colorectal cancer update for healthcare providers may 2013

Colorectal Cancer UpdateColorectal Cancer Update

for Healthcare Providersfor Healthcare Providers

May 2013May 2013

Maryland Department of Health and Mental HygienePrevention and Health Promotion Administration

Cigarette Restitution Fund ProgramCenter for Cancer Prevention and Control

Prevention and Health Promotion Administration May 2013

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CRC Incidence, Mortality, and CRC Incidence, Mortality, and Survival in the U.S.Survival in the U.S.


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Colorectal CancerColorectal Cancer

Third most commonly diagnosed cancer in Maryland among both men and women

Second leading cause of cancer-related mortality

Incidence and mortality have been decreasing in recent years


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Colorectal Cancer Incidence and Mortality RatesColorectal Cancer Incidence and Mortality Ratesby Year of Diagnosis or Death, Maryland,by Year of Diagnosis or Death, Maryland,

2002-20082002-2008

Maryland Cancer Registry (incidence rates) NCHS Compressed Mortality File in CDC WONDER (mortality rates)


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Source: SEER 9 areas. SEER Source: SEER 9 areas. SEER Program, National Cancer Institute. Program, National Cancer Institute.

5-year CRC survival has improved over the past 30 years in

the U.S.

Colorectal Cancer


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CRC ScreeningCRC Screening


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Colorectal Cancer Screening Status of People Colorectal Cancer Screening Status of People Age 50 Years and OlderAge 50 Years and Older

Maryland Cancer Surveys and BRFSS, 2002-2010Maryland Cancer Surveys and BRFSS, 2002-2010

2317

1011

41

10

26

50

2320

59

11

67

18

7

98

66

5

22

0 10 20 30 40 50 60 70

Up-to-date withcolonoscopy

Up-to-date withFOBT and/or

sigmoidoscopy

Tested but not up-to-date*

Never tested

Percent

2002 2004 2006 2008 2010

Maryland Cancer Survey, 2002-2008BRFSS, 2010


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80% of people 50+ in 80% of people 50+ in Maryland reported having a Maryland reported having a provider provider recommend recommend endoscopy…..

of those, 88% got screened

88%

24%

0%

25%

50%

75%

100%

Providerrecommended

No providerrecommended

Per

cen

t S

cree

ned

w

ith

En

do

sco

py

Maryland Cancer Survey, 2008

Provider Recommendation is KEY to Screening

Of the 20% who did NOT report a provider recommendation….only 24% got screened


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Colorectal Cancer Screening with

colonoscopy or sigmoidoscopy?

(50+ years)

Never screened withcolonoscopy orsigmoidoscopy

25%

Ever screened with colonoscopy or Sigmoidoscopy

75%



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Colorectal Cancer Screening

with colonoscopy orsigmoidoscopy?

(50+ years)

Never screenedwith colonoscopy or

sigmoidoscopy25%

Ever screened with colonoscopy orSigmoidoscopy

75%

85% 85% have been to doctor have been to doctor

for “routine checkup”for “routine checkup” in past 2 yearsin past 2 years

Only 15%have NOT had checkup



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Patient:Family and personal historyPast screeningSymptoms

Primary Doctor:Referral

Pathologist:Pathology report

Case Management and Communication

Colonoscopist:Risk historyMedication changesPrep instructionsPost colonoscopy instructionsColonoscopy report

FindingsRecommendations


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Who needs screening?Who needs screening?


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0

50

100

150

200

250

300

350

400

450

Ag

e-s

pec

ific

rat

e p

er 1

00,0

00 p

op

ula

tio

n

Age Group

Colorectal Cancer Age-Specific Incidence Ratesby Gender, Maryland and U.S., 2004-2008

MD Male MD Female U.S. Male U.S. Female

Source: Maryland Cancer Registry


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Colorectal Cancer Cases by Risk HistoryColorectal Cancer Cases by Risk History

Sporadic Sporadic (average risk) (65%–85%)(average risk) (65%–85%)

FamilyFamilyhistoryhistory(10%–30%)(10%–30%)

Hereditary nonpolyposis Hereditary nonpolyposis colorectal cancer (HNPCC, 2-3%)colorectal cancer (HNPCC, 2-3%)

Familial adenomatous Familial adenomatous polyposis (FAP) (<1%)polyposis (FAP) (<1%)

Rare syndromes Rare syndromes (<0.1%)(<0.1%)

http://www.cancer.gov/cancertopics/pdq/genetics/colorectal/HealthProfessional


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Risk of CRCRisk of CRC

Group Approx. lifetime risk of CRC

General Population 5-6%

One first degree relative (FDR) with CRC 2--3-fold increase over general population

Two FDRs with CRC 3--4-fold increase

FDR with CRC diagnosed < 50 3--4-fold increase

One second or third degree relative About 1.5-fold increase

Two second degree relatives About 2--3-fold increase

Inflammatory Bowel Disease

(ulcerative colitis and Crohn’s colitis)

7-10% have CRC after having ulcerative colitis for 20 years;

then ~1%/year

Familial adenomatous polyposis (FAP)

