colorectal cancer paula m. rechner m.d. war memorial hospital october 13, 2005

Colorectal Colorectal CancerCancer

Paula M. Rechner M.D.Paula M. Rechner M.D.War Memorial HospitalWar Memorial Hospital

October 13, 2005October 13, 2005

GoalsGoals

Identify Colorectal Cancer as a serious health Identify Colorectal Cancer as a serious health problem in the USproblem in the US

Provide current guidelines Provide current guidelines Outline present day insurance coverageOutline present day insurance coverage Identify targets for preventionIdentify targets for prevention Provide a rural surgeon’s perspective on Provide a rural surgeon’s perspective on

colorectal cancercolorectal cancer

American Cancer SocietyAmerican Cancer SocietyColorectal Cancer Facts & Figures – Special Colorectal Cancer Facts & Figures – Special

Edition 2005Edition 2005

145,290 new diagnoses expected in 145,290 new diagnoses expected in 20052005Colon: 104,950Colon: 104,950Rectum: 40,3410Rectum: 40,3410


Edition 2005Edition 2005 56,290 predicted deaths56,290 predicted deaths

5 year localized survival rate: 90%5 year localized survival rate: 90%Only 39% CRC found at this stage Only 39% CRC found at this stage

due to low screening ratesdue to low screening rates 5 year survival with metastatic disease: 5 year survival with metastatic disease:

10%10% 5 year overall survival rate: 63%5 year overall survival rate: 63%



5.6% OF Americans will 5.6% OF Americans will develop CRC in their livesdevelop CRC in their lives


Edition 2005Edition 2005 Third most common type of cancerThird most common type of cancer Second most common cause of cancer deathSecond most common cause of cancer death When men and women are considered When men and women are considered

separately CRC is the third most common separately CRC is the third most common cause of death in each sexcause of death in each sex



THE LEADING CAUSE OF THE LEADING CAUSE OF CANCER DEATH AMONG CANCER DEATH AMONG NONSMOKING AMERICANSNONSMOKING AMERICANS

U.S. Colorectal Cancer IncidenceU.S. Colorectal Cancer Incidence

0

10

20

30

40

50

60

70

1982 1986 1990 1994 1998 2002

White

Hispanic

African Americans

Asian

American Indians

U.S. Colorectal Cancer MortalityU.S. Colorectal Cancer Mortality

0

5

10

15

20

25

30

1982 1986 1990 1994 1998 2002

Whites

Hispanics

African Americans

Asians or PacificIslanders

AmericanIndians/AlaskanNatives

Colorectal Cancer Colorectal Cancer Risk FactorsRisk Factors

MayoClinic.comMayoClinic.comRisk Factors for Colorectal CancerRisk Factors for Colorectal Cancer

Age: 90% are age > 50Age: 90% are age > 50 Inflammatory Bowel DiseaseInflammatory Bowel Disease

MayoClinic.comMayoClinic.comRisk Factors for Colorectal CancerRisk Factors for Colorectal Cancer

Family History Family History HereditaryHereditary Shared environmental exposure to a carcinogen, Shared environmental exposure to a carcinogen,

diet or lifestylediet or lifestyle Familial Adenomatous Polyposis (FAP)Familial Adenomatous Polyposis (FAP)

Cancer by age 40!!!Cancer by age 40!!! Hereditary Nonpolyposis Colorectal Cancer Hereditary Nonpolyposis Colorectal Cancer

(HNPCC)(HNPCC) Ashkenazi JewsAshkenazi Jews

(Fewer than 10% of CRC are caused by inherited gene mutations)(Fewer than 10% of CRC are caused by inherited gene mutations)

MayoClinic.com MayoClinic.com (continued)(continued)

DietDiet Low fiberLow fiber High FatHigh Fat High CaloriesHigh Calories

Sedentary LifestyleSedentary Lifestyle Increased transit timeIncreased transit time Prolonged colonic exposure to carcinogensProlonged colonic exposure to carcinogens

