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CDC Vital Signs: Colorectal Cancer Screening, Incidence, and Mortality

Tuesday, July 5, 2011 – 12:00pm ET

Operator: Welcome and thank you for standing by. At this time, all participants are in a listen-only mode. During the question and answer session today, you may press star 1 to ask a question. Today's conference is being recorded, and I'm going to turn the call over to Mr. Tom Skinner.

Tom Skinner: Thank you, Shirley, and thank you all for joining us today for the latest release of CDC's Vital Signs report. This one is on colorectal cancer screening, incidence and mortality for the U.S. 2002-2010. With us today is the director of the CDC, Dr. Thomas Frieden. And also with us today is Dr. Lisa C. Richardson who is the associate director for science in the Division of Cancer Prevention and Control. Dr. Frieden is going to provide a few opening remarks, and then we will get to your questions. So without further adieu, Dr. Frieden.

Thomas Frieden: Thank you very much for joining us this afternoon. The news we have is good news today. Colon cancer deaths are down significantly and even more progress is possible. Colon cancer remains the leading cause of cancer death in nonsmokers in this country, but most colon cancer can be prevented. We've seen a remarkable increase in the level of screening until now. Nearly two-thirds of Americans were screened by 2010. However, there were still 22 million people in the age group of 50 to 75 who should have been screened, would have benefited from screening and weren't screened. Colon cancer is largely preventable. Because of the increased screening, as well as other improvements in our health system and health status, colon cancer rates have decreased by more than 10 percent over the past five years. This decrease accounts for nearly 66,000 fewer people who got colon cancer and more than 30,000 people who didn't die from colon cancer who would have died otherwise. About half of both of those decreases were because of increased colon cancer screening. If you are between 50 and 75 years of age, or at high risk for colon cancer because of a strong family history or other reasons, you should get screened for colon cancer and you should discuss with your doctor the various ways to do that. Essentially there are three. One, a blood – test for blood in the stool that is done at home every year. Second, is flexible sigmoidoscopy that's done every five years along with the blood – the test for blood in stool or a colonoscopy which doesn't need to be done, if it's normal, more than every ten years.

The proportion of Americans who are getting screened for colon cancer has increased very dramatically in recent years, but we're concerned it may be beginning to level off. So we do need to continue to improve the proportion of people, or increase the proportion of people who are tested for colon cancer. One of the unique things about both sigmoidoscopy and colonoscopy is that not only does it diagnose the risk for cancer, but in a colonoscopy at the time you can remove the polyps and prevent that cancer from happening. So it's not only a screening test but a preventive intervention. And that's very important for people to understand. Not only does colon cancer kill more than 50,000 Americans every year but colon cancer is costly. The treatment is costly. The estimated direct medical costs of colorectal cancer care was more than $14 billion in 2010, and, of course, the tragic deaths from colon cancer also deprive our society of the productivity that could be accrued by those people continuing to work and be productive in society.

There have been important advances not only in understanding what works for colon cancer screening but also what works for health care providers to do a better job getting people screened. Systems in doctors' offices and health centers to track who has been screened and who hasn't been screened, reminders going out, systems changed to make it easier for people to get colon cancer screening without going through multiple steps. And of course, the Affordable Care Act will eliminate co-payments for new health insurance programs and co-payments can be quite substantial. So we think this will also help increase the number of people who get screened for colon cancer and have colon cancer prevented. Doctors, nurses and other health care providers can do a lot by making colon cancer screening routine.

The largest single risk factor for not being screened for colon cancer is someone's doctor not recommending that they be screened. So doctors have a lot to do, and individuals have a lot to do to make sure that they follow up on appointments and identify what services are available to them. Again, everyone age 50 to 75 should be screened for colorectal cancer. If you are younger than 50 and have a strong family history or other risk factors for colon cancer at a young age, you should be screened as well. I will say for myself that I turned 50 a few months ago, but I do have a strong family history of colorectal cancer, so I did have a colonoscopy at age 40. It was entirely normal. At age 50, I had another colonoscopy. I had four polyps, two of them large. All of them removed before they became cancerous. If I hadn't had a colon cancer screening, I could well be dead in another 10 or 15 years. Now I anticipate I will never have colon cancer because I will continue to get follow-ups to ensure that if there are growths to have them removed before they become cancerous. That's what I hope every American has the ability to have. Every American has access to and takes advantage of colon cancer screening so that we can see the number of colon cancer cases and deaths continue to fall substantially. With that, I'll close and open it up for questions.

