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GOOD AFTERNOON
I'M JOHN ISKANDER.
WELCOME TO THE JULY 2013 SESSION OF CDC PUBLIC GRAND ROUNDS.
CONTINUING EDUCATION CREDITS FOR PUBLIC HEALTH GRAND ROUNDS ARE
AVAILABLE FOR PHYSICIANS, NURSES, PHARMACISTS, HEALTH
EDUCATORS AND OTHERS. FOR MORE INFORMATION, PLEASE
CONSULT OUR WEBSITE. GRAND ROUNDS IS AVAILABLE ON
FACEBOOK, TWITTER AND YOUTUBE. WE HAVE A NEW FEATURED VIDEO
SEGMENT CALLED BEYOND THE DATA, WHICH WE POST ON OUR WEBSITE AND
ON YOUTUBE SHORTLY AFTER THE SESSION.
SCIENTIFIC ARTICLES RELEVANT TO THIS MONTH'S GRAND ROUNDS ARE
FEATURED IN THIS WEEK'S ISSUE OF SCIENCE CLIPS, WHICH IS PRODUCED
AND DISTRIBUTED IN CONJUNCTION WITH THE CDC LIBRARY.
PLEASE CONSULT THE WEBSITE FOR SUBSCRIPTION INFORMATION AND
ARTICLES WHERE AVAILABLE. WE WANTED OUR AUDIENCE TO BE
AWARE OF A SPECIAL EXHIBIT ON CANCER SURVIVORS CURRENTLY AT
THE CDC MUSEUM THROUGH THIS SEPTEMBER.
DENISE'S IMAGE AND NAME ARE USED WITH HER PERMISSION.
ON THE DAY OF BASEBALL'S ALL-STAR GAME, WE BRING YOU OUR
OWN ALL-STAR LINEUP FOR TODAY. WE NOW HAVE SOME INTRODUCTORY
REMARKS FROM THE CDC DIRECTOR, DR. TOM FRIEDEN.
>> CANCER KILLS MORE YOUNG PEOPLE IN THIS COUNTRY THAN ANY
OTHER DISEASE. EVERY YEAR, MORE THAN 1 MILLION
AMERICANS ARE DIAGNOSED WITH INVASIVE CANCER.
SCREENING TESTS CAN HELP DETECT CERTAIN CANCERS EARLY, MAKING
THEM EASIER TO TREAT OR CURE. THAT'S PARTICULARLY THE CASE FOR
CERVICAL AND COLORECTAL CANCERS WHICH OFTEN DON'T HAVE ANY EARLY
SYMPTOMS. BUT TOO FEW PEOPLE GET SCREENED,
AND THAT CAUSES AVOIDABLE SUFFERING AND PREMATURE DEATH.
PUBLIC HEALTH AGENCIES CAN INCREASE CANCER SCREENING RATES
BY WORKING WITH STATE MEDICAID PROGRAMS AND STATE INSURANCE
EXCHANGES TO HELP PROMOTE, COORDINATE AND MONITOR CANCER
SCREENING. THEY CAN ALSO CONVENE PROVIDERS,
PATIENTS, COMMUNITY ORGANIZATIONS AND OTHERS TO
DEVELOP COMMUNITYWIDE PROGRAMS TO SUPPORT PATIENTS.
THIS APPROACH CAN ALSO REDUCE DISPARITIES IN SCREENING RATES.
TODAY, PUBLIC HEALTH HAS A TREMENDOUS OPPORTUNITY.
WE CAN OFFER SCREENING TO EVERY PERSON IN THE UNITED STATES WHO
NEEDS IT. EARLY SCREENING IS AN ESSENTIAL
LIFE SAVING TOOL IN OUR FIGHT AGAINST CERTAIN CANCERS.
LET'S WORK TOGETHER TO MAKE SURE THAT SCREENING GETS DONE AND
FOLLOW UP GETS DONE, AS WELL.
OUR FIRST SPEAKER IS DR. OTIS BRAWLEY.
>> THANK YOU.
IT'S A TRUE PLEASURE TO SPEAK HERE TODAY.
I ESPECIALLY WANT TO THANK THE ORGANIZERS OF THIS EVENT BECAUSE
THIS IS A VERY WELL RUN GRAND ROUND.
I AM A CANCER DOC. I'M AN EPIDEMIOLOGIST.
I'M INTERESTED IN OUTCOMES. THESE ARE MY DISCLOSURES.
WHAT I'M GOING TO TALK TO YOU OVER THE NEXT 12 MINUTES ABOUT
IS SCREENING. I'M GOING TO TELL YOU ITS
PURPOSES AS WELL AS TALK ABOUT SOME OF THE PRINCIPALS AND GIVE
SOME REAL EXAMPLES IN SCREENING AS WE APPLY IT TO THE REAL
WORLD. THE AIMS OF SCREENING ARE
PRIMARILY REDUCTION IN CANCER RELATED MORTALITY AND
SECONDARILY REDUCTION IN CANCER RELATED MORBIDITY.
SCREENINGS CAN CAUSE INTERVENTION.
ALWAYS IMPORTANT IN ASSESSING A
SCREENING TEST IS THE BENEFIT TO HARM RATIO IN POPULATION TO BE
SCREENED. THERE ARE TESTS THAT HAVE A
SIGNIFICANT NET BENEFIT AND I'M GOING TO TALK ABOUT SOME TESTS
IN WHICH THE HARMS MAY VERY WELL OUTWEIGH ANY BENEFIT.
THE BEST WAY TO TELL IF A SCREENING TEST SAVES LIVES IS
THROUGH A PROSPECTIVE RANDOMIZED SCREENING TRIAL, WHERE PEOPLE
ARE RANDOMIZED AFTER ENTRY EITHER TO A SCREEN GROUP OR TO A
CONTROL GROUP THAT IS UNSCREENED AND THEIR MORTALITY IS WATCHED
OVER TIME. THIS REDUCES BIAS.
BIAS IS MOST REDUCED THROUGH GRANT IMMUNIZATION.
THERE ARE ALSO GOING TO BE SOME HEALTHY VOLUNTEER EFFECTS
BECAUSE PEOPLE THAT GO INTO OUR SCREENING TRIALS TEND TO BE
HEALTHIER THAN THE GENERAL POPULATION.
ONE HAS TO WORRY ABOUT DROP IN AND DROP OUT.
DROP IN IS WHEN PEOPLE WHO ARE IN THE UNSCREENED ARM DECIDE TO
GET THE SCREENING TEST. DROP OUT, OF COURSE, IS WHEN
PEOPLE WHO ARE SUPPOSED TO BE SCREENED REGULARLY DECIDE NOT TO
GET SCREENED. WE ALSO HAVE TO BE CAREFUL OF
RANDOMIZATION BY CENSUS ROLLS, WHICH HAS BECOME INCREDIBLY
IMPORTANT OR POPULAR, I SHOULD SAY, IN EUROPE WHERE THEY TAKE
LISTS OF MEN AGE 55 AND ABOVE AND RANDOMIZE THEM TO BE
SCREENED OR NOT SCREENED IN PROSTATE CANCER STUDIES, FOR
EXAMPLE. ANOTHER IMPORTANT PRINCIPAL IS
LEAD TIME BIAS. THIS IS THE REASON WHY WE DO NOT
LOOK AT SURVIVAL AS EVIDENCE OF SCREENING BENEFIT.
WE LOOK AT DECLINE IN MORTALITY AND NOT SURVIVAL BECAUSE LEAD
TIME BIAS IS SIMPLY SOMEONE GETS SCREENED AND THEY ARE DIAGNOSED
EARLIER. THEY STILL MAY DIE AT THE EXACT
SAME TIME IF THEY HAD NOT BEEN SCREENED AS YOU SEE HERE AND THE
DIFFERENCE BETWEEN SOMEONE WHO IS DIAGNOSED DUE TO SYMPTOMS AND
SOMEONE WHO IS SCREENED AND DIAGNOSED IS THE LEAD TIME.
NOW, SCREENING TESTS ARE ACTUALLY BENEFICIAL WHEN THEY
HAVE A LEAD TIME LIKE THIS AND YOU ALSO KICK THE TIME TO DEATH
OUT FURTHER TO THE RIGHT. VERY, VERY IMPORTANT IN THE
CONCEPT OF SCREENING IS AN UNDERSTANDING OF CANCER BIOLOGY
AND THAT IS LESS BIAS. IF WE ACTUALLY TAKE A LARGE
POPULATION AND SCREEN THEM ANNUALLY FOR A SPECIFIC DISEASE,
SAY, FOR EXAMPLE, BREAST CANCER, OR IT CAN BE LUNG OR SERVE IX
CANCER OR PROSTATE CANCER FOR THAT MATTER, THE PEOPLE WHO ARE
GOING TO DO THE BEST ARE THE PEOPLE WHO ARE BEST AT THE
INITIAL SCREEN, THE DOWNWARD CLICK ON THE LEFT THERE.
THE POPULATION THAT IS GOING TO DO THE SECOND BEST IS THE
POPULATION DIAGNOSED AT THE SECOND, THIRD OR FOURTH SCREENED
AND THE POPULATION DOING THE WORST IS THE POPULATION IN
BETWEEN SCHEDULED SCREENS. THIS IS THE CONCEPT THAT THERE
IS VARYING BIOLOGICAL BEHAVIORS. MORE AGGRESSIVE TUMORS ARE LESS
AMENABLE TO SCREENING WHEREAS LESS AGGRESSIVE TUMORS,
SOMETIMES TUMORS THAT GROW VERY SLOWLY CAN BE EASILY PICKED UP
IN SCREENING. THERE IS A SLOW-GROWING TUMOR
CALLED AN OVER DIAGNOSIS TUMOR. THINK OF CANCER DEVELOPING IN AN
INDIVIDUAL AND THEY ARE DIAGNOSED DUE TO SCREENING,
TREAT IT AND CURED AND THEY GO ON TO DIE AT A CERTAIN TIME
LATER IN LIFE. BUT THINK OF AN IDENTICAL TWIN,
BOTH GENETICALLY AND ENVIRONMENTALLY WHO DEVELOPS
CANCER, IS NEVER DIAGNOSED OR TREATED FOR THAT CANCER, BUT
STILL GROWS OLD AND DIES OF SOMETHING TOTALLY UNRELATED TO
THE CANCER, NEVER KNOWING THAT THEY ACTUALLY HAD THE DISEASE.
