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Update on Colorectal Cancer Screening

What every clinician should know

Ilche T. Nonevski, MD, MBAAssistant Clinical Professor, UIC-Rockford

Rockford Gastroenterology Associates May 6, 2016

Outline Primer on Colorectal Cancer Screening

CRC: The numbers National numbers Local success stories

CRC: the science Screening and Prevention Approaches

Guideline based approach Pros and cons Emphasis on quality

Take home points Questions and discussion

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RGA Background Founded in 1976 National leaders in GI quality

National Committee members New England Journal of Medicine article (2006)

Comprehensive GI Care 15 Physicians 8 Nurse Practitioners

Colorectal Cancer 2016 ACS Estimates: 134,490 cases

95,270 new cases of colon cancer 39,220 new cases of rectal cancer 49,190 deaths

2nd leading cause of cancer related death Lifetime risk for colorectal cancer

1 in 20 (5%)

Infamous Cancer in Famous People

Pope John Paul II72

President Ronald Reagan 74

Vince Lombardi57

Justice Ginsburg66

Darryl Strawberry36

Sharon Osbourne49

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CRC: Overall Incidence

Screening comparisons Colon Cancer Mortality reduction 70-90%

Colonoscopy: 61-89% reduction in CRC1 In GETTING colon cancer, NOT dying from it

Mammogram (50-69 year olds) 2 Death is 40% preventable PSA for prostate screening 3 Relative risk reduction for death is 21%

1. Am J Gastroenterol. 2016 Jan 12.2. N Engl J Med 2015; 372:2353-23583. Cochrane Database Syst Rev. 2013

CRC: The Numbers Incidence of colon cancer 2000-20101

Decreased by 30%!!! 50-80 year olds

Parallels widespread use of colonoscopy Detection CRC at early stage is surgically

curable Success!!

What about in Rockford?

1. CA Cancer J Clin 2015;65:5-29

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CRC: The Numbers Incidence of colon cancer 2000-20101

Decreased by 30%!!! 50-80 year olds

Parallels widespread use of colonoscopy Detection CRC at early stage is surgically

curable Success!!

What about in Rockford?

1. CA Cancer J Clin 2015;65:5-29

Rockford: CRC Prevention is working!1 of only 6 counties in Illinois with below

average rates

Source: Illinois Department of Health

CRC Screening Success!! Not so fast

23,000,000 eligible patients are NOT getting screened Access, cost, reluctance

“My doctor didn’t mention it!!” #2 reason given by age-eligible adults who are not up-to-date with

CRC screening1

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CRC Screening Success!! Not so fast

Incidence of colon cancer in patients

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CRC Risk Factors Dietary

High red meat/processed meat Low vegetables and fiber

Physical inactivity Obesity Type II Diabetes Smoking Heavy alcohol use

Source: American Cancer Society

Un-Modifiable CRC Risk Factors Age

Racial & ethnic background Personal history of CRC/adenomas Personal history of IBD

UC & Crohn’s colitis > 8 years Family history of CRC/adenomas Inherited syndromes

Familial Adenomatous Polyposis (FAP) Lynch Syndrome (HNPCC)

Source: American Cancer Society

Why is CRC easier to screenand prevent?

Johns Hopkins Online

Adenoma to Carcinoma Sequence

Fewer than 10% of all adenomas become cancerous. However, more than 95% of colorectal cancers develop from adenomas

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Adenoma to Carcinoma Sequence

CMS.gov

Stage of Diagnosis Predicts Survival

Stage of Diagnosis Predicts Survival

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Average Risk CRC Screening

Am Fam Physician. 2015 Jan 15;91(2):93-100.

CRC Screening Options High sensitivity FOBT (FIT)

30-50% reduction in mortality No impact on preventing colon cancer

Sigmoidoscopy plus FOBT Effective for left-sided CRC Misses right colon polyps

Including sessile serrated adenomas

CT colonography Cologuard Stool DNA testing Colonoscopy

CT Colonography

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CT Colonography 90% sensitivity for polyps & cancer >10mm Can miss flat sessile adenomas in right colon

Higher risk for malignancy Requires colon prep

Colonoscopy slot scheduled afterward Radiation exposure (likely overstated) Management of extra-colonic findings

Incidental findings Potentially added costs for workup Increased anxiety for patients

CT Colonography Ideal for:

Incomplete colonoscopy due to anatomy (not poor prep)

Patients reluctant to have colonoscopy But willing to have colonoscopy if polyp found

Willing to undergo prep and potentially 2 procedures

Willing to repeat every 5 years regardless of findings

Willing to drive to Madison or Chicago

Cologuard

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Cologuard Stool DNA

Detects 2 different types of mutations common in colorectal cancer (CRC) and advanced adenomas (AA) and occult bleeding

FDA approved CMS approved

Average risk colon cancer screening (ages 50-85) Expected to pay for test every 3 years Cost is $600 per test

CRC Screening Comparisons

Test SensitivityColorectal

Cancer

SensitivityAdvancedAdenoma

False Positives FalseNegatives

(Miss Rate)

