Long-term colorectal-cancer incidence and mortality after lower endoscopy

Efficacy, tolerability, and safety of oral sulfate tablet versus 2 L-polyethylene glycol/ascorbate for bowel preparation in older patients: prospective, multicenter, investigator single-blinded, randomized study

BACKGROUND

We compared the efficacy, tolerability, and safety of oral sulfate tablets (OST, which contains simethicone) and 2 L-polyethylene glycol/ascorbate (2 L-PEG/Asc) with a split-dosing regimen in older individuals aged ≥ 70 years who underwent scheduled colonoscopy.

METHODS

This prospective, randomized, investigator-blinded, multicenter study was conducted between June 2022 and October 2023. Participants aged ≥ 70 years were randomized at a ratio of 1:1 to the OST or 2 L-PEG/Asc groups.

RESULTS

In total, 254 patients were evaluated using a modified full analysis set. Successful overall bowel preparation was excellent and similar between the OST and 2 L-PEG/Asc groups for the Boston Bowel Preparation Scale (BBPS) (96.5% vs. 96.6%) and Harefield Cleansing Scale (HCS) (96.5% vs. 97.4%). The overall high-quality preparation rate was higher in the OST group than in the 2 L-PEG/Asc group (BBPS: 55.7% vs. 28.4%, P < 0.001; HCS: 66.1% vs. 38.8%, P < 0.001). The overall adenoma detection rate (54.8% vs. 35.3, P = 0.003) was superior in the OST group compared to the 2 L-PEG/Asc group. Tolerability scores, including overall satisfaction, were generally higher in the OST group than in the 2 L-PEG/Asc group. The incidence of major solicited adverse events was comparable between the two groups (55.7% vs. 68.1, P = 0.051), and there were no clinically significant changes in the serum laboratory profiles on the day of or 7 days after colonoscopy.

CONCLUSIONS

OST is an effective and safe low-volume agent for colonoscopy, with better tolerance than 2 L-PEG/Asc, in older individuals aged ≥ 70 years.

One-day versus three-day low-residue diet bowel preparation regimens before colonoscopy: a meta-analysis of randomized controlled trials

BACKGROUND AND AIM

Although studies have shown that the quality of bowel preparation with low-residue diet (LRD) is as effective as that of clear fluid diet (CLD), there is currently no consensus on how long an LRD should last. The aim of this study was to compare a 1-day versus 3-day LRD on bowel preparation before colonoscopy.

METHODS

A systematic review search was conducted in MEDLINE/PubMed, EMBASE, Web of Science, and Cochrane database from inception to April 2023. We identified randomized controlled trials (RCTs) that compared 1-day with 3-day LRD bowel cleansing regiments for patients undergoing colonoscopy. The rate of adequate bowel preparation, polyp detection rate, adenoma detection rate, tolerability, willingness to repeat preparation, and adverse events were estimated using odds ratios (OR) and 95% confidence interval (CI). We also performed meta-analysis to identify risk factors and predictors of inadequate preparation.

RESULTS

Four studies published between 2019 and 2023 with 1927 participants were included. The present meta-analysis suggested that 1-day LRD was comparable with 3-day LRD for adequate bowel preparation (OR 0.89; 95% CI, 0.65-1.21; P = 0.45; I2 = 0%; P = 0.52). The polyp detection rate (OR 0.94; 95% CI, 0.77-1.14; P = 0.52; I2 = 23%; P = 0.27) and adenoma detection rate (OR 0.87; 95% CI, 0.71-1.08; P = 0.21; I2 = 0%; P = 0.52) were similar between the groups. There were significantly higher odds of tolerability in patients consuming 1-day LRD compared with 3-day LRD (OR 1.64; 95% CI, 1.13-2.39; P < 0.01; I2 = 47%; P = 0.15). In addition, constipation was identified as the independent predictor of inadequate preparation (OR 1.98; 95% CI, 1.27-3.11; P < 0.01; I2 = 0%; P = 0.46).

CONCLUSION

The present study demonstrated that a 1-day LRD was as effective as a 3-day CLD in the quality of bowel preparation before colonoscopy and significantly improved tolerability of patients. In addition, constipation is an independent risk factor of poor bowel preparation, and the duration of LRD in patients with constipation still needs further clinical trials.

Influence of Colorectal Cancer Risk Factors on Predictive Value of a Positive Multitarget Stool DNA Test

GOALS

We analyzed if the predictive value of multitarget stool-based DNA (mt-sDNA) varied when patients had pre-existing known colorectal cancer (CRC) risk factors.

BACKGROUND

mt-sDNA test is approved for CRC screening in average-risk patients. Whether patients with a personal history of adenomatous colon polyps or a family history of CRC (CRC risk factors) benefit from mt-sDNA testing is unknown.

STUDY

We reviewed charts for all positive mt-sDNA referrals between 2017 and 2021. Diagnostic colonoscopy adherence rates were calculated. In those who had colonoscopy, we compared detection rates for any colorectal neoplasia (CRN), multiple (3 or more) adenomas, sessile serrated polyps (SSP), advanced CRN, and CRC between patients with and without known CRC risk factors.

RESULTS

Of 1297 referrals for positive mt-sDNA, 1176 (91%) completed a diagnostic colonoscopy. The absence of neoplasia was noted in 27% of colonoscopy exams. When neoplasia was identified, findings were as follows: any CRN (73%), multiple adenomas (34%), SSP (23%), advanced CRN (33%), and CRC (2.5%). One or more CRC risk factors were present in 229 (19%) of cases. In the CRC risk factor subgroup, patients having a prior history of adenomatous polyps or a family history of CRC were no more likely to have any CRN, multiple adenomas, SSP, advanced CRN, or CRC compared to average-risk patients when mt-sDNA was positive.

CONCLUSIONS

In this real-world analysis of positive mt-sDNA referrals, adherence to subsequent diagnostic colonoscopy recommendations was high. The presence of pre-existing CRC risk factors did not affect the positive predictive value of mt-sDNA.

Colon Polyp Surveillance: Separating the Wheat From the Chaff

One goal of colorectal cancer (CRC) screening is to prevent CRC incidence by removing precancerous colonic polyps, which are detected in up to 50% of screening examinations. Yet, the lifetime risk of CRC is 3.9%-4.3%, so it is clear that most of these individuals with polyps would not develop CRC in their lifetime. It is, therefore, a challenge to determine which individuals with polyps will benefit from follow-up, and at what intervals. There is some evidence that individuals with advanced polyps, based on size and histology, benefit from intensive surveillance. However, a large proportion of individuals will have small polyps without advanced histologic features (ie, "nonadvanced"), where the benefits of surveillance are uncertain and controversial. Demand for surveillance will further increase as more polyps are detected due to increased screening uptake, recent United States recommendations to expand screening to younger individuals, and emergence of polyp detection technology. We review the current understanding and clinical implications of the natural history, biology, and outcomes associated with various categories of colon polyps based on size, histology, and number. Our aims are to highlight key knowledge gaps, specifically focusing on certain categories of polyps that may not be associated with future CRC risk, and to provide insights to inform research priorities and potential management strategies. Optimization of CRC prevention programs based on updated knowledge about the future risks associated with various colon polyps is essential to ensure cost-effective screening and surveillance, wise use of resources, and inform efforts to personalize recommendations.

Effects of joint screening for prostate, lung, colorectal, and ovarian cancer - results from a controlled trial

Background

Although screening is widely used to reduce cancer burden, untargeted cancers are frequently missed after single cancer screening. Joint cancer screening is presumed as a more effective strategy to reduce overall cancer burden.

Methods

Gender-specific screening effects on PLCO cancer incidence, PLCO cancer mortality, all-neoplasms mortality and all-cause mortality were evaluated, and meta-analyses based on gender-specific screening effects were conducted to achieve the pooled effects. The cut-off value of time-dependent receiver-operating-characteristic curve of 10-year combined PLCO cancer risk was used to reclassify participants into low- and high-risk subgroups. Further analyses were conducted to investigate screening effects stratified by risk groups and screening compliance.

Results

After a median follow-up of 10.48 years for incidence and 16.85 years for mortality, a total of 5,506 PLCO cancer cases, 1,845 PLCO cancer deaths, 3,970 all-neoplasms deaths, and 14,221 all-cause deaths were documented in the screening arm, while 6,261, 2,417, 5,091, and 18,516 outcome-specific events in the control arm. Joint cancer screening did not significantly reduce PLCO cancer incidence, but significantly reduced male-specific PLCO cancer mortality (hazard ratio and 95% confidence intervals [HR(95%CIs)]: 0.88(0.82, 0.95)) and pooled mortality [0.89(0.84, 0.95)]. More importantly, joint cancer screening significantly reduced both gender-specific all-neoplasm mortality [0.91(0.86, 0.96) for males, 0.91(0.85, 0.98) for females, and 0.91(0.87, 0.95) for meta-analyses] and all-cause mortality [0.90(0.88, 0.93) for male, 0.88(0.85, 0.92) for female, and 0.89(0.87, 0.91) for meta-analyses]. Further analyses showed decreased risks of all-neoplasm mortality was observed with good compliance [0.72(0.67, 0.77) for male and 0.72(0.65, 0.80) for female] and increased risks with poor compliance [1.61(1.40, 1.85) for male and 1.30(1.13, 1.40) for female].

