1. 1234 “FIT” IT IN! Make time to ensure your patients get screened for colon cancer

2. An education program to help increase your screening percentage to using a blended strategy of FIT and colonoscopy.

3. Pre Test Time!

4. Our Challenge – Colon cancer is the leading cancer killer among non- smoking men and women, despite being a highly preventable disease – As of 2013, Kentucky is ranked #1 in incidence rate in the nation.

5. Our Mission and Work – Eliminate preventable colon cancer death and suffering by increasing screening rates through education, advocacy, health systems improvement, and survivor support.

6. Our Impact – Kentucky has improved from 49 th state for screening rates to 20 th in the last decade – Kentucky’s colon cancer mortality rate has decreased by over 28% in the last several years – Advanced Cancer Diagnosis fallen from 75% to 48% over the last decade

7. A National picture of colon screenings in CHC’s

8. What is colon cancer? Colon cancer is cancer that occurs in the colon or rectum. Colon cancer begins when cells that are not normal grow inside the colon or rectum.

9. German immigrant family, Pennsylvania in the early 1700s. Movements of family from Pennsylvania through North Carolina, Alabama, Kentucky, Missouri, Iowa, Nebraska, Utah, Texas, and California Incomplete penetrance and variable expressivity Gene incidence may be much higher “Founders genes” aka Lynch syndrome

10. Incidence and mortality trends

11. Relationship between Areas with High Arsenic Levels and High Colorectal Cancer Incidence Rates in Kentucky Arsenic and colorectal cancer incidence rates. (Top) Arsenic content and coal field locations in Kentucky; (Bottom) Incidence of colorectal cancer in the Appalachian versus Non-Appalachian region of Kentucky.

12. What are the symptoms There usually are NO SYMPTOMS of colon polyps or cancer at first. Remember, the best time to detect colon polyps or cancer is before symptoms develop

13. When the disease is more advanced, common symptoms include: – Blood in the stool – Change in bowel habits and frequency – Persistent abdominal pain – Unexplained weight loss – Feeling run down or tired – Frequently vomiting – Unexplained Anemia.

14. What is screening? Screening means looking for signs of disease before symptoms appear. There are several tests that screen for colon polyps or cancer.

15. Colon Polyp to Cancer takes about 10- 15 years Colon Polyp to Cancer takes about 10- 15 years

16. Why screen for colon cancer? Colon cancer is the second leading cause of cancer deaths in the US when men and women are combined, yet it can often be prevented or detected at an early stage. The healthcare landscape is changing and barriers to colorectal cancer screening are breaking down. 203,000 lives can be saved nationally if 80% x 2018 SCREENING SAVES LIFES

17. Why screen for Colon Cancer? Insurance reporting requirements include your practices screening rates. All clinicians that accept reimbursement from private insurance are affected. Colon cancer was added to HEIDES in 2003 and reporting started in 2006. SCREENING SAVES LIFES

18. What are some other risk factors? Increased risk with: – Personal history – Family history – Behavioral risks Individuals with these risk factors may require earlier and more intensive screening

19. SUMMARY OF COLON CANCER SCREENING GUIDELINES

20. The U.S. Preventive Services Task Force (USPSTF) recommends screening for colon cancer using high-sensitivity fecal occult blood testing, sigmoidoscopy, or colonoscopy beginning at age 50 years and continuing until age 75 years. People at higher risk of developing colon cancer should begin screening at a younger age, and may need to be tested more frequently. The decision to be screened after age 75 should be made on an individual basis. If you are older than 75, ask your doctor if you should be screened. Colorectal Cancer Screening Guidelines

21. Screening Modalities We are discussing the success in using a Blended Strategy of FIT and Colonoscopy in the Community Health Centers.

22. “FIT” describes fecal tests that measure hemoglobin in feces by immunochemical methodology. Advantages of FIT over standard gFOBT screening tests include: Rabeneck L, Rumble RB, Thompson F, Can J Gastroenterol. 2012;26:131-47 Allison JE, Fraser CF, Halloran SP et al Gastroenterology 2012;142:422–431 FIT Education 101

23. FIT TESTING fecal immunochemical test Detects human globin  more specific for human blood than GUAIC Detects human globin  more specific for human blood than GUAIC Less affected by dietary considerations Less affected by dietary considerations – GUAIAC False-Positives: red meat, cruciferous veggies, some fruits – False-Negatives: high-dose Vitamin C 1 sample required 1 sample required – FOBT – 3 consecutive stool samples More expensive More expensive Sensitivity for CRC ~80% (GUAIAC ~65%) Sensitivity for CRC ~80% (GUAIAC ~65%) Sensitivity for Adv. Adenomas ~30% (GUAIAC ~10%) Sensitivity for Adv. Adenomas ~30% (GUAIAC ~10%)

