Dr. Murphy presents slides discussing general screening trends in the US, including how the US compares to other countries, different screening modalities, and differences in screening by: -Age -Gender -Geography -Race/Ethnicity

1. Colorectal cancer screening trends in the U.S.
Caitlin C. Murphy, PhD, MPH
Department of Population & Data Sciences
UT Southwestern Medical Center
Fight CRC
Monday, October 26, 2020
@caitlincmurphy

2. What are the overall trends in colorectal cancer incidence and mortality?
What tests are available for colorectal cancer screening?
What do guidelines recommend for persons at average risk?
How many people in the U.S. are up-to-date with screening?
What is the impact of disparities in screening on incidence and mortality?
My agenda for today
2

3. What are the overall trends in colorectal cancer incidence and mortality?
What tests are available for colorectal cancer screening?
What do guidelines recommend for persons at average risk?
How many people in the U.S. are up-to-date with screening?
What is the impact of disparities in screening on incidence and mortality?
My agenda for today
3

4. Overall, declining rates of colorectal cancer incidence and mortality
4
0
10
20
30
40
50
60
1992 1996 2000 2004 2008 2012 2016
Rateper100,000
New Cases
Deaths
SEER 13 Incidence & U.S. Mortality 1992-2016, Age-Adjusted

5. Dramatic declines in incidence rates among older adults
5
0
100
200
300
400
500
600
20 25 30 35 40 45 50 55 60 65 70 75 80 85
Incidenceper100,000
1985-89 2012-16
Murphy CC et al., Clin Gastroenterol Hepatol 2017; 15(6):903-9

6. Dramatic declines in incidence rates among older adults
6
0
100
200
300
400
500
600
20 25 30 35 40 45 50 55 60 65 70 75 80 85
Incidenceper100,000
1985-89 2012-16
Murphy CC et al., Clin Gastroenterol Hepatol 2017; 15(6):903-9

7. Dramatic declines in incidence rates among older adults
7
0
50
100
150
200
250
300
350
1992 1995 1998 2001 2004 2007 2010 2013 2016
Incidenceper100,000
20-49 50-64 65+
Surveillance, Epidemiology, and End Results Program (www.seer.cancer.gov): Incidence - SEER Research Data, 13 Registries, 1992-2017

8. And dramatic declines in mortality rates
8
0
20
40
60
80
100
120
140
160
1992 1995 1998 2001 2004 2007 2010 2013 2016
Deathsper100,000
20-49 50-64 65+
Surveillance, Epidemiology, and End Results Program (www.seer.cancer.gov): Mortality - All COD, Total U.S., 1990-2018

9. What are the overall trends in colorectal cancer incidence and mortality?
What tests are available for colorectal cancer screening?
What do guidelines recommend for persons at average risk?
How many people in the U.S. are up-to-date with screening?
What is the impact of disparities in screening on incidence and mortality?
My agenda for today
9

10. What tests are available for colorectal cancer screening?
10
Direct visualization
Allows direct examination of colorectum
Often more invasive
Can identify and remove precancerous lesions
Colonoscopy, sigmoidoscopy, CT colonography
Stool-based tests
Easy, non-invasive
Screen for blood or biomarkers in stool
If positive, may need another test
FOBT, FIT, FIT-DNA

11. What tests are available for colorectal cancer screening?
11
Colonoscopy
Invasive, requires conscious sedation or anesthesia
Doctor uses a long, flexible tube with a light at the end
Examines the entire colorectum
Must clean or “prep” colorectum in advance of test
Can identify and remove precancerous lesions
If normal, complete every 10 years

12. What tests are available for colorectal cancer screening?
12
Sigmoidoscopy
“Mini” colonoscopy
Only examines the lower part of the colon and rectum
Less invasive, less complex preparation, less sedation
Can identify and remove precancerous lesions but may
require follow-up with colonoscopy
If normal, complete every 5 years

