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DigestiveTrac DIGESTIVE DISEASES • SUMMER 2014, ISSUE 11

INSIDE THIS ISSUE: Barrett’s Esophagus Screening and Surveillance Can Prevent Esophageal Cancer Colorectal Screenings Save Lives and High Costs of Cancer Treatment Basic Health Screenings Key to Quality Care and High Outcomes Primary Care Physicians: How Digestive Disease Expertise Can Help Your Practice

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Dear Colleagues, Recommended screenings can make all the difference in the development of serious and life-threatening gastrointestinal conditions. This issue of Digestive Trac is designed to give primary care providers the information they need to help their patients understand the importance of preventive care. One key example is that of colorectal cancer. Studies show that people who are screened as recommended have a 90 percent reduced risk of developing colorectal cancer. Colonoscopy allows removal of precancerous polyps – preventing cancer before it can develop in the first place. Yet colorectal cancer is still the second leading cause of all cancer-related deaths, and only 62 percent of adults in South Dakota are up to date with colorectal screenings. Another example is that of esophageal cancer. While less common, the seriousness of esophageal cancer warrants awareness. Barrett’s esophagus, a complication of acid reflux disease, is not a lifethreatening condition in itself. Yet those who develop this condition have a 30 to 125 times higher risk of developing cancer. Surveillance and well-timed treatment also can prevent this dangerous form of cancer. We at Avera Digestive Disease remain dedicated to providing the highest quality care through our multidisciplinary team, which offers a full range of treatment options, patient navigation and support services. As always, it is our privilege to work closely with primary care physicians for our patients’ best interest and continuity of care. Please feel free to contact us at 605-322-7797 with questions or for more information. Sincerely,

Scott L. Baker, MD, FACS, FASCRS Colorectal Surgery Surgical Institute of South Dakota Surgical Director of Avera Digestive Disease Institute

Multidisciplinary Team Includes the Following Areas of Specialty: Colorectal Surgery: Scott L. Baker, MD, FACS, FASCRS Gastroenterology and Hepatology: Steven Condron, MD, MHES, FACP Cristina Hill Jensen, MD Christopher Hurley, MD Dany Shamoun, MD General Surgery: Scott L. Baker, MD, FACS, FASCRS Michael Bauer, MD, FACS Wade E. Dosch, MD, FACS David Flanagan, MD Thomas E. Fullerton, MD Michael Person, MD, FACS David A. Strand, MD, FACS Bradley C. Thaemert, MD, FACS Donald J. Wingert, MD, FACS Genetics: Kayla York, CGC, MS GI Navigation: Liz Harden, CNP Hepatology: Hesham Elgouhari, MD, FACP Mumtaz Niazi, MD, FACP Medical Oncology: David Elson, MD, FACP Mark R. Huber, MD Michael McHale, MD, FACP Heidi McKean, MD Benjamin Solomon, MD Addison R. Tolentino, MD Pathology: Steven P. Olson, MD Bruce R. Prouse, MD Raed A. Sulaiman, MD Radiation Oncology: Barbara Schlager, MD Kathleen L. Schneekloth, MD James Simon, MD

Steven Condron, MD, MHES, FACP Gastroenterology and Hepatology Avera Medical Group Gastroenterology Medical Director of Avera Digestive Disease Institute

Radiology: Sabina Choudhry, MD Brad A. Paulson, MD Research (Cancer clinical trials)

Be A Survivor Learn more about successfully dealing with a colorectal cancer diagnosis. BeASurvivorAveraColon.com

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Transplant Surgery: R. Christopher Auvenshine, DO Jeffery Steers, MD, FACS Urogynecology: Matthew A. Barker, MD, FACOG


