Ccpc13 20 Att2 CRC Slides Providers

Colorectal Cancer Update
for Healthcare Providers

May 2013
Maryland Department of Health and Mental Hygiene
Prevention and Health Promotion Administration
Cigarette Restitution Fund Program
Center for Cancer Prevention and Control
CRC Incidence, Mortality, and

Survival in the U.S.

May 2013
2
Colorectal Cancer
Third most commonly diagnosed cancer
in Maryland among both men and
women
Second leading cause of cancer-related
mortality
Incidence and mortality have been
decreasing in recent years

May 2013
3
Colorectal Cancer Incidence and Mortality Rates

by Year of Diagnosis or Death, Maryland,
2002-2008
70
60
54.6
51.5
48.6
Age-adjusted rate
per 100,000 population
50
46.3
41.3
41.6
42.5
40
30
20.9
19.6
19.2
18.8
18.6
17.7
16.7
2003
2004
2005
2006
2007
2008
20
10
0
2002
Year of Diagnosis or Death
Incidence
Maryland Cancer Registry (incidence rates)

NCHS Compressed Mortality File in CDC WONDER (mortality rates)
Mortality

May 2013
4
Colorectal Cancer
5-year CRC survival

has improved over
the past 30 years in
the U.S.
Source: SEER 9 areas. SEER

Program, National Cancer Institute.

May 2013
5
CRC Screening

May 2013
6
Colorectal Cancer Screening Status of People

Age 50 Years and Older
Maryland Cancer Surveys and BRFSS, 2002-2010
18
20
Never tested
8
Tested but not upto-date*
22
23
26
11
10
10
Up-to-date with
FOBT and/or
sigmoidoscopy
11
17
23
66
67
Up-to-date with
colonoscopy
41
10
20
30
40
50
59
50
60
2008
2010
70
Percent
2002
Maryland Cancer Survey, 2002-2008
BRFSS, 2010
2004
2006

May 2013
7
Provider Recommendation is KEY to Screening
Of the 20% who did NOT

report a provider
recommendation.only
24% got screened
Maryland Cancer Survey, 2008
100%
Percent Screened
with Endoscopy
80% of people 50+ in

Maryland reported having a
provider recommend
endoscopy..
of those, 88% got screened
88%
75%
50%
24%
25%
0%
Provider
recommended
No provider
recommended

May 2013
8
Colorectal Cancer Screening

with
colonoscopy or
sigmoidoscopy?
(50+ years)
Never screened with

colonoscopy or
sigmoidoscopy
25%
Ever screened with

colonoscopy or
Sigmoidoscopy
75%

May 2013
9
Colorectal Cancer
Screening
with colonoscopy or
sigmoidoscopy?
(50+ years)
Never screened
with colonoscopy or
sigmoidoscopy
25%
85%
have been to doctor
for routine checkup
in past 2 years
Ever screened with

colonoscopy or
Sigmoidoscopy
75%
Only 15%
have NOT had checkup

May 2013
10
Patient:
Family and personal history
Past screening
Symptoms
Primary Doctor:
Referral
Case
Management and
Communication
Colonoscopist:
Risk history
Medication changes
Prep instructions
Post colonoscopy instructions
Colonoscopy report
Findings
Recommendations
Pathologist:
Pathology report
May 2013
11
Who needs screening?

May 2013
12
Colorectal Cancer Age-Specific Incidence Rates

by Gender, Maryland and U.S., 2004-2008
Age-specific rate
per 100,000 population
450
400
350
300
250
200
150
100
50
0
Age Group
MD Male
MD Female
U.S. Male
U.S. Female
Source: Maryland Cancer Registry

May 2013
13

May 2013
14
Colorectal Cancer Cases by Risk History

Sporadic
(average risk) (65%85%)
Family
history
(10%30%)
Rare
syndromes
(<0.1%)
Hereditary nonpolyposis
colorectal cancer (HNPCC, 2-3%)
Familial adenomatous
polyposis (FAP) (<1%)
http://www.cancer.gov/cancertopics/pdq/genetics/colorectal/HealthProfessional

May 2013
15
Risk of CRC
Group
Approx. lifetime risk of CRC
General Population
5-6%
One first degree relative (FDR) with CRC
2--3-fold increase over general

population
Two FDRs with CRC
3--4-fold increase
FDR with CRC diagnosed < 50
3--4-fold increase
One 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 having

ulcerative colitis for 20 years;
then ~1%/year
Familial adenomatous polyposis (FAP)

Hereditary non-polyposis colorectal cancer (HNPCC)
~100%
~80+%
Burt RW. Gastroenterology 2000;119:837-53

Winawer S, et al. Gastroenterology 2003;124:544-560
May 2013
16
Maryland Screening Recommendations:

