Systematic review with meta-analysis: the incidence of advanced neoplasia after polypectomy in patients with and without low-risk adenomas

Longer Colonoscopy Withdrawal Time Is Associated With the Detection of Visible Dysplasia in Patients With Inflammatory Bowel Disease

Background

Colonoscopy withdrawal time (CWT) of at least 6-9 minutes is the minimum time needed for adequate adenoma detection in the general population. The ideal CWT in patients with inflammatory bowel disease (IBD) has not been determined. We aimed to identify the optimal CWT associated with the detection of visible dysplasia in patients with IBD.

Methods

This is a retrospective study from 1/1/2017 to 9/1/2022 of adult patients with IBD in endoscopic healing undergoing surveillance via high-definition white light colonoscopy. The primary outcome was the association of CWT with visible dysplasia detection.

Results

A total of 259 patients (mean age 56 ± 14.8 years; 51.3% female, 68% with ulcerative colitis; 8.9% with primary sclerosing cholangitis) underwent 330 colonoscopies. Patients with visible dysplasia were more likely to be older (P < .001) and have a personal history of visible dysplasia (P < .001) and invisible dysplasia (P = .023). The mean CWT was significantly longer in the visible dysplasia group at 26 minutes (interquartile range [IQR] 20-38.5) vs. 21 minutes (IQR 15-28) in procedures without visible dysplasia (P < .001). On multivariable analysis, increased age (P < .001), increased CWT (P = .001), and personal history of visible dysplasia (P = .013) were independently associated with the detection of visible dysplasia. A CWT of ≥15 minutes (odds ratio [OR] 2.71; 95% confidence interval [CI], 1.11-6.6; P = .02] and not ≥9 minutes (OR 2.57; 95% CI, 0.33-20.2; P = .35) is significantly associated with detection of visible dysplasia.

Conclusions

For patients with IBD undergoing surveillance via high-definition white light colonoscopy, the mean CWT was independently associated with the detection of visible dysplasia.

Sporadic Polyps of the Colorectum

Colorectal polyps are common, and their diagnosis and classification represent a major component of gastrointestinal pathology practice. The majority of colorectal polyps represent precursors of either the chromosomal instability or serrated neoplasia pathways to colorectal carcinoma. Accurate reporting of these polyps has major implications for surveillance and thus for cancer prevention. In this review, we discuss the key histologic features of the major colorectal polyps with a particular emphasis on diagnostic pitfalls and areas of contention.

Distinct Signatures of Tumor-Associated Microbiota and Metabolome in Low-Grade vs. High-Grade Dysplastic Colon Polyps: Inference of Their Role in Tumor Initiation and Progression

According to the driver-passenger model for colorectal cancer (CRC), the tumor-associated microbiota is a dynamic ecosystem of bacterial species where bacteria with carcinogenic features linked to CRC initiation are defined as "drivers", while opportunistic bacteria colonizing more advanced tumor stages are known as "passengers". We reasoned that also gut microbiota-associated metabolites may be differentially enriched according to tumor stage, and be potential determinants of CRC development. Thus, we characterized the mucosa- and lumen-associated microbiota (MAM and LAM, respectively) and mucosa-associated metabolites in low- vs. high-grade dysplastic colon polyps from 78 patients. We show that MAM, obtained with a new biopsy-preserving approach, and LAM differ in composition and α/β-diversity. By stratifying patients for polyp histology, we found that bacteria proposed as passengers by previous studies colonized high-grade dysplastic adenomas, whereas driver taxa were enriched in low-grade polyps. Furthermore, we report altered "mucosa-associated metabolite" levels in low- vs. high-grade groups. Integrated microbiota-metabolome analysis suggests the involvement of the gut microbiota in the production and consumption of these metabolites. Altogether, our findings support the involvement of bacterial species and associated metabolites in CRC mucosal homeostasis in a tumor-stage-specific manner. These distinct signatures may be used to distinguish low-grade from high-grade dysplastic polyps.

Korean Guidelines for Postpolypectomy Colonoscopic Surveillance: 2022 revised edition

Colonoscopic polypectomy is effective in decreasing the incidence and mortality of colorectal cancer (CRC). Premalignant polyps discovered during colonoscopy are associated with the risk of metachronous advanced neoplasia. Postpolypectomy surveillance is the most important method for managing advanced metachronous neoplasia. A more efficient and evidence-based guideline for postpolypectomy surveillance is required because of the limited medical resources and concerns regarding colonoscopy complications. In these consensus guidelines, an analytic approach was used to address all reliable evidence to interpret the predictors of CRC or advanced neoplasia during surveillance colonoscopy. The key recommendations state that the high-risk findings for metachronous CRC following polypectomy are as follows: adenoma ≥10 mm in size; 3 to 5 (or more) adenomas; tubulovillous or villous adenoma; adenoma containing high-grade dysplasia; traditional serrated adenoma; sessile serrated lesion containing any grade of dysplasia; serrated polyp of at least 10 mm in size; and 3 to 5 (or more) sessile serrated lesions. More studies are needed to fully comprehend the patients who are most likely to benefit from surveillance colonoscopy and the ideal surveillance interval to prevent metachronous CRC.

The Risk of Metachronous Advanced Neoplasia After Colonoscopy in Patients Aged 40-49 Years Compared With That in Patients Aged 50-59 Years

INTRODUCTION

This study investigated the risk of metachronous advanced neoplasia (AN) after colonoscopy in individuals aged 40-49 years compared with that in individuals aged 50-59 years.

METHODS

A retrospective cohort study was performed among Kaiser Permanente Northern California members aged 40-59 years who had their first (index) colonoscopy in 2010-2013. Participants were followed up until death, disenrollment, AN on surveillance colonoscopy, or December 31, 2018. The risk for the development of AN was estimated using the Cox regression, adjusted for confounders.

RESULTS

The study included 11,374 patients (2,396 aged 40-49 years and 8,978 aged 50-59 years). When comparing the 40-49 years group with the 50-59 years group, AN was detected in 2.2% vs 4.4% ( P = 0.0003) on surveillance colonoscopy after index colonoscopy finding of no adenoma, in 4.6% vs 7.0% ( P = 0.03) after a finding of nonadvanced adenoma (NAA), and in 7.9% vs 11.7% ( P = 0.06) after a finding of advanced adenoma (AA), respectively. Compared with the 50-59 years group, the 40-49 years group had a lower risk of metachronous AN when no adenoma was detected on index colonoscopy (hazard ratio [HR] 0.58; 95% confidence interval [CI] 0.39-0.83) and no difference when NAA (HR 0.84; 95% CI 0.54-1.24) or AA (HR 0.83; 95% CI 0.51-1.31) was detected.

DISCUSSION

Compared with patients aged 50-59 years, patients aged 40-49 years may have a lower risk of developing metachronous AN when no adenoma is detected on index colonoscopy and a similar risk when NAA or AA is detected. These data suggest current surveillance colonoscopy guidelines may be applicable to patients aged 40-49 years who undergo colonoscopy.

Sporadic Rectocolic Polyps Prevalence and Management

Objective To evaluate the prevalence of polyps and their treatments.

Materials and Method This is a retrospective study conducted in our department over 20 years and 3 months between January 2000 and March 2021. All patients with colorectal polyps who underwent endoscopic resection were included. We evaluated the resection techniques and the management of complications.

