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Ladabaum U, Mannalithara A, Meester RGS, Gupta S, Schoen RE. Cost-Effectiveness and National Effects of Initiating Colorectal Cancer Screening for Average-Risk Persons at Age 45 Years Instead of 50 Years. Gastroenterology 2019; 157:137-148. [PMID: 30930021 PMCID: PMC7161092 DOI: 10.1053/j.gastro.2019.03.023] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/12/2019] [Accepted: 03/15/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS The American Cancer Society has recommended initiating colorectal cancer (CRC) screening at age 45 years instead of 50 years. We estimated the cost effectiveness and national effects of adopting this recommendation. METHODS We compared screening strategies and alternative resource allocations in a validated Markov model. We based national projections on screening participation rates by age and census data. RESULTS Screening colonoscopy initiation at age 45 years instead of 50 years in 1000 persons averted 4 CRCs and 2 CRC deaths, gained 14 quality-adjusted life-years (QALYs), cost $33,900/QALY gained, and required 758 additional colonoscopies. These 758 colonoscopies could instead be used to screen 231 currently unscreened 55-year-old persons or 342 currently unscreened 65-year-old persons, through age 75 years. These alternatives averted 13-14 CRC cases and 6-7 CRC deaths and gained 27-28 discounted QALYs while saving $163,700-$445,800. Improving colonoscopy completion rates after abnormal results from a fecal immunochemical test yielded greater benefits and savings. Initiation of fecal immunochemical testing at age 45 years instead of 50 years cost $7700/QALY gained. Shifting current age-specific screening rates to 5 years earlier could avert 29,400 CRC cases and 11,100 CRC deaths over the next 5 years but would require 10.7 million additional colonoscopies and cost an incremental $10.4 billion. Improving screening rates to 80% in persons who are 50-75 years old would avert nearly 3-fold more CRC deaths at one third the incremental cost. CONCLUSIONS In a Markov model analysis, we found that starting CRC screening at age 45 years is likely to be cost effective. However, greater benefit, at lower cost, could be achieved by increasing participation rates for unscreened older and higher-risk persons.
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Affiliation(s)
- Uri Ladabaum
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California.
| | - Ajitha Mannalithara
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Reinier G S Meester
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Samir Gupta
- Veterans Affairs San Diego Healthcare System, Division of Gastroenterology, Department of Internal Medicine, Moores Cancer Center, University of California-San Diego, San Diego, California
| | - Robert E Schoen
- Division of Gastroenterology, Hepatology and Nutrition, and Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
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Mangas-Sanjuan C, Jover R, Cubiella J, Marzo-Castillejo M, Balaguer F, Bessa X, Bujanda L, Bustamante M, Castells A, Diaz-Tasende J, Díez-Redondo P, Herráiz M, Mascort-Roca JJ, Pellisé M, Quintero E. Vigilancia tras resección de pólipos de colon y de cáncer colorrectal. Actualización 2018. GASTROENTEROLOGIA Y HEPATOLOGIA 2019; 42:188-201. [PMID: 30621911 DOI: 10.1016/j.gastrohep.2018.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 11/08/2018] [Accepted: 11/12/2018] [Indexed: 02/07/2023]
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Iwai T, Imai K, Hotta K, Ito S, Yamaguchi Y, Kawata N, Tanaka M, Kakushima N, Takizawa K, Ishiwatari H, Matsubayashi H, Ono H. Endoscopic prediction of advanced histology in diminutive and small colorectal polyps. J Gastroenterol Hepatol 2019; 34:397-403. [PMID: 30070395 DOI: 10.1111/jgh.14409] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 07/15/2018] [Accepted: 07/20/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM Most polyps detected during colonoscopies are diminutive or small, and they rarely have advanced histology. Real-time prediction of advanced histology would help clinicians to assess the need for pathological evaluation. Here, we investigated endoscopic predictors of advanced histology in diminutive and small polyps. METHODS Consecutive patients with adenomatous polyps (<10 mm) removed endoscopically from January 2013 to December 2014 at a single tertiary cancer center were eligible for inclusion. Two endoscopists reviewed all endoscopic images to identify significant findings associated with advanced histology using multivariate models. The sensitivity, specificity, and negative predictive value of the identified endoscopic predictors for advanced histology were calculated. RESULTS Of 6170 polyps (4746 diminutive) removed from 2611 patients, 320 (5.2%) showed advanced histology, including five submucosal invasive cancers. In multivariate analysis, advanced histology was significantly associated with the following: loss of lobulation (odds ratio [OR] 61.7; 95% confidence interval [95% CI]: 19.1-199.0); heterogeneity in mucosal patterns (OR 29.0; 95% CI: 14.6-57.3); non-polypoid growth (OR 15.7; 95% CI: 4.4-55.5); white spots (OR 13.5; 95% CI: 7.8-23.5); and surface redness (OR 6.6; 95% CI: 3.0-14.5); and irregular capillary pattern (OR 4.8; 95% CI: 2.5-9.1). These significant predictors successfully predicted all submucosal invasive cancers as advanced histology. The sensitivity, specificity, and negative predictive values were 37.2%, 97.8%, and 96.6%. CONCLUSIONS We identified six endoscopic predictors for advanced histology in diminutive or small colon polyps. Diminutive and small polyps lacking these predictors would not be considered to have advanced histology.
