Dr. Indran Krishnan and Georgia Governor Nathan Deal

Indran Krishnan, MD, FRCP (London), FRCP(C), FACP, FACG is fighting colorectal cancer on many fronts. As a gastroenterologist, he personally screens people every week. As an associate professor at Emory University, he trains the next generation of physicians. As an advocate, he serves on Fight Colorectal Cancer’s Board of Directors, and was a founding member of the Georgia Colon Cancer Coalition. In the first 4 months of 2012, Indran stepped up his efforts by:

• Meeting with Georgia Governor Nathan Deal and members of the Georgia legislature to introduce them to Fight Colorectal Cancer and spread the word about screening;
• Attending this year’s Call-on Congress, our annual advocacy training and lobby day;

• Participating in a CVS Caremark webinar to speak about colorectal cancer awareness and the role of pharmacists as advocates for early detection and prevention of colorectal cancer;
• Providing the keynote speech at a “Closing Out March, Colorectal Cancer Awareness Month” ceremony sponsored by Given Imaging; and
• Answering questions about screening via Talk About Health. We thought you might enjoy reading Indran’s responses:

1. At the time of colon cancer screening what questions should a patient ask a physician?
2. Would you share what colon cancer screening is and what it entails?
3. How is it determined if someone is at high risk for colon cancer?
4. If my primary care physician suspects colon cancer, what are the next steps?
5. Is there any link between IBS (irritable bowel syndrome) and colon cancer?
6. Are there any new promising treatments or medications for men with IBS (irritable bowel syndrome)?
7. How do you decide what colon cancer screening option should be used for a particular patient?
8. If polyps are found during a colonoscopy, should I be worried? What are the next steps?

When patients  were offered a choice of colorectal cancer screening with either FOBT or colonoscopy, they were significantly more likely to complete that screening than when their doctors recommended only FOBT or only colonoscopy.

Nearly 1000 racially and ethnically diverse patients in urban primary care practices were randomly assigned to get colorectal cancer screening via:

• Fecal occult blood testing (FOBT)
• Colonoscopy, or
• Their choice of either FOBT or colonoscopy.

Overall, 58 percent were screened within the next year. 

• 67 percent of those offered an FOBT home test finished screening.
• 38 percent of those who got a colonoscopy recommendation actually had the exam.
• 69 percent of patients who had a choice were screened.

Non-whites were more likely to complete FOBT, while whites accepted colonoscopy more often. Latinos and Asians were more likely to complete screening than African Americans

John M. Inadomi, MD and his team concluded,

The common practice of universally recommending colonoscopy may reduce adherence to CRC screening, especially among racial/ethnic minorities. Significant variation in overall and strategy-specific adherence exists between racial/ethnic groups; however, this may be a proxy for health beliefs and/or language. These results suggest that patient preferences should be considered when making CRC screening recommendations.

SOURCE: Inadomi et al, Archives of Internal Medicine, Volume 172, Number 7, April 9, 2012.

Alaska Native Americans have a much higher rate of both colorectal cancer and resulting deaths than other populations—about twice those of the U.S. white population (age-adjusted) for the period of 2004 to 2008. They also have the highest rate of CRC cases of all Native American groups—nearly five times higher than American Indians living in the Southwest, for example.

The reasons? Unknown. But health officials do know that improved screening can prevent CRC, and earlier CRC detection saves lives. And in fact, statewide screening rates among Alaskan Natives improved from 29 percent in 2000, to 41 percent in 2005.

A study in the March 2012 journal Gastrointestinal Endoscopy described pilot projects conducted from 2005 to 2010 designed to increase CRC screening in rural and remote Alaskan Native populations.

Projects included training rural mid-level practitioners in flexible sigmoidoscopy; sending an endoscopist to remote areas to conduct CRC screening at three regional hospitals; creation and use of a CRC first-degree relative database to find and screen people at heightened risk; and training patient navigators to help guide patients through the screening and track results to ensure complete followup of positive results.

