Breast and Colorectal Cancer Breast and Colorectal Cancer Screening in Family Care Clinic Screening in Family Care Clinic

and their Outcomesand their Outcomes

Presented by Presented by Liana Poghosyan, MDLiana Poghosyan, MDNe Moe, MDNe Moe, MD

May 19, 2008May 19, 2008

IntroductionIntroductionEpidemiology and Clinical ConsequencesEpidemiology and Clinical Consequences

Breast cancer is the most common non-skin malignancy among women in Breast cancer is the most common non-skin malignancy among women in the United States and second only to lung cancer as a cause of cancer-the United States and second only to lung cancer as a cause of cancer-related deathrelated death

In 2001, an estimated 192,200 new cases of breast cancer were diagnosed In 2001, an estimated 192,200 new cases of breast cancer were diagnosed in American women, and 40,200 women died of the diseasein American women, and 40,200 women died of the disease

The risk for developing breast cancer increases with age beginning in the The risk for developing breast cancer increases with age beginning in the fourth decade of lifefourth decade of life

The probability of developing invasive breast cancer over the next 10 years The probability of developing invasive breast cancer over the next 10 years is 0.4 percent for women aged 30-39, 1.5 percent for women aged 40-49, is 0.4 percent for women aged 30-39, 1.5 percent for women aged 40-49, 2.8 percent for women aged 50-59, and 3.6 percent for women aged 60-692.8 percent for women aged 50-59, and 3.6 percent for women aged 60-69

Individual factors other than age that increase the risk for developing Individual factors other than age that increase the risk for developing breast cancer include family history or a personal history of breast cancer, breast cancer include family history or a personal history of breast cancer, biopsy-confirmed atypical hyperplasia, and having a first child after age 30. biopsy-confirmed atypical hyperplasia, and having a first child after age 30.

Epidemiology and Clinical Epidemiology and Clinical ConsequencesConsequences

Colorectal cancer is the fourth most Colorectal cancer is the fourth most common cancer in the United States and common cancer in the United States and the third leading cause of cancer deaththe third leading cause of cancer death

A person at age 50 has about a 5 percent A person at age 50 has about a 5 percent lifetime risk of being diagnosed with lifetime risk of being diagnosed with colorectal cancer and a 2.5 percent colorectal cancer and a 2.5 percent chance of dying form it, the average chance of dying form it, the average patient dying of colorectal cancer loses 13 patient dying of colorectal cancer loses 13 years of lifeyears of life

BackgroundBackgroundFortunately, we can detect these fatal disease in Fortunately, we can detect these fatal disease in pre-cancerous stage, these cancers are pre-cancerous stage, these cancers are preventable. Therefore, cancer screenings are preventable. Therefore, cancer screenings are extremely important in all populationextremely important in all population

In order to know the performance of FCC in In order to know the performance of FCC in screening those two preventable cancers, we screening those two preventable cancers, we reviewed a total of 200 charts. According to reviewed a total of 200 charts. According to exclusion criteria, we needed to exclude 47 exclusion criteria, we needed to exclude 47 patients, therefore our data is based on 153 patients, therefore our data is based on 153 patients who came to our FCC within 5 years backpatients who came to our FCC within 5 years back

Material and MethodMaterial and Method Out of 153, there were 116 women and 37 menOut of 153, there were 116 women and 37 men

Among 116 women, 30 were under 50Among 116 women, 30 were under 50

No colorectal screening were done under 50 No colorectal screening were done under 50 years of age on both gendersyears of age on both genders

All females were older than 40, and we reviewed All females were older than 40, and we reviewed for Breast cancer screeningfor Breast cancer screening

Both for female and male older than 50, we Both for female and male older than 50, we reviewed only for Colorectal cancer screeningreviewed only for Colorectal cancer screening

Exclusion criteria:Exclusion criteria:

Younger than 40 for female and 50 Younger than 40 for female and 50 for malefor male

Less than 3 visitsLess than 3 visits

More than 5 yearsMore than 5 years

Inclusion criteria:Inclusion criteria: Female over 40Female over 40

Male over 50Male over 50

More than 2 visitsMore than 2 visits

Seen last 5 yearsSeen last 5 years

Reviewed both Attendings and Residents Reviewed both Attendings and Residents chartscharts