Results The total number of patients was 273, with a mean age of 57.26 ± 14.058 (18–90) and a M/W sex ratio of 2. The prevalence was 3.35% and the mean number of polyps was 1.33 ± 0.69. The most frequent symptoms were rectal bleeding (23.5%) and constipation (12.1%). The median size was 6 mm (4–12 mm). The left colonic location was the most frequent site (43%). All polyps were classified according to the Paris classification, with a predominance of sessile polyps in 45.75%, followed by pedunculated polyps, representing 42.4%. Endoscopic resection was performed either by biopsy forceps, polypectomy, or mucosectomy in 30.2%, 27.4%, and 25.4% of cases, respectively. Our study noted immediate bleeding in 1.5% of cases, and no perforations or late complications. All complications were treated endoscopically, and no patient required blood transfusion or surgical intervention.

Conclusion Endoscopic resection of rectocolic polyps is the ideal treatment for these lesions. In our department, the prevalence was 3.35%, the most used resection techniques were forceps resection and polypectomy, and the complication rate was 1.5%.

Korean guidelines for postpolypectomy colonoscopic surveillance: 2022 revised edition

Colonoscopic polypectomy is effective in decreasing the incidence and mortality of colorectal cancer (CRC). Premalignant polyps discovered during colonoscopy are associated with the risk of metachronous advanced neoplasia. Postpolypectomy surveillance is the most important method for the management of advanced metachronous neoplasia. A more efficient and evidence-based guideline for postpolypectomy surveillance is required because of limited medical resources and concerns regarding colonoscopy complications. In these consensus guidelines, an analytic approach was used to address all reliable evidence to interpret the predictors of CRC or advanced neoplasia during surveillance colonoscopy. The key recommendations state that the high-risk findings for metachronous CRC following polypectomy are as follows: (1) adenoma ≥10 mm in size; (2) 3 to 5 (or more) adenomas; (3) tubulovillous or villous adenoma; (4) adenoma containing high-grade dysplasia; (5) traditional serrated adenoma; (6) sessile serrated lesion (SSL) containing any grade of dysplasia; (7) serrated polyp of at least 10 mm in size; and (8) 3 to 5 (or more) SSLs. More studies are needed to fully comprehend the patients most likely to benefit from surveillance colonoscopy and the ideal surveillance interval to prevent metachronous CRC.

[Korean Guidelines for Postpolypectomy Colonoscopic Surveillance: 2022 Revised Edition]

Colonoscopic polypectomy is effective in decreasing the incidence and mortality of colorectal cancer (CRC). Premalignant polyps discovered during colonoscopy are associated with the risk of metachronous advanced neoplasia. Postpolypectomy surveillance is the most important method for managing advanced metachronous neoplasia. A more efficient and evidence-based guideline for postpolypectomy surveillance is required because of the limited medical resources and concerns regarding colonoscopy complications. In these consensus guidelines, an analytic approach was used to address all reliable evidence to interpret the predictors of CRC or advanced neoplasia during surveillance colonoscopy. The key recommendations state that the high-risk findings for metachronous CRC following polypectomy are as follows: 1) adenoma ≥10 mm in size; 2) 3-5 (or more) adenomas; 3) tubulovillous or villous adenoma; 4) adenoma containing high-grade dysplasia; 5) traditional serrated adenoma; 6) sessile serrated lesion (SSL) containing any grade of dysplasia; 7) serrated polyp of at least 10 mm in size; and 8) 3-5 (or more) SSLs. More studies are needed to fully comprehend the patients who are most likely to benefit from surveillance colonoscopy and the ideal surveillance interval to prevent metachronous CRC.

The risk of advanced neoplasia after polypectomy of one to two non-advanced adenomas less than 5 mm in size vs. normal colonoscopy

BACKGROUND

Current guidelines are inconsistent regarding the follow-up of patients with 1-2 diminutive (1-5 mm) non-advanced adenomas (DNAAs).

AIMS

To evaluate the risk of metachronous advanced neoplasia (AN), defined as cancer or advanced adenoma (AA), among patients with either normal colonoscopy or 1-2 DNAAs.

METHODS

A retrospective cohort study. Cohort I included 2,347 subjects with normal colonoscopy and 483 subjects with polypectomy of 1-2 DNAAs followed by colonoscopy. Cohort II included 11,881 subjects with normal colonoscopy and 1,342 subjects with 1-2 DNAAs followed through the cancer registry.

RESULTS

In cohort I, the rate of AN, cancer and AA among the polypectomy group vs. normal colonoscopy was 5.0% vs. 2.5%, Hazard Ratio (HR) 2.96 (95%CI [Confidence Interval]1.86-4.78) for AN; 0.6% vs. 0.3%, HR 3.32 (95%CI 0.85-13) for cancer; 4.3% vs. 2.2% HR 2.91 (95%CI 1.75-4.86) for AA. In cohort II, cancer occurred in 0.4% of the polypectomy group and 0.2% of the normal colonoscopy group, HR 2.27 (95% CI 0.56-9.19).

CONCLUSION

Compared to subjects with normal colonoscopy, subjects with polypectomy of 1-2 DNAAs, are at increased risk for AA when followed by colonoscopy, while the risk for cancer is non-significantly increased. Our findings suggest that patients with 1-2 DNNAs should be followed more tightly than patients with normal colonoscopy.

Risk of total metachronous advanced neoplasia in patients with both small tubular adenomas and serrated polyps

BACKGROUND AND AIMS

The impact of concomitant small serrated polyps (SPs) on the risk of subsequent neoplasia when small tubular adenomas (TAs) are found is uncertain.

METHODS

Patients who on index colonoscopy had ≤2 TAs of <10 mm in size in isolation were compared with those with concomitant ≤2 small-sized SPs. SP was inclusive of polyps described by pathology as sessile serrated lesions (SSLs) or proximal hyperplastic polyps (HPs) <10 mm in size. The primary endpoint was the rate of total metachronous advanced neoplasia (T-MAN) compared among the TAs in the isolation group and the groups inclusive of SPs (SSLs or proximal HPs).

RESULTS

For patients with TAs and small SPs found concomitantly, the rate of T-MAN was 9.6% (24/251), which was significantly higher than the rate of T-MAN in patients with isolated small TAs (5.2% [59/1138], P = .011). Within the concomitant SP cohort, the rate of T-MAN in the proximal HP subgroup remained significantly increased (9% [19/212]) compared with the isolated small TA group (P = .037).

CONCLUSIONS

When small TAs are found concomitantly with small SPs, there is an increase in the rate of T-MAN in comparison with isolated TAs. This increase in T-MAN also occurs when small TAs are found in conjunction with small proximal HPs. The presence of concomitant small SPs should be considered in determining surveillance intervals when small TAs are identified in colonoscopy screening programs.

Surveillance Recommendation for Colonoscopy after Polypectomy

The incidence and mortality of colorectal cancer (CRC) have declined over the past several decades, largely due to improvement and uptake in screening, particularly with colonoscopy. The US Multi-Society Task Force on CRC published guidelines for surveillance after polypectomy in 2012, which were updated in 2020 with some important changes, and this review will provide an updated overview of evidence and outcomes of surveillance after polypectomy. Notable modifications to surveillance guidelines include increasing interval time between colonoscopies from 5 to 7 to 10 years for 1 to 2 low-risk adenomas (<10 mm) and from 3 years to 3 to 5 years when 3 to 4 low-risk adenomas are identified.

