Breast and Colorectal Cancer Screening in Family Care Clinic and their Outcomes Presented by Liana Poghosyan, MD Ne Moe, MD May 19, 2008

Introduction Epidemiology and Clinical Consequences Breast cancer is the most common non-skin malignancy among women in the United States and second only to lung cancer as a cause of cancer- related death In 2001, an estimated 192,200 new cases of breast cancer were diagnosed in American women, and 40,200 women died of the disease The risk for developing breast cancer increases with age beginning in the fourth decade of life The probability of developing invasive breast cancer over the next 10 years is 0.4 percent for women aged 30-39, 1.5 percent for women aged 40-49, 2.8 percent for women aged 50-59, and 3.6 percent for women aged Individual factors other than age that increase the risk for developing breast cancer include family history or a personal history of breast cancer, biopsy-confirmed atypical hyperplasia, and having a first child after age 30.

Epidemiology and Clinical Consequences Colorectal cancer is the fourth most common cancer in the United States and the third leading cause of cancer death A person at age 50 has about a 5 percent lifetime risk of being diagnosed with colorectal cancer and a 2.5 percent chance of dying form it, the average patient dying of colorectal cancer loses 13 years of life

Background Fortunately, we can detect these fatal disease in pre-cancerous stage, these cancers are preventable. Therefore, cancer screenings are extremely important in all population In order to know the performance of FCC in screening those two preventable cancers, we reviewed a total of 200 charts. According to exclusion criteria, we needed to exclude 47 patients, therefore our data is based on 153 patients who came to our FCC within 5 years back

Material and Method Out of 153, there were 116 women and 37 men Among 116 women, 30 were under 50 No colorectal screening were done under 50 years of age on both genders All females were older than 40, and we reviewed for Breast cancer screening Both for female and male older than 50, we reviewed only for Colorectal cancer screening

Exclusion criteria: Younger than 40 for female and 50 for male Less than 3 visits More than 5 years

Inclusion criteria: Female over 40 Male over 50 More than 2 visits Seen last 5 years Reviewed both Attendings and Residents charts

Cont Materials and Methods We reviewed: age, sex, medical records, date of birth, and screening tests In the screening tests: for breast cancer, we reviewed for mammogram, results, follow up, outcome For Colorectal cancer, we reviewed for FOBT, DCBE, Flex Sig, Colonoscopy, and their results, follow up, and outcomes The time frame is 5 years back The study is retrospective

Results All females reviewed were older than 40 years old Mammogram srceening tests were done on 104 patients out of 116 which is 90% compliance rate

Result For female Breast cancer screening under 50, mammography was done on 22 patients out of 30 which is 73% None of them found mass or calcification For female breast cancer screening older than 50, mammography was done on 82 patients out of 86, which is 95% compliance rate Out of these 82 patients who got mammogram, 22 patients which is 27% of female older than 50 have found to have mass or calcification 18 patients (82%) got follow up mammo, spot compression mammo, ultrasound, or stereotatic biopsy None of them has breast cancer

Result Among 153 patients, there were 123 patients (80%) eligible to be sreened for colorectal cancer in both male and female 83 patients (67%) were screened for colorectal cancer Out of 123 combined male and female, 37 (27%) were male and 86 (73%) were female

Result For female colorectal cancer screening, there were total of 86 females older than 50 who were eligible to be screened for Colorectal cancer Among them, 51 patients were screened for colorectal cancer that is 60% of eligible patients Several screening methods were used: FOBT, DCBE, Flex Sig, Colonoscopy FOBT 38 (75%) is the most commonly screening tool, Flexible sigmoidoscopy 2 (4%) is the least method to used. Others are: Colonoscopy 8 (16%), double contrast barium enema 3 (6%)

Result Out of 153 patient population, we reviewed 37 male patients Among them, 32 patients were older than 50 years and eligible to screen for colorectal cancer 22 patients were screened for colorectal cancer which is 68.8% of patient population who are eligible to be screened 22 patients were screened for colorectal cancer which is 68.8% of patient population who are eligible to be screened FOBT is the most common screening method, 18 out of 22 (82%) and second most common method is Colonoscopy: 4 out of 22 (18%) There were no double contrast barium enema or flexible sigmoidoscopy in male population in FCC

Analysis Total: 200 Data Pool: 153 Male: Female ratio – 37 (24.2%): 116 (75.8%)

Analysis Female above 40 years old mammo compliance rate: 90% Both gender colorectal screening older than 50 years old: 67%

Gender Ratio

Female Mammogram

FCC Colorectal Screening

Discussion By knowing about our performance and compliance in FCC, we can find out the barriers for these screening tests and ways to overcome these barriers so that we can improve the quality of care for our patient population we are serving