From 2005 to 2010, the Alaskan Native screening rate rose from 41 percent to 55 percent, with improved outreach to average-risk and increased risk rural families. However, the study also identified remaining challenges—geography; a limited capacity in the healthcare system; high staff turnover; and difficulty getting patients to screening appointments.

Source: American Society for Gastrointestinal Endoscopy, “Reducing Colorectal Cancer Disparities in Alaska Native Population,” March 2012 Gastrointestinal Endoscopy (a special issue devoted to CRC).

Take-away lesson: Awareness of a huge disparity in cases and deaths, along with initial planning to improve screening was, in itself, associated with a large improvement in screening a rural, at-risk population. But despite using multi-prong approaches to overcome geography and lack of health care access, more work is needed. It’s not good enough to screen just over half of a population that gets and dies from CRC at so much higher rates.

Improved CRC screening results, challenges to reach Alaska Natives

Alaska Native Americans have a much higher rate of both colorectal cancer and resulting deaths than other populations—about twice those of the U.S. white population (age-adjusted) for the period of 2004 to 2008. They also have the highest rate of CRC cases of all Native American groups—nearly five times higher than American Indians living in the Southwest, for example.

The reasons? Unknown. But health officials do know that improved screening can prevent CRC, and earlier CRC detection saves lives. And in fact, statewide screening rates among Alaskan Natives improved from 29 percent in 2000, to 41 percent in 2005.

A study in the March 2012 journal Gastrointestinal Endoscopy described pilot projects conducted from 2005 to 2010 designed to increase CRC screening in rural and remote Alaskan Native populations.

Projects included training rural mid-level practitioners in flexible sigmoidoscopy; sending an endoscopist to remote areas to conduct CRC screening at three regional hospitals; creation and use of a CRC first-degree relative database to find and screen people at heightened risk; and training patient navigators to help guide patients through the screening and track results to ensure complete followup of positive results.

From 2005 to 2010, the Alaskan Native screening rate rose from 41 percent to 55 percent, with improved outreach to average-risk and increased risk rural families. However, the study also identified remaining challenges—geography; a limited capacity in the healthcare system; high staff turnover; and difficulty getting patients to screening appointments.

Source: American Society for Gastrointestinal Endoscopy, “Reducing Colorectal Cancer Disparities in Alaska Native Population,” March 2012 Gastrointestinal Endoscopy (a special issue devoted to CRC).

Take-away lesson: Awareness of a huge disparity in cases and deaths, along with initial planning to improve screening was, in itself, associated with a large improvement in screening a rural, at-risk population. But despite using multi-prong approaches to overcome geography and lack of health care access, more work is needed. It’s not good enough to screen just over half of a population that gets and dies from CRC at so much higher rates.

A Colon Polyp Snared and Gone

We thought it was true . . . and now research comes along with evidence.

Colonoscopy reduces death from colorectal cancer.

In a follow-up analysis from the National Polyp Study, people who had adenomas — the risky kind of polyps — removed during the study were much less likely to die from colon or rectal cancer than  the general US population.  In fact, removing adenomas cut the death rate from colorectal cancer in half.

We knew that colonoscopies find and remove precancerous polyps and reduce the number of new colorectal cancers, but this is the first study to actually link colonoscopy to cutting back death from colorectal cancer.

There was good news in the study for people who didn’t have adenomas too. They had a very low risk of colorectal cancer death. Only one person out of nearly 800 with no adenomas found at the initial exam  died of colorectal cancer.

Between 1980 and 1990, the National Polyp Study (NPS) enrolled patients  who were having a colonoscopy to rule out colorectal cancer due to symptoms or positive finding on another test.  All polyps were removed during the exam. Patients with adenomas had another colonoscopy 1 or 3 years later and again at 6 years. Patients with no polyps or only benign hyperplastic ones had no further testing.

For this long-term follow-up study, Ann Zauber, PhD, and her team used the National Death Index to find those patients in the NPS who died from colorectal cancer. The researchers used the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) registry to figure out how many colorectal cancers could be expected in a group of people with the same age, race, and sex of the NPS participants.

