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Zhang Y, Wang X, Zhang W, Zhou X, Ren M, Chen H, Pan H. Incidence of colorectal cancer at different screening intervals after index colonoscopy and post-polypectomy: a meta-analysis of 811,181 participants. Expert Rev Gastroenterol Hepatol 2022; 16:1101-1114. [PMID: 36408602 DOI: 10.1080/17474124.2022.2147925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To examine the evidence on the incidence of colorectal cancers (CRCs) at a follow-up screening colonoscopy (after index colonoscopy and post-polypectomy) in individuals with no adenoma, low-risk adenomas, and high-risk adenomas. METHODS We included studies reporting the incidence of CRCs at different screening intervals after index colonoscopy and post-polypectomy. The main outcome was pooled cumulative incidence rate of CRCs stratified by intervals of 3, 5, 10, and >10 years. RESULTS Fourteen studies with 811,181 participants were analyzed, including 10 multicenter studies and 3 national CRC screening programs. The cumulative incidence of CRCs was 0.63% (95% confidence interval [CI]: 0.30, 0.97) in the high-risk-adenoma group at 3 years, 0.37% (95% CI: 0.13, 0.61) and 0.67% (95% CI: 0.36, 0.99) in the low-risk-adenoma group at 5 and 10 years, respectively, and 0.32% (95% CI: 0.20, 0.45) and 0.50% (95% CI: 0.30, 0.69) in the no-adenoma-group at 10 and >10 years, respectively. CONCLUSION This meta-analysis summarizes the results of colonoscopy surveillance programs with detailed data support for different screening intervals. The data on date suggest that reasonable surveillance intervals are within 3 years for the high-risk-adenoma group, 5-10 years for the low-risk-adenoma group, and ≥10 years for the no-adenoma group.
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Affiliation(s)
- Yu Zhang
- Cancer Center, Department of Gastroenterology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China
| | - Xueli Wang
- College of Pharmaceutical Science, Zhejiang University of Technology, Hangzhou, Zhejiang, China
| | - Wei Zhang
- Department of General Surgery, the Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Xinxin Zhou
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Mengting Ren
- Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Huiyan Chen
- School of Laboratory Medicine and Life Sciences, Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Hanghai Pan
- Cancer Center, Department of Gastroenterology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China
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Doyle JB, Krigel A, Lebwohl B. Prevalence of Adenomas on Surveillance Colonoscopies for Patients with a History of Colonic Polyps of Unknown Histology. Dig Dis Sci 2022; 67:3239-3243. [PMID: 34156591 DOI: 10.1007/s10620-021-07108-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/09/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Guidelines for surveillance colonoscopy depend on polyp histology. When patients present to a new healthcare system and report a personal history of "colon polyps," however, information on polyp histology is frequently unavailable. AIMS To assess adenoma prevalence in patients with a history of colonic polyps of unknown histology and to compare it to patients undergoing either screening colonoscopy or surveillance colonoscopy for known adenomatous polyps. METHODS This cohort study evaluated colonoscopies of patients ≥ 50 years of age over a 14-year period at a single institution. The exposure of interest was colonoscopy indication, categorized into three groups: screening colonoscopy, surveillance colonoscopy for history of colonic polyp(s) of unknown histology, and surveillance colonoscopy for history of adenoma(s). The primary outcome was adenoma detection rate. Multivariable logistic regression was used to assess the association between colonoscopy indication and adenoma detection rate. RESULTS Of 31,856 colonoscopies, the adenoma prevalence was 26.1% for patients undergoing screening colonoscopy, 32.9% for patients with a history of polyps of unknown histology, and 41.9% for patients with a history of known adenomatous polyps. Relative to screening colonoscopies, there were higher odds of adenoma detection in surveillance colonoscopies for polyps of unknown histology (aOR compared to screening 1.42, 95% CI 1.30-1.55) and even higher odds among surveillance colonoscopies for a history of adenoma (aOR compared to screening 1.89, 95% CI 1.75-2.05). CONCLUSION The adenoma prevalence on surveillance colonoscopy for patients with polyps of unknown histology was higher than that of screening colonoscopies but lower than that of surveillance colonoscopies for patients with adenomatous polyps.
