Early Colonoscopy Improves the Outcome of Patients With Symptomatic Colorectal Cancer

Impact of an Evidence-Based Prioritization System and Electronic Consultation in Early Diagnosis of Colorectal Cancer

(1) Background: Colorectal cancer (CRC) is one of the most common causes of cancer. Timely diagnosis is critical, with even minor delays impacting prognosis. Primary care providers face obstacles in accessing specialist care. This study investigates the impact of implementing an electronic consultation (eConsult) system combined with a specific prioritization system on CRC diagnosis delay and tumor staging. (2) Methods: The study analyzes 245 CRC patients from November 2019 to February 2022, comparing those referred before and after the eConsult system's implementation during the COVID-19 pandemic. Data on referral reasons, pathways, diagnosis delays, and staging were collected. Multivariate analysis aimed to identify independent risk factors for advanced staging at diagnosis. (3) Results: The eConsult system significantly reduced CRC diagnosis delay from 68 to 26 days. The majority of patients referred via eConsult presented with symptoms. Despite expedited diagnoses, no discernible difference in CRC staging emerged between eConsult and traditional referrals. Notably, patients from screening programs or with a positive fecal immunochemical test (FIT) experienced earlier-stage diagnoses. A positive FIT without symptoms and being a never-smoker emerged as protective factors against advanced-stage CRC. (4) Conclusions: This study highlights eConsult's role in reducing CRC diagnosis delay, improving diagnostic efficiency and prioritizing urgent cases, emphasizing FIT effectiveness.

Three-dimensional ordered DNA network constructed by a biomarker pair for accurate monitoring of colorectal cancer

Precise and early screening of colorectal cancer (CRC) is one crucial yet challenging task for its treatment, and the analysis of multi-targets of CRC in a single assay with high accuracy is essential for pathological research and clinical diagnosis. Here, a CRC-related biomarker pair, microRNA-211 (miRNA-211) and H₂S, was detected by constructing a three-dimensional (3D) ordered DNA network. First, trace amount of miRNA-211 could initiate a hybridization chain reaction-based amplification process. A highly ordered 3D DNA network was formed based on the organized assembly of DNA-cube frameworks that were constructed by DNA origamis and Ag nanoparticles (NPs) encapsulated inside. In the presence of the H₂S, Ag NPs within the network can be etched to generate Ag₂S quantum dots, which could be better visualized in fluorescence in situ cell imaging. Using the 3D DNA ordered network as the sensing platform, it can acquire dual analysis of biomolecule (miRNA-211) and inorganic gas (H₂S) in vitro, overcoming the limitations of single type of biomarker detection in a single assay. This assay achieved a wide linearity range of H₂S from 0.05 to 10 μM, and exhibited a low limit of detection of 4.78 nM. This strategy allows us to acquire the spatial distributions of H₂S and miRNA expression levels in living CRC cells simultaneously, providing a highly sensitive and selective tool for early screening and monitoring of CRC.

A Point-of-Care Faecal Test Combining Four Biomarkers Allows Avoidance of Normal Colonoscopies and Prioritizes Symptomatic Patients with a High Risk of Colorectal Cancer

Most colonoscopies performed to evaluate gastrointestinal symptoms detect only non-relevant pathologies. We aimed to evaluate the diagnostic accuracy of a qualitative point-of-care (POC) test combining four biomarkers (haemoglobin, transferrin, calprotectin, and lactoferrin), a quantitative faecal immunochemical test (FIT) for haemoglobin, and a quantitative faecal calprotectin (FC) test in symptomatic patients prospectively recruited. Colorectal cancer (CRC), adenoma requiring surveillance, inflammatory bowel disease (IBD), microscopic colitis, and angiodysplasia were considered significant pathologies. A total of 571 patients were included. Significant pathology was diagnosed in 118 (20.7%), including 30 CRC cases (5.3%). The POC test yielded the highest negative predictive values: 94.8% for a significant pathology and 100% for CRC or IBD if the four markers turned negative (36.8% of the patients). Negative predictive values of FIT, FC, and its combination for diagnosis of a significant pathology were 88.4%, 87.6%, and 90.8%, respectively. Moreover, the positive predictive value using the POC test was 82.3% for significant pathology when all biomarkers tested positive (6% of the patients), with 70.6% of these patients diagnosed with CRC or IBD. The AUC of the POC test was 0.801 (95%CI 0.754-0.848) for the diagnosis of a significant pathology. Therefore, this POC faecal test allows the avoidance of unnecessary colonoscopies and prioritizes high risk symptomatic patients.

