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Crescent City GI Cancer Update, September 22-23, 2016
Presented byJohn D. McKee III, MD, FACP
� Overview challenges of CRC Prevention/Detection◦ Education
◦ Publicity
◦ Public policy
◦ Cost
� Compare, Contrast Methods◦ Stool tests
◦ Endoscopy
� Improving colonoscopyImproving colonoscopyImproving colonoscopyImproving colonoscopy
◦ Radiology
◦ Serology
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Zauber AG, NEJM 2012;366:687ACS CRC Roundtable 2015CDC: CRC by State 2016
� CRC Incidence 134,490
� Death 49,190
� Death: C’scope Q10 @ 50y -53%
� Screening rate 50-75 55%
� Medicare rate 64%
� Median age presentation 68
� Early CRC 5y survival 90%
� Mississippi early CRC <40%
ACG 80 by 2018
� Organizations endorsing >750
� 2030 Incidence -277,000
� 2030 Death -203,000
� Social impact◦ Experience
◦ Work force
◦ Family
� Shift of focus◦ Training of residents & fellows
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NFL Stadium Facts 2016
� Super dome expanded capacity Super dome expanded capacity Super dome expanded capacity Super dome expanded capacity 76,46876,46876,46876,468
� - Incidence 277,000/76,468= 3.62 X’s3.62 X’s3.62 X’s3.62 X’s
� - Death 203,000/76,468= 2.65 X’s2.65 X’s2.65 X’s2.65 X’s
� Physician referral
� Transient GI symptoms
� Relatives
� Acquaintances
� PSA’s
� Social media
� Employer◦ Benefits
� Health fairs
� Church & Civic
� News
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� Text Message from office manager:
� “Call now, HELP!”
� Joe is en route…
� “Can it wait?”
� Office Manager “No!”
� Summary:
� Joe’s screening C’scope benefit was denied!◦ Ros: Mentioned “loose stools after Mexican food”
◦ Fam Hx: Brother with polyps◦ C’scope: 4mm tubular adenoma removed
� $650.00 Co-pay
� Family vacation cancelled
� Joe wants to have a word with you
� Hold on! We’re about to cover public policy stuff…Hold on! We’re about to cover public policy stuff…Hold on! We’re about to cover public policy stuff…Hold on! We’re about to cover public policy stuff…
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Ransohoff DA, JAMA. 2016;315(23):2529-2531
� Multi modality◦ Colonoscopy Q 10 >50◦ Annual Fitt (+/- ) Flex Sig Q5-10◦ Annual Guaiac◦ Flex Sig Q 5/10◦ Fitt/DNA Cologuard Q3
� Sensitivity 92%� Specificity 73%
� Not recommended◦ CT colonography◦ Serum Sep9
� Sensitivity 48%
� Barium studies
Ransohoff DA, JAMA. 2016;315(23):2529-2531
� Average Risk Recommendations◦ Age 50-75
◦ Above 75� Considerations
� 10y life expectancy
� Prior history of screening?
� Age>75: Pitfalls of Colonoscopy>Benefit◦ Anxiety
◦ Prep◦ Sedation
◦ Bleeding ◦ Perforation
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� 10-12y◦ FAP yearly
� CRC Onset in young 1st degree relative ----10y10y10y10y◦ Routine
� IBD Pancolitis Onset + 8-12y (duration)◦ Q 1-2y
� IBD Left sided colitis Onset + 12-15y◦ Q1-2y
� 40y◦ PolypsPolypsPolypsPolyps or CRC in relatives age>50y
� 45y◦ African American *AGA recommendation
Ransohoff DA, JAMA. 2016;315(23):2529-2531
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Ransohoff DA, JAMA. 2016;315(23):2529-2531
Ransohoff DA, JAMA. 2016;315(23):2529-2531
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Ransohoff DA, JAMA. 2016;315(23):2529-2531
� “Cost sharing” vs. Screening Benefit (free)◦ Screening denials
� History reflects “other indication” for colonoscopy� Diarrhea
� Wt loss
� Change in bowel habits
� Any blood loss
� Positive screening test
� Solutions in practice� Documentation:
� “Sole indication for colonoscopy is preventative screening for CRC.”Sole indication for colonoscopy is preventative screening for CRC.”Sole indication for colonoscopy is preventative screening for CRC.”Sole indication for colonoscopy is preventative screening for CRC.”