Cont Materials and MethodsCont Materials and MethodsWe reviewed: age, sex, medical records, date of We reviewed: age, sex, medical records, date of birth, and screening testsbirth, and screening tests

In the screening tests: for breast cancer, we In the screening tests: for breast cancer, we reviewed for mammogram, results, follow up, reviewed for mammogram, results, follow up, outcomeoutcome

For Colorectal cancer, we reviewed for FOBT, For Colorectal cancer, we reviewed for FOBT, DCBE, Flex Sig, Colonoscopy, and their results, DCBE, Flex Sig, Colonoscopy, and their results, follow up, and outcomesfollow up, and outcomes

The time frame is 5 years backThe time frame is 5 years back

The study is retrospectiveThe study is retrospective

ResultsResults

All females reviewed were older than All females reviewed were older than 40 years old40 years old

Mammogram srceening tests were Mammogram srceening tests were done on 104 patients out of 116 done on 104 patients out of 116 which is 90% compliance ratewhich is 90% compliance rate

ResultResultFor female Breast cancer screening under 50, For female Breast cancer screening under 50, mammography was done on 22 patients out of 30 which is mammography was done on 22 patients out of 30 which is 73%73%

None of them found mass or calcificationNone of them found mass or calcification

For female breast cancer screening older than 50, For female breast cancer screening older than 50, mammography was done on 82 patients out of 86, which is mammography was done on 82 patients out of 86, which is 95% compliance rate95% compliance rate

Out of these 82 patients who got mammogram, 22 patients Out of these 82 patients who got mammogram, 22 patients which is 27% of female older than 50 have found to have which is 27% of female older than 50 have found to have mass or calcificationmass or calcification

18 patients (82%) got follow up mammo, spot compression 18 patients (82%) got follow up mammo, spot compression mammo, ultrasound, or stereotatic biopsymammo, ultrasound, or stereotatic biopsy

None of them has breast cancerNone of them has breast cancer

ResultResultAmong 153 patients, there were 123 Among 153 patients, there were 123 patients (80%) eligible to be sreened for patients (80%) eligible to be sreened for colorectal cancer in both male and femalecolorectal cancer in both male and female

83 patients (67%) were screened for 83 patients (67%) were screened for colorectal cancercolorectal cancer

Out of 123 combined male and female, 37 Out of 123 combined male and female, 37 (27%) were male and 86 (73%) were (27%) were male and 86 (73%) were femalefemale

ResultResultFor female colorectal cancer screening, there For female colorectal cancer screening, there were total of 86 females older than 50 who were were total of 86 females older than 50 who were eligible to be screened for Colorectal cancereligible to be screened for Colorectal cancer

Among them, 51 patients were screened for Among them, 51 patients were screened for colorectal cancer that is 60% of eligible patientscolorectal cancer that is 60% of eligible patients

Several screening methods were used: FOBT, Several screening methods were used: FOBT, DCBE, Flex Sig, ColonoscopyDCBE, Flex Sig, Colonoscopy

FOBT 38 (75%) is the most commonly screening FOBT 38 (75%) is the most commonly screening tool, Flexible sigmoidoscopy 2 (4%) is the least tool, Flexible sigmoidoscopy 2 (4%) is the least method to used. Others are: Colonoscopy 8 method to used. Others are: Colonoscopy 8 (16%), double contrast barium enema 3 (6%)(16%), double contrast barium enema 3 (6%)

ResultResultOut of 153 patient population, we reviewed 37 Out of 153 patient population, we reviewed 37 male patientsmale patients

Among them, 32 patients were older than 50 Among them, 32 patients were older than 50 years and eligible to screen for colorectal canceryears and eligible to screen for colorectal cancer

22 patients were screened for colorectal cancer 22 patients were screened for colorectal cancer which is 68.8% of patient population who are which is 68.8% of patient population who are eligible to be screenedeligible to be screened

FOBT is the most common screening method, 18 FOBT is the most common screening method, 18 out of 22 (82%) and second most common out of 22 (82%) and second most common method is Colonoscopy: 4 out of 22 (18%)method is Colonoscopy: 4 out of 22 (18%)