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Affiliation(s)
- John B Doyle
- Department of Medicine, Columbia University Medical Center, 180 Fort Washington Avenue, Suite 936, New York, NY, 10032, USA
| | - Anna Krigel
- Department of Medicine, Columbia University Medical Center, 180 Fort Washington Avenue, Suite 936, New York, NY, 10032, USA
| | - Benjamin Lebwohl
- Department of Medicine, Columbia University Medical Center, 180 Fort Washington Avenue, Suite 936, New York, NY, 10032, USA. .,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
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Kahi CJ, Myers LJ, Stump TE, Imler TD, Sherer EA, Larson J, Imperiale TF. Tailoring Surveillance Colonoscopy in Patients With Advanced Adenomas. Clin Gastroenterol Hepatol 2022; 20:847-854.e1. [PMID: 33775897 DOI: 10.1016/j.cgh.2021.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/06/2021] [Accepted: 03/23/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with advanced colorectal adenomas (AAs) are directed to undergo intensive surveillance. However, the benefit derived from surveillance may be outweighed by the risk of death from non-colorectal cancer (CRC) causes, leading to uncertainty on how best to individualize follow-up. The aim of this study was to derive a risk prediction model and risk index that estimate and stratify the risk for non-CRC cancer mortality (NCM) subsequent to diagnosis and removal of AA. METHODS We conducted a retrospective cohort study of veterans ≥40 years old who had colonoscopy for diagnostic or screening indications at 13 Veterans Affairs Medical Centers between 2002 and 2009 and had 1 or more AAs. The primary outcome was NCM using a fixed follow-up time period of 5 years. Logistic regression using the lasso technique was used to identify factors independently associated with NCM, and an index based on points from regression coefficients was constructed to estimate risk of 5-year NCM. RESULTS We identified 2943 veterans with AA (mean age [standard deviation] 63 [8.6] years, 98% male, 74% white), with an overall 5-year mortality of 16.7%, which was nearly all due to NCM (16.6%). Age, comorbidity burden, specific comorbid conditions, and hospitalization within the preceding year were independently associated with NCM. The risk prediction model had a goodness of fit (calibration) P value of .41 and c-statistic (discrimination) of 0.74 (95% confidence interval, 0.71-0.76). On the basis of comparable 5-year risks of NCM, the scores comprised 3 risk categories: low (score of 0-1), intermediate (score of 2-4), and high (score of ≥5), in which NCM occurred in 6.5%, 14.1%, and 33.2%, respectively. CONCLUSIONS We derived a risk prediction model that identifies veterans with advanced adenomas who are at high risk of NCM within 5 years, and who are thus unlikely to benefit from further surveillance.
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Affiliation(s)
- Charles J Kahi
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University, Indianapolis; Health Services Research & Development, Richard L. Roudebush VA Medical Center, Indianapolis; Indiana University School of Medicine, Indianapolis.
| | - Laura J Myers
- Health Services Research & Development, Richard L. Roudebush VA Medical Center, Indianapolis; Indiana University School of Medicine, Indianapolis
| | - Timothy E Stump
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis
| | | | - Eric A Sherer
- Health Services Research & Development, Richard L. Roudebush VA Medical Center, Indianapolis
| | - Jason Larson
- Health Services Research & Development, Richard L. Roudebush VA Medical Center, Indianapolis
| | - Thomas F Imperiale
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University, Indianapolis; Health Services Research & Development, Richard L. Roudebush VA Medical Center, Indianapolis; Indiana University School of Medicine, Indianapolis; The Regenstrief Institute, Indianapolis, Indiana
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4
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Duvvuri A, Chandrasekar VT, Srinivasan S, Narimiti A, Dasari C, Nutalapati V, Kennedy KF, Spadaccini M, Antonelli G, Desai M, Vennalaganti P, Kohli D, Kaminski MF, Repici A, Hassan C, Sharma P. Risk of Colorectal Cancer and Cancer Related Mortality After Detection of Low-risk or High-risk Adenomas, Compared With No Adenoma, at Index Colonoscopy: A Systematic Review and Meta-analysis. Gastroenterology 2021; 160:1986-1996.e3. [PMID: 33524401 DOI: 10.1053/j.gastro.2021.01.214] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 01/20/2021] [Accepted: 01/22/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS The risk of metachronous colorectal cancer (CRC) among patients with no adenomas, low-risk adenomas (LRAs), or high-risk adenomas (HRAs), detected at index colonoscopy, is