Tom Skinner: Shirley, we're ready for questions, please.

Operator: Thank you. We will now begin the question and answer session. If you would like to ask a question, please press star 1 and record your name clearly. Again, press star 1 to ask a question. And one moment for our first question. One moment please. Our first question is from Bill Hendrick with WebMD. You may ask your question.

Bill Hendrick: Hello, doctor. I'm a little confused. I like the age 50 better than probably every ten years better. But I've been told by doctors that I trust that one should be tested every ten years and another doctor says every five years with a colonoscopy, not sigmoidoscopy.

Thomas Frieden: For colonoscopy, the recommendation is every ten, if it's negative. If you have polyps it may well be more frequent. If you have polyps that are large it may be even more frequent. And depending on your family history—if you have a strong family history—it may be more frequent as well. It's important to discuss that with your doctor, but the general recommendation for someone who is not at elevated risk is every ten years. There is still some scientific discussion and debate about that, but that is the current recommendation.

Bill Hendrick: Thank you.

Operator: Next question from Mike Stobbe with the Associated Press. You may ask your question.

Mike Stobbe: Hi, doctor, thanks for taking the question. If you don't mind me asking, you gave a personal example that you'd been through a screening at 40 and were clean and then 50 and they – if you don't mind me asking, did you – was that last year 2010, or this year and you said four polyps, all of them removed?

Thomas Frieden: It was within the past few months. I don't remember honestly whether it was the end of '10 or early '11. I would have to look that up. But, yes, four polyps, all of them removed. Two of them rather large. But all of them – but none of them cancerous.

Mike Stobbe: Okay. Removed as just a precaution?

Thomas Frieden: Yes. When polyps are found on colonoscopy, they are removed because the natural history of polyps is they become larger. When they reach a certain size, they tend to become precancerous or cancerous and then if they grow for too long, even if they are removed, it may have already spread to the colon or other parts of the body. So that's the wonderful thing about endoscopy—that it's able to identify polyps and remove them before they become cancerous.

Mike Stobbe: Thank you.

Operator: Next question from David Beasley with Reuters. You may ask your question.

David Beasley: Yes, doctor. Two-thirds of the – who are screened and one-third are not, is that of the overall population or only of those people that actually go to the doctor? I was –

Thomas Frieden: That's of the overall population. So of every American between age 50 and 75, our data suggests that two-thirds or just about two-thirds have been screened at least once for colon cancer, but 22 million people, which is the other third have not been screened even once.

David Beasley: Okay. That one just kind of sounded high to me to think that that high a percentage of people in that age group would actually go to the doctor and then get checked, particularly when –

Thomas Frieden: Yes, and actually what we've seen is a steady increase in screening rates.

David Beasley: Okay.

Thomas Frieden: And if you look at figure one from the early release MMWR you can see really a striking increase in screening, particularly by lower endoscopy so that it's gone from, in 2002, just a little over 50 percent to now, where it's nearly two-thirds. So this is a significant progress. This is good news that we now understand that colon cancer screening can save your life and more and more Americans are taking advantage of it. And we want that increase to continue so that we can continue to drive down colon cancer rates.

David Beasley: How do you – when you hear about the large number of uninsured, that's why I'm somewhat skeptical with the numbers. You hear of millions of people without insurance at all.

Thomas Frieden: Sure. We can go over with you separately how we come up with the data. We're very confident in it. Remember that 50 to 75 includes 65 to 75 and most people 65 to 75 have Medicare, which will cover. For the 50 to 64s, one of the things that the Affordable Care Act will do, in addition to expanding coverage more fully, is remove co-payments so that it will be easier for people to be screened without having to pay for that. But again, we can give you the basis of it. We're quite confident in the results. You can go to the next question.

Operator: Thank you. The next question comes from Richard Knox with NPR. You may ask your question.

Richard Knox: Hi. Thanks very much. Two things. One, I noticed in the report that it references a survey showing that 31 percent of respondents would choose not to be screened even if their preferred screening test was offered. That sounds like it's a big part of the problem. The great majority if not all of the people are not getting screened really don't want to be. So I wondered what you could say about that problem and how you tackle it. And secondly, a lot of variability among states in both the decline in incidents of colon cancer and the decline in the death rate. Do you have any idea why it's so variable?

