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Vashi B, Norwood DA, Sullivan R, Hegazy Y, Sánchez-Luna SA, Ajayi-Fox P, Ahmed AM, Baig KRKK, Peter S, Mulki R. Social determinants of health influencing the adherence to post-endoscopic mucosal resection surveillance. Clin Res Hepatol Gastroenterol 2024; 48:102301. [PMID: 38355006 DOI: 10.1016/j.clinre.2024.102301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 02/04/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND AND AIMS Colorectal cancer (CRC) is a global health challenge, particularly in Alabama, where the incidence rates exceed national averages. This study investigated the factors influencing adherence to post-endoscopic mucosal resection (EMR) colonoscopies, focusing on travel distance and socioeconomic status. This study aimed to provide evidence-based insights to improve patient care in CRC management. METHODS This retrospective study in a tertiary care referral center analyzed 465 patients who underwent EMR. The data included demographics, clinical details, and travel-related variables. Descriptive statistics, logistic regression, and spatial analysis were used to assess the factors affecting adherence. RESULTS Of 465 patients, 36.6 % had adequate follow-up, 21.8 % had inadequate follow-up, and 41.6 % were lost to follow-up. Noteworthy demographic variations were observed, with median ages differing across adherence groups. Traveled distances showcased compelling insights, indicating a median distance of 22.2 miles for adequate follow-up, 15.7 miles for inadequate follow-up, and 31.6 miles for the lost-to-follow-up group (p<0.001). Longer travel distances were associated with better adherence. Longer travel distances from the hospital were associated with significantly lower odds of inadequate follow-up: 10-25 miles OR:0.29, 25-85 miles OR:0.35, and >80 miles OR:0.24 compared to the first quartile (<10 miles). Socioeconomic factors, particularly educational attainment, significantly influenced the follow-up rates. CONCLUSIONS This study revealed suboptimal post-EMR follow-up rates and underscored the impact of travel distance and socioeconomic factors. Targeted interventions addressing distance-related barriers can enhance treatment adherence and ensure timely CRC surveillance after EMR. Further research is needed in diverse healthcare settings.
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Affiliation(s)
- Bijal Vashi
- Heersink School of Medicine, The University of Alabama at Birmingham, AL 35205, United States
| | - Dalton A Norwood
- Division of Preventive Medicine, Heersink School of Medicine, The University of Alabama at Birmingham, AL 35205, United States
| | - Rebecca Sullivan
- Department of Medicine, Heersink School of Medicine, The University of Alabama at Birmingham, AL 35205, United States
| | - Yassmin Hegazy
- Department of Medicine, Heersink School of Medicine, The University of Alabama at Birmingham, AL 35205, United States
| | - Sergio A Sánchez-Luna
- Division of Gastroenterology, Heersink School of Medicine, The University of Alabama at Birmingham, AL 35205, United States
| | - Patricia Ajayi-Fox
- Division of Gastroenterology, Heersink School of Medicine, The University of Alabama at Birmingham, AL 35205, United States
| | - Ali M Ahmed
- Division of Gastroenterology, Heersink School of Medicine, The University of Alabama at Birmingham, AL 35205, United States
| | - Kondal R Kyanam Kabir Baig
- Division of Gastroenterology, Heersink School of Medicine, The University of Alabama at Birmingham, AL 35205, United States
| | - Shajan Peter
- Division of Gastroenterology, Heersink School of Medicine, The University of Alabama at Birmingham, AL 35205, United States
| | - Ramzi Mulki
- Division of Gastroenterology, Heersink School of Medicine, The University of Alabama at Birmingham, AL 35205, United States.
