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
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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.
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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
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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
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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
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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)
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CRC Mortality – Iowa SEER Data
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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.
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AHRQ Study
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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)
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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
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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
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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
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IDPH Contract
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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.
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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.
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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
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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.
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American Cancer Society Study
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Interventions to Improve Colon Cancer Screening in Poor, Rural Iowa Counties
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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
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Final Outcome
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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.
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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
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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)
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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)
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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.
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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.
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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).