Conclusion

Joint cancer screening could be recommended as a potentially strategy to reduce the overall cancer burden. More compliance, more benefits. However, organizing a joint cancer screening not only requires more ingenious design, but also needs more attentions to the potential harms.

Trial registration

NCT00002540 (Prostate), NCT01696968 (Lung), NCT01696981 (Colorectal), NCT01696994 (Ovarian).

Germline genetic regulation of the colorectal tumor immune microenvironment

OBJECTIVE

To evaluate the contribution of germline genetics to regulating the briskness and diversity of T cell responses in CRC, we conducted a genome-wide association study to examine the associations between germline genetic variation and quantitative measures of T cell landscapes in 2,876 colorectal tumors from participants in the Molecular Epidemiology of Colorectal Cancer Study (MECC).

METHODS

Germline DNA samples were genotyped and imputed using genome-wide arrays. Tumor DNA samples were extracted from paraffin blocks, and T cell receptor clonality and abundance were quantified by immunoSEQ (Adaptive Biotechnologies, Seattle, WA). Tumor infiltrating lymphocytes per high powered field (TILs/hpf) were scored by a gastrointestinal pathologist. Regression models were used to evaluate the associations between each variant and the three T-cell features, adjusting for sex, age, genotyping platform, and global ancestry. Three independent datasets were used for replication.

RESULTS

We identified a SNP (rs4918567) near RBM20 associated with clonality at a genome-wide significant threshold of 5 × 10- 8, with a consistent direction of association in both discovery and replication datasets. Expression quantitative trait (eQTL) analyses and in silico functional annotation for these loci provided insights into potential functional roles, including a statistically significant eQTL between the T allele at rs4918567 and higher expression of ADRA2A (P = 0.012) in healthy colon mucosa.

CONCLUSIONS

Our study suggests that germline genetic variation is associated with the quantity and diversity of adaptive immune responses in CRC. Further studies are warranted to replicate these findings in additional samples and to investigate functional genomic mechanisms.

Detailed Superiority of the CAD EYE Artificial Intelligence System over Endoscopists for Lesion Detection and Characterization Using Unique Movie Sets

Objectives

Detailed superiority of CAD EYE (Fujifilm, Tokyo, Japan), an artificial intelligence for polyp detection/diagnosis, compared to endoscopists is not well examined. We examined endoscopist's ability using movie sets of colorectal lesions which were detected and diagnosed by CAD EYE accurately.

Methods

Consecutive lesions of ≤10 mm were examined live by CAD EYE from March-June 2022 in our institution. Short unique movie sets of each lesion with and without CAD EYE were recorded simultaneously using two recorders for detection under white light imaging (WLI) and linked color imaging (LCI) and diagnosis under blue laser/light imaging (BLI). Excluding inappropriate movies, 100 lesions detected and diagnosed with CAD EYE accurately were evaluated. Movies without CAD EYE were evaluated first by three trainees and three experts. Subsequently, movies with CAD EYE were examined. The rates of accurate detection and diagnosis were evaluated for both movie sets.

Results

Among 100 lesions (mean size: 4.7±2.6 mm; 67 neoplastic/33 hyperplastic), mean accurate detection rates of movies without or with CAD EYE were 78.7%/96.7% under WLI (p<0.01) and 91.3%/97.3% under LCI (p<0.01) for trainees and 85.3%/99.0% under WLI (p<0.01) and 92.6%/99.3% under LCI (p<0.01) for experts. Mean accurate diagnosis rates of movies without or with CAD EYE for BLI were 85.3%/100% for trainees (p<0.01) and 92.3%/100% for experts (p<0.01), respectively. The significant risk factors of not-detected lesions for trainees were right-sided, hyperplastic, not-reddish, in the corner, halation, and inadequate bowel preparation.

Conclusions

Unique movie sets with and without CAD EYE could suggest it's efficacy for lesion detection/diagnosis.

Early-Onset Gastrointestinal Malignancies: An Investigation into a Rising Concern

There is growing recognition of early-onset gastrointestinal (GI) malignancies in young adults < 50 years of age. While much of the literature has emphasized colorectal cancer, these also include esophageal, gastric, liver, pancreatic, and biliary tract malignancies. Various factors, including lifestyle, hereditary, and environmental elements, have been proposed to explain the rising incidence of GI malignancies in the younger population. This review aims to provide an overview of the recent literature, including global trends and information regarding genetic and environmental risk factors.

Analysis of the Characteristics of Coexisting Lesions in Colorectal Cancer Patients in an International Study: A Subgroup Analysis of the ATLAS Trial

INTRODUCTION

We investigated coexisting lesion types in patients with invasive colorectal cancer (CRC) in a multinational study for comprehending the adenoma-carcinoma and serrated pathway about the development of CRC.

METHODS

We retrospectively reviewed 3,050 patients enrolled in the international randomized controlled trial (ATLAS study) to evaluate the colorectal polyp detection performance of image-enhanced endoscopy in 11 institutions in four Asian countries/regions. In the current study, as a subgroup analysis of the ATLAS study, 92 CRC patients were extracted and compared to 2,958 patients without CRC to examine the effects of age, sex, and coexisting lesion types (high-grade adenoma [HGA], low-grade adenoma with villous component [LGAV], 10 adenomas, adenoma ≥10 mm, sessile serrated lesions [SSLs], and SSLs with dysplasia [SSLD]). Additional analyses of coexisting lesion types were performed according to sex and location of CRC (right- or left-sided).

RESULTS

A multivariate analysis showed that HGA (odds ratio [95% confidence interval] 4.29 [2.16-8.18]; p < 0.01), LGAV (3.02 [1.16-7.83], p = 0.02), and age (1.04 [1.01-1.06], p = 0.01) were independently associated with CRC. According to sex, the coexisting lesion types significantly associated with CRC were LGAV (5.58 [1.94-16.0], p < 0.01) and HGA (4.46 [1.95-10.20], p < 0.01) in males and HGA (4.82 [1.47-15.80], p < 0.01) in females. Regarding the location of CRC, SSLD (21.9 [1.31-365.0], p = 0.03) was significant for right-sided CRC, and HGA (5.22 [2.39-11.4], p < 0.01) and LGAV (3.46 [1.13-10.6], p = 0.02) were significant for left-sided CRC.

CONCLUSIONS

The significant coexisting lesions in CRC differed according to sex and location. These findings may contribute to comprehending the pathogenesis of CRC.

Colorectal Cancer: Epidemiology, Risk Factors, and Prevention

Colorectal cancer (CRC) is the third most common cancer and the second most common cause of cancer mortality worldwide. There are disparities in the epidemiology of CRC across different populations, most probably due to differences in exposure to lifestyle and environmental factors related to CRC. Prevention is the most effective method for controlling CRC. Primary prevention includes determining and avoiding modifiable risk factors (e.g., alcohol consumption, smoking, and dietary factors) as well as increasing protective factors (e.g., physical activity, aspirin). Further studies, especially randomized, controlled trials, are needed to clarify the association between CRC incidence and exposure to different risk factors or protective factors. Detection and removal of precancerous colorectal lesions is also an effective strategy for controlling CRC. Multiple factors, both at the individual and community levels (e.g., patient preferences, availability of screening modalities, costs, benefits, and adverse events), should be taken into account in designing and implementing CRC screening programs. Health policymakers should consider the best decision in identifying the starting age and selection of the most effective screening strategies for the target population. This review aims to present updated evidence on the epidemiology, risk factors, and prevention of CRC.

In vivo pilot study into superficial microcirculatory characteristics of colorectal adenomas using novel high-resolution magnifying endoscopy with blue laser imaging

BACKGROUND

No studies have yet been conducted on changes in microcirculatory hemodynamics of colorectal adenomas in vivo under endoscopy. The microcirculation of the colorectal adenoma could be observed in vivo by a novel high-resolution magnification endoscopy with blue laser imaging (BLI), thus providing a new insight into the microcirculation of early colon tumors.

AIM

To observe the superficial microcirculation of colorectal adenomas using the novel magnifying colonoscope with BLI and quantitatively analyzed the changes in hemodynamic parameters.

METHODS

From October 2019 to January 2020, 11 patients were screened for colon adenomas with the novel high-resolution magnification endoscope with BLI. Video images were recorded and processed with Adobe Premiere, Adobe Photoshop and Image-pro Plus software. Four microcirculation parameters: Microcirculation vessel density (MVD), mean vessel width (MVW) with width standard deviation (WSD), and blood flow velocity (BFV), were calculated for adenomas and the surrounding normal mucosa.

RESULTS

A total of 16 adenomas were identified. Compared with the normal surrounding mucosa, the superficial vessel density in the adenomas was decreased (MVD: 0.95 ± 0.18 vs 1.17 ± 0.28 μm/μm2, P < 0.05). MVW (5.11 ± 1.19 vs 4.16 ± 0.76 μm, P < 0.05) and WSD (11.94 ± 3.44 vs 9.04 ± 3.74, P < 0.05) were both increased. BFV slowed in the adenomas (709.74 ± 213.28 vs 1256.51 ± 383.31 μm/s, P < 0.05).

CONCLUSION

The novel high-resolution magnification endoscope with BLI can be used for in vivo study of adenoma superficial microcirculation. Superficial vessel density was decreased, more irregular, with slower blood flow.

Should we perform sigmoidoscopy for colorectal cancer screening in people under 45 years?

