United States Capitol Building

Dear Advocates,

Your efforts are making an impact. Every time you exercise your right as a US citizen to communicate with Congress, you are changing the landscape for colorectal cancer patients. We applaud you for your passion and advocacy.

Has Your Representative Cosponsored H.R. 1070? ACTION REQUESTED

Rep. Charlie Dent (R-PA) introduced on March 15 the “Removing Barriers to Colorectal Cancer Screening Act,” (H.R. 1070).The bill would waive Medicare beneficiary coinsurance for colorectal cancer screening colonoscopy when a polyp is removed.  As of May 16, the bill had 28 cosponsors. To find out if your representative has cosponsored H.R. 1070 go to www.thomas.gov and search by bill number.  If your representative has not cosponsored H.R. 1070 please contact your representative’s office at 202-224-3121 and ask for their cosponsorship of H.R. 1070.

Still Looking for a Republican 

Sen. Sherrod Brown (D-OH) has agreed to introduce the companion measure to H.R. 1070 in the Senate. Sen. Brown is expected to introduce his bill in the near future; however, introduction has been delayed with Sen. Brown’s preference to introduce the bill with a Republican.

Kudos to Rep. Charlie Dent

On March 29, the Lehigh Valley News published a letter written by Fight Colorectal Cancer president Carlea Bauman commending Rep. Dent for his leadership on the Medicare coinsurance issue. The letter was submitted in response to a letter published in the paper that criticized Rep. Dent for appearing in advertisements published in the Morning Call and Express Times encouraging Pennsylvanians to get screened for colorectal cancer.  The ads were paid for by the Courtney Anne Diacont Memorial Foundation.

President’s Budget Cuts CDC Colorectal Funds 

In April, President Obama released his FY 2014 budget which would cut nearly $4 million from the Centers for Disease Control and Prevention’s (CDC) Colorectal Cancer Control Program (CRCCP). The CDC estimates that the loss of funding will mean at least five fewer state programs (out of the current 29) working to prevent colorectal cancer. The president’s budget assumes that less federal funding is needed for direct screenings, such as colorectal, breast, and cervical screenings, because most health plans are required to cover these screenings without co-pays or deductibles, and because, starting in 2014, the Affordable Care Act ensures that no one can be denied health insurance because of a pre-existing condition. Fight Colorectal Cancer will be advocating preserving current CRCCP funding levels and will need your help. Stay tuned. (Read Fight Colorectal Cancer’s statement on this issue.)

Fight Colorectal Cancer Meets with CDC Officials

On May 8, 2013, Fight Colorectal Cancer was represented at a meeting with officials from the CDC to discuss how funding for the CRCCP and the National Breast and Cervical Cancer Early Detection Program can be protected in an era of health care reform.

House Lawmakers Support Funding for CRCCP – GREAT JOB ADVOCATES!

Thanks to all the Fight Colorectal Cancer advocates who asked their representatives to sign a letter in support of the CRCCP. The letter was circulated by Rep. Donald Payne, Jr. and called upon appropriators to fully fund the CRCCP in FY 2014. Rep. Payne was joined by 53 of his House colleagues on the letter.

Action on FY 2013 Spending Bills Complete 

In March Congress completed work on FY 2013 spending bills. The Labor-HHS-Education spending bill was finalized as a continuing resolution, meaning that programs, including the CRCCP will be funded at FY 2012 levels through the remainder of the fiscal year which ends September 30. The CRCCP is funded at $43 million which will be subject to sequestration and other rescissions. Fight Colorectal Cancer has learned that state colorectal cancer programs will be notified at the end of June by CDC of their FY 2013 funding allocations.

DoD Cancer Research Program Gets Funding Boost – GREAT JOB ADVOCATES!

In March Congress passed and the President signed into law a FY 2013 Department of Defense spending bill. The bill provides $15 million for the Peer Reviewed Cancer Research Program (a $2.2 million increase over FY 2012).

NIH Takes Cut for FY 2013

The FY 2013, when sequestration and department transfers are accounted for, the National Institutes of Health (NIH’s) FY 2013 budget will be $28.926 billion (compared to $30.623 billion in FY 2012) and the NCI’s budget will be $4 .779 billion (compared to $5.069 billion in FY 2012).