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Sullivan BA, Qin X, Redding TS, Weiss D, Upchurch J, Sims KJ, Dominitz JA, Stone A, Ear B, Williams CD, Lieberman DA, Hauser ER. Colorectal Cancer Polygenic Risk Score Is Associated With Screening Colonoscopy Findings but Not Follow-Up Outcomes. GASTRO HEP ADVANCES 2023; 3:151-161. [PMID: 39129957 PMCID: PMC11307447 DOI: 10.1016/j.gastha.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/03/2023] [Indexed: 08/13/2024]
Abstract
Background and Aims Colorectal cancer (CRC) polygenic risk scores (PRS) may help personalize CRC prevention strategies. We investigated whether an existing PRS was associated with advanced neoplasia (AN) in a population undergoing screening and follow-up colonoscopy. Methods We evaluated 10-year outcomes in the Cooperative Studies Program #380 screening colonoscopy cohort, which includes a biorepository of selected individuals with baseline AN (defined as CRC or adenoma ≥10 mm or villous histology, or high-grade dysplasia) and matched individuals without AN. A PRS was constructed from 136 prespecified CRC-risk single nucleotide polymorphisms. Multivariate logistic regression was used to evaluate the PRS for associations with AN prevalence at baseline screening colonoscopy or incident AN in participants with at least one follow-up colonoscopy. Results The PRS was associated with AN risk at baseline screening colonoscopy (P = .004). Participants in the lowest PRS quintile had more than a 70% decreased risk of AN at baseline (odds ratio 0.29, 95% confidence interval 0.14-0.58; P < .001) compared to participants with a PRS in the middle quintile. Using a PRS cut-off of more than the first quintile to indicate need for colonoscopy as primary screening, the sensitivity for detecting AN at baseline is 91.8%. We did not observe a relationship between the PRS and incident AN during follow-up (P = .28). Conclusion A PRS could identify individuals at low risk for prevalent AN. Ongoing work will determine whether this PRS can identify a subset of individuals at sufficiently low risk who could safely delay or be reassured about noninvasive screening. Otherwise, more research is needed to augment these genetic tools to predict incident AN during long-term follow-up.
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Affiliation(s)
- Brian A. Sullivan
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, North Carolina
- Division of Gastroenterology, Duke University, Durham, North Carolina
| | - Xuejun Qin
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, North Carolina
- Division of Gastroenterology, Duke University, Durham, North Carolina
| | - Thomas S. Redding
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, North Carolina
| | - David Weiss
- Cooperative Studies Program Coordinating Center, Perry Point VA Medical Center, Perry Point, Maryland
| | - Julie Upchurch
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, North Carolina
| | - Kellie J. Sims
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, North Carolina
| | - Jason A. Dominitz
- Division of Gastroenterology, VA Puget Sound Health Care System, Seattle, Washington
- Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington
| | - Anjanette Stone
- Cooperative Studies Program Pharmacogenomics Analysis Laboratory, Central Arkansas Veterans Health System, Little Rock, Arkansas
| | - Belinda Ear
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, North Carolina
| | - Christina D. Williams
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, North Carolina
- Division of Gastroenterology, Duke University, Durham, North Carolina
| | - David A. Lieberman
- Division of Gastroenterology, VA Portland Health Care System, Portland, Oregon
- Division of Gastroenterology, Oregon Health & Science University, Portland, Oregon
| | - Elizabeth R. Hauser
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, North Carolina
- Division of Gastroenterology, Duke University, Durham, North Carolina
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Kang YW, Lee JH, Lee JY. The Utility of Narrow-Band Imaging International Colorectal Endoscopic Classification in Predicting the Histologies of Diminutive Colorectal Polyps Using I-Scan Optical Enhancement: A Prospective Study. Diagnostics (Basel) 2023; 13:2720. [PMID: 37627979 PMCID: PMC10453535 DOI: 10.3390/diagnostics13162720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 08/13/2023] [Accepted: 08/19/2023] [Indexed: 08/27/2023] Open
Abstract
(1) Background: This study aimed to evaluate the accuracy of predicting the histology of diminutive colonic polyps (DCPs) (≤5 mm) using i-scan optical enhancement (OE) based on the narrow-band imaging international colorectal endoscopic (NICE) classification. The study compared the diagnostic accuracy between experts who were already familiar with the NICE classification and trainees who were not, both before and after receiving brief training on the NICE classification. (2) Method: This prospective, single-center clinical trial was conducted at the Dong-A University Hospital from March 2020 to August 2020 and involved two groups of participants. The first group comprised two experienced endoscopists who were proficient in using i-scan OE and had received formal training in optical diagnosis and dye-less chromoendoscopy (DLC) techniques. The second group consisted of three endoscopists in the process of training in internal medicine at the Dong-A University Hospital. Each endoscopist examined the polyps and evaluated them using the NICE classification through i-scan OE. The results were not among the participants. Trained endoscopists were divided into pre- and post-training groups. (3) Results: During the study, a total of 259 DCPs were assessed using i-scan OE by the two expert endoscopists. They made real-time histological predictions according to the NICE classification criteria. For the trainee group, before training, the area under the receiver operating characteristic curves (AUROCs) for predicting histopathological results using i-scan OE were 0.791, 0.775, and 0.818. However, after receiving training, the AUROCs improved to 0.935, 0.949, and 0.963, which were not significantly different from the results achieved by the expert endoscopists. (4) Conclusions: This study highlights the potential of i-scan OE, along with the NICE classification, in predicting the histopathological results of DCPs during colonoscopy. In addition, this study suggests that even an endoscopist without experience in DLC can effectively use i-scan OE to improve diagnostic performance with only brief training.