BACKGROUND

The strategy for preventing colorectal cancer is screening by colonoscopy, which offers a direct way for detection and removal of adenomatous polyps (APs). American College of Gastroenterology guidelines recommend that people aged ≥ 45 years should undergo colonoscopy; however, how to deal with people aged ≤ 45 years is still unknown.

AIM

To compare the prevalence of APs and high-grade neoplasia between the left and right colon in patients ≤ 45 years.

METHODS

A retrospective observational study was conducted at a single tertiary III hospital in China. This study included patients aged 18-45 years with undergoing initial colonoscopy dissection and pathological diagnosis AP or high-grade neoplasia between February 2014 and January 2021. The number of APs in the entire colon while screening and post-polypectomy surveillance in following 1-3 years were evaluated.

RESULTS

A total of 3053 cases were included. The prevalence of APs in the left and right colon was 55.0% and 41.6%, respectively (OR 1.7, 95%CI 1.6-2.4; P < 0.05). For APs with high-grade neoplasia, the prevalence was 2.7% and 0.9%, respectively (OR 3.0, 95%CI 2.0-4.6; P < 0.05). Therefore, the prevalence of APs and high-grade neoplasia in the left colon was significantly higher than in the right colon in patients aged ≤ 45 years. There were 327 patients who voluntarily participated in post-polypectomy surveillance in following 1-3 years, and APs were found in 216 cases (66.1%); 170 cases had 1-3 polyps (52.0%) and 46 cases had > 3 polyps (14.1%; OR 0.3, 95%CI 0.1-0.6; P < 0.05).

CONCLUSION

This study suggests that flexible sigmoidoscopy would be an optimal approach for initial screening in people aged ≤ 45 years and would be a more cost-effective and safe strategy.

Colorectal cancer screening: A review of current knowledge and progress in research

Colorectal cancer (CRC) is one of the most prevalent malignancies worldwide, being the third most commonly diagnosed malignancy and the second leading cause of cancer-related deaths globally. Despite the progress in screening, early diagnosis, and treatment, approximately 20%-25% of CRC patients still present with metastatic disease at the time of their initial diagnosis. Furthermore, the burden of disease is still expected to increase, especially in individuals younger than 50 years old, among whom early-onset CRC incidence has been increasing. Screening and early detection are pivotal to improve CRC-related outcomes. It is well established that CRC screening not only reduces incidence, but also decreases deaths from CRC. Diverse screening strategies have proven effective in decreasing both CRC incidence and mortality, though variations in efficacy have been reported across the literature. However, uncertainties persist regarding the optimal screening method, age intervals and periodicity. Moreover, adherence to CRC screening remains globally low. In recent years, emerging technologies, notably artificial intelligence, and non-invasive biomarkers, have been developed to overcome these barriers. However, controversy exists over the actual impact of some of the new discoveries on CRC-related outcomes and how to effectively integrate them into daily practice. In this review, we aim to cover the current evidence surrounding CRC screening. We will further critically assess novel approaches under investigation, in an effort to differentiate promising innovations from mere novelties.

Screening for Colorectal Cancer

Colorectal cancer (CRC) is the second leading cause of cancer death. Screening has been proven to reduce both cancer incidence and cancer-related mortality. Various screening tests are available, each with their own advantages and disadvantages and varying levels of evidence to support their use. Clinicians should offer CRC screening to average-risk persons aged 50 to 75 years; starting screening at age 45 years remains controversial. Screening may be beneficial in select persons aged 76 to 85 years, based on their overall health and screening history. Offering a choice of screening tests or sequentially offering an alternate test for those who do not complete screening can significantly increase participation.

Next-Generation Multitarget Stool DNA Test for Colorectal Cancer Screening

BACKGROUND

A next-generation multitarget stool DNA test, including assessments of DNA molecular markers and hemoglobin level, was developed to improve the performance of colorectal cancer screening, primarily with regard to specificity.

METHODS

In a prospective study, we evaluated a next-generation multitarget stool DNA test in asymptomatic adults 40 years of age or older who were undergoing screening colonoscopy. The primary outcomes were sensitivity of the test for colorectal cancer and specificity for advanced neoplasia (colorectal cancer or advanced precancerous lesions). Advanced precancerous lesions included one or more adenomas or sessile serrated lesions measuring at least 1 cm in the longest dimension, lesions with villous histologic features, and high-grade dysplasia. Secondary objectives included the quantification of sensitivity for advanced precancerous lesions and specificity for nonneoplastic findings or negative colonoscopy and comparison of sensitivities for colorectal cancer and advanced precancerous lesions between the multitarget stool DNA test and a commercially available fecal immunochemical test (FIT).

RESULTS

Of 20,176 participants, 98 had colorectal cancer, 2144 had advanced precancerous lesions, 6973 had nonadvanced adenomas, and 10,961 had nonneoplastic findings or negative colonoscopy. With the next-generation test, sensitivity for colorectal cancer was 93.9% (95% confidence interval [CI], 87.1 to 97.7), and specificity for advanced neoplasia was 90.6% (95% CI, 90.1 to 91.0). Sensitivity for advanced precancerous lesions was 43.4% (95% CI, 41.3 to 45.6), and specificity for nonneoplastic findings or negative colonoscopy was 92.7% (95% CI, 92.2 to 93.1). With the FIT, sensitivity was 67.3% (95% CI, 57.1 to 76.5) for colorectal cancer and 23.3% (95% CI, 21.5 to 25.2) for advanced precancerous lesions; specificity was 94.8% (95% CI, 94.4 to 95.1) for advanced neoplasia and 95.7% (95% CI, 95.3 to 96.1) for nonneoplastic findings or negative colonoscopy. As compared with FIT, the next-generation test had superior sensitivity for colorectal cancer (P<0.001) and for advanced precancerous lesions (P<0.001) but had lower specificity for advanced neoplasia (P<0.001). No adverse events occurred.

CONCLUSIONS

The next-generation multitarget stool DNA test showed higher sensitivity for colorectal cancer and advanced precancerous lesions than FIT but also showed lower specificity. (Funded by Exact Sciences; BLUE-C ClinicalTrials.gov number, NCT04144738.).

Genome-wide polygenic risk scores for colorectal cancer have implications for risk-based screening

BACKGROUND

Hereditary factors, including single genetic variants and family history, can be used for targeting colorectal cancer (CRC) screening, but limited data exist on the impact of polygenic risk scores (PRS) on risk-based CRC screening.

METHODS

Using longitudinal health and genomics data on 453,733 Finnish individuals including 8801 CRC cases, we estimated the impact of a genome-wide CRC PRS on CRC screening initiation age through population-calibrated incidence estimation over the life course in men and women.

RESULTS

Compared to the cumulative incidence of CRC at age 60 in Finland (the current age for starting screening in Finland), a comparable cumulative incidence was reached 5 and 11 years earlier in persons with high PRS (80-99% and >99%, respectively), while those with a low PRS (< 20%) reached comparable incidence 7 years later. The PRS was associated with increased risk of post-colonoscopy CRC after negative colonoscopy (hazard ratio 1.76 per PRS SD, 95% CI 1.54-2.01). Moreover, the PRS predicted colorectal adenoma incidence and improved incident CRC risk prediction over non-genetic risk factors.

CONCLUSIONS

Our findings demonstrate that a CRC PRS can be used for risk stratification of CRC, with further research needed to optimally integrate the PRS into risk-based screening.

Additional 30-Second Observation of the Right-Sided Colon for Missed Polyp Detection With Texture and Color Enhancement Imaging Compared with Narrow Band Imaging: A Randomized Trial

INTRODUCTION

The efficacy of texture and color enhancement imaging (TXI) in the novel light-emitting diode endoscopic system for polyp detection has not been examined. We aimed to evaluate the noninferiority of the additional 30-second (Add-30-s) observation of the right-sided colon (cecum/ascending colon) with TXI compared with narrow band imaging (NBI) for detecting missed polyps.

METHODS

We enrolled 381 patients ≥40 years old who underwent colonoscopy from September 2021 to June 2022 in 3 institutions and randomly assigned them to either the TXI or NBI groups. The right-sided colon was first observed with white light imaging in both groups. Second, after reinsertion from hepatic flexure to the cecum, the right-sided colon was observed with Add-30-s observation of either TXI or NBI. The primary endpoint was to examine the noninferiority of TXI to NBI using the mean number of adenomas and sessile serrated lesions per patient. The secondary ones were to examine adenoma detection rate, adenoma and sessile serrated lesions detection rates, and polyp detection rates in both groups.

RESULTS

The TXI and NBI groups consisted of 177 and 181 patients, respectively, and the noninferiorities of the mean number of adenomas and sessile serrated lesions per patients in the second observation were significant (TXI 0.29 [51/177] vs NBI 0.30 [54/181], P < 0.01). The change in adenoma detection rate, adenoma and sessile serrated lesions detection rate, and polyp detection rate for the right-sided colon between the TXI and NBI groups were not different (10.2%/10.5% [ P = 0.81], 13.0%/12.7% [ P = 0.71], and 15.3%/13.8% [ P = 0.71]), respectively.

DISCUSSION

Regarding Add-30-s observation of the right-sided colon, TXI was noninferior to NBI.

Up-to-Date Colonoscopy Use in Asian and Hispanic Subgroups in New York City, 2003-2016

BACKGROUND

Colorectal cancer screening uptake in the United States overall has increased, but racial/ethnic disparities persist and data on colonoscopy uptake by racial/ethnic subgroups are lacking. We sought to better characterize these trends and to identify predictors of colonoscopy uptake, particularly among Asian and Hispanic subgroups.

