1. D EPARTMENT of F AMILY M EDICINE Colon Cancer Screening in Iowa Barcey T. Levy, PhD, MD Professor, Family Medicine and Epidemiology University of Iowa 2012 Iowa Cancer Summit October 4, 2012

2. D EPARTMENT of F AMILY M EDICINE Objectives 1. Review the current guidelines for colorectal cancer (CRC) screening. 2. Review CRC trends in Iowa. 3. Review the Iowa Cancer 2.0 maps created as part of the RC4 project. 4. Provide some practical advice for practices and organizations trying to improve CRC screening.

3. D EPARTMENT of F AMILY M EDICINE Why do we care about CRC screening?  Iowa has the 5 th highest rate of CRC incidence of all of the SEER registries, 2005-2007  Rate 54.6 per 100,000 (age-adjusted to the U.S. standard population) (Utah is 38.1)  Iowa is 4 th highest for percentage diagnosed with late stage CRC (53.3%) – (Connecticut and Utah each ~47%)

4. D EPARTMENT of F AMILY M EDICINE CDC Interactive Cancer Atlas  http://www.cdc.gov/features/canceratlas/ http://www.cdc.gov/features/canceratlas/  http://apps.nccd.cdc.gov/DCPC_INCA/DCPC_INCA.a spx

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6. 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).

7. D EPARTMENT of F AMILY M EDICINE 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;149:627-637

8. D EPARTMENT of F AMILY M EDICINE 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

9. D EPARTMENT of F AMILY M EDICINE Comparison of Tests for CRC TestSensitivitySpecificityPositivity rate Serious harms Cost Fecal immuno chemic al test 61 to 91%91 to 98%5 to 19%Very low$40 Colonos copy 95%90%40% adenoma bx; 3 to 5% for cancer 2.8/1000 procedures $4,000

10. D EPARTMENT of F AMILY M EDICINE Key Point  A 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(659-669)

11. D EPARTMENT of F AMILY M EDICINE CRC Trends in Iowa

12. D EPARTMENT of F AMILY M EDICINE CRC maps 2.0 website  On the Iowa Cancer Consortium webpage  http://www.canceriowa.org/family_practice_info_re sources.aspx http://www.canceriowa.org/family_practice_info_re sources.aspx  Link to cancer maps 2.0  http://www.uiowa.edu/iowacancermaps2/

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14. Screening is primarily opportunistic, not systematic  Patients need to present to their primary care physician to be advised to be screened.  Other issues often take precedence.  Physicians often don’t use checklists to remind them of basic preventive strategies.  Patients have financial, personal, or family issues that get in the way of being tested.  Some health systems have developed a systematic approach to CRC screening, that takes it out of the hands of individual doctors (e.g. Kaiser Permanente)

15. D EPARTMENT of F AMILY M EDICINE How can we reduce CRC incidence and mortality in Iowa?

16. D EPARTMENT of F AMILY M EDICINE What do CRC screening rates look like at the individual family medicine practice level? AHRQ funded study

17. D EPARTMENT of F AMILY M EDICINE Patients with CRC tests

18. D EPARTMENT of F AMILY M EDICINE Predictors of Being Up-To-Date: Univariate Odds Ratios VariableOR (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)<.001 * Not considered in multivariate model

19. D EPARTMENT of F AMILY M EDICINE Physicians’ Reasons for Specific Patients Not Being Up to Date with CRC Guidelines When CRC screening was not discussed  Lack of opportunity to discuss screening Patients came in only for acute visits or problems Patients came in sporadically or saw other providers for health maintenance care No tracking system Not enough time during appointments  Physician forgetfulness  Assessment that cost or lack of insurance would be prohibitive to patient  Patient had life issues or other health problems that distracted from screening  Expected patient refusal or lack of interest

20. D EPARTMENT of F AMILY M EDICINE Physicians’ Reasons for Specific Patients Not Being Up to Date with CRC Guidelines When CRC screening was discussed, but patient declined  Cost of screening  Lack of interest in screening  Patient autonomy  Patients had life issues or other health problems  Fear of screening test procedure  No symptoms or family history of CRC

21. D EPARTMENT of F AMILY M EDICINE IDPH “Iowa Get Screened” 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.

22. D EPARTMENT of F AMILY M EDICINE FIT results  Of 449 who indicated an interest (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.

23. D EPARTMENT of F AMILY M EDICINE Colonoscopy Results  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

24. D EPARTMENT of F AMILY M EDICINE 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.

25. D EPARTMENT of F AMILY M EDICINE Interventions to Improve Colon Cancer Screening in Poor, Rural Iowa Counties (funded by American Cancer Society

26. D EPARTMENT of F AMILY M EDICINE CRC Testing Rates by Different Methods (some subjects screened by more than one method)

27. D EPARTMENT of F AMILY M EDICINE Conclusions from CRC screening intervention trial  A physician chart reminder did not increase screening over usual care.  Mailed educational materials, including FITs, had a very significant positive effect on screening.  Practices wishing to increase screening rates may wish to provide educational mailings to their patients, along with FITs.  If using FITs, the test needs to be performed annually!

28. D EPARTMENT of F AMILY M EDICINE Document, document, document  Physicians need to make sure to DOCUMENT their CRC screening discussions with patients!  If patients decline, that needs to be NOTED in the medical record. If it is not recorded, it did not happen.  Practices should have a policy on CRC screening and make sure everyone in the office is involved in screening – TEAM EFFORT!

29. D EPARTMENT of F AMILY M EDICINE To increase CRC screening rates  Health systems should adopt organized CRC screening  Educational mailings to patients  Explicit directions on how to obtain tests  Include FITs in the mailing to make it easier for patients who choose this method  Between 2005 and 2010, screening rates increased from 37% to 69% among those with commercial insurance and 41% to 79% among those with Medicare. Levin TR, Epidemiol Rev 2011;33:101-110

30. D EPARTMENT of F AMILY M EDICINE References 1. Levy BT, et al. Colorectal cancer testing among patients cared for by Iowa family physicians. Am J Prev Med. 2006;31(3):193-201. 2. 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):458-468. 3. Levy BT, et al. The “Iowa Get Screened” Colon Cancer Screening Program. J Prim Care Com Health. 2010;1(1):43-49. 4. http://www.uiowa.edu/iowacancermaps/colorectal_mortality.html http://www.uiowa.edu/iowacancermaps/colorectal_mortality.html 5. Zauber AG, et al. Evaluating test strategies for CRC screening: a decision analysis for the U. S. Preventive Services Task Force. Ann Intern Med. 2008;149(9):659-669. 6. USPSTF. Screening for CRC: U. S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2008;149(9):627-637. 7. Levy BT, Daly JM, Schmidt EJ, Xu Y. The need for office systems to improve colorectal cancer screening. J Prim Care Com Health. 2012;3(3):180-186.

31. D EPARTMENT of F AMILY M EDICINE References (cont’d) 8. Levy BT, Daly JM, Xu Y, Ely JW. Mailed fecal immunohistochemical tests plus education materials to improve colon cancer: screening rates in Iowa Research Network (IRENE) practices. J Am Board Fam Med. 2012;25(1):73-82. 9. Daly JM, Xu Y, Ely J, Levy BT. A Randomized Colorectal Cancer Screening Intervention Trial in the Iowa Research Network: Study Recruitment Methods and Baseline Results. J Am Board Fam Med. 2012;25(1):63-72. 10. Levin TR, Jamieson L, Burley DA et al. Organized Colorectal Cancer Screening in Integrated Health Care Systems. Epidemiol Rev. 2011;33(1):101-110.