Hereditary non-polyposis colorectal cancer (HNPCC)

~100%

~80+%

Burt RW. Gastroenterology 2000;119:837-53 Winawer S, et al. Gastroenterology 2003;124:544-560


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Average Risk

Increased Risk

Colonoscopy, every 10 years orFOBT or FIT annually if refuse endoscopy orFlexible sigmoidoscopy, every 5 years with a high sensitivity fecal occult blood test* (FOBT), every 3 years

Colonoscopy(interval for repeat depends on risk, history, and prior colonoscopy results)

Maryland Screening Recommendations:Medical Advisory Committee on CRC

* Hemoccult SENSA or fecal immunochemical test (FIT)


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Risk Category Age to Begin Screening

Average risk Age 50 years

Increased risk

Family History

Colorectal cancer or adenomatous polyp(s)* in an FDR age <60, or in 2 or more FDRs at any age

* Especially if advanced adenomas: > 1 cm; villous histology; or high grade dysplasia

Age 40 years, or 10 years before the youngest case in the immediate family, whichever is earlier

Genetic syndrome:

Familial adenomatous polyposis (FAP)

Hereditary non-polyposis colorectal

cancer (HNPCC)

Age 10 to 12 years

Age 20 to 25 years, or 10 years before the youngest case in the immediate family

Inflammatory bowel disease Cancer risk begins to be significant 8 years after the onset of pancolitis (involvement of entire large intestine), or 12-15 years after the onset of left-sided colitis

Rex DK, et al. Am J Gastroenterol 2009:104;739-750American Cancer Society, 2012 http://www.cancer.org/Cancer/ColonandRectumCancer/MoreInformation/ColonandRectumCancerEarlyDetection/colorectal-cancer-early-detection-acs-recommendations

Age to Begin Screening by Risk Category


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Guidelines

Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008:

A Joint Guideline from the American Cancer Society,

the U.S. Multi-Society Task Force on CRC, and the American College of Radiology

CA Cancer J Clin 58: 130-160 (May 2008)


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Tests that Find Both Polyps and Cancer

Flexible sigmoidoscopy every 5 years

Colonoscopy every 10 years

Double contrast barium enema every 5 years

CT colonography (virtual colonoscopy) every 5 years

Guidelines, American Cancer Society, June 2012http://www.cancer.org/Cancer/ColonandRectumCancer/MoreInformation/ColonandRectumCancerEarlyDetection/colorectal-cancer-early-detection-screening-tests-used


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Tests that Primarily Find Cancer

High sensitivity FOBT every yearHemoccult SENSA or fecal immunochemical test (FIT)

Stool DNA test (unclear how often this is needed,

not currently available commercially is U.S.)

Guidelines, American Cancer Society, 2012http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/colorectal-cancer-detection-recommendationsUnited States Preventive Services Task Force http://www.uspreventiveservicestaskforce.org/uspstf08/colocancer/coloartzaub.htm#results


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CRC Screening Guidelines CRC Screening Guidelines American Cancer Society, June 2012American Cancer Society, June 2012

Beginning at age 50, men and women at average risk for CRC should use one of the screening tests.

The tests that are designed to find both early cancer and polyps are preferred if these tests are available to the patient and the patient is willing to have one of these more invasive tests.

Talk to your doctor about which test is best for you.


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CRC Screening under the CRC Screening under the Cigarette Restitution Fund Cigarette Restitution Fund

Program (CRFP) in Maryland Program (CRFP) in Maryland


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25


26


27


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Summary of Cigarette Restitution FundSummary of Cigarette Restitution FundColorectal Cancer Screening in MarylandColorectal Cancer Screening in Maryland

As of December 31, 2012:

23,203 23,203 People have had one or more People have had one or more screening proceduresscreening procedures

____________________________________________________________________________

8,356 FOBTs (all income levels)FOBTs (all income levels) 181 SigmoidoscopiesSigmoidoscopies21,355 ColonoscopiesColonoscopies

DHMH, CCPC, Client Database, C-CoPD, as of 2/25/2013


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Summary of Cigarette Restitution FundSummary of Cigarette Restitution FundColorectal Cancer ScreeningColorectal Cancer Screening________ County, Maryland________ County, Maryland

2000-20XX:

XXXX Individuals screened for CRC Individuals screened for CRC by one or more methodby one or more method++

____________________________________________________________

XXXX FOBTs* FOBTs*XX Colonoscopies*XX Colonoscopies*____________________________________________________________

XX Cancers* Cancers* X High grade dysplasia*X High grade dysplasia* XX Adenoma(s)*XX Adenoma(s)*

DHMH, CCPC, Client Database, C-CoPD, as of xx/xx/xxxx DHMH, CCPC, Client Database, C-CoP, as of xx/xx/xxxx

Obtain numbers for y

our

jurisdiction from th

e Client

Database, C-CoPD and C-CoP

reports, o

r call L

orraine

Underwood 410-767-0791


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Gender of 23,173 Screened* for CRC Gender of 23,173 Screened* for CRC Maryland, 2000-December 2012Maryland, 2000-December 2012