Medical Advisory Committee on CRC
Average Risk
Increased Risk
Colonoscopy, every 10 years

or
FOBT or FIT annually if refuse endoscopy
or
Flexible sigmoidoscopy, every 5 years
with a high sensitivity fecal occult blood
test* (FOBT), every 3 years
Colonoscopy
(interval for repeat depends
on risk, history, and
prior colonoscopy results)
* Hemoccult SENSA or fecal immunochemical test (FIT)

May 2013
17
Age to Begin Screening by Risk Category

Risk Category
Average risk
Age to Begin Screening

Age 50 years
Increased risk
Family History
Colorectal cancer or adenomatous polyp(s)*
in an FDR age <60, or in 2 or more FDRs at
any age
* Especially if advanced adenomas: > 1 cm; villous
histology; or high grade dysplasia
Genetic syndrome:
Familial adenomatous polyposis (FAP)
Hereditary non-polyposis colorectal
cancer (HNPCC)
Inflammatory bowel disease
Age 40 years, or 10 years before the

youngest case in the immediate
family, whichever is earlier
Age 10 to 12 years
Age 20 to 25 years, or 10 years
before the youngest case in the
immediate family
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 leftsided colitis
Rex DK, et al. Am J Gastroenterol 2009:104;739-750

American Cancer Society, 2012
http://www.cancer.org/Cancer/ColonandRectumCancer/MoreInformation/ColonandRectumCancer
EarlyDetection/colorectal-cancer-early-detection-acs-recommendations

May 2013
18
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, and
the American College of Radiology
CA Cancer J Clin 58: 130-160 (May 2008)

May 2013
19
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 2012

http://www.cancer.org/Cancer/ColonandRectumCancer/MoreInformation/ColonandRect
umCancerEarlyDetection/colorectal-cancer-early-detection-screening-tests-used

May 2013
20
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, 2012

http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/colorectal-cancerdetection-recommendations
United States Preventive Services Task Force
http://www.uspreventiveservicestaskforce.org/uspstf08/colocancer/coloartzaub.htm#results

May 2013
21
CRC Screening Guidelines

American Cancer Society, June 2012
Beginning at age 50, men and women at average

risk for CRC should use one of the screening
tests.
The tests that are designed to find both early

cancer and polyps are preferred if these tests are
available to the patient and the patient is willing
to have one of these more invasive tests.
Talk to your doctor about which test is best for

you.
May 2013
22
CRC Screening under the

Cigarette Restitution Fund
Program (CRFP) in Maryland

May 2013
23

May 2013
24

May 2013
25

May 2013
26

May 2013
27
Summary of Cigarette Restitution Fund

Colorectal Cancer Screening in Maryland
As of December 31, 2012:

23,203
People have had one or more

screening procedures
______________________________________
8,356
181
21,355
FOBTs (all income levels)

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

May 2013
28
Summary of Cigarette Restitution Fund

Colorectal Cancer Screening
________ County, Maryland
2000-20XX:
XX
Individuals screened for CRC

by 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

May 2013
29
Gender of 23,173 Screened* for CRC

Maryland, 2000-December 2012
Men
7,587
(33%)
Women
15,586
(67%)
*Of clients with known gender screened with one or more of the following:
FOBT, flexible sigmoidoscopy, colonoscopy, imaging

May 2013
30
Minority Status of 23,203 New People Screened* for CRC,

Non-minority or
Unknown
11,110 (48%)
Minority
12,093 (52%)
*Of clients screened with one or more of the following:

FOBT, flexible sigmoidoscopy, colonoscopy, imaging

May 2013
31
Results* of 21,356 Colonoscopies

Maryland Cigarette Restitution Fund Program
Inadequate col but
no f indings, 306,
1%
Negativ e, 3294,
15%
Cancer/Suspect
Cancer, 243, 1%
Adenoma HighGrade, 88, 0%
Adenomas, Other,
5,074, 24%
Other f indings,
7,771, 36%
Other poly ps,

4,580, 22%
* Most advanced finding on colonoscopy

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

May 2013
32
Recall Interval
Recommended screening
after initial screening-rescreening or surveillance
colonoscopy
May 2013
33
After first colonoscopy, then what?

Interval between colonoscopies will depend
on:
findings on last colonoscopy,
risk history, and
symptoms
May 2013
34
For the recommended recall intervals,

please see:
DHMH Colorectal Cancer Minimal Elements
http://phpa.dhmh.maryland.gov/cancer/Shared%20Documents/ccpc1324--att_CRCMinimalElements2013[1].pdf
(or http://phpa.dhmh.maryland.gov/cancer/
under Resources)

May 2013
35
Guidelines for Recall Intervals

Following Colonoscopy
Lieberman DA, Rex DK, Winawer SJ, Giardiello FM, Johnson

DA, Levin TR. Guidelines for Colonoscopy Surveillance After
Screening and Polypectomy: A Consensus Update by the US
Multi-Society Task Force on Colorectal Cancer.
Gastroenterology, 2012;143:844857
Rex DK, Ahnen DJ, Baron JA, Batts KP, Burke CA, et al.
Serrated lesions of the colorectum: Review and
recommendations from an expert panel. Am J Gastroenterol.
2012:109;1315-29.

