Measure Guideline: Condensing Boilers - Control Strategies - NREL
Thank you for joining The Guideline Advantage this afternoon!wcm/@tga/documents... · 2013. 12....
68
This event is being streamed. It is recommended that you listen via your computer speakers. We will be starting the presentation shortly. Thank you for joining The Guideline Advantage this afternoon! 1
Transcript of Thank you for joining The Guideline Advantage this afternoon!wcm/@tga/documents... · 2013. 12....
This event is being streamed It is recommended
that you listen via your computer speakers
We will be starting the presentation shortly
Thank you for joining The Guideline Advantage this afternoon
1
Cancer Screening Colorectal Cancer Opportunities for Improvement Webinar Presented December 04 2013
To improve the health of all patients through widespread application of primary and secondary prevention guidelines in the United States through data collection analysis feedback
and quality improvement in the ambulatory setting
Vision amp Goal
Vision
To improve the long-term compliance with the ACS ADA and AHAACC guidelines which in turn supports our shared
organizational mission to prevent chronic diseases and to improve the lives of those living with the nationrsquos most
prevalent chronic diseases
Goal
The Guideline Advantage is based on the success of nearly 10 years experience in inpatient quality improvement and over 2 millions lives touched
bull Providers can use several different
technology platforms
bull Practices submit collective clinical data to Forward Health Group for The Guideline Advantage
bull Data are processed analyzed and provided back to the practice via
a practice portal
1
2
3
bull Performance is measured Professionals can set
measureable goals and chart improvements in performance
4
Program Model
As a part of quality improvement clinical data must be aggregated into a data warehouse to facilitate analysis and reporting
Data Extract
Data import
ELECTRONIC MEDICAL RECORD Data
Infrastructure
Key activities include - Data Alignment
- Denominator Calculation - Numerator Calculations
- Attribution - Benchmarking Customer
Data Mart
Technically speakinghellip how does it work
Database
Program Functionality The Guideline Advantage Measure Sets + an Additional Measure Set available as
defined by the customer Patient Lists and action list functionality Views amp filtering options for Teams Comparison Benchmarking amp Historical Trending Customer Driven Functionality including demographic information displays incentive
program tracking amp non-clinical custom groupings Complete data advisory service including comprehensive consultations and guidance
in identifying data sources mapping data cleansing and alignment Fixed implementation fee and annual licenses
On-demand access to quality improvement data using a web-based tool Available physician-level reporting Clinic and system aggregation Tools for creating action lists Alignment with key national initiatives National and State Benchmarking Practice Network opportunities including virtual workshops and national recognition
Advantages to Practices amp Physicians
Diabetes Mellitus
bull HbA1c Control bull LDL Control bull High Blood
Pressure Control bull Annual
nephropathy screening (urine albumin)
Preventive Care Screening
bull BMI Screening amp Follow-up
bull Influenza Vaccination
bull Tobacco Use and Counseling
bull Blood Pressure Screening
bull LDL Measurement
Cancer
bull Colorectal Cancer Screening
bull Mammography Screening
bull Cervical Cancer Screening
Cardiovascular
bull Ischemic Vascular Disease Aspirin Use amp Lipid panel
bull Hypertension Blood Pressure Control
bull CAD Lipid-lowering Therapy
bull CAD Antiplatelet Therapy
bull CAD Blood Pressure Control
bull CAD Tobacco Use
The Guideline Advantagersquos Measures
Measures are subject to change
Alignment with National Programs
Million Hearts Initiative The Guideline Advantage reports on the ldquoABCSrdquo measures of interest to Million Hearts httpmillionheartshhsgovindexhtml
Uniform Data System (UDS)
The program reports all adult UDS measures of interest to Community Health Centers and Federally Qualified Health Centers httpwwwudsmrorg
Leading practices for effective participation
Use existing EHR platform donrsquot interrupt work flow to collect data offer vend or neutral program model
Provide tools and resources (Webinars CME programs etc) to help develop a culture of quality improvement
Provide feedback and consult with practices on how to disseminate information
Encourage focus on 1-2 areas only
Direct practices to resources to support improvement
Recognize and link to incentives
These are just a few of the best practices shared by the program
Colorectal Cancer Opportunities for Improvement
Lewis Foxhall MD
VP for Health Policy UT MD Anderson Cancer Center Professor Clinical Cancer Prevention
Cancer Screening
Colorectal Cancer Learning Objectives
Following this lecture participants will be able to
Understand recommendations for colorectal cancer screening
Assess risk for colorectal cancer and assist patients in determining the screening method(s) most appropriate for them
Recognize common barriers to colorectal cancer screening and learn about strategies to address those barriers
Take steps to improve screening in practice
QUESTION
After lung cancer what is the most frequent cause of mortality from cancer in the US
Breast Prostate Colon Leukemia
Colorectal Cancer
The third most common cancer in US and the second deadliest bull 142820 estimated new cases 2013 bull 50830 deaths nationwide
More than 1 million US colorectal cancer
survivors
Cancer Facts and Figures 2013 wwwcancerorg
Cancer Death Rates by Race and Ethnicity US 2005-2009
RaceEthnicity Male Female
All Races 522 per 100000 men 393 per 100000 women
White 513 per 100000 men 384 per 100000 women
Black 643 per 100000 men 492 per 100000 women
AsianPacific Islander 438 per 100000 men 327 per 100000 women
American IndianAlaska Native a 441 per 100000 men 366 per 100000 women
Hispanic b 455 per 100000 men 316 per 100000 women
Incidence Rates by Race 2006-2010
httpseercancergovstatfactshtmlcolorecthtml
Colorectal Cancer Incidence
RaceEthnicity Male Female
All Races 196 per 100000 men 139 per 100000 women
White 191 per 100000 men 134 per 100000 women
Black 287 per 100000 men 190 per 100000 women
AsianPacific Islander 131 per 100000 men 97 per 100000 women American IndianAlaska Native a 187 per 100000 men 154 per 100000 women
Hispanic b 161 per 100000 men 102 per 100000 women
Death Rates by Race 2006-2010
Colorectal Cancer Mortality
QUESTION
For colorectal cancer what is the approximate survival rate for disease confined to primary site (Localized)
10 30 50 90
For cancer that has metastasized (Distant) 10 30 50 90
Polyp to Carcinoma Pathway
Normal to Adenoma to Carcinoma
Human colon carcinogenesis progresses by the dysplasiaadenoma
to carcinoma pathway
Polyp Charactoristics
Hyperplastic bull minimal cancer potential
Adenomatous bull approximately 90 of colon
and rectal cancers arise from adenomas
Stage at Diagnosis Stage Distribution ()
5-year Relative Survival ()
Localized (confined to primary site) 40 903
Regional (spread to regional lymphnodes) 36 704
Distant (cancer has metastasized) 20 125
Unknown (unstaged) 5 336
Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for 2003-2009 All Races Both Sexes
Stage Distribution and Survival
Colorectal Screening Rates
Opportunity for Improvement
Only 40 of colorectal cancers are detected at the earliest stage
A little more than half of Americans over age 50 report having had a recent colorectal cancer screening test
Slow but steady improvement in these numbers over the past decade
Screening rates remain lower in the underserveduninsured population than in the general population
Colorectal Cancer Risk Factors
Age bull 90 of cases occur in people 50 and older bull Average age of diagnosis 69
Gender bull slight male predominance but common in both men and women
RaceEthnicity bull African Americans have highest incidence and mortality rate of
all groups in US Hispanics the lowest (with considerable variation depending on country of origin)
bull Increased rates also documented in Alaska Natives some American Indian tribes Ashkenazi Jews
Colorectal Cancer Risk Factors
Sporadic (average risk) (65ndash85)
Family history
(10ndash30)
Hereditary nonpolyposis colorectal cancer
(HNPCC) (5) Familial adenomatous
polyposis (FAP) (1)
Rare syndromes
(lt01)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Cancer Screening Colorectal Cancer Opportunities for Improvement Webinar Presented December 04 2013
To improve the health of all patients through widespread application of primary and secondary prevention guidelines in the United States through data collection analysis feedback
and quality improvement in the ambulatory setting
Vision amp Goal
Vision
To improve the long-term compliance with the ACS ADA and AHAACC guidelines which in turn supports our shared
organizational mission to prevent chronic diseases and to improve the lives of those living with the nationrsquos most
prevalent chronic diseases
Goal
The Guideline Advantage is based on the success of nearly 10 years experience in inpatient quality improvement and over 2 millions lives touched
bull Providers can use several different
technology platforms
bull Practices submit collective clinical data to Forward Health Group for The Guideline Advantage
bull Data are processed analyzed and provided back to the practice via
a practice portal
1
2
3
bull Performance is measured Professionals can set
measureable goals and chart improvements in performance
4
Program Model
As a part of quality improvement clinical data must be aggregated into a data warehouse to facilitate analysis and reporting
Data Extract
Data import
ELECTRONIC MEDICAL RECORD Data
Infrastructure
Key activities include - Data Alignment
- Denominator Calculation - Numerator Calculations
- Attribution - Benchmarking Customer
Data Mart
Technically speakinghellip how does it work
Database
Program Functionality The Guideline Advantage Measure Sets + an Additional Measure Set available as
defined by the customer Patient Lists and action list functionality Views amp filtering options for Teams Comparison Benchmarking amp Historical Trending Customer Driven Functionality including demographic information displays incentive
program tracking amp non-clinical custom groupings Complete data advisory service including comprehensive consultations and guidance
in identifying data sources mapping data cleansing and alignment Fixed implementation fee and annual licenses
On-demand access to quality improvement data using a web-based tool Available physician-level reporting Clinic and system aggregation Tools for creating action lists Alignment with key national initiatives National and State Benchmarking Practice Network opportunities including virtual workshops and national recognition
Advantages to Practices amp Physicians
Diabetes Mellitus
bull HbA1c Control bull LDL Control bull High Blood
Pressure Control bull Annual
nephropathy screening (urine albumin)
Preventive Care Screening
bull BMI Screening amp Follow-up
bull Influenza Vaccination
bull Tobacco Use and Counseling
bull Blood Pressure Screening
bull LDL Measurement
Cancer
bull Colorectal Cancer Screening
bull Mammography Screening
bull Cervical Cancer Screening
Cardiovascular
bull Ischemic Vascular Disease Aspirin Use amp Lipid panel
bull Hypertension Blood Pressure Control
bull CAD Lipid-lowering Therapy
bull CAD Antiplatelet Therapy
bull CAD Blood Pressure Control
bull CAD Tobacco Use
The Guideline Advantagersquos Measures
Measures are subject to change
Alignment with National Programs
Million Hearts Initiative The Guideline Advantage reports on the ldquoABCSrdquo measures of interest to Million Hearts httpmillionheartshhsgovindexhtml
Uniform Data System (UDS)
The program reports all adult UDS measures of interest to Community Health Centers and Federally Qualified Health Centers httpwwwudsmrorg
Leading practices for effective participation
Use existing EHR platform donrsquot interrupt work flow to collect data offer vend or neutral program model
Provide tools and resources (Webinars CME programs etc) to help develop a culture of quality improvement
Provide feedback and consult with practices on how to disseminate information
Encourage focus on 1-2 areas only
Direct practices to resources to support improvement
Recognize and link to incentives
These are just a few of the best practices shared by the program
Colorectal Cancer Opportunities for Improvement
Lewis Foxhall MD
VP for Health Policy UT MD Anderson Cancer Center Professor Clinical Cancer Prevention
Cancer Screening
Colorectal Cancer Learning Objectives
Following this lecture participants will be able to
Understand recommendations for colorectal cancer screening
Assess risk for colorectal cancer and assist patients in determining the screening method(s) most appropriate for them
Recognize common barriers to colorectal cancer screening and learn about strategies to address those barriers
Take steps to improve screening in practice
QUESTION
After lung cancer what is the most frequent cause of mortality from cancer in the US
Breast Prostate Colon Leukemia
Colorectal Cancer
The third most common cancer in US and the second deadliest bull 142820 estimated new cases 2013 bull 50830 deaths nationwide
More than 1 million US colorectal cancer
survivors
Cancer Facts and Figures 2013 wwwcancerorg
Cancer Death Rates by Race and Ethnicity US 2005-2009
RaceEthnicity Male Female
All Races 522 per 100000 men 393 per 100000 women
White 513 per 100000 men 384 per 100000 women
Black 643 per 100000 men 492 per 100000 women
AsianPacific Islander 438 per 100000 men 327 per 100000 women
American IndianAlaska Native a 441 per 100000 men 366 per 100000 women
Hispanic b 455 per 100000 men 316 per 100000 women
Incidence Rates by Race 2006-2010
httpseercancergovstatfactshtmlcolorecthtml
Colorectal Cancer Incidence