*Of clients with known gender screened with one or more of the following: FOBT, flexible sigmoidoscopy, colonoscopy, imaging

Women15,586(67%)

Men7,587(33%)



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Minority Status of 23,203 New People Screened* for CRC, Minority Status of 23,203 New People Screened* for CRC, Maryland, 2000-December 2012Maryland, 2000-December 2012

*Of clients screened with one or more of the following: FOBT, flexible sigmoidoscopy, colonoscopy, imaging

Non-minority or Unknown11,110 (48%)

Minority12,093 (52%)



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Results* of 21,356 ColonoscopiesResults* of 21,356 Colonoscopies Maryland Cigarette Restitution Fund Program Maryland Cigarette Restitution Fund Program

Maryland, 2000-December 2012Maryland, 2000-December 2012

* Most “advanced” finding on colonoscopy

DHMH, CCPC, Client Database, C-CoP, as of 2/27/2013

Cancer/Suspect Cancer, 243, 1%

Adenoma High-Grade, 88, 0%

Adenomas, Other, 5,074, 24%

Other poly ps, 4,580, 22%

Other f indings, 7,771, 36%

Negativ e, 3294, 15%

Inadequate col but no f indings, 306, 1%


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Recommended screening Recommended screening afterafter initial screening-- initial screening--

rescreening or surveillance rescreening or surveillance colonoscopycolonoscopy

“Recall Interval”


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After first colonoscopy, then whatthen what?

Interval between colonoscopies will depend on: – findings on last colonoscopy, – risk history, and– symptoms


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For the recommended recall intervals, please see:

DHMH Colorectal Cancer Minimal Elements

http://phpa.dhmh.maryland.gov/cancer/Shared%20Documents/ccpc13-24--att_CRCMinimalElements2013[1].pdf

(or http://phpa.dhmh.maryland.gov/cancer/ under Resources)


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Guidelines for Recall Intervals Guidelines for Recall Intervals Following ColonoscopyFollowing Colonoscopy

Lieberman DA, Rex DK, Winawer SJ, Giardiello FM, Johnson DA, Levin TR. Guidelines for Colonoscopy Surveillance After Screening and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology, 2012;143:844–857

Rex DK, Ahnen DJ, Baron JA, Batts KP, Burke CA, et al. Serrated lesions of the colorectum: Review and recommendations from an expert panel. Am J Gastroenterol. 2012:109;1315-29.


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Keys to the right recallKeys to the right recall

1. Colonoscopy Report

2. Pathology Report

3. Recommendation based on guidelines

4. Communication

Prevention and Health Promotion Administration [Date]

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Standards for Colonoscopy Reports—Standards for Colonoscopy Reports—CO-RADS*CO-RADS*

Colonoscopy report should include:

Date and Time - Procedure Patient description Risk factorsASA class IndicationsConsent signed Sedation Colonoscope Bowel prep adequacy

Whether cecum reached Colonoscopy withdrawal time Findings Specimen(s) to path lab Impression Complications Pathology Recommendations Follow-up plan/Recall Other

*Standardized colonoscopy reporting and data system: report of the Quality Assurance Task Group of the National Colorectal Cancer Roundtable, Lieberman et al., Gastrointestinal Endoscopy 2007; 65: 757-766


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Adequacy of First ColonoscopyAdequacy of First ColonoscopyAmong 16,813* First Cycle ColonoscopiesAmong 16,813* First Cycle Colonoscopies

Maryland, 2000-December 2012Maryland, 2000-December 2012

*16,813 of the 17,915 first colonoscopies had information on “adequacy” of the col in CRFP.DHMH, CCPC, Client Database, Data Download, 2/27/2013

Adequate 15,258 (91%)

Not Adequate 1,555 (9%)

(Inadequate prep OR didn't reach

cecum)


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Reporting on

Colonoscopy Findings: – Number of masses, polyps, other lesions

(try to give actual or estimated number rather than “several” or “multiple”)

– Findings: for EACH mass/polyp/lesion

locationsize description tattoo biopsy(ies) taken method of each biopsywhether lesion completely removed or not

whether there was piecemeal removal whether specimens retrievedwhether saline lift usednumber of specimens sent to pathology


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How will your patients be reminded How will your patients be reminded about their about their nextnext colonoscopy?colonoscopy?


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Patient:Family and personal historyPast screeningSymptoms

Primary Doctor:Referral

Pathologist:Pathology report

Case Management and Communication

Colonoscopist:Risk historyMedication changesPrep instructionsPost colonoscopy instructionsColonoscopy report

FindingsRecommendations


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Acknowledgements

•Funding from the Maryland Cigarette Restitution Fund (CRF)

•Staff and partners of Local Public Health Department Programs in MD and their contracted providers

•DHMH Center for Cancer Prevention and Control (CCPC)• Database and Quality assurance• Surveillance and Evaluation Unit including

- University of Maryland at Baltimore- Ciber, Inc.

• CCPC CRF Programs Unit• Maryland Cancer Registry

•Minority Outreach Technical Assistance Partners

http://phpa.dhmh.maryland.gov

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