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American College of Gastroenterology Updates Its CRC Screening Guidelines

March 2021 brought 21 updated recommendations and guidelines from the American College of Gastroenterology (ACG) regarding colorectal cancer (CRC) screening.

While the American Cancer Society recommends CRC screening for those aged 45 and up, the ACG recommends regular CRC screening for those aged 50-75, which follows the current recommendations set by the U.S. Preventive Services Task Force and the Multi-Speciality Task Force. For those aged 76 and beyond, the ACG recommends that the decision to screen for CRC be dependent on the health status and lifestyle of each individual, as the risks of CRC screening can outweigh the benefits depending on the individual’s situation. 

The recommendation to start screening at age 50 is only for those at average risk for CRC. For those who have a family history of CRC or advanced polyps and are therefore at a two-fold increased CRC risk, the ACG recommends screening starting at the age of 40 or 10 years before the youngest affected relative—whichever comes first. 

The various CRC screening options include:

  • Stool-based tests like fecal immunochemical test (FIT) and multitarget stool DNA (mtsDNA)
  • Blood-based tests like Septin 9
  • Direct visualization like colonoscopy, flexible sigmoidoscopy, CT colonography, and colon capsule

The ACG recommends that colonoscopy and FIT should be the primary CRC screening methods. While advising against the Septin 9 blood test due to its low CRC detection sensitivity, the ACG does recommend the other screening methods outlined above for individuals who do not want to undergo a colonoscopy or FIT. It is important to note that all non-colonoscopy screening methods require a follow-up colonoscopy in the case of a positive result.  

In terms of chemopreventive methods, multiple long term studies have indicated that aspirin can reduce CRC incidence and mortality. However, these studies showed mixed results and did not break down the results by individual CRC screening history, so the ACG recommends against the usage of aspirin as a substitute for traditional CRC screening methods. 

Recommendations for Improving the Quality of Colonoscopy Screening 

Of all the screening methods, a direct visualization test like the colonoscopy is the most commonly performed procedure in the U.S. However, the colonoscopy does come with a main drawback: the results of the test are dependent upon the colonoscopist. The Adenoma Detection Rate (ADR), defined by “the fraction of persons aged 50+ who have one or more adenomas detected and removed,” is a good indicator of colonoscopy performance quality. Several studies have identified a link between colonoscopists with higher ADR rates and a reduction in CRC in their patients. Therefore, the ACG recommends remedial training for colonoscopists with an ADR of <25%.

The ACG further recommends that colonoscopists spend at least six minutes inspecting the mucosa before the scope is withdrawn from the anus, as a withdrawal time of six minutes or more increased the detection of neoplastic lesions and reduced the risk of post-colonoscopy CRC (PCCRC). An additional indicator of colonoscopy quality is the cecal intubation rate (CIR), which is defined as “the passage of the colonoscope tip into the cecal caput.” It is recommended that colonoscopists achieve a CIR of at least 95%, as studies have shown that a low CIR is associated with an increased risk of PCCRC.

Recommendations for Increasing Awareness About CRC Screening

As CRC remains the third leading cause of cancer in the U.S. among men and women, screening outreach is essential to increase participation in CRC screening. Studies have found that various screening outreach methods like brochures, invitations, reminders, patient navigation, patient reminders, clinical interventions, and clinical reminders were associated with increased CRC screening rates. Additionally, having primary care providers involved in screening outreach methods increased patient participation in CRC screenings. Therefore, the ACG recommends all the above to increase screening participation. 

To improve adherence to follow-up colonoscopies after positive non-colonoscopy results, the ACG recommends mail and phone reminders, patient navigation, and provider interventions.

The Colon Cancer Foundation implemented various campaigns this March to increase CRC screening participation in honor of National Colon Cancer Awareness Month. One of the most notable was the #GiveaCrapChallenge, where CCF partnered with Squatty Potty and DuClaw Brewing Company to screen 100 people for colon cancer. Participants traded a stool sample via a FIT kit for a limited edition, six-pack brew sample from DuClaw. These types of innovative screening outreach methods can increase participation in CRC screening, allowing for earlier detection of CRC.

Early detection can significantly reduce the incidence and mortality of CRC. Though there are currently no randomized clinical trials that compare the various CRC screening intervals in terms of the number of life-years gained, the Cancer Intervention and Surveillance Modeling Network, through various studies, recommends the following:

  • Annual FIT
  • Colonoscopy every 10 years
  • mtsDNA test every 3 years
  • Flexible sigmoidoscopy every 5-10 years
  • CT colonography every 5 years
  • Colon capsule every 5 years

 

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Colorectal Cancer Prevention Success in Kentucky: In Conversation With Dr. Whitney Jones

With activities in full swing across the U.S. during National Colorectal Awareness month in March, the Colon Cancer Foundation (CCF) spoke to Whitney Jones, MD, founder of the Colon Cancer Prevention Project (CCPP, Louisville, Kentucky), about the foundation’s history, their success with flipping colorectal cancer (CRC) screening rates in the state, and their vision for the future.

Back in 2003, Dr. Jones, a gastrointestinal specialist, was shocked when he encountered several individuals who should have been screened for CRC, presenting with advanced colon cancer in his clinic. Intrigued by this, he found out that Kentucky ranked 49th for CRC screening rates and led the nation in incidence and mortality. It was then that he decided to make changes in the space and started the foundation the same year.

