d epartment of f amily m edicine colorectal cancer screening: update on guidelines and projects...

DEPARTMENT of FAMILY MEDICINE

Colorectal Cancer Screening:Update on Guidelines and Projects

Barcey T. Levy, PhD, MDProfessor, Department of Family Medicine2011 Iowa Dialogue on Colorectal Cancer

September 16, 2011


Objectives

1. Provide review of colon cancer screening guidelines.2. Share information from several studies concerning

colon cancer screening conducted in the University of Iowa Department of Family Medicine.


United States Preventive Services Task Force Guidelines

Recommends screening for CRC using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults beginning at age 50 and continuing until age 75.

Recommends AGAINST routine screening in those 76 to 85 years.

Recommends AGAINST screening in those older than 85 years.

Ann Intern Med 2008;149:627-637


Appropriate Intervals for CRC Testing for Average Risk Individuals

ANY of the following: Annual sensitive fecal test for occult blood

(Hemoccult Sensa or a fecal immunochemical test (FIT)).

Flexible sigmoidoscopy every 5 years. Colonoscopy every 10 years.

Consistent with ACS/American Gastroenterological Association/USPSTF guidelines


Comparison of Tests for CRC

Test Sensitivity Specificity Positivity rate

Serious harms

Cost

Fecal immunochemical test

61 to 91% 91 to 98% 5 to 19% Very low $40

Colonoscopy

95% 90% 40% adenoma bx; 3 to 5% for cancer

2.8/1000 procedures

$4,000


Key Point A decision analysis found no difference in life-years

gained using any of the following strategies: Colonoscopy every 10 years Annual screening with a sensitive FOBT or FIT Sensitive FOBT every two to three years with

flexible sigmoidoscopy every 5 years Thus, a sensitive stool test for occult blood done

annually is perfectly acceptable!

Zauber, et al, Ann Intern Med 2008;149(659-669)


CRC Mortality – Iowa SEER Data


Projects AHRQ funded study to examine CRC screening

among rural Iowans. Factors predicting screening Doctor’s reasons for not screening specific

patients IDPH contract to screen underserved Iowans. American Cancer Society funded randomized clinical

trial, testing four interventions of increasing intensity to improve CRC screening.


AHRQ Study


Patients with CRC tests

0%

10%

20%

30%

40%

50%

60%

70%

80%

Perc

enta

ge

..

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Overall

Physician

Proportion Current (ACS guidelines) Proportion Screened (no symptoms)


Predictors of Being Up-To-Date: Univariate Odds Ratios

Variable OR (95% CI) p-value

Patient recalls MD recommendation* 6.4 (4.2, 9.6) <.001

MD documented CRC discussion* 14.1 (8.5, 23.3) <.001

* Not considered in multivariate model


Physicians’ Reasons for Specific Patients Not Being Up to Date with CRC Guidelines

When CRC screening was not discussed Lack of opportunity to discuss screening

• Patients came in only for acute visits or problems• Patients came in sporadically or saw other providers for health

maintenance care• No tracking system• Not enough time during appointments

Physician forgetfulness Assessment that cost or lack of insurance would be prohibitive to

patient Patient had life issues or other health problems that distracted from

screening Expected patient refusal or lack of interest


Physicians’ Reasons for Specific Patients Not Being Up to Date with CRC Guidelines

When CRC screening was discussed, but patient declined Cost of screening Lack of interest in screening Patient autonomy Patients had life issues or other health problems Fear of screening test procedure No symptoms or family history of CRC


IDPH Contract


IDPH Contract

Implemented a screening program for uninsured or underinsured Iowans.

Used a fecal immunochemical test (FIT) kit that required a small sample from a single stool.

The FIT is a very sensitive test for small amounts of human blood and does not require the dietary restrictions of the hemoccult test.


FIT results

Of 449 who indicated an interest (23% of study population), 297 were given an FIT kit.

Return rate on FITs was 79% (235 returned). Of the 235 kits returned, 186 tested negative (79%)

and 49 (21%) tested positive. Each individual with a positive result was telephoned

and their result explained to them. Colonoscopies were strongly encouraged for those

with positive results.