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Affiliation(s)
- Tomohiro Iwai
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, Japan
| | - Kenichiro Imai
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, Japan
| | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, Japan
| | - Sayo Ito
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, Japan
| | - Yuichiro Yamaguchi
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, Japan
| | - Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, Japan
| | - Masaki Tanaka
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, Japan
| | - Naomi Kakushima
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, Japan
| | - Kohei Takizawa
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, Japan
| | - Hirotoshi Ishiwatari
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, Japan
| | | | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka, Japan
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Lansdorp-Vogelaar I, Jagsi R, Jayasekera J, Stout NK, Mitchell SA, Feuer EJ. Evidence-based sizing of non-inferiority trials using decision models. BMC Med Res Methodol 2019; 19:3. [PMID: 30612554 PMCID: PMC6322228 DOI: 10.1186/s12874-018-0643-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 12/13/2018] [Indexed: 12/26/2022] Open
Abstract
Background There are significant challenges to the successful conduct of non-inferiority trials because they require large numbers to demonstrate that an alternative intervention is “not too much worse” than the standard. In this paper, we present a novel strategy for designing non-inferiority trials using an approach for determining the appropriate non-inferiority margin (δ), which explicitly balances the benefits of interventions in the two arms of the study (e.g. lower recurrence rate or better survival) with the burden of interventions (e.g. toxicity, pain), and early and late-term morbidity. Methods We use a decision analytic approach to simulate a trial using a fixed value for the trial outcome of interest (e.g. cancer incidence or recurrence) under the standard intervention (pS) and systematically varying the incidence of the outcome in the alternative intervention (pA). The non-inferiority margin, pA – pS = δ, is reached when the lower event rate of the standard therapy counterbalances the higher event rate but improved morbidity burden of the alternative. We consider the appropriate non-inferiority margin as the tipping point at which the quality-adjusted life-years saved in the two arms are equal. Results Using the European Polyp Surveillance non-inferiority trial as an example, our decision analytic approach suggests an appropriate non-inferiority margin, defined here as the difference between the two study arms in the 10-year risk of being diagnosed with colorectal cancer, of 0.42% rather than the 0.50% used to design the trial. The size of the non-inferiority margin was smaller for higher assumed burden of colonoscopies. Conclusions The example demonstrates that applying our proposed method appears feasible in real-world settings and offers the benefits of more explicit and rigorous quantification of the various considerations relevant for determining a non-inferiority margin and associated trial sample size.
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Affiliation(s)
- Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | | | - Natasha K Stout
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Sandra A Mitchell
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | - Eric J Feuer
- Statistical Research and Applications Branch, Surveillance Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, Room 4E534, Bethesda, MD, 20892-9765, USA.
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Abstract
Colorectal cancer is the second leading cause of cancer death in the United States. Prospective studies demonstrate that colorectal cancer screening reduces incidence and mortality, but uptake remains suboptimal. More than a third of age-eligible Americans are not up to date on screening. There are several available screening tests, which may cause primary care providers to ponder which is the best test. This article provides an overview of the available test options and the evidence for each; a summary of major guidelines; and a comparison of the two most widely used tests, colonoscopy and fecal immunochemical testing.
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Affiliation(s)
- Peter S Liang
- Gastroenterology Section, Department of Medicine, VA New York Harbor Health Care System, 423 East 23rd Street, 11N, New York, NY 10010, USA; Division of Gastroenterology, Department of Medicine, NYU Langone Health, New York, NY, USA
| | - Jason A Dominitz
- Gastroenterology Section, VA Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, USA; Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
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Dekker E, Kaminski MF. Take a pill for no more polyps: is it that simple? Lancet 2018; 392:2519-2521. [PMID: 30466865 DOI: 10.1016/s0140-6736(18)32322-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 09/13/2018] [Indexed: 01/15/2023]
Affiliation(s)
- Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, Netherlands.
| | - Michal F Kaminski
- Department of Gastroenterological Oncology and Department of Cancer Prevention, The Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland; Department of Gastroenterology, Hepatology, and Oncology, Medical Centre for Postgraduate Education, Warsaw, Poland; Institute of Health and Society, University of Oslo, Oslo, Norway
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Imperiale TF. Thinking Big About Small Adenomas: Moving Toward "Precision Surveillance". Am J Gastroenterol 2018; 113:1760-1762. [PMID: 30353059 PMCID: PMC6768625 DOI: 10.1038/s41395-018-0397-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 09/25/2018] [Indexed: 12/11/2022]
Abstract
Quality metrics and technological advances for colonoscopy are contributing to detection of more diminutive and small adenomas, increasing the proportion of persons undergoing surveillance for non-advanced neoplasia. In this issue, Kim and colleagues report surveillance colonoscopy findings in average-risk Koreans who had one or more adenomas on a first screening colonoscopy and found a similar risk of metachronous advanced neoplasia between those with 1-2 non-advanced adenoma (the "low-risk adenoma" group) and those with 3 or more small adenomas. The validity, generalizability, and clinical implications of the findings are considered along with recent similar studies. In sum, these studies support expanding the low-risk subgroup to include up to four diminutive tubular adenomas and perhaps persons with up to four small tubular adenomas. They also prompt consideration of "precision surveillance" that considers features of not just the polyps, but of the patient and endoscopist.
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Affiliation(s)
- Thomas F. Imperiale
- 1Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,2Center for Innovation, Health Services Research and Development, The Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.,3Regenstrief Institute, Inc, Indianapolis, IN, USA
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Jover R, Dekker E, Schoen RE, Hassan C, Pellise M, Ladabaum U. Colonoscopy quality requisites for selecting surveillance intervals: A World Endoscopy Organization Delphi Recommendation. Dig Endosc 2018; 30:750-759. [PMID: 29971834 DOI: 10.1111/den.13229] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 07/02/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Different post-polypectomy guidelines underscore the need for high-quality baseline colonoscopy before appropriate surveillance recommendations can be made. Standards for colonoscopy practice have been advocated by gastrointestinal societies. Our aims were to define standards for the procedural practice of colonoscopy in this particular setting of surveillance and to generate a colonoscopy procedural quality checklist that could be implemented in clinical practice. METHODS This study was based on the Delphi process methodology. The baseline questionnaire included 12 domains and 56 individual statements. A total of three rounds were carried out between September 2015 and March 2016 until consensus or lack of consensus was reached. RESULTS In total, consensus was reached on 27 statements in nine domains. High levels of agreement and consensus were reached that: (i) colonoscopy should be considered complete only if the whole cecum has been inspected, including the ileocecal valve and the appendiceal orifice (agreement score 4.63; degree of consensus 82%); (ii) quality of the bowel preparation should always be reported (agreement score 4.9, degree of consensus 94%); and (iii) it is preferable to use a segmental validated scale (agreement score 4.36, degree of consensus 86%). Consensus was also reached regarding multiple statements related to documentation of polyps and their resection. Finally, a colonoscopy quality checklist was drafted. CONCLUSION Consensus on different statements regarding quality of colonoscopy has been reached. Based on this consensus, we propose a colonoscopy quality checklist that would be helpful for post-polypectomy surveillance recommendations.