unclear. We performed a systematic review and meta-analysis to compare incidence rates of metachronous CRC and CRC-related mortality after a baseline colonoscopy for each group. METHODS We searched the PubMed, Embase, Google Scholar, and Cochrane databases for studies that reported the incidence of CRC and adenoma characteristics after colonoscopy. The primary outcome was odds of metachronous CRC and CRC-related mortality per 10,000 person-years of follow-up after baseline colonoscopy for all the groups. RESULTS Our final analysis included 12 studies with 510,019 patients (mean age, 59.2 ± 2.6 years; 55% male; mean duration of follow up, 8.5 ± 3.3 years). The incidence of CRC per 10,000 person-years was marginally higher for patients with LRAs compared to those with no adenomas (4.5 vs 3.4; odds ratio [OR], 1.26; 95% CI, 1.06-1.51; I2=0), but significantly higher for patients with HRAs compared to those with no adenoma ( 13.8 vs 3.4; odds ratio [OR], 2.92; 95% CI, 2.31-3.69; I2=0 ) and patients with HRAs compared to LRAs (13.81 vs 4.5; OR, 2.35; 95% CI, 1.72-3.20; I2=55%). However, the CRC-related mortality per 10,000 person-years did not differ significantly for patients with LRAs compared to no adenomas (OR, 1.15; 95% CI, 0.76-1.74; I2=0) but was significantly higher in persons with HRAs compared with LRAs (OR, 2.48; 95% CI, 1.30-4.75; I2=38%) and no adenomas (OR, 2.69; 95% CI, 1.87-3.87; I2=0). CONCLUSIONS The results of this systematic review and meta-analysis demonstrate that the risk of metachronous CRC and mortality is significantly higher for patients with HRAs, but this risk is very low in patients with LRAs, comparable to patients with no adenomas. Follow-up of patients with LRAs detected at index colonoscopy should be the same as for persons with no adenomas.
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Affiliation(s)
- Abhiram Duvvuri
- Division of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas.
| | | | - Sachin Srinivasan
- Division of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas
| | - Anvesh Narimiti
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts
| | - ChandraShekhar Dasari
- Department of Gastroenterology, Veteran Affairs Medical Center, Kansas City, Missouri
| | - Venkat Nutalapati
- Division of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas
| | - Kevin F Kennedy
- Department of Gastroenterology, Veteran Affairs Medical Center, Kansas City, Missouri
| | - Marco Spadaccini
- Department of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Giulio Antonelli
- Digestive Endoscopy Unit, Sapienza University of Rome, Rome, Italy
| | - Madhav Desai
- Department of Gastroenterology, Veteran Affairs Medical Center, Kansas City, Missouri
| | | | - Divyanshoo Kohli
- Department of Gastroenterology, Veteran Affairs Medical Center, Kansas City, Missouri
| | | | - Alessandro Repici
- Department of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Cesare Hassan
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Prateek Sharma
- Department of Gastroenterology, Veteran Affairs Medical Center, Kansas City, Missouri
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Pinsky PF, Schoen RE. Contribution of Surveillance Colonoscopy to Colorectal Cancer Prevention. Clin Gastroenterol Hepatol 2020; 18:2937-2944.e1. [PMID: 32017987 PMCID: PMC7549191 DOI: 10.1016/j.cgh.2020.01.037] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 01/16/2020] [Accepted: 01/24/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The contribution of surveillance colonoscopy, as opposed to that of initial colonoscopy examination, to prevention of colorectal cancer (CRC) is uncertain. We estimated the preventive effect of surveillance colonoscopy by applying the recently developed metric of adenoma dwell time avoided needed to prevent 1 CRC case (DTA). METHODS We followed subjects in the prostate, lung, colorectal and ovarian (PLCO) cancer screening trial who underwent colonoscopies following positive findings from sigmoidoscopies (colonoscopy cohort, n = 15,935) for CRC incidence for 10 years. The number and timing of adenomas removed during surveillance were measured in a subset (n = 3492) of patients and extrapolated to the entire cohort to estimate the total avoided adenoma dwell time. A previously determined DTA value of 612 dwell years was applied to estimate the number of CRC cases prevented by surveillance. Proportional reduction in CRC was computed as CP/(CO+CP), where CO and CP are observed and estimated prevented cases, respectively. RESULTS In the colonoscopy cohort of the PLCO, 2882 subjects had advanced adenomas (AAs), 572 had 3 or more non-advanced adenomas (NAA3+), 4496 had 1-2 non-advanced adenomas (NAA1-2), and 7985 had no adenoma (NA). The mean number of subsequent colonoscopy examinations over 10 years were 1.80 for subjects