BARRETT’S ESOPHAGUS

Screening and Surveillance Can Prevent Esophageal Cancer

Barrett’s esophagus is estimated to affect 2 million to 7 million adults over 40 years of age. While Barrett’s is not a painful or life-threatening condition in itself, patients with Barrett’s esophagus have a risk of developing cancer of the esophagus that is 30 to 125 times higher than patients without this condition. For this reason, it is important that Barrett’s be properly diagnosed, treated and monitored. Adenocarcinoma of the esophagus is a very serious disease, often with a poor prognosis. Yet with proper diagnosis and surveillance of patients with Barrett’s, numerous cases of esophageal cancer can be prevented. The inner lining or mucosa of the esophagus normally consists of flat squamous cells. In Barrett’s, the squamous cells are replaced by columnar cells characteristic of the stomach and intestine. In response to the presence of acid, the esophagus attempts to replicate the lining of the stomach. The typical sufferer of Barrett’s is a white male, with an average age of 55 who is overweight, although it can affect all ages, both genders, and people of all body types. “Esophageal cancer most often is seen in white men, in their 60s who have a history

of tobacco and alcohol use, although we’re finding it more often in women,” said Cristina Hill Jensen, MD, board-certified Gastroenterologist. The incidence of Barrett’s is increasing in correlation with a higher incidence of acid reflux disease. Increasing obesity rates are also to blame. Due to the rarity of this condition, screening for the general population is not recommended. Yet patients with significant risk factors, including a family history of Barrett’s esophagus or esophageal cancer, and a personal history of acid reflux disease, should be considered for an upper endoscopy.

Schedule a Colonoscopy Avera Digestive Disease Institute offers open access to colonoscopy services. Referring physicians and patients who meet screening guidelines can schedule a colonoscopy by calling 605-322-7797 without an initial appointment for consultation.

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“It is very well established that Barrett’s leads to esophageal cancer,” said Christopher Hurley, MD, board-certified gastroenterologist. Of people with acid reflux disease, 10-15 percent develop Barrett’s. Of these patients, 10 percent might develop worrisome dysplasia or cell changes. While a very small percentage of people with acid reflux develop esophageal cancer, because it is such a dangerous disease and is largely preventable through surveillance of Barrett’s, it’s reasonable to consider testing patients with acid reflux to check for any evidence of cell changes.

BARRETT’S ESOPHAGUS • Affects 2 million to 7 million adults • Raises risk of esophageal cancer by 30 to 125 times •

Affects both genders and all body types, although typical patient is a middle-age, overweight white male

• Diagnosed and monitored with upper endoscopy

For patients who have had significant heartburn with worrisome symptoms such as swallowing difficulty, bleeding or weight loss, we usually recommend that they be evaluated with an upper endoscopy.

Symptoms of Barrett’s may be non-existent, or they may mimic symptoms of acid reflux. Yet Barrett’s is often accompanied by atypical symptoms of acid reflux, such as sore throat, chronic cough or chest pain.

– Christopher Hurley, MD, board-certified Gastroenterologist

During upper endoscopy, gastroenterologists can look for the physical changes that are consistent with Barrett’s, and also take a small biopsy of cells during the same procedure. The mucosa appears as salmon colored, with tissue that projects out like tongues. Barrett’s was named after Dr. Norman Barrett who described the condition in the 1950s. Typically, Barrett’s is a very slowly progressive disease. Cancer risk increases 0.5 percent per year. If Barrett’s is diagnosed, surveillance should continue every three years, unless more aggressive cell changes are noted.

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The first stage of change is metaplasia (non-dysplastic). Low-grade dysplasia is the next progression, in which less than 50 percent of the abnormal cells have begun to change in size, shape or organization and may show an increase in their growth rate. If low-grade dysplasia is present, a rebiopsy is recommended in six months to a year to see how fast the disease is progressing. Treatment for Barrett’s esophagus in non-dysplastic and low-grade stages includes suppressing inflammation with anti-inflammatory medications and treating the acid reflux aggressively with acid-suppressors, most often, proton pump inhibitors. Lifestyle changes are also recommended, such as decreasing red meat in the diet, and increasing intake of fresh fruits and vegetables, and cessation of smoking and alcohol use. In high-grade dysplasia, more than 50 percent of cells demonstrate a higher increase in abnormal growth rate and pattern. Risk of developing cancer at this stage increases dramatically, and in fact, many of these patients have esophageal cancer already.