DiabetesDiabetes 40% increased risk of developing colorectal cancer40% increased risk of developing colorectal cancer

MayoClinic.com MayoClinic.com (continued)(continued)

SmokingSmoking 1 in 10 fatal colon cancers may be caused by smoking1 in 10 fatal colon cancers may be caused by smoking Once diagnosed with colorectal cancer, smokers face a 30 Once diagnosed with colorectal cancer, smokers face a 30

to 40 percent increased risk of dying of the diseaseto 40 percent increased risk of dying of the disease AlcoholAlcohol

1 drink per day for women1 drink per day for women 2 drinks per day for males2 drinks per day for males

Personal History of Colorectal Cancer or PolypsPersonal History of Colorectal Cancer or Polyps

American Cancer SocietyAmerican Cancer SocietyRRRR

Family History (First Degree Relative)Family History (First Degree Relative) 1.81.8

IBD >10 yearsIBD >10 years 1.51.5

Obesity (BMI>30)Obesity (BMI>30) 1.5-2.01.5-2.0

Red Meat (>7/week vs. 1/mo)Red Meat (>7/week vs. 1/mo) 1.51.5

Smoking (Current vs. never)Smoking (Current vs. never) 1.51.5

Alcohol (>4/week vs. none)Alcohol (>4/week vs. none) 1.41.4

Physical Activity (>3hr/week vs. none)Physical Activity (>3hr/week vs. none) 0.60.6

Vegetable & Fruit consumption (>5 vs. Vegetable & Fruit consumption (>5 vs. <3/day)<3/day)

0.70.7

Colorectal Cancer Diagnosis and Colorectal Cancer Diagnosis and ScreeningScreening

MayoClinic.com MayoClinic.com Screening and Diagnostic Screening and Diagnostic

ProceduresProcedures Digital Rectal ExamDigital Rectal Exam

Limited examLimited exam Likely to miss small polypsLikely to miss small polyps

Fecal Occult Blood TestFecal Occult Blood Test False Positive False Positive False NegativeFalse Negative

Flexible SigmoidoscopyFlexible Sigmoidoscopy Limited ExamLimited Exam Minimal perforation riskMinimal perforation risk

MayoClinic.com MayoClinic.com Screening and Diagnostic Procedures Screening and Diagnostic Procedures

(continued)(continued)

Barium EnemaBarium Enema ““significantly high rate of missing important significantly high rate of missing important

lesions…especially in the lower bowel and lesions…especially in the lower bowel and rectum”rectum”

Flexible sigmoidoscopy may be done in addition to Flexible sigmoidoscopy may be done in addition to BEBE

ColonoscopyColonoscopy ““most sensitive test for colon cancer, rectal cancer most sensitive test for colon cancer, rectal cancer

and polyps”and polyps”

MayoClinic.com MayoClinic.com Screening and Diagnostic Procedures Screening and Diagnostic Procedures

(continued)(continued)

New TechnologiesNew Technologies Virtual colonoscopyVirtual colonoscopy

2 minute CT scan2 minute CT scan No prep – potential in the futureNo prep – potential in the future Less accurate than colonoscopyLess accurate than colonoscopy Diagnostic not therapeuticDiagnostic not therapeutic Not widely availableNot widely available

American Cancer SocietyAmerican Cancer SocietyScreening and SurveillanceScreening and Surveillance

At Age 50 for men and women at average riskAt Age 50 for men and women at average risk FOBT or FIT every year-take home kit not DREFOBT or FIT every year-take home kit not DRE

6 samples from 3 consecutive BM’s6 samples from 3 consecutive BM’s Flexible Sigmoidoscopy every 5 yearsFlexible Sigmoidoscopy every 5 years FOBT or FIT every year + Flex Sig every 5 yearsFOBT or FIT every year + Flex Sig every 5 years Double-contrast barium enema every 5 yearsDouble-contrast barium enema every 5 years Colonoscopy every 10 yearsColonoscopy every 10 years


