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 3 rd 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 • Developed and implemented • Other options (outside of by Cancer Care Ontario CCC) for CRC screening: • Men and women aged 50 – 74, who are at average risk of colorectal cancer should be o Flexible Sigmoidoscopy screened using the Fecal Occult Blood Test (FOBT) every 2 years o Colonoscopy • 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 Benefits of FIT • • Limited uptake from primary care Better test (sensitivity, specificity) • providers and endoscopists Higher participation rates in • Limited buy in from public due to dietary programmatic screening are expected restrictions and number of samples (one sample, no dietary restrictions, required primary care uptake)

Introduction - Background Advantages of FIT versus FOBT • Easier to collect Better usability • No dietary restrictions 16% IMPROVEMENT in • One specimen participation over gFOBT • Less stool contact • Great for detecting advanced adenomas • Better than gFOBT at detecting cancer • Simple, safe and accessible

Introduction – Accuracy FIT vs. FOBTg Sensitivity Specificity FIT 1 82% 94% (n=19 studies) gFOBT 2 47.1% 96.1% (n=9 studies) FIT has improved sensitivity with minimal loss of specificity 1 Lee J, et al. Ann Intern Med 2014;160:171-181. 2 Canadian 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 Opportunistic Screening Screening Offered systematically to Offered to an individual all individuals in defined without symptoms of the target group within a disease when he/she framework of agreed presents to a healthcare policy, protocols, quality provider for reasons management, monitoring unrelated to that disease and evaluation E.g. CCC Program, FOBT

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 FIT 1 82% 94% (n=19 studies) Colonoscopy 94.7% 99.8% (Ir J Cancer prevention, 2011) FIT less accurate for colon cancer, even worse for advanced adenomas 1 Lee J, et al. Ann Intern Med 2014;160:171-181. 2 Canadian Task Force on Preventive Health Care. Screening for Colorectal Cancer. 2014.

Pro Colonoscopy- Diagnostic Yield Patients that Agree to Screening Colonoscopy FIT (n=4953) (n=8983) CRC 30 18 Advanced adenoma 514 127 Quintero E., et. al., NEJM 2012;366:697-706

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 once 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? o 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 Evidence • 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 *Selected cut-off: 75 ng Hb/ml Quintero E., et. al., NEJM 2012;366:697-706

Pro FIT – As good as Colonoscopy 26,703 26,599 invited for colonoscopy invited for FIT 36% responded 28% responded 23% offered colonoscopy 1% offered FIT opted for FIT opted for colonoscopy 8983 completed 4953 completed FIT colonoscopy Overall c’scope participation: 24.6% Overall FIT participation: 34.2% P<0.001 P<0.001 Quintero E., et. al., NEJM 2012;366:697-706

Pro FIT- As good as Colonoscopy Diagnostic Yield – Intention to Screen Colonoscopy FIT P-value (n=26,703) (n=26,599) CRC 30 33 N.S. Advanced adenoma 514 231 <0.001 # needed to screen to 191 281 find 1 CRC # needed to scope to 191 18 find 1 CRC Complication rate 24 10 <0.001 N.S. Not significant Quintero E., et. al., NEJM 2012;366:697-706

Pro FIT- As good as Colonoscopy Other Evidence • 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

Pro FIT - Risk of Harm with Colonoscopy Primum Non Nocere • 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 o Should we start with the most invasive test first?

Pro FIT - Risk of Harm with Colonoscopy Colonoscopy Associated Complications Pooled* Ontario N= 97,091 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 26,703 26,599 invited for colonoscopy invited for FIT 36% responded 28% responded 23% offered colonoscopy 1% offered FIT opted for FIT opted for colonoscopy 8983 completed 4953 completed FIT colonoscopy Quintero E., et. al., NEJM 2012;366:697-706