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Affiliation(s)
| | | | - Jong Yoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University College of Medicine, Busan 49201, Republic of Korea; (Y.W.K.); (J.H.L.)
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Knudsen MD, Wang K, Wang L, Polychronidis G, Berstad P, Wu K, He X, Hang D, Fang Z, Ogino S, Chan AT, Giovannucci E, Wang M, Song M. Development and validation of a risk prediction model for post-polypectomy colorectal cancer in the USA: a prospective cohort study. EClinicalMedicine 2023; 62:102139. [PMID: 37599907 PMCID: PMC10432960 DOI: 10.1016/j.eclinm.2023.102139] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/12/2023] [Accepted: 07/20/2023] [Indexed: 08/22/2023] Open
Abstract
Background Effective risk stratification tools for post-polypectomy colorectal cancer (PPCRC) are lacking. We aimed to develop an effective risk stratification tool for the prediction of PPCRC in three large population-based cohorts and to validate the tool in a clinical cohort. Methods Leveraging the integrated endoscopic, histopathologic and epidemiologic data in three U.S population-based cohorts of health professional (the Nurses' Health Study (NHS) I, II and Health Professionals Follow-up Study (HPFS)), we developed a risk score to predict incident PPCRC among 26,741 patients with a polypectomy between 1986 and 2017. We validated the PPCRC score in the Mass General Brigham (MGB) Colonoscopy Cohort (Boston, Massachusetts, U.S) of 76,603 patients with a polypectomy between 2007 and 2018. In all four cohorts, we collected detailed data on patients' demographics, endoscopic history, polyp features, and lifestyle factors at polypectomy. The outcome, incidence of PPCRC, was assessed by biennial follow-up questionnaires in the NHS/HPFS cohorts, and through linkage to the Massachusetts Cancer Registry in the MGB cohort. In all four cohorts, individuals who were diagnosed with CRC or died before baseline or within six months after baseline were excluded. We used Cox regression to calculate the hazard ratio (HR), 95% confidence interval (CI) and assessed the discrimination using C-statistics and reclassification using the Net Reclassification Improvement (NRI). Findings During a median follow-up of 12.8 years (interquartile range (IQR): 9.3, 16.7) and 5.1 years (IQR: 2.7, 7.8) in the NHS/HPFS and MGB cohorts, we documented 220 and 241 PPCRC cases, respectively. We identified a PPCRC risk score based on 11 predictors. In the validation cohort, the PPCRC risk score showed a strong association with PPCRC risk (HR for high vs. low, 3.55, 95% CI, 2.59-4.88) and demonstrated a C-statistic (95% CI) of 0.75 (0.70-0.79), and was discriminatory even within the low- and high-risk polyp groups (C-statistic, 0.73 and 0.71, respectively) defined by the current colonoscopy surveillance recommendations, leading to a NRI of 45% (95% CI, 36-54%) for patients with PPCRC. Interpretation We developed and validated a risk stratification model for PPCRC that may be useful to guide tailored colonoscopy surveillance. Further work is needed to determine the optimal surveillance interval and test the added value of other predictors of PPCRC beyond those included in the current study, along with implementation studies. Funding US National Institutes of Health, the American Cancer Society, the South-Eastern Norway Regional Health Authority, the Deutsche Forschungsgemeinschaft.