Comparing  2602 NPS adenoma patients to what was expected in the general population there were:

• Overall, 12 deaths in the NPS group compared to an expected 25.4.
• In less than 10 years 4 NPS deaths compared to an expected 9.1.
• For more than 10 years 8 NPS deaths compared to 16.3

In the follow-up study, 2602 patients had adenomas found during their initial colonoscopy, another 773 didn’t.

About a third of the people in the control group did have polyps. But they were the safer hyperplastic type. Only one person in that group of 773 died of colorectal cancer. She died about 8 years after her initial colonoscopy.

Ann Zauber PhD and her team concluded,

These findings support the hypothesis that colonoscopic removal of adenomatous polyps prevents death from colorectal cancer.

Dr. Zauber also wrote,

A demonstrated reduction in mortality with colonoscopic polypectomy is a critical prerequisite for continued recommendations of screening colonoscopy in clinical practice while we wait for the results of randomized, controlled trials of screening colonoscopy.

SOURCE: Zauber et al, New England Journal of Medicine, February 23, 2012.

 What This Means for Patients

Advocates can confidently say that colonoscopy saves lives. Not only does it prevent colorectal cancer from ever happening, it cuts deaths in half.

However, deaths were not zero. Patients who have had adenomas removed during a colonoscopy need to remain aware of the symptoms of colorectal cancer and have them evaluated with another colonoscopy if they occur.

It is also important to remember that the National Polyp Study involved high quality colonoscopies. The gastroenterologists who performed them were experts and all cases included in the study reached the top of the colon.

New guidance from the American College of Physicians advises doctors to evaluate each patient’s individual risk and base colorectal cancer screening on that assessment.

The four point guidance statement says:

• Clinicians should perform an individual colorectal cancer risk assessment for all adults.
• Average risk adults should be screened at age 50. Individuals at high risk should begin screening at age 40 or 10 years before the youngest relative was diagnosed with colorectal cancer.
• Average risk individuals should be screened with a stool-based test, flexible sigmoidoscopy, or optical colonoscopy. Colonoscopy should be used to screen patients who are at high risk.
• Clinicians should stop screening for patients over 75 or adults with less than 10 years of life expectancy.

Rather than develop a brand-new set of colorectal cancer screening guidelines for healthcare providers, the Clinical Guidelines Committee of American College of Physicians (ACP) reviewed and evaluated existing guidelines in the National Guidelines Clearinghouse including:

• A Joint Guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology
• American College of Radiology Appropriateness Criteria on Colorectal Cancer Screening
• Screening for Colorectal Cancer: US Preventive Services Task Force  Recommendation Statement
• Institute for Clinical Systems Improvement Healthcare Guideline: Colorectal Cancer Screening

After reviewing the published guidelines and rating them using the Agree II standards, the committee, agreed on the four Guidance Statements:

• Guidance Statement 1: ACP recommends that clinicians perform individualized assessment of risk for colorectal cancer in all adults.
• Guidance Statement 2: ACP recommends that clinicians screen for colorectal cancer in average-risk adults starting at the age of 50 years and in high-risk adults starting at the age of 40 years or 10 years younger than the age at which the youngest affected relative was diagnosed with colorectal cancer.
• Guidance Statement 3: ACP recommends using a stool-based test,flexible sigmoidoscopy, or optical colonoscopy as a screening test in patients who are at average risk. ACP recommends using optical colonoscopy as a screening test in patients who are at high risk. Clinicians should select the test based on the benefits and harms of the screening test, availability of the screening test, and patient preferences.
• Guidance Statement 4: ACP recommends that clinicians stop screening for colorectal cancer in adults over the age of 75 years or in adults with a life expectancy of less than 10 years.

