Systematic review of colorectal cancer screening guidelines for average-risk adults: Summarizing the current global recommendations

Oxidative imbalance increases the risk for colonic polyp and colorectal cancer development

BACKGROUND

The role of oxidative stress in the pathogenesis of colorectal carcinoma (CRC) has garnered considerable interest recently. Specific oxidative factors have been implicated in the pathogenesis of adenomatous polyps and ultimately adenocarcinoma.

AIM

To evaluate the effect of oxidative imbalance as quantified by specific serological markers in the development of sporadic colon adenocarcinoma.

METHODS

A total of 170 patients that underwent endoscopy of the lower gastrointestinal tract in a tertiary center within 3 years were included in the study. They were allocated in three groups; those with sporadic colon adenocarcinoma (n = 56, 32.9%), those with colonic polyps (n = 33, 19.4%) and healthy controls (n = 81, 47.7%). All patients were evaluated for oxidant activity and antioxidant capacity with serum measurements of specific markers such as vitamins A, 25(OH) D3, E, C, B12, folic acid, glutathione, selenium (Se), zinc (Zn), free iron (Fe²⁺), and malondialdehyde and results were compared between groups.

RESULTS

Serum levels of vitamins C, E, D, Se, Zn, vitamin B12 and total antioxidant capacity were significantly lower in the combined neoplasia/polyp group than in the control group (P = 0.002, P = 0.009, P < 0.001, P < 0.001, P < 0.001, P = 0.020 and P < 0.001, correspondingly). Increased levels of vitamin E (P = 0.004), vitamin D (P < 0.001), Se (P < 0.001) and Zn (P < 0.001) seem to bestow a protective effect on the development of CRC. For vitamin D (P < 0.001) and Zn (P = 0.036), this effect seems to extend to the development of colon polyps as well. On the other hand, elevated serum levels of malondialdehyde are associated with a higher risk of CRC (OR = 2.09 compared to controls, P = 0.004). Regarding colonic polyp development, increased concentrations of vitamin Α and Fe²⁺ are associated with a higher risk, whereas lower levels of malondialdehyde with a lower risk.

CONCLUSION

Increased oxidative stress may play an important role in the pathogenesis and progression of CRC. Antioxidants’ presence may exert a protective effect in the very early stages of colon carcinogenesis.

The Challenges of Colorectal Cancer Surgery during the COVID-19 Pandemic in Romania: A Three-Year Retrospective Study

The predictions on the influence of the SARS-CoV-2 pandemic on access to medical services in Romania predicted a 35% drop in oncological hospitalizations in 2020 compared to the previous decade, raising the hypothesis that patients with colorectal cancer can become indirect victims of the ongoing pandemic. Therefore, the aim of the current research was to observe how the COVID-19 pandemic influenced colorectal cancer surgery in Romania, to determine the level of addressability towards specialized care, to compare the cancer staging between the pandemic and pre-pandemic periods, and to observe the risk factors for disease progression. This retrospective study was spread over three years, respectively, from March 2019 to March 2022, and included a total of 198 patients with a history of colorectal cancer surgery. It was decided to perform a parallel comparison of 2019, 2020, and 2021 to observe any significant changes during the pandemic. Our clinic encountered a significant decrease in all interventions during the pandemic; although the number of CRC surgeries remained constant, the cases were more difficult, with significantly more patients presenting in emergency situations, from 31.3% in 2019 to 50.0% in 2020 and 57.1% in 2021. Thus, the number of elective surgeries decreased significantly. The proportion of TNM (tumor-node-metastasis) staging was, however, statistically significant between the pre-pandemic and pandemic period. In 2019, 13.3% of patients had stage IIa, compared with 28.8% in 2020 and 13.1% in 2021. Similarly, the proportion of very advanced colorectal cancer was higher during the pandemic period of 2020 and 2021 (12.0% in 2019 vs. 12.5% in 2020 and 25.0% in 2021), which was represented by a significantly higher proportion of patients with bowel perforation. Patients with an advanced TNM stage had a 6.28-fold increased risk of disease progression, followed by lymphovascular invasion (HR = 5.19). However, the COVID-19 pandemic, represented by admission years 2020 and 2021, did not pose a significant risk for disease progression and mortality. In-hospital mortality during the pandemic also did not change significantly. After the pandemic restrictions have been lifted, it would be advisable to conduct a widespread colorectal cancer screening campaign in order to identify any instances of the disease that went undetected during the SARS-CoV-2 pandemic.

Predictors of colorectal cancer screening intention based on the integrated theory of planned behavior among the average-risk individuals

Background

This study aimed to determine the predictors of colorectal cancer screening intention based on the integrated theory of planned behavior among average -risk individuals in Urmia. Identifying these predictors will help design and implement various interventions, including educational interventions, according to the needs of this group, thereby taking a step towards improving the colorectal cancer screening index.

Methods

The present cross-sectional study was performed on 410 individuals at average risk of colorectal cancer referring to the comprehensive health services centers of Urmia in Iran. The data collection tool was a researcher-made questionnaire consisting of two parts. The first part captured the demographic information and medical history of the participants. The second part involved questions designed based on constructs of motivational phase of health action process approach, and theory of planned behavior, as well as behavioral intent to perform colorectal cancer screening. Data analysis was performed using SPSS software.

Results

Outcome expectancies, risk perception, action self-efficacy, and normative beliefs, respectively had the largest impact and were significant and positive predictors of colorectal cancer screening intention. The study’s conceptual framework explained about 36% of the variance of behavioral intention among the average-risk individuals in Urmia.

Conclusions

Constructs of motivational phase of health action process approach, and theory of planned behavior are valuable and appropriate to identify the factors affecting the intention to undergo colorectal cancer screening as well as to design and implement educational interventions in this field. The four constructs of outcome expectancies, risk perception, action self-efficacy, and normative beliefs are suggested to be integrated into all educational interventions designed and implemented to improve the colorectal cancer screening index.

Attributes in stated preference elicitation studies on colorectal cancer screening and their relative importance for decision-making among screenees: a systematic review

INTRODUCTION

The SIGMO study (Sigmoidoscopy as an evidence-based colorectal cancer screening test - a possible option?) examines screening eligible populations' preferences for colorectal cancer (CRC) screening in Germany using a discrete choice experiment (DCE). Attribute identification and selection are essential for the construction of choice tasks and should be evidence-based. As a part of the SIGMO study this systematic review provides an overview of attributes included in studies eliciting stated preferences for CRC screening tests and their relative importance for decision-making.

METHODS

Systematic search (November 2021) for English-language studies published since January 2000 in PubMed, Embase, Web of Science, Biomedical Reference Collection: Corporate Edition, LIVIVO and PsycINFO. DCEs and conjoint analysis ranking or rating tasks on screening eligible populations' preferences for stool testing, sigmoidoscopy, and/or colonoscopy were included. Attributes were extracted and their relative importance was calculated and ranked. Risk of bias (RoB) of included studies was assessed using a modified GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Study selection and RoB rating were carried out independently by two reviewers. Data were extracted by one reviewer and checked by another one.

RESULTS

A total of 23 publications on 22 studies were included. Overall RoB was rated as serious/critical for 21 studies and as moderate for 2 studies. Main reasons for high RoB were non-random sampling, low response rates, lack of non-responder analyses, and, to a lesser extent, weaknesses in the measurement instrument and data analysis. Extracted attributes (n = 120) referred to procedure-related characteristics (n = 42; 35%), structural characteristics of health care (n = 24; 20%), test characteristics (n = 23; 19%), harms (n = 16; 13%), benefits (n = 13; 11%), and level of evidence (n = 2; 2%). Most important attributes were reduction in CRC mortality (and incidence) (n = 7), test sensitivity (n = 7), out-of-pocket costs (n = 4), procedure (n = 3), and frequency (n = 2).