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Affiliation(s)
- Markus Dines Knudsen
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
- Section of Bowel Cancer Screening, Cancer Registry of Norway, Ullernchausseen 64, Oslo, Norway
- Division of Surgery, Inflammatory Diseases and Transplantation, Department of Transplantation Medicine, Oslo University Hospital, Sognsvannsveien 20, Oslo, Norway
| | - Kai Wang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
| | - Liang Wang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
- Centre of Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshaner Rd, Yuexiu District, Guangzhou, Guangdong Province, China
| | - Georgios Polychronidis
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
- Department of General Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, Heidelberg, Germany
| | - Paula Berstad
- Section of Bowel Cancer Screening, Cancer Registry of Norway, Ullernchausseen 64, Oslo, Norway
| | - Kana Wu
- Department of Nutrition, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
| | - Xiaosheng He
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA, USA
- Department of Colorectal Surgery, The Six Affiliated Hospital, Sun Yat-sen University, 135, Xingang Xi Road, Guangzhou, China
| | - Dong Hang
- Department of Nutrition, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
- Department of Epidemiology and Biostatistics, Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, 101 Longmian Avenue, Nanjing, China
| | - Zhe Fang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
| | - Shuji Ogino
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
- Department of Pathology, Program in Molecular Pathological Epidemiology, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA, USA
- Broad Institute of MIT and Harvard, Merkin Building, 415 Main St, Cambridge, MA, USA
| | - Andrew T. Chan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 181 Longwood Avenue, Boston, MA, USA
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
| | - Edward Giovannucci
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
| | - Molin Wang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 181 Longwood Avenue, Boston, MA, USA
| | - Mingyang Song
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA, USA
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Jayasankar B, Balasubramaniam D, Abdelsaid K, Frowde K, Galloway E, Hassan M. Through the Looking Glass: Surveillance Following Colonoscopic Polypectomy of Malignant Polyps. Cureus 2023; 15:e38027. [PMID: 37228528 PMCID: PMC10205146 DOI: 10.7759/cureus.38027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2023] [Indexed: 05/27/2023] Open
Abstract
Introduction Colonoscopic polypectomy is a well-established screening and surveillance modality for malignant colorectal polyps. Following the detection of a malignant polyp, patients are either put on endoscopic surveillance or planned for a surgical procedure. We studied the outcome of colonoscopic excision of malignant polyps and their recurrence rates. Methods We performed a retrospective analysis over a period of five years (2015-2019) of patients who underwent colonoscopy and resection of malignant polyps. Size of polyp, follow-up with tumour markers, CT scan, and biopsy were considered individually for pedunculate and sessile polyps. We analysed the percentage of patients who underwent surgical resection, the percentage of patients who were managed conservatively, and the percentage of recurrence post-excision of malignant polyps. Results A total of 44 patients were included in the study. Of the 44 malignant polyps, most were present in the sigmoid colon at 43% (n=19), with the rectum containing 41% (n=18). The ascending colon accounted for 4.5% (n=2), transverse colonic polyps were 7% (n=3), and the descending colon polyps were 4.5% (n=2). Pedunculated polyps made up 55% (n=24). These were Level 1-3 based on Haggits classification; 14 were Haggits Level 1, eight were Haggits Level 2, and two were Haggits Level 3. The rest were sessile polyps making up 45% (n=20). Based on the Kikuchi classification, these were predominantly SM1 (n=12) and SM2 (n=8). Out of 44 cases, 11% (n=5) underwent surgical resection on follow-up in the form of bowel resection. This included three right hemicolectomies, one sigmoid colectomy, and one low anterior resection. Seven per cent (n=3) underwent endoscopic resection as trans-anal endoscopic mucosal resection (TEMS) and 82% (n=36) of the remaining cases were managed with regular follow-up and surveillance. Conclusions Colonoscopic polypectomy offers excellent benefits in detecting colorectal cancer and treating pre-malignant polyps. Colonoscopic polypectomy provides excellent benefits in colorectal cancer (CRC) detection and treatment of malignant polyps. However, it remains to be seen if post-polypectomy surveillance for low-risk polyp cancers would require a change in surveillance.
