Colon Cancer Screening - Knowing The Guidelines - Getting It Done

1. Colon Cancer Screening- Knowing The Guidelines- Getting It Done! Richard C. Wender, MD Alumni Professor and Chair Department of Family & Community Medicine Thomas Jefferson University Philadelphia, PA Past President, American Cancer Society

2. Colorectal Cancer � 2010 Update From CA Estimated new cases � 142,570 Estimated deaths � 51,370 2a2a

3. 3a Most of the increase in cancer death rates for men prior to 1990 was attributable to lung cancer. However, since 1990, the age-adjusted lung cancer death rate in men has been decreasing; this decrease has been estimated to account for about 40% of the overall decrease in cancer death rates in men. Stomach cancer mortality has decreased considerably since 1930. Death rates for prostate and colorectal cancers have also been declining. 3a Most of the increase in cancer death rates for men prior to 1990 was attributable to lung cancer. However, since 1990, the age-adjusted lung cancer death rate in men has been decreasing; this decrease has been estimated to account for about 40% of the overall decrease in cancer death rates in men. Stomach cancer mortality has decreased considerably since 1930. Death rates for prostate and colorectal cancers have also been declining.

4. 4a Lung cancer is currently the most common cause of cancer death in women, with the death rate more than twice what it was 30 years ago. In comparison, breast cancer death rates changed little between 1930 and 1990, but decreased 27% between 1990 to 2005. The death rates for stomach and uterine cancers have decreased steadily since 1930; colorectal cancer death rates have been decreasing for more than 50 years. 4a Lung cancer is currently the most common cause of cancer death in women, with the death rate more than twice what it was 30 years ago. In comparison, breast cancer death rates changed little between 1930 and 1990, but decreased 27% between 1990 to 2005. The death rates for stomach and uterine cancers have decreased steadily since 1930; colorectal cancer death rates have been decreasing for more than 50 years.

7. Where We Are: CRC Screening in PA & US( Age 50 and over; BRFSS, CDC) 2002 2008 PA | US PA | US Stool Tests (2 yrs) 29% 30% 19% 21% Endoscopy* (ever) 38% 48.6% 62% 62.5%

9. Where we want to be:PA CRC Screening Goals Increase the percentage of CRC Screening in the Pennsylvania adult population age 50 and above to 80% by 2014. Decrease the incidence of late-stage CRC diagnoses among Pennsylvania adults age 50 and above to 44% by 2014.

10. Question 1:Which approach most accurately describes your current approach to colon cancer screening? Colonoscopy for all � no specific back-up plan Colonoscopy for all � digital rectal FOBT as a back-up plan Colonoscopy for all � FOBT at home OR in-office as a back-up Colonoscopy for all � home FOBT as back-up FOBT/FIT or Colonoscopy offered - patient chooses FOBT/FIT is primary screening approach Other No correct answerNo correct answer

11. Reaching Our Goal?

13. CRC Screening Guidelines: New Concepts A 50% sensitivity threshold for cancer Tests that predominantly target prevention versus tests that predominantly target cancer 7a7a

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15. Tests That Primarily Detect Cancer Annual gFOBT with at least 50% test sensitivity for cancer, or� Annual FIT with at least 50% test sensitivity for cancer, or� sDNA at uncertain screening interval 9a9a

16. What Is A Highly Sensitive Stool Blood Test?

17. Fecal Immunochemical Tests (FIT�s) May Replace Guiac FOBT FIT�s Demonstrate superior sensitivity and specificity Are specific for colon blood and are unaffected by diet or medications Some can be developed by automated readers Some improve patient participation in screening

18. FIT�s available in the US

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21. Tests That Detect Adenomatous Polyps and Cancer Flexible sigmoidoscopy every 5 years, or� Colonoscopy every 10 years, or� Double-contrast barium enema every 5 years, or� CT colonography every 5 years 11a11a

22. ACS Screening Guideline Versus USPSTF Guideline � Key Differences

23. But ACS & USPSTF Guidelines Agree on All Key Components All adults over 50 y.o. must be screened The screening options on both lists are: Colonoscopy every 10 years High Sensitivity FOBT or FIT annually Flexible sigmoidoscopy every 5 years Flex sig plus FOBT/FIT Screening with FOBT at time of digital rectal IS NOT recommended

25. CRC Screening and Aging The USPSTF recommends routine screening up until age 75 From 76 to 85 y.o. � Do not screen routinely Ages 86 and over � Do not screen 23a23a