with AAs, 1.63 for subjects with NAA3+, and 1.46 for subjects with NAA1-2. Average years of avoided adenoma dwell time per subject were 4.0 for subjects with AAs, 5.5 for subjects with NAA3+, and 2.4 for subjects with NAA1-2. There were 56 cases of CRC in subjects with AAs, 4 cases of CRC in subjects with NAA3+, and 33 cases of CRC in subjects with NAA1-2. Estimated proportional reductions in CRC incidence were 25.0% in subjects with AAs (95% CI, 16%-34%), 34.4% in subjects with NAA1-2 (95% CI, 25%-40%), and 30.4% overall (in subjects with AAs, NAA3+, or NAA1-2; 95% CI, 25%-40%). Absolute CRC incidence reductions were 7.1 per 10,000 PY in subjects with AAs and 4.1 per 10,000 PY in subjects with NAA1-2. CONCLUSIONS Using the recently developed metric of DTA, we estimated that surveillance colonoscopy in the PLCO colonoscopy cohort during 10 years of follow up prevented 30% of CRC cases. Because the methodology for estimation is indirect, the true effect is uncertain.
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Affiliation(s)
- Paul F. Pinsky
- Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Robert E. Schoen
- Division of Gastroenterology, Hepatology and Nutrition, Departments of Medicine and Epidemiology, University of Pittsburgh, Pittsburgh, PA
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Abstract
Population screening and endoscopic surveillance are used widely to prevent the development of and death from colorectal cancer (CRC). However, CRC remains a major cause of cancer mortality and the increasing burden of endoscopic investigations threatens to overwhelm some health services. This Perspective describes the rationale for and approach to improved risk stratification and decision-making for CRC prevention and diagnosis. Limitations of current approaches will be discussed using the UK as an example of the challenges faced by a particular health-care system, followed by discussion of novel risk biomarker utilization. We explore how risk stratification will be advantageous to current health-care providers and users, enabling more efficient use of limited colonoscopy resources. We discuss risk stratification in the setting of population screening as well as the surveillance of high-risk groups and investigation of symptomatic patients. We also address challenges in the development and validation of risk stratification tools and identify key research priorities.
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7
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Xie C, Wen P, Su J, Li Q, Ren Y, Liu Y, Shen R, Ren J. Elevated serum triglyceride and low-density lipoprotein cholesterol promotes the formation of colorectal polyps. BMC Gastroenterol 2019; 19:195. [PMID: 31752704 PMCID: PMC6873463 DOI: 10.1186/s12876-019-1115-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 11/13/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Hyperlipidaemia may be a potential risk factor for the occurrence of intestinal polyps. This study aimed to evaluate correlation between lipidaemia and the formation of colorectal polyps. METHODS One hundred and fourteen patients with colorectal polyps and forty-eight healthy controls were included in this study. Colonoscopies were performed for all patients and controls within 1 week before blood samples were taken. The concentrations of serum lipids and lipoproteins were measured simultaneously using an automatic biochemical analyser. The colorectal lesions were classified based on pathological characteristics, and four types were identified in the study: hyperplastic polyp (HP), tubular adenoma (TA), tubulovillous adenoma (TVA) and adenoma with high-grade dysplasia (A-HGD). Advanced adenoma was classified according to the number, size and histological type of polyps. RESULTS The value of low-density lipoprotein cholesterol (LDL-C) was significantly higher in the group with advanced adenoma than in the controls (p < 0.05). Moreover, the LDL-C values in the HP and TA groups were higher when compared to that of controls (p < 0.05). Obesity, age, and increased TG and LDL-C were independent risk factors for the formation of colorectal polyps. The cut-off values of triglyceride (TG) and LDL-C to distinguish polyp patients from healthy controls were 0.96 mmol/L (AUC = 0.604, p = 0.036) and 3.05 mmol/L (AUC = 0.654, p = 0.002). The combined use of increased LDL-C and TG levels to distinguish polyp patients was effective, with a sensitivity of 50.0% and a specificity of 89.6% (AUC = 0.733, p < 0.01). CONCLUSIONS Colorectal polyps are more often found in obese and older patients. Increased LDL-C and TG were correlated with the occurrence of polyps. Combination of the two serum indicators was useful to assess risk of colorectal lesions, maybe more effective in screening hyperplastic polyp, tubular adenoma and advanced adenoma.