13. What tests are available for colorectal cancer screening?
13
CT colonography or virtual colonoscopy
CT scan provides 2-D and 3-D image of the coloretcum
Less invasive but still must clean or “prep” colorectum in advance of test
Positive tests (40%) must be followed by colonoscopy
If normal, complete every 5 years

14. What tests are available for colorectal cancer screening?
14
Fecal occult blood test (FOBT) or fecal immunochemical test (FIT)
Stool-based test done at home
Non-invasive
Looks for small amount of blood that may be a sign of cancer
Positive tests (5%) must be followed by colonoscopy
If normal, complete every 1-2 years

15. What tests are available for colorectal cancer screening?
15
FIT-DNA (Cologuard)
Stool-based test done at home
Non-invasive
Looks for small amount of blood that may be a sign of cancer PLUS pre-cancer and cancer biomarkers
Positive tests (15%) must be followed by colonoscopy
 If normal, complete every 3 years

16. What tests are available for colorectal cancer screening?
16
Double contrast barium enema
Less invasive
Takes x-rays of colorectum
Barium, a silver-white metallic compound, is used to outline the colorectum on the x-ray
No sedation required but still must clean or “prep” colorectum
Positive tests must be followed by colonoscopy
If normal, complete every 5-10 years
Not routinely available

17. What are the overall trends in colorectal cancer incidence and mortality?
What tests are available for colorectal cancer screening?
What do guidelines recommend for persons at average risk?
How many people in the U.S. are up-to-date with screening?
What is the impact of disparities in screening on incidence and mortality?
My agenda for today
17

18. What do the guidelines recommend for persons at average risk?
18
Age to start screening
Age to stop screening
Recommended tests
Other considerations

19. What do the guidelines recommend for persons at average risk?
19
USPSTF
Age to start screening 50
Age to stop screening 75
Recommended tests
FIT/FOBT,
colonoscopy,
sigmoidoscopy,
CT colonography,
FIT-DNA
Other considerations
“Offer the test
that will get done”

20. What do the guidelines recommend for persons at average risk?
20
USPSTF
Multi-Society
Task Force
Age to start screening 50 50
Age to stop screening 75 75
Recommended tests
FIT/FOBT,
colonoscopy,
sigmoidoscopy,
CT colonography,
FIT-DNA
FIT, colonoscopy
(Tier 1)
Other considerations
“Offer the test
that will get done”
Screening at age
45 for Black
persons

21. What do the guidelines recommend for persons at average risk?
21
USPSTF
Multi-Society
Task Force
American
College of
Physicians
Age to start screening 50 50 50
Age to stop screening 75 75 75
Recommended tests
FIT/FOBT,
colonoscopy,
sigmoidoscopy,
CT colonography,
FIT-DNA
FIT, colonoscopy
(Tier 1)
FIT/FOBT,
colonoscopy,
sigmoidoscopy,
CT colonography,
FIT-DNA, barium
enema
Other considerations
“Offer the test
that will get done”
Screening at age
45 for Black
persons

22. What do the guidelines recommend for persons at average risk?
22
USPSTF
Multi-Society
Task Force
American
College of
Physicians
American
Cancer Society
Age to start screening 50 50 50 45
Age to stop screening 75 75 75 75
Recommended tests
FIT/FOBT,
colonoscopy,
sigmoidoscopy,
CT colonography,
FIT-DNA
FIT, colonoscopy
(Tier 1)
FIT/FOBT,
colonoscopy,
sigmoidoscopy,
CT colonography,
FIT-DNA, barium
enema
FIT/FOBT,
colonoscopy,
sigmoidoscopy,
CT colonography,
FIT-DNA
Other considerations
“Offer the test
that will get done”
Screening at age
45 for Black
persons
Qualified
recommendation
to start at age 45

23. What are the overall trends in colorectal cancer incidence and mortality?
What tests are available for colorectal cancer screening?
What do guidelines recommend for persons at average risk?
How many people in the U.S. are up-to-date with screening?
What is the impact of disparities in screening on incidence and mortality?
My agenda for today
23