Colonoscopy Results 30 of the 49 (61%) individuals had a colonoscopy

20 individuals had at least 1 polyp biopsied 13 individuals had at least 1 tubular adenoma 2 had adenomas more than 1 cm in diameter No colon cancers were identified

No complications from any of the colonoscopies


Conclusions from IDPH Underinsured patients had a 79% return rate for the FIT

kits. The rate of positive tests was much higher than

anticipated, leading to many more colonoscopies than originally anticipated.

Population-based strategies for offering FIT could significantly increase CRC screening among disadvantaged individuals.

Programs will have to develop sustainable mechanisms to include the necessary organization and address substantial costs of providing mass screening, as well as facilitating and providing colonoscopies for those who test positive.


American Cancer Society Study


Interventions to Improve Colon Cancer Screening in Poor, Rural Iowa Counties


Educational mailings – overall 47% screened by FIT

0

10

20

30

40

50

60

Returned FIT Ready for a test Not Ready

Perc

enta

ge

FIT Returned and Test Readiness

Group 3 Group 4

P < .0001


Final Outcome


Colonoscopy Reports (ACS)

Colonoscopy reports were examined to assess several quality indicators, including:1) presence of a colonoscopy report on the medical record, if the medical record indicated a colonoscopy had been completed2) cecal intubation rate3) adenoma detection rate 4) the content of the colonoscopy report.


Results Colonoscopy Reports (ACS) 581 colonoscopies reported as completed in 14

offices. 492 (85%) had a report on the medical record Main reasons for colonoscopy:

236 (48%) for screening 98 (20%) obvious blood in stool 90 (18%) family history colon cancer 70 (14%) history of colon polyp 66 (13%) change in bowel habit


Results of Screening Colonoscopies (n=236)

Polyp detection rate was 34% Adenoma detection rate was 24%

Men 31% (expected 25% based on national norms)

Women 19% (expected 15% based on national norms)


Results (continued)

Items Provided on Colonoscopy Report (N = 492)

All SubjectsN (%)

Depth of insertion 491 (100)How the patient tolerated procedure 287 (58)Name of anesthetic drug provided 268 (55)Informed consent obtained 220 (45)Follow-up interval for next colonoscopy 223 (45)Ileocecal valve landmark mentioned 159 (33)Bowel preparation quality 164 (33)Appendiceal orifice landmark mentioned 103 (21)


Take Home Points

There is wide variation in screening rates across Iowa.

There is wide variation in CRC mortality across Iowa. Simple interventions such as direct-to-patient

mailings with FIT can work. Colonoscopy reports should be standardized. Screening programs need to allow for significant

resources for organization and follow-up.


References1. Levy, et al. Colorectal cancer testing among patients cared for

by Iowa family physicians. Am J Prev Med 2006;21:193-201.2. Levy BT, et al. Why hasn’t this patient been screened for colon

cancer? An Iowa Research Network Study. J Am Board Fam Med. 2007;20(5):458-468

3. Levy, et al. The “Iowa Get Screened” Colon Cancer Screening Program. J of Primary Care & Comm Health 2010;1(1):43-49.

4. http://www.uiowa.edu/iowacancermaps/colorectal_mortality.html

5. Zauber, et al. Evaluating and testing strategies for CRC screening. Ann Intern Med 2008;149(9):659-669.

6. USPSTF. Screening for CRC. Ann Intern Med 2008;149:627-637.

http://www.uiowa.edu/iowacancermaps/colorectal_mortality.html

http://www.uiowa.edu/iowacancermaps/colorectal_mortality.html


References (cont’d)7. Levy BT, Daly JM, Schmidt EJ, Xu Y. The need for office

systems to improve colorectal cancer screening. Journal of Primary Care and Community Health 2011 (In press).

8. Levy BT, Daly JM, Xu Y, Ely JW. Mailed fecal immunohistochemical tests plus education materials to improve colon cancer: screening rates in Iowa Research Network (IRENE) practices. Journal of the American Board of Family Medicine 2011 (In press).

9. Daly JM, Xu, Y, Ely J, Levy BT. A Colorectal Cancer Screening Intervention Trial in the Iowa Research Network: Study Recruitment Methods and Baseline Results. Journal of the American Board of Family Medicine 2011 (In press).

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