Survival in patients with colorectal cancer diagnosed by screening colonoscopy

Refining the targeted population and achieving better for colorectal cancer screening

This editorial comments on the article entitled “Stage at diagnosis of colorectal cancer through diagnostic route: Who should be screened?” by Agatsuma et al, who conducted a retrospective study aiming at clarifying the stage at colorectal cancer (CRC) diagnosis based on different diagnostic routes. We share our opinion about CRC screening programs. The current situation suggests the need for a more specific and targeted population for CRC screening.

Refining the targeted population and achieving better for colorectal cancer screening

This editorial comments on the article entitled “Stage at diagnosis of colorectal cancer through diagnostic route: Who should be screened?” by Agatsuma et al, who conducted a retrospective study aiming at clarifying the stage at colorectal cancer (CRC) diagnosis based on different diagnostic routes. We share our opinion about CRC screening programs. The current situation suggests the need for a more specific and targeted population for CRC screening.

Early colorectal cancer screening–no time to lose

In this editorial, we comment on the article entitled “Stage at diagnosis of colorectal cancer through diagnostic route: Who should be screened?” by Agatsuma et al. Colorectal cancer (CRC) is emerging as an important health issue as its incidence continues to rise globally, adversely affecting the quality of life. Although the public has become more aware of CRC prevention, most patients lack screening awareness. Some poor lifestyle practices can lead to CRC and symptoms can appear in the early stages of CRC. However, due to the lack of awareness of the disease, most of the CRC patients are diagnosed already at an advanced stage and have a poor prognosis.

Stage at diagnosis of colorectal cancer through diagnostic route: Who should be screened?

BACKGROUND

Colorectal cancer (CRC) is a global health concern, with advanced-stage diagnoses contributing to poor prognoses. The efficacy of CRC screening has been well-established; nevertheless, a significant proportion of patients remain unscreened, with > 70% of cases diagnosed outside screening. Although identifying specific subgroups for whom CRC screening should be particularly recommended is crucial owing to limited resources, the association between the diagnostic routes and identification of these subgroups has been less appreciated. In the Japanese cancer registry, the diagnostic routes for groups discovered outside of screening are primarily categorized into those with comorbidities found during hospital visits and those with CRC-related symptoms.

AIM

To clarify the stage at CRC diagnosis based on diagnostic routes.

METHODS

We conducted a retrospective observational study using a cancer registry of patients with CRC between January 2016 and December 2019 at two hospitals. The diagnostic routes were primarily classified into three groups: Cancer screening, follow-up, and symptomatic. The early-stage was defined as Stages 0 or I. Multivariate and univariate logistic regressions were exploited to determine the odds of early-stage diagnosis in the symptomatic and cancer screening groups, referencing the follow-up group. The adjusted covariates were age, sex, and tumor location.

RESULTS

Of the 2083 patients, 715 (34.4%), 1064 (51.1%), and 304 (14.6%) belonged to the follow-up, symptomatic, and cancer screening groups, respectively. Among the 2083 patients, CRCs diagnosed at an early stage were 57.3% (410 of 715), 23.9% (254 of 1064), and 59.5% (181 of 304) in the follow-up, symptomatic, and cancer screening groups, respectively. The symptomatic group exhibited a lower likelihood of early-stage diagnosis than the follow-up group [P < 0.001, adjusted odds ratio (aOR), 0.23; 95% confidence interval (95%CI): 0.19-0.29]. The likelihood of diagnosis at an early stage was similar between the follow-up and cancer screening groups (P = 0.493, aOR for early-stage diagnosis in the cancer screening group vs follow-up group = 1.11; 95%CI = 0.82-1.49).

CONCLUSION

CRCs detected during hospital visits for comorbidities were diagnosed earlier, similar to cancer screening. CRC screening should be recommended, particularly for patients without periodical hospital visits for comorbidities.