24. Behavioral Risk Factor Surveillance System (BRFSS)
Telephone surveys that collect information about health-related risk behaviors, chronic health
conditions, and use of preventive service
Collects data in all 50 U.S. states, D.C., and three territories
More than 400,000 surveys each year
National Health Interview Survey (NHIS)
Household (in-person) interviews collect information about a broad range of health topics
Collects data in all 50 U.S. states and D.C.
About 30,000 adult and 9,000 child interviews each year
How do we measure colorectal cancer screening in the U.S. ?
24

25. 0
10
20
30
40
50
60
70
80
90
100
2000 2003 2005 2010 2015 2018
%up-to-datewithscreening
Any recent CRC test
Increasing uptake of colorectal cancer screening
25
National Health Interview Survey (https://www.cdc.gov/nchs/nhis), 2000 – 2018

26. 0
10
20
30
40
50
60
70
80
90
100
2000 2003 2005 2010 2015 2018
%up-to-datewithscreening
Any recent CRC test COL past 10 years
Increasing uptake of colorectal cancer screening
26
National Health Interview Survey (https://www.cdc.gov/nchs/nhis), 2000 – 2018

27. 0
10
20
30
40
50
60
70
80
90
100
2000 2003 2005 2010 2015 2018
%up-to-datewithscreening
Any recent CRC test COL past 10 years FOBT past year
Increasing uptake of colorectal cancer screening
27
National Health Interview Survey (https://www.cdc.gov/nchs/nhis), 2000 – 2018

28. Lag behind other screening tests (e.g., mammogram) and national goals
Barriers: cost, time required, lack of awareness, fear/embarrassment, access
Important difference by age, sex, race/ethnicity, poverty and income, insurance type, education, and
geography
Still a lot of work to do!
28

29. 0
10
20
30
40
50
60
70
80
90
100
2014 2016 2018
%up-to-datewithscreening
50-59 60-69 70-75
Lower screening uptake among 50-year-olds
29
Behavioral Risk Factor Surveillance System (https://www.cdc.gov/brfss), 2014 – 2018

30. Differences in screening uptake among women vs. men
30
74.0% of women up-
date-with screening
66.3% of men up-
date-with screening
Behavioral Risk Factor Surveillance System (https://www.cdc.gov/brfss), 2014 – 2018

31. 0
10
20
30
40
50
60
70
80
90
100
2008 2010 2012 2014 2016
%up-to-datewithscreening
NH White NH Black Hispanic Asian
Racial/ethnic disparities in screening persist over time
31
May FP et al., Clin Gastroenterol Hepatol 2020; 18(8):1796-1804

32. 0
10
20
30
40
50
60
70
80
90
100
Category 1
English Spanish
A closer look at disparities in screening among Hispanic persons
32
0
10
20
30
40
50
60
70
80
90
100
English Spanish
Colonoscopy only FIT or FOBT only Sigmoidoscopy Multiple
Viramontes O et al., Prev Med 2020; 138:106146

33. 0
10
20
30
40
50
60
70
80
90
100
2010 2018
%up-to-datewithscreening
Poor Near poor Not poor
Striking differences in screening uptake by neighborhood poverty level
33
National Health Interview Survey (https://www.cdc.gov/nchs/nhis), 2000 – 2018

34. 25%
73%
69%
47%
63%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Uninsured
Military coverage
Medicare
Medicaid or other public
Employer-sponsored
% up-to-date with screening
Low screening uptake among uninsured and Medicaid-insured
34
de Moor JS et al., Prev Med 2018; 112:199-206

35. 0
10
20
30
40
50
60
70
80
90
100
Men Women
%up-to-datewithscreening
Less than high school High school graduate Some college College graduate
Screening up-to-date decreases with educational attainment
35
Hall IJ et al., Prev Chronic Dis 2018; 15:E97

36. Geographic differences in screening uptake
36
Behavioral Risk Factor Surveillance System (https://www.cdc.gov/brfss), 2014 – 2018