RaceEthnicity Male Female
All Races 196 per 100000 men 139 per 100000 women
White 191 per 100000 men 134 per 100000 women
Black 287 per 100000 men 190 per 100000 women
AsianPacific Islander 131 per 100000 men 97 per 100000 women American IndianAlaska Native a 187 per 100000 men 154 per 100000 women
Hispanic b 161 per 100000 men 102 per 100000 women
Death Rates by Race 2006-2010
Colorectal Cancer Mortality
QUESTION
For colorectal cancer what is the approximate survival rate for disease confined to primary site (Localized)
10 30 50 90
For cancer that has metastasized (Distant) 10 30 50 90
Polyp to Carcinoma Pathway
Normal to Adenoma to Carcinoma
Human colon carcinogenesis progresses by the dysplasiaadenoma
to carcinoma pathway
Polyp Charactoristics
Hyperplastic bull minimal cancer potential
Adenomatous bull approximately 90 of colon
and rectal cancers arise from adenomas
Stage at Diagnosis Stage Distribution ()
5-year Relative Survival ()
Localized (confined to primary site) 40 903
Regional (spread to regional lymphnodes) 36 704
Distant (cancer has metastasized) 20 125
Unknown (unstaged) 5 336
Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for 2003-2009 All Races Both Sexes
Stage Distribution and Survival
Colorectal Screening Rates
Opportunity for Improvement
Only 40 of colorectal cancers are detected at the earliest stage
A little more than half of Americans over age 50 report having had a recent colorectal cancer screening test
Slow but steady improvement in these numbers over the past decade
Screening rates remain lower in the underserveduninsured population than in the general population
Colorectal Cancer Risk Factors
Age bull 90 of cases occur in people 50 and older bull Average age of diagnosis 69
Gender bull slight male predominance but common in both men and women
RaceEthnicity bull African Americans have highest incidence and mortality rate of
all groups in US Hispanics the lowest (with considerable variation depending on country of origin)
bull Increased rates also documented in Alaska Natives some American Indian tribes Ashkenazi Jews
Colorectal Cancer Risk Factors
Sporadic (average risk) (65ndash85)
Family history
(10ndash30)
Hereditary nonpolyposis colorectal cancer
(HNPCC) (5) Familial adenomatous
polyposis (FAP) (1)
Rare syndromes
(lt01)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
To improve the health of all patients through widespread application of primary and secondary prevention guidelines in the United States through data collection analysis feedback
and quality improvement in the ambulatory setting
Vision amp Goal
Vision
To improve the long-term compliance with the ACS ADA and AHAACC guidelines which in turn supports our shared
organizational mission to prevent chronic diseases and to improve the lives of those living with the nationrsquos most
prevalent chronic diseases
Goal
The Guideline Advantage is based on the success of nearly 10 years experience in inpatient quality improvement and over 2 millions lives touched
bull Providers can use several different
technology platforms
bull Practices submit collective clinical data to Forward Health Group for The Guideline Advantage
bull Data are processed analyzed and provided back to the practice via
a practice portal
1
2
3
bull Performance is measured Professionals can set
measureable goals and chart improvements in performance
4
Program Model
As a part of quality improvement clinical data must be aggregated into a data warehouse to facilitate analysis and reporting
Data Extract
Data import
ELECTRONIC MEDICAL RECORD Data
Infrastructure
Key activities include - Data Alignment
- Denominator Calculation - Numerator Calculations
- Attribution - Benchmarking Customer
Data Mart
Technically speakinghellip how does it work
Database
Program Functionality The Guideline Advantage Measure Sets + an Additional Measure Set available as
defined by the customer Patient Lists and action list functionality Views amp filtering options for Teams Comparison Benchmarking amp Historical Trending Customer Driven Functionality including demographic information displays incentive
program tracking amp non-clinical custom groupings Complete data advisory service including comprehensive consultations and guidance
in identifying data sources mapping data cleansing and alignment Fixed implementation fee and annual licenses
On-demand access to quality improvement data using a web-based tool Available physician-level reporting Clinic and system aggregation Tools for creating action lists Alignment with key national initiatives National and State Benchmarking Practice Network opportunities including virtual workshops and national recognition
Advantages to Practices amp Physicians
Diabetes Mellitus
bull HbA1c Control bull LDL Control bull High Blood
Pressure Control bull Annual
nephropathy screening (urine albumin)
Preventive Care Screening
bull BMI Screening amp Follow-up
bull Influenza Vaccination
bull Tobacco Use and Counseling
bull Blood Pressure Screening
bull LDL Measurement
Cancer
bull Colorectal Cancer Screening
bull Mammography Screening
bull Cervical Cancer Screening
Cardiovascular
bull Ischemic Vascular Disease Aspirin Use amp Lipid panel
bull Hypertension Blood Pressure Control
bull CAD Lipid-lowering Therapy
bull CAD Antiplatelet Therapy
bull CAD Blood Pressure Control
bull CAD Tobacco Use
The Guideline Advantagersquos Measures
Measures are subject to change
Alignment with National Programs
Million Hearts Initiative The Guideline Advantage reports on the ldquoABCSrdquo measures of interest to Million Hearts httpmillionheartshhsgovindexhtml
Uniform Data System (UDS)
The program reports all adult UDS measures of interest to Community Health Centers and Federally Qualified Health Centers httpwwwudsmrorg
Leading practices for effective participation
Use existing EHR platform donrsquot interrupt work flow to collect data offer vend or neutral program model
Provide tools and resources (Webinars CME programs etc) to help develop a culture of quality improvement
Provide feedback and consult with practices on how to disseminate information
Encourage focus on 1-2 areas only
Direct practices to resources to support improvement
Recognize and link to incentives
These are just a few of the best practices shared by the program
Colorectal Cancer Opportunities for Improvement
Lewis Foxhall MD
VP for Health Policy UT MD Anderson Cancer Center Professor Clinical Cancer Prevention
Cancer Screening
Colorectal Cancer Learning Objectives
Following this lecture participants will be able to
Understand recommendations for colorectal cancer screening
Assess risk for colorectal cancer and assist patients in determining the screening method(s) most appropriate for them
Recognize common barriers to colorectal cancer screening and learn about strategies to address those barriers
Take steps to improve screening in practice
QUESTION
After lung cancer what is the most frequent cause of mortality from cancer in the US
Breast Prostate Colon Leukemia
Colorectal Cancer
The third most common cancer in US and the second deadliest bull 142820 estimated new cases 2013 bull 50830 deaths nationwide
More than 1 million US colorectal cancer
survivors
Cancer Facts and Figures 2013 wwwcancerorg
Cancer Death Rates by Race and Ethnicity US 2005-2009
RaceEthnicity Male Female
All Races 522 per 100000 men 393 per 100000 women
White 513 per 100000 men 384 per 100000 women
Black 643 per 100000 men 492 per 100000 women
AsianPacific Islander 438 per 100000 men 327 per 100000 women
American IndianAlaska Native a 441 per 100000 men 366 per 100000 women
Hispanic b 455 per 100000 men 316 per 100000 women
Incidence Rates by Race 2006-2010
httpseercancergovstatfactshtmlcolorecthtml
Colorectal Cancer Incidence
RaceEthnicity Male Female
All Races 196 per 100000 men 139 per 100000 women
White 191 per 100000 men 134 per 100000 women
Black 287 per 100000 men 190 per 100000 women
AsianPacific Islander 131 per 100000 men 97 per 100000 women American IndianAlaska Native a 187 per 100000 men 154 per 100000 women
Hispanic b 161 per 100000 men 102 per 100000 women
Death Rates by Race 2006-2010
Colorectal Cancer Mortality
QUESTION
For colorectal cancer what is the approximate survival rate for disease confined to primary site (Localized)
10 30 50 90
For cancer that has metastasized (Distant) 10 30 50 90
Polyp to Carcinoma Pathway
Normal to Adenoma to Carcinoma
Human colon carcinogenesis progresses by the dysplasiaadenoma
to carcinoma pathway
Polyp Charactoristics
Hyperplastic bull minimal cancer potential
Adenomatous bull approximately 90 of colon
and rectal cancers arise from adenomas
Stage at Diagnosis Stage Distribution ()
5-year Relative Survival ()
Localized (confined to primary site) 40 903
Regional (spread to regional lymphnodes) 36 704
Distant (cancer has metastasized) 20 125
Unknown (unstaged) 5 336
Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for 2003-2009 All Races Both Sexes
Stage Distribution and Survival
Colorectal Screening Rates
Opportunity for Improvement
Only 40 of colorectal cancers are detected at the earliest stage
A little more than half of Americans over age 50 report having had a recent colorectal cancer screening test
Slow but steady improvement in these numbers over the past decade
Screening rates remain lower in the underserveduninsured population than in the general population
Colorectal Cancer Risk Factors
Age bull 90 of cases occur in people 50 and older bull Average age of diagnosis 69
Gender bull slight male predominance but common in both men and women
RaceEthnicity bull African Americans have highest incidence and mortality rate of
all groups in US Hispanics the lowest (with considerable variation depending on country of origin)
bull Increased rates also documented in Alaska Natives some American Indian tribes Ashkenazi Jews
Colorectal Cancer Risk Factors
Sporadic (average risk) (65ndash85)
Family history
(10ndash30)
Hereditary nonpolyposis colorectal cancer
(HNPCC) (5) Familial adenomatous
polyposis (FAP) (1)
Rare syndromes
(lt01)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
bull Providers can use several different
technology platforms
bull Practices submit collective clinical data to Forward Health Group for The Guideline Advantage
bull Data are processed analyzed and provided back to the practice via
a practice portal
1
2
3
bull Performance is measured Professionals can set
measureable goals and chart improvements in performance
4
Program Model
As a part of quality improvement clinical data must be aggregated into a data warehouse to facilitate analysis and reporting
Data Extract
Data import
ELECTRONIC MEDICAL RECORD Data
Infrastructure
Key activities include - Data Alignment
- Denominator Calculation - Numerator Calculations
- Attribution - Benchmarking Customer
Data Mart
Technically speakinghellip how does it work
Database
Program Functionality The Guideline Advantage Measure Sets + an Additional Measure Set available as
defined by the customer Patient Lists and action list functionality Views amp filtering options for Teams Comparison Benchmarking amp Historical Trending Customer Driven Functionality including demographic information displays incentive
program tracking amp non-clinical custom groupings Complete data advisory service including comprehensive consultations and guidance
in identifying data sources mapping data cleansing and alignment Fixed implementation fee and annual licenses
On-demand access to quality improvement data using a web-based tool Available physician-level reporting Clinic and system aggregation Tools for creating action lists Alignment with key national initiatives National and State Benchmarking Practice Network opportunities including virtual workshops and national recognition
Advantages to Practices amp Physicians
Diabetes Mellitus
bull HbA1c Control bull LDL Control bull High Blood
Pressure Control bull Annual
nephropathy screening (urine albumin)
Preventive Care Screening
bull BMI Screening amp Follow-up
bull Influenza Vaccination
bull Tobacco Use and Counseling
bull Blood Pressure Screening
bull LDL Measurement
Cancer
bull Colorectal Cancer Screening
bull Mammography Screening
bull Cervical Cancer Screening
Cardiovascular
bull Ischemic Vascular Disease Aspirin Use amp Lipid panel
bull Hypertension Blood Pressure Control
bull CAD Lipid-lowering Therapy
bull CAD Antiplatelet Therapy
bull CAD Blood Pressure Control
bull CAD Tobacco Use
The Guideline Advantagersquos Measures
Measures are subject to change
Alignment with National Programs
Million Hearts Initiative The Guideline Advantage reports on the ldquoABCSrdquo measures of interest to Million Hearts httpmillionheartshhsgovindexhtml
Uniform Data System (UDS)
The program reports all adult UDS measures of interest to Community Health Centers and Federally Qualified Health Centers httpwwwudsmrorg
Leading practices for effective participation
Use existing EHR platform donrsquot interrupt work flow to collect data offer vend or neutral program model
Provide tools and resources (Webinars CME programs etc) to help develop a culture of quality improvement
Provide feedback and consult with practices on how to disseminate information
Encourage focus on 1-2 areas only
Direct practices to resources to support improvement
Recognize and link to incentives
These are just a few of the best practices shared by the program
Colorectal Cancer Opportunities for Improvement
Lewis Foxhall MD
VP for Health Policy UT MD Anderson Cancer Center Professor Clinical Cancer Prevention
Cancer Screening
Colorectal Cancer Learning Objectives
Following this lecture participants will be able to
Understand recommendations for colorectal cancer screening
Assess risk for colorectal cancer and assist patients in determining the screening method(s) most appropriate for them
Recognize common barriers to colorectal cancer screening and learn about strategies to address those barriers
Take steps to improve screening in practice
QUESTION
After lung cancer what is the most frequent cause of mortality from cancer in the US
