1
|
Polychronidis G, He MM, Vithayathil M, Knudsen MD, Wang K, Song M. Risk of colorectal neoplasia after removal of conventional adenomas and serrated polyps: a comprehensive evaluation of risk factors and surveillance use. Gut 2024; 73:1675-1683. [PMID: 38839270 DOI: 10.1136/gutjnl-2023-331729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 05/20/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Surveillance colonoscopy after polyp removal is recommended to prevent subsequent colorectal cancer (CRC). It is known that advanced adenomas have a substantially higher risk than non-advanced ones, but optimal intervals for surveillance remain unclear. DESIGN We prospectively followed 156 699 participants who had undergone a colonoscopy from 2007 to 2017 in a large integrated healthcare system. Using multivariable Cox proportional hazards regression we estimated the subsequent risk of CRC and high-risk polyps, respectively, according to index colonoscopy polyps, colonoscopy quality measures, patient characteristics and the use of surveillance colonoscopy. RESULTS After a median follow-up of 5.3 years, we documented 309 CRC and 3053 high-risk polyp cases. Compared with participants with no polyps at index colonoscopy, those with high-risk adenomas and high-risk serrated polyps had a consistently higher risk of CRC during follow-up, with the highest risk observed at 3 years after polypectomy (multivariable HR 5.44 (95% CI 3.56 to 8.29) and 8.35 (95% CI 4.20 to 16.59), respectively). Recurrence of high-risk polyps showed a similar risk distribution. The use of surveillance colonoscopy was associated with lower risk of CRC, with an HR of 0.61 (95% CI 0.39 to 0.98) among patients with high-risk polyps and 0.57 (95% CI 0.35 to 0.92) among low-risk polyps. Among 1548 patients who had high-risk polyps at both index and surveillance colonoscopies, 65% had their index polyps in the proximal colon and 30% had index and interval polyps in the same segments. CONCLUSION Patients with high-risk polyp findings were at higher risk of subsequent CRC and high-risk polyps and may benefit from early surveillance within 3 years. The subsite distribution of the index and recurrent high-risk polyps suggests the contribution of incomplete resection and missed lesions to the development of interval neoplasia.
Collapse
Affiliation(s)
- Georgios Polychronidis
- Department of Epidemiology, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- Department of General,Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Study Centre of the German Surgical Society, German Surgical Society/Heidelberg University Hospital, Heidelberg, Germany
| | - Ming-Ming He
- Department of Epidemiology, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- State Key Laboratory of Oncology in South China, Department of Medical Oncology, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Mathew Vithayathil
- Department of Epidemiology, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- Imperial College Healthcare NHS Trust, London, UK
| | - Markus D Knudsen
- Department of Epidemiology, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
- Department of Transplantation Medicine, Division of Surgery,Inflammatory Diseases and Transplantation, Oslo University Hospital, Oslo, Norway
| | - Kai Wang
- Department of Epidemiology, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Mingyang Song
- Department of Epidemiology, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Jørgensen SF, Larsen PT, Erichsen R, Andersen B, Rebolj M, Njor S. Adherence to follow-up and resource use after abnormal FIT-screening: Evaluation of the Danish colorectal cancer screening program. Endosc Int Open 2024; 12:E649-E658. [PMID: 38707595 PMCID: PMC11068436 DOI: 10.1055/a-2297-9622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 03/21/2024] [Indexed: 05/07/2024] Open
Abstract
Background and study aims The effectiveness of colorectal cancer screening programs depends on adherence to surveillance protocols for screening-positive individuals. We evaluated adherence in the Danish population-based screening program and estimated the volume of diagnostic resources required to achieve this adherence. Patients and methods In this register- and population-based study, we included individuals with a positive fecal immunochemical test (FIT) screening from 2014 to 2017 and followed them until mid-2022. All endoscopic, imaging, and surgical procedures performed at public and private hospitals were identified. Adherence to national protocols was reported in terms of proportions and timeliness. Use of diagnostic and surveillance procedures was estimated during a 4-year post-screening period. Results Among 82,221 individuals with a positive FIT test, 84% had a baseline colonoscopy within 1 month. After removal of intermediate or high-risk adenomas, 12% and 6%, respectively, did not have any follow-up. Only ~50% had timely surveillance. Approximately 10% to 20%, depending on their referral diagnosis, did not have a second surveillance colonoscopy. In addition, 12% with a negative colonoscopy had a second colonoscopy within 4 years. Conclusions High adherence to baseline colonoscopy after positive FIT-screening is followed by lower adherence throughout the adenoma surveillance program. Better adherence to the guidelines could potentially improve the effectiveness and efficiency of the screening program.
