So thanks, Gerard. I have to take a moment to say we have really covered a lot today, truly terrific talks from all, and so glad to have everybody actively participating. For our final segment of the day, we will discuss community engagement by GI endoscopy healthcare teams. Kicking us off will be T.R. Levin. Dr. Levin is a gastroenterologist and health service researcher with Kaiser Permanente in Northern California. He is the Interim Associate Director of Cancer Research at the Kaiser Permanente Division of Research, clinical lead for colorectal cancer screening for the Permanente Medical Group, and a professor of health system science at the Kaiser Permanente School of Medicine. Dr. Levin currently serves on the ASGE Quality Assurance and Endoscopy Committee. T.R., the audience is all yours. Thank you for joining us. So one disclosure, Freenom, I'm doing research with them, and then we're going to talk a little bit about fecal screening, and I'm sure many of you are wondering, hey, wait a minute, I'm at an American Society of Gastrointestinal Endoscopy course, why are we so concerned about fecal testing? Well, number one, fecal testing has now moved up on the menu of options as kind of a tier one test according to the U.S. Multi-Society Task Force, along with colonoscopy. This fecal testing could be either FIT or multi-target stool DNA, although the FIT testing is less expensive, a little bit simpler to do, and is actually in the tier one, whereas the stool DNA is on tier two for the Multi-Society Task Force guidelines. I want to get us away from the old way of thinking. This is a 2008 guideline, a joint guideline with the American Cancer Society and the Multi-Society Task Force, where we divided tests up into those that detected polyps and cancer or those that primarily detect cancer. I really think we just need to get away from this way of thinking and think about, okay, what is the relative value or the relative contribution or anticipated benefit of doing fecal screening versus colonoscopy? This is from the United States Preventive Services Task Force, kind of a non-specialty organization. They did a modeling study comparing three different models, CIR-C, CIR-C SPIN, and MyScan, and then kind of averaged the benefits. So in terms of deaths averted for 1,000 individuals who are 100 percent adherent with screening, you might save an additional two years or two deaths averted compared to colonoscopy compared to FIT. But this comes at a cost, and it comes at a cost of inconvenience for patients. And in terms of total numbers of colonoscopies that have to be performed, it's nearly twice as—it's a little more than twice as many colonoscopies for just those two additional deaths. The—I'm sure many of you have seen or heard about the Nordic colonoscopy screening study out of Europe, and many of us thought the results were disappointing because—and one of the key drivers, actually, of that disappointment was really the low participation rate on the colonoscopy arm. These people were invited by mail. They weren't referred by an individual physician. But clearly, participation makes a huge deal. And since it's all about adherence to screening, there's no detection and no cancer prevention or cancer detection without actually getting people to screen. I referenced a couple of RCTs that were done now about 10 years ago. And really, in every setting, when FOBT or FIT is offered as an alternative to colonoscopy, there's much better adherence when people have a fecal option, and that's important to bear in mind. And more recently, there's a Skrisko study out of Sweden, which demonstrated that after two rounds of screening with FIT—this was FIT versus colonoscopy—they haven't reported the actual mortality benefit just yet, but after two rounds of screening with FIT compared to a baseline colonoscopy, you can see there was much higher participation in the FIT arm compared to the colonoscopy arm, 55% versus 35%. And that resulted in actually more cancers being detected in the FIT arm than in the colonoscopy arm. There were twice as many people in the FIT arm, so bear that in mind. But there's also, in terms of a percentage basis, still higher, and clearly FIT is not inferior to colonoscopy in terms of cancer detection. And then in terms of advanced adenomas, still colonoscopy has the edge on advanced adenomas, but remember that not all advanced adenomas are going to progress to cancer. It's probably about 10% over a period of 10 years. So if you're doing FIT on an annual basis, you have multiple opportunities to detect that adenoma and remove it before it becomes a cancer. Let me just advance this one. There's also many different ways that you can incorporate both tests into your practice or into a screening program. This is data from Poland, and you can see that you can either only offer colonoscopy, in which case 17.5% of people will participate. You could offer colonoscopy first, and then people who don't adhere to the colonoscopy or don't accept it, you could subsequently offer FIT, or you give people a choice. It turns out it probably doesn't matter between those two, but you definitely get more people participating when you have another option. As we're recovering from the COVID pandemic, and in addition, as we're dealing with 20% additional increase in number of people due for screening as we start screening at 45, and we start asking people what tests would they prefer, you can clearly see that, especially among the younger patients, but even older ones, people seem to prefer, people who haven't been screened yet certainly have a preference for fecal screening. You can think of it as kind of like the gateway drug of colon screening. People who aren't yet willing to do a colonoscopy, they can do a FIT for a few years and get used to the idea that they even have a colon or that they need to be screened, and at some point they may convert over to colonoscopy later. We do a very large mass mailing outreach for FIT at our setting here at Kaiser Permanente and has multiple steps with a primer letter, FIT kit, a robocall that follows, and reminder letters, and lots of outreach happening on local levels. Of course, people have option for colonoscopy if they're high risk or if they just prefer it based on doing something once every 10 years versus every year, and the impact of this has been a very large uptick in the amount of people that we've screened. When we started doing this work in the early 2000s, we were in a 40% range for screening, and now we're well above 80%. Most of that is driven by FIT, but there's also been a steady uptick in colonoscopy. We estimate that if you do FIT annually, if you have a population of people you do FIT annually over 10 years, you're going to see probably about a third of people who end up with a colonoscopy, and it's probably the population most likely to benefit. This translates into a 50% decline in colorectal cancer mortality and a 26% decline in colorectal cancer incidence. Now, obviously, there's a lot of colonoscopy going on in our population as well, but the big driver and the most things where there's most participation was with FIT. We've also seen that by raising, by systematically offering screening to every member of our population through mass mailing, whether they're coming into the office or not, taking that decision-making many ways out of the individual physician's hands. We've successfully eliminated disparities. We saw improvement in both our Black patients and our White patients, and this translated into