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AGA White Paper: Roadmap for the Future of Colorectal Cancer Screening in the United States. Clin Gastroenterol Hepatol 2020; 18:2667-2678.e2. [PMID: 32634626 DOI: 10.1016/j.cgh.2020.06.053] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 05/26/2020] [Accepted: 06/15/2020] [Indexed: 02/07/2023]
Abstract
The American Gastroenterological Association's Center for Gastrointestinal Innovation and Technology convened a consensus conference in December 2018, entitled, "Colorectal Cancer Screening and Surveillance: Role of Emerging Technology and Innovation to Improve Outcomes." The goal of the conference, which attracted more than 60 experts in screening and related disciplines, including the authors, was to envision a future in which colorectal cancer (CRC) screening and surveillance are optimized, and to identify barriers to achieving that future. This White Paper originates from that meeting and delineates the priorities and steps needed to improve CRC outcomes, with the goal of minimizing CRC morbidity and mortality. A one-size-fits-all approach to CRC screening has not and is unlikely to result in increased screening uptake or desired outcomes owing to barriers stemming from behavioral, cultural, and socioeconomic causes, especially when combined with inefficiencies in deployment of screening technologies. Overcoming these barriers will require the following: efficient utilization of multiple screening modalities to achieve increased uptake; continued development of noninvasive screening tests, with iterative reassessments of how best to integrate new technologies; and improved personal risk assessment to better risk-stratify patients for appropriate screening testing paradigms.
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Hsu WF, Cheng SY, Shun CT, Chang LC, Tu CH, Wang HP, Wu MS, Chiu HM. Higher risk of advanced histology in adenoma less than 10 mm in fecal immunochemical test screening: Implication for management. J Gastroenterol Hepatol 2020; 35:1738-1745. [PMID: 32187748 DOI: 10.1111/jgh.15040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 03/02/2020] [Accepted: 03/15/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIM Whether diminutive or small adenomas detected by fecal immunochemical tests (FITs) are associated with a higher risk of advanced histology remains unknown. We investigated the prevalence of advanced histology in diminutive and small adenomas detected by FIT and compared with that detected by colonoscopy screening. METHODS We prospectively compared 1860 FIT-positive patients (FIT-positive cohort) and 6691 average-risk patients (screening colonoscopy cohort). Both groups underwent colonoscopies and were shown to have neoplastic lesions. The prevalence of advanced histology was determined, as was the associations with size and FIT positivity. RESULTS We analyzed 3920 neoplastic lesions from the FIT-positive cohort and 9789 neoplastic lesions from the screening colonoscopy cohort. Eighty (4.3%) diminutive lesions in FIT-positive cohort had advanced histology but without any invasive cancer. Twenty-one patients in the FIT-positive cohort and 49 in the screening colonoscopy cohort with diminutive adenomas displayed advanced histology (3.5% vs 1.2%; adjusted odds ratio [aOR] = 2.99, 95% confidence interval [CI]: 1.77-5.06). Sixteen patients in the FIT-positive cohort (2.7%) with diminutive adenomas might have changed the surveillance interval if a resect-and-discard strategy was applied, with a higher likelihood compared with the screening colonoscopy cohort (aOR = 2.76, 95% CI: 1.53-4.99). CONCLUSIONS Fecal immunochemical test screening detected more diminutive and small adenomas with advanced histology compared with colonoscopy screening. Its impact on current management of diminutive polyp is limited.
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Affiliation(s)
- Wen-Feng Hsu
- Department of Medicine, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Shao-Yi Cheng
- Department of Family Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Tung Shun
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Chun Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Hung Tu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Shiang Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Han-Mo Chiu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Meester RGS, Lansdorp-Vogelaar I, Winawer SJ, Zauber AG, Knudsen AB, Ladabaum U. High-Intensity Versus Low-Intensity Surveillance for Patients With Colorectal Adenomas: A Cost-Effectiveness Analysis. Ann Intern Med 2019; 171:612-622. [PMID: 31546257 PMCID: PMC8115352 DOI: 10.7326/m18-3633] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Surveillance of patients with colorectal adenomas has limited long-term evidence to support current practice. OBJECTIVE To compare the lifetime benefits and costs of high- versus low-intensity surveillance. DESIGN Microsimulation model. DATA SOURCES U.S. cancer registry, cost data, and published literature. TARGET POPULATION U.S. patients aged 50, 60, or 70 years with low-risk adenomas (LRAs) (1 to 2 small adenomas) or high-risk adenomas (HRAs) (3 to 10 small adenomas or ≥1 large adenoma) removed after screening with colonoscopy or fecal immunochemical testing (FIT). TIME HORIZON Lifetime. PERSPECTIVE Societal. INTERVENTION No further screening or surveillance, routine screening after 10 years, low-intensity surveillance (10 years after LRA removal and 5 years after HRA removal), and high-intensity surveillance (5 years after LRA removal and 3 years after HRA removal). OUTCOME MEASURES Colorectal cancer (CRC) incidence and incremental cost-effectiveness. RESULTS OF BASE-CASE ANALYSIS Without surveillance or screening, lifetime CRC incidence for patients aged 50 years was 10.9% after LRA removal and 17.2% after HRA removal at screening colonoscopy. Subsequent colonoscopic screening, low-intensity surveillance, or high-intensity surveillance decreased incidence by 39%, 46% to 48%, and 55% to 56%, respectively. Incidence of CRC and surveillance benefits were higher for adenomas detected at FIT screening and lower for older patients. High-intensity surveillance cost less than $30 000 per quality-adjusted life-year (QALY) gained compared with low-intensity surveillance. RESULTS OF SENSITIVITY ANALYSIS High-intensity surveillance cost less than $100 000 per QALY gained in most alternative scenarios for adenoma recurrence, CRC incidence, longevity, quality of life, screening ages, surveillance ages, test performance, disutilities, and cost. LIMITATION Few surveillance outcome data exist. CONCLUSION The model suggests that high-intensity surveillance as recommended in the United States provides modest but clinically relevant benefits over low-intensity surveillance at acceptable cost. PRIMARY FUNDING SOURCE National Cancer Institute.
