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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?