Colorectal Cancer A Preventable Burden

Citywide Colorectal Cancer Control Coalition

Ambassador Program

NYC Coalition Mission

“To increase awareness & screening for colorectal cancer & adenomatous polyps in NYC men and women in order to reduce the incidence & mortality of this disease”

C5 Ambassadors Program:

GoalsTo educate health care providers:

1. CRC as a public health problem

2. Effectiveness of CRC screening

3. What are the current guidelines

4. Recommendations of the NYC DOHMH

U.S. Burden of Colorectal CancerU.S. Burden of Colorectal CancerProcrastinationProcrastination

• 147,500 new cases in 2005

• 57,100 deaths in 2005

• 150 deaths/day

• 11% of all cancer deaths

• 758,000 person-years of life lost

• Lifetime risk of developing CRC = 5%

• Cost of treatment $6 billion

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Incidence Rate*

Mortality Rate*

Men

African American 58.358.3 27.7

CaucasianCaucasian 52.7 21.3

Hispanic-AmericanHispanic-American 35.7 13.1

Women

African-AmericanAfrican-American 45.2 19.9

CaucasianCaucasian 36.6 14.3

Hispanic-AmericanHispanic-American 23.6 8.3

There Are Major Health Disparities of Colorectal Cancer in the U.S

* Rates per 100,000U

IBD1%

FAP1%

HNPCC5%

FH 15%-20%

Sporadic(Average Risk)

~75%

Colorectal Cancer Risk Groups

Winawer, Schottenfeld, Flehinger, JNCI 1991: 83:243-253.

FAP

5%

HNPCC-Hereditary Non-Polyposis Colorectal Cancer

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Normalcecum3/95

Cecalcecum5/96

Hereditary Non-Polyposis Colorectal Cancer (HNPCC)

Amsterdam Criteria

• Three or more relatives with Hereditary Non-Polyposis Colorectal Cancers – One a first degree relative of the other two

• Two or more generations

• One with cancer < age 50

Vasen et al. GE 1999; 116 (6): 1453

Lifetime Risks Of Colorectal Cancer

Population risk of CRCPopulation risk of CRC 1 in 201 in 20

1 first-degree relative1 first-degree relative 1 in 171 in 17

1 FDR & 1 second-degree relative 1 FDR & 1 second-degree relative 1 in 12 1 in 12

1 relative aged under 451 relative aged under 45 1 in 101 in 10

2 first-degree relatives2 first-degree relatives 1 in 6 1 in 6

Autosomal dominant pedigreeAutosomal dominant pedigree 1 in 21 in 2

Colorectal Cancer

“The most preventable, but least prevented, cancer”

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The Best Screening Test Is

THE ONE THAT GETS DONE.

Low Screening Rates

• CRC has far lower screening rates than breast or cervical cancer

0

10

20

30

40

50

60

70

80

90

% Screened

CRCBreastCervical

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Why Screen for Colon Cancer?

• Proven effectiveness of screening• Highly preventable cancer• Well defined pre-malignant phase (adenoma)• Adenomas take 5-10 years to become cancer• Molecular basis of carcinogenesis is the best

understood of all solid tumors (molecular diagnostics)

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Barriers to CRC Screening

•Lack of physician recommendation

•Lack of worrisome symptoms

•Fear of the results (need for further testing)

•Negative attitudes about the test:

–FOBT: embarrassing, distasteful

–Sigmoidoscopy / Colonoscopy: pain, discomfort, injury

•Practical issues–Poor Patient Adherence

–Conflicts with work/family commitments

–Inconvenience

–Lack of interest

–Cost

% Mortality Reduction Using Different Screening Methods

1000

AnnualFOBT33%*

SigmoidoscopyEvery 5-10 years

30%*

ColonoscopyEvery 10 years

90%†

*Observed†Estimated

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Effectiveness of FOBTProspective, randomized, controlled trialsProspective, randomized, controlled trials

MandelMandel HardcastleHardcastle KronborgKronborg

((USA)USA) ((UK)UK) ((Denmark)Denmark)

DurationDuration 1975-921975-92 1981-951981-95 1985-951985-95

Subjects (n) Subjects (n) 46,55146,551 152,850152,850 140,000140,000

FrequencyFrequency annual/annual/biennial biennialbiennial biennial biennialbiennial

F/U duration (yrs) F/U duration (yrs) 13 13 7.8 7.8 10 10

CRC mortalityCRC mortality 33%/21%33%/21% 15% 15% 18% 18%

ReductionReduction

Colorectal Cancer Mortality Reduction By Sigmoidoscopy

Colorectal Cancer Mortality Study Design Reduction Published

Kaiser Retrospective, 30% Selby, NEJMPermanente, Case Control 1992USA

Univ. Retrospective, 40% Newcomb,Wisconsin, Case Control JNCI 1992USA

Reviewed in Colorectal Cancer Screening: Clinical Guidelines and Rationale.Winawer, Fletcher, et al., Gastroenterology, Feb. 1997.

