Endoscopy in Gastrointestinal Oncology - Slide 15 - D. Fisher - Colorectal cancer screening
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Endoscopy in Gastrointestinal Oncology - Slide 15 - D. Fisher - Colorectal cancer screening
- 1. Colorectal Cancer Screening - Update Deborah A. Fisher, MD, MHS Associate Professor of Medicine Duke University Medical Center Durham, North Carolina, USA March 12, 2011
- 2. Duke, Durham, North Carolina, USA
- 7. Efficacy – Ideal conditions
- 8. Effectiveness –Real world Dina Goldstein www.dinagoldstein.com
- 14. Model of quality: cancer care continuum adapted from Zapka Cancer Epidemiol Biomarkers Prev 2003 Types of Care Outcomes Potential Failures during Processes of Care Risk Assessment Primary Prevention Detection -screening -diagnostic testing Diagnosis Treatment Surveillance Clinical status Functional status Quality of life Survival Failure to identify need for screen /counsel Failure in access to care Failure in primary prevention Failure to screen Failure to detect Failure during follow-up of abnormal result Failure during diagnostic evaluation Failure of treatment Failure to follow surveillance plan Failure of surveillance Failure in access to care
- 17. Screening hubris Horner http://seer.cancer.gov/
- 24. Right vs Left colon controversy Mandel 2000 1993 Atkin 2010 Brenner 2011 Singh 2010 Brenner 2010 Baxter 2009 Source M:0.88 NS W:0.99 NS M:0.44 W:0.44 M:0.59 W:0.71 Incidence 45985 Cohort Canada County Design N Outcome Overall Distal Proximal Canada Case-control 61752 Death 0.63 0.33 0.99 NS Germany Case-control 3287 Incidence (adv neoplasia) 0.52 0.33 1.05 NS Germany Case-control 3620 Incidence 0.23 0.16 0.44 UK RCT Flex Sig 170432 Incidence Death 0.77 0.69 0.64 0.98 NS US RCT FOBT 46,551 Incidence Death 0.80 0.67
- 28. EU guideline performance standards >300 300 Annual volume of colonoscopies per endoscopist >95% >90% Rate of cecal intubation >90% 85% Compliance with follow-up colonoscopy after + sigmoidoscopy >95% >90% ≤ 31 days from + test until referral for colonoscopy >95% 90% Referral for colonoscopy after + test >65% >45% Uptake rate >95% 95% Invitation coverage Desirable level Acceptable level Quality Indicator
- 31. Sample Selection Screening Colonoscopy N=3121 Polyps N=1680 No Polyps N=1441 Interval Colonoscopy N=302 Interval Neoplasia N=49 Interval Colonoscopy N=891 No Neoplasia N=362 No Neoplasia N=253 Interval Neoplasia N=529
- 35. ADR and interval cancer Cumulative hazard rates for interval CRC by endoscopist’s ADR
- 39. sunset
Notes de l'éditeur
- And they live happily forever after
- The patient comes in complaining of Index and you offer screening because they are over 50
- Our discussions of prevention and screening will be for AVERAGE risk patients. There are additional guidelines and considerations for patients with symptoms or individuals at increased risk for colorectal cancer Not all polyps carry a risk of future cancer. Adenomatous polyps are pre-cancer lesion – not all will become cancers, but they have the potential Hyperplastic polyps are not pre-cancer lesions and do not place an individual at higher future risk of cancer
- These (EU) aims fit into the model of quality for cancer care as a continuum, a process, and not a single event
- GI and VA faculty Most available screening option
- The shift from cancer death to cancer prevention is a fundamental redefining of what a screening test is meant to do. A set up for failure and liability VA is an example of population screening
- The shift from cancer death to cancer prevention is a fundamental redefining of what a screening test is meant to do. A set up for failure and liability VA is an example of population screening
- NEED to update with new data Add country Not all polyps carry a risk of future cancer. Adenomatous polyps are pre-cancer lesion – not all will become cancers, but they have the potential 1 in 20 will Could the lack of effectiveness (remember vs efficacy) in the right colon be overcome with optimal quality?? Are all observational studies and not necessarily of SCREENING colonoscopy
- The shift from cancer death to cancer prevention is a fundamental redefining of what a screening test is meant to do. A set up for failure and liability VA is an example of population screening
- More definitions
- Along the same lines of all the services that are recommended to be performed - many quality indicators are ratios of individuals receiving a recommended service - such as a screening test – to all the eligible individuals being measured. This is usually cross sectional with a different denominator at each measurement. Also a bench mark is chosen – what proportion is acceptable These are usually designed to address underuse of a service. There is not a consideration of duplicate testing among individuals or assessment of testing in individuals who are eligible. There is also concern that to meet the targets overuse or misuse may occur
- Along the same lines of all the services that are recommended to be performed - many quality indicators are ratios of individuals receiving a recommended service - such as a screening test – to all the eligible individuals being measured. This is usually cross sectional with a different denominator at each measurement. Also a bench mark is chosen – what proportion is acceptable These are usually designed to address underuse of a service. There is not a consideration of duplicate testing among individuals or assessment of testing in individuals who are eligible. There is also concern that to meet the targets overuse or misuse may occur
- 1171 had neoplasia in phase I 501 without neoplasia assigned to return at 5 years Total numbers (1193 at 5 years) – 93 advanced neoplasia, 485 adenomas In no polyps group, 41 adenomas, 7 advanced adenomas and 1 invasive cancer
- And even reminders
- And even reminders
- Maui, Hawaii