Laura C. Seeff

Annual Report to the Nation on the Status of Cancer, 1975-2006, Featuring Colorectal Cancer Trends and Impact of Interventions (Risk Factors, Screening, and Treatment) to Reduce Future Rates

The American Cancer Society, the Centers for Disease Control and Prevention (CDC), the National Cancer Institute (NCI), and the North American Association of Central Cancer Registries (NAACCR) collaborate annually to provide updated information regarding cancer occurrence and trends in the United States. This years report includes trends in colorectal cancer (CRC) incidence and death rates and highlights the use of microsimulation modeling as a tool for interpreting past trends and projecting future trends to assist in cancer control planning and policy decisions.

Complications of Colonoscopy in an Integrated Health Care Delivery System

Context Data on the frequency of colonoscopy complications from population-based samples are lacking. Contribution The authors searched electronic health records at Kaiser-Permanente of Northern California for patients who died or who had complications due to colonoscopy within 30 days of the procedure. Almost all procedures were diagnostic or for surveillance of previous abnormal findings. Of16318 eligible procedures, 82 involved serious complications (5 in 1000 procedures). Of the 82 complications, 95% followed biopsy or removal of polyps, and 62% of the polyps removed were smaller than 10 mm. The perforation rate was 1 in 1000 procedures. One death was related to colonoscopy. Cautions Less than 1% of procedures studied were screening colonoscopies, so these complication rates might not apply to screening examinations. The Editors Colonoscopy is the final step in colorectal cancer screening, regardless of the initial test chosen, and is recommended for primary colorectal cancer screening in average- risk persons (14). Colorectal cancer screening targets apparently healthy people; therefore, the magnitude of the risk and severity of the harms from screening are important issues to consider when selecting a screening strategy (5). Described complications of colonoscopy include colonic perforation, postbiopsy and postpolypectomy bleeding, and postpolypectomy syndrome (a transmural colonic burn, marked by localized abdominal pain without evidence of frank perforation) (6). Diverticulitis, which is caused by a microscopic perforation of the colon, can also theoretically be caused by colonoscopy in persons with preexisting diverticulosis. Most estimates of colonoscopy complications come from referral centers (712) or closely monitored clinical trials (13), limiting the generalizability of the results to community practice. In a large series by a group of ambulatory endoscopy centers (14), endoscopists self-reported complications, possibly underestimating them (15). In this study, researchers were unable to evaluate postpolypectomy bleeding. Postpolypectomy bleeding is particularly difficult to assess in studies because its occurrence is often delayed. The U.S. Preventive Services Task Force (16), in a recent evidence review of colonoscopy complications, concluded that postpolypectomy bleeding was reported in relatively few studies and delayed bleeding was not reported at all. Studies using administrative databases typically lack access to detailed records, including indications, depth of insertion, and whether or how polyps are removed (17). For the present study, we relied on the automated data of Kaiser Permanente, Northern California (KPNC), an integrated health care delivery system. Colonoscopy was most often used to follow-up other tests, such as fecal occult blood tests, flexible sigmoidoscopy, or barium enema, or to conduct surveillance in persons with a personal or family history of colorectal cancer or colorectal adenoma. Few colonoscopies were performed for primary screening. We identified patients undergoing colonoscopy and followed them for 30 days after the procedure for hospitalization for procedure-related complications. For this analysis, we defined any procedure-related complication that led to hospitalization as a serious complication. Methods We used KPNC electronic medical records to select patients who had undergone colonoscopies between 1 January 1994 and 16 July 2002. This was an observational study, conducted in medical centers throughout the KP health care system, evaluating practice patterns as they existed at the time the included colonoscopies were performed by the endoscopists in the study. Electronic records were reviewed to identify immediate complications, outpatient visits, or hospital admission within 30 days of colonoscopy. Colonoscopies were included in the analysis if they were performed for patients 40 years of age or older who were undergoing coloscopy because of a family history of colorectal cancer or adenomatous polyp, as a follow-up to a positive screening test (that is, polyp or cancer at sigmoidoscopy, positive results on a fecal occult blood test, or abnormal barium enema radiography), for surveillance because of a previously detected adenomatous polyp or colorectal cancer, or for primary screening. Colonoscopies were not included if the procedure was being performed to diagnose symptoms (for example, diarrhea, abdominal pain, gastrointestinal bleeding, history of rectal bleeding, or anemia) or if patients had outpatient visits 6 months before the