FOBTFOBT Reduces risk of death from CRC by 15-33%Reduces risk of death from CRC by 15-33% FOBT reduces incidence of CRC by 20%FOBT reduces incidence of CRC by 20%

Detection of polypsDetection of polyps Early removal of polyps found thus preventing CRCEarly removal of polyps found thus preventing CRC

Flexible Sigmoidoscopy (FS)Flexible Sigmoidoscopy (FS) Reduces CRC mortality by 60% for cancers within Reduces CRC mortality by 60% for cancers within

reach of the instrumentreach of the instrument FS followed by Colonoscopy if a polyp is found FS followed by Colonoscopy if a polyp is found

identifies 70-80% of individuals with CRCidentifies 70-80% of individuals with CRC


FOBT and Flexible SigmoidoscopyFOBT and Flexible Sigmoidoscopy One test would compensate for the limitations and One test would compensate for the limitations and

may improve early detectionmay improve early detection ColonoscopyColonoscopy

National Polyp StudyNational Polyp Study 76-90% CRC Prevention76-90% CRC Prevention Most sensitive test for CRC and PolypsMost sensitive test for CRC and Polyps Gold Standard for ScreeningGold Standard for Screening Screening, Diagnostic and TherapeuticScreening, Diagnostic and Therapeutic


Barium Enema with Air ContrastBarium Enema with Air Contrast Less sensitive than colonoscopyLess sensitive than colonoscopy Colonoscopy is required if a polyp is foundColonoscopy is required if a polyp is found

DNA based fecal screening and Virtual DNA based fecal screening and Virtual ColonoscopyColonoscopy Are not recommended at this timeAre not recommended at this time

Screening and Surveillance for Screening and Surveillance for Increased Risk PatientsIncreased Risk Patients

Increased RiskIncreased Risk Age to beginAge to begin RecommendationRecommendation commentcomment

1 < 1cm adenoma1 < 1cm adenoma 3-6 yrs after 3-6 yrs after polypectomypolypectomy

colonoscopycolonoscopy If normal return to If normal return to screeningscreening

1 > 1cm adenoma, 1 > 1cm adenoma, multiple adenomas or multiple adenomas or adenomas with high adenomas with high grade dysplasia or grade dysplasia or villous changes 1cmvillous changes 1cm

Within 3 yrs of Within 3 yrs of polypectomypolypectomy

colonoscopycolonoscopy If normal, repeat in 3 If normal, repeat in 3 yrs, if then normal, yrs, if then normal, return to screeningreturn to screening

Personal history of Personal history of curative intent resection curative intent resection of CRCof CRC

Within 1 year of Within 1 year of cancer resectioncancer resection

colonoscopycolonoscopy If normal, repeat in 3 If normal, repeat in 3 yrs, if then normal yrs, if then normal repeat every 5 yrsrepeat every 5 yrs

Either CRC or Either CRC or adenomatous polyps in any adenomatous polyps in any first degree relative before first degree relative before age 60, or in 2 or more first age 60, or in 2 or more first degree relatives at any age degree relatives at any age (if not a hereditary (if not a hereditary syndrome)syndrome)

Age 40, or 10 years Age 40, or 10 years before the youngest before the youngest casecase

colonoscopycolonoscopy Every 5-10 yearsEvery 5-10 years

Screening and Surveillance for High Screening and Surveillance for High Risk PatientsRisk Patients

High RiskHigh Risk Age to beginAge to begin RecommendationRecommendation CommentComment

Family history of Family history of FAPFAP

PubertyPuberty Early surveillance, Early surveillance, with endoscopy, +/- with endoscopy, +/- genetic testinggenetic testing

If genetic If genetic testing +, testing +, colectomycolectomy

Family history of Family history of HNPCCHNPCC

Age 21Age 21 Colonoscopy and Colonoscopy and counseling to counseling to consider genetic consider genetic testingtesting

If genetic test +, If genetic test +, or no testing, or no testing, every 1-2 years every 1-2 years until 40 then until 40 then annuallyannually