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Affiliation(s)
- Chenxi Xie
- Department of Gastroenterology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, Fujian Province 361000 People’s Republic of China
| | - Pingwu Wen
- Department of Gastroenterology, Meizhou Affiliated Hospital of Sun Yat-sen University, Meizhou, Guangdong Province 514000 People’s Republic of China
| | - Jingling Su
- Department of Gastroenterology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, Fujian Province 361000 People’s Republic of China
| | - Qin Li
- Guangzhou Center for Disease Control and Prevention, Guangzhou, Guangdong Province 510080 People’s Republic of China
| | - Yandan Ren
- Department of Gastroenterology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, Fujian Province 361000 People’s Republic of China
| | - Yueyu Liu
- Department of Gastroenterology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, Fujian Province 361000 People’s Republic of China
| | - Renze Shen
- Department of Gastroenterology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, Fujian Province 361000 People’s Republic of China
- Renze Shen, Department of Stomatology, Zhongshan Hospital, Xiamen University, Xiamen, Fujian Province 361000 People’s Republic of China
| | - Jianlin Ren
- Department of Gastroenterology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, Fujian Province 361000 People’s Republic of China
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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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Smoking Habits are Strongly Associated With Colorectal Polyps in a Population-based Case-control Study. J Clin Gastroenterol 2018; 52:805-811. [PMID: 29210901 DOI: 10.1097/mcg.0000000000000935] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
GOALS The goal of this study is to test the association between lifetime smoking habits and colorectal polyps of different classifications. BACKGROUND Smoking is an established risk factor for several cancers, including colorectal cancer. However, the association between lifetime smoking habits including intensity, duration, and cessation, and premalignant colorectal polyps is yet to be established. STUDY A case-control study among 828 consecutive subjects aged 40 to 70 years, undergoing screening or diagnostic colonoscopy. Exclusion criteria were: medically treated diabetes, colectomy, and belonging to colorectal cancer high risk group. Polyps were stratified according to histology (serrated or adenomatous polyp) and location. All participants underwent anthropometric measurements and a structured medical and lifestyle interview. RESULTS Current-smoking was more strongly associated with increased odds for distal rather than proximal polyps [odds ratio (OR), 4.00; 95% confidence interval (CI), 2.40-6.68 and OR, 2.52; 95% CI, 1.46-4.36, respectively], with serrated-polyps rather than adenomas (OR, 6.36; 95% CI, 2.77-14.57 and OR, 3.01; 1.90-4.74, respectively). All levels of smoking intensity (daily cigarettes) were associated with colorectal polyps. A dose-response association was seen between smoking duration and colorectal polyps. Smoking duration of ≥20 years was strongly associated with distal polyps (OR, 4.01; 95% CI, 1.62-9.84), independently of potential confounders, smoking intensity and years since smoking cessation. All associations were stronger for distal serrated polyps. CONCLUSIONS Smoking duration is associated with colorectal plyps, independently of other potential confounders, smoking intensity, and cessation. The association is stronger with distal rather than proximal polyps, and with serrated polyps rather than adenomas.