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Affiliation(s)
- Reinier G S Meester
- Erasmus MC University Medical Center, Rotterdam, the Netherlands, and Stanford University, Stanford, California (R.G.M.)
| | | | - Sidney J Winawer
- Memorial Sloan Kettering Cancer Center, New York, New York (S.J.W., A.G.Z.)
| | - Ann G Zauber
- Memorial Sloan Kettering Cancer Center, New York, New York (S.J.W., A.G.Z.)
| | - Amy B Knudsen
- Massachusetts General Hospital, Boston, Massachusetts (A.B.K.)
| | - Uri Ladabaum
- Stanford University, Stanford, California (U.L.)
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Rex DK, Sagi SV, Kessler WR, Rogers NA, Fischer M, Bohm ME, Dewitt JM, Lahr RE, Searight MP, Sullivan AW, McWhinney CD, Garcia JR, Broadley HM, Vemulapalli KC. A comparison of 2 distal attachment mucosal exposure devices: a noninferiority randomized controlled trial. Gastrointest Endosc 2019; 90:835-840.e1. [PMID: 31319060 DOI: 10.1016/j.gie.2019.06.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 06/30/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Endocuff (Arc Medical Design, Leeds, UK) and Endocuff Vision (Arc Medical Design, Leeds, UK) are effective mucosal exposure devices for improving polyp detection during colonoscopy. AmplifEYE (Medivators Inc, Minneapolis, Minn, USA) is a device that appears similar to the Endocuff devices but has received minimal clinical testing. METHODS We performed a randomized controlled clinical trial using a noninferiority design to compare Endocuff Vision with AmplifEYE. RESULTS The primary endpoint of adenomas per colonoscopy was similar in AmplifEYE at 1.63 (standard deviation 2.83) versus 1.51 (2.29) with Endocuff Vision (P = .535). The 95% lower confidence limit was 0.88 for ratio of means, establishing noninferiority of AmplifEYE (P = .008). There was no difference between the arms for mean insertion time, and mean inspection time (withdrawal time minus polypectomy time and time for washing and suctioning) was shorter with AmplifEYE (6.8 minutes vs 6.9 minutes, P = .042). CONCLUSIONS AmplifEYE is noninferior to Endocuff Vision for adenoma detection. The decision on which device to use can be based on cost. Additional comparisons of AmplifEYE with Endocuff by other investigators are warranted. (Clinical trial registration number: NCT03560128.).
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Affiliation(s)
- Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sashidhar V Sagi
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | | | - Monika Fischer
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Matthew E Bohm
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John M Dewitt
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rachel E Lahr
- Indiana University School of Medicine, Indianapolis, Indiana, USA
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Vleugels JLA, Hazewinkel Y, Fockens P, Dekker E. Natural history of diminutive and small colorectal polyps: a systematic literature review. Gastrointest Endosc 2017; 85:1169-1176.e1. [PMID: 28024986 DOI: 10.1016/j.gie.2016.12.014] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Accepted: 12/15/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Diminutive (1-5 mm) and small (6-9 mm) polyps comprise 90% of detected lesions during colonoscopy and rarely contain advanced histology or colorectal cancer (CRC). Routine removal of these lesions results in a significant burden to colonoscopy programs. At the same time, the risk for progression of these polyps to CRC is unclear. We performed a systematic review to explore the natural history of diminutive and small colorectal polyps. METHODS We searched MEDLINE and EMBASE for studies investigating the natural history of colorectal polyps. Studies were considered eligible when they assessed patients with 1- to 9-mm polyps that were not treated with polypectomy and that underwent follow-up. We excluded studies in patients with inflammatory bowel disease, polyposis syndromes, and previously diagnosed CRC. We independently extracted study characteristics and evaluated CRC and advanced adenoma (size ≥ 10 mm, containing high-grade dysplasia or villous features) as outcome parameters. RESULTS Of 8775 retrieved studies, 9 studies with 721 patients were included that prospectively evaluated the evolution of 1- to 9-mm polyps. In 7 studies the average duration of observation was 2 to 3 years. There was only 1 study in which 1 small polyp might have progressed to cancer. Of 1034 adenomas sized 1 to 9 mm in those studies, 6% progressed to advanced adenomas over time. CONCLUSIONS Based on this systematic review, it appears that some 1- to 9-mm adenomas progress to advanced adenomas within 2 to 3 years. No information on long-term CRC transition rates was found. Defining the biologic significance of these polyps is needed to balance between benefits and harm of polypectomy. (PROSPERO database registration number: CRD42016036577.).