Collapse
Affiliation(s)
- Susanne Fogh Jørgensen
- University Research Clinic for Cancer screening, Randers Regional Hospital, Randers, Denmark
- Department of Data, Innovation and Research, Lillebaelt Hospital, Vejle, Denmark
| | - Pernille Thordal Larsen
- University Research Clinic for Cancer screening, Randers Regional Hospital, Randers, Denmark
- Department of Clinical Medicine, Aarhus University Faculty of Health Sciences, Aarhus, Denmark
| | - Rune Erichsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Randers, Denmark
- Department of Surgery, Randers Regional Hospital, Randers, Denmark
| | - Berit Andersen
- University Research Clinic for Cancer screening, Randers Regional Hospital, Randers, Denmark
- Department of Clinical Medicine, Aarhus University Faculty of Health Sciences, Aarhus, Denmark
| | - Matejka Rebolj
- Centre for Cancer Screening, Prevention, and Early Detection, Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom of Great Britain and Northern Ireland
| | - Sisse Njor
- University Research Clinic for Cancer screening, Randers Regional Hospital, Randers, Denmark
- Department of Data, Innovation and Research, Lillebaelt Hospital, Vejle, Denmark
- Department of Clinical Medicine, Aarhus University Faculty of Health Sciences, Aarhus, Denmark
| |
Collapse
|
3
|
Knudsen MD, Wang K, Wang L, Polychronidis G, Berstad P, Wu K, He X, Hang D, Fang Z, Ogino S, Chan AT, Giovannucci E, Wang M, Song M. Development and validation of a risk prediction model for post-polypectomy colorectal cancer in the USA: a prospective cohort study. EClinicalMedicine 2023; 62:102139. [PMID: 37599907 PMCID: PMC10432960 DOI: 10.1016/j.eclinm.2023.102139] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/12/2023] [Accepted: 07/20/2023] [Indexed: 08/22/2023] Open
Abstract
Background Effective risk stratification tools for post-polypectomy colorectal cancer (PPCRC) are lacking. We aimed to develop an effective risk stratification tool for the prediction of PPCRC in three large population-based cohorts and to validate the tool in a clinical cohort. Methods Leveraging the integrated endoscopic, histopathologic and epidemiologic data in three U.S population-based cohorts of health professional (the Nurses' Health Study (NHS) I, II and Health Professionals Follow-up Study (HPFS)), we developed a risk score to predict incident PPCRC among 26,741 patients with a polypectomy between 1986 and 2017. We validated the PPCRC score in the Mass General Brigham (MGB) Colonoscopy Cohort (Boston, Massachusetts, U.S) of 76,603 patients with a polypectomy between 2007 and 2018. In all four cohorts, we collected detailed data on patients' demographics, endoscopic history, polyp features, and lifestyle factors at polypectomy. The outcome, incidence of PPCRC, was assessed by biennial follow-up questionnaires in the NHS/HPFS cohorts, and through linkage to the Massachusetts Cancer Registry in the MGB cohort. In all four cohorts, individuals who were diagnosed with CRC or died before baseline or within six months after baseline were excluded. We used Cox regression to calculate the hazard ratio (HR), 95% confidence interval (CI) and assessed the discrimination using C-statistics and reclassification using the Net Reclassification Improvement (NRI). Findings During a median follow-up of 12.8 years (interquartile range (IQR): 9.3, 16.7) and 5.1 years (IQR: 2.7, 7.8) in the NHS/HPFS and MGB cohorts, we documented 220 and 241 PPCRC cases, respectively. We identified a PPCRC risk score based on 11 predictors. In the validation cohort, the PPCRC risk score showed a strong association with PPCRC risk (HR for high vs. low, 3.55, 95% CI, 2.59-4.88) and demonstrated a C-statistic (95% CI) of 0.75 (0.70-0.79), and was discriminatory even within the low- and high-risk polyp groups (C-statistic, 0.73 and 0.71, respectively) defined by the current colonoscopy surveillance recommendations, leading to a NRI of 45% (95% CI, 36-54%) for patients with PPCRC. Interpretation We developed and validated a risk stratification model for PPCRC that may be useful to guide tailored colonoscopy surveillance. Further work is needed to determine the optimal surveillance interval and test the added value of other predictors of PPCRC beyond those included in the current study, along with implementation studies. Funding US National Institutes of Health, the American Cancer Society, the South-Eastern Norway Regional Health Authority, the Deutsche Forschungsgemeinschaft.
Collapse
Affiliation(s)
- Markus Dines Knudsen
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
- Section of Bowel Cancer Screening, Cancer Registry of Norway, Ullernchausseen 64, Oslo, Norway
- Division of Surgery, Inflammatory Diseases and Transplantation, Department of Transplantation Medicine, Oslo University Hospital, Sognsvannsveien 20, Oslo, Norway
| | - Kai Wang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
| | - Liang Wang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
- Centre of Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshaner Rd, Yuexiu District, Guangzhou, Guangdong Province, China
| | - Georgios Polychronidis
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
- Department of General Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, Heidelberg, Germany
| | - Paula Berstad
- Section of Bowel Cancer Screening, Cancer Registry of Norway, Ullernchausseen 64, Oslo, Norway
| | - Kana Wu
- Department of Nutrition, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
| | - Xiaosheng He
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA, USA
- Department of Colorectal Surgery, The Six Affiliated Hospital, Sun Yat-sen University, 135, Xingang Xi Road, Guangzhou, China
| | - Dong Hang
- Department of Nutrition, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
- Department of Epidemiology and Biostatistics, Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, 101 Longmian Avenue, Nanjing, China
| | - Zhe Fang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
| | - Shuji Ogino
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
- Department of Pathology, Program in Molecular Pathological Epidemiology, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA, USA
- Broad Institute of MIT and Harvard, Merkin Building, 415 Main St, Cambridge, MA, USA
| | - Andrew T. Chan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 181 Longwood Avenue, Boston, MA, USA
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
| | - Edward Giovannucci
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
| | - Molin Wang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 181 Longwood Avenue, Boston, MA, USA
| | - Mingyang Song
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA, USA
| |
Collapse
|
4
|
Shen MH, Huang CC, Chen YT, Tsai YJ, Liou FM, Chang SC, Phan NN. Deep Learning Empowers Endoscopic Detection and Polyps Classification: A Multiple-Hospital Study. Diagnostics (Basel) 2023; 13:diagnostics13081473. [PMID: 37189575 DOI: 10.3390/diagnostics13081473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 04/03/2023] [Accepted: 04/12/2023] [Indexed: 05/17/2023] Open
Abstract
The present study aimed to develop an AI-based system for the detection and classification of polyps using colonoscopy images. A total of about 256,220 colonoscopy images from 5000 colorectal cancer patients were collected and processed. We used the CNN model for polyp detection and the EfficientNet-b0 model for polyp classification. Data were partitioned into training, validation and testing sets, with a 70%, 15% and 15% ratio, respectively. After the model was trained/validated/tested, to evaluate its performance rigorously, we conducted a further external validation using both prospective (n = 150) and retrospective (n = 385) approaches for data collection from 3 hospitals. The deep learning model performance with the testing set reached a state-of-the-art sensitivity and specificity of 0.9709 (95% CI: 0.9646-0.9757) and 0.9701 (95% CI: 0.9663-0.9749), respectively, for polyp detection. The polyp classification model attained an AUC of 0.9989 (95% CI: 0.9954-1.00). The external validation from 3 hospital results achieved 0.9516 (95% CI: 0.9295-0.9670) with the lesion-based sensitivity and a frame-based specificity of 0.9720 (95% CI: 0.9713-0.9726) for polyp detection. The model achieved an AUC of 0.9521 (95% CI: 0.9308-0.9734) for polyp classification. The high-performance, deep-learning-based system could be used in clinical practice to facilitate rapid, efficient and reliable decisions by physicians and endoscopists.
