KMA Journal - March 2009 by Kentucky Medical Association

Award-Winning Publication of the Kentucky Medical Association

March 2009/ VOL 107/ NO 3

C OVER S TORY 86

Confronting the Barriers to Colorectal Cancer Screening and Treatment Whitney F. Jones, MD; Robert C. Martin, MD, PhD

The Role of Primary Care Physicians in the Prevention and Management of Colorectal Cancer Phillip W. Bale, MD, FAAFP; Kevin Pearce, MD, PhD

Colorectal Cancer Chemotherapy Thomas M. Woodcock, MD

Radiation in Rectal Carcinoma William J. Spanos Jr, MD

A Practical Approach to Colorectal Cancer Screening and Surveillance Guidelines for the Primary Care Physician Robert Wells, MD; Harry Elvanides, MD; Edward C. Adler, MD; Willem J. S. de Villiers, MD, PhD

E DITORIAL 107

A Dual Military Family Donna Stewart, MD

COVER: Our cover story focuses on colorectal cancer awareness. The KMA Cancer Committee has assembled articles dealing with various aspects of this topic and the crucial role that primary care physicians, in particular, can play in its prevention, early detection, and treatment. Artwork by Lee Wade of Spencer County, KY

A SSOCIATION 115 108 83 111

Application for Scientific Exhibits Awards Nomination Form Monitoring Medicine People

D EPARTMENTS 81 118 109 117 114 116

President's Page Advertisers' Guide Alliance Page Classified FYI Capsules Guidelines for Authors

March 2009/ VOL 107

TRUSTEES OFFICERS President 2009 James F. Beattie, MD 250 Park Street Bowling Green, KY 42101 (270) 745-1316 jbeat10689@aol.com

President-Elect John R. White, MD 166 Pasadena Drive Lexington, KY 40503 (859) 278-0319

2009

jwhite1218@insightbb.com

Immediate Past President 2009 Thomas K. Slabaugh, MD 1401 Harrodsburg Rd, #C-405 Lexington, KY 40504-3702 (859) 277-2280 t.slabaugh@insightbb.com

Vice President 2009 Shawn C. Jones, MD PO Box 9686 Paducah, KY 42002-9686 (270) 441-4903 scjonesmd@comcast.net

Secretary-Treasurer 2011 Linda H. Gleis, MD VAMC, Dept. PM&R (117) 800 Zorn Ave Louisville, KY 40206 (502) 287-5105 (VA) lhgmd@bellsouth.net

Chair, Board of Trustees 2009 Uday V. Dave, MD 200 Clinic Dr Madisonville, KY 42431 (270) 825-7377 manutoffi@newwavecomm.net

Vice Chair 2009 Gordon R. Tobin II, MD 401 E. Chestnut St, Ste 710 Louisville, KY 40202 (502) 583-8303 gordon.tobin@louisville.edu Speaker, House of Delegates 2010 Nancy C. Swikert, MD 8780 US Hwy 42 Florence, KY 41042 (859) 384-2660 DDwarrow@aol.com

Vice Speaker 2010 Maurice J. Oakley, MD 1901 Winchester Ave, Ste 102 Ashland 41101-7741 (606) 329-2211 mjoakleymd@yahoo.com

DISTRICT TRUSTEES First 2010 Bradley T. Rankin, MD 2312 Kentucky Ave Paducah, KY 42003 (270) 442-5151 brankin0001@comcast.net

Second 2009 William C. Harrison, MD Owensboro Medical Health System Department of Radiology 811 East Parrish Ave Owensboro, 42303 (270) 688-2190 wchblue@roadrunner.com

March 2009/ VOL 107

Third 2010 Uday V. Dave, MD Trover Clinic Madisonville, KY 42431 (270) 825-7377

Fifteenth Truman Perry, MD 121 Bishop St Corbin, KY 40701 (606) 528-2124

manutoffi@newwavecomm.net

doctors2@msn.com

Fourth 2010 Syed R.P. Quadri, MD 425 E. Eagle Pass Rd Elizabethtown, KY 42701 (270) 776-1476

Delegates to the AMA Preston P. Nunnelley, MD 1740 Nicholasville Rd Lexington 40503 (859) 260-6257

hinmed@gmail.com

preston@pnunnelley.com

Fifth 2011 Gordon R. Tobin, II, MD 401 E. Chestnut St, Ste 710 Louisville, KY 40202 (502) 583-8303

2009

gordon.tobin@louisville.edu

djswikert@stelizabeth.com

Sixth Robert J. Emslie, MD 201 Park St Bowling Green 42101 (270) 780-2496

2011

emslier@ggclinic.com

Seventh 2009 Joseph J. Dobner, MD 101 Medical Hgts Dr, Ste F Frankfort, KY 40601-4180 (502) 875-1766 dobner6@netscape.net

Eighth 2011 Theodore H. Miller, MD 20 Medical Village Dr, Ste 394 Edgewood, KY 41017-3490 (859) 341-1100 thmmdphd@pol.net

Ninth 2009 G. LeRoy Gallenstein, MD 1350 Medical Park Dr Maysville 41056-1547 (606) 759-7878 drgallenstein@maysvilleky.net

Tenth 2009 David J. Bensema, MD 1780 Nicholasville Rd #103 Lexington, KY 40503-1411 (859) 260-4347 dbensema@bhsi.com

Eleventh 2011 John M. Johnstone, MD 793 Eastern Bypass, Ste 201 Richmond, KY 40475 (859) 624-8647

Donald J. Swikert, MD 413 S Loop Rd Edgewood 41017 (859) 301-3830 2010 J. Gregory Cooper, MD 1210 Ky Hwy 36E, Ste 2C Cynthiana 41031-7492 (859) 234-6000 gregcoopermd@yahoo.com

2009 Baretta R. Casey, MD Director, UK Center for Rural Health 750 Morton Blvd, Rm B-418 Hazard, KY 41701 (606) 439-3557, Ext 83514 bcase2@email.uky.edu

2010 Bruce A. Scott, MD 6420 Dutchmans Pkwy, Ste 380 Louisville 40205-3355 (502) 894-8441 brucescott@insightbb.com

2010 Alternate Delegates to the AMA Andrew R. Pulito, MD MS-235 Medical Center 0298 Lexington 40536 (859) 323-5289

EDITOR Stephen Z. Smith, MD MANAGING EDITOR Sharon A. Heckel DEPARTMENTAL EDITORS Daniel W. Varga, MD Scientific ASSISTANT EDITORS Kimberly A. Alumbaugh, MD John J. Buchino, MD Daniel P. Garcia, MD James E. McKiernan, Jr, MD Bryan D. Murphy, MD Patrick J. Murphy, Jr, MD Mark Newstadt, MD Christopher J. Schrodt, MD Donna Stewart, MD EXECUTIVE EDITOR Patrick T. Padgett ASSOCIATE EXECUTIVE EDITOR Diane M. Maxey Journal of the Kentucky Medical Association (ISSN #023-0294) is published monthly by the Kentucky Medical Association, 4965 US Hwy 42, Suite 2000, Louisville, KY 40222, under the direction of the Board of Trustees. USPS #280-700 Periodicals postage paid at Louisville, KY and additional offices. Canada Agreement number: PM40063731. Return Undeliverable Canadian Addresses to: Station A, PO Box 54, Windsor, Ontario N9A 6J5; Email: returnsil@imex.pb.com Yearly subscription rates: $45 domestic; $65 foreign. Single issues $8 per copy prepaid. POSTMASTER: Send address change to Journal of the Kentucky Medical Association, The KMA Building, 4965 US Hwy 42, Suite 2000, Louisville, KY 40222. Telephone 502/426-6200 Fax 502/426-6877 Email member@kyma.org

2010

Listed in Index Medicus. Printed on acid-free paper effective with Volume 87, Issue 4, 1989.

William B. Monnig, MD Attn: Sandy Carter 20 Medical Village Dr, #308 Edgewood 41017 (859) 341-2672

EDITORIAL AND ADVERTISING: Contact Sharon Heckel, JKMA, The KMA Building, 4965 US Hwy 42, Suite 2000, Louisville, KY 40222. Phone 502/ 426-6200; FAX 502/426-6877.

arpuli@uky.edu

wmonnig@insightbb.com

cardcare2003@yahoo.com

2010

Twelfth 2010 David C. Liebschutz, MD PO Box 245 Danville, KY 40423-0245 (859) 236-4121

Donald R. Stephens, MD 439 E Pleasant St Cynthiana 41031 (859) 234-4494

mdlieb@bellsouth.net

2009

Thirteenth 2009 Henry C. Goodman, MD 2301 Lexington Ave, Ste 300 Ashland 41101 (606) 329-2823

Robert A. Zaring, MD 217 E. Chestnut St Louisville, KY 40202 (502) 587-4330 robert.zaring@jhhs.org 2009

Claims for undelivered copies will not be honored beyond 6 months after the date of publication.

Fourteenth 2010 Jyotin V. Chandarana, MD 755 Morton Blvd Hazard, KY 41701 (606) 436-5763

Donald R. Neel, MD 2816 Veach Rd Owensboro 42303 (270) 926-9821

naroda54@hotmail.com

2009

henrycgoodman@gmail.com

drsmd@hotmail.com

docneel1@aol.com

The Journal, its editors, and the Kentucky Medical Association do not assume responsibility for the opinions and statements of its contributors and advertisers. The Journal reserves the right to make the final decision on all content and advertisements.

Printed by the Ovid Bell Press, Inc, Fulton, Missouri 65251.

Web site: www.kyma.org

P R E S I D E N T ’ S PAG E

CHANGE

hange was the dominant theme in this past fall’s general election. We have multiple aphorisms that address change from “Change is inevitable” to “We never change.” Change can be a very positive event, but also can have negatives for individuals or organizations. Physicians can be both very tradition bound and avoid change in some aspects of their lives and practice, or be quite willing to accept change if it can be shown to improve their practice. One of my associates loves to repeat the story of one of his med school instructors whose mantra was “becausethat’s-the-way-we-do-it-every-time.” Yet physicians are quite ready to change their procedural techniques or practice patterns if something can be shown to be more efficient or have a better result. Sometimes we actively decide to make changes, and sometimes we are forced to make changes. Both of these have been involved with events regarding the KMA. For instance, KMA has not been immune to the economic downturn of the past year. We have also monitored changes being made by the press, publishing industry and medical publications in how they provide information to the public. All of this has caused the leadership of the KMA to initiate changes that we hope will improve the efficiency of the organization, as well as participation in the many activities of the organization without decreasing the service to the membership. Some of these changes are occurring at the headquarters office and may not be evident to most members. More visible

changes will be occurring with the KMA has not Annual Meeting. Efforts been immune to the are being made to streamline the meeting, economic downturn. promote member participation in policy discussions, and control meeting costs. We think these will improve the experience of members attending the meeting and the House of Delegates. KMA President Jim Beattie, MD, will have more to say about these changes in a future issue. Additionally, I will be chairing a committee to look at the communication efforts of our organization. Significant costs are associated with this, and other publications, and we will be looking at ways to convey the information in these publications to the membership in a timely and costeffective manner. This organization has a history of over 150 years of providing information to our membership and we have to realize this is one of our core functions. At the same time, we have new members who not infrequently have a preference of electronic communiations over print. Our committee will be trying to balance these facts with due consideration of our financial situation. Our findings will be reported to the Board of Trustees at its April meeting. John R. White, MD President-Elect

March 2009/ VOL 107

MONITORING Medicine

NEWS FOR KENTUCKY PHYSICIANS High School Sports and the KMA

n recent years, media attention has been given to the unfortunate deaths of athletes exposed to extreme heat. When pro football player Korey Stringer died in 2001 from complications of heat stroke after a Minnesota Vikings’ practice, the story made national headlines and drew significant attention to the need for caution when athletes practice or play in weather too hot for the human body to withstand. Recognizing the need for medical input in these situations, the KMA Committee on Physical Education and Medical Aspects of Sports developed one of the first sets of heat injury prevention and treatment guidelines for high school sports in the nation. In 2002, the Kentucky High School Athletic Association adopted the guidelines for its coaches and players. Heat-related deaths among high school students garnered recent media attention when a Kentucky high school football player died in 2008 and the young man’s coach was charged in his

death. The KMA Sports Committee will continue to assess heat guidelines on an annual basis to ensure the most up-to-date information is provided to KHSAA for improved athlete safety. To inform the KMA membership and general public about the dedication of the Committee on Physical Education and Medical Aspects of Sports to athletics in Kentucky, provided below is a brief history and list of its accomplishments.

KMA COMMITTEE ON PHYSICAL EDUCATION AND THE MEDICAL ASPECTS OF SPORTS The committee was formed over thirty years ago to oversee medical aspects of children’s athletic activities, to serve in an advisory capacity to local schools, and to assist in coordinating direct medical care at sporting events. Most of the original members were affiliated with local schools by virtue of having their own children involved in athletics, or were self-proclaimed team physicians motivated by community spirit. Team physicians typically attended all local games gratis and most still do. Later, when the committee was instrumental in initiating required pre-participation physical examinations, many physicians also provided these exams gratis, and this practice continues today in many locales.