COVID-19 Pandemic Had Minimal Impact on Colonoscopy Completion After Colorectal Cancer Red Flag Sign or Symptoms in US Veterans

BACKGROUND

Delays in colonoscopy work-up for red flag signs or symptoms of colorectal cancer (CRC) during the COVID-19 pandemic are not well characterized.

AIMS

To examine colonoscopy uptake and time to colonoscopy after red flag diagnosis, before and during the COVID-19 pandemic.

METHODS

Cohort study of adults ages 50-75 with iron deficiency anemia (IDA), hematochezia, or abnormal stool blood test receiving Veterans Health Administration (VHA) care from April 2019 to December 2020. Index date was first red flag diagnosis date, categorized into "pre" (April-December 2019) and "intra" (April-December 2020) policy implementation prioritizing diagnostic procedures, allowing for a 3-month "washout" (January-March 2020) period. Outcomes were colonoscopy completion and time to colonoscopy pre- vs. intra-COVID-19, examined using multivariable Cox models with hazard ratios (aHRs) and 95% confidence intervals (CIs).

RESULTS

There were 52,539 adults with red flag signs or symptoms (pre-COVID: 25,154; washout: 7527; intra-COVID: 19,858). Proportion completing colonoscopy was similar pre- vs. intra-COVID-19 (27.0% vs. 26.5%; p = 0.24). Median time to colonoscopy among colonoscopy completers was similar for pre- vs. intra-COVID-19 (46 vs. 42 days), but longer for individuals with IDA (60 vs. 49 days). There was no association between time period and colonoscopy completion (aHR: 0.99, 95% CI 0.95-1.03).

CONCLUSIONS

Colonoscopy work-up of CRC red flag signs and symptoms was not delayed within VHA during the COVID-19 pandemic, possibly due to VHA policies supporting prioritization and completion. Further work is needed to understand how COVID-19 policies on screening and surveillance impact CRC-related outcomes, and how to optimize colonoscopy completion after a red flag diagnosis.

Appropriateness of high-priority criteria and safety of endoscopy procedures during the COVID-19 lockdown

BACKGROUND

During the coronavirus-19 disease (COVID-19) pandemic, gastroenterology guidelines recommended the suspension or reduction of non-urgent endoscopy. We aimed to assess the appropriateness and safety of endoscopic activity during the pandemic first wave lockdown using European Society of Gastrointestinal Endoscopy (ESGE) recommendations.

METHODS

We identified scheduled patients from the onset of the lockdown in Spain since March 16, 2020) to April 14, 2020. Daily hospital COVID-19-related burden was also registered. A similar cohort from a period immediately before the lockdown was studied (pre-lockdown cohort) to compare appropriateness.

RESULTS

454 endoscopy procedures were performed during the studied period, comprising a 49.7% reduction compared to the pre-lockdown cohort (n = 913). There was a significant increase in ESGE high-priority indications (62.1% vs. 45.6%, p<0.001) associated with an increase in relevant endoscopic findings (p = 0.006), advanced neoplasia/cancer (p = 0.004) and cancer detection rate (p = 0.010). There were no differences in the rate of admissions or infection among scheduled patients in the lockdown cohort. None of the staff members tested positive for COVID-19 in the 7 days after the adoption of protective measures.