There were no double contrast barium enema or There were no double contrast barium enema or flexible sigmoidoscopy in male population in FCC flexible sigmoidoscopy in male population in FCC

AnalysisAnalysis

Total: 200Total: 200

Data Pool: 153Data Pool: 153

Male: Female ratio – 37 (24.2%): 116 Male: Female ratio – 37 (24.2%): 116 (75.8%)(75.8%)

AnalysisAnalysis

Female above 40 years old mammo Female above 40 years old mammo compliance rate: 90%compliance rate: 90%

Both gender colorectal screening Both gender colorectal screening older than 50 years old: 67%older than 50 years old: 67%

Gender RatioGender Ratio

Male, 37

Female, 116

0

20

40

60

80

100

120

Numbers

1

Gender

Gender Distribution

Male

Female

Female MammogramFemale Mammogram

Total Female, 116

Mammo, 104

98 100 102 104 106 108 110 112 114 116

1

FCC Compliance

Mammo

Total Female

Mammo 104

Total Female 116

1

FCC Colorectal ScreeningFCC Colorectal Screening

123

83(67%)

0

20

40

60

80

100

120

140

Total Eligible Colorectal sreening

Series1

DiscussionDiscussion

By knowing about our performance By knowing about our performance and compliance in FCC, we can find and compliance in FCC, we can find out the barriers for these screening out the barriers for these screening tests and ways to overcome these tests and ways to overcome these barriers so that we can improve the barriers so that we can improve the quality of care for our patient quality of care for our patient population we are serving population we are serving

DiscussionDiscussionAdding ultrasonography to mammography may improve breast Adding ultrasonography to mammography may improve breast

cancer detection, research suggestscancer detection, research suggests

USA Today (5/14, 7D, Szabo) reports, "Screening women with both USA Today (5/14, 7D, Szabo) reports, "Screening women with both ultrasounds and mammograms allows doctors to find more breast ultrasounds and mammograms allows doctors to find more breast cancers than if they rely on mammograms alone," according to a cancers than if they rely on mammograms alone," according to a study published in the May 14 issue of the study published in the May 14 issue of the Journal of the American Medical AssociationJournal of the American Medical Association. But, "the combination . But, "the combination also leads to many more unnecessary biopsies, and experts don't also leads to many more unnecessary biopsies, and experts don't recommend it to most patients." recommend it to most patients."

                For the study, "almost 3,000 women recruited from 21 For the study, "almost 3,000 women recruited from 21 centers" were randomized "to receive either mammography alone, centers" were randomized "to receive either mammography alone, or mammography plus ultrasound performed by a physician," or mammography plus ultrasound performed by a physician," HealthDayHealthDay (5/13, Gordon) added. The results revealed that the (5/13, Gordon) added. The results revealed that the diagnostic yield for mammography was "7.6 cancers" per 1,000 diagnostic yield for mammography was "7.6 cancers" per 1,000 women screened. Mammogram plus ultrasound "found 31 of the women screened. Mammogram plus ultrasound "found 31 of the cancers," which produces a yield of "11.8 cancers" per 1,000 cancers," which produces a yield of "11.8 cancers" per 1,000 women. This finding suggests that ultrasonography increased the women. This finding suggests that ultrasonography increased the yield by 4.2 per 1,000 over mammography aloneyield by 4.2 per 1,000 over mammography alone

              

DiscussionDiscussionMedPageMedPage Today Today (5/13, Bankhead) noted, "Mammography alone (5/13, Bankhead) noted, "Mammography alone had a diagnostic accuracy (area under the curve) of 0.78, which had a diagnostic accuracy (area under the curve) of 0.78, which increased to 0.91 with supplemental ultrasound (P=0.003)." In increased to 0.91 with supplemental ultrasound (P=0.003)." In addition, "[t]he positive predictive value of biopsy addition, "[t]he positive predictive value of biopsy recommendation after complete diagnostic workup was 22.6 recommendation after complete diagnostic workup was 22.6 percent for mammography (19 of 84), 8.9 percent for ultrasound percent for mammography (19 of 84), 8.9 percent for ultrasound (21 of 235), and 11.2 percent for combined imaging (31 of 276)." (21 of 235), and 11.2 percent for combined imaging (31 of 276)." But, the "number of false-positive diagnoses increased from 116 But, the "number of false-positive diagnoses increased from 116 (for mammography alone), to 275 (for the combined use of (for mammography alone), to 275 (for the combined use of mammography and ultrasound)mammography and ultrasound)