CONCLUSIONS

Health preference studies on CRC were found to have a high RoB. The composition of choice tasks revealed a lack of attributes on patient-important outcomes (like incidence reduction), while attributes not considered relevant for individual screening decisions (like sensitivity) were frequently used. Future studies eliciting stated preferences in cancer screening should apply the principles of informed decision-making in attribute identification and selection.

Colon Capsule Endoscopy in the Diagnosis of Colon Polyps: Who Needs a Colonoscopy?

Colon screening programs have reduced colon cancer mortality. Population screening should be minimally invasive, safe, acceptably sensitive, cost-effective, and scalable. The range of screening modalities include guaiac or immunochemical fecal occult blood testing and CT colonography and colonoscopy. A number of carefully controlled studies concur that second-generation capsule endoscopy has excellent sensitivity for polyp detection and a high negative predictive value. Colon capsules fulfill the screening expectation of safety, high sensitivity for polyp detection, and patient acceptance, and appear to straddle the divide between occult blood testing and colonoscopy. While meeting these criteria, there remains the challenges of scaling, capsule practitioner training, resource allocation, and implementing change of practice. Like CT colonography, capsule screening presents the clinician with a decision on the threshold for colonoscopy referral. Overall, colon capsules are an invaluable tool in polyp detection and colon screening and offer a filter that determines “who needs a colonoscopy?”.

Optimizing bowel preparation for colonoscopy: A cross-sectional study of the Chinese population

Background

The quality of bowel preparation is an important factor in the success of colonoscopy. However, the quality of bowel preparation is often affected by multiple factors. The main objective of this study was to explore the specific factors that affect the quality of bowel preparation.

Methods

Patients were consecutively recruited from the gastroenterology department in Union Hospital, Tongji Medical College, Huazhong University of Science and Technology in Wuhan from May 2018 to December 2018. All patients were undergoing colonoscopy. Bowel preparation was evaluated by the Ottawa Bowel preparation Scale (OBPS) and all patients were categorized into 2 groups according to the OBPS. Multivariate analysis was conducted to identify the factors associated with bowel preparation quality.

Results

A total of 910 patients were included in the analysis with an average age of 48.62 ± 13.57 years. Patient source (P < 0.001) and the preparation method (P = 0.029) were correlated with OBPS adequacy. In addition, after stratified by age, preparation method (P = 0.022) was a significant factor among patients under 50 years old; whereas waiting time (P = 0.005) was a significant factor among patients over 50 years old.

Conclusion

Bowel preparation should be tailored based on the age of the patients to determine the most appropriate plan, including the most appropriate waiting time and the most appropriate purgative combination. Doctors should also focus more on the quality of bowel preparation in inpatients, who are more likely than outpatients to have an inadequate bowel preparation.

HunCRC: annotated pathological slides to enhance deep learning applications in colorectal cancer screening

Histopathology is the gold standard method for staging and grading human tumors and provides critical information for the oncoteam’s decision making. Highly-trained pathologists are needed for careful microscopic analysis of the slides produced from tissue taken from biopsy. This is a time-consuming process. A reliable decision support system would assist healthcare systems that often suffer from a shortage of pathologists. Recent advances in digital pathology allow for high-resolution digitalization of pathological slides. Digital slide scanners combined with modern computer vision models, such as convolutional neural networks, can help pathologists in their everyday work, resulting in shortened diagnosis times. In this study, 200 digital whole-slide images are published which were collected via hematoxylin-eosin stained colorectal biopsy. Alongside the whole-slide images, detailed region level annotations are also provided for ten relevant pathological classes. The 200 digital slides, after pre-processing, resulted in 101,389 patches. A single patch is a 512 × 512 pixel image, covering 248 × 248 μm² tissue area. Versions at higher resolution are available as well. Hopefully, HunCRC, this widely accessible dataset will aid future colorectal cancer computer-aided diagnosis and research.

Measurement(s)	H&E slide staining • ex vivo light microscopy with immunohistochemistry and digital image analysis • Image Annotation Statement • Screening Colonoscopy
Technology Type(s)	Hematoxylin and Eosin Staining Method • bright-field microscopy • Observation • Biopsy of Colon
Factor Type(s)	screening status of colon cancer or normal tissue
Sample Characteristic - Organism	Homo sapiens
Sample Characteristic - Location	Central Hungary

Disparities in Screening for Colorectal Cancer Based on Limited Language Proficiency

BACKGROUND

This study analyzes the association between limited language proficiency and screening for colorectal cancer.

METHODS

This is a retrospective cohort study from the 2015 sample of the National Health Interview Survey database utilizing univariate and multivariate regression analysis. The study population includes subjects between 50 and 75 years of age. The main outcome analyzed was rates of screening colonoscopies between limited English-language proficiency (LEP) subjects and those fluent in English. Secondary outcomes included analysis of baseline, socioeconomic, access to health care variables, and other modalities for colorectal cancer screening between the groups.

RESULTS

Incidence of limited language proficiency was 4.8% (n = 1978, count = 4 453 599). They reported lower rates of screening colonoscopies (61% vs 34%, P < .001), less physician recommendation for a colonoscopy (87 vs 60%, P < .001), fewer polyps removed in the previous 3 years (24% vs 9.1%; P < .001), and fewer fecal occult blood samples overall (P < .001). Additionally, Hispanic non-LEP subjects have higher rates of colonoscopies compared to those with language barriers (50% vs 33%, P < .001). On multivariate analysis, LEP was associated with a lower likelihood to have a screening colonoscopy (OR .67 95% CI .49-.91). A second regression model with "Spanish language" and "other language" variables included, associated Spanish speakers with a lower likelihood for a screening colonoscopy (OR .71 95% CI .52-.97) when controlling for baseline, socioeconomic, and access to health care covariates.

DISCUSSION

Patients with limited English-language proficiency are associated with lower rates of screening for colorectal cancer, in particular the Spanish speaking subgroup.

Colorectal cancer mortality after randomized implementation of FIT-based screening - a nationwide cohort study

Objective

Evidence of reduction in colorectal cancer (CRC) mortality following CRC screening based on the faecal immunochemical test (FIT) is insufficient. This study aimed to analyse if CRC mortality was reduced after implementing FIT-based screening.

Setting

The Danish national CRC screening programme.

Methods

This nationwide cohort study included residents aged 50–71 years invited to the prevalence round of the screening programme. Invitation order was decided by randomising on birth month; the first two birth months to be invited were classified as invited and the five last were classified as not-yet-invited and given a pseudo invitation data. Follow-up was from (pseudo)invitation date until 31 December 2017, emigration or death. Relative risk (RR) of CRC death was calculated with 95% confidence intervals (CIs).

Results

A total of 897,812 residents were included (29% invited and 71% not-yet-invited). The median follow-up was 3.3 years. The RR of CRC death at end of follow-up was 0.83 (95% CI 0.66; 1.03) among those invited to screening compared with those not yet invited. For men aged 60–71 years, this RR was 0.68 (95% CI 0.49; 0.94). For those participating in screening compared with a similar group of not-yet-invited residents, the RR was 0.71 (95% CI 0.46–1.08). For male participants aged 60–71 years, this RR was 0.49 (95% CI 0.27−0.89). For women and men aged 50–59 years, RRs were small and statistically non-significant.

