PENN

How toHow to Increase Colorectal Cancer Increase Colorectal Cancer Screening Rates in Practice: A Screening Rates in Practice: A

Primary Care Clinician’s Evidence-Primary Care Clinician’s Evidence-based Toolbox and Guidebased Toolbox and Guide

Carmen E. Guerra, M.D., M.S.C.E., F.A.C.PCarmen E. Guerra, M.D., M.S.C.E., F.A.C.PAssociate Professor of MedicineAssociate Professor of Medicine

Division of General Internal Medicine Division of General Internal Medicine

University of Pennsylvania School of MedicineUniversity of Pennsylvania School of Medicine

Board Member &Board Member &

Chair, Provider Awareness Work Group, Colorectal Cancer Screening Task ForceChair, Provider Awareness Work Group, Colorectal Cancer Screening Task Force

American Cancer Society, Pennsylvania DivisionAmerican Cancer Society, Pennsylvania Division

February 4, 2009February 4, 2009

Overview

• Colorectal cancer (CRC) incidence and survivalColorectal cancer (CRC) incidence and survival• Risk factors for CRCRisk factors for CRC• Pathogenesis Pathogenesis • CRC screening and surveillance guidelinesCRC screening and surveillance guidelines• CRC screening rates in the U.S.CRC screening rates in the U.S.• Increasing Colorectal Cancer Screening Rates in Increasing Colorectal Cancer Screening Rates in

PracticePractice– Essential 1: Importance and Barriers of Physician RecommendationEssential 1: Importance and Barriers of Physician Recommendation– Essential 2: An Office PolicyEssential 2: An Office Policy– Essential 3: A Reminder SystemEssential 3: A Reminder System– Essential 4: An Effective Communication SystemEssential 4: An Effective Communication System

• SummarySummary

Colorectal Cancer

• Colorectal cancer (CRC) is 2Colorectal cancer (CRC) is 2ndnd leading cause of cancer deaths leading cause of cancer deaths in U.S.in U.S.

• In 2008, an estimate 148,810 In 2008, an estimate 148,810 cases and 49,960 deaths are cases and 49,960 deaths are expectedexpected

Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin 2008;58:71-a–96Clin 2008;58:71-a–96

Colorectal Cancer

• Average lifetime risk of CRC Average lifetime risk of CRC approaches 6% (1 in 18)approaches 6% (1 in 18)

• Incidence is decreasingIncidence is decreasing– 66.3 cases/100,000 in 198566.3 cases/100,000 in 1985

– 49.5 cases/100,000 in 200349.5 cases/100,000 in 2003

• Mortality is decreasingMortality is decreasing

Incidence by Race/Ethnicity and Sex

Race/Ethnicity

Male

(Cases/

100,000)

Female

(Cases/

100,000)All races/ethnicities 60.8 44.6African-American 72.6 55.0

White 60.4 44.0Asian/Pacific Islander 49.7 35.3

American Indian/Alaska Native 42.1 39.6

Hispanic Americans 47.5 32.9

Source: SEER. http://seer.cancer.gov/csr/1975_2004/, based on November 2006 Source: SEER. http://seer.cancer.gov/csr/1975_2004/, based on November 2006 SEER data submission, posted to the SEER web site, 2007. SEER data submission, posted to the SEER web site, 2007.

Survival

Duke Stage

Extent of Disease

Proportion diagnosed

(%)

5-year survival

(%)I Mucosa 39 90

II/III Submucosa or Muscularis/

Regional Lymph Node

36 68

IV Metastatic 19 10

Survival by Race/Ethnicity

• The overall 5-year relative survival rate for 1996-2003 from 17 SEER geographic areas was 64.0%

• Five-year relative survival rates by race and sex were:

– 64.9% for white men– 64.9% for white women– 55.2% for black men– 54.7% for black women

Risk Factors

• Age• A personal history of colorectal cancer or polyps• A family history of colorectal cancer or polyps• A personal history of inflammatory bowel disease• Ashkenazi Jewish ethnicity• African American race• Diet from animal sources• Physical inactivity• Obesity• Smoking• Alcohol intake• Diabetes

