Screening or Symptoms? How Do We Detect Colorectal Cancer in an Equal Access Health Care System?

Colorectal cancer pre-diagnostic symptoms are associated with anatomic cancer site

BACKGROUND

Signs and red flag symptoms in colorectal cancer (CRC) patients who are below the recommended screening age are often overlooked, leading to delayed diagnosis and worse prognosis. This study investigates how patient pre-diagnostic symptoms are associated with anatomic site of their cancer and whether the association varies by age at CRC diagnosis.

METHODS

We ascertained CRC patients' experienced symptoms and screening through medical abstractions from an ongoing population-based study of CRC patients identified through a SEER cancer registry (N = 626). We used logistic regression to estimate odds ratios and 95% confidence intervals for the association between symptoms and CRC anatomic site. Additional analyses were stratified by age at diagnosis. Early-onset was defined as less than 50 years of age at CRC diagnosis.

RESULTS

Participants who experienced blood in stool were more likely (odds ratio (95% confidence interval)) to have rectal (vs. colon) cancer (4.37 (3.02, 6.33)), as were patients who experienced changes to stool (1.78 (1.21, 2.60)). Patients diagnosed with colon cancer were more likely to present with abdominal pain (0.30 (0.19, 0.47)), anemia (0.40 (0.21, 0.75)), other symptoms (0.33 (0.19, 0.55)) and no symptoms (0.68 (0.44, 1.04)). When stratifying by age at diagnosis, we found that the association between blood in stool and rectal tumor location was particularly pronounced for patients with early-onset CRC (6.48 (2.73, 15.41)).

CONCLUSIONS

Common pre-diagnostic red flag symptoms are associated with CRC anatomic site. These findings can inform best practices for gastroenterologist triage of care and early evaluation of CRC and are of key importance given the rise of early-onset (pre-screening age) CRC.

TRIAL REGISTRATION

Not applicable to this study and analysis.

Universal Healthcare Coverage Does Not Ensure Adherence to Initial Colorectal Cancer Screening Guidelines

INTRODUCTION

Colorectal cancer is the second leading cause of cancer deaths in the USA, and screening tests are underutilized. The aim of this study was to determine the proportion of individuals at average risk who utilized a recommended initial screening test in a universal healthcare coverage system.

MATERIALS AND METHODS

This is a retrospective cohort study of active duty and retired military members as well as civilian beneficiaries of the Military Health System. Individuals born from 1960 to 1962 and eligible for full benefits on their 50th birthday were evaluated. Military rank or rank of benefits sponsor was used to determine socioeconomic status. Adherence to the U.S. Preventive Services Task Force guidelines for initial colorectal cancer screening was determined using "Current Procedural Terminology" and "Healthcare Common Procedure Coding System" codes for colonoscopy, sigmoidoscopy, fecal occult blood test, and fecal immunohistochemistry test. Average risk individuals who obtained early screening ages 47 to 49 were also identified.

RESULTS

This study identified 275,665 individuals at average risk. Of these, 105,957 (38.4%) adhered to screening guidelines. An additional 19,806 (7.2%) individuals were screened early. Colonoscopy (82.7%) was the most common screening procedure. Highest odds of screening were associated with being active duty military (odds ratio [OR] 3.63, 95% confidence interval [CI] 3.43 to 3.85), having highest socioeconomic status (OR 2.37, 95% CI 2.31 to 2.44), and having managed care insurance (OR 4.36, 95% CI 4.28 to 4.44).

CONCLUSIONS

Universal healthcare coverage does not ensure initial colorectal cancer screening utilization consistent with guidelines no does it eliminate disparities.

Can Ultrasound Elastography Discriminate between Rectal Adenoma and Cancer? A Systematic Review

BACKGROUND

Rectal cancer is a common malignancy. Since the introduction of bowel-screening programs, the number of patients with advanced adenomas and early rectal cancer has increased. Despite improved diagnostics, the discrimination between rectal adenomas and early rectal cancer (i.e., pT1-T2) remains challenging. The purpose of this systematic review was to evaluate the diagnostic performance of endorectal ultrasound (ERUS) elastography in discriminating rectal adenomas from cancer.

METHOD

Using PRISMA guidelines, a systematic search was performed on PubMed, Embase, and MEDLINE databases. Studies evaluating the primary staging of rectal adenomas and cancer using ERUS elastography were included.