Conclusion

This nationwide study showed that even within a median follow-up of only 3.3 years, implementing FIT-based CRC screening reduced CRC mortality among older men.

Colorectal cancer screening participation among citizens not recommended to be screened: a cohort study

BACKGROUND

Guidelines on colorectal cancer (CRC) screening recommend screening of average-risk adults only. In addition, screening of individuals with active inflammatory bowel disease (IBD) might result in too many false-positive cases. However, the organisers of CRC screening programmes are often uninformed of whom to exclude due to an elevated CRC risk or active IBD. It is therefore unknown how often high-risk individuals (i.e. individuals with a previous diagnosis of CRC or polyps associated with hereditary CRC syndromes and certain patient groups with a diagnosis of inflammatory bowel disease (IBD) or multiple polyps) and individuals with active IBD participate in CRC screening following invitation.

MATERIALS AND METHODS

We used data from the first two years of the Danish CRC screening programme (2014-2015). Information on invitations, participations and FIT test results were obtained from the national screening database, while information on previous CRC, hereditary CRC syndromes, IBD or multiple polyps diagnoses were obtained from the Danish Cancer Registry and the Danish Patient Register. Screening participation rates and FIT-positive rates were calculated and compared for high-risk invitees, invitees having IBD and an average risk group of remaining invitees not diagnosed with colorectal polyps in 10 years preceding the invitation.

RESULTS

When invited to CRC screening, 28-48% of high-risk residents (N: 29; 316; 5584) and 55% of residents with IBD (N: 2217; 6927) chose to participate. The participation rate was significantly higher (67%) among residents without previous colorectal disease, i.e. the average risk group (N = 585,624). In this average group 6.7% of the participants had a positive FIT test. The proportion of positive FIT results was higher among all disease groups (7.7-14.8%), though not statistically significant for participants with prior CRC diagnosis and participants with high-risk IBD.

CONCLUSION

When high-risk residents and residents with IBD receive an invitation to CRC screening, many participate despite being recommended not to. The screening program was not intended for these groups and further research is needed as several of these groups have a higher rate of positive screening result than the average risk population.

Cross-cultural validation of stool Based Colorectal cancer screening methods in the North West of Iran

Background

Globally, colorectal cancer (CRC) is the third most common cancer and the second leading cause of death from cancer. Incidence and mortality from CRCboth can be reduced and prevented using screening and early detection programs. The current study aimed to assess the feasibility of the colorectal cancer screening program in Northwest of Iran.

Methods

The study designed as a cross-cultural analytic study, to evaluate the diagnostic accuracy of stool-based tests compared with colonoscopy, during 2016–2020. All individuals first were assessed with our CRC risk assessment tool, then eligible volunteers entered the study. Colonoscopy was performed on all participants, also stool-based tests including traditional guaiac, high-sensitivity guaiac-based, fecal immunochemical test (FIT), and multitarget stool DNA (Mt-sDNA) panel tests were performed.

Results

Mt-sDNA test panel had a sensitivity of 77.8% (95% CI: 40–97.2)for detecting colorectal cancer with a specificity of 91.2% (95% CI:85.4–95.2). The FIT test alone had a lower sensitivity (66.7%; 95% CI:29.9–92.5) and almost the same specificity of 93.9% (95% CI: 88.7–97.2) for cancer detection. Mt-sDNA test had better diagnostic accuracy than the FIT (AUC = 0.85 vs 0.80), and is a more useful screening test. Positive and negative predictive values for cancer detection for both Mt-sDNA and FIT tests were almost the same results, however Mt-sDNA test had better NPV results than the FIT test alone.

Conclusion

Our results showed that both Mt-sDNA panel and the FIT test had acceptable cut-off points for cancer detection, however, Mt-sDNA test had better diagnostic accuracy.

•

A priority of Iranian health policy must be to develop an executive plan to identify the appropriate CRC screening method.

•

This study provides a first step toward the design of a population-based CRC screening program in East Azerbaijan, Iran.

•

The current study has been performed to evaluate the diagnostic accuracy of stool-based tests for CRC screening.

•

Our results showed that both Mt-sDNA panel and the FIT test had acceptable cut-off points for cancer detection.

•

Among four stool -based tests, Mt-sDNA test had the highest sensitivity for detection of cancer and advanced adenoma.

A fluorescent microsphere-based immunochromatographic strip is effective for quantitative fecal blood testing in colorectal cancer screening

Background: Colorectal cancer (CRC) represents a major health concern that can be screened for by the fecal immunochemical test (FIT), which detects blood in the stool. CRC detection sensitivity for hemoglobin (Hb) combined with transferrin (Tf) is higher than for hemoglobin alone. Methods: We developed a europium fluorescent microsphere-based quantitative lateral flow immunochromatography strip to detect fecal Hb and Tf. Performance was tested using fecal samples from 51 patients with CRC and 122 normal subjects. Test strips were generated using paired mouse anti-human Hb and mouse anti-human Tf monoclonal antibodies and tested using standard Hb and Tf samples. Fluorescence was observed at 365 nm and quantitatively measured using a portable fluorescent strip reader. Results: At cutoff values of 100 ng/mL (10 µg/g feces) and 25 ng/mL (2.5 µg/g feces) for Hb and Tf, respectively, the positive rates for Hb, Tf, and Hb+Tf in normal subjects were 6.56%, 5.74%, and 10.66%, respectively, compared to 88.24%, 64.71%, and 94.12% in patients with CRC. The sensitivity and specificity of the FIT combined detection technique were 87.5% and 89.2%, respectively, and the area under the curve (AUC) was 0.92. The sensitivity, specificity, and AUC for the Tf assay were 63.8%, 68.4%, and 0.759, respectively, and those for Hb testing were 69.7%, 70.2%, and 0.774, respectively. The AUC for Hb+Tf was significantly higher than those for Tf or Hb alone (P < 0.001). Conclusions: Fluorescent microsphere-based immunochromatographic strips sensitively detect fecal Hb and Tf, and sensitivity and specificity are improved for Hb+Tf. This system represents a rapid and portable alternative for on-site early CRC screening.

Evaluation of fecal SYPL1 as a diagnostic biomarker in colorectal cancer

BACKGROUND

At present, there is still no ideal non-invasive biomarker for colorectal cancer (CRC) screening. Previously, we foundserum synaptophysin like 1 (SYPL1) served as a potential biomarker for CRC diagnosis. However, whether fecal SYPL1 (fSYPL1) are more sensitive and specific for CRC remains unclear.

METHODS

We analyzed fSYPL1 in controls (n = 70), adenoma patients (n = 80), CRC patients (n = 150) and postoperative CRC patients (n = 25) by ELISA.

RESULTS

SYPL1 was stable in feces. The fSYPL1 levels were significantly higher in CRC patients than in either controls or adenoma patients (P < 0.0001). ROC curves showed that fSYPL1 performed superbly in distinguishing CRC patients from controls (AUC = 0.947; 95% CI: 0.920 - 0.974, P < 0.0001, sensitivity: 80.67%, specificity: 100.00%), which showed much stronger performance than the traditional biomarkers (FOBT, CEA and CA19-9). Meanwhile, the fSYPL1 level positively correlated with tumor size, tumor invasion, lymph node invasion and clinical stage (P < 0.05). In addition, the detection rate of fSYPL1 was high in early CRC (75.00% in stage I and II). The fSYPL1 levels in CRC patients declined substantially after surgery (P = 0.0002). By means of a lower cut off level, 73.58% of high-risk adenomas were detected. The combination of fSYPL1 and FOBT performed better than the combination of plasma SYPL1, CEA and CA199 in distinguishing CRC patients from controls.