Glimmer of Good News for NIH Funding

In a bit of good news for NIH funding, Sens. Durbin (D-IL) and Moran (R-KS) were successful in including an amendment to the Senate Budget Resolution that would create a deficit-neutral reserve fund that effectively provides a framework for growth of the NIH budget over the next decade. Establishing a reserve fund allows the Budget Committee chair to adjust the budget resolution’s overall spending and revenue limits and the spending allocations for particular congressional committees to ensure that legislation accomplishing a reserve fund’s goal — in this case, increasing funding for NIH research — will not be subject to a procedural bar if it breaches those limits or allocations, so long as the legislation does not increase the deficit.

President’s Budget Offers Slight NIH Funding Increase 

President Obama’s FY 2014 budget request includes an NIH funding increase of $471 million (a 1.5 percent increase) over FY 2012 amounts. The NIH estimates this would result in 351 more research project grants in FY 2014.

Patient Equal Access to Chemotherapy Bill Introduced – ACTION REQUESTED

The “Cancer Drug Coverage Parity Act” (H.R. 1801) was introduced by Rep. Higgins on April 26. The bill requires insurers that cover anticancer medications that are intravenously administered or injected to provide no less favorable coverage for oral anti-cancer medications. Please email your representative to urge him/her to cosponsor this legislation.

A study published in the March 11 JAMA-Internal Medicine suggests that 23 percent of over-75-year-olds have colonoscopies that may be “potentially inappropriate” according to national guidelines which include an upper age limit, as well as how often negative colonoscopies should be repeated.

In a retrospective population study, University of Texas researchers looked at billings for 100 percent of colonoscopies performed in Medicare beneficiaries in Texas who were aged 70 years and older who had a colonoscopy in 2008 or 2009. They also examined a nationwide sample of 5% of Medicare claims. Colonscopies were classified as “screening” if records (including claims from 2000 to 2009) did not indicate a diagnosis, or any visits for related symptoms in the previous 3 months.

Colonoscopies were labeled “potentially inappropriate” based on patient age over 75, or because the procedure was done less than 10 years after a previously negative colonoscopy. (The study population did not include anyone with a history of colon cancer, inflammatory bowel disease, colon resection, or whose procedure was performed during a hospital admission or emergency room visit.)

Among Texas residents, overall percentages of potentially unnecessary colonoscopies were:

• Age 70-75: 9.9 % of procedures done
• Ages 76-85: 38.8%
• Aged 86-plus: 24.9%.

There was wide variation in geographic areas of Texas, plus among individual doctors doing the screening procedures. The researchers did note that reasons for doing a colonoscopy in an individual patient cannot be assumed from billing information alone. (In fact only 15% of the claims included a screening code, although experts believe about two-thirds of colonoscopies are for routine screening.) The authors noted that there might be poor communication between a primary care doctor and the gastroenterologist; there could be financial incentives to do the procedure, or doctors might disagree with the national guidelines.

What are the guidelines?

In fact, there are different sets of guidelines. The U.S. Preventive Services Task Force (and recently, the American College of Physicians) specify age limits. The USPSTF says “For adults aged 76 to 85 years, there is moderate certainty that the net benefits of screening are small….and [for] adults older than age 85 years, there is moderate certainty that the benefits of screening do not outweigh the harms.”

However, joint guidelines developed by the American Cancer Society, the U.S. Multi-Society Task force on Colorectal Cancer, and the American College of Radiology do not include age limits. Part of the problem is lack of evidence: experts note that far too few population studies and clinical trials include those over age 75, even though about 30% of colorectal cancers are diagnosed in those 75 or older.

Increased risks might outweigh benefits for colonoscopy in those over age 75

Although the USPSTF urges caution in any screening over age 75, colonoscopy itself carries higher risks to elderly patients. Both this study’s authors and guideline developers urge extra caution—especially in unnecessary procedures—in the elderly who face higher risks from the preparation (fluid imbalance, start of a diarrhea/constipation cycle, dizziness or a rush to bathroom causing falls) plus effects of anesthesia in elderly patients.

Some over 75 will benefit

A caveat common among the experts: Among those who have never been screened, a screening colonoscopy might be indicated—especially if the older person is healthy, active, has few other diseases, and has an expected lifespan of more than 7 years.

Another study in the March 5 2013 Annals of Internal Medicine showed that in four HMOs, screening among people aged 55 to 85 did reduced the risk of advanced colorectal cancer by 70% in average-risk adults. However, the study showed that annual stool samples in this population (particularly when reminders and stool-sample kits were mailed to people’s homes) were as effective as colonoscopy.

What to do?

Probably the Centers of Disease Control & Prevention says it best: “The decision to be screened after age 75 should be made on an individual basis. If you are older than 75, ask your doctor if you should be screened.”

