DEBATE DEBATE Presenters PRESENTATION MODERATOR Dr. Praveen Bansal - - PowerPoint PPT Presentation

Be it Resolved that FIT is the Best Way to Screen for Colorectal Cancer

DEBATE

DEBATE Presenters

PRESENTATION MODERATOR

• Dr. Praveen Bansal -MD, CCFP FCFP

Regional Primary Care Lead, Integrated Cancer Screening, MHCW Regional Cancer Program PRO COLONOSCOPY SPEAKER

• Dr. Paul Philbrook - MD, CCFP

Regional Primary Care Lead, Integrated Cancer Screening, MHCW Regional Cancer Program PRO FIT SPEAKER

• Dr. Andrew Bellini – MD, FRCP (C)

Regional Lead, Colorectal Screening/GI Endoscopy

DEBATE Agenda

1.0 Ground Rules & Introduction – 7 mins 2.0 Pro Colonoscopy Argument – 8 mins 3.0 Pro FIT Argument – 8 mins 4.0 Panel Discussion & Audience Q & A – 7 mins

DEBATE Grand Rules

#1 Each SPEAKE EAKER R will have an opportunity to state their case without questions or interruptions. #2 AUD UDIE IENC NCE, , please save your questions and comments for the panel discussion portion of today’s presentation. #3 Event staff will be keeping track of the time for each section.

Introduction- Colorectal Cancer in Ontario

• In 2015, approximately 5,110 men were diagnosed

with colorectal cancer and approximately 1,850 died from it

• Second leading cause of cancer deaths
• In 2015, approximately 4,100 women were

diagnosed with colorectal cancer and approximately 1,500 died from it

• Third leading cause of cancer deaths

Colorectal cancer is the 3rd most commonly diagnosed cancer in Ontario

Introduction- Principles of Cancer Screening

Characteristics of an IDEAL screening test:

• Condition should be reasonably common in screened

population

• Condition should be burdensome
• Safe and easy to implement screening test
• Pre- or cancerous lesion detectable and treatable

Improved mortality Cost effective

• WHO. Screening for various cancers. Cited: Mar 2016.

http://www.who.int/cancer/detection/variouscancer/en/

Introduction- Ontario’s Colorectal Cancer Screening Program

• Other options (outside of

CCC) for CRC screening:

• Flexible Sigmoidoscopy
• Colonoscopy
• Developed and implemented

by Cancer Care Ontario

• Men and women aged 50 –

74, who are at average risk of colorectal cancer should be screened using the Fecal Occult Blood Test (FOBT) every 2 years

• Average risk: no personal or

family history of colorectal cancer, no symptoms of colorectal cancer

• If an individual’s FOBT result

is positive, the MRP coordinates a colonoscopy

Introduction - Background

Cancer Care Ontario is changing the average risk colorectal cancer screening test from the FOBT to the Fecal Immunochemical Test (FIT)

Fecal Occult Blood Test (FOBT)

Challenges with FOBT

• Limited uptake from primary care

providers and endoscopists

• Limited buy in from public due to dietary

restrictions and number of samples required Benefits of FIT

• Better test (sensitivity, specificity)
• Higher participation rates in

programmatic screening are expected (one sample, no dietary restrictions, primary care uptake)

Introduction - Background

Advantages of FIT versus FOBT

• Easier to collect
• No dietary restrictions
• One specimen
• Less stool contact

Better usability

16% IMPROVEMENT in participation over gFOBT

• Great for detecting advanced adenomas
• Better than gFOBT at detecting cancer
• Simple, safe and accessible

Introduction – Accuracy FIT vs. FOBTg

Sensitivity Specificity FIT1 (n=19 studies) 82% 94% gFOBT2 (n=9 studies) 47.1% 96.1%

FIT has improved sensitivity with minimal loss of specificity

1Lee J, et al. Ann Intern Med 2014;160:171-181. 2Canadian Task Force on Preventive Health Care. Screening for Colorectal Cancer. 2014.