Partnerships to Help Move the Needle on Preventive Screening

While early years were focused on developing informational flyers and attending health fairs, by 2008 CCPP’s attention shifted to influencing policy changes, such as making sure CRC screening received preventive care coverage. They simultaneously developed a screening program for the state’s uninsured populations under the oversight of an advisory committee (healthcare providers, policy experts, and legislators) that continues to meet on a monthly basis even today.

In 2015, CCPP began promoting lead-time messaging and on-time screening, with a particular emphasis on high-risk and younger populations. “We called out, not the guidelines, but in fact our strategy for implementing our guidelines,” he said, which culminated in a paper on establishing a standard process for timely messaging for CRC screening for both average-risk and high-risk individuals, with an overall goal of changing mindsets. “If we have to reach disparate populations, we have to start earlier, message more frequently, and offer more choices,” Dr. Jones said.

CRC screening compliance is mainly driven by primary care providers (PCPs) and health care systems. “Gastroenterologists are the catchers, and the PCPs and health systems are the pitchers,” he said. “We can no longer trust opportunistic screening as in the past. We need to aim for a more systematic, longitudinal, benchmarked system for evidence-based and guideline-driven screening.”

This, he added, will require participation from payers, Medicaid, and the Department of Insurance to instill policies such as coverage for a colonoscopy following a positive FIT test, or genetic testing for those who meet criteria. Additionally, partnering with organizations that understand the local landscape—such as the Cancer Prevention Programs at a safety-net university-based hospital—provides vital on-the-grounds insight. Dr. Jones’ recommendation is for each state to create a statute for an advisory committee or a technical advisory committee that includes lawmakers and insurance companies, to help develop, clarify, and implement CRC policy.

To spread the success of their state-based screening programs, CCPP is partnering with FightCRC to replicate Kentucky’s success in other states—especially in the context of stakeholder engagement. “The key was really in engaging all of our partners that we have now and asking them, ‘What power can you bring from your organization to really advance something?’” He strongly believes that having a CRC-focused organization lead the charge can have a huge impact on moving the needle and getting things done for the community.

Family Health History for On-Time Screening

We all know that disparate platforms make it difficult for sharing information across electronic health records (EHRs). Add to that the time constraints faced by practitioners and gathering accurate information about a person’s family health history (FHH) could be really challenging. Dr. Jones’ vision rises a step above that—using an AI-based system that will gather FHH, critical to Hereditary Cancer Risk Assessment, prior to a patient’s appointment and integrate it within their EHR, compare it to existing guidelines, and provide the physician with a recommendation that can guide the conversation during the patient visit. “Logistics and informatics will play a significant role in improving our struggles with on-time screening,” Dr. Jones added.

45 IS The New 50: Now What?

While the debate over when to start screening average-risk adults is over (see USPSTF draft recommendation), onboarding 20-21 million people across the country in the 45-49 age group is going to be a challenge, especially during the COVID-19 pandemic. Catching-up will require a dramatic increase in the utilization of stool-based testing. “While we cannot conduct colonoscopy in all the new population, we can definitely send them stool-based testing kits. That’s what health systems should focus on,” Dr. Jones said.

In Kentucky, CCPP has been preparing hospitals, health systems, insurance companies, and large group payers since mid-2020 to adopt these guidelines as soon as they are finalized. The focus is on communicating with folks in their late 30s to inform them about symptoms, screening the high-risk population at age 40 or sooner with colonoscopy, identifying candidates for whom genetic testing is appropriate and for average risk individuals, and screening with either stool-based tests or colonoscopy in a shared decision-making model.

“Forty-five should be the finish line for starting risk-based CRC screening communication, not the starting point,” Dr. Jones said.

 

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When Do You Stop Screening for Colorectal Cancer?

Colorectal cancer (CRC) is the third most common cancer in terms of incidence and mortality in both males and females in the U.S. Screening remains the best method to detect the disease early and can reduce the incidence of advanced cancers. Depending on which guidance is followed, average-risk adults should start screening at 45 or 50 years, However, there is limited information on the ideal age to stop CRC screening. 

The US Preventive Services Task Forces (USPSTF) recommends CRC screening is beneficial only until age 75. In their study published in Clinical Gastroenterology and Hepatology, Cenin et al discuss the age at which men and women should stop screening based on their comorbidities and prior screening results. The authors used a CRC microstimulation model known as Microsimulation Screening Analysis (MISCAN)-colon, which works by answering questions in relation to an individual’s screening and age. The model assesses individuals based on an approach of benefit versus risk using a 76-year-old individual with an exemplary prior screening history as a measure by which all other cases are compared. But, the MISCAN model did not take into account an individual’s prior adherence to screening. 

Comparatively, Lansdorp-Vogelaar et al determined that colorectal cancer (CRC) screening with the fecal immunochemical testing (FIT) was reasonable up until 76 years of age, but only up to 66 years of age in individuals who had underlying comorbidities. Furthermore, Tian et al have emphasized the importance of the family history of CRC, primarily because it contributes towards CRC risk and when to stop screening. 