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Affiliation(s)
- Rodrigo Jover
- Servicio de Medicina Digestiva Hospital General Universitario de Alicante, Instituto de Investigacion Sanitaria, ISABIAL, Alicante, Spain
| | - Evelien Dekker
- Department of Gastroenterology & Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Robert E Schoen
- Department of Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Cesare Hassan
- Endoscopy Unit, 'Nuovo Regina Margherita' Hospital, Rome, Italy
| | - Maria Pellise
- Gastroenterology Department, Hospital Clınic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBERehd), Universitat de Barcelona, Barcelona, Spain
| | - Uri Ladabaum
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, USA
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Hoffmeister M, Holleczek B, Stock C, Zwink N, Stolz T, Stegmaier C, Brenner H. Utilization and determinants of follow-up colonoscopies within 6 years after screening colonoscopy: Prospective cohort study. Int J Cancer 2018; 144:402-410. [DOI: 10.1002/ijc.31862] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 07/20/2018] [Accepted: 08/10/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Michael Hoffmeister
- Division of Clinical Epidemiology and Aging Research; German Cancer Research Center (DKFZ); Heidelberg Germany
| | | | - Christian Stock
- Division of Clinical Epidemiology and Aging Research; German Cancer Research Center (DKFZ); Heidelberg Germany
| | - Nadine Zwink
- Division of Clinical Epidemiology and Aging Research; German Cancer Research Center (DKFZ); Heidelberg Germany
| | - Thomas Stolz
- Gastroenterological Practice Völklingen; Germany
| | | | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research; German Cancer Research Center (DKFZ); Heidelberg Germany
- Division of Preventive Oncology; German Cancer Research Center (DKFZ), National Center for Tumor Diseases (NCT); Heidelberg Germany
- German Cancer Consortium (DKTK); German Cancer Research Center (DKFZ); Heidelberg Germany
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Pinsky PF, Loberg M, Senore C, Wooldrage K, Atkin W, Bretthauer M, Cross AJ, Hoff G, Holme O, Kalager M, Segnan N, Schoen RE. Number of Adenomas Removed and Colorectal Cancers Prevented in Randomized Trials of Flexible Sigmoidoscopy Screening. Gastroenterology 2018; 155:1059-1068.e2. [PMID: 29935150 DOI: 10.1053/j.gastro.2018.06.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 05/29/2018] [Accepted: 06/14/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND & AIMS Screening for colorectal cancer (CRC) with sigmoidoscopy reduces CRC incidence by detecting and removing adenomas. The number needed to screen is a measure of screening efficiency, but is not directly associated with adenoma removal. We propose the following 2 new metrics for quantifying the relationship between adenoma removal and CRC prevented: number of adenomas needed to remove (NNR) and adenoma dwell time avoided (DTA). METHODS We collected data from 4 randomized trials of sigmoidoscopy screening (1 in the United States and 3 in Europe) to assess NNR and DTA. For each trial, NNR was computed as the number of adenomas removed from subjects in the intervention group, divided by the number of CRCs prevented. DTA was computed similarly but taking into account the timing of adenoma removal. Combined results across trials were assessed using standard meta-analytic techniques. RESULTS The estimated NNR for the PLCO (Prostate, Lung, Colorectal and Ovarian) trial was 74 (95% confidence interval [CI], 56-110), for the NORCCAP (Norwegian Colorectal Cancer Prevention) trial was 71 (95% CI, 44-174), for the SCORE (Screening for Colon Rectum) trial was 27 (95% CI, 14-135), and for the UKFSST (UK Flexible Sigmoidoscopy Screening Trial) was 36 (95% CI, 28-52). The combined estimate (meta-analysis) of NNR was 52 (95% CI, 36-93) assuming heterogeneity (P for heterogeneity = .014). DTA estimates among trials ranged from 278 to 730 years, with a combined estimate of 500 (95% CI, 344-833) years assuming heterogeneity (P for heterogeneity = .035), or 2 CRC cases prevented per 1000 adenoma dwell years avoided. The combined estimates of NNR and DTA restricted to advanced adenomas were 13 (95% CI, 9-22) and 122 (95% CI, 90-190) years, respectively. CONCLUSIONS We collected data from 4 randomized trials of sigmoidoscopy screening for CRC to develop metrics of endoscopic efficiency, NNR and DTA, which are directly linked to adenoma detection and removal. They can be used to compare screening among endoscopic modalities and to more precisely measure adenoma to carcinoma transition rates.