STUDY

We used data from the New York City Community Health Survey to generate estimates of up-to-date colonoscopy use in Asian and Hispanic subgroups across 6 time periods spanning 2003-2016. For each subgroup, we calculated the percent change in colonoscopy uptake over the study period and the difference in uptake compared to non-Hispanic Whites in 2015-2016. We also used multivariable logistic regression to identify predictors of colonoscopy uptake.

RESULTS

All racial and ethnic subgroups with reliable estimates saw a net increase in colonoscopy uptake between 2003 and 2016. In 2015-2016, compared with non-Hispanic Whites, Puerto Ricans, Dominicans, and Central/South Americans had higher colonoscopy uptake, whereas Chinese, Asian Indians, and Mexicans had lower uptake. On multivariable analysis, age, marital status, insurance status, primary care provider, receipt of flu vaccine, frequency of exercise, and smoking status were the most consistent predictors of colonoscopy uptake (≥4 time periods).

CONCLUSIONS

We found significant variation in colonoscopy uptake among Asian and Hispanic subgroups. We also identified numerous demographic, socioeconomic, and health-related predictors of colonoscopy uptake. These findings highlight the importance of examining health disparities through the lens of disaggregated racial/ethnic subgroups and have the potential to inform future public health interventions.

Colorectal cancer screening uptake and adherence by modality at a large tertiary care center in the United States: a retrospective analysis

OBJECTIVE

Real-world data is crucial to inform existing opportunistic colorectal cancer (CRC) prevention programs. This study aimed to assess CRC screening adherence and utilization of various screening modalities within a Primary Care network over a three-year period (2017-2019).

METHODS

A retrospective review of individuals aged 50-75 years at average CRC risk, with at least one clinic visit in the previous 24 months. The primary outcome, CRC screening adherence (overall and by modality) was examined among the entire eligible population and newly adherent individuals each calendar year. The final sample included 107,366 patients and 218,878 records.

RESULTS

Overall CRC screening adherence increased from 71% in 2017 to 78% in 2019. For "up-to-date" individuals, colonoscopy was the predominant modality (accounting for approximately 74%, versus 4% of adherence for non-invasive options). However, modality utilization trends changed over time in these individuals: mt-sDNA increased 10.2-fold, followed by FIT (1.6-fold) and colonoscopy (1.1-fold). Among newly adherent individuals, the proportion screened by colonoscopy and FOBT decreased over time (89% to 80% and 2.4% to 1.2%, respectively), while uptake of FIT and mt-sDNA increased (7.7% to 11.5% and 0.9% to 6.8%, respectively). Notably, FIT and mt-sDNA increases were most evident in age and race-ethnicity groups with the lowest screening rates.

CONCLUSIONS

In an opportunistic CRC screening program, adherence increased but remained below the national 80% goal. While colonoscopy remained the most utilized modality, new colonoscopy uptake declined, compared with rising mt-sDNA and FIT utilization. Among minority populations, new uptake increased most with mt-sDNA and FIT.

Artificial intelligence-assisted real-time monitoring of effective withdrawal time during colonoscopy: a novel quality marker of colonoscopy

BACKGROUND AND AIMS

The importance of withdrawal time during colonoscopy cannot be overstated in mitigating the risk of missed lesions and postcolonoscopy colorectal cancer. We evaluated a novel colonoscopy quality metric called the effective withdrawal time (EWT), which is an artificial intelligence (AI)-derived quantitative measure of quality withdrawal time, and its association with various colonic lesion detection rates as compared with standard withdrawal time (SWT).

METHODS

Three hundred fifty video recordings of colonoscopy withdrawal (from the cecum to the anus) were assessed by the new AI model. The primary outcome was adenoma detection rate (ADR) according to different quintiles of EWT. Multivariate logistic regression, adjusting for baseline covariates, was used to determine the adjusted odd ratios (ORs) for EWT on lesion detection rates, with the lowest quintile as reference. The area under the receiver-operating characteristic curve of EWT was compared with SWT.

RESULTS

The crude ADR in different quintiles of EWT, from lowest to highest, was 10.0%, 31.4%, 33.3%, 53.5%, and 85.7%. The ORs of detecting adenomas and polyps were significantly higher in all top 4 quintiles when compared with the lowest quintile. Each minute increase in EWT was associated with a 49% increase in ADR (aOR, 1.49; 95% confidence interval [CI], 1.36-1.65). The area under the receiver-operating characteristic curve of EWT was also significantly higher than SWT on adenoma detection (.80 [95% CI, .75-.84] vs .70 [95% CI, .64-.74], P < .01).

CONCLUSIONS

AI-derived monitoring of EWT is a promising novel quality indicator for colonoscopy, which is more associated with ADR than SWT.

The effect of genetic variants of SLC22A18 on proliferation, migration, and invasion of colon cancer cells

Solute carrier family (SLC) transporters are expressed in the digestive system and play important roles in maintaining physiological functions in the body. In addition, SLC transporters act as oncoproteins or tumor-suppressor proteins during the development, progression, and metastasis of various digestive system cancers. SLC22A18, a member of the SLC22 gene family, is an orphan transporter with an unknown endogenous substrate. Previous study revealed that SLC22A18 is downregulated in colorectal cancer tissues and that it acts as a suppressor in colorectal cancer, although the effects of SLC22A18 variants on colon cancer cell proliferation, migration, and invasion are unknown. Therefore, in this study, we identified SLC22A18 variants found in multiple populations by searching public databases and determined the in vitro effects of these missense variations on transporter expression and cancer progression. Our results indicated that three missense SLC22A18 variants-p.Ala6Thr, p.Arg12Gln, and p.Arg86His-had significantly lower cell expression than the wild type, possibly owing to intracellular degradation. Furthermore, these three variants caused significantly higher proliferation, migration, and invasion of colon cancer cells than the wild type. Our findings suggest that missense variants of SLC22A18 can potentially serve as biomarkers or prognostic tools that enable clinicians to predict colorectal cancer progression.

CYP1B1-AS1 Delays the Malignant Progression of Colorectal Cancer by Binding with NOP58

BACKGROUND

Colorectal cancer (CRC) is a prevalent type of gastrointestinal cancer, and its poor prognosis is mainly attributed to the occurrence of invasion and metastasis. CYP1B1-AS1, as non-coding RNA, plays an important role in tumorigenesis and progression. However, the mechanism by which CYP1B1-AS1 acts in CRC is not yet understood.

AIMS

The objective of this study was to investigate how CYP1B1-AS1 contributes to the development of CRC, and provide a base for CRC diagnosis and treatment.

METHODS

RT-qPCR was used to detect the expression level of CYP1B1-AS1 in CRC and adjacent tissues. CCK-8, Edu, scratch healing, and transwell experiments were used to detect the changes of proliferation, migration, and invasion ability of CRC cells after overexpression or knockdown of CYP1B1-AS1 respectively. The RNA binding protein NOP58 combined with CYP1B1-AS1 was verified by RIP and RNA Pull-down experiments. Functional recovery experiments validated the interaction between CYP1B1-AS1 and NOP58 in CRC cells. The changes of EMT-related proteins were detected by Western blot, and the half-life of transcription factor SNAIL mRNA were detected by RT-qPCR after overexpression or knockdown of NOP58.

RESULTS

CYP1B1-AS1 was found to be significantly downregulated in CRC compared to adjacent noncancerous tissues. Experiments conducted in vitro and in vivo confirmed that upregulation of CYP1B1-AS1 significantly inhibited the proliferation, migration, and invasion of CRC cells. In addition, CYP1B1-AS1 can directly bind to NOP58 and negatively regulate NOP58. The effect of overexpression CYP1B1-AS1 was reversed by NOP58 overexpression. NOP58 regulates the EMT process of CRC cells by affecting the stability of EMT-related transcription factor SNAIL mRNA, and then affects the progress of CRC.

CONCLUSION

This research proves that CYP1B1-AS1 can inhibit the occurrence of EMT in CRC by binding with NOP58, thus delaying the progress of CRC. This finding indicates that CYP1B1-AS1 may be a novel biomarker to improve the diagnosis and treatment of CRC.

Impact of AI-aided colonoscopy in clinical practice: a prospective randomised controlled trial

OBJECTIVE

Colorectal cancer (CRC) has a significant role in cancer-related mortality. Colonoscopy, combined with adenoma removal, has proven effective in reducing CRC incidence. However, suboptimal colonoscopy quality often leads to missed polyps. The impact of artificial intelligence (AI) on adenoma and polyp detection rate (ADR, PDR) is yet to be established.

DESIGN

We conducted a randomised controlled trial at Sahlgrenska University Hospital in Sweden. Patients underwent colonoscopy with or without the assistance of AI (AI-C or conventional colonoscopy (CC)). Examinations were performed with two different AI systems, that is, Fujifilm CADEye and Medtronic GI Genius. The primary outcome was ADR.

RESULTS

Among 286 patients, 240 underwent analysis (average age: 66 years). The ADR was 42% for all patients, and no significant difference emerged between AI-C and CC groups (41% vs 43%). The overall PDR was 61%, with a trend towards higher PDR in the AI-C group. Subgroup analysis revealed higher detection rates for sessile serrated lesions (SSL) with AI assistance (AI-C 22%, CC 11%, p=0.004). No difference was noticed in the detection of polyps or adenomas per colonoscopy. Examinations were most often performed by experienced endoscopists, 78% (n=86 AI-C, 100 CC).