Based on the many studies conducted, it has been apparent that prior screening history holds far more importance than the number of underlying comorbidities in individuals. Additionally, the age to stop screening differs drastically between men and women. In women with similar comorbidities as men, screening tests were stopped 12-20 years prior depending on screening history, and as early as 24 years if a colonoscopy was done. 

Cenin et al’s study is based on FIT, which is not as relevant in countries where colonoscopy is used as a primary screening test. Individuals who opt for a colonoscopy have longer protection, as opposed to those who opt for FIT. CRC screening can stop at 74 years if the individual had a colonoscopy, irrespective of comorbidities. Therefore, in the U.S., the USPSTF recommends that screening should be stopped at 75 years of age because the primary screening test used is a colonoscopy. According to Pilonis et al, a negative colonoscopy has the ability to provide protection for up to 17.4 years, thereby reducing mortality by 81%. 

Cenin et al’s study also emphasizes the importance of attaining a full screening history and past medical history in order to determine what is the best age to stop CRC screening.

 

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What Should Patients Know About Colorectal Cancer Screening? 

March is National Colorectal Cancer Awareness Month—an observance of patients, survivors, caregivers, and advocates to educate their communities about the disease. It is also an opportune time to promote awareness about the importance of screening, prevention, and treatment.

The third most common cancer diagnosed in the US, colorectal cancer (CRC) is one of the leading causes of morbidity and mortality worldwide. Although CRC incidence rates have declined in the U.S., disease burden remains high. About 19 million colonoscopies were done in the USA in 2017 and the number seems to be increasing primarily due to various screening programs. The U.S. Preventive Services Task Force currently recommends average-risk adults to begin screening at the age of 50 years, while the American Cancer Society suggests starting earlier, at 45 years.

Screening tests can successfully recognize precancerous polyps and can help catch early-stage colon tumors. Numerous screening options are currently available and your doctor can help you choose the right test:

Stool-based tests: 

  • Guaiac Fecal occult blood test (gFOBT)
    • gFOBT analyzes the presence of blood in stool. The stool is put on guaiac saturated paper and if blood is present, a reaction occurs which causes the paper to turn blue.
    • Although this is a common screening test, it has a high incidence rate of false positives, which can occur if you have consumed red meat prior to testing
  • Fecal immunochemical test (FIT)
    • FIT analyzes the presence of blood in stool but at a higher accuracy as compared to gFOBT. It identifies blood via antibodies found on the surface of red blood cells.
    • FIT does not have high false positive rates after patients consume red meat.
    • However, FIT may miss tumors that do not bleed at all and the test has to be refrigerated in order to perform accurately.
  • Stool DNA test (FIT-DNA test)
    • FIT-DNA is similar to FIT but is a multi-target test that has the ability to identify small amounts of blood in stool as well as cells that have been shed in the stool.

Blood-based tests:

  • Septin 9 is a blood-based test to screen for CRC.

Structural Tests:

  • Flexible Sigmoidoscopy (FS)
    • Outpatient procedure
    • Patients are told to avoid food/drinks from midnight the night before
    • No sedation required
    • The time commitment required for a FS is 3-4 hours compared to a colonoscopy, which requires 48 hours
  • Colonoscopy
    • Gold Standard
    • Outpatient procedure in which the patients are under sedation. A tool is inserted to visualize any abnormalities and/or polyps. A device is inserted alongside the tool to remove tissue for examinations/biopsies.
    • A few downsides to this screening test are:
      • Invasiveness of the procedure
      • Advance bowel preparation with dietary restrictions
    • Risk of tears and bleeds
  • CT Colonography (Virtual Colonoscopy)
    • Minimally-invasive test to visualize the entire colon
    • High sensitivity to polyps and CRC detection
    • Alternative in patients who refuse or are unable to undergo a colonoscopy procedure

Screening for CRC should be offered to those older than 50 years as well those who have a family history of CRC and/or predisposing conditions. Patients should discuss their choice of screening test with their doctor, depending on their situation and preferences. For example, screening tests such as FIT and FS are cost-effective, yet decrease the risk of CRC.

Early detection of CRC can help improve both response to treatment and survival!

 

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Disparity Among Young Colorectal Cancer Patients Seeking Genetic Counseling

Colorectal cancer (CRC) is the leading gastrointestinal neoplasia, which has historically been known to primarily affect individuals over 50 years of age, and screening is currently recommended for those 50 and older. This might soon change to 45 years and older. While CRC incidence has been decreasing among individuals older than 55 years, young-onset CRC has shown an opposite trend. From 2000 to 2017, the incidence rates of young adults with CRC has increased, particularly among those aged 40-49 years. Evidence suggests a discrepancy among racial and ethnic minorities, markedly amidst those who are of non-Hispanic and African American descent. 

About 20% of hereditary colon cancer syndromes are prevalent in young adults with CRC, which makes accessibility to genetic testing of utmost importance to reduce future development of the disease. Despite the need for overall accessibility, ethnic and racial groups are disparately referred to genetic counseling services.