CONCLUSION

A prioritized endoscopic activity is not associated with higher contagion after adopting protective measures. In addition, a triage of procedures that follow the ESGE criteria increases the rate of relevant endoscopic findings. These considerations may reduce the impact of the delays of diagnosis after the pandemic.

Interventions to improve early cancer diagnosis of symptomatic individuals: a scoping review

OBJECTIVES

To summarise the current evidence regarding interventions for accurate and timely cancer diagnosis among symptomatic individuals.

DESIGN

A scoping review following the Joanna Briggs Institute's methodological framework for the conduct of scoping reviews and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist.

DATA SOURCES

MEDLINE (Ovid), CINAHL (EBSCOhost) and PsycINFO (Ovid) bibliographic databases, and websites of relevant organisations. Published and unpublished literature (grey literature) of any study type in the English language were searched for from January 2017 to January 2021.

ELIGIBILITY AND CRITERIA

Study participants were individuals of any age presenting at clinics with symptoms indicative of cancer. Interventions included practice guidelines, care pathways or other initiatives focused on achieving predefined benchmarks or targets for wait times, streamlined or rapid cancer diagnostic services, multidisciplinary teams and patient navigation strategies. Outcomes included accuracy and timeliness of cancer diagnosis.

DATA EXTRACTION AND SYNTHESIS

We summarised findings graphically and descriptively.

RESULTS

From 21 298 retrieved citations, 88 unique published articles and 16 unique unpublished documents (on 18 study reports), met the eligibility for inclusion. About half of the published literature and 83% of the unpublished literature were from the UK. Most of the studies were on interventions in patients with lung cancer. Rapid referral pathways and technology for supporting and streamlining the cancer diagnosis process were the most studied interventions. Interventions were mostly complex and organisation-specific. Common themes among the studies that concluded intervention was effective were multidisciplinary collaboration and the use of a nurse navigator.

CONCLUSIONS

Multidisciplinary cooperation and involvement of a nurse navigator may be unique features to consider when designing, delivering and evaluating interventions focused on improving accurate and timely cancer diagnosis among symptomatic individuals. Future research should examine the effectiveness of the interventions identified through this review.

Impact of a colorectal cancer screening program implantation on delays and prognosis of non-screening detected colorectal cancer

BACKGROUND

The implementation of a colorectal cancer (CRC) screening programme may increase the awareness of Primary Care Physicians, reduce the diagnostic delay in CRC detected outside the scope of the screening programme and thus improve prognosis.

AIM

To determine the effect of implementation of a CRC screening programme on diagnostic delays and prognosis of CRC detected outside the scope of a screening programme.

METHODS

We performed a retrospective intervention study with a pre-post design. We identified 322 patients with incident and confirmed CRC in the pre-implantation cohort (June 2014 – May 2015) and 285 in the post-implantation cohort (June 2017 - May 2018) in the Cancer Registry detected outside the scope of a CRC screening programme. In each patient we calculated the different healthcare diagnostics delays: global, primary and secondary healthcare, referral and colonoscopy-related delays. In addition, we collected the initial healthcare that evaluated the patient, the home location (urban/rural), and the CRC stage at diagnosis. We determined the two-year survival and we performed a multivariate proportional hazard regression analysis to determine the variables associated with survival.