Pathogenesis

• Most CRCs develop from adenomatous polyps

• However, only 10% of adenomas progress to cancer

• “Dwell time” is approximately 10 years

• Prolonged dwell time allows for screening and intervention

 U.S. Preventive Services Task Force Guidelines 2008

• The USPSTF strongly recommends that clinicians screen men and women 50 years of age or older for colorectal cancer

• Grade A recommendation• http://www.ahrq.gov/clinic/3rduspstf/

colorectal/colorr.htm

2008 ACS/USMSTF/ACR CRC Screening

Guidelines• Uniform guidelines from American Cancer Uniform guidelines from American Cancer

Society, American College of Radiology and Society, American College of Radiology and the U.S. Multisociety Task Force on Colorectal the U.S. Multisociety Task Force on Colorectal CancerCancer

– American Gastroenterological AssociationAmerican Gastroenterological Association– American College of GastroenterologyAmerican College of Gastroenterology– American Society of Gastrointestinal EndoscopistsAmerican Society of Gastrointestinal Endoscopists– American College of PhysiciansAmerican College of Physicians

• Originally published in 1997, updated in 2003 Originally published in 1997, updated in 2003 and 2008and 2008

2008 ACS/USMSTF/ACR CRC Screening

GuidelinesTests That Detect Adenomatous Polyps and CancerTests That Detect Adenomatous Polyps and Cancer

Flexible sigmoidoscopy (FSIG) every 5 years, or

Colonoscopy every 10 years, or

Double contrast barium enema (DCBE) every 5 years*, or

CT colonography (CTC) every 5 years

Tests That Primarily Detect CancerTests That Primarily Detect Cancer

Annual guaiac-based fecal occult blood test (gFOBT) with high test sensitivity for cancer or

Annual fecal immunochemical test (FIT) with high test sensitivity for cancer or

Stool DNA test (sDNA), with high sensitivity for cancer, interval uncertain

Guidelines Article and CME Quiz

•Levin B, et al. Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Ca Cancer J Clin 2008;58:130-160

•This article is available online at http://CAonline.AmCancerSoc.org

•Free CME credit for successfully completing the online quiz http://CME.AmCancerSoc.org

Recommendation ACS/USMSTF/ACR USPSTF

Age to begin and end screening, and test prioritizationAge to begin and end

screening in average risk adults

Begin and age 50, and end screening at a point where curative therapy would not be offered due to life-limiting co-morbidity

Begin screening at age 50. Routine screening between ages 76-85 is not recommended.

Screening after age 85 is not recommended.

Screening in high risk adults Detailed recommendations based on personal risk and family history

No specific recommendations for age to begin testing or type of testing

Prioritization of tests Tests are grouped into those that (1) primarily are effective at detecting cancer, and (2) those that are effective at detecting cancer and adenomatous polyps. Group 2 is preferred over group 1 due to the greater potential for prevention.

No specific prioritization of tests, though recommendations acknowledge that direct visualization techniques offer substantial benefit over fecal tests

Comparison of Recommendations

Guidelines for Polypectomy Surveillance

Polyp Characteristic Recommended Follow-up

Hyperplastic polyp 10 years

1 or 2 tubular adenomas, <1 cm

5-10 years

(consider family history, findings of prior colonoscopy and patient preference)

> 2 adenomas, > 1 cm, high grade dysplasia, or

villous

3 years

(shorter interval if >10 adenomas)

Large (>2cm) sessile polyp

3-6 months if removed piecemeal

5 years once completely removed

Malignant polyp with favorable criteria

3 months

Winawer SJ et al. Guidelines for colonoscopy surveillance after polypectomy. A Winawer SJ et al. Guidelines for colonoscopy surveillance after polypectomy. A consensus update by the US Multisociety Task Force on Colorectal Cancer and the consensus update by the US Multisociety Task Force on Colorectal Cancer and the American Cancer Society. CA Cancer J Clin 2006; 56:143-159American Cancer Society. CA Cancer J Clin 2006; 56:143-159

Important Points About CRCS

• The digital exam is not a recommended CRCS strategy

• A single office FOBT is not adequate screening• A positive FOBT should never be repeated; it should

always be followed up by colonoscopy• FOBT is not adequate surveillance for patients with a

history of adenomas• Success of screening stool tests depends on

participation in a screening program• FOBTs, FITs and sDNA tests vary in sensitivity and

specificity and guidelines recommend high sensitivity– FOBT: e.g. Hemoccult SENSA– FIT: e.g. immoCARE-C and FOB advanced have higher sensitivity and specificity– sDNA: e.g. EXACT Sciences

CRC Screening Rates in the U.S.

