Be it Resolved that FIT is the Best Way to Screen for Colorectal Cancer DEBATE
DEBATE Presenters PRESENTATION MODERATOR Dr. Praveen Bansal -MD, CCFP FCFP Regional Primary Care Lead, Integrated Cancer Screening, MHCW Regional Cancer Program PRO COLONOSCOPY SPEAKER Dr. Paul Philbrook - MD, CCFP Regional Primary Care Lead, Integrated Cancer Screening, MHCW Regional Cancer Program PRO FIT SPEAKER Dr. Andrew Bellini MD, FRCP (C) Regional Lead, Colorectal Screening/GI Endoscopy
DEBATE Agenda 1.0 Ground Rules & Introduction 7 mins 2.0 Pro Colonoscopy Argument 8 mins 3.0 Pro FIT Argument 8 mins 4.0 Panel Discussion & Audience Q & A 7 mins
DEBATE Grand Rules #1 Each SPEAKER will have an opportunity to state their case without questions or interruptions. #2 AUDIENCE, please save your questions and comments for the panel discussion portion of today s presentation. #3 Event staff will be keeping track of the time for each section.
Introduction- Colorectal Cancer in Ontario In 2015, approximately 5,110 men were diagnosed with colorectal cancer and approximately 1,850 died from it Second leading cause of cancer deaths In 2015, approximately 4,100 women were diagnosed with colorectal cancer and approximately 1,500 died from it Third leading cause of cancer deaths Colorectal cancer is the 3 rd most commonly diagnosed cancer in Ontario
Introduction- Principles of Cancer Screening Characteristics of an IDEAL screening test: Condition should be reasonably common in screened population Condition should be burdensome Safe and easy to implement screening test Pre- or cancerous lesion detectable and treatable Improved mortality WHO. Screening for various cancers. Cited: Mar 2016. http://www.who.int/cancer/detection/variouscancer/en/ Cost effective
Introduction- Ontario s Colorectal Cancer Screening Program Developed and implemented by Cancer Care Ontario Men and women aged 50 74, who are at average risk of colorectal cancer should be screened using the Fecal Occult Blood Test (FOBT) every 2 years Average risk: no personal or family history of colorectal cancer, no symptoms of colorectal cancer If an individual s FOBT result is positive, the MRP coordinates a colonoscopy Other options (outside of CCC) for CRC screening: o Flexible Sigmoidoscopy o Colonoscopy
Introduction - Background Cancer Care Ontario is changing the average risk colorectal cancer screening test from the FOBT to the Fecal Immunochemical Test (FIT) Fecal Occult Blood Test (FOBT) Challenges with FOBT Limited uptake from primary care providers and endoscopists Limited buy in from public due to dietary restrictions and number of samples required Benefits of FIT Better test (sensitivity, specificity) Higher participation rates in programmatic screening are expected (one sample, no dietary restrictions, primary care uptake)
Introduction - Background Advantages of FIT versus FOBT Easier to collect No dietary restrictions One specimen Less stool contact Better usability 16% IMPROVEMENT in participation over gfobt Great for detecting advanced adenomas Better than gfobt at detecting cancer Simple, safe and accessible
Introduction Accuracy FIT vs. FOBTg FIT 1 (n=19 studies) gfobt 2 (n=9 studies) Sensitivity Specificity 82% 94% 47.1% 96.1% FIT has improved sensitivity with minimal loss of specificity 1 Lee J, et al. Ann Intern Med 2014;160:171-181. 2 Canadian Task Force on Preventive Health Care. Screening for Colorectal Cancer. 2014.
Introduction Definitions The benefit of Colorectal Cancer(CRC) Screening is NOT up for debate! If you wish to converse with me, define your terms. Voltaire
Introduction - Programmatic vs Opportunistic Screening Programmatic Screening Offered systematically to all individuals in defined target group within a framework of agreed policy, protocols, quality management, monitoring and evaluation E.g. CCC Program, FOBT Opportunistic Screening Offered to an individual without symptoms of the disease when he/she presents to a healthcare provider for reasons unrelated to that disease
Introduction Advanced Polyp or Lesion What we prefer to see. What we struggle to see..
Introduction Advanced Polyp or Lesion What we don t want to see As an physician, finding a cancer feels like a failure A missed opportunity for prevention
Introduction - Definitions Size (> 1 cm) Advanced Polyp or Lesion Histology ( High Grade dysplasia, villous histology, Cancer) Screen Relevant Lesion is a cancer or an advanced polyp
DEBATE Colonoscopy versus FIT for Average Risk Colorectal Cancer Screening
DEBATE Pro Colonoscopy
Pro Colonoscopy Accuracy FIT 1 (n=19 studies) Colonoscopy (Ir J Cancer prevention, 2011) Sensitivity Specificity 82% 94% 94.7% 99.8% FIT less accurate for colon cancer, even worse for advanced adenomas 1 Lee J, et al. Ann Intern Med 2014;160:171-181. 2 Canadian Task Force on Preventive Health Care. Screening for Colorectal Cancer. 2014.