CONCLUSION

The fSYPL1 might be a potential biomarker for CRC screening, early diagnosis, prognosis prediction and therapeutic effect monitoring.

The Role of Clips in Preventing Delayed Bleeding After Colorectal Polyp Resection: An Individual Patient Data Meta-Analysis

BACKGROUND & AIMS

Nonpedunculated colorectal polyps are normally endoscopically removed to prevent neoplastic progression. Delayed bleeding is the most common major adverse event. Clipping the resection defect has been suggested to reduce delayed bleedings. Our aim was to determine if prophylactic clipping reduces delayed bleedings and to analyze the contribution of polyp characteristics, extent of defect closure, and antithrombotic use.

METHODS

An individual patient data meta-analysis was performed. Studies on prophylactic clipping in nonpedunculated colorectal polyps were selected from PubMed, Embase, Web of Science, and Cochrane database (last selection, April 2020). Authors were invited to share original study data. The primary outcome was delayed bleeding ≤30 days. Multivariable mixed models were used to determine the efficacy of prophylactic clipping in various subgroups adjusted for confounders.

RESULTS

Data of 5380 patients with 8948 resected polyps were included from 3 randomized controlled trials, 2 prospective, and 8 retrospective studies. Prophylactic clipping reduced delayed bleeding in proximal polyps ≥20 mm (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.44-0.88; number needed to treat = 32), especially with antithrombotics (OR, 0.59; 95% CI, 0.35-0.99; number needed to treat = 23; subgroup of anticoagulants/double platelet inhibitors: n = 226; OR, 0.40; 95% CI, 0.16-1.01; number needed to treat = 12). Prophylactic clipping did not benefit distal polyps ≥20 mm with antithrombotics (OR, 1.41; 95% CI, 0.79-2.52).

CONCLUSIONS

Prophylactic clipping reduces delayed bleeding after resection of nonpedunculated, proximal colorectal polyps ≥20 mm, especially in patients using antithrombotics. No benefit was found for distal polyps. Based on this study, patients can be identified who may benefit from prophylactic clipping. (PROSPERO registration number CRD42020104317.).

Effect of colorectal cancer screening on long-term survival of colorectal cancer patients: Results of the Korea National Cancer Screening Program

The Korea National Cancer Screening Program (KNCSP) provides fecal immunochemical test-based colorectal cancer (CRC) screening for people aged ≥50 years. This study aimed to investigate the long-term survival effects of CRC screening based on screening history and interval time since screening. The study cohort was obtained by linking three national databases, namely the Korea Central Cancer Registry, KNCSP database, and Death Certificate. We included 32 509 CRC patients diagnosed in 2008-2009, who underwent CRC screening via the KNCSP between 2004 and 2009. The patients were followed-up until 2019, and their survival was assessed according to their CRC screening history. Cox proportional hazards regression was used to compare time to deaths among CRC patients according to CRC screening history, after adjusting for covariates. Of the 32 509 patients, 20 022 (61.5%) patients were alive by the end of 2019. Long-term survival was significantly higher among screened patients (68.2%) than non-screened (57.2%) individuals. Compared with never-screened patients, the hazard ratio (HR) for CRC-specific death in screened patients was 0.77 (95% CI%, 0.73-0.80). Lowest HR was observed in screened, localized CRC patients (HR, 0.48; 95% CI, 0.42-0.56); HR for CRC-specific death was the lowest in patients screened within 12 months of diagnosis (HR, 0.70; 95% CI, 0.66-0.74), following which, the HRs increased with increasing time interval. CRC screening was positively associated with favorable prognosis in CRC patients aged 50-79 years. The effects on long-term survival according to interval time was the best among individuals screened within one year before diagnosis. This article is protected by copyright. All rights reserved.

Comparison in the development of colorectal cancer after screening colonoscopy between elderly and younger population

BACKGROUND AND AIMS

This study aimed to evaluate and compare the incidence of colorectal cancer (CRC) in elderly participants aged ≥75 years and those <75 years who had previously undergone a colonoscopy.

METHODS

This retrospective cohort study was conducted at the Center for Preventive Medicine at St. Luke's International Hospital in Japan. All participants who underwent screening colonoscopy between 2005 and 2015 were included and followed up until 2020. Our primary outcome was the identification of CRC as confirmed by pathology after screening colonoscopy. We compared the development of CRC between the two groups using survival analyses. A sub-analysis to evaluate the incidence of CRC among participants with and without neoplastic polyp resection at initial colonoscopy was also performed.

RESULTS

A total of 8350 participants were enrolled; the median follow-up period was 2982 days (interquartile range:1932-4141), mean age was 52.5 years (SD: 11.5) and 5274 (61.3%) participants were men. The incidence of CRC during the follow-up period was 82 (0.95%) among all participants and 11 (4.31%) among the elderly participants. Elderly participants showed a significantly higher incidence of CRC than the other group [hazard ratio, 2.56; 95% confidence interval (CI), 1.14-5.75]. The sub-analysis showed that out of 2878 participants with a neoplastic polyp at the initial colonoscopy, 52 (1.81%) developed CRC (hazard ratio, 2.85; 95% CI, 1.16-6.98).

CONCLUSIONS

A repeat colonoscopy might be warranted in people with high activities of daily living and few comorbidities, especially if there is a history of neoplastic polypectomy at the first colonoscopy.

Diagnostic Accuracy of Multitarget Stool DNA Testing for Colorectal Cancer Screening: A Systematic Review and Meta-analysis

This study aimed to collect and summarize test data and conduct a meta-analysis, with respect to the Multitarget Stool DNA test sensitivity and specificity, compared to colonoscopy. All manuscripts were screened for eligibility according to inclusion criteria. Participants were a normal population at an average risk of developing CRC. Intervention was Stool based and DNA panel tests compared with colonoscopy, and outcome was detection of CRC and any pre-cancerous lesions. Inter-study and inconsistency (using the I-squared test) were assessed. Meta-analyses of the Mt-sDNA test showed a combined sensitivity of 89%, 51%, and 76% for the detection of CRC, advanced adenoma (AA), and combined CRC and AA, respectively. The overall specificity was 91%, 89%, and 90% for the detection of CRC, AA, and combined CRC and AA, respectively. Mt-sDNA had significantly acceptable diagnostic accuracy for CRC and AA diagnosis, but still has lower sensitivity and specificity than colonoscopy.

Colorectal Cancer Prevalence and Survival in Cuenca (Spain)

BACKGROUND

Colorectal cancer is the most commonly diagnosed cancer type and the second cause of cancer death in Spain. The primary risk factor for colorectal cancer is age, with 90% of all diagnosed patients aged over 50 years. Prognosis mainly depends on tumour stage.

AIM

Conduct a colorectal cancer prevalence and survival study in Cuenca (Spain) since there are almost no studies based on small populations. This is the first study about survival in screening of colorectal cancer carried out in hospitals in Castilla-La Mancha.

METHODS

Retrospective descriptive cohort study was performed to include patients with colorectal cancer diagnosed by colonoscopy between May 2015 and April 2016, and who were followed up for 48 months. The study considered sociodemographic and clinical data of the patients. Survival curves were estimated using the Kaplan-Meier method. The proportional hazard rate associated with age, gender, stage, and presence of metastasis was calculated using the Cox regression method.