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Affiliation(s)
- Balaji Jayasankar
- Colorectal Surgery, Belfast Health and Social Care Trust, Belfast, GBR
| | - Dinesh Balasubramaniam
- General Surgery, Maidstone and Tunbridge Wells NHS (National Health Service) Trust, Maidstone, GBR
| | - Kirolos Abdelsaid
- General Surgery, Maidstone and Tunbridge Wells NHS (National Health Service) Trust, Tunbridge Wells, GBR
| | - Kyle Frowde
- General Surgery, East Kent Hospitals University NHS (National Health Service) Foundation Trust, Canterbury, GBR
| | - Emily Galloway
- General Surgery, Maidstone and Tunbridge Wells NHS (National Health Service) Trust, Tunbridge Wells, GBR
| | - Mohamed Hassan
- Surgery, Maidstone and Tunbridge Wells NHS (National Health Service) Trust, Tunbridge Wells, GBR
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Kobe EA, Sullivan BA, Qin X, Redding TS, Hauser ER, Madison AN, Miller C, Efird JT, Gellad ZF, Weiss D, Sims KJ, Williams CD, Lieberman DA, Provenzale D. Longitudinal assessment of colonoscopy adverse events in the prospective Cooperative Studies Program no. 380 colorectal cancer screening and surveillance cohort. Gastrointest Endosc 2022; 96:553-562.e3. [PMID: 35533738 PMCID: PMC9531542 DOI: 10.1016/j.gie.2022.04.1343] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/30/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Data are limited regarding colonoscopy risk during long-term, programmatic colorectal cancer screening and follow-up. We aimed to describe adverse events during follow-up in a colonoscopy screening program after the baseline examination and examine factors associated with increased risk. METHODS Cooperative Studies Program no. 380 includes 3121 asymptomatic veterans aged 50 to 75 years who underwent screening colonoscopy between 1994 and 1997. Periprocedure adverse events requiring significant intervention were defined as major events (other events were minor) and were tracked during follow-up for at least 10 years. Multivariable odds ratios (ORs) were calculated for factors associated with risk of follow-up adverse events. RESULTS Of 3727 follow-up examinations in 1983 participants, adverse events occurred in 105 examinations (2.8%) in 93 individuals, including 22 major and 87 minor events (examinations may have had >1 event). Incidence of major events (per 1000 examinations) remained relatively stable over time, with 6.1 events at examination 2, 4.8 at examination 3, and 7.2 at examination 4. Examinations with major events included 1 perforation, 3 GI bleeds requiring intervention, and 17 cardiopulmonary events. History of prior colonoscopic adverse events was associated with increased risk of events (major or minor) during follow-up (OR, 2.7; 95% confidence interval, 1.6-4.6). CONCLUSIONS Long-term programmatic screening and surveillance was safe, as major events were rare during follow-up. However, serious cardiopulmonary events were the most common major events. These results highlight the need for detailed assessments of comorbid conditions during routine clinical practice, which could help inform individual decisions regarding the utility of ongoing colonoscopy follow-up.