RESULTS

Six studies were identified; three evaluated the discrimination between adenomas and cancer; two evaluated adenomas and early rectal cancer (i.e., pT1-T2); one evaluated performance on different T categories. All studies reported increased diagnostic accuracy of ERUS elastography compared to ERUS. Sensitivity, specificity and accuracy ranged 0.93-1.00, 0.83-1.00 and 0.91-1.00, respectively, when discriminating adenomas from cancer. In the differentiation between adenomas and early rectal cancer, the sensitivity, specificity and accuracy were 0.82-1.00, 0.86-1.00 and 0.84-1.00, respectively.

CONCLUSION

Elastography increases the accuracy of ERUS and may provide valuable information on malignant transformation of rectal lesions.

Optimal diagnostic accuracy of quantitative faecal immunochemical test positivity thresholds for colorectal cancer detection in primary health care: A community-based cohort study

Background

Optimizing colonoscopy resources is challenging, and information regarding performing diagnostic quantitative faecal immunochemical test (FIT) in daily clinical practice in primary health care is still limited. This study aimed to assess the sensitivity, specificity, positive predictive value and negative predictive value of varying FIT positivity thresholds on colorectal cancer (CRC) detection in primary health care.

Methods

A retrospective cohort study of 38,675 asymptomatic and symptomatic patients with a FIT (OC‐Sensor™) performed between 2012 and 2016 in a primary health‐care setting, using a clinical laboratory database of two Spanish areas linked with the National Health System's Hospital Discharge Records Database. The primary outcome was 2‐year CRC incidence.

Results

The mean age of the participants was 63.2 years; 17,792 (46.0%) were male. CRC prevalence was 1.7% (650/38,675). The percentage of patients with a FIT result above the threshold was 20.7% and 14.6% for 10 μg Hb/g faeces and 20 μg Hb/g faeces thresholds, respectively. Sensitivity was 90.5% (95% confidence interval 88.0%–92.5%) at a 10 μg Hb/g faeces threshold, and this decreased by 3.1% when a 20 μg Hb/g faeces threshold was used. The negative predictive value for CRC was at least 99.2% in any subgroup analysed. At a 20 μg Hb/g faeces threshold, less than one additional CRC would be missed per 1000 patients investigated, while approximately 1.3 times more colonoscopy examinations were needed to identify an incidence of CRC using the lowest threshold for any situation analysed.

Conclusions

In primary health care, a quantitative FIT threshold should be tailored to colonoscopy capacity and CRC prevalence in specific populations.

Presentation and survival among patients with colorectal cancer before the age of screening: a systematic review and meta-analysis

Background

The incidence of colorectal cancer in North America is rising among patients younger than 50 years. Available data are conflicting regarding presentation and outcomes in this population. This review aimed to synthesize literature regarding young patients with colorectal cancer with respect to patient demographics, disease extent and survival, compared with patients older than 50 years.

Methods

We searched Medline, Embase, the Cochrane Central Register of Controlled Trials and PubMed for articles published between 1990 and the time of search. Articles comparing North American patients with colorectal cancer younger and older than 50 years were eligible for inclusion. We used a random-effects model to pool odds ratios.

Results

Eight retrospective studies were eligible for inclusion (n = 790 959). Mean age was 42.6 years (standard deviation [SD] 5.07) in the younger group, and 69.1 years (SD 9.25) in the older group. Young patients were more likely to present with regional (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.16–1.40) and distant disease (OR 1.47, 95%CI 1.30–1.67). Considering patients at all stages of disease, differences in 5-year overall survival (OR 1.54, 95%CI 0.96–2.47) and cancer-specific survival (OR 1.01, 95%CI 0.91–1.13) were not statistically significant between groups. However, when controlling for disease extent, 5-year cancer-specific survival was significantly higher among young patients with local (OR 1.69, 95%CI 1.43–1.99), regional (OR 1.37, 95%CI 1.16–1.63) and distant disease (OR 1.79, 95%CI 1.45–2.21).

Conclusion

North American patients presenting with colorectal cancer before the age of 50 years are more likely to have advanced disease. Although overall and cancer-specific survival is not significantly different between these groups, younger patients have improved survival when controlling for cancer stage.