RESULTS

Fifty-seven patients were included in the study. The mean follow-up was 45.5 months. Ten patients died during the study; in seven cases, the cause was colorectal cancer. The percentage of patients alive at a 48-month follow-up was 82.4%.

CONCLUSION

Colon cancer is a high-prevalence pathology, with adenocarcinoma being the most common histology. The results seem to indicate that it affects men more frequently, mortality rises with tumour stage at diagnosis and declines with use of chemotherapy. We present a study that could justify large-scale epidemiological studies for the regional surveillance and evolution of colorectal cancer in Spain.

A comprehensive framework for early-onset colorectal cancer research

Sporadic colorectal cancer has traditionally been viewed as a malignancy of older individuals. However, as the global prevalence of the disease diagnosed in younger individuals (<50 years) is expected to increase within the next decade, greater recognition is now being given to early-onset colorectal cancer. The cause of the predicted rise in prevalence is largely unknown and probably multifactorial. In this Series paper, we discuss the potential underlying causes of early-onset colorectal cancer, the role of energy balance, biological and genomic mechanisms (including microbiome aspects), and the treatment of early-onset colorectal cancer. We have specifically considered the psychosocial challenges of being diagnosed with colorectal cancer at younger age and the potential financial toxicity that might ensue. This Series paper brings a comprehensive review based on the existing data in the hopes of optimising the overall outcomes for patients with early-onset colorectal cancer.

Predictive factors of inadequate bowel preparation for elective colonoscopy

Aim

This study aimed to evaluate the effects of factors like demographic items, comorbidities, and drug history on the inadequacy of colonic preparation before colonoscopy.

Background

Inadequate bowel preparation can lead to lower polyp detection rates, longer procedure times, and lower cecal intubation rates.

Methods

This population-based study was conducted on 2476 Iranian adults who were referred to two tertiary centers for elective colonoscopy between 2017 and 2018. Bowel preparation quality was scored by the Boston bowel preparation scale (BBPS). Univariate and multivariate logistic regressions were used to find the independent predictors of bowel preparation inadequacy.

Results

The results showed that 31.8% of patients had inadequate bowel preparation before their colonoscopy. Higher age, BMI>25, abdominal circumference>95 cm, low fruit consumption, and history of smoking were independently correlated with bowel preparation inadequacy. Additionally, using NSAIDs and SSRIs were correlated with bowel preparation adequacy in multivariate regression analysis. Finally, age, gender, ethnicity, BMI, abdominal circumference, fruit consumption, smoking, NSAIDs, SSRIs, education, constipation, physical activity, and diabetes entered the predictive model of this study. The area under the curve (AUC) reached 0.70 in the final step.

Conclusion

The independent risk factors associated with colonic preparation inadequacy were identified, and herein, a predictive model is suggested for identifying patients with a high risk of bowel preparation inadequacy before a colonoscopy so that alternative preparation techniques can be employed among high-risk groups to yield optimal preparation quality.

Colorectal Cancer Screening - Approach, Evidence, and Future Directions

Colorectal Cancer ScreeningScreening for colorectal cancer is widespread and successful but screening programs across the globe differ in their recommendations. In this article, Helsingen and Kalager review the evidence for different approaches to colorectal cancer screening and propose a framework for the evaluation of screening programs going forward.

The impact of cumulative colorectal cancer screening delays: A simulation study

OBJECTIVE

Annual fecal immunochemical tests can reduce colorectal cancer incidence and mortality. However, screening is a multi-step process and most patients do not perfectly adhere to guideline-recommended screening schedules. Our objective was to compare the reduction in colorectal cancer incidence and life-years gained based on US guideline-concordant fecal immunochemical test screening to scenarios with a range of delays.

METHOD

The Colorectal Cancer Simulated Population model for Incidence and Natural history (CRC-SPIN) microsimulation model was used to estimate the effect of systematic departures from fecal immunochemical test screening guidelines on lifetime screening benefit.

RESULTS

The combined effect of consistent modest delays in screening initiation (1 year), repeated fecal immunochemical test screening (3 months), and receipt of follow-up or surveillance colonoscopy (3 months) resulted in up to 1.3 additional colorectal cancer cases per 10,000, 0.4 additional late-stage colorectal cancer cases per 10,000 and 154.7 fewer life-years gained per 10,000. A 5-year delay in screening initiation had a larger impact on screening effectiveness than consistent small delays in repeated fecal immunochemical test screening or receipt of follow-up colonoscopy after an abnormal fecal immunochemical test. The combined effect of consistent large delays in screening initiation (5 years), repeated fecal immunochemical test screening (6 months), and receipt of follow-up or surveillance colonoscopy (6 months) resulted in up to 3.7 additional colorectal cancer cases per 10,000, 1.5 additional late-stage colorectal cancer cases per 10,000 and 612.3 fewer life-years gained per 10,000.

CONCLUSIONS

Systematic delays across the screening process can result in meaningful reductions in colorectal cancer screening effectiveness, especially for longer delays. Screening delays could drive differences in colorectal cancer incidence across patient groups with differential access to screening.

The prevalence of sessile serrated lesion in the colorectum and its relationship to synchronous colorectal advanced neoplasia: a systemic review and meta-analysis

BACKGROUND

The aim of this systemic review and meta-analysis was to evaluate the prevalence of sessile serrated lesion (SSL) and its relationship to synchronous colorectal advanced neoplasia.

MATERIALS AND METHODS

Comprehensive, computerized research was performed on PubMed and published from 1 January 2010 to 6 July 2018 which searched relevant articles without any language limitations. Clinical trials were included in the narrative systemic review if they matched the following inclusion criteria: (1) published as a case-controlled study, cohort study or cross-sectional study; (2) defined objectively for diagnosis of SSL within the studies; (3) addressed the prevalence and characteristics of SSL. Within these trials, if they met additional criteria involving the reported outcome of risk regarding advanced neoplasia in relation to SSL, they were enrolled into meta-analysis.

RESULTS

Forty-one trials were enrolled for the systematic review, with a total of eight analyzed for the meta-analysis. The prevalence of all SSL ranged from 0.038 to 20.23% and the prevalence by pooled analysis was 2.7%. In a subgroup analysis, the overall prevalence of SSL during the periods of 2010-2014 and 2015-2018 was shown to be 2.7 and 2.8%, respectively. We calculated the pooled data on the cancer risk of SSL and the risk of synchronous advanced neoplasia in patients with SSL made available from the eight trials, which resulted in a pooled odds ratio of 3.53 (95% confidence interval 2.39-5.20, I2 = 4%, P = 0.40).

CONCLUSION

In this systemic review, SSL was found to be associated with an increased risk of synchronous advanced neoplasia in the colorectum.

Incidence, mortality, survival, risk factor and screening of colorectal cancer: A comparison among China, Europe, and northern America

Colorectal cancer (CRC) is one of the most common malignancies worldwide. China, Europe and northern America account for more than half of the new CRC cases and associated deaths globally. This review summarizes the current status and temporal trends of CRC in China, Europe, and northern America. The potential primary preventive strategies and latest advances in CRC screening techniques and programs are discussed. Recently, the incidence and mortality of CRC in some European and northern American countries have decreased; conversely, CRC incidence and mortality continue to increase in China. The overall 5-year relative survival rate for CRC is similar between these regions, but there is considerable heterogeneity among European countries. Implementing population-based CRC screening programs can effectively address the growing disease burden. The effectiveness of nationwide CRC screening programs in these regions has been limited by relatively low coverage and participation rate. The deployment of state-of-the-art techniques and precise risk-adapted screening strategies incorporating effective risk prediction models and screening techniques may boost screening effectiveness. Our review provides novel foundations for the development and optimization of CRC preventive strategies.