Small sessile serrated polyps might not be at a higher risk for future advanced neoplasia than low-risk adenomas or polyp-free groups

BACKGROUND

Polypectomy surveillance colonoscopy is recommended according to the risk stratification of initially removed polyps. This study aimed to evaluate the risk of advanced neoplasia following low-risk SSPs compared with that following LRAs and polyp-free groups.

MATERIALS AND METHODS

From September 2013 to August 2017, asymptomatic Koreans aged 50-75 years who underwent surveillance colonoscopy post-baseline colonoscopy were enrolled. The 1314 participants who met the study design criteria were stratified into three groups according to the presence of LRAs or low-risk SSPs. The rate of advanced neoplasia was then compared between groups by surveillance colonoscopy.

RESULTS

A total of 1314 participants were classified according to baseline colonoscopy findings: no polyp (n = 551), LRA (n = 707), and low-risk SSP (n = 56). All participants underwent surveillance colonoscopy after an average of 28.1 ± 8.7 months. The rate of advanced neoplasia at surveillance was not different between groups: no polyp group (13/551, 2.4%), LRA group (27/707, 3.8%), and low-risk SSP group (0/56, 0%). The LRA group exhibited a significantly higher rate of low- and high-risk polyps (47.5, 13.4%) than did the no polyp (35.6, 7.4%, p < .001, p = .001), but no significant differences to the low-risk SSP group (35.7, 7.1%, p = .117, p = .253), respectively.

CONCLUSIONS

Patients with low-risk SSPs were not at a higher risk of advanced neoplasia than LRA patients, even in the polyp-free group. We suggest that surveillance colonoscopy after the removal of low-risk SSPs is not required more often than for LRAs.

Prognostic Value of Inflammation-based Prognostic Scores in Patients with Colorectal Cancer

Background Anatomopathological staging is the primary method to determine the prognosis of patients with colorectal carcinoma (CRC). However, new tools have been developed that can complement it, such as the analysis of the elevation of systemic inflammatory markers.

Objective To evaluate the impact of the elevation of scores based on inflammatory markers (the neutrophil-to-lymphocyte ratio [NLR], the Glasgow Prognostic Score [GPS], and isolated C-reactive protein [CRP]) in the prognosis of patients diagnosed with CRC and submitted to potentially curative surgery in Hospital de Braga, Portugal, between January 1st, 2005, and December 31st, 2010.

Methods A retrospective analysis of the data of 426 patients was performed, with a collection of several clinico-pathological variables, as well as the levels of lymphocytes, neutrophils, albumin and CRP, in the pre- and postoperative periods, to apply the different scores to the sample.

Results From the analysis of the survival curves, we concluded that patients with increased NLR in the pre- and postoperative periods present a lower cancer-related survival than patients with normal NLR (preoperative period: 93.7 versus 122 months; p < 0.001; postoperative period: 112 versus 131 months; p = 0.002). Patients with increased NLR in the pre- and postoperative periods also had a lower disease-free survival (preoperative period: 88.0 versus 122 months; p < 0.001; postoperative period: 111 versus 132 months; p = 0.002). In addition, increased pre- and postoperative NLR was associated with a higher risk of death due to CRC (preoperatively: hazard ratio [HR] = 2.25; p < 0.001; postoperatively: HR = 2.18; p = 0.003). However, the multivariate analysis shows that only postoperative NLR (ajusted HR = 2.66; p = 0.002) does so independently of the remaining variables.

Conclusion Regarding the scores applied to the sample, the NLR was the one that most consistently related to the prognosis of the patients. However, it would be useful to develop a prospective study that could confirm this relationship.

Long-term cumulative incidence of metachronous advanced colorectal neoplasia after colonoscopy and a novel risk factor: a cohort study

BACKGROUND AND AIM

Long-term cumulative incidence of and risk factors for metachronous advanced colorectal neoplasia, including both advanced colorectal adenoma (≥10 mm, or with villous or high-grade dysplasia) and colorectal cancer, are critical for surveillance strategies. The aim of this study was to determine the cumulative incidence of metachronous advanced colorectal neoplasia and its risk factors.

METHODS

A retrospective cohort study was conducted on 6720 consecutive individuals who underwent general health check-ups and colonoscopy. Colorectal adenomas at initial colonoscopy were categorized as low-risk (1-2 small [<10 mm] tubular adenomas) or high-risk adenoma (≥3 tubular adenomas of any size; at least one adenoma ≥10 mm; or villous adenoma or adenoma with high-grade dysplasia). Kaplan-Meier estimates and hazard ratio by Cox-proportional hazard regression were calculated.

RESULTS

The cumulative incidence (95% confidence interval [CI]) of metachronous advanced colorectal neoplasia at 5 and 10 years was 5.7% [4.6-7.1], and 11% [8.9-14] in the low-risk adenoma group, and 10% [8.6-13], and 17% [14-21] in high-risk adenoma group, respectively. Adjusted hazard ratio [95% CI] of low-risk adenoma (vs. no colorectal adenoma), high-risk adenoma (vs. no colorectal adenoma), current smoking and positive fecal immunochemical test were 1.34 [1.04-1.74], 1.94 [1.48-2.55], 1.55 [1.2-2.02] and 1.69 [1.35-2.1], respectively. Adjusted hazard ratio [95% CI] of positive fecal immunochemical test was 1.88 [1.29-2.74] in those with normal colonoscopy.

CONCLUSIONS

Both low-risk and high-risk adenomas confer substantial risk for metachronous advanced colorectal neoplasia at 10 years. Positive fecal immunochemical test was a significant risk factor for metachronous advanced colorectal neoplasia despite normal colonoscopy.

Updates, Controversies, and Emerging Approaches in Colorectal Screening

Colorectal cancer (CRC) is the third most common cancer worldwide and the second leading cause of cancer-related deaths. Despite the threatening statistics, the US burden for CRC has been decreasing, which is likely multifactorial and has partial contribution from widespread timely screening, more advanced CRC treatment, and daily aspirin use in some patients. While overall death rate from CRC decreased by approximately a half between 1975 and 2012, epidemiologic studies demonstrate that CRC incidence is increasing in the younger population. This pattern has prompted the American Cancer Society (ACS) to revise their guidelines. In this review, we plan to discuss the most recent changes in guidelines, data to support them, controversies concerning CRC screening methods, age to start and to stop screening, and post-colonoscopy/polypectomy surveillance guidelines.

A new method for investigating microbiota-produced small molecules in adenomatous polyps

The intestinal microbiota is composed of a large number of different bacteria that produce a variety of metabolites. Colorectal cancer, which typically develops from adenomatous polyps, is highly influenced by microbiota. Since a variety of molecular changes may occur as these polyps transform from benign tumor to malignant carcinoma, the ability to study the microbiota-produced metabolites can lead to new discoveries about the development and progression of this cancer. However, to address the complexity of the microbiota-produced molecules, novel methods are needed. To this aim, in the present work, we developed a high-throughput metabolomics method to capture the metabolic complexity of the microbiota metabolome adherent to adenomatous polyps and adenocarcinoma. For the first time, the method enables the simultaneous quantification of almost 300 metabolites, while preserving the integrity of the original sample. The metabolomics approach was analytically validated and had excellent performances in terms of recovery, linearity, specificity, intra- and inter-day precision, limits of detection, and quantification. Furthermore, the clinical potential of the method was demonstrated in adenoma collected for a colorectal adenoma study.