Pro Colonoscopy- Diagnostic Yield Patients that Agree to Screening Colonoscopy (n=4953) FIT (n=8983) CRC 30 18 Advanced adenoma 514 127 Quintero E., et. al., NEJM 2012;366:697-706
Pro Colonoscopy - Sessile Serrated Polyps Approximately 20-30% of CRC felt to arise from Sessile Serrated Polyps These are hard to detect via colonoscopy and not detectable by FIT
Pro Colonoscopy - Cost, Convenience and Opportunity Colonoscopy if normal needs be done only once every 10 years; may be advantageous for hard to reach populations (remote areas) Heitman et al in 2010 showed FIT to be most cost effective strategy for CRC screening of average risk individuals (Canadian costing) However, if administrative costs >$50 per case, colonoscopy became the most cost effective model
Colonoscopy - Programmatic vs. Opportunistic Screening Programmatic screening felt to be the best approach by most experts USA has opportunistic model with colonoscopy as the primary strategy They have one of the highest participation rates in the world and the largest yearly decline in CRC incidence and mortality (annual decreases of 3-4%/year since 2000)
Pro Colonoscopy- Does One Size FIT all? Are we trying to provide population centred care or person centred care? Does patient preference play a role? Should we promote colon cancer screening, have a great FIT program and (not or) offer colonoscopy screening to those who prefer this method? o Target higher risk groups (Smokers, African Canadians) and those most likely to benefit and less likely to be harmed for colonoscopy i.e. younger populations
Pro Colonoscopy Conclusion Colonoscopy is the best way to screen for CRC Better accuracy, more opportunity for prevention Finds Sessile Serrated Polyps; FIT doesn t Opportunistic screening can be effective and should be combined with population based FIT screening Patient should be involved in the choice May be more cost effective
DEBATE Pro Fecal Immunochemical Test (FIT)
Pro FIT As good as Colonoscopy Evidence Large RCT in Spain Ages 50 69 yrs old *FIT Q 2 yrs versus one-time colonoscopy Mailed invitation to participate Primary outcome: CRC-death at 10 yrs *Selected cut-off: 75 ng Hb/ml Quintero E., et. al., NEJM 2012;366:697-706
Pro FIT As good as Colonoscopy 26,599 invited for FIT 26,703 invited for colonoscopy 36% responded 28% responded 23% offered colonoscopy opted for FIT 8983 completed FIT Overall FIT participation: 34.2% P<0.001 1% offered FIT opted for colonoscopy 4953 completed colonoscopy Overall c scope participation: 24.6% P<0.001 Quintero E., et. al., NEJM 2012;366:697-706
Pro FIT- As good as Colonoscopy Diagnostic Yield Intention to Screen Colonoscopy (n=26,703) FIT (n=26,599) P-value CRC 30 33 N.S. Advanced adenoma 514 231 <0.001 # needed to screen to find 1 CRC # needed to scope to find 1 CRC 191 281 191 18 Complication rate 24 10 <0.001 N.S. Not significant Quintero E., et. al., NEJM 2012;366:697-706
Pro FIT- As good as Colonoscopy Other Evidence FIT has 40+% Advanced Adenoma detection rates Improved sensitivity of FIT vs FOBT makes it a good test to detect advanced adenomas as well, particularly if repeated at biannual intervals
Pro FIT - Risk of Harm with Colonoscopy Primum Non Nocere Consider 95% of people being screened will never die of CRC These people can only be harmed by screening Even very small risks can expose large groups to harm oshould we start with the most invasive test first?
Pro FIT - Risk of Harm with Colonoscopy Colonoscopy Associated Complications Pooled* N= 97,091 Ontario N= 67,632 Bleeding 1.64/1000 101 Perforation 0.85/1000 40 Death N/A 5 Rabeneck L., et. Al., Gastroenterology 2008; 1899-1906.
Pro FIT Patient Preference 26,599 invited for FIT 26,703 invited for colonoscopy 36% responded 28% responded 23% offered colonoscopy opted for FIT 8983 completed FIT 1% offered FIT opted for colonoscopy 4953 completed colonoscopy Quintero E., et. al., NEJM 2012;366:697-706
Pro FIT Patient Preference Simple, easy to collect and no dietary restrictions, as compared to FOBT Completed from the comfort of home No visit to hospital for a screening test or having to take a day off work No arduous prep, as compared to colonoscopy
Pro FIT Primary Care Preference Market Forces of Alberta FIT Roll Out 1000 1500 Monthly Figure 3: referral 2013-14 for Monthly colonoscopy, Referral 2013-2014 Volumes 500 0 FIT introduced Nov 2013 Jan/13 Apr Jul Oct Jan/14 April July Oct Month gfobt+/fit+ Average Risk for CRC CCSC 2015; courtesy of Dr Bob Hilsden 34
Percentage Pro FIT Cost and Value Lesions Detected at Colonoscopy 100 90 80 70 60 50 40 30 20 10 0 Cancer Normal Low risk adenoma Advanced adenoma Average Risk Normal Low risk adenoma Advanced adenoma FIT+ Cancer
Pro FIT - FIT+ Colonoscopy Outcomes
Pro FIT Conclusion FIT is the best test for population based CRC screening Easy for patients, higher participation (reach more people, more effective, prevent more CRC deaths) Highest yield - targets those most likely to benefit from a colonoscopy Lowest cost - both cost effective and less potential for harm Best suited for a centralized population based screening program best opportunity to reach all communities and populations (diversity)
DEBATE Panel Discussion and Audience Q & A
DEBATE Thank you Check out the FIT HUB for Primary Care at: https://archive.cancercare.on.ca/fithub?redirect= true