RESULTS

We did not detect any differences in the patient or CRC baseline-related variables. A total of 20.1% of patients was detected with metastatic disease. There was a significant increase in direct referral to colonoscopy from primary healthcare (25.5%, 35.8%; P = 0.04) in the post-implantation cohort. Diagnostic delay was reduced by 24 d (106.64 ± 148.84 days, 82.84 ± 109.31 d; P = 0.02) due to the reduction in secondary healthcare delay (46.01 ± 111.65 d; 29.20 ± 60.83 d; P = 0.02). However, we did not find any differences in CRC stage at diagnosis or in two-year survival (70.3%; P = 0.9). Variables independently associated with two-year risk of death were age (Hazard Ratio-HR: 1.06, 95%CI: 1.04-1.07), CRC stage (II HR: 2.17, 95%CI: 1.07-4.40; III HR: 3.07, 95%CI: 1.56-6.08; IV HR: 19.22, 95%CI: 9.86-37.44; unknown HR: 9.24, 95%CI: 4.27-19.99), initial healthcare consultation (secondary HR: 2.93, 95%CI: 1.01-8.55; emergency department HR: 2.06, 95%CI: 0.67-6.34), hospitalization during the diagnostic process (HR: 1.67, 95%CI: 1.17-2.38) and urban residence (HR: 1.44, 95%CI: 1.06-1.98).

CONCLUSION

Although implementation of a CRC screening programme can reduce diagnostic delays for CRC detected in symptomatic patients, this has no effect on CRC stage or survival.

A H2S-Triggered Dual-Modal Second Near-Infrared/Photoacoustic Intelligent Nanoprobe for Highly Specific Imaging of Colorectal Cancer

An endogenous H₂S-triggered intelligent optical nanoprobe combining second near-infrared (NIR-II) fluorescence with photoacoustic (PA) imaging can provide more comprehensive information to further improve the sensitivity and reliability of diagnosis for colorectal tumor, which is rarely explored. Herein, an endogenous H₂S-triggered SiO₂@Ag nanoprobe was designed for in situ dual-modal NIR-II/PA imaging of colorectal cancer. The designed dual-modal nanoprobe can be converted to SiO₂@Ag₂S after in situ biosynthesis via a sulfuration reaction with the over-expressed endogenous H₂S in the colorectal tumor. More importantly, the designed SiO₂@Ag nanoprobe exhibits high sensitivity and specificity for diagnosing colorectal cancer in vivo via dual-modal NIR-II/PA imaging. These results provide a new NIR-II/PA dual-modal imaging strategy for noninvasive intelligent detection of colorectal cancer.

Colorectal cancer screening and diagnosis: omics-based technologies for development of a non-invasive blood-based method

Introduction: Colorectal cancer (CRC) is one of the most important health problems in the Western world. In order to reduce the burden of the disease, two strategies are proposed: screening and prompt detection in symptomatic patients. Although diagnosis and prevention are mainly based on colonoscopy, fecal hemoglobin detection has been widely implemented as a noninvasive strategy. Various studies aiming to discover blood-based biomarkers have recently emerged.Areas covered: The burgeoning omics field provides diverse high-throughput approaches for CRC blood-based biomarker discovery. In this review, we appraise the most robust and commonly used technologies within the fields of genomics, transcriptomics, epigenomics, proteomics, and metabolomics, together with their targeted validation approaches. We summarize the transference process from the discovery phase until clinical translation. Finally, we review the best candidate biomarkers and their potential clinical applicability.Expert opinion: Some available biomarkers are promising, especially in the field of epigenomics: DNA methylation and microRNA. Transference requires the joint collaboration of basic researchers, intellectual property experts, technology transfer officers and clinicians. Blood-based biomarkers will be selected not only based on their diagnostic accuracy and cost but also on their reliability, applicability to clinical analysis laboratories and their acceptance by the population.

Not so FAST. Commentary on the article "Appraisal of the faecal haemoglobin, age and sex test (FAST) score in assessment of patients with lower bowel symptoms: an observational study"

A recent study by Digby et al. in BMC Gastroenterology evaluated the faecal haemoglobin, age and sex test (FAST) score in the assessment of patients with lower bowel symptoms attended in primary healthcare. This article is a valuable source of information but the conclusions must be carefully assessed. Authors evaluated the FAST score threshold with a 99% sensitivity (≥ 2.12) for colorectal cancer (CRC). Although the number of patients meeting this criteria is high, 53.5% of the patients not referred initially to secondary healthcare, the results on the patients referred to colonoscopy validate the prediction model. The sensitivity and the specificity for CRC detection were 99.0 and 23.2% with a positive and negative predictive value of 8.0 and 99.7%. Additionally, the sensitivity and the specificity for significant bowel disease were 96.1 and 26.2% with a positive and negative predictive value of 24.3 and 96.1%, consistent with our initial results. To conclude, although we need the information regarding the risk of CRC in those patients not referred to colonoscopy, a FAST Score < 2.12 allows to determine a group of patients with a low risk of CRC detection that requires no further evaluation.