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

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.

Outcomes Of Patients with Delayed Surveillance Colonoscopy

BACKGROUND

Surveillance colonoscopy has been shown to be an effective tool for prevention of CRC in high-risk populations, if adhered to. We aimed to discover the sequelae of late surveillance in a cohort of patient's overdue for colonoscopy, in particular the development of colorectal cancer (CRC) or advanced adenoma (AA) within surveillance subgroups.

METHOD

We conducted a retrospective cohort study on all patients from the Bay of Plenty District Health Board region, New Zealand, placed on the colonoscopy surveillance waitlist from 2006 onwards who had their procedure completed between 1 November 2016 and 31 January 2018, when the total surveillance list was declared up-to-date. Patients with overdue surveillance, defined as done later than 90 days after the recommended due date were compared to patients who were done either early, or on time.

RESULTS

786 patients were recorded as overdue for surveillance colonoscopy, and 386 were completed early or on time. The median time overdue was 22 months. Three cases (0.4%) of CRC were found in overdue patients compared to 4 cases (1%) for those done on time (adjusted p=0.24). There were 86 (11%) AA in patient's overdue compared to 27 (7%) in those not overdue (odds ratio (OR) 1.6, 95% confidence interval (CI) [1.0,2.5], p=0.04). Overdue status increased the expected risk of AA by approximately 60% (adjusted; 95% CI [1%,253%], p=0.04) or 19% per year overdue (95% CI [7%,32%], p=0.002). Surveillance of 248 low-risk post-polypectomy patients demonstrated 26/211 with AA in overdue patients compared to 2/37 (12.3% vs 5.4%, unadjusted p=0.23) for those done on time. Surveillance of 180 high-risk post-polypectomy patients identified 2 CRC's and 8/43 AA in those overdue, as compared to no CRC and 9/137 AA (18.6% vs 6.6%, OR 1.79 (95% CI [1.07,2.0], unadjusted p=0.03) in those done on time.

CONCLUSION

Whilst overdue surveillance is not predictive of increased CRC, it is associated with an increase in expected number of AA, particularly in patients having surveillance for previous high-risk polypectomy. This article is protected by copyright. All rights reserved.

Patient Preferences in Surveillance: Findings From a Discrete Choice Experiment in the "My Follow-Up" Study

OBJECTIVES

Approximately 800 000 people die globally from colorectal cancer (CRC) every year. Prevention programs promote early detection, but for people with precancerous lesions, tailoring surveillance to include lifestyle-change programs could enhance prevention potential and improve outcomes.

METHODS

Those with intermediate or high-risk polyps removed during CRC screening colonoscopy within the Northern Ireland CRC Screening Programme were invited to complete 8 discrete choice questions about tailored surveillance, analyzed using random-parameters logit and a latent class modeling approach.

RESULTS

A total of 231 participants (77% male) self-reported comorbid hypertension (53%), high cholesterol (48%), and mean body mass index of 28.7 (overweight). Although 39% of participants were unaware of their CRC risk status, 30.9% indicated they were already making changes to reduce their risk. Although all respondents were significantly risk- and cost-averse, the latent class analysis identified 3 segments (classes): 1. Class 1 (26.8%) significantly favored phone or email support for a lifestyle change, a 17-month testing interval, and noninvasive testing. 2. Class 2 (48.4%) preferred the status quo. 3. Class 3 (24.7%) significantly favored further risk reduction and invasive testing.

CONCLUSIONS

This is the first documented preference study focusing on postpolypectomy surveillance offering lifestyle interventions. Although current care is strongly preferred, risk and cost aversion are important for participants. Latent class analysis shows that some respondents are willing to change diet and lifestyle behaviors, reflecting a teachable moment, with opportunities to personalize and optimize surveillance. Significant discordance between perceived and known risk of recurrence and limited recall of risk information provided within current practice suggest necessary improvements to surveillance programs.

The predictive value of small versus diminutive adenomas for subsequent advanced neoplasia

BACKGROUND AND AIMS

Patients with previous colorectal adenomas are at increased risk of colorectal cancer. Current guidelines for postpolypectomy surveillance intervals treat all tubular adenomas 1 to 9 mm in size with low-grade dysplasia as carrying the same level of risk. We evaluated whether 6 to 9 mm adenomas detected at colonoscopy are associated with greater risk of advanced neoplasia at follow-up compared with baseline 1 to 5 mm adenomas.

METHODS

We retrospectively evaluated a colonoscopy database at a single U.S. academic center. Patients with baseline examinations demonstrating tubular adenomas 1 to 9 mm in size with low-grade dysplasia and no advanced adenomas were included. Follow-up colonoscopies were performed at least 200 days later and were assessed for incident advanced neoplasia (cancer, high-grade dysplasia, adenoma ≥10 mm in size, or villous elements).

RESULTS

There were 2477 qualifying baseline colonoscopies. The absolute risk of metachronous advanced neoplasia increased from 3.6% in patients with 1 to 5 mm adenomas to 6.9% in patients with at least 1 adenoma of 6 to 9 mm (P = .001). Patients with 5 or more adenomas 1 of which was at least 6 to 9 mm had the highest risk of advanced neoplasia at follow-up (10.4%, P = .006). When only screening colonoscopies were considered, all baseline groups (1-2 adenomas, 3-4 adenomas, ≥5 adenomas) with adenomas 6 to 9 mm in size had an increased risk for metachronous advanced neoplasia (odds ratio [OR], 4.07; 95% confidence interval [CI], 1.50-11.04; OR, 4.91; 95% CI, 1.44-16.75; OR, 4.71; 95% CI, 1.30-17.05, respectively).

CONCLUSIONS

Patients with baseline small (6-9 mm) adenomas have an increased risk of advanced lesions on follow-up compared with patients with only diminutive (1-5 mm) adenomas. Postpolypectomy guidelines should consider risk stratification based on small versus diminutive adenomas.

Further Defining the 2012 Multi-Society Task Force Guidelines for Surveillance of High-risk Adenomas: Is a 3-Year Interval Needed for All Patients?

GOALS

We set out to determine whether variation from this 3-year follow-up interval was associated with the finding of subsequent high-risk adenoma (HRA).

BACKGROUND

HRAs include the following: (1) an adenoma measuring ≥10 mm, (2) ≥3 adenomas found during a single procedure, and (3) an adenoma with high-grade dysplasia or villous architecture. The current Multi-Society Task Force guideline for timing of surveillance colonoscopy after removal of a HRA is 3 years.

STUDY

In 2016, we analyzed 495 patients who had a HRA removed during a 2008 colonoscopy. We compared the frequency of finding another HRA at follow-up intervals. We used the current guidelines as our referent group and performed logistical regression to identify whether any patient characteristics, procedural factors, or type of HRA predicted the development of HRAs on follow-up colonoscopy.