Women require routine opioids to prevent painful colonoscopies: a randomised controlled trial

BACKGROUND

Women are at high risk for painful colonoscopy. Pain, but also sedation, are barriers to colorectal cancer (CRC) screening participation. In a randomised controlled trial, we compared on-demand with pre-colonoscopy opioid administration to control pain in women at CRC screening age.

METHODS

Women, aged 55-79 years, attending colonoscopy at two Norwegian endoscopy units were randomised 1:1:1 to (1) fentanyl on-demand, (2) fentanyl prior to colonoscopy, or (3) alfentanil on-demand. The primary endpoint was procedural pain reported by the patients on a validated four-point Likert scale and further dichotomized for the study into painful (moderate or severe pain) and non-painful (slight or no pain) colonoscopy. Secondary endpoints were: willingness to repeat colonoscopy, adverse events, cecal intubation time and rate, and post-procedure recovery time.

RESULTS

Between June 2017 and May 2020, 183 patients were included in intention-to-treat analyses in the fentanyl on-demand group, 177 in the fentanyl prior to colonoscopy group, and 179 in the alfentanil on-demand group. Fewer women receiving fentanyl prior to colonoscopy reported a painful colonoscopy compared to those who were given fentanyl on-demand (25.2% vs. 44.1%, p < .001). There was no difference in the proportion of painful colonoscopies between fentanyl on-demand and alfentanil on-demand (44.1% vs. 39.5%, p = .40). No differences were observed for adverse events or any of the other secondary endpoints between the three groups.

CONCLUSIONS

Fentanyl prior to colonoscopy provided better pain control than fentanyl or alfentanil on-demand. Fentanyl before colonoscopy should be recommended to all women at screening age. Trial registration: Clinicaltrials.gov (NCT01538550). Norwegian Medicines Agency (16/16266-13). EU Clinical Trials Register (EUDRACTNR. 2016-005090-13).

Stemness, Inflammation and Epithelial-Mesenchymal Transition in Colorectal Carcinoma: The Intricate Network

In global cancer statistics, colorectal carcinoma (CRC) ranks third by incidence and second by mortality, causing 10.0% of new cancer cases and 9.4% of oncological deaths worldwide. Despite the development of screening programs and preventive measures, there are still high numbers of advanced cases. Multiple problems compromise the treatment of metastatic colorectal cancer, one of these being cancer stem cells—a minor fraction of pluripotent, self-renewing malignant cells capable of maintaining steady, low proliferation and exhibiting an intriguing arsenal of treatment resistance mechanisms. Currently, there is an increasing body of evidence for intricate associations between inflammation, epithelial–mesenchymal transition and cancer stem cells. In this review, we focus on inflammation and its role in CRC stemness development through epithelial–mesenchymal transition.

Colorectal Cancer Detected by Machine Learning Models Using Conventional Laboratory Test Data

Background: Current diagnostic methods for colorectal cancer (CRC) are colonoscopy and sigmoidoscopy, which are invasive and complex procedures with possible complications. This study aimed to determine models for CRC identification that involve minimally invasive, affordable, portable, and accurate screening variables. Methods: This was a retrospective study that used data from electronic medical records of patients with CRC and healthy individuals between July 2017 and June 2018. Laboratory data, including liver enzymes, lipid profiles, complete blood counts, and tumor biomarkers, were extracted from the electronic medical records. Five machine learning models (logistic regression, random forest, k-nearest neighbors, support vector machine [SVM], and naïve Bayes) were used to identify CRC. The performances were evaluated using the areas under the curve (AUCs), sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV). Results: A total of 1164 electronic medical records (CRC patients: 582; healthy controls: 582) were included. The logistic regression model achieved the highest performance in identifying CRC (AUC: 0.865, sensitivity: 89.5%, specificity: 83.5%, PPV: 84.4%, NPV: 88.9%). The first four weighted features in the model were carcinoembryonic antigen (CEA), hemoglobin (HGB), lipoprotein (a) (Lp(a)), and high-density lipoprotein (HDL). A diagnostic model for CRC was established based on the four indicators, with an AUC of 0.849 (0.840-0.860) for identifying all CRC patients, and it performed best in discriminating patients with late colon cancer from healthy individuals with an AUC of 0.905 (0.889-0.929). Conclusions: The logistic regression model based on CEA, HGB, Lp(a), and HDL might be a powerful, noninvasive, and cost-effective method to identify CRC.

Change in Colorectal Cancer Tests Submitted for Reimbursement in Switzerland 2012-2018: Evidence from Claims Data of a Large Insurance

Objectives: Guidelines recommend colorectal cancer (CRC) screening by fecal occult blood test (FOBT) or colonoscopy. In 2013, Switzerland introduced reimbursement of CRC screening by mandatory health insurance for 50-69-years-olds, after they met their deductible. We hypothesized that the 2013 reimbursement policy increased testing rate.

Methods: In claims data from a Swiss insurance, we determined yearly CRC testing rate among 50-75-year-olds (2012–2018) and the association with socio-demographic, insurance-, and health-related covariates with multivariate-adjusted logistic regression models. We tested for interaction of age (50–69/70–75) on testing rate over time.

Results: Among insurees (2012:355′683; 2018:348′526), yearly CRC testing rate increased from 2012 to 2018 (overall: 8.1–9.9%; colonoscopy: 5.0–7.6%; FOBT: 3.1–2.3%). Odds ratio (OR) were higher for 70–75-year-olds (2012: 1.16, 95%CI 1.13–1.20; 2018: 1.05, 95%CI 1.02–1.08). Deductible interacted with changes in testing rate over time (p < 0.001). The increase in testing rate was proportionally higher among 50-69-years-olds than 70-75-year-olds over the years.

Conclusions: CRC testing rate in Switzerland increased from 2012 to 2018, particularly among 50-69-years-olds, the target population of the 2013 law. Future studies should explore the effect of encouraging FOBT or waiving deductible.

Clinical significance of microRNA-1180-3p for colorectal cancer and effect of its alteration on cell function

An early diagnosis and effective prognostic factors would greatly reduce the mortality rate of colorectal cancer (CRC). This research is intended to complete the evaluation of the prognostic value and potential role of miR-1180-3p in CRC. The miR-1180-3p levels were reduced in CRC patients’ tissues, blood, and human CRC cell lines. The ability of miR-1180-3p was explored in discrimination of CRC patients and healths and the value in overall survival estimate. The effect of miR-1180-3p dysregulation on the CRC cellular function was investigated. miR-1180-3p is downregulated in CRC tissues, blood and cells than normal ones. This lower expression was correlated with vascular invasion, lymph node metastasis, and TNM stage. With the use of ROC curve, miR-1180-3p showed discriminating ability in CRC patients and healthy subjects. With the result of Kaplan–Meier analysis and multi-multivariate Cox analysis, miR-1180-3p was an independent predictor for CRC patients’ overall survival. Utilizing CCK-8, Transwell and matrigel assays, overexpression of miR-1180-3p reduced cancer cell proliferation and mobility, but induced apoptosis, by targeting COL12A1. miR-1180-3p might function as a suppressor in CRC progression and allowed the discovery of a new biomarker for diagnosis, prognosis and therapy target for CRC.