procedure for abdominal pain, anemia, diarrhea, or constipation. A total of 35945 procedures performed at KPNC between 1 January 1994 and 16 July 2002 were identified by using 2 electronic KPNC endoscopy databases. The first database, the Colorectal Cancer Prevention (CoCaP) program database, contains detailed information from 1994 to 1996 on sigmoidoscopies, follow-up colonoscopies, and the results of pathologic testing. Information available in the CoCaP database includes depth of insertion; size, number, and treatment of polyps; limitations of the procedure; and identity of the examiner. The second database, the EndoLog Pro database, includes colonoscopy reports from 1995 to 2002 from 5 KP facilities. The database contains information on number of polyps found and their treatment, depth of insertion, quality of bowel preparation, identity of the examiner, and any immediate complications. Some patients underwent more than 1 colonoscopy during the study period. If a colonoscopy was incomplete because of poor bowel preparation, and a second colonoscopy was performed within 3 months, only the second colonoscopy was included in the cohort. If a patient required a second colonoscopy to complete removal of a polyp, only the first colonoscopy was included in the cohort. Patients requiring frequent surveillance may have been screened more than once during the 7-year study period; colonoscopies were included for these patients if the interval between the colonoscopies was greater than 6 months. Identification of Eligible Cases Of the 35945 procedures, 4646 were excluded because patients were younger than 40 years of age; 9499 were excluded because the procedures were performed for excluded indications or for symptoms; and 2411 were excluded because of poor preparation (with a second examination rescheduled in 90 days), interval since previous procedure was less than 6 months, previous colon surgery, or because the procedure was for follow-up removal of residual polyps or for marking polyp site for surgery. Inpatient procedures (n= 125) and procedures for KPNC nonmembers (n= 57) were excluded. Procedures were also excluded if patients had inpatient or outpatient visits for lower gastrointestinal bleeding, abdominal pain, anemia, diarrhea, or constipation 6 months before the procedures (n= 2689). A total of 16318 procedures were included in the analysis. Identification of Possible Complications A 2-step procedure was used to identify serious complications. First, we analyzed KP electronic databases for evidence of patients being admitted to the hospital (a KPNC or nonprogram hospital) within 30 days of colonoscopy. We focused on admissions that could be associated with colonoscopy complications or complications of procedural sedation, including colonic perforation (International Classifications of Diseases, 9th revision, [ICD-9] codes 569.83 and 998.2]; lower gastrointestinal bleeding (ICD-9 558.9, 578.1, 995.2, 995.89, and 998.1 to 998.13); anemia, not explained by preexisting conditions (ICD-9 280.0 and 285.0 to 285.9); diverticulitis (ICD-9 562.11); colitis, not present during initial endoscopy (ICD-9 556 to 556.9); aspiration pneumonia (ICD-9 507); pneumonia, organism unspecified (ICD-9 486); infection (ICD-9 780.6, 790.7, and 424.9 to 424.99); abdominal pain (ICD-9 789.0 to 789.09); complications of procedure (E872, E872.8, E872.9, E879, E879.8, and E879.9); complications secondary to anesthesia (ICD-9 995.4, 997.1, and 997.3); myocardial infarction (ICD-9 410 to 410.92 and 414); and stroke (ICD-9 436). Deaths within 30 days of colonoscopy were identified through linkage with the National Death Index. After possible cases were identified from electronic records, medical records analysts at KPNC reviewed the hardcopy medical records, computerized medical records, and laboratory records of 183 patients by using chart review forms. Analysts made photocopies of histories and physicals, discharge summaries, colonoscopy reports, operative notes, and pathology reports, and these were used to make decisions. Two physicians reviewed the photocopied records to determine whether the hospitalization or death was related to colonoscopy. Clinical judgment was used in making these decisions through a collaborative process, and decisions were made by mutual agreement. A third physician adjudicated the 1 case in which there were ongoing questions. A subsample of 44 records was reviewed by both physicians independently. The -statistic for this statistical analysis was 0.71 (CI, 0.52 to 0.89). Statistical Analysis Individual complication measures were created to reflect the incidence of serious complications in the first 30 days after colonoscopy for the following: 1) colonic perforation; 2) the postpolypectomy syndrome; 3) bleeding requiring overnight hospitalization, overall and separately for patients with or without surgery or transfusion; 4) diverticulitis requiring overnight hospitalization, overall and separately for patients with or without surgery; and 5) any other hospitalization within 30 days that was likely to have been caused or exacerbated by the procedure. Two aggregate measures were used. The first was for all of the above categories combined and the second for the most serious complications, including perforation, bleeding with transfusion, and diverticulitis requiring surgery. For each complication measure, we calculated the inc