FREE DIGITAL PUBLICATION FOR PATIENTS At AveraGI.org, patients can receive a free educational publication in electronic format. Patients will learn: • How colonoscopy is a first line of defense against colorectal cancer Treatment aim for high-grade dysplasia is getting rid of the condition, either surgically or by non-surgical interventions such as radio frequency ablation (RFA). RFA is indicated in a select number of cases, and this option is best discussed with a gastroenterology specialist. During an outpatient endoscopic procedure, RFA is used to thermally injure the superficial layer of the esophagus – about 1 mm of tissue. In the healing process, the affected layer sloughs away, and new, healthy esophageal lining tissue grows in its place. For selected patients, this procedure has a 90 to 98 percent five-year success rate of curing Barrett’s, depending upon how advanced the disease is. The Avera Digestive Disease Institute uses the HALO System by Barrx Medical. RFA is a safe procedure with few side effects.

• Risk factors for colorectal cancer • How good colon prep is absolutely key to accurate testing •

The benefits of a multidisciplinary team approach in the care of digestive disease diagnosis and care

AveraGI.org

“With Barrett’s esophagus, careful surveillance is the main focus. Patients with this diagnosis should have upper endoscopy every three years, or as frequently as every year if dysplasia is present. Surveillance and prevention are key in dealing with esophageal cancer in the setting of reflux disease,” Dr. Hurley said.

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COLORECTAL SCREENINGS Save Lives and High Costs of Cancer Treatment

– Cristina Hill Jensen, board-certified Gastroenterologist

While colorectal screening is recommended for all adults beginning at age 50, only 62 percent of adults in South Dakota are up to date with screenings for colorectal cancer.

“Age 50 is the absolute latest that any adult should have a screening colonoscopy, and there are reasons why some people should have it done sooner,” said Christopher Hurley, MD, board-certified Gastroenterologist. For example, recommendations state that people of African American descent should have screening beginning at age 45, and people with a family history of colorectal cancer should have screening 10 years before the age at which their family member was diagnosed.

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We need to instill in patients that getting colorectal screening is just as important as other screening tests, such as regular Pap tests or mammograms.

Although other screening options exist, colonoscopy is considered the “gold standard” in colorectal screening. It examines the entire colon for signs of colorectal cancer and precancerous polyps. It gives the best visibility of abnormalities, and provides the opportunity to remove precancerous polyps during the same procedure. Colonoscopy is recommended every 10 years, because that is the typical amount of time that it takes for precancerous polyps to develop into colorectal cancer. Colonoscopy is recommended beginning at age 50, because that is 10 years before the peak age of colorectal cancer diagnosis, which is 60. So if colonoscopy is successful in finding and removing polyps before they become cancerous, this tool can effectively eliminate the potential of cancer. In fact, studies show that people who are screened have a 90 percent reduced risk of developing colorectal cancer. Patients might object that they don’t have any troublesome symptoms, and therefore do not need to have a colonoscopy. Yet colonoscopy catches early-stage cancer and polyps before


symptoms appear. By the time there are symptoms, such as bleeding from the rectum, pain or a change in bowel habits, cancer is often far advanced. Patients also might put off the test due to embarrassment or fear of pain. Yet patients are given sedation medications before the test, and they often wake up afterward and don’t even realize it has taken place. Patients do need to set aside an entire day for the test. They can begin their colon prep the night before and complete it the morning of the test. Time at the clinic or outpatient hospital setting typically is three hours or less, and the actual procedure time is approximately 30 minutes. Because of the sedation, patients need someone to drive them home after the test, and they should not return to work until the next day. If patients are not insured, colonoscopy is a test they might be reluctant to pay for out of pocket. Yet coverage of colonoscopy screenings is a requirement of the Affordable Care Act. For greatest effectiveness, colonoscopy should be performed by an experienced specialist. Over the past 10 years, concerns have been raised in differences between the efficacy of colonoscopy in large clinical trials and the community at large. Drivers of colonoscopy quality include the quality of colon prep, which in part is dependent upon the patient, as well as the instructions he or she receives. Drivers that are dependent upon the endoscopist include the percentage of time that the endoscopist reaches the cecum (top of the colon), time spent inspecting the colon during the withdrawal phase of the exam, and adenoma detection rate. Because of their greater experience in doing these exams, gastroenterologists have the highest rate of polyp and cancer detections.