MONITORING Medicine

An early relationship was formed with the Kentucky High School Athletic Association (KHSAA), a semi-autonomous organization affiliated with the Kentucky Department of Edution, but with distinct statutory recognition. KHSAA has authority over all athletic activities conducted through public schools and participating parochial and private schools. This authority includes composition of sports league levels, scheduling, rule making, tournaments, and school coach training requirements. KHSAA has routinely sought input on athletic activities from the KMA Sports Committee. While the KMA committee has no authority to dictate any activities, its advisory capacity has provided benefit to schools, student athletes, KHSAA, and individual physicians. The primary function of the committee has been to develop and organize annual seminars, which all athletic coaches whose schools are overseen by KHSAA are required to attend every two years. In coordination with KHSAA, curriculum is selected, format is chosen, selected teaching materials are furnished, sponsors are solicited, and programs approved, and post activity certi-

fication is awarded. All sponsors must be licensed Kentucky physicians, who must complete affiliation disclosure forms and reconcile expenses and income. The committee approves 12-15 seminars a year, including a separate seminar for cheerleader coaches. In addition to annual seminars, the committee is involved in a variety of other sports-related issues. These have included: • Developed protection and remediation guidelines for athletes exposed to possible blood-borne pathogen diseases, eg, HIV, Hepatitis B • Studied sudden cardiac death and the use of automatic external defibrillators • Conducted a literature study of the efficacy of creatine as a performance-enhancing substance • Developed KMA policy in opposition to all performanceenhancing substances • Made recommendations on Body Mass Index measurements and testing standards for wrestlers • Examined the incidence and occurrence of head injuries in soccer and protective headgear use • Conducted an original study of the incidence and sports venue for female anterior cruciate ligament (ACL) injuries

• Studied the general use/benefit of protective eyewear in all sports • Developed hydration levels for endurance sport athletes • Urged KHSAA to reduce the number of competitive races allowed for each runner in a single day • Made recommendation to the KDE restricting students from competing at levels above their age groups • Developed one of the first sets of HIPAA guidelines in the nation for team physicians treating/examining public school athletes and private school athletes, both in and outside of sports venues. • Urged all school superintendents in the state to rely on physicians rather than nonphysicians for physical examination oversight and medical consultations • Undertook a study, with the KHSAA, on steroid use, that revealed a variety of programs underway in various school districts to test students for all dangerous, mood-altering drugs of abuse. • Instituted a program to provide honorary passes to “distinguished team physicians” at all sports activities in the state.

C OV E R S TO R Y

CONFRONTING THE BARRIERS TO COLORECTAL CANCER SCREENING AND TREATMENT Whitney F. Jones, MD; Robert C. G. Martin, MD, PhD

COLORECTAL CANCER IN KENTUCKY: WHY CAN’T WE PICK THE LOWHANGING FRUIT?

hat can physicians do to prevent unnecessary suffering and premature deaths from colorectal cancer (CRC)? Why can’t we pick the low-hanging fruit? The topics in this issue were chosen both to review the incredible advances in treatment, and to highlight the challenges for the frontline of primary care physicians, focusing on the preferred strategy of prevention and early detection/surveillance. Finally, the public health nature of this “low-hanging fruit” with a statewide call to action of dramatically reducing unnecesary suffering and premature deaths from CRC is discussed. The article on treatment highlights the multimodality nature of advanced disease management such as the revolutionary biological chemotherapy agents and hepatic-directed treatment for metastatic disease including hepatic resection, radio embolization, and ablative therapies such as radiofrequency ablation. With these advances, patients diagnosed with advanced CRC are seeing both improved survival and quality of life, but not without significant personal and financial costs. Unfortunately only ~ 4 in 10 Kentuckians are receiving appropriate screening and the progress in increasing the percentage is excruciatingly

March 2009/ VOL 107

C OV E R S TO R Y

slow given the chance to save over 90% of lost lives, not to mention the great costs and suffering this disease has on our families, communities, and state. Due to our elevated risk factors (smoking, obesity) and low rates of screening, we rank among the highest states in the nation for CRC incidence and deaths. Almost 50 years since the development of the flexible fiberoptic endoscope, 40 years after polyethylene glycol colonic lavage for improved preparations, and almost 20 years after the adenomatous polyp → cancer sequence was proposed and confirmed, our generation of physicians faces one remaining hurdle: how do we increase the rate of screening? Four barriers are identified by patients who are at risk but have not undergone screening. 1. No referral for the test made by physician/provider. 2. Embarrassment about the test. 3. Dislike of the preparation required. 4. Fear of the pain associated with the test. We as providers of health care to our state can change the course of this disease now by systematically asking all persons over age 40 about their family history of adenomatous polyps or CRC and if there are any current symptoms of colon problems. This group needs evaluation now, with colonoscopy being the preferred test. Seven percent of CRC cases occur in the fourth decade of life with tragic consequences of delayed diagnosis. If patients are over 50 and have not yet been screened, then make the referral or provide the screening service as outlined by the current American Cancer Society guidelines. One simple no-cost system is to charge the office person taking the vital signs with documenting CRC risks and flagging the chart for the physician to begin the conversation. This opening promotes the conversation to review test options and inform patients that the variety of options have never been easier, less painful, or more effective than NOW. The KMA Journal is to be recognized and thanked for focusing this issue on colorectal cancer. The cancer committee of the KMA ap-

Dr Martin is Chair, KMA Cancer Committee, 601 S. Floyd St Ste 700, Louisville, KY 40202. Dr Jones is Founder of the Colon Cancer Prevention Project, and Chair, Kentucky Colon Cancer Screening Program Advisory Committee. Corresponding Author Whitney F. Jones, MD, 115 S. Ewing St, Louisville, KY 40202; www.c2p2ky.org.

preciates the opportunity to address and engage Kentucky’s physicians in solving our colon cancer problem. We are hopeful that the information provided will be beneficial to reinforce the standards of care for prevention, early detection, and treatment when necessary. Now is the time, and ours is the generation of physicians uniquely presented with the combination of information, screening tools, and opportunity to dramatically increase the rate of new screenings of Kentuckians at risk and work toward elimination once and for all this common and preventable cancer killer. For you, your family, your patients, and your community, let’s make screening for colorectal cancer as much of a priority as we have with smoking cessation, breast cancer, HIV/ AIDS, and prostate cancer. A very gratifying note is that the Kentucky General Assembly passed House Bill 415 in the 2008 session. This bill establishes a colorectal cancer screening program for persons aged 5064, and others at high risk who lack access to screening, through the Kentucky Department of Health and Area Development Districts. The bill also provides for referral and treatment linkages. Passage of this legislation is the result of a lot of work by many individuals and groups who support this cause. No funding was appropriated, but we’ll seek to expand this “official” start in coming sessions. Senate Bill 96 also passed in the 2008 session and became effective on January 1, 2009. This bill mandates health insurance coverage of American Cancer Society colon cancer screening tests, including colonoscopies. For more information on how to increase screening in your office and for office tools and systems, call or email the coloncancerpreven tionproject.org (502.290.0288).

March 2009/ VOL 107

C OV E R S TO R Y

THE ROLE OF PRIMARY CARE PHYSICIANS IN THE PREVENTION AND MANAGEMENT OF COLORECTAL CANCER Phillip W. Bale, MD, FAAFP; Kevin Pearce, MD, MPH

rimary care is often referred to as the “backbone” of America’s health care system. Primary care physicians (PCP) pride themselves as being doctors who strive to see the whole patient and who routinely put prevention services into practice. As such, PCPs have critical opportunities and responsibilities in the prevention and management of colorectal cancer (CRC). Most Americans receive medical care from a PCP more frequently than any other physician; the average adult at risk for CRC makes three to five visits per year to his or her PCP.1, 2 PCP recommendations about cancer screening are among the most powerful predictors of appropriate cancer surveillance.3, 4 The frequency of patient contact along with the comprehensive and longitudinal relationship inherent to primary care places PCPs in the best position to recognize patients at increased CRC risk, and to advise all patients on such matters as healthy diet, NSAID use, and estrogen use as they relate to CRC prevention. These same characteristics of primary care give the PCP a pivotal role in assuring appropriate and continued followup for the patients who have had a colon adenoma or CRC. Demographics give us some insight into the reasons for Kentucky being a laggard with respect to CRC screening. In most areas of Kentucky, PCPs are especially critical in the battle against CRC, while facing special challenges in minimizing the impact of CRC on their communities. Forty-five percent of Kentuckians live

March 2009/ VOL 107

in rural areas.5 Seventy-five percent of Kentucky counties are designated as medically underserved6 and thus access to screening may present a significant barrier. Rural Americans tend to be older, poorer, less educated, and more likely to be medically uninsured than their urban counterparts. They also bear a higher burden of chronic illness and disability and report poorer overall health than residents of urban communities.7, 8 Understanding these socioeconomic disparities which exist in a predominantly rural, relatively underserved population could lead to effective strategies for reducing the burden of CRC in Kentucky. Physician and public education efforts along with overcoming barriers to access in the rural setting are critical to increasing CRC screening rates. The reality in Kentucky is that most rural communities have physician shortages, and most medical care is provided by busy PCPs practicing in small groups with narrow financial margins.8, 9 What the PCPs ask, advise, perform and/or arrange largely determines whether a given patient will get CRC screening and follow-up.3, 4, 10 Herein lies the challenge for Kentucky’s PCPs. There is consensus that CRC screening can reduce CRC morbidity and mortality by finding and removing precancerous colon polyps, and CRC survival is heavily dependent on early detection.11, 12 However, participation in CRC screening is low in the United States, and even lower in Kentucky, with estimated rates of 24.0% for FOBT in the past two

C OV E R S TO R Y

years and 47.2% for ever having had a sigmoidoscopy or colonoscopy.13 Although PCP recommendation is a major determinant of CRC screening, appropriate recommendations are often not made and/or screening services are often not offered.3, 4 With the explosion of new information, technology, and pharmaceuticals over the past decades even the best communicators in our profession have a difficult, if not impossible, task of educating our patients about what services make sense and which ones may not make sense for each individual. With each patient encounter, there is a virtual cornucopia of possible preventive and treatment interventions to be discussed. The PCP must sort through a dizzying array of competing demands and opportunities for each patient. Choices for preventive services alone include immunizations, car safety, counseling on multiple health behaviors and lifestyle choices, chemoprevention of diseases such as coronary disease, and screening for cancer and other diseases. For a busy primary care physician running 30 or more minutes behind schedule and facing governmental and insurance payment cuts, being forced to choose which preventive and/or therapeutic services to address, and which to ignore, is an altogether too familiar scenario. An article published in JAMA [2007;298 (17):20048-2055] November 7, 2007, points out some of the reasons why current evidencebased medicine is not consistently incorporated into patients’ lives. “The 15-18 minute physician visit and resulting lack of patient participation and education may be a primary reason why more than 60% of patients with chronic diseases have poor control of their condition.” It emphasized the difficulty of putting prevention into practice while recognizing that “many clinicians are working in a rushed atmosphere permeated by competing demands.” The resultant reality is too often a system of care based upon the “tyranny of the urgent.” Given the fact that reimbursement structures still favor treatment over prevention, the obstacles to providing optimal preventive services to each patient sometimes seem over-

Dr Bale is with Primary Care Associates of Southern Kentucky, 1330 N. Race St, Glasgow, KY 42141; pbale@glasgow-ky.com. Dr Pearce is Professor and Vice Chair for Academic Affairs, Department of Family and Community Medicine, University of Kentucky, KY; kearce@email.uky.edu.

whelming. So how can time and resource challenged PCPs rise to the occasion and improve upon our currently dismal statistics? In a recent landmark study, the Partnership for Prevention has provided America’s physicians with timely and valuable information with which to prioritize strategies for improving America’s health. Through analysis of 25 preventive services recommended by the United States Preventive Services Task Force and the Advisory Committee of Immunization Pracces, they were able to rank or prioritize what preventive services would provide the most gains in health if utilization rates were increased.1 Chaired by former surgeon general David Satcher, the National Commission on Preven tion Priorities helped guide the approach used to rank these services in anticipation that it will draw more attention to those of highest value.2 Appropriate screening for CRC3 ranked only behind tobacco use screening and brief intervention and aspirin chemo prophylaxis as interventions that would provide the most health benefits if utilization rates were increased (Table 1). Kentucky has the 2nd highest cancer mortality in the nation; colorectal cancer is the 2nd leading cause of cancer-related deaths, and CRC screening rates are lower in Kentucky than the United States as a whole, falling well below the Healthy People 2010 target. Thus the potential for saving lives in the Commonwealth through improved CRC surveillance is great.4, 5, 6 What ingredients then are essential to the process of actually implementing the convincing evidence that screening for CRC is a highimpact, cost-effective preventive service into everyday practice routines? What is required to put prevention into practice and for all proven preventive services to truly become the cornerstone of a quality health care system? There no doubt are many determinants to these questions

