Colorectal cancer: what should patients and families be told to lower the risk of colorectal cancer?

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.

Early onset colorectal cancer in Canterbury, New Zealand

BACKGROUND

The overall incidence of colorectal cancer is decreasing in much of the world, yet the incidence in those under 50 years of age is increasing (early onset colorectal cancer (EOCRC)). The reasons for this are unclear. This study was undertaken to describe the clinical, pathological and familial characteristics of patients with EOCRC and their oncological outcomes and compare this with previously published data on late onset colorectal cancer (LOCRC).

METHODS

A retrospective review of all patients diagnosed with EOCRC in Canterbury between 2010 and 2017 was conducted. Data was collected on demographics, family history, treatment, and oncologic outcomes. Kaplan-Meier survival curves were calculated to assess overall survival based on disease stage.

RESULTS

During the study period (2010-2017) there were 3340 colorectal cancers diagnosed in Canterbury, of which 201 (6%) were in patients under 50 years (range: 17-49). Of these, 87 (43.3%) were female and 125 (62.2%) were aged between 40 and 49 years. 28 (13.9%) were associated with hereditary conditions. Of the 201 patients, 139 (69.2%) had rectal or left-sided cancers. 142 (70.6%) patients presented with either stage 3 or 4 disease and the 5-year overall survival by stage was 79.1% and 14.4%, respectively.

CONCLUSION

EOCRC is increasing and usually presents as distal left sided cancers, and often at an advanced stage. They do not appear to have the common risk factors of family history or inherited pre-disposition for colorectal cancer. Planning by healthcare providers for this epidemiological change is imperative in investigating symptomatic patients under 50 and optimizing early detection and prevention.

Inulin as a Delivery Vehicle for Targeting Colon-Specific Cancer

Natural polysaccharides, as well as biopolymers, are now days widely developed for targeting colon cancer using various drug delivery systems. Currently, healing conformations are being explored that can efficiently play a multipurpose role. Owing to the capability of extravagance colonic diseases with the least adverse effects, biopolymers for site specific colon delivery have developed an increased curiosity over the past decades. Inulin (INU) was explored for its probable application as an entrapment material concerning its degradation by enzymes in the colonic microflora and its drug release behavior in a sustained and controlled manner. INU is a polysaccharide and it consists of 2 to 1 linkage having an extensive array of beneficial uses such as a carrier for delivery of therapeutic agents as an indicative/investigative utensil or as a dietary fiber with added well-being aids. In the main, limited research, as well as information, is available on the delivery of therapeutic agents using inulin specifically for colon cancer because of its capability to subsist in the stomach's acidic medium. This exceptional steadiness and robustness properties are exploited in numerous patterns to target drugs securely for the management of colonic cancer, where they effectively act and kills colonic tumor cells easily. In this review article, recent efforts and inulin-based nano-technological approaches for colon cancer targeting are presented and discussed.

Select group of patients might benefit from early colonoscopic screening for colorectal cancer

BACKGROUND

Recently, the American Cancer Society made a qualified recommendation to start colorectal cancer (CRC) screening at 45 years of age in all average-risk individuals. In this study, our primary aim is to calculate the prevalence and also evaluate the predictors of increased prevalence of detected adenomas in the 40-49-year-old individuals undergoing colonoscopy.

METHODS

A retrospective cross-sectional study was performed using our endoscopy database. Study subjects included all 40-49-year-old patients undergoing their first colonoscopy at our institution from January 1, 2010 to September 30, 2017. Exclusion criteria included patients who underwent colonoscopy for overt gastrointestinal bleeding, inflammatory bowel disease, a history of familial adenomatous polyposis, hereditary non-polyposis CRC. Univariate analysis and multivariate analysis were performed to identify factors associated with increased adenoma detection rate (ADR).

RESULTS

A total of 2059 patients were included in the study, and 317 of these patients had family history (FH) of CRC. Patients with FH of CRC had significantly higher ADR (27.8% vs. 19.7%, p = 0.001) as compared to those without FH of CRC. There was no significant difference in ADR in patients between 40-44 years and 45-49 years of age (17.7% vs. 21.4%, p = 0.058). On a multivariate analysis while adjusting for multiple patient and procedural variables, FH of CRC, male sex, BMI > 30 kg/m², chronic kidney disease, and age were associated with high ADR.

CONCLUSIONS

Our study shows that in addition to FH of CRC, age, male sex, BMI, and CKD are independent predictors of increased ADR in patients between 40 and 49 years of age.

ARE OBESITY AND ADENOMA DEVELOPMENT ASSOCIATED AS COLORECTAL CANCER PRECURSORS?

BACKGROUND

One of the most important concerns on health is the increased rates of obesity in population and the speed in which this number is increasing. This number translates a serious public health problem, since it also increases the risk of several other diseases associated with obesity resulting in significant morbidity and mortality. Among them, it seems to be connected to several neoplasms, such as colorectal carcinoma.

AIM

To evaluate the impact of obesity as a risk factor for colorectal carcinoma through the detection of adenoma, and to discuss the mechanisms that could establish a link between obesity and neoplasm.

