1. Colorectal Cancer Paula M. Rechner M.D. War Memorial Hospital October 13, 2005

2. Goals Identify Colorectal Cancer as a serious health problem in the US Identify Colorectal Cancer as a serious health problem in the US Provide current guidelines Provide current guidelines Outline present day insurance coverage Outline present day insurance coverage Identify targets for prevention Identify targets for prevention Provide a rural surgeon’s perspective on colorectal cancer Provide a rural surgeon’s perspective on colorectal cancer

3. American Cancer Society Colorectal Cancer Facts & Figures – Special Edition 2005 145,290 new diagnoses expected in 2005 145,290 new diagnoses expected in 2005 Colon: 104,950 Colon: 104,950 Rectum: 40,3410 Rectum: 40,3410

4. American Cancer Society Colorectal Cancer Facts & Figures – Special Edition 2005 56,290 predicted deaths 56,290 predicted deaths 5 year localized survival rate: 90% 5 year localized survival rate: 90% Only 39% CRC found at this stage due to low screening rates Only 39% CRC found at this stage due to low screening rates 5 year survival with metastatic disease: 10% 5 year survival with metastatic disease: 10% 5 year overall survival rate: 63% 5 year overall survival rate: 63%

5. American Cancer Society Colorectal Cancer Facts & Figures – Special Edition 2005 5.6% OF Americans will develop CRC in their lives 5.6% OF Americans will develop CRC in their lives

6. American Cancer Society Colorectal Cancer Facts & Figures – Special Edition 2005 Third most common type of cancer Third most common type of cancer Second most common cause of cancer death Second most common cause of cancer death When men and women are considered separately CRC is the third most common cause of death in each sex When men and women are considered separately CRC is the third most common cause of death in each sex

7. American Cancer Society Colorectal Cancer Facts & Figures – Special Edition 2005 THE LEADING CAUSE OF CANCER DEATH AMONG NONSMOKING AMERICANS THE LEADING CAUSE OF CANCER DEATH AMONG NONSMOKING AMERICANS

8. U.S. Colorectal Cancer Incidence

9. U.S. Colorectal Cancer Mortality

10. Colorectal Cancer Risk Factors

11. MayoClinic.com Risk Factors for Colorectal Cancer Age: 90% are age > 50 Age: 90% are age > 50 Inflammatory Bowel Disease Inflammatory Bowel Disease

12. MayoClinic.com Risk Factors for Colorectal Cancer Family History Family History Hereditary Hereditary Shared environmental exposure to a carcinogen, diet or lifestyle Shared environmental exposure to a carcinogen, diet or lifestyle Familial Adenomatous Polyposis (FAP) Familial Adenomatous Polyposis (FAP) Cancer by age 40!!! Cancer by age 40!!! Hereditary Nonpolyposis Colorectal Cancer (HNPCC) Hereditary Nonpolyposis Colorectal Cancer (HNPCC) Ashkenazi Jews Ashkenazi Jews (Fewer than 10% of CRC are caused by inherited gene mutations)

13. MayoClinic.com (continued) Diet Diet Low fiber Low fiber High Fat High Fat High Calories High Calories Sedentary Lifestyle Sedentary Lifestyle Increased transit time Increased transit time Prolonged colonic exposure to carcinogens Prolonged colonic exposure to carcinogens Diabetes Diabetes 40% increased risk of developing colorectal cancer 40% increased risk of developing colorectal cancer

14. MayoClinic.com (continued) Smoking Smoking 1 in 10 fatal colon cancers may be caused by smoking 1 in 10 fatal colon cancers may be caused by smoking Once diagnosed with colorectal cancer, smokers face a 30 to 40 percent increased risk of dying of the disease Once diagnosed with colorectal cancer, smokers face a 30 to 40 percent increased risk of dying of the disease Alcohol Alcohol 1 drink per day for women 1 drink per day for women 2 drinks per day for males 2 drinks per day for males Personal History of Colorectal Cancer or Polyps Personal History of Colorectal Cancer or Polyps

