Transcript Colorectal Cancer - Michigan Cancer Registrar's Association

Colorectal
Cancer
Paula M. Rechner M.D.
War Memorial Hospital
October 13, 2005
Goals
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Identify Colorectal Cancer as a serious health
problem in the US
Provide current guidelines
Outline present day insurance coverage
Identify targets for prevention
Provide a rural surgeon’s perspective on
colorectal cancer
American Cancer Society
Colorectal Cancer Facts & Figures – Special
Edition 2005
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145,290 new diagnoses expected in
2005
 Colon: 104,950
 Rectum: 40,3410
American Cancer Society
Colorectal Cancer Facts & Figures – Special
Edition 2005
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56,290 predicted deaths
 5 year localized survival rate: 90%
 Only 39% CRC found at this stage
due to low screening rates
 5 year survival with metastatic disease:
10%
 5 year overall survival rate: 63%
American Cancer Society
Colorectal Cancer Facts & Figures – Special
Edition 2005
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5.6% OF Americans will
develop CRC in their lives
American Cancer Society
Colorectal Cancer Facts & Figures – Special
Edition 2005
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Third most common type of cancer
Second most common cause of cancer death
When men and women are considered
separately CRC is the third most common
cause of death in each sex
American Cancer Society
Colorectal Cancer Facts & Figures – Special
Edition 2005
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THE LEADING CAUSE OF
CANCER DEATH AMONG
NONSMOKING AMERICANS
U.S. Colorectal Cancer Incidence
70
60
50
White
Hispanic
African Americans
Asian
American Indians
40
30
20
10
0
1982
1986
1990
1994
1998
2002
U.S. Colorectal Cancer Mortality
Whites
30
25
Hispanics
20
African Americans
15
10
Asians or Pacific
Islanders
5
0
1982
1986
1990
1994
1998
2002
American
Indians/Alaskan
Natives
Colorectal Cancer
Risk Factors
MayoClinic.com
Risk Factors for Colorectal Cancer
Age: 90% are age > 50
 Inflammatory Bowel Disease
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MayoClinic.com
Risk Factors for Colorectal Cancer
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Family History
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Hereditary
Shared environmental exposure to a carcinogen,
diet or lifestyle
Familial Adenomatous Polyposis (FAP)
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Cancer by age 40!!!
Hereditary Nonpolyposis Colorectal Cancer
(HNPCC)
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Ashkenazi Jews
(Fewer than 10% of CRC are caused by inherited gene mutations)
MayoClinic.com
(continued)
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Diet
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Sedentary Lifestyle
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Low fiber
High Fat
High Calories
Increased transit time
Prolonged colonic exposure to carcinogens
Diabetes
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40% increased risk of developing colorectal cancer
MayoClinic.com
(continued)
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Smoking
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Alcohol
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1 in 10 fatal colon cancers may be caused by smoking
Once diagnosed with colorectal cancer, smokers face a 30
to 40 percent increased risk of dying of the disease
1 drink per day for women
2 drinks per day for males
Personal History of Colorectal Cancer or Polyps
American Cancer Society
Family History (First Degree Relative)
IBD >10 years
Obesity (BMI>30)
Red Meat (>7/week vs. 1/mo)
Smoking (Current vs. never)
Alcohol (>4/week vs. none)
Physical Activity (>3hr/week vs. none)
Vegetable & Fruit consumption (>5 vs.
