USPSTF Colorectal Cancer Screening Guidelines: What’s New? Appathurai Balamurugan, MD, DrPH, MPH State Chronic Disease Director Medical Director/Associate Director for Science Chronic Disease Branch/Center for Health Advancement Arkansas Department of Health & Clinical Assistant Professor Dept of Family and Preventive Medicine/ Dept of Epidemiology UAMS College of Medicine & Public Health Thank you Dr. Bates. Good Morning, March is Colon Cancer Awareness month. When Dr. Bates asked me to present at the Grand Rounds, I decided to talk about Colorectal cancer in Arkansas, and how at this day and age, a significant proportion of our population is not getting their preventive screenings for colon cancer and are found too late to do much about it. I am going to start my presentation with a news article published by USA Today a few months ago about the challenges for colorectal cancer screening in rural America especially here in Arkansas.

Overview 2016 USPSTF update Multiple recommendations Barriers to screening Next steps

Natural History of Colorectal Cancer Normal Colon Adenoma (pre-cancer) Early Intermediate Late Cancer Key Point Most CRC develops from noncancerous growth of adenomatous polyps in the colon and rectum The progression process is a generally stepwise histological sequence usually over a period of more than 10 years It is estimated that nearly 40% of Americans aged ≥50 years have adenomatous polyps Reference Amersi F, Agustin M, Ko CY. Colorectal cancer: epidemiology, risk factors, and health services. Clin Colon Rectal Surg. 2005;18(3):133-140. ~ 10 – 15 years Source: Amersi F et al. Clin Colon Rectal Surg. 2005;18(3):133-140; 2. Rozen P, Young G, Levin B, et al. Colorectal Cancer in Clinical Practice, Prevention, Early Detection and Management, Second Edition. CRC Press; 2006.

Genetic and Molecular Epidemiology of Colorectal Cancer Source: Adami H, Hunter D, Trichopoulos D. Textbook of Cancer Epidemiology. Chapter 9. Colorectal Cancer

Colorectal Cancer Screening Tests Sensitivity Specificity Cancer Polyp Invasive Tests Colonoscopy1 95% 90% Sigmoidoscopy1 ~50% (95% distal only) 92% CT Colonography2-4 96% 94% 86%-96% Non-invasive Tests Fecal Immunochemical test (FIT)1 70% 22% Stool DNA test 42% gFOBT (Hemoccult SENSA)1 24% 93% gFOBT (Hemoccult II)1 40% 12% 98% Key Point There are significant variations in performance (sensitivity and specificity) among different CRC screening tests, especially between invasive and non-invasive testing Source: 1. Zauber AG et al. Evaluating Test Strategies for Colorectal Cancer Screening; A Decision Analysis of Colorectal Cancer Screening for the US Preventative Services Task Force. Rockville (MD): Agency for Healthcare Research and Quality (US); 2009 Mar. (Evidence Syntheses, No. 65.2.); 2. Pickhardt PJ et al. Radiology. 2011;259(2):393-405; 3. Pickhardt PJ et al. N Engl J Med. 2003;349(23):2191-2200; 4. Johnson CD et al. N Engl J Med. 2008;359(12):1207-1217.

Characteristics of Colorectal Cancer Screening Strategies

Colon Cancer Screening Multiple recommendations!! U.S. Preventive Services Task Force (USPSTF) - 2016 update American College of Gastroenterology (ACG) American Cancer Society (ACS) U.S. Multi-Society Task Force (USMSTF)

USPSTF 2016 recommendations Population Recommendation Grade Adults aged 50 to 75 years The USPSTF recommends screening for colorectal cancer starting at age 50 years and continuing until age 75 years. The risks and benefits of different screening methods vary. A Adults aged 76 to 85 years The decision to screen for colorectal cancer in adults aged 76 to 85 years should be an individual one, taking into account the patient’s overall health and prior screening history. Adults in this age group who have never been screened for colorectal cancer are more likely to benefit. Screening would be most appropriate among adults who 1) are healthy enough to undergo treatment if colorectal cancer is detected and 2) do not have comorbid conditions that would significantly limit their life expectancy. C

Colon Cancer Screening USPSTF recommendations Screen adults 50 years and older. Continue until 75 years of among those with negative previous screening. Use FOBT, flexible sigmoidoscopy, or colonoscopy. Insufficient evidence that newer screening modalities improve health outcomes.

Colon Cancer Screening ACG recommendations Colonoscopy is the preferred modality. Alternative methods - FOBT every year; flexible sigmoidoscopy every five years; and combined yearly FOBT and flexible sigmoidoscopy every five years. Not recommended due to conflicting results – CT colonography and stool DNA

Colon Cancer Screening ACS recommendations Adults 50 years and older Screen with FOBT or a fecal immunochemical test every year; or a stool DNA test (no recommended interval). Screen with flexible sigmoidoscopy, double-contrast barium enema, or CT colonography every five years; or colonoscopy every 10 years.

Colon Cancer Screening USMSTF recommendations Begin at age 50, and end screening at a point where curative therapy would not be offered due to life- limiting co-morbidity Annual screening with high sensitivity guaiac based tests FOBT or FIT. Stool DNA test is an acceptable option. Screen with flexible sigmoidoscopy every 5 years, or colonoscopy every 10 years

So with all the conflicting recommendations, what is the clinician to do?

Barriers to Patient Compliance Specific to endoscopy Patient Reporting Key Point Barriers experienced by patients affect the uptake of CRC screening A survey was mailed to 660 patients aged 50–75 years posing an open-ended question about “the most important barrier” to CRC screening Responses to the open-ended survey question, answered by 74% of respondents, identified fear and the bowel preparation as the most important barriers to screening Three of the eleven top barriers were specific to endoscopy: bowel prep, pain, and fear of tube/procedure Only 5 (1.6%) responses specifically alluded to the failure of a physician to recommend screening Reference Jones RM, Devers KJ, Kuzel AJ, Woolf SH. Patient-reported barriers to colorectal cancer screening: a mixed-methods analysis. Am J Prev Med. 2010;38(5):508-516. Source: Jones RM et al. Am J Prev Med. 2010;38(5):508–516.

Colorectal Cancer Screening in Arkansas In 2012, only 57.0% of adults (50-75 years of age) received CRC screening in Arkansas. This equates to the fourth lowest screening rate in the nation. Source: State Cancer Profiles (Directly Estimated 2012 BRFSS Data) http://statecancerprofiles.cancer.gov/risk * 95% CI = 54.5-59.5

Source: Arkansas BRFSS, Health Statistics Branch, http://www.healthy.arkansas.gov/programsServices/healthStatistics/Brfss/Documents/Maps/2010/ColorectalTestBRFSS2010.pdf

Simplistic Screening Options Fecal Immunochemical Test Colonoscopy * In near future - Stool DNA test

In the End….. Want Find Prevent