15. American Cancer Society RR Family History (First Degree Relative) 1.8 IBD >10 years 1.5 Obesity (BMI>30) 1.5-2.0 Red Meat (>7/week vs. 1/mo) 1.5 Smoking (Current vs. never) 1.5 Alcohol (>4/week vs. none) 1.4 Physical Activity (>3hr/week vs. none) 0.6 Vegetable & Fruit consumption (>5 vs. 5 vs. <3/day)0.7

16. Colorectal Cancer Diagnosis and Screening

17. MayoClinic.com Screening and Diagnostic Procedures Digital Rectal Exam Digital Rectal Exam Limited exam Limited exam Likely to miss small polyps Likely to miss small polyps Fecal Occult Blood Test Fecal Occult Blood Test False Positive False Positive False Negative False Negative Flexible Sigmoidoscopy Flexible Sigmoidoscopy Limited Exam Limited Exam Minimal perforation risk Minimal perforation risk

18. MayoClinic.com Screening and Diagnostic Procedures (continued) Barium Enema Barium Enema “significantly high rate of missing important lesions…especially in the lower bowel and rectum” “significantly high rate of missing important lesions…especially in the lower bowel and rectum” Flexible sigmoidoscopy may be done in addition to BE Flexible sigmoidoscopy may be done in addition to BE Colonoscopy Colonoscopy “most sensitive test for colon cancer, rectal cancer and polyps” “most sensitive test for colon cancer, rectal cancer and polyps”

19. MayoClinic.com Screening and Diagnostic Procedures (continued) New Technologies New Technologies Virtual colonoscopy Virtual colonoscopy 2 minute CT scan 2 minute CT scan No prep – potential in the future No prep – potential in the future Less accurate than colonoscopy Less accurate than colonoscopy Diagnostic not therapeutic Diagnostic not therapeutic Not widely available Not widely available

20. American Cancer Society Screening and Surveillance At Age 50 for men and women at average risk At Age 50 for men and women at average risk FOBT or FIT every year-take home kit not DRE FOBT or FIT every year-take home kit not DRE 6 samples from 3 consecutive BM’s 6 samples from 3 consecutive BM’s Flexible Sigmoidoscopy every 5 years Flexible Sigmoidoscopy every 5 years FOBT or FIT every year + Flex Sig every 5 years FOBT or FIT every year + Flex Sig every 5 years Double-contrast barium enema every 5 years Double-contrast barium enema every 5 years Colonoscopy every 10 years Colonoscopy every 10 years

21. American Cancer Society Screening and Surveillance FOBT FOBT Reduces risk of death from CRC by 15-33% Reduces risk of death from CRC by 15-33% FOBT reduces incidence of CRC by 20% FOBT reduces incidence of CRC by 20% Detection of polyps Detection of polyps Early removal of polyps found thus preventing CRC Early removal of polyps found thus preventing CRC Flexible Sigmoidoscopy (FS) Flexible Sigmoidoscopy (FS) Reduces CRC mortality by 60% for cancers within reach of the instrument Reduces CRC mortality by 60% for cancers within reach of the instrument FS followed by Colonoscopy if a polyp is found identifies 70-80% of individuals with CRC FS followed by Colonoscopy if a polyp is found identifies 70-80% of individuals with CRC

22. American Cancer Society Screening and Surveillance FOBT and Flexible Sigmoidoscopy FOBT and Flexible Sigmoidoscopy One test would compensate for the limitations and may improve early detection One test would compensate for the limitations and may improve early detection Colonoscopy Colonoscopy National Polyp Study National Polyp Study 76-90% CRC Prevention 76-90% CRC Prevention Most sensitive test for CRC and Polyps Most sensitive test for CRC and Polyps Gold Standard for Screening Gold Standard for Screening Screening, Diagnostic and Therapeutic Screening, Diagnostic and Therapeutic

