ACTIVITY DISCLAIMER Colorectal Cancer Alvin B. Lin, MD, FAAFP The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP. DISCLOSURE It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose. The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices. Alvin B. Lin, MD, FAAFP Physician, Solo private practice, Las Vegas, Nevada Dr. Lin completed his medical degree at Bowman Gray School of Medicine (now the Wake Forest School of Medicine) in Winston-Salem, North Carolina, and completed his family medicine residency at Merrithew Memorial Hospital, Martinez, California, which is part of the UC Davis School of Medicine network of affiliated residency programs. He gained experience as a locum tenens physician, working under a dozen state licenses. He completed a fellowship in geriatric medicine at Pitt County Memorial Hospital, Greenville, North Carolina, in conjunction with the Brody School of Medicine at East Carolina University, and then joined the faculty. Subsequently, he was recruited to advance the science of hypogonadism and healthy aging in a private practice in Las Vegas, Nevada. In October 2016, he made the leap to solo practice. Dr. Lin lectures for the Nevada Academy of Family Physicians, chairs the American Academy of Family Physicians (AAFP's) Geriatric Medicine Live Course, and serves as faculty for the AAFP s Care of Chronic Conditions Live Course and for various Knowledge Self- Assessments (KSAs). Learning Objectives 1. Screen for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adult patients, beginning at age 50 years and continuing until age 75 years. 2. Utilize documentation of clinical decision tools to foster patient engagement and facilitate share decision making about CRC screening options. 3. Establish an automated or staff-driven process, to send CRC screening invitations, containing personalized risk-estimates to patients. 4. Coordinate communication with the oncologist, including formal survivorship care plans, to outline follow-up plans for surveillance after polypectomy and CRC resection. Audience Engagement System Step 1 Step 2 Step 3 1
Ken Stabler 1945-2015 passed peacefully 7/8/15 battled Stage 4 colon cancer since being diagnosed in February 2015 Monday AM Pearls Involve whole office in screening Make screening recommendation to every eligible patient at every visit Don t bother w/in-office stool testing Individualize screening options http://ftw.usatoday.com/2015/07/ken stabler obituary sweet home alabama Signs & Symptoms A change in bowel habits, such as diarrhea, constipation, or narrowing of the stool, that lasts for more than a few days A feeling that you need to have a bowel movement that is not relieved by doing so http://www.cancer.org/cancer/news/features/signs and symptoms of colon cancer Signs & Symptoms Rectal bleeding, dark stools, or blood in the stool (often, though, the stool will look normal) Cramping or abdominal (belly) pain Weakness and fatigue Unintended weight loss http://www.cancer.org/cancer/news/features/signs and symptoms of colon cancer Get screened for colon cancer Eat lots of vegetables, fruits, and whole grains Get regular exercise Watch your weight Don t smoke Limit alcohol Low dose aspirin for 1o prevention New since April 2016 2
The USPSTF recommends initiating lowdose aspirin use for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC) in adults aged 50 to 59 years who have a 10% or greater 10- year CVD risk... https://www.uspreventiveservicestaskforce.org/page/doc ument/updatesummaryfinal/aspirin to preventcardiovascular disease and cancer... are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years. Grade B recommendation 4/16 The decision to initiate low-dose aspirin use for the primary prevention of CVD and CRC in adults aged 60 to 69 years who have a 10% or greater 10-year CVD risk should be an individual one...... Persons who are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take lowdose aspirin daily for at least 10 years are more likely to benefit...... Persons who place a higher value on the potential benefits than the potential harms may choose to initiate low-dose aspirin. Grade C recommendation 4/16 The current evidence is insufficient to assess the balance of benefits and harms of initiating aspirin use for the primary prevention of CVD and CRC in adults younger than 50 years. Grade I recommendation 4/16 3