A study conducted at UT Southwestern Medical Center and Parkland Health and Hospital System assessed 385 young adults between the ages of 18-49 years old with colorectal adenocarcinoma. The study measured the following outcomes: 

  • Are patients receiving a referral to get a genetic test?
  • Did the patient attend the genetic counseling appointment?Number of patients who were able to complete a genetic test

The study determined that 50% (n=225) of patients with young-onset CRC received a referral for genetic counseling services. Nonetheless, it was reported that a smaller portion of African American (n=49) patients were referred to receive genetic counseling as opposed to Hispanic patients (n=116). A downward trend was consistently noticed in African American patients from being referred to and attending appointments. Many patients report that they did not attend an appointment because they either missed it or never scheduled it. The most common reasons for not receiving the genetic test were  the inability to afford the cost, not receiving a referral to genetic counseling services, or the patient not returning their saliva sample.

Similar trends were reported among 1,647 African American women with breast cancer <50 years old who were enrolled in the Florida State Cancer Registry a year after their diagnosis. A population-based study was conducted which suggested that roughly 50% of these women were referred to and/or had access to genetic counseling services, even though the national guidelines specify that all patients should be referred. Likewise, several studies on ovarian cancers report similar disparities which need to be addressed.

All patients diagnosed with young-onset CRC should be referred to or have access to genetic counseling, regardless of their racial or ethnic background. Genetic counseling services can be of help in guiding and managing treatments among those diagnosed with CRC. 

 

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Should Financial Hardship be a Quality Care Measure After a Cancer Diagnosis?

Cancer is one of the most expensive conditions to treat worldwide. Financial stress and hardship after a cancer diagnosis is a well-documented fact in the U.S. Cancer patients spend more out-of-pocket for medical care and treatment than their counterparts without cancer, adding to their financial hardship. In addition to leaving patients and their families with debt and potential bankruptcy, these financial stressors also compound negative physical health effects.

Despite this, screening for financial hardships is not currently a part of clinical practice, and discussions around patient financial stressors occur infrequently in clinics. To address these challenges, screening for financial hardship after a diagnosis should be introduced to improve cancer patients’ quality of life during treatment and survivorship.

The Financial Burden of Cancer Patients and Survivors

 Dr. Robin Yabroff of the American Cancer Society said in an interview that cancer survivors experience consistent financial stress related to their diagnosis and post-treatment—40% of Americans cannot afford an unexpected expense over $400. In fact, over 50% of cancer survivors report being stressed about paying high medical bills or have delayed medical care due to high costs. Given that financial burden is strongly correlated with gap in insurance programs, unsurprisingly cancer survivors aged between 18-64 are more likely to experience financial stress relative to non-cancer survivors. With many new drugs and medical devices priced at $100,000 or higher, financial hardship has increased exponentially for cancer patients. Moreover, health insurers are constantly shifting care costs to patients by introducing higher deductibles, copayments, and coinsurance. To top all of this, a cancer diagnosis indefinitely and negatively impacts employment, resulting in loss of income and employment-sponsored health insurances in some cases.

Consequently, patients with cancer and their families experience ‘financial toxicity’, a term associated with hardships with paying medical expenses, psychological stress about affording to pay, and delaying or forgoing medical care due to costs. A recent study co-authored by Dr. Yabroff and Dr. Yousuf Zafar in CA: A Cancer Journal for Clinicians, highlights three main factors contributing to financial hardship as the rising cost of cancer treatments:

  • Increase in patient eligibility to treatment concurrent with expanding treatment options
  • Increase in duration of said treatment
  • Changing health-insurance design, which has shifted costs on patients

In addition, newer radiation and surgical oncology treatments are expensive. A simultaneous rise in the number of uninsured and underinsured patients and an increased prevalence of high-deductible and copayment health insurance options complicate matters.

Need for Financial Hardship Screening After Cancer Diagnoses

 Financial hardship negatively impacts a cancer patient’s mental health, physical willpower, and financial wellbeing as seen through increased debt, savings depletions, and filing for bankruptcy protection. This in turn can affect treatment adherence through forgone or delayed medical care, resulting in reduced survival. The higher the out-of-pocket costs for cancer therapeutics, the higher the risk for delayed treatment initiation or abandonment, risking early mortality and/or diminished quality of life.

A pilot study by Shankaran et al., revealed that introducing financial navigation programs could serve to lower anxiety surrounding the cost of medical expenditures, even if the actual cost remains the same. Training programs infinancial navigation provided by hospital staff can decrease and/or optimize patient out-of-pocket spending while reducing losses to health care facilities. However, a real-time online survey of oncology navigators found that 50% identified lack of resources as a barrier for getting financial assistance, highlighting the considerable room for improvement when connecting patients to the resources they need.

Treatment-related financial toxicity has been addressed by various professional outlets, patient-advocacy organizations, and the National Cancer Institute (NCI). For instance, the American Society of Clinical Oncologysuggests that cancer treatment providers should discuss treatment costs with their patients. Other organizations, including the National Academies of Sciences, Engineering, and Medicine and the President’s Cancer Panel recommend addressing the high costs of cancer care. While a large majority of NCI-designated cancer centers conduct some version of financial screening, only a small fraction actively follow-up on the effectiveness of the screen and connecting patients to financial resources. The collective research in this space highlights the need for implementing financial hardship screening and mitigation after cancer diagnoses to improve patients’ quality of life during and after treatment.