Collapse
Affiliation(s)
- Ming-Hung Shen
- Department of Surgery, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City 24205, Taiwan
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City 24205, Taiwan
| | - Chi-Cheng Huang
- Department of Surgery, Taipei Veterans General Hospital, Taipei City 11217, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei City 10663, Taiwan
| | - Yu-Tsung Chen
- Department of Internal Medicine, Fu Jen Catholic University Hospital, New Taipei City 24205, Taiwan
| | - Yi-Jian Tsai
- Division of Colorectal Surgery, Department of Surgery, Fu Jen Catholic University Hospital, New Taipei City 24205, Taiwan
- Graduate Institute of Biomedical Electronics and Bioinformatics, Department of Electrical Engineering, National Taiwan University, Taipei City 10663, Taiwan
| | | | - Shih-Chang Chang
- Division of Colorectal Surgery, Department of Surgery, Cathay General Hospital, Taipei City 106443, Taiwan
| | - Nam Nhut Phan
- Bioinformatics and Biostatistics Core, Centre of Genomic and Precision Medicine, National Taiwan University, Taipei City 10055, Taiwan
| |
Collapse
|
5
|
Kapinos KA, Halm EA, Murphy CC, Santini NO, Loewen AC, Skinner CS, Singal AG. Cost Effectiveness of Mailed Outreach Programs for Colorectal Cancer Screening: Analysis of a Pragmatic, Randomized Trial. Clin Gastroenterol Hepatol 2022; 20:2383-2392.e4. [PMID: 35144024 PMCID: PMC9357235 DOI: 10.1016/j.cgh.2022.01.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Clinical guidelines for colorectal cancer (CRC) screening suggest use of either stool-based tests or colonoscopy - modalities that differ in recommended screening intervals, adherence, and costs. We know little about the long-term cost differences in population-health outreach strategies to promote these strategies. METHODS We conducted a cost-effectiveness analysis to compare 2 mailed outreach strategies to increase CRC screening from a pragmatic, randomized clinical trial: mailed fecal immunochemical test (FIT) kits vs invitations to complete a screening colonoscopy. We built a 10-year Markov chain Monte Carlo microsimulation model to account for differences in screening intervals, adherence, and costs. RESULTS Mailed FIT kits had a lower 10-year average per-person cost of screening relative to colonoscopy invitations ($1139 vs $1725) but with 10.89 fewer months of compliance and 60 fewer advanced neoplasia detected (37 advanced adenomas and 23 CRC). Incremental cost effectiveness ratios for colonoscopy invitations compared with mailed FIT kits were $55.23, $15.84, and $25.48 per additional covered month, advanced adenoma, and CRC, respectively. Although FIT was the preferred strategy at low willingness-to-pay thresholds, the 2 strategies were equal at a willingness-to-pay threshold of $41.31 per covered month gained. CONCLUSION Mailed FIT or colonoscopy invitations are both options to improve CRC screening completion and advanced neoplasia detection, and the choice of outreach strategy may differ by a health system's willingness-to-pay threshold. Mailed FIT kits are less expensive than colonoscopy invitations but result in fewer months of screening compliance and advanced neoplasia detected.
Collapse
Affiliation(s)
- Kandice A Kapinos
- The Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Comprehensive Cancer Center, Dallas, Texas; RAND Corporation, Arlington, Virginia.