The current evidence is insufficient to assess the balance of benefits and harms of initiating aspirin use for the primary prevention of CVD and CRC in adults aged 70 years or older. Grade I recommendation 4/16 AES POLL QUESTION Who is responsible for improving colorectal cancer screening rates? A. Front desk personnel B. Clinical support staff C. Physician & other care providers D. All of the above Understand power of physician recommendation Measure colon CA screening rate in your office systematize screening http://nccrt.org/wp content/uploads/14893 80_2018 PROVIDER PHYS 4 PAGER 11 10.pdf Understand screening options for colon CA Make sure pts & staff understand that most insurance companies are required to cover colon CA screening http://nccrt.org/wp content/uploads/14893 80_2018 PROVIDER PHYS 4 PAGER 11 10.pdf Understand power of physician recommendation Surveys show 90% who reported physician recommendation were screened vs 17% who did not have provider recommendation Understand power of physician recommendation My doctor didn t recommend it #1 reason Blacks did not get screened #3 reasons Hispanics did not get screened http://nccrt.org/wp content/uploads/14893 80_2018 PROVIDER PHYS 4 PAGER 11 10.pdf http://nccrt.org/wp content/uploads/14893 80_2018 PROVIDER PHYS 4 PAGER 11 10.pdf 4
Measure colon CA screening rate in your office Insurers looking over your shoulders Can be used to meet CME requirements http://nccrt.org/wp content/uploads/14893 80_2018 PROVIDER PHYS 4 PAGER 11 10.pdf systematize screening patient letters http://www.cancer.org/acs/groups/content/do cuments/document/acspc-024589.pdf http://www.cancer.org/acs/groups/content/do cuments/document/acspc-024613.pdf systematize screening patient letters http://www.cancer.org/acs/groups/content/do cuments/document/acspc-024614.pdf systematize screening phone scripts http://www.cancer.org/acs/groups/content/do cuments/document/acspc-024615.pdf http://www.cancer.org/acs/groups/content/do cuments/document/acspc-024616.pdf AES POLL QUESTION Colorectal cancer screening discussions should be reserved for annual wellness visits only A. True B. False C. What s the annual wellness visit? systematize screening Use opportunistic or global approach, like vaccines Don t wait for preventive health visits to make screening recommendations 5
systematize screening Make screening recommendations during ALL visits Understand screening options for colon CA Tests that find polyps & cancer (preferred) Flexible sigmoidoscopy Colonoscopy Barium enema CT colonography Understand screening options for colon CA Tests that find primarily cancer Fecal occult blood tests (FOBT) Stool DNA AES POLL QUESTION Is an in-office FOBT as part of digital rectal exam an acceptable means of colorectal cancer screening? A. True B. False C. Didn t USPSTF tell us not to bother w/dre? In-Office FOBT or Not? 3 card take-home FOBT found 23.9% of cancers found by colonoscopy In-office FOBT found just 4.9% In-Office FOBT or Not? Single digital FOBT is a poor screening method for colorectal neoplasia and cannot be recommended as the only test. Ann Intern Med. 2005; 142(2):81 5 Ann Intern Med. 2005; 142(2):81 5 6
In-Office FOBT or Not? When digital FOBT is performed as part of a primary care physical examination, negative results do not decrease the odds of advanced neoplasia. Persons with these results should be offered at-home 6-sample FOBT or another type of screening test. Ann Intern Med. 2005; 142(2):81 5 In-Office FOBT or Not? Mortality reductions demonstrated with FOBT in clinical trials may not be realized in community practice because of the common use of in-office tests and inappropriate follow-up of positive results. Ann Intern Med. 2005; 142(2):81 5 In-Office FOBT or Not? Education of providers and system-level interventions are needed to improve the quality of screening implementation. Ann Intern Med. 2005; 142(2):81 5 Post-Polypectomy Surveillance Hyperplastic polyp 1-2 tubular adenomas <1cm >2 tubular adenomas >1cm, high grade dysplasia or villous Large >2cm sessile polyp Malignant polyp w/favorable criteria CA Cancer J Clin. 2006;56:143 59 10yrs 5-10yrs 3yrs 3-6mo 3mo Who is at high risk? Hereditary non-polyposis colorectal cancer (HNPCC) 80% risk of CRC Start biennial colonoscopies @ 20-25yo Who is at high risk? Familial adenomatous polyposis (FAP) 100% risk Cumulative number of adenomas 100s- 1000s Start annual colonoscopies @ 10-12yo 7
