Overcoming Barriers to Cancer Screening Durado Brooks, MD, MPH Director, Prostate and Colorectal Cancer American Cancer Society
Cancer Disparities
Cancer Disparities: A Definition Cancer health disparities are differences in the incidence, prevalence, mortality, and burden of cancer and related adverse health conditions, beyond what would be expected under equitable circumstances, that exist among specific population groups in the United States. These population groups may be characterized by gender, age, race/ethnicity, education, income, social class, disability, geographic location, or sexual orientation. 1 Adapted from the National Cancer Institute, Division of Cancer Control and Population Sciences
Disparities in Health Health Status Disparities - unequal health status and/or outcomes between different groups -higher rates of disease -higher rates of side effects, complications, deaths Health Care Disparities - unequal consumption of health care services, or unequal quality of provided services -Some consume too little (Necessary care not given) -Some consume too much (Unnecessary care given)
Contributors to Health Disparities Patient variables Attitudes, expectations, preferences, biases, biology Clinician variables Biases, uncertainty System variables Administrative, financing, accessibility
Cancer Death Rates* by Race and Ethnicity, US, 2003-2007
Colorectal cancer death rates by educational attainment and race/ethnicity, ages 25-64 years, 2008
Poverty and Cancer Survival 100 Cancer Survival Among Men 80 60 40 20 0 Non-Hispanic White African American American Asian/Pacific Indian/Alaska Islander Native Hispanic- Latino Census tract poverty rate <10% 10-19.9% 20% or higher
Cancer Survival by Insurance Status* Covariate Adjusted Survival Private Insurance Medicaid Uninsured Survival Time in Months *Patients aged 18-64 years diagnosed from 1999-2000. Covariates included in the model are age, race, sex, and zip-code based income. Data Source: National Cancer Data Base. Ward, E. et al. CA Cancer J Clin 2008;58:9-31
Total number of premature (ages 25 to 64) cancer deaths that could have been avoided in 2007 by eliminating economic and racial disparities
Cervical Cancer
Cervical Cancer Incidence and mortality rates decreased 67% over the past three decades, mainly due to the Pap test 2012 estimates in US o o 12,170 cases of invasive cervical cancer 4220 deaths Highest incidence and death rates in: o African American o American Indian/Alaska Native o Hispanic/Latina 60% - 80% of women with advanced cervical cancer have not had a Pap test in the past five years.
Pap Smear w/in Past 3 Years (18 and older)
Pap Smear by State, Age, Insurance Status
2012 Cervical Screening Recommendations Women <21 No screening Women ages 21-29 Women ages 30-65 Women ages >65 After Hysterectomy Screening after HPV vaccination Pap test every 3 years Recommend AGAINST annual Paps HPV + Pap cotesting every 5 years (preferred) or Every 3 years with Pap alone (acceptable) Recommend AGAINST more frequent screening Discontinue after age 65 if 3 negative Pap tests or 2 negative HPV tests in last 10 years with most recent test in last 5 years Discontinue if for benign reason Follow age-appropriate recommendations (same as unvaccinated women)
2012 Cervical Screening Recommendations Women at any age should NOT be screened annually by any screening method HPV testing should NOT be used for screening women <30 years of age Screening by HPV testing alone is not recommended for most clinical settings. These guidelines do NOT address women 1) with a history of cervical cancer, 2) who were exposed in utero to DES, or 3) who are immune-compromised, e.g. HIV+
Comparison of Guidelines ACS-ASCCP-ASCP (2012) USPSTF (2012) Age to start Age 21 Age 21 Pap test every 3 years (liquid or conventional) Women ages 21-29 Recommend AGAINST annual Pap Pap test every 3 years (liquid or conventional) Women ages 30-65 Women ages >65 Cotesting every 5 years (preferred) or Every 3 years with Pap alone (acceptable) Recommend AGAINST more frequent screening Discontinue after age 65 if 3 negative Pap tests or 2 negative HPV tests in last 10 years with most recent test in last 5 years Cotesting every 5 years or Every 3 years with Pap alone Discontinue after age 65 if adequate prior screening (3 negative Pap tests or 2 negative HPV tests in last 10 years with most recent test in last 5 years) Post-Hysterectomy Discontinue if for benign reason Discontinue if for benign reason Screening after HPV vaccination Same as for unvaccinated Same as for unvaccinated