May 2013
36
Keys to the right recall
1.
2.
3.
4.
Colonoscopy Report
Pathology Report
Recommendation based on guidelines
Communication

May 2013
37
Standards for Colonoscopy Reports

CO-RADS*
Colonoscopy report should include:
Date and Time - Procedure

Patient description
Risk factors
ASA class
Indications
Consent signed
Sedation
Colonoscope
Bowel prep adequacy
Whether cecum reached

Colonoscopy withdrawal time
Findings
Specimen(s) to path lab
Impression
Complications
Pathology
Recommendations
Follow-up plan/Recall
Other
*Standardized colonoscopy reporting and data system: report of the Quality Assurance
Task Group of the National Colorectal Cancer Roundtable, Lieberman et al.,
Gastrointestinal Endoscopy 2007; 65: 757-766
[Date]
38
Adequacy of First Colonoscopy

Among 16,813* First Cycle Colonoscopies
Not Adequate
1,555 (9%)
(Inadequate prep
OR didn't reach
cecum)
Adequate
15,258 (91%)
*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
May 2013
39
Reporting on
Colonoscopy Findings:
Number of masses, polyps, other lesions
(try to give actual or estimated

number rather than several or
multiple)
Findings: for EACH mass/polyp/lesion
location
size
description
tattoo
biopsy(ies) taken
method of each biopsy
whether lesion completely
removed or not
whether there was piecemeal removal

whether specimens retrieved
whether saline lift used
number of specimens sent to pathology

May 2013
40
How will your patients be reminded

about their next colonoscopy?

May 2013
41
Patient:
Family and personal history
Past screening
Symptoms
Primary Doctor:
Referral
Colonoscopist:
Case
Risk history
Management and Medication changes
Communication
Prep instructions
Post colonoscopy instructions
Colonoscopy report
Findings
Recommendations
Pathologist:
Pathology report
May 2013
42
Acknowledgements
Funding from the Maryland Cigarette Restitution Fund (CRF)
Staff and partners of Local Public Health Department
Programs 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
May 2013
43
PREVENTION AND
HEALTH PROMOTION
ADMINISTRATION
http://phpa.dhmh.maryland.gov

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Colorectal Cancer Update

for Healthcare Providers

CRC Incidence, Mortality, and

Prevention and Health Promotion Administration

Prevention and Health Promotion Administration

Colorectal Cancer Incidence and Mortality Rates

Year of Diagnosis or Death

Maryland Cancer Registry (incidence rates)

Prevention and Health Promotion Administration

5-year CRC survival

Source: SEER 9 areas. SEER

Prevention and Health Promotion Administration

Prevention and Health Promotion Administration

Colorectal Cancer Screening Status of People

Prevention and Health Promotion Administration

Provider Recommendation is KEY to Screening

Of the 20% who did NOT

Maryland Cancer Survey, 2008

80% of people 50+ in

Prevention and Health Promotion Administration

Colorectal Cancer Screening

Never screened with

Maryland Cancer Survey, 2008

Ever screened with

Prevention and Health Promotion Administration

Ever screened with

Prevention and Health Promotion Administration

Who needs screening?

Colorectal Cancer Age-Specific Incidence Rates

Source: Maryland Cancer Registry

Prevention and Health Promotion Administration

Prevention and Health Promotion Administration

Colorectal Cancer Cases by Risk History

Prevention and Health Promotion Administration

Approx. lifetime risk of CRC

One first degree relative (FDR) with CRC

2--3-fold increase over general

Two FDRs with CRC

FDR with CRC diagnosed < 50

One second or third degree relative

About 1.5-fold increase

Two second degree relatives

About 2--3-fold increase

Inflammatory Bowel Disease

7-10% have CRC after having

Familial adenomatous polyposis (FAP)

Burt RW. Gastroenterology 2000;119:837-53

Maryland Screening Recommendations:

Colonoscopy, every 10 years

* Hemoccult SENSA or fecal immunochemical test (FIT)

Age to Begin Screening by Risk Category

Age to Begin Screening

Age 40 years, or 10 years before the

Rex DK, et al. Am J Gastroenterol 2009:104;739-750

Prevention and Health Promotion Administration

Prevention and Health Promotion Administration

Tests that Find Both Polyps and Cancer

Flexible sigmoidoscopy every 5 years

Guidelines, American Cancer Society, June 2012

Prevention and Health Promotion Administration

Tests that Primarily Find Cancer

High sensitivity FOBT every year

Stool DNA test (unclear how often this is needed,