� Appeals
� Legislation
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Congressional Record 2001
State Legislature Records California, Oregon & Kentucky
� Federal◦ Rep Ben Cardin: Screen for Life 2001
� Average risk: access granted
◦ ACA◦ Screen Act 2015
� State◦ California, Oregon and Kentucky
� Mississippi◦ Opposition to legislation
� Cost to insurance� Liability for inappropriate denial
◦ Support� Patient & family� Health care professionals
◦ Under utilization of covered benefit� 52% estimate
ACG Timeline Colonoscopy 2016
� Covered Average Risk for CRC 2001◦ 2002-10
� +10% utilization C’scope benefit
� 64% screened
◦ 2010-13
� Modest increase 3% screened
◦ 2013-15
� -7% incidence
� -3% death
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ACG Timeline Colonoscopy 2016
� 2000 Colonoscopy◦ $250 professional component
� 2000-2016 increase cost◦ Inflation
◦ EMR◦ Single use
◦ Compliance◦ Estimate 20%
� 2016 Colonoscopy◦ $200 professional component
� 20% drop �
� Increase % Screened◦ Younger age
◦ Age 45 at 15y interval?
� Decrease cost of screening
� Increase safety
� Increase quality
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� Hypothetical Perfect Stool Test (PST)◦ PST 100% sensitive & specific for TA polyps & CRC
◦ PST Cost 10% of Colonoscopy cost
◦ Colonoscopy improves: perfect detection & resection
◦ Comparison Colonoscopy Q10=X
◦ PST + PRN Colonoscopy= .1X + .3X = .4X
◦ PST + PRN Colonoscopy Cost 40%
◦ Economic impact
� Work place fewer lost days for patient & driver
� Decreased cost for better outcome
� Exfoliative stool tests◦ 1st Generation=Fitt/DNA
� Serologic Tests◦ 1st Generation=Sep9
� Chromosomal Genetic Tests� Imaging◦ Concerns� Cost
� Prep
� Incidental findings
� Sensitivity/specificity
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� Prep quality: Split preps
� Cecal intubation & withdrawal time
� ADR
� Sessile polyp detection/removal� Blue injectate, digital chromo, chromoendoscopy
� Complete polypectomies
� Complication rates
� Adherence to surveillance recommendations
� 0-1y◦ CRC, Piece meal polyps, Low resections for 2y
� 1-2y◦ CRC initial, IBD, Lynch, FAP
� 3y◦ 3-10 small adenomas; 10? FAP
◦ 1 large adenoma
� 5-10y◦ 1-2 small adenomas low grade dysplasia
� 10y◦ Hyperplastic polyps (non syndrome)
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Prep qualityPrep qualityPrep qualityPrep quality----Grading scales: Boston, Ottawa
-Split preps-Adequate prep (>85%)-Allows detection of polyp > 5mm-Can follow surveillance guidelines
Am J Gastroenterol 2015; 110:72–90
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� Score each segment p washing (0-3)
� Total (0-9)
� > 2 in each segment = adequate prep
Lai, GIE 2009
Adenomas > 5mm missedAdenomas > 5mm missedAdenomas > 5mm missedAdenomas > 5mm missedClark BT Gastro
Score 0>1Score 0>1Score 0>1Score 0>115.6% missed15.6% missed15.6% missed15.6% missed
0 1
2 3
Score 2>3Score 2>3Score 2>3Score 2>35.5% missed5.5% missed5.5% missed5.5% missed
◦ Higher ADR= lower interval cancers� Kaminski NEJM 2010;362:1795-8
◦ Longer Withdrawal Time � lower interval ca� Shaukat A Gastro 2015 149(4): 952-957
◦ Cecal Intubation rate >95%� lower interval ca� Baxter Gastro 2011:140:65
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� ADR range: 139 experienced GI physicians
� Highest ADR 52.5%
� Lowest ADR 7.4%
� Adjusted risk of interval cancer of 0.520.520.520.52
� With 1% increase in ADR:
◦ 3% 3% 3% 3% reduction in interval CRC risk
◦ 4% 4% 4% 4% reduction in CRC death
� Corley D. N Engl J Med 2014;370370370370:1298
� Immersion or “Swimming”� CO2◦ “Safety” concerns
� Scope Selection◦ Right tool for the job
� Adult� Pediatric� EGD� SB
� Maneuvers◦ Retroflexion R colon◦ Flat polyp technique
� Injection/Snare/Argon/Clips
� See something, say something...◦ The “Mary” standard
� “Right” Lateral Position???