• 60.8% of adults over 50 years of age have had FOBT within the previous year of lower endosocopy within the previous 10 years

– BRFSS, 2006

• ~90% of patients who have not had CRCS report that a doctor’s recommendation would motivate them to undergo CRCS

Barriers to Recommending CRCS

• All eligible patients do not consistently receive All eligible patients do not consistently receive a provider recommendation for CRCSa provider recommendation for CRCS

• Barriers are at all levels: patient, physician, Barriers are at all levels: patient, physician, systemsystem

• Interventions are needed to address the Interventions are needed to address the multiple barriers to address patient, physician multiple barriers to address patient, physician and system level barriersand system level barriers

Guerra, CE et al. Barriers to Physician Recommendation of Colorectal Cancer Screening. J Guerra, CE et al. Barriers to Physician Recommendation of Colorectal Cancer Screening. J Gen Intern Med. 2007;22(12):1681-8.Gen Intern Med. 2007;22(12):1681-8.

How to Increase Colorectal Cancer Screening Rates in Practice: A

PCC Evidence-based Toolbox and Guide– Educational guide and compendium of tools to increase primary care

providers’ recommendation of colorectal cancer screening – Written by

» Mona Sarfaty, M.D., Research Assistant Professor, Dept of Health Policy, Thomas Jefferson University

– Edited by » Karen Peterson, Ph.D., Cancer Research and Prevention Foundation » Richard Wender, M.D., Professor and Chair, Dept of Family and Community

Medicine, Thomas Jefferson University

– Published » The National Colorectal Cancer Roundtable

– Funded by» American Cancer Society and Centers for Disease Control and Prevention

– Available at: http://www.nccrt.org/Documents/General/IncreaseColorectalCancerScreeningRates.pdf

The Toolbox Article and CME Quiz

• Sarfaty M, Wender R. How to increase colorectal cancer screening rates in practice. Ca Cancer J Clin 2007;57:354-366

• This article is available online at http://CAonline.AmCancerSoc.org

• Free CME credit for successfully completing the online quiz http://CME.AmCancerSoc.org

Toolbox

• Your recommendation

• Office policy

• Reminder system

• Communication strategies

Essential 1: Physician Recommendation

• Although many physicians recommend CRCS for their patients, few screen every eligible patient

• Why screen for CRCS?– Screening prevents CRC and reduces mortality

– Insurance reporting requirements (HEDIS®)

– P4P

– Malpractice suits involving missed diagnosis of CRC are costly

– CME

Impact of Physician Recommendation

• Physician recommendation is strongly associated with patient intent to undergo CRCS and completion of CRCS

Physician Recommendation

• Requires an opportunistic/global approach

– Don’t limit efforts to “check-ups” or “physicals”

• Requires a system that doesn’t depend on the doctor alone

Essential 2: An Office Policy

• An office policy is vital because it provides a systematic approach

• Only a systematic approach can insure that the physician’s recommendation is delivered to all patients

Essential 2: An Office Policy

• Policy takes into account – patient risk level: average, increased, high

» Tools included on how to risk stratify patients

– local medical resources» Access to CRCS tests in region; FOBT requires no facilities or

personnel

– insurance coverage» Insured? Covered? Deductible? Copay?