26. Post Polypectomy Surveillance 24a24a

28. Colonoscopy � Is It Truly a Gold Standard? Distal vs. proximal colon cancer Colonoscopy confers only 12-33% protection against proximal colon cancer; 80% against distal Distal colon cancer in the US is declining. Proximal colon cancer rates are flat 21a21a

29. Why Has Colonoscopy Been Disappointing For Right-Sided Cancers? Quality of colonoscopy Right-sided cancers may more likely derive from flat polyps Right-sided cancers may grow faster Timing of prep may not be ideal 22a22a

30. Colonoscopy is the Best Screening Test for Colon Cancer �. isn�t it? 26a26a

31. Maybe Not! 27a27a

32. Evaluating Test Strategies for Colorectal Cancer Screening Zauber and her team conducted a decision analysis using microsimulation models Zauber AG et.al. Ann of Int Med. 2008, 149; 659-669 28a28a

33. Number of life-years gained is essentially identical regardless of screening strategy used: Sensitive guiac FOBT annually Fecal Immunochemical Test (FIT) annually Flexible sigmoidoscopy every 5 years with midinterval sensitive FOBT Colonoscopy every 10 years 29a29a

34. Less Effective Strategies Flexible sigmoidoscopy every 5 years or Low sensitivity FOBT annually 30a30a

35. The Key Determinant of Effectiveness of Colon Cancer Screening Getting it done! 31a31a

36. Barriers to Physician Recommendation of CRCS Patient Comorbidity Patients who previously refused screening Language barriers Distrustful patients Patient already under the care of a GI specialist Perceived lack of patient acceptability Addressing patient comorbidites, even if these are stable, in a limited period of time causes the physician to defer or even miss the discussion of CRCS Diabetes, psychiatric disease and cognitive impairment were less likely to receive a screening recommendation Severe comorbidity: terminal illness (e.g. end-stage heart failure, end-stage emphysema), was considered life-threatening (e.g. insulin-induced hypoglycemia) or if the prep for colonoscopy was contraindicated by the comorbidity (e.g. uncompensated heart failure, electrolyte imbalances). Language barriers � even with help of translator Distrustful patients � �suspicious� or �anti-medicine� in part to preserve the relationship Patient already under the care of a GI specialist Perceived lack of patient acceptability Addressing patient comorbidites, even if these are stable, in a limited period of time causes the physician to defer or even miss the discussion of CRCS Diabetes, psychiatric disease and cognitive impairment were less likely to receive a screening recommendation Severe comorbidity: terminal illness (e.g. end-stage heart failure, end-stage emphysema), was considered life-threatening (e.g. insulin-induced hypoglycemia) or if the prep for colonoscopy was contraindicated by the comorbidity (e.g. uncompensated heart failure, electrolyte imbalances). Language barriers � even with help of translator Distrustful patients � �suspicious� or �anti-medicine� in part to preserve the relationship Patient already under the care of a GI specialist Perceived lack of patient acceptability

37. Barriers to Physician Recommendation of CRCS Physician Forgetfulness Outdated knowledge of guidelines Fatigue Last patient of the dayLast patient of the day

38. Barriers to Physician Recommendation of CRCS System Acute care visits Due to lack of time, higher acuity and de-prioritization of screening Lack of time Too many active issues and/or patient concerns Lack of reminder systems Absence of reliable test tracking system Lack of insurance coverage Delays in colonoscopy scheduling In some cases, patients are �added-on� because of their urgent problem are being squeezed into already tight physician schedules. At best, some physicians suggested that the patient return for a health maintenance visit Discussion of colonoscopy is a lengthier discussion than discussion of other cancer screening tests because you need time to explain the choices, the procedure, the referral process, the prep and transportation needs. Physicians report that when there is limited time, screening is often deferred or omitted from the visit because it is given the lower priority. In some cases, patients are �added-on� because of their urgent problem are being squeezed into already tight physician schedules. At best, some physicians suggested that the patient return for a health maintenance visit Discussion of colonoscopy is a lengthier discussion than discussion of other cancer screening tests because you need time to explain the choices, the procedure, the referral process, the prep and transportation needs. Physicians report that when there is limited time, screening is often deferred or omitted from the visit because it is given the lower priority.