Breast Prostate Colon Leukemia
Colorectal Cancer
The third most common cancer in US and the second deadliest bull 142820 estimated new cases 2013 bull 50830 deaths nationwide
More than 1 million US colorectal cancer
survivors
Cancer Facts and Figures 2013 wwwcancerorg
Cancer Death Rates by Race and Ethnicity US 2005-2009
RaceEthnicity Male Female
All Races 522 per 100000 men 393 per 100000 women
White 513 per 100000 men 384 per 100000 women
Black 643 per 100000 men 492 per 100000 women
AsianPacific Islander 438 per 100000 men 327 per 100000 women
American IndianAlaska Native a 441 per 100000 men 366 per 100000 women
Hispanic b 455 per 100000 men 316 per 100000 women
Incidence Rates by Race 2006-2010
httpseercancergovstatfactshtmlcolorecthtml
Colorectal Cancer Incidence
RaceEthnicity Male Female
All Races 196 per 100000 men 139 per 100000 women
White 191 per 100000 men 134 per 100000 women
Black 287 per 100000 men 190 per 100000 women
AsianPacific Islander 131 per 100000 men 97 per 100000 women American IndianAlaska Native a 187 per 100000 men 154 per 100000 women
Hispanic b 161 per 100000 men 102 per 100000 women
Death Rates by Race 2006-2010
Colorectal Cancer Mortality
QUESTION
For colorectal cancer what is the approximate survival rate for disease confined to primary site (Localized)
10 30 50 90
For cancer that has metastasized (Distant) 10 30 50 90
Polyp to Carcinoma Pathway
Normal to Adenoma to Carcinoma
Human colon carcinogenesis progresses by the dysplasiaadenoma
to carcinoma pathway
Polyp Charactoristics
Hyperplastic bull minimal cancer potential
Adenomatous bull approximately 90 of colon
and rectal cancers arise from adenomas
Stage at Diagnosis Stage Distribution ()
5-year Relative Survival ()
Localized (confined to primary site) 40 903
Regional (spread to regional lymphnodes) 36 704
Distant (cancer has metastasized) 20 125
Unknown (unstaged) 5 336
Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for 2003-2009 All Races Both Sexes
Stage Distribution and Survival
Colorectal Screening Rates
Opportunity for Improvement
Only 40 of colorectal cancers are detected at the earliest stage
A little more than half of Americans over age 50 report having had a recent colorectal cancer screening test
Slow but steady improvement in these numbers over the past decade
Screening rates remain lower in the underserveduninsured population than in the general population
Colorectal Cancer Risk Factors
Age bull 90 of cases occur in people 50 and older bull Average age of diagnosis 69
Gender bull slight male predominance but common in both men and women
RaceEthnicity bull African Americans have highest incidence and mortality rate of
all groups in US Hispanics the lowest (with considerable variation depending on country of origin)
bull Increased rates also documented in Alaska Natives some American Indian tribes Ashkenazi Jews
Colorectal Cancer Risk Factors
Sporadic (average risk) (65ndash85)
Family history
(10ndash30)
Hereditary nonpolyposis colorectal cancer
(HNPCC) (5) Familial adenomatous
polyposis (FAP) (1)
Rare syndromes
(lt01)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
As a part of quality improvement clinical data must be aggregated into a data warehouse to facilitate analysis and reporting
Data Extract
Data import
ELECTRONIC MEDICAL RECORD Data
Infrastructure
Key activities include - Data Alignment
- Denominator Calculation - Numerator Calculations
- Attribution - Benchmarking Customer
Data Mart
Technically speakinghellip how does it work
Database
Program Functionality The Guideline Advantage Measure Sets + an Additional Measure Set available as
defined by the customer Patient Lists and action list functionality Views amp filtering options for Teams Comparison Benchmarking amp Historical Trending Customer Driven Functionality including demographic information displays incentive
program tracking amp non-clinical custom groupings Complete data advisory service including comprehensive consultations and guidance
in identifying data sources mapping data cleansing and alignment Fixed implementation fee and annual licenses
On-demand access to quality improvement data using a web-based tool Available physician-level reporting Clinic and system aggregation Tools for creating action lists Alignment with key national initiatives National and State Benchmarking Practice Network opportunities including virtual workshops and national recognition
Advantages to Practices amp Physicians
Diabetes Mellitus
bull HbA1c Control bull LDL Control bull High Blood
Pressure Control bull Annual
nephropathy screening (urine albumin)
Preventive Care Screening
bull BMI Screening amp Follow-up
bull Influenza Vaccination
bull Tobacco Use and Counseling
bull Blood Pressure Screening
bull LDL Measurement
Cancer
bull Colorectal Cancer Screening
bull Mammography Screening
bull Cervical Cancer Screening
Cardiovascular
bull Ischemic Vascular Disease Aspirin Use amp Lipid panel
bull Hypertension Blood Pressure Control
bull CAD Lipid-lowering Therapy
bull CAD Antiplatelet Therapy
bull CAD Blood Pressure Control
bull CAD Tobacco Use
The Guideline Advantagersquos Measures
Measures are subject to change
Alignment with National Programs
Million Hearts Initiative The Guideline Advantage reports on the ldquoABCSrdquo measures of interest to Million Hearts httpmillionheartshhsgovindexhtml
Uniform Data System (UDS)
The program reports all adult UDS measures of interest to Community Health Centers and Federally Qualified Health Centers httpwwwudsmrorg
Leading practices for effective participation
Use existing EHR platform donrsquot interrupt work flow to collect data offer vend or neutral program model
Provide tools and resources (Webinars CME programs etc) to help develop a culture of quality improvement
Provide feedback and consult with practices on how to disseminate information
Encourage focus on 1-2 areas only
Direct practices to resources to support improvement
Recognize and link to incentives
These are just a few of the best practices shared by the program
Colorectal Cancer Opportunities for Improvement
Lewis Foxhall MD
VP for Health Policy UT MD Anderson Cancer Center Professor Clinical Cancer Prevention
Cancer Screening
Colorectal Cancer Learning Objectives
Following this lecture participants will be able to
Understand recommendations for colorectal cancer screening
Assess risk for colorectal cancer and assist patients in determining the screening method(s) most appropriate for them
Recognize common barriers to colorectal cancer screening and learn about strategies to address those barriers
Take steps to improve screening in practice
QUESTION
After lung cancer what is the most frequent cause of mortality from cancer in the US
Breast Prostate Colon Leukemia
Colorectal Cancer
The third most common cancer in US and the second deadliest bull 142820 estimated new cases 2013 bull 50830 deaths nationwide
More than 1 million US colorectal cancer
survivors
Cancer Facts and Figures 2013 wwwcancerorg
Cancer Death Rates by Race and Ethnicity US 2005-2009
RaceEthnicity Male Female
All Races 522 per 100000 men 393 per 100000 women
White 513 per 100000 men 384 per 100000 women
Black 643 per 100000 men 492 per 100000 women
AsianPacific Islander 438 per 100000 men 327 per 100000 women
American IndianAlaska Native a 441 per 100000 men 366 per 100000 women
Hispanic b 455 per 100000 men 316 per 100000 women
Incidence Rates by Race 2006-2010
httpseercancergovstatfactshtmlcolorecthtml
Colorectal Cancer Incidence
RaceEthnicity Male Female
All Races 196 per 100000 men 139 per 100000 women
White 191 per 100000 men 134 per 100000 women
Black 287 per 100000 men 190 per 100000 women
AsianPacific Islander 131 per 100000 men 97 per 100000 women American IndianAlaska Native a 187 per 100000 men 154 per 100000 women
Hispanic b 161 per 100000 men 102 per 100000 women
Death Rates by Race 2006-2010
Colorectal Cancer Mortality
QUESTION
For colorectal cancer what is the approximate survival rate for disease confined to primary site (Localized)
10 30 50 90
For cancer that has metastasized (Distant) 10 30 50 90
Polyp to Carcinoma Pathway
Normal to Adenoma to Carcinoma
Human colon carcinogenesis progresses by the dysplasiaadenoma
to carcinoma pathway
Polyp Charactoristics
Hyperplastic bull minimal cancer potential
Adenomatous bull approximately 90 of colon
and rectal cancers arise from adenomas
Stage at Diagnosis Stage Distribution ()
5-year Relative Survival ()
Localized (confined to primary site) 40 903
Regional (spread to regional lymphnodes) 36 704
Distant (cancer has metastasized) 20 125
Unknown (unstaged) 5 336
Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for 2003-2009 All Races Both Sexes
Stage Distribution and Survival
Colorectal Screening Rates
Opportunity for Improvement
Only 40 of colorectal cancers are detected at the earliest stage
A little more than half of Americans over age 50 report having had a recent colorectal cancer screening test
Slow but steady improvement in these numbers over the past decade
Screening rates remain lower in the underserveduninsured population than in the general population
Colorectal Cancer Risk Factors
Age bull 90 of cases occur in people 50 and older bull Average age of diagnosis 69
Gender bull slight male predominance but common in both men and women
RaceEthnicity bull African Americans have highest incidence and mortality rate of
all groups in US Hispanics the lowest (with considerable variation depending on country of origin)
bull Increased rates also documented in Alaska Natives some American Indian tribes Ashkenazi Jews
Colorectal Cancer Risk Factors
Sporadic (average risk) (65ndash85)
Family history
(10ndash30)
Hereditary nonpolyposis colorectal cancer
(HNPCC) (5) Familial adenomatous
polyposis (FAP) (1)
Rare syndromes
(lt01)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Program Functionality The Guideline Advantage Measure Sets + an Additional Measure Set available as
defined by the customer Patient Lists and action list functionality Views amp filtering options for Teams Comparison Benchmarking amp Historical Trending Customer Driven Functionality including demographic information displays incentive
program tracking amp non-clinical custom groupings Complete data advisory service including comprehensive consultations and guidance
in identifying data sources mapping data cleansing and alignment Fixed implementation fee and annual licenses
On-demand access to quality improvement data using a web-based tool Available physician-level reporting Clinic and system aggregation Tools for creating action lists Alignment with key national initiatives National and State Benchmarking Practice Network opportunities including virtual workshops and national recognition
Advantages to Practices amp Physicians
Diabetes Mellitus
bull HbA1c Control bull LDL Control bull High Blood
Pressure Control bull Annual
nephropathy screening (urine albumin)
Preventive Care Screening
bull BMI Screening amp Follow-up
bull Influenza Vaccination
bull Tobacco Use and Counseling
bull Blood Pressure Screening
bull LDL Measurement
Cancer
bull Colorectal Cancer Screening
bull Mammography Screening
bull Cervical Cancer Screening
Cardiovascular
bull Ischemic Vascular Disease Aspirin Use amp Lipid panel
bull Hypertension Blood Pressure Control
bull CAD Lipid-lowering Therapy
bull CAD Antiplatelet Therapy
bull CAD Blood Pressure Control
bull CAD Tobacco Use
The Guideline Advantagersquos Measures
Measures are subject to change
Alignment with National Programs
Million Hearts Initiative The Guideline Advantage reports on the ldquoABCSrdquo measures of interest to Million Hearts httpmillionheartshhsgovindexhtml
Uniform Data System (UDS)
The program reports all adult UDS measures of interest to Community Health Centers and Federally Qualified Health Centers httpwwwudsmrorg
Leading practices for effective participation
Use existing EHR platform donrsquot interrupt work flow to collect data offer vend or neutral program model
Provide tools and resources (Webinars CME programs etc) to help develop a culture of quality improvement
Provide feedback and consult with practices on how to disseminate information
Encourage focus on 1-2 areas only
Direct practices to resources to support improvement
Recognize and link to incentives
These are just a few of the best practices shared by the program
Colorectal Cancer Opportunities for Improvement
Lewis Foxhall MD
VP for Health Policy UT MD Anderson Cancer Center Professor Clinical Cancer Prevention
Cancer Screening
Colorectal Cancer Learning Objectives
Following this lecture participants will be able to
Understand recommendations for colorectal cancer screening
Assess risk for colorectal cancer and assist patients in determining the screening method(s) most appropriate for them
Recognize common barriers to colorectal cancer screening and learn about strategies to address those barriers
Take steps to improve screening in practice
QUESTION
After lung cancer what is the most frequent cause of mortality from cancer in the US
Breast Prostate Colon Leukemia
Colorectal Cancer
The third most common cancer in US and the second deadliest bull 142820 estimated new cases 2013 bull 50830 deaths nationwide
More than 1 million US colorectal cancer
survivors
Cancer Facts and Figures 2013 wwwcancerorg
Cancer Death Rates by Race and Ethnicity US 2005-2009
RaceEthnicity Male Female
All Races 522 per 100000 men 393 per 100000 women
White 513 per 100000 men 384 per 100000 women
Black 643 per 100000 men 492 per 100000 women
AsianPacific Islander 438 per 100000 men 327 per 100000 women
American IndianAlaska Native a 441 per 100000 men 366 per 100000 women
Hispanic b 455 per 100000 men 316 per 100000 women
Incidence Rates by Race 2006-2010
httpseercancergovstatfactshtmlcolorecthtml
Colorectal Cancer Incidence
RaceEthnicity Male Female
All Races 196 per 100000 men 139 per 100000 women
White 191 per 100000 men 134 per 100000 women
Black 287 per 100000 men 190 per 100000 women