                In an accompanying editorial, Christiane Kuhl, M.D., of the In an accompanying editorial, Christiane Kuhl, M.D., of the University of Bonn, wrote that "the issue of false positives, while University of Bonn, wrote that "the issue of false positives, while troubling, is less of an issue with ultrasound than with troubling, is less of an issue with ultrasound than with mammography, because biopsies can often be performed during mammography, because biopsies can often be performed during the screening with ultrasound-guided biopsy," the screening with ultrasound-guided biopsy," WebMDWebMD (5/13, (5/13, Boyles) reported. This week's JAMA Report video features the Boyles) reported. This week's JAMA Report video features the study. study.

DiscussionDiscussionVirtual ColonoscopyVirtual Colonoscopy

Virtual colonoscopyVirtual colonoscopy is a procedure that uses a series of x- is a procedure that uses a series of x-rays called rays called computed tomographycomputed tomography to make a series of to make a series of pictures of the colonpictures of the colon

A computer puts the pictures together to create detailed A computer puts the pictures together to create detailed images that may show polyps and anything else that seems images that may show polyps and anything else that seems unusual on the inside surface of the colon. This test is also unusual on the inside surface of the colon. This test is also called colonography or CT colonographycalled colonography or CT colonography

Clinical trials are comparing virtual colonoscopy with Clinical trials are comparing virtual colonoscopy with commonly used colorectal cancer screening tests. Other commonly used colorectal cancer screening tests. Other clinical trials are testing whether drinking a clinical trials are testing whether drinking a contrast materialcontrast material that coats the stool, instead of using that coats the stool, instead of using laxativeslaxatives to clear the colon, shows polyps clearly to clear the colon, shows polyps clearly

Advantages of CTCAdvantages of CTCAccurate detection of 4 mm or larger polypsAccurate detection of 4 mm or larger polypsNon-invasive with virtually no riskNon-invasive with virtually no riskSignificantly less expensiveSignificantly less expensiveCost: $475Cost: $475Time efficient exam: Can work the same day Time efficient exam: Can work the same day Flexible viewing and analysisFlexible viewing and analysisRecord: 3D electronic modelRecord: 3D electronic modelSensitivity: 93.8% for polys >1 cm vs 87.5% Sensitivity: 93.8% for polys >1 cm vs 87.5% with colonoscopywith colonoscopySpecificity: 96% Specificity: 96%

DiscussionDiscussion

DNA stool testDNA stool test

This test checks DNA in stool cells for This test checks DNA in stool cells for genetic changes that may be a sign genetic changes that may be a sign of colorectal cancerof colorectal cancer

Sensitivity: 89%Sensitivity: 89%

Specificity: 86%Specificity: 86%

4 times more sensitive than FOBT4 times more sensitive than FOBT

Cost: $150Cost: $150

ConclusionConclusionIn our FCC, the compliance rate for Breast cancer is 90% and In our FCC, the compliance rate for Breast cancer is 90% and colorectal cancer is 67%colorectal cancer is 67%

While there is room to improve in breast cancer screening, FCC While there is room to improve in breast cancer screening, FCC performance in colorectal screening needs to improve significantly performance in colorectal screening needs to improve significantly to meet the standard of careto meet the standard of care

Should consider not only FOBT, needs to schedule more for Flex Should consider not only FOBT, needs to schedule more for Flex Sig in FCCSig in FCC

Should also encourage administration to make other test options Should also encourage administration to make other test options available such as Virtual Colonoscopy and DNA tool testavailable such as Virtual Colonoscopy and DNA tool test

There should be a system in place to schedule an appointment for There should be a system in place to schedule an appointment for a patient just exclusively to discuss, evaluate and order screening a patient just exclusively to discuss, evaluate and order screening tests for disease prevention and health promotion at least once a tests for disease prevention and health promotion at least once a yearyear