NOW, THESE CANCERS THAT WOULD NOT GO ON TO CAUSE DEATH OR O R
OVERDIAGNOSIS CANCERS ARE TUMORS THAT PEOPLE FREQUENTLY DON'T
THINK ABOUT, BUT THEY DO EXIST AND THEY EXIST IN LARGE NUMBERS.
SOME STUDIES ESTIMATE THAT 60% OF LOCALLY DIAGNOSED PROSTATE
CANCERS ARE OVERLY DIAGNOSED TUMORS.
OTHERS SHOW THAT PERHAPS 50% OF RADIOLOGIC DIAGNOSED TUMORS.
IT'S IMPORTANT THAT WE ACTUALLY TALK ABOUT OUR DEFINITION OF
CANCER BECAUSE THAT'S SOMETHING THAT NEEDS TO EVOLVE.
AND THAT'S ONE OF THE REASONS WE HAVE THIS DIFFICULTY WITH
OVER DIAGNOSIS. HERE, THIS WAS A PATHOLOGIST
SHOWN IN THE MID 19th CENTURY. HE AND A NUMBER OF GERMAN
PATHOLOGISTS DID A NUMBER OF BIOPSIES WITH A LIGHT
MICROSCOPE. THEY DEFINED THE PROFILES WE USE
TODAY FOR CANCER. THESE PROFILE RES STILL USED
TODAY DESPITE SAUL OF OUR ADVANCES IN DIAGNOSIS.
LOOK AT ALL OF THE THINGS THAT WE'VE DEVELOPED OVER THE LAST
160 YEARS. TO THE POINT THAT TODAY IN A
HOSPITAL NEAR HERE, A BIOPSY IS BEING DONE ON A FIVE OR 6
MILLIMETER TUMOR IN A WOMAN'S BREAST, THE SAME STAINING THAT
VEERKAU USED IS GOING TO BE USED.
A MICROSCOPE IS GOING TO BE USED TO LOOK AT THAT BIOPSY AND THE
PATHOLOGIST IS GOING TO SAY THIS LOOKS JUST LIKE WHAT VEERKAU
SAID KILLED THAT WOMAN 150 YEARS AGO.
THIS FITS THE PROFILE OF CANCER. WHAT WE DESPERATELY NEED TODAY
IS A 21st CENTURY OF CANCER MOVING AWAY FROM THE MORPHLOGIC
DEFINITION OF CANCER. WE DO NOT KNOW IF THAT FIVE
MILLIMETER TUMOR WHICH LOOKS LIKE CANCER IS GEE NOMICILY
PROGRAMMED TO GROW, METASTASIZE, SPREAD AND CAUSE HARM.
THAT BEING SAID, THERE ARE CLEARLY SCREENING TESTS THAT
HAVE BEEN PUT TO STUDY AND HAVE BEEN SHOWN TO BE BENEFICIAL AT
THE TO HAPPEN POPULATION LEVEL, MEANING IF THEY SAVE LIVES AND
THIS IS THE FOCUS OF MUCH OF THIS GRAND ROUNDS.
THERE'S SOME SCREENING TESTS THAT HAVE BEEN FOUND TO BE
BENEFICIAL FOR CERTAIN HIGH RISKS GROWTHS.
WE'LL HAVE AN EXAMPLE OF THAT. AND THEN THERE'S SCREENING TESTS
WHERE THE EVIDENCE SHOWS THAT THE HARMS ARE CLEARLY
OUTWEIGHING THE BENEFITS. THE U.S. PREVENTIVE SERVICES
TASK FORCE IS AN INDEPENDENT PANEL OF NONFEDERAL EXPERTS IN
PREVENTION AND SCIENTIFIC REVIEW OF EVIDENCE AND THEY ARE
PRELIMINARILY RESPONSIBLE FOR HEALTH RECOMMENDATIONS BASED ON
HEALTH SCREENING RECOMMENDATIONS.
THAT BEING SAID, CONSISTENTLY DEMONSTRATED MORTALITY
DEMONSTRATIONS, A NUMBER OF STUDIES FOR COLON CANCER, A
NUMBER OF STUDIES FOR PAP NOTE WITH THE STARS THE STUDIES
THAT HAVE NOT BEEN SHOWN TO BE BENEFICIAL WITH PROSPECTIVE
RANDOMIZED TRIALS, BUT WE STILL HOLD THEM TO BE BENEFICIAL.
RECOMMENDED BASED ON RISK FACTOR ASSESSMENT IS LOGO SPIRAL CT
SCREENING. LET'S TALK NOW ABOUT COLORECTAL
CANCER SCREENING. IT IS INCREDIBLY IMPORTANT
BECAUSE AS DR. FRIEDEN SAID EARLIER, A LARGE NUMBER OF LIVES
CAN BE SAVED IF WE SIMPLY DID COLORECTAL CANCER SCREENING IN
AN AGGRESSIVE, ORGANIZED WAY. WE ESTIMATE THAT 15,000 TO
20,000 ADDITIONAL LIVES COULD BE SAVED IN THE UNITED STATES EVERY
YEAR IF THE 40% TO 45% OF THE AMERICAN POPULATION OVER THE AGE
OF 50 AND UNDER THE AGE OF 75 WHO DO NOT UNDERGO COLORECTAL
CANCER SCREENING BY ANY RECOMMENDATION RIGHT NOW WERE TO
ACTUALLY START GETTING COLORECTAL CANCER SCREENING AND
AGGRESSIVE FOLLOW-UP IN TREATMENT.
SUBSEQUENT GRAND ROUNDS SPEAKERS WILL ADDRESS WAYS TO ADDRESS
BARRIERS TO INCREASING SCREENING RATES.
IN THE CASE OF PROSTATE CANCER SCREENING, 11 OUT OF 11
RANDOMIZED TRIALS HAVE SHOWN THE HARMS OF PROSTATE CANCER
SCREENING WITH, MEANING CONSIDERABLE DIAGNOSIS AND
TREATMENT WITH NUMEROUS HARMS TO INCLUDE FEVER, SEPSIS, METAL
ANGUI ANGUISH, POOR QUALITY OF LIFE.
TWO OF THOSE STUDIES SHOW A SMALL REDUCED MORTALITY DUE TO
PROSTATE SCREENING. BUT ALL 11 TRIAL VES METHLOGICAL
LAWS. TODAY MANY ORGANIZATIONS
RECOMMEND THAT MEN UNDERSTAND THIS AND MAKE AN INFORMED
DECISION ABOUT WHETHER THEY WANT TO BE SCREENED.
CHEST X-RAY SCREENING FOR LUNG CANCER IN THE 1960s ACTUALLY
INCREASED SURVIVAL AND WAS THOUGHT TO BE A GOOD THING.
WHEN PROSPECTIVE RANDOMIZED STUDIES WERE DONE, IT WAS SHOWN
THAT IT DID NOT DECREASE MORTALITY.
INDEED, THERE WAS A TREND TOWARD AN INCREASE IN MORTALITY IN THE
SCREENED ARM VERSUS THE CONTROL GROUP.
THE NATIONAL LUNG SCREENING TRIAL, WHICH WAS DONE BY THE
CENTERS FOR -- DONE BY THE NATIONAL CANCER INSTITUTE IN THE
EARLY PART OF THIS CENTURY, RANDOMIZED 54,000 PEOPLE HAD
HIGH RISK BECAUSE OF SMOKING AND AGE, HIGH RISK OF LUNG CANCER TO
A SPIRAL CT OR A SHAM CREST X-RAY.
THIS IS DONE AT 30 SITES WITH EXPERTISE IN LUNG CANCER
TRAINING AND TREATMENT. AND AFTER TEN YEARS, IT WAS
DEMONSTRATED A 20% DECLINE IN MORTALITY IN THE SCREENED GROUP
VERSUS THE CONTROL GROUP. OF THE 27,000 OR SO PEOPLE WOULD
WERE SCREENED, THIS TRANSLATED INTO 87 FEWER DEATHS, BUT THERE
WERE STILL ABOUT 350 LUNG CANCER DEATHS.
AND VERY IMPORTANTLY, THERE WERE 16 DEATHS THAT HAD BEEN
ATTRIBUTED TO INTERVENTIONS CAUSED BY THE SCREENING.
IN THIS HIGH RISK GROUP FOR LUNG CANCER, THE BENEFIT RISK RATIO
WAS 5.4 LIVES SAVED FOR EVERY ONE LIFE LOST, 87 OVER 16 IS
5.4. THE BENEFIT RISK RATIO IN TERMS
OF PUTTING PEOPLE INTO INTENSIVE CARE UNITS AND HAVING MAJOR
COMPLICATIONS WAS EVEN LOWER, 2.7 TO 1.
AGAIN, THE AMES OF SCREENING ARE PRIMARILY REDUCTION AND
MORTALITY. SECONDARILY REDUCTION AND
MORBIDITY. SCREENING CAN CAUSE HARM.
THEREFORE, THE BENEFIT HARM RATIO SCREENING IS ALWAYS
IMPORTANT AS IS THE RISK OF THE POPULATION TO BE SCREENED.
AND WE DESPERATELY NEED A 21st CENTURY DEFINITION OF CANCER, A
WAY THAT WE CAN SAY TO A PATIENT, YOU HAVE SOMETHING THAT
LOOKS LIKE CANCER, BUT GEE NOMICILY WEBB IT IS NOT GOING TO
GROW, SPREAD AND METASTASIZE OR YOU HAVE SOMETHING THAT LOOKS
LIKE CANCER AND WE KNOW GENOMICALLY THIS IS SOMETHING WE
NEED TO TREAT BECAUSE IF IT IS NOT TREATED, IT IS ULTIMATELY
GOING TO CAUSE YOU HARM. OUR NEXT SPEAKER WILL BE DR.
RACHEL BALLARD-BARBASH. >> GOOD AFTERNOON.
