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Colorectal Cancer Updatefor Healthcare Providers

May 2013

Maryland Department of Health and Mental Hygiene

Prevention and Health Promotion Administration

Cigarette Restitution Fund ProgramCenter for Cancer Prevention and Control


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Prevention and Health Promotion AdministrationMay 20132

CRC Incidence, Mortality, and

Survival in the U.S.


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Colorectal Cancer

Third most commonly diagnosed cancerin Maryland among both men andwomenSecond leading cause of cancer-relatedmortality

Incidence and mortality have beendecreasing in recent years


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Prevention and Health Promotion AdministrationMay 2013 4

Colorectal Cancer Incidence and Mortality Ratesby Year of Diagnosis or Death, Maryland,

2002-2008

Maryland Cancer Registry (incidence rates)NCHS Compressed Mortality File in CDC WONDER (mortality rates)

51.554.6

48.646.3

41.3 41.6 42.5

20.9 19.6 19.2 18.8 18.6 17.7 16.7

0

10

20

30

40

50

60

70

2002 2003 2004 2005 2006 2007 2008

A g e - a

d j u s

t e d r a

t e

p e r

1 0 0

, 0 0 0 p

o p u

l a t i o n

Year of Diagnosis or Death

Incidence Mortality


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Source: SEER 9 areas. SEER

Program, National Cancer Institute.

5-year CRC survivalhas improved over

the past 30 years inthe U.S.

Colorectal Cancer


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CRC Screening


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Colorectal Cancer Screening Status of PeopleAge 50 Years and Older

Maryland Cancer Surveys and BRFSS, 2002-2010

2317

1011

41

10

26

50

2320

59

11

67

18

7

98

66

5

22

0 10 20 30 40 50 60 70

Up-to-date withcolonoscopy

Up-to-date withFOBT and/or

sigmoidoscopy

Tested but not up-to-date*

Never tested

Percent

2002 2004 2006 2008 2010

Maryland Cancer Survey, 2002-2008BRFSS, 2010


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80% of people 50+ inMaryland reported having aprovider r e c o m m e n dendoscopy..

of those, 88% got screened

88%

24%

0%

25%

50%

75%

100%

Provider recommended

No provider recommended

P e r c e n

t S c r e e n e

d

w i t h E n

d o s c o p y

Maryland Cancer Survey, 2008

Provider Recommendation is KEY to Screening

Of the 20% who did NOTreport a providerrecommendation.only24% got screened


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Colorectal Cancer Screeningwith

colonoscopy orsigmoidoscopy?

(50+ years)

Never screened withcolonoscopy or

sigmoidoscopy25%

Ever screened withcolonoscopy or

Sigmoidoscopy75%



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Colorectal CancerScreening

with colonoscopy or

sigmoidoscopy?(50+ years)

Never screenedwith colonoscopy or

sigmoidoscopy25%

Ever screened withcolonoscopy orSigmoidoscopy

75%

85%have been to doctor

for routine checkup in past 2 years

Only 15%have NOT had checkup



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Patient:Family and personal historyPast screeningSymptoms

Primary Doctor:Referral

Pathologist:Pathology report

Case

Management andCommunication

Colonoscopist:

Risk historyMedication changesPrep instructionsPost colonoscopy instructionsColonoscopy report

Findings

Recommendations


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Who needs screening?


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0

50

100150

200

250

300

350

400

450

A g e - s p e c

i f i c r a

t e

p e r

1 0 0

, 0 0 0 p o p u

l a t i o n

Age Group

Colorectal Cancer Age-Specific Incidence Ratesby Gender, Maryland and U.S., 2004-2008

MD Male MD Female U.S. Male U.S. Female

Source: Maryland Cancer Registry


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Risk of CRC

Group Approx. lifetime risk of CRCGeneral Population 5-6%

One first degree relative (FDR) with CRC 2--3-fold increase over generalpopulation

Two FDRs with CRC 3--4-fold increase

FDR with CRC diagnosed < 50 3--4-fold increaseOne second or third degree relative About 1.5-fold increase

Two second degree relatives About 2--3-fold increase

Inflammatory Bowel Disease(ulcerative colitis and Crohns colitis)