AsianPacific Islander 131 per 100000 men 97 per 100000 women American IndianAlaska Native a 187 per 100000 men 154 per 100000 women
Hispanic b 161 per 100000 men 102 per 100000 women
Death Rates by Race 2006-2010
Colorectal Cancer Mortality
QUESTION
For colorectal cancer what is the approximate survival rate for disease confined to primary site (Localized)
10 30 50 90
For cancer that has metastasized (Distant) 10 30 50 90
Polyp to Carcinoma Pathway
Normal to Adenoma to Carcinoma
Human colon carcinogenesis progresses by the dysplasiaadenoma
to carcinoma pathway
Polyp Charactoristics
Hyperplastic bull minimal cancer potential
Adenomatous bull approximately 90 of colon
and rectal cancers arise from adenomas
Stage at Diagnosis Stage Distribution ()
5-year Relative Survival ()
Localized (confined to primary site) 40 903
Regional (spread to regional lymphnodes) 36 704
Distant (cancer has metastasized) 20 125
Unknown (unstaged) 5 336
Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for 2003-2009 All Races Both Sexes
Stage Distribution and Survival
Colorectal Screening Rates
Opportunity for Improvement
Only 40 of colorectal cancers are detected at the earliest stage
A little more than half of Americans over age 50 report having had a recent colorectal cancer screening test
Slow but steady improvement in these numbers over the past decade
Screening rates remain lower in the underserveduninsured population than in the general population
Colorectal Cancer Risk Factors
Age bull 90 of cases occur in people 50 and older bull Average age of diagnosis 69
Gender bull slight male predominance but common in both men and women
RaceEthnicity bull African Americans have highest incidence and mortality rate of
all groups in US Hispanics the lowest (with considerable variation depending on country of origin)
bull Increased rates also documented in Alaska Natives some American Indian tribes Ashkenazi Jews
Colorectal Cancer Risk Factors
Sporadic (average risk) (65ndash85)
Family history
(10ndash30)
Hereditary nonpolyposis colorectal cancer
(HNPCC) (5) Familial adenomatous
polyposis (FAP) (1)
Rare syndromes
(lt01)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
On-demand access to quality improvement data using a web-based tool Available physician-level reporting Clinic and system aggregation Tools for creating action lists Alignment with key national initiatives National and State Benchmarking Practice Network opportunities including virtual workshops and national recognition
Advantages to Practices amp Physicians
Diabetes Mellitus
bull HbA1c Control bull LDL Control bull High Blood
Pressure Control bull Annual
nephropathy screening (urine albumin)
Preventive Care Screening
bull BMI Screening amp Follow-up
bull Influenza Vaccination
bull Tobacco Use and Counseling
bull Blood Pressure Screening
bull LDL Measurement
Cancer
bull Colorectal Cancer Screening
bull Mammography Screening
bull Cervical Cancer Screening
Cardiovascular
bull Ischemic Vascular Disease Aspirin Use amp Lipid panel
bull Hypertension Blood Pressure Control
bull CAD Lipid-lowering Therapy
bull CAD Antiplatelet Therapy
bull CAD Blood Pressure Control
bull CAD Tobacco Use
The Guideline Advantagersquos Measures
Measures are subject to change
Alignment with National Programs
Million Hearts Initiative The Guideline Advantage reports on the ldquoABCSrdquo measures of interest to Million Hearts httpmillionheartshhsgovindexhtml
Uniform Data System (UDS)
The program reports all adult UDS measures of interest to Community Health Centers and Federally Qualified Health Centers httpwwwudsmrorg
Leading practices for effective participation
Use existing EHR platform donrsquot interrupt work flow to collect data offer vend or neutral program model
Provide tools and resources (Webinars CME programs etc) to help develop a culture of quality improvement
Provide feedback and consult with practices on how to disseminate information
Encourage focus on 1-2 areas only
Direct practices to resources to support improvement
Recognize and link to incentives
These are just a few of the best practices shared by the program
Colorectal Cancer Opportunities for Improvement
Lewis Foxhall MD
VP for Health Policy UT MD Anderson Cancer Center Professor Clinical Cancer Prevention
Cancer Screening
Colorectal Cancer Learning Objectives
Following this lecture participants will be able to
Understand recommendations for colorectal cancer screening
Assess risk for colorectal cancer and assist patients in determining the screening method(s) most appropriate for them
Recognize common barriers to colorectal cancer screening and learn about strategies to address those barriers
Take steps to improve screening in practice
QUESTION
After lung cancer what is the most frequent cause of mortality from cancer in the US
Breast Prostate Colon Leukemia
Colorectal Cancer
The third most common cancer in US and the second deadliest bull 142820 estimated new cases 2013 bull 50830 deaths nationwide
More than 1 million US colorectal cancer
survivors
Cancer Facts and Figures 2013 wwwcancerorg
Cancer Death Rates by Race and Ethnicity US 2005-2009
RaceEthnicity Male Female
All Races 522 per 100000 men 393 per 100000 women
White 513 per 100000 men 384 per 100000 women
Black 643 per 100000 men 492 per 100000 women
AsianPacific Islander 438 per 100000 men 327 per 100000 women
American IndianAlaska Native a 441 per 100000 men 366 per 100000 women
Hispanic b 455 per 100000 men 316 per 100000 women
Incidence Rates by Race 2006-2010
httpseercancergovstatfactshtmlcolorecthtml
Colorectal Cancer Incidence
RaceEthnicity Male Female
All Races 196 per 100000 men 139 per 100000 women
White 191 per 100000 men 134 per 100000 women
Black 287 per 100000 men 190 per 100000 women
AsianPacific Islander 131 per 100000 men 97 per 100000 women American IndianAlaska Native a 187 per 100000 men 154 per 100000 women
Hispanic b 161 per 100000 men 102 per 100000 women
Death Rates by Race 2006-2010
Colorectal Cancer Mortality
QUESTION
For colorectal cancer what is the approximate survival rate for disease confined to primary site (Localized)
10 30 50 90
For cancer that has metastasized (Distant) 10 30 50 90
Polyp to Carcinoma Pathway
Normal to Adenoma to Carcinoma
Human colon carcinogenesis progresses by the dysplasiaadenoma
to carcinoma pathway
Polyp Charactoristics
Hyperplastic bull minimal cancer potential
Adenomatous bull approximately 90 of colon
and rectal cancers arise from adenomas
Stage at Diagnosis Stage Distribution ()
5-year Relative Survival ()
Localized (confined to primary site) 40 903
Regional (spread to regional lymphnodes) 36 704
Distant (cancer has metastasized) 20 125
Unknown (unstaged) 5 336
Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for 2003-2009 All Races Both Sexes
Stage Distribution and Survival
Colorectal Screening Rates
Opportunity for Improvement
Only 40 of colorectal cancers are detected at the earliest stage
A little more than half of Americans over age 50 report having had a recent colorectal cancer screening test
Slow but steady improvement in these numbers over the past decade
Screening rates remain lower in the underserveduninsured population than in the general population
Colorectal Cancer Risk Factors
Age bull 90 of cases occur in people 50 and older bull Average age of diagnosis 69
Gender bull slight male predominance but common in both men and women
RaceEthnicity bull African Americans have highest incidence and mortality rate of
all groups in US Hispanics the lowest (with considerable variation depending on country of origin)
bull Increased rates also documented in Alaska Natives some American Indian tribes Ashkenazi Jews
Colorectal Cancer Risk Factors
Sporadic (average risk) (65ndash85)
Family history
(10ndash30)
Hereditary nonpolyposis colorectal cancer
(HNPCC) (5) Familial adenomatous
polyposis (FAP) (1)
Rare syndromes
(lt01)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Diabetes Mellitus
bull HbA1c Control bull LDL Control bull High Blood
Pressure Control bull Annual
nephropathy screening (urine albumin)
Preventive Care Screening
bull BMI Screening amp Follow-up
bull Influenza Vaccination
bull Tobacco Use and Counseling
bull Blood Pressure Screening
bull LDL Measurement
Cancer
bull Colorectal Cancer Screening
bull Mammography Screening
bull Cervical Cancer Screening
Cardiovascular
bull Ischemic Vascular Disease Aspirin Use amp Lipid panel
bull Hypertension Blood Pressure Control
bull CAD Lipid-lowering Therapy
bull CAD Antiplatelet Therapy
bull CAD Blood Pressure Control
bull CAD Tobacco Use
The Guideline Advantagersquos Measures
Measures are subject to change
Alignment with National Programs
Million Hearts Initiative The Guideline Advantage reports on the ldquoABCSrdquo measures of interest to Million Hearts httpmillionheartshhsgovindexhtml
Uniform Data System (UDS)
The program reports all adult UDS measures of interest to Community Health Centers and Federally Qualified Health Centers httpwwwudsmrorg
Leading practices for effective participation
Use existing EHR platform donrsquot interrupt work flow to collect data offer vend or neutral program model
Provide tools and resources (Webinars CME programs etc) to help develop a culture of quality improvement
Provide feedback and consult with practices on how to disseminate information
Encourage focus on 1-2 areas only
Direct practices to resources to support improvement
Recognize and link to incentives
These are just a few of the best practices shared by the program
Colorectal Cancer Opportunities for Improvement
Lewis Foxhall MD
VP for Health Policy UT MD Anderson Cancer Center Professor Clinical Cancer Prevention
Cancer Screening
Colorectal Cancer Learning Objectives
Following this lecture participants will be able to
Understand recommendations for colorectal cancer screening
Assess risk for colorectal cancer and assist patients in determining the screening method(s) most appropriate for them
Recognize common barriers to colorectal cancer screening and learn about strategies to address those barriers
Take steps to improve screening in practice
QUESTION
After lung cancer what is the most frequent cause of mortality from cancer in the US
Breast Prostate Colon Leukemia
Colorectal Cancer
The third most common cancer in US and the second deadliest bull 142820 estimated new cases 2013 bull 50830 deaths nationwide
More than 1 million US colorectal cancer
survivors
Cancer Facts and Figures 2013 wwwcancerorg
Cancer Death Rates by Race and Ethnicity US 2005-2009
RaceEthnicity Male Female
All Races 522 per 100000 men 393 per 100000 women
White 513 per 100000 men 384 per 100000 women
Black 643 per 100000 men 492 per 100000 women
AsianPacific Islander 438 per 100000 men 327 per 100000 women
American IndianAlaska Native a 441 per 100000 men 366 per 100000 women
Hispanic b 455 per 100000 men 316 per 100000 women
Incidence Rates by Race 2006-2010
httpseercancergovstatfactshtmlcolorecthtml
Colorectal Cancer Incidence
RaceEthnicity Male Female
All Races 196 per 100000 men 139 per 100000 women
White 191 per 100000 men 134 per 100000 women
Black 287 per 100000 men 190 per 100000 women
AsianPacific Islander 131 per 100000 men 97 per 100000 women American IndianAlaska Native a 187 per 100000 men 154 per 100000 women
Hispanic b 161 per 100000 men 102 per 100000 women
Death Rates by Race 2006-2010
Colorectal Cancer Mortality
QUESTION
For colorectal cancer what is the approximate survival rate for disease confined to primary site (Localized)
10 30 50 90
For cancer that has metastasized (Distant) 10 30 50 90
Polyp to Carcinoma Pathway
Normal to Adenoma to Carcinoma
Human colon carcinogenesis progresses by the dysplasiaadenoma
to carcinoma pathway
Polyp Charactoristics
Hyperplastic bull minimal cancer potential
Adenomatous bull approximately 90 of colon
and rectal cancers arise from adenomas
Stage at Diagnosis Stage Distribution ()
5-year Relative Survival ()
Localized (confined to primary site) 40 903
Regional (spread to regional lymphnodes) 36 704
Distant (cancer has metastasized) 20 125
Unknown (unstaged) 5 336
Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for 2003-2009 All Races Both Sexes
Stage Distribution and Survival
Colorectal Screening Rates
Opportunity for Improvement
Only 40 of colorectal cancers are detected at the earliest stage
A little more than half of Americans over age 50 report having had a recent colorectal cancer screening test
Slow but steady improvement in these numbers over the past decade
Screening rates remain lower in the underserveduninsured population than in the general population
Colorectal Cancer Risk Factors
Age bull 90 of cases occur in people 50 and older bull Average age of diagnosis 69
Gender bull slight male predominance but common in both men and women
RaceEthnicity bull African Americans have highest incidence and mortality rate of
all groups in US Hispanics the lowest (with considerable variation depending on country of origin)
bull Increased rates also documented in Alaska Natives some American Indian tribes Ashkenazi Jews
Colorectal Cancer Risk Factors
Sporadic (average risk) (65ndash85)
Family history
(10ndash30)
Hereditary nonpolyposis colorectal cancer
(HNPCC) (5) Familial adenomatous
polyposis (FAP) (1)
Rare syndromes
(lt01)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Alignment with National Programs
Million Hearts Initiative The Guideline Advantage reports on the ldquoABCSrdquo measures of interest to Million Hearts httpmillionheartshhsgovindexhtml
Uniform Data System (UDS)
The program reports all adult UDS measures of interest to Community Health Centers and Federally Qualified Health Centers httpwwwudsmrorg
Leading practices for effective participation
Use existing EHR platform donrsquot interrupt work flow to collect data offer vend or neutral program model
Provide tools and resources (Webinars CME programs etc) to help develop a culture of quality improvement
Provide feedback and consult with practices on how to disseminate information
Encourage focus on 1-2 areas only
