Men 314,290 Women 281,400 26% Lung & bronchus 14% Breast 8% Colon & rectum 7% Pancreas 5% Ovary 4% Uterine corpus 4% Leukemia 3% Non-Hodgkin lymphoma 3% Liver & intrahepatic bile duct 2% Brain & other nervous system 24% All other sites 14,910 cancer deaths in Virginia Source: American Cancer Society. Cancer Facts & Figures Accessed at

4 Incidence Colorectal Cancer 2016 Estimates Mortality US VA US VA 134,490 3,240 49,190 1,160 Source: American Cancer Society. Cancer Statistics Center. Accessed at 4

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9 Colorectal Cancer 5-year relative survival rates, Source: American Cancer Society. Cancer Statistics Center. Accessed at 9

10 Decline In Deaths From Colorectal Cancer

11 BRFSS: Key Findings 2014 Colorectal Cancer Screening* U.S. Virginia 66.11% 69.1% *2014 BRFSS results for respondents meeting USPSFT CRC screening guidelines

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13 Our goal is big but so is the potential impact. 13

14 If we can achieve 80% by 2018, 277,000 cases and 203,000 colon cancer deaths would be prevented by

15 The nation has become energized by the goal of 80% by So what will it really take?

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17 10 Steps to Achieving 80% by 18 17

18 10 Steps to Achieving 80% by Convene and educate clinicians, insurers, employers, and the general public. 2. Find strategies to reach newly insured Americans. 3. More effectively engage employers and payers. 4. Find new ways to communicate with the insured, unworried well. 5. Make sure that colonoscopy is available to everyone.

19 10 Steps to Achieving 80% by Ensure everyone can be offered a stool blood test option. 7. Create powerful, reliable, committed medical neighborhoods around Federally Qualified Health Centers. 8. Recruit as many partner organizations as possible. 9. Implement intensive efforts to reach low socioeconomic populations. 10. Believe we will achieve this goal!

20 5. Make Colonoscopy as Widely Available as Possible The increase in CRC screening rates between 2000 and 2010 resulted from a 36% increase in colonoscopy rates. Getting to 80% demands that colonoscopy must be available to everyone.

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22 Three Key Components of Colonoscopy Quality Screen the right patients at the right intervals. Maximize bowel prep quality and patient show rates. Monitor adenoma detection rate. 22

23 Patient Navigation: The Key to Better Show Rates and Better Bowel Preps Navigators have been proven to significantly improve colonoscopy show rates and quality of bowel preps. Lynn Butterly, MD, in New Hampshire has proven that patient navigation can reduce noshow rate and inadequate bowel prep rate to essentially zero. Colonoscopy navigation is now proven to be cost effective and should become a care standard. 23

24 The Most Important Measure of Quality Colonoscopy: Adenoma Detection Rate Definition: The percent of screening exams with at least one adenoma detected Current Targets: ADR should be: 30% male screening patients 20% female screening patients 24

25 6. Ensure Everyone Can be Offered a Stool Blood Test Option Some people will not or cannot have a colonoscopy. Anyone who hesitates should be offered a Fecal Immunochemical Test. In some settings, FIT needs to be offered as the primary screening strategy.

26 Advantages of Stool Blood Testing Stool blood testing Is less expensive. Can be offered by any member of the health team. Requires no bowel preparation. Can be done in privacy at home. Does not require time off work or assistance getting home after the procedure. Is non-invasive and has no risk of causing pain, bleeding, bowel perforation, or other adverse outcomes. Colonoscopy is required only if stool blood testing is abnormal.

27 Many Patients Prefer Home Stool Testing Randomized clinical trial in which 997 ethnically diverse patients in San Francisco community health centers received different recommendations for screening. Colonoscopy recommended: FOBT recommended: Colonoscopy or FOBT: 38% completed colonoscopy 67% completed FOBT 69% completed a test Adherence to Colorectal Cancer Screening: A Randomized Clinical Trial of Competing Strategies

28 Many Patients Prefer Home Stool Testing Some patients may forgo ANY colorectal cancer screening if they are not offered a home stool blood testing alternative to colonoscopy. Clinical evidence indicates that selecting annual stool blood testing instead of colonoscopy is a reasonable choice for average-risk patients. However, patients who select stool blood testing must also be prepared to accept follow-up colonoscopy if the stool blood test is abnormal.

29 Fecal Immunochemical Tests (FITs) Should Replace Guaiac FOBT FITs Demonstrate superior sensitivity and specificity Are specific for colon blood and are unaffected by diet or medications Some can be developed by automated readers Some improve patient participation in screening Allison JE, et.al. J Natl Cancer Inst. 2007; 191:1-9 Cole SR, et.al. J Med Screen. 2003; 10:

30 Fecal Immunochemical Tests (FIT) FIT tests are based on the immunochemical detection of human hemoglobin (Hb) as an indicator of blood in the stool. Immunochemical tests use a monoclonal or polyclonal antibody that reacts with the intact globin protein portion of human hemoglobin. More user friendly!

31 Remember: Stool Collection Should Be Done AT HOME! Stool collected on rectal exam may not be sufficient or sufficiently representative of stool collected from a complete bowel movement. There is no evidence that any type of stool blood testing is sufficiently sensitive when used on a stool sample collected during a rectal exam. Therefore, HS-gFOBT and FIT should be completed by the patient at home, and NOT as an in-office test.

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34 Here s the painful truth: There is nothing we can do to reach 80% colon cancer screening rates by except everything.

35 We Need More Partners! One way to keep the momentum going is to keep enlisting new partners, creating new ways to convene, and setting more and more segmented, local goals.

36 Thank You!