 

Conclusions

 The convergence of increasingly high-cost cancer care and treatment options, lack of health insurance or underinsurance, high out-of-pocket costs, and widening disparities in the ability to cover medical expenses or access quality medical care, provide a strong argument for the implementation of financial hardship screening for cancer patients and their loved ones along with access to suitable financial resources.

The Colon Cancer Foundation provides information on financial assistance programs that patients can access.

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A Closer Look at Symptom Management During Chemotherapy Treatment

Much of the illness trajectory in cancer patients is strongly associated with symptom management during—and maybe even years after—chemotherapy treatment. Though chemotherapy drugs are the more common  mode of cancer treatment, along with surgery and radiation, patients may experience side effects associated with their quality of life.

According to a study published by the Paediatrics and Child Health Journal, supportive care during intensive chemotherapy is credited with improvements in overall morbidity and mortality rates in adults and children. Symptom and pain management may be classified as supportive care for patients in active treatment. While chemotherapy-related side effects can be anticipated, it is rather challenging to predict if the effects will be mild, moderate, or severe. Of the 236 cancer patients studied in the article, the effects ranged sporadically and were individually unique.

Supportive care methods and recommendations were addressed during a recent CURE Educated Patient Metastatic Colorectal Cancer Webinar hosted by speakers Nina N. Grenon, DNP, AOCN; Amber S. Norton, RN, BSN, OCN; and Kelley A. Rone, APRN, BSN. Speaking from their clinical and patient experiences, the care providers agreed that chemotherapy treatment may look different on a day-to-day basis, but the key, according to Ms. Grenon is “to make adequate adjustments” and to “dose adjust, rather than hold out from continuing treatment.” The expert panelists encouraged patients to communicate as much as they can with their providers, so that dose adjustments, paint management, or overall symptom management can happen early, rather than letting it get to the point where their cancer treatment needs to be paused.

Appetite suppression and fatigue are the most common side effects of a chemotherapy regimen, and the research article emphasizes that this can coincide with other symptoms such as nausea or vomiting, which is typically experienced by almost half the patients receiving chemotherapy.

The panelists noted that appetite suppression and fatigue directly correlate with each other; if a patient does not eat, then they will be fatigued or if a patient is fatigued then they will not want to eat. In order to break this cycle, they recommend:

  • Smaller meals
  • Flavoring water
  • Foods that will not increase nausea
  • Keeping the mouth moist
  • Setting an alarm to eat

Most importantly, patience is a crucial element to any treatment regimen. Encouraging the patient to eat whatever they can throughout the day is a great place to start. “You don’t have to eat three meals a day…eat what you can throughout the day, even if you just eat small bites all day long, at least you’re getting something opposed to nothing,” Norton reassures. With that, following up with a nutritionist and maintaining communication with your provider can make all the difference. Having a holistic approach to care rather than isolating focus on specific symptoms tends to provide a less challenging segway into survivorship and healing.

Assessment and identification of sources of distress in cancer patients provide an opportunity to improve quality of life during care and restoration of dignity. Adequate communication amongst the patient’s care team will allow the patient to make good progress and respond well to the primary treatment, while also ensuring that their quality of life is maintained.

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Medicaid Expansion Under the Affordable Care Act Was Good News for Colorectal Cancer Care

Medicaid expansion under the Affordable Care Act (ACA) in 2014 has had a notable impact on the diagnoses of early stage colorectal cancer compared to non-expansion states, according to a recent study published in the Journal of American College of Surgeons (JACS). In addition to cancer diagnoses, changes in cancer staging, surgical outcomes, and decisions regarding treatment all saw a positive effect of Medicaid expansion.

The study included Medicaid and uninsured patients listed in the National Cancer Database before the expansion (2011-2012) as well as post expansion (2015-2016). Specifically, the study analyzed 4,438 patients who resided in 19 states that have implemented the expansion as well as 6,017 patients who resided in 19 non-expansion states. Comparatively, patients in states that had expanded Medicaid access saw a multitude of benefits including:

  • Increase in stage I diagnoses
  • Increased treatment at integrated network programs
  • Quicker treatment post-diagnosis (within 30 days)
  • More palliative care for stage IV patients
  • More minimally invasive surgeries

Expansion in all-but 12 states has allowed for more low-income patients to receive crucial public health screenings including colonoscopies, which is one of the screening methods that detects colorectal cancer. The 12 states that did not adopt the expansion include: Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming. People who were most impacted by the expansion, according to the study, were in the 40 to 64 age group without health insurance or who had Medicaid.

According to the American Cancer Society (ACS), having adequate access to health care and screenings is especially crucial for colorectal cancer, the fourth most common cancer in the U.S, as research has shown that rates of diagnoses amongst people below the age of 65 are increasing. The ACS also reports that one in three people who should receive regular screenings do not, due to lack of insurance or barriers to health care access.

The expansion of the ACA is a step in the right direction for increasing screenings. However, the positive impact of the ACA doesn’t stop with increased screening—-it improves surgical outcomes and limits invasive procedures, as well as limits the number of cases of advanced colorectal cancer.

