The challenging role of general practitioner in the screening and diagnosis of CRC

1. The challenging role of general practitioner in the screeningand diagnosis of CRC Christos LionisMD PhD FRCGP (Hon) FSC FWONCA in collaboration with Dimitra Sifaki-PistollaMPH PhD School of Medicine, University of Crete, Greece

2. Outline of the presentation • CRC screening: an old issue for General Practice and Primary Health Care • The role of Primary Health Care in the management of CRC • Why Primary Health Care in the management of CRC (data from Crete)? • To improve CRC survival (how feasible is it?) • What we need to change the current situation • Concluding remarks

3. Colorectal cancer screening: the challenging role of GPs, an old issue • The involvement of GPs in CRC screening • Key issues to be addressed in regards to the involvement of GPs in CRC screening • Significant determinants of screening behavior of physicians • CRC screening as an issue of quality assurance • The issue of health utilization (from theory to practice) • The issue of health inequalities-lessons from health policy Lionis, Quality in Primary Care, 2007

4. prescriber.co.uk Prescriber April 2016 ❚ 45 “The management of cancer patients has traditionally been a secondary care responsibility but increasing survival rates and new models of care mean that the role of primary care is evolving and a restructuring of cancer services to provide more integrated care is now required” Cancer Care Manitoba-Uniting Primary Care and Oncology

5. Role of general practice in CRC screening • How can general practice support participation? • Displaying brochures, flyers and posters • Talking to patient aged 50-74 years about bowel cancer screening • Demonstrating how to use a kit • Sending a letter to 49 years old patients to encourage participation • Knowing the program (this series of short videos) http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/role-of-GPs

6. What the patients say? • 22 patients were interviewed • Although patients perceived their GP is involved in CRC care, they would prefer their follow-up care in a hospital setting. • Future follow-up care that become more relying on testing the markers may change the incorporation of this task in the current GP routines Brandenbarg et al, Fam Pract, 2017

7. Cancer Registry of Crete (http://www.crc.uoc.gr) Data collection and analysis • Quality controls • Rates for: incidence, mortality and survival • All rates are Age-Standardized using the European Standard Population and the Cretan population pyramid; expressed per 100,000/year

8. Our registrars and scientific collaborators VE Chatzea I. Vasilaki E. Frouzi S.Lionakis N. Epitropaki T. Romanidou D. Sifaki-Pistolla D. Mavroudis Μ. Kouroupi G. Pistolla F.Koinis I. Tsiligianni N.Tzanakis V.Georgoulias C.Lionis

9. Most frequent malignancy in Crete Cancer Registry of Crete (http://www.crc.uoc.gr)

10. Cretan and mean European incidence and mortality rates per cancer type Ferlay, 2013, IACR, ENCR Cancer Registry of Crete (http://www.crc.uoc.gr)

11. The diagnosis of Gastrointestinal Cancer-Comparison between rates in the Mediterranean • Although, systematic review of comparative data between Southern-European Mediterranean and Northern European countries are lacking, several variations are also observed between genders • Southern-Mediterranean countries present much lower rates compared to the average EU-27 and the Northern European countries • Dimitra Sifaki-Pistolla and Christos Lionis. Gastro-Intestinal (GI) cancers and their diagnosis: A European-Mediterranean perspective. • ESPCG EuroDigest Issue 4 Cancer Issue. Available at: http://sprpublishing.com/espcg-eurodigest/espcg-eurodigest-issue-4/

12. Colorectal cancer Incidence rates (Ι) meanASR/100,000: • Crete= 25.1 • Males=30.1 • Females=19.9 Cancer Registry of Crete (http://www.crc.uoc.gr)

13. Colorectal cancer observed and predicted incidence per municipality (ΙΙ) * Rates projection was performed through interpolation prediction models with 95% CI. Cancer Registry of Crete (http://www.crc.uoc.gr)

14. Colon cancer incidence rates per age group (under and over 50years)-I • The mean Age-Specific Incidence Rates (ASpIR) of colon patients <50 years were 5.1/100,000/year (Fig.A), while for patients≥50 years the ASpIR was 150/100,000/year (Fig.B). • Males presented significantly higher rate comparing to females (p=0.02) especially after the ages of 30 and 70 years. • Contrary to that, females aged 20-24 years presented slightly higher ASpIR comparing to males (Fig.A). • The ASpIR seem to start declining slightly after the age of 85-89 years old (Fig.B). Cancer Registry of Crete (http://www.crc.uoc.gr)

15. Colon cancer incidence rates per age group (under and over 50years)-II • ASpIR presented 29,7% increase from 1992 to 2013 in the age group of 20-34 years and further increase is expected from 2014 to 2024 (projected change, 36.9%). • Similar trends were observed in the age group of 35-49 years from 1992 to 2013, as well as in the age group of 50-49 from 1992 to 2002. To the contrary, the ages over 50 years presented declines in the ASpIR starting from -12.6% for individuals aged 50-74 years (2003-2013) to -31.4% for those aged >75 years (1992-2013). Cancer Registry of Crete (http://www.crc.uoc.gr)