CONCLUSION

Amidst the ongoing AI integration, ADR did not improve with AI. Particularly noteworthy is the enhanced detection rates for SSL by AI assistance, especially since they pose a risk for postcolonoscopy CRC. The integration of AI into standard colonoscopy practice warrants further investigation and the development of improved software might be necessary before enforcing its mandatory implementation.

TRIAL REGISTRATION NUMBER

NCT05178095.

Boston bowel preparation scale score 6 has more missed lesions compared with 7-9

Adequate bowel preparation is an important factor in high-quality colonoscopy. It is generally accepted that a Boston Bowel Preparation Scale (BBPS) score ≥ 6 is adequate, but some reports suggest ≥ 7. Subjects who underwent colonoscopy at least twice within 3 years from August 2015 to December 2019 were included. Polyp detection rates (PDRs), adenoma detection rates (ADRs), and number of polyps including adenomas were compared stratified by baseline colonoscopy (C1) BBPS score. Among 2352 subjects, 529 had BBPS 6 (group 1) and 1823 had BBPS 7-9 (group 2) at C1. There was no significant difference in PDR or ADR at C1 and follow-up colonoscopy (C2) between the two groups. However, the numbers of polyps (1.84 vs. 1.56, P = 0.001) and adenomas (1.02 vs. 0.88, P = 0.034) at C2 were significantly higher in group 1 than group 2, respectively. Segmental BBPS score 2 in group 1 compared to group 2, especially, showed higher PDR (P = 0.001) and ADR (P = 0.007) at C2. BBPS 6 is associated with a higher number of polyps and adenomas in short-term follow-up colonoscopy than BBPS 7-9. To reduce the risk of missed polyps, a thorough examination is necessary for BBPS 6.

The effect of nurse assisted colonoscopy on adenoma detection rates: A meta-analysis of randomized controlled trials

BACKGROUND

Adenoma's detection rates have been reported to vary with the participation status of endoscopic nurses during colonoscopy. This meta-analysis was conducted to determine whether the participation of endoscopy nurses during colonoscopy contributed to the improved detection rate of polyps and adenomas.

METHODS

We retrieved English original research from PubMed, Embase, Web of Science, and Cochrane library databases and Chinese original research from the CNKI Data database. We searched for randomized controlled trials (RCTs) comparing the effect of participation of endoscopy nurses during colonoscopy of colorectal polyps and adenomas on polyp detection rates to that of nonparticipation. RevMan5.4 software was used to perform the meta-analysis.

RESULTS

This meta-analysis included 11 randomized controlled trials involving 8278 patients. The results showed no significant difference between colonoscopies performed by nurses and endoscopists, but colonoscopies performed by two nurses significantly improved the detection rate of polyps and adenomas. In the random effects model, there was a significant difference in PDR between the single-observation and dual-observation groups (RR, 1.27; 95%CI, 1.05, 1.54; Z = 2.51; P = 0.01). The ADR difference between the single observation group and the double observation group was statistically significant (RR, 1.15; 95%CI, 1.05, 1.26; Z = 2.91; P = 0.004).

CONCLUSION

Endoscopy nurses' participation in colonoscopy can improve the detection rate of polyps and adenomas, However, more research is needed to confirm the results.

Accuracy of GPT-4 in histopathological image detection and classification of colorectal adenomas

AIMS

To evaluate the accuracy of Chat Generative Pre-trained Transformer (ChatGPT) powered by GPT-4 in histopathological image detection and classification of colorectal adenomas using the diagnostic consensus provided by pathologists as a reference standard.

METHODS

A study was conducted with 100 colorectal polyp photomicrographs, comprising an equal number of adenomas and non-adenomas, classified by two pathologists. These images were analysed by classic GPT-4 for 1 time in October 2023 and custom GPT-4 for 20 times in December 2023. GPT-4's responses were compared against the reference standard through statistical measures to evaluate its proficiency in histopathological diagnosis, with the pathologists further assessing the model's descriptive accuracy.

RESULTS

GPT-4 demonstrated a median sensitivity of 74% and specificity of 36% for adenoma detection. The median accuracy of polyp classification varied, ranging from 16% for non-specific changes to 36% for tubular adenomas. Its diagnostic consistency, indicated by low kappa values ranging from 0.06 to 0.11, suggested only poor to slight agreement. All of the microscopic descriptions corresponded with their diagnoses. GPT-4 also commented about the limitations in its diagnoses (eg, slide diagnosis best done by pathologists, the inadequacy of single-image diagnostic conclusions, the need for clinical data and a higher magnification view).

CONCLUSIONS

GPT-4 showed high sensitivity but low specificity in detecting adenomas and varied accuracy for polyp classification. However, its diagnostic consistency was low. This artificial intelligence tool acknowledged its diagnostic limitations, emphasising the need for a pathologist's expertise and additional clinical context.

Trends in the incidence and survival of cancer in individuals aged 55 years and older in the United States, 1975-2019

BACKGROUND

In ageing societies such as the United States, evaluating the incidence and survival rates of cancer in older adults is essential. This study aimed to analyse the incidence and survival rates of cancer in individuals aged 55 years or older in the United States.

METHODS

This retrospective study (1975-2019) was conducted using combined registry data from the Surveillance, Epidemiology, and End Results database. Data from the 9, 12, and 17 Registries (Nov 2021 Sub) datasets were used.

RESULTS

In 2019, the incidence of cancer in individuals older than 55 years and the overall population was 1322.8 and 382.1 per 100,000 population, respectively. From 2000 to 2019, the incidence of cancer in individuals older than 55 years showed a decreasing trend, whereas their five-year survival rates showed an increasing trend. The incidence of cancer in the 75-79 and 80-84 year age groups was the highest among all age groups.

CONCLUSIONS

The incidence of colon cancer declined significantly, whereas that of intrahepatic bile duct cancer increased considerably. These trends may be due to increased screening for cancers with high incidence rates and improved control of the risk factors for cancer. Rapid development of targeted therapy and immunotherapy combined with early tumour detection may be an important reason for the improved survival rates.

Serrated colorectal cancer: preclinical models and molecular pathways

Serrated lesions are histologically heterogeneous, and detection can be challenging as these lesions have subtle features that may be missed by endoscopy. Furthermore, while approximately 30% of colorectal cancers (CRCs) arise from serrated lesions, only 8-10% of invasive serrated CRCs exhibit serrated morphology at presentation, suggesting potential loss of apparent characteristics with increased malignancy. Thus, understanding the genetic basis driving serrated CRC initiation and progression is critical to improve diagnosis and identify therapeutic biomarkers and targets to guide disease management. This review discusses the preclinical models of serrated CRCs reported to date and how these systems have been used to provide mechanistic insights into tumor initiation, progression, and novel treatment targets.

Impact of an artificial intelligence-aided endoscopic diagnosis system on improving endoscopy quality for trainees in colonoscopy: Prospective, randomized, multicenter study

OBJECTIVE

This study was performed to evaluate whether the use of CAD EYE (Fujifilm, Tokyo, Japan) for colonoscopy improves colonoscopy quality in gastroenterology trainees.

METHODS

The patients in this multicenter randomized controlled trial were divided into Group A (observation using CAD EYE) and Group B (standard observation). Six trainees performed colonoscopies using a back-to-back method in pairs with gastroenterology experts. The primary end-point was the trainees' adenoma detection rate (ADR), and the secondary end-points were the trainees' adenoma miss rate (AMR) and Assessment of Competency in Endoscopy (ACE) tool scores. Each trainee's learning curve was evaluated using a cumulative sum (CUSUM) control chart.

RESULTS

We analyzed data for 231 patients (Group A, n = 113; Group B, n = 118). The ADR was not significantly different between the two groups. Group A had a significantly lower AMR (25.6% vs. 38.6%, P = 0.033) and number of missed adenomas per patient (0.5 vs. 0.9, P = 0.004) than Group B. Group A also had significantly higher ACE tool scores for pathology identification (2.26 vs. 2.07, P = 0.030) and interpretation and identification of pathology location (2.18 vs. 2.00, P = 0.038). For the CUSUM learning curve, Group A showed a trend toward a lower number of cases of missed multiple adenomas by the six trainees.

CONCLUSION

CAD EYE did not improve ADR but decreased the AMR and improved the ability to accurately locate and identify colorectal adenomas. CAD EYE can be assumed to be beneficial for improving colonoscopy quality in gastroenterology trainees.

TRIAL REGISTRATION

University Hospital Medical Information Network Clinical Trials Registry (UMIN000044031).

Endoscopist-related factors affecting adenoma detection during colonoscopy: Data from the J-SCOUT study

OBJECTIVES

Colonoscopy withdrawal times are associated with the adenoma detection rate (ADR). However, the relationship between ADR and cecal insertion time has been inadequately characterized. We aimed to evaluate endoscopist-related factors involved in the ADR, including the average individual colonoscopy insertion and withdrawal times.

METHODS

This observational study used a colonoscopy database with pathology data from routine clinical practice in Japanese institutions. The odds ratios (OR) of endoscopist-related factors related to ADRs were examined using a generalized linear mixed model.