Updates, Controversies, and Emerging Approaches in Colorectal Screening

Colorectal cancer (CRC) is the third most common cancer worldwide and the second leading cause of cancer-related deaths. Despite the threatening statistics, the US burden for CRC has been decreasing, which is likely multifactorial and has partial contribution from widespread timely screening, more advanced CRC treatment, and daily aspirin use in some patients. While overall death rate from CRC decreased by approximately a half between 1975 and 2012, epidemiologic studies demonstrate that CRC incidence is increasing in the younger population. This pattern has prompted the American Cancer Society (ACS) to revise their guidelines. In this review, we plan to discuss the most recent changes in guidelines, data to support them, controversies concerning CRC screening methods, age to start and to stop screening, and post-colonoscopy/polypectomy surveillance guidelines.

The implementation of colorectal cancer screening interventions in low-and middle-income countries: a scoping review

BACKGROUND

Low- and middle-income countries (LMICs) experienced increasing rates of colorectal cancer (CRC) incidence in the last decade and lower 5-year survival rates compared to high-income countries (HICs) where the implementation of screening and treatment services have advanced. This review scoped and mapped the literature regarding the content, implementation and uptake of CRC screening interventions as well as opportunities and challenges for the implementation of CRC screening interventions in LMICs.

METHODS

We systematically followed a five-step scoping review framework to identify and review relevant literature about CRC screening in LMICs, written in the English language before February 2020. We searched Medline, Embase, Web of Science and Google Scholar for studies targeting the general, asymptomatic, at-risk adult population. The TIDieR tool and an implementation checklist were used to extract data from empirical studies; and we extracted data-informed insights from policy reviews and commentaries.

RESULTS

CRC screening interventions (n = 24 studies) were implemented in nine middle-income countries. Population-based screening programmes (n = 11) as well as small-scale screening interventions (n = 13) utilised various recruitment strategies. Interventions that recruited participants face-to-face (alone or in combination with other recruitment strategies) (10/15), opportunistic clinic-based screening interventions (5/6) and educational interventions combined with screening (3/4), seemed to be the strategies that consistently achieved an uptake of > 65% in LMICs. FOBT/FIT and colonoscopy uptake ranged between 14 and 100%. The most commonly reported implementation indicator was 'uptake/reach'. There was an absence of detail regarding implementation indicators and there is a need to improve reporting practice in order to disseminate learning about how to implement programmes.

CONCLUSION

Opportunities and challenges for the implementation of CRC screening programmes were related to the reporting of CRC cases and screening, cost-effective screening methods, knowledge about CRC and screening, staff resources and training, infrastructure of the health care system, financial resources, public health campaigns, policy commitment from governments, patient navigation, planning of screening programmes and quality assurance.

The classification capability of the Asia Pacific Colorectal Screening score in Korea: an analysis of the Cancer Screenee Cohort

OBJECTIVES

This study aimed to validate a simple risk assessment tool for estimating the advanced colorectal neoplasia (ACN) risk at colonoscopy screenings and potential factors relevant for implementing this tool in the Korean population.

METHODS

Our study analyzed data from the Cancer Screenee Cohort Study conducted by the National Cancer Center in Korea. The risk level was assessed using the Asia Pacific Colorectal Screening (APCS) score developed by the Asia-Pacific Working Group on Colorectal Cancer. Logistic regression models were used to examine the associations between colorectal-related outcomes and the risk level by APCS score. The discriminatory performance of the APCS score for various colorectal-related outcomes was assessed using C-statistics.

RESULTS

In 12,520 individuals, 317 ACN cases and 4,528 adenoma cases were found. The APCS tool successfully classified the study population into different risk groups, and significant differences in the ACN rate and other outcomes were observed. The APCS score demonstrated acceptable discrimination capability with area under the curve values ranging from 0.62 to 0.65 for various outcomes. The results of the multivariate logistic regression model revealed that the high-risk group had a 3.1-fold higher risk of ACN (95% confidence interval, 2.08 to 4.67) than the average-risk group. Body mass index (BMI) was identified as a significant predictor of ACN in both multivariate and subgroup analyses.

CONCLUSIONS

Our study highlighted significant differences in colorectal-related screening outcomes by colorectal risk level measured using the APCS score, and BMI could be used to improve the discriminatory capability of the APCS score.

Machine Learning Models Cannot Replace Screening Colonoscopy for the Prediction of Advanced Colorectal Adenoma

Screening for colorectal cancer (CRC) continues to rely on colonoscopy and/or fecal occult blood testing since other (non-invasive) risk-stratification systems have not yet been implemented into European guidelines. In this study, we evaluate the potential of machine learning (ML) methods to predict advanced adenomas (AAs) in 5862 individuals participating in a screening program for colorectal cancer. Adenomas were diagnosed histologically with an AA being ≥ 1 cm in size or with high-grade dysplasia/villous features being present. Logistic regression (LR) and extreme gradient boosting (XGBoost) algorithms were evaluated for AA prediction. The mean age was 58.7 ± 9.7 years with 2811 males (48.0%), 1404 (24.0%) of whom suffered from obesity (BMI ≥ 30 kg/m²), 871 (14.9%) from diabetes, and 2095 (39.1%) from metabolic syndrome. An adenoma was detected in 1884 (32.1%), as well as AAs in 437 (7.5%). Modelling 36 laboratory parameters, eight clinical parameters, and data on eight food types/dietary patterns, moderate accuracy in predicting AAs with XGBoost and LR (AUC-ROC of 0.65–0.68) could be achieved. Limiting variables to established risk factors for AAs did not significantly improve performance. Moreover, subgroup analyses in subjects without genetic predispositions, in individuals aged 45–80 years, or in gender-specific analyses showed similar results. In conclusion, ML based on point-prevalence laboratory and clinical information does not accurately predict AAs.

New scoring systems for predicting advanced proximal neoplasia in asymptomatic adults with or without knowing distal colorectal findings: a prospective, cross-sectional study

BACKGROUND

Models estimating risk for advanced proximal colorectal neoplasia (APN) may be used to select colorectal cancer (CRC) screening test, either prior to knowing distal colorectal findings or afterward. Current models have only fair discrimination and nearly all require knowing distal findings.

OBJECTIVE

Derive and test risk prediction models for APN with and without distal findings.

SETTING

Selected endoscopy centers within central Indiana, USA.

PARTICIPANTS

Average-risk persons undergoing first-time screening colonoscopy.

INTERVENTIONS

Demographics, personal and family medical history, lifestyle factors and physical measures were linked to the most advanced finding in proximal and distal colorectal segments. For both models, logistic regression identified factors independently associated with APN on a derivation set. Based on equation coefficients, points were assigned to each factor, and risk for APN was examined for each score. Scores with comparable risks were collapsed into risk categories. Both models and their scoring systems were tested on the validation set.

MAIN OUTCOME

APN, defined as any adenoma or sessile serrated lesion ≥1 cm, one with villous histology or high-grade dysplasia, or CRC proximal to the descending colon.