16. Retrosigmoid and rectal incidence rates per age group (under and over 50years)-I • ASpIR of rectal patients per age group presented almost similar trends with those of colon patients. • The mean ASpIR of rectal patients <50 years were 3.2/100,000/year (Fig.A), while for patients≥50 years the ASpIR was 96.3/100,000/year (Fig. B). • Males presented significantly higher rate comparing to females (p=0.04) especially after the ages of 40, 75 and 85 years. • The ASpIR presented decreasing trends after the age of 85 years (Fig. B). Cancer Registry of Crete (http://www.crc.uoc.gr)

17. Retrosigmoid and rectal incidence rates per age group (under and over 50years)-II • In the age group of 20-34 years, the ASpIR presented 34.8% increase from 1992 to 2013, with a projected increase of 43.6% from 2014 to 2024. In the age group of 35-49 years, similar trends were observed reaching the 37.2% increase from 1992 to 2013. • To the contrary, the ages over 50 years presented declines in the ASpIR (50-74 years: APC, -21.8; projected APC, -36.3 and >70 years: APC, -38.5; projected APC, -41.2). Cancer Registry of Crete (http://www.crc.uoc.gr)

18. The role of PHC services in early diagnosis of colorectal cancer as well as in integrated care of patients and survivors • Personal physician and health team in PHC (follow-up, risk assessment, recommendations / individual screening): • Establishing a baseline and standardized health record including the genogram and the cancer determinants, utilized in all PHC units visitors for risk assessment and recommendations for screening with G-fecal ocular blood test / FOBT, fecal immunochemical test / FIT kit and / or colonoscopy. • Participation in the follow-up of cancer patients in the context of every day practice in PHC units, in collaboration with the oncology team. • Support cancer survivors • Participation in integrated care (from the Unit to the Hospital and the Relief Unit and at home) • Conducting day-to-day information and personal information meetings before the examination, focusing on the high-risk groups of the population and targeting the behavior change of the population of Crete • Units and services, public health services, community bodies, regional authorities (coordination and monitoring of a population-based screening program): • Organize and implement comprehensive screening programs with the participation of GPs, hospitals and a reference center in Crete, with the coordination and support of the 7th Regional Authority of Crete and the Cancer Registry of Crete. -Buckland. Role of primary care in the management of cancer patients. Prescriber, 2016 -The changing face of UK primary cancer care. The Lancet Oncology -Triantafilidis, et al. Screening for colorectal cancer: the role of the primary care physician. Eur J Gastroenterol Hepatol, 2016

19. Cancer-specific survival per age group Cancer Registry of Crete (http://www.crc.uoc.gr)

20. A current target: to improve survival in CRC • GPs have a complex task in promoting: • Earlier diagnosis of CRC in their patients • The combination of initiatives (including use of risk assessment tools, better access to investigation) • At present the reason for the relatively poor CRC survival data in countries such as England and Denmark is unclear Rubin et al, Br J Gen Pract, 2013

21. Motivational Interviewing: another example of a conversational style that can guide our goal to change behavior in both, PHC physicians and patients The founders of MI since 1989 William Miller Stephen Rollnick A definition: Motivational interviewing is a collaborative conversation style for strengthening a person’s own motivation and commitment to change Motivational Interviewing (resources for clinicians, researchers, and trainers) http://www.motivationalinterview.org/ Miller and Rollnick, 2013 21 FRAMES • Feedback • Responsibility • Advice • Menu • Empathy • Supporting Self Efficacy 21

22. Motivational Interviewing: another example of a conversational style that can guide our goal to change behavior in both, PHC physicians and patients Oikonomidou et al. BMC Gastroenterology 2011 «Engaging is about “Shall we travel together?” «Focusing asks “Where to?” «Evoking is about “Whether” and “Why”?” «Planning is about “How” and “When”?” Miller and Rollnick, 2013

23. Applying health behaviour theories to research • Behavioural learning theory • Health belief model • Protection motivation theory • Revised protection motivation theory • Social cognitive theory • Theory of reasoned action • Theory of Planned Behavior • Information motivation behavioral skills model • Self regulation theory • Transtheoretical model Germeni et al, Inj Prev, 2009

24. Applying health behaviour theories to research Tsiantou el al, Health Policy, 2015

25. Concluding remarks: what we need to change in the current situation • Tailor made behavioral change interventions focusing on raising awareness of the general population • We need GPs well trained in approaches to motivate people in behavioral change • To establish a network for GI monitoring and control CRC • A new contract between Primary Care Practitioners and Ministry of Health • Dimitra Sifaki-Pistolla and Christos Lionis. Gastro-Intestinal (GI) cancers and their diagnosis: A European-Mediterranean perspective. • ESPCG EuroDigest Issue 4 Cancer Issue. Available at: http://sprpublishing.com/espcg-eurodigest/espcg-eurodigest-issue-4/ 6

26. Many thanks for your attendance