Patient Take-Away

• All guidelines recommend a colonoscopy only every 10 years, unless you have symptoms, family history, or a previous removal of polyps or an adenoma. (In those cases, plan your “surveillance colonoscopy” with your doctor.)
• People aged 75 or older should pause to consider the need for a routine screening colonoscopy, especially if it’s less than 10 years since a previous negative colonoscopy. You can also consider other screening methods, such as a yearly stool sampling that is very effective at finding early cancer.
• Discussions about cancer (and other) preventive screening probably are best with your primary-care doctor, who knows all of your other health conditions, your general fitness level, etc.
• If you do have a colonoscopy, it’s best to get your own written record of the results, including number and type of any polyps. A common cause of getting too-frequent colonoscopies could be that a different doctor doesn’t know the results of your previous test(s).

As always, stay tuned for updates on both screening and colorectal cancer treatment in the elderly: As boomers age in, and hopefully more seniors are included in clinical and prevention studies, the science will get clearer.

For More information:

* CDC brief summary of guidelines

* Choosing Wisely: on colonoscopies

* Who is the USPSTF? “A Conversation with Dr. Virginia Moyer, Chair, U.S. Preventive Services Task Force, Nov. 27 2012 NCI Cancer Bulletin.

Sources:

“Potentially Inappropriate Screening Colonoscopy in Medicare Patients,” Kristin M. Sheffield, Ph.D. et al,  JAMA Internal Medicine, published online March 11, 2013

Other coverage of this study includes: “Seniors Getting Unnecessary Colonoscopies: Study,” Monday, Mar. 11 HealthDay News; and “Many Colonoscopies for Seniors May be Inappropriate,” Christian Nordqvist, 12 Mar. 2013 Medical News Today.

See previous Research News blogs, including the Feb. 14 2013 “Colorectal Cancer is (or Could Be) the Poster Child for Cancer Prevention” and
the May 16 2011 “Fight CRC Site Update: Some People Getting Colonoscopy Screening Too Often.”

Other recent articles about screening: “CRC Screening Tools—The Data and the Guidelines,” Linda Rabeneck, M.D., M.P.H., at January 2013 ASCO GI-Symposium; and  “Screening Colonoscopy and Risk for Incident Late-Stage Colorectal Cancer Diagnosis in Average-Risk Adults,” March 5 Annals of Internal Medicine .

A new virus causing diarrhea and vomiting has spread rapidly nationwide, causing an increasing number of outbreaks of what many call the “stomach flu,” according to a Jan. 24 2013 report issued by the CDC (Centers for Disease Control).

The new norovirus strain (named GII.4 Sydney) is highly contagious, and seems to cause more hospitalizations than other gastrointestinal viruses. It hits suddenly with diarrhea, abdominal pain, vomiting, fever, chills, and headache. Most people get better in one or two days, after the stomach or intestinal inflammation eases, but they are still contagious for 3 more days..

Dehydration is Danger

Even healthy people can get dehydrated with this illness if you don’t drink enough liquids to replace the fluids lost from throwing up or having diarrhea many times a day. Special rehydration drinks (such as Gatorade) are best, because they contain nutrients and minerals lost in diarrhea or vomiting.

Norovirus infection can quickly become serious  in young children, the elderly, and people with other health conditions if they become seriously dehydrated. Symptoms include urinating less often,  a dry mouth and throat, and feeling dizzy when standing up—which, for elderly or weakened individuals, greatly increases the chance of a fall during a rush to the bathroom.

Highly contagious

People ill with a norovirus are contagious from the moment they begin feeling sick until at least 3 days after they recover. Some people may be contagious for even longer. So even if you feel better, remember that you can still be infecting others. This is a hardy virus which can survive in food and especially on surfaces for quite awhile–such as bathroom appliances, door handles, bedding, and even on pets.

The CDC recommends that when norovirus hits a household:

(1)    Handwashing is the first defense, scrubbing with soap and water or alcohol-based cleanser before and after cooking and eating, using the bathroom, coming in contact with anyone who is ill, touching your pet, and especially before and after treating a cut or wound or caring for your catheter, port, or ostomy.

(2)    If you are ill, do not prepare food for yourself or others while you have symptoms and then for 3 more days;

(3)    Clean and disinfect contaminated surfaces. After throwing up or having diarrhea, contaminated surfaces should be immediately cleaned with a bleach-based disinfectant.