Quadruple Multiple Primary Malignancies: Early Detection of Second Primary Malignancy by Esophagogastroduodenoscopy/Colonoscopy Is Crucial for Patients with Classic Kaposi's Sarcoma

Currently, Kaposi's sarcoma (KS) is treated following the recommendations of international guidelines. These guidelines recommend esophagogastroduodenoscopy/colonoscopy for detecting multicentric KS of visceral lesions. Second primary malignancies (SPMs) are also a common KS complication; however, information on their detection and treatment is unfortunately not yet indicated in these guidelines. This paper reports on an 86-year-old man who suffered from quadruple primary malignancies: skin classic KS with colon adenocarcinoma, oral squamous cell carcinoma (maxilla), and well-differentiated stomach adenocarcinoma. Gastric cancer was incidentally detected during esophagogastroduodenoscopy, which was performed to detect visceral KS. We suggest that esophagogastroduodenoscopy/colonoscopy be routinely performed during the follow-up of patients with KS. As SPMs are crucial complications in patients with KS, these malignancies should be detected as early as possible.

Delayed Colonoscopy Following a Positive Fecal Test Result and Cancer Mortality

Background

A fecal test followed by diagnostic colonoscopy for a positive result is a widely endorsed screening strategy for colorectal cancer (CRC). However, the relationship between the time delay from the positive test to the follow-up colonoscopy and CRC mortality has not been established.

Methods

From a population-based screening program, we identified CRC patients newly diagnosed from 2005 through 2015 by a positive fecal occult test followed by a colonoscopy. The primary outcome measure was CRC-specific mortality according to four categories for the time elapsed between the positive result and the subsequent colonoscopy.

Results

The 1749 patients underwent colonoscopies within 0–3 months (n = 981, 56.1%), 4–6 months (n = 307, 17.5%), 7–12 months (n = 157, 9.0%), and later than 12 months (n = 304, 17.4%). CRC-specific deaths according to exposure groups were: 13.8% (135 of 981) for 0–3 months, 10.7% (33 of 307) for 4–6 months (crude hazards ratio [HR] = 0.74, 95% confidence interval [CI] = 0.51 to 1.14), 11.5% (18 of 157) for 7–12 months (crude HR = 0.83, 95% CI = 0.51 to 1.42), and 22.7% (69 of 304) for longer than 12 months (crude HR = 1.40, 95% CI = 1.04 to 1.90). The only variable that was associated with mortality risk was the number of positive slides (P = .003). High positivity was twice the value in the 0–3 as the longer-than-12 months group: 51.9% vs 25.0% and similar for the 4–6 and 7–12 months groups (38.1% and 36.5%), respectively. The adjusted HRs for CRC mortality were 0.81 (95% CI = 0.55 to 1.19); 0.83 (95% CI = 0.50 to 1.41), and 1.53 (95% CI = 1.13 to 2.12, P = .006) for the 4–12, 7–12, and longer-than-12-months groups, respectively, compared with the shortest delay group.

Conclusions

Among screen-diagnosed CRC patients, performance of colonoscopy more than 12 months after the initial positive fecal occult blood test was associated with more advanced disease and higher mortality due to CRC.

How asymptomatic are early cancer patients of five organs based on registry data in Japan

BACKGROUND

One reason for the low cancer screening rate in Japan is that people are not concerned about cancer if they do not have symptoms.

METHODS

The authors retrospectively analyzed 18,405 cancer patients using hospital-based cancer registry data collected between 2007 and 2013 at the 13 hospitals of Shimane Prefecture, Japan. The symptomatic rates of five cancers (stomach, colorectal, lung, breast, and cervix) at each stage and the time of early diagnosis were investigated. The early detection rates of symptomatic and asymptomatic individuals were investigated.

RESULTS

The percentages of symptomatic cases tended to increase with progressive stages. The odds ratio (OR) of stage IV compared with that of stage I was 12.23 for stomach, 7.21 for colorectal, 16.91 for lung, 10.30 for breast, and 51.62 for cervical cancer. The proportions of early symptomatic cases at the time of diagnosis were low. Compared with the percentage of early symptomatic cases of stomach cancer of 25.5%, the percentage of lung cancer was the lowest, at 8.2% (OR 0.26), and the percentage of breast cancer was the highest, at 30.2% (OR 1.26). The percentages of early symptomatic cases of colorectal and cervical cancer were 18.9% (OR 0.68) and 19.9% (OR 0.73), respectively. The early detection rates of the asymptomatic and symptomatic groups were 77.6 and 36.1%, respectively.