– patient preference » Tools are available for determining patient adherence

Office Policy: Determining Patient Risk

1. Have you or any members of your family had CRC?

2. Have you or any members of your family had an adenomatous polyp?

3. Has any member of your family had a CRC or adenomatous polyp when they were under the age of 50? (If yes, consider a hereditary syndrome)

4. Do you have a history of Crohn’s disease or ulcerative colitis (for more than 8 years)?

5. Do you or any members of your family have a history of cancer of the endometrium, small bowel, ureter, or renal pelvis? (If yes, consider HNPCC)

Office Policy: Determining Patient Risk

• Average risk – No personal history or first degree relatives with

colorectal polyps or cancer– Options for screening

» Flex sig every 5 years» Colonoscopy every 10 years» Double contrast barium enema every 5 years» CT colonography every 5 years» Guaiac-based FOBT» FIT» stool DNA

Office Policy: Determining Patient Risk

• Increased Risk– Has a personal or family history of colorectal polyps or CRC Or – Has a personal history of inflammatory bowel disease for more

than 8 years

• 18-20% of population is at increased risk • Patients are not given options for screening• Colonoscopy is the preferred screening test• Screening should begin earlier (age 40 or

younger)

Office Policy: Determining Patient Risk

• High Risk (hereditary colorectal cancer syndromes)–Hereditary non-polyposis colorectal

cancer (HNPCC)–Familial adenomatous polyposis (FAP)–Attenuated FAP

Office Policy: Determining Patient Risk

• High Risk– Suspect in someone with

» A family history of an adenomatous polyp or CRC in relative under age 50

» Two or more relatives with CRC

» Multiple colorectal adenomas (usually 10 or more) diagnosed over one or more exams

– Refer to local cancer genetic counselor www.nsgc.org

Recommendations at a Glance Using Risk Stratification

Risk Category Age to Screen Recommendation

Average Risk No risk factors and No symptoms

> Age 50Options:

–stool tests–endoscopy –radiologic studies

Increased RiskCRC/Adenomain a 1º relative

Age 40 or 10 years prior to earliest

diagnosis in family

Colonoscopy

High Risk Familial syndrome or IBD>8 years

Any ageSpecialty referral, colonoscopy, +/- genetic test

Office Policy: Determining Patient RiskOffice Policy: Determining Patient Risk

Assess Risk: Personal and FamilyAssess Risk: Personal and Family

Average Risk = no personal or family Average Risk = no personal or family hx of CRC or adenomatous polyphx of CRC or adenomatous polyp

<50 yrs<50 yrs +Personal history+Personal history

Do Not Do Not ScreenScreen

+Family History+Family History

If + f/u with If + f/u with diagnostic diagnostic

ColonoscopyColonoscopy

Adenoma or Adenoma or CancerCancer

Surveillance Surveillance ColonoscopyColonoscopy

begin in begin in childhoodchildhood

AdenomaAdenomaCRC CRC Or Or IBDIBD

Screen 10 yrs Screen 10 yrs before youngest before youngest relative or age 40relative or age 40

Surveillance Surveillance ColonoscopyColonoscopy

Germline Germline SyndromeSyndrome

Increased risk = + family Increased risk = + family or personal hx of CRC or adenomatousor personal hx of CRC or adenomatous

polyp, IBD > 8 yrspolyp, IBD > 8 yrsHigh risk = HNPCC related ca, FAP, aFAPHigh risk = HNPCC related ca, FAP, aFAP

>>50 yrs50 yrs

ScreenScreen

Insurance Coverage

• Currently, there is no federal legislation that requires insurers to cover preventive health screening

• As of 2009, only 28 states including the District of Columbia required insurance coverage of colorectal cancer screening

– Entertainment Industry Foundation

Insurance Coverage

• States that have enacted legislation that requires insurers to cover all CRCS options

– New Jersey, Maryland, Washington, DC, and Delaware, Pennsylvania (as of Jan 1, 2009)

Local Medical Resources

• The screening options available to the patients in your community

– FOBT requires no facilities or personnel other than the patient and staff of the office practice

– However, a positive screen requires a complete diagnostic exam by colonoscopy

Patient Preference

• Video decision aid for colorectal cancer screening (CHOICE) developed by UNC-Chapel Hill investigators

– Pignone M, et al. Videotape-based decision aid for colon cancer screening. A randomized, controlled trial. Ann Intern Med, 2000;133(10):761-9.