39. Barriers to Recommending CRCS All eligible patients do not consistently receive a provider recommendation for CRCS Interventions are needed to address the multiple barriers to address patient, physician and system level barriers Guerra, CE et al. Barriers to Physician Recommendation of Colorectal Cancer Screening. J Gen Intern Med. 2007;22(12):1681-8. A multifaceted approaches are more effective than a single faceted ones A multifaceted approaches are more effective than a single faceted ones

40. The Biggest Barrier Of All Lack of payment to support outreach to entire enrolled population of patients

42. The Journal Article Sarfaty M, Wender R. How to increase colorectal cancer screening rates in practice. Ca Cancer J Clin 2007;57:354-366 This article is available online at http://CAonline.AmCancerSoc.org Free CME credit for successfully completing the online quiz http://CME.AmCancerSoc.org

44. Interactive Web-based Toolbox

45. Toolbox Your recommendation Office policy Reminder system Communication strategies

46. Essential 1: Physician Recommendation Physician recommendation is the most effective intervention for encouraging patients to be screened 74-90% of patients who have not had CRCS report they would schedule CRCS if their physician recommended the test Lewis SF, et al.; Guerra CE, et al. IntentIntent

47. Impact of Physician Recommendation Lack of physician recommendation of CRCS is strongly associated with NOT undergoing CRCS Harewood GC et al.; Guerra CE, et al.; Klabunde CN et al. Conversely, physician recommendation of CRCS is one of the most important facilitators of adherence to CRCS Subramanian S, et al.; Teng EJ, et al.; Zapka JG et al.; Myers RE, et al.; Mandelson MT, et al; Bejes C, et al; Holt WS Jr, et al. Actual behaviorActual behavior

48. Goal Every eligible patient enrolled in your practice should receive a recommendation to undergo CRCS

49. Essential 2: An Office Policy Takes into account patient risk level: average, increased, high local medical resources insurance coverage patient preferences

50. Office Policy: Determining Patient Risk Have you or any members of your family had CRC? Have you or any members of your family had an adenomatous polyp? Has any member of your family had a CRC or adenomatous polyp when they were under the age of 50? (If yes, consider a hereditary syndrome) Do you have a history of Crohn�s disease or ulcerative colitis (for more than 8 years)? Do you or any members of your family have a history of cancer of the endometrium, small bowel, ureter, or renal pelvis? (If yes, consider HNPCC) Answer yes to any of these places patient at either increased or high riskAnswer yes to any of these places patient at either increased or high risk

51. Office Policy: Determining Patient Risk If an individual answers yes to any of these questions, that individual is at increased risk

52. Office Policy: Determining Patient Risk Increased Risk Has a personal or family history of colorectal polyps or CRC Or Has a personal history of inflammatory bowel disease for more than 8 years 18-20% of population is at increased risk Patients are not given options for screening Colonoscopy is the preferred screening test Screening should begin earlier (age 40 or younger)

53. Office Policy: Determining Patient Risk High Risk (hereditary colorectal cancer syndromes) Hereditary non-polyposis colorectal cancer (HNPCC) Familial adenomatous polyposis (FAP) Attenuated FAP HNPCC is an autosomal dominant inherited cancer syndrome that accounts for 1-5% of CRC cases. It is caused by a germline mutation in 1 of 5 mismatch repair genes. Mean age of CRC development is 44 yrs. Tumors tend to be right sided and poorly differentiated, demonstrate microsatellite instabilityHNPCC is an autosomal dominant inherited cancer syndrome that accounts for 1-5% of CRC cases. It is caused by a germline mutation in 1 of 5 mismatch repair genes. Mean age of CRC development is 44 yrs. Tumors tend to be right sided and poorly differentiated, demonstrate microsatellite instability

54. Office Policy: Determining Patient Risk High Risk Suspect in someone with A family history of an adenomatous polyp or CRC in relative under age 50 Two or more relatives with CRC Multiple colorectal adenomas (usually 10 or more) diagnosed over one or more exams Refer to local cancer genetic counselor www.nsgc.org NOT eligible for this program National society of genetic counselorsNational society of genetic counselors

55. Office Policy: Determining Patient Risk

56. Office Policy Once an office policy is created, the office staff must be engaged to actualize it Present office policy to staff and offer them the opportunity to ask questions Depict it using an algorithm Post it Disseminate it Build incentives around team goals

57. Examples of an Office Policy Recommend colonoscopy for all patients. For those who hesitate, order Fecal Immunochemical Test (InSure) All positives undergo colonoscopy Offer all patients the choice to have colonoscopy or a high sensitivity gFOBT (Hemoccult Sensa) Recommend annual FIT for all Once the office policy is designed, physician must Depict and present it: Algorithm Communicate it to the staff Engage the staff in implementing it Allow staff to ask questions about the policy Once the office policy is designed, physician must Depict and present it: Algorithm Communicate it to the staff Engage the staff in implementing it Allow staff to ask questions about the policy