Chronic Chronic Ulcerative Colitis Ulcerative Colitis or Crohn’s or Crohn’s diseasedisease

8 yrs after onset 8 yrs after onset of pan colitis, or of pan colitis, or 12-15 yrs after 12-15 yrs after onset of left-sided onset of left-sided colitis colitis

Colonoscopy with Colonoscopy with biopsies for biopsies for dysplasiadysplasia

Every 1-2 yearsEvery 1-2 years

COSTCOST


Cost RangeCost Range

FOBTFOBT Less than $20Less than $20

Flexible SigmoidoscopyFlexible Sigmoidoscopy $150-$200$150-$200

Double-contrast Barium Double-contrast Barium EnemaEnema

$300-$400$300-$400

ColonoscopyColonoscopy $400+$400+

Insurance CoverageInsurance Coverage

MedicareMedicare

CRC screening covered since 1998CRC screening covered since 1998 All recommended screening options covered All recommended screening options covered

since 2001since 2001 AnAn initial initial preventative health care visit for all preventative health care visit for all

Medicare beneficiaries Medicare beneficiaries within 6 months of within 6 months of enrolling in Medicareenrolling in Medicare covered since January covered since January 2005!2005!

Medicare CoverageMedicare Coverage FOBT-Once every 12 monthsFOBT-Once every 12 months Flexible Sigmoidoscopy-Once every 48 monthsFlexible Sigmoidoscopy-Once every 48 months Screening ColonscopyScreening Colonscopy

High Risk-Once every 24 monthsHigh Risk-Once every 24 months Average risk-Once every 10 years, but not within 48 Average risk-Once every 10 years, but not within 48

months of screening FS months of screening FS Barium Enema-In place of FS onlyBarium Enema-In place of FS only

High Risk-Every 24 monthsHigh Risk-Every 24 months Average Risk-Every 48 monthsAverage Risk-Every 48 months

Medicare CoverageMedicare Coverage

You pay nothing for FOBTYou pay nothing for FOBT You pay 20% of the Medicare-approved You pay 20% of the Medicare-approved

amount after the yearly Part B deductible, for amount after the yearly Part B deductible, for all other testsall other tests

You pay 25% of the Medicare-approved You pay 25% of the Medicare-approved amount after the yearly part deductible, if amount after the yearly part deductible, if endoscopy is done in a hospital outpatient endoscopy is done in a hospital outpatient departmentdepartment

Blue Cross Blue Shield CoverageBlue Cross Blue Shield CoverageMI 2005MI 2005

Provider TypeProvider Type M.D. or D.O. (otherwise not payable)M.D. or D.O. (otherwise not payable)

Payable under Preventive coveragePayable under Preventive coverage Age > 50Age > 50 1 Per 10 Years unless “high risk”1 Per 10 Years unless “high risk”

““Average Risk”Average Risk”

25% of “average risk” adults at 25% of “average risk” adults at age 50 will have adenomatous age 50 will have adenomatous polypspolyps

70-80% of all Colorectal 70-80% of all Colorectal Cancers develop in “average Cancers develop in “average risk” patientsrisk” patients

Blue Cross Blue Shield High Risk Blue Cross Blue Shield High Risk DiagnosisDiagnosis

25-40 years old25-40 years old V1005V1005 V1006V1006 V160V160 V1000V1000 V7641V7641 V7650V7650 V7651V7651

1 per 2 years1 per 2 years

> 40 years old> 40 years old V1005V1005 V1006V1006 V160V160 V1000V1000 V7641V7641 V7650V7650 V7651V7651

Any Appropriate Any Appropriate FrequencyFrequency

V CODESV CODES V1005-Personal history of malignant neoplasm of the large V1005-Personal history of malignant neoplasm of the large

intestineintestine V1006-Personal history of malignant neoplasm of the rectumV1006-Personal history of malignant neoplasm of the rectum V160-Family history of malignant neoplasm of the V160-Family history of malignant neoplasm of the

gastrointestinal tractgastrointestinal tract V1000-Personal history of malignant neoplasm of the V1000-Personal history of malignant neoplasm of the

gastrointestinal tractgastrointestinal tract V7641-Special screening for malignant neoplasms of the V7641-Special screening for malignant neoplasms of the

rectumrectum V7650-Special screening for malignant neoplasms of the V7650-Special screening for malignant neoplasms of the

intestineintestine V7651-Special screening for malignant neoplasms of the colonV7651-Special screening for malignant neoplasms of the colon