IT'S A APPRECIATE MR. YOUR TO BE HERE TODAY AND TO SEE SO MANY
FACES AND TO FOLLOW ON. ONE OF MY ACCOMPLISHMENTS IN
COLLEGE WAS I WAS A SECOND BASEMAN FOR A WOMAN'S SOFTBALL
LEAGUE AND WE WON OUR LEAGUE. SO JUST TO GIVE YOU A SENSE THAT
THE WAY WE, IN FACT, ARE FOLLOWING THAT ILLUSION.
SO I WAS ASKED, WHAT CAN WE REALLY LEARN FROM CANCER
SCREENING IN INTERNATIONAL SETTINGS?
FIST, I THINK IT'S REALLY IMPORTANT, OTIS JUST FINISHED AN
EXCELLENT OVERVIEW AND A DISCUSSION OF SOME SPECIFIC
TESTS THAT HAVE BEEN EVALUATED BY A RANDOMIZED CONTROL TRIALS.
BUT WE KNOW THAT SCREEN SG A PROCESS.
IT'S NOT JUST ONE TEST. AND IT INVOLVES THE AREAS OF
ASSESSING RISK IN INDIVIDUALS AND FIGURING OUT WHO REALLY
NEEDS TO BE SCREENED, DOING SPECIFIC TESTS TO DETECT CANCER
AND THEM DOING MORE EXTENSIVE FOLLOW-UP AND DIAGNOSTIC
EVALUATION TO UNDERSTAND IF THE ABNORMALITIES DETECTED, IN FACT,
ARE CANCER AND FAILURE COMMITTEES OCCUR THROUGHOUT THAT
ENTIRE PROCESS. SO WHAT MIGHT WE LEARN FROM SOME
INTERNATIONAL MODELS OF INNOVATION?
AND SPECIFIC, THE QUESTION I WAS ASKED TO THINK ABOUT WAS HOW A
PUBLIC HEALTH APPROACHES VENUES IN OTHER COUNTRIES.
SO IT'S IMPORTANT, OF COURSE, TO UNDERSTAND THAT OTHER COUNTRIES
HAVE VERY DIFFERENT HEALTH CARE SYSTEMS.
AND FOR MANY OF THESE COUNTRIES, MOST OF THE ORGANIZED SCREENING
PROGRAMS HAVE BEEN ORGANIZED AS PUBLIC HEALTH PROGRAMS OUTSIDE
THE CONTEXT OF ROUTINE CLINICAL CARE.
AND IT'S BECAUSE OF THAT THEY HAVE VERY ACTIVE AND
COMPREHENSIVE DATA COLLECTION AND EVALUATION SYSTEMS.
AND THEY LOOK AT THAT ENTIRE SCREENING PROCESS AND A GOAL AND
OBJECTIVE OF QUALITY IMPROVEMENT, QUALITY ASSESSMENT.
THEY ALSO FOCUS VERY MUCH ON TRYING TO IDENTIFY AND INVITE
THE RELEVANT POPULATION FOR SCREENING TO LOOK AT ALL THE
PROCESSES, AS WELL AS THE OAKS. BOTH THE NEAR TERM AND THE
LONG-TERM. AND ONE OF THE INNOVATIONS
THAT'S HAPPENING NOW IN MANY COUNTRIES, PARTICULARLY WITH
ELECTRONICS SYSTEMS IS THEY ARE BUILDING TIMELY AND ACTIVE
FEEDBACK SYSTEMS TO PERSONNELS AND FACILITIES TO HELP AND
IMPROVE QUALITY. I WOULDN'T SAY ON AN IMMEDIATELY
REALTIME BASIS, BUT ON A VERY ROUTINE BASIS THAT ALLOWS PEOPLE
TO CHANGE AS THEY'RE PROVIDING CARE.
I THOUGHT IT WOULD BE HELPFUL FOR THE GROUP TO HAVE AN
UNDERSTANDING ABOUT AN EFFORT NCI HAS BEEN DIRECTING SINCE
ABOUT THE LATE 1990s. THE INTERNATIONAL CANCER
SCREENING NETWORK AND THIS WAS INITIATED TO HELP US UNDERSTAND
IF THE PROMISE OF BREAST CANCER SCREENING THAT HAD BEEN
IDENTIFIED FOR RANDOMIZED CONTROL TRIALS WAS ACTUALLY
REALIZED WHEN IT WENT INTO PRACTICE.
IT STARTED WITH 11 COUNTRIES AND WE EXPANDED THIS ABOUT SEVEN OR
EIGHT YEARS AGO TO LOOK AT SCREENING FOR MULTIPLE OTHER
CANCERS. IT INCLUDES NOW 35 COUNTRIES
AROUND THE WORLD. AND THE PURPOSE OF THIS EFFORT
IS TO USE AND COMPARE DATA FROM ORGANIZED SCREENING PROGRAMS OR
IN THE CASE OF COUNTRIES LIKE THE U.S. NATIONAL DATA ON
SCREENING WHERE THAT SCREENING MAY BE OPPORTUNISTIC IN MANY
CASES RATHER THAN ORGANIZED AND TO REALLY DEVELOP THE METHOD
THROUGH EVALUATING THE IMPACT OF THESE PROGRAMS.
WHILE RANDOMIZED CONTROL TRIALS WERE A MAJOR PROGRESS IN THE
LAST HALF OF THE LAST CENTURY, I THINK OUR PROGRESS FOR THE NEXT
HALF OF THIS CENTURY IS TO REALLY UNDERSTAND HOW DO WE USE
DATA FROM CLINICAL PRACTICE? SO YOU CAN SEE FROM THIS MAP
THAT MANY OF THE COUNTRIES THAT PARTICIPATE ARE PREDOMINANTLY
FROM EUROPE AND THE U.S. SOME FROM SOUTHEAST ASIA.
THERE'S VERY FEW IN SOUTH AMERICA OR AFRICA IN PART
BECAUSE THEY DON'T HAVE ORGANIZED PROGRAMS AND SCREENING
FOR CANCER OTHER THAN SOME CIRCUMSTANCES SUCH AS CERVICAL
CANCER HAS NOT BEEN A MAJOR AREA OF FOCUS FOR THOSE COUNTRIES.
I'M GOING TO TALK ABOUT TWO AREAS, CERVICAL CANCER AND COLON
SCREENING CANCER PROGRAM TOES GIVE YOU A SENSE OF WHAT WE'RE
LEARNING FROM THIS INTERNATIONAL LANDSCAPE OF RESEARCH.
SO IN THE CASE OF CERVICAL CANCER SCREENING, A COMPARISON
BETWEEN THE U.S. AND THE NETHERLANDS, IT'S IMPORTANT TO
LOOK AT THE PARAMETERS THAT DETERMINE HOW THESE SCREENING
PROGRAMS MOVE FORWARD. IN THE UNITED STATES, THE
ORGANIZATION IS THROUGH MEDICAL SCREENING, SEEING A PHYSICIAN.
THEY'RE OPPORTUNISTIC OR, IN FACT, THE PHRASE THAT IS USED IN
MOST OF THE REST OF THE WORLD IS WILD SCREENING.
AND IN COMPARISON TO THE NETHERLANDS, IT'S ORGANIZED
UNDER A PUBLIC HEALTH MODEL. YOU CAN SEE SIMILARLY THE
DIFFERENTS IN AGE GROUPS IN THE U.S. MUCH BROADER.
THEY DON'T HAVE UPPER AGE LIMITS, A MORE NARROW
CONSTRAINTS IN THE NETHERLANDS, MUCH MORE OFTEN RECOMMENDED
INTERVALS UNTIL VERY RECENTLY IN THE UNITED STATES COMPARED TO
THE NETHERLANDS AND DIFFERENCES IN REIMBURSEMENT.
ONE OF THE ISSUES THAT THEY MOVE FORWARD IN MANY COUNTRIES NOW
THAT HAVE ORGANIZE ONNED PROGRAMS IS THAT THEY PROVIDE
REIMBURSEMENT FOR THEIR CANCER SCREENINGS.
WE SEE HOW THAT SHIFTS WHETHER OR NOT SCREENING IS RESISTED
ACCORDING TO GUIDANCE. THIS SLIDE ABOUT THE NUMBER OF
LIFETIME PAP SMEARS THAT A WOMAN WOULD RECEIVE IF ONE FOLLOWED
DIFFERENT GUIDELINES RECOMMENDED ARE VERY IMPORTANT.
THE FIRST LINE IS FOR THE NETHERLANDS.
OVER HER LIFETIME, A WOMAN MIGHT RECEIVE OVER SEVEN PAP SMEARS IN
CONTRAST, THE RANGE IN THE UNITED STATES IS HUGE ACROSS
DIFFERENT GUIDELINES, ANYWHERE FROM ABOUT 16 TO -- OR CLOSE TO
50 DEPENDING ON THE GROUPS THAT YOU LOOK AT.
SO WE HAVE THREE TO FOUR FOLD MORE PAP SMEARS DONE IN THE
UNITED STATES THAT ARE DECREASES IN CERVICAL CANCER MORTALITY
BETWEEN THESE TWO COUNTRIES HAS BEEN NEARLY IDENTICAL.
THIS SAME STORY HAS HELD IN OTHER AREAS OF CANCER, SOMEWHAT
SIMILAR, ALSO, FOR EXAMPLE, IN BREAST CANCER.
MOVING ON NOW TO TALK BRIEFLY ABOUT THE ORGANIZATION STRUCTURE
IN THE UNITED KINGDOM ABOUT CANCER SCREENING PROGRAMS, THEY
IMPLEMENTED A PUBLIC HEALTH MODEL.
IT WAS BASED ON EVALUATINING DA AND THEY SELECTED FOBT FOR A
NARROW RANGE OF PEOPLE THAN WE DO IN THE UNITED STATES FOR 60
TO 69-YEAR-OLDS AND IF THERE WAS AN ABNORMAL FOBT, THOSE PEOPLE
WOULD BE EVALUATED BY COLONOSCOPY.
SO THEY PICKED THIS REGULARMAN IN PART BECAUSE THEY ONLY MOVE
FORWARD IF THEY HAVE SUFFICIENT RESOURCES TO SCREEN ALL THE
WIDELY DEVELOPED GROUPS. MORE TO HOW DOES ONE COVER THE
POPULATION? AND THEIR ORGANIZATION REFLECTS
THE PUBLIC HEALTH MODEL. THEY SET UP HUBS THAT COVER A
VERY LARGE POPULATION, 10 MILLION PEOPLE IN THIS INSTANCE.