a closing of a mortality gap between Whites and Blacks in terms of death from colorectal cancer over the period from 2006 until 2018, 2019. The reason I'm really talking to you about community engagement is that the real opportunity for gastroenterologists is to engage with those primary care physicians who are testing their patients with FIT and need somewhere to refer those patients. And as gastroenterologists, we have a responsibility really to work together with our primary care colleagues to make it as easy as possible for their patients to get colonoscopy. Because obviously, doing a FIT by itself doesn't help anyone in terms of cancer detection or cancer prevention. It is really the colonoscopy that happens after that, but it's not a simple procedure. It has multiple steps. This is the way we've approached it. You can see we did sort of a stepwise improvement process over many years as we were trying to get better and better at this, at getting people screened. And you can see that our FIT-positive patients, we have some where the patient is identified from a list that the gastroenterologist received from a laboratory, and they just have staff that are assigned to work those lists right away. In other settings where there's not as much manpower in the GI department, primary care will make a referral. And then we have dedicated policies and procedures for how many contacts we make to reach a patient in order to schedule their colonoscopy. We send letters if people are unable to be reached, if we can't reach them by phone or they don't respond. At that point, then, we also notify their primary care provider that we need their help to get the patient screened. The patients who are successfully appointed and scheduled for their colonoscopy and complete their colonoscopy then go to a follow-up based on findings, follow-up findings, go into surveillance algorithm, normal colonoscopy, resume screening in 10 years. And this has resulted in year-over-year increased performance on our follow-up to the point now where we're well above 80%, closer to 85% of our patients with positive FITs get a colonoscopy. This has also been looked at by Ma Samsuk at San Francisco General Hospital, and he broke it down into the steps involved for a safety-net-oriented fecal screening program, certainly starting with the FIT outreach. If the FIT is abnormal, looking for patients who are not referred after 14 days, in which case the screening program or the provider team will start to intervene to try and make sure people get scheduled. And in addition, people who are not scheduled after 41 days, the provider team also gets involved and then people eventually get scheduled. And if people miss or cancel their procedure, the endoscopy unit is involved at that point to attempt to reschedule, identify barriers, and also alerting the primary care physician with the ultimate goal of really trying to get everyone screened with their colonoscopy after their FIT is positive. So a couple of conclusions and takeaway messages for you that just remember that non-invasive tests are on the first line as options for colorectal cancer screening, but definitely not the only line, and there's plenty of room for colonoscopy to continue. And I think one thing to bear in mind is as you launch or as you participate with your primary care physicians potentially on getting additional people screened by offering an alternative to colonoscopy, you will find that there's going to be need for more colonoscopies because there's a lot of people who are coming into your department, into your ASC to get their colonoscopy who are not getting any screening. So you're kind of bringing more people under that overall umbrella or tent that's needed for colon screening. It's very about FIT screening in particular and stool-based screening, very valuable for organized screening programs, particularly those that are able to leverage a mailed outreach with FIT that's very effective. There's lots of resources available to help you kind of get that going. And depending on the size of your program, you may be able to outsource some of the mailing to a third party mailing house. Colonoscopy obviously has a huge role, follow up with positive FIT. And remember that it's very difficult for some people to think about or conceive of a way to get a colonoscopy. Some people are not necessarily well enough to have a colonoscopy, or at least should kind of think twice before having it and maybe have one if it's really going to benefit them, but not just as a routine test. Many people are unwilling, particularly on first mention, and need some time to kind of adapt to the idea of getting screened. Some people don't necessarily have resources or available transportation. And particularly if they're lacking housing or the colonoscopist is multiple miles away, it's really useful to have that first step before people need to go straight to colonoscopy. Stool-based testing is great to reach patients who aren't up to date with screening. Those who aren't coming into the office very often. There are people who have decreased trust in the healthcare system, and it's particularly a great way to kind of open the door for those folks. People have difficulty missing work. If your department, like many, is dealing with backlogs and other things in terms of surveillance and diagnostic procedures, and you're kind of catching up from the COVID pandemic and the shelter-in-place and loss of capacity. And remember now that we're accountable for screening 45- to 49-year-olds, and this is great news. I think it's a great opportunity to make a difference in a lot of people's lives. But the overall prevalence of disease is particularly lower in this population. So finding some way to select patients for colonoscopy I think is particularly useful. And non-invasive testing is a great way to do that. So just in terms of how to maximize the Fitch follow-up and what can you do as a gastroenterology group or as an endoscopy group to really help that. Reach out to your primary care physicians who are generating these patients. Make sure that they know that you're available and you're willing to help them get their patients followed up and provide services for them. This is particularly problematic for FQHCs or other kind of low-income environments. Many of them don't have a reliable gastroenterologist they can refer to. And that's where kind of the community outreach component of this talk really plays a role. Having a champion in your department for this work who can help navigate patients and also facilitate communication between the referring colonoscopy practice and the referring physicians. And you can identify patients who are FIT positive either directly from a lab if it's being processed that way, creating logs and sorting patients and re-evaluating those who are inappropriate for colonoscopy. People who have difficulty getting scheduled letters are a great way to just provide a second reminder, give people time to think about it with a phone number. And then the other thing we do in our practice is that we send annual letters to those who are still due after a year. And we do get five or 10% of people who actually then will call us in to schedule their colonoscopy at that point, just with that second reminder. So that's really, that's all I have and I appreciate your time and let me know if there's any questions.

community engagement

GI endoscopy healthcare teams

colorectal cancer screening

Fecal immunochemical testing (FIT)

Kaiser Permanente