Introduction – Definitions

The benefit of Colorectal Cancer(CRC) Screening is NOT up for debate!

“If you wish to converse with me, define your terms.” Voltaire

Introduction - Programmatic vs Opportunistic Screening

Programmatic Screening

Offered systematically to all individuals in defined target group within a framework of agreed policy, protocols, quality management, monitoring and evaluation E.g. CCC Program, FOBT

Opportunistic Screening

Offered to an individual without symptoms of the disease when he/she presents to a healthcare provider for reasons unrelated to that disease

Introduction – Advanced Polyp or Lesion

What we prefer to see…. What we struggle to see..

Introduction – Advanced Polyp or Lesion

What we don’t want to see…

• As an physician, finding

a cancer feels like a failure

• A missed opportunity for

prevention

Introduction - Definitions

Advanced Polyp or Lesion

• Size (> 1 cm)
• Histology ( High Grade dysplasia, villous

histology, Cancer)

• Screen Relevant Lesion is a cancer or an

advanced polyp

DEBATE

Colonoscopy versus FIT for Average Risk Colorectal Cancer Screening

DEBATE

Pro Colonoscopy

Pro Colonoscopy – Accuracy

Sensitivity Specificity FIT1 (n=19 studies) 82% 94% Colonoscopy

(Ir J Cancer prevention, 2011)

94.7% 99.8%

FIT less accurate for colon cancer, even worse for advanced adenomas

1Lee J, et al. Ann Intern Med 2014;160:171-181. 2Canadian Task Force on Preventive Health Care. Screening for Colorectal Cancer.

2014.

Colonoscopy (n=4953) FIT (n=8983) CRC 30 18 Advanced adenoma 514 127

Quintero E., et. al., NEJM 2012;366:697-706

Patients that Agree to Screening

Pro Colonoscopy- Diagnostic Yield

Pro Colonoscopy - Sessile Serrated Polyps

• Approximately 20-30% of

CRC felt to arise from Sessile Serrated Polyps

• These are hard to detect

via colonoscopy and not detectable by FIT

Pro Colonoscopy - Cost, Convenience and Opportunity

• Colonoscopy if normal needs be done only
• nce every 10 years; may be advantageous for

hard to reach populations (remote areas)

• Heitman et al in 2010 showed FIT to be most

cost effective strategy for CRC screening of average risk individuals (Canadian costing)

• However, if administrative costs >$50 per case,

colonoscopy became the most cost effective model

Colonoscopy - Programmatic vs. Opportunistic Screening

• Programmatic screening felt to be the best

approach by most experts

• USA has opportunistic model with colonoscopy

as the primary strategy

• They have one of the highest participation

rates in the world and the largest yearly decline in CRC incidence and mortality (annual decreases of 3-4%/year since 2000)

Pro Colonoscopy- Does One Size FIT all?

• Are we trying to provide population centred

care or person centred care?

• Does patient preference play a role?
• Should we promote colon cancer screening,

have a great FIT program and (not or) offer colonoscopy screening to those who prefer this method?

• Target higher risk groups (Smokers, African

Canadians) and those most likely to benefit and less likely to be harmed for colonoscopy i.e. younger populations

Pro Colonoscopy – Conclusion

• Colonoscopy is the best way to screen for CRC
• Better accuracy, more opportunity for

prevention

• Finds Sessile Serrated Polyps; FIT doesn’t
• Opportunistic screening can be effective and

should be combined with population based FIT screening

• Patient should be involved in the choice
• May be more cost effective

DEBATE

Pro Fecal Immunochemical Test (FIT)

Pro FIT – As good as Colonoscopy

• Large RCT in Spain
• Ages 50 – 69 yrs old
• *FIT Q 2 yrs versus one-time colonoscopy
• Mailed invitation to participate
• Primary outcome: CRC-death at 10 yrs