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Affiliation(s)
- Elizabeth A Kobe
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC; School of Medicine, Duke University, Durham, NC
| | - Brian A Sullivan
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC; Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Xuejun Qin
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - Thomas S Redding
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC
| | - Elizabeth R Hauser
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - Ashton N Madison
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC
| | - Cameron Miller
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Jimmy T Efird
- Cooperative Studies Program Coordinating Center, Boston VA Health Care System, Boston, MA
| | - Ziad F Gellad
- Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - David Weiss
- Cooperative Studies Program Coordinating Center, Perry Point Veterans Affairs Medical Center, Perry Point, MD
| | - Kellie J Sims
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC
| | - Christina D Williams
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC; Department of Medicine, Duke University Medical Center, Durham, NC
| | - David A Lieberman
- Portland Veteran Affairs Medical Center, Portland, OR; Division of Gastroenterology and Hepatology, School of Medicine, Oregon Health and Science University, Portland, OR
| | - Dawn Provenzale
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC; Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, NC
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Rosas US, Pan JY, Sundaram V, Su A, Fazal M, Dinh P, Ladabaum U. Adherence to Recommendations for Repeat Surveillance After Publication of New Postpolypectomy Guidelines. GASTRO HEP ADVANCES 2022; 2:132-143. [PMID: 39130145 PMCID: PMC11307611 DOI: 10.1016/j.gastha.2022.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/19/2022] [Indexed: 08/13/2024]
Abstract
Background and Aims The 2012 and 2020 US Multi-Society Task Force postpolypectomy guidelines have recommended progressively longer surveillance intervals for patients with low-risk adenomas (LRAs). These guidelines require data from past colonoscopies. We examined the impact of the 2012 guidelines for second surveillance on clinical practice, including the availability of prior colonoscopy data, with the aim of informing the implementation of the 2020 guidelines. Methods We identified surveillance colonoscopies at Stanford Health Care and the Palo Alto Veterans Affairs Health Care System in 3 periods: preguideline (March-August 2012), postguideline (January-June 2013), and delayed postguideline (July-September 2017). We collected data on the most recent previous colonoscopy, findings at the study entry surveillance colonoscopy, and recommendations for subsequent surveillance. Results Among 977 patients, the most recent prior colonoscopy data were available in 78% of preguideline, 78% of postguideline, and 61% of delayed postguideline cases (P < .001). The fraction of surveillance colonoscopy reports that deferred recommendations awaiting pathology increased from 6% to 11% in preguideline and postguideline to 59% in delayed postguideline cases (P < .001). Overall adherence to guidelines for subsequent surveillance was similar in all 3 periods (54%-67%; P = .089). In the postguideline and delayed postguideline periods combined, a 10-year subsequent surveillance interval was recommended in 0 of 29 cases with LRA followed by normal surveillance colonoscopy. Conclusion In patients undergoing surveillance, prior colonoscopy data were not always available and recommendations were often deferred awaiting pathology. Adherence to subsequent surveillance guidelines was suboptimal, especially for LRA followed by normal colonoscopy. Strategies addressing these gaps are needed to optimize implementation of the updated 2020 postpolypectomy guidelines.
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Affiliation(s)
- Ulysses S. Rosas
- Department of Medicine, Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jennifer Y. Pan
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
- Department of Medicine, Division of Gastroenterology and Hepatology, VA Palo Alto Health Care System, Palo Alto, California
| | - Vandana Sundaram
- Department of Medicine, Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
| | - Andrew Su
- Department of Medicine, Division of Digestive Diseases, UCLA, Los Angeles, California
| | - Muhammad Fazal
- Residency Program, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Philip Dinh
- Residency Program, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Uri Ladabaum
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
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Abstract
Colorectal cancer is the second leading cause of cancer-associated mortality, with a lifetime risk of approximately 4% to 5%. Colorectal cancer develops from the sequential acquisition of defined genetic mutations in the colonic epithelium. Tumorigenesis from normal tissue to cancer occurs largely through 3 pathways: the chromosomal instability pathway, the microsatellite instability pathway, and the sessile serrated pathway. Colorectal cancer incidence and mortality have decreased by approximately 35% since the beginning of screening programs in the 1990s, although other factors such as use of aspirin for coronary disease prevention and decreased smoking rates may also be important. In this review, we discuss the etiology, epidemiology, and histology of colorectal polyps and cancer.