Doctors assure patients that colorectal cancer is relatively manageable and treatable if detected early. Dr. Samer T. Tohme, surgical oncologist at University of Pittsburgh Medical Center (UPMC) Hillman Cancer Center and one of the lead authors of the current JACS study, says, “Studies show that patients who are diagnosed with cancer at an earlier stage are more likely to have better treatment options, improved quality of care, and longer survival.” Once diagnosed at an early stage, the patient may be spared the tough job of making significant decisions regarding their treatment plan.

Advanced stages of colorectal cancer are associated with increased length of treatment, cost, distance traveled, and overall complexity of care, according to the research study. Medicaid expansion gives a large population of people a chance to avoid many of the stressors associated with dealing with an advanced chronic illness.

Patients in expansion states diagnosed with advanced colorectal cancer have access to palliative care services if needed. Palliative care is an essential element of health care since it provides people with the dignity of symptom relief and comfort during end-stages of a terminal illness.

Overall, the ACA has provided a key framework for the future of oncology care and prevention in the U.S. According to Dr. Richard S. Hoen, surgical oncology fellow at UPMC and a co-author of the study, “Studies like ours are building an increasing body of network that suggests the Affordable Care Act and Medicaid expansion are improving health care access and treatment for cancer patients.”

The advances that the ACA expansion was able to deliver to colorectal cancer patients across the U.S. are also improving overall cancer care while reducing morbidity and mortality rates. To evaluate your risk for colorectal cancer or obtain a colonoscopy, contact your primary care provider.

 

 

 

 

 

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In Conversation With Dr. Dooreck: Colorectal Cancer Provider Outreach Program: Part I

The Colon Cancer Foundation’s Lakshmi Yeturu sat down (virtually!) with Dr. Brian Dooreck to find out more about his initiative to arm newly diagnosed colorectal cancer patients and caregivers with substantial resources as they bravely face their diagnosis and treatment.

Can you tell me a little bit about yourself: your personal and academic background and your interests?

My name is Dr. Brian Dooreck. I am a gastroenterologist focused on GI [gastrointestinal] and liver disease. I trained at the University of Miami Jackson Memorial Hospital and have been in clinical practice for 15 years in South Florida, seeing patients for all GI-related issues. My training goes back to New York, Boston, Tel Aviv, NYC, and Miami. As a clinical gastroenterologist, I am quite involved with my patients in a relatively busy practice, but I am also engaged in other aspects of the medical, nonprofit, and entrepreneurial worlds.

The Colorectal Cancer Provider Outreach Program [CRC POP] was just an idea a few months ago that quickly became reality. What I have repeatedly experienced over the years is that when we diagnose people with colorectal cancer, we’re telling them that they have a problem. As they are waking up from sedation [following a colonoscopy], we tell them: ‘You have a problem and this is what we need to do: you need to get labs, you need to get a CAT scan, you need to see a surgeon, you need to get the follow-up biopsies and then see me in a week or two. We will get through this; we will work together.’

But what we have not been doing—and I have realized this now after having spoken to groups representing over 1200 gastroenterologists—is telling patients, ‘Listen, go home, look into these websites and call these numbers. I will see you in a week or two and we will go over things.’ But you have support starting now:

  1. You want to take out your phone and text this number: COLON to 48-48-48, which pops up a PDF with all the organizations, their websites, and their phone numbers
  2. Go to our website, go to the Colorectal Cancer Help Page that has links to the websites of patient organizations
  3. Look at your EMR discharge instructions; you’ll find more information there

So, there are these three areas which we can share with patients at the bedside, post-procedure as we’re delivering their diagnosis, and it can direct them to resources that they are otherwise, and most likely, going to trip over if they were Googling, ‘Am I going to die from colon cancer?’ They’re not going to find it on their own, but they may join a social media network group and see a Facebook posting. They’ll probably trip over rather than go to it directly, or they’ll go to it much later in the game.

What I am trying to do is get patients to these resources much earlier, when they have just been diagnosed.

What prompted you to work within gastroenterology and hepatology? Specifically, within colorectal cancer?

I chose gastroenterology early on in my internal medicine training, probably by my first or second year in New York City. I specifically remember just having related to it. From the aspect of your social life or social disposition, having abdominal pain, colitis, diarrhea, or bloody stools is a real damper to your Saturday night dating and it would really affect your social life.

I also understood it. I think we’ve all had diarrhea, we’ve all had abdominal pain and I know what it’s like. You can walk around with heart disease, kidney failure, lung disease, and lung cancer and you may not have to tell someone. But to have to urgently run to the bathroom, not be able to eat meals, have severe cramping, or if you are losing weight because of it, you will be forced to tell someone. That really is something I related to. I felt I could help people’s quality of life in a much broader, quicker way.

Would you mind describing your past work and research efforts within this field and their significance to colorectal cancer?

Over the years, during my clinical research and fellowship at the university, I have been involved in different aspects of research and I’ve always had an alignment with colorectal cancer. I started realizing that GI is my field of interest quite early on. I remember rotating through Memorial Sloan Kettering Cancer Center, where Dr. Sidney Winawer was one of the pioneers of colon polyp detection. So, for me I’ve always had a proximity and drive towards it; I’ve always been much more interested in the clinical aspects of the field.