RESULTS

Individuals who followed-up at a median of 4.5 years did not have more HRA on follow-up compared with those who followed-up at 3 years (25.2% vs. 21.0%, P=0.062). These groups had similar baseline characteristics. Older individuals, male gender, having a history of polyps, and piecemeal resection of an HRA predicted future HRAs. The removal of ≥3 adenomas in 2008 as well as a combination of multiple, large, and advanced polyps showed a higher risk of future HRAs.

CONCLUSIONS

The 2012 Multi-Society Task Force recommendation of 3-year follow-up after removal of HRAs may not apply to all patients. We showed that a combination of patient demographics, procedural factors, and pathology best determines the surveillance colonoscopy interval.

Association of small versus diminutive adenomas and the risk for metachronous advanced adenomas: data from the New Hampshire Colonoscopy Registry

BACKGROUND AND AIMS

Limited data are available to investigate the impact of index adenoma size on the risk of metachronous advanced adenomas. Our goal was to examine the impact of having small (5-9 mm) versus diminutive (<5 mm) adenomas on the future risk of advanced adenomas within the categories for polyps <1 cm currently used in the United States: 1 to 2 and 3 or more tubular adenomas.

METHODS

We included data from individuals participating in the statewide, population-based New Hampshire Colonoscopy Registry (NHCR). Groups were based on index findings: (1) 1 to 2 adenomas <5 mm (both diminutive), (2) 1 to 2 adenomas <1 cm (one or both small), (3) 3 to 10 adenomas <5 mm (all diminutive), (4) 3 to 10 adenomas <1 cm (one or more small), and (5) advanced adenomas (AA). AAs were defined as adenomas ≥1cm or those with villous elements or high-grade dysplasia or colorectal cancer (CRC). Outcomes were the absolute and adjusted risk of metachronous AAs. Covariates included age, sex, body mass index, family history of CRC, lifestyle factors, presence of serrated polyps, and time since the index examination.

RESULTS

After adjusting for the covariates, we observed that having 1 to 2 adenomas with at least one 5 to 9 mm adenoma (adjusted odds ratio [AOR], 1.54; 95% confidence interval [CI], 1.12-2.11), 3 to 10 diminutive adenomas (AOR, 1.75; 95% CI, 1.03-2.95), 3 to 10 adenomas <1 cm (1 or more small) (AOR, 2.14; 95% CI, 1.39-3.29) or AAs (AOR, 2.77; 95% CI, 2.05-3.74) were associated with an increased risk for metachronous AA compared with having 1 to 2 diminutive adenomas. A further stratification of group 2 showed that those with exactly 2 small adenomas had an absolute risk of future AA of 7.6% (11/144) (95% CI, 4.3%-13.2%), higher than the absolute risk in the 1 to 2 diminutive polyp group, and similar to the risk for 3 to 10 adenomas of 8.2% (95% CI, 5.4-11.9).

CONCLUSIONS

For individuals with 1 to 2 adenomas <1 cm, having at least 1 small adenoma increased the metachronous risk of AA compared with having only diminutive adenomas. Furthermore, the subset with 2 small adenomas had a risk of future AA similar to the risk for 3 to 10 adenomas. These data suggest that individuals with at least 1 small adenoma may be at higher risk for future AAs and thus require closer follow-up than those with only diminutive adenomas. These data may be valuable to guideline committees for the creation of future surveillance recommendations.

Incidence of Advanced Colorectal Neoplasia in Individuals With Untreated Diminutive Colorectal Adenomas Diagnosed by Magnifying Image-Enhanced Endoscopy

OBJECTIVES

Because of the increasing number of detected diminutive colorectal adenomas, the "diagnose-and-do-not-resect" approach has recently attracted attention as an alternative to resection. We evaluated the cumulative incidence of advanced colorectal neoplasia (ACN) in individuals with untreated diminutive adenomas and compared this incidence in individuals without adenomas.

METHODS

Data from 1,378 individuals who underwent first screening colonoscopy (CS) and at least one follow-up CS without polypectomy were analyzed. Patients with no adenomas or with only nonadvanced diminutive adenomas (<5 mm) diagnosed by magnifying image-enhanced endoscopy were scheduled to undergo a follow-up CS within 5 years after the initial CS without treatment. The participants were divided into 2 groups: those with untreated diminutive adenomas (group A) and those with no adenomas (group B). The cumulative incidence of ACN and the hazard ratio were assessed using Gray's test and the Fine and Gray model.

RESULTS

During the median follow-up period of 60.9 months, 21 ACNs were detected. The 5-year cumulative incidences of ACN in group A (n = 361) and group B (n = 1,017) were 1.4% (95% confidence interval [CI]: 0.5-3.4) and 0.8% (95% CI: 0.3-1.7), respectively, without a statistically significant difference (P = 0.23). No ACNs developed from unresected adenomas. The smoking status was significantly associated with the incidence of ACN, and the hazard ratio for ACN in group A vs group B adjusted for smoking status was 1.43 (95% CI: 0.52-3.90; P = 0.48).

DISCUSSION

The low 5-year cumulative incidence of ACN suggests the potential to adopt the "diagnose-and-do-not-resect" strategy as an alternative option for diminutive adenomas not requiring excessive surveillance.

The significance of the small adenoma: a longitudinal study of surveillance colonoscopy in an Australian population

BACKGROUND

The international guidelines for surveillance following the finding of a small tubular adenoma vary between no surveillance or colonoscopy at 5 or 10 years, whereas surveillance after an advanced adenoma is 3 years. Optimization of surveillance reduces the risk of colorectal cancer (CRC) with efficient use of colonoscopy resources. We assessed the risks of advanced colorectal neoplasia following a baseline finding of a small adenoma compared with advanced adenoma.

PATIENTS AND METHODS

A retrospective audit was undertaken of patients enrolled in a CRC surveillance program, wherein regular colonoscopies and screening with faecal immunochemical test (FIT) were provided. Patients diagnosed with either small or advanced adenoma followed by at least one surveillance colonoscopy were included. Advanced adenoma included adenomas with features of villous change, size of at least 10 mm, high-grade dysplasia, three or more small tubular adenomas and traditional and sessile serrated adenomas. Subdistribution hazard ratios were calculated for advanced neoplasia (CRC or advanced adenoma).

RESULTS

Overall, 378 patients (62.6±11.2 years, 57.9% male) were included, with 44.2% diagnosed with small adenoma and 55.5% with advanced adenoma at baseline. The crude cumulative incidence of advanced neoplasia at first surveillance was 13.2 and 18.5% after small and advanced adenoma (P=0.16) (at 45.9 and 35.6 months, respectively), which became significant for advanced adenoma after adjustment (subdistribution hazard ratio=2.55, 95% confidence interval=1.49-4.35, P<001). A positive FIT was the only independent predictor of advanced neoplasia after a small adenoma at baseline colonoscopy (odds ratio=5.05, 95% confidence interval=1.27-20.02, P=0.02).

CONCLUSIONS

The risk of advanced neoplasia following a small adenoma was lower than that following an advanced adenoma, but was strongly predicted by a positive FIT. Reducing frequency of colonoscopy while providing regular FIT might be a more efficient use of resources for this population.