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10
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Click B, Pinsky PF, Hickey T, Doroudi M, Schoen RE. Association of Colonoscopy Adenoma Findings With Long-term Colorectal Cancer Incidence. JAMA 2018; 319:2021-2031. [PMID: 29800214 PMCID: PMC6583246 DOI: 10.1001/jama.2018.5809] [Citation(s) in RCA: 188] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Individuals with adenomatous polyps are advised to undergo repeated colonoscopy surveillance to prevent subsequent colorectal cancer (CRC), but the relationship between adenomas at colonoscopy and long-term CRC incidence is unclear. OBJECTIVE To compare long-term CRC incidence by colonoscopy adenoma findings. DESIGN, SETTING, AND PARTICIPANTS Multicenter, prospective cohort study of participants in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer randomized clinical trial of flexible sigmoidoscopy (FSG) beginning in 1993 with follow-up for CRC incidence to 2013 across the United States. Participants included 154 900 men and women aged 55 to 74 years enrolled in PLCO of whom 15 935 underwent colonoscopy following their first positive FSG screening result. The final day of follow-up was December 31, 2013. EXPOSURES Enrolled participants had been randomized to FSG or usual care. Participants who underwent FSG and had abnormal findings were referred for follow-up. Subsequent colonoscopy findings were categorized as advanced adenoma (≥1 cm, high-grade dysplasia, or tubulovillous or villous histology), nonadvanced adenoma (<1 cm without advanced histology), or no adenoma. MAIN OUTCOMES AND MEASURES The primary outcome was CRC incidence within 15 years of the baseline colonoscopy. The secondary outcome was CRC mortality. RESULTS There were 15 935 participants who underwent colonoscopy (men, 59.7%; white, 90.7%; median age, 64 y [IQR, 61-68]). On initial colonoscopy, 2882 participants (18.1%) had an advanced adenoma, 5068 participants (31.8%) had a nonadvanced adenoma, and 7985 participants (50.1%) had no adenoma; median follow-up for CRC incidence was 12.9 years. CRC incidence rates per 10 000 person-years of observation were 20.0 (95% CI, 15.3-24.7; n = 70) for advanced adenoma, 9.1 (95% CI, 6.7-11.5; n = 55) for nonadvanced adenoma, and 7.5 (95% CI, 5.8-9.7; n = 71) for no adenoma. Participants with advanced adenoma were significantly more likely to develop CRC compared with participants with no adenoma (rate ratio [RR], 2.7 [95% CI, 1.9-3.7]; P < .001). There was no significant difference in CRC risk between participants with nonadvanced adenoma compared with no adenoma (RR, 1.2 [95% CI, 0.8-1.7]; P = .30). Compared with participants with no adenoma, those with advanced adenoma were at significantly increased risk of CRC death (RR, 2.6 [95% CI, 1.2-5.7], P = .01), but mortality risk in participants with nonadvanced adenoma was not significantly different (RR, 1.2 [95% CI, 0.5-2.7], P = .68). CONCLUSIONS AND RELEVANCE Over a median of 13 years of follow-up, participants with an advanced adenoma at diagnostic colonoscopy prompted by a positive flexible sigmoidoscopy result were at significantly increased risk of developing colorectal cancer compared with those with no adenoma. Identification of nonadvanced adenoma may not be associated with increased colorectal cancer risk. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00002540.
