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Learning and Earning with Gateway
Professional Education CME/CEU Webinar Series
Best Practices for Colorectal Cancer Screening
March 14, 2018
12:00pm – 1:00pm
Robert A. Smith, PhD Joe Mastalski
Vice President, Cancer Screening Manager, Quality Improvement
American Cancer Society Gateway HealthSM
Learning and Earning with Gateway
Professional Education CME/CEU Webinar Series
To receive CME/CEU credit for today’s webinar:
• Call xxx-xxx-xxxx from the cell phone number you provided when you enrolled
in the webinar series
• Enter code: **code would have been provided at time of live webinar**
• You MUST call by the end of the day today to receive credit!
• Next webinar: April 4, 2018 HPV and Cervical Cancer
• Forgot to enroll? Enroll today to get CME credit for attending our next webinar
at https://www.surveymonkey.com/r/NZJYDF7
• Questions? Email us at ProviderEngagementTeam@GatewayHealthPlan.com
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for
Continuing Medical Education (ACCME) through the joint providership of Allegheny General Hospital and Gateway Health Plan. Allegheny
General Hospital is accredited by the ACCME to provide continuing medical education for physicians.
Allegheny General Hospital designates this live webinar activity for a maximum of 1.0 AMA PRA Category 1 CreditTM. Physicians should claim only
the credit commensurate with the extent of their participation in the activity.
2
Shout Out!
Washington Health System
Washington, PA
CTC: Carol Rhodes
To arrange for a group viewing and lunch at your practice
for a future webinar, please contact your Gateway Clinical
Transformation Consultant (CTC).
3
Today’s Presenters:
Robert A. Smith PhD Joe Mastalski
Vice President, Cancer Screening Manager, Quality Improvement
American Cancer Society Quality Improvement
Gateway HealthSM
4
Screening for Colorectal Cancer
Robert A. Smith, PhD
Vice President, Cancer Screening, American Cancer Society
Adjunct Professor of Epidemiology
Emory University Rollins School of Public Health
Disclosures • I have no financial disclosures or conflicts of interest to declare
Outline of Today’s Presentation
• Recent trends
• Screening guidelines
• The screening tests,
including strengths,
limitations, and
quality issues
• Strategies to increase
screening rates
• Resources
Colorectal cancer screening reduces CRC mortality by finding cancer early, and by detecting and removing precursor lesions 1. Prevention 2. Early Detection Find and remove polyps to Find cancer in the early stages, prevent cancer when best chance for a cure
CRC Statistics—Trends in Disease
Rates & Screening Rates
Long-Term Trends in Colorectal Cancer Incidence
(1975-2013) and Mortality (1930-2014) Rates* by
Sex, United States.
• The dramatic declines in
colorectal cancer
incidence & mortality over
the past decade have
been attributed to the
widespread uptake of
colonoscopy screening,
which increased from
19% in 2000 to 63% in
2015 among adults aged
50 to 75 years.
10
Siegel RL, et al. CA Cancer J Clin 2017;67:177-193.Trend in Colorectal Cancer Mortality: Age-standardized
Rate vs. Number of Deaths, United States, 1975-2014
The decline in
death rates
accelerated
beginning around
2000, and notably
has been of
sufficient
magnitude to
overcome the
aging and growth
of the population
Siegel RL, et al. CA Cancer J Clin 2017;67:177-193.Decline in CRC Incidence and Mortality
Decline due to:
Screening earlier cancer detection improved survival
Improvements in treatment
Survival Rates by Disease Stage*
100 90.3%
90
80 70.4%
70
5-yr 60
50
Survival 40
30
12.5%
20
10
0
Lo cal Reg io n al Distan t
St age of Det ect ionColorectal Cancer Screening (%), Adults Ages 50 Years or Older, United States, 2015 Siegel RL, et al. CA Cancer J Clin 2017;67:177-193.
Colorectal Cancer Screening (%), Adults Ages 50 Years or Older, United States, 2015 Siegel RL, et al. CA Cancer J Clin 2017;67:177-193.