23. American Cancer Society Screening and Surveillance Barium Enema with Air Contrast Barium Enema with Air Contrast Less sensitive than colonoscopy Less sensitive than colonoscopy Colonoscopy is required if a polyp is found Colonoscopy is required if a polyp is found DNA based fecal screening and Virtual Colonoscopy DNA based fecal screening and Virtual Colonoscopy Are not recommended at this time Are not recommended at this time

24. Screening and Surveillance for Increased Risk Patients Increased Risk Age to begin Recommendationcomment 1 < 1cm adenoma 3-6 yrs after polypectomy colonoscopy If normal return to screening 1 > 1cm adenoma, multiple adenomas or adenomas with high grade dysplasia or villous changes 1cm Within 3 yrs of polypectomy colonoscopy If normal, repeat in 3 yrs, if then normal, return to screening Personal history of curative intent resection of CRC Within 1 year of cancer resection colonoscopy If normal, repeat in 3 yrs, if then normal repeat every 5 yrs Either CRC or adenomatous polyps in any first degree relative before age 60, or in 2 or more first degree relatives at any age (if not a hereditary syndrome) Age 40, or 10 years before the youngest case colonoscopy Every 5-10 years

25. Screening and Surveillance for High Risk Patients High Risk Age to begin RecommendationComment Family history of FAP Puberty Early surveillance, with endoscopy, +/- genetic testing If genetic testing +, colectomy Family history of HNPCC Age 21 Colonoscopy and counseling to consider genetic testing If genetic test +, or no testing, every 1-2 years until 40 then annually Chronic Ulcerative Colitis or Crohn’s disease 8 yrs after onset of pan colitis, or 12-15 yrs after onset of left-sided colitis Colonoscopy with biopsies for dysplasia Every 1-2 years

26. COST

27. American Cancer Society Screening and Surveillance Cost Range FOBT Less than $20 Flexible Sigmoidoscopy $150-$200 Double-contrast Barium Enema $300-$400 Colonoscopy$400+

28. Insurance Coverage

29. Medicare CRC screening covered since 1998 CRC screening covered since 1998 All recommended screening options covered since 2001 All recommended screening options covered since 2001 An initial preventative health care visit for all Medicare beneficiaries within 6 months of enrolling in Medicare covered since January 2005! An initial preventative health care visit for all Medicare beneficiaries within 6 months of enrolling in Medicare covered since January 2005!

30. Medicare Coverage FOBT-Once every 12 months FOBT-Once every 12 months Flexible Sigmoidoscopy-Once every 48 months Flexible Sigmoidoscopy-Once every 48 months Screening Colonscopy Screening Colonscopy High Risk-Once every 24 months High Risk-Once every 24 months Average risk-Once every 10 years, but not within 48 months of screening FS Average risk-Once every 10 years, but not within 48 months of screening FS Barium Enema-In place of FS only Barium Enema-In place of FS only High Risk-Every 24 months High Risk-Every 24 months Average Risk-Every 48 months Average Risk-Every 48 months

31. Medicare Coverage You pay nothing for FOBT You pay nothing for FOBT You pay 20% of the Medicare-approved amount after the yearly Part B deductible, for all other tests You pay 20% of the Medicare-approved amount after the yearly Part B deductible, for all other tests You pay 25% of the Medicare-approved amount after the yearly part deductible, if endoscopy is done in a hospital outpatient department You pay 25% of the Medicare-approved amount after the yearly part deductible, if endoscopy is done in a hospital outpatient department

32. Blue Cross Blue Shield Coverage MI 2005 Provider Type Provider Type M.D. or D.O. (otherwise not payable) M.D. or D.O. (otherwise not payable) Payable under Preventive coverage Payable under Preventive coverage Age > 50 Age > 50 1 Per 10 Years unless “high risk” 1 Per 10 Years unless “high risk”