» CRCS was ordered in 47.2% of intervention and 36.8% of the control (auto safety video) (difference 20.8%, CI 8.6-32.9%)

» CRCS was completed in 36.8% of intervention and 22.6% of control (difference 14.2%, CI 3.0-25.4%)

– Available in VHS or DVD format for $25 from:» Jennifer Griffith, Sheps Center for Health Services Research, 725 Martin

Luther King Jr. Blvd, CB# 7590, Chapel Hill, NC 27599-7590

• Most physicians have a preferred screening strategy and will offer alternative strategies if patients refuse the preferred strategy

Example of Office Policy: FOBT Example of Office Policy: FOBT

Give FOBT kit to all patients over 50 at average riskGive FOBT kit to all patients over 50 at average risk

Patient returns FOBT kit in 1 monthPatient returns FOBT kit in 1 month

NoNo YesYes

Send reminder letter/postcardSend reminder letter/postcardPlace patient’s letter/postcard in next Place patient’s letter/postcard in next

year’s tickeryear’s ticker

Patient returns FOBT w/in 1 monthPatient returns FOBT w/in 1 month Record results in chart and notify pt of Record results in chart and notify pt of resultsresults

NoNo YesYes

Direct ContactDirect Contact

NegativeNegative PositivePositive

Repeat in 1 yr or offer FS or CSRepeat in 1 yr or offer FS or CS Schedule CSSchedule CS

Office Policy

• Once an office policy is created, the office staff must be engaged to actualize it

– Present office policy to staff and offer them the opportunity to ask questions

– Depict it using an algorithm– Post it– Disseminate it– Staff reminders

Office Policy

• Physicians fall into the pattern that they alone must change in order to improve practice patterns

• Physicians often fail to recognize that to effect change, the office system must be changed

– By engaging other office members, staff– By developing reminder systems and cues to

action

Office Policy: Sample Script

“Dr. Smith would like for you to be tested for CRCS. You have two choices:

1. You may choose the take home method called fecal occult blood test or FOBT. With an FOBT, if a problem is found, you will need a colonoscopy or

2. You may go directly to colonoscopy.”

Essential 3: An Office Reminder System

• Reminder systems are “Cues to Action”

• Reminder systems can be directed at patients, clinicians, or both

• Reminder systems can be simple, or complex, with the more complex systems having the greatest benefit

• 58% of physicians do not use reminder systems; 37% have a paper reminder system

Essential 3: An Office Reminder System

• Reminders for patients– Passive

» Letters » Postcards» Prescriptions» Pamphlets» DVDs, videos» Websites» List of agencies that have available educational material included in

Toolbox

– Active» Telephone scripts» In-person» Electronic: For highly motivated patients: myhealthtestreminder.com

Patient Reminder Letters

Patient Reminder Postcard

Telephone Scripts

www.MyHealthTestReminder.com

Patient Cues to Action

• Patient educational material – ACS posters, brochures, videos can be ordered

for free via the web: cancer.org/colonmd

American Cancer Society

Patient Education ToolsThis free brochure encourages your patients to talk with you about colorectal cancer screening and provides a list of questions to ask to help facilitate the conversation.

Available at www.cancer.org/colonmd

American Cancer Society

Patient Education Tools

Available at www.cancer.org/colonmd

This free kit includes a brochure, a seven minute informational DVD, and a booklet on testing options. The information explains the most commonly used screening methods including test preparation, in simple language.