American Cancer Society and United States Preventive
Services Task Force Guidelines for CRC Screening, 2008
15CRC Screening in Average Risk Adults: 2008
Recommendation ACS, USMSTF, ACR
Stool Testing Annual screening with high sensitivity (HS) gFOBT
• gFOBT or FIT, or
• FIT Mt-sDNA every 3 years
•mtsDNA
Low sensitivity gFOBT not recommended
Flexible sigmoidoscopy Screening every 5 years
Screening every 5 years, with annual gFOBT or FIT
is an option
Colonoscopy Screening every 10 years
CT Colonography Screening every 5 years• On June 20, 2016, the USPSTF released update CRC screening
recommendations, providing an update of their 2008
recommendations
• The recommendations covered colorectal cancer screening with
FOBT (gFOBT, FIT, and FIT-DNA), endoscopy (colonoscopy and
flexible sigmoidoscopy), and CT colonography
• Two tests not endorsed in the draft recommendations released
in 2015 (FIT-DNA and CT colonography) were endorsed in the
2016 final recommendations.
JAMA June 21, 2016 Volume 315, Number 23USPSTF CRC Screening Recommendation Statement
• In the current recommendation, instead of
emphasizing specific screening approaches,
the USPSTF has instead chosen to highlight
that there is convincing evidence that
colorectal cancer screening substantially
reduces deaths from the disease among
adults aged 50 to 75 years and that not
enough adults in the United States are
using this effective preventive intervention.
JAMA June 21, 2016 Volume 315, Number 23USPSTF CRC Screening Recommendations, 2016— How does
these changes compare with the 2008 ACS guideline?
ACS endorses screening Q 3 yrs.
Same
ACS does not emphasize
combined FSIG/FOBT
JAMA June 21, 2016 Volume 315, Number 23Screening for Colorectal Cancer—Test Performance & Clinical Considerations
Stool Test: Guaiac (gFOBT) • Most common type of FOBT • Best evidence (3 RCT’s) • 30 year f/u (NEJM Oct 2013) • Need specimens from 3 bowel movements • Non-specific • Results influenced by foods and medications • Older forms (Hemoccult II) not recommended! • Better sensitivity with newer versions (Hemoccult Sensa)
Minnesota Colon Cancer Control Study
• 33,020 participants, with 30 years
of follow-up
• Rehydrated guaiac –based FOBT
• Screening reduced colorectal-cancer
mortality
• Relative risk for annual screening:
• 0.68; (95% CI, 0.56 to 0.82)
• Relative risk for biennial screening:
• 0.78; (95% CI, 0.65 to 0.93)
• Conclusion: After 30 years of
follow-up, an invitation to annual
FOBT screening was associated
with 32% fewer CRC deaths, and a
biennial invitation was associated
with 22% fewer deathsMinnesota FOBT Trial—Comparative
Incidence in the Invited & Control Group
• Screening with FOBT is
associated with a reduction
in incidence of colorectal
cancer
– 18 yrs. after randomization,
there was 20% lower CRC
incidence in the annual
screening group
• Annual group = 32/1,000
• Control group = 39/1,000
• In the Minnesota Trial,
there was a high
colonoscopy referral rate
due to the use of
rehydrated FOBTSingle Test Performance Characteristics of
gFOBT Variants: Hemoccult & Hemoccult II
• Low test sensitivity (vs. Study with Sensitivity for Specificity
program sensitivity) One-Time Cancer
• Sensitivity improved with Testing
rehydration, but specificity Collins, et 9.5% 97.5%
suffers al. AIM, [ In Office,
2005 Single Panel
• Dietary restrictions reduce gFOBT]
patient adherence Lieberman, 50% 93.8%
• Interpretation of test et al. NEJM, (w/rehydration)
results is subjective 2001
• Lower patient completion
Imperiale, 14.1% 95.2%
compared with FIT et al.
• NOT RECOMMENDED BY NEJM, 2004
ACS or USPSTF FOR CRC Allison, et 37.1% 97.7%
SCREENING al.