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Affiliation(s)
- Benjamin Click
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Paul F. Pinsky
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland
| | - Tom Hickey
- Information Management Services, Rockville, Maryland
| | - Maryam Doroudi
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland
| | - Robert E. Schoen
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
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11
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Dubé C, Yakubu M, McCurdy BR, Lischka A, Koné A, Walker MJ, Peirson L, Tinmouth J. Risk of Advanced Adenoma, Colorectal Cancer, and Colorectal Cancer Mortality in People With Low-Risk Adenomas at Baseline Colonoscopy: A Systematic Review and Meta-Analysis. Am J Gastroenterol 2017; 112:1790-1801. [PMID: 29087393 DOI: 10.1038/ajg.2017.360] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 08/02/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We conducted a systematic review and meta-analysis of the risk of advanced adenomas (AAs), colorectal cancer (CRC), and/or CRC-related death among individuals with low-risk adenomas (LRAs). METHODS We searched PubMed and Embase for studies published between January 2006 and July 2015. Quality and strength of the evidence were rated using the Newcastle-Ottawa Scale (NOS) and the GRADE framework, respectively. RESULTS Eleven observational studies (n=64,317) were included. A meta-analysis of eight cohort studies (n=10,139, 3 to 10 years' follow-up) showed a small but statistically significant increase in the incidence of AAs in individuals with LRAs compared with those with a normal baseline colonoscopy (RR 1.55 (95% CI 1.24-1.94); P=0.0001; I2=0%). The pooled 5-year cumulative incidence of AA was 3.28% (95% CI: 1.85-5.10%), 4.9% (95% CI: 3.18-6.97%), and 17.13% (95% CI: 11.97-23.0%) for the no adenoma, LRA, and AA baseline groups, respectively. Two studies, which could not be pooled, showed a reduction in the risk of CRC in individuals with LRAs compared with the general population (standardized incidence ratio 0.68 (95% CI 0.44-0.99) at a median follow-up of 7.7 years and OR 0.4 (95% CI 0.2-0.6) at 3-5 years). One large retrospective cohort study found a 25% reduction in CRC mortality in individuals with LRAs compared with the general population (SMR 0.75 (95% CI 0.63-0.88) at a median follow-up of 7.7 years). CONCLUSIONS We observed a small but significant increase in the risk of AAs in people with LRAs compared with those with a normal baseline colonoscopy, but compared with the general population, people with LRAs have significantly lower risks of CRC and of CRC-related mortality.
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Affiliation(s)
- Catherine Dubé
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Cancer Care Ontario, Toronto, Ontario, Canada
| | - Mafo Yakubu
- Cancer Care Ontario, Toronto, Ontario, Canada
| | | | | | - Anna Koné
- Cancer Care Ontario, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Meghan J Walker
- Cancer Care Ontario, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Jill Tinmouth
- Cancer Care Ontario, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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12
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Fliss-Isakov N, Zelber-Sagi S, Webb M, Halpern Z, Shibolet O, Kariv R. Distinct Metabolic Profiles are Associated with Colorectal Adenomas and Serrated Polyps. Obesity (Silver Spring) 2017; 25 Suppl 2:S72-S80. [PMID: 29086511 DOI: 10.1002/oby.22001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 08/03/2017] [Accepted: 08/09/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Prevention of colorectal cancer (CRC) by colonoscopy is recommended according to age and personal/familial history. Metabolic alterations are associated with colorectal adenomas, but data are scarce regarding serrated polyps and advanced polyps. The aim of this study was to evaluate the association between metabolic alterations and colorectal polyp type and advanced polyps. METHODS A case-control study was conducted among consecutive subjects, 40 to 70 years old, who underwent screening/diagnostic colonoscopy from 2010 to 2015. Subjects who were treated for diabetes, who had a family/personal history of CRC, and who were at high risk for CRC were excluded. Participants underwent anthropometric, laboratory, and ultrasonographic evaluations and a medical and lifestyle interview. Polyps were histologically classified as adenomatous or serrated polyps and divided into advanced and non-advanced categories. RESULTS The study included 828 participants (58.4 ± 6.6 years, 50.4% men). Abdominal obesity (odds ratio [OR] = 1.67, 95% CI: 1.20-2.30), hypertension (OR = 1.47, 95% CI: 1.03-2.09), and a high glycosylated hemoglobin percentage (HbA1c%) (OR = 1.57, 95% CI: 1.06-2.34) were independently associated with colorectal adenomas, whereas a high triglyceride to high-density lipoprotein cholesterol (TG/HDL) ratio was independently associated with serrated polyps (OR = 2.31, 95% CI: 1.32-4.03). A combination of three metabolic alterations was strongly associated with colorectal polyps. CONCLUSIONS Abdominal obesity, hypertension, and a high HbA1c% are independently associated with adenomas, whereas a high TG/HDL ratio is associated with serrated polyps. These parameters are easily accessible in clinical practice and may help define high-risk groups for CRC.