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Affiliation(s)
- Paul F Pinsky
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland.
| | | | | | | | | | - Michael Bretthauer
- University of Oslo, Oslo, Norway; Frontier Science Foundation, Boston, Massachusetts
| | | | | | - Oyvind Holme
- University of Oslo, Oslo, Norway; Sorlandet Hospital, Kristiansand, Norway
| | | | | | - Robert E Schoen
- Department of Medicine and Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
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Dekker E, IJspeert JEG. Serrated pathway: a paradigm shift in CRC prevention. Gut 2018; 67:1751-1752. [PMID: 28765475 DOI: 10.1136/gutjnl-2017-314290] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 07/06/2017] [Accepted: 07/10/2017] [Indexed: 01/26/2023]
Affiliation(s)
- Evelien Dekker
- Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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Bretthauer M, Kalager M. When no guideline recommendation is the best recommendation. Lancet 2018; 392:898-899. [PMID: 30238877 DOI: 10.1016/s0140-6736(18)31671-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 07/18/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Michael Bretthauer
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway; Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway; Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA; Frontier Science Foundation, Boston, MA 02446, USA.
| | - Mette Kalager
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway; Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway; Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
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Rutter MD, Beintaris I, Valori R, Chiu HM, Corley DA, Cuatrecasas M, Dekker E, Forsberg A, Gore-Booth J, Haug U, Kaminski MF, Matsuda T, Meijer GA, Morris E, Plumb AA, Rabeneck L, Robertson DJ, Schoen RE, Singh H, Tinmouth J, Young GP, Sanduleanu S. World Endoscopy Organization Consensus Statements on Post-Colonoscopy and Post-Imaging Colorectal Cancer. Gastroenterology 2018; 155:909-925.e3. [PMID: 29958856 DOI: 10.1053/j.gastro.2018.05.038] [Citation(s) in RCA: 208] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 04/25/2018] [Accepted: 05/15/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Colonoscopy examination does not always detect colorectal cancer (CRC)- some patients develop CRC after negative findings from an examination. When this occurs before the next recommended examination, it is called interval cancer. From a colonoscopy quality assurance perspective, that term is too restrictive, so the term post-colonoscopy colorectal cancer (PCCRC) was created in 2010. However, PCCRC definitions and methods for calculating rates vary among studies, making it impossible to compare results. We aimed to standardize the terminology, identification, analysis, and reporting of PCCRCs and CRCs detected after other whole-colon imaging evaluations (post-imaging colorectal cancers [PICRCs]). METHODS A 20-member international team of gastroenterologists, pathologists, and epidemiologists; a radiologist; and a non-medical professional met to formulate a series of recommendations, standardize definitions and categories (to align with interval cancer terminology), develop an algorithm to determine most-plausible etiologies, and develop standardized methodology to calculate rates of PCCRC and PICRC. The team followed the Appraisal of Guidelines for Research and Evaluation II tool. A literature review provided 401 articles to support proposed statements; evidence was rated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. The statements were voted on anonymously by team members, using a modified Delphi approach. RESULTS The team produced 21 statements that provide comprehensive guidance on PCCRCs and PICRCs. The statements present standardized definitions and terms, as well as methods for qualitative review, determination of etiology, calculation of PCCRC rates, and non-colonoscopic imaging of the colon. CONCLUSIONS A 20-member international team has provided standardized methods for analysis of etiologies of PCCRCs and PICRCs and defines its use as a quality indicator. The team provides recommendations for clinicians, organizations, researchers, policy makers, and patients.
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Affiliation(s)
- Matthew D Rutter
- University Hospital of North Tees, Stockton-on-Tees, UK; Northern Institute for Cancer Research, Newcastle University, UK.
| | | | - Roland Valori
- Gloucestershire Hospitals National Health Service Foundation Trust, Gloucestershire, UK
| | | | - Douglas A Corley
- San Francisco Medical Center, Kaiser Permanente Division of Research, San Francisco, California
| | - Miriam Cuatrecasas
- Hospital Clínic and Tumour Bank-Biobank, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | | | - Anna Forsberg
- Institution of Medicine Solna Karolinska Institutet, Stockholm, Sweden
| | | | - Ulrike Haug
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology, Bremen Institute for Prevention Research and Social Medicine, Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany
| | - Michal F Kaminski
- The Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland
| | | | - Gerrit A Meijer
- Netherlands Cancer Institute, Amsterdam, The Netherlands; University Medical Center Utrecht, Utrecht, The Netherlands
| | - Eva Morris
- Leeds Institute of Cancer and Pathology, University of Leeds, St James's Institute of Oncology, St James's University Hospital, Leeds, UK
| | | | - Linda Rabeneck
- Cancer Care Ontario, University of Toronto, Toronto, Ontario, Canada
| | - Douglas J Robertson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | | | | | - Jill Tinmouth
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Click B, Pinsky PF, Hickey T, Doroudi M, Schoen RE. Association of Colonoscopy Adenoma Findings With Long-term Colorectal Cancer Incidence. JAMA 2018; 319:2021-2031. [PMID: 29800214 PMCID: PMC6583246 DOI: 10.1001/jama.2018.5809] [Citation(s) in RCA: 188] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Individuals with adenomatous polyps are advised to undergo repeated colonoscopy surveillance to prevent subsequent colorectal cancer (CRC), but the relationship between adenomas at colonoscopy and long-term CRC incidence is unclear. OBJECTIVE To compare long-term CRC incidence by colonoscopy adenoma findings. DESIGN, SETTING, AND PARTICIPANTS Multicenter, prospective cohort study of participants in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer randomized clinical trial of flexible sigmoidoscopy (FSG) beginning in 1993 with follow-up for CRC incidence to 2013 across the United States. Participants included 154 900 men and women aged 55 to 74 years enrolled in PLCO of whom 15 935 underwent colonoscopy following their first positive FSG screening result. The final day of follow-up was December 31, 2013. EXPOSURES Enrolled participants had been randomized to FSG or usual care. Participants who underwent FSG and had abnormal findings were referred for follow-up. Subsequent colonoscopy findings were categorized as advanced adenoma (≥1 cm, high-grade dysplasia, or tubulovillous or villous histology), nonadvanced adenoma (<1 cm without advanced histology), or no adenoma. MAIN OUTCOMES AND MEASURES The primary outcome was CRC incidence within 15 years of the baseline colonoscopy. The secondary outcome was CRC mortality. RESULTS There were 15 935 participants who underwent colonoscopy (men, 59.7%; white, 90.7%; median age, 64 y [IQR, 61-68]). On initial colonoscopy, 2882 participants (18.1%) had an advanced adenoma, 5068 participants (31.8%) had a nonadvanced adenoma, and 7985 participants (50.1%) had no adenoma; median follow-up for CRC incidence was 12.9 years. CRC incidence rates per 10 000 person-years of observation were 20.0 (95% CI, 15.3-24.7; n = 70) for advanced adenoma, 9.1 (95% CI, 6.7-11.5; n = 55) for nonadvanced adenoma, and 7.5 (95% CI, 5.8-9.7; n = 71) for no adenoma. Participants with advanced adenoma were significantly more likely to develop CRC compared with participants with no adenoma (rate ratio [RR], 2.7 [95% CI, 1.9-3.7]; P < .001). There was no significant difference in CRC risk between participants with nonadvanced adenoma compared with no adenoma (RR, 1.2 [95% CI, 0.8-1.7]; P = .30). Compared with participants with no adenoma, those with advanced adenoma were at significantly increased risk of CRC death (RR, 2.6 [95% CI, 1.2-5.7], P = .01), but mortality risk in participants with nonadvanced adenoma was not significantly different (RR, 1.2 [95% CI, 0.5-2.7], P = .68). CONCLUSIONS AND RELEVANCE Over a median of 13 years of follow-up, participants with an advanced adenoma at diagnostic colonoscopy prompted by a positive flexible sigmoidoscopy result were at significantly increased risk of developing colorectal cancer compared with those with no adenoma. Identification of nonadvanced adenoma may not be associated with increased colorectal cancer risk. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00002540.