NEJM, 1996Single Panel FOBT Following Digital
Rectal Exam
• In-Office FOBT is common CRC
screening strategy
• Reasons to STOP single sample
FOBT
– Not recommended by any
CRC screening guideline
– Not recommended by the
manufacturer of any test
– Lowest sensitivity of all CRC
screening tests, i.e., less than
5% for advanced neoplasiaStool Test: Immunochemical (FIT) • Slightly more costly than guaiac tests • Higher sensitivity for cancer & adenomas than guaiac-based FOBT • Specific for human blood and for lower GI bleeding • Results not influenced by foods or medications • Most types require only 1 or 2 stool specimens • Patients prefer FIT to gFOBT— Test Completion Rate is Higher!!
Meta-analysis of FIT vs. Hemoccult Sensa
FIT Hemoccult Sensa
Sensitivity: 73-89% 64-80%
Specificity: 92-95% 87-90%
Two Key Points:
1. Only high sensitivity stool tests are recommended for
screening
2. FIT is a superior option for annual stool testing.
Lee, JK et. al. Ann Intern Med. 2014 160 (3): 171Adherence with FIT is consistently better
than with guaiac-based stool tests
Adherence
Study FIT Guaiac
Hoffman (2010) 61.4% 50.5%
Hol (2010) 61.5% 49.5%
Van Rossum (2008) 59.6% 49.6%
Cole (2003) 39.6% 23.4%
Source: TR Levin, MDMulti-Target Stool DNA Test Only one test currently available (Cologuard) Combines tests for stool DNA markers associated with cancers and adenomas plus an FIT
NEJM 2014
Cologuard—Guidelines & Coverage
FDA has cleared it for marketing as CRC screening
test Q 3 years
CMS has agreed to cover Cologuard for average risk
Medicare beneficiaries age 50 – 85 yrs
Medicare will reimburse ~ $500 Q 3 yrs. for the
test (price includes “navigation” component)
Private insurance coverage – limited
All positive tests must be evaluated by colonoscopy
Included in current ACS guidelines, and USPSTF
recommendationsColonoscopy • Allows direct visualization of entire colon lumen • Screening, diagnostic and therapeutic • 10 yr. interval • The most common screening test in US (>80%)
Colonoscopy
• Polypectomy prevents
colorectal cancer
• The National Polyp Study
observed a 76-90%
reduction in CRC
incidence after
polypectomy
Winawer et al, NEJM 1993Long-Term Colorectal-Cancer incidence and
Mortality after Lower Endoscopy
• Data from two prospective
cohort studies:
– the Nurses’ Health Study,
which included 121,700 U.S.
female nurses, 30 to 55
years of age at enrollment in
1976;
– the Health Professionals
Follow-up Study, which
included 51,529 U.S. male
health professionals, 40 to
75 years of age at
enrollment in 1986.
• Examined the association
between lower endoscopy
(1988-2008) and colorectal
cancer incidence and
mortality through June 2012.Long-Term Colorectal-Cancer incidence and Mortality after Lower Endoscopy NEJM, 2013, vol. 369 no. 12
Quality Issues with Colonoscopy
• Poor pre-procedure documentation
• Poor prep
• Failure to reach the cecum
• Rapid withdrawal time
• Adverse events
• Highly variable adenoma detection rate
• Interval cancers
• Over and under utilization of the
procedure
• Highly variable reports
• Poor feedback
• Most endoscopists are unaware of “their
numbers,” since most facilities do not track
their data.What do the quality data on
colonoscopy reveal?
• Adenoma detection rate (ADR) is highly
variable.