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da Silva WC, Godman B, de Assis Acúrcio F, Cherchiglia ML, Martin A, Maruszczyk K, Izidoro JB, Portella MA, Lana AP, Campos Neto OH, Andrade EIG. The Budget Impact of Monoclonal Antibodies Used to Treat Metastatic Colorectal Cancer in Minas Gerais, Brazil. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2021; 19:557-577. [PMID: 33506317 DOI: 10.1007/s40258-020-00626-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/23/2020] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Biological medicines have increased the cost of cancer treatments, which also raises concerns about sustainability. In Brazil, three monoclonal antibodies (mAbs)-bevacizumab, cetuximab, and panitumumab-are indicated for the treatment of metastatic colorectal cancer (mCRC) but not currently funded by the Unified Health System (SUS). However, successful litigation has led to funding in some cases. OBJECTIVE Our objective was to evaluate the budgetary impact of including the mAbs bevacizumab, cetuximab, and panitumumab in standard chemotherapy for the treatment of mCRC within the SUS of Minas Gerais (MG), Brazil. METHOD A budget impact analysis of incorporating mAbs as first-line treatment of mCRC in MG was explored. The perspective taken was that of the Brazilian SUS, and a 5-year time horizon was applied. Data were collected from lawsuits undertaken between January 2009 and December 2016, and the model was populated with data from national databases and published sources. Costs are expressed in $US. RESULTS In total, 351 lawsuits resulted in funding for first-line treatment with mAbs for mCRC. The three alternative scenarios analyzed resulted in cost increases of 348-395% compared with the reference scenario. The use of panitumumab had a budgetary impact of $US103,360,980 compared with the reference scenario over a 5-year time horizon, and bevacizumab and cetuximab had budgetary impacts of $US111,334,890 and 113,772,870, respectively. The use of the anti-epidermal growth factor receptor (EGFR) mAbs (cetuximab and panitumumab) is restricted to the approximately 41% of patients with KRAS mutations, so the best cost alternative for incorporation would be the combination of panitumumab and bevacizumab, with a cost of approximately $US106 million. CONCLUSION These results highlight the appreciable costs for incorporating bevacizumab, cetuximab, and panitumumab into the SUS. Appreciable discounts are likely to be necessary before incorporation of these mAbs is approved.
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Affiliation(s)
- Wânia Cristina da Silva
- Postgraduate Program in Medicines and Pharmaceutical Services, School of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Brazil.
| | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden
- Health Economics Centre, University of Liverpool Management School, Liverpool, UK
- Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Francisco de Assis Acúrcio
- Postgraduate Program in Medicines and Pharmaceutical Services, School of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Brazil
- Postgraduate Program in Public Health, School of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Mariângela Leal Cherchiglia
- Postgraduate Program in Medicines and Pharmaceutical Services, School of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Brazil
- Postgraduate Program in Public Health, School of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Antony Martin
- Health Economics Centre, University of Liverpool Management School, Liverpool, UK
| | | | - Jans Bastos Izidoro
- Divisão de Medicamentos Essenciais, Departamento de Assistência Farmacêutica, Secretaria de Estado de Saúde de Minas Gerais, Belo Horizonte, Brazil
| | | | - Agner Pereira Lana
- Postgraduate Program in Public Health, School of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | | | - Eli Iola Gurgel Andrade
- Postgraduate Program in Medicines and Pharmaceutical Services, School of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Brazil
- Postgraduate Program in Public Health, School of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
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Honda M, Naoe H, Gushima R, Miyamoto H, Tateyama M, Sakurai K, Oda Y, Murakami Y, Tanaka Y. Risk stratification for advanced colorectal neoplasia based on the findings of the index and first surveillance colonoscopies. PLoS One 2021; 16:e0245211. [PMID: 33481809 PMCID: PMC7822265 DOI: 10.1371/journal.pone.0245211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 12/23/2020] [Indexed: 12/24/2022] Open
Abstract
Risk stratification by index colonoscopy is well established for first surveillance endoscopy, but whether the previous two colonoscopies affect the subsequent advanced neoplasias has not been established. Therefore, the subsequent risk based on the findings of the index and first surveillance colonoscopies were investigated. This retrospective, cohort study was conducted in two clinics and included participants who had undergone two or more colonoscopies after index colonoscopy. High-risk was defined as advanced adenoma (≥ 1 cm, or tubulovillous or villous histology, or high-grade dysplasia). Based on the findings of the index and first surveillance colonoscopies, patients were classified into four categories: category A (both colonoscopy findings were normal), category B (no high-risk findings both times), category C (one time high-risk finding), and category D (high-risk findings both times). The incidence of subsequent advanced neoplasia was examined in each category. A total of 13,426 subjects were included and surveyed during the study periods. The subjects in category D had the highest risk of advanced neoplasia (27.4%, n = 32/117). The subjects in category A had the lowest risk (4.0%, n = 225/5,583). The hazard ratio for advanced neoplasia of category D compared to category A was 9.90 (95% Confidence interval 6.82-14.35, P<0.001). Classification based on the findings of index and first surveillance colonoscopies more effectively stratifies the risk of subsequent advanced neoplasia, resulting in more proper allocation of colonoscopy resources after two consecutive colonoscopies.