Precision Medicine Versus Population Medicine in Colon Cancer: From Prospects of Prevention, Adjuvant Chemotherapy, and Surveillance

With the advances of technologic revolution that provides new insights into human biology, genetics and cancer, as well as advantages of big data which amasses large amounts of information for us to approach cancer treatment and prevention, we are facing challenges of organically combining data from studies based on general population and information from individual testing and setting out precisional recommendations in cancer diagnosis, prevention, and treatment. We are obligated to accelerate the adaptation of new scientific discoveries into effective treatments and prevention for cancer. In this review, we introduce our opinions on bringing knowledge of precision and population medicine together to guide our clinical practice from the prospects of colorectal cancer prevention, stage III colon cancer adjuvant therapy, and postsurgery surveillance.

Curriculum review: colorectal cancer surveillance and management of dysplasia in IBD

The significantly increased risk of colorectal cancer (CRC) in longstanding colonic inflammatory bowel disease (IBD) justifies the need for endoscopic surveillance. Unlike sporadic CRC, IBD-related CRC does not always follow the predictable sequence of low-grade to high-grade dysplasia and finally to invasive carcinoma, probably because the genetic events shared by both diseases occur in different sequences and frequencies. Surveillance is recommended for patients who have had colonic disease for at least 8-10 years either annually, every 3 years or every 5 years with the interval dependant on the presence of additional risk factors. Currently, the recommended endoscopic strategy is high-definition chromoendoscopy with targeted biopsies, although the associated lengthier procedure time and need for experienced endoscopists has limited its uniform uptake in daily practice. There is no clear consensus on the management of dysplasia, which continues to be a challenging area particularly when endoscopically invisible. Management options include complete resection (and/or referral to a tertiary centre), close surveillance or proctocolectomy. Technical advances in endoscopic imaging such as confocal laser endomicroscopy, show exciting potential in increasing dysplasia detection rates but are still far from being routinely used in clinical practice.

Visceral obesity as a risk factor for colorectal adenoma occurrence in surveillance colonoscopy

BACKGROUND AND AIMS

The aim of this study was to examine the prospective association between visceral obesity and the incidence and recurrence of colorectal adenoma.

METHODS

We conducted a cohort study involving 2244 participants between 2006 and 2007. The study participants were prospectively followed until 2014 according to the initial colonoscopy and histopathology findings. Incident and recurrent colorectal adenoma groups were defined as individuals with a positive follow-up colonoscopy result from the normal results and adenoma groups, respectively, at the baseline colonoscopy.

RESULTS

Among the 1163 patients (51.8%) who received a follow-up colonoscopy, 509 (43.8%) and 654 (56.2%) were grouped into the normal and adenoma cohorts. Colorectal adenomas occurred in 592 patients (50.9%) during the median period of 43 months, with an incident adenoma prevalence of 39.1% and a recurrent adenoma prevalence of 60.1%. An increase in the visceral adipose tissue (VAT) area was associated with a higher incidence of adenoma (highest quintile vs lowest quintile of the VAT hazard ratios [HRs], 2.16; 95% confidence interval [CI], 1.26-3.71; HR 1.32 [per 1-standard deviation]; 95% CI, 1.10-1.60) in the multivariable analysis. Increases in body mass index and waist circumference were associated with recurrent adenomas (HR 1.33 [per 1 kg/m²], 95% CI, 1.18-1.46; HR 1.04 [per 1 cm], 95% CI, 1.01-1.07, respectively) in the multivariate analysis.

CONCLUSION

A higher VAT area was dose-dependently associated with a higher risk of incident adenoma. Furthermore, increases in body mass index and waist circumference as surrogate markers of abdominal obesity were associated with a higher risk of recurrent adenoma.

Family history of colorectal cancer in first-degree relatives and metachronous colorectal adenoma

OBJECTIVES

Little is known about the relationship between having a first-degree relative (FDR) with colorectal cancer (CRC) and risk for metachronous colorectal adenoma (CRA) following polypectomy.

METHODS

We pooled data from seven prospective studies of 7697 patients with previously resected CRAs to quantify the relationship between having a FDR with CRC and risk for metachronous adenoma.

RESULTS

Compared with having no family history of CRC, a positive family history in any FDR was significantly associated with increased odds of developing any metachronous CRA (OR = 1.14; 95% CI = 1.01-1.29). Higher odds of CRA were observed among individuals with an affected mother (OR = 1.27; 95% CI = 1.05-1.53) or sibling (OR = 1.34; 95% CI = 1.11-1.62) as compared with those without, whereas no association was shown for individuals with an affected father. Odds of having a metachronous CRA increased with number of affected FDRs, with ORs (95% CIs) of 1.07 (0.93-1.23) for one relative and 1.39 (1.02-1.91) for two or more. Younger age of diagnosis of a sibling was associated with higher odds of metachronous CRA, with ORs (95% CIs) of 1.66 (1.08-2.56) for diagnosis at <54 years; 1.34 (0.89-2.03) for 55-64 years; and 1.10 (0.70-1.72) for >65 years (p-trend = 0.008). Although limited by sample size, results for advanced metachronous CRA were similar to those for any metachronous CRA.

CONCLUSIONS

A family history of CRC is related to a modestly increased odds of metachronous CRA. Future research should explore whether having a FDR with CRC, particularly at a young age, should have a role in risk stratification for surveillance colonoscopy.

Risk of metachronous neoplasia on surveillance colonoscopy in young patients with colorectal neoplasia

BACKGROUND AND AIMS

Few prior reports exist that address the appropriate colonoscopy surveillance interval for individuals <50 years old. We compared the risk of metachronous neoplasia between younger (20-49 years) and older (50-54 years) cohorts.

METHODS

This multicenter retrospective cohort study compared the incidence of metachronous neoplasia in younger and older cohorts according to baseline risk stratification. Subjects were eligible if they underwent their first colonoscopy between June 2006 and May 2010 and had at least 1 or more surveillance colonoscopy up to June 2015.

RESULTS

Among a total of 10,477 subjects who underwent baseline colonoscopy, 9722 were eligible after excluding 755 subjects. Of those 9722 subjects, 43% underwent surveillance colonoscopy. In the baseline high-risk adenoma group (n = 840), the 3-year risk of metachronous advanced neoplasia was 10.7% in the younger patients on screening colonoscopy and 8.9% in the older patients (P > .1). In the baseline low-risk adenoma group (n = 1869), the 5-year risk of metachronous advanced neoplasia was 4.9% in the younger patients on screening colonoscopy and 5.1% in the older patients (P > .1). Similarly, in the baseline no neoplasia group (n = 7013), the 5-year risk of metachronous advanced neoplasia was 4.1% in the younger patients on screening colonoscopy and 5.6% in the older patients (P > .1).

CONCLUSIONS

Considering the similar risk of metachronous advanced neoplasia in younger and older individuals, we suggest a 3-year surveillance interval for high-risk adenoma and a 5-year surveillance interval for low-risk adenoma in young individuals without a strong family history.

Effects of physical activity on colorectal cancer risk among family history and body mass index subgroups: a systematic review and meta-analysis

Background

Physical activity is consistently associated with a reduced risk of colorectal cancer in epidemiologic studies. This association among higher risk subgroups, such as those with a first-degree family history of colorectal cancer or high body mass index remains unclear.