Thomas Frieden: Well, first off, in terms of the first question, as more people understand that colon cancer screening can save your life, I think the resistance to being screened goes down. And as more doctors are clearer with their patients that this is really important, I've been screened, my family is being screened, I think you should be screened… that makes a big impact on patients. Again, the strongest risk factor to not being screened isn't being resistant to being screened but not being told to be screened by your doctor. So I think there's a lot that we can do in the health care system to improve screening rates. For example, some systems have made it easier for people to be directly referred. Some health systems have used fecal occult blood testing and gotten that out to people directly as an automatic measure. So they've been able to get screening levels up to 80 percent, 90 percent of their beneficiaries or even higher. So we know that health systems that focus on prevention can make a really big difference. In terms of the variability, I think there are a few things that can be said. Let me first turn that over to Dr. Richardson.

Lisa Richardson: The numbers we have in our report are age-adjusted, but there are other reasons that people may develop colon cancer or die from colon cancer, including racial/ ethnic differences, access to care at the state level. As you know, resources available in each state are quite different. A wealthy state may have more access than another; an urban area may have more access than another. So those are some of the reasons that that may be occurring.

Thomas Frieden: There are also differences in other risk factors in terms of nutrition, physical activity, smoking, all of which can affect the rate of colon cancer. So we do tend to see diseases tracking together because of those risk factors, as well as the very different levels of screening. But one thing we know is that screening works and the more people get screened, the lower the colon cancer death rates are going to go. Let's go to the next question.

Operator: Out next question comes from Mary Bro – I'm sorry, Mary Brophy Marcus from USA Today. You may ask your question.

Mary Brophy Marcus: Hi. Two questions. Does the preparation process itself, which is pretty uncomfortable from what I understand, deter people from doing this test, the cleansing, bowel cleansing process?

Thomas Frieden: Yes, I think certainly the prep, particularly for colonoscopy tends to be unpleasant and much less so than the procedure itself for which there is sedation and usually people feel nothing. But the preparation process is unpleasant. There are efforts to make it less so, but right now, that's what you have to go through. It's a whole lot less unpleasant than getting cancer.

Mary Brophy Marcus: The other question is Katie Couric, as everyone knows, is so famous for the public health awareness she's brought to colon cancer. Do you think her impact, being a high-profile person with a show that had a lot of exposure has impacted these numbers at all?

Thomas Frieden: Yes. In fact, there's something in the scientific literature that's actually called the "Couric Effect". And you can see the increase in screening rates that occurred and persisted after Katie Couric had her on-air colonoscopy. We can go to the next question.

Operator: The next question comes from Jane Norman with Congressional Quarterly. You may ask your question.

Jane Norman: Hi, thanks. My question was somewhat similar to that. I'm wondering how much public education about the process itself has made a difference in this, in addition to doctors actively making suggestions that people be tested.

Thomas Frieden: We do think that greater public awareness of the importance of colon cancer screening is quite important. There's a public/private partnership to promote awareness of colon cancer and the importance of colon cancer screening. CDC also has a colon cancer prevention program, where we fund states around the U.S. to increase both public education and the effectiveness of health care systems and ensuring that people get screened and if they are positive, get followed up to get the care that they need. There are many cancer prevention and control programs in different states that have been effective in this regard and, of course, many medical providers and health care systems have done a lot to improve their care. So there's a lot that can be done on the public education front, on the medical practice front and on the structure of health care front. Things like eliminating co-payments for colon cancer screening and putting in place reminder systems and tracking systems for health care providers to ensure that they offer and help facilitate all of their patients to be screened.

Jane Norman: If I could just ask as a follow-up, the funding in particular at the CDC that's provided these programs. Is that intact? Is there any risk to that funding?

Thomas Frieden: In 2011, CDC experienced an 11 percent decline to our budget authority, reduction of about $740 million. So far the colorectal cancer prevention program has not been cut, but we'll see what happens in fiscal '12 and fiscal '13. Go to the next question.

Operator: Next question comes from Stacey Singer with the Palm Beach Post. You may ask your question.

Stacey Singer: Hi. Thanks for taking the question. In my community, there are urgent care clinics that are promoting and selling in-office fecal occult tests, and I have heard that a single one of these tests is really useless. And so I wonder if you could address the extent to which these in-office tests are valid or give false negatives. Thank you.

Lisa Richardson: The in-office tests – I'm sorry. This is Lisa Richardson. With the fecal occult blood testing or blood testing on stools you need multiple samples to verify that you have a positive or to verify that you have a negative. In in-office FOBT is, on one occasion, not sufficient for detecting colorectal cancer—and is not currently in any recommendations.

Stacey Singer: Is it paid for by Medicare?

Lisa Richardson: I don't know the answer to that question. We can get back to you.

Thomas Frieden: We'll take two more questions.