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◦ Left Colon
� 33-56% reduction
� Lieberman DA Gastro 2012;143:844.
� Baxter N, J Clin Onco 2012;30:2664
◦ Right colon
� No reduction!
� Baxter NN, Ann Intern Med 2009, 150:1
� Singh H, Gastro 2010 139;1128
◦ Issues� Quality and completeness of exams
� Gastroenterologists vs. Non GI trained physicians
◦ Prep quality in the past sub optimal
� Split prep solution
◦ Lower detection of sessile serrated and flat polyps
� 70-80% located in right colon
◦ Rapid Adenoma to carcinoma sequence of some proximal polyps
� May account for 1/3 of interval cancers
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◦ ∆ pH, bacterial composition, apoptotic index
◦ Different pathways to carcinogenesis
� Traditional adenoma� carcinoma
� CIN (Chromosomal Instability)
� May represent only 50-70% cancers
� Pathophysiology profile◦ CIMP, MSI pathways
� 2-3x more likely
◦ Proximal colon
� 3x more likely to be in
◦ Smaller size
◦ Previous polypectomy sites
� 30%
Mojarad Gastro Hep Bed Ben 2013 6(3): 120–128.
Shaukat A Gastro 2015 149(4): 952-957
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� Digital/Chromo, injection with indigo carmine
◦ Right colon
◦ Mucus cap
◦ Pale Color
◦ Interruption of vascular pattern
◦ Non-descript pit pattern
◦ Bumpy surface contour
◦ Prominent superficial vessel
Tadepalli GIE 2011
Gancayco J, Aslanian Am J Gastro 2011
SSP NBI
Tadepalli GIE 2011
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Moss AJG 2013
◦ Prospective multicenter study
◦ 10% 10% 10% 10% of polyps were incompletely resected
� 1-2 cm polyps had 17% incomplete resection
� Sessile serrated polyps (30(30(30(30----50%) 50%) 50%) 50%) > adenomas
� Pohl H. Gastro 2013;144:74-80
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� Spending more time alone did not improve ADR� 7 min mandate
� Sawhney MS Gastro 2008;135:1892
◦ Technique training works
� 15 Mayo colonosocopists randomized: training
� Monthly feedback on ADR and withdrawal time
� ADR training ADR training ADR training ADR training groupgroupgroupgroup����increasedincreasedincreasedincreased 36363636----47%47%47%47%
� No change in control group� Coe SG Am J Gastro 2013;108:219-226
◦ Feedback and Internal benchmarking
� 11% Increase in mean ADR
� Keswani R Am J Gastroenterol. 2015;110(8):1134
◦ Training > Feedback only
� ADR Increase 8.2 v 1.1%
� Kaminski MF Gut 2015, Feb 10 epub
Goal
�colonoscopy effectiveness
IncentivesIncentivesIncentivesIncentives
-Requirements of payers, credentialing
“Gold Standard” Challenges“Gold Standard” Challenges“Gold Standard” Challenges“Gold Standard” Challenges
----Right colon: effectiveness reduced
-Colonoscopy miss ratesmiss ratesmiss ratesmiss rates: up to 17%
-tandem studies and CTCCTCCTCCTC
-adenomas > 10 mm
----Interval cancers
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� “Colonoscopists who cannot improve their detection rates to reach recommended ADRADRADRADRthresholds through education and technical measures should have their colonoscopy privileges removed, because current evidence indicates that lowlowlowlow----level detection endangers level detection endangers level detection endangers level detection endangers patientspatientspatientspatients. “
This recommendation holds for colonoscopists of all specialties.
Am J Gastroenterol 2015; 110:72–90
� Effective Efforts to Prevent, Detect and Cure◦ Need for increased patient participation
◦ Improved technology
◦ Improved safety
◦ Less “out of pocket “
� Future Protocols◦ More selective colonoscopy
What happened to Joe?
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� Conversation went well
� Appeal was approved
� Screening benefit covered
� While on vacation Joe decided to run for office to improve health care system
� His campaign manager expects your support
� So ends this Jambalaya session…