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Affiliation(s)
- Jasper L A Vleugels
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Yark Hazewinkel
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
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Jiang AC, Buckingham L, Barbanera W, Korang AY, Bishesari F, Melson J. LINE-1 is preferentially hypomethylated within adenomatous polyps in the presence of synchronous colorectal cancer. Clin Epigenetics 2017; 9:25. [PMID: 28293326 PMCID: PMC5345219 DOI: 10.1186/s13148-017-0325-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 03/02/2017] [Indexed: 12/31/2022] Open
Abstract
Background Conventional tubular adenomas are frequently detected in patients undergoing average risk screening colonoscopy and are over-represented in patients who will develop colorectal cancer (CRC). Whether features of adenomas could serve as predictors of synchronous CRC is not known. Here, we investigate whether global methylation markers, including LINE-1, differ within adenomas in patients with and without synchronous CRC. Methods Colorectal tubular/tubulovillous adenomatous polyps in the absence (P group, n = 45) and in the presence of synchronous CRC (PC group, n = 32) were identified. Global methylation and demethylation by ELISA for 5-methylcytosine (5-mC) and 5-hydroxymethyl cytosine (5-hmC), respectively, were assessed in polyps and adjacent normal non-neoplastic tissue. LINE-1 hypomethylation was assessed by pyrosequencing of bisulfite-converted DNA as well. Results Global methylation (5-mC) showed no differences in overall methylation status in the adenomatous polyps in the two groups (5-mC relative to control %, PC group 0.117; P group 0.161, p = 0.148). Global hydroxymethylation 5-hmC was also not significantly different in adenomatous polyps of the PC group than in those of the P group (0.0059 vs 0.0097, p = 0.681). Similarly, global 5-hmC was not different between normal tissues from patients without neoplasia in comparison to those from CRC patients (0.0461 ± 0.080 vs 0.039 ± 0.159, p = 0.215). In contrast, adenomatous polyps of the PC group had lower levels of LINE-1 methylation compared to the adenomas in the P group (53.07 ± 4.5 vs 59.95 ± 5.4, p < 0.001). LINE-1 methylation was also significantly lower in the normal tissue from cancer patients compared to that from patients without any neoplasia (58.07 ± 3.78 vs 71.50 ± 6.47, p < 0.001). Conclusions LINE-1 hypomethylation of precancerous adenomas correlates with the presence of synchronous CRC. Measurement of DNA hypomethylation levels of colorectal adenomas by LINE-1 could have future implications in approaches to defining CRC risk in screening programs.
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Affiliation(s)
- Alice Chu Jiang
- Department of Internal Medicine, Rush University Medical Center, 1717 W Congress Parkway, 10 Kellogg, Chicago, IL 60612 USA
| | - Lela Buckingham
- Department of Pathology, Rush University Medical Center, 600 S. Paulina Street, 1014 AAC, Chicago, IL 60612 USA
| | - William Barbanera
- Department of Pathology, Rush University Medical Center, 600 S. Paulina Street, 1014 AAC, Chicago, IL 60612 USA
| | - Amoah Yeboah Korang
- Department of Internal Medicine, Rush University Medical Center, 1717 W Congress Parkway, 10 Kellogg, Chicago, IL 60612 USA
| | - Faraz Bishesari
- Department of Internal Medicine, Rush University Medical Center, 1717 W Congress Parkway, 10 Kellogg, Chicago, IL 60612 USA.,Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, 1725 West Harrison, Suite 206, Chicago, IL 60612 USA
| | - Joshua Melson
- Department of Internal Medicine, Rush University Medical Center, 1717 W Congress Parkway, 10 Kellogg, Chicago, IL 60612 USA.,Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, 1725 West Harrison, Suite 206, Chicago, IL 60612 USA
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CT Colonographic Screening of Patients With a Family History of Colorectal Cancer: Comparison With Adults at Average Risk and Implications for Guidelines. AJR Am J Roentgenol 2017; 208:794-800. [PMID: 28125785 DOI: 10.2214/ajr.16.16724] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The purposes of this study were to compare rates of lesion detection at CT colonographic (CTC) screening of adults without symptoms who had and who did not have a family history of colorectal cancer according to American Cancer Society guidelines and to consider the clinical implications. MATERIALS AND METHODS Over 134 months, consecutively registered CTC cohorts of adults without symptoms who had (n = 156; 88 [56.4%] women; 68 [43.6%] men; mean age, 56.3 years) and who did not have (n = 8857; 4757 [53.7%] women; 4100 [46.3%] men; mean age, 56.6 years) an American Cancer Society-defined family history of colorectal cancer (first-degree relative with diagnosis before age 60 years or two first-degree relatives with diagnosis at any age) were compared for relevant colorectal findings. RESULTS For the family history versus no family history cohorts, the frequency of all nondiminutive polyps (≥ 6 mm) reported at CTC was 23.7% versus 15.5% (p = 0.007); small polyps (6-9 mm), 13.5% versus 9.1% (p = 0.068); and large polyps (≥ 10 mm), 10.2% versus 6.5% (p = 0.068). The rate of referral for colonoscopy was greater for the family history cohort (16.0% vs 10.5%; p = 0.035). However, the frequencies of proven advanced adenoma (4.5% vs 3.2%; p = 0.357), nonadvanced adenoma (5.1% vs 2.6%; p = 0.070), and cancer (0.0% vs 0.4%; p = 0.999) were not significantly increased. The difference in positive rates between the two cohorts (11.5% vs 4.3%; p < 0.001) was primarily due to nonneoplastic findings of no colorectal cancer relevance, such as small hyperplastic polyps, diverticular disease, and false-positive CTC findings. CONCLUSION Although the overall CTC-positive and colonoscopy referral rates were higher in the family history cohort, the clinically relevant frequencies of advanced neoplasia and cancer were not sufficiently increased to preclude CTC screening. These findings support the use of CTC as a front-line screening option in adults with a family history of colorectal cancer.