| | - Ethan A Halm
- Department of Medicine, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Caitlin C Murphy
- The Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas; School of Public Health, University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
| | | | - Adam C Loewen
- The Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Celette Sugg Skinner
- The Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Comprehensive Cancer Center, Dallas, Texas
| | - Amit G Singal
- The Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Comprehensive Cancer Center, Dallas, Texas
| |
Collapse
|
6
|
Petros V, Tsambikos E, Madhoun M, Tierney WM. Impact of Community Referral on Colonoscopy Quality Metrics in a Veterans Affairs Medical Center. Clin Transl Gastroenterol 2022; 13:e00460. [PMID: 35081542 PMCID: PMC8963833 DOI: 10.14309/ctg.0000000000000460] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 12/06/2021] [Indexed: 12/09/2022] Open
Abstract
INTRODUCTION The Veterans Access, Choice, and Accountability Act of 2014 expands the number of options veterans have to ensure timely access to high-quality care. There are minimal data currently available analyzing the impact and quality of colonoscopy metrics in veterans receiving procedures within the Department of Veterans' Affairs (VA) vs community settings. METHODS All patients at our academic VA medical center who were referred to a community care colonoscopy (CCC) for positive fecal immunochemical testing, colorectal cancer screening, and adenoma surveillance from 2015 to 2018 were identified and matched for sex, age, and year of procedure to patients referred for a VA-based colonoscopy (VAC). Metrics measured included time to procedure measured in days, adenoma detection rate (ADR), advanced ADR (AADR), adenomas per colonoscopy, sessile serrated polyp detection rate, cecal intubation rate, bowel preparation quality, and compliance with guideline recommendations for surveillance. Patient comorbidities were also recorded. Variable associations with adenoma detection and compliance with surveillance guidelines were analyzed with univariate and multivariate logistic regression. RESULTS In total, 235 veterans (mean age, 64.6 years, and 95.7% male) underwent a CCC and had an appropriately matched VAC. ADR in the community was 36.9% compared with 62.6% for the VAC group (P < 0.0001). The mean number of adenomas per procedure in the community was 0.77 compared with 1.83 per VAC (P < 0.0001). CCC AADR was 8.9% compared with 18.3% for VAC (P = 0.003). The cecal intubation rate for community colonoscopies was 90.6% compared with 95.3% for VA colonoscopies (P = 0.047). Community care compliance with surveillance guidelines was 74.9% compared with 93.3% for VA (P < 0.0001). This nonconformity was primarily due to recommending a shorter interval follow-up in the CCC group (15.3%) compared with the VAC group (5.5%) (P = 0.0012). The mean time to procedure was 58.4 days (±33.7) for CCC compared with 83.8 days (±38.6) for VAC (P < 0.0001). In multivariate regression, CCC was associated with lower ADR (odds ratio 0.39; 95% confidence interval, 0.20-0.63) and lower compliance with surveillance guidelines (odds ratio 0.21; 95% confidence interval, 0.09-0.45) (P < 0.0001 for both). DISCUSSION Time to colonoscopy was significantly shorter for CCC compared with VAC. However, compared with VA colonoscopies, there was significantly lower ADR, AADR, and surveillance guideline compliance for services rendered by community providers. This impact on quality of care should be further studied to ensure that colonoscopy quality standards for veterans are not compromised by the process of care and site of care.
Collapse
Affiliation(s)
- Vincent Petros
- Digestive Diseases and Nutrition Section, Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma, USA
- Oklahoma City VA Medical Center, Oklahoma City, Oklahoma, USA
| | - Erin Tsambikos
- Internal Medicine Section, Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Mohammad Madhoun
- Digestive Diseases and Nutrition Section, Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma, USA
- Oklahoma City VA Medical Center, Oklahoma City, Oklahoma, USA
| | - William M. Tierney
- Digestive Diseases and Nutrition Section, Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma, USA
- Oklahoma City VA Medical Center, Oklahoma City, Oklahoma, USA
| |
Collapse
|
7
|
Rutter CM, Inadomi JM, Maerzluft CE. The impact of cumulative colorectal cancer screening delays: A simulation study. J Med Screen 2021; 29:92-98. [PMID: 34894841 DOI: 10.1177/09691413211045103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Annual fecal immunochemical tests can reduce colorectal cancer incidence and mortality. However, screening is a multi-step process and most patients do not perfectly adhere to guideline-recommended screening schedules. Our objective was to compare the reduction in colorectal cancer incidence and life-years gained based on US guideline-concordant fecal immunochemical test screening to scenarios with a range of delays. METHOD The Colorectal Cancer Simulated Population model for Incidence and Natural history (CRC-SPIN) microsimulation model was used to estimate the effect of systematic departures from fecal immunochemical test screening guidelines on lifetime screening benefit. RESULTS The combined effect of consistent modest delays in screening initiation (1 year), repeated fecal immunochemical test screening (3 months), and receipt of follow-up or surveillance colonoscopy (3 months) resulted in up to 1.3 additional colorectal cancer cases per 10,000, 0.4 additional late-stage colorectal cancer cases per 10,000 and 154.7 fewer life-years gained per 10,000. A 5-year delay in screening initiation had a larger impact on screening effectiveness than consistent small delays in repeated fecal immunochemical test screening or receipt of follow-up colonoscopy after an abnormal fecal immunochemical test. The combined effect of consistent large delays in screening initiation (5 years), repeated fecal immunochemical test screening (6 months), and receipt of follow-up or surveillance colonoscopy (6 months) resulted in up to 3.7 additional colorectal cancer cases per 10,000, 1.5 additional late-stage colorectal cancer cases per 10,000 and 612.3 fewer life-years gained per 10,000. CONCLUSIONS Systematic delays across the screening process can result in meaningful reductions in colorectal cancer screening effectiveness, especially for longer delays. Screening delays could drive differences in colorectal cancer incidence across patient groups with differential access to screening.