CONCLUSION

Cancer registry data indicate that early cancers are asymptomatic, and once symptoms appear, treatment may not be effective. Policy makers should inform people of the necessity of cancer screening before they have symptoms.

Reliability and validity assessment of administrative databases in measuring the quality of rectal cancer management

PURPOSE

Measurement and monitoring of the quality of care using a core set of quality measures are increasing in health service research. Although administrative databases include limited clinical data, they offer an attractive source for quality measurement. The purpose of this study, therefore, was to evaluate the completeness of different administrative data sources compared to a clinical survey in evaluating rectal cancer cases.

METHODS

Between May 2012 and November 2014, a clinical survey was done on 498 Lombardy patients who had rectal cancer and underwent surgical resection. These collected data were compared with the information extracted from administrative sources including Hospital Discharge Dataset, drug database, daycare activity data, fee-exemption database, and regional screening program database. The agreement evaluation was performed using a set of 12 quality indicators.

RESULTS

Patient complexity was a difficult indicator to measure for lack of clinical data. Preoperative staging was another suboptimal indicator due to the frequent missing administrative registration of tests performed. The agreement between the 2 data sources regarding chemoradiotherapy treatments was high. Screening detection, minimally invasive techniques, length of stay, and unpreventable readmissions were detected as reliable quality indicators. Postoperative morbidity could be a useful indicator but its agreement was lower, as expected.

CONCLUSIONS

Healthcare administrative databases are large and real-time collected repositories of data useful in measuring quality in a healthcare system. Our investigation reveals that the reliability of indicators varies between them. Ideally, a combination of data from both sources could be used in order to improve usefulness of less reliable indicators.

Performance of a quantitative fecal immunochemical test for detecting advanced colorectal neoplasia: a prospective cohort study

BACKGROUND

The fecal immunochemical test (FIT) is easier to use and more sensitive than the guaiac fecal occult blood test, but it is unclear how to optimize FIT performance. We compared the sensitivity and specificity for detecting advanced colorectal neoplasia between single-sample (1-FIT) and two-sample (2-FIT) FIT protocols at a range of hemoglobin concentration cutoffs for a positive test.

METHODS

We recruited 2,761 average-risk men and women ages 49-75 referred for colonoscopy within a large nonprofit, group-model health maintenance organization (HMO), and asked them to complete two separate single-sample FITs. We generated receiver-operating characteristic (ROC) curves to compare sensitivity and specificity estimates for 1-FIT and 2-FIT protocols among those who completed both FIT kits and colonoscopy. We similarly compared sensitivity and specificity between hemoglobin concentration cutoffs for a single-sample FIT.

RESULTS

Differences in sensitivity and specificity between the 1-FIT and 2-FIT protocols were not statistically significant at any of the pre-specified hemoglobin concentration cutoffs (10, 15, 20, 25, and 30 μg/g). There was a significant difference in test performance of the one-sample FIT between 50 ng/ml (10 μg/g) and each of the higher pre-specified cutoffs. Disease prevalence was low.

CONCLUSIONS

A two-sample FIT is not superior to a one-sample FIT in detection of advanced adenomas; the one-sample FIT at a hemoglobin concentration cutoff of 50 ng/ml (10 μg/g) is significantly more sensitive for advanced adenomas than at higher cutoffs. These findings apply to a population of younger, average-risk patients in a U.S. integrated care system with high rates of prior screening.

Intervening factors for the initiation of treatment of patients with stomach and colorectal cancer

Objective:

to identify the time between symptoms, the request for care and the beginning of treatment in patients with stomach and colorectal cancer as well as the factors that interfere in these processes.

Method:

correlational descriptive study, including 101 patients diagnosed with stomach or colorectal cancer, treated in a hospital specialized in oncology.

Results:

the 101 patients investigated there was predominance of males, mean age of 61.7 years. The search for medical care occurred within 30 days after the onset of symptoms, in most cases. The mean total time between the onset of symptoms and the beginning of treatment ranged from 15 to 16 months, and the mean time between the search for medical care and the diagnosis was 4.78 months. The family history of cancer (p=0.008) and the implementation of preventive follow-up (p<0.001) were associated with shorter periods between the search for care and the beginning of treatment. Nausea, vomiting, hematochezia, weight loss and pain were associated with faster demand for care.

Conclusion:

the longer interval between the search for medical care and the diagnosis was possibly due to the non-association between the presented symptoms and the disease.