Personally, being engaged with social media platforms, I saw a great ability to leverage technology to further benefit our patients. This tool that we have created allows patients to get the support they need at the time of diagnosis ‘here and now,’ and it will alleviate so many levels of burden. There is nothing more shocking than telling someone ‘you have cancer.’ There are about 14,000 gastroenterologists in the United States and about 150,000 people diagnosed each year with colorectal cancer. So, we have 14,000 gastroenterologists making those diagnoses each year. You can add multiples of that to account for family members and other people that are simultaneously affected by that one diagnosis.

How many of those people are going to go through the support services that are available from the five organizations we’re partnering with at the time of diagnosis? We expect that very soon, the support that we are providing at the time of diagnosis can not only help the patient and their family, but also promote screening and prevention for those organizations that have preventive screening programs. So, the benefits are huge and using the providers for this is our goal.

What was your primary inspiration to develop this program aimed at newly diagnosed colorectal cancer patients?

Like I said, having seen this now a thousand times if not more. We are not leveraging the available resources, and you know it is quite different for colorectal cancer. For breast cancer, for example, if you feel a lump, you can get a mammogram, get a biopsy and ultrasound, and follow up with the doctor. It is a period of 2-3 weeks, probably, and you as the patient know what’s going on and you’re aware of the conversation. With prostate cancer, you know something is not feeling right if the PSA is high, the physical exam is off. When you get the biopsy results, you are awake or aware the whole time, so you know what’s going on and you are a part of the conversation.

In the case of colon cancer, you come to me saying, ‘I have some rectal bleeding’, ‘Oh I have hemorrhoids’, ‘I feel perfectly fine’, ‘I need to get a screening’, ‘I’ve been 5 six years late’, ‘OMG I have colon cancer and I kind of blew it off for a few years.’ You come to me feeling fine and not suspecting a problem. Then you go to sleep [for the colonoscopy procedure], wake up 15-20 minutes later and you have colon cancer. We don’t hear anything after the cancer diagnosis. That’s our differentiator and what we do in my field, in my space, in my world is we’re dealing with a cancer where the diagnosis is made at the bedside post-sedation and more than ever everything becomes very clouded for the patient. So, with CRC POP, we can help people through that cloud.

 What inspired you to be at the forefront of the Colorectal Cancer Provider Outreach Program (CRC POP)? Who are your lead collaborators on this project and are you looking to expand your partner organizations?

The focus of the Colorectal Cancer Provider Outreach Program [CRC POP] is reaching the providers who will then share the resources with their patients.

We are currently partnering with five supporting organizations: American Cancer Society, Colorectal Cancer Alliance, Fight Colorectal Cancer, Colon Cancer Coalition, and the Colon Cancer Foundation. These five organizations are, in my eyes, equal partners and our goal is to reach providers and to give patients the options of these five organizations. Each organization has its own strengths and weakness, specialty, and focus—it is up to the patients to find what best serves their needs.

We received support from a company called Easy Texting that’s giving us the ability to allow patients to text the word ‘COLON’ to 48-48-48 at the bedside. This will generate a PDF with the link and phone numbers to these five organizations. My goal is to work closely with three national associations: the American College of Gastroenterology, the American Gastrointestinal Association, and the American Society of Gastrointestinal Endoscopy, to develop better communication with the 14,000 gastroenterologists in the U.S., and to use their influence to quickly, and easily, reach more providers and in turn more patients.

Part II of this interview can be found here.

 

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Has COVID-19 Reshaped the Future of Surgical Oncology in High-Income Countries for the Better or Worse?

As COVID-19 continues to spread like wildfire, it becomes increasingly important to tackle the growing backlog of cancer surgeries. While returning to normal is currently not an option, a lot of hospitals around the world, especially hospitals in COVID-19 hot spots, have begun implementing COVID-19 surgical pathways to help ease the surgical burden. The 2020 European Society of Surgical Oncology (ESSO)’s virtual summit opened our eyes to the inescapable fact that COVID-19 will reshape the face of surgical oncology.

 

Impact of COVID-19 on High-Income Regions

With the pandemic in full swing and cases ever on the rise, surgeons, particularly cancer surgeons, across the world are debating the necessities of implementing long-term change with operation scheduling, minimal person-to-person contact, and elective surgery cancellations. As expected, COVID-19 has resulted in a drastic reduction of surgical activity worldwide, with coronavirus hot spots Europe and the U.S. seeing massive reductions.

 

What Was the Cancer Surgery Burden in Europe’s Biggest Hotspot, Italy?

An elective oncological survey was conducted by Marco Montorsi, MD, and his team to understand how COVID-19 had affected surgical care of Italian cancer patients. The survey was sent to 54 surgical units in three stages: before, during, and after the first wave of the COVID-19 pandemic in March 2020.

During the peak of the first wave, the survey identified a clear reduction in the number of cancer resections scheduled per week, alongside:

  • 70% reduction in surgical beds
  • 76% reduction in surgical activity
  • Almost complete cancellation of outpatient surgeries

Also seen was a prolongation in the time-interval between cancer multidisciplinary team (MDT) discussions and the surgery itself. Disease biology, tumor aggressiveness, and interval from neoadjuvant treatments were the three primary criteria that defined the urgency of the surgery and thereby its need to be performed during the pandemic.