Quintero E., et. al., NEJM 2012;366:697-706

*Selected cut-off: 75 ng Hb/ml

Evidence

Pro FIT – As good as Colonoscopy

26,599 invited for FIT

Quintero E., et. al., NEJM 2012;366:697-706

26,703 invited for colonoscopy 36% responded 28% responded

8983 completed FIT 4953 completed colonoscopy

23% offered colonoscopy

• pted for FIT

1% offered FIT

• pted for colonoscopy

Overall FIT participation: 34.2%

P<0.001

Overall c’scope participation: 24.6%

P<0.001

Pro FIT- As good as Colonoscopy

Colonoscopy (n=26,703) FIT (n=26,599) P-value CRC 30 33 N.S. Advanced adenoma 514 231 <0.001 # needed to screen to find 1 CRC 191 281 # needed to scope to find 1 CRC 191 18 Complication rate 24 10 <0.001

Quintero E., et. al., NEJM 2012;366:697-706

N.S. Not significant

Diagnostic Yield – Intention to Screen

Pro FIT- As good as Colonoscopy

• FIT has 40+% Advanced Adenoma detection

rates

• Improved sensitivity of FIT vs FOBT makes it a

good test to detect advanced adenomas as well, particularly if repeated at biannual intervals

Other Evidence

Pro FIT - Risk of Harm with Colonoscopy

• Consider…
• 95% of people being screened will never die of

CRC

• These people can only be harmed by screening
• Even very small risks can expose large groups to

harm

• Should we start with the most invasive test first?

Primum Non Nocere

Pro FIT - Risk of Harm with Colonoscopy

Colonoscopy Associated Complications

Pooled* N= 97,091 Ontario N= 67,632 Bleeding 1.64/1000 101 Perforation 0.85/1000 40 Death N/A 5

Rabeneck L., et. Al., Gastroenterology 2008; 1899-1906.

Pro FIT – Patient Preference

26,599 invited for FIT Quintero E., et. al., NEJM 2012;366:697-706 26,703 invited for colonoscopy 36% responded 28% responded

8983 completed FIT 4953 completed colonoscopy

23% offered colonoscopy

• pted for FIT

1% offered FIT

• pted for colonoscopy

Pro FIT – Patient Preference

• Simple, easy to collect and no dietary

restrictions, as compared to FOBT

• Completed from the comfort of home
• No visit to hospital for a screening test or

having to take a day off work

• No arduous prep, as compared to colonoscopy

Pro FIT – Primary Care Preference

34

CCSC 2015; courtesy of Dr Bob Hilsden

FIT introduced Nov 2013

500 1000 1500 Jan/13 Apr Jul Oct Jan/14 April July Oct Month gFOBT+/FIT+ Average Risk for CRC

Figure 3: 2013-14 Monthly Referral Volumes

Monthly referral for colonoscopy, 2013-2014

Market Forces of Alberta FIT Roll Out

Pro FIT – Cost and Value

10 20 30 40 50 60 70 80 90 100

Average Risk FIT+ Percentage

Cancer Low risk adenoma Low risk adenoma Advanced adenoma

Advanced adenoma

Cancer

Lesions Detected at Colonoscopy

Normal Normal

Pro FIT - FIT+ Colonoscopy Outcomes

Pro FIT – Conclusion

• FIT is the best test for population based CRC

screening

• Easy for patients, higher participation (reach more

people, more effective, prevent more CRC deaths)

• Highest yield - targets those most likely to benefit

from a colonoscopy

• Lowest cost - both cost effective and less potential

for harm

• Best suited for a centralized population based

screening program –best opportunity to reach all communities and populations (diversity)

DEBATE

Panel Discussion and Audience Q & A

DEBATE

Thank you

Check out the FIT HUB for Primary Care at: https://archive.cancercare.on.ca/fithub?redirect= true