<3/day)
RR
1.8
1.5
1.5-2.0
1.5
1.5
1.4
0.6
0.7
Colorectal Cancer Diagnosis and
Screening
MayoClinic.com
Screening and Diagnostic
Procedures
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Digital Rectal Exam
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Fecal Occult Blood Test
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Limited exam
Likely to miss small polyps
False Positive
False Negative
Flexible Sigmoidoscopy
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Limited Exam
Minimal perforation risk
MayoClinic.com
Screening and Diagnostic Procedures
(continued)
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Barium Enema
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“significantly high rate of missing important
lesions…especially in the lower bowel and
rectum”
Flexible sigmoidoscopy may be done in addition to
BE
Colonoscopy
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“most sensitive test for colon cancer, rectal cancer
and polyps”
MayoClinic.com
Screening and Diagnostic Procedures
(continued)
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New Technologies
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Virtual colonoscopy
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2 minute CT scan
No prep – potential in the future
Less accurate than colonoscopy
Diagnostic not therapeutic
Not widely available
American Cancer Society
Screening and Surveillance
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At Age 50 for men and women at average risk
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FOBT or FIT every year-take home kit not DRE
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6 samples from 3 consecutive BM’s
Flexible Sigmoidoscopy every 5 years
FOBT or FIT every year + Flex Sig every 5 years
Double-contrast barium enema every 5 years
Colonoscopy every 10 years
American Cancer Society
Screening and Surveillance
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FOBT
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Reduces risk of death from CRC by 15-33%
FOBT reduces incidence of CRC by 20%
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Detection of polyps
Early removal of polyps found thus preventing CRC
Flexible Sigmoidoscopy (FS)
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Reduces CRC mortality by 60% for cancers within
reach of the instrument
FS followed by Colonoscopy if a polyp is found
identifies 70-80% of individuals with CRC
American Cancer Society
Screening and Surveillance
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FOBT and Flexible Sigmoidoscopy
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One test would compensate for the limitations and
may improve early detection
Colonoscopy
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National Polyp Study
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76-90% CRC Prevention
Most sensitive test for CRC and Polyps
Gold Standard for Screening
Screening, Diagnostic and Therapeutic
American Cancer Society
Screening and Surveillance
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Barium Enema with Air Contrast
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Less sensitive than colonoscopy
Colonoscopy is required if a polyp is found
DNA based fecal screening and Virtual
Colonoscopy
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Are not recommended at this time
Screening and Surveillance for
Increased Risk Patients
Increased Risk
Age to begin
Recommendation
comment
1 < 1cm adenoma
3-6 yrs after
polypectomy
colonoscopy
If normal return to
screening
1 > 1cm adenoma,
multiple adenomas or
adenomas with high
grade dysplasia or
villous changes 1cm
Within 3 yrs of
polypectomy
colonoscopy
If normal, repeat in 3
yrs, if then normal,
return to screening
Personal history of
curative intent resection
of CRC
Within 1 year of
cancer resection
colonoscopy
If normal, repeat in 3
yrs, if then normal
repeat every 5 yrs
colonoscopy
Every 5-10 years
Either CRC or
Age 40, or 10 years
adenomatous polyps in any before the youngest
first degree relative before case
age 60, or in 2 or more first
degree relatives at any age
(if not a hereditary
syndrome)
Screening and Surveillance for High
Risk Patients
High Risk
Age to begin
Recommendation
Comment
Family history of
FAP
Puberty
Early surveillance, If genetic
with endoscopy, +/- testing +,
genetic testing
colectomy
Family history of
HNPCC
Age 21
Colonoscopy and
counseling to
consider genetic
testing
Chronic
Ulcerative Colitis
or Crohn’s
disease
8 yrs after onset
Colonoscopy with
of pan colitis, or
biopsies for
12-15 yrs after
dysplasia
onset of left-sided
colitis
If genetic test +,
or no testing,
every 1-2 years
until 40 then
annually
Every 1-2 years
COST
American Cancer Society
Screening and Surveillance
Cost Range
FOBT
Less than $20
Flexible Sigmoidoscopy
$150-$200
Double-contrast Barium
Enema
Colonoscopy
$300-$400
$400+
Insurance Coverage
Medicare
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CRC screening covered since 1998
All recommended screening options covered
since 2001
An initial preventative health care visit for all
Medicare beneficiaries within 6 months of
enrolling in Medicare covered since January
2005!
Medicare Coverage
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FOBT-Once every 12 months
Flexible Sigmoidoscopy-Once every 48 months
Screening Colonscopy
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High Risk-Once every 24 months
Average risk-Once every 10 years, but not within 48
months of screening FS
Barium Enema-In place of FS only
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High Risk-Every 24 months
Average Risk-Every 48 months
Medicare Coverage
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You pay nothing for FOBT
You pay 20% of the Medicare-approved
amount after the yearly Part B deductible, for
all other tests
You pay 25% of the Medicare-approved
amount after the yearly part deductible, if
endoscopy is done in a hospital outpatient
department
Blue Cross Blue Shield Coverage
MI 2005
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Provider Type
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M.D. or D.O. (otherwise not payable)
Payable under Preventive coverage
Age > 50
1 Per 10 Years unless “high risk”
“Average Risk”
25% of “average risk” adults at
age 50 will have adenomatous
polyps
 70-80% of all Colorectal
Cancers develop in “average
risk” patients
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Blue Cross Blue Shield High Risk
Diagnosis
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25-40 years old
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V1005
V1006
V160
V1000
V7641
V7650
V7651
1 per 2 years
> 40 years old
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V1005
V1006
V160
V1000
V7641
V7650
V7651
Any Appropriate
Frequency
V CODES
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V1005-Personal history of malignant neoplasm of the large
intestine
V1006-Personal history of malignant neoplasm of the rectum
V160-Family history of malignant neoplasm of the
gastrointestinal tract
V1000-Personal history of malignant neoplasm of the
gastrointestinal tract
V7641-Special screening for malignant neoplasms of the
rectum
V7650-Special screening for malignant neoplasms of the
intestine
V7651-Special screening for malignant neoplasms of the colon
State of MI PPO & GM Hourly and
Salary Benefits for High Risk
1 Per 10 years
 Age >50
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Colorectal Cancer Screening
Statistics
American Cancer Society
Colorectal Cancer Facts & Figures – Special
Edition 2005

Less than 50% of people
aged 50 or older have
had a recent
colonoscopy!!!!