Detection and Yield of Colorectal Cancer Surveillance in Adults with PTEN Hamartoma Tumour Syndrome

Colorectal cancer surveillance (CCS) with colonoscopy every five years is advised for PTEN Hamartoma Tumour Syndrome (PHTS) patients aged ≥40 due to an increased colorectal cancer (CRC) risk. However, data to support CCS guidelines are scarce and available CRC risks are low (0-5% at age 50) and likely overestimated. We aimed to assess the detection and yield of CCS for PHTS patients without a CRC history. A retrospective cohort study including PHTS patients aged ≥40 with CCS at a PHTS expertise centre between 2011 and 2022. Adenomas with a ≥10 mm size, (tubulo)villous histology, or high-grade dysplasia were considered advanced. During 67 follow-up years, 37 patients (median age 47 years) underwent 61 colonoscopies. CCS yielded no CRCs. Adenomas were diagnosed in 13/37 (35%) patients during 23/100 colonoscopies (95% CI: 14-36), including one advanced adenoma. Baseline adenoma detection rates were similar to follow-up and higher in patients aged above 50 (50/100, 95% CI: 24-76) vs. age 50 or below (11/100, 95% CI: 3-30; p = 0.021). The low CRC and advanced adenoma yield allow for a more personalised surveillance program. Following our findings combined with literature on CRC risk and progression, we suggest starting CCS at age 40 with variable follow-up intervals between 1 and 10 years depending on previous colonoscopy findings.

Early detection of colorectal neoplasia: application of a blood-based serological protein test on subjects undergoing population-based screening

BACKGROUND

Blood-based biomarkers used for colorectal cancer screening need to be developed and validated in appropriate screening populations. We aimed to develop a cancer-associated protein biomarker test for the detection of colorectal cancer in a screening population.

METHODS

Participants from the Danish Colorectal Cancer Screening Program were recruited. Blood samples were collected prior to colonoscopy. The cohort was divided into training and validation sets. We present the results of model development using the training set. Age, sex, and the serological proteins CEA, hsCRP, TIMP-1, Pepsinogen-2, HE4, CyFra21-1, Galectin-3, ferritin and B2M were used to develop a signature test to discriminate between participants with colorectal cancer versus all other findings at colonoscopy.

RESULTS

The training set included 4048 FIT-positive participants of whom 242 had a colorectal cancer. The final model for discriminating colorectal cancer versus all other findings at colonoscopy had an AUC of 0.70 (95% CI: 0.66-0.74) and included age, sex, CEA, hsCRP, HE4 and ferritin.

CONCLUSION

The performance of the biomarker signature in this FIT-positive screening population did not reflect the positive performance of biomarker signatures seen in symptomatic populations. Additional biomarkers are needed if the serological biomarkers are to be used as a frontline screening test.

OUP accepted manuscript

Background

This study compared patients undergoing colorectal cancer surgery in 20 hospitals of northern Italy in 2019 versus 2020, in order to evaluate whether COVID-19-related delays of colorectal cancer screening resulted in more advanced cancers at diagnosis and worse clinical outcomes.

Method

This was a retrospective multicentre cohort analysis of patients undergoing colorectal cancer surgery in March to December 2019 versus March to December 2020. Independent predictors of disease stage (oncological stage, associated symptoms, clinical T4 stage, metastasis) and outcome (surgical complications, palliative surgery, 30-day death) were evaluated using logistic regression.

Results

The sample consisted of 1755 patients operated in 2019, and 1481 in 2020 (both mean age 69.6 years). The proportion of cancers with symptoms, clinical T4 stage, liver and lung metastases in 2019 and 2020 were respectively: 80.8 versus 84.5 per cent; 6.2 versus 8.7 per cent; 10.2 versus 10.3 per cent; and 3.0 versus 4.4 per cent. The proportions of surgical complications, palliative surgery and death in 2019 and 2020 were, respectively: 34.4 versus 31.9 per cent; 5.0 versus 7.5 per cent; and 1.7 versus 2.4 per cent. Cancers in 2020 (versus 2019) were more likely to be symptomatic (odds ratio 1.36 (95 per cent c.i. 1.09 to 1.69)), clinical T4 stage (odds ratio 1.38 (95 per cent c.i. 1.03 to 1.85)) and have multiple liver metastases (odds ratio 2.21 (95 per cent c.i. 1.24 to 3.94)), but were not more likely to be associated with surgical complications (odds ratio 0.79 (95 per cent c.i. 0.68 to 0.93)).

Conclusion

Colorectal cancer patients who had surgery between March and December 2020 had an increased risk of advanced disease in terms of associated symptoms, cancer location, clinical T4 stage and number of liver metastases.

Long-term trends in colorectal cancer: incidence, localization, and presentation

Background

The purpose of this study was to assess trends in incidence and presentation of colorectal cancer (CRC) over a period of 37 years in a stable population in Mid-Norway. Secondarily, we wanted to predict the future burden of CRC in the same catchment area.

Methods

All 2268 patients diagnosed with CRC at Levanger Hospital between 1980 and 2016 were included in this study. We used Poisson regression to calculate the incidence rate ratio (IRR) and analyse factors associated with incidence.

