Zachary Jarou, MD Candidate, Class of 2014 Family Medicine Clerkship, Spring 2013 Michigan State University College of Human Medicine

3. Prevalence
Reduction in Morbidity/Mortality
Sensitivity, Specificity, Reliability
Reasonable Cost
Low Risk from Screening Test

4. ~140k
new cases
each year
~50k
yearly
deaths
Lifetime risk of CRC diagnosis in US is 5% (1 in 20)

5. 10%
⅓
96%
adenomas progress
to colorectal cancer
of colorectal cancers develop
from adenomatous polyps
over a period of 10-15 years
of adults develop ≥ 1 polyps by
age 50, this increases with age Early detection & removal of
polyps eliminates the possibility
they become cancerous.
Routine screening could save ~19,000 lives per year

6. • Sensitivity (Sn)
– Hemoccult II < FIT ≤ Hemoccult SENSA
<FSIG < colonoscopy
• Specificity (Sp)
– Hemoccult SENSA < FIT ≈ Hemoccult II
<FSIG = colonoscopy
• Reliability
– FSIG, CTC, colonoscopy = operator-dependent (better
training/more experience improve Sn)
– quality standards/minimum volume requirements
USPSTF (2008)

7. • Colonoscopy has superior single-test accuracy compared to
other screening modalities
– FS+FOBT failed to identify 24% of advanced colonic neoplasia in
one study
– CTC or DCBE missed 2.1% 10+ mm polyps and miss rate as high
as 26% for smaller polyps
• Single FOBT by DRE will miss 95% of CRC
– Patients should take home 3 testing cards with 2 windows each,
use one card per day
– Cochrane review = 16% reduction in mortality (RR = 0.84, 95% CI
= 0.78-0.90)
– NNS = 1,176; 10k persons completing FOBT annually will prevent
8.5 deaths over 10 years
AFP (2008)

8. Regardless of screening method, the cost per life-year saved
($10-25k) compares favorably with other commonly
endorsed preventive health care interventions
Pignone et al. (2002), AFP (2008)
Median cost of colonoscopy is $1,736

9. • Bowel Perforation
– CTC = 0-6 per 10,000
– DCBE = 1 per 25,000
– FSIG = 1 per 25,000-50,000
– Colonoscopy = 1 per 2,000-3,000 (65% are sigmoid)
• Serious Complications
– deathor event requiring hospitalization (perforation,
major bleeding, diverticulitis, severe abdominal pain,
and cardiovascular events)
– FSIG = 3.4 per 10,000 procedures
– Colonoscopy = 25 per 10,000 procedures

10. • Conscious Sedation
– FSIG = most performed without (some discomfort)
– Colonoscopy = most performed with (cardiopulmonary
complications are ~½ of all adverse events); patients will
also miss a day of work and need a chaperone for
transportation
• Bowel Prep
– FSIG = less intensive (complete or partial)
– Colonoscopy = more intensive (complete required)
– DCBE/CTC* = complete required, if same day colonoscopy
not available a second bowel prep will be required

11. • False Reassurance from False-Negative Results
(gFOBT/FIT)
• Unnecessary Invasive Tests Due to False-
Positive Results (CTC)
– 10% of first-time CTcolonographiesfound to have
extracolonic abnormalities which may or may not
be clinically significant; potential for both benefit
& harm

12. • Radiation Exposure (CTC)
– radiation exposure reported to be 10 mSv perCTC
– at this level of exposure, 1 additional individual per
1000 would develop cancer in his or her lifetime
– cumulative radiation risk should be considered in the
context of the growinguse of other diagnostic and
screening tests that involve radiation exposure.
– improvements in CT colonography technology and
practice are lowering this radiation dose

14. Detect both adenomatous
polyps and cancers.

15. Detect primarily cancer.

16. • American Cancer Society/US Multi-society
Task Force on Colorectal Cancer/American
College of Radiology (ACS/USMSTF/ACR)
• Kaiser Permanente Care Management
Institute (KPCMI)
• US Preventive Services Task Force (USPSTF)