58. Essential 3: An Office Reminder System Reminders for patients Passive Letters Postcards Prescriptions Pamphlets DVDs, videos Websites List of agencies that have available educational material included in Toolbox Active Telephone scripts In-person Electronic: For highly motivated patients: www.myhealthtestreminder.com Physicians do not consistently recommend CRCSPhysicians do not consistently recommend CRCS

59. Patient Reminder Letters

60. Patient Reminder Postcard

61. Telephone Scripts

62. www.MyHealthTestReminder.com Blood donation reminder Cholesterol test reminder Colon cancer screening reminder Diabetes test reminder Mammogram reminder Pap test reminder Blood donation reminder Cholesterol test reminder Colon cancer screening reminder Diabetes test reminder Mammogram reminder Pap test reminder

63. Patient Cues to Action Patient educational material DOH and ACS posters, brochures, videos can be ordered for free via the web: www.cancer.org/colonmd

65. American Cancer Society Patient Education Tools This free brochure encourages your patients to talk with you about colorectal cancer screening and provides a list of questions to ask to help facilitate the conversation.

66. Reminders for Clinicians Behavioral Chart stickers Screening schedules/flow sheets Electronic reminders: Required in meaningful use Tracking databases: paper and electronic (COMMAND, PECS2) Cognitive: Audit and Feedback, Ticklers (provides national benchmarks and targets) System: Staff assignments Office staff can pull the charts of patients before their visits and identify and flag the charts of patients who should be screened with a reminder or sticker Patients who are at increased risk of CRCS, should have this fact listed on the problem list Age appropriate screening schedules can be obtained from professional, govt and insurance based industries Comorbid Disease Management Database by Mississippi Quality Improvement Organization Patient Electronic Care System by Texas Association of Community Health Centers Office staff can pull the charts of patients before their visits and identify and flag the charts of patients who should be screened with a reminder or sticker Patients who are at increased risk of CRCS, should have this fact listed on the problem list Age appropriate screening schedules can be obtained from professional, govt and insurance based industries Comorbid Disease Management Database by Mississippi Quality Improvement Organization Patient Electronic Care System by Texas Association of Community Health Centers

67. Preventive Service Schedule Based on USPSTF recommendations; available for adults and children; published 2006Based on USPSTF recommendations; available for adults and children; published 2006

68. Flow Sheets

69. Sample Paper Tracking Template (�Tickler�)

70. Electronic Medical Records Vista-Office Electronic Health Record (VOE) project. More information can be obtained at: http://www.worldvista.org/ Free, online rating system for electronic medical records by the AC group based on the Institute of Medicine�s requirements for a computerized patient record at: www.acgroup.org/pages/396843/index.htm , established by the American Academy of Family Physicians, is currently working with the major technology companies to promote and facilitate the use of health information technology by primary care physicians. According to the Center for Health Information Technology, the price of such systems should be reduced by 15-50%. Passive Reminders Physician must click on icon to pull up a screen containing health maintenance reminders Active Reminders Automatically appear in patients due for screening Intrusiveness ranges from pop-ups to inability to close the chart unless screening is addressed , established by the American Academy of Family Physicians, is currently working with the major technology companies to promote and facilitate the use of health information technology by primary care physicians. According to the Center for Health Information Technology, the price of such systems should be reduced by 15-50%. Passive Reminders Physician must click on icon to pull up a screen containing health maintenance reminders Active Reminders Automatically appear in patients due for screening Intrusiveness ranges from pop-ups to inability to close the chart unless screening is addressed