Results

The incidence of CRC increased from 43/100,000 person-years during 1980–1984 to 84/100,000 person-years during 2012–2016. Unadjusted IRR increased by 1.8% per year, corresponding to an overall increase in incidence of 94.5%. Changes in population (ageing and sex distribution) contributed to 28% of this increase, whereas 72% must be attributed to primary preventable factors associated with lifestyle. Compared with the last observational period, we predict a further 40% increase by 2030, and a 70% increase by 2040. Acute colorectal obstruction was associated with tumours in the left flexure and descending colon. Spontaneous colorectal perforation was associated with tumours in the descending colon, caecum, and sigmoid colon. The incidence of obstruction remained stable, while the incidence of perforation decreased throughout the observational period. The proportion of earlier stages at diagnosis increased significantly in recent decades.

Conclusion

CRC incidence increased substantially from 1980 to 2016, mainly due to primary preventable factors. The incidence will continue to increase during the next two decades, mainly due to further ageing of the population.

Self-Reported Lower Gastrointestinal Endoscopy Use and Changes in Colorectal Cancer Mortality Rates in European Countries

To quantify the association of self-reported lower gastrointestinal endoscopy use measured in 2004/05 with colorectal cancer (CRC) mortality changes over 2004–2015 in Europe.

Risk of Colorectal Polyps and Malignancies Among Predominantly Rural Hispanics

Colorectal cancer is the fourth most frequently diagnosed cancer. However, due to variations in diet, it was hypothesized that risk of adenomatous or hyperplastic polyps or malignancies would be lower among Hispanics. Participants (n = 1671) underwent a colonoscopy. Results were grouped into one of four groups: normal, hyperplastic polyps only, adenomatous polyps, and malignancies. As expected, Hispanics had a lower risk of hyperplastic (p = .031, OR = 0.47) and adenomatous polyps (p = .031, OR = 0.66) than non-Hispanic Whites. Comparison between malignancies was not possible as no Hispanics had a malignancy. Contrary to expectations, risk of hyperplastic and adenomatous polyps and malignancies were no different between non-Hispanic Blacks and Whites. Among rural and mostly rural populations, Hispanics had a lower risk of hyperplastic and adenomatous polyps.

Screening for Colorectal Cancer Is Associated With Lower Disease Stage: A Population-Based Study

BACKGROUND & AIMS

Screening for colorectal cancer (CRC) using fecal occult blood tests (FOBT) is associated with reduced CRC incidence and mortality. Population-based FOBT screening has led to identification of CRCs at earlier stages and longer patient survival times. We investigated the stage distribution of CRCs detected by colonoscopy in a large outpatient cohort.

METHODS

We performed a retrospective analysis of colonoscopies performed on 524,954 outpatients (age, ≥55 y) in Germany from January 2006 through December 2009. Patients with chronic inflammatory bowel diseases, and those with a personal history of adenoma or CRC, were excluded. Colonoscopy findings were categorized on the basis of the most advanced lesion found; histologic samples were obtained from all patients with suspected cancer and analyzed. Cancers were staged based on Union Internationale Contre le Cancer criteria. We analyzed absolute and relative frequencies of CRCs identified and tumor stages for patients who underwent colonoscopy for screening, evaluation of a positive FOBT, and evaluation of symptoms.

RESULTS

Of the 6065 CRCs identified, 1750 were found in the screening group, 1075 in subjects with positive FOBT, and 3240 in patients with symptoms. Stage I CRC was detected more frequently in subjects who received screening colonoscopies (41.15%) or in those with positive FOBT (39.10%), than in individuals with symptoms (24.42%; P < .001). In contrast, the detection rates of stage IV CRC were 10.67%, 10.76%, and 18.64%, respectively (P < .001). We observed a shift toward lower T stages in the screening and FOBT work-up groups compared with the group with symptoms. Compared with subjects with symptoms, the odds of diagnosing CRC at an advanced stage were significantly lower in the screening group (odds ratio, 0.533; 95% confidence interval, 0.451-0.631) and the FOBT work-up group (odds ratio, 0.570; 95% confidence interval, 0.469-0.694).

CONCLUSIONS

In this large population-based study, CRC detected by colonoscopies performed for screening and evaluation of positive FOBTs had a lower stage than those diagnosed by colonoscopies in symptomatic patients. These findings support the value of screening colonoscopy to reduce the burden of CRC.

