Colorectal Cancer A Preventable Burden Citywide Colorectal Cancer

Colorectal Cancer A Preventable Burden Citywide Colorectal Cancer Control Coalition Ambassador Program

NYC Coalition Mission “To increase awareness & screening for colorectal cancer & adenomatous polyps in NYC men and women in order to reduce the incidence & mortality of this disease”

C 5 Ambassadors Program: Goals To educate health care providers: 1. CRC as a public health problem 2. Effectiveness of CRC screening 3. What are the current guidelines 4. Recommendations of the NYC DOHMH

There Are Major Health Disparities of Colorectal Cancer in the U. S Incidence Rate* Mortality Rate* African American 58. 3 27. 7 Caucasian 52. 7 21. 3 Hispanic-American 35. 7 13. 1 African-American 45. 2 19. 9 Caucasian 36. 6 14. 3 Hispanic-American 23. 6 8. 3 Men Women U * Rates per 100, 000

Colorectal Cancer Risk Groups FAP 5% HNPCC-Hereditary Non-Polyposis Colorectal Cancer Winawer, Schottenfeld, Flehinger, JNCI 1991: 83: 243 -253. U

Hereditary Non-Polyposis Colorectal Cancer (HNPCC) Normal cecum 3/95 Cecal cecum 5/96

Amsterdam Criteria • Three or more relatives with Hereditary Non -Polyposis Colorectal Cancers – One a first degree relative of the other two • Two or more generations • One with cancer < age 50 Vasen et al. GE 1999; 116 (6): 1453

Lifetime Risks Of Colorectal Cancer Population risk of CRC 1 first-degree relative 1 FDR & 1 second-degree relative 1 relative aged under 45 2 first-degree relatives Autosomal dominant pedigree 1 in 20 1 in 17 1 in 12 1 in 10 1 in 6 1 in 2

Colorectal Cancer “The most preventable, but least prevented, cancer” U

The Best Screening Test Is THE ONE THAT GETS DONE.

Low Screening Rates • CRC has far lower screening rates than breast or cervical cancer U

Why Screen for Colon Cancer? • • • Proven effectiveness of screening Highly preventable cancer Well defined pre-malignant phase (adenoma) Adenomas take 5 -10 years to become cancer Molecular basis of carcinogenesis is the best understood of all solid tumors (molecular diagnostics) U

Barriers to CRC Screening • Lack of physician • Negative attitudes • Practical issues recommendation about the test: –Poor Patient Adherence –FOBT: • Lack of worrisome embarrassing, –Conflicts with symptoms distasteful work/family • Fear of the results commitments –Sigmoidoscopy / (need for further Colonoscopy: –Inconvenience pain, discomfort, testing) –Lack of interest injury –Cost

% Mortality Reduction Using Different Screening Methods 1000 Annual FOBT 33%* Colonoscopy Sigmoidoscopy Every 5 -10 years Every 10 †years 90% 30%* *Observed †Estimated U

Effectiveness of FOBT Prospective, randomized, controlled trials Duration Subjects (n) Frequency F/U duration (yrs) CRC mortality Reduction Mandel Hardcastle (USA) (UK) 1975 -92 1981 -95 46, 551 152, 850 annual/ biennial 13 7. 8 33%/21% 15% Kronborg (Denmark) 1985 -95 140, 000 biennial 10 18%

Colorectal Cancer Mortality Reduction By Sigmoidoscopy Colorectal Cancer Mortality Reduction Study Design Kaiser Permanente, USA Retrospective, Case Control 30% Selby, NEJM 1992 Univ. Wisconsin, USA Retrospective, Case Control 40% Newcomb, JNCI 1992 Reviewed in Colorectal Cancer Screening: Clinical Guidelines and Rationale. Winawer, Fletcher, et al. , Gastroenterology, Feb. 1997. Published

What Do You Find If You Perform Screening Colonoscopy on Average-risk Subjects? Lieberman 1 Setting VA; Multi-center No. Of subjects 3, 121 Male 96. 8% Age (mean) 62. 9 yrs Cancer 1. 0% Adenoma (any) 37. 0% Adenoma >1 cm 7. 9% Adenoma w/ HGD 1. 6% U Imperiale 2 Eli Lilly co 1, 994 58. 9% 59. 8 yrs 0. 6% ---1 2 N Engl J med 343: 162, 2000 N Engl J med 343: 169, 2000

15 -22 cancers are prevented or detected early per 1, 000 screening colonoscopies 1, 000 average-risk asymptomatic men and women aged 50 and older COLONOSCOPY 5% - 6% will have advanced adenomas ► 50 -60 advanced adenomas detected by screening 20% (10 -12) would have developed cancer over 20 years 0. 5% - 1% will have cancer ► 5 -10 cancers detected early by screening

Cost Effectiveness of Colon Cancer Screening vs. Other Measures Cost ($) per added year of life (x 1000) Colon Hypertension Screening* Mammography Cholesterol *Any colon screening The cost varies with the model used; this is a ballpark number Lieberman 2003.

National Polyp Study • • Randomized trial Surveillance intervals Surveillance methods Colorectal Cancer incidence • Adenoma-carcinoma model • 7 clinical centers • Memorial Sloan Kettering Coord. Center

Colorectal Cancer Incidence in NPS Following Colonoscopic Polypectomy (1418 pts ; 8401 person yrs)

Resources Less Intensive Surveillance Increased Resources for Screening

Alternative and Future Colorectal Cancer Screening Methods

Virtual Colonoscopy

Virtual Colonoscopy § § § § Prep Needed Air Discomfort No Biopsy No Polypectomy 50– 60% Need “Real Time” Colonoscopy Miss rate of small adenomas? Radiation

Stool DNA Testing

Stool DNA Testing Tail Pail Mail

Stool DNA Testing Cancer 1. 20/22 (91%) 2. 33/52 (64%) Advanced adenomas 9/11 (82%) 16/28 (57%) specificity: 26/28 (93%) 204/212 (96%) 1. Ahlquist et al. Gastroenterology 2000 2. Tagore et al. Clin colorectal cancer 2003

Breaking Down Barriers U

Successful Strategies in New York City • Systematic referral of all outpatients over age 50 • Electronic medical record prompts, preventive flow sheets, chartstickers or postcards to all patients over the age of 50 • Patient navigators • Direct endoscopy referral (DERs) to simplify process for increasing screening U

NYC Colorectal Cancer Screening Advisory Panel: Rationale • About 1, 500 NYC residents die annually from colorectal cancer • Most deaths are preventable • Colonoscopy preferred • Examines entire colon • Sensitive & Specific for adenomas and cancer • Provides screening, diagnosis, treatment • Sufficient Capacity in N. Y. C. • Preferred recommendation may reduce confusion • Other options are available (National Guidelines)

The Best Screening Test Is THE ONE THAT GETS DONE.

Adenomatous Polyp

Adenoma to Carcinoma Pathway Normal APC loss Adenoma K-ras mutation Chrom 18 loss Cancer p 53 loss Normal Hyper. Early Intermediate Late Cancer Epithelium proliferation Adenoma

US Rates of Colorectal Cancer Incidence (age 50+) SEER: 1993 -1997 U