Screening Colonoscopy • Recommended for all adults, every 10 years, beginning at age 50 – Earlier for those with a family history or of African American descent • Screens for early-stage cancer and precancerous polyps, which can be removed during the same procedure • Equally important as other recommended screening tests, including Pap tests and mammograms • Only 62 percent of South Dakota adults are up to date with screenings • Primary care providers are a key influence in patients’ decision to have this vital test • Recommended screenings can reduce cancer risk by 90 percent • Coverage of colonoscopy screenings is a requirement of the Affordable Care Act

Quality metrics are becoming increasingly important in the current climate of health care reform, and primary care providers play an important role in whether or not patients get the basic recommended screenings. As a quality metric, not only should primary care providers offer screenings such as colonoscopy, they should then document that the screening was offered in the medical record. In the near future, the electronic medical record will trigger reminders, taking care of this vital function. For payors, colorectal cancer is a disease that is much more expensive to treat than prevent. Colonoscopy is not an inexpensive test, yet it can prevent costly surgeries and chemotherapy, in addition to the personal losses experienced by individuals and families. It is estimated that increased use of all types of preventive screening could avert the loss of 2 million life years annually and save $3.7 billion.

Colorectal cancer is the third most common type of cancer in both men and women, with 143,000 Americans diagnosed each year. It is the second-leading cause of cancer-related deaths, with more than 50,000 deaths per year nationwide. 6


BASIC HEALTH SCREENINGS Key to Quality Care and High Outcomes

More than just another item to check off the “to do” list, basic health screenings save lives. This is the message that primary care providers are asked to share with their patients at annual exams, and at other opportunities as well, said Tad Jacobs, DO, Chief Medical Officer for Avera Medical Group. Dr. Jacobs gave the real-life example of a patient with diabetes, whose appointments through the years focused upon managing his diabetes – not routine health screenings. This patient ended up developing both prostate cancer and colon cancer, and ultimately died of cancer. He did not receive the basic screenings that could have caught these illnesses in the earliest stages, or prevented them from developing in the first place. “Primary care providers have a lot to think about when they are doing an annual physical. If an existing or new health issue is brought to the forefront, talking about these screenings can be so easy to set aside,” said Dr. Jacobs, who formerly practiced family medicine in Flandreau, S.D., for a number of years. Aside from a spouse or other close family member, the primary care provider is the greatest influence upon whether or not patients will decide to get recommended screenings. For the gastrointestinal system, regular colorectal cancer screenings are the main emphasis, although primary care providers can also discover other GI issues by evaluating symptoms, or conducting an abdominal exam and rectal exam.

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– Tad Jacobs, DO, Chief Medical Officer for Avera Medical Group

Colonoscopy continues to be the “gold standard” in colorectal screening. It is recommended every 10 years beginning at age 50, or earlier for people who have a family history of colorectal cancer or a personal history of colon polyps. Colonoscopy is such a beneficial tool because it can detect early colorectal cancer as well as precancerous polyps. Polyps can be removed during the same procedure, virtually eliminating the chance that these polyps could develop into colorectal cancer. Studies show that people who are screened have a 90 percent reduced risk of developing colon cancer. Yet nationwide, a third of people who are eligible for regular recommended screenings do not take advantage of it. There are many reasons why patients don’t get colonoscopies as recommended. After all, colonoscopy is the type of test that is joked about by late-night television comedians. Yet most patients who actually have the procedure say that the prep is the worst part, and the latest formulations make colon prep as easy as possible. If patients are uninsured, and are healthy and feeling well, they are unlikely to opt for paying for this test out of pocket. In addition, there are those who don’t get the test because they don’t understand the importance and don’t take ownership of their own health management. In the future, health systems and physicians will be asked by insurers to take ownership and responsibility for the health of a population. As this happens, offering the basic screening tests like colonoscopy will become a quality metric that is tied to reimbursement.