33. “Average Risk” 25% of “average risk” adults at age 50 will have adenomatous polyps 25% of “average risk” adults at age 50 will have adenomatous polyps 70-80% of all Colorectal Cancers develop in “average risk” patients 70-80% of all Colorectal Cancers develop in “average risk” patients

34. Blue Cross Blue Shield High Risk Diagnosis 25-40 years old 25-40 years old V1005 V1005 V1006 V1006 V160 V160 V1000 V1000 V7641 V7641 V7650 V7650 V7651 V7651 1 per 2 years 1 per 2 years > 40 years old > 40 years old V1005 V1005 V1006 V1006 V160 V160 V1000 V1000 V7641 V7641 V7650 V7650 V7651 V7651 Any Appropriate Frequency Any Appropriate Frequency

35. V CODES V1005-Personal history of malignant neoplasm of the large intestine V1005-Personal history of malignant neoplasm of the large intestine V1006-Personal history of malignant neoplasm of the rectum V1006-Personal history of malignant neoplasm of the rectum V160-Family history of malignant neoplasm of the gastrointestinal tract V160-Family history of malignant neoplasm of the gastrointestinal tract V1000-Personal history of malignant neoplasm of the gastrointestinal tract V1000-Personal history of malignant neoplasm of the gastrointestinal tract V7641-Special screening for malignant neoplasms of the rectum V7641-Special screening for malignant neoplasms of the rectum V7650-Special screening for malignant neoplasms of the intestine V7650-Special screening for malignant neoplasms of the intestine V7651-Special screening for malignant neoplasms of the colon V7651-Special screening for malignant neoplasms of the colon

36. State of MI PPO & GM Hourly and Salary Benefits for High Risk 1 Per 10 years 1 Per 10 years Age >50 Age >50

37. Colorectal Cancer Screening Statistics

38. American Cancer Society Colorectal Cancer Facts & Figures – Special Edition 2005 Less than 50% of people aged 50 or older have had a recent colonoscopy!!!! Less than 50% of people aged 50 or older have had a recent colonoscopy!!!!

39. American Cancer Society Populations associated with even less screening Age 50-64 Age 50-64 Non-white race Non-white race Fewer years of education Fewer years of education Lack of health insurance Lack of health insurance Immigration to the US < 10 years Immigration to the US < 10 years

40. American Cancer Society Overall US Population FOBT 17.3 % Endoscopy 30 % FOBT/Endoscopy39.4% Any screening Less than 50 %

41. American Cancer Society Michigan Residents Age 50 and Older White Non-Hispanic ~53% screened White Non-Hispanic ~53% screened Ranked 12 th in the Nation Ranked 12 th in the Nation African American Non-Hispanic ~57% screened African American Non-Hispanic ~57% screened Ranked 5 th in the Nation Ranked 5 th in the Nation

42. American Cancer Society Barriers to CRC Screening Health Care Providers Health Care Providers Communication with patients Communication with patients Several studies show patients are more likely to be screened if it is recommended to them Several studies show patients are more likely to be screened if it is recommended to them Attitudes and Beliefs Attitudes and Beliefs Effectiveness of screening Effectiveness of screening Familiarity with screening guidelines Familiarity with screening guidelines Perception of patient preference and adherence Perception of patient preference and adherence Lack of training to perform tests Lack of training to perform tests Lack of adequate reminder systems within their practices Lack of adequate reminder systems within their practices

43. Barriers to CRC Screening American Cancer Society Health Insurance Health Insurance If patient has any If patient has any If benefits include screening If benefits include screening Highly variable Highly variable

44. Barriers to CRC Screening American Cancer Society Patients Patients “Too busy” “Too busy” “Lack of physician recommendation” “Lack of physician recommendation” “Inconvenience” “Inconvenience” “Lack of interest” “Lack of interest” “Cost” “Cost” “Embarrassment” “Embarrassment” “unpleasantness of the test” “unpleasantness of the test” Unaware of benefits Unaware of benefits Lack understanding of importance of screening Lack understanding of importance of screening