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Affiliation(s)
- Benjamin Click
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Paul F. Pinsky
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland
| | - Tom Hickey
- Information Management Services, Rockville, Maryland
| | - Maryam Doroudi
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland
| | - Robert E. Schoen
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
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Castells A. Post-colonoscopy colorectal cancer: Next enemy to beat. Med Clin (Barc) 2018; 150:24-25. [PMID: 28711214 DOI: 10.1016/j.medcli.2017.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 06/06/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Antoni Castells
- Servei de Gastroenterologia, Hospital Clínic, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, España.
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Bénard F, Barkun AN, Martel M, von Renteln D. Systematic review of colorectal cancer screening guidelines for average-risk adults: Summarizing the current global recommendations. World J Gastroenterol 2018; 24:124-138. [PMID: 29358889 PMCID: PMC5757117 DOI: 10.3748/wjg.v24.i1.124] [Citation(s) in RCA: 181] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 12/12/2017] [Accepted: 12/19/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To summarize and compare worldwide colorectal cancer (CRC) screening recommendations in order to identify similarities and disparities. METHODS A systematic literature search was performed using MEDLINE, EMBASE, Scopus, CENTRAL and ISI Web of knowledge identifying all average-risk CRC screening guideline publications within the last ten years and/or position statements published in the last 2 years. In addition, a hand-search of the webpages of National Gastroenterology Society websites, the National Guideline Clearinghouse, the BMJ Clinical Evidence website, Google and Google Scholar was performed. RESULTS Fifteen guidelines were identified. Six guidelines were published in North America, four in Europe, four in Asia and one from the World Gastroenterology Organization. The majority of guidelines recommend screening average-risk individuals between ages 50 and 75 using colonoscopy (every 10 years), or flexible sigmoidoscopy (FS, every 5 years) or fecal occult blood test (FOBT, mainly the Fecal Immunochemical Test, annually or biennially). Disparities throughout the different guidelines are found relating to the use of colonoscopy, rank order between test, screening intervals and optimal age ranges for screening. CONCLUSION Average risk individuals between 50 and 75 years should undergo CRC screening. Recommendations for optimal surveillance intervals, preferred tests/test cascade as well as the optimal timing when to start and stop screening differ regionally and should be considered for clinical decision making. Furthermore, local resource availability and patient preferences are important to increase CRC screening uptake, as any screening is better than none.
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Affiliation(s)
- Florence Bénard
- Department of Medicine, University of Montreal (UdeM), and University of Montreal Hospital Research Center (CRCHUM), Montreal, QC H2X 0A9, Canada
| | - Alan N Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, QC H3G 1A4, Canada
| | - Myriam Martel
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, QC H3G 1A4, Canada
| | - Daniel von Renteln
- Department of Medicine, Division of Gastroenterology, University of Montreal Hospital (CHUM), University of Montreal Hospital Research Center (CRCHUM), Montreal, QC H2X 0A9, Canada
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Emilsson L, Løberg M, Bretthauer M, Holme Ø, Fall K, Jodal HC, Adami HO, Kalager M. Colorectal cancer death after adenoma removal in Scandinavia. Scand J Gastroenterol 2017; 52:1377-1384. [PMID: 28906163 DOI: 10.1080/00365521.2017.1377763] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Improved understanding of the subsequent risk death from colorectal cancer (CRC) among individuals who had adenomas removed is needed. We aimed to quantify this risk using prospectively collected data from population-based cohorts. MATERIALS AND METHODS Using Norwegian and Swedish registries, a cohort of 90,864 individuals with colorectal adenomas removed between 1980 and 2013 was identified. Surveillance was only recommended for high-risk adenomas. The validity of the registry data did not allow classification into low- and high-risk adenomas. Virtually complete follow-up was achieved through linkage to nationwide registers. We calculated incidence-based standardised mortality ratios (SMRs) with 95% confidence intervals (CI). RESULTS The median follow-up was 7.2 years; 48,058 individuals were followed for more than 10 years. We observed 819 deaths (0.9%) from CRC and expected 731 CRC deaths (0.8%), corresponding to an absolute excess risk of 88 cases (0.1%) and a relative risk of 12% (SMR 1.12; 95%CI 1.05-1.20). The relative risk of CRC death following adenoma removal was slightly higher in Sweden (SMR 1.22; 95%CI 1.11-1.34) than in Norway (SMR 1.03; 95%CI 0.93-1.14), and higher in women (SMR 1.24; 95%CI 1.12-1.36) than in men (SMR 1.02; 95%CI 0.93-1.13). Among individuals with more than 10 years of follow-up, the estimates were similar to the overall cohort, absolute excess risk 0.1% (SMR 1.15; 95%CI 1.06-1.24). CONCLUSION The excess risk of CRC death following adenoma removal is small. Optimal surveillance recommendations should be tested in randomised trials.