• In one large series, ADR varied from 7% - 52%
– 8% interval cancer rate
– ADR inversely associated with the interval cancer
rate
– ADR inversely associated with colorectal cancer
deathVariability in the Adenoma Detection Rate is 10
fold, and is Associated with Withdrawal Time
Barclay et al. NEJM;2006;355:2533Adenoma Detection Rate and Risk of CRC
Incidence, Interval Cancer, and Death
• Setting: Kaiser Permanente
of Northern California
• 264,972 Colonoscopies
among 223,842 patients
were eligible for assessment
• 927,523 person-years of
follow-up and detection of
712 interval CRCs)
• Outcome: Risk of CRC 6
months to 10 years after
colonoscopyHazard ratios for ADR and risk of advanced stage
CRC, and fatal CRC
Advance
Stage CRC
Fatal CRCKey Quality Indicators
• Adenoma Detection Rate (ADR)
– Entire Unit and Individual Endoscopists
– Improvement plans are initiated if ADR rate is not ≥ 25% for men and ≥
15% for women, or > 20% overall
• Cecal Intubation Rate (CIR)
– Improvement plans are initiated if complete colonoscopy is not
accomplished in > 90% of all patients and > 95% of those undergoing
screening and surveillance procedures, for both the unit as a whole
and for each individual endoscopist
• Quality of Preparation
– Improvement plans are initiated if prep quality is not “adequate for
detection of all polyps > 5 mm” in > 90% of patients.Key Quality Indicators
• Complete Procedure Documentation
– Patient demographics
– ASA Score (assessment of procedural risk)
– Procedure Indications (screening, surveillance, symptoms, etc.)
– Procedural Technical Description (medications, extent of exam, adequacy
of preparation, ease and tolerance, retroflexion, other maneuvers)
– Colonoscopic Findings
– Diagnosis and Assessment
– Unplanned Events
– Follow-up Plan
• Incomplete unit or endoscopist documentation
shall initiate improvement planRecommended, But
Less Common CRC
Screening Tests
44Flexible Sigmoidoscopy • The scope on the right is a 60 cm flexible scope. Others include smaller 35 cm flexible scope, and the 25 cm rigid scope.
Once-only flexible sigmoidoscopy screening in
prevention of colorectal cancer: a multicentre
randomised controlled trial
• 14 UK centers
• 170,432 eligible men and
women
• 57,237 to the intervention
group, of which 71%
underwent a single flexible
sigmoidoscopy
• Outcomes of interest:
– Colorectal cancer incidence
– Colorectal cancer mortality
• Findings:
– 23% reduced incidence
– 31% reduced mortalityRadiographic CRC Screening Tests
Double Contrast Barium CT Colonography, aka Virtual
Enema Colonoscopy• Results: For all samples, sensitivity of Plasma Septin9 for CRC detection was 73.3%, and 68.0% for FIT. • Specificity of the Plasma Septin9 test was 81.5% compared with 97.4% for FIT. • When test results for Plasma Septin9 and FIT were combined, CRC detection was 88.7% at a specificity of 78.8%. • Conclusions: At a sensitivity of 72%, the Plasma Septin9 test is non- inferior to FIT for CRC detection, although at a lower specificity. PLOS ONE | www.plosone.org 1 June 2014 | Volume 9 | Issue 6 | e98238
Improving Colorectal
Cancer Screening Rates
Offer Your Patients the
Option of Colonoscopy OR
FOBTColonoscopy should be regarded as
an effective screening test, not the
best screening test for all adults
While colonoscopy is viewed as the best
screening test, many patients face barriers or
are not willing to undergo colonoscopy
Often recommended despite access or other
challenges
Focus on colonoscopy associated with low
screening rates in a number of studies
Patient preferences rarely solicitedPrimary Care Provider Perceptions
of Screening Tests
FOBT/FIT used, but:
Effectiveness questioned by many
clinicians
Lack of knowledge re: performance
of new vs. older forms of stool
tests, other quality issuesBenefits, Harms, and Burdens of Recommended
Screening Strategies Over a Lifetime
Source: CISNET, 2015Many Patients Prefer FOBT
Randomized clinical trial in which 997 patients in the San
Francisco PH care system received different recommendations
for screening:
Recommended Test Completed Screening
Colonoscopy 38%
FOBT 67%
Colonoscopy or FOBT 69%
Many patients will forgo screening
if they are not offered an alternative to
colonoscopy.