7-10% have CRC after havingulcerative colitis for 20 years;then ~1%/year

Familial adenomatous polyposis (FAP)Hereditary non-polyposis colorectal cancer (HNPCC)

~100%~80+%

Burt RW. Gastroenterology 2000;119:837-53Winawer S, et al. Gastroenterology 2003;124:544-560


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Average Risk

Increased Risk

Colonoscopy, every 10 yearsor

FOBT or FIT annually if refuse endoscopyor

Flexible sigmoidoscopy, every 5 years

with a high sensitivity fecal occult bloodtest* (FOBT), every 3 years

Colonoscopy(interval for repeat dependson risk, history, andprior colonoscopy results)

Maryland Screening Recommendations:Medical Advisory Committee on CRC

* Hemoccult SENSA or fecal immunochemical test (FIT)


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Risk Category Age to Begin Screening

Average risk Age 50 years

Increased risk

Family HistoryColorectal cancer or adenomatous polyp(s)*in an FDR age 1 cm; villous

histology; or high grade dysplasia

Age 40 years, or 10 years before theyoungest case in the immediatefamily, whichever is earlier

Genetic syndrome:Familial adenomatous polyposis (FAP)

Hereditary non-polyposis colorectalcancer (HNPCC)

Age 10 to 12 years

Age 20 to 25 years, or 10 yearsbefore the youngest case in the

immediate family Inflammatory bowel disease Cancer risk begins to be significant 8

years after the onset of pancolitis(involvement of entire large intestine),or 12-15 years after the onset of left-sided colitis

Rex DK, et al. Am J Gastroenterol 2009:104;739-750 American Cancer Society, 2012http://www.cancer.org/Cancer/ColonandRectumCancer/MoreInformation/ColonandRectumCancer EarlyDetection/colorectal-cancer-early-detection-acs-recommendations

Age to Begin Screening by Risk Category


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Guidelines Screening and Surveillance for the Early Detection of Colorectal

Cancer and Adenomatous Polyps, 2008:

A Joint Guideline from the American Cancer Society,

the U.S. Multi-Society Task Force on CRC, andthe American College of Radiology

C A Cancer J Clin 58: 130-160 (May 2008)


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Tests that Find Both Polyps and Cancer

Flexible sigmoidoscopy every 5 years

Colonoscopy every 10 years

Double contrast barium enema every 5 years

CT colonography (virtual colonoscopy) every 5 years

Guidelines, American Cancer Society, June 2012http://www.cancer.org/Cancer/ColonandRectumCancer/MoreInformation/ColonandRectumCancerEarlyDetection/colorectal-cancer-early-detection-screening-tests-used


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Tests that Primarily Find Cancer

High sensitivity FOBT every year

Hemoccult SENSA or fecal immunochemical test (FIT)Stool DNA test (unclear how often this is needed,

not currently available commercially is U.S.)

Guidelines, American Cancer Society, 2012http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/colorectal-cancer-detection-recommendationsUnited States Preventive Services Task Force

http://www.uspreventiveservicestaskforce.org/uspstf08/colocancer/coloartzaub.htm#results


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CRC Screening Guidelines American Cancer Society, June 2012

Beginning at age 50, men and women at averagerisk for CRC should use one of the screening

tests.The tests that are designed to find both earlycancer and polyps are preferred if these tests areavailable to the patient and the patient is willingto have one of these more invasive tests.

Talk to your doctor about which test is best foryou.


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CRC Screening under theCigarette Restitution Fund

Program (CRFP) in Maryland


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Summary of Cigarette Restitution FundColorectal Cancer Screening in Maryland

As of December 31, 2012:

23,203 People have had one or morescreening procedures

______________________________________

8,356 FOBTs (all income levels)

181 Sigmoidoscopies21,355 Colonoscopies

DHMH, CCPC, Client Database, C-CoPD, as of 2/25/2013


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Summary of Cigarette Restitution FundColorectal Cancer Screening ________ County, Maryland

2000-20XX:

XX Individuals screened for CRCby one or more method +

____________________________________________________________

XX FOBTs*XX Colonoscopies*

____________________________________________________________

X Cancers*X High grade dysplasia*

XX Adenoma(s)*

DHMH, CCPC, Client Database, C-CoPD, as of xx/xx/xxxx

DHMH, CCPC, Client Database, C-CoP, as of xx/xx/xxxx


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Gender of 23,173 Screened* for CRCMaryland, 2000-December 2012