37. What are the overall trends in colorectal cancer incidence and mortality?
What tests are available for colorectal cancer screening?
What do guidelines recommend for persons at average risk?
How many people in the U.S. are up-to-date with screening?
What is the impact of disparities in screening on incidence and mortality?
My agenda for today
37

38. Higher colorectal cancer mortality rates in Southeast and Appalachia
38
Naishadham D et al., Cancer Epidemiol Biomarkers Prev 2011; 20(7):1296-1302

39. 0
10
20
30
40
50
60
70
80
90
100
1992 1995 1998 2001 2004 2007 2010 2013 2016
Incidenceper100,000
NH White NH Black
Persistently higher colorectal cancer incidence rates in Black persons
39
Surveillance, Epidemiology, and End Results Program (www.seer.cancer.gov): Incidence - SEER Research Data, 13 Registries, 1992-2017

40. 0
10
20
30
40
50
60
70
NH White NH Black
%ofdiagnoses
Local Regional Distant
Higher proportion of Black persons diagnosed with late stage disease
40
Surveillance, Epidemiology, and End Results Program (www.seer.cancer.gov): Incidence - SEER Research Data, 13 Registries, 1992-2017

41. 0
10
20
30
40
50
60
70
NH White NH Black
%ofdiagnoses
Local Regional Distant
Higher proportion of Black persons diagnosed with late stage disease
41
19.8%
25.4%
Surveillance, Epidemiology, and End Results Program (www.seer.cancer.gov): Incidence - SEER Research Data, 13 Registries, 1992-2017

42. Higher stage-specific mortality among Black persons
42
Robins AS et al., J Clin Oncol 2012; 30(4):401-5

43. 0
5
10
15
20
25
Incidenceper100,000
Less than HS High school
Some college College degree
Post-graduate degree
Differences in colorectal cancer incidence by education and poverty
43
Doubeni CA et al., Cancer 2013; 118(14):3636-44

44. 0
5
10
15
20
25
Incidenceper100,000
Less than HS High school
Some college College degree
Post-graduate degree
Differences in colorectal cancer incidence by education and poverty
44
40%
difference in
incidence
rates
Doubeni CA et al., Cancer 2013; 118(14):3636-44

45. Differences in colorectal cancer incidence by education and poverty
45
0
5
10
15
20
25
Q1 (least deprived) Q2 Q3 Q4 Q5 (most deprived)
Doubeni CA et al., Cancer 2013; 118(14):3636-44

46. Differences in colorectal cancer incidence by education and poverty
46
0
5
10
15
20
25
Q1 (least deprived) Q2 Q3 Q4 Q5 (most deprived)
20%
difference in
incidence
rates
Doubeni CA et al., Cancer 2013; 118(14):3636-44

47. Overall, colorectal cancer incidence and mortality rates are decreasing
Many tests are recommended for average-risk colorectal cancer screening – “do the test that gets done”
Screening uptake has increased in the U.S. but lags behind other cancer screening tests
Marked disparities in screening by age, sex, race/ethnicity, poverty and income, insurance type,
education, and geography
Disparities in screening contribute to disparities in incidence, stage at diagnosis, and mortality
Summary
47

48. Population impact of colorectal cancer screening
48
2020 2030
Incidence rates
decrease by
17%
Incidence rates
decrease by
22%
= 277,000 total cases
averted
Mortality rates
decrease by
19%
Mortality rates
decrease by
33%
= 203,000 total deaths
averted
Meester RG et al., Cancer 2015; 121(13):2281-5

49. Thank you!
Caitlin C. Murphy, PhD, MPH
Department of Population & Data Sciences
caitlin.murphy@utsouthwestern.edu
(214) 648-9551
@caitlincmurphy
49

51. 0
5
10
15
20
25
30
35
40
US Born Foreign Born
%colorectalcancerdeaths
Q1 (high poverty) Q2 Q3 Q4 Q5 (no poverty)
51
Tao L et al., Cancer 2014; 120(22):3510-8