Outcomes and adverse factors for endoscopic mucosal resection (EMR) of colorectal polyps in elderly patients

INTRODUCTION

Endoscopic mucosal resection (EMR) is an invaluable technique, however it is associated with significant risks. In the elderly in particular, the long-term survival benefits of polyp resection with EMR are unknown. The aim of this study was to determine the long-term outcomes in elderly patients who had undergone EMR and to identify any adverse factors.

METHOD

A retrospective observational study on patients of 75 years of age or greater, who underwent EMR of colorectal polyps, in a single tertiary centre, from 2005 to 2014. Demographics of the patients, including Charlson Comorbidity Index (CCI), endoscopic and histological data, were reviewed to identify potential factors predicting outcomes.

RESULTS

The patients' median age was 80 years. In total 239 procedures were performed in 206 unique patients. The complication rate was 1.6%. Mean overall survival was 6.7 years with only one patient dying from metastatic colorectal cancer (0.5%) and 49 dying from non-colorectal cancer conditions (24%). Age more than 79 years and CCI more than 2 were independent predictors of significantly shorter survival (p=<0.01). Gender, size of the removed polyps and total number of polyps were not statistically significantly affecting survival. Patients who had more than two colonoscopies were found to have a survival benefit (p=0.02).

CONCLUSION

EMR of colonic polyps is safe even for elderly patients. However, the decision to proceed to complex endoscopic therapy should be individualised considering the patients' age and comorbidities. CCI can help to objectively assess the comorbid state of a patient prior to such decisions.

Long-term outcomes in patients newly diagnosed with iron deficiency anaemia in general practice: a retrospective cohort study

OBJECTIVES

To describe all iron deficiency anaemia (IDA)-related causes during follow-up of patients newly diagnosed with IDA and to assess whether a delayed colorectal cancer (CRC) diagnosis influences survival.

DESIGN AND SETTING

Retrospective cohort study of patients from general practices in the Dordrecht area, the Netherlands.

PARTICIPANTS

Men and women aged ≥50 years with a new diagnosis of IDA (ie, no anaemia 2 years previously).

METHOD

From February 2007 to February 2018, all relevant data were collected from the files of the referral hospital. Early IDA-related cause was defined as established within 18 weeks after IDA diagnosis. Cox proportional-hazards regression was used to analyse survival of patients with CRC diagnosis.

RESULTS

587 patients with IDA were included with a median follow-up of 4.6 years. Early and late IDA-related causes could be established in 32% and 8% of patients, respectively. Early and late CRC was found in 8% and 2% of patients, respectively, and were located mainly right sided. After adjustment for age, gender and TNM classification, mortality risk was lower in patients with IDA with early CRC diagnosis, but not significantly (HR 0.30, 95% CI 0.09 to 1.02).

CONCLUSION

Even with extended follow-up, the cause of IDA remains elusive in the majority of patients with IDA in general practice. However, patients with IDA are at increased risk for in particular right-sided CRC and a late diagnosis of CRC appears to have a detrimental effect on survival in patients with IDA.

The effect of diagnostic delay attributable to the healthcare system on the prognosis of colorectal cancer

OBJECTIVES

To analyse the effect of a delay attributable to the healthcare system on a consecutive cohort of outpatients diagnosed with colorectal cancer in the healthcare area of Ourense (Spain).