45. Strategies to Increase Utilization of CRC Screening Physician office and health systems Physician office and health systems Computer reminder systems Computer reminder systems Identify eligible patients for screening Identify eligible patients for screening Organized support for referrals and follow up Organized support for referrals and follow up Health Insurance Health Insurance Only 9 of 29 states, where CRC screening is under 50%, have passed legislation to require CRC screening!!!!!! Only 9 of 29 states, where CRC screening is under 50%, have passed legislation to require CRC screening!!!!!! 16 states and D.C. have such legislation 16 states and D.C. have such legislation Education for Patients and Providers Education for Patients and Providers

46. MayoClinic.com Prevention Eat 5 or more fruits and vegetables per day Eat 5 or more fruits and vegetables per day Limit fat Limit fat < 30% Fat in daily calories < 30% Fat in daily calories < 10% of saturated fats < 10% of saturated fats Vitamins and Minerals that prevent CRC Vitamins and Minerals that prevent CRC Calcium Calcium Pyridoxine (vitamin B-6) Pyridoxine (vitamin B-6) Vitamin B-9 Vitamin B-9 Magnesium Magnesium

47. Prevention of Colorectal Cancer

48. MayoClinic.com Prevention (continued) Limit alcohol consumption Limit alcohol consumption Stop smoking Stop smoking Exercise 30 minutes per day Exercise 30 minutes per day Hormone Replacement Therapy (HR) Hormone Replacement Therapy (HR) May reduce risk of CRC May reduce risk of CRC Women on HR who develop CRC may have a faster growing form of the disease Women on HR who develop CRC may have a faster growing form of the disease Consider taking statins for high cholesterol Consider taking statins for high cholesterol NEJM (5/26/2005)– reduced risk in patients taking statins for five years or more NEJM (5/26/2005)– reduced risk in patients taking statins for five years or more

49. American Cancer Society Aspirin and aspirin like drugs Aspirin and aspirin like drugs May lower the risk of colorectal cancer May lower the risk of colorectal cancer ACS does not encourage NSAIDs or Cox-2 inhibitors ACS does not encourage NSAIDs or Cox-2 inhibitors Gastric side effects Gastric side effects Heart attack Heart attack Consult with physician Consult with physician

50. NCI Colorectal Cancer Research Investment

51. The American Cancer Society Funded $49.6 million as of July 2004 Funded $49.6 million as of July 2004 90 colon cancer-related grants 90 colon cancer-related grants Survey’s public knowledge, attitudes and practices Survey’s public knowledge, attitudes and practices Education Education www.cancer.org www.cancer.org www.cancer.org 1-800-ACS-2345 1-800-ACS-2345 National colon cancer public awareness campaign National colon cancer public awareness campaign

52. Michigan Legislation 2004 Screening law requires insurers to offer coverage but does not assure coverage or there are no state requirements for coverage Screening law requires insurers to offer coverage but does not assure coverage or there are no state requirements for coverage

53. Surgical Plan

54. Surgical Management Polyp Adenoma <10 Polypectomy 10-100 Partial Colectomy With Ileorectal anastamosis >100 Total Colectomy With Ileal Pouch Carcinoma Staging

55. Surgical Management Carcinoma Locally Confined Segmental Resection Liver Metastasis Wedge resection Of Metastasis Chemotherapy +/- Radiation Spread to Adjacent Organs En bloc Resection Chemotherapy +/- Radiation Diffuse Disease Diverting Colostomy Chemotherapy +/- Radiation

56. A Rural Surgeon’s Perspective Benefit of providing both screening and therapy for Colorectal Cancer Benefit of providing both screening and therapy for Colorectal Cancer Continuity of Patient Care Continuity of Patient Care Family Education Family Education Long Term Follow-up for surveillance Long Term Follow-up for surveillance

57. Questions?