*Of clients with known gender screened with one or more of the following:FOBT, flexible sigmoidoscopy, colonoscopy, imaging

Women15,586(67%)

Men7,587(33%)



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Minority Status of 23,203 New People Screened* for CRC,Maryland, 2000-December 2012

*Of clients screened with one or more of the following:FOBT, flexible sigmoidoscopy, colonoscopy, imaging

Non-minority orUnknown11,110 (48%)

Minority12,093 (52%)



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Results* of 21,356 ColonoscopiesMaryland Cigarette Restitution Fund Program

Maryland, 2000-December 2012

* Most advanced finding on colonoscopy

DHMH, CCPC, Client Database, C-CoP, as of 2/27/2013

Cancer/SuspectCancer, 243, 1%

Adenoma High-Grade, 88, 0%

Adenomas, Other,5,074, 24%

Other poly ps,4,580, 22%

Other f indings,7,771, 36%

Negativ e, 3294,15%

Inadequate col butno f indings, 306,1%


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Recommended screeningafter initial screening--

rescreening or surveillancecolonoscopy

Recall Interval


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After first colonoscopy, then what ?

Interval between colonoscopies will dependon:

findings on last colonoscopy,

risk history, and symptoms


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For the recommended recall intervals,please see:DHMH Colorectal Cancer Minimal Elements

http://phpa.dhmh.maryland.gov/cancer/Shared%20Documents/ccpc13-24--att_CRCMinimalElements2013[1].pdf

(or http://phpa.dhmh.maryland.gov/cancer/ under Resources )


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Keys to the right recall

1. Colonoscopy Report2. Pathology Report

3. Recommendation based on guidelines4. Communication


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Prevention and Health Promotion Administration[Date]

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Standards for Colonoscopy Reports CO-RADS*

Colonoscopy report should include:

Date and Time - ProcedurePatient descriptionRisk factors

ASA classIndicationsConsent signedSedationColonoscope

Bowel prep adequacy

Whether cecum reachedColonoscopy withdrawal timeFindingsSpecimen(s) to path lab

ImpressionComplicationsPathologyRecommendationsFollow-up plan/RecallOther

*Standardized colonoscopy reporting and data system: report of the Quality AssuranceTask Group of the National Colorectal Cancer Roundtable, Lieberman et al.,Gastrointestinal Endoscopy 2007; 65: 757-766


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Adequacy of First Colonoscopy Among 16,813* First Cycle Colonoscopies

Maryland, 2000-December 2012

*16,813 of the 17,915 first colonoscopies had information on adequacy of the col in CRFP. DHMH, CCPC, Client Database, Data Download, 2/27/2013

Adequate15,258 (91%)

Not Adequate1,555 (9%)

(Inadequate prepOR didn't reach

cecum)


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Reporting onColonoscopy Findings:

Number of masses, polyps, other lesions(try to give actual or estimatednumber rather than several ormultiple )

Findings: for EACH mass/polyp/lesion

locationsizedescriptiontattoobiopsy(ies) takenmethod of each biopsywhether lesion completelyremoved or not

whether there was piecemeal removalwhether specimens retrievedwhether saline lift usednumber of specimens sent to pathology


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How will your patients be remindedabout their next colonoscopy?


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Patient:Family and personal historyPast screening

Symptoms

Primary Doctor:Referral

Pathologist:Pathology report

CaseManagement andCommunication

Colonoscopist:

Risk historyMedication changesPrep instructionsPost colonoscopy instructionsColonoscopy report

FindingsRecommendations


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Acknowledgements

Funding from the Maryland Cigarette Restitution Fund (CRF)

Staff and partners of Local Public Health DepartmentPrograms in MD and their contracted providers

DHMH Center for Cancer Prevention and Control (CCPC) Database and Quality assurance Surveillance and Evaluation Unit including

- University of Maryland at Baltimore- Ciber, Inc.

CCPC CRF Programs Unit Maryland Cancer Registry

Minority Outreach Technical Assistance Partners


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http://phpa.dhmh.maryland.gov

PREVENTION AND

HEALTH PROMOTIONADMINISTRATION