Direct practices to resources to support improvement
Recognize and link to incentives
These are just a few of the best practices shared by the program
Colorectal Cancer Opportunities for Improvement
Lewis Foxhall MD
VP for Health Policy UT MD Anderson Cancer Center Professor Clinical Cancer Prevention
Cancer Screening
Colorectal Cancer Learning Objectives
Following this lecture participants will be able to
Understand recommendations for colorectal cancer screening
Assess risk for colorectal cancer and assist patients in determining the screening method(s) most appropriate for them
Recognize common barriers to colorectal cancer screening and learn about strategies to address those barriers
Take steps to improve screening in practice
QUESTION
After lung cancer what is the most frequent cause of mortality from cancer in the US
Breast Prostate Colon Leukemia
Colorectal Cancer
The third most common cancer in US and the second deadliest bull 142820 estimated new cases 2013 bull 50830 deaths nationwide
More than 1 million US colorectal cancer
survivors
Cancer Facts and Figures 2013 wwwcancerorg
Cancer Death Rates by Race and Ethnicity US 2005-2009
RaceEthnicity Male Female
All Races 522 per 100000 men 393 per 100000 women
White 513 per 100000 men 384 per 100000 women
Black 643 per 100000 men 492 per 100000 women
AsianPacific Islander 438 per 100000 men 327 per 100000 women
American IndianAlaska Native a 441 per 100000 men 366 per 100000 women
Hispanic b 455 per 100000 men 316 per 100000 women
Incidence Rates by Race 2006-2010
httpseercancergovstatfactshtmlcolorecthtml
Colorectal Cancer Incidence
RaceEthnicity Male Female
All Races 196 per 100000 men 139 per 100000 women
White 191 per 100000 men 134 per 100000 women
Black 287 per 100000 men 190 per 100000 women
AsianPacific Islander 131 per 100000 men 97 per 100000 women American IndianAlaska Native a 187 per 100000 men 154 per 100000 women
Hispanic b 161 per 100000 men 102 per 100000 women
Death Rates by Race 2006-2010
Colorectal Cancer Mortality
QUESTION
For colorectal cancer what is the approximate survival rate for disease confined to primary site (Localized)
10 30 50 90
For cancer that has metastasized (Distant) 10 30 50 90
Polyp to Carcinoma Pathway
Normal to Adenoma to Carcinoma
Human colon carcinogenesis progresses by the dysplasiaadenoma
to carcinoma pathway
Polyp Charactoristics
Hyperplastic bull minimal cancer potential
Adenomatous bull approximately 90 of colon
and rectal cancers arise from adenomas
Stage at Diagnosis Stage Distribution ()
5-year Relative Survival ()
Localized (confined to primary site) 40 903
Regional (spread to regional lymphnodes) 36 704
Distant (cancer has metastasized) 20 125
Unknown (unstaged) 5 336
Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for 2003-2009 All Races Both Sexes
Stage Distribution and Survival
Colorectal Screening Rates
Opportunity for Improvement
Only 40 of colorectal cancers are detected at the earliest stage
A little more than half of Americans over age 50 report having had a recent colorectal cancer screening test
Slow but steady improvement in these numbers over the past decade
Screening rates remain lower in the underserveduninsured population than in the general population
Colorectal Cancer Risk Factors
Age bull 90 of cases occur in people 50 and older bull Average age of diagnosis 69
Gender bull slight male predominance but common in both men and women
RaceEthnicity bull African Americans have highest incidence and mortality rate of
all groups in US Hispanics the lowest (with considerable variation depending on country of origin)
bull Increased rates also documented in Alaska Natives some American Indian tribes Ashkenazi Jews
Colorectal Cancer Risk Factors
Sporadic (average risk) (65ndash85)
Family history
(10ndash30)
Hereditary nonpolyposis colorectal cancer
(HNPCC) (5) Familial adenomatous
polyposis (FAP) (1)
Rare syndromes
(lt01)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Leading practices for effective participation
Use existing EHR platform donrsquot interrupt work flow to collect data offer vend or neutral program model
Provide tools and resources (Webinars CME programs etc) to help develop a culture of quality improvement
Provide feedback and consult with practices on how to disseminate information
Encourage focus on 1-2 areas only
Direct practices to resources to support improvement
Recognize and link to incentives
These are just a few of the best practices shared by the program
Colorectal Cancer Opportunities for Improvement
Lewis Foxhall MD
VP for Health Policy UT MD Anderson Cancer Center Professor Clinical Cancer Prevention
Cancer Screening
Colorectal Cancer Learning Objectives
Following this lecture participants will be able to
Understand recommendations for colorectal cancer screening
Assess risk for colorectal cancer and assist patients in determining the screening method(s) most appropriate for them
Recognize common barriers to colorectal cancer screening and learn about strategies to address those barriers
Take steps to improve screening in practice
QUESTION
After lung cancer what is the most frequent cause of mortality from cancer in the US
Breast Prostate Colon Leukemia
Colorectal Cancer
The third most common cancer in US and the second deadliest bull 142820 estimated new cases 2013 bull 50830 deaths nationwide
More than 1 million US colorectal cancer
survivors
Cancer Facts and Figures 2013 wwwcancerorg
Cancer Death Rates by Race and Ethnicity US 2005-2009
RaceEthnicity Male Female
All Races 522 per 100000 men 393 per 100000 women
White 513 per 100000 men 384 per 100000 women
Black 643 per 100000 men 492 per 100000 women
AsianPacific Islander 438 per 100000 men 327 per 100000 women
American IndianAlaska Native a 441 per 100000 men 366 per 100000 women
Hispanic b 455 per 100000 men 316 per 100000 women
Incidence Rates by Race 2006-2010
httpseercancergovstatfactshtmlcolorecthtml
Colorectal Cancer Incidence
RaceEthnicity Male Female
All Races 196 per 100000 men 139 per 100000 women
White 191 per 100000 men 134 per 100000 women
Black 287 per 100000 men 190 per 100000 women
AsianPacific Islander 131 per 100000 men 97 per 100000 women American IndianAlaska Native a 187 per 100000 men 154 per 100000 women
Hispanic b 161 per 100000 men 102 per 100000 women
Death Rates by Race 2006-2010
Colorectal Cancer Mortality
QUESTION
For colorectal cancer what is the approximate survival rate for disease confined to primary site (Localized)
10 30 50 90
For cancer that has metastasized (Distant) 10 30 50 90
Polyp to Carcinoma Pathway
Normal to Adenoma to Carcinoma
Human colon carcinogenesis progresses by the dysplasiaadenoma
to carcinoma pathway
Polyp Charactoristics
Hyperplastic bull minimal cancer potential
Adenomatous bull approximately 90 of colon
and rectal cancers arise from adenomas
Stage at Diagnosis Stage Distribution ()
5-year Relative Survival ()
Localized (confined to primary site) 40 903
Regional (spread to regional lymphnodes) 36 704
Distant (cancer has metastasized) 20 125
Unknown (unstaged) 5 336
Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for 2003-2009 All Races Both Sexes
Stage Distribution and Survival
Colorectal Screening Rates
Opportunity for Improvement
Only 40 of colorectal cancers are detected at the earliest stage
A little more than half of Americans over age 50 report having had a recent colorectal cancer screening test
Slow but steady improvement in these numbers over the past decade
Screening rates remain lower in the underserveduninsured population than in the general population
Colorectal Cancer Risk Factors
Age bull 90 of cases occur in people 50 and older bull Average age of diagnosis 69
Gender bull slight male predominance but common in both men and women
RaceEthnicity bull African Americans have highest incidence and mortality rate of
all groups in US Hispanics the lowest (with considerable variation depending on country of origin)
bull Increased rates also documented in Alaska Natives some American Indian tribes Ashkenazi Jews
Colorectal Cancer Risk Factors
Sporadic (average risk) (65ndash85)
Family history
(10ndash30)
Hereditary nonpolyposis colorectal cancer
(HNPCC) (5) Familial adenomatous
polyposis (FAP) (1)
Rare syndromes
(lt01)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Colorectal Cancer Opportunities for Improvement
Lewis Foxhall MD
VP for Health Policy UT MD Anderson Cancer Center Professor Clinical Cancer Prevention
Cancer Screening
Colorectal Cancer Learning Objectives
Following this lecture participants will be able to
Understand recommendations for colorectal cancer screening
Assess risk for colorectal cancer and assist patients in determining the screening method(s) most appropriate for them
Recognize common barriers to colorectal cancer screening and learn about strategies to address those barriers
Take steps to improve screening in practice
QUESTION
After lung cancer what is the most frequent cause of mortality from cancer in the US
Breast Prostate Colon Leukemia
Colorectal Cancer
The third most common cancer in US and the second deadliest bull 142820 estimated new cases 2013 bull 50830 deaths nationwide
More than 1 million US colorectal cancer
survivors
Cancer Facts and Figures 2013 wwwcancerorg
Cancer Death Rates by Race and Ethnicity US 2005-2009
RaceEthnicity Male Female
All Races 522 per 100000 men 393 per 100000 women
White 513 per 100000 men 384 per 100000 women
Black 643 per 100000 men 492 per 100000 women
AsianPacific Islander 438 per 100000 men 327 per 100000 women
American IndianAlaska Native a 441 per 100000 men 366 per 100000 women
Hispanic b 455 per 100000 men 316 per 100000 women
Incidence Rates by Race 2006-2010
httpseercancergovstatfactshtmlcolorecthtml
Colorectal Cancer Incidence
RaceEthnicity Male Female
All Races 196 per 100000 men 139 per 100000 women
White 191 per 100000 men 134 per 100000 women
Black 287 per 100000 men 190 per 100000 women
AsianPacific Islander 131 per 100000 men 97 per 100000 women American IndianAlaska Native a 187 per 100000 men 154 per 100000 women
Hispanic b 161 per 100000 men 102 per 100000 women
Death Rates by Race 2006-2010
Colorectal Cancer Mortality
QUESTION
For colorectal cancer what is the approximate survival rate for disease confined to primary site (Localized)
10 30 50 90
For cancer that has metastasized (Distant) 10 30 50 90
Polyp to Carcinoma Pathway
Normal to Adenoma to Carcinoma
Human colon carcinogenesis progresses by the dysplasiaadenoma
to carcinoma pathway
Polyp Charactoristics
Hyperplastic bull minimal cancer potential
Adenomatous bull approximately 90 of colon
and rectal cancers arise from adenomas
Stage at Diagnosis Stage Distribution ()
5-year Relative Survival ()
Localized (confined to primary site) 40 903
Regional (spread to regional lymphnodes) 36 704
Distant (cancer has metastasized) 20 125
Unknown (unstaged) 5 336
Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for 2003-2009 All Races Both Sexes
Stage Distribution and Survival
Colorectal Screening Rates
Opportunity for Improvement
Only 40 of colorectal cancers are detected at the earliest stage
A little more than half of Americans over age 50 report having had a recent colorectal cancer screening test
Slow but steady improvement in these numbers over the past decade
Screening rates remain lower in the underserveduninsured population than in the general population
Colorectal Cancer Risk Factors
Age bull 90 of cases occur in people 50 and older bull Average age of diagnosis 69
Gender bull slight male predominance but common in both men and women
RaceEthnicity bull African Americans have highest incidence and mortality rate of
all groups in US Hispanics the lowest (with considerable variation depending on country of origin)
bull Increased rates also documented in Alaska Natives some American Indian tribes Ashkenazi Jews
Colorectal Cancer Risk Factors
Sporadic (average risk) (65ndash85)
Family history
(10ndash30)
Hereditary nonpolyposis colorectal cancer
(HNPCC) (5) Familial adenomatous
polyposis (FAP) (1)
Rare syndromes
(lt01)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Colorectal Cancer Learning Objectives
Following this lecture participants will be able to
Understand recommendations for colorectal cancer screening
Assess risk for colorectal cancer and assist patients in determining the screening method(s) most appropriate for them
Recognize common barriers to colorectal cancer screening and learn about strategies to address those barriers
Take steps to improve screening in practice
QUESTION
After lung cancer what is the most frequent cause of mortality from cancer in the US
Breast Prostate Colon Leukemia
Colorectal Cancer
The third most common cancer in US and the second deadliest bull 142820 estimated new cases 2013 bull 50830 deaths nationwide
More than 1 million US colorectal cancer
survivors
Cancer Facts and Figures 2013 wwwcancerorg
Cancer Death Rates by Race and Ethnicity US 2005-2009
RaceEthnicity Male Female
All Races 522 per 100000 men 393 per 100000 women
White 513 per 100000 men 384 per 100000 women
Black 643 per 100000 men 492 per 100000 women
AsianPacific Islander 438 per 100000 men 327 per 100000 women
American IndianAlaska Native a 441 per 100000 men 366 per 100000 women
Hispanic b 455 per 100000 men 316 per 100000 women
Incidence Rates by Race 2006-2010
httpseercancergovstatfactshtmlcolorecthtml
Colorectal Cancer Incidence
RaceEthnicity Male Female
All Races 196 per 100000 men 139 per 100000 women
White 191 per 100000 men 134 per 100000 women
Black 287 per 100000 men 190 per 100000 women
AsianPacific Islander 131 per 100000 men 97 per 100000 women American IndianAlaska Native a 187 per 100000 men 154 per 100000 women
Hispanic b 161 per 100000 men 102 per 100000 women
Death Rates by Race 2006-2010
Colorectal Cancer Mortality
QUESTION
For colorectal cancer what is the approximate survival rate for disease confined to primary site (Localized)
10 30 50 90
For cancer that has metastasized (Distant) 10 30 50 90
Polyp to Carcinoma Pathway