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Jover R, Dekker E. Surveillance after colorectal polyp removal. Best Pract Res Clin Gastroenterol 2016; 30:937-948. [PMID: 27938788 DOI: 10.1016/j.bpg.2016.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 10/13/2016] [Indexed: 02/07/2023]
Abstract
Surveillance colonoscopy is aimed to reduce CRC incidence and mortality by removing adenomas and detecting CRC in early stage. However, colonoscopy is an invasive and expensive procedure and surveillance colonoscopy should be targeted at those who are most likely to benefit at the minimum frequency required to protect for cancer. Surveillance recommendations are based on guidelines, but the recommendations in those guidelines are based on moderate to low quality evidence and adherence to these guidelines is poor. As surveillance colonoscopy is one of the main indications for colonoscopy and surveillance colonoscopies are filling colonoscopy lists, the current surveillance practice results in spending lots of money and capacity in a suboptimal way. Randomized controlled trials to compare surveillance intervals are not available. However, current evidence based on several case-control and cohort studies suggests there is no need for surveillance in patients with low-risk adenomas, i.e. 1-2 adenomas smaller than 10 mm. Patients with 3 or more adenomas or any adenoma larger than 10 mm seem to be the ones at real risk for metachronous adenomas or cancer. In those patients, surveillance colonoscopy is indicated at 3 years after baseline until ongoing studies will confirm the safety of enlarging this interval. Randomized controlled trials and experimental research are important in order to provide the necessary scientific evidence for the optimization of follow-up strategies for patients with adenomas and serrated polyps.
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Affiliation(s)
- Rodrigo Jover
- Unidad de Gastroenterología, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria ISABIAL, C/ Pintor Baeza 12, 03010 Alicante, Spain.
| | - Evelien Dekker
- Department of Gastroenterology & Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Lowery JT, Ahnen DJ, Schroy PC, Hampel H, Baxter N, Boland CR, Burt RW, Butterly L, Doerr M, Doroshenk M, Feero WG, Henrikson N, Ladabaum U, Lieberman D, McFarland EG, Peterson SK, Raymond M, Samadder NJ, Syngal S, Weber TK, Zauber AG, Smith R. Understanding the contribution of family history to colorectal cancer risk and its clinical implications: A state-of-the-science review. Cancer 2016; 122:2633-45. [PMID: 27258162 PMCID: PMC5575812 DOI: 10.1002/cncr.30080] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 01/08/2016] [Accepted: 01/15/2016] [Indexed: 12/14/2022]
Abstract
Persons with a family history (FH) of colorectal cancer (CRC) or adenomas that are not due to known hereditary syndromes have an increased risk for CRC. An understanding of these risks, screening recommendations, and screening behaviors can inform strategies for reducing the CRC burden in these families. A comprehensive review of the literature published within the past 10 years has been performed to assess what is known about cancer risk, screening guidelines, adherence and barriers to screening, and effective interventions in persons with an FH of CRC and to identify FH tools used to identify these individuals and inform care. Existing data show that having 1 affected first-degree relative (FDR) increases the CRC risk 2-fold, and the risk increases with multiple affected FDRs and a younger age at diagnosis. There is variability in screening recommendations across consensus guidelines. Screening adherence is <50% and is lower in persons under the age of 50 years. A provider's recommendation, multiple affected relatives, and family encouragement facilitate screening; insufficient collection of FH, low knowledge of guidelines, and poor family communication are important barriers. Effective interventions incorporate strategies for overcoming barriers, but these have not been broadly tested in clinical settings. Four strategies for reducing CRC in persons with familial risk are suggested: 1) improving the collection and utilization of the FH of cancer, 2) establishing a consensus for screening guidelines by FH, 3) enhancing provider-patient knowledge of guidelines and communication about CRC risk, and 4) encouraging survivors to promote screening within their families and partnering with existing screening programs to expand their reach to high-risk groups. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2633-2645. © 2016 American Cancer Society.