State of MI PPO & GM Hourly and State of MI PPO & GM Hourly and Salary Benefits for Salary Benefits for High RiskHigh Risk

1 Per 10 years1 Per 10 yearsAge >50Age >50

Colorectal Cancer Screening Colorectal Cancer Screening StatisticsStatistics



Less than 50% of people Less than 50% of people aged 50 or older have aged 50 or older have had a recent had a recent colonoscopy!!!!colonoscopy!!!!

American Cancer SocietyAmerican Cancer SocietyPopulations associated with even less screeningPopulations associated with even less screening

Age 50-64Age 50-64 Non-white raceNon-white race Fewer years of educationFewer years of education Lack of health insuranceLack of health insurance Immigration to the US < 10 yearsImmigration to the US < 10 years

American Cancer SocietyAmerican Cancer Society

Overall US PopulationOverall US Population

FOBTFOBT 17.3 %17.3 %

EndoscopyEndoscopy 30 %30 %

FOBT/EndoscopyFOBT/Endoscopy 39.4%39.4%

Any screeningAny screening Less than 50 %Less than 50 %

American Cancer SocietyAmerican Cancer SocietyMichigan Residents Age 50 and OlderMichigan Residents Age 50 and Older

White Non-Hispanic ~53% screenedWhite Non-Hispanic ~53% screened Ranked 12Ranked 12thth in the Nation in the Nation

African American Non-Hispanic ~57% African American Non-Hispanic ~57% screenedscreened Ranked 5Ranked 5thth in the Nation in the Nation

American Cancer SocietyAmerican Cancer SocietyBarriers to CRC ScreeningBarriers to CRC Screening

Health Care ProvidersHealth Care Providers Communication with patientsCommunication with patients Several studies show patients are more likely to be Several studies show patients are more likely to be

screened if it is recommended to themscreened if it is recommended to them Attitudes and Beliefs Attitudes and Beliefs

Effectiveness of screeningEffectiveness of screening Familiarity with screening guidelinesFamiliarity with screening guidelines Perception of patient preference and adherencePerception of patient preference and adherence Lack of training to perform testsLack of training to perform tests Lack of adequate reminder systems within their practicesLack of adequate reminder systems within their practices

Barriers to CRC ScreeningBarriers to CRC Screening American Cancer SocietyAmerican Cancer Society

Health InsuranceHealth Insurance If patient has anyIf patient has any If benefits include screeningIf benefits include screening Highly variableHighly variable

Barriers to CRC ScreeningBarriers to CRC Screening American Cancer SocietyAmerican Cancer Society

PatientsPatients ““Too busy”Too busy” ““Lack of physician recommendation”Lack of physician recommendation” ““Inconvenience”Inconvenience” ““Lack of interest”Lack of interest” ““Cost”Cost” ““Embarrassment”Embarrassment” ““unpleasantness of the test”unpleasantness of the test” Unaware of benefitsUnaware of benefits Lack understanding of importance of screeningLack understanding of importance of screening

Strategies to Increase Utilization of Strategies to Increase Utilization of CRC ScreeningCRC Screening

Physician office and health systemsPhysician office and health systems Computer reminder systemsComputer reminder systems Identify eligible patients for screeningIdentify eligible patients for screening Organized support for referrals and follow upOrganized support for referrals and follow up

Health InsuranceHealth Insurance Only 9 of 29 states, where CRC screening is under 50%, Only 9 of 29 states, where CRC screening is under 50%,

have passed legislation to require CRC screening!!!!!!have passed legislation to require CRC screening!!!!!! 16 states and D.C. have such legislation16 states and D.C. have such legislation