(Inadomi et al. 2012)Many Patients Prefer FOBT/FIT
Diverse sample of 323 adults given detailed side-by-side description of
FOBT and colonoscopy (DeBourcy et al. 2007)
53% preferred FOBT
212 patients at 4 health centers rated different screening options with
different attributes (Hawley et al. 2008)
37% preferred colonoscopy
31% preferred FOBT
Nationally representative sample of 2068 VA patients given brief
descriptions of each screening mode (Powell et al. 2009)
37% preferred colonoscopy
29% preferred FOBTSummary--Advantages of Stool
Tests
Newer tests are very accurate
Preferred by a significant % of patients
Less expensive
No bowel preparation.
Done in privacy at home.
No need for time off work or assistance
getting home after the procedure.
Non-invasive – no risk of pain, bleeding,
perforation
Limits need for colonoscopies – required
only if stool blood testing is abnormal.Improving Colorectal
Cancer Screening Rates
Take Advantage of
Checkups to Refer for CRC
ScreeningCancer Screening & the Periodic
Preventive Health Exam
• Retrospective cohort study
• 64,288 adults ages 52-78 in
a managed care plan
• Outcomes focused on
completion of:
– CRC screening
– Breast cancer screening
– Prostate cancer screeningAdjusted Incidence of 3 Cancer Screening Tests
by Receipt of Preventive Health Exam (PHE)
CRC Screening Mammography PSA Testing
Received PHE Did Not Receive PHE
Approximately 50% of adults who had received a PHE completed
CRC screening within 5 annual visitsImproving Colorectal
Cancer Screening Rates
Expand Opportunities for
CRC Screening During the
Delivery of Other Preventive
CareFlu-FIT is an intervention designed to use
the opportunity when adults are
receiving flu shots to promote colorectal
cancer screeningCRC Screening Outreach During Annual Flu Shot
Activities
Potential Benefits of “Flu-FOBT” or “Flu-FIT”
Programs:
Reaches patients at a time each year when they are already
thinking about prevention
Creates a seasonal focus on cancer screening that may add to
other screening efforts
Time-efficient way to involve non-physician staff in screening
activities
Educates patients that “just like a flu shot, you need FOBT/FIT
every year”
Slide courtesy of M. Potter, MDSan Francisco General Hospital Randomized Trial
(Flu shot clinic attendees randomized to Flu Only vs. Flu + FOBT on different
dates – included telephone follow-up for FOBT recipients)
FLU Only FLU + FOBT
(N=268) (N= 246)
Up-to-Date Before Flu 52.9% 54.5%
Season
Up-to-Date After Flu Season 57.3% 84.3%
Change: (pImproving Colorectal Cancer
Screening Rates
Make CRC Screening a
Practice Priority and
Implement Evidence-Based
Interventions to Improve
Screening Rates“Action Plan” Toolkit Version This 8 page guide introduces clinicians and staff to concepts and tools provided in the full Toolkit Contains links to the full Toolkit, tools and resources Not colorectal-specific; practical, action-oriented assistance that can be used in the office to improve screening rates for multiple cancer sites (colorectal, breast and cervical) Available at http://nccrt.org/about/provider-education/crc-clinician-guide/
Communication
Clinician Reminder Systems Are
Essential!!
Chart Prompts
Problem lists
Screening schedules
Integrated summaries
Alerts – “Flags” placed in chart
Follow-Up Reminders
Tickler System
Logs and Tracking
Electronic Reminder SystemsColorectal Cancer Screening Uptake among Patients Receiving Usual Care in the Systems of Support to Increase Colorectal Cancer Screening Trial, by Exposure to a Patient-Centered Medical Home Patients in PCMHs 8 months or longer were 29% more likely to receive CRC screening than patients with fewer months in the PCMH
What is State of the Art Colorectal
Cancer Screening?