Cologuard 92% 42% 13% 8%For CRC

Fit Testing 74% 24% 10 mm

Cologuard—Take Home Points Very effective for detecting colon cancer Not effective for detecting advanced

adenomas (pre-cancerous) Does not prevent colon cancer Higher false positives (compared to FIT) More expensive than colonoscopy (Medicare

data) Ideal for average risk patients reluctant to have

colonoscopy

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High Risk CRC Screening

Am Fam Physician. 2015 Jan 15;91(2):93-100.Consider 40 for family history of ANY polyp if

pathology results are not available

CRC Prevention Options Colonoscopy is the gold standard

Only test that can prevent cancer over entire colon 60-90 % reduction in new cancers Up to 68 % reduction in deaths

Colonoscopy is the most cost-effective screening tool Through reduction in mortality

Sonnenberg, Ann Int Med, 2000

Old data

Goal of Colonoscopy Perform the safest, highest quality procedure Remove precancerous polyps

Completely Polyp types

Hyperplastic: nearly universally benign Tubular Adenoma: most common precancerous

polyp Tubulovillous adenoma: Villous adenoma (more aggressive) Sessile serrated adenomas (small but aggressive)

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Colonoscopy

Villous adenoma

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Serrated Adenoma

Serrated Adenoma

Colon Cancer

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Colon Cancer

Colon Cancer

CRC Screening-Summary

CRC screening is effective CRC prevention is preferred Colonoscopy is the gold standard

Only test that can prevent colorectal cancer over the entire colon

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Quality Measures for Colonoscopy

Cecal intubation rate for Avg Risk Screening Acceptable standard > 95%

RGA 98% Adenoma Detection Rate (ADR)

Standards: Males >30% Females >20%

RGA Males 55% Females 37%

Reasons for Patient Reluctanceto have Colonoscopy

Invasive Concern for intolerance of prep Concern for safety of procedures

Joan Rivers Self-conscious of body image Logistics

Day off work plus driver Costs

High deductible co-pays

Colonoscopy Risks Major complications for average risk screening ASGE Guidelines 2011 Cardiopulmonary

0.9% Perforation (0.3-0.07%)

1 in 2,000 is considered standard of care (0.05%) RGA: 1 in 14,000 or 0.01%

Source: ASGE Guidelines 2011

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Colonoscopy Risks Post-polypectomy bleeding

Standard of care: 1 in 100 (1%) Medicare data 2 in 1,000 (0.2%) RGA 2 in 1,000 (0.2%)

Take out larger, more complicated polyps Can have up to 10 % bleeding rate

Death directly attributable to colonoscopy 19 in 284,000, or 0.007%

Source: ASGE Guidelines 2011

Risk In Perspective

Medicare Reimbursement for CRC Screening

Screening horizon: 10 years

Colonoscopy (no intervention) $588 National average (private) cost $1,200

CT colonography Every 5 years ($600 x 2) $1200

Cologuard Every 3 years ($600 x3) $1800

FIT testing Every 1 year ($25 x 10) $250

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Cost of Screening: Perspective 81 % of all American Households: HDTVs1

52% have multiple HDTVs 68% of households with income < $50,000

Average cost 32” HDTV (2012) 2 Decreasing $435 Yet, average cost paid increasing $1224

Average replacement cycle 2 6 years Average life span of HDTV 7-9 years1. Source: Leichtman Research Group 2014, 20152. IHS Technology. Com survey 2012

But wait! Too much of a good thing? The impact of over-screening

1 in 4 colonoscopies Potentially inappropriate

1 in 5 colonoscopies1 Probably inappropriate

GI recommendations Inconsistent with guidelines 60% of time2

1. JAMA Intern Med. 2013;173(7):542-550.2. Am J Prev Med. 2007;33(6):471-478.

Appropriate Utilization 94 %

80 %

Source: GI Quic national database

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Impact of over-screening

Higher risk of complications Minimal impact on CRC rates Negative impact on patient outcomes

“Break a hip on the way to the bathroom” Life expectancy

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Take Home Points Colon cancer is prevalent Colon cancer is deadly Colon cancer rates are rising for younger

patients Colon cancer and death is nearly entirely

preventable 23 million eligible patients are not screened ANY SCREENING IS BETTER THAN

NO SCREENING

Take Home Points Colonoscopy remains the gold standard and

the only test that prevents cancer of entire colon—start at age 50 Preferred test for average risk screening Only recommended test for high risk population

FIT testing is most cost effective option For patients reluctant to have colonoscopy

Do NOT recheck if negative colonoscopy < 5 years

CT colonography and Cologuard are alternative options Have diagnostic limitations and drawbacks

Take Home Points Ask family history of colon polyps as well as

cancer in every patient Recommend colonoscopy at age 40 in

patients with family history of any polyp if pathology not available to confirm hyperplastic Or 10 years before age advanced adenoma was

detected Identify patients with multiple cancers and

family members Think hereditary cancer syndromes

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Take Home Points Colonoscopy is safe

Think lifetime risk of dying from car accident Colonoscopy is cost effective

Think cost of cancer treatment Think HDTV life cycle

Demand high quality colonoscopy with: High cecal intubation rates High adenoma detection rates Low complication rates Proper adherence to national guidelines

Take Home Points Know when to stop screening

75-80 years old depending on age, family history co-morbidities

Discuss CRC prevention and screening at every visit

Help prevent colon cancer!!

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Thank you Contact info

Phone 815.397.7340 Email: DrNonevski@rockfordgi.com

Reach out anytime with any GI questions