17. •
•

18. Modality USPSTF KPCMI ACS/USMSTF/ACR
Standard
gFOBT
✗
✗
✗
HS-gFOBT/FIT
✔
✔
✔
FSIG ✔ ✔
✔
Colonoscopy
✔ ✔ ✔
CTC ✗ ✗ ✔
sDNA ✗ ✗ ✔
DCBE
✗
✔

19. Modality
USPSTF
Recommended?
Standard
gFOBT
✗
HS-
gFOBT/FIT ✔
FSIG ✔
Colonoscopy
✔
CTC ✗
sDNA ✗
 between ages 50-75
years old, all are equally
effective in life-years
gained (assuming 100%
adherence)
 against routine screening
in adults 76-85 years old
 strategies differ in total
number of colonoscopies
required to gain similar
numbers of life-years

20. Modality
KPCMI
Recommended?
Standard
gFOBT
✗
HS-
gFOBT/FIT
✔
FSIG ✔
Colonoscopy ✔
CTC
✗
sDNA
✗
DCBE
✗
with history of
routine screening,
discontinue at 75
without history of
routine screening,
discontinue at 80
this study also
includes screening
recommendations for
those at increased
risk of CRC

21. Modality
ACS/USMSTF/ACR
Recommended?
Standard
gFOBT
✗
HS-
gFOBT/FIT ✔
FSIG
✔
Colonoscopy
✔
CTC
✔
✔
do not specify age to
discontinue
screening
if colonoscopy is
contraindicated due
to life-limiting co-
morbidity neither
CTC nor any other
screening tests are
appropriate

22. Modality USPSTF KPCMI ACS/USMSTF/ACR
Standard
gFOBT
✗
✗
✗
HS-gFOBT/FIT
✔
✔
✔
FSIG ✔ ✔
✔
Colonoscopy
✔ ✔ ✔
CTC ✗ ✗ ✔
sDNA ✗ ✗ ✔
DCBE
✗
✔

23. Follow the
USPSTF Guidelines.

24. African Americans have 20% higher incidence
and 45% higher mortality from CRC than whites

26. Effect of Affordable Care Act on
Colorectal Cancer Screening
All new private health plans are
required to cover CRC screening
tests with “A”/“B” USPSTF ratings
(effective beginning 2011)
Medicare preventive services will
have no out-of-pocket costs
& are exempt from deductibles,
even with polypectomy
(effective October 2010)

27. • Information from Your Family Doctor: Colon
Cancer Screening (2008).
http://www.aafp.org/afp/2008/1215/p1393.h
tml
• National Cancer Institute. Colorectal Cancer
Screening (PDQ).
http://www.cancer.gov/cancertopics/pdq/scre
ening/colorectal/Patient

28. • American Cancer Society/US Multisociety Task Force on Colorectal
Cancer/American College of Radiology (ACS/USMSTF/ACR).
Screening and surveillance for the early detection of colorectal
cancer and adenomatous polyps, 2008: a joint guideline from the
American Cancer Society, the US Multi-Society Task Force on
Colorectal Cancer, and the American College of Radiology. CA
Cancer J Clin 2008 May-Jun;58(3):130-60.
• Kaiser Permanente Care Management Institute (KPCMI).
Colorectal cancer screening clinical practice guideline. Oakland (CA):
Kaiser Permanente Care Management Institute; 2008 Dec. 190 p.
• US Preventive Services Task Force (USPSTF). Screening for
colorectal cancer: U.S. Preventive Services Task Force
recommendation statement. Ann Intern Med 2008 Nov
4;149(9):627-37.

29. • American Cancer Society. Colorectal Cancer Facts
& Figures 2011-2013.
• Pignoneet al (2002). Cost-effectiveness Analyses
of Colorectal Cancer Screening: A Systematic
Review for the U.S. Preventive Services Task
Force. AHRQ Pub. No. 03-519
• Wilkins T and ReynoldsPL (2008). Colorectal
Cancer: A Summary of the Evidence for Screening
and Prevention. American Family Physician.
http://www.aafp.org/afp/2008/1215/p1385.html