Barriers to colorectal cancer screening: A comparison of reports from primary care physicians and average-risk adults

Background:Barriers to colorectal cancer (CRC) screening are not well understood. Objectives:We sought to compare barriers to CRC screening reported by primary care physicians (PCPs) and by average-risk adults, and to examine characteristics of average-risk adults who identified lack of provider recommendation as a major barrier to CRC screening. Research Design:This was a comparative study using data from the 1999–2000 Survey of Colorectal Cancer Screening Practices and the 2000 National Health Interview Survey (NHIS). Subjects:We recruited nationally representative samples of PCPs (n= 1235) from the SCCSP and average-risk adults (n = 6497) from the NHIS. Measures:We measured barriers to CRC screening identified by PCPs and average-risk adults who were not current with screening. Results:Both PCPs and average-risk adults identified lack of patient awareness and physician recommendation as key barriers to obtaining CRC screening. PCPs also frequently cited patient embarrassment/anxiety about testing and test cost/lack of insurance coverage, but few adults identified these as major barriers. Of adults not current with testing, those who had visited a doctor in the past year or had health insurance were more likely to report lack of physician recommendation as the main reason they were not up-to-date compared with their counterparts with no doctor visit or health insurance. Only 10% of adults not current with testing and who had a doctor visit in the past year reported receiving a screening recommendation. Conclusions:A need exists for continued efforts to educate the public about CRC and the important role of screening in preventing this disease. Practice-based strategies to systematically prompt health care providers to discuss CRC screening with eligible patients also are required.

Colorectal Cancer Test Use from the 2005 National Health Interview Survey

Background: Screening is effective in reducing colorectal cancer mortality. Recommended colorectal cancer screening options include a home fecal occult blood test (FOBT) or colorectal endoscopy (sigmoidoscopy or colonoscopy). Past surveys have indicated that colorectal cancer screening prevalence in the United States is low. The purpose of this analysis was to determine the prevalence of colorectal cancer test use in the United States by various factors and to examine reasons for not having a colorectal cancer test. Methods: Data on respondents ages ≥50 years from the 2005 National Health Interview Survey (n = 13,269) were analyzed. The proportion of the U.S. population that had home FOBT within the past year or endoscopy within the past 10 years was examined by sociodemographic, health-care access, and other health-related factors. Reported reasons for not having FOBT or endoscopy were also analyzed. Results: The age-standardized proportion of respondents who reported FOBT within the past year and/or endoscopy within the past 10 years was 50.0% [95% confidence interval (95% CI), 48.8-51.2]. Colorectal cancer testing rates were particularly low among people without health-care coverage (24.1%; 95% CI, 19.2-29.7) or without a usual source of health care (24.7%; 95% CI, 20.8-29.0). The most commonly reported reason for not having a colorectal cancer test was “never thought about it.” Conclusions: In 2005, about half of Americans ages ≥50 years did not have appropriate colorectal cancer testing. Increased efforts to expand health-care coverage or to provide colorectal cancer tests to people without health-care coverage are needed to increase colorectal cancer screening. (Cancer Epidemiol Biomarkers Prev 2008;17(7):1623–30)