• Take and regularly update family history
– Include maternal and paternal sides for 3 generations
• Counsel your patients about signs and symptoms
of colorectal cancer
• Follow ACS or USPSTF guidelines, with particular
attention to adherence
• Offer your patients colonoscopy AND a high
sensitivity FOBT, preferably FIT
• Identify a screening services with
gastroenterologists who track their performancewww.cancer.org/colonmd www.cancer.org/professionals
High Quality Stool Testing
Clinicians Reference: FOBT
One page document designed
to educate clinicians about
important elements of colorectal
cancer screening using fecal
occult blood tests (FOBT).
Provides state-of-the-science
information about guaiac and
immunochemical FOBT, test
performance and
characteristics of high quality
screening programs.
Available at
www.cancer.org/colonmdNCCRT Tools, Resources and Publications
Available at:
nccrt.orgwww.nccrt.org
http://www.cdc.gov/cancer/colorectal/quality/index.htm
Thank you
Colorectal Cancer Screening
Initiatives
Joseph Mastalski, Manager, Quality
Improvement
1 | DATE| PRESENTED BY:HEDIS Measure
• Looks at the percentage of Medicare
members who are up to date with
screening
• Target Population
– Men and women
– Ages 50-75 years
– No history of colorectal cancer or total
colectomy
76 | DATE | PRESENTED BY:HEDIS Measure
• There are currently 5 acceptable tests for
screening:
– Fecal Occult Blood Test (FOBT) – Every year
– Flexible Sigmoidoscopy – Every 5 years
– Colonoscopy – Every 10 years
– CT Colonography* - Every 5 years
– FIT-DNA Test – Every 3 years
*CT Colonography is not currently covered by Gateway Health
77 | DATE | PRESENTED BY:Member Outreach and Education
• Interactive Voice Response (IVR)/ Email/ SMS
campaigns focused around education,
screening reminders and appointment
scheduling
• Cobranded letter with the American Cancer
Society
• Social media posts and newsletter articles
• Annual iFOBT campaign
78 | DATE | PRESENTED BY:Provider Initiatives
• Practice reference guide with HEDIS
specifications and helpful tips
• Clinical Transformation Consultant
support
• Gateway to Practitioner Excellence
(GPE®) provider incentive
79 | DATE | PRESENTED BY:2017 GPE® Program*
• Follows the HEDIS specification:
– Members ages 50-75 years of age who receive an
appropriate screening
– No history of colorectal cancer or total colectomy
• $10 per member per year for submission of a
CPT/HCPCS code for screening
– The CPT/HCPCS codes do not need to be submitted
by the PCP. Credit is given for getting the member
screened.
*2018 program is currently being developed
80 | DATE | PRESENTED BY:Applicable Codes for GPE®
Definition CPT® Category I HCPCS
G0105, G0121
Colonoscopy
Flexible
G0104
Sigmoidoscopy
FOBT 82270, 82274 G0328
FIT-DNA Test 81528 G0464
81 | DATE | PRESENTED BY:Learning and Earning with Gateway
Professional Education CME/CEU Webinar Series
To receive CME/CEU credit for today’s webinar:
• Call xxx-xxx-xxxx from the cell phone number you provided when you enrolled
in the webinar series
• Enter code: **code would have been provided at time of live webinar**
• You MUST call by the end of the day today to receive credit!
• Next webinar: April 4, 2018 HPV and Cervical Cancer
• Forgot to enroll? Enroll today to get CME credit for attending our next webinar
at https://www.surveymonkey.com/r/NZJYDF7
• Questions? Email us at ProviderEngagementTeam@GatewayHealthPlan.com
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for
Continuing Medical Education (ACCME) through the joint providership of Allegheny General Hospital and Gateway Health Plan. Allegheny
General Hospital is accredited by the ACCME to provide continuing medical education for physicians.
Allegheny General Hospital designates this live webinar activity for a maximum of 1.0 AMA PRA Category 1 CreditTM. Physicians should claim only
the credit commensurate with the extent of their participation in the activity.
82Slides will be posted at
www.gatewayhealthplan.com/provider/provider-resources/educational-tools
(CME credit only for enrolled participants in live webinar)
83You can also read