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Affiliation(s)
- Munenori Honda
- Department of Gastroenterology and Hepatology, Kumamoto University Hospital, Kumamoto, Japan
| | - Hideaki Naoe
- Department of Gastroenterology and Hepatology, Kumamoto University Hospital, Kumamoto, Japan
| | - Ryosuke Gushima
- Department of Gastroenterology and Hepatology, Kumamoto University Hospital, Kumamoto, Japan
| | - Hideaki Miyamoto
- Department of Gastroenterology and Hepatology, Kumamoto University Hospital, Kumamoto, Japan
| | - Masakuni Tateyama
- Department of Gastroenterology and Hepatology, Kumamoto University Hospital, Kumamoto, Japan
| | | | - Yasushi Oda
- Oda GI Endoscopy and Gastroenterology Clinic, Kumamoto, Japan
| | | | - Yasuhito Tanaka
- Department of Gastroenterology and Hepatology, Kumamoto University Hospital, Kumamoto, Japan
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11
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Petersen MM, Ferm L, Kleif J, Piper TB, Rømer E, Christensen IJ, Nielsen HJ. Triage May Improve Selection to Colonoscopy and Reduce the Number of Unnecessary Colonoscopies. Cancers (Basel) 2020; 12:E2610. [PMID: 32932734 PMCID: PMC7563245 DOI: 10.3390/cancers12092610] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/11/2020] [Accepted: 09/11/2020] [Indexed: 12/18/2022] Open
Abstract
Implementation of population screening for colorectal cancer by direct colonoscopy or follow-up colonoscopy after a positive fecal blood test has challenged the overall capacity of bowel examinations. Certain countries are facing serious colonoscopy capacity constraints, which have led to waiting lists and long time latency of follow-up examinations. Various options for improvement are considered, including increased cut-off values of the fecal blood tests. Results from major clinical studies of blood-based, cancer-associated biomarkers have, however, led to focus on a Triage concept for improved selection to colonoscopy. The Triage test may include subject age, concentration of hemoglobin in a feces test and a combination of certain blood-based cancer-associated biomarkers. Recent results have indicated that Triage may reduce the requirements for colonoscopy by around 30%. Such results may be advantageous for the capacity, the healthcare budgets and in particular, the subjects, who do not need an unnecessary, unpleasant and risk-associated bowel examination.
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Affiliation(s)
- Mathias M. Petersen
- Department of Surgical Gastroenterology, Hvidovre Hospital, 2650 Hvidovre, Denmark; (M.M.P.); (L.F.); (J.K.); (T.B.P.); (E.R.); (I.J.C.)
| | - Linnea Ferm
- Department of Surgical Gastroenterology, Hvidovre Hospital, 2650 Hvidovre, Denmark; (M.M.P.); (L.F.); (J.K.); (T.B.P.); (E.R.); (I.J.C.)
| | - Jakob Kleif
- Department of Surgical Gastroenterology, Hvidovre Hospital, 2650 Hvidovre, Denmark; (M.M.P.); (L.F.); (J.K.); (T.B.P.); (E.R.); (I.J.C.)
| | - Thomas B. Piper
- Department of Surgical Gastroenterology, Hvidovre Hospital, 2650 Hvidovre, Denmark; (M.M.P.); (L.F.); (J.K.); (T.B.P.); (E.R.); (I.J.C.)
| | - Eva Rømer
- Department of Surgical Gastroenterology, Hvidovre Hospital, 2650 Hvidovre, Denmark; (M.M.P.); (L.F.); (J.K.); (T.B.P.); (E.R.); (I.J.C.)
| | - Ib J. Christensen
- Department of Surgical Gastroenterology, Hvidovre Hospital, 2650 Hvidovre, Denmark; (M.M.P.); (L.F.); (J.K.); (T.B.P.); (E.R.); (I.J.C.)
| | - Hans J. Nielsen
- Department of Surgical Gastroenterology, Hvidovre Hospital, 2650 Hvidovre, Denmark; (M.M.P.); (L.F.); (J.K.); (T.B.P.); (E.R.); (I.J.C.)
- Institute of Clinical Medicine, University of Copenhagen, 2100 Copenhagen, Denmark
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