A National Survey of Primary Care Physicians' Methods for Screening for Fecal Occult Blood

Context Authorities recommend at-home fecal occult blood tests (FOBTs), using 2 samples from 3 consecutive bowel movements, as one of several options for colorectal cancer screening. Content The authors asked a national sample of 1147 primary care physicians about their colorectal cancer screening practices. Approximately 33% reported using only a single in-office stool sample for FOBT. To follow up positive results, approximately 30% said that they repeated the FOBT, and about the same percentage recommended sigmoidoscopy rather than total colon examination. Implications Many primary care physicians in the United States may use inadequate methods to screen for colorectal cancer. The Editors The fecal occult blood test (FOBT) is the least expensive and simplest of the tests recommended in national guidelines for colorectal cancer screening (1-6). Nevertheless, implementation requires several decisions that determine the effectiveness of screening. These include the brand of FOBT to use, whether to give patients the multiple-specimen home kit or to conduct in-office FOBT with a single specimen obtained during a digital rectal examination, and selection of a follow-up test for patients with positive results (7). While randomized, controlled trials have shown that FOBT reduces colorectal cancer incidence and mortality (8-13), the effectiveness and cost-effectiveness of FOBT screening in general clinical practice depend on the degree to which health professionals follow recommended testing guidelines. National colorectal cancer screening and clinical practice guidelines (1-6, 14) recommend performing FOBT screening with the home test, the method used in the randomized, controlled trials. To our knowledge, no studies have examined the efficacy of in-office FOBT, and a recent study showed that the in-office test is substantially less sensitive than the home test (15). Patients with positive results on FOBT should have an examination of the entire colon and rectum (2-7). Repeating FOBT before diagnostic work-up to increase test specificity is not recommended because of the significant probability of finding colorectal cancer or a large adenoma among patients with a positive test result (7). We report on the practice of FOBT in the United States as ascertained in the national Survey of Colorectal Cancer Screening Practices (SCCSP) in Health Care Organizations. This survey asked primary care physicians about how they used FOBT in their practices (16). To determine whether physician responses were consistent with those of the public, we also examined data from the nationally representative sample of the U.S. population that completed the 2000 National Health Interview Survey (NHIS) (17). Methods Survey of Colorectal Cancer Screening Practices The National Cancer Institute conducted the SCCSP in collaboration with the Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services. The researchers used the American Medical Associations Physician Masterfile to form a nationally representative sample of primary care physicians, including general practitioners, family practitioners, general internists, and obstetriciansgynecologists. The survey took place between November 1999 and April 2000. Eligible respondents were physicians 75 years of age or younger who had an active license to practice medicine and whose major professional activity was patient care. Physicians who were retired; in residency training; or involved in full-time teaching, research, or administration were excluded. Obstetriciansgynecologists were included in the sample because they provide preventive services for many women in the United States (18). Respondents were offered a choice of response modes (mail, fax, telephone, or secure Internet Web site). Ninety percent responded by mail. Additional details of the sampling and survey methods have been described elsewhere (16). Physicians were asked how many times they ordered or performed colorectal cancer screening with FOBT for asymptomatic average-risk patients. Respondents who ordered or performed FOBT at least once during a typical month were also asked the brand of test they used, whether they used in-office FOBT, home FOBT, or both (Complete a single FOBT card in the office during a digital rectal exam, Give or mail patients a set of three FOBT cards to complete at home, Both of the above, or Other [describe]) for most of their patients, and whether they had a mechanism to ensure that patients who were given or mailed home FOBT kits completed and returned them. Physicians were asked which procedure or procedures they usually recommended to healthy, average-risk patients as an initial follow-up test after positive results on FOBT: repeated FOBT, flexible sigmoidoscopy, colonoscopy, double-contrast barium enema (DCBE), or other (describe). Respondents were allowed to check more than 1 procedure, indicated in this report by test a/test b (for