Note that the definition of high risk in Guidance Statement 2 is not clear. While age, race, and family history are considered, personal medical history is not. No specific guidance is provided for people with inherited colorectal cancer syndromes. The authors write:

Clinicians should perform individualized assessment of colorectal cancer risk in all adults to help in deciding when to begin screening. Risks for colorectal cancer include age, race, and family history (for example, diagnosis of colorectal cancer, hereditary nonpolyposis, or familial adenomatous polyposis). Diagnosis of colorectal cancer in a first degree relative, especially before age 50 years, increases the probability of colorectal cancer in all adults; a thorough family history, including the age of diagnosis of colorectal cancer for primary and secondary relatives, is important for assessing this risk. African Americans have the highest incidence of colorectal cancer compared with other races.

A simple set of screening questions is available online for health professionals to use to identify Lynch syndrome (hereditary non-polyposis colon cancer) in patients as young as 25.

What Does This Mean for Patients

The ACP guidelines are nothing new.  They review existing colorectal cancer screening guidelines and provide a simple four point guide for deciding on when and how to screen for colorectal cancer.

Perhaps the strongest take-away message is that the first step in deciding what is the right screening test and the right time to begin screening is to assess individual risk for colorectal cancer.

• Patients with average risk should begin screening at age 50. The best test is for people of average risk is based on risks and benefits for the patient, is available, and is preferred by the patient.
• Patients at higher risk need to begin screening at age 40 with colonoscopy.  According to the ACP this includes African Americans and people with a family history of colorectal cancer.
• Be aware some patients with a strong family history of colorectal or uterine cancer may have inherited a mutation for Lynch syndrome and need to begin screening much earlier than age 40. Be sure that your doctor’s assessment includes that assessment.

The ACP has a Summary for Patients that reviews the guidance statement.

Fight Colorectal Cancer has more help in assessing your risk for colorectal cancer.

Ms. Butt Meddler, the singing and dancing gastroenterologist, tells African Americans to Start at 45.

African Americans have a high rate of new colorectal cancers and they are diagnosed earlier in life. And their death rate is higher than the rest of the US population. The American College of Gastroenterology guidelines call for them to be screened beginning when they are 45.

Patricia Raymond MD, AKA Ms. Butt Meddler, sings and dances and recommends that blacks start screening at 45, rather than 50.

Dr. Raymond is a board-certified gastroenterologist who “. . .takes medicine seriously and herself lightly.”  She tells people who are afraid of colonoscopy to Laugh Their Fears Away at Colonjoke.net.

And if you haven’t watched and laughed at Ms Butt Meddler’s Looking Up My Back Door, enjoy!

Making those New Year’s Resolutions?

You can do a lot to prevent colon and rectal cancer this year . . . and in the future.

Number One Resolution — Be screened for colorectal cancer if you are 50 or over, earlier if you are at higher risk.

In addition you can reduce your  colorectal cancer risk by:

• Exercising regularly.
• Keeping your weight normal.
• Eating less red meat, no processed meat at all, and mostly plant-based foods.
• Increasing the amount of fiber in your food.

Start on Monday, January 2, and review your progress toward better diet and exercise every Monday all year.  Research from leading public health schools for The Monday Campaigns shows that most people view Monday as a day for fresh starts.  They were most likely to begin exercising, start a diet, or stop smoking on Monday.

For the latest evidence on food, nutrition, and physical activity and their influence on colorectal cancer, read the World Cancer Research Fund’s Continuous Update Project focus on colorectal cancer.

Happy, healthy New Year!

A patient navigator who speaks the patient’s language and has time to spend answering questions and removing barriers makes a difference in whether that patient will get colorectal screening.

A study in Boston randomly assigned community patient navigators to half of a diverse group of low-income patients who were behind in colorectal cancer screening.  Compared to patients who received usual health care, patients who got help from a patient navigator were more likely to complete screening, have a colonoscopy, and have polyps detected and removed.

After getting an introductory letter from their primary care doctor, patients in four community health centers and two public hospital clinics got a call from a patient navigator who spoke their language.  The navigator helped them decide how they wanted to be screened — with fecal occult blood testing or colonoscopy.