What Changed from the Previous Guideline? Age to start Women ages 21-29 Women ages 30-65 Women ages >65 2002 2012 3 years after initiating sexual activity or age 21 Age 21 Cytology every year (conventional Cytology every 3 years (liquid or Pap) or conventional) Every 2 years (liquid Pap) Recommend AGAINST annual Pap Pap plus HPV test ( Cotesting ) every 3 years or Every 2-3 years with Pap (liquid or conventional) May discontinue after age 70 if 3 negative Pap tests in last 10 years Cotesting every 5 years (preferred) or Every 3 years with Pap alone (acceptable) Recommend AGAINST more frequent screening Discontinue after age 65 if 3 negative Pap tests or 2 negative HPV tests in last 10 years with most recent test in last 5 years Post- Hysterectomy Discontinue if for benign reason Discontinue if for benign reason Screening after HPV vaccination 2007 guideline: Same as for unvaccinated Same as for unvaccinated
Human Papilloma Virus (HPV) and Cervical Cancer HPV is the most common sexually transmitted infection in the US, with approximately 6.2 million people becoming newly infected annually. There are more than 100 types of HPV, more than 40 of which can infect the genitals. Although most HPV infections are benign and transient, virtually all cervical cancers are causally related to infections by HPV. Approximately 70% of cervical cancers are caused by HPV types 16 or 18. HPV vaccines prevent persistent new infections and reduce precursor lesions (adenoma in situ or intraepithelial neoplasia) in the cervix.
Human Papilloma Virus (HPV) and Cervical Cancer Two vaccines: Cervarix Protects against HPV-16 and HPV-18 Approved for use in females 9 to 25 years of age Gardasil Protects against four HPV types (16 and 18, as well as HPV-6 and HPV-11) Approved for use in females 9 to 26 years of age Also approved for use in males 9 to 26 years of age to prevent genital warts, anal cancer and associated precancerous lesions (about 90% of anal cancers have been linked to HPV infection)
Recommendations for HPV Vaccine Use to Prevent Cervical Cancer and Its Precursors Routine HPV vaccination is recommended for females 11 to 12 years of age. Females as young as 9 years of age may receive HPV vaccination. The HPV vaccination is also recommended for females 13 to 18 year of age to catch up on missed vaccine or to complete the vaccination series. There are currently insufficient data* to recommend for or against universal vaccination of females 19 to 26 years of age in the general population. The HPV vaccination is not recommended for women over 26 years of age. * Decision should be based on risk of previous HPV exposure and potential benefit from vaccination
HPV Vaccine Trends Among US girls 13 to 17 years of age, HPV vaccine initiation (at least one of the three-dose HPV vaccination series) increased from 25.1% in 2007 to 48.7% in 2010. 32.0% of girls had the complete three-shot vaccine series by 2010. Lower initiation and completion rates among poor and minority girls. Increase in catch-up vaccine among previously unvaccinated women between the ages of 13 and 26 o 17.1% had received at least one dose of HPV vaccination in 2009 compared to 10.5% in 2008. Non-Hispanic white women had higher catch-up HPV vaccine uptake (19.8%), than African American women (13.3%) or Hispanic women (12.6%).
Colorectal Cancer
Colorectal Cancer Third most common cancer, 2 nd deadliest o o 141,000 new cases 49,000 deaths Highest incidence and death rates in: o African American o American Indian/Alaska Native 1.1 million individuals living with current or past CRC
Colorectal Cancer Risk Factors Age 90% of cases occur in people 50 and older Gender slight male predominance, but common in both men and women Race/Ethnicity Increased rates documented in African Americans, Alaska Natives, some American Indian tribes, Ashkenazi Jews
Colorectal Cancer Risk Factors Modifiable Risk Factors Diet Obesity Physical Activity Tobacco Alcohol
Non-Modifiable Risk Factors Increased risk with: Personal history of inflammatory bowel disease, adenomatous polyps or colon cancer Family history of adenomatous polyps, colon cancer, other conditions Individuals with these risk factors may require earlier and more intensive screening The remainder of this presentation will focus on the average risk population.