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Affiliation(s)
- Louise Emilsson
- a Institute of Health and Society , University of Oslo , Oslo , Norway.,b Vårdcentralen Värmlands Nysäter and Centre for Clinical Research , County Council of Värmland , Värmland , Sweden.,c Department of Epidemiology , Harvard T.H. Chan School of Public Health , Boston , MA , USA
| | - Magnus Løberg
- a Institute of Health and Society , University of Oslo , Oslo , Norway.,d Department of Transplantation Medicine and K. G. Jebsen Center for Colorectal Cancer Research , Oslo University Hospital , Oslo , Norway
| | - Michael Bretthauer
- a Institute of Health and Society , University of Oslo , Oslo , Norway.,c Department of Epidemiology , Harvard T.H. Chan School of Public Health , Boston , MA , USA.,d Department of Transplantation Medicine and K. G. Jebsen Center for Colorectal Cancer Research , Oslo University Hospital , Oslo , Norway
| | - Øyvind Holme
- a Institute of Health and Society , University of Oslo , Oslo , Norway.,e Department of Medicine , Sørlandet Hospital , Kristiansand , Norway
| | - Katja Fall
- c Department of Epidemiology , Harvard T.H. Chan School of Public Health , Boston , MA , USA.,f Clinical Epidemiology and Biostatistics, School of Medical Sciences , Örebro University , Örebro , Sweden.,g Department of Medical Epidemiology and Biostatistics , Karolinska Institutet , Stockholm , Sweden
| | - Henriette C Jodal
- a Institute of Health and Society , University of Oslo , Oslo , Norway
| | - Hans-Olov Adami
- a Institute of Health and Society , University of Oslo , Oslo , Norway.,c Department of Epidemiology , Harvard T.H. Chan School of Public Health , Boston , MA , USA.,g Department of Medical Epidemiology and Biostatistics , Karolinska Institutet , Stockholm , Sweden
| | - Mette Kalager
- a Institute of Health and Society , University of Oslo , Oslo , Norway.,c Department of Epidemiology , Harvard T.H. Chan School of Public Health , Boston , MA , USA
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Mangas-Sanjuan C, Zapater P, Cubiella J, Murcia Ó, Bujanda L, Hernández V, Martínez-Ares D, Pellisé M, Seoane A, Lanas Á, Nicolás-Pérez D, Herreros-de-Tejada A, Chaparro M, Cacho G, Fernández-Díez S, Marín-Gabriel JC, Quintero E, Castells A, Jover R. Importance of endoscopist quality metrics for findings at surveillance colonoscopy: The detection-surveillance paradox. United European Gastroenterol J 2017; 6:622-629. [PMID: 29881618 DOI: 10.1177/2050640617745458] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 11/06/2017] [Indexed: 12/25/2022] Open
Abstract
Background Guidelines recommend surveillance colonoscopies based exclusively on findings at baseline colonoscopy. This recommendation leads to the paradox that the higher the baseline colonoscopy quality, the more surveillance colonoscopies will be indicated according to current guidelines. Objective The aim of this study was to evaluate the effect on follow-up findings of different quality metrics of the endoscopist performing the baseline colonoscopy. Methods This retrospective cohort study included individuals with advanced adenomas at baseline colonoscopy. Adenoma detection rate (ADR) and adenomas per colonoscopy rate (APCR) were determined for 44 endoscopists. Surveillance colonoscopies were checked after systematic tracking. Results A total of 574 individuals were diagnosed with advanced adenomas, of whom 270 received a surveillance colonoscopy. Patients whose baseline colonoscopy endoscopist had an ADR lower than the median of 33.8% had significantly higher rates of advanced neoplasia at follow-up (13.1% vs 4.0%; p = 0.001). On univariate analysis, high-risk advanced adenomas at baseline (HR 0.43; 95% CI 0.19-0.97) and ADR (HR 0.94; 95% CI 0.89-0.99) showed a significant relationship with advanced neoplasia at surveillance. In a multivariate Cox model, the ADR of the endoscopist who performed the baseline colonoscopy was the only independent predictor of risk for developing advanced neoplasia at follow-up (HR 0.94; 95% CI 0.89-0.99). Conclusions Our results suggest that the risk of identifying advanced adenomas at follow-up is closely related to the quality metrics of the endoscopist who performs the baseline colonoscopy.