AND THOSE HUBS MANAGE THAT ENTIRE PROCESS OF SCREENING.
ONCE THEY HAVE AN ABNORMAL TEST, THE PEOPLE ARE REFERRED TO
SCREENING CENTERS THAT ARE ACTUALLY RUN BY NURSES AND THE
NURSES DO THE SCREENING, EVALUATION AND THE SCREENING
ENDOSCOPY. SO THEY SPEND A LOT OF TIME
TRAINING NURSE END OPT ENDOSCOP. THIS IS JUST ONE EXAMPLE OF ONE
OF THE EFFORTS THAT THEY DID. THEY WERE TRYING TO TRACK UPTAKE
IN THEIR SCREENING PROGRAM. AND THIS ROUND REFERS TO THE
FACT THAT PEOPLE ARE INVITED, A CROSS-SECTION OF THE POPULATION.
IN THIS CASE BECAUSE IT'S ANNUAL FOBT, PEOPLE ARE INVITED EVERY
YEAR. SO SOMEWHAT DIFFERENTLY THAN
SOME EARLY WORK IN THE UNITED STATES, IT APPEARS THAT WOMEN
ARE SCREENED AT SLIGHTLY HIGHER RATES THAN MEN WITH COLON CANCER
SCREENING. IT'S VERY SIMILAR TO RESULTS IN
THE UNITED STATES. PEOPLE WHO HAVE A HIGH SOCIAL
DEPRIVATION SCORE THAT RELATES TO A WHOLE RANGE OF NEIGHBORHOOD
ENVIRONMENTAL KU YAAL CONTEXT I HAVE MUCH LOWER RATES OF
SCREENING, ONLY ABOUT 40% COMPARED TO 60% OR 70% WITH
PEOPLE WHO ARE AT THE HIGH -- WHO HAVE MUCH MOORE RESOURCES.
SIMILARLY, IF THEY LOOK AT SPECIFIC RACIAL ETHNIC GROUPS,
THEY LOOK AT THE PERCENTAGE OF POPULATION COMING FROM AN INDIAN
SUBCONTINENT WHERE PEOPLE CAME FROM AREAS WHERE THERE WERE A
HIGH PROPORTION OF PEOPLE FROM THE INDIAN SUBCONTINENT, ALSO
THESE INDIVIDUALS HAD HIGHER SOCIAL DEPRIVATION SCORES.
THEY HAD MUCH LOWER RATES OF SCREENING.
AND WE KNOW THAT PEOPLE WHO DO NOT RESPOND TO SCREENING, AND IN
THIS INSTANCE WHEN THEY LOOKED AT PEOPLE WHO DIFFERENT RESPOND
TO THE FIRST ROUND, ONLY ABOUT 10% OF THEM EVER CAME IN TO A
FUTURE ROUND, THIS IS THE -- WE HAVE THE HIGHEST RATES OF LATE
STAGE DISEASE AMONG PEOPLE WHO HAVE NEVER BEEN SCREENED.
SO WE REALLY NEED TO PERHAPS SHIFT OUR ATTENTION TO JUST
GETTING PEOPLE TO SCREEN MORE WHO ARE ALREADY BEING SCREENED
AND FOCUS ON THOSE PEOPLE WHO NEVER COME IN FOR SCREENING.
SO I WANT TO CLOSE WITH BRIEFLY TALKING ABOUT THE PROVIDER
PARTICIPANT SYSTEMS AND ORGANIZATIONAL FACTORS THAT CAN
IMPROVE UPTAKE AND OUR FUTURE SPEAKERS ADDRESS THIS IN MORE
DETAIL. WE KNOW THAT FROM MANY COUNTRIES
THAT PEOPLE WITH HIGHER SCS IN EDUCATION, PEOPLE WHO ARE WHITE,
OLDER, MEN IN TERMS OF COLORECTAL CANCER AND MARRIED
PEOPLE HAVE AN INCREASE IN UPTAKE.
BUT WE ALSO KNOW THAT THERE ARE A NUMBER OF FACTORS THAT CAN
HELP TO INCREASE THIS UPTAKE. IF YOU LOOK AT THE SYSTEM LEVEL
HAVING SPECIALIZED SCREENING SERVICES AND STAFF THAT ARE
FOCUSED ON INCREASING UPTAKE ACTUALLY PLANNING YOUR RESOURCES
AND PROGRAMS SO THAT YOU WILL MEET THE ANTICIPATED DESIGN.
THERE ARE A NUMBER OF WHAT PEOPLE MIGHT CALL IN-REACH KIND
OF EFFORTS TO MOBILIZE AND TRAIN HEALTH CARE PROVIDERS AND IN
TERMS OF HAVING THEM UNDERSTAND CUES TO ACTION FOR TARGETING
NONCOMPLIANCE. AND AS ALL THINGS GIVING
PROVIDERS REPORT CARDS, TRAINING AND FEEDBACK REALLY MAKE A
DIFFERENCE. IT HAS BEEN WELL ESTABLISHED
THAT IN TERMS OF PATIENTS OUR HEALTH CARE USERS THAT REMIND,
STANLS, PERSONAL OUTREACH AND EDUCATION MAKE A DIFFERENCE.
THAT CLOSES MY REMARKS AND WE'RE MOVING NOW TO NED CALONGE WHO
WILL ADDRESS THE NEXT TOPIC. >> THANKS, RACHEL.
I'M THRILLED TO BE HERE TODAY TO TALK ABOUT THE AFFORDABLE CARE
ACT AND HOW IT'S GOING TO PROVIDE OPPORTUNITIES TO IMPROVE
POPULATION BASED CANCER SCREENING.
I THINK THIS IS AN UNPRECEDENTED TIME FOR PUBLIC HEALTH.
I DON'T KNOW IF YOU'VE ACTUALLY READ THE BILL.
IT'S ONLY 973 PAGES, WHICH IS ONLY 140 PAGES LONGER THAN
"HARRY POTTER AND THE DEATHLY HOLLOWS."
BUT IT REALLY IS GENERATED A LOT OF INTEREST IN PUBLIC HEALTH,
INCLUDING THIS LANDMARK REPORT FROM THE INSTITUTE OF MEDICINE.
PRIMARY CARE AND PUBLIC HEALTH, EXPLORING INTEGRATION TO IMPROVE
POPULATION HEALTH. AND IT'S INTERESTING THAT WITHIN
THIS REPORT THEY ACTUALLY RECOMMEND MAKING POPULATION
BASED COLORECTAL CANCER SCREENING BETTER BY INTEGRATING
PUBLIC HEALTH AND PRIMARY CARE. THE REPORT IDENTIFIES SPECIFIC
PROVISIONS OF THE ACA THAT CAN SUPPORT THIS INTEGRATION.
AND I WANTED TO JUST TALK ABOUT A FEW OF THOSE.
FIRST, FOR THOSE OF YOU IN PUBLIC HEALTH, YOU KNOW ABOUT
THE COMMUNITY TRANSFORMATION GRANTS.
SO THESE ARE OPPORTUNITIES THAT LOCAL HEALTH DEPARTMENTS HAVE TO
APPLY AND SOME OF YOU HAVE AND SOME OF YOU HAVE BEEN AWARDED
AND SOME OF YOU ARE STILL WAITING.
BUT TO LOOK AT A POPULATION APPROACH TO YOUR COMMUNITIES,
THE COMMUNITY HEALTH NEEDS ASSESSMENTS, I ALWAYS LIKE TO
INCLUDE THAT NONPROFIT HOSPITALS NOW HAVE TO ASSESS THE HEALTH
NEEDS OF THEIR COMMUNITY AS PART OF THEIR COMMUNITY BENEFIT.
AND THEY REALIZED, GUESS WHAT? LOCAL PUBLIC HEALTH HAS BEEN
DOING THIS FOR YEARS AND MANY OF YOU HAVE COMPLETED A RECENT
ORGANIZATION. THE MEDICAID PREVENTIVE SERVICES
IS AN OPTIONAL GRANT PROGRAM THAT STATES AND LOCAL HEALTH
DEPARTMENTS CAN APPLY FOR AND LOCAL HEALTH DEPARTMENTS CAN
ACTUALLY EITHER ALONE OR IN PARTNERSHIP WITH SAFE NET
CLINICS BECOME MEDICAID PROVIDERS AND REACH OUT TO THOSE
HARD TO REACH POPULATIONS THAT WE NEED TO REACH IN ORDER TO
IMPROVE POPULATION HEALTH. THE NEXT TWO ACCOUNTABLE CARE
ORGANIZATIONS AND PATIENTS THAT ARE IN MEDICAL HOMES ARE LOOKING
FOR WAYS TO BETTER INTEGRATE CARE AND TAKE CARE OF AN ENTIRE
POPULATION. AND I WOULD TELL THAW I CAN'T
SEE THAT YOU CAN REALLY IMPROVE THE ENTIRE POPULATION AND BE
TRULY ACCOUNTABLE WITHOUT REACHING OUT AND INCLUDING
PUBLIC HEALTH OPINION FINALLY, THE LAST TWO, PRIMARY CARE
EXTENSION PROGRAMS AND THE COMMUNITY HEALTH CARE CENTERS
ARE STRENGTHENING OUR PRIMARY CARE SAFETY NETS.
AND I THINK LOOKING FOR PARTNERSHIPS, AGAIN, WITH LOCAL
PUBLIC HEALTH THAT HAS THE EXPERIENCE AND THE KNOWLEDGE
ABOUT HOW TO REACH OUT TO HARD TO REACH POPULATIONS IS A REAL
OPPORTUNITY. THERE ARE SPECIFIC PROVISIONS IN
THE AFFORDABLE CARE ACT THAT I THINK CAN REALLY PUSH AND
IMPROVE POPULATION BASED SCREENING.
FOR EXAMPLE, THERE'S NOW A FIRST DOLLAR COVERAGE, WHICH IS NO
ADDITIONAL OUT OF POCKET COSTS FOP EVIDENCE BASED CANCER
SCREENING, SPECIFICALLY BREAST, CERVICAL AND COLORECTAL BASED ON
THE U.S. PREVENTIVE SERVICES TASK FOR RECOMMENDATION PS THESE
ARE THE A & B RECOMMENDATIONS THAT LIKE DR. BRAWLEY REFERRED
TO, CLEARED OUTWEIGHED THE HARMS.