Even today, sending patients letters when they are due for screening tests is among Meaningful Use requirements. Leveraging the electronic medical record (EMR) will help primary care providers fulfill this role. Avera began implementation of its EMR in 2007 and continues on that journey.

We encourage patients to take ownership of their own health, and partner with primary care practitioners to cover all the bases when it comes to recommended health screenings, including colonoscopy.

Endoscopic suites designed for patient comfort and privacy are located on the fifth floor of Plaza 1 on

Tools like the patient portal provide opportunities to communicate with patients and engage them in their own health, and automatically post reminders of recommended screenings. “We’re now at the point where we can begin optimizing the EMR to provide guidance and tracking for the populations we care for,” Dr. Jacobs said.

the Avera McKennan campus. These suites have less of a “hospital” feel, and are more like a physician’s office.

605-322-7797

BE A SURVIVOR Avera’s Guide to Colorectal Cancer Treatment This unique patient education web site features information, 3-D graphics and video interviews with Avera physicians, staff and patients to help patients and their loved ones cope with a colorectal cancer diagnosis.

BeASurvivorAveraColon.com

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When a patient presents with complex gastrointestinal disease or unexplained symptoms, the multidisciplinary team of the Avera Digestive

Primary Care Physicians: How Digestive Disease Expertise Can Help Your Practice

Disease Institute is here and ready to help. DDI specialists serve patients with diagnoses including colorectal cancer and other cancers of the GI tract, irritable bowel syndrome and inflammatory bowel disease, Crohn’s disease, ulcerative colitis, unresolved gastroesophageal reflux disease (GERD), Barrett’s esophagus, liver disease, abdominal and pelvic pain, incontinence and more Avera DDI specialists also are concerned that patients receive the recommended screenings for colorectal cancer. Avera’s endoscopy program has open access, allowing patients who meet screening guidelines to get accurate screenings in a private, patient-friendly environment with no advance consult visit. Patients with cancer and other complex diagnoses have access to navigator services, provided by Liz Harden, a certified nurse practitioner (CNP). She helps patients navigate the health care system as they see different specialists and go through the various aspects of care outlined in their treatment plan. She answers questions, resolves concerns, and ensures that tests or procedures are completed in a timely manner. Certain specialties offer telemedicine through Avera eConsult, as well as outreach services. Also through the DDI, patients have access to integrative medicine, including nutrition counseling, acupuncture, massage, aromatherapy, mind-body movement and weight loss programs. DDI specialists want to partner with primary care physicians in the care of their patients.

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Because of the volume of cases, the Avera DDI team has the experience and expertise to deal with the more rare conditions of esophageal cancer and pancreatic cancer. Avera is home to the region’s only practice dedicated to liver disease, and a Level 1B Accredited Bariatric Center.

The weekly Digestive Disease Conference reviews referred malignant and non-malignant cases of digestive disease. A multidisciplinary team of specialists represents the following specialty areas:

• Colorectal surgery

• Gastroenterology

• Genetics

• Transplant

• Medical Oncology

• Pathology

• Radiation oncology

• Radiology

• Surgery

• Chaplaincy

• Social workers

From screening and diagnosis to treatment and follow-up care, our multidisciplinary team of medical professionals is committed to helping patients experience the best possible outcomes.

Upon request, opportunity can be provided for physicians to take part in weekly Digestive Disease Conferences via teleconference when a referred patient’s case is presented, and physicians also can be provided with a case summary.

– Scott Baker, MD, Fellowship-Trained Colorectal Surgeon

Please don’t hesitate to contact DDI at 605-322-7797 to learn more about our program. 10


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Digestive Trac • Summer 2014, Issue 11