Patients spoke English, Haitian Creole, Portuguese, or Spanish as their primary language.

For the 465 patients in the study, patients assigned navigators were more likely to:

• Be screened for colorectal cancer within one year (33.6 % vs 20%).
• Be screened using colonoscopy (26.4% vs 13%).
• Have adenomas (polyps) detected (8.1% vs 3.9%).

Use of a patient navigator was particularly helpful for blacks and those who didn’t speak English as a their primary language:

• 39.7 % of blacks in the navigator group were screened compared to 18.6 % in the usual care group.
• 39.8 % of non-English speakers helped by navigators got screened compared to 16.7 % who didn’t have a navigator.

The patient navigators were lay people in the community who guided patients through the medical and screening system, answering questions, helping them to get insurance, and arranging transportation and childcare.  They were able to reach 7 out of 100 patients assigned to the program and contacted each individual a median of 8.5 times, spending an average of 107 minutes with each patient.

In a commentary, Thomas Bodenheimer, MD, of the University of California San Francisco, observed that the intervention worked because physicians had help from a team.  He said,

In this era of primary-care-physician shortage and excessive panel sizes [numbers of patients per physician], quality improvement requires reducing panel size or delegating responsibilities from the physician to a healthcare team.

Writing in the Archives of Internal Medicine, Karen E. Lasser, MD, MPH and her colleagues concluded,

Patient navigation increased completion of CRC screening among ethnically diverse patients. Targeting patient navigation to black and non–English-speaking patients may be a useful approach to reducing disparities in CRC screening.

SOURCE: Lasser et al., Archives of Internal Medicine, Volume 171, Number 10, May 23, 2011. doi:10.1001/archinternmed.2011.201

After a normal colonoscopy when no polyps are found, guidelines call for a repeat test in 10 years.

However, almost half of Medicare patients with a negative colonoscopy got another exam within 7 years, and for one in four there was no clear evidence that they needed one.

Because colonoscopies have real risks and are expensive, over-testing can be both dangerous and costly. Given limited numbers of physicians who do colonoscopies, unecessary procedures add to long waiting lists for screening and for necessary follow-up exams.

Although Medicare regulations call for reimbursement only after 10 years in cases where the first procedure didn’t find a problem, payments are being made for earlier exams.  In fact, Medicare denied payment for only 2 percent of colonoscopies for which there was no clear indication of need.

Researchers at the University of Texas in Galveston reviewed a representative sample of Medicare claims for a  colonoscopy between 2001 and 2003.  Since they were looking for average risk patients who had a negative screening colonoscopy, they filtered out any tests that included removing a polyp or a biopsy or other procedure done during the exam.  They also removed any colonoscopies that included a diagnosis such as bleeding or pain and any that were done for patients who had a Medicare claim in the previous 3 months that included a diagnosis or symptoms of colorectal disease that might have indicated need for a  diagnostic colonoscopy.

In their sample of 5% of the Medicare population:

• 236,145 Medicare patients 66 and older had a colonoscopy in 2001-2003.
• 114,468 had an negative exam with no polyps removed, no biopsies or other procedure.
• 24,071 had a negative screening colonoscopy after all possible medical reasons for doing the test were eliminated.

The research team then looked for repeated colonoscopies within 5 and 7 years of the first test.  Again they eliminated any exams for which a diagnosis or other Medicare claims indicated a good reason to repeat the test.  If they couldn’t find a reason, they classified the colonoscopy as repeated with no clear indication.

In their sample of 24,071 who had a completely negative screening colonoscopy between 2001 and 2003,  8,608 had another colonoscopy within 7 years, and for 3,656 no reason other than routine screening could be found for doing the test.

However, only 86 patients (2 percent) actually had payment denied by Medicare.

Although the US Preventive Services Task Force recommends against routine screening for people between age 75 and 84 and against any screening for those over 85, one third of patients who were 80 or older at their initial negative screening colonoscopy had another exam within 7 years.

The study authors pointed out,

This is of special concern, given the increased potential for complications and decreased benefit of this examination in the very old.