THE ACA FORMALLY AUTHORIZED THE COMMUNITY PREVENTIVE TASK FORCE
WHICH IS A CDC PROGRAM AND DIRECT BOTH TASK FORCES TO LOOK
FOR, QUOTE, HOW EACH TASK FORCE RECOMMENDATIONS INTERACT AT THE
NECK CLINIC AND COMMUNITY. THE GUIDE TO PREVENTIVE
SERVICES, WHICH IS HOSTED BY THE CENTERS FOR DISEASE CONTROL
PUBLISHES RECOMMENDATIONS MADE BY THE TASK FORCE.
ANOTHER NCHT NONFEDERAL VOLUNTEER BODY OF EXPERTS OF
PUBLIC HEALTH AND PREVENT YOP RESEARCH PRACTICE AND POLICY.
THE RECOMMENDATIONS FOR THE COMMUNITY GUIDE ARE ALSO BASED
ON STRENGTH OF SCIENTIFIC EVIDENCE AND I DON'T THINK IT'S
ANY MISTAKE THAT THERE ARE NO FEWER THAN 11 COMMUNITY LEVEL
INTERVENTION S DESIGNED TO INCREASE PARTICIPATION IN
EFFECTIVE CANCER SCREENING. SO, FOR EXAMPLE, RACHEL TALKED
ABOUT REMINDER IS SYSTEMS, INREACH ANDOUT REACH, REMIND THE
PROVIDER, REMIND THE PATIENT, PROMPT THEM TO GET SERVICES.
THOSE ARE STRONGLY RECOMMENDED THROUGH THE COMMUNITY GUIDE.
SO YOU MIGHT ASK WHY SHOULD WE TAKE A PUBLIC HEALTH APPROACH TO
CLINICAL PREVENTIVE SERVICES? AND I GUESS THERE'S AN ANSWER
WE'RE TRYING TO SOLVE. IT'S CLEAR THAT THE U.S. HEALTH
SYSTEM IS FRAGMENTED. WE HAVE TRIED TO ADDRESS THAT
THROUGH WHAT WE HAVE. FOR EXAMPLE, QUALITY
MEASUREMENTS SUCH AS THE NCQA DATA HAS BEEN SHOWN TO INCREASE
SCREENING RATES, BUT ONLY IN STABLE SUBSCRIBERS ARE VERY
LITTLE POPULATION IMPACT MANIFESTED BY THE FACT THAT OUR
BREAST CANCER SCREENING RATES HAVE NOT CHANGED APPRECIABLY
SINCE 2000. SO WHY CANCER SCREENING IN
PUBLIC HEALTH? AS DR. BRAWLEY TALKED ABOUT,
CANCER SCREENING IS DIFFERENT FROM OTHER SCREENINGS IN THAT IT
IDENTIFIES PRECLINICAL DISEASE. WHEN WE LOOK AT OUR
RECOMMENDATION SCREENINGS, LIKE SCREENING FOR CARDIOVASCULAR
DISEASE RISK FACTORS, IT'S CRITICAL THE TIME THAT YOU GIVE
THE SCREENING TESTS BECAUSE EARLY DETECTION IS TIME
CRITICAL. WE HAVE TO CATCH THE CANCER AT
THE TIME WHERE EARLY INTERVENTION MAKES A DIFFERENCE.
I GUESS THE OTHER POINT I WOULD BRING UP IN CANCER SCREENING IS
THAT THERE REALLY ARE REMARKABLE HEALTH DISPARITIES, ESPECIALLY
IN COLORECTAL CANCER. THIS IS FROM THE 2010 NATIONAL
HEALTH INTERVIEW SURVEY AND POINTS OUT THE DISPARITIES IN
THE DIFFERENT FORMS OF CANCER SCREENING.
AND YOU CAN SEE THE REAL DIFFERENCE THERE INCO LOW REC
TALL CANCER. THOSE OF YOU FROM OTHER STATES
KNOW THAT THESE DISPARITIES VARY BY STATE, SO IN COLORADO WE HAVE
MORE IS SIGNIFICANT DISPARITIES THAN BREAST AND CERVICAL CANCER
THAN IN MANIFESTED BY THE NATIONAL DATA.
ALL RIGHT. SO THAT IS A GOOD REASON TO DO
CANCER SCREENING. WHY PUBLIC HEALTH SUPPORTED
POPULATION BASED SCREENING? WELL, I THINK OF THE TWO
SPEAKERS BEFORE ME TALKED ABOUT, THE BENEFITS OF SCREENING ARE
MAXIMIZED WHEN EVERYONE IN THE COMMUNITY PARTITICIPATES.
AS RACHEL TALKED ABOUT, PREVENTABLE LATE STAGE DISEASE
IS MORE PREVALENT IN PEOPLE WHO DON'T GET SCREENED AT ALL.
FOR EXAMPLE, LATE STAGE CERVICAL CANCERS ARE FOUND IN WOMEN WHO
NEVER GET SCREENED MUCH LESS FREQUENTLY IN WOMEN GETTING
EVERY THREE YEARS SCREENING. THE OTHER POINT I WOULD MAKE IS
THAT WE UNDERSTAND PUBLIC HEALTH SERVICES CAN MAKE WONDERFUL
USES. NEARLY 74% OF OUR SENIORS 64
YEARS AND OLDER ARE IMMUNIZED AGAINST INFLUENZA.
AND THEN I POINT OUT THAT 80% OF THOSE VACCINES ARE GIVEN OUTSIDE
OF THE MEDICAL CARE SYSTEM. EITHER IN PUBLIC HEALTH CLINICS
OR OTHER CLINICS USING A PUBLIC HEALTH APPROACH.
WE ALSO KNOW FROM COLORADO'S EXPERIENCE THAT WE CAN DO CANCER
SCREENING. WE HAVE TEN LOCAL PUBLIC HEALTH
DEPARTMENTS THAT PROVIDE DIRECT SERVICES IN BREAST AND CERVICAL
CANCER SCREENING FUNDED BY BOTH THE STATE AND THE NATIONAL
BREAST AND CERVICAL CANCER EARLY DETECTION PROGRAM AIMED
SPECIFICALLY AT LOW-INCOME WOMEN.
WE ALSO HAVE THE STATE FUNDED COLORECTAL CANCER CONTROL
PROGRAM WHICH SUPPORTS CRC SCREENING THROUGH A UNIVERSITY
COORDINATED XHUND LOCATED POPULATION BASED PROGRAM.
AND SOME OF OUR LOCAL HEALTH DEPARTMENTS ARE LOOKING FOR
DIRECT SERVICES FOR CRC SCREENING IN PARTNERSHIP WITH
SAFETY NET CLINICS. SO I WANT TO FINISH WITH KIND OF
PROVIDING YOU WITH A BOLD VISION OF THE FUTURE FOR CANCER
SCREENING. AND JUST TALK A LITTLE BIT ABOUT
THE PUBLIC UTILITY MODEL. SO IF YOU REMEMBER THE PUBLIC
UTILITY MODEL WORKS TO PROVIDE CORE SERVICES TO THIS
GEOGRAPHICAL DEFINED POPULATION. AND WHY NOT TAKE THAT APPROACH
TO CANCER SCREENING? VERMONT HEALTH CARE REFORM
THROUGH THEIR DEPARTMENT OF VERMONT HEALTH ACCESS PROVIDES
KIND OF AN EXAMPLE OF HOW ONE STATE IS DOING THAT.
SO THROUGH HEALTH DEPARTMENT ORIGINATED PROGRAM, THEY ARE
PROVIDING CHRONIC DISEASE MANAGEMENT, BEHAVIORAL HEALTH
AND WELLNESS AND PREVENTIVE SERVICES THROUGHOUT THE STATE IN
KIND OF THIS PUBLIC UTILITY MODEL.
I BELIEVE THAT SUPPORTED BY THE PROVISIONS OF THE AFFORDABLE
CARE ACT, THE FUTURE OF CANCER SCREENING MAY WELL SEE THE
DEVELOPMENT OF SCREENING AS A PUBLIC UTILITY THAT PROVIDES
POPULATION BASED SERVICES AND ARE REMARKABLE IMPROVEMENT IN
OVERALL POPULATION AND HEALTH. SO I THANK YOU FOR MY TIME WITH
YOU TODAY AND I'D LIKE TO TURN THINGS OVER TO TR LEVIN.
>> GOOD AFTERNOON. IT'S ANY PLEASURE TO BE HERE
WITH SO MANY FACES IN THE AUDIENCE.
I'M DR. T.R. LEVIN. BEFORE TALKING ABOUT OUR
SCREENING PROGRAM, IT IS WORTHWHILE TO REVIEW SOME OF THE
EVIDENCE ABOUT THE VALUE OF THE FECAL CHEMICAL TEST OR F.I.T.
I ALSO REVIEW OUR OUR SCREENING PROGRAM IS STRUCTURED AND REVIEW
SOME OF THE PATIENT OUTCOME THAT'S WE'VE SEEN SINCE WE'VE
BEEN INCREASING SCREENING RATES. IN DECIDING BETWEEN VARIOUS
SCREENING TESTS, AN IMPORTANT CONSIDERATION IS WHICH TEST WILL
PATIENTS DO AND THE BEST TEST, REALLY, IS THE ONES THE PATIENT
WILL DO. THE F.I.T. USES AN ANTIBODY
SPECIFIC FOR HEMOGLOBIN. MULTIPLE STUDIES INDICATE HERE
PATIENTS ARE MUCH MORE LIKELY TO COMPLY WITH F.I.T. TEST WHG
COMPARED TO GOYAK. WHILE ADHERENCE IN BOTH ARMS OF
THE STUDY WERE LOW, THE ADHERENCE WITH F.I.T. WAS
SIGNIFICANTLY HIGHER THAN WITH COLONOSCOPY LEADING TO MORE
CANCERS BEING DEAT THIS TIME TEXTED IN THE F.I.T. ARM.
BUT THESE RESULTS REFLECT ONLY ONE ROUND OF SCREENING.