Normal to Adenoma to Carcinoma
Human colon carcinogenesis progresses by the dysplasiaadenoma
to carcinoma pathway
Polyp Charactoristics
Hyperplastic bull minimal cancer potential
Adenomatous bull approximately 90 of colon
and rectal cancers arise from adenomas
Stage at Diagnosis Stage Distribution ()
5-year Relative Survival ()
Localized (confined to primary site) 40 903
Regional (spread to regional lymphnodes) 36 704
Distant (cancer has metastasized) 20 125
Unknown (unstaged) 5 336
Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for 2003-2009 All Races Both Sexes
Stage Distribution and Survival
Colorectal Screening Rates
Opportunity for Improvement
Only 40 of colorectal cancers are detected at the earliest stage
A little more than half of Americans over age 50 report having had a recent colorectal cancer screening test
Slow but steady improvement in these numbers over the past decade
Screening rates remain lower in the underserveduninsured population than in the general population
Colorectal Cancer Risk Factors
Age bull 90 of cases occur in people 50 and older bull Average age of diagnosis 69
Gender bull slight male predominance but common in both men and women
RaceEthnicity bull African Americans have highest incidence and mortality rate of
all groups in US Hispanics the lowest (with considerable variation depending on country of origin)
bull Increased rates also documented in Alaska Natives some American Indian tribes Ashkenazi Jews
Colorectal Cancer Risk Factors
Sporadic (average risk) (65ndash85)
Family history
(10ndash30)
Hereditary nonpolyposis colorectal cancer
(HNPCC) (5) Familial adenomatous
polyposis (FAP) (1)
Rare syndromes
(lt01)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
QUESTION
After lung cancer what is the most frequent cause of mortality from cancer in the US
Breast Prostate Colon Leukemia
Colorectal Cancer
The third most common cancer in US and the second deadliest bull 142820 estimated new cases 2013 bull 50830 deaths nationwide
More than 1 million US colorectal cancer
survivors
Cancer Facts and Figures 2013 wwwcancerorg
Cancer Death Rates by Race and Ethnicity US 2005-2009
RaceEthnicity Male Female
All Races 522 per 100000 men 393 per 100000 women
White 513 per 100000 men 384 per 100000 women
Black 643 per 100000 men 492 per 100000 women
AsianPacific Islander 438 per 100000 men 327 per 100000 women
American IndianAlaska Native a 441 per 100000 men 366 per 100000 women
Hispanic b 455 per 100000 men 316 per 100000 women
Incidence Rates by Race 2006-2010
httpseercancergovstatfactshtmlcolorecthtml
Colorectal Cancer Incidence
RaceEthnicity Male Female
All Races 196 per 100000 men 139 per 100000 women
White 191 per 100000 men 134 per 100000 women
Black 287 per 100000 men 190 per 100000 women
AsianPacific Islander 131 per 100000 men 97 per 100000 women American IndianAlaska Native a 187 per 100000 men 154 per 100000 women
Hispanic b 161 per 100000 men 102 per 100000 women
Death Rates by Race 2006-2010
Colorectal Cancer Mortality
QUESTION
For colorectal cancer what is the approximate survival rate for disease confined to primary site (Localized)
10 30 50 90
For cancer that has metastasized (Distant) 10 30 50 90
Polyp to Carcinoma Pathway
Normal to Adenoma to Carcinoma
Human colon carcinogenesis progresses by the dysplasiaadenoma
to carcinoma pathway
Polyp Charactoristics
Hyperplastic bull minimal cancer potential
Adenomatous bull approximately 90 of colon
and rectal cancers arise from adenomas
Stage at Diagnosis Stage Distribution ()
5-year Relative Survival ()
Localized (confined to primary site) 40 903
Regional (spread to regional lymphnodes) 36 704
Distant (cancer has metastasized) 20 125
Unknown (unstaged) 5 336
Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for 2003-2009 All Races Both Sexes
Stage Distribution and Survival
Colorectal Screening Rates
Opportunity for Improvement
Only 40 of colorectal cancers are detected at the earliest stage
A little more than half of Americans over age 50 report having had a recent colorectal cancer screening test
Slow but steady improvement in these numbers over the past decade
Screening rates remain lower in the underserveduninsured population than in the general population
Colorectal Cancer Risk Factors
Age bull 90 of cases occur in people 50 and older bull Average age of diagnosis 69
Gender bull slight male predominance but common in both men and women
RaceEthnicity bull African Americans have highest incidence and mortality rate of
all groups in US Hispanics the lowest (with considerable variation depending on country of origin)
bull Increased rates also documented in Alaska Natives some American Indian tribes Ashkenazi Jews
Colorectal Cancer Risk Factors
Sporadic (average risk) (65ndash85)
Family history
(10ndash30)
Hereditary nonpolyposis colorectal cancer
(HNPCC) (5) Familial adenomatous
polyposis (FAP) (1)
Rare syndromes
(lt01)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Colorectal Cancer
The third most common cancer in US and the second deadliest bull 142820 estimated new cases 2013 bull 50830 deaths nationwide
More than 1 million US colorectal cancer
survivors
Cancer Facts and Figures 2013 wwwcancerorg
Cancer Death Rates by Race and Ethnicity US 2005-2009
RaceEthnicity Male Female
All Races 522 per 100000 men 393 per 100000 women
White 513 per 100000 men 384 per 100000 women
Black 643 per 100000 men 492 per 100000 women
AsianPacific Islander 438 per 100000 men 327 per 100000 women
American IndianAlaska Native a 441 per 100000 men 366 per 100000 women
Hispanic b 455 per 100000 men 316 per 100000 women
Incidence Rates by Race 2006-2010
httpseercancergovstatfactshtmlcolorecthtml
Colorectal Cancer Incidence
RaceEthnicity Male Female
All Races 196 per 100000 men 139 per 100000 women
White 191 per 100000 men 134 per 100000 women
Black 287 per 100000 men 190 per 100000 women
AsianPacific Islander 131 per 100000 men 97 per 100000 women American IndianAlaska Native a 187 per 100000 men 154 per 100000 women
Hispanic b 161 per 100000 men 102 per 100000 women
Death Rates by Race 2006-2010
Colorectal Cancer Mortality
QUESTION
For colorectal cancer what is the approximate survival rate for disease confined to primary site (Localized)
10 30 50 90
For cancer that has metastasized (Distant) 10 30 50 90
Polyp to Carcinoma Pathway
Normal to Adenoma to Carcinoma
Human colon carcinogenesis progresses by the dysplasiaadenoma
to carcinoma pathway
Polyp Charactoristics
Hyperplastic bull minimal cancer potential
Adenomatous bull approximately 90 of colon
and rectal cancers arise from adenomas
Stage at Diagnosis Stage Distribution ()
5-year Relative Survival ()
Localized (confined to primary site) 40 903
Regional (spread to regional lymphnodes) 36 704
Distant (cancer has metastasized) 20 125
Unknown (unstaged) 5 336
Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for 2003-2009 All Races Both Sexes
Stage Distribution and Survival
Colorectal Screening Rates
Opportunity for Improvement
Only 40 of colorectal cancers are detected at the earliest stage
A little more than half of Americans over age 50 report having had a recent colorectal cancer screening test
Slow but steady improvement in these numbers over the past decade
Screening rates remain lower in the underserveduninsured population than in the general population
Colorectal Cancer Risk Factors
Age bull 90 of cases occur in people 50 and older bull Average age of diagnosis 69
Gender bull slight male predominance but common in both men and women
RaceEthnicity bull African Americans have highest incidence and mortality rate of
all groups in US Hispanics the lowest (with considerable variation depending on country of origin)
bull Increased rates also documented in Alaska Natives some American Indian tribes Ashkenazi Jews
Colorectal Cancer Risk Factors
Sporadic (average risk) (65ndash85)
Family history
(10ndash30)
Hereditary nonpolyposis colorectal cancer
(HNPCC) (5) Familial adenomatous
polyposis (FAP) (1)
Rare syndromes
(lt01)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Cancer Death Rates by Race and Ethnicity US 2005-2009
RaceEthnicity Male Female
All Races 522 per 100000 men 393 per 100000 women
White 513 per 100000 men 384 per 100000 women
Black 643 per 100000 men 492 per 100000 women
AsianPacific Islander 438 per 100000 men 327 per 100000 women
American IndianAlaska Native a 441 per 100000 men 366 per 100000 women
Hispanic b 455 per 100000 men 316 per 100000 women
Incidence Rates by Race 2006-2010
httpseercancergovstatfactshtmlcolorecthtml
Colorectal Cancer Incidence
RaceEthnicity Male Female
All Races 196 per 100000 men 139 per 100000 women
White 191 per 100000 men 134 per 100000 women
Black 287 per 100000 men 190 per 100000 women
AsianPacific Islander 131 per 100000 men 97 per 100000 women American IndianAlaska Native a 187 per 100000 men 154 per 100000 women
Hispanic b 161 per 100000 men 102 per 100000 women
Death Rates by Race 2006-2010
Colorectal Cancer Mortality
QUESTION
For colorectal cancer what is the approximate survival rate for disease confined to primary site (Localized)
10 30 50 90
For cancer that has metastasized (Distant) 10 30 50 90
Polyp to Carcinoma Pathway
Normal to Adenoma to Carcinoma
Human colon carcinogenesis progresses by the dysplasiaadenoma
to carcinoma pathway
Polyp Charactoristics
Hyperplastic bull minimal cancer potential
Adenomatous bull approximately 90 of colon
and rectal cancers arise from adenomas
Stage at Diagnosis Stage Distribution ()
5-year Relative Survival ()
Localized (confined to primary site) 40 903
Regional (spread to regional lymphnodes) 36 704
Distant (cancer has metastasized) 20 125
Unknown (unstaged) 5 336
Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for 2003-2009 All Races Both Sexes
Stage Distribution and Survival
Colorectal Screening Rates
Opportunity for Improvement
Only 40 of colorectal cancers are detected at the earliest stage
A little more than half of Americans over age 50 report having had a recent colorectal cancer screening test
Slow but steady improvement in these numbers over the past decade
Screening rates remain lower in the underserveduninsured population than in the general population
Colorectal Cancer Risk Factors
Age bull 90 of cases occur in people 50 and older bull Average age of diagnosis 69
Gender bull slight male predominance but common in both men and women
RaceEthnicity bull African Americans have highest incidence and mortality rate of
all groups in US Hispanics the lowest (with considerable variation depending on country of origin)
bull Increased rates also documented in Alaska Natives some American Indian tribes Ashkenazi Jews
Colorectal Cancer Risk Factors
Sporadic (average risk) (65ndash85)
Family history
(10ndash30)
Hereditary nonpolyposis colorectal cancer
(HNPCC) (5) Familial adenomatous
polyposis (FAP) (1)
Rare syndromes
(lt01)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
RaceEthnicity Male Female
All Races 522 per 100000 men 393 per 100000 women
White 513 per 100000 men 384 per 100000 women
Black 643 per 100000 men 492 per 100000 women
AsianPacific Islander 438 per 100000 men 327 per 100000 women
American IndianAlaska Native a 441 per 100000 men 366 per 100000 women
Hispanic b 455 per 100000 men 316 per 100000 women
Incidence Rates by Race 2006-2010
httpseercancergovstatfactshtmlcolorecthtml
Colorectal Cancer Incidence
RaceEthnicity Male Female
All Races 196 per 100000 men 139 per 100000 women
White 191 per 100000 men 134 per 100000 women
Black 287 per 100000 men 190 per 100000 women
AsianPacific Islander 131 per 100000 men 97 per 100000 women American IndianAlaska Native a 187 per 100000 men 154 per 100000 women
Hispanic b 161 per 100000 men 102 per 100000 women
Death Rates by Race 2006-2010
Colorectal Cancer Mortality
QUESTION
For colorectal cancer what is the approximate survival rate for disease confined to primary site (Localized)
10 30 50 90
For cancer that has metastasized (Distant) 10 30 50 90
Polyp to Carcinoma Pathway
Normal to Adenoma to Carcinoma
Human colon carcinogenesis progresses by the dysplasiaadenoma
to carcinoma pathway
Polyp Charactoristics
Hyperplastic bull minimal cancer potential
Adenomatous bull approximately 90 of colon
and rectal cancers arise from adenomas
Stage at Diagnosis Stage Distribution ()
5-year Relative Survival ()
Localized (confined to primary site) 40 903
Regional (spread to regional lymphnodes) 36 704
Distant (cancer has metastasized) 20 125
Unknown (unstaged) 5 336
Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for 2003-2009 All Races Both Sexes
Stage Distribution and Survival
Colorectal Screening Rates
Opportunity for Improvement
Only 40 of colorectal cancers are detected at the earliest stage
A little more than half of Americans over age 50 report having had a recent colorectal cancer screening test
Slow but steady improvement in these numbers over the past decade
Screening rates remain lower in the underserveduninsured population than in the general population
Colorectal Cancer Risk Factors
Age bull 90 of cases occur in people 50 and older bull Average age of diagnosis 69
Gender bull slight male predominance but common in both men and women
RaceEthnicity bull African Americans have highest incidence and mortality rate of
all groups in US Hispanics the lowest (with considerable variation depending on country of origin)
bull Increased rates also documented in Alaska Natives some American Indian tribes Ashkenazi Jews
Colorectal Cancer Risk Factors
Sporadic (average risk) (65ndash85)
Family history
(10ndash30)
Hereditary nonpolyposis colorectal cancer
(HNPCC) (5) Familial adenomatous
polyposis (FAP) (1)
Rare syndromes
(lt01)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
RaceEthnicity Male Female
All Races 196 per 100000 men 139 per 100000 women
White 191 per 100000 men 134 per 100000 women
Black 287 per 100000 men 190 per 100000 women
AsianPacific Islander 131 per 100000 men 97 per 100000 women American IndianAlaska Native a 187 per 100000 men 154 per 100000 women