Operator: Thank you. Next question is from Heidi Splete with Internal Medicine News. You may ask your question.

Heidi Splete: Hello. Thank you for taking my question. This is a bit of a follow-up on the systems in place and what health care providers can do. I was wondering whether any of your data suggest that increased use of medical – electronic medical records either has or potentially will in the future, make it easier to set up these reminders and maybe get even more people in for screening that way.

Thomas Frieden: There's certainly enormous potential of electronic health records to improve adherence to preventative recommendations. For example, registry systems which are now required for the meaningful use criteria allow providers—really with the click of a mouse—to pull out the names and information of everyone who is at risk for colon cancer, who hasn't been screened yet, and then to send them as the patient prefers, an e-mail or letter or do a phone call as a service to patients. It also allows tracking of people at high risk who may need more frequent follow-up to make sure that they get the follow-up tests. So, absolutely major potential to further improve, and it's one of the examples of what practices can do to improve colon cancer screening. It's a high-tech way of doing that. But there are also high-touch ways of improving colon cancer screening by talking to patients, by addressing any concerns they may have about the process, by exploring different options for different screenings that could be done. So all of these are quite important to improve the health care system and get more health value for the health dollars that we're spending.

Heidi Splete: Thank you.

Operator: Next question comes from Miriam Falco with CNN Medical News. You may ask your question.

Miriam Falco: Hi, Dr. Frieden. Thanks for taking our questions. You talked about your personal experience and you certainly had the incentive. And two-thirds of the Americans who should be getting colonoscopies either have been convinced by Katie Couric or family members, et cetera. And we talked about this a little bit. But one-third isn't going yet. What could you say – I think there are a lot of myths about how painful or difficult this might be. You are knocked out when this is happening. You don't even feel it. What practical tips would you give? How would you convince this one-third that may never be convinced to go because they don't want to go to the doctor in the first place?

Thomas Frieden: Well, I think the best person to convince them is their own personal physician. But what I would say to a patient is, do it once because what you don't know not only can hurt you but might kill you. This is a way of finding out what's going on. It's the only way, if someone is absolutely not willing to do a colonoscopy or sigmoidoscopy then, by all means, do the three FOBTs. But if you've got blood in your stool on a fecal occult blood test, then by all means, get a colonoscopy. It's much better to know and do something about it because this really is a case where if you find it early enough, you can prevent cancer. And, yes, there's no doubt that the prep is unpleasant. As unpleasant as getting a case of food poisoning pretty much. And that's not pleasant. And that happens many times a year to Americans. But it's, again, a whole lot more unpleasant to have the pain of cancer and to die young from a preventable illness.

Tom Skinner: I think we have time for one more question.

Operator: Thank you. Our final question from Amy Burkholder with CBS News. You may ask your question.

Amy Burkholder: Hi, Dr. Frieden. Thank you. My question dovetails with what you were just saying. Having covered the University of Washington longevity report several weeks ago it was pretty dismal. And I guess I have to say, what is CDC doing to expand the conversation beyond health care systems and screening to these prevention messages for these preventable cancers?

Thomas Frieden: CDC does quite a bit to focus on prevention in terms of the risk factors, as well as the screening. So there's tobacco control. CDC hosts the Office of Smoking and Health for Health and Human Services, and we work closely with the Food and Drug Administration and others. We support state and local governments to reduce tobacco use and, of course, quitting smoking not only reduces your risk of lung cancer but also colon cancer and heart attack and stroke and a whole host of health problems in yourself and those around you. Improved nutrition is critically important and we work, including through the Community Transformation Grants that were announced just last month and will be awarded in the next few months to have communities take steps to improve nutrition. This will not only reduce obesity and heart disease and stroke but also reduce the risk of colon cancer and then colon cancer screenings specifically. We work with states throughout the U.S., health care providers and other parts of the federal government to focus on the general efforts to promote prevention, as well as the specific efforts to increase screening for colon cancer. Because colon cancer is one disease which is overwhelmingly preventable. And by increasing screening, we can drive rates down so that the number of people dying from colon cancer continues to fall and fall substantially.

The bottom line in closing is that colon cancer can be prevented. Screening is highly effective. And by preventing colon cancer, we can help people live longer, healthier, more productive lives while reducing health care costs associated with treatment of colon cancer. I want to thank you all for joining us and for your interest in this very important topic. And look forward to talking to you in the future as well. Thank you.

Operator: Thank you. And this does conclude today's conference. We thank you for your participation. At this time, you may disconnect your line.

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