Methods

We searched MEDLINE for studies examining physical activity and colorectal cancer risk among higher risk subgroups through July 11, 2017. Fifteen and three studies were eligible for inclusion for body mass index and first-degree family history of colorectal cancer subgroups, respectively. Estimates of the highest to lowest comparison of physical activity for each subgroup of risk were pooled using random-effects models.

Results

The pooled associations of physical activity and colorectal cancer risk for those without and with a first-degree family history of colorectal cancer were 0.56 (95% confidence interval (CI) = 0.39–0.80) and 0.72 (95% CI = 0.39–1.32), respectively (p_{heterogeneity} = 0.586). The pooled associations of physical activity and colorectal cancer risk for the low and high body mass index groups were 0.74 (95% CI = 0.66–0.83) and 0.65 (95% CI = 0.53–0.79), respectively (p_{heterogeneity} = 0.389).

Conclusions

Overall, a stronger relative risk of physical activity on colorectal cancer risk was observed in the higher body mass index group, although the difference was not statistically significant, suggesting an added benefit of physical activity as a cancer prevention strategy in population groups with strong risk factors for colorectal cancer. Additional research among these subgroups is warranted.

Electronic supplementary material

The online version of this article (10.1186/s12885-017-3970-5) contains supplementary material, which is available to authorized users.

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

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.

Factors Associated With Shorter Colonoscopy Surveillance Intervals for Patients With Low-Risk Colorectal Adenomas and Effects on Outcome

BACKGROUND & AIMS

Endoscopists do not routinely follow guidelines to survey individuals with low-risk adenomas (LRAs; 1-2 small tubular adenomas, < 1 cm) every 5-10 years for colorectal cancer; many recommend shorter surveillance intervals for these individuals. We aimed to identify the reasons that endoscopists recommend shorter surveillance intervals for some individuals with LRAs and determine whether timing affects outcomes at follow-up examinations.

METHODS

We collected data from 1560 individuals (45-75 years old) who participated in a prospective chemoprevention trial (of vitamin D and calcium) from 2004 through 2008. Participants in the trial had at least 1 adenoma, detected at their index colonoscopy, and were recommended to receive follow-up colonoscopy examinations at 3 or 5 years after adenoma identification, as recommended by the endoscopist. For this analysis we collected data from only participants with LRAs. These data included characteristics of participants and endoscopists and findings from index and follow-up colonoscopies. Primary endpoints were frequency of recommending shorter (3-year) vs longer (5-year) surveillance intervals, factors associated with these recommendations, and effect on outcome, determined at the follow-up colonoscopy.

RESULTS

A 3-year surveillance interval was recommended for 594 of the subjects (38.1%). Factors most significantly associated with recommendation of 3-year vs a 5-year surveillance interval included African American race (relative risk [RR] to white, 1.41; 95% confidence interval [CI], 1.14-1.75), Asian/Pacific Islander ethnicity (RR to white, 1.7; 95% CI, 1.22-2.43), detection of 2 adenomas at the index examination (RR vs 1 adenoma, 1.47; 95% CI, 1.27-1.71), more than 3 serrated polyps at the index examination (RR=2.16, 95% CI, 1.59-2.93), or index examination with fair or poor quality bowel preparation (RR vs excellent quality, 2.16; 95% CI, 1.66-2.83). Other factors that had a significant association with recommendation for a 3-year surveillance interval included family history of colorectal cancer and detection of 1-2 serrated polyps at the index examination. In comparisons of outcomes, we found no significant differences between the 3-year vs 5-year recommendation groups in proportions of subjects found to have 1 or more adenomas (38.8% vs 41.7% respectively; P = .27), advanced adenomas (7.7% vs 8.2%; P = .73) or clinically significant serrated polyps (10.0% vs 10.3%; P = .82) at the follow-up colonoscopy.

CONCLUSIONS

Possibly influenced by patients' family history, race, quality of bowel preparation, or number or size of polyps, endoscopists frequently recommend 3-year surveillance intervals instead of guideline-recommended intervals of 5 years or longer for individuals with LRAs. However, at the follow-up colonoscopy, similar proportions of participants have 1 or more adenomas, advanced adenomas, or serrated polyps. These findings support the current guideline recommendations of performing follow-up examinations of individuals with LRAs at least 5 years after the index colonoscopy.

Risk stratification of individuals with low-risk colorectal adenomas using clinical characteristics: a pooled analysis

OBJECTIVE

For individuals with 1-2 small (<1 cm) low-risk colorectal adenomas, international guidelines range from no surveillance to offering surveillance colonoscopy in 5-10 years. We hypothesised that the risks for metachronous advanced neoplasia (AN) among patients with low-risk adenomas differ based on clinical factors distinct from those currently used.

DESIGN

We pooled data from seven prospective studies to assess the risk of metachronous AN. Two groups with 1-2 small adenomas were defined based on guidelines from the UK (n=4516) or the European Union (EU)/US (n=2477).

RESULTS

Absolute risk of metachronous AN ranged from a low of 2.9% to a high of 12.2%, depending on specific risk factor and guideline used. For the UK group, the highest absolute risks for metachronous AN were found among individuals with a history of prior polyp (12.2%), villous histology (12.2%), age ≥70 years (10.9%), high-grade dysplasia (10.9%), any proximal adenoma (10.2%), distal and proximal adenoma (10.8%) or two adenomas (10.1%). For the EU/US group, the highest absolute risks for metachronous AN were among individuals with a history of prior polyp (11.5%) or the presence of both proximal and distal adenomas (11.0%). In multivariate analyses, strong associations for increasing age and history of prior polyps and odds of metachronous AN were observed, whereas more modest associations were shown for baseline proximal adenomas and those with villous features.

CONCLUSIONS

Risks of metachronous AN among individuals with 1-2 small adenomas vary according to readily available clinical characteristics. These characteristics may be considered for recommending colonoscopy surveillance and require further investigation.

Evaluation of the Effectiveness and Cost-Effectiveness of Personalized Surveillance After Colorectal Adenomatous Polypectomy

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.

Surveillance after colorectal polyp removal

Surveillance colonoscopy is aimed to reduce CRC incidence and mortality by removing adenomas and detecting CRC in early stage. However, colonoscopy is an invasive and expensive procedure and surveillance colonoscopy should be targeted at those who are most likely to benefit at the minimum frequency required to protect for cancer. Surveillance recommendations are based on guidelines, but the recommendations in those guidelines are based on moderate to low quality evidence and adherence to these guidelines is poor. As surveillance colonoscopy is one of the main indications for colonoscopy and surveillance colonoscopies are filling colonoscopy lists, the current surveillance practice results in spending lots of money and capacity in a suboptimal way. Randomized controlled trials to compare surveillance intervals are not available. However, current evidence based on several case-control and cohort studies suggests there is no need for surveillance in patients with low-risk adenomas, i.e. 1-2 adenomas smaller than 10 mm. Patients with 3 or more adenomas or any adenoma larger than 10 mm seem to be the ones at real risk for metachronous adenomas or cancer. In those patients, surveillance colonoscopy is indicated at 3 years after baseline until ongoing studies will confirm the safety of enlarging this interval. Randomized controlled trials and experimental research are important in order to provide the necessary scientific evidence for the optimization of follow-up strategies for patients with adenomas and serrated polyps.