March 2009/ VOL 107

C OV E R S TO R Y THE ROLE OF PRIMARY CARE PHYSICIANS IN THE PREVENTION AND MANAGEMENT OF COLORECTAL CANCER

with no one universal set of answers. However, like politics, all health care may be distilled down to local issues and in a most practical sense, CRC surveillance will depend upon a combination of these factors: • PCP knowledge and skills • Competing demands and reimbursement structures • PCP office systems that facilitate preventive practices • Patients’ insurance coverage • Patient’ knowledge, attitudes, and preferences • Availability of endoscopic and/or radiographic services. Too often PCPs fail to recommend or provide any CRC screening due to one or more of the above factors. PCPs who wish to optimize CRC surveillance for their patients should give attention to each of the determinants listed above, address barriers that they can lower, and be realistic about what they can achieve.3, 4, 14 The precise mechanism of screening will usually depend upon local standards of care and the factors listed above. While colonoscopy has established itself as the “gold standard,” in many locales there remains a role for other forms of testing in certain situations. Serial home fecal occult blood testing or the new fecal immuno-chemical testing as complements to flexible sigmoidoscopy or double contrast barium enemas remain viable strategies where colonoscopy is not readily available or in the face of serious individual patient or physician concerns about the risks of sedation or colonoscopic injury. The recently reported results of the American College of Radiology Imaging Network (ACRIN) trial utilizing CT colonography (CTC) showed a per-patient sensitivity of 90% for detecting polyps or cancers 10mm or larger in diameter. CTC may become more mainstream as a first-line screening tool, although there is great concern over the possibility of missing smaller lesions, exposure to significant radiation, and persistent need for optical colonoscopy when any abnormalities are found. As previously mentioned, competing demands and reimbursement issues also influence the success of routine implementation of CRC

March 2009/ VOL 107

screening. The best way to address both of these is to give systematic attention to practice management with an aim to streamlining (even automating) practices that should have minimal variation from patient to patient, and periodically audit how you are doing.3, 4 Examples of ways to accomplish these things include: • Standing orders that direct clinic staff to ask each patient over the age of 50 when he/she last had a CRC screening test • Reminder systems that prompt the PCP and/or the patient to discuss CRC screening (these can include chart forms or stickers, prompts built into electronic medical records, automated mailings, and prevention-oriented practice newsletters) • Flow sheets in the medical record that track all age and gender-appropriate preventive services (or similar automated systems in electronic medical records) • Logs that track CRC screening tests and referrals to help assure appropriate discussion of results and follow-up • Standardized age-specific health questionnaires that capture CRC risk factors • Delegation of patient education and FOBT instructions to trained office staff • Automated coding and billing procedures that capture all appropriate charges related to preventive counseling, FOBT and office endoscopy • Periodic self-audit of 10 or 20 charts of patients over age 50 to objectively assess whether you are meeting your goals Patient-level barriers related to patient knowledge and attitudes can be addressed through patient education. In many practices, the most cost-effective way to do this will be through printed materials coupled with encouragement and explanation from the nurse or medical assistant. However, PCPs should keep in mind that physician recommendation is key, and so delegated patient education should be coupled by at least brief physician advice. Patients’ financial and geographic barriers that block access to CRC screening are the most difficult to address. In most cases, at least FOBT can be performed, and some payers will cover

C OV E R S TO R Y

diagnostic and therapeutic procedures (ie, for the diagnosis of fecal occult bleeding) even when they will not pay for screening. As mentioned, patients’ reluctance to travel a long distance for colonoscopy after a positive screening test may be lower than their reluctance to do so for primary screening. A recent study done in PCP practices in Oklahoma supports these concepts. 15 The Oklahoma Physicians Resource/Research Network is in the final stages of a 3-year project that uses best practices research methods to identify effective and efficient CRC screening processes in primary care practices. They conducted detailed structured interviews with PCPs about the delivery of CRC screening using the Patient Path Model. Data about practice, provider, and patient characteristics were also collected. Practice Enhancement Assistants (PEAs) performed medical record (chart) audits to determine rates of appropriate CRC screening. Best practices were identified and defined via the PCPs who had exemplary CRC screening rates, defined as at or above the 75th percentile in performance. The investigators found that these exemplars focused their efforts on only one or two screening strategies (usually FOBT and/or colonoscopy). Exemplars also used reminder systems that fit into their practice’s clinical record-keeping system (often low tech). Exemplars used rehearsed “spiels” to initially inform and motivate their patients about screening, adding counseling techniques, and repetition of messages (tailored to their patients’ attitudes and readiness) as needed. Finally, they addressed scheduling and reimbursement barriers. All of this information demonstrates that the process of screening for colorectal cancer requires several steps that primary care physicians are uniquely positioned to provide. Typically they are the physicians who have the most ongoing interaction with patients and families. Assessment of a patient’s risk and placement in a risk category often is apparent whenever care has been provided in a continuous, comprehensive manner. Pri mary care physicians are most apt to be familiar with fam-

ily histories which are critical to risk stratification. Questions pertaining to inflammatory bowel disease and history of colon polyps or cancer should be part of the medical record and higher risk patients should be counseled and encouraged to have screening according to current increased risk guidelines. However, since 65% to 85% of colon cancers are sporadic with no family history, the greatest challenge is to screen and make appropriate recommendations to the average risk, over age 50 population. Training programs and all forms of continued medical education venues should pay more attention to the work of National mission on Prevention Priorities and the Congressional Prevention Coalition. Of the latter organization, it may be symbolic that of the 17 senators and 36 representatives who are members of this bipartisan, bicameral caucus charged with increasing knowledge in Congress about disease prevention and health promotion, none are from Kentucky. No one is better situated to be an advocate for CRC screening than our state’s primary care physicians. They are in the best position to see the wisdom and necessity of allocating limited resources to services that will give the biggest return for the investments. No one has more outpatient encounters or is geographically more available than primary care physicians. They have the most opportunity and the most responsibility for combining the art and science of medicine to make personalized recommendations for each of their patients. As community leaders, primary care physicians can make health issues an important part of local and statewide health care agendas. In one rural Kentucky town with encouragement and assistance of a local primary care physician, the community hospital, chamber of commerce, and one local bank took CRC on as a project. Notices with facts and advice to discuss CRC screening with their physician were sent out with over 50,000 bank statements, radio public service announcements were broadcast, and billboards were utilized with similar messages. Public and physician awareness was increased with the hope that more screening

March 2009/ VOL 107

C OV E R S TO R Y THE ROLE OF PRIMARY CARE PHYSICIANS IN THE PREVENTION AND MANAGEMENT OF COLORECTAL CANCER

services would be requested, recommended, and delivered. Health care networks like the ones being organized by The Center for Rural Health at the University of Kentucky could and should prove useful in prioritizing issues that make the most sense in terms of disease burden and cost-effectiveness. Opportunities for collaborations like these can be fashioned for any community, large or small, and offer promise toward winning the battle against CRC. As evidence-based medicine becomes progressively more central to the practices of Kentucky’s PCPs, CRC screening efforts must increase dramatically. Armed with the powerful and compelling study from the Partnership for Prevention, primary care physicians must reexamine their prevention priorities and make a more concerted effort toward implementing those services with the most “bang for the buck.” CRC screening has been shown to be a high-impact service that is very cost-effective.1 In the year 2000, it is estimated that the cost-effectiveness of offering patients aged 50 or older a choice of colorectal cancer screening options cost $11,900 per year of life gained. This makes colorectal cancer screening one of the most important missed opportunities for improving health at a reasonable cost in the United States and particularly in Kentucky.

REFERENCES 1. Maciosek MV, Coffield AB, Edwards NM, Goodman MJ, Flottemesch TJ, Solberg. Services: results of a systematic review and analysis. Am J Prev Med. 2006. 2. Satcher D. Priorities among effective clinical preventive services. Am J Prev Med. 2006;31(1). 3. CDC and Prevention National Health Interview Survey 2003, public use data set. Accessed Aug 10, 2005. 4. ACS: CA Facts and Figures 2006. Website: http:// www.concer.org/downloads/STT/CAFF2006PWSecur ed.pdf last accessed 9/8/06. 5. Ky Cancer Registry. Website: www.kcr.uky.edu last accessed 9/8/06.

March 2009/ VOL 107

6. CDC Behavioral Risk Factor Surveillance System Prevalence Data on Colorectal Cancer Screening Website: http//apps.need.cdc.gov/brfss/pate.asp?cat=CC& state=All#CC last accessed 9/8/06 7. Swan J, Breen N, Coates R, et al. Progress in cancer screening practices in the United States: Results from the 2000 National Health Interview survey. Cancer 2003;97(6):1528-1540. 8. Patel P, Forjuoh SM, Avots-Avotins A, Patel T. Identifying opportunities for improved colorectal cancer screening in primary care. Prev Med 2004 Aug; 39(2): 239-46.

C OV E R S TO R Y

COLORECTAL CANCER CHEMOTHERAPY Thomas M. Woodcock, MD

he past five years have seen meaningful advances in the understanding of colorectal carcinomas and improved treatment options. Large-scale clinical trials managed by cooperative groups in the US and internationally have provided detailed information about the evaluation and treatment of this common group of malignancies. Application of this new data allows more precise assessment of an individualâ&#x20AC;&#x2122;s risk of cancer recurrence after primary surgical therapy, and better targeting of palliative chemotherapy for patients with recurrent or unresectable disease. New therapeutic agents have provided additional treatment benefits as well, and ongoing clinical trials will define the role of the new agents in treatment algorithms. Clinicians everywhere continue to have the ability to speed the development of improved therapy by encouraging clinical trial participation for their patients, at any stage of their illness.

RISK ASSESSMENT For patients who have undergone definitive surgical therapy for colon cancer, prognostic factors that influence the risk of a patient suffering a recurrence of cancer now include not only the size, depth of penetration, and presence of involved mesenteric lymph nodes, but the actual number of nodes involved. This influence is so pronounced that it has changed the staging criteria; N1 designates 3 or fewer nodes involved, and N2 indicates 4 or more nodes, reflecting the higher risk of recurrence with 4 or more nodes involved. The total number of nodes removed at surgery is a favorable prognostic finding not reflected in the staging criteria. Reviewing the total number of nodes removed at surgery now provides a qualityof-care measure for surgeons and pathologists.

Corresponding Author: Thomas M. Woodcock, MD, Louisville Oncology, 315 E. Broadway 4th Floor, Louisville, KY 40202

ADJUVANT THERAPY Adjuvant, postoperative therapy for patients who have had curative resections now focuses on node-positive, or Stage III patients. The primary treatment tool is chemotherapy following surgery using one of the newer treatment programs including infusional 5-fluorouracil, leucovorin, and oxaliplatin. Oxaliplatin has added to the overall clinical benefit: robust clinical trial data show that this drug has added about 10% to the survival rate for patients with node-positive, resected colon and rectal cancers compared to non-oxaliplatin adjuvant chemotherapy with about 61% of patients remaining well after older chemotherapy versus 70+% with oxaliplatin continuing programs. Capecitabine, an oral fluorouracil analog with a favorable toxicity profile appears as active as infusional 5-fluorouracil and seems likely to replace infusional fluorouracil-based therapies in the immediate future, facilitating adjuvant therapy for many patients. The use of post-operative therapy for individuals after resection of node-negative, Stage II lesions remains less defined, but with available data suggesting a 4% to 5% survival benefit. Several trials underway now should help clarify the risk/benefit characteristics of adjuvant chemotherapy for Stage II postoperative patients. The usefulness of bevacizumab with adjuvant chemotherapy is another critical clinical trial result expected soon. If becacizumab offers adjuvant benefit analogous to its benefits in advanced colon cancer treatment, it will be another major advance in the prevention of colon cancer relapse after surgical resection.

March 2009/ VOL 107

C OV E R S TO R Y COLORECTAL CANCER CHEMOTHERAPY

THERAPY FOR ADVANCED DISEASE Chemotherapy for patients with metastatic or recurrent colon cancer is markedly better compared to therapies available 10 years ago. It is expected that 80% to 90% of patients with advanced disease will respond to chemotherapy, and most will enjoy 2 or more years of survival even with advanced, metastatic cancer. Key to this improvement are several newer medicines. Infusional 5-fluorouracil and leucovorin represent a core therapy to which additional drugs have been combined. Oxaliplatin, irinotecan, and bevacizumab have been extensively studied in this setting, with major improvement in remission rates, and survival observed. Bevacizumab is an engineered antibody that appears to enhance the utility of co-administered chemotherapy, with modest toxicity. All of the most active palliative chemotherapy treatment programs now contain bevacizumab. Two other antibody drugs, cetuximab and panitumumab, target a cell-surface enzyme, epidermal growth factor receptor (EGFR) important in the progression of colon cancers. The use of cetuximab and panitumumab in early palliative colon cancer chemotherapy is still under study. As in adjuvant treatments, capecitabine may replace the cumbersome infusional chemotherapies now widely used. Special attention needs to be directed to patients initially presenting with metastatic or recurrent colorectal cancer, as advances in therapy can now offer some of these patients the hope of cure. Examples would include colon or rectal cancer patients with limited hepatic, pulmonary, or retroperitoneal metastasis. In patients with the ability to tolerate rigorous therapy, integrated chemotherapy and surgical therapies (such as partial hepatectomy) can lead to high rates of disease-free survival. Identification of these patients and coordinating therapies is an ongoing, difficult challenge. The intent and implementation of palliative therapies is markedly different from the aggressive, risky multimodality care required for potentially curative therapy. Proper patient selection, honest discussion with patients and families, and consultation with surgeons in advance should help identify whether the purely palliative approach or aggressive, multimodality approach is best for an individual patient.