Hispanic b 161 per 100000 men 102 per 100000 women
Death Rates by Race 2006-2010
Colorectal Cancer Mortality
QUESTION
For colorectal cancer what is the approximate survival rate for disease confined to primary site (Localized)
10 30 50 90
For cancer that has metastasized (Distant) 10 30 50 90
Polyp to Carcinoma Pathway
Normal to Adenoma to Carcinoma
Human colon carcinogenesis progresses by the dysplasiaadenoma
to carcinoma pathway
Polyp Charactoristics
Hyperplastic bull minimal cancer potential
Adenomatous bull approximately 90 of colon
and rectal cancers arise from adenomas
Stage at Diagnosis Stage Distribution ()
5-year Relative Survival ()
Localized (confined to primary site) 40 903
Regional (spread to regional lymphnodes) 36 704
Distant (cancer has metastasized) 20 125
Unknown (unstaged) 5 336
Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for 2003-2009 All Races Both Sexes
Stage Distribution and Survival
Colorectal Screening Rates
Opportunity for Improvement
Only 40 of colorectal cancers are detected at the earliest stage
A little more than half of Americans over age 50 report having had a recent colorectal cancer screening test
Slow but steady improvement in these numbers over the past decade
Screening rates remain lower in the underserveduninsured population than in the general population
Colorectal Cancer Risk Factors
Age bull 90 of cases occur in people 50 and older bull Average age of diagnosis 69
Gender bull slight male predominance but common in both men and women
RaceEthnicity bull African Americans have highest incidence and mortality rate of
all groups in US Hispanics the lowest (with considerable variation depending on country of origin)
bull Increased rates also documented in Alaska Natives some American Indian tribes Ashkenazi Jews
Colorectal Cancer Risk Factors
Sporadic (average risk) (65ndash85)
Family history
(10ndash30)
Hereditary nonpolyposis colorectal cancer
(HNPCC) (5) Familial adenomatous
polyposis (FAP) (1)
Rare syndromes
(lt01)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
QUESTION
For colorectal cancer what is the approximate survival rate for disease confined to primary site (Localized)
10 30 50 90
For cancer that has metastasized (Distant) 10 30 50 90
Polyp to Carcinoma Pathway
Normal to Adenoma to Carcinoma
Human colon carcinogenesis progresses by the dysplasiaadenoma
to carcinoma pathway
Polyp Charactoristics
Hyperplastic bull minimal cancer potential
Adenomatous bull approximately 90 of colon
and rectal cancers arise from adenomas
Stage at Diagnosis Stage Distribution ()
5-year Relative Survival ()
Localized (confined to primary site) 40 903
Regional (spread to regional lymphnodes) 36 704
Distant (cancer has metastasized) 20 125
Unknown (unstaged) 5 336
Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for 2003-2009 All Races Both Sexes
Stage Distribution and Survival
Colorectal Screening Rates
Opportunity for Improvement
Only 40 of colorectal cancers are detected at the earliest stage
A little more than half of Americans over age 50 report having had a recent colorectal cancer screening test
Slow but steady improvement in these numbers over the past decade
Screening rates remain lower in the underserveduninsured population than in the general population
Colorectal Cancer Risk Factors
Age bull 90 of cases occur in people 50 and older bull Average age of diagnosis 69
Gender bull slight male predominance but common in both men and women
RaceEthnicity bull African Americans have highest incidence and mortality rate of
all groups in US Hispanics the lowest (with considerable variation depending on country of origin)
bull Increased rates also documented in Alaska Natives some American Indian tribes Ashkenazi Jews
Colorectal Cancer Risk Factors
Sporadic (average risk) (65ndash85)
Family history
(10ndash30)
Hereditary nonpolyposis colorectal cancer
(HNPCC) (5) Familial adenomatous
polyposis (FAP) (1)
Rare syndromes
(lt01)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Polyp to Carcinoma Pathway
Normal to Adenoma to Carcinoma
Human colon carcinogenesis progresses by the dysplasiaadenoma
to carcinoma pathway
Polyp Charactoristics
Hyperplastic bull minimal cancer potential
Adenomatous bull approximately 90 of colon
and rectal cancers arise from adenomas
Stage at Diagnosis Stage Distribution ()
5-year Relative Survival ()
Localized (confined to primary site) 40 903
Regional (spread to regional lymphnodes) 36 704
Distant (cancer has metastasized) 20 125
Unknown (unstaged) 5 336
Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for 2003-2009 All Races Both Sexes
Stage Distribution and Survival
Colorectal Screening Rates
Opportunity for Improvement
Only 40 of colorectal cancers are detected at the earliest stage
A little more than half of Americans over age 50 report having had a recent colorectal cancer screening test
Slow but steady improvement in these numbers over the past decade
Screening rates remain lower in the underserveduninsured population than in the general population
Colorectal Cancer Risk Factors
Age bull 90 of cases occur in people 50 and older bull Average age of diagnosis 69
Gender bull slight male predominance but common in both men and women
RaceEthnicity bull African Americans have highest incidence and mortality rate of
all groups in US Hispanics the lowest (with considerable variation depending on country of origin)
bull Increased rates also documented in Alaska Natives some American Indian tribes Ashkenazi Jews
Colorectal Cancer Risk Factors
Sporadic (average risk) (65ndash85)
Family history
(10ndash30)
Hereditary nonpolyposis colorectal cancer
(HNPCC) (5) Familial adenomatous
polyposis (FAP) (1)
Rare syndromes
(lt01)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Polyp Charactoristics
Hyperplastic bull minimal cancer potential
Adenomatous bull approximately 90 of colon
and rectal cancers arise from adenomas
Stage at Diagnosis Stage Distribution ()
5-year Relative Survival ()
Localized (confined to primary site) 40 903
Regional (spread to regional lymphnodes) 36 704
Distant (cancer has metastasized) 20 125
Unknown (unstaged) 5 336
Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for 2003-2009 All Races Both Sexes
Stage Distribution and Survival
Colorectal Screening Rates
Opportunity for Improvement
Only 40 of colorectal cancers are detected at the earliest stage
A little more than half of Americans over age 50 report having had a recent colorectal cancer screening test
Slow but steady improvement in these numbers over the past decade
Screening rates remain lower in the underserveduninsured population than in the general population
Colorectal Cancer Risk Factors
Age bull 90 of cases occur in people 50 and older bull Average age of diagnosis 69
Gender bull slight male predominance but common in both men and women
RaceEthnicity bull African Americans have highest incidence and mortality rate of
all groups in US Hispanics the lowest (with considerable variation depending on country of origin)
bull Increased rates also documented in Alaska Natives some American Indian tribes Ashkenazi Jews
Colorectal Cancer Risk Factors
Sporadic (average risk) (65ndash85)
Family history
(10ndash30)
Hereditary nonpolyposis colorectal cancer
(HNPCC) (5) Familial adenomatous
polyposis (FAP) (1)
Rare syndromes
(lt01)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Stage at Diagnosis Stage Distribution ()
5-year Relative Survival ()
Localized (confined to primary site) 40 903
Regional (spread to regional lymphnodes) 36 704
Distant (cancer has metastasized) 20 125
Unknown (unstaged) 5 336
Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for 2003-2009 All Races Both Sexes
Stage Distribution and Survival
Colorectal Screening Rates
Opportunity for Improvement
Only 40 of colorectal cancers are detected at the earliest stage
A little more than half of Americans over age 50 report having had a recent colorectal cancer screening test
Slow but steady improvement in these numbers over the past decade
Screening rates remain lower in the underserveduninsured population than in the general population
Colorectal Cancer Risk Factors
Age bull 90 of cases occur in people 50 and older bull Average age of diagnosis 69
Gender bull slight male predominance but common in both men and women
RaceEthnicity bull African Americans have highest incidence and mortality rate of
all groups in US Hispanics the lowest (with considerable variation depending on country of origin)
bull Increased rates also documented in Alaska Natives some American Indian tribes Ashkenazi Jews
Colorectal Cancer Risk Factors
Sporadic (average risk) (65ndash85)
Family history
(10ndash30)
Hereditary nonpolyposis colorectal cancer
(HNPCC) (5) Familial adenomatous
polyposis (FAP) (1)
Rare syndromes
(lt01)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Colorectal Screening Rates
Opportunity for Improvement
Only 40 of colorectal cancers are detected at the earliest stage
A little more than half of Americans over age 50 report having had a recent colorectal cancer screening test
Slow but steady improvement in these numbers over the past decade
Screening rates remain lower in the underserveduninsured population than in the general population
Colorectal Cancer Risk Factors
Age bull 90 of cases occur in people 50 and older bull Average age of diagnosis 69
Gender bull slight male predominance but common in both men and women
RaceEthnicity bull African Americans have highest incidence and mortality rate of
all groups in US Hispanics the lowest (with considerable variation depending on country of origin)
bull Increased rates also documented in Alaska Natives some American Indian tribes Ashkenazi Jews
Colorectal Cancer Risk Factors
Sporadic (average risk) (65ndash85)
Family history
(10ndash30)
Hereditary nonpolyposis colorectal cancer
(HNPCC) (5) Familial adenomatous
polyposis (FAP) (1)
Rare syndromes
(lt01)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Colorectal Cancer Risk Factors
Age bull 90 of cases occur in people 50 and older bull Average age of diagnosis 69
Gender bull slight male predominance but common in both men and women
RaceEthnicity bull African Americans have highest incidence and mortality rate of
all groups in US Hispanics the lowest (with considerable variation depending on country of origin)
bull Increased rates also documented in Alaska Natives some American Indian tribes Ashkenazi Jews
Colorectal Cancer Risk Factors
Sporadic (average risk) (65ndash85)
Family history
(10ndash30)
Hereditary nonpolyposis colorectal cancer
(HNPCC) (5) Familial adenomatous
polyposis (FAP) (1)
Rare syndromes
(lt01)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Colorectal Cancer Risk Factors
Sporadic (average risk) (65ndash85)
Family history
(10ndash30)
Hereditary nonpolyposis colorectal cancer
(HNPCC) (5) Familial adenomatous
polyposis (FAP) (1)
Rare syndromes
(lt01)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Family History CRC bull 1 first degree relative 22 bull gt 1 relative 40 bull Relative dx lt 45 39
Colorectal Cancer Risk Factors
Medical History bull Crohnrsquos colon 26 bull UC colon 28 bull UC rectum
19 bull DM 12 bull Obesity
12 bull Red meat 12 bull Processed meat 12 bull Smoking 12 bull Alcohol 11
ACS Colorectal Cancer Facts and Figures 2011-2013
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Benefits of Screening
Improved survival bull Early detection markedly improves chances
of long term survival
Cancer Prevention bull Removal of pre-cancerous polyps prevent cancer
(unique aspect of colon cancer screening)
Cost-effective bull Cost of CRC screening compares favorably to many other
common interventions (ie mammograms) bull Treatment costs for advanced disease have risen greatly in
recent years
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
ACS CRC Screening Guidelines
Tests 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 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
Colonoscopy should be done if test results are positive For gFOBT or FIT used as a screening test the take-home multiple sample method should be used
gFOBT or FIT done during a digital rectal exam in the doctors office is not adequate for screening
USPSTF ldquoIrdquo Rating
USPSTF ldquoIrdquo Rating
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
2008 USPSTF Guidelines (Annals Int Med 2008)
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
CRC Guidelines Points to Consider
ldquoNo CRC screening test is perfect either for cancer
detection or adenoma detection Each test has unique advantages each has been
shown to be cost-effective and each has associated limitations and risks
Patient preferences and availability of resources play an important role in the selection of screening testsrdquo
The best test is the one that gets done
wwwcancerorg
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Colorectal Screening Barriers (according to Patients)
Low awareness of CRC as a personal health threat
Lack of knowledge of screening benefits
Fear embarrassment discomfort
Time
Cost (including co-pays)
Access
ldquoMy doctor never talked to me about itrdquo
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
System Barriers
Medical practice is demand (patient) driven Practice demands are numerousdiverse Few practices currently have mechanisms to assure
that every eligible patient gets a recommendation for screening
Screening rates are less for persons with less education lower SES no health insurance
-Lack of health insurance is an strong predictor of screening status Higher co-pays and deductibles also lead to decreased screening rates
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Quality Issues
The medical literature reflects quality concerns related to essentially all forms of testing
Examples include bull Inadequate flex sig insertion depth bull Abbreviated colonoscopy withdrawal times bull Lower sensitivity tests bull Poor sensitivity of in-office FOBT
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
QUESTION