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Affiliation(s)
- Carolina Mangas-Sanjuan
- 1Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Alicante, Spain
| | - Pedro Zapater
- 2Unit of Clinical Pharmacology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Alicante, Spain
| | - Joaquín Cubiella
- Department of Gastroenterology, Complexo Hospitalario de Ourense, Instituto de Investigación Biomédica Ourense, Pontevedra y Vigo, Ourense, Spain
| | - Óscar Murcia
- 1Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Alicante, Spain
| | - Luis Bujanda
- Department of Gastroenterology, Hospital Donostia/Instituto Biodonostia, CIBERehd, Universidad del País Vasco, San Sebastián, Spain
| | - Vicent Hernández
- Department of Gastroenterology, Grupo de Investigación en Patología Digestiva, Instituto de Investigación Biomédica, Xerencia de Xestión Integrada de Vigo, Vigo, Spain
| | - David Martínez-Ares
- Department of Gastroenterology, Grupo de Investigación en Patología Digestiva, Instituto de Investigación Biomédica, Xerencia de Xestión Integrada de Vigo, Vigo, Spain
| | - María Pellisé
- Department of Gastroenterology, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Agustín Seoane
- Department of Gastroenterology, Parc de Salut Mar, Hospital del Mar, Barcelona, Spain
| | - Ángel Lanas
- Department of Gastroenterology, Hospital Clínico Lozano Blesa, Universidad de Zaragoza, CIBERehd, Zaragoza, Spain
| | - David Nicolás-Pérez
- Department of Gastroenterology, Hospital Universitario de Canarias, Instituto Universitario de Tecnologías Biomédicas y Centro de Investigación Biomédica de Canarias (CIBICan), Departamento de Medicina Interna, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
| | | | - María Chaparro
- Department of Gastroenterology, Hospital de la Princesa, Madrid, Spain
| | - Guillermo Cacho
- Department of Gastroenterology, Fundación Hospital de Alcorcón, Madrid, Spain
| | | | | | - Enrique Quintero
- Department of Gastroenterology, Hospital Universitario de Canarias, Instituto Universitario de Tecnologías Biomédicas y Centro de Investigación Biomédica de Canarias (CIBICan), Departamento de Medicina Interna, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
| | - Antoni Castells
- Department of Gastroenterology, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Rodrigo Jover
- 1Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Alicante, Spain
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Cerdán Santacruz C, Esteban López-Jamar JM, Sánchez López E, Cerdán Miguel J. Contribution of intraoperative colonoscopy in a colorectal surgery unit . Scand J Gastroenterol 2017; 52:1292-1297. [PMID: 28768440 DOI: 10.1080/00365521.2017.1362465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Intraoperative colonoscopy (IC) is routinely used in colorectal surgery procedures, both oncologic and benign ones. Despite its extensive use there is a lack of literature addressing this important issue. The aims of this paper are to determine the contributions of this tool, especially considering changes in attitude from preoperative designed intervention. MATERIALS AND METHODS This study is a retrospective analysis of a prospective maintained database. Patients who underwent colorectal resection and IC during a four-year period (2009-2012). The indications for performing IC in our unit are: Incomplete preoperative colonoscopy, confirm the exact location of the tumor and polypectomy of any lesion distant from the planned resection segment. RESULTS The success rate in performing IC is 100%, including 42% of them made trans-anastomotic. No postoperative complications that were attributable to the endoscopy were detected. Routine practice led to a change in attitude in 5% of the patients analyzed; 2% of the global sample corresponded to synchronous tumors finding. Of those patients in whom polypectomies where achieved during the procedure a 14.3% of potentially malignant lesions were resected. CONCLUSIONS Intraoperative colonoscopy is a useful and safe tool that in view of these results should be taken into account at any colorectal surgery unit. Trans-anastomotic techniques do not raise morbidity.
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Affiliation(s)
| | | | - Esther Sánchez López
- c Department of General Surgery , Hospital General de Almansa , Almansa , Albacete , Spain
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O'Connell B, Hafiz N, Crockett S. The Serrated Polyp Pathway: Is It Time to Alter Surveillance Guidelines? Curr Gastroenterol Rep 2017; 19:52. [PMID: 28853002 DOI: 10.1007/s11894-017-0588-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW In this manuscript, we review current surveillance guidelines for serrated polyps (SPs) and discuss how recent studies inform the selection of appropriate surveillance intervals for patients with SPs. RECENT FINDINGS Large and/or proximal SPs, particularly sessile serrated polyps (SSPs), are associated with increased risk of both synchronous and metachronous neoplasia, including advanced adenomas and colorectal cancer (CRC). Persons harboring multiple SSPs or dysplastic SSPs are at the highest risk. Moreover, a high percentage of large and/or proximal SPs are reclassified as SSPs when read by trained gastrointestinal pathologists, even if they were originally reported as hyperplastic polyps. These findings support the adoption of surveillance guidelines that prescribe closer surveillance of large and/or proximal SPs, regardless of subtype. SSPs remain a challenge to reliably identify, resect, and diagnose via histology. The increased risk of future neoplasia in patients with SSPs is likely driven by a combination of underdetection, inadequate removal, misclassification, and biology. Until further evidence emerges, we support guidelines that recommend close surveillance of patients with a history of large and/or proximal SPs and SSPs specifically in order to mitigate the threat of interval CRC.
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Affiliation(s)
- Brendon O'Connell
- Department of Medicine, University of North Carolina School of Medicine, CB 7080, Chapel Hill, NC, 27599, USA
| | - Nazar Hafiz
- Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Seth Crockett
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
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71
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The Diagnostic Yield of Colonoscopy Stratified by Indications. Gastroenterol Res Pract 2017; 2017:4910143. [PMID: 28819357 PMCID: PMC5551535 DOI: 10.1155/2017/4910143] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 06/08/2017] [Accepted: 06/18/2017] [Indexed: 01/13/2023] Open
Abstract
Introduction Danish centers reserve longer time for screening colonoscopies and allocate the most experienced endoscopists to these cases. The objective of this study is to determine the diagnostic yield in colonoscopies for different indications to improve planning of colonoscopy activity and allocation of the highly skilled endoscopists. Methods Nine hundred and ninety-nine randomly collected patients from a prospectively maintained database were grouped in defined referral indication groups. Five groups were compared in respect of the detection rate of adenomas and cancers. Results Two hundred and eighty-nine of 1098 colonoscopies in 999 patients showed significant neoplastic findings, resulting in 591 adenoma resections. Eighty-five percent were treated with a snare resection, and 15% with endoscopic mucosa resection (EMR). Positive findings in the indication groups were (1) symptoms, 25%; (2) positive screening, 17%; (3) previous resection of adenomas, 45%; (4) previous resection of colorectal cancer, 15%; and (5) surveillance of patients with high-risk family history of cancer, 35%. Conclusion The majority of adenomas found during colonoscopy can be treated with simple techniques. If individualized time slots are considered, the adenoma follow-up colonoscopies are likely to be the most time-consuming group with more than twice the number of adenomas detected as compared to other indications.