March 2009/ VOL 107

Consideration for elderly or ill patients should include capecitabine. This oral agent has very modest toxicity and may provide excellent clinical benefit in the setting of multisystem illnesses that would prohibit other programs, either for adjuvant or palliative use.

ECONOMIC CONCERNS Discussion of these advances would be incomplete without a word about the associated costs. Chemotherapy using current palliative programs can involve $250,000 in drug charges alone over a 24-month period. The impact of these costs on overall health care financing is not easily quantified. Clinical trials now underway may help understand how to use these programs in the most cost-responsible way.

CLINICAL TRIALS AND DEVELOPING THERAPIES Rapidly changing treatment options including new drugs and multimodality approaches make it difficult for physicians to be comfortable talking with patients about their best treatment choices for colorectal cancer. Poor choices by patients and families may follow misinformation provided by the Internet or other sources. Two excellent Internet sites with highquality, in-depth information about colorectal cancer to address the information gap for doctors and patients are recommended. Both sites offer information customized to either patients or physicians, have Spanish language support, and are rigorously documented and frequently updated. The National Cancer Instituteâ&#x20AC;&#x2122;s site (www.cancer.gov) provides detailed, text-based data via the PDQ service. Included are details of staging, breaking research findings, and stageby-stage treatment options. PDQ also includes information about available clinical trials. More pragmatic, step-by-step treatment algorithms are presented by the NCCN, a consortium of the American Cancer Society and 20 of the largest US cancer centers, at www.nccn.org. Using a flow chart summary, the NCCN guidelines assist patients and physicians follow consensus recommendations for diagnostics, specific therapies, and follow-up care.

C OV E R S TO R Y

RADIATION IN RECTAL CARCINOMA William J. Spanos Jr, MD

adiation is frequently indicated as adjuvant treatment and infrequently as primary treatment in the management of rectal carcinoma. The indications for radiation and the treatment specifics are detailed below.

EARLY (T1, T2, N0) Early carcinomas of the rectum that are managed with a low anterior or abdominal perineal resection do not require postoperative radiation. Early rectal cancers (T1 or T2) removed by transrectal resection because of patient factors or preference have an increased risk of local failure as high as 15% to 20% depending on margins and pathologic findings and require consideration of postoperative radiation. 1, 2 Since the risk of failure is primarily local, radiation fields can be limited to the portion of the pelvis below the SI joint. The field arrangement is either a 3 or 4 field using high energy (>10MV) photons if available. Chemotherapy (5FU) should be given concomitant with radiation. It should be noted that even with radiation and chemotherapy, local failure continues to be high and patients should be followed closely.

ADVANCED (T3, T4, OR N+) This category of patients has been the subject of a number of phase 2 and 3 trials regarding the indications for adjuvant radiation and chemotherapy. The local/regional relapse risk for this category of patients can be as high as 50% depending on nodal status and local extension after standard surgical resection. Numerous trials have demonstrated the efficacy of radiation and chemotherapy in the reduction of risk of local/regional recurrence to approximately 5%.3-7 These trials with one exception have not demonstrated an improvement in overall survival. The

Corresponding Author: William J. Spanos Jr, MD, University Radiotherapy Associate, Brown Cancer Center, 529 S. Jackson Street, Louisville, KY 40202 one exception is a Swedish trial of preoperative radiation followed by surgery compared with surgery alone.11 Neither arm received adjuvant chemotherapy. The impact on survival from radiation is yet undetermined since the trials with a non radiation arm were not powered to detect small survival differences.

TOTAL MESORECTAL EXCISION Total Mesorectal Excision (TME) has become more widely used as a surgical technique and has demonstrated a lower risk of local regional relapse in this group of patients. However, when radiation is used in this setting, there is further reduction of local relapse.8, 9 The selection criteria for patients treated by TME that may require adjuvant radiation are still being refined. Therefore, at this time, it is reasonable to consider all patients with T 3 , T 4 lesions and/or N+ nodes status for adjuvant radiation with concomitant chemotherapy.

PREOPERATIVE RADIATION Radiation may be given either preoperatively or postoperatively. There are valid considerations in favor of both approaches. Most of the randomized trials demonstrating the benefit of radiation were done with postoperative radiation. However, data from multiple sources including nonrandomized institutional data and randomized trials have created a compelling case in favor of preoperative radiation. A recent publication of the results of a trial randomizing preoperative radiation and chemotherapy with postoperative radiation and chemotherapy demonstrated an improvement in favor of preoperative radiation for

March 2009/ VOL 107

C OV E R S TO R Y RADIATION IN RECTAL CARCINOMA

local control and disease-free survival.10 The advantages of preoperative radiation include reduced bowel toxicity and decrease in the clonegincity and growth factor effect post resection. Potential delay in postoperative healing is one potential downside to preoperative radiation.

TECHNIQUE Radiation technique should include the pelvis utilizing a multifield (3 or 4) technique with high energy photons (>=10 MV). Generous coverage of the sacral hollow is an important parameter, as this is a common site of recurrence. In the event of an abdominoperineal resection, the perineal scar should included in treatment. It has been demonstrated that placing the patient prone on a “belly board” (a support platform with a cut-out allowing for anterior displacement of abdominal contents) reduces the amount of small bowel at risk of radiation. CT treatment planning is a benefit to refine the radiation field boundaries and decrease radiation dose inhomogeneities with the use of beam modifiers. There is no demonstrated benefit to the use of IMRT in this setting.

ADVANCED (UNRESECTABLE OR MARGINALLY RESECTABLE) Some rectal carcinomas present with clinical features that make surgical removal with clear margins unlikely. These patients should be considered for preoperative radiation with concomitant chemotherapy. With preoperative radiation, approximately 75% of inoperable patients become operable. The same field arrangements noted above are appropriate for the initial part of radiation. However, for the field reduction boost, 3 Dimensional CT planning is even more important to ensure adequate coverage of the tumor. The final dose through reduced fields should be increased to 9-14 Gy.

RECURRENT Local or regional recurrences should be managed surgically if at all possible. For the patient who has not previously received radiation and does not have

March 2009/ VOL 107

evidence of distant metastases, postoperative radiation as described above is recommended. The patient who presents with local or regional recurrence with a history of prior pelvic radiation represents a difficult challenge. If intraoperative radiation is available, the surgery should be done at a center with the intraoperative radiation to be used if there are close margins, adherence of the tumor, or clearly positive margins. For the patient with local or regional recurrence who is not a surgical candidate, the use of IMRT radiation technique can limit the radiation dose to previously radiated bowel and achieve palliation of pelvic symptoms.

REFERENCES 1. Steele GD, Herndon JE, Bleday R, et al. Sphincter-sparing treatment for distal rectal adenocarcinoma. Ann Surg Oncol. 1999;6:433-441. 2. Russell AH, Harris J, Rosenberg PJ, et al. Anal sphincter conservation for patients with adenocarcinoma of the distal rectum: long-term results of radiation therapy oncology group protocol 89-02. Int J Radiat Oncol Biol Phys. 2000;46:313-322. National Institutes of Health Consensus Conference: Adjuvant therapy for patients with colon and rectal cancer. JAMA. 1990;264:1444-1450. 3. Gastrointestinal Tumor Study Group. Prolongation of the disease-free survival in surgically treated rectal carcinoma. N Engl J Med. 1985;312:1465-1472. 4. Krook JE, Moertel CG, Gunderson LL, et al. Effective surgical adjuvant therapy for high-risk rectal carcinoma. N Engl J Med. 1991;324:709-715. 5. Fisher B, Wolmark N, Rockette H, et al. Postoperative adjuvant chemotherapy or radiation therapy for rectal cancer: Results from NSABP Protocol R-01. J Natl Cancer Inst. 1988;80:21-29. 6. National Institutes of Health Consensus Conference: Adjuvant therapy for patients with colon and rectal cancer. JAMA. 1990;264:1444-1450. 7. Colorectal cancer collaborative group. Adjuvant radiotherapy for rectal cancer—A systematic overview of 8,507 patients from 22 randomised trials. Lancet. 2001;358:1291-1304. 8. Kapiteijn E, Kranenbarg EK, Steup WH, et al. Total mesorectal excision (TME) with or without preoperative radiotherapy in the treatment of primary rectal cancer: Prospective randomised trial with standard operative and histopathological techniques—Dutch ColoRectal Cancer Group. Eur J Surg. 1999;165:410-420. 9. Kapiteijn E, Marijnen CA, Nagtegaal ID, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med. 2001;345:638-646. 10. Sauer R, Becker H, Hohenberger W, Rodel C. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med. 2004;351(17):1731-1740. 11. Improved survival with preoperative radiotherapy in resectable rectal cancer. Swedish Rectal Cancer Trial. N Engl J Med. 1997;336(14):980-987.

C OV E R S TO R Y

A PRACTICAL APPROACH TO COLORECTAL CANCER SCREENING AND SURVEILLANCE GUIDELINES FOR THE PRIMARY CARE PHYSICIAN Robert Wells, MD; Harry Elvanides, MD; Edward C. Adler, MD; Willem J. S. de Villiers, MD, PhD

INTRODUCTION

olorectal cancer (CRC) is responsible for more than 50,000 deaths per year, making it the second leading cause of cancer-related deaths in the United States. As the fourth most frequently diagnosed cancer, it has an annual incidence of 140,000. 1 Early stage CRC has a 5-year survival rate greater than 90%, whereas metastatic disease has a 5-year survival rate less than 10%.2 The purpose of this article is to serve as a resource in helping raise awareness of the importance and need of colorectal cancer screening and surveillance. Different screening modalities and strategies will be reviewed. Additionally, recommendations, guidelines, and perhaps more importantly, limitations of various screening tools will be addressed.3 Current evidence supports that most CRC develop from adenomatous polyps with an average of 10 years for a <1 cm adenomatous polyp to become an invasive CRC.4 As precursor lesions are usually asymptomatic, there is continued growing support, from both a costeffective and medical-legal perspective, that asymptomatic individuals should undergo screening for early cancer detection and prevention. Although CRC screening is associated with cost-effectiveness ratios below $50,000 per

From the Division of Digestive Diseases and Nutrition, University of Kentucky Medical Center (Wells, Elvanides, and de Villiers), 800 Rose Street, Rm MN649, Lexington, KY 40536, and the Gastroenterology Associates of Louisville (Adler), 4001 Dutchmans Ln Ste 7B, Louisville, KY 40207. Corresponding Author: Willem J. S. de Villiers, MD, Email: willem.devilliers@uky.edu life year saved, adherence rates for screening are less than 50%. This percentage is well below the rates for breast, cervical, and prostate cancer screening, despite the fact that the costeffectiveness of and evidence base for CRC screening surpasses that of each of these other cancers.5 Furthermore, the most frequent explanation provided by patients who have not undergone CRC screening is that it was not advised to them by their primary care physician. From a medical-legal view it is estimated that over 50% of all GI disease malpractice claims charged against primary care physicians result from a delay in diagnosing CRC. The following are three of the most common mistakes made by primary care physicians. Although only approximately 7% of CRCs occur in individuals younger than age 50 years, a first mistake is attributing rectal bleeding in young patients to non-cancerous etiologies including hemorrhoids, fissures, trauma, or other anorectal causes.

March 2009/ VOL 107

C OV E R S TO R Y A PRACTICAL APPROACH TO COLORECTAL CANCER SCREENING AND SURVEILLANCE GUIDELINES FOR THE PRIMARY CARE PHYSICIAN

Colonoscopy is the preferred modality in all individuals beginning at age 40 years who present with rectal bleeding. Flexible sigmoidoscopy may be acceptable in younger patients, if it leads to a diagnosis with appropriate treatment resulting in resolution of symptoms at follow-up. A second mistake is an inappropriate followup evaluation of a positive fecal occult blood test (FOBT). Currently, the only acceptable followup of a positive FOBT is colonoscopy. In a recent US national survey of 1,147 primary care physicians who pursued workup of a positive FOBT, only 52% recommended evaluation with colonoscopy.6 There is no reason to repeat a positive FOBT. If a repeat FOBT is negative, and an initial positive test is ignored, it is considered malpractice if the patient later presents with CRC. Flexible sigmoidoscopy alone is inadequate, and air contrast barium enema should be performed only if colonoscopy cannot be performed. Finally, not offering indicated CRC screening to appropriate patients constitutes a third common mistake. A discussion about CRC screening may be pursued during regular health visits. Documentation of discussing and offering CRC screening to eligible patients should be included.