What Do You Find If You Perform Screening Colonoscopy on

Average-risk Subjects?LiebermanLieberman11 ImperialeImperiale22

SettingSetting VA; Multi-centerVA; Multi-center Eli Lilly coEli Lilly coNo. Of subjectsNo. Of subjects 3,121 3,121 1,9941,994MaleMale 96.8% 96.8% 58.9%58.9%Age (mean)Age (mean) 62.9 yrs 62.9 yrs 59.8 yrs59.8 yrsCancerCancer 1.0% 1.0% 0.6%0.6%Adenoma (any)Adenoma (any) 37.0% 37.0% ----Adenoma >1 cmAdenoma >1 cm 7.9% 7.9% ----Adenoma w/ HGD 1.6%Adenoma w/ HGD 1.6% ----

11 N Engl J medN Engl J med 343:162, 2000 343:162, 200022 N Engl J medN Engl J med 343:169, 2000 343:169, 2000

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1,000 average-risk asymptomatic men and women

aged 50 and older

5% - 6% will have advanced adenomas ►50-60 advanced adenomas

detected by screening

0.5% - 1% will have cancer► 5-10 cancers

detected early by screening

20% (10-12) would have developed cancer over 20 years

COLONOSCOPY

15-22 cancers are prevented or detected early per 1,000 screening colonoscopies

Cost Effectiveness of Colon Cancer Screening vs. Other

Measures

Lieberman 2003.

0

5

10

15

20

25

30

35

40

Cost ($)peraddedyear of life(x 1000)

Colon Hypertension Mammography CholesterolScreening*

*Any colon screeningThe cost varies with the model used; this is a ballpark number

National Polyp Study

• Randomized trial• Surveillance intervals• Surveillance methods• Colorectal Cancer

incidence

• Adenoma-carcinoma model

• 7 clinical centers• Memorial Sloan

Kettering Coord. Center

Colorectal Cancer Incidence in NPS Following Colonoscopic Polypectomy (1418 pts ; 8401 person yrs)

Resources

Less Intensive Surveillance

Increased Resources for Screening

Alternative and Future Colorectal Cancer Screening

Methods

Virtual Colonoscopy

Virtual Colonoscopy

Prep Needed

Air Discomfort

No Biopsy

No Polypectomy

50–60% Need “Real Time” Colonoscopy

Miss rate of small adenomas?

Radiation

Stool DNA Testing

Stool DNA Testing

Tail

Pail

Mail

Stool DNA Testing

AdvancedAdvanced CancerCancer adenomasadenomas specificity:specificity:1. 20/22 (91%)1. 20/22 (91%) 9/11 (82%)9/11 (82%) 26/28 (93%)26/28 (93%)2. 33/52 (64%)2. 33/52 (64%) 16/28 (57%)16/28 (57%) 204/212 (96%)204/212 (96%)

1. Ahlquist et al. 1. Ahlquist et al. GastroenterologyGastroenterology 2000 20002. Tagore et al. 2. Tagore et al. Clin colorectal cancerClin colorectal cancer 2003 2003

Breaking Down Barriers

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Successful Strategies in New York City

• Systematic referral of all outpatients over age 50• Electronic medical record prompts, preventive

flow sheets, chartstickers or postcards to all patients over the age of 50

• Patient navigators• Direct endoscopy referral (DERs) to simplify

process for increasing screening

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NYC Colorectal Cancer Screening Advisory Panel:

Rationale• About 1,500 NYC residents die annually from colorectal

cancer

• Most deaths are preventable

• Colonoscopy preferred

• Examines entire colon

• Sensitive & Specific for adenomas and cancer

• Provides screening, diagnosis, treatment

• Sufficient Capacity in N.Y.C.

• Preferred recommendation may reduce confusion

• Other options are available (National Guidelines)

The Best Screening Test Is

THE ONE THAT GETS DONE.

Adenomatous Polyp

Adenoma to Carcinoma Pathway

APCloss

NormalEpithelium

EarlyAdenoma

CancerHyper-

proliferationIntermediate

AdenomaLate

Adenoma

K-rasmutation

Chrom 18loss

p53loss

AdenomaNormal Cancer

US Rates of Colorectal Cancer Incidence (age 50+)

0

100

200

300

400

500

20-24 30-34 40-44 50-54 60-64 70-74 80-84

Age (years)

Rate

Per

100

,000

Incidence Rate Mortality RateSEER: 1993-1997SEER: 1993-1997

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