High prevalence of advanced colorectal neoplasia in the Thai population: a prospective screening colonoscopy of 1,404 cases

Background

Increasing morbidity and mortality from colorectal cancer is evident in recent years in the developing Asian nations. Particularly in Thailand and most neighbouring low-income countries, screening colonoscopy is not yet recommended nor implemented at the national policy level.

Methods

Screening colonoscopy was offered to 1,500 healthy volunteers aged 50–65 years old who were registered into the program between July 2009 and June 2010. Biopsy and surgery was performed depending on the identified lesions. Fecal immunochemical tests (FIT) were additionally performed for comparison with colonoscopy.

Results

There were 1,404 participants who underwent colonoscopy. The mean age of the cohort was 56.9 ± 4.2 years and 69.4 % were females. About 30 % (411 cases) of all colonoscopies had abnormal colonoscopic findings, and of these, 256 cases had adenomatous polyps. High risk adenomas (villous or tubulovillous or high grade dysplasia or size > 1 cm or > 3 adenomatous polyps) were found in 98 cases (7 %), low risk adenoma in 158 cases (11.3 %), and hyperplastic polyps in 119 cases (8.5 %). Eighteen cases (1.3 %) had colorectal cancer and 90 % of them (16 cases) were non-metastatic including five stage 0 cases, seven stage I cases, and four stage IIA cases. Only two cases had metastasis: one to regional lymph nodes (stage IIIB) and another to other organs (stage IVA). The most common cancer site was the distal intestine including rectum (7 cases, 38.9 %) and sigmoid colon (7 cases, 38.9 %). Ten colorectal cancer cases had positive FIT whereas 8 colorectal cancer cases were FIT-negative. The sensitivity and specificity of FIT was 55.6 % and 96.2 %, respectively, while the positive predictive value was 16.4 % and negative predictive value was 99.4 %. The overall survival of colorectal cancer cases at 5-year was 83.3 %.

Conclusion

High prevalence of colorectal cancer and high-risk adenoma was found in the Thai population aged 50–65 years old by screening colonoscopy. FIT was not sensitive enough to detect colorectal cancer in this asymptomatic cohort. Integration of screening colonoscopy into the national cancer screening program should be implemented to detect early cases of advanced colorectal neoplasia and improve survival of colorectal cancer patients in Thailand.

Investigating intra-tumor heterogeneity and expression gradients of miR-21, miR-92a and miR-200c and their potential of predicting lymph node metastases in early colorectal cancer

INTRODUCTION

miR-21, miR-92a and miR-200c are regulators of pathways involved in migration, intravasation and metastasis, and their tumor expression levels have been proposed as potential prognostic markers in colorectal cancer (CRC). In two parallel cohorts we examine intra-tumor expression levels in early stage CRC tissue in order to determine intra-tumor heterogeneity, potential systematic intra-tumor expression gradients of the miRNAs and to investigate the association to metastatic disease in early stage CRC.

MATERIAL AND METHODS

Two parallel studies on archived formalin-fixed paraffin-embedded (FFPE) CRC tissue. Intra-tumor and inter-patient variances were analyzed in 9 early metastatic CRCs by measuring expression levels by qRT-PCR on isolated tissue samples from luminal, central and invasive border zones. Associations between miRNA expression levels and early metastasizing tumors was investigated in FFPE tissue from invasive border and central tumor zones from 47 early metastatic CRCs matched with 47 non-metastatic CRCs. Intra-tumor expression gradients were analyzed on both cohorts.

RESULTS

Mean intra-tumor coefficient of variation in the heterogeneity cohort was 38.5% (range: 33.1-49.0%) only slightly less than variation between patients (45.1%, range 37.0-49.5%). We demonstrated systematic expression gradients between tumor zones equal to a 3.23 (p=0.003) and 1.36 (p=0.014) fold lower expression in invasive areas for miR-200c, 1.52 (p<0.001) and 1.27 (p=0.021) fold lower expression in invasive areas for miR-92a. For miR-21 we found a 1.75 (p<0.001) and 1.21 (p=0.064) fold higher expression in invasive areas compared to luminal and central zones, respectively. No significant difference in expression levels between metastatic and non-metastatic tumors was demonstrated, nor a difference in intra-tumor gradients between metastatic and non-metastatic tumors.

CONCLUSION

This study provides evidence for moderate intra-tumor and inter-patient heterogeneities of three well-described potential prognostic markers in CRC. We demonstrate intra-tumor expression gradients indicating a differentiated expression of the target miRNAs between functional tumor zones, but the potential role as markers of early metastatic disease is still not fully clarified.