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Affiliation(s)
- Naomi Fliss-Isakov
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shira Zelber-Sagi
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Department of Nutrition, Health and Behavior, School of Public Health, University of Haifa, Haifa, Israel
| | - Muriel Webb
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zamir Halpern
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oren Shibolet
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Revital Kariv
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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13
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Laish I, Seregeev I, Naftali T, Konikoff FM. Surveillance after positive colonoscopy based on adenoma characteristics. Dig Liver Dis 2017. [PMID: 28641945 DOI: 10.1016/j.dld.2017.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with adenomatous polyps are at increased risk for developing colorectal cancer based on the characteristics and number of polyps, but less is known about the individual and combined contribution of these factors. This study aimed to better characterize the risk of advanced adenoma and cancer in patients with positive baseline colonoscopy. METHODS Patients who had polyps at baseline colonoscopy were included in this retrospective cohort study (N=1165) and were categorized into 6 groups: (1) 1-2 non-advanced adenomas (NAA's), (2) ≥3 NAA's, (3) advanced tubular adenoma, (4) small tubulovillous adenoma (TVA), (5) large TVA and (6) multiple advanced adenomas (MAA's). Findings at surveillance colonoscopy were documented in each group. RESULTS The combined incidence of advanced adenoma, ≥3 NAA's, and colorectal cancer at surveillance colonoscopy was significantly higher in the baseline large TVA (29.2%) than small TVA groups (13.5%, P<0.001), as well as in the MAA's group (44.1%) compared with large TVA group (P=0.02). The incidence of colorectal cancer, however, was not significantly different between the groups. CONCLUSIONS The size of the polyp and the number of advanced lesions are more important than its histology for predicting the risk of high-risk metachronous lesions at follow-up.
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Affiliation(s)
- Ido Laish
- Gastroenterology and Hepatology Institute, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Ilia Seregeev
- Gastroenterology and Hepatology Institute, Meir Medical Center, Kfar Saba, Israel
| | - Timna Naftali
- Gastroenterology and Hepatology Institute, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Fred M Konikoff
- Gastroenterology and Hepatology Institute, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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14
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McFerran E, O'Mahony JF, Fallis R, McVicar D, Zauber AG, Kee F. Evaluation of the Effectiveness and Cost-Effectiveness of Personalized Surveillance After Colorectal Adenomatous Polypectomy. Epidemiol Rev 2017; 39:148-160. [PMID: 28402402 PMCID: PMC5858033 DOI: 10.1093/epirev/mxx002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 01/17/2017] [Accepted: 01/18/2017] [Indexed: 12/18/2022] Open
Abstract
Lifetime risk of developing colorectal cancer is 5%, and 5-year survival at early stage is 92%. Individuals with precancerous lesions removed at primary screening are typically recommended surveillance colonoscopy. Because greater benefits are anticipated for those with higher risk of colorectal cancer, scope for risk-specific surveillance recommendations exists. This review assesses published cost-effectiveness estimates of postpolypectomy surveillance to consider the potential for personalized recommendations by risk group. Meta-analyses of incidence of advanced neoplasia postpolypectomy for low-risk cases were comparable to those without adenoma, with both rates under the lifetime risk of 5%. This group may not benefit from intensive surveillance, which risks unnecessary harm and inefficient use of often scarce colonoscopy capacity. Therefore, greater personalization through deintensified strategies for low-risk individuals could be beneficial. The potential for noninvasive testing, such as fecal immunochemical tests, combined with primary prevention or chemoprevention may reserve colonoscopy for targeted use in personalized risk-stratified surveillance. This review appraised evidence supporting a program of personalized surveillance in patients with colorectal adenoma according to risk group and compared the effectiveness of surveillance colonoscopy with alternative prevention strategies. It assessed trade-offs among costs, benefits, and adverse effects that must be considered in a decision to adopt or reject personalized surveillance.
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Affiliation(s)
- Ethna McFerran
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom
| | - James F O'Mahony
- Centre for Health Policy and Management, Trinity College Dublin, the University of Dublin, Dublin, Ireland
| | - Richard Fallis
- Medical Library, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Duncan McVicar
- Queen's Management School, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Ann G Zauber
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Frank Kee
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom
- the United Kingdom Clinical Research Collaboration
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