SCREENING STRATEGIES FOR AVERAGE-RISK PATIENTS Colonoscopy Screening at age 50 should be offered to averagerisk individuals. Colonoscopy is the preferred screening modality. Offering the advantages of mucosal visualization, removal of detected polyps, and diagnostic sampling of cancers, colonoscopy with polypectomy has been proven to markedly reduce the expected incidence of CRC by 76% to 90% in multiple cohort studies.7, 8 As a screening modality, colonoscopy is cost-effective, allows for diagnostic and therapeutics in a single exam, is well tolerated, and has an approximate miss rate of only 6% for lesions >10 mm.9 It provides long-lasting protection against CRC with a recommended 10-year exam interval for a negative study. Additionally, further screen-

March 2009/ VOL 107

Table 1. CRC screening tests. Preferred modality Colonoscopy every 10 years Alternatives Annual FOBT Flexible sigmoidoscopy every 5 years Annual FOBT and flexible sigmoidoscopy every 5 years

ing tests, including FOBT, do not need to be repeated for 10 years if no polyps or cancerous lesions are detected on a well-prepped colonoscopy. Potential disadvantages include inconvenience of bowel prep, dependence on the skill and technique of the endoscopist, and risks associated with sedation and perforation. The risk of perforation is less than 0.1%.10 Currently, the American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy endorse colonscopy as the preferred screening modality for CRC in average-risk individuals.3, 11

Flexible Sigmoidoscopy This modality evaluates only the distal colon. Several studies have shown that advanced lesions (villous adenoma, adenoma â&#x2030;Ľ1cm in size, adenoma with high-grade dysplasia, or invasive cancer) in the proximal colon can occur in the absence of lesions in the distal segment. In one prospective multicenter study of 116 averagerisk patients with colon cancer proximal to the splenic flexure, over 58% had no distal polyps.12 If flexible sigmoidoscopy is to be used as a screening modality, multiple colleges and societies recommend 5-year exam intervals +/- annual FOBT.

FOBT The correct use of this home-based screening tool includes two samples from each of 3 consecutive spontaneously passed stools on an annual basis starting at age 50. Colonoscopy needs to be performed for any positive test. Prospective randomized studies have demonstrated between a 15% to 33% reduction in CRC associated mortality when positive FOBT were

C OV E R S TO R Y

Table 2. CRC screening and surveillance intervals. Patient

Screening

Surveillance

Average Risk

Colonoscopy at 50 yrs

Colonoscopy every 10 yrs

Positive family history 1 first-degree relative ≥60 with CRC or adenoma

Colonoscopy at age 50 yrs (individualize timing)

Colonoscopy every 10 yrs

≥2 first-degree relatives or any first-degree relative ≤60 with CRC or adenoma

Colonoscopy at age 40 yrs or 10 yrs prior to diagnosis of CRC in affected relative

Colonoscopy every 3-5 yrs

FAP with positive genetic test in proband and relative relative with positive genetic test

Offer genetic testing and counseling Annual flex sigmoidoscopy at age 10-12 yrs

Annual flex sigmoidoscopy until age 40 yrs, then every 3-5 yrs

Relative with negative genetic test

Offer sigmoidoscopy every 7-10 yrs until age 40 yrs

Colonoscopy every 5 yrs after age 40 yrs

HNPCC

Colonoscopy every 1-2 yrs at age 20-25 yrs or 10 yrs prior to diagnosis of CRC in affected relative

Annual colonoscopy after age 40 yrs

Genetic Cancer Disorder

followed by colonoscopy. Rehydrating samples and/or obtaining samples by digital rectal exam has a higher rate of false positives. A single digital rectal exam with FOBT is not recommended and should not be performed.3

FOBT with Flexible Sigmoidoscopy Currently no evidence exists that combining annual FOBT with flexible sigmoidoscopy every 5 years reduces CRC mortality. A recent study demonstrated that sigmoidoscopy identified 70% of patients with advanced neoplasia. The addition of FOBT increased detection by only 5%. If FOBT and flexible sigmoidoscopy are planned together as a strategy for CRC screening, FOBT should be performed first since a positive test would need to be followed by a colonoscopy.13

Double-contrast Barium Enema (DCBE) A prospective study comparing DCBE and colonoscopy showed that DCBE detected 53% of 6 to 10 mm polyps and 48% of >10 mm polyps compared to colonoscopy.14 Furthermore, a second study determined that the sensitivity for de-

tecting CRC was 83% for DCBE compared to 95% for colonoscopy.15 In addition to having decreased sensitivity, it lacks therapeutic capability, is associated with significant discomfort, and a positive test requires a patient to undergo further bowel preparations for colonoscopy. DCBE is not recommended for CRC screening unless colonoscopy is not feasible.

Virtual Colonoscopy (VC) Also known as CT colonography, VC utilizes helical CT scanning of the colon. It requires bowel prep, inflation of the colon, and CTs performed in prone and supine position. Compared to colonoscopy it has sensitivity of 55% to 100% and specificity of 94% to 98% for detecting polyps >10 mm and a sensitivity of 39% to 94% and specificity of 79% to 92% for polyps measuring 6-9 mm.16, 17 At this time, potential disadvantages include concern over radiation posure, higher cost-effectiveness ratios, lack of therapeutics, and lack of coverage by third-party payers. There is also controversy over which patients should be selected for colonoscopy depending on the size of detected polyps. Further advances in stan-

March 2009/ VOL 107

C OV E R S TO R Y A PRACTICAL APPROACH TO COLORECTAL CANCER SCREENING AND SURVEILLANCE GUIDELINES FOR THE PRIMARY CARE PHYSICIAN

Table 3. CRC surveillance in patients with a history of colorectal lesions.

Table 4. CRC surveillance in patients with history of IBD

History

Surveillance

Prior colon cancer

UC and/or extensive Crohn’s colitis of 8-10 yrs duration

Prior rectal cancer

Complete Colonoscopy, DBCE, VC, or intraoperative colonoscopy at or around time of resection followed by colonoscopy 1 yr after resection, then at 3 yr interval, then at 5 yr intervals if negative exam Flex sigmoidoscopy every 3 to 6 months for 2 to 3 yrs after low anterior resection without total mesorectal excision, and/or no neoadjuvant radiation therapy for locally advanced disease. Complete colonoscopy performed at 1 year.

Prior adenomatous lesions ≤2 small (1cm) tubular Colonoscopy at 5 yrs adenomas and/or lowgrade dysplasia 3-10 adenomas and/or advanced neoplasia

Colonoscopy at 3 yrs

>10 adenomas

Colonoscopy within 3 yrs

Incomplete excision of large sessile polyp

Colonoscopy within 2-6 months

Negative surveillance Colonoscopy

Colonoscopy at 5 yrs

dardization of the technique and improvements in technology and training are required before VC can be recommended as a widespread screening modality. Currently VC is not recommended as a preferred modality for CRC screening, but is a promising evolving technique.17, 18

Fecal DNA Testing The molecular genetics of CRC provides the basis for fecal DNA testing. Adenomas and CRC arise from at least 3 different genetic pathways: chromosomal instability, microsatellite instability, and CpG island methylation. Previous studies that used fecal DNA testing in individuals with advanced, symptomatic lesions have reported sensitivities between 62% to 91% for cancer and 27% to 82% for advanced adenomas,

100

March 2009/ VOL 107

Colonoscopy every 1-2 yrs with biopsies to rule out dysplasia

with specificities between 93% and 96%.19 A large prospective study comparing fecal DNA testing with FOBT for CRC screening in average-risk individuals showed that the sensitivity of fecal DNA testing was 4 times that of FOBT (Hemoccult II; Beckman Coulter, formerly SmithKline Diagnostics) for detecting invasive cancer and more than double for adenomas containing high-grade dysplasia. The sensitivity of fecal DNA testing compared with colonoscopy in detecting invasive cancers was 51%.20 There are currently no studies demonstrating a reduction in CRC-related mortality from fecal DNA testing, and the technique for the test has not been standardized. The use of this test is still in development and cannot be recommended at this time for CRC screening.

SCREENING STRATEGIES FOR HIGH-RISK PATIENTS Patients with a Positive Family History of CRC or Adenomatous Polyps A two-to-four fold increased risk for CRC exists for individuals with ≥1 first degree relatives diagnosed with CRC or adenomatous polyps. Individuals with a first-degree relative with CRC or adenoma should undergo screening oscopy beginning at age 40 years, or 10 years prior to the age of the relative’s diagnosis. If screening exam is normal, colonoscopy should be repeated every 3 to 5 years for patients with ≥2 first-degree relatives or any first-degree relative diagnosed with CRC or adenomatous polyps at age <60 years. In patients with first-degree relatives diagnosed with CRC or adenomatous polyps ≥60 years of age, colonoscopy should be repeated at 10 years following a normal screening exam. Patients with a second- or third-degree relative with CRC should undergo screening as recommended for average-risk individuals.4

C OV E R S TO R Y

Patients with Familial Adenomatous Polyposis (FAP) FAP is an autosomal dominant disorder that presents with >100 adenomas throughout the colon. It is caused by mutations in the adenomatous polyposis coli (APC) gene. Individuals with (FAP) have approximately 100% risk for the development of CRC in their 5th to 6th decade of life. Patients with FAP, and at risk family members, should be offered genetic testing (to identify the disease-producing gene) and genetic counseling. If a mutation is identified, family members â&#x2030;Ľ10 years of age should be tested for the APC gene mutation. Patients with a positive test should have an annual sigmoidoscopy beginning at age 10-12 years. Colectomy is indicated when multiple adenomas are discovered on exam. If no evidence of adenomas is found, annual sigmoidoscopy should continue up to age 40 years. Screening should then take place every 3 to 5 years. Annual sigmoidoscopy should also be preformed in all family members beginning at age 10 if affected kindred has a negative genetic test and/or testing is not available. There is also an attenuated form of FAP. Having a variable number of adenomas (usually 20-100) with a more proximal distribution and an approximate 10year delayed onset of CRC, patients with this variant of FAP should undergo annual colonoscopy beginning in the late teens to early 20s.21

Patients with Hereditary Nonpolyposis Colorectal Cancer (HNPCC) Also known as Lynch syndrome, HNPCC is an autosomal dominant syndrome that is associated with early development (average age 44 years) of CRC with predominance of cancer developing proximal to the splenic flexure. The disease is due to germline mutations in DNA mismatch repair genes. These mutations can lead to microsatellite instability (MSI) found in >90% of CRCs in patients with HNPCC, and decreased protein production of MLH1 and/or MSH2 gene products. Screening CRC tissue for MSI and immunohistochemical staining for low levels of MLH1 and MSH2 proteins is recommended in

Table 5. Average risk screening test options beginning at age 50 Flexible sigmoidoscopy every 5 years# Colonoscopy every 10 years Double contrast barium enema every 5 years# CT colonography (virtual colonoscopy) every 5 years# Fecal occult blood test (FOBT) every year#, ## Fecal immunochemical test (FIT) every year#, ## Stool DNA test (sDNA), interval uncertain# #Perform colonoscopy for positive test. ##Take-home multiple sample method. FOBT and/or FIT obtained with digital rectal exam in doctorâ&#x20AC;&#x2122;s office is inadequate for screening.

patients suspected for HNPCC. If positive, the patient should undergo genetic testing for germline mutations in the mismatch repair genes. First-degree relatives of a patient with an identified mutation should undergo genetic testing and concominant genetic counseling. Individuals potentially affected with HNPCC should undergo colonoscopy every one to two years beginning at age 20 to 25 years, or 10 years prior to the age of diagnosis in an affected family member. Annual colonoscopy is then recommended beginning at age 40 years.22, 23

SURVEILLANCE STRATEGIES Patients with Personal History of CRC Patients with a diagnosis of CRC need a complete colonoscopy performed at the time of diagnosis to rule out synchronous cancerous lesions and to remove any additional adenomas. Synchronous lesions occur in 3% to 5% of patients diagnosed with CRC.24 If malignant obstruction prevents a complete colonoscopy, DCBE, VC or intraoperative colonoscopy may be performed to evaluate proximal lesions. Otherwise, postoperative colonoscopy should be preformed within 6 months of resection to rule out proximal lesions. Furthermore, because of the increased risk for cancer recurrence and/or the development of metachronous lesions in this patient population, surveillance colonoscopy is advised at 1 year after resection of CRC. If negative, repeat in 3 years, and if that colonoscopy is negative, repeat in 5 years. Currently, surveillance endoscopy intervals in patients with low anterior rectal cancer re-

March 2009/ VOL 107

101

C OV E R S TO R Y A PRACTICAL APPROACH TO COLORECTAL CANCER SCREENING AND SURVEILLANCE GUIDELINES FOR THE PRIMARY CARE PHYSICIAN

Table 6. CRC screening and surveillance in patients with increased risk: Personal history of polyps on previous colonoscopy Risk Category

Age to begin

Recommended tests

Comment

Small rectal hyperplastic polyps

Same as average risk

Colonoscopy or other screening modalities at regular intervals as for those at average risk

Patients with hyperplastic polyposis syndrome are at increased risk for adenomatous polyps and CRC, and should have more intensive follow-up.