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Affiliation(s)
- Jan T Lowery
- Colorado School of Public Health, Aurora, Colorado
| | - Dennis J Ahnen
- School of Medicine and Gastroenterology of the Rockies, University of Colorado, Boulder, Colorado
| | - Paul C Schroy
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Heather Hampel
- Comprehensive Cancer Center, Ohio State University, Columbus, Ohio
| | | | | | - Randall W Burt
- Huntsman Cancer Institute, University of Utah Health Care, Salt Lake City, Utah
| | - Lynn Butterly
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | | | - W Gregory Feero
- Maine Dartmouth Family Medicine Residency Program, Augusta, Maine
| | | | - Uri Ladabaum
- Stanford University School of Medicine, Stanford, California
| | | | | | - Susan K Peterson
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - N Jewel Samadder
- Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, Utah
| | | | | | - Ann G Zauber
- Memorial Sloan Kettering Cancer Center, New York, New York
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Pickhardt PJ, Pooler BD, Mbah I, Weiss JM, Kim DH. Colorectal Findings at Repeat CT Colonography Screening after Initial CT Colonography Screening Negative for Polyps Larger than 5 mm. Radiology 2016; 282:139-148. [PMID: 27552558 DOI: 10.1148/radiol.2016160582] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Purpose To determine the rate and types of polyps detected at repeat computed tomographic (CT) colonography screening after initial negative findings at CT colonography screening. Materials and Methods Among 5640 negative CT colonography screenings (no polyps ≥ 6 mm) performed before 2010 at one medical center, 1429 (25.3%; mean age, 61.4 years; 736 women, 693 men) patients have returned for repeat CT colonography screening (mean interval, 5.7 years ± 0.9; range, 4.5-10.7 years). Positive rates and histologic findings of initial and repeat screening were compared in this HIPAA-compliant, institutional review board-approved study. For all patients with positive findings at repeat CT colonography, the findings were directly compared against the initial CT colonography findings. Fisher exact, Pearson χ2, and Student t tests were applied as indicated. Results Repeat CT colonography screening was positive for lesions 6 mm or larger in 173 (12.1%) adults (compared with 14.3% at initial CT colonography screening, P = .29). In the 173 patients, 29.5% (61 of 207) of nondiminutive polyps could be identified as diminutive at the initial CT colonography and 12.6% (26 of 207) were missed. Large polyps, advanced neoplasia (advanced adenomas and cancer), and invasive cancer were seen in 3.8% (55 of 1429), 2.8% (40 of 1429), and 0.14% (two of 1429), respectively, at follow-up, compared with 5.2% (P = .02), 3.2% (P = .52), and 0.45% (P = .17), respectively, at initial screening. Of 42 advanced lesions in 40 follow-up screenings, 33 (78.6%) were right sided and 22 (52.4%) were flat, compared with 45.4% (P < .001) and 11.3% (P < .001), respectively, at initial screening. Large right-sided serrated lesions were confirmed in 20 individuals (1.4%), compared with 0.5% (P < .001) confirmed at initial screening. Conclusion Positive rates for large polyps at repeat CT colonography screening (3.7%) were lower compared with those at initial screening (5.2%). However, more advanced right-sided lesions were detected at follow-up CT colonography, many of which were flat, serrated lesions. The cumulative findings support both the nonreporting of diminutive lesions and a 5-10-year screening interval. © RSNA, 2016 An earlier incorrect version of this article appeared online. This article was corrected on August 30, 2016.