 

Dr. Montorsi stated that a follow-up elective survey is in the making to monitor the effects of the ongoing second wave. He explained that the aims of the second survey are “to investigate the impact of COVID-19 in surgical departments in the past months of heavy pandemic, understand outcomes of COVID-19 patients undergoing oncological surgery, and to investigate how many alternative treatments to surgery have been performed and how many of these are considered to be a bridge to surgery.”

Dr. Montorsi also highlighted that during the heat of the pandemic in Italy, surgeons tried to devise a new priority model for elective surgeries performed on cancer patients. They found that of the minimally invasive surgeries performed during the COVID-19 pandemic, liver and pancreatic cancer surgeries were vastly reduced but colorectal cancer surgery rates in Italy remained similar to previous years, showing that certain hospitals remained a safe environment to perform cancer surgeries in, if strict Personal Protective Equipment guidelines were followed.

However, as the pandemic continues to be a destructive force in the health care industry, an increasing number of surgeons are becoming unavailable to perform surgeries after contracting COVID-19. So, the large question remains, “How do we proceed?” Dr. Montorsi asked. In Italy alone, an estimated 400,000 cancer surgeries need reprogramming in the gap between the COVID-19 waves, and with more and more of the workforce becoming susceptible to COVID-19, this question really needs to be addressed sooner rather than later.

 

How Does the U.S. Compare to Italy?

Let’s look at the big picture. The U.S is now the worst COVID-19 affected country worldwide, with a total of 13.5 million cases and 268k deaths by December 1st 2020 and climbing. It is no surprise that cancer patients are suffering more and fighting harder to survive than they have ever before. The fight is real for everyone but increasing amounts of data show that cancer patients are more vulnerable to worsened outcomes if they contract SARS-CoV-2, which includes increased need for oxygenation via ventilation and raised infection-associated mortality.

Secondly, cancer patients are getting delayed diagnoses due to the decreased availability or suspension of diagnostic and screening services. This alone is terrifying because a patient’s diagnosis for their cancer stage and grade is the only way treatment can be determined. Additionally, pre-diagnosed but un-staged cancer patients are also reluctant to be screened because they do not want to risk contracting COVID-19. This effectively means that patients are being diagnosed later and later, thereby worsening their prognosis and increasing their fight for survival by 100-fold. Thirdly, pre-determined treatment options for patients prior to COVID-19 outbreaks have been altered or cancelled altogether depending on the rate of tumor progression, to free hospital bed availability for terminal or life-threatening COVID-19 patients and to minimize exposure to vulnerable immunosuppressed individuals like cancer patients during treatment or surgery. While this is done with careful consideration by the patients’ MDT, there is no guarantee that tumor progression is unaffected when the patient is not receiving treatment or is receiving an alternative treatment.

 

What Are the Implications for Cancer Surgery?

Capacity for surgery has been drastically reduced as operation theatre space and ventilators have been reallocated to provide for the critical care capacity of COVID-19 patients. Moreover, reports have shown that there is increased risk for contracting COVID-19 postoperatively for any non-COVID elective surgeries, making patients, especially vulnerable ones (i.e., cancer patients, immunosuppressed, and the elderly), more reluctant to undergo surgery in COVID-19 overflow hospitals. Studies conducted in China, Europe, and North America have shown that cancer patients, particularly lung-cancer patients, who contract COVID-19 have a higher risk of mortality, increased ICU admission risk, and severe clinical effects when compared to non-cancer COVID-19 patients. Additionally, a recent meta-analysis showed that all-cause mortality was significantly higher in cancer patients when compared to non-cancer patients, and similar to previous coronavirus outbreaks, the reported mortality rate was 84% in cancer patients compared to 39% in non-cancer patients, further demonstrating the vulnerability of cancer patients to the SARS-CoV-2 infection.

As a result, most MDT’s have opted to put their patients on neoadjuvant chemotherapy, radiotherapy, or hormonal therapy as therapeutic buffers until surgery become available again. However, these options are usually not effective as primary treatment options and therefore also increase the risk of cancer-associated mortality. In order to help oncologists and cancer surgeons navigate this complex field of decisions, the American College of Surgeons “has recommended that in early stages of the pandemic, semi-elective surgery, such as for nearly obstructing colon cancers, stenting for oesophageal cancers and most gynecological cancers, should continue.” In response, health care facilities like hospitals, cancer care centers, and surgical centers are trying to rapidly reorganize elective cancer procedures to ensure that cancer patients continue to receive all the essential care while minimizing their exposure to the deadly COVID-19 infection.

 

Conclusion

The COVID-19 pandemic has led to a catastrophic global disruption in the field of surgical oncology, severely delayed cancer diagnoses and treatment, and halted many ground-breaking surgical clinical trials. Many studies including Dr. Montorsi’s elective oncological survey, Mehta and Goel’s COVID-19 and cancer patient outcome, Rickards et al., study on COVID-19’s impact, have repeatedly tried to objectively quantify the impact of COVID-19 on cancer care. However, with the continuous progress of this pandemic, it has become impossible to gather data and understand the real-time effects on surgical care. While models are under development to try and ease this burden, much of the work to recenter surgical oncology remains to be done.

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