Colorectal Cancer Screening in Appalachia PA:

a pilot intervention projectWilliam Curry, MD, MS

Dept of Family & Community MedicineM.S.Hershey Medical Center

7 MAY 2008

Colorectal Cancer Screening in Appalachia PA:

a pilot intervention project

Mark Dignan, PhDGene Lengerich, PhD

Alan Adelman, MD, MSBrenda Kluhsman, MS

Marie Graybill, BSN

Colorectal Cancer• Second leading cause of cancer

deaths– 150,000 new cases annually– 57,000 annual deaths

• In Pennsylvania– 8,200 new cases annually– Rates decreasing except in black males

• 75/100,000 black males, 49/100,000 white females

– 3,000 annual deaths• 26/100,000 males, 18/100,000 females

Pennsylvania CountiesParticipating Practices

Hershey Medical Center

Burden of Disease• Union County

– 130 cases per year• 20% more cases in males than expected

– 32 deaths per year• 18/100,000 males, 12/100,000 females

• Northumberland County– 190 cases per year

• 20% more cases in males than expected

– 163 deaths per year• 30/100,000 males, 19/100,000 females

Burden of Disease• Centre County

– 271 cases per year• 7% fewer cases in males than expected

– 93 deaths per year• 20/100,000 males, 14/100,000 females

• Snyder– 137 cases per year

• 32% more cases in females than expected

– 38 deaths per year• 19/100,000 males, 17/100,000 females

Colorectal Cancer Screening• Screening of population is less

than optimal– 53% in US

– 49% in PA

• 44% in Appalachian PA

Only 32% of colorectal cancers are Only 32% of colorectal cancers are found at local stage in rural found at local stage in rural Appalachia.Appalachia.

ACS CRC Screening Guidelines

• Fecal occult blood test (FOBT)*

• or fecal immunochemical test (FIT)* every year**

*For FOBT or FIT, the take-home multiple sample method should be used.

**Colonoscopy should be done if the FOBT or FIT shows blood in the stool

ACS CRC Screening Guidelines

• Flexible sigmoidoscopy every 5 years**

**Colonoscopy should be done if sigmoidoscopy results show a polyp

ACS CRC Screening Guidelines

• an FOBT* or FIT* every year plus flexible sigmoidoscopy every 5 years**

(Of these first 3 options, the combination of FOBT or FIT every year plus flexible sigmoidoscopy every 5 years is preferable.)

**Colonoscopy should be done if the FOBT or FIT shows blood in the stool or sigmoidoscopy results show a polyp

ACS CRC Screening Guidelines

• Double-contrast barium enema every 5 years**

**Colonoscopy should be done if DCBE shows a polyp

ACS CRC Screening Guidelines

• Colonoscopy every 10 years **

**If possible, polyps should be removed during the colonoscopy.

ACS CRC Screening Guidelines

• Other alternatives– Stool DNA– CT Colonography (virtual colonoscopy)

Colorectal Cancer Screening

• Interventions– Audit & Feedback– CME– Provider reminders

• Despite these efforts, CRC screening Despite these efforts, CRC screening rates remain lower than breast, rates remain lower than breast, cervical and prostate cancer cervical and prostate cancer screenings.screenings.

Colorectal Cancer Screening• Academic Detailing

– One-on-One interaction between provider and trained educator

• Interactive information presentation

– Evidence for Academic Detailing?• Reduced inappropriate and over-prescribing• Tobacco cessation• Improved rural diabetes care• Increased mammography use• Decreased inappropriate PSA ordering

Colorectal Cancer Screening• Academic Detailing

– One study that showed improved follow-up of positive FOBT1

– Mixed evidence about effectiveness with CRC screening

• Physician recommendation is an important factor in patient willingness to be screened

Colorectal Cancer Screening• Study Design

– Baseline Provider Survey• Screening practices• Follow-up practices• Referral patterns

– Practice Assessment• Key informant interviews• Assess current screening practices

Colorectal Cancer Screening• Study Design

– Medical Record Abstraction• Patients 50 and older• Seen in practice in the previous 2 months• Estimate number of patients offered

screening and who had screening completed– Exclusion criteria

» History of colon cancer, polyps» Symptoms of colon cancer» Acute visit

Colorectal Cancer Screening• Study Design

– Academic Detailing• Visit 1 – Lunch and Learn• Visit 2 & 3 – Tailored intervention based on

practice assessment and Visit 1• Visit 4 – Follow-up and final physician

assessment

– Post-intervention Provider survey– Post-intervention medical record

abstraction

Colorectal Cancer Screening• Study Design

– Post-intervention Key-informant interviews

• Qualitative assessment

Colorectal Cancer Screening• Data Collection with caBIG

– Working with Univ of Minnesota, capturing chart abstraction via web to NCI database

• caBIG™ Goal: To create a virtual web of interconnected data, individuals, and organizations redefining how research is conducted, care is provided, and patients/ participants interact with the biomedical research enterprise

– CDEs - Completed– Output is an Excel datafile to research

team

Results• Four practices

– Initial 3 visits completed– Initial provider surveys collected– Record review

• 280 patient records abstracted– 105 entered into CaBIG

» 64 completed– Initial Datafile returned from CaBIG

– 45% screening rate (preliminary)• Patient factors• Physician/system factors

Lunch and Learn Lessons• Providers and staff engaged

• Each practice has different outlook– Wall Charts– Handouts– Engaging staff

• Story telling

• Want information on their performance

Acknowledgements

• National Cancer Institute

• ACTION Health

• The four practice sites

• Research Team

References1. Myers RE , Turner B , Weinberg D , et al. Impact of a

physician-oriented intervention on follow-up in colorectal cancer screening Preventive Medicine, 2004 ;38(4):375-381

2. Soumerai SB, McLaughlin TJ, Gurwitz JH, Guadagnoli E, Hauptman PJ, Borbas C, et al. Effect of local medical opinion leaders on quality of care for acute myocardial infarction: a randomized controlled trial. JAMA 1998;279(17):1358-63.

References3. Centers for Medicare and Medicaid Services. Colon

Cancer Screening. 2008. Available at: http://www.cms.hhs.gov/ColorectalCancerScreening. Accessed January 31, 2008.

4. American Cancer Society. Detailed Guide: Colon and Rectum Cancer. 2008. Available at: http://www.cancer.org/docroot/CRI/CRI_2_3x.asp?dt=10.

Colorectal Cancer Screening

Questions?Questions?