Thinking about in office single sample digital FOBT about what proportion of advanced neoplasic high risk lesions will be missed
10 25 75 95
(adenomas gt 1cm high grade dysplasia or gt25 villous)
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
In-Office FOBT Points to Consider
Conclusion ldquoSingle digital FOBT is a poor screening method
for colorectal neoplasia and cannot be recommended as the only test Sensitivity lt 5
When digital FOBT is performed as part of a primary care physical examination negative results do not decrease the odds of advanced neoplasia
Persons with these results should be offered at-home 6-sample FOBT or another type of screening testrdquo
Collins et al Annals of Int Med Jan 2005
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
QUESTION
If you order or perform FOBT screening what type do you usually recommend
In office only Home only Both
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Home (three card) tests should be used
National Survey 1999-2000
In office only 325 Both 412 Home only 263
Follow up study 2010 showed no improvement In office only 249 Both 529 Home only 222 75 still using in office test in 2010
Guidelines recommend HOME TEST
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
Nearly 75 reported using single-sample in-office FOBT as primary method of screening
In-office single digital FOBT not recommended as screening tool for CRC
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Follow up of abnormal FOBT
Follow up of abnormal test 2005
bull Repeat FOBT 297 Of these 288 no further tests if negative Further tests if negative 722
bull Colonoscopy 52 bull Sigmoidoscopy 275
Follow up of abnormal test 2010
bull Repeat FOBT 178 Of these 225 no further tests if negative
bull Colonoscopy 93 bull Sigmoidoscopy 46
Nadel et al Annals of Int Med Jan 2005 Nadel Jnl Gen Int Med April 2010
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
QUESTION
If you use FOBT testing what type do you use bull Standard guaiac-based cards such as Hemoccult II bull Higher-sensitivity FOBTs such as Hemoccult SENSA bull Fecal immunochemical tests bull did not know brand of test
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Stool Tests
Three different types of fecal occult blood testing available Guaiac (gFOBT)
bull Hemoccult II (lower sensitivity) ndash no longer recommended for screening
bull Hemoccult SENSA (higher sensitivity) Immunochemical (FIT) ndash higher sensitivity
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Guaiac-based fecal occult blood test
Most common type used in US Best evidence (3 RCTrsquos) Requires collection of specimens from 3 different
bowel movements Reacts with heme portion of the hemoglobin
molecule non-specific Results may be influenced by some foods and
medications
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Fecal Immunochemical Test (FIT)
Based on the immunochemical detection of human hemoglobin gt enhanced specificity Results not influenced by food medication Antibody reacts with the intact globin portion of
human hemoglobin Globin breaks down during passage from upper to lower
GI tract Positive fecal immunochemical test is specific for lower GI
origin
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Fecal Immunochemical Test (FIT)
Test performance is superior to Hemoccult II and comparable to Hemoccult SENSA
Some FITs demonstrate good performance with only 2 samples
Costs more than guaiac-based tests
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Higher Sensitivity Tests Recommended
Opinion of effectiveness of tests FOBT (guaiac) very or somewhat effective 854 FIT very or somewhat effective 541 Donrsquot know about FIT 384
Types of tests used Standard guaiac-based cards such as Hemoccult II 611 Higher-sensitivity FOBTs such as Hemoccult SENSA 220 Fecal immunochemical tests 89 did not know brand of test 147 HIGHER SENSITIVITY TESTS RECOMMENDED
Fecal Occult Blood Testing Beliefs and Practices of US Primary Care Physicians Serious Deviations from Evidence-Based Recommendations Marion R Nadel Jnl Gen Int Med 4-2010
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Tools and Resources
Colorectal cancer is a serious threat to our patients Evidence based screening guidelines exist Screening rates are far below recommended levels
Our patients suffer and die needlessly from colorectal
cancer
How can we make a difference
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Patient Education
ldquoGet Tested For Colon Cancer Heres Howrdquo
An 7-minute video reviewing options for colorectal cancer screening tests including test preparation Access at wwwcancerorgcolonmd
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
For Patients and Caregivers
American Cancer Societyrsquos Complete Guide to Colorectal Cancer Comprehensive matter-of-fact Easy to read and assuring Helpful charts and illustrations resources for patients and a special section designed for caregivers Includes real-life stories from people with cancer and their loved ones and caregivers More than 400 pages on risk factors prevention testing treatment choices coping and life after treatment Written by a team of world-class experts 1800ACS2345
wwwcancerorgbookstore
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Physician Office Wall Chart
bull Screening guidelines for Breast Cervical Colon Prostate and other cancers
bull General prevention
Tobacco cessation Healthy diet Weight etc
bull English and Spanish
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Continuing Medical Education
Free Journal-Based CME For Internists Family Physicians and other
primary care clinicians
Available at the website of the American Cancer Societyrsquos journal CA A Cancer Journal for Clinicians httpcacancerjournalcom
See section on guidelines for current screening recommendations
Read articles then take on-line CME or CE quiz(es)
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
Developed by National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Four Essentials for Improved Screening Rates
Your Recommendation
An Office Policy
An Office Reminder System
An Effective Communication System
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
The Tool Kit Contains Ready to Use ldquoToolsrdquo
Interactive web based and pdf versions available
Both provide bull Step-by-step guidance
on how to implement office systems
bull Forms and templates
bull Useful web sites
Available at wwwcancerorgcolonmd
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Addressing Underserved Populations
Opportunities for community health centers bull National Prevention Strategy bull National Quality Strategy bull Serve vulnerable populations
24 limited English speakers 62 ethnic minorities 36 uninsured39 Medicaid 93 low income Homeless farm workers public housing residents
bull ACA provides additional FQHC support bull Transition to Patient Centered Medical Homes bull CRC screening added UDS requirement by HRSA 2012 bull No costs to individuals covered in Health Exchange plans bull IOM report recommends integrating public health - primary care
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Strategies for Clinic Based Screening Develop a screening policy
Risk assessment Documentation of prior screening Recommendation for all eligible patients Define responsibilities Plan for evaluation of abnormal tests and treatment Surgeon Anesthesiology Pathology Oncology
Reminders Patients and clinicians Follow up unreturned tests
Tracking system Results Compliance with follow upcolonoscopy Rescheduling protocol (clinic vs endoscopist)
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Strategies for Clinic Based Screening
Standing orders Define referral process for endoscopy and treatment Tag charts for non-responders Chart review or EMR to identify eligible patients Patient educationcoaching Set a goal Track outcomes Identify opportunities for improvement - PDSA cycle
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
FLU-FIT Program
Flu-FIT an effective approach to screening bull Based in six community clinics in SF area bull Screening rates increased from 325 to 455 bull Eligible patients completing screening increased 22X
Method bull Adults 50-75 years of age offered FITFOBT screening at time of
annual influenza vaccination bull Standing orders executed by nursing staff bull One hour training for LVNrsquos MArsquos bull Log Sheet reminder to check eligibility at time of visit bull Visual aide for patients bull Multilingual written instructions bull Video instructions bull Stamped envelopes for return of tests
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Strategies for Clinic Based Screening
Resources bull USPHSUNC guide to improve screening
ncspeedorgsitesdefaultfilesCRC_Toolkitpdf bull ACS CRC tool and resources
cancerorgcolonmd bull CDC Screen for Life
cdcgovcancercolorectalsfl
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Strategies for Clinic Based Screening
Resources bull Articles and presentations
Promoting cancer screening within the patient centered medical home Sarfaty CA Cancer J Clin 201161397-408
Strategies for expanding colorectal cancer screening at community health centers Sarfaty CA Cancer J for Clin 2013 63 221-231
Effectiveness of the FLU-FOBT program in primary care A randomized trial Potter Am J Prev Med 2011 41 1 9-16
FLU-FIT FLU-FOBT presentation pdf ndash httpcacoloncancerorgdocumentsroundtablePotter20FLU-
FOBTpdf FLU-FIT Materials
ndash httpflufitorg
bull Ongoing trials FLU-FIT Program at Kaiser Permanente Northern California
ndash httpclinicaltrialsgovshowNCT01210235
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Personal Action Plan
What steps will you take to improve prevention and early detection of colorectal cancer in your practice bull List three things you will do to reduce colorectal cancer
deaths in your patients
1
2
3
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Acknowledgement
Durado D Brooks MD MPH
bull American Cancer Society
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Lewis E Foxhall MD lfoxhallmdandersonorg
wwwmdandersonorg
Live Long amp ProsPer
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
1Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies and therefore the interval before the subsequent colonoscopy should be 10 years An exception is patients with a hyperplastic polyposis syndrome They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up 2Patients with only one or two small (lt1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings family history and the preferences of the patient and judgment of the physician) 3Patients with 3 to 10 adenomas or any adenoma gt1 cm or any adenoma with villous features or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia then the interval for the subsequent examination should be 5 years 4Patients who have more than 10 adenomas at one examination should be examined at a shorter (lt3 years) interval established by clinical judgment and the clinician should consider the possibility of an underlying familial syndrome 5Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal Once complete removal has been established subsequent surveillance needs to be individualized based on the endoscopistrsquos judgment Completeness of removal should be based on both endoscopic and pathologic assessments 6More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer
ACSMSTF Colorectal Cancer Surveillance Guidelines ACA Coverage of Screening
httpkaiserfamilyfoundationfileswordpresscom2013018351pdf
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
Please take a few minutes to complete the survey
seen on your screen at the end of this presentation Please type questions into the QampA tab located at the top of your screen
Additional questions email laurajanskyheartorg
You will be able to download the slide deck and view the recording of this
presentation within 7-10 working days from GuidelineAdvantageorg
Questions
68
- Thank you for joining The Guideline Advantage this afternoon
- Slide Number 2
- Vision amp Goal
- Slide Number 4
- Slide Number 5
- Program Functionality
- Advantages to Practices amp Physicians
- The Guideline Advantagersquos Measures
- Alignment with National Programs
- Slide Number 11
- Colorectal Cancer Learning Objectives
- QUESTION
- Colorectal Cancer
- Slide Number 15
- Slide Number 16
- Cancer Death Rates by Race and Ethnicity US 2005-2009
- Slide Number 18
- Slide Number 19
- QUESTION
- Polyp to Carcinoma Pathway
- Polyp Charactoristics
- Slide Number 23
- Colorectal Screening Rates
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Colorectal Cancer Risk Factors
- Benefits of Screening
- ACS CRC Screening Guidelines
- 2008 USPSTF Guidelines (Annals Int Med 2008)
- CRC Guidelines Points to Consider
- Trends in the Prevalence of Fecal Occult Blood Test by Health Insurance Status US 2000-2010
- Flexible Sigmoidoscopy or Colonoscopy Prevalence by RaceEthnicity and Health Insurance Status US 2010
- Slide Number 34
- Slide Number 35
- Colorectal Screening Barriers(according to Patients)
- System Barriers
- Quality Issues
- QUESTION
- In-Office FOBT Points to Consider
- QUESTION
- Home (three card) tests should be used
- Follow up of abnormal FOBT
- QUESTION
- Stool Tests
- Guaiac-based fecal occult blood test
- Fecal Immunochemical Test (FIT)
- Fecal Immunochemical Test (FIT)
- Higher Sensitivity Tests Recommended
- Tools and Resources
- Patient Education
- For Patients and Caregivers
- Physician Office Wall Chart
- Continuing Medical Education
- Evidence-Based Toolkit and Guide to Increase Colorectal Cancer Screening Rates
- Four Essentials for Improved Screening Rates
- The Tool Kit Contains Ready to Use ldquoToolsrdquo
- Addressing Underserved Populations
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- FLU-FIT Program
- Strategies for Clinic Based Screening
- Strategies for Clinic Based Screening
- Personal Action Plan
- Acknowledgement
- Slide Number 66
- ACSMSTF Colorectal Cancer Surveillance GuidelinesACA Coverage of Screening
- Questions
-