Reminders for Physicians

• Behavioral– Chart stickers– Problem lists– Screening schedules/flow sheets– Integrated summary– Paper tracking templates– Electronic reminders: EMR (Vista-Office Electronic Health Record ;

AC-group/IOM requirements for EMRs)– Tracking databases: paper and electronic (COMMAND, PECS2)

• Cognitive: Audit and Feedback, Ticklers (provides national benchmarks and targets)

• System: Staff assignments

Preventive Service Schedule

http://www.ahrq.gov/ppip/timelinead.pdf

Flow Sheets

http://www.nyc.gov/html/doh/http://www.nyc.gov/html/doh/downloads/pdf/csi/hyperkit-clin-ptvcare-downloads/pdf/csi/hyperkit-clin-ptvcare-flowsht.pdfflowsht.pdf

http://www.aafp.org/fpm/20010200/http://www.aafp.org/fpm/20010200/preventivecareflowsheets.pdfpreventivecareflowsheets.pdf

Sample Paper Tracking Template (“Tickler”)

MRN

Tel #

Name Sex Race/Ethnicity

DOB RiskA/I/H

FOBT distribution date

FOBT result

FS referral date

CS referral date

NeedsFOBT, FS, CS, none

Date reminder written/Telephone contact

Test result and notification date

Comment

Electronic Medical Records

• Vista-Office Electronic Health Record (VOE) project. More information can be obtained at: http://www.worldvista.org/

• Free, online rating system for electronic medical records by the AC group based on the Institute of Medicine’s requirements for a computerized patient record at: www.acgroup.org/pages/396843/index.htm

Electronic Tracking Systems

•COMORBID DISEASE MANAGEMENT DATABASE from MI Quality Improvement Organization: COMORBID DISEASE MANAGEMENT DATABASE from MI Quality Improvement Organization: http://www.iqh.org/index.php3?area=command&topic=101671 http://www.iqh.org/index.php3?area=command&topic=101671

•PATIENT ELECTRONIC CARE SYSTEM TX Assoc of Community Health Centers: www.pecsusers.netPATIENT ELECTRONIC CARE SYSTEM TX Assoc of Community Health Centers: www.pecsusers.net

Audit and Feedback

• Chart audit – Review a prerequisite number of charts to document whether a certain

elements are found on the chart– Produces an 18.6% improvement in screening rates– Can produce feedback for a provider or a practice– Overcomes physician recall bias or inability to self-assess the

proportion of their patients that have been screened

• A repeat audit may be conducted to assess the impact of an intervention

– Time interval for repeat audit varies depending on » size of the practice» patient population» staffing level» intervention that has been implemented

Chart Audits Template

Staff Involvement

• Key Point…..the Doctor Can’t Do It All

• The time that patients spend with non-physician staff is underutilized

• Standing orders can empower nurses, PA’s, intake staff, etc. to distribute materials, distribute patient surveys to be completed in the waiting room, stool blood cards, schedule appointments for colonoscopy, etc.

• Involve staff in meetings to discuss progress in achieving office goals for improving the delivery of preventive services

Essential 4: Effective Communication

• Stage-based communication – Based on the Transtheoretical Model (Prochaska & Based on the Transtheoretical Model (Prochaska &

DiClemente)DiClemente)

• Individuals who are candidates for Individuals who are candidates for making a health behavior change do making a health behavior change do so in different stages of readinessso in different stages of readiness

EducationEducation

Examine Examine patient patient barriersbarriers

Practical Practical how-to how-to informationinformation

Readdress Readdress screening screening at a later at a later timetime

Select a Select a screening screening option and option and provide provide motivational motivational informationinformation

Summary

• Every eligible patient should receive a recommendation for CRCS

• This is most likely to occur if – The provider or the staff provide a personal recommendation to each

patient– There is an office policy to assure that each patient receives a CRCS

recommendation from their provider– There are reminder systems in place targeting providers/staff and

patients– There is effective, stage-based communication

• The Toolbox contains many tools to systematically recommend CRCS to each eligible patient

• Toolbox can be accessed at: cancer.org/colonmd

Conclusion

The barrier to reducing the number of deaths from colorectal cancer is not a lack of scientific data but a lack of organizational, financial and societal commitment.

– Daniel K. Podolsky, MD (NEJM, 7/20/00)

Acknowledgement

• Funding support– National Cancer Institute grant number K22CA133186

– Robert Wood Johnson Foundation Amos Medical Faculty Development Award

• American Cancer Society, PA division– Diana Fox, Director, Strategic Collaborations

– Mauricio Conde, Project Manager, Health Systems

• Toolbox authors, editors, developers including the CDC, ACS and NCCRT

Questions?