example, sigmoidoscopy/colonoscopy). We analyzed follow-up of positive FOBT results in 2 steps (Figure). Among the 1120 physicians who performed FOBT at least once per month and responded to the follow-up question, we looked first at whether they recommended repeating the FOBT. We then examined which tests were recommended for the diagnostic work-up. At this second step, we did not include respondents who only reported recommending repeated FOBT (n= 151) and those who only indicated that they referred patients to another physician (specialist or primary care) for follow-up of positive FOBT results (n= 44). Figure. Two-step analysis of follow-up of positive results on fecal occult blood tests ( FOBTs ). The American Cancer Society and the GI Consortium have provided explicit guidelines on method of specimen collection and follow-up of positive test results (2, 3). We considered physicians to be influenced by guidelines if they responded that at least 1 of these guidelines was very influential in their screening recommendations. Respondents were also asked to comment on the capacity to perform colonoscopy in their geographic practice area and whether, in the past 3 years, they had completed continuing medical education courses on colorectal cancer screening. NHIS The NHIS, conducted by the Centers for Disease Control and Preventions National Center for Health Statistics, is an in-person survey that collects health behavior and sociodemographic information from the civilian, noninstitutionalized U.S. population by using multistage sampling. The 2000 NHIS Cancer Control Module included questions on the use of cancer screening. The final response rate for the module was 72% (17). A total of 11365 men and women 50 years of age or older responded to questions about FOBT use. Respondents were asked whether they had ever had a blood stool test using a home test kit, the time since their last test, and whether they had ever had a home blood stool test with abnormal results. Those responding affirmatively were asked what additional tests or surgery they had because of these results. After the series of questions related to home FOBT, respondents were asked if they had ever had an in-office test and how much time had passed since their last test. Respondents were not asked about abnormal results on in-office tests. Statistical Analysis We conducted univariate and multivariate analyses of data from the SCCSP. For the univariate analysis, we estimated percentages and confidence intervals for each level of an explanatory variable. We performed a Pearson chi-square test to test the association between each explanatory variable and the response variable for Tables 1 and 2. For the multivariate analysis, we used logistic regression and computation of predictive margins to estimate the probability of each outcome variable when we controlled for all other independent variables in Tables 1, 2, and 3. These adjusted percentages (that is, predictive margins) are a type of direct standardization that averages the predicted values from the logistic regression models over the covariate distribution in the population (19). These adjusted percentages do not reflect actual use in the population but allow comparisons across categories of the variables included in the models. They are easier to interpret than odds ratios and do not require designating one of the groups as the referent group. Table 1. Percentage of Physicians Who Use In-Office Fecal Occult Blood Tests Table 2. Percentage of Physicians Who Repeat Fecal Occult Blood Tests after Abnormal Results Table 3. Percentage of Physicians Who Recommend Alternative Diagnostic Work-up after Positive Results on Fecal Occult Blood Tests We did a Wald chi-square test to test the association between each explanatory variable and the response variable while adjusting for all other variables in the table. To permit generalization of the results of both the univariate and multivariate analyses to the U.S. population of practicing primary care physicians, we used sampling weights to account for the probability of selection and nonresponse. We used the SAS statistical package, version 9.0 (SAS Institute, Inc., Cary, North Carolina) (20), and SUDAAN, version 8.0.2 (Research Triangle Institute, Research Triangle Park, North Carolina) (21), to compute prevalence rates, predictive margins, confidence intervals, and P values. We conducted univariate analyses of the NHIS data, using SUDAAN to compute point estimates and confidence intervals to account for the complex survey design (17). Role of the Funding Sources The funding sources, the National Cancer Institute and the Centers for Disease Control and Prevention, had a role in the design, conduct, and reporting of the study. Results Survey of Colorectal Cancer Screening Practices Description of Respondents Of the 1718 eligible physicians, 1235 responded to the survey (overall response rate, 72%). Personal and practice characteristics of these respondents have been described el