RESULTS

Of the 186,293 colonoscopies performed during the study period, 47,705 colonoscopies by 189 endoscopists in four hospitals were analyzed for ADR. The overall ADR was 38.3% (95% confidence interval [CI] 37.8, 38.7). Compared to endoscopists with mean cecal insertion times of <5 min, the OR of ADR for those with mean cecal insertion times of 5-9, 10-14, and ≥15 min were 0.84 (95% CI 0.71, 0.99), 0.68 (95% CI 0.52, 0.90), and 0.45 (95% CI 0.25, 0.78), respectively. Compared to endoscopists with mean withdrawal times of <6 min, the OR of ADR for those with mean withdrawal times of 6-9, 10-14, and ≥15 min were 1.38 (95% CI 1.03, 1.85), 1.48 (95% CI 1.09, 2.02), and 1.68 (95% CI 1.04, 2.61), respectively. There were no significant differences in ADRs by endoscopist specialty, gender, or the total number of examinations performed.

CONCLUSION

Individual mean colonoscopy insertion time was associated with ADR and might be considered as a colonoscopy quality indicator as well as withdrawal time.

Epidemiology and early screening strategies for colorectal cancer in China

China ranks the first worldwide in the number of new colorectal cancer (CRC) cases and CRC-related deaths. The increasing incidence of early-onset CRC in recent years highlights the challenges related to CRC screening and prevention. High-quality colonoscopy is the universally used gold standard for CRC screening. Risk assessment combined with a two-step screening strategy based on colonoscopy and non-invasive examinations was proven to be highly effective. However, systematic use of well-established risk factors associated with CRC, beyond age, could better identify those who might harbor advanced colorectal neoplasia, improve the diagnostic yield of current screening modalities, and optimize the selection of individuals who might benefit most from preventive strategies. "Personalization" and "Standardization" are the future development directions of CRC screening, from the initiation of screening in those at high risk for CRC to follow-up after treatment, which are the key to ensure the screening efficiency.

ENDOANGEL versus water exchange for the detection of colorectal adenomas

Background

Recently, the ENDOANGEL (EN) system, a computer-assisted detection technique, and water exchange (WE) assisted colonoscopy have both been shown to increase the colorectal adenoma detection rate (ADR).

Objectives

The aim of this study was to compare the ADR between EN- and WE-assisted colonoscopy.

Design

This was a retrospective study.

Methods

Data from patients who underwent either EN- or WE-assisted colonoscopy between October 2021 and August 2022 were analysed consecutively. The primary outcome measure was the ADR.

Results

The ADR was found to be similar between the EN and WE groups, with 80 out of 199 (40.2%) patients in the EN group compared to 78 out of 174 (44.8%) patients in the WE group [1.21; 95% confidence interval (CI), 0.80-1.83]. In the analysis using stabilized inverse probability treatment weighting after adjustment for confounding factors, both colonoscopy methods had similar performance in terms of ADR (1.41; 95% CI, 0.88-2.27).

Conclusion

EN was found to be comparable to WE in terms of ADR during colonoscopy, and both methods may be effectively used in clinical practice.

Colorectal Cancer: Is it Still a Disease of the Elderly?

<b><br>Introduction:</b> Colorectal cancer is becoming an increasingly significant health issue, being one of the more commonly diagnosed malignancies. Colorectal tumors account for 10% of all malignant cancers in women and 12% in men. Incidence is higher in the male population, especially among younger individuals. It is commonly believed that colorectal cancer is predominantly associated with advanced age. However, colorectal surgeons, who specialize in the treatment of this type of cancer, are observing a growing number of cases among middle-aged and younger individuals.</br> <b><br>Aim:</b> The aim of our study was to investigate whether colorectal cancer still predominantly affects elderly individuals, how frequently it is diagnosed in younger patients, and whether the location of tumors in the intestines of younger patients aligns with data from elderly individuals.</br> <b><br>Materials and methods:</b> The study was conducted retrospectively and included a cohort of 1771 patients who underwent surgical procedures due to colorectal cancer between 2012 and 2015 at the Department of General and Colorectal Surgery at the Medical University of Łódź and between 2014 and 2017 at the Department of General Surgery with a Division of Surgical Oncology at the District Health Center in Brzeziny. Data were analyzed regarding the frequency of colorectal cancer occurrence by age, tumor location in different age groups, and disease stage according to age. Age groups included <40 years, 41-50 years, 51-70 years, and >70 years.</br> <b><br>Results:</b> The study encompassed a total of 1771 patients, with 988 (55.79%) being males and 783 (44.21%) females. The mean age of the patients was 65.27 11.12 years. The highest number of cases was observed in the age range of 60-70 years and 70-80 years. It was found that colorectal tumors in males more frequently occurred on the left side of the colon and rectum, while in females, they were more commonly located on the right side of the colon, which was statistically significant (P = 0.007). Younger age groups of patients (<40 years, 40-50 years) had a similar male-to-female ratio, whereas in age groups above 50 years, males significantly outnumbered females (P = 0.049). The study revealed that in the group of patients below 40 years of age, an advanced stage of colorectal cancer was significantly more common; stage D occurred over twice as often as in the 51-70 age group and over three times as often as in the >70 age group.</br> <b><br>Conclusions:</b> The incidence of colorectal cancer in Poland is steadily increasing, with a growing number of diagnoses in younger individuals. Research findings demonstrate that males, especially those in younger age groups, are at a higher risk of developing colorectal cancer. A higher disease stage is more frequently observed in younger patients, possibly due to delayed diagnosis and symptomatic treatment. Screening programs should be adjusted to the changing age groups at higher risk. Our study underlines the need to raise public awareness regarding colorectal cancer, particularly among the younger population.</br>.

Interval post-colonoscopy colorectal cancer following a negative colonoscopy in a fecal immunochemical test-based screening program

BACKGROUND

 In the Dutch colorectal (CRC) screening program, fecal immunochemical test (FIT)-positive individuals are referred for colonoscopy. If no relevant findings are detected at colonoscopy, individuals are reinvited for FIT screening after 10 years. We aimed to assess CRC risk after a negative colonoscopy in FIT-positive individuals.

METHODS

 In this cross-sectional cohort study, data were extracted from the Dutch national screening information system. Participants with a positive FIT followed by a negative colonoscopy between 2014 and 2018 were included. A negative colonoscopy was defined as a colonoscopy during which no more than one nonvillous, nonproximal adenoma < 10 mm or serrated polyp < 10 mm was found. The main outcome was interval post-colonoscopy CRC (iPCCRC) risk. iPCCRC risk was reviewed against the risk of interval CRC after a negative FIT (FIT IC) with a 2-year screening interval.

RESULTS

 35 052 FIT-positive participants had a negative colonoscopy and 24 iPCCRCs were diagnosed, resulting in an iPCCRC risk of 6.85 (95 %CI 4.60-10.19) per 10 000 individuals after a median follow-up of 1.4 years. After 2.5 years of follow-up, age-adjusted iPCCRC risk was approximately equal to FIT IC risk at 2 years.

CONCLUSION

 Risk of iPCCRC within a FIT-based CRC screening program was low during the first years after colonos-copy but, after 2.5 years, was the same as the risk in FIT-negative individuals at 2 years, when they are reinvited for screening. Colonoscopy quality may therefore require further improvement and FIT screening interval may need to be reduced after negative colonoscopy.

Endoscopy Unit Level Interventions to Improve Adenoma Detection Rate: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Adenoma detection rate (ADR) is inversely correlated with the risk of interval colon cancer and is a key target for quality improvement in endoscopy units. We conducted a systematic review and meta-analysis to identify and evaluate the effectiveness of interventions that can be implemented at the endoscopy unit level to improve ADRs.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search was conducted in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases between January 1990 and December 2022 to identify relevant studies. Both randomized controlled trials and observational studies were eligible. Data for the primary outcome of ADR were analyzed and reported on the log-odds scale with 95% CIs using a random-effects meta-analysis model using the empiric Bayes estimator.

RESULTS

From 10,778 initial citations, 34 studies were included in the meta-analysis comprising 371,041 procedures and 1501 endoscopists. The provision of report cards (odds ratio [OR], 1.28; 95% CI, 1.13-1.45; P < .001) and the presence of an additional observer to identify polyps (OR, 1.25; 95% CI, 1.09-1.43; P = .002) were associated with significant increases in ADRs whereas multimodal interventions were borderline significant (OR, 1.18; 95% CI, 1.00-1.40; P = .05) and withdrawal time monitoring was not associated significantly with an increase in ADRs (OR, 1.35; 95% CI, 0.93-1.96; P = .11).

CONCLUSIONS

The provision of report cards and the presence of an additional observer to identify polyps are associated with improved ADRs and should be considered for implementation in endoscopy facilities.

Growing Deficit in New Cancer Diagnoses 2 Years Into the COVID-19 Pandemic: A National Multicenter Study

BACKGROUND

Large decreases in cancer diagnoses were seen early in the COVID-19 pandemic. However, the evolution of these deficits since the end of 2020 and the advent of widespread vaccination is unknown.

METHODS

This study examined data from the Veterans Health Administration (VA) from 1 January 2018 through 28 February 2022 and identified patients with screening or diagnostic procedures or new cancer diagnoses for the four most common cancers in the VA health system: prostate, lung, colorectal, and bladder cancers. Monthly procedures and new diagnoses were calculated, and the pre-COVID era (January 2018 to February 2020) was compared with the COVID era (March 2020 to February 2022).