THE PARTICIPANTS IN THE F.I.T. ARM WERE DUE TO HAVE FOUR MORE
ROUNDS OF BUY ANNUAL SCREENING IN WHICH THEIR -- MAY HAVE BEEN
DETECTED. F.I.T., JOHN ENDOMIE DID A STUDY
IN SAN FRANCISCO. PROVIDERS WERE RANDOMIZED IN
THREE-MONTH-BLOCKS OFFERING THE GEE NOM TEST, THE COLONOSCOPY OR
A CHOICE OF FOBT. THE CALIFORNIA NORTHERN REGION
STENTSDZ FROM SANTA ROSA IN THE NORTH, FRESNO IN THE SOUTH, SAN
FRANCISCO TO THE WEST AND SACRAMENTO TO THE EAST.
WE CURRENTLY HAVE A 46% MARKET SHARE AND OUR PATIENTS ARE
GENERALLY REPRESENTATIVE OF THE SURROUNDING POPULATION.
WITH THE EXCEPTION OF THE EXTREME HIGHS AND LOWS OF
SOCIOECONOMIC STATUS. OURCO LOW REC TALLER SCREENING
CONSISTED OF BOTH AN OUTREACH AND AN INREACHED.
IN REACH REFERS TO THE ELECTRONIC SYSTEMS THAT PROMPT
SUPPORT STAFF AND PHYSICIANS TO REMIND MEMBERS THAT ARE COMING
DUE FOR SCREENING AND DISTRIBUTE TEST KITS.
WE ALSO USE ELECTRONIC SYSTEM TOES TRACK PATIENTS WHO ARE FIT
POSITIVE TO ENSURE THAT THEY GET THEIR FOLLOW-UP COLONOSCOPIES.
OUR OUTREACH PROGRAM BEGINS WITH THE IDENTIFICATION THAT ARE
ELIGIBLE FOR THE HETUS MEASURE. THE ELECTRONIC DATABASES ARE
REVIEWED TO IDENTIFY WHO IS OVERDUE OR COMING DUE FOR ACO
LOW REC TALL CANCER SCREENING THIS YEAR AND AT THE NOTED
SCREENING INTERVALS. A SAMPLE OF 13,000 OR MORE
MEMBERS ARE MAILED TEST KIDD KITS EACH WEEK FROM JANUARY TO
SEPTEMBER. WE USE A VENDOR TO ASSEMBLE THE
TEST KITS ON DEMAND. AFTER USING DEMOGRAPHIC DATA
THAT WE UPLOAD USING HIPPA COMPLIANCE TEST SITES.
WE USE A SINGLE SAMPLE TEST WITH A CUT OFF OF 100 -- THE OUTREACH
SALE KIT. LOCAL TEAMS AT LEAST MEDICAL
CENTER ARE SEND SECURITY MESSAGES AND MAKE PHONE CALLS.
THE KITS MAY BE DISTRIBUTED AS CLINIC VISITS OR DURING THE FALL
FLU SHOT CLINICS. WE HAVE SEVERAL REPORTS AND
REMINDER SYSTEM THAT'S WE WORK WITH TO HELP MOVE THE WORK
FORWARD. WE REPORT TO EACH MEDICAL CENTER
MONTHLY INFORMATION ON THEIR SCREENING RATES, THE ACCESS TO
COLONOSCOPY, COLONOSCOPY PRODUCTIVITY AND ADMOMA
DETECTION RATES. AT THE POINT OF TEAR, THE HEALTH
CARE TEAM CAN SEE A PREVENTIVE HEALTH CARE PROMPT WHICH WILL BE
INVOLVED INTO A POPULATION REMINDING OUTREACH MONITOR AND
PATIENT TRACKING TOOL. WE REPORT THE FOLLOW-UP AND WHY
PATIENTS ARE. OVER TIME, WE HAVE SEEN
SIGNIFICANT IMPROVEMENT IN OUR SCREENING RATES AS MEASURED BY
THE QUALITY OF CARE MEASURE IS. BOTH FOR OUR MEDICARE AND OUR
COMMERCIAL MEMBERS. THE SCREENING RATES STARTED
INCREASING IN 2007 AS OUR OUTREACH PROGRAM RAMPED UP.
BEFORE STARTING OUTREACH, OUR PROGRAM HAS NOW SEEN HIGHER
RATES AND WE ARE ABOVE THE 90% PROFILE.
THE RESULT OF THIS IS THAT AS IN EVERY SCREENING, STUDY OR
EFFORT, WHEN SCREENING RATES INCREASE, THERE WAS AN INCREASE
IN DIAGNOSIS OF PREVALENT CANCERS.
AS OUR SCREENING STARTED TO INCREASE, WE SAW AN APPARENT
RISE RISE IN COLORECTAL INCIDENCE.
WE'RE TRACKING SURVIVAL, AS WELL.
WE HAVE SUCCESSFULLY INCREASED SCREENING RATES BY TAKING THE
APPROACH WE USE IN OUR SYSTEM FOR ALL POPULATION CARE
INITIATIVES. LEADERS THROUGHOUT THE
ORGANIZATION ARE COMMITTED TO THE GOAL OF IMPROVINGCO LOW REC
TALL SCREENING RATES. AS A MEDICAL GROUP, WE SET
TARGETS FOR OUR POPULATION SCREENING RATES PRIOR TO THE
START OF EVERY YEAR. OUR INCENTIVES ARE ALIGALIGNED.
THIS REPRESENTS A TRUE COLLABORATION BETWEEN PRIMARY
CARE AND SPECIALIST. THERE HAS BEEN A CONCERTED
EFFORT TO MONITOR AND EXPAND COLONOSCOPY CAPACITY AND WE USE
A MIX OF TESTS, ALLOWING PRIMARY CARE PROVIDERS FOR SCREENING OF
COLONOSCOPY AND ACTIVELY OUTREACH WOULD FIT.
MOST PATIENTS ARE SCREENED BECAUSE OF F.I.T., BUT A GROWING
PROPORTION ARE SCREENED BY COLONOSCOPY.
WE USE ORGANIZED SYSTEMS IN BOTHOUT REACH AND IP REACH TO
PROVIDE EDUCATION AND ENCOURAGEMENT AND RESULTS ARE
MONITORED. QUALITY MANAGEMENT STAFF ARE
AWARE OF HOW MUCH ADDITIONAL WORK NEEDS TO BE DONE.
ON A REGIONAL BASIS, IT IS OUR JOB TO ACTIVELY STUDY LOCATIONS
THAT ARE DOING WHOLE AND WORK FOR THEM.
PE SKILL HAVE AN ONGOING GAME. AT THIS POINT, I WILL TURN IT
OVER TO MARCUS PLESCIA. >> WELL, THANK YOU VERY MUCH.
I'D LIKE TO CLOSE BY TAKING A COUPLE OF MINUTES TO JUST
DESCRIBE A LITTLE BIT OF THE CURRENT PROGRAMS WE HAVE THAT
ARE FOCUSED ON CANCER SCREENING HERE AT CENTERS FOR DISEASE
CONTROL. AND THEN I'D LIKE TO DESCRIBE
SOME OF THE APPROACHES WE HOPE TO TAKE IN THE FUTURE TO BEGIN
TO MOVE OUR PROGRAMS MORE IN THE DIRECTIONS OF SOME OF THE IDEAS
THAT YOU'VE HEARD DURING THE COURSE OF THESE GRAND ROUNDS.
THE NATIONAL BREAST AND CERVICAL CANCER EARLY DETENTION PROGRAM
IS CDC'S CORE CANCER SCREENING PROGRAM.
AND THIS PROGRAM SINCE ITS INCEPTION HAS BEEN DESIGNED TO
REACH AND PROVIDE SERVICES TO WOMEN IN THE UNITED STATES WHO
DON'T HAVE HEALTH INSURANCE. AS YOU CAN SEE FROM THE SLIDE,
THE REACH OF THIS PROGRAM HAS BEEN QUITE SIGNIFICANT OVER THE
LAST TWO DECADES. BUT, YOU KNOW, TWAL EQUALLY
IMPORTANT, WE'RE VERY PROUD OF THE FACT THAT NOT ONLY HAVE WE
BEEN ABLE TO REACH A LOT OF WOMEN WITH THESE PROGRAMS, BUT
THESE ARE WOMEN WHO WERE GENERALLY FROM UNDERSERVED
COMMUNITIES AND WE FEEL THAT THE NATIONAL BREAKFAST AND CERVICAL
PROGRAM IS PROBABLY ONE OF THE CORE REASONS WHY OVER THE LAST
TWO DECADE, WE'VE BEEN ABLE TO CLOSE SOME OF THE GAPS IN
SCREENING DISPARITIES ACROSS OUR DIFFERENT POPULATIONS.
IN ADDITION TO SIGNIFICANT REACH, OUR SCREENING PROGRAMS AT
CDC ALSO, I THINK, PERHAPS EVEN MORE IMPORTANTLY HAVE
SUBSTANTIAL CAPACITY. YOU SEE FROM THIS SLIDE -- WE
HAVE -- WE FUND EVERY STATE IN THE UNITED STATES TO PROVIDE
SCREENING SERVICES. WE FUND 11 TRIBES.
AND WE FUND FIVE TERRITORIES. AND EACH OF THOSE HEALTH
DEPARTMENTS, THEN, HAS AN EXTENSIVE NETWORK OF CLINICAL
PROVIDERS THEY WORK WITH TO PROVIDE THESE SERVICES.
AND SO YOU SEE THAT FROM THIS SLIDE.
OUR INTERESTS IN THE FUTURE, PARTICULARLY AS WE BEGIN TO SEE
IMPLEMENTATION OF THE AFFORDABLE CARE ACT IS TO THINK ABOUT HUK
WE USE THIS SUBSTANTIAL CAPACITY WE'VE BUILT, TO MOVE THE BAR AND
SOME OF THESE OTHER SOLUTIONS ARE MORE POPULATION BASED.
I'D LIKE TO SPEND THE LAST COUPLE OF MINUTES TALKING ABOUT
A COUPLE OF EXAMPLES OF SOME OF THE WORK THAT WE'RE DOING.