RESULTS

Among 3025 subjects in the derivation set (mean age 57.3 ± 6.5 years; 52% women), APN prevalence was 4.5%; 2859 (94.5%) had complete data on risk factors. Independently associated with APN were age, sex, cigarette smoking, cohabitation status, metabolic syndrome, non-steroidal anti-inflammatory drug use and physical activity. This model (without distal findings) was well-calibrated (P = 0.62) and had good discrimination (c-statistic = 0.73). In low-, intermediate- and high-risk groups that comprised 21, 58 and 21% of the sample, respectively, APN risks were 1.47% (95% CI, 0.67-2.77%), 3.09% (CI, 2.31-4.04%) and 11.6% (CI, 9.10-14.4%), respectively (P < 0.0001), with no proximal CRCs in the low-risk group and 2 in the intermediate-risk group. When tested in the validation set of 1455, the model retained good metrics (calibration P = 0.85; c-statistic = 0.83), with APN risks in low- (22%), intermediate- (56%) and high-risk (22%) subgroups of 0.62% (CI, 0.08-2.23%) 2.20% (CI, 1.31-3.46%) and 13.0% (CI, 9.50-17.2%), respectively (P < 0.0001). There were no proximal CRCs in the low-risk group, and two in the intermediate-risk group. The model with distal findings performed comparably, with validation set metrics of 0.18 for calibration, 0.76 for discrimination and APN risk (% sample) in low-, intermediate-, and high-risk groups of 1.1 (69%), 8.3 (22%) and 22.3% (9%).

CONCLUSION

These models stratify large proportions of average-risk persons into clinically meaningful risk groups, and could improve screening efficiency, particularly for noncolonoscopy-based programs.

Uptake of Genetic Testing Among Patients with Cancer At Risk for Lynch Syndrome in the National Health Interview Survey

Lynch syndrome is the most common inherited cancer syndrome that increases the risk of developing colorectal and endometrial cancer. Universal screening guidelines were first recommended by the Centers for Disease Control and Prevention (CDC) in 2009 and are updated annually by multiple societies. Therefore, one would expect genetic testing rates to increase over time. But testing remains underutilized among those with colorectal or endometrial cancer, even though early detection can improve prognosis and survival rates. In this study, we aimed to understand differences in genetic testing uptake among those with colorectal cancer or endometrial cancer from 2005, 2010, 2015, using data from the National Health Interview Survey (NHIS). We examined genetic testing uptake across cancer-type, age (≤50 or ≥51), sex, race, insurance, and education using a χ² statistical analysis. Despite an upward genetic testing trend in 2010, we found no significant differences in genetic testing uptake over time. In 2010, non-White individuals experienced the highest increase from 2005 in comparison with White individuals. However, genetic testing rates declined for both groups by 2015. Our findings show that genetic testing for colorectal cancer and endometrial cancer did not increase over a 10-year period in spite of guidelines that recommend testing. PREVENTION RELEVANCE: Genetic testing uptake for colorectal cancer and endometrial cancer has not increased over a 10-year period in spite of universal screening guidelines. More genetic testing education is needed at the provider and patient level to improve screening strategies for cancer patients who are most at risk for Lynch syndrome.

Proton pump inhibitor omeprazole suppresses carcinogen induced colonic adenoma progression to adenocarcinoma in F344 rat

Colorectal cancer (CRC) causes over 53,000 deaths annually in the United States. Its rising incidences worldwide and particularly in young adults is a major concern. Here, we evaluated the efficacy of omeprazole (OME) that is clinically approved for treating acid-reflux, to enable its repurposing for CRC prevention. In the azoxymethane (AOM)-induced rat CRC model, dietary OME (250 and 500 ppm) was administered at early adenoma stage (8 weeks after AOM) to assess the progression of early lesions to adenocarcinoma. Administration of OME at 250 ppm or 500 ppm doses led to suppression of total colon adenocarcinoma incidence by 15.7% and 32% (p<0.01), respectively. Importantly, invasive carcinoma incidence was reduced by 59% (p<0.0005) and 90% (p<0.0001) in OME administered rats in a dose-dependent manner. There was also a strong and dose-dependent inhibition in the adenocarcinoma multiplicity in rats exposed to OME. Administration of 250 and 500 ppm OME inhibited total colon adenocarcinoma multiplicity by ~49% and ~65% (p<0.0001), respectively. While non-invasive adenocarcinomas multiplicity was suppressed by ~34% to ~48% (p<0.02), the invasive carcinomas multiplicity was reduced by ~74% to ~94% (p<0.0001) in OME exposed rats in comparison to the untreated rats. Biomarker analysis results showed a decrease in cell proliferation and anti-apoptotic/pro-survival proteins with an increase in apoptosis. Transcriptome analysis of treated tumors revealed a significant increase in adenocarcinoma inhibitory genes (Olmf4; Spink4) expression and down regulation of progression promoting genes (SerpinA1, MMP21, IL6). In summary, OME showed significant protection against the progression of adenoma to adenocarcinoma.

Should colorectal cancer screening start at different ages for men and women? Cost-effectiveness analysis for a resource-constrained service

BACKGROUND

Men have a greater risk of colorectal cancer (CRC) than women, but population screening currently starts at the same age for both sexes.

AIM

This analysis investigates whether, in a resource-constrained setting, it would be more effective and cost-effective for men and women to start screening for CRC at different ages.

METHODS AND RESULTS

An economic modeling analysis was carried out using the Microsimulation Model in Cancer of the Bowel to compare sex-stratification against screening everyone from the same age, taking an English National Health Service perspective. Screening men from age 56 and women from age 60, rather than screening everyone from age 58 using a Fecal Immunochemical Test (FIT) threshold of 120 μg/g is expected to produce an additional 0.0004 QALYs for a cost of £0.55 per person at model start (Incremental Cost-effectiveness Ratio = £1392), and to reduce CRC cases and mortality by 25 and 19 per 100 000 people respectively, while using a similar amount of screening resources. Probabilistic sensitivity analysis indicates a 61% probability that sex-stratification is more cost-effective than screening everyone at age 58. Similar benefits of sex-stratification are found at other FIT thresholds, but become negligible if mean screening start age is reduced to 50.

CONCLUSION

Where resources are constrained and it is not feasible to screen everyone from the age of 50, starting screening earlier in men than women is likely to be more cost-effective and gain more health benefits overall than strategies where men and women start screening at the same age.

The effectiveness of using an abdominal binder during colonoscopy: a randomized, double-blind, sham-controlled trial

BACKGROUND

Prolongation of cecal intubation time (CIT) directly affects the comfort of the patient and the colonoscopist. In this study, the effectiveness of using an abdominal binder (AB) during colonoscopy on procedure time and colonoscopy outcomes was investigated.

METHODS

We conducted a parallel randomized double-blind sham-device-controlled study of patients who underwent elective outpatient colonoscopy between 1 May 2020, and 31 August 2020. Participants were randomly assigned to AB (n = 173) and sham binder (SB) (n = 173) groups. The primary outcome was CIT. Secondary outcomes were the need for auxiliary maneuvers, the cecum intubation length (CIL) of the colonoscope, visual analog scale (VAS) score, narcotic analgesic dose, and colonoscopy results. Moreover, subgroup analysis was performed in terms of age and obesity indices.

RESULTS

A total of 346 patients were enrolled in the study. The mean CIT was similar between groups (AB group 240 secs, control group 250 secs, p > .05). Manual pressure requirement was less in the AB group (27 vs. 36%, p = .069). VAS score and the need for extra narcotic analgesic drugs were prominently lower in the AB group (p < .001, p = .016, respectively). In the subgroup analyses, in participants at the age of <60 and waist-to-height ratio (WHtR) ≥0.5, manual pressure requirements were significantly shorter in the AB group (p = .017, p = .032, respectively).

CONCLUSION

AB use in selected patients may be advantageous during colonoscopy because it reduces the need for analgesics and post-procedure pain, and reduces the need for auxiliary maneuvers in relatively young and obese patients.