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Abstract
OPINION STATEMENT Colonoscopy is one of the most commonly performed endoscopic procedures. It is the gold standard examination for work-up of colonic symptoms, for follow-up of positive colorectal cancer screening tests and for detection and removal of neoplastic polyps. Colonoscopy is a complex and invasive procedure with a potential not only for colorectal cancer prevention, but also for serious complications. Numerous factors may affect the balance of benefit versus harm of colonoscopy, including the performance of the endoscopist. These factors are commonly called quality indicators. As an increasing number of countries are recommending the general population to undergo colorectal cancer screening, the quality of colonoscopy should be considered a public health concern. Key quality indicators have been identified, and several professional organizations have issued recommendation statements to promote high-quality colonoscopy. To achieve high quality, these key quality indicators must be monitored, results must be analysed, and measures must be undertaken to correct substandard performance. High-quality training in colonoscopy and polypectomy should be a quality assurance priority.
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Winawer SJ, Zauber AG. Can post-polypectomy surveillance be less intensive? Lancet Oncol 2017; 18:707-709. [PMID: 28457710 DOI: 10.1016/s1470-2045(17)30305-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 03/30/2017] [Indexed: 12/24/2022]
Affiliation(s)
- Sidney J Winawer
- Gastroenterology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York 10065-6007, NY, USA.
| | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York 10065-6007, NY, USA
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Estimating the Effect of Targeted Screening Strategies: An Application to Colonoscopy and Colorectal Cancer. Epidemiology 2017; 28:470-478. [PMID: 28368944 PMCID: PMC5453827 DOI: 10.1097/ede.0000000000000668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Supplemental Digital Content is available in the text. Screening behavior depends on previous screening history and family members’ behaviors, which can act as both confounders and intermediate variables on a causal pathway from screening to disease risk. Conventional analyses that adjust for these variables can lead to incorrect inferences about the causal effect of screening if high-risk individuals are more likely to be screened. Analyzing the data in a manner that treats screening as randomized conditional on covariates allows causal parameters to be estimated; inverse probability weighting based on propensity of exposure scores is one such method considered here. I simulated family data under plausible models for the underlying disease process and for screening behavior to assess the performance of alternative methods of analysis and whether a targeted screening approach based on individuals’ risk factors would lead to a greater reduction in cancer incidence in the population than a uniform screening policy. Simulation results indicate that there can be a substantial underestimation of the effect of screening on subsequent cancer risk when using conventional analysis approaches, which is avoided by using inverse probability weighting. A large case–control study of colonoscopy and colorectal cancer from Germany shows a strong protective effect of screening, but inverse probability weighting makes this effect even stronger. Targeted screening approaches based on either fixed risk factors or family history yield somewhat greater reductions in cancer incidence with fewer screens needed to prevent one cancer than population-wide approaches, but the differences may not be large enough to justify the additional effort required. See video abstract at, http://links.lww.com/EDE/B207.
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Jover R, Dekker E. Surveillance after colorectal polyp removal. Best Pract Res Clin Gastroenterol 2016; 30:937-948. [PMID: 27938788 DOI: 10.1016/j.bpg.2016.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 10/13/2016] [Indexed: 02/07/2023]
Abstract
Surveillance colonoscopy is aimed to reduce CRC incidence and mortality by removing adenomas and detecting CRC in early stage. However, colonoscopy is an invasive and expensive procedure and surveillance colonoscopy should be targeted at those who are most likely to benefit at the minimum frequency required to protect for cancer. Surveillance recommendations are based on guidelines, but the recommendations in those guidelines are based on moderate to low quality evidence and adherence to these guidelines is poor. As surveillance colonoscopy is one of the main indications for colonoscopy and surveillance colonoscopies are filling colonoscopy lists, the current surveillance practice results in spending lots of money and capacity in a suboptimal way. Randomized controlled trials to compare surveillance intervals are not available. However, current evidence based on several case-control and cohort studies suggests there is no need for surveillance in patients with low-risk adenomas, i.e. 1-2 adenomas smaller than 10 mm. Patients with 3 or more adenomas or any adenoma larger than 10 mm seem to be the ones at real risk for metachronous adenomas or cancer. In those patients, surveillance colonoscopy is indicated at 3 years after baseline until ongoing studies will confirm the safety of enlarging this interval. Randomized controlled trials and experimental research are important in order to provide the necessary scientific evidence for the optimization of follow-up strategies for patients with adenomas and serrated polyps.
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Affiliation(s)
- Rodrigo Jover
- Unidad de Gastroenterología, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria ISABIAL, C/ Pintor Baeza 12, 03010 Alicante, Spain.
| | - Evelien Dekker
- Department of Gastroenterology & Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Holme Ø, Løberg M. Methodological considerations for surveillance in GI practice. Best Pract Res Clin Gastroenterol 2016; 30:867-878. [PMID: 27938782 DOI: 10.1016/j.bpg.2016.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 10/20/2016] [Accepted: 10/21/2016] [Indexed: 01/31/2023]
Abstract
Surveillance is recommended for various GI cancers, and substantial resources are invested. However, little is known about the effect of surveillance, neither for good, nor for bad. Most evidence stems from observational studies, but observational studies of surveillance can be subject to various biases that may severely influence the results. In this chapter we discuss challenges related to various research questions, study designs, choice of endpoints, and how to deal with different forms of bias. We hope this chapter will be helpful for researchers when performing high-quality studies of surveillance, and to enable physicians and policy-makers to understand the possibilities and limitations of current evidence.
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Affiliation(s)
- Øyvind Holme
- Sørlandet Hospital Kristiansand, Department of Medicine, Kristiansand, Norway; University of Oslo, Institute of Health and Society, Department of Health Management and Health Economics, Oslo, Norway.
| | - Magnus Løberg
- University of Oslo, Institute of Health and Society, Department of Health Management and Health Economics, Oslo, Norway; Oslo University Hospital, Department of Transplantation Medicine and K. G. Jebsen Center for Colorectal Cancer Research, Oslo, Norway
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