1 or 2 small (<1cm) tubular adenoma (TA) with low- grade dysplasia

5 to 10 years after removal of polyp(s)

Colonoscopy

Surveillance intervals should be based on other factors including findings on prior colonoscopy, family history, and patient and doctor preferences.

3 to 10 adenomas, large adenoma (≥1cm), or adenoma with high-grade

3 years after removal of polyp(s)

Colonoscopy

Complete removal of polyp required. If colonoscopy is normal or shows only 1 or 2 small TA(s) with low-grade dysplasia, surveillance colonoscopies can be performed every 5 years.

>10 adenomas on single exam

Within 3 years after removal of polyps

Colonoscopy

Consider possibility of a genetic syndrome (such as FAP, HNPCC).

Sessile adenomas with piecemeal resection

2 to 6 months after removal of polyp(s)

Colonoscopy

If entire adenoma completely removed, further testing should be based on physician’s judgment.

section, has not been elucidated. At this time it is recommended that patients who did not undergo total mesorectal excision, and/or did not receive neoadjuvant radiation therapy for locally advanced disease should undergo postoperative sigmoidoscopy every 3 to 6 months for 2 to 3 years. Furthermore, these patients should have a complete colonoscopy performed at 1 year.3

Patients with Personal History of Adenomatous Polyps Surveillance colonoscopy in patients with a history of adenomatous polyps has been shown to reduce the incidence of subsequent CRC. The timing of repeat colonoscopy is dependent on the size, the number, and histological findings of the polyps removed. Patients with ≤2 small (<1 cm) tubular adenomas with low-grade dysplasia should undergo repeat colonoscopy in 5 years. Patients with ≥3 adenomas and/or advanced adenomatous lesions (villous adenoma, adenoma ≥1 cm in size, or adenoma with high-

102

March 2009/ VOL 107

grade dysplasia) should undergo repeat colonoscopy in 3 years. Patients who have had an incomplete colonoscopy (inadequate bowel prep and/or inability to reach the cecum) or the finding of >10 adenomatous polyps should have a repeat colonoscopy performed in 1 to 3 years. Patients who have had piecemeal polypectomy of large, sessile adenomatous polyps should undergo follow-up colonoscopy within 2 to 6 months to exclude and/or remove any remnant polypoid tissue. Follow up colonoscopies should be performed every 5 years after a normal surveillance colonoscopy.3

Inflammatory Bowel Disease Long-standing ulcerative colitis and extensive Crohn’s colitis are associated with increased risk for development of CRC. The risk of developing CRC increases with younger age of disease onset, extent and duration of colitis, family history of CRC, presence of backwash ileitis, and personal history of primary scleros-

C OV E R S TO R Y

Table 7. CRC screening and surveillance in patients with increased risk: Family history of CRC Risk Category

Age to begin

Recommended tests

Comment

CRC or adenomatous polyps in any 1st degree relative <60 years of age, or ≥2 1st degree relatives at any age (if not a hereditary syndrome)

40 years of age or 10 years prior to diagnosis in 1st degree relative

Colonoscopy

Repeat colonoscopy every 5 years

CRC or adenomatous polyps in any 1st degree relative ≥60 years of age, or ≥2 2nd degree relatives at any age

40 years of age

Same options as for those patients with average risk

Same intervals as for those patients with average risk

Table 8. CRC screening and surveillance in patients with increased risk: Personal history of CRC Risk Category

Age to begin

Recommended tests

Comment

Patients with CRC

At time of CRC surgery or 3-6 months later if patient doesn’t have cancer spread that can’t be removed

Colonoscopy to view entire colon and remove all polyps

CT colonography (with IV contrast) or DCBE should be performed if tumor prevents complete colonoscopy from being performed.

Patients who have had surgical resection of CRC

Within 1 year after resection (or 1 year after colonoscopy to make sure rest of colon/ rectum was clear)

Colonoscopy

If colonoscopy is normal, repeat in 3 years. If this colonoscopy is normal, repeat in 5 years. Time between exams may be shorter if polyps found and/or there is suspicion of HNPCC. After low anterior resection for rectal cancer, exams of the rectum may be performed every 3 to 6 months for the first 2 to 3 years to look for signs of recurrence.

ing cholangitis. Patients with left-sided ulcerative colitis or pancolitis have increased risk. In patients with Crohn’s colitis involving more than a third of the colon, the increased risk of CRC is similar to that of patients with UC. Proctitis alone does not appear to be associated with an increased risk for CRC. Currently, there are no prospective, randomized trials evaluating the efficacy of surveillance colonoscopy in UC or Crohn’s colitis. In a case-control study of patients with UC undergoing colonoscopic surveillance, there was a reduction in mortality from CRC in those patients in surveillance programs. Patients with UC or extensive Crohn’s colitis (greater than

one-third colonic involvement) should undergo surveillance colonoscopy every 1 to 2 years beginning 8 to 10 years after disease onset. Four biopsy specimens of the colon in patients with documented pancolitis should be obtained every 10 cm from the cecum to the rectum, to obtain a minimum of 32 biopsy samples. In patients with less extensive colitis, biopsy specimens can be limited to the microscopically involved segments. The presence of high-grade dysplasia or multifocal low-grade dysplasia in flat mucosa is an indication for colectomy. The management of unifocal low-grade dysplasia is controversial as to whether colectomy should be performed. Biopsy specimens should be ob-

March 2009/ VOL 107

103

C OV E R S TO R Y A PRACTICAL APPROACH TO COLORECTAL CANCER SCREENING AND SURVEILLANCE GUIDELINES FOR THE PRIMARY CARE PHYSICIAN

Table 9. CRC screening and surveillance in patients with high risk: Risk Category

Age to begin

Recommended tests

Comment

Familial adenomatous polyposis (FAP) diagnosed by genetic testing, or suspected FAP without genetic testing

10 to 12 years of age

Annual flexible sigmoidoscopy to evaluate for signs of FAP; counseling to consider genetic testing if not already done

If genetic testing is positive, colectomy should be considered.

Hereditary non-polyposis colon cancer (HNPCC), or at increased risk based on family history without genetic testing

20 to 25 years of age, or 10 years prior to earliest affected or 10 years prior to immediate family

Colonoscopy every 1 to 2 years; counseling to consider genetic testing if not already done

Genetic testing should be offered to 1st degree relatives of patients found to have HNPCC mutations by genetic testing. It should also be offered if 1 of the first 3 of the modified Bethesda criteria is met.

Inflammatory bowel disease -Chronic ulcerative colitis -Crohn’s disease

Risk of colon cancer begins to increase 8 years after onset of pancolitis (involvement of the entire large intestine), or 12 to 15 years after onset of left-sided colitis

Colonoscopy every 1 to 2 years with biopsies for dysplasia

Patients are best referred to a center with experience in the surveillance and management of inflammatory bowel disease.

tained of strictures, mass lesions, and macroscopic abnormalities other than pseudopolyps. Adenomatous-appearing polyps should be completely removed by polypectomy and biopsy specimens should be obtained from the adjacent flat mucosa to determine the presence of dysplasia. If a dysplastic polyp is identified outside an area of inflammation and there is no evidence of dysplasia in the adjacent mucosa, it can be managed as a sporadic polyp, similar to polyps in individuals without UC or Crohn’s colitis. If a dysplastic polyp is in an area of active inflammation (dysplasia associated lesion or mass) and there is evidence of dysplasia in the adjacent mucosa, colectomy is indicated.25

CONCLUSIONS The mortality associated with CRC, the medicallegal issues surrounding appropriate evaluation of screening tests, and the multiple CRC screening and surveillance modalities available, make understanding the need, the options, and the recommendations for CRC screening and surveillance an important and topical issue. An increased awareness, not only by physicians, but also by the public, is key to more efficiently navigating

104

March 2009/ VOL 107

through and properly managing the various CRC screening and surveillance tools and exams. Currently, colonoscopy is the preferred modality for CRC screening and surveillance. Flexible sigmoidoscopy, except in FAP, is not a preferred screening modality, but if utilized should be preformed every 5 years. Virtual colonoscopy is an evolving potential strategy, but at this time is not a preferred screening modality. Single digital rectal exam with FOBT and DCBE are not recommended for CRC screening. The tables in this article are a summary of current CRC screening and surveillance recommendations. Tables 1 through 4, as referenced in this article, are recommendations adapted from current guidelines endorsed by the American Society for Gastrointestinal Endoscopy (ASGE). Tables 5 through 9 are recommendations adapted from current guidelines endorsed by the American Cancer Society (ACS).

REFERENCES 1. Jemal A, Murray T, Ward E, et al. Cancer statistics, 2005. CA Cancer J Clin. 2005;55:10-30. 2. O’Connell JB, Maggard MA, Ko CY. Colon cancer survival rates with the new American Joint Committee on Cancer sixth edition staging. J Natl Cancer Inst. 2004; 96:1420-1425.

C OV E R S TO R Y

3. Davila RE, RajanE, Baron TH, et al. ASGE guideline: colorectal cancer screening and surveillance. Gastrointest Endosc. 2006:63:546-557. 4. Winawer S, Fletcher R, Rex D, et al. Colorectal cancer screening and surveillance: clinical guidelines and rationale-Update based on new evidence. Gastroenterology .2003;124:544-560. 5. Thorpe LE, Mostashari F, Hajat A, et al. Colon cancer screening practices in New York City, 2003: results of a large random-digit dialed telephone survey. Cancer. 2005;104:1075-1082. 6. Nadel MR, Shapiro JA, Klabunde CN, et al. A national survey of primary care physiciansâ&#x20AC;&#x2122; methods for screening for fecal occult blood. Ann Intern Med. 2005;142:86-94. 7. Citarda F, Tomaselli G, Capocaccia R, et al. Efficacy in standard clinical practice of colonoscopic polypectomy in reducing colorectal cancer incidence. Gut. 2001;48:812815. 8. Winawer SJ, Zauber AG, Ho MN, et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med. 1993;329:1977-1981. 9. Rex DK, Cutler CS, Lemmel GT, et al. Colonoscopic miss rates of adenomas determined by back-to-back colonoscopies. Gastroenterology. 1997;112:24-28. 10. Dominitz JA, Eisen GM, Baron, TH, et al. Complications of colonoscopy. Gastrointest Endosc. 2003;7:441-445. 11. Rex DK, Johnson DA, Lieberman DA, et al.Colorectal cancer prevention 2000: screening recommendations of the American College of Gastroenterology. Am J Gastroenterol. 2000;95:868-877. 12. Lieberman DA, Weiss DG, Bond JH, et al. Use of colonoscopy to screen asymptomatic adults for colorectal cancer. Veterans Affairs Cooperative Study Group 380. N Engl J Med. 2000;343:162-168. 13. Lieberman DA, Weiss DG. One-time screening for colorectal cancer with combined fecal occult-blood testing and examination of the distal colon. N Engl J Med. 2001.345:555-560. 14. Winawer SJ, Stewart ET, Zauber AG, et al. A comparison of colonoscopy and double-contrast barium enema

15.

16.

17.

18. 19.

20.