PERHAPS THE BEST CHAMP OF THIS NEW DIRECTION THAT WE'RE TRYING
TO MOVE CDC'S CANCER SCREENING PROGRAMS IS COLORECTAL CANCER
SCREENING PROGRAM. IT'S PROGRAM WE FUNDED ABOUT
THREE OWE OR FOUR YEARS AGO TO LOOK AT THE ISSUE OF COLON
CANCER SCREENING IN THE UNITED STATES WHERE WE FEEL THAT WE ARE
VERY MUCH BEHIND. AND YOU SEE IN THE SLIDE THAT
THE ORDER OF PRIVATE IS REVERSED.
WE STILL PROVIDE FUND TO GO STATES TO PAY FOR SCREENINGS,
BUT THE REAL EMPHASIS OF THIS PROGRAM IS IN POPULATION BASED
SCREENING PROMOTION. WE'VE USED EVIDENCE BASED
MODALITIES AMONGST OUR DIFFERENT GRANTEES AND OUR GRANTEES HAVE
BEEN ABLE TO WORK WITH OUR WIDE SELECTION.
WE CAN BEGIN TO BRING ABOUT SOME OF THESE MORE ORGANIZED TYPES OF
APPROACHES. ANOTHER EXAMPLE THAT I'M
PARTICULARLY INTERESTED IN IS COLLABORATIONS BETWEEN HEALTH
DEPARTMENTS AND STATE MEDICINE CARE CADE PROGRAMS.
I THINK EVERYBODY KNOWS THAT IN MOST SETTINGS, THE MEDICAID
PROGRAM IS SOME OF THE PLACES THAT THE MOST UNDERSERVED
PATIENTS AND COMMUNITIES RESIDE IN.
SO A NUMBER OF COMMUNITIES ARE LOOKING FOR WAYS TO REACH OUT TO
THEIR SISTER MEDICAID AGENCIES AND LOOK AT WAYS TO SYSTEMICALLY
REACH THIS POPULATION. A GOOD EXAMPLE OF THIS IS THE
STATE OF MINNESOTA. CDC HAS FUNDED MINNESOTA FOR
WHAT WE THINK IS A VERY INNOVATIVE PROGRAM WITH THEIR
STATE MEDICAID PROGRAM WHERE MINNESOTA IS USING MEDICAID
CLAIMS DATED TO ACTIVE LY. AND THEN WHEN WE DO VERY
AGGRESSIVE OUTREACH AND REMINDER SYSTEMS AND EVEN INCENTIVES TO
TRY TO REACH THOSE PATIENTES AND BRING THEM IN.
AND ENCOURAGE THEM TO PARTICIPATE IN CANCER SCREENING.
SO I'D LIKE TO CLOSE BY JUST SUMMARIZING A LITTLE BIT OF SOME
OF THE IDEAS AND THE DIRECTIONS I THINK WE CAN GO AS WE THINK
ABOUT NEW, MORE POPULATION BASED AND MORE ORGANIZED APPROACHES TO
CANCER SCREENING IN THE UNITED STATES.
AND YOU SEE IN THIS SLIDE, REALLY, I THINK THE TWO
DIFFERENT AREAS WE CAN WORK IN. ON THE RIGHT ARE PATIENT
CENTERED OR PATIENT ORIENTED APPROACHES.
ON THE LEFT ARE POPULATION ORIENTED APPROACHES.
I THINK PATIENT ORIENTED APPROACHES TO IMPROVE SCREENING
IN THE HEALTH CARE SYSTEM ARE EXTREMELY IMPORTANT AT THE POINT
THAT WE HAVE RIGHT NOW. THESE ARE CERTAINLY AREAS WHERE
WINK PUBLIC HEALTH DEPARTMENTS CAN BE ENGAGED TO BRING SOME OF
THESE CHANGES ABOUT. ULTIMATELY, I THINK THE
LEADERSHIP WILL -- PARTICULARLY IN PUBLIC HEALTH PRACTICE, THE
LEADERSHIP ROLE AND THE OPPORTUNITY TO ADD VALUE TO THE
AFFORDABLE CARE ACT IS AN ADVANCING SOME OF THESE LARGE
SCALE POPULATION BASED ORGANIZED APPROACHES TO SCREENING.
LIKE YOU SEE ON THE LEFT HAND OF SH SLIDE.
AND LIKE SOME OF THE EXAMPLES YOU'VE HEARD FROM OF SPEAKERS.
I THINK IF WE REALLY WANT TO OVERTHE COMMUNITY HEALTH
MEASURES THAT WE IN PUBLIC HEALTH ARE RESPONSIBLE FOR.
ULTIMATELY, IF WE WANT TO BEGIN TO TURN THE TIDE AUTO SOME OF
THESE PERNICIOUS HEALTH DISPARITIES WE SEE IN CANCER
CONTROL. THANK YOU VERY MUCH FOR YOUR
INTEREST AND ATTENTION AND I'M NOW GOING TO OPEN THINGS UP FOR
QUESTIONS FOR OUR PANELISTS. >> I'LL WARM PEOPLE UP A LITTLE
BIT AND ASK ANY OF THE PANELISTS WHO WANT TO RESPOND.
WE TALKED ABOUT THESE NEW ROLES FOR PUBLIC HEALTH.
ONE OF THE INTERESTING ISSUES IS, YOU KNOW, WHAT ARE THE SKILL
SETS THAT OUR PUBLIC HEALTH WORKFORCE NEEDS TO DEVELOP TO
REALLY BE ABLE TO PERFORM WELL IN THESE KIND OF ROLES?
WOULD ANYBODY LIKE TO SPEAK TO YOUR IDEAS ABOUT THAT?
>> WELL, I'LL START OFF. I PERSONALLY BELIEVE THAT HEALTH
EDUCATION OF THE POPULOUS IS GOING TO BE INCREDIBLY
IMPORTANT. IF THE AFFORDABLE CARE ACT IS
GOING TO BE SUCCESSFUL, IF WE'RE GOING TO SKIM THE TIDE OF THE
OBESITY EPIDEMIC. AND WHEN I LOOK AT HEALTH IN THE
UNITED STATES, TEACHING PEOPLE HOW TO EAT, TEACHING PEOPLE HOW
TO EXERCISE AND TEACHING PEOPLE HOW TO CONSUME HEALTH CARE IS
GOING TO BE INCREDIBLY IMPORTANT.
>> YOU KNOW, MARK, I THINK THE ADVICE I WOULD LIVE TO LOVE
HEALTH DEPARTMENTS OF ANY SIZE, AND MAYBE IT'S A WILLINGNESS TO
ENGAGE THE MEDICAL CARE SYSTEM. INTEGRATION WITH PRIMARY CARE
CAN ONLY HALF IF THE TWO SIDES ARE STANDING BY EACH OTHER.
LOCAL HEALTH DIRECTIVES, I THEY NEED TO REACH OUT AND LOOK FOR
THOSE NATURAL ALLIANCES. I THINK THAT'S THE ONLY WAY
WE'RE GOING TO SEE THE INTEGRATION.
SO MOVING FROM THE TRADITIONAL THINGS THAT YOU STILL HAVE TO
DO, DISEASE CONTROL, PUBLIC HEALTH IMMUNIZATIONS AND
THINKING OUTSIDE THE BOX TO CANCER SCREENING AND CHRONIC
DISEASE MANAGEMENT, LOOKING FOR THOSE RELATIONSHIPS WITH THE
EXISTING CARE SYSTEM ARE ESSENTIAL.
REACHING OUT TO THE KAISER PERMANENTES, THOPTS, IS OTHER
SOURCES OF CARE, THAT'S HOW INTEGRATION AND THE WHOLE
POPULAR APPROVEMENT. >> MY LEARNING OVER THE LAST
FIVE OR SEVEN YEARS I'VE BEEN DOING THIS IS THE VALUE OF
MAKING AN EMOTIONAL CONNECTION TO THE WORK IN ADDITION TO JUST
TAN L THE ANALYTICAL INFORMATION THAT
WE HAVE BEEN TAUGHT IN SCHOOL. IF YOU WANT TO CHANGE BEHAVIOR,
PEOPLE HAVE THE ANALYTICAL SIDE, BUT YOU HAVE TO CONNECT WITH
THEM ON AN EMOTIONAL LEVEL TO MAKE THEM WANT TO KNOW
SOMEWHERE, AS WELL. >> QUESTIONS FROM THE AUDIENCE.
BOB. >> THANK YOU.
SO LET ME JUST SAY FIRST OF ALL, THOSE WERE OUTSTANDING
PRESENTATIONS. AND I RESPECT APPRECIATE THE
COMMON THEMES RUNING ACROSS THEM.
THE QUESTIONS THAT YOU WERE ASKING, MARK, IT REALLY SPEAKS
TO WHAT IS THE OPPORTUNITY TO ACTUALLY ACHIEVE THE KIND OF
QUALITY IN AN INCIDENT APPROACHED FOR CLEANING.
WE HAVE FOLLOW UP THAT DOESN'T TAKE PLACE AFTER SCREENING TAKES
PLACE. WE HAVE A PERSISTENT PROBLEM
THAT WE -- IT'S ALMOST AS IF THE MARKET HAS TO SOLVE IT WHERE
THERE'S LOW ACCESS TO SERVICES, GEOGRAPHIC ACCESS IN SOME
INSTANCES AND WE'RE WATCHING, FOR EXAMPLE, THAT WE HAVE NOT
IDEAL ACCESS TO G.I. SERVICES, SOME WOMEN HAVE TO TRAVEL
FURTHER .FURTHER DISTANCE TOES MAMMOGRAPHY.
SO I'M WONDERING, TO A CERTAIN DEGREE, HOW MIGHT THE AFFORDABLE
CARE ACT TIGHTEN UP A LOT OF THESE LOOSE ENDS?
>> I THINK IT'S A GREAT QUESTION.
YOU KNOW WA IS REMARKABLE TO ME IS THAT ALL OF THE ELEMENTS ARE
IN THE ACT, BUT THEY WON'T HAPPEN BY THEMSELVES.
IT'S GOING TO TAKING LIKE THE CRAIG JONES, THE REACHING OUT
AND TAKE ADVANTAGE AND LOOKING FOR THE OPPORTUNITIES.