Discussion Adding ultrasonography to mammography may improve breast cancer detection, research suggests USA TodayUSA Today (5/14, 7D, Szabo) reports, "Screening women with both ultrasounds and mammograms allows doctors to find more breast cancers than if they rely on mammograms alone," according to a study published in the May 14 issue of the Journal of the American Medical Association. But, "the combination also leads to many more unnecessary biopsies, and experts don't recommend it to most patients." Journal of the American Medical Association USA TodayJournal of the American Medical Association For the study, "almost 3,000 women recruited from 21 centers" were randomized "to receive either mammography alone, or mammography plus ultrasound performed by a physician," HealthDay (5/13, Gordon) added. The results revealed that the diagnostic yield for mammography was "7.6 cancers" per 1,000 women screened. Mammogram plus ultrasound "found 31 of the cancers," which produces a yield of "11.8 cancers" per 1,000 women. This finding suggests that ultrasonography increased the yield by 4.2 per 1,000 over mammography alone For the study, "almost 3,000 women recruited from 21 centers" were randomized "to receive either mammography alone, or mammography plus ultrasound performed by a physician," HealthDay (5/13, Gordon) added. The results revealed that the diagnostic yield for mammography was "7.6 cancers" per 1,000 women screened. Mammogram plus ultrasound "found 31 of the cancers," which produces a yield of "11.8 cancers" per 1,000 women. This finding suggests that ultrasonography increased the yield by 4.2 per 1,000 over mammography alone HealthDay

Discussion MedPage TodayMedPage Today (5/13, Bankhead) noted, "Mammography alone had a diagnostic accuracy (area under the curve) of 0.78, which increased to 0.91 with supplemental ultrasound (P=0.003)." In addition, "[t]he positive predictive value of biopsy recommendation after complete diagnostic workup was 22.6 percent for mammography (19 of 84), 8.9 percent for ultrasound (21 of 235), and 11.2 percent for combined imaging (31 of 276)." But, the "number of false-positive diagnoses increased from 116 (for mammography alone), to 275 (for the combined use of mammography and ultrasound) MedPage Today In an accompanying editorial, Christiane Kuhl, M.D., of the University of Bonn, wrote that "the issue of false positives, while troubling, is less of an issue with ultrasound than with mammography, because biopsies can often be performed during the screening with ultrasound-guided biopsy," WebMD (5/13, Boyles) reported. This week's JAMA Report video features the study. In an accompanying editorial, Christiane Kuhl, M.D., of the University of Bonn, wrote that "the issue of false positives, while troubling, is less of an issue with ultrasound than with mammography, because biopsies can often be performed during the screening with ultrasound-guided biopsy," WebMD (5/13, Boyles) reported. This week's JAMA Report video features the study.WebMDvideoWebMDvideo

Discussion Virtual Colonoscopy Virtual colonoscopyVirtual colonoscopy is a procedure that uses a series of x- rays called computed tomography to make a series of pictures of the colon computed tomography Virtual colonoscopycomputed tomography A computer puts the pictures together to create detailed images that may show polyps and anything else that seems unusual on the inside surface of the colon. This test is also called colonography or CT colonography Clinical trials are comparing virtual colonoscopy with commonly used colorectal cancer screening tests. Other clinical trials are testing whether drinking a contrast material that coats the stool, instead of using laxatives to clear the colon, shows polyps clearly contrast materiallaxativescontrast materiallaxatives

Advantages of CTC Accurate detection of 4 mm or larger polyps Non-invasive with virtually no risk Significantly less expensive Cost: $475 Time efficient exam: Can work the same day Flexible viewing and analysis Record: 3D electronic model Sensitivity: 93.8% for polys >1 cm vs 87.5% with colonoscopy Specificity: 96%

Discussion DNA stool test This test checks DNA in stool cells for genetic changes that may be a sign of colorectal cancer DNAcells geneticDNAcells genetic Sensitivity: 89% Specificity: 86% 4 times more sensitive than FOBT Cost: $150

Conclusion In our FCC, the compliance rate for Breast cancer is 90% and colorectal cancer is 67% While there is room to improve in breast cancer screening, FCC performance in colorectal screening needs to improve significantly to meet the standard of care Should consider not only FOBT, needs to schedule more for Flex Sig in FCC Should also encourage administration to make other test options available such as Virtual Colonoscopy and DNA tool test There should be a system in place to schedule an appointment for a patient just exclusively to discuss, evaluate and order screening tests for disease prevention and health promotion at least once a year