1. Colorectal Cancer Screening Guidelines
Barcey T. Levy, PhD, MD
Professor, Department of Family Medicine
Iowa Cancer Summit
September 21, 2010

2. Objectives Discuss current colorectal cancer screening guidelines.
Show Iowa mortality maps for colorectal cancer.
Give examples of health disparities in Iowa.
Discuss some of our CRC screening projects.

3. Why CRC screening?
Colorectal cancer is the 2nd leading cause of cancer-related death in both men and women.
75 – 90% of cases can be prevented or cured if caught early.
Over half of Americans age 50+ are not up to date with CRC screening.
Average risk patients should begin screening at age 50.
22 million Americans age 50 to 75 have NOT been tested; testing could save 25,000 lives per year (ABC news, September 2010).

4. Tubular adenoma

6. United States Preventive Services Task Force Guidelines
Recommends screening for CRC using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults beginning at age 50 and continuing until age 75.
Recommends AGAINST routine screening in those 76 to 85 years.
Recommends AGAINST screening in those older than 85 years.
Ann Intern Med 2008;149:

7. Appropriate Intervals for CRC Testing for Average Risk Individuals
ANY of the following:
Annual sensitive fecal test for occult blood (Hemoccult Sensa or a fecal immunochemical test (FIT)).
Flexible sigmoidoscopy every 5 years.
Colonoscopy every 10 years.
Consistent with ACS/American Gastroenterological Association/USPSTF guidelines

8. Key Point
A recent decision analysis found no difference in life-years gained using any of the following strategies:
Colonoscopy every 10 years
Annual screening with a sensitive FOBT or FIT
Sensitive FOBT every two to three years with flexible sigmoidoscopy every 5 years
Thus, a sensitive stool test for occult blood done annually is perfectly acceptable!
Zauber, et al, Ann Intern Med 2008;149( )

9. CRC Mortality – Iowa SEER Data

10. Health disparities in Iowa
SEER ; Adjusted rates per 100,000 U.S. standard population

11. Projects
AHRQ funded study to examine CRC screening among rural Iowans.
Factors predicting screening
Doctor’s reasons for not screening specific patients
IDPH contract to screen underserved Iowans.
American Cancer Society funded randomized clinical trial, testing four interventions to improve CRC screening.
FIT vs. colonoscopy comparative effectiveness study

13. Patients with CRC tests: current and true screening

14. Predictors of Being Up-To-Date: Univariate Odds Ratios
Variable
OR (95% CI)
p-value
Patient recalls MD recommendation*
6.4 (4.2, 9.6)
<.001
MD documented CRC discussion*
14.1 (8.5, 23.3)
* Not considered in multivariate model

16. Educational mailings – overall 47% screened by FIT

17. IDPH Contract
Implemented a screening program for uninsured or underinsured Iowans.
Used a fecal immunochemical test (FIT) kit that required a small sample from a single stool.
The FIT is a very sensitive test for small amounts of human blood and does not require the dietary restrictions of the hemoccult test.

18. FIT results
Of 449 who completed eligibility forms (23% of study population), 297 were given an FIT kit.
Return rate on FITs was 79% (235 returned).
Of the 235 kits returned, 186 tested negative (79%) and 49 (21%) tested positive.
Each individual with a positive result was telephoned and their result explained to them.
Colonoscopies were strongly encouraged for those with positive results.

19. Colonoscopy Results No complications from any of the colonoscopies
30 of the 49 (61%) individuals had a colonoscopy
20 individuals had at least 1 polyp biopsied
13 individuals had at least 1 tubular adenoma
2 had adenomas more than 1 cm in diameter
No colon cancers were identified
No complications from any of the colonoscopies

20. Conclusions from IDPH
Underinsured patients had a 79% return rate for the FIT kits.
The rate of positive tests was much higher than anticipated, leading to many more colonoscopies than originally anticipated.
Population-based strategies for offering FIT could significantly increase CRC screening among disadvantaged individuals.
Programs will have to develop sustainable mechanisms to include the necessary organization and address substantial costs of providing mass screening, as well as facilitating and providing colonoscopies for those who test positive.

21. Take Home Points
CRC screening should occur regularly between ages 50 and 75 for average risk individuals.
There is wide variation in screening rates across Iowa.
There is wide variation in CRC mortality across Iowa.
Simple interventions can work.
Screening programs need to allow for significant resources for organization and follow-up.

22. References
Levy, et al. Colorectal cancer testing among patients cared for by Iowa family physicians. Am J Prev Med 2006;21:
Levy BT, et al. Why hasn’t this patient been screened for colon cancer? An Iowa Research Network Study. J Am Board Fam Med. 2007;20(5):
Levy, et al. The “Iowa Get Screened” Colon Cancer Screening Program. J of Primary Care & Comm Health 2010;1(1):43-49.
Zauber, et al. Evaluating and testing strategies for CRC screening. Ann Intern Med 2008;149(9):
USPSTF. Screening for CRC. Ann Intern Med 2008;149: