Alaska Health Summit 2005

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Alaska Health Summit 2005 Powered By Docstoc
					Colorectal Cancer and
      Screening
  in Alaska Natives
          November 2005

        Frank D. Sacco, MD
           Chief, Surgery
    Alaska Native Medical Center
          Objectives
1. Burden of Colorectal Cancer (CRC)
    among Alaska Natives

2. CRC Screening and Screening Barriers
   among Alaska Natives

3. Strategies to Improve CRC Screening

4. Conclusion
Diagram of the Colon and Rectum
                     Splenic
                     flexure
                 Screening =
     Prevention + Early Detection
   Prevention    polyp removal
 decreased incidence (80% reduction in CR
    incidence with flex sig program)
   Early detection    earlier stage
 decreased mortality ( 60% reduction in CR
    mortality with flex sig program)
Natural History
              Advanced
              bleeding
Polyp          cancer
 Natural History of Colon Polyps
 226 patients with polyps > 1cm identified on
  BE during preendoscopy era at the Mayo Clinic.
 Risk of Cancer at the polyp site.

         5yrs 2.5%
        10yrs 8%
        20yrs 24%
There are also number of studies show evidence of
  regression of polyps especially those 5mm-1cm.
     The Burden of
    Colorectal Cancer
Among Alaska Native People
              Leading Causes of Death
                         Among Alaska Natives
                                         1998-2002
                                                       Cancer
                                                        20%
                           All Other
                              27%




         Chronic Liver
                                                                 Heart Disease
             2%
                                                                     15%
        Homicide
           3%
Pneumonia & Influenza
        2%                  COPD
                             5%
                           Cerebrovascular           Accidents
                                 5%        Suicide     15%
                                             6%

           OANHR/CHS/ANTHC – updated 10/05
             Five Leading Cancers
                           Incidence 1999-2003

Alaska Natives                         US Whites
1.      Colon/Rectum                   1. Breast

                                       2. Prostate
2.      Lung
                                       3. Lung
3.      Breast
4.      Prostate                       4.   Colon/Rectum
5.      Stomach                        5.   Bladder



     OANHR/CHS/ANTHC – updated 10/05
                                      Cancer Mortality
                                       Gastrointestinal Sites
                                  Alaska Natives vs. US Whites,1998-2002
                    45

                                                  39.4
                    40

                    35

                    30
Rates per 100,000




                    25

                                        18               20
                    20
                                                                                               15.2
                    15

                          9.5                                                                         10.3
                    10
                                                                    5.7
                                4.2          4                            3.3
                    5
                                                                                   1.2   0.7
                    0
                         Esophagus     Stomach   Colorectal          Liver       Gallbladder   Pancreas
                                                  Alaska Natives   U.S. Whites




                    OANHR/CHS/ANTHC – updated 10/05
                     Average Annual Age-Adjusted Incidence Rates
                                              Colorectal Cancer
                                     Alaska Natives and US Races 1993-2002

                   120

                   110
                   100

                    90

                    80
Rate per 100,000




                    70

                    60

                    50

                    40

                    30

                    20

                    10
                     0

                          Alaska Native    US White   US Black   All AI/AN   Asian/PI




                         OANHR/CHS/ANTHC
Five Year Average Annual Age-Adjusted Cancer
     Incidence Rates for Colorectal Cancer
                           Alaska Native 1969-2003 and US White 1973-2002
                                                 Men
                     120



                     100



                     80
  Rate per 100,000




                     60



                     40



                     20



                      0
                            1969-1973   1974-1978   1979-1983         1984-1988     1989-1993    1994-1998   1999-2003
                                                      Alaska Native      US White     US Black




 OANHR/CHS/ANTHC
Five Year Average Annual Age-Adjusted Cancer
     Incidence Rates for Colorectal Cancer
                           Alaska Native 1969-2003 and US White 1973-2002
                                               Women
                     120



                     100



                     80
  Rate per 100,000




                     60



                     40



                     20



                      0
                            1969-1973   1974-1978   1979-1983         1984-1988     1989-1993    1994-1998   1999-2003
                                                      Alaska Native      US White     US Black




 OANHR/CHS/ANTHC
                          Stage at Diagnosis
                                Colorectal Cancer
                          Alaska Native and US White 1993-2002
          50



          40



          30
Percent




          20



          10



          0
                in situ       Localized       Regional           Distant   Unstaged
                                          AK Native   US White




           OANHR/CHS/ANTHC
 CRC Screening and
  Screening Barriers
Among Alaska Natives
             The Problem
   Low CRC screening rates
   Lack of patient awareness
   Need for patient travel
   Lack of screening capacity / resources
   Providing colonoscopy for everyone not
    feasible option
   Provider confusion re: recommendations
Current CRC Screening Rates
  Compared to 2010 Goals
                        100
                         90
                         80
   % persons screened




                         70
                                                              Healthy Alaskans
                         60
                         50                                   Healthy People

                         40                      37%
                         30                       US
                                   9-19%
                         20
                                   AN/AI
                         10
                          0         GPRA 2004   NHIS - 1998



NOTE:                         ASU (1998 10.4%) vs YK SU (1998 8.0%)
       Colon Cancer Screening
    Recommendations- average risk
   Colonoscopy every 10 years.
   Flex sigmoidoscopy every 5 years with or
    without yearly FOBT.
   Double Contrast Barium Enema with or without
    flexible sigmoidoscopy.
   FOBT every year.
        ANMC Recommendations
          for CRC Screening
   For average risk - 50 yr or older:
       Flex sig q 5years or
       Colonoscopy q 7-10yrs.
   For increased risk
       Colonoscopy q 5yrs at age 50 or 10 years before the age of
        the index case
   Comment on FOBT:
       Not recommended in Alaska Natives because of very high
        false positives and a significant percentage of false negatives.
   Comment on DCBE:
       Not recommended to add to flex sig but is listed as an option
        on national recommendations.
    Two step program for average risk
                patients
   Imperiale NEJM Flex sig with biopsy of all
    polyps , colonscopy for adenomatous changes
    on biopsy or for polyps> 1cm.
   Results 1031 patients
       4 patients with proximal polyps > 1cm or
    cancer were “missed”
What is missed by doing flex sigs on
      averaage risk patients?
   Meta analysis 2-5% of patients will have
    proximal lesions that would be missed.
   Proximal lesions –polyps >1cm, villous changes
    , dysplastic polyps, invasive cancer.
           Strategies using flexible
                sigmoidoscopy
   UK screening trial Single flex sig at age 55-64.
   40,674 pts screened ,colonoscopy for multiple
    adenomatous polyps or high risk lesions.
   140 cancers 62% dukes Stage A
   Australia Flex sig at 55-64
   14 cancers found , Increase in Dukes A lesions
    from 12% to 28%
    one cancer in a patient who had a negative flex
    sig
     Strategies to
Improve CRC Screening
 Among Alaska Natives
    Population needing Screening
   18,000+ Alaska Natives over 50.
   Approximately 500 living with a personal history
    of colorectal cancer.
   Rough estimate approximately 3000 with a
    family history.
   Approximately 3000 with history of
    adenomatous polyps.
            Screening Capacity
   ANMC approximately 1000 colonoscopies a
    year.
   Field capacity varies by location but we can do ~
    500/yr at regional .
      Current strategies to
     provide CRC screening
   Field visits by surgeons from ANMC
   Training of physicians to perform
    colonoscopy in rural hospitals
   In ASU, flexible sigmoidoscopy clinic in
    Primary Care Center
   Mid-level providing screening and
    surveillance colonoscopy
Issues with current strategies
   Field visits by surgeons from ANMC
        -> significant no-show rates; not enough visits to meet the need

   Training of physicians to perform colonoscopy in rural hospitals
        -> steep learning curve
        -> hi turnover as well as multiple other competing priorities;
        -> colonoscopies often done for diagnosis rather than screening

   Backlog of patients requiring surveillance, family history, or
    screening colonoscopy

   In ASU, flexible sigmoidoscopy clinic with non-MD provider
        -> working but still have ~½ eligible population unscreened

   Dedicated mid-level providing screening and surveillance
    colonoscopy
        -> working, but limited
                                                    RESULTS:
                Change in ASU Screening Rates
                                  from March, 2001 to December, 2003
                                        Historical data: ASU (1998 10.4%)
   15.8%
5000
                                                                                                                          48.2%
                                                                                                                     4506     4494
4500                                                                                      4156     4207
                                                                                                            4318
                                                               4105     4110     4093
                                                      4015
4000                                         3879
                  3589     3515     3554
         3501
3500
                                                                                                                                       Number
3000                                                                                                                                   Screened
2500                                                                                                                                   Eligible
                                                                                                                   2167     2166
                                                                      1907     1932     1970     2007     2064
                                                                                                                                       Patients
2000                                       1711     1786
                                                             1864


1500                                                                                                                                  Healthy
                                  956
1000
       553      614
                         696                                                                                                          People
500                                                                                                                                  2010 Goal
  0
                                                                                                                                       = 50%
       Mar- May- Jul- Nov- Mar- Jun- Sep- Oct- Dec- Jan- Apr- Jun- Sep- Dec-
        01   01   01   01   02   02   02   02   02   03   03   03   03   03

                                                                                           (# screened of 50 yrs and over in ASU)
 Screening Results in ASU
               asymptomatic,
              (asymptomatic, average risk)
               0.4%
      17.8%

                                             normal
                                             hyperplastic
   14%                                       diverticulosis
                             59%             adenomatous
                                             cancer
     8.0%



n = 1500      * 18.2% had adenomatous polyps or cancer
     Potential future strategies to
       provide CRC screening
   Program to train additional mid-levels for flexible
    sigmoidoscopy for clinics at remote sites

   Provide regionally-based mass CRC screening
    clinics with itinerant endoscopists

   ?Others
                 Conclusions
   There is a disparity in the burden of CRC
    among Alaska Natives
   CRC is preventable
   Screening rates are low among Alaska Natives
   Need to continue to work towards improving
    screening for all eligible Alaska Natives

				
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