Poor predictive value of lower gastrointestinal alarm features in the diagnosis of colorectal cancer in 1981 patients in secondary care

BACKGROUND

Clinicians are advised to refer patients with lower gastrointestinal (GI) alarm features for urgent colonoscopy to exclude colorectal cancer (CRC). However, the utility of alarm features is debated.

AIM

To assess whether performance of alarm features is improved by using a symptom frequency threshold to trigger referral, or by combining them into composite variables, including minimum age thresholds, as recommended by the National Institute for Health and Care Excellence (NICE).

METHODS

We collected data prospectively from 1981 consecutive adults with lower GI symptoms. Assessors were blinded to symptom status. The reference standard to define CRC was histopathological confirmation of adenocarcinoma in biopsy specimens from a malignant-looking colorectal lesion. Controls were patients without CRC. Sensitivity, specificity, positive predictive values (PPVs) and negative predictive values were calculated for individual alarm features, as well as combinations of these.

RESULTS

In identifying 47 (2.4%) patients with CRC, individual alarm features had sensitivities ranging from 11.1% (family history of CRC) to 66.0% (loose stools), and specificities from 30.5% (loose stools) to 75.6% (family history of CRC). Using higher symptom frequency thresholds improved specificity, but to the detriment of sensitivity. NICE referral criteria also had higher specificities and lower sensitivity, with PPVs above 4.8%. More than 80% of those with CRC met at least one of the NICE referral criteria.

CONCLUSIONS

Using higher symptom frequency thresholds for alarm features improved specificity, but sensitivity was low. NICE referral criteria had PPVs above 4.8%, but sensitivities ranged from 2.2% to 32.6%, meaning many cancers would be missed.

Development of a Risk Prediction Score for Occult Cancer in Patients With VTE

BACKGROUND

The benefits of a diagnostic workup for occult cancer in patients with VTE are controversial. Our aim was to provide and validate a risk score for occult cancer in patients with VTE.

METHODS

We designed a nested case-control study in a cohort of patients with VTE included in the RIETE (Registro Informatizado Enfermedad TromboEmbólica) registry from 2001 to 2014. Cases included cancer detected beyond the first 30 days and up to 24 months after VTE. Control subjects were defined as patients with VTE with no cancer in the same period.

RESULTS

Of 5,863 eligible patients, 444 (7.6%; 95% CI, 6.8%-8.2%) were diagnosed with occult cancer. On multivariable analysis, variables selected were male sex, age > 70 years, chronic lung disease, anemia, elevated platelet count, prior VTE, and recent surgery. We built a risk score assigning points to each variable. Internal validity was confirmed using bootstrap analysis. The proportion of patients with cancer who scored ≤ 2 points was 5.8% (241 of 4,150) and that proportion in those who scored ≥ 3 points was 12% (203 of 1,713). We also identified scores divided by sex and age subgroups.

CONCLUSIONS

This is the first risk score that has identified patients with VTE who are at increased risk for occult cancer. Our score needs to be externally validated.

Cancer screening barriers and facilitators for under and never screened populations: A mixed methods study

BACKGROUND

Cancer screening is below targets in Ontario, Canada. Our objective was to identify and quantify the barriers and facilitators for breast, cervical and colorectal cancer screening for under and never screened (UNS) residents living in Ontario between 2011 and 2013.

METHODS

We used a multi-phased mixed methods study design. Results from thematic analysis of focus group discussions with health care providers and UNS community members were used to develop an on-line, province-wide, cross-sectional survey to estimate the prevalence of barriers and facilitators for the provincial population. Adjusted prevalence odds ratios and 95% confidence intervals were estimated for UNS compared to regularly screened participants using logistic regression.

RESULTS

Four focus groups were held with health service providers and sixteen with UNS community members. Top barriers and facilitators themed around provider-patient communication, fear and embarrassment, history of physical or sexual abuse, social determinants of health (including low literacy, lack of awareness, and health insurance), symptoms appearing, and family and friends. 3075 participants completed the online survey. Compared to regularly screened participants, UNS had significantly higher odds of reporting: no regular health care provider; not feeling comfortable talking about screening; or the Doctor or Nurse Practitioner not suggesting screening. UNS also had significantly higher odds of reporting the facilitators: the test being less scary/painful or uncomfortable; friend/family insisting on getting screened; starting to have symptoms; or an easier test that could be done at home.

CONCLUSIONS

Interventions addressing fear through individual, interpersonal and structural facilitators may increase cancer screening.