1. Colon Cancer Screening Alison Little, MD, MPH Medical Director, Medicaid

2. Colon Cancer Screening

3. Overdiagnosis When an individual is diagnosed with a condition that will never cause symptoms or death

4. Colon Cancer Screening Overdiagnosis Makes people feel vulnerable and less healthy Leads to excessive treatment, which can cause significant harm

5. Colon Cancer Screening Overdiagnosis Case Study Lara – 55 yo W female - asymptomatic Screening DEXA finds T score + -1.8, started HRT HRT stopped after WHI study Put on bisphosphonate, developed severe esophagitis (diagnosed by EGD) Put on raloxefine, developed painful rash Sent to endocrinologist to treat her osteopenia Endocrinologist exams her thyroid, finds a mass Has ultrasound, finds 3 nodules Had a needle biopsy, finds possible malignancy She gets lucky…. The surgeon she is referred to stops, noting that there are 1600 annual deaths from thyroid cancer per year in US, compared to 37,000 diagnoses

6. Colon Cancer Screening Examples of overdiagnosis (lower and lower threshholds for “disease”, better and better ways of finding abnormalities): Hypertension Diabetes Hyperlipidemia Osteoporosis Gallstones Meniscal tears Vertebral disc disease Aortic aneurism Cancer –Breast –Prostate –Thyroid –Lung –Melanoma

7. Colon Cancer Screening Two cancers with little or no overdiagnsois: Colon and Cervical Colon Cancer: –Screening for 25 years –Number of diagnosis has not risen, but instead has fallen since 1985 –Number of deaths from colon cancer has also fallen –If this was due to finding cancer precursors and removing them, true success story –But, polypectomy uncommon until mid 1990s, 10 years after the onset of the decline in colon cancer

8. Colon Cancer Screening Overdiagnosis associated with colon cancer screening is diagnosis of polyps Many polyps removed that will never become cancer Identification of polyps results in increased screening, and associated harms of overdiagnosis

9. Colon Cancer Screening