RESULTS

The study identified 2.5 million patients who underwent a diagnostic or screening procedure related to the four cancers. A new cancer was diagnosed for 317,833 patients. During the first 2 years of the pandemic, VA medical centers performed 13,022 fewer prostate biopsies, 32,348 fewer cystoscopies, and 200,710 fewer colonoscopies than in 2018-2019. These persistent deficits added a cumulative deficit of nearly 19,000 undiagnosed prostate cancers and 3300 to 3700 undiagnosed cancers each for lung, colon, and bladder. Decreased diagnostic and screening procedures correlated with decreased new diagnoses of cancer, particularly cancer of the prostate (R = 0.44) and bladder (R = 0.27).

CONCLUSION

Disruptions in new diagnoses of four common cancers (prostate, lung, bladder, and colorectal) seen early in the COVID-19 pandemic have persisted for 2 years. Although reductions improved from the early pandemic, new reductions during the Delta and Omicron waves demonstrate the continued impact of the COVID-19 pandemic on cancer care.

Efficacy and safety of oral sodium sulfate tablet compared with 1-L polyethylene glycol plus ascorbate: a prospective, randomized, endoscopist-blinded trial

BACKGROUND AND AIM

Low-volume bowel preparation solutions, including 1-L polyethylene glycol plus ascorbate (PEG-A), have been developed to improve tolerability. The oral sodium sulfate tablet (OST) is a new agent with simethicone as a preloaded component. We investigated the efficacy, safety, and tolerability of OST compared to 1-L PEG-A.

METHODS

A single-center, prospective, controlled study was performed with randomization into the OST (group A) and 1-L PEG-A (group B) groups. Bowel preparation efficacy was assessed on the Boston Bowel Preparation Scale (BBPS) and Bubble Scale. Safety and tolerability were evaluated using a questionnaire and laboratory examination.

RESULTS

Final analysis was performed on 171 patients (group A: 87, group B: 84). The proportion of bowel preparation success (BBPS ≥ 2 for each colonic segment) in group A was not inferior compared to group B (95.4% vs 96.4%, P = 0.736, 1-sided 97.5% lower confidence limit -7.0%). The adenoma detection rate was not different (59.6% vs 41.9%; P = 0.087). The bubble scale was better in group A (0.2 ± 0.9 vs 1.9 ± 1.7, P < 0.001). All adverse events were mild in both groups. Nausea was less frequent in group A (14.9% vs 38.1%, P = 0.001). Overall satisfaction was better in group A (8.1 ± 2.1 vs 6.4 ± 2.8, P < 0.001). No clinically significant laboratory abnormality developed in both groups. These findings were similarly shown in old patients ≥65 years.

CONCLUSIONS

Both OST and 1-L PEG-A were efficacious, safe, and tolerable for bowel preparation of colonoscopy. The OST showed fewer bubbles and slightly better tolerability.

Recurrence rates of advanced colorectal neoplasia (ACN) in subjects with baseline ACN followed up at different surveillance intervals

BACKGROUND

Current clinical guidelines recommend that a baseline finding of advanced colorectal neoplasia (ACN) should be followed-up within 1-3 years.

AIM

We compared the recurrence rate of ACN at 1 year vs. 3 years among individuals with ACN detected and polypectomised at baseline colonoscopy.

METHODS

We extracted data from eligible patients in a Chinese population database from 2008 to 2018. The outcome variables included recurrence of advanced adenoma and advanced neoplasia, respectively, at follow-up colonoscopy. Binary logistic regression modeling was constructed to examine the association between length of surveillance and the outcome variables, controlling for risk factors of colorectal cancer, including age, gender, smoking, alcohol drinking, body mass index and chronic diseases.

RESULTS

We included 147,270 subjects who have received a baseline colonoscopy from our dataset. They were aged 69.3 years and 59.7% of them were male subjects. The crude 1-year and 3-year recurrence rate of ACN was 7.57% and 7.74%. From a binary logistic regression model, individuals with surveillance colonoscopy performed at 3 years did not have significantly higher recurrence rate of ACN than those followed-up at 1 year.

CONCLUSIONS

No statistically significantly difference in recurrence of ACN between individuals who received workup at 1vs. 3 years. These findings support a 3-year surveillance period after baseline ACN was polypectomised.

Risk of recurrent advanced colorectal neoplasia in individuals with baseline non-advanced neoplasia followed up at 5 vs 7-10 years

BACKGROUND AND AIM

Colorectal cancer (CRC) is one of the commonest cancers, especially among the Asian populations. We compared the recurrence rate of advanced colorectal neoplasia (ACN) at 5 year vs 7-10 years among individuals with non-advanced adenoma (NAA) detected and polypectomized at baseline colonoscopy in a large Chinese population.

METHODS

We extracted data of a large Chinese population with NAA polypectomized who received surveillance colonoscopy after 5 or 7-10 years from a large database (2008-2018). The outcome variable included recurrence of ACN at surveillance colonoscopy. We examined the association between length of surveillance and the outcome variable, whilst controlling for risk factors of colorectal cancer.

RESULTS

We include 109 768 subjects who have received a baseline colonoscopy from our dataset. They were aged 67.35 (SD 9.84) years, and 60.9% of them were male subjects. The crude 5-year and 10-year recurrence rate of ACN was 1.50% and 2.42%, respectively (crude odds ratio = 1.629, 95% CI 1.362 to 1.949, P < 0.001). From the binary logistic regression model, individuals with surveillance colonoscopy performed at 10 years had a statistically higher recurrence rate of ACN than those followed-up at 5 year (adjusted odds ratio [aOR] = 1.544, 95% CI 1.266 to 1.877, P < 0.001), but the effect size of aOR is small.

CONCLUSIONS

There is a small difference in recurrence of ACN between individuals who received colonoscopy workup at 5 years vs 7-10 years. These findings support a 7-10 years surveillance period after baseline NAA was polypectomized.

Public Imaging Datasets of Gastrointestinal Endoscopy for Artificial Intelligence: a Review

With the advances in endoscopic technologies and artificial intelligence, a large number of endoscopic imaging datasets have been made public to researchers around the world. This study aims to review and introduce these datasets. An extensive literature search was conducted to identify appropriate datasets in PubMed, and other targeted searches were conducted in GitHub, Kaggle, and Simula to identify datasets directly. We provided a brief introduction to each dataset and evaluated the characteristics of the datasets included. Moreover, two national datasets in progress were discussed. A total of 40 datasets of endoscopic images were included, of which 34 were accessible for use. Basic and detailed information on each dataset was reported. Of all the datasets, 16 focus on polyps, and 6 focus on small bowel lesions. Most datasets (n = 16) were constructed by colonoscopy only, followed by normal gastrointestinal endoscopy and capsule endoscopy (n = 9). This review may facilitate the usage of public dataset resources in endoscopic research.

Comparison of a novel mini-oral sulfate tablet and the conventional oral sulfate tablet in bowel preparation for colonoscopy: a prospective, randomized, investigator-blinded, multicenter, non-inferior, phase 3 trial

BACKGROUND AND AIMS

The use of conventional oral sulfate tablets (OSTs) has gained popularity; nonetheless, they may be not only inconvenient to swallow but also difficult to dissolve. A novel mini-OST has recently been developed to enhance compliance with conventional OST use. This study aimed to compare the efficacy, tolerability, and safety between mini-OST and conventional OST.

METHODS

This was a prospective, randomized, investigator-blinded, multicenter, and non-inferior phase 3 trial conducted between September 2022 and December 2022. The efficacy, safety, and tolerability were compared between mini-OST and conventional OST.

RESULTS

Exactly 83 patients were evaluated based on a full analysis set (FAS), whereas 82 patients were evaluated as a per-protocol set (PPS). With respect to the efficacy of preparation, successful and high-quality preparation was excellent in the mini-OST and conventional OST groups on both FAS and PPS analyses, without significant differences between the two groups. On the FAS analysis, the satisfaction and tolerability scores were high in both groups, without significant differences. The first bowel movement after taking the investigational product occurred 30 min earlier in the mini-OST group than in the OST group. Mild, moderate, and severe adverse events (AEs) were comparable between the two groups; however, any AEs were more common in the mini-OST group than in the conventional OST group overall.

CONCLUSIONS

Compared with conventional OST, the novel mini-OST preparation showed similar efficacy, tolerability, and safety, including mild eight solicited AEs and moderate-to-severe AEs. Clinical trial registration NCT05670470.

Hub-and-Spoke centralized intervention to optimize colorectal cancer screening and follow-up: A pragmatic, cluster-randomized controlled trial protocol

BACKGROUND

Guidelines recommend screening for colorectal cancer (CRC), but participation and abnormal test follow up rates are suboptimal, with disparities by demography. Evidence-based interventions exist to promote screening, but community adoption and implementation are limited.