METHODS

Patients who underwent colonoscopy were included. Personal and anthropometric data, clinical history, and results of the tests were analyzed in order to verify the correlation of BMI and the presence of adenomatous polyps.

RESULTS

A total of 142 patients were studied, which a mean age of 62 years. Of the patients, 74 (52.1%) were men and 68 (47.9%) were. Obesity was identified in 16.2% of the patients. Polyps were found in 61 (42.9%), mostly smaller than 1 cm. Obese individuals were 1.56 times more likely to present colorectal adenoma than patients with normal weight.

CONCLUSION

This study, although showing the greater presence of colorectal adenomas in obese individuals, did not show a significant difference in the occurrence of pre-malignant lesions.

Risk Factors for Early-Onset Colorectal Cancer

BACKGROUND & AIMS

Colorectal cancer (CRC) incidence and mortality are increasing among persons younger than 50 years old in the United States, but risk factors associated with early-onset CRC (EOCRC) have not been widely studied.

METHODS

We conducted a case-control study of US veterans 18 to 49 years old who underwent colonoscopy examinations from 1999 through 2014. EOCRC cases were identified from a national cancer registry; veterans who were free of CRC at their baseline colonoscopy through 3 years of follow-up were identified as controls. We collected data on age, sex, race/ethnicity, body weight, body mass index (BMI), diabetes, smoking status, and aspirin use. Multivariate-adjusted EOCRC odds were estimated for each factor, with corresponding 95% confidence interval (CI) values.

RESULTS

Our final analysis included 651 EOCRC cases and 67,416 controls. Median age was 45.3 years, and 82.3% were male. Higher proportions of cases were older, male, current smokers, nonaspirin users, and had lower BMIs, compared with controls (P < .05). In adjusted analyses, increasing age and male sex were significantly associated with increased risk of EOCRC, whereas aspirin use and being overweight or obese (relative to normal BMI) were significantly associated with decreased odds of EOCRC. In post hoc analyses, weight loss of 5 kg or more within the 5-year period preceding colonoscopy was associated with higher odds of EOCRC (odds ratio 2.23; 95% CI 1.76-2.83).

CONCLUSIONS

In a case-control study of veterans, we found increasing age and male sex to be significantly associated with increased risk of EOCRC, and aspirin use to be significantly associated with decreased risk; these factors also affect risk for CRC onset after age 50. Weight loss may be an early clinical sign of EOCRC. More intense efforts are required to identify the factors that cause EOCRC and signs that can be used to identify individuals at highest risk.

CircCSPP1 Functions as a ceRNA to Promote Colorectal Carcinoma Cell EMT and Liver Metastasis by Upregulating COL1A1

The aberrant regulation of circular RNAs (circRNAs), ring structures formed by exon or intron backsplicing, has been identified as a novel characteristic of multiple cancers. However, the role of circRNAs in colorectal carcinoma remains to be elucidated. In the present study, we investigated the mRNA level and the promoting effect of circRNA CSPP1 (circCSPP1) in colorectal carcinoma liver metastasis. By bioinformatic analysis of 10 paired samples of colorectal carcinoma and adjacent mucosal tissues, we identified circCSPP1 as a significantly upregulated circRNA in colorectal carcinoma tissues, and its upregulation was correlated with a higher M stage. The gain- and loss-of-function assays revealed that circCSPP1 promotes the migration and invasion of colorectal carcinoma cells in vitro and in vivo. Mechanistically, similar miRNA response elements are shared between circCSPP1 and COL1A1. We demonstrated that circCSPP1 upregulates the mRNA levels of COL1A1, which plays a pivotal role in the process of epithelial–mesenchymal transition (EMT), by competitively binding to miR-193a-5p and preventing miR-193a-5p from decreasing the expression of COL1A1. In conclusion, this finding indicates that circCSPP1 may act as a promising therapeutic target by regulating the EMT process in colorectal carcinoma via activation of the circCSPP1/miR-193a-5p/COL1A1 axis.

Colorectal carcinoma screening: Established methods and emerging technology

Colorectal carcinoma screening programs have shown success in lowering both the incidence and mortality rate of colorectal carcinoma at a population level, in part because this carcinoma is relatively slow growing and has an identifiable premalignant lesion. Still, many patients do not undergo the recommended screening for colorectal carcinoma, and of those who do, a subset may be over- or under-diagnosed by the currently available testing methods. The primary purpose of this article is to review the data regarding currently available colorectal cancer screening modalities, which include fecal occult blood testing, direct colonic visualization, and noninvasive imaging techniques. In addition, readers will be introduced to a variety of biomarkers that may serve as stand-alone or adjunct tests in the future. Finally, there is a brief discussion of the current epidemiologic considerations that public health officials must address as they create population screening guidelines. The data we provide as laboratory physicians and scientists are critical to the construction of appropriate recommendations that ultimately decrease the burden of disease from colorectal carcinoma.

Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society

In the United States, colorectal cancer (CRC) is the fourth most common cancer diagnosed among adults and the second leading cause of death from cancer. For this guideline update, the American Cancer Society (ACS) used an existing systematic evidence review of the CRC screening literature and microsimulation modeling analyses, including a new evaluation of the age to begin screening by race and sex and additional modeling that incorporates changes in US CRC incidence. Screening with any one of multiple options is associated with a significant reduction in CRC incidence through the detection and removal of adenomatous polyps and other precancerous lesions and with a reduction in mortality through incidence reduction and early detection of CRC. Results from modeling analyses identified efficient and model-recommendable strategies that started screening at age 45 years. The ACS Guideline Development Group applied the Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria in developing and rating the recommendations. The ACS recommends that adults aged 45 years and older with an average risk of CRC undergo regular screening with either a high-sensitivity stool-based test or a structural (visual) examination, depending on patient preference and test availability. As a part of the screening process, all positive results on noncolonoscopy screening tests should be followed up with timely colonoscopy. The recommendation to begin screening at age 45 years is a qualified recommendation. The recommendation for regular screening in adults aged 50 years and older is a strong recommendation. The ACS recommends (qualified recommendations) that: 1) average-risk adults in good health with a life expectancy of more than 10 years continue CRC screening through the age of 75 years; 2) clinicians individualize CRC screening decisions for individuals aged 76 through 85 years based on patient preferences, life expectancy, health status, and prior screening history; and 3) clinicians discourage individuals older than 85 years from continuing CRC screening. The options for CRC screening are: fecal immunochemical test annually; high-sensitivity, guaiac-based fecal occult blood test annually; multitarget stool DNA test every 3 years; colonoscopy every 10 years; computed tomography colonography every 5 years; and flexible sigmoidoscopy every 5 years. CA Cancer J Clin 2018;68:250-281. © 2018 American Cancer Society.

Endoscopic tattooing of colorectal lesions: Is it a risk-free procedure?

Endoscopic tattooing is one of the most useful tools for the localization of small colorectal lesions especially in the laparoscopic setting. This is a minimally invasive endoscopic procedure without risk of major complications. However, many studies have revealed complications resulting from this procedure. In this article, several topics are reviewed including the accuracy, substance preparation, injected techniques and complications related to this procedure.

A telematic tool to predict the risk of colorectal cancer in white men and women: ColoRectal Cancer Alert (CRCA)

Colorectal cancer is an important disease because of its severity and also since it affects much of the population. Nothing helps patients and doctors to determine the risk of suffering from colorectal cancer during their lives, except for medical tests such as the colonoscopy. There have been several studies and research to try to estimate the relative risks of colorectal cancer based on various factors and the applications to calculate the risk of this cancer, but these are not within everyone's research. This project offers a multilingual Web tool, called ColoRectal Cancer Alert (CRCA), to calculate the risk of colorectal cancer for life in men and women of white race. With this application, doctors can carry out research in a few minutes to explore this risk when they are seeing a patient. The platform is designed in such a way that anyone can use it. It is easy to use and intuitive. We should keep in mind that this tool does not replace diagnostic tests such as the colonoscopy or the sigmoidoscopy. It is designed so that users with the assistance of their doctor know the risk and act accordingly (for example, having more checkups on the disease in case of high risk). To access the tool a computer with Internet connection will be required. Currently, 250 users of white race under the supervision of a specialist have completed the questionnaire.

Colonic polyps: inheritance, susceptibility, risk evaluation, and diagnostic management

Colorectal cancer (CRC) is the third-ranked neoplasm in order of incidence and mortality, worldwide, and the second cause of cancer death in industrialized countries. One of the most important environmental risk factors for CRC is a Western-type diet, which is characterized by a low-fiber and high-fat content. Up to 25% of patients with CRC have a family history for CRC, and a fraction of these patients are affected by hereditary syndromes, such as familial adenomatous polyposis, Gardner or Turcot syndromes, or hereditary nonpolyposis colorectal cancer. The onset of CRC is triggered by a well-defined combination of genetic alterations, which form the bases of the adenoma-carcinoma sequence hypothesis and justify the set-up of CRC screening techniques. Several screening and diagnostic tests for CRC are illustrated, including rectosigmoidoscopy, optical colonoscopy (OC), double contrast barium enema (DCBE), and computed tomography colonography (CTC). The strengths and weaknesses of each technique are discussed. Particular attention is paid to CTC, which has evolved from an experimental technique to an accurate and mature diagnostic approach, and gained wide acceptance and clinical validation for CRC screening. This success of CTC is due mainly to its ability to provide cross-sectional analytical images of the entire colon and secondarily detect extracolonic findings, with minimal invasiveness and lower cost than OC, and with greater detail and diagnostic accuracy than DCBE. Moreover, especially with the advent and widespread availability of modern multidetector CT scanners, excellent quality 2D and 3D reconstructions of the large bowel can be obtained routinely with a relatively low radiation dose. Computer-aided detection systems have also been developed to assist radiologists in reading CTC examinations, improving overall diagnostic accuracy and potentially speeding up the clinical workflow of CTC image interpretation.