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Affiliation(s)
- Perry J Pickhardt
- From the Departments of Radiology (P.J.P., B.D.P., I.M., D.H.K.) and Gastroenterology (J.M.W.), University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53705
| | - B Dustin Pooler
- From the Departments of Radiology (P.J.P., B.D.P., I.M., D.H.K.) and Gastroenterology (J.M.W.), University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53705
| | - Ifeanyi Mbah
- From the Departments of Radiology (P.J.P., B.D.P., I.M., D.H.K.) and Gastroenterology (J.M.W.), University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53705
| | - Jennifer M Weiss
- From the Departments of Radiology (P.J.P., B.D.P., I.M., D.H.K.) and Gastroenterology (J.M.W.), University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53705
| | - David H Kim
- From the Departments of Radiology (P.J.P., B.D.P., I.M., D.H.K.) and Gastroenterology (J.M.W.), University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53705
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Emerging stool-based and blood-based non-invasive DNA tests for colorectal cancer screening: the importance of cancer prevention in addition to cancer detection. Abdom Radiol (NY) 2016; 41:1441-4. [PMID: 27259335 DOI: 10.1007/s00261-016-0798-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Colorectal cancer (CRC) screening can be undertaken utilizing a variety of distinct approaches, which provides both opportunities and confusion. Traditionally, there has often been a trade-off between the degree of invasiveness of a screening test and its ability to prevent cancer, with fecal occult blood testing (FOBT) and optical colonoscopy (OC) at each end of the spectrum. CT colonography (CTC), although currently underutilized for CRC screening, represents an exception since it is only minimally invasive, yet provides accurate evaluation for advanced adenomas. More recently, the FDA approved a multi-target stool DNA test (Cologuard) and a blood-based test (Epi proColon) for average-risk CRC screening. This commentary will provide an overview of these two new non-invasive tests, including the clinical indications, mechanism of action, and diagnostic performance. Relevance to radiology practice, including a comparison with CTC, will also be discussed.
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Kaltenbach T, Rastogi A, Rouse RV, McQuaid KR, Sato T, Bansal A, Kosek JC, Soetikno R. Real-time optical diagnosis for diminutive colorectal polyps using narrow-band imaging: the VALID randomised clinical trial. Gut 2015; 64:1569-77. [PMID: 25387891 DOI: 10.1136/gutjnl-2014-307742] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 09/09/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Diminutive (≤ 5 mm) colorectal polyps are common, and overwhelmingly benign. Routinely, after polypectomy, they are examined pathologically to determine the surveillance intervals. Advances in equipment and techniques, such as narrow-band imaging (NBI) colonoscopy, now permit reliable real-time optical diagnosis. METHODS We conducted a randomised single-masked study involving three institutions to determine whether optical diagnosis of diminutive colorectal polyps meets clinical practice standards and reduces the need for histopathology. We randomly assigned eligible patients undergoing routine high-definition colonoscopy to optical diagnosis using near focus versus standard view, using computer-generated block sequence. By validated criteria, we rendered an optical diagnosis and a confidence level (high vs low) for all polyps, using NBI. Our primary endpoint was the number of accurate high-confidence optical diagnoses compared with central blinded pathology in the two groups. We analysed data using intention to treat. FINDINGS We enrolled 558 subjects, and randomly assigned 281 to near focus and 277 to standard view optical diagnosis. We detected 1309 predominantly diminutive (74.5%) and neoplastic (60.0%) polyps. Endoscopists were significantly more likely, OR 2.2 (95% CI 1.6 to 3.0, p<0.0001), to make a high-confidence optical diagnosis with near focus (85.1%) than standard (72.6%) view. High-confidence diagnoses had 96.4% and 92.0% negative predictive value, respectively. Of all polyps, 75.3% (95% CI71.3% to 78.9%) had a high-confidence accurate prediction using near focus, compared with 63.1% (95% CI 58.5% to 67.6%) using standard view. Optical versus histopathological diagnosis showed excellent agreement between the surveillance intervals, 93.5% in near focus and 92.2% in standard view. The median diagnosis time was 14 s. CONCLUSIONS Real-time optical diagnosis using NBI colonoscopy may replace the pathology diagnosis for the majority of diminutive colorectal polyps. Using colonoscopy with near focus view increases the confidence level of the optical diagnosis. Optical diagnosis would be a paradigm shift in clinical practice of colonoscopy for colorectal cancer screening. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier: NCT01288833.