Colorectal Cancer Sporadic (average risk) (65% 85%) Rare syndromes (<0.1%) Family history (10% 30%) Hereditary nonpolyposis colorectal cancer (HNPCC) (5%) Familial adenomatous polyposis (FAP) (1%) CENTERS FOR DISEASE CONTROL AND PREVENTION
Risk Factor - Polyps Types of polyps: Hyperplastic minimal cancer potential Adenomatous approximately 90% of colon and rectal cancers arise from adenomas
Normal to Adenoma to Carcinoma Human colon carcinogenesis progresses by the dysplasia/adenoma to carcinoma pathway
Benefits of Colorectal Screening Survival Rates by Disease Stage* 5-yr Survival *1996-2003 100 90 80 70 60 50 40 30 20 10 0 89.8% 67.7% 10.3% Lo cal Reg io n al Distan t Stage of Detection
Trends in Recent* CRC Screening Prevalence (%), by Educational Attainment and Health Insurance S Adults 50-75 Years, US, 2000-2010 Source: Klabunde et al, Cancer Epidemiol Biomarkers Prev 2011;20:1611-1621 National Health Interview Survey Public Use Data File 2010, National Center for Health Statistics, Centers for Disease Control and Prevention, 2011. American Cancer Society, Surveillance Research, 2011.
Lower use of colorectal screening examinations in minority populations
ACS Screening Guidelines Options for Average risk adults age 50 and older Tests That Detect Adenomatous Polyps and Cancer Colonoscopy every 10 years, or Flexible sigmoidoscopy (FSIG) every 5 years, or Double contrast barium enema (DCBE) every 5 years, or CT colonography (CTC) every 5 years Tests That Primarily Detect Cancer Guaiac-based fecal occult blood test (gfobt) with high test sensitivity for cancer, or Fecal immunochemical test (FIT) with high test sensitivity for cancer, or Stool DNA test (sdna), with high sensitivity for cancer
Comparison of Guidelines ACS-USMSTF (2008) USPSTF (2010) Age to start Age 50 Age 50 Stool Occult Blood: Guaiac FOBT Fecal Immuno Flexible sigmoidoscopy Annual screening with high sensitivity gfobt or FIT Low sensitivity guaiac tests not recommended Screening every 5 years Addition of annual FOBT/FIT is an option Annual screening with high sensitivity gfobt or FIT Screening every 5 years, with FOBT/FIT every 3 years Colonoscopy Screening every 10 years Screening every 10 years CRC screening between ages 76-85 Adults in good health who would be candidates for treatment should continue screening Recommend against routine screening in adults 76-85. There may be considerations that support screening in an individual patient. CRC screening >85 Adults in good health who would be candidates for treatment should continue screening Screening not recommended in adults > 85 years
Colonoscopy
Why Not Colonoscopy for All? Evidence does not support best test or gold standard Colonoscopy misses ~ 10% of significant lesions in expert settings Higher potential for patient injury than other tests Test performance is highly operator dependent Greater patient requirements for successful completion Requires a bowel prep and facility visit, and often a preprocedure specialty office visit (all with associated costs) Patient factors Some may not have access to the invasive tests due to lack of coverage or local resources Many individuals don t want an invasive test or a test that requires a bowel prep
Patient Preferences Inadomi, Arch Intern Med 2012
Stool Guaiac Tests Most common type in U.S. Best evidence (3 RCT s) Need specimens from 3 bowel movements Non-specific Results influenced by foods and medications Older forms (Hemoccult II) have unacceptably low sensitivity Better sensitivity with newer versions (Hemoccult Sensa)
Fecal Immunochemical Tests (FIT) Specific for human blood and for lower GI bleeding Results not influenced by foods or medications Some types require only 1 or 2 stool specimens Higher sensitivity than older forms of guaiac-based FOBT Slightly more costly than guaiac tests FIT use in the US will likely increase due to recent elimination of guiaic- based testing by LabCorp and Quest Labs