71. Audit and Feedback Chart audit Review a prerequisite number of charts to document whether a certain elements are found on the chart Produces an 18.6% improvement in screening rates Can produce feedback for a provider or a practice A repeat audit may be conducted to assess the impact of an intervention . Evidence from meta-analysis indicates that audit and feedback is an effective strategy to increase screening rates. However, there is evidence that this type of feedback is more effective if it is specific to a clinician. After a requisite number of charts are reviewed, the results are tallied. The time interval for repeat audits depends on the size of the practice, the patient population, the staffing level and the type of intervention that is put into place. A baseline audit, a follow-up audit, and an additional audit after a year has gone by will provide insight about the effectiveness and endurance of changes (s) in practice. While chart audits are time consuming, collecting this information is not complicated and is essential for maintaining quality of practice. Furthermore, audits now generate continuing medical education credit toward the physician�s Recognition Award as part of the American Medical Association initiative to provide credits for performance improvement activities. Finally, the American Academy of Family Physicians has established a practice-based performance measurement project, �metric� which offers CME credits for completing practice based performance measurement projects and the American Board of Internal Medicine has similar modules that soon will incorporate colorectal cancer screening audits into their maintenance of certification programs. When feedback is provided, it is helpful to cite national or local benchmarks for preventive services. This helps providers understand the practice�s results in the context of national trends and goals. National benchmarks are available on-line from the National Committee for Quality Assurance (NCQA) at: http://www.ncqa.org/Communications/SOHC2006/SOHC_2006.pdf. [insert sample chart audit template page 131] and goals and measures with which to track them have been set forth by national collaboratives such as the Bureau of Primary care in the federal Health Resources Services Administration at: http://www.healthdisparities.net/hdc/html/home.aspx.. Evidence from meta-analysis indicates that audit and feedback is an effective strategy to increase screening rates. However, there is evidence that this type of feedback is more effective if it is specific to a clinician. After a requisite number of charts are reviewed, the results are tallied. The time interval for repeat audits depends on the size of the practice, the patient population, the staffing level and the type of intervention that is put into place. A baseline audit, a follow-up audit, and an additional audit after a year has gone by will provide insight about the effectiveness and endurance of changes (s) in practice. While chart audits are time consuming, collecting this information is not complicated and is essential for maintaining quality of practice. Furthermore, audits now generate continuing medical education credit toward the physician�s Recognition Award as part of the American Medical Association initiative to provide credits for performance improvement activities. Finally, the American Academy of Family Physicians has established a practice-based performance measurement project, �metric� which offers CME credits for completing practice based performance measurement projects and the American Board of Internal Medicine has similar modules that soon will incorporate colorectal cancer screening audits into their maintenance of certification programs. When feedback is provided, it is helpful to cite national or local benchmarks for preventive services. This helps providers understand the practice�s results in the context of national trends and goals. National benchmarks are available on-line from the National Committee for Quality Assurance (NCQA) at: http://www.ncqa.org/Communications/SOHC2006/SOHC_2006.pdf. [insert sample chart audit template page 131] and goals and measures with which to track them have been set forth by national collaboratives such as the Bureau of Primary care in the federal Health Resources Services Administration at: http://www.healthdisparities.net/hdc/html/home.aspx.

72. Essential 4: Effective Communication Stage-based communication Based on the Transtheoretical Model (Prochaska & DiClemente) Individuals who are candidates for making a health behavior change do so in different stages of readiness

73. Stage-based communication Transtheoretical Model (Prochaska & DiClemente) Individuals who are candidates for making a health behavior change do so in different stages of readinessStage-based communication Transtheoretical Model (Prochaska & DiClemente) Individuals who are candidates for making a health behavior change do so in different stages of readiness

74. Patients that Previously Refused CRCS Stage-based communication theory suggests that individuals cycle in and out of stages Therefore, individuals who previously refused screening, may re-contemplate and ultimately consider screening Physicians should readdress CRCS even in patients who previously refused

75. The Toolkit: Short Version Available on-line in a few months Based on the �Five Basic Truths�

76. Five Basic Truths of Colon Cancer Screening If you only recommend colonoscopy and are not prepared to offer FOBT/FIT, you can only achieve a 70% screening rate�at best! 36a36a

77. Five Basic Truths of Colon Cancer Screening If you only offer screening to patients who are coming to a primary care office, you can achieve very good but not spectacular screening rates 36a36a

78. Population management is the central challenge confronting primary care practices Unlike disease management, cancer screening can be addressed almost entirely by the team 37a37a

79. Five Basic Truths of Colon Cancer Screening If you give out FIT or FOBT tests but do not track whether the patient returns the test and prompt them to do so, return rates will be poor 38a38a

80. This demands teamwork, technology and tenacity 39a39a

81. You have to have a registry of all enrolled patients over age 50 and younger patients with risk factors 39a39a

82. Five Basic Truths of Colon Cancer Screening If you ask a patient to schedule their colonoscopy but do not schedule it before they leave the office, only about one half of them will call and schedule 40a40a

83. Patient Quote from June 17, 2010 �If you had not made the call while I was here, I never would have done it�

84. Sit down with your colonoscopist and tell them what you expect 41a41a

85. Five Basic Truths of Colon Cancer Screening If you are �screening� patients with a stool blood test at the time of a rectal exam, it�s time to stop. This method doesn�t work. 42a42a

87. Summary Know who your patients are Figure out if they�re at increased risk Assign and implement an outreach program Have a team approach to screening The clinician may have to do nothing more than say � �It�s time to be screened� Offer colonoscopy and a high sensitivity FOBT/FIT Provide patient navigation

88. How can we achieve an 80% colon cancer screening rate in Pennsylvania? One Practice at a Time!

89. You and Your Team Can Make This Happen