Who is at high risk? Attenuated FAP Cumulative number of adenomas = 10-100 Begin annual surveillance by teens to early 20s AES POLL QUESITON Everyone should get a screening colonoscopy rather than flexible sigmoidoscopy or FOBT A. True B. False C. Huh? this isn t Burger King s Have it your way USPSTF: Who, When, How & Grade Grade A Adults 50-75yo Routine screening w/any approved method Grade C Adults 76-85yo Decision to screen should be individualized Final/colorectal cancer screening2 CDC & USPSTF Recommendations Stool-based tests Guaiac-based fecal occult blood test (gfobt) q1yr Fecal immunochemical test (FIT) q1yr FIT-DNA aka stool DNA test q1-3yr http://www.cdc.gov/cancer/colorectal/basic_info/screening/tests.htm CDC & USPSTF Recommendations Flexible sigmoidoscopy Every 5yrs Every 10yrs w/fit every year Colonoscopy Every 10yrs CDC & USPSTF Recommendations CT colonography aka virtual colonoscopy Every 5yrs http://www.cdc.gov/cancer/colorectal/basic_info/screening/tests.htm http://www.cdc.gov/cancer/colorectal/basic_info/screening/tests.htm 8
But s/he is >75yo... Microsimulation modeling study using both observational & experimental studies Assumed unscreened avg risk 76-90yo w/no, mod or severe comorbidities But s/he is >75yo... If no comorbidities, colon CA screening cost-effective using Colonoscopy until 83yo Sigmoidoscopy until 84yo FIT until 86yo But s/he is >75yo... If moderate comorbidities, colon CA screening cost-effective using Colonoscopy until 80yo Sigmoidoscopy until 81yo FIT until 83yo But s/he is >75yo... Moderate comorbidities ulcer, rheumatologic disease, peripheral vascular disease, diabetes, paralysis, cerebrovascular disease or h/o AMI But s/he is >75yo... If severe comorbidities, colon CA screening cost-effective using Colonoscopy until 77yo Sigmoidoscopy until 78yo FIT until 80yo But s/he is >75yo... Severe comorbidities COPD, CHF, CKD, dementia, cirrhosis/chronic hepatitis, or AIDS 9
Medicare s Input Barium enema Every 48mo if >50yo Every 24mo if high risk Colonoscopy Every 24mo if high risk Every 120mo if avg risk 48mo after flex sig http://www.medicare.gov/coverage/colorectal cancer screenings.html Medicare s Input FOBT Every 12mo if >50yo Stool DNA Every 3yrs if asx 50-85yo & avg risk Flexible sigmoidoscopy Every 48mo if >50yo 120mo after colonoscopy http://www.medicare.gov/coverage/colorectal cancer screenings.html If you have Original Medicare For stool DNA or gfobt, pt pays nothing For barium enemas, pt pays 20% of Medicare-approved amount For screening colonoscopy or flexible sigmoidoscopy, pt pays nothing if doctor accepts assignment http://www.medicare.gov/coverage/colorectal cancer screenings.html If you have Original Medicare But if screening endoscopy results in biopsy during same visit, procedure is now considered diagnostic and pt may have to pay coinsurance and/or copayment http://www.medicare.gov/coverage/colorectal cancer screenings.html Teamwork Opportunities throughout visit to plant seed & discuss appropriate colorectal CA screening At patient check-in While in waiting room During visit of course! At patient check-out After visit http://www.cancer.org/acs/groups/content/@edit orial/documents/document/acspc 028274.pdf Barriers to Practice Barriers to Practice Going it alone Waiting for annual physical Debating merits of rectal exam & in-office FOBT testing 10
Barriers to Practice Giving same screening options/recommendations to everyone Time not enough Barriers to Practice Best Practice Recommendations Involve whole office in screening Make screening recommendation to every eligible patient at every visit Don t bother w/in-office stool testing Individualize screening options Questions 11