Appropriateness of endoscopic surveillance recommendations in organised colorectal cancer screening programmes based on the faecal immunochemical test

OBJECTIVES

To assess the appropriateness of recommendations for endoscopic surveillance in organised colorectal cancer (CRC) screening programmes based on the faecal immunochemical test (FIT).

DESIGN

74 Italian CRC screening programmes provided aggregated data on the recommendations given after FIT-positive colonoscopies in 2011 and 2013. Index colonoscopies were divided into negative/no adenoma and low- risk, intermediate-risk and high-risk adenomas. Postcolonoscopy recommendations included a return to screening (FIT after 2 years or 5 years), an endoscopic surveillance after 6 months or after 1 year, 3 years or 5 years, surgery or other. We assessed the deviation from the postcolonoscopy recommendations of the European Guidelines in 2011 and 2013 and the correlation between overuse of endoscopic surveillance in 2011 and the process indicators associated with the endoscopic workload in 2013.

RESULTS

49 704 postcolonoscopy recommendations were analysed. High-risk, intermediate-risk and low-risk adenomas, and no adenomas were reported in 5.9%, 19.3%, 15.3% and 51.5% of the cases, respectively. Endoscopic surveillance was inappropriately recommended in 67.4% and 7%, respectively, of cases with low-risk and no adenoma. Overall, 37% of all endoscopic surveillance recommendations were inappropriate (6696/17 860). Overuse of endoscopic surveillance was positively correlated with the extension of invitations (correlation coefficient (cc) 0.29; p value 0.03) and with compliance with post-FIT+ colonoscopy (cc 0.25; p value 0.05), while it was negatively correlated with total colonoscopy waiting times longer than 60 days (cc -0.26; p value 0.05).

CONCLUSIONS

In organised screening programmes, a high rate of inappropriate recommendations for patients with low risk or no adenomas occurs, affecting the demand for endoscopic surveillance by a third.

Optimizing post-polypectomy surveillance: A practical guide for the endoscopist

Several gastrointestinal societies strongly recommend colonoscopy surveillance after endoscopic and surgical resection of colorectal neoplasms. Common denominators to these recommendations include: high-quality baseline colonoscopy before inclusion in a surveillance program; risk stratification based on clinicopathological profiles to guide surveillance intervals; and endoscopist responsibility for providing surveillance advice. Considerable variability also exists between guidelines (i.e. regarding risk classification and surveillance intervals). In this review, we examine key factors for quality of post-polypectomy surveillance practice, in particular bowel preparation, endoscopic findings at baseline examination and adherence to surveillance recommendations. Frequently asked questions by the practising endoscopist are addressed.

Surveillance of colonic polyps: Are we getting it right?

Colorectal cancer (CRC) is the third most commonly diagnosed cancer worldwide. The identification of colonic polyps can reduce CRC mortality through earlier diagnosis of cancers and the removal of polyps: the precursor lesion of CRC. Following the finding and removal of colonic polyps at an initial colonoscopy, some patients are at an increased risk of developing CRC in the future. This is the rationale for post-polypectomy surveillance colonoscopy. However, not all individuals found to have colonic adenomas have a risk of CRC higher than that of the general population. This review examines the literature on post-polypectomy surveillance including current international clinical guidelines. The potential benefits of surveillance procedures must be weighed against the burden of colonoscopy: resource use, the potential for patient discomfort, and the risk of complications. Therefore surveillance colonoscopy is best utilised in a selected group of individuals at a high risk of developing cancer. Further study is needed into the specific factors conferring higher risk as well as the efficacy of surveillance in mitigating this risk. Such evidence will better inform clinicians and patients of the relative benefits of colonoscopic surveillance for the individual. In addition, the decision to continue with surveillance must be informed by the changing profile of risks and benefits of further procedures with the patient’s advancing age.

Adenoma detection rate in high-risk patients differs from that in average-risk patients

BACKGROUND

Adenoma detection rates (ADRs) are established as quality targets in average-risk (AR) individuals undergoing colorectal cancer (CRC) screening colonoscopy. Little is known about the ADR in high-risk (HR) individuals undergoing index or surveillance colonoscopy.

OBJECTIVE

To determine and compare ADR in HR versus AR individuals undergoing colonoscopy.

DESIGN AND SETTING

Retrospective study, tertiary care center.

PATIENTS AND INTERVENTION

We reviewed records of 7357 patients who underwent colonoscopy by 66 multispecialty endoscopists at our institution during the period 2008 to 2009. Both screening and surveillance colonoscopies in AR and HR patients for CRC were studied. HR patients were further divided into 3 subgroups: those with a (1) personal history of polyps (PHP), (2) family history of polyps (FHP), and (3) family history of CRC (FHCRC). Multivariable logistic regression analysis was performed to evaluate differences in ADR between the groups after adjusting for possible confounders.

MAIN OUTCOME MEASUREMENTS

ADR in HR patients.

RESULTS

The study included 4141 patients, of whom 2170 were AR and 1971 were HR. Patients in the HR group were older (64.5 ± 9.1 years vs 59.1 ± 7.9 years, P < .001). HR patients were more likely to have adenomas (30.7% vs 25.6%, P < .001). Adenomas were detected more often in the proximal colon than in the distal colon (29.3% vs 21.0%, P < .001 and 22.8% vs 15.8%, P < .001, respectively). Patients with a PHP had the highest ADR (33.1%, P < .001). However, after adjusting for confounders, HR status was not found to be associated with ADR (odds ratio [OR] 1.2; 95% confidence interval [CI], 0.93-1.6; P = .15 for females and 0.93; 95% CI, 0.70-1.2; P = .61 for males). HR females were found to have a 40% greater likelihood of having proximal adenomas than AR females (1.4; 95% CI, 1.01-2; P = .04).

LIMITATIONS

Retrospective design, single tertiary center.

CONCLUSIONS

Patients with a PHP have a significantly higher ADR compared with AR patients. Defining a minimum target ADR for individuals with a PHP undergoing surveillance colonoscopy is important.

Sessile serrated adenomas versus conventional adenomas. Different polyps in different populations?

PURPOSE

The aim of this study was to determine risk factors for the development of sessile serrated adenomas (SSA/Ps) as well as to study differences between groups with SSA/Ps and conventional adenomas (tubular, tubulovillus and villus) in the general population.

METHODS

One hundred patients with normal colonoscopies, 27 patients with 53 SSA/Ps and 69 patients with 156 conventional adenomas were studied, epidemiological data were collected and calculations of body mass index and waist-to-hip ratio were performed prior to endoscopy. A univariate and a multivariate logistic regression analysis were performed using Stata 9.0.

RESULTS

SSA/Ps had a positive association with increasing age (p = 0.01), heavy smoking (≥20 packet years) (p = 0.001) and past history of polyps (p = 0.004) in comparison to normal population. SSA/Ps showed an inverse association with conventional adenomas for diabetes mellitus (p < 0.001) and arterial hypertension (p = 0.001). Meanwhile, female sex was positively associated with SSA/P development in comparison to conventional adenomas (p = 0.031).

CONCLUSIONS

Heavy smoking as a significant risk factor for developing SSA/Ps was confirmed from this study. It also seemed that patients with diabetes mellitus and/or hypertension developed conventional adenomas more frequently than SSA/Ps; on the contrary, females were at higher risk of developing SSA/Ps than conventional adenomas.