24. Fit Facts Who What When Where Why

25. Who Average risk patients at age 50 The American Cancer Society recommends African Americans screen at 45

26. What A stool test done in the patient’s home at their convenience.

27. When Once a year. Start the conversation at age 40 Annual Colon Screening

28. Where In the privacy of their own home

29. Why Why: non-invasive, convenient, option

30. Screening and Surveillance for Colon Cancer Colonoscopy remains the dominant Colon Cancer screening strategy in the U.S. but is less effective at preventing right sided Colon Cancer than previously thought FIT has emerged as an effective low cost alternative to colonoscopy and is considered by some an equivalent or superior approach to screening as compared to colonoscopy Kahi CJ, Anderson JC, Rex DK GIE 2013 77:335-350

31. STEPS TO INCREASE COLON CANCER SCREENING IN YOUR PRACTICE

32. 80% by 2018 Primary care providers working together to save lives. As a primary care provider, here are five things you can do to be a part of 80% by 2018: 1.Physician Recommendation 2.Measure your performance 3.Develop Evidence based systems and options 4.Promote Screening options: FIT or colonoscopy 5. Reassure patients regarding insurance

33. EVIDENCE BASED PRACTICES (USING THE FOUR ESSENTIAL STRATEGIES) 1.Make a Recommendation Per American Cancer Society Guidelines

34. Evidence-Based Practice Changes More screening doesn’t have to mean more work for you. Rely on your staff to alert you to patients who are due for screening and follow up. Have standing protocols in place to make sure every age – and risk eligible – patient gets a recommendation when they are due for screening.

35. EVIDENCE BASED PRACTICES (USING THE FOUR ESSENTIAL STRATEGIES) 2. Develop a Screening Policy Per American Cancer Society Guidelines

36. Design Your Practice’s Screening Strategy Blended strategy There is no evidence from randomized controlled trials that one screening method is “best.” Based on adherence for stool testing and colonoscopy, years of life saved through an annual high-quality stool-blood screening program are COMPARABLE to a high quality colonoscopy-based screening program when positive stool tests are followed by colonoscopy. The best test is the one that gets done!

37. EVIDENCE BASED PRACTICES (USING THE FOUR ESSENTIAL STRATEGIES) 3.Be Persistent with Reminders Per American Cancer Society Guidelines

38. Evidence-Based Practice Changes More screening doesn’t have to mean more work for you. Set up reminder systems, patients need to hear about screening multiple times. – EHR – Post card reminders – Chart prompts – Post-it notes – Phone calls – “Are You At Risk” Brochures in waiting rooms – Posters in triage rooms

39. EVIDENCE BASED PRACTICES (USING THE FOUR ESSENTIAL STRATEGIES) 4. Measure Practice Progress Per American Cancer Society Guidelines

40. Measure the Colon Cancer Screening Rate Set goals to get screening rates up. Recognize providers in your practice who are meeting screening goals. Share advice with those who can be doing better. Tools are available to help your staff understand how to accurately measure screening rates. Involve your staff to make screening more effective.

41. Recommend Colon Cancer Screening to Your Patients Surveys show that 90% of people who reported a physician recommendation for colon cancer testing were screened – Only 17% of those who reported that they did not have a provider recommendation got screened 90% SCREENED

42. Colon Cancer Screenings are Covered Affordability is a very real barrier for some patients, but most insurance companies are now required to cover colon cancer screening tests – Usually with no out-of-pocket costs for your patients. Know the resources and support available in your area to recommend the best option for screening and appropriate follow-up. KCCSP – uninsured population SB 61 – no cost sharing for any screening strategy

43. Screening Program Resources Kentucky Colon Cancer Screening Program 1) Barren River District Health Dept. 2) Boyle County Health Dept. 3) Christian County Health Dept. 4) Floyd County Health Dept. 5) Jessamine County Health Dept. 6) KY River District Health Dept. 7) Knox County Health Dept. 8) Lake Cumberland District Health Dept. 9) Lexington-Fayette County Health Dept. 10) Lawrence County Health Dept. 11) Louisville Metro Dept. for Public Health & Wellness 9) Laurel County Health Dept. 10) Montgomery County Health Dept. 11) Purchase District Health Dept. 12) Wedco District Health Dept. Surgery on Sunday 1.Louisville 2.Lexington

44. Resources for Providers www.kycancerprogram.org Materials: Brochures, posters, videos, … Fighters’ Fund: Grant for patients in care www.cancer.org/colonmd kickingButt.org http://chfs.ky.gov/dph/coloncancer.htm Nccrt.org Colon Cancer Prevention Project – multiple resources

45. QUESTIONS?

46. Posttest Time

47. “FIT” IT IN! Make time to ensure your patients get screened for colon cancer Thanks!