PATIENTS AND METHODS

We performed a retrospective cohort study that included patients diagnosed between 2009 and 2017. Delay attributable to the healthcare system was defined as the time between the first consultation with symptoms and the diagnostic confirmation. A logistic regression model was performed to evaluate the relationship between stage IV CRC and diagnostic delay. To analyse which variables were associated independently with overall mortality and mortality due to CRC we used a Cox regression model.

RESULTS

575 patients were included (men 64.5%, age 71.9 ± 11.5 years), with a delay attributable to the healthcare system of 115 ± 153 days. None of the variables analysed were associated with tumour stage at diagnosis. With a mean follow-up of 30.6 ± 21 months, 121 patients died (79.3% due to CRC). The variables independently associated with CRC-related mortality were metastatic CRC (HR 50.65, 95% CI 12.28-209), age (HR 1.04, 95% CI 1.02-1.05) and colonoscopy requested from the Primary Healthcare level (HR 0.55, 95% CI 0.36-0.88).

CONCLUSIONS

Diagnostic delay attributable to the healthcare system is not related to the prognosis or stage of CRC. However, a direct referral to colonoscopy from the Primary Healthcare level reduces the risk of mortality in our patients.

Plasma Inter-Alpha-Trypsin Inhibitor Heavy Chains H3 and H4 Serve as Novel Diagnostic Biomarkers in Human Colorectal Cancer

Objective

Inter-alpha-trypsin inhibitor heavy chain H3 (ITIH₃) and inter-alpha-trypsin inhibitor heavy chain H4 (ITIH₄) are heavy chains of protein members belonging to the ITI family, which was associated with inflammation and carcinogenesis. However, the diagnostic value of ITIH₃ and ITIH₄ in human colorectal cancer (CRC) remains unknown.

Methods

In total, 101 CRC patients and 156 healthy controls were enrolled. The concentrations of ITIH₃ and ITIH₄ proteins in plasma samples of participants were assessed using enzyme-linked immunosorbent assay. ITIH₃ and ITIH₄ expressions in human CRC tissues were additionally assessed via immunohistochemical staining (IHC). Receiver operating characteristic (ROC) was applied to estimate the diagnostic power of the two proteins, and the net reclassification improvement (NRI) was adopted to evaluate the incremental predictive ability of ITIH₃/ITIH₄ when added to the tissue inhibitor of metalloproteinase-1 (TIMP-1).

Results

The plasma concentration of ITIH₃ in CRC patients (median: 4.370 μg/mL; range: 2.152–8.170 μg/mL) was significantly lower than that in healthy subjects (median: 4.715 μg/mL; range: 2.665–10.257 μg/mL; p < 0.001), while the ITIH₄ plasma level in subjects with CRC (median: 0.211 μg/mL; range: 0.099–0.592 μg/mL) was markedly increased relative to that in the control group (median: 0.134 μg/mL; range: 0.094–0.460 μg/mL, p < 0.001). Consistently, IHC score assessment showed a dramatic reduction in ITIH₃ expression and, conversely, upregulation of ITIH₄ in colorectal carcinoma specimens relative to adjacent normal colorectal tissues (p < 0.001 in both cases). The area under the curve (AUC) of the ROC for ITIH₄ (AUC = 0.801, 95% CI: 0.745–0.857) was higher than that for ITIH₃ (AUC = 0.638, 95% CI: 0.571–0.704, both p values < 0.001). The AUC of the ROC for combined ITIH₃ and ITIH₄ was even higher than that for carcinoembryonic antigen. NRI results showed that combining ITIH₃ and ITIH₄ with TIMP-1 significantly improved diagnostic accuracy (NRI = 17.12%, p = 0.002) for CRC patients compared to TIMP-1 alone.

Conclusions

Circulating ITIH₃ and ITIH₄ levels are associated with carcinogenesis in CRC, supporting their potential diagnostic utility as surrogate biomarkers for colorectal cancer detection.