Education for Patients and ProvidersEducation for Patients and Providers

MayoClinic.comMayoClinic.comPreventionPrevention

Eat 5 or more fruits and vegetables per dayEat 5 or more fruits and vegetables per day Limit fat Limit fat

< 30% Fat in daily calories< 30% Fat in daily calories < 10% of saturated fats< 10% of saturated fats

Vitamins and Minerals that prevent CRCVitamins and Minerals that prevent CRC CalciumCalcium Pyridoxine (vitamin B-6)Pyridoxine (vitamin B-6) Vitamin B-9 Vitamin B-9 MagnesiumMagnesium

Prevention of Colorectal CancerPrevention of Colorectal Cancer

MayoClinic.comMayoClinic.comPrevention (continued)Prevention (continued)

Limit alcohol consumptionLimit alcohol consumption Stop smokingStop smoking Exercise 30 minutes per dayExercise 30 minutes per day Hormone Replacement Therapy (HR)Hormone Replacement Therapy (HR)

May reduce risk of CRCMay reduce risk of CRC Women on HR who develop CRC may have a faster Women on HR who develop CRC may have a faster

growing form of the diseasegrowing form of the disease Consider taking statins for high cholesterolConsider taking statins for high cholesterol

NEJM (5/26/2005)– reduced risk in patients taking statins NEJM (5/26/2005)– reduced risk in patients taking statins for five years or morefor five years or more

American Cancer SocietyAmerican Cancer Society

Aspirin and aspirin like drugsAspirin and aspirin like drugs May lower the risk of colorectal cancerMay lower the risk of colorectal cancer ACS does not encourage NSAIDs or Cox-2 ACS does not encourage NSAIDs or Cox-2

inhibitorsinhibitors Gastric side effectsGastric side effects Heart attackHeart attack

Consult with physicianConsult with physician

NCI Colorectal Cancer Research NCI Colorectal Cancer Research InvestmentInvestment

0

50

100

150

200

250

300

2000 2001 2002 2003 2004 2005

The American Cancer SocietyThe American Cancer Society

Funded $49.6 million as of July 2004Funded $49.6 million as of July 2004 90 colon cancer-related grants90 colon cancer-related grants Survey’s public knowledge, attitudes and Survey’s public knowledge, attitudes and

practicespractices EducationEducation

www.cancer.orgwww.cancer.org 1-800-ACS-23451-800-ACS-2345

National colon cancer public awareness National colon cancer public awareness campaigncampaign

Michigan Legislation 2004Michigan Legislation 2004

Screening law requires insurers to offer Screening law requires insurers to offer coverage but does not assure coverage or there coverage but does not assure coverage or there are no state requirements for coverageare no state requirements for coverage

Surgical PlanSurgical Plan

Surgical ManagementSurgical Management

Polyp

Adenoma Carcinoma

<10 10-100

Polypectomy

>100

Partial Colectomy With

Ileorectal anastamosis

Total ColectomyWith

Ileal Pouch

Staging

Surgical ManagementSurgical Management

Carcinoma

Locally Confined

Liver Metastasis

Spread to Adjacent Organs

Diffuse Disease

SegmentalResection

Wedge resectionOf Metastasis

En bloc Resection Diverting Colostomy

Chemotherapy+/- Radiation



A Rural Surgeon’s PerspectiveA Rural Surgeon’s Perspective

Benefit of providing both screening and Benefit of providing both screening and therapy for Colorectal Cancertherapy for Colorectal Cancer

Continuity of Patient CareContinuity of Patient Care Family EducationFamily Education Long Term Follow-up for surveillanceLong Term Follow-up for surveillance

Questions?Questions?

colorectal cancer paula m. rechner m.d. war memorial hospital october 13, 2005

Documents

colorectal cancer slide

colorectal cancer age

colorectal cancer paula

colorectal cancer risk

common type of cancer

common cause of cancer

leading cause of cancer

sex slide