Collapse
Affiliation(s)
- Carolyn M Rutter
- Economics, Sociology & Statistics, RAND Corporation, Santa Monica, CA, USA
| | - John M Inadomi
- Division of Gastroenterology, Department of Internal Medicine, 12348University of Utah School of Medicine, Salt Lake City, UT, USA
| | | |
Collapse
|
8
|
Peterson E, May FP, Kachikian O, Soroudi C, Naini B, Kang Y, Myint A, Guyant G, Elmore J, Bastani R, Maehara C, Hsu W. Automated identification and assignment of colonoscopy surveillance recommendations for individuals with colorectal polyps. Gastrointest Endosc 2021; 94:978-987. [PMID: 34087201 DOI: 10.1016/j.gie.2021.05.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/24/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Determining surveillance intervals for patients with colorectal polyps is critical but time-consuming and challenging to do reliably. We present the development and assessment of a pipeline that leverages natural language processing techniques to automatically extract and analyze relevant polyp findings from free-text colonoscopy and pathology reports. Using this information, we categorized individual patients into 6 postcolonoscopy surveillance intervals defined by the U.S. Multi-Society Task Force on Colorectal Cancer. METHODS Using a set of 546 randomly selected colonoscopy and pathology reports from 324 patients in a single health system, we used a combination of statistical classifiers and rule-based methods to extract polyp properties from each report type, associate properties with unique polyps, and classify a patient into 1 of 6 risk categories by integrating information from both report types. We then assessed the pipeline's performance by determining the positive predictive value (PPV), sensitivity, and F-score of the algorithm, compared with the determination of surveillance intervals by a gastroenterologist. RESULTS The pipeline was developed using 346 reports (224 colonoscopy and 122 pathology) from 224 patients and evaluated on an independent test set of 200 reports (100 colonoscopy and 100 pathology) from 100 patients. We achieved an average PPV, sensitivity, and F-score of .92, .95, and .93, respectively, across targeted entities for colonoscopy. Pathology extraction achieved a PPV, sensitivity, and F-score of .95, .97, and .96. The system achieved an overall accuracy of 92% in assigning the recommended interval for surveillance colonoscopy. CONCLUSIONS This study demonstrates the feasibility of using machine learning to automatically extract findings and classify patients to appropriate risk categories and corresponding surveillance intervals. Incorporating this system can facilitate proactive and timely follow-up after screening colonoscopy and enable real-time quality assessment of prevention programs and providers.
Collapse
Affiliation(s)
- Emma Peterson
- Department of Radiological Sciences, Data Integration, Architecture, and Analytics Group, University of California Los Angeles, Los Angeles, California, USA
| | - Folasade P May
- Department of Medicine, Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; UCLA Center for Cancer Prevention and Control Research, UCLA Kaiser Permanente Center for Health Equity and Department of Health Policy and Management, Fielding School of Public Health and Jonsson Comprehensive Cancer Center, Los Angeles, California, USA; Division of Gastroenterology, Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Odet Kachikian
- Department of Radiological Sciences, Data Integration, Architecture, and Analytics Group, University of California Los Angeles, Los Angeles, California, USA
| | - Camille Soroudi
- Department of Medicine, Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Bita Naini
- Department of Pathology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Yuna Kang
- Department of Pathology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Anthony Myint
- Department of Medicine, Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Gordon Guyant
- Department of Radiological Sciences, Data Integration, Architecture, and Analytics Group, University of California Los Angeles, Los Angeles, California, USA
| | - Joann Elmore
- Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Roshan Bastani
- UCLA Center for Cancer Prevention and Control Research, UCLA Kaiser Permanente Center for Health Equity and Department of Health Policy and Management, Fielding School of Public Health and Jonsson Comprehensive Cancer Center, Los Angeles, California, USA
| | - Cleo Maehara
- Department of Radiological Sciences, Data Integration, Architecture, and Analytics Group, University of California Los Angeles, Los Angeles, California, USA
| | - William Hsu
- Department of Radiological Sciences, Data Integration, Architecture, and Analytics Group, University of California Los Angeles, Los Angeles, California, USA
| |
Collapse
|
9
|
Del Vecchio Blanco G, Dwairi R, Giannelli M, Palmieri G, Formica V, Portarena I, Grasso E, Di Iorio L, Benassi M, Giudice EA, Nardecchia A, Rossi P, Roselli M, Sica G, Monteleone G, Paoluzi OA. Clinical care pathway program versus open-access system: a study on appropriateness, quality, and efficiency in the delivery of colonoscopy in the colorectal cancer. Intern Emerg Med 2021; 16:1197-1206. [PMID: 33555540 PMCID: PMC8310505 DOI: 10.1007/s11739-020-02565-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 11/06/2020] [Indexed: 12/15/2022]
Abstract
Open-access colonoscopy (OAC), whereby the colonoscopy is performed without a prior office visit with a gastroenterologist, is affected by inappropriateness which leads to overprescription and reduced availability of the procedure in case of alarming symptoms. The clinical care pathway (CCP) is a healthcare management tool promoted by national health systems to organize work-up of various morbidities. Recently, we started a CCP dedicated to colorectal cancer (CRC), including a colonoscopy session for CRC diagnosis and prevention. We aimed to evaluate the appropriateness, the quality, and the efficiency in the delivery of colonoscopy with the open-access system and a CCP program in the CRC. Quality indicators for colonoscopy in subjects in the CCP were compared to referrals by general practitioners (OAC) or by non-gastroenterologist physicians (non-gastroenterologist physician colonoscopy, NGPC). Attendance rate to colonoscopy was greater in the CCP group and NGPC group than in the OAC group (99%, 99%, and 86%, respectively). Waiting time in the CCP group was shorter than in the OAC group (3.88 ± 2.27 vs. 32 ± 22.31 weeks, respectively). Appropriateness of colonoscopy prescription was better in the CCP group than in the OAC group (92 vs. 50%, respectively). OAC is affected by the lack of timeliness and low appropriateness of prescription. A CCP reduces the number of inappropriate colonoscopies, especially for post-polypectomy surveillance, and improves the delivery of colonoscopy in patients requiring a fast-track examination. The high rate of inappropriate OAC suggests that this modality of healthcare should be widely reviewed.