Repeating a colonoscopy early after a negative exam was more likely to occur when:

• Endoscopist doing the first colonoscopy did more than 1,200 procedures a year.
• Exam took place in a doctor’s office rather than hospital or ambulatory surgical center.
• Patients were male.
• Exam took place in the Middle Atlantic or North Central regions of the United States.
• Patients had less than a high school education.

For average risk patients without a family history of inherited colorectal cancer, the natural development of cancer from even quite large polyps is slow.  Before the era of colonoscopy, doctors at the Mayo Clinic followed 226 patients who had barium enemas with advanced adenomas (over 1 cm) for 5, 10, and even 20 years.  During that time only 2.5% became cancer at 5 years and 8% at 10 years.  Seven out of ten cancers were found at an early stage before spreading to lymph nodes or distant sites.

After analyzing their results, James Goodwin, MD, and his colleagues at the University of Texas concluded,

A large proportion of Medicare patients who undergo screening colonoscopy do so more frequently than recommended. Current Medicare regulations intending to limit reimbursement for screening colonoscopy to every 10 years would not appear to be effective.

SOURCE:  Goodman et al., Archives of Internal Medicine, online first May 9, 2011.

What This Means for Patients

Although the research was done in Medicare patients over 65, there is no reason to believe that younger patients are not also being screened more often than guidelines call for for.

• After your screening colonoscopy, be sure that you have a copy of the the results that describe if adenomas (polyps) were found and what their size and description was. If you don’t understand the report, ask your doctor to explain it.
• Check to see if the recommendation for the next screening exam fits within the guidelines for colorectal cancer screening.  If the return recommendation is sooner that guidelines call for, ask why!

For people at average risk of colorectal cancer, colonoscopy screening is recommended beginning at age 50 and then every 10 years unless adenomas or cancer are found.

The US Preventive Services Task Force says that elderly people between 75 and 84 should not be routinely screened for colorectal cancer and those over 85 should not be screened at all.  If your older relative is getting colonoscopy recommendation that don’t fit the guidelines, ask why. They are at higher risk for complications from the procedure and may well not benefit from screening.

But remember:

• Symptoms of colorectal cancer at any time – even after a negative screening colonoscopy — and at any age call for diagnostic colonoscopy.
• People with a family history of colorectal cancer or a personal medical history of cancer, adenomas, or inflammatory bowel disease (ulcerative colitis or Crohn’s disease) are not at average risk. They should follow screening and surveillance programs for increased and high risk, including beginning earlier than 50 and being screened more often.

Colorectal cancer screening rates for colorectal cancer improved between 2000 and 2008 for white, black and Asian-Americans aged 50 and over—but barely improved for Hispanics and actually worsed for American Indians and Alaska Natives.

The latest statistics, just reported by the federal Agency for Healthcare Research and Quality on March 23, found that:

• In 2008, among adults aged 50 or over, about 60 percent of whites reported ever having been screened (up from 51 percent in 2000);
• About 55 percent of blacks and Asian Americans had been screened at least once (compared to 44 percent in 2000);
• In the same age group, only 44 percent of Hispanics reported ever having been screened (slightly increased from just 35 percent in 2000), even though this population has the third-highest death rate from colorectal cancer;
• Screening rates actually decreased among American Indians and Alaska Natives, to only 37 percent in 2008 (compared to 41 percent in 2000).

Among people without health insurance, screening rates were significantly lower in all ethnic groups:

• Among both whites and blacks with no health insurance, the at-least-once screening rate was about 30 percent (increased barely from 26% in 2000);
• Screening worsened to an abysmal 13 percent (down from 16 percent in 2000) among Hispanics with no health insurance.

In summary, even among those with insurance, only half—and often far fewer—people over age 50 are getting even one screening. Among the uninsured, screening is just not being done for a cancer that can be prevented or cured if caught early.

Source: Agency for Healthcare Research and Quality, 2010 National Healthcare Quality and Disparities Reports