21. 22. 23. 24. 25.

for surveillance after polypectomy. National Polyp Study Work Group. N Engl J Med. 2000;342:1766-1772. Rex DK, Rahmani EY, Haseman JH, et al. Relative sensitivity of colonoscopy and barium enema for detection of colorectal cancer in clinical practice. Gastroenterology. 1997;112:17-23. Cotton PB, Durkalski VL, Pineau BC, et al. Computed tomographic colonography (virtual colonoscopy): a multicenter comparison with standard colonoscopy for detection of colorectal neoplasia. JAMA. 2004;291:17131719. Pickhardt PJ, Choi JR, Hwang I., et al. Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med. 2003;349:2191-2200. Kim DH, Pickhardt PJ, Taylor AJ, et al. CT colonography versus colonoscopy for the detection of advanced neoplasia. N Engl J Med. 2007;357:1403-1412. Ahlquist DA, Skoletsky JE, Boynton KA, et al.Colorectal cancer screening by detection of altered human DNA in stool: feasibility of a multitarget assay panel. Gastroenterology. 2000;119:1219-1227. Imperiale TF, Ransohoff D F, Itzkowitz SH, et al. Fecal DNA versus fecal occult blood for colorectal-cancer screening in an average-risk population. N Engl J Med. 2004;351:2704-2714. Giardiello FM, Brensinger JD, Petersen GM. AGA technical review on hereditary colorectal cancer and genetic testing. Gastroenterology. 2001;121:198-213. Lynch HT, de la Chapelle A. Hereditary colorectal cancer. N Engl J Med. 2003;348:919-932. Young, Y, Terdiman JP. Endoscopic management of familial colonic neoplasia. Gastrointest Endosc Clin N Am. 2005;15:549-580, ix-x. Passman MA, Pommier RF, Vetto JT. Synchronous colon primaries have the same prognosis as solitary colon cancers. Dis Colon Rectum. 1996;39:329-334. Itzkowitz SH, Present DH. Consensus conference: Colorectal cancer screening and surveillance in inflammatory bowel disease. Inflamm Bowel Dis. 2005;11:314321

March 2009/ VOL 107

105

EDITORIAL

A DUAL MILITARY FAMILY Donna Stewart, MD

am an officer in the Kentucky Air National Guard (KYANG), so I can at least understand some of the reasons why the military wants and needs my husband, Christan, to go to Afghanistan again. My views are entirely positive in regard to our military commitments. For our family, it is a small sacrifice to pay in return for the freedom we have here in the USA. The time away from family and work is not nearly as great as it could be and is inevitable for so many of our military colleagues who spend at least a year or two over in the sandbox. Still, my heart is weary with concern for Christan and those who are deployed in a war zone. So many military members, often part-timers who serve in reserve or guard units across the country, humbly respond to similar calls of duty because it is the right thing to do. These heroes and their families go beyond the usual everyday stress to serve our country. Please thank them. In the November 11, 2008 issue of Woman’s Day Magazine, an article highlighted a military family’s connection with a Fort Campbell soldier, Major Bruce Beyers, while he was deployed to Iraq. Samantha, Beyers’ teenage daughter, sent her own artwork to her Dad as a means of communication and coping. She wrote, “It helped me get my mind off things. My heart stopped each

time the phone rang because I thought it was bad news . . . The only reason we can lie down at night, shut our eyes and dream our dreams is because of people like my father.” As tears welled up in the back of my throat, I could not agree any more with this child. In theater, there is no “safe zone” anywhere. These guys and gals come back changed people. And they change a bit each time they are deployed. The families left behind certainly evolve as well. Yes, the day-to-day efforts are tasked harder when your partner is away for a significant period of time. No doubt the extra duties make getting through the day more of a challenge. These extra duties also become a blessing in a way because you have less time to dwell on the absence of your spouse, a part of your being that makes life so wonderful to experience. Bed time is the worst. I imagine that Christan’s bed is old, dank and built in a dark bunker. He can only read with his issued hand light in his shared room. In his “free time” he flies, exercises, and reads military manuals, with some light reading in between. His time is more regimented than mine, even with the additional responsibilities I have at home. I cannot complain, but I miss him and I worry . . . Please pray for our troops. Pray for their safety and health.

These heroes and their families go beyond the usual everyday stress to serve our country. Pray that we, as part of the United States of America, are making a difference somewhere and in some way. Pray that our troops are able to come back home soon and that world leaders can find a suitable and peaceable alternative to war. Lastly, if you see anyone in military dress, please let them know that you support them. No matter how old or young they appear, you never know what they have sacrificed to wear that uniform to keep our country safe and to maintain the freedom we daily enjoy. Donna Stewart, MD The views expressed in this editorial are those of the individual editor and do not necessarily reflect the opinion of the full Editorial Board or the KMA Board of Trustees. The Journal of the Kentucky Medical Association wishes to foster the free exchange of ideas and opinions regarding articles that appear in these pages. If you wish to submit a Letter to the Editor, it should be written in clear, concise language, and the length should not exceed approximately two typed, double-spaced pages. Letters will be published in part, or in their entirety, at the discretion of the Editorial Board.

March 2009/ VOL 107

107

ALLIANCE

DOCTORS’ DAY Cheryl Broster

ith the onset of spring, we know it’s that time again—so buy your red carnations and order your celebratory cake: Doctors’ Day is right around the corner! The very first Doctors’ Day observance was held on March 30,1933, by the Barrow County Alliance, in Winder, Georgia. This initial event was reported at the Southern Medical Association Alliance annual meeting and quickly took root, eventually growing to become a national celebration in 1990 when President George H.W. Bush signed the resolution designating March 30th as National Doctors’ Day. March 30 was selected because it is the anniversary of the first administration of general anesthesia in surgery. In 1842, Dr Crawford W. Long of Barrow County administered sulfuric ether on a towel to the patient for the removal of a tumor on the back of his neck. Dr Long has a Kentucky connection: a portion of his medical studies occurred at Transylvania University in Lexington, Kentucky. SMAA and the AMA Alliance continue to encourage their members to promote the observance of this day honoring physicians, to remind the public of doctors’

dedication to the health and welfare of patients, and to increase awareness of the positive role of physicians in the community. Here in Kentucky, the county Alliances will be busy recognizing and honoring physicians in a variety of special ways. This year the Hopkins County Medical Alliance invited elementary school students to either write notes or create artwork thanking their physicians. One student’s work from each school will be showcased on a display board at a Doctors’ Day Appreciation Dinner. The Greater Louisville Medical Society Alliance hosts a luncheon for its retired physicians. Each year they recognize

A heartfelt “thank you” to all Kentucky physicians. one retired physician for his or her “post-practice” contributions to the community. For many years, the Lexington Medical Society Aliance has collected donations and donated these funds to McDowell House in Danville in the name of Lexington Physicians. Warren County is arranging a potluck to

Doctors’ Day is right around the corner! generate proceeds. They plan to use these proceeds to purchase and plant trees at the hospitals in Bowling Green as a memorial to Jerre Fitts and Dr Kela Fee, two members of their Alliance who passed away at the end of last year. This year Henderson County Medical Alliance plans to have a Doctors’ Day breakfast with a red carnation, the symbol of Doctors’ Day, for the physicians. The Daviess County Medical Society and Alliance will have a joint dinner meeting at the end of March where they will honor and provide special recognition to the physicians who have been practicing medicine for 30 or more years. A heartfelt “thank you” to all Kentucky physicians for your dedication and contributions in the community! Like other holidays, let’s make Doctors’ Day a routine celebration in our lives. Cheryl Broster KMA Alliance President Portions summarized with permission from the Web site of Southern Medical Association Alliance

March 2009/ VOL 107

109

ALLIANCE Kentucky Medical Association Alliance Board Meeting & Spring Luncheon April 21, 2009 9:30 a.m. – 1:30 p.m (EST) Greentree Antiques & Tearoom 521 West Short Street Lexington, Kentucky 859-455-9660

www.greentreetearoom.com Y ou are cordially invited to attend the KMA Alliance Spring Meeting with featured guest speaker Sandi Frost, AMAA President On Monday, April 20th, the evening prior to the meeting, the Lexington Medical Society Alliance is hosting a cocktail party at the home of Jane and Sloan Warner, 791 Harbor Point, at 7:00 p.m. All meeting attendees and their guests are invited to attend. Please RSVP below.

Tuesday, APRIL 21 9:30 – 10:00 AM 10:00 – 10:45 AM 10:45 – 11:15 AM 11:15 – 12:00 PM 12:00 – 1:30 PM

Welcome & Registration FOR County Presidents, County President Elects, & State Board Members Board Meeting Welcome & Registration FOR All Membership Presentation by Sandi Frost, AMA Alliance President: 21st Century Medical Families: Engaged, Enlightened and Empowered Lunch at the Tearoom

Hotel information KMA ALLIANCE Annual Spring Meeting to be held in beautiful horse farm area, Lexington, Kentucky! President Cheryl Broster along with Spring Meeting hosts, Jane Warner and Karen Milligan and the Lexington Medical Society Alliance will be hosting the meeting. Rooms are available April 20 & 21 with check out on April 22, at the Fairfield Inn by Marriott: 3050 Lakecrest Circle, Lexington, Kentucky, 859-224-3338. These rooms are being held with a special group rate for the KMA Alliance of $99, group #G1213, and will be released March 20, 2009. Keeneland opens on Wednesday so be sure to make your hotel reservations EARLY (before March 20, 2009). All meetings held at Greentree Antiques. *********************************************************************************** I plan to attend (please indicate number of attendees): LMSA Cocktail Party on Monday, April 20 Lunch at the Tearoom on Tuesday, April 21

_____ @ free _____ @ $25 per person Total enclosed

$________

Your Name__________________________________________________ If bringing guests, please list names:____________________________________________________ Address _________________________City ____________ZIP _________ Phone ____________________E-mail _____________________________ Please make check payable to KMAA. Send the registration form and check to: Karen Milligan, 3665 Winding Wood Lane, Lexington, KY 40515-1284 by April 10th. If you have questions regarding the Spring Meeting please contact Spring Meeting Chairs Karen Milligan, 859-245-3349, or Jane Warner, 859-269-6652. 110

March 2009/ VOL 107

PEOPLE

LIFE MEMBERS The Kentucky Medical Association would like to recognize physicians who have recently become Life Members of the Association. BOONE James R. Schrand, MD Florence KY Albert J. Vesper, MD Richwood KY CALLOWAY Hal E. Houston, MD Murray KY EDMONSON Omkar N. Bhatt, MD Bowling Green KY FAYETTE William E. Blackburn, MD Lexington KY John E. Boso, MD Lexington KY William L. Cooper, MD Lexington KY James C. Ridenour, MD Lexington KY JEFFERSON Arnold M. Belker, MD Louisville KY James L. Bersot, MD Prospect KY Bryant A. Bloss, MD Evansville IN Stanley R. Frager, PhD Louisville KY Francis T. Gardner, MD Louisville KY John H. Hines, MD Louisville KY J. William Holmes, MD Louisville KY

Kenneth R. Jaegers, MD Louisville KY George S. Johnson, MD Louisville KY Harold E. Kleinert, MD Louisville KY Donald T. McAllister, MD Louisville KY Stephen P. Mowry, MD Naples FL Chandrakant C. Patel, MD Louisville KY Sonia Ruth Teller, MD Boynton Beach FL John W. Thomas, MD Louisville KY J. Roy Watson, MD Prospect KY KENTON Gordon W. Air, MD Crescent Springs KY Charles F. Allnutt, MD Union KY Frank Garamy, MD Crescent Springs KY Robert T. Longshore, MD Lakeside Park KY LAUREL William D. Pratt, MD London KY MCCRACKEN Lloyd W. Housman, MD Grand Rivers KY Charles L. Shields, MD Paducah KY METCALFE Lawrence P. Emberton, MD Edmonton KY PERRY Muraleedhara P. B. Menon, MD Memphis TN

WARREN Prana R. Bhatt, MD Bowling Green KY WHITLEY Richard F. Park, MD Corbin KY

NEW MEMBERS Members of the Kentucky Medical Association and their respective county medical societies join in welcoming the following new members to these organizations. BARREN Azizur Rahman, MD Glasgow 1978, Dow Med Coll

OPH

CALLOWAY Derek L. Morgan, MD Murray 2002, U of Arkansas

ORS

CLARK Marc R. Ford, MD Winchester 1992, U of Tennessee

FAYETTE Gregory E. Mick, DO NS Lexington 1980, Kansas City Coll of Osteopathy & Surgery, Kansas City GRAVES Eric B. Metz, DO Mayfield 2002, Pikeville Coll, Sch of Osteopathic Med JEFFERSON Melissa D. Agan, MD Louisville 2005, U of Louisville

ORS

March 2009/ VOL 107

111

PEOPLE

Raza Ali, MD NEP Louisville Mohammad Alsorogi, MD N Louisville 1996, Ain Shams U Haizia Amsler, MD IM Louisville 1996, U of Algiers Joseph Baisden, MD PhD R Louisville 2003, West Virginia U Vinod Balasa, MD PDHC Louisville 1990, M.S. Ramaiah Med Coll, Bangalore U Yasier Basheer-Gowi, MD FM Louisville 1992, Russian People’s Friendship U Carol Ellen Brees, MD OBG Louisville 1983, U of California, LA Abraham J. Bronner, MD R Louisville 1979, Johns Hopkins U Nicholas Carricato, MD OBG Louisville 2004, U of Louisville Rebecca Christensen, MD PTH Prospect 1996, U of Louisville Anthony E. Dragun, MD RO Louisville 2002, Hahnemann Med Coll of Philadelphia George B. Dunn, MD R Louisville 1999, Indiana U Rebecca S. Feller, MD R Louisville 2002, U of Louisville David Hasselbacher, MD PUD Louisville 2001, U of Louisville Hao Tuan Le, MD IM Louisville 2005, U of Dominica, Ross U

112

March 2009/ VOL 107

Jennifer Feiler Le, MD P Louisville 2002, U of Louisville Thomas Maher, MD AN Louisville 2002, Indiana U Joshua W. Meier, MD ORS Louisville 2002, Med Coll of Wisconsin Shirley J. Meredith, MD IM Louisville 1995, U of Louisville Pradeep S. Mohan, MD HS Louisville 1999, American U of the Caribbean G. Ramachandran, DO ORS New Albany 2097, U of New England Coll of Osteopathic Med Chandhiran Rangaswamy, MD C Louisville 1998, U of Louisville Shlomit Schaal, MD OPH Louisville 1996, Israel Inst of Technology Kathryn M. Schat, MD FM Louisville 1994, McGill U, Montreal Jody Tucker Sepich, MD IM Louisville 2003, East Carolina U Tariq S. Siddiqui, MBBS IM Louisville 1996, Dow Med Sch Sameet Singh Sohi, MD OTO Louisville 2003, U of Louisville Sarah K. Wagers, MD PMR Louisville 1999, U of Louisville Lina Yassine, MD END Louisville 2000, Jordan U Med Sch

PIKE Thomas K. Ison, DO Pikeville 2002, Pikeville Coll, Sch of Osteopathic Med

OPH

ROWAN Charles R. Hughes, MD Winchester 1973, U of Louisville

IN-TRAINING JEFFERSON Bruce Espenshade, MD

OBITUARIES William J. Brown, PhD Louisville, KY 1924 – 2009 William J. Brown, PhD, a retired Audiologist, died January 5, 2009. A 1958 graduate of the State University of New York at Syracuse (Upstate), Dr Brown was a life member of the KMA. Donald Chatham, MD Shelbyville, KY 1926 – 2009 Donald Chatham, MD, a retired Family Practitioner, died February 3, 2009. Dr Chatham was a 1952 graduate from the University of Louisville School of Medicine and a life member of the KMA.