Collapse
Affiliation(s)
| | - Rami Dwairi
- Department of Internal Medicine, University of Mutah, Karak, Jordan
| | - Mario Giannelli
- Department of Systems Medicine, Gastroenterology Unit, University of Rome "Tor Vergata", Rome, Italy
| | - Giampiero Palmieri
- Department of Biomedicine and Prevention, Anatomic Pathology Unit, University "Tor Vergata", Rome, Italy
| | - Vincenzo Formica
- Department of Oncohematology, Oncology Unit, University Tor Vergata, Rome, Italy
| | - Ilaria Portarena
- Department of Oncohematology, Oncology Unit, University Tor Vergata, Rome, Italy
| | - Enrico Grasso
- Department of Systems Medicine, Gastroenterology Unit, University of Rome "Tor Vergata", Rome, Italy
| | - Laura Di Iorio
- Department of Systems Medicine, Gastroenterology Unit, University of Rome "Tor Vergata", Rome, Italy
| | - Michela Benassi
- Department of Diagnostic Imaging, Interventional Radiology and Radiotherapy, University "Tor Vergata", Rome, Italy
| | - Emilia Anna Giudice
- Department of Diagnostic Imaging, Interventional Radiology and Radiotherapy, University "Tor Vergata", Rome, Italy
| | - Antonella Nardecchia
- Department of Diagnostic Imaging, Interventional Radiology and Radiotherapy, University "Tor Vergata", Rome, Italy
| | - Piero Rossi
- Department of Surgery, University Tor Vergata, Rome, Italy
| | - Mario Roselli
- Department of Oncohematology, Oncology Unit, University Tor Vergata, Rome, Italy
| | - Giuseppe Sica
- Department of Surgery, University Tor Vergata, Rome, Italy
| | - Giovanni Monteleone
- Department of Systems Medicine, Gastroenterology Unit, University of Rome "Tor Vergata", Rome, Italy
| | - Omero Alessandro Paoluzi
- Department of Systems Medicine, Gastroenterology Unit, University of Rome "Tor Vergata", Rome, Italy
| |
Collapse
|
10
|
Gastroenterology visitation and reminders predict surveillance uptake for patients with adenomas with high-risk features. Sci Rep 2021; 11:8764. [PMID: 33888839 PMCID: PMC8062682 DOI: 10.1038/s41598-021-88376-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 04/05/2021] [Indexed: 01/19/2023] Open
Abstract
Individuals diagnosed with colorectal adenomas with high-risk features during screening colonoscopy have increased risk for the development of subsequent adenomas and colorectal cancer. While US guidelines recommend surveillance colonoscopy at 3 years in this high-risk population, surveillance uptake is suboptimal. To inform future interventions to improve surveillance uptake, we sought to assess surveillance rates and identify facilitators of uptake in a large integrated health system. We utilized a cohort of patients with a diagnosis of ≥ 1 tubular adenoma (TA) with high-risk features (TA ≥ 1 cm, TA with villous features, TA with high-grade dysplasia, or ≥ 3 TA of any size) on colonoscopy between 2013 and 2016. Surveillance colonoscopy completion within 3.5 years of diagnosis of an adenoma with high-risk features was our primary outcome. We evaluated surveillance uptake over time and utilized logistic regression to detect factors associated with completion of surveillance colonoscopy. The final cohort was comprised of 405 patients. 172 (42.5%) patients successfully completed surveillance colonoscopy by 3.5 years. Use of a patient reminder (telephone, electronic message, or letter) for due surveillance (adjusted odds = 1.9; 95%CI = 1.2-2.8) and having ≥ 1 gastroenterology (GI) visit after diagnosis of an adenoma with high-risk features (adjusted odds = 2.6; 95%CI = 1.6-4.2) significantly predicted surveillance colonoscopy completion at 3.5 years. For patients diagnosed with adenomas with high-risk features, surveillance colonoscopy uptake is suboptimal and frequently occurs after the 3-year surveillance recommendation. Patient reminders and visitation with GI after index colonoscopy are associated with timely surveillance completion. Our findings highlight potential health system interventions to increase timely surveillance uptake for patients diagnosed with adenomas with high-risk features.
Collapse
|
11
|
Doubeni CA, Selby K, Levin TR. Disparities in Preventable Mortality from Colorectal Cancer: Are They the Result of Structural Racism? Gastroenterology 2021; 160:1022-1025. [PMID: 33417932 DOI: 10.1053/j.gastro.2020.12.071] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/29/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Chyke A Doubeni
- Center for Health Equity and Community Engagement Research and, Department of Family Medicine and, Department of General Internal Medicine, Mayo Clinic, Rochester, Minnesota; Department of Family Medicine, Mayo Clinic, Phoenix, Arizona.