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Affiliation(s)
- Tonya Kaltenbach
- Veterans Affairs Palo Alto, GI Endoscopy Unit and Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Amit Rastogi
- Veterans Affairs Kansas City, Gastroenterology Section and Department of Medicine, Division of Gastroenterology, University of Kansas, Kansas City, Missouri, USA
| | - Robert V Rouse
- Veterans Affairs Palo Alto, Pathology and Laboratory Medicine Service and Department of Pathology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Kenneth R McQuaid
- Veterans Affairs San Francisco, Gastrointestinal Diagnostic Unit and Division of Gastroenterology, University California San Francisco, San Francisco, California, USA
| | - Tohru Sato
- Veterans Affairs Palo Alto, GI Endoscopy Unit and Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ajay Bansal
- Veterans Affairs Kansas City, Gastroenterology Section and Department of Medicine, Division of Gastroenterology, University of Kansas, Kansas City, Missouri, USA
| | - Jon C Kosek
- Veterans Affairs Palo Alto, Pathology and Laboratory Medicine Service and Department of Pathology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Roy Soetikno
- Veterans Affairs Palo Alto, GI Endoscopy Unit and Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California, USA
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Meester RGS, Doubeni CA, Lansdorp-Vogelaar I, Jensen CD, van der Meulen MP, Levin TR, Quinn VP, Schottinger JE, Zauber AG, Corley DA, van Ballegooijen M. Variation in Adenoma Detection Rate and the Lifetime Benefits and Cost of Colorectal Cancer Screening: A Microsimulation Model. JAMA 2015; 313:2349-58. [PMID: 26080339 PMCID: PMC4631392 DOI: 10.1001/jama.2015.6251] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Colonoscopy is the most commonly used colorectal cancer screening test in the United States. Its quality, as measured by adenoma detection rates (ADRs), varies widely among physicians, with unknown consequences for the cost and benefits of screening programs. OBJECTIVE To estimate the lifetime benefits, complications, and costs of an initial colonoscopy screening program at different levels of adenoma detection. DESIGN, SETTING, AND PARTICIPANTS Microsimulation modeling with data from a community-based health care system on ADR variation and cancer risk among 57,588 patients examined by 136 physicians from 1998 through 2010. EXPOSURES Using modeling, no screening was compared with screening initiation with colonoscopy according to ADR quintiles (averages 15.3%, quintile 1; 21.3%, quintile 2; 25.6%, quintile 3; 30.9%, quintile 4; and 38.7%, quintile 5) at ages 50, 60, and 70 years with appropriate surveillance of patients with adenoma. MAIN OUTCOMES AND MEASURES Estimated lifetime colorectal cancer incidence and mortality, number of colonoscopies, complications, and costs per 1000 patients, all discounted at 3% per year and including 95% confidence intervals from multiway probabilistic sensitivity analysis. RESULTS In simulation modeling, among unscreened patients the lifetime risk of colorectal cancer incidence was 34.2 per 1000 (95% CI, 25.9-43.6) and risk of mortality was 13.4 per 1000 (95% CI, 10.0-17.6). Among screened patients, simulated lifetime incidence decreased with lower to higher ADRs (26.6; 95% CI, 20.0-34.3 for quintile 1 vs 12.5; 95% CI, 9.3-16.5 for quintile 5) as did mortality (5.7; 95% CI, 4.2-7.7 for quintile 1 vs 2.3; 95% CI, 1.7-3.1 for quintile 5). Compared with quintile 1, simulated lifetime incidence was on average 11.4% (95% CI, 10.3%-11.9%) lower for every 5 percentage-point increase of ADRs and for mortality, 12.8% (95% CI, 11.1%-13.7%) lower. Complications increased from 6.0 (95% CI, 4.0-8.5) of 2777 colonoscopies (95% CI, 2626-2943) in quintile 1 to 8.9 (95% CI, 6.1-12.0) complications of 3376 (95% CI, 3081-3681) colonoscopies in quintile 5. Estimated net screening costs were lower from quintile 1 (US $2.1 million, 95% CI, $1.8-$2.4 million) to quintile 5 (US $1.8 million, 95% CI, $1.3-$2.3 million) due to averted cancer treatment costs. Results were stable across sensitivity analyses. CONCLUSIONS AND RELEVANCE In this microsimulation modeling study, higher adenoma detection rates in screening colonoscopy were associated with lower lifetime risks of colorectal cancer and colorectal cancer mortality without being associated with higher overall costs. Future research is needed to assess whether increasing adenoma detection would be associated with improved patient outcomes.
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Affiliation(s)
- Reinier G S Meester
- the Netherlands Institute of Health Sciences, Erasmus MC University Medical Center, Rotterdam2Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Chyke A Doubeni
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia4Department of Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia5The Leonard Davis Center for Health
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Miriam P van der Meulen
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Virginia P Quinn
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | | | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York
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Imler TD, Morea J, Imperiale TF. Clinical decision support with natural language processing facilitates determination of colonoscopy surveillance intervals. Clin Gastroenterol Hepatol 2014; 12:1130-6. [PMID: 24316106 DOI: 10.1016/j.cgh.2013.11.025] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 11/19/2013] [Accepted: 11/19/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS With an increased emphasis on improving quality and decreasing costs, new tools are needed to improve adherence to evidence-based practices and guidelines in endoscopy. We investigated the ability of an automated system that uses natural language processing (NLP) and clinical decision support (CDS) to facilitate determination of colonoscopy surveillance intervals. METHODS We performed a retrospective study at a single Veterans Administration medical center of patients age 40 years and older who had an index outpatient colonoscopy from 2002 through 2009 for any indication except surveillance of a previous colorectal neoplasia. We analyzed data from 10,798 reports, with 6379 linked to pathology results and 300 randomly selected reports. NLP-based CDS surveillance intervals were compared with those determined by paired, blinded, manual review. The primary outcome was adjusted agreement between manual review and the fully automated system. RESULTS κ statistical analysis produced a value of 0.74 (P < .001) for agreement between the full text annotation and the NLP-based CDS system. Fifty-five reports (18.3%; 95% confidence interval, 14.1%-23.2%) differed between manual review and CDS recommendations. Of these, NLP error accounted for 30 (54.5%), incomplete resection of adenomatous tissue accounted for 14 (25.5%), and masses observed without biopsy findings of cancer accounted for 4 (7.2%). NLP-based CDS surveillance intervals had higher levels of agreement with the standard (81.7%) than the level agreement between experts (72% agreement between paired reviewers). CONCLUSIONS A fully automated system that uses NLP and a guideline-based CSD system can accurately facilitate guideline-recommended adherence surveillance for colonoscopy.