PEOPLE

Gordon Hollis, MD Harlan, KY 1933 – 2008 Gordon Hollis, MD, a retired Pediatrician, died December 12, 2008. A 1959 graduate of the Vanderbilt University School of Medicine, Nashville, Dr Hollis was a life member of the KMA.

Thomas J. Huth, MD Ft. Mitchell, KY 1921 – 2008 Thomas J. Huth, MD, a retired General Practitioner, died December 7, 2008. Dr Huth was a 1948 graduate of the Medical College of Ohio, Cincinnati, and a life member of the KMA.

John A. Petry, MD Louisville, KY 1925 – 2009 John A. Petry, MD, a retired OB/GYN, died January 21, 2009. A 1950 graduate of the University of Louisville School of Medicine, Dr Petry was a life member of KMA.

+HOSLQJ \RX PDNH WKH PRVW RI \RXU SUDFWLFH + HOSLQJ \RX PD DNH WK KH PRVW RI \RXU SUDFWLFH &DOO WRGD\ IRU D IUHH FRQVXOWDWLRQ &DOO WRGD\ IRU D \ D IUHH FRQVXOWDWLRQ Trusted T rusted r by Successful Doctors Since 1945

Management Consulting ,Q GHSWK SUDFWLFH ,Q GHSWK SUDFWLFH DVVHVVPHQWV 2YHUKHDG UHGXFWLRQ ,PSURYHG FROOHFWLRQV &RQWUDFW HYDOXDWLRQ 6WDII SURGXFWLYLW\ 'LYLVLRQ RI SURÀW 'L L L I ÀW

Lexington

(859) 254-3906 254- 3906 Louisville

(502) 636636-0825 0825 Toll-Free T o oll-Free

(800) 359359-3970 3970 ZZZ VFURJJLQV FRP ZZZ Z VFURJJLQV FRP

Financial Services 7D[ SODQQLQJ SUHSDUDWLRQ 7D D[ SODQQLQJ SUHSDUDWLR 5HWLUHPHQW SODQ GHVLJQ 5HWLUHPHQW SODQ GHVLJQ DQG DGPLQLVWUDWLRQ Medical Billing Pictured left to right: Mark D. Scroggins, MBA, CHBC, Paul R. Trenz, MS-Tax, CHBC, David C. Scroggins, MBA, CHBC, Robert C. Scroggins, JD, CHBC

March 2009/ VOL 107

113

FYI CAPSULES

Medical Conference on HIV Treatment Updates Highlights from the 16th Conference on Retroviruses and Opportunistic Infections will be presented on March 28, 2009, at the Eric P. Newman Education Center, St. Louis, Missouri. Sponsored by the AIDS Clinical Trials Unit, Infectious Diseases Division, Department of Internal Medicine, and the Midwest AIDS Training & Education Centerâ&#x20AC;&#x201D; Missouri. For additional course information, contact Susan Wightman, BSN, ACRN, with Washington University in St. Louis at 314.454.8275 or email swightma@im.wustl.edu.

Correctional Health Care Conference Scheduled Updates in Correctional Health Care will be held April 4-7, 2009, at the Flamingo Las Vegas. A program of 55-plus presentations will include sessions that present research and the conceptual foundations of correctional health care, as well as those that

114

March 2009/ VOL 107

provide information on how to improve the quality of work delivered in correctional facilities. For more information or to register visit the Web site at www.ncchc.org.

AMA Launches a New Interactive Web Site The American Medical Association (AMA) recently launched a new Web site to help physicians, residents, and medical students easily obtain resources and tools relevant to their individual professional needs. Visit http://www.amaassn.org to view and use the redesigned Web site. The new AMA Web site is provides AMA messages and news pages updated daily. Dedicated sections for physicians, residents, and medical students are filled with information and resources specific to each group. Physicians can find useful billing and reimbursement resources, along with numerous tools ranging from patient education to clinical practice standards.

Medical residents can benefit from tips on how to survive the rigors of residency, including advice on handling medical school education debt. Medical students can access information on financial aid, choosing a medical specialty, and understanding medical ethics. In addition to exploring the site by professional status, visitors can also search content by subject matter. Topics include physician resources, education and the profession, legislation and advocacy, and AMA news and events. In addition to its new and updated appearance, the AMA Web site now has more content directly available from the home page allowing for faster access to needed information, such as links to Continuing Medical Education (CME), Current Procedural Terminology (CPT) and medical journals. Medical Students can link to FREIDA Online to find accredited training programs. Topic menus that expand or collapse can be tailored to the userâ&#x20AC;&#x2122;s preference and related links now appear to direct users to other relevant content.

GUIDELINES FOR AUTHORS The Kentucky Medical Association (KMA) has published a medical journal for more than 100 years. The Journal of the KMA is published monthly under the direction of the Board of Trustees and is indexed by the National Library of Medicine in Index Medicus/MEDLINE. Articles will be accepted for consideration with the understanding that they are original and are contributed solely to this Journal. Preference is given to articles of importance to practicing physicians and medical educators in Kentucky and those that deal with issues related to the health and well-being of Kentuckians. Submission—Electronic submission is preferred, and the document should be e-mailed to the managing editor at heckel@kyma.org. If a hard copy is sent, please retain a copy for proofreading and submit the original and one copy to Sharon Heckel, Managing Editor, Journal of the Kentucky Medical Association, 4965 US Hwy 42, Suite 2000, Louisville, KY 40222. The cover letter should designate one author as correspondent and include the author’s address, telephone number, fax number, and e-mail address. Receipt of manuscripts will be acknowledged and unused manuscripts returned. Copyright Assignment—A copyright transmittal letter to the editor must contain the following language and must be signed by all authors: In consideration of the Journal of the Kentucky Medical Association taking action in reviewing and editing our submission, the author(s) undersigned hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership to the Kentucky Medical Association in the event such work is published by the Journal of the Kentucky Medical Association and/or published in other venues of the Kentucky Medical Association. The Journal of the Kentucky Medical Association is copyrighted by the Kentucky Medical Association. Written permission from the editor must be obtained before reproducing any material published in the Journal. Conflicts—Authors must reveal any potential conflicts that might exist between themselves and other entities or persons. In this regard, authors are responsible for disclosing any financial and/or personal relationship that might bias their work product or article. Preparation—Manuscripts should be typewritten in double spacing throughout, including references, tables, legends, quotations, and acknowledgements. Ordinarily, articles should not exceed 3,000 words in length. Titles should include the words most suitable for indexing the article, should stress the main point, and should be short. Bylines may contain no more than six names and shall include only those individuals who can attest that they have contributed significantly to the article. Other contributors may be recognized in an acknowledgment. The full names of all authors should be included, along with their highest academic degrees and professional/institutional affiliations. A synopsis-abstract must accompany all scientific manuscripts. The abstract should be a factual (not descriptive) summary, and should briefly state the question considered, the methods used, the results, and the conclusions supported by those results. References—References must be typed in double spacing on separate sheets and numbered consecutively as

116

March 2009/ VOL 107

they are cited in the text. All references should be cited as superscripts, not footnotes, within the manuscript. There should be no more than 30 references, and they should conform to the AMA Manual of Style, 10th edition. Authors are responsible for reference accuracy. The minimum acceptable data include: Journals: Authors, article title, journal, year, volume, issue number, inclusive pages Books: Author, title, place of publication, publisher, year Other sources: Enough information so that the material can be identified and retrieved Illustrations—All illustrations, photographs, tables, charts, and figures must be submitted as separate images and not embedded in the text. Electronic versions (tiff, pdf, jpg) are preferred, and photographs should be at high resolution (300 DPI or better). Otherwise, illustrations must be submitted in duplicate and the sequence number and author’s name should appear on the back of each. Legends for illustrations should be typewritten (double-spaced) on a separate sheet. Tables must have a title and be numbered. Illustrations other than the author’s will not be accepted for publication unless accompanied by written permission from the original source. If a patient in a photo is identifiable, a written release form from the subject must accompany the photo. The author will be billed for the cost of reproduction of illustrated material for publication in excess of three average illustrations and/or tables. Style—Please use the JAMA style or consult the AMA Manual of Style, 10th edition. Use generic drug names, unless citing a brand name relevant to your findings; brand names in parentheses may follow generic names if desired. Do not use abbreviations in the title, and limit their use in the text. Letters to the Editor—Letters should be written in clear, concise language, and the length should be about two pages, typed with double spacing. Letters will be published at the discretion of the Editorial Board. Disclaimer—All material is reviewed by the Editorial Board. KMA and the editorial board assume no responsibility for the opinions, claims, and recommendations made in articles appearing in the Journal of the Kentucky Medical Association, nor does publication constitute an endorsement of the views expressed therein. MANUSCRIPT SUBMISSION CHECKLIST Before you submit your paper, please be sure you have included the following: Abstract provided Information provided for all authors Copyright assignment signed by all authors Conflict of interest statement from all authors References in the text are in correct numerical order Reference list reflects order cited in the text and conforms to correct style All figures and tables are formatted correctly and fully identified Any necessary permission letters are included

CLASSIFIED

Classified Ads All orders for classified advertising must be placed in writing and will be subject to approval by the Editorial Board. The right is reserved to decline or withdraw advertisements at the publisherʼs discretion. Deadline: First day of month prior to month of publication. Word count: Count as one word all single words, two initials of a name, single numbers or groups of numbers, hyphenated words, and abbreviations. Rates: $40 per insertion ($20 for KMA members) for the first 30 words; 50¢ for each additional word.

FOR SALE MEDICAL EQUIPMENT Ritter Model F operating table, Wilmot Castle Model 51 exam light, Two American Sterilizer Company model 1080 operating tables. Located in Corbin, KY. Delivery options available. Contact David Jorjani at (606) 258-1600.

Online version: KMA now offers the option of an online version of your classified ad with links from the Journal section of the KMA Web site (www.kyma.org). The additional cost to have the printed classified ad listed online is $20 per month ($15 for KMA members)—no word restrictions. Placement of the online version starts on the 2nd Friday of the publication month and runs for four (4) weeks. Contact the Journal office or visit the KMA Web site for details. Send advance payment with order to: The Journal of KMA, The KMA Building, 4965 US Hwy 42, Suite 2000, Louisville, KY 40222.

March 2009/ VOL 107

117

THANKS TO OUR ADVERTISERS

American Medical Association . . . . . . . . . . . . 106

Medical Protective . . . . . . . . . . . . . . . . . . Cover IV

American Physicians Assurance Corporation . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

ProAssurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Classified . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Clayton Scroggins . . . . . . . . . . . . . . . . . . . . . . . . 113

St. Jude Childrenâ&#x20AC;&#x2122;s Research Hospital . . . . . . . 113 State Volunteer Mutual Insurance Company . . . . . . . . . . . . . . . . . . . . . . . . . Cover II

KMA 2009 Annual Meeting . . . . . . . . . . . Cover III The Cancer Project . . . . . . . . . . . . . . . . . . . . . . . . 92 KMA Member-Get-A-Member Campaign . . . . . . . . . . . . . . . . . . . . . . . . Cover III

Valenti Hanley & Robinson. . . . . . . . . . . . . . . . . 85

CHANGING ADDRESS? Please notify us at least two months in advance. Send new address to: Journal of the Kentucky Medical Association The KMA Building 4965 US HWY 42 Suite 2000 Louisville, KY 402226301 502-426-6200 FAX 502-426-6877

118

March 2009/ VOL 107