| | - Kevin Selby
- Center for Primary Care and Public Health (Unisanté), Lausanne, Switzerland
| | - Theodore R Levin
- Kaiser Permanente Medical Center, Walnut Creek, California; Division of Research, Kaiser Permanente Northern California, Oakland, California
| |
Collapse
|
12
|
Lieberman D. Does Colon Surveillance After Polypectomy Prevent Colon Cancer and Save Lives? Clin Gastroenterol Hepatol 2020; 18:2876-2878. [PMID: 32289542 DOI: 10.1016/j.cgh.2020.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/03/2020] [Indexed: 02/07/2023]
Affiliation(s)
- David Lieberman
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon
| |
Collapse
|
13
|
Rutter CM, Knudsen AB, Lin JS, Bouskill KE. Black and White Differences in Colorectal Cancer Screening and Screening Outcomes: A Narrative Review. Cancer Epidemiol Biomarkers Prev 2020; 30:3-12. [PMID: 33144285 DOI: 10.1158/1055-9965.epi-19-1537] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 05/06/2020] [Accepted: 10/21/2020] [Indexed: 11/16/2022] Open
Abstract
Racial disparities in colorectal cancer incidence are widely documented. There are two potential mechanisms for these disparities: differences in access to screening, including screening follow-up, and differences in underlying risk of colorectal cancer. We reviewed the literature for evidence of these two mechanisms. We show that higher colorectal cancer incidence in blacks relative to whites emerged only after the dissemination of screening and describe evidence of racial disparities in screening rates. In contrast to the strong evidence for differences in colorectal cancer screening utilization, there is limited evidence for racial differences in adenoma prevalence. In general, black and white patients who are screened have similar adenoma prevalence, though there is some evidence that advanced adenomas and adenomas in the proximal colon are somewhat more likely in black than white patients. We conclude that higher rates of colorectal cancer incidence among black patients are primarily driven by lower rates of colorectal cancer screening. Our findings highlight the need to increase black patients' access to quality screening to reduce colorectal cancer incidence and mortality.
Collapse
Affiliation(s)
| | - Amy B Knudsen
- Institute for Technology Assessment, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jennifer S Lin
- Kaiser Permanente Center for Health Research, Portland, Oregon
| | | |
Collapse
|
14
|
Levin TR, Jensen CD, Chawla NM, Sakoda LC, Lee JK, Zhao WK, Landau MA, Herm A, Eby E, Quesenberry CP, Corley DA. Early Screening of African Americans (45-50 Years Old) in a Fecal Immunochemical Test-Based Colorectal Cancer Screening Program. Gastroenterology 2020; 159:1695-1704.e1. [PMID: 32702368 PMCID: PMC9007323 DOI: 10.1053/j.gastro.2020.07.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 07/06/2020] [Accepted: 07/12/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Some guidelines recommend starting colorectal cancer (CRC) screening before age 50 years for African Americans, but there are few data on screening uptake and yield in this population. METHODS We performed a prospective study of fecal immunochemical test (FIT) screening among African American members of the Kaiser Permanente Northern California health plan. We compared data from African American members screened when they were 45-50 years old (early screening group) in 2018 with data from previously unscreened African American, white, Hispanic, and Asian/Pacific Islander health plan members who were 51-56 years old. Screening outreach was performed with mailed FIT kits. Logistic regression models, adjusted for sex, were used to evaluate differences among groups in screening uptake, colonoscopy follow-up of abnormal test results, and test yield. RESULTS Among 10,232 African Americans in the early screening group who were mailed a FIT, screening was completed by 33.1%. Among the 4% with positive test results, 85.3% completed a follow-up colonoscopy: 57.8% had any adenoma, 33.6% had an advanced adenoma (adenoma with advanced histology or polyp ≥10 mm), and 2.6% were diagnosed with CRC. African Americans in the early screening group were modestly more likely to have completed screening than previously unscreened African Americans, whites, and Hispanics 51-56 years old. The groups did not differ significantly in positive results from the FIT (range, 3.8%-4.6%) and more than 74% received a follow-up colonoscopy after a positive test result. The test yields for any adenoma (range, 56.7%-70.7%), advanced adenoma (range, 20.0%-33.6%), and CRC (range, 0%-7.1%) were similar. CONCLUSIONS Proportions of African Americans who participated in early (aged 45-50 years) FIT screening and test yield were comparable to those of previously unscreened African Americans, whites, Hispanics, and Asian/Pacific Islanders who were 51-56 years old.
Collapse
Affiliation(s)
- Theodore R. Levin
- Kaiser Permanente Medical Center, Walnut Creek, CA.,Division of Research, Kaiser Permanente Northern California, Oakland, CA.,Co-first authors
| | - Christopher D. Jensen
- Division of Research, Kaiser Permanente Northern California, Oakland, CA.,Co-first authors
| | - Neetu M. Chawla
- Division of Research, Kaiser Permanente Northern California, Oakland, CA.,Veterans Administration, Los Angeles, CA
| | - Lori C. Sakoda
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Jeffrey K. Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Wei K. Zhao
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Molly A. Landau
- The Permanente Medical Group Consulting Services, Kaiser Permanente Northern California, CA
| | - Ariel Herm
- Regional Health Education, Kaiser Permanente Northern California, CA
| | - Eryn Eby
- The Permanente Medical Group Consulting Services, Kaiser Permanente Northern California, CA
| | | | - Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| |
Collapse
|
15
|
Djinbachian R, Iratni R, Durand M, Marques P, von Renteln D. Rates of Incomplete Resection of 1- to 20-mm Colorectal Polyps: A Systematic Review and Meta-Analysis. Gastroenterology 2020; 159:904-914.e12. [PMID: 32437747 DOI: 10.1053/j.gastro.2020.05.018] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 04/29/2020] [Accepted: 05/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Incomplete resection of neoplastic colorectal polyps can result in postcolonoscopy colorectal cancer. We performed a systematic review and meta-analysis to determine the incomplete resection rate (IRR) of colorectal polyps and associated factors. METHODS We searched MEDLINE, EMBASE, EBM Reviews, and CINAHL to identify full-text articles that reported IRRs of polyps 1 to 20 mm, published until March 2019. Exclusion criteria were studies of inflammatory bowel disease cohorts, referrals for difficult polypectomy, polyp sizes larger than 20 mm, and endoscopic submucosal resection and/or dissection as polypectomy approaches. IRRs were calculated based on findings from biopsies taken at polypectomy sites or assessments of margins of resected polyps. The primary outcome was IRR for snare removal of polyps 1 to 20 mm. Secondary outcomes included IRR for polyps 1 to 10 mm and 10 to 20 mm, IRR for hot and cold snare removal of polyps 1 to 10 mm and 10 to 20 mm, IRR of snare removal with or without submucosal injection, and IRR for forceps and cold snare removal of polyps 1 to 5 mm. RESULTS We identified 6148 reports and used 32 studies, with a total of 9282 polyps, in our quantitative analysis. The IRR for snare removal of polyps 1 to 20 mm was 13.8% (95% confidence interval [CI] 10.3-17.3; 13 studies, 5128 polypectomies). IRRs were 15.9% for snare removal of polyps 1 to 10 mm (95% CI 9.6-22.1; 9 studies, 2531 polypectomies) and 20.8% for snare removal of polyps 10 to 20 mm (95% CI 12.9-28.8; 6 studies, 412 polypectomies). The IRR for hot snare removal of polyps 1 to 10 mm was 14.2% (95% CI 5.2-23.2) vs 17.3% for cold snare polypectomy (95% CI 14.3‒20.3). The IRR for forceps removal of polyps 1 to 5 mm was 9.9% (95% CI 7.1-13.0) vs 4.4% for snare polypectomy (95% CI 2.9-6.1). CONCLUSIONS In a systematic review and meta-analysis, we found that colorectal polyps 1 to 20 mm are frequently incompletely resected, and that risk increases for polyps 10 mm or larger. There is no difference in IRRs of cold vs hot snares for polyps 1 to 10 mm. Snare polypectomy should be used over forceps for polyps 1 to 5 mm.