Colorectal cancer-screening tests and associated health behaviors

BACKGROUND Studies have shown that screening reduces colorectal cancer mortality. We analyzed national survey data to determine rates of use of fecal occult blood testing (FOBT) and sigmoidoscopy, and to determine if these rates differ by demographic factors and other health behaviors. METHODS A total of 52,754 respondents aged >or=50 years were questioned in the 1997 Behavioral Risk Factor Surveillance System (BRFSS) survey (a random-digit-dialing telephone survey of the non-institutionalized U.S. population) about their use of FOBT and sigmoidoscopy. RESULTS The age-adjusted proportion of respondents who reported having had a colorectal cancer screening test during the recommended time interval (past year for FOBT and past 5 years for sigmoidoscopy) was 19.8% for FOBT, 30.5% for sigmoidoscopy, and 41.1% for either FOBT or sigmoidoscopy. Rates of use of colorectal cancer screening tests were higher for those who had other screening tests (mammography, Papanicolaou smear, and cholesterol check). There were also differences in rates of use of colorectal cancer screening tests according to other health behaviors (smoking, seat belt use, fruit and vegetable intake, and physical activity) and several demographic factors. However, none of the subgroups that we examined reported a rate of FOBT use above 29% within the past year or a rate of sigmoidoscopy use above 41% within the past 5 years. CONCLUSIONS While rates of use of FOBT and sigmoidoscopy were higher among people who practiced other healthy behaviors, rates of use were still quite low in all subgroups. There is a need for increased awareness of the importance of colorectal cancer screening.

Patterns of Colorectal Cancer Test Use, Including CT Colonography, in the 2010 National Health Interview Survey

Background: Recommended colorectal cancer (CRC) screening tests for adults ages 50 to 75 years include home fecal occult blood tests (FOBT), sigmoidoscopy with FOBT, and colonoscopy. A newer test, computed tomographic (CT) colonography, has been recommended by some, but not all, national organizations. Methods: We analyzed 2010 National Health Interview Survey data, including new CT colonography questions, from respondents ages 50 to 75 years (N = 8,952). We (i) assessed prevalence of CRC test use overall, by test type, and by sociodemographic and health care access factors and (ii) assessed reported reasons for not having a CRC test. Results: The age-standardized percentage of respondents reporting FOBT, sigmoidoscopy, or colonoscopy within recommended time intervals was 58.3% [95% confidence interval (CI), 57.0–59.6]. Colonoscopy was the most commonly reported test [within past 10 years: 54.6% (95% CI, 53.2–55.9)]. Home FOBT and sigmoidoscopy with FOBT were less frequently used [FOBT within past year: 8.8% (95% CI, 8.1–9.6); sigmoidoscopy within past 5 years with FOBT within past 3 years: 1.3% (95% CI, 1.0–1.6)]. CT colonography was rare: 1.3% (95% CI, 1.0–1.7). Increasing age, education, income, having health care insurance, and having a usual source of health care were associated with higher CRC test use. Test use within recommended time intervals was particularly low among individuals ages 50 to 64 years without health care insurance [21.2% (95% CI, 18.3–24.4)]. The most common reason for nonuse was “no reason or never thought about it.” Conclusions: About 40% of Americans ages 50 to 75 years do not meet the recommendations for having CRC screening tests. Impact: Expanded health care coverage and greater awareness of CRC screening are needed to further decrease CRC mortality. Cancer Epidemiol Biomarkers Prev; 21(6); 895–904. ©2012 AACR.

Colorectal cancer incidence in the United States, 1999-2004 : an updated analysis of data from the National Program of Cancer Registries and the Surveillance, Epidemiology, and End Results Program.

By using recent national cancer surveillance data, the authors investigated colorectal cancer (CRC) incidence by subpopulation to inform the discussion of demographic‐based CRC guidelines.

Breast, cervical, and colorectal carcinoma screening in a demographically defined region of the southern U.S.†

The “Southern Black Belt,” a term used for > 100 years to describe a subregion of the southern U.S., includes counties with high concentrations of African Americans and high levels of poverty and unemployment, and relatively high rates of preventable cancers.

Increase in screening for colorectal cancer in older Americans: results from a national survey.

OBJECTIVES: To compare the proportions of the U.S. population aged 65 and older who underwent tests for colorectal cancer (CRC) in 2000 and 2005 to examine the effect of the change in Medicare reimbursement for screening colonoscopy that occurred in 2001.