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Affiliation(s)
- Timothy D Imler
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Department of Medical Informatics, Regenstrief Institute, Indianapolis, Indiana; Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.
| | - Justin Morea
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Thomas F Imperiale
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Center of Excellence for Implementation of Evidence-Based Practice, Richard L. Roudebush VA Medical Center, Indiana University, Indianapolis, Indiana
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Chiu HM, Chang LC, Shun CT, Wu MS, Wang HP. Current management of diminutive colorectal polyps in Taiwan. Dig Endosc 2014; 26 Suppl 2:64-7. [PMID: 24750151 DOI: 10.1111/den.12260] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Accepted: 01/17/2014] [Indexed: 02/08/2023]
Abstract
The majority of polyps detected during colonoscopy are diminutive polyps, for which the cost of pathological analysis is substantial. In our analysis of a screening cohort of 10737 subjects undergoing screening colonoscopy, a total of 15877 neoplastic lesions were detected, of which 10816 (68.1%) were diminutive lesions. Of those diminutive lesions, 90 (0.83%) had a villous component, 14 (0.1%) had high-grade dysplasia, and none had invasive cancer. Only 1.3% of patients were advised to decrease their surveillance interval because of unfavorable histology. Laws regulating medical practice, uncertainty regarding the accuracy of endoscopic diagnosis of diminutive polyps outside of academic centers, and the relatively low cost of pathological analysis are among the barriers to adopting a 'resect and discard' practice in Taiwan.
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Affiliation(s)
- Han-Mo Chiu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Colonoscopy Quality Assurance Working Group, The Digestive Endoscopy, Society of Taiwan, Taipei, Taiwan
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Song Z, Fendrick AM, Safran DG, Landon B, Chernew ME. Global Budgets and Technology-Intensive Medical Services. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2013; 1:15-21. [PMID: 24772385 PMCID: PMC3997740 DOI: 10.1016/j.hjdsi.2013.04.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND In 2009-2010, Blue Cross Blue Shield of Massachusetts entered into global payment contracts (the Alternative Quality contract, AQC) with 11 provider organizations. We evaluated the impact of the AQC on spending and utilization of several categories of medical technologies, including one considered high value (colonoscopies) and three that include services that may be overused in some situations (cardiovascular, imaging, and orthopedic services). METHODS Approximately 420,000 unique enrollees in 2009 and 180,000 in 2010 were linked to primary care physicians whose organizations joined the AQC. Using three years of pre-intervention data and a large control group, we analyzed changes in utilization and spending associated with the AQC with a propensity-weighted difference-in-differences approach adjusting for enrollee demographics, health status, secular trends, and cost-sharing. RESULTS In the 2009 AQC cohort, total volume of colonoscopies increased 5.2 percent (p=0.04) in the first two years of the contract relative to control. The contract was associated with varied changes in volume for cardiovascular and imaging services, but total spending on cardiovascular services in the first two years decreased by 7.4% (p=0.02) while total spending on imaging services decreased by 6.1% (p<0.001) relative to control. In addition to lower utilization of higher-priced services, these decreases were also attributable to shifting care to lower-priced providers. No effect was found in orthopedics. CONCLUSIONS As one example of a large-scale global payment initiative, the AQC was associated with higher use of colonoscopies. Among several categories of services whose value may be controversial, the contract generally shifted volume to lower-priced facilities or services.
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Affiliation(s)
- Zirui Song
- Department of Health Care Policy, Harvard Medical School
- National Bureau of Economic Research
| | - A. Mark Fendrick
- Departments of Internal Medicine and Health Management & Policy, Center for Value-Based Insurance Design, University of Michigan
| | - Dana Gelb Safran
- Blue Cross Blue Shield of Massachusetts
- Department of Medicine, Tufts University School of Medicine
| | - Bruce Landon
- Department of Health Care Policy, Harvard Medical School
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center
| | - Michael E. Chernew
- Department of Health Care Policy, Harvard Medical School
- National Bureau of Economic Research
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