LOOKING FOR THE OPPORTUNITIES THAT CDC AND CMS COULD TAKE
WORKING TOGETHER BETWEEN THE INNOVATION CENTER AND THE
COMMUNITY TRANSFORMATION GRANT, TRYING TO TEAM UP TO ADDRESS
EXACTLY THOSE CAPS AND CANCER SCREENING THAT WE COULD FILL IN
WITH FUNDING AND OPPORTUNITY FROM THE AFFORDABLE CARE ACT.
SO I GUESS I WANT TO MAKE SURE THAT THE THAT PEOPLE KNOW THAT
THE ABILITY TO DO IT IS THERE AND THE OPPORTUNITY TO DO IT IS
NOW. THERE NEEDS TO BE LEADERSHIP AND
A FEW ZELL YOTS OUT THERE TO TAKE ADVANTAGE OF IT.
>> ONE MORE QUESTION BACK HERE. >> THE U.S. PREVENTIVE SERVICES
TOUGH WITH RESPECT TO VARIOUS CANCER SCREENINGS.
THE VAST MAJORITY OF THE RECOMMENDATIONS ARE FOR NOT
SCREENING. THERE IS A LOT OF CONTROVERSY
ABOUT OVARIAN CANCER SCREENING. WE HAVE NUMBER OF ORGANS THAT,
YOU KNOW, THAT SHOULD NOT BE SCREENED AND THE CONVERSATION
THAT I HAVE HEARD IS PROMOTING EFFECTIVE SCREENING.
WHAT I DO NOT HEAR IS EFFECTIVE WAYS OF PROMOTING NOT SCREENING
FOR CASES THAT SCREEN SG INJURIOUS AND HAS NEGATIVE
OUTCOME AND A GOOD PART OF IT IS THE ISSUE OF REIMBURSEMENT.
SAY A 70-YEAR-OLD MAN UNDER MEDICARE CAN GO AND GET SCREENED
FOR PROSTATE CANCER R CONSIDER. GIVING A RECOMMENDATION FOR
SCREENING. SO THERE IS SOME SORT OF A
DISCONNECT. AND I WOULD LOVE TO HEAR SOME
THOUGHT ON THE PART OF THIS PARTICULAR AS TO WHAT ARE BEING
DONE, LIKE THE KAISER PERMANENTE MODEL.
I WANTED TO ASK THE SPEAKER, HAVE YOU MONITORED THE UPTAKE OF
PSA TESTING? AT THE -- AS A MONIKER, THAT
SHOULD NOT BE UNIVERSITY USE IN THE POPULATION SETTING OF YOUR
INSTITUTION. >> I CAN TELL YOU WHAT WE DO AT
KAISER, CERTAINLY FOR THE EVIDENCE BASED SCREENINGS THAT
ARE PART OF THE HETUS MEASURE. WE ARE ACTIVELY PROMOTING,
ADVERTISING, REACHING OUT TO PEOPLE.
FOR PROSTATE CANCER, IT'S VERY MUCH OF A SHARED DECISION MAKING
MODEL. THERE ARE SOME PRABLG TISSUE
NERS WHO ARE STRONG ZELL YOT Z DOING IT.
WE DON'T HAVE REMINDERS FOR PEOPLE WHEN THEY COME INTO THE
OFFICE TO MAKE SURE THAT THEY HAVE IT DONE.
BUT WE'RE STILL INMAKER, SO PEOPLE ARE LOUD TO --
>> BUT I GET. THE PROBLEM I HAVE IS IF THE
RECOMMENDATION IS AGAINST, WHY ARE WE EVEN PROMOTING INFORMED
SHARE DECISION MAKING? I MEAN, THE RECOMMENDATION MEANS
THAT THE PHYSICIAN SHOULD NOT EVEN DISCUSS IT, SHOULD NOT
BRING IT UP. >> OTIS, THIS IS YOUR FAVORITE
TOPIC. >> WELL, I'VE BEEN DEALING WITH
THIS FOR ABOUT 20 YEARS. I THINK THAT PEOPLE ARE NOW
STARTING TO UNDERSTAND THAT FINDING THE DISEASE EARLY AND
CUTTING IT OUT IS NOT ALWAYS THE APPROPRIATE ANSWER.
PEOPLE ARE STARTING TO UNDERSTAND THAT SCREENING TESTS
CAN BE HARMFUL. I WAS TELLING DR. COLANGE I
THOUGHT THAT THE PREVENTIVE SERVICES TASK FORCE
RECOMMENDATION WAS -- IS NOW VIEWED BY MOST PEOPLE AS BEING A
VERY WISE ONE NOW THAT JUST WITHIN THE LAST TWO MONTHS THE
AMERICAN NEUROLOGICAL ASSOCIATION HAS REALLY
TIGHTENED.THEIR RECOMMENDATIONS ON PROSTATE SCREENING.
THEY NO LONGER SAY ALL MEN SHOULD BE SCREENED.
THEY SAY MEN AGE 55 TO 07 SHOULD BE TOLD ABOUT THE POTENTIAL
RICKS AND IT IS POTENTIAL BENEFITS AND ARE ENCOURAGED TO
MAKE A DECISION. SO THERE IS A CHANGE, A SMALL
EXCHANGE, BUT THERE'S A CHANGE FOR THE BEST WITHIN THE MEDICAL
COMMUNITY AS WE START LEARNING THE SCREENING CAN BE HARMFUL.
I'LL BE RIGHT OR CALL YOU. >> ALSO I AM NOTE A FEDERAL
EMPLOYEE AND KEGGING. IN 2007, WHEN THE LARGEST STUDY
WAS DONE TO SAVE LIVES, CONGRESS PASSED A LAW DECOMPLAINING THAT
PSA SCREENING DOES SAVE LIVES AND THAT'S WHY MEDICARE HAS TO
PAY FOR IT. >> SO I THINK THE FIRST THING
I'D POINT OUT IS THAT PSA IS AN EXAMPLE OF PREMATURE ACCEPTANCE.
HOW MANY RANDOMIZED CONTROL TRIALS DID WE HAVE BEFORE WE
STARTED RECOMMENDING PSA? ZERO.
BUT WE PREMATURELY ACCEPTED IT AND OFFERED PROMISE.
IT WAS VERY WELL SOCIALLY MARKETED.
NOW TRYING TO PULL ALL THAT BACK IN WAS DIFFERENT.
>> THE MOST COMMON RATING IS THE "I," INSUFFICIENT EVIDENCE,
WHICH IS NOT A RECOMMENDATION FOR OR AGAINST, BUT A REQUEST,
NOT FOR THIS ROOM, BUT FOR OUR FRIENDS OVER AT THE NATIONAL
CANCER INSTITUTE OR SOMEONE TO DO RESEARCH TO FILL IN THOSE
GAPS. ABOUT WHETHER OR NOT THE
BENEFITS OUTWEIGH THE HARMS. AND SO IT'S A LITTLE DIFFERENT
THAN DON'T DO IT. IT'S LIKE WE REALLY DON'T KNOW.
>> WE HAVE A COUPLE OF QUESTIONS FOR PEOPLE OUTSIDE THE REMOTE.
I CAN MOVE ON. >> ONE POINT, THAT, IN FACT, YOU
MAY NEED THE MOST DISCUSSION ABOUT THE TEST THAT YOU
SHOULDN'T BE USING. 24R IS SO MUCH PUSH TO THE
POPULATION THAT THEY SHOULD DO THESE THINGS.
IT'S REALLY TO CONVINCE PEOPLE THAT THEY SHOULDN'T BE DOING
THOSE THINGS. SO THAT ISSUE SAYING IT NEEDS TO
BE DISCUSSED IS A KEY ONE. >> IT TAKES MUCH LONGER FOR A
CLINICIAN TO SUGGEST WHY YOU SHOULDN'T DO SOMETHING THAN IT
DOES TO JUST ORDER IT. >> SOME OF OUR ONLINE AND SOCIAL
MEDIA AUDIENCES, GIVEN THAT THERE'S NOW DATA SUPPORTING LOW
DOSE CT SCANS FOR SMOKERS WHO HAVE QUIT FOR LESS THAN 15
YEARS, IS LUNG CANCER GOING TO BE INCLUDED AND PAID FOR FOR
THOSE PEOPLE WHO MEET ALL THE CRITERIA.
AND WHAT WILL PERSUADE OTHER HEALTH INSURANCE PROVIDERS TO
COVER IT? >> IF I CAN VERY QUICKLY, SO WE
CAN GET TO MORE QUESTIONS, THE PREVENTIVE SERVICES TASK FORCE
HAS NOT YET SPOKEN ABOUT LUNG CANCER SCREENING.
SOME ORGANIZATIONS LIKE THE ACS, THE AMERICAN CANCER SOCIETY THAT
I WORK FOR RECOMMEND INFORMED DECISIONS FOR THOSE WHO WOULD
HAVE QUALIFIED FOR THE TRIAL. THERE ARE INCREASING STUDY
THAT'S SHOW THAT LUNG CANCER SCREENING IS MORE BENEFICIAL FOR
PEOPLE IN THAT TRIAL WHO WERE VERY, VERY HEAVY SMOKERS AND NOT
VERY QUALIFIED FOR THE STUDY. SO THIS IS GOING TO BE A -- YOU
KNOW, BASED TEST FOR PEOPLE AT VERY HIGH RISK.
AND IT'S GOING TO REQUIRE INFORMED DECISION MAKING.
>> THAT'S GOING TO HAVE TO BE OUR LAST QUESTION.
I DID WANT TO SAY ONE THING. I REALLY DO APPRECIATE OUR
SPEAKERS WHO CAME OUT FOR THIS. AND I WANT TO SAY BECAUSE WE HAD
FOLKS WHO ARE SOS STEAMED IN THEIR FIELD AND WERE WILLING TO
TRAVEL SUCH A LONG WAY, WE WERE DETERMINED TO FILL THIS AUD
FORMUS AND WE DID. SO THANK YOU, THOSE OF WHO YOU
CAME. >> THANK YOU ALL VERY MUCH.
THANKS TO OUR SPEAKERS FOR OUR IN-PERSON AUDIENCE.
THERE IS AN EVENT AT THE CDC MUSEUM.
FOR THE REST OF OUR AUDIENCE, WE HAVE AN ENCORE PRESENTATION NEXT
MONTH. OUR NEXT LIVE PUBLIC HEALTH
GRAND ROUNDS WILL BE IN SEPTEMBER.
THANK YOU.