METHODS

The San Diego Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science (ACCSIS) program is an academic-community partnership testing regional implementation of a Hub-and-Spoke model for increasing CRC screening and follow-up. The "hub" is a non-academic, non-profit organization that includes 17 community health center (CHC) systems, serving over 190 rural and urban clinic sites. The "spokes" are 3 CHC systems that oversee 11-28 clinics each, totaling over 60 clinics. Using a cluster-randomized trial design, 9 clinics were randomized to intervention and 16 to usual care. Within intervention clinics, approximately 5000 eligible patients not up-to-date with CRC screening per year were identified for intervention. Interventions include an invitation primer, a mailed fecal immunochemical test with completion instructions, and phone and text-based reminders (hub) and patient navigation protocol to promote colonoscopy completion after abnormal FIT (spoke). Outcomes include: 1) proportion of patients up-to-date with screening after three years in intervention versus non-intervention clinics; 2) proportion of patients with abnormal FIT completing colonoscopy within six months of the abnormal result. Implementation science measures are collected to assess acceptability, intervention and usual care adaptations, and sustainability of the intervention strategies.

CONCLUSION

This large-scale, regional cluster randomized trial among CHCs serving diverse populations is anticipated to accelerate progress in CRC prevention in underserved populations.

TRIAL REGISTRATION

NCT04941300.

Establishment and validation of symptomatic patients colorectal screening score for predicting colorectal neoplasia risk

OBJECTIVES

Currently, most colorectal neoplasia (CRN) screening strategies target asymptomatic individuals. However, studies on patients with non-specific gastrointestinal symptoms (NSGS) are limited. We aimed to develop a CRN risk score specifically for patients with NSGS.

METHODS

We prospectively enrolled patients who underwent initial colonoscopy between June 2020 and June 2021. A new risk scoring system was constructed and its applicability was evaluated.

RESULTS

A total of 1522 consecutive patients were enrolled, among whom 1016 symptomatic patients were randomly divided into a training cohort and a validation cohort at a ratio of 7:3. The constructed Symptomatic Patients Colorectal Screening (SPCS) score showed higher diagnostic efficacy and sensitivity than several previous scoring systems. Using the SPCS score, the patients were divided into a low-risk group (-2 to 3 points) and a high-risk group (4-10 points) for CRN. Additionally, the detection rate of CRN in the training and validation cohorts of the high-risk group were 41.7% and 37.0%, respectively. The SPCS score detected 79.3% (188/237) of CRN and 87.5% (42/48) of advanced CRN in the high-risk group, which reduced the workload of colonoscopy to 45.9% (466/1016).

CONCLUSION

An effective CRN risk scoring system was established and validated for symptomatic patients, which accurately classified individuals into low-risk and high-risk groups for CRN and might be used to optimize colonoscopic resource allocation.

AGA Clinical Practice Update on Risk Stratification for Colorectal Cancer Screening and Post-Polypectomy Surveillance: Expert Review

DESCRIPTION

Since the early 2000s, there has been a rapid decline in colorectal cancer (CRC) mortality, due in large part to screening and removal of precancerous polyps. Despite these improvements, CRC remains the second leading cause of cancer deaths in the United States, with approximately 53,000 deaths projected in 2023. The aim of this American Gastroenterological Association (AGA) Clinical Practice Update Expert Review was to describe how individuals should be risk-stratified for CRC screening and post-polypectomy surveillance and to highlight opportunities for future research to fill gaps in the existing literature.

METHODS

This Expert Review was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPUC and external peer review through standard procedures of Gastroenterology. These Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: All individuals with a first-degree relative (defined as a parent, sibling, or child) who was diagnosed with CRC, particularly before the age of 50 years, should be considered at increased risk for CRC. BEST PRACTICE ADVICE 2: All individuals without a personal history of CRC, inflammatory bowel disease, hereditary CRC syndromes, other CRC predisposing conditions, or a family history of CRC should be considered at average risk for CRC. BEST PRACTICE ADVICE 3: Individuals at average risk for CRC should initiate screening at age 45 years and individuals at increased risk for CRC due to having a first-degree relative with CRC should initiate screening 10 years before the age at diagnosis of the youngest affected relative or age 40 years, whichever is earlier. BEST PRACTICE ADVICE 4: Risk stratification for initiation of CRC screening should be based on an individual's age, a known or suspected predisposing hereditary CRC syndrome, and/or a family history of CRC. BEST PRACTICE ADVICE 5: The decision to continue CRC screening in individuals older than 75 years should be individualized, based on an assessment of risks, benefits, screening history, and comorbidities. BEST PRACTICE ADVICE 6: Screening options for individuals at average risk for CRC should include colonoscopy, fecal immunochemical test, flexible sigmoidoscopy plus fecal immunochemical test, multitarget stool DNA fecal immunochemical test, and computed tomography colonography, based on availability and individual preference. BEST PRACTICE ADVICE 7: Colonoscopy should be the screening strategy used for individuals at increased CRC risk. BEST PRACTICE ADVICE 8: The decision to continue post-polypectomy surveillance for individuals older than 75 years should be individualized, based on an assessment of risks, benefits, and comorbidities. BEST PRACTICE ADVICE 9: Risk-stratification tools for CRC screening and post-polypectomy surveillance that emerge from research should be examined for real-world effectiveness and cost-effectiveness in diverse populations (eg, by race, ethnicity, sex, and other sociodemographic factors associated with disparities in CRC outcomes) before widespread implementation.

Low Incidence of Colorectal Advanced Neoplasia During Surveillance in Individuals with a Family History of Colorectal Cancer

BACKGROUND

Family history of colorectal cancer (CRC) is used to stratify individuals into risk categories which determine timing of initial screening and ongoing CRC surveillance. Evidence for long-term CRC risk following a normal index colonoscopy in family history populations is limited.

AIMS

To assess the incidence of advanced neoplasia and associated risk factors in a population undergoing surveillance colonoscopies due to family history of CRC.

METHODS

Surveillance colonoscopy findings were examined in 425 individuals with a family history of CRC, a normal index colonoscopy and a minimum of 10 years of follow-up colonoscopies. Advanced neoplasia risk was determined for three CRC family history categories (near-average, medium and high-risk), accounting for demographics and time after the first colonoscopy.

RESULTS

The median follow-up was 13.5 years (IQR 11.5-16.0), with an incidence of advanced neoplasia of 14.35% (61/425). The number of affected relatives and age of CRC diagnosis in the youngest relative did not predict the risk of advanced neoplasia (p > 0.05), with no significant differences in advanced neoplasia incidence between the family history categories (p = 0.16). Patients ≥ 60 years showed a fourfold (HR 4.14, 95% CI 1.33-12.89) higher advanced neoplasia risk during surveillance than those < 40 years at index colonoscopy. With each subsequent negative colonoscopy, the risk of advanced neoplasia at ongoing surveillance was reduced.

CONCLUSIONS

The incidence of advanced neoplasia was low (14.35%), regardless of the family history risk category, with older age being the main risk for advanced neoplasia. Delaying onset of colonoscopy or lengthening surveillance intervals could be a more efficient use of resources in this population.

Frequency of endoscopic photodocumentation of large colorectal polyps

BACKGROUND AND AIMS

Colonoscopy quality affects colorectal cancer (CRC) incidence and mortality. The U.S. Multi-Society Task Force on Colorectal Cancer strongly recommends photodocumentation (PD) of lesions ≥10 mm in size (ie, large polyps [LPs]) pre-resection and suggests PD postresection to enhance the quality of colonoscopy. No studies have assessed the frequency of LP PD. We evaluated the frequency of and factors associated with PD of LPs.

METHODS

Reports from endoscopists performing ≥50 colonoscopies with LP resection between 2016 and 2021 were reviewed. The frequency of LP PD pre-resection and post-resection and factors associated with PD were collected. A composite score of 2 quality metrics (PD of completeness of examination and bowel preparation quality) was created. Endoscopists were divided into 2 tiers based on the frequency of the score on all included examinations: Tier 1, ≥95% of examinations; and Tier 2, <95% of examinations. Univariate and multivariate analyses were used to assess factors associated with PD.

RESULTS

A total of 1322 colonoscopies, 1693 LPs, and 25 endoscopists were included in this study. PD of LPs occurred in 1392 (82%) pre-resection and in 878 (52%) post-resection. Factors associated with pre-resection PD include endoscopist subspecialty (colorectal surgery vs gastroenterology: odds ratio [OR], .12; 95% confidence interval [CI], .04-.42); >1 LP on examination (2 vs 1 LP: OR, .41 [95% CI, .27-.61]; and ≥3 vs 1 LP: OR, .41 [95% CI, .24-.70]), and longer withdrawal time (OR, 1.02; 95% CI, 1.01-1.04).

CONCLUSIONS

We provide the first data on PD of LP pre-resection and post-resection, which can inform future benchmarking in this area. The implications of PD on metachronous advanced neoplasia need to be studied.

Application of artificial intelligence in colorectal cancer screening by colonoscopy: Future prospects (Review)

Colorectal cancer (CRC) has become a severe global health concern, with the third‑high incidence and second‑high mortality rate of all cancers. The burden of CRC is expected to surge to 60% by 2030. Fortunately, effective early evidence‑based screening could significantly reduce the incidence and mortality of CRC. Colonoscopy is the core screening method for CRC with high popularity and accuracy. Yet, the accuracy of colonoscopy in CRC screening is related to the experience and state of operating physicians. It is challenging to maintain the high CRC diagnostic rate of colonoscopy. Artificial intelligence (AI)‑assisted colonoscopy will compensate for the above shortcomings and improve the accuracy, efficiency, and quality of colonoscopy screening. The unique advantages of AI, such as the continuous advancement of high‑performance computing capabilities and innovative deep‑learning architectures, which hugely impact the control of colorectal cancer morbidity and mortality expectancy, highlight its role in colonoscopy screening.