(4)    Wash laundry thoroughly: any clothing or linens that may be contaminated with vomit or stool should be handled carefully (ideally, wearing gloves, not agitating them to avoid spreading virus, and washing hands after handling). Wash with detergent on the longest possible cycle, and then machine dry.

 Cancer patients, especially if getting chemotherapy, should take special precautions

The CDC also provides clear advice for cancer patients, stating that if you get a fever during your chemotherapy treatment, it’s a medical emergency because infection during chemotherapy can be life-threatening.

And of course for patients with colorectal cancer or having an ostomy, dehydration also can become serious quickly. The CDC advises cancer patients to take your temperature any time you feel warm, flushed, chilled, or not well. If your temperature is 100.4°F (38°C) or higher for more than one hour, or 101°F (38.3°C) or higher for any length of time and you are on chemotherapy especially, call your doctor right away, even if it happens in the middle of the night.

You and anyone who comes around you, including all members of your household, your doctors, and nurses, should clean their hands frequently.

Sources: “Emergence of New Norovirus,” Jan. 25 CDC Morbidity and Mortality Weekly Report ;  “New Norovirus Strain Hits US,” Jan. 24 Medscape ]; “CDC Researchers Spot Increase in New ‘Stomach Bug’ Strain,” Jan. 24 HealthDay News; general tips to “Prevent the Spread of Norovirus,” and “Preventing Infections in Cancer Patients,” Centers for Disease Control.

The Centers for Disease Control is urging doctors to prescribe antiviral medications to high-risk patients suspected of having the flu, even without a positive test. When given within 48 hours of symptoms appearing, antivirals like Tamiflu or Relenza can ease symptoms, shorten illness, and prevent serious complications.

Clinicians are not prescribing antiviral medications as often as in previous years, even though the 2013 flu season is causing more hospitalizations and deaths according to government figures. Complications from this year’s predominant flu strain are especially high among the elderly, causing half of hospitalizations and 90% of deaths so far.

With a sharp increase in both hospitalizations and deaths in the 2^nd week of January, the Centers for Disease Control (CDC) issued a physician advisory urging use of antivirals for more people–especially those at high risk–as soon as flu symptoms appear.

“When given promptly, they work,” CDC Director Thomas Frieden, MD, told a Jan. 18^th press briefing. “They can reduce symptoms, shorten the duration of illness, and prevent serious complications including hospitalization and death.”

Frieden also advised clinicians not to wait for test results or a positive ‘rapid flu test’ when probably flu appears in people at high risk for complications: anyone over age 65 or under age 2, or having any ongoing serious illness (including cancer survivors no longer in treatment).

Only halfway through the flu season

The number of influenza-related hospitalizations and deaths will rise in the coming weeks even as the  national average of new cases begins to slow, Frieden warned, partly because there is a lag time between when flu hits and when complications like pneumonia appear.

And even though flu rates are leveling out in much of the east and south, the outbreak is just beginning in California, Arizona, Hawaii, and Nevada. “Folks out West, you still have most of the flu season yet to come,” Frieden said.

What this means for you:

• Experts are still strongly recommending that anyone over 2 years old should get a flu shot for protection—of you and others—over the next several months.
• Even if you got vaccinated, you can still get a strain of influenza.
• If you begin to have flu symptoms and are “high-risk” or have contact with high-risk people, you should get antiviral medication with 48 hours. (High risk includes cancer survivors, even if you’re no longer in treatment. Even if it’s later than 2 days, you might still benefit, so call your doctor.)
• Flu symptoms include fever, cough, sore throat, body aches.
• You are contagious to anyone within 6 feet until you have been without a fever for 24 hours.  Stay home.

Sources:

• “CDC Urges Tamiflu RX to Curb Flu Death Rate,” Jan. 18 2013 Medscape
• Jan. 15 2013 CDC Health Advisory: Summary of CDC Recommendations for Influenza Antiviral Medications

This weekend, Congress completed work on a large spending bill that maintains funding for colorectal cancer research and prevention. In the current budget-cutting environment, holding the line on research and prevention programs is a remarkable accomplishment and reflects the power of grassroots advocacy.

I congratulate the Fight Colorectal Cancer volunteers who took action this year to protect colorectal cancer research and prevention funding. We should be proud of our achievements, but we cannot become complacent. We must prepare for the Fiscal Year 2013 budget battle that lies ahead. Please register to attend Fight Colorectal Cancer’s Call-on Congress next March – where advocates from around the country will be urging their legislators to continue to protect colorectal cancer research funding.

The following are the spending outcomes on Fight Colorectal Cancer’s three appropriations priorities:

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