American Cancer Society
Populations associated with even less screening
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Age 50-64
Non-white race
Fewer years of education
Lack of health insurance
Immigration to the US < 10 years
American Cancer Society
Overall US Population
FOBT
17.3 %
Endoscopy
30 %
FOBT/Endoscopy
39.4%
Any screening
Less than 50 %
American Cancer Society
Michigan Residents Age 50 and Older
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White Non-Hispanic ~53% screened
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Ranked 12th in the Nation
African American Non-Hispanic ~57%
screened
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Ranked 5th in the Nation
American Cancer Society
Barriers to CRC Screening
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Health Care Providers
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Communication with patients
Several studies show patients are more likely to be
screened if it is recommended to them
Attitudes and Beliefs
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Effectiveness of screening
Familiarity with screening guidelines
Perception of patient preference and adherence
Lack of training to perform tests
Lack of adequate reminder systems within their practices
Barriers to CRC Screening
American Cancer Society
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Health Insurance
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If patient has any
If benefits include screening
Highly variable
Barriers to CRC Screening
American Cancer Society
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Patients
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“Too busy”
“Lack of physician recommendation”
“Inconvenience”
“Lack of interest”
“Cost”
“Embarrassment”
“unpleasantness of the test”
Unaware of benefits
Lack understanding of importance of screening
Strategies to Increase Utilization of
CRC Screening
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Physician office and health systems
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Health Insurance
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Computer reminder systems
Identify eligible patients for screening
Organized support for referrals and follow up
Only 9 of 29 states, where CRC screening is under 50%,
have passed legislation to require CRC screening!!!!!!
16 states and D.C. have such legislation
Education for Patients and Providers
MayoClinic.com
Prevention
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Eat 5 or more fruits and vegetables per day
Limit fat
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< 30% Fat in daily calories
< 10% of saturated fats
Vitamins and Minerals that prevent CRC
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Calcium
Pyridoxine (vitamin B-6)
Vitamin B-9
Magnesium
Prevention of Colorectal Cancer
MayoClinic.com
Prevention (continued)
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Limit alcohol consumption
Stop smoking
Exercise 30 minutes per day
Hormone Replacement Therapy (HR)
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May reduce risk of CRC
Women on HR who develop CRC may have a faster
growing form of the disease
Consider taking statins for high cholesterol
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NEJM (5/26/2005)– reduced risk in patients taking statins
for five years or more
American Cancer Society
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Aspirin and aspirin like drugs
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May lower the risk of colorectal cancer
ACS does not encourage NSAIDs or Cox-2
inhibitors
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Gastric side effects
Heart attack
Consult with physician
NCI Colorectal Cancer Research
Investment
300
250
200
150
100
50
0
2000
2001
2002
2003
2004
2005
The American Cancer Society
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Funded $49.6 million as of July 2004
90 colon cancer-related grants
Survey’s public knowledge, attitudes and
practices
Education
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www.cancer.org
1-800-ACS-2345
National colon cancer public awareness
campaign
Michigan Legislation 2004
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Screening law requires insurers to offer
coverage but does not assure coverage or there
are no state requirements for coverage
Surgical Plan
Surgical Management
Polyp
Adenoma
<10
Carcinoma
>100
10-100
Partial Colectomy
Polypectomy
With
Ileorectal anastamosis
Staging
Total Colectomy
With
Ileal Pouch
Surgical Management
Carcinoma
Locally
Confined
Liver
Metastasis
Spread to
Adjacent Organs
Diffuse
Disease
Segmental
Resection
Wedge resection
Of Metastasis
En bloc Resection
Diverting Colostomy
Chemotherapy
+/- Radiation
Chemotherapy
+/- Radiation
Chemotherapy
+/- Radiation
A Rural Surgeon’s Perspective
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Benefit of providing both screening and
therapy for Colorectal Cancer
Continuity of Patient Care
Family Education
Long Term Follow-up for surveillance
Questions?