Stool Test Quality Issues CRC screening by FOBT should be performed with high-sensitivity FOBT - either FIT or a highly sensitive gfobt (such as Hemoccult SENSA). Older, less sensitive guiaic tests (such as Hemoccult II) should not be used for CRC screening. Annual testing In-office FOBT is essentially worthless as a screening tool for CRC and must be strongly discouraged. All positive screening tests should be evaluated by colonoscopy
Stool Test Quality Issues Clinicians Reference: FOBT One page document designed to educate clinicians about important elements of colorectal cancer screening using fecal occult blood tests (FOBT). Provides state-of-the-science information about guaiac and immunochemical FOBT, test performance and characteristics of high quality screening programs. Available at www.cancer.org/colonmd
Improving Screening Rates
Opportunistic vs. Organized Preventive Care Most preventive care for adults in the U.S. is opportunistic, i.e. occurs incidentally during encounters with healthcare professionals Opportunistic care depends on a coincidence of encounters, circumstances, and interests between patient and provider This means some adults get some preventive care on some occasions and at some interval Few adults receive the full package, or even the majority of recommended preventive services
Clinician s Toolbox Inadomi, Arch Intern Med 2012
Community Health Center Version Customized to meet unique needs of patients and providers in these settings Step-by-step guidance on how to implement systems change in CHCs Developed by UNC researcher Dr. Catherine Rowheder (rohweder@email.unc.edu, 919-966-6879) Available at: http://www.ncspeed.org/sites/default/files/crc_toolkit.pdf Funding for this project was provided by the University Cancer Research Fund of The UNC Lineberger Comprehensive Cancer Center
4 Essentials to Improve Screening
Clinician Recommendation
Office Screening Policy
Reminders
Measure and Track Progress
Flu/FIT
CRC Screening Outreach During Annual Flu Shot Activities Potential Benefits of Flu-FOBT or Flu-FIT Programs: Reaches patients at a time each year when they are already thinking about prevention Creates a seasonal focus on cancer screening that may add to other screening efforts Time-efficient way to involve non-physician staff in screening activities Educates patients that just like a flu shot, you need FOBT/FIT every year Slide courtesy of M. Potter, MD
Results SFGH Randomized Trial (Flu shot clinic attendees randomized to Flu Only vs. Flu + FOBT on different dates included telephone follow-up for FOBT recipients) FLU Only days FLU+FOBT days (246 patients) (268 patients) Up-to-Date Before Flu Season 52.9% 54.5% (Oct 16, 2006) Up-to-Date After Flu Season 57.3% 84.3% (Mar 31, 2007) Change: (p<0.001) +4.4 points +29.8 points Ann Fam Med, 2009
FLU-FOBT/FIT FLU-FOBT/FIT Interventions Has been tailored and results replicated in: (1) primary care underserved settings, (2) high volume managed care flu shot clinics (3) commercial pharmacies where flu shots are increasingly provided Can be done with limited resources Leads to higher screening rates
Flu/FIT Implementation Guide and Materials http://flufobt.org
ACS Resources
www.cancer.org/professionals ACS Guidelines Facts for Professionals Cancer Presentations COLONMD PROSTATEMD Asian Pacific Education Materials Easy Reading Materials Other ACS Resources Global Health
Patient Education Get Tested For Colon Cancer: Here's How." An 7-minute video reviewing options for colorectal cancer screening tests, including test preparation. English and Spanish versions. Available in DVD and VHS format, or you can refer patients to the URL to view from their personal computer. www.cancer.org/colonmd
Office Wall Chart Screening guidelines for Breast, Cervical, Colon, Prostate and other cancers General lifestyle/prevention Tobacco cessation Healthy diet Weight, etc English and Spanish
Keys to Quality Stool Testing Clinicians Reference: FOBT One page document designed to educate clinicians about important elements of colorectal cancer screening using fecal occult blood tests (FOBT). Provides state-of-the-science information about guaiac and immunochemical FOBT, test performance and characteristics of high quality screening programs. Available at www.cancer.org/colonmd