Collapse
Affiliation(s)
- Roupen Djinbachian
- Division of Internal Medicine, Montreal University Hospital Center (CHUM), Montreal, Canada; Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Ryma Iratni
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada; Faculty of Medicine, University of Montreal, Montreal, Canada
| | - Madeleine Durand
- Division of Internal Medicine, Montreal University Hospital Center (CHUM), Montreal, Canada; Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Paola Marques
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada; Bahia State University (UNEB), Salvador, Brazil
| | - Daniel von Renteln
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada; Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada.
| |
Collapse
|
16
|
Lee JK, Jensen CD, Levin TR, Doubeni CA, Zauber AG, Chubak J, Kamineni AS, Schottinger JE, Ghai NR, Udaltsova N, Zhao WK, Fireman BH, Quesenberry CP, Orav EJ, Skinner CS, Halm EA, Corley DA. Long-term Risk of Colorectal Cancer and Related Death After Adenoma Removal in a Large, Community-based Population. Gastroenterology 2020; 158:884-894.e5. [PMID: 31589872 PMCID: PMC7083250 DOI: 10.1053/j.gastro.2019.09.039] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/12/2019] [Accepted: 09/24/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS The long-term risks of colorectal cancer (CRC) and CRC-related death following adenoma removal are uncertain. Data are needed to inform evidence-based surveillance guidelines, which vary in follow-up recommendations for some polyp types. Using data from a large, community-based integrated health care setting, we examined the risks of CRC and related death by baseline colonoscopy adenoma findings. METHODS Participants at 21 medical centers underwent baseline colonoscopies from 2004 through 2010; findings were categorized as no-adenoma, low-risk adenoma, or high-risk adenoma. Participants were followed until the earliest of CRC diagnosis, death, health plan disenrollment, or December 31, 2017. Risks of CRC and related deaths among the high- and low-risk adenoma groups were compared with the no-adenoma group using Cox regression adjusting for confounders. RESULTS Among 186,046 patients, 64,422 met eligibility criteria (54.3% female; mean age, 61.6 ± 7.1 years; median follow-up time, 8.1 years from the baseline colonoscopy). Compared with the no-adenoma group (45,881 patients), the high-risk adenoma group (7563 patients) had a higher risk of CRC (hazard ratio [HR] 2.61; 95% confidence interval [CI] 1.87-3.63) and related death (HR 3.94; 95% CI 1.90-6.56), whereas the low-risk adenoma group (10,978 patients) did not have a significant increase in risk of CRC (HR 1.29; 95% CI 0.89-1.88) or related death (HR 0.65; 95% CI 0.19-2.18). CONCLUSIONS With up to 14 years of follow-up, high-risk adenomas were associated with an increased risk of CRC and related death, supporting early colonoscopy surveillance. Low-risk adenomas were not associated with a significantly increased risk of CRC or related deaths. These results can inform current surveillance guidelines for high- and low-risk adenomas.
Collapse
Affiliation(s)
- Jeffrey K. Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco, San Francisco, CA,Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Theodore R. Levin
- Division of Research, Kaiser Permanente Northern California, Oakland, CA.,Department of Gastroenterology, Kaiser Permanente Walnut Creek, Walnut Creek, CA
| | - Chyke A. Doubeni
- Department of Family Medicine, and the Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, MN
| | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington,Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington
| | - Aruna S. Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Joanne E. Schottinger
- Department of Quality and Clinical Analysis, Kaiser Permanente Southern California, Pasadena, CA
| | - Nirupa R. Ghai
- Department of Regional Clinical Effectiveness, Kaiser Permanente Southern California, Pasadena, CA
| | - Natalia Udaltsova
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Wei K. Zhao
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Bruce H. Fireman
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - E. John Orav
- Department of Biostatistics, Harvard University T.H. Chan School of Public Health, Boston, MA
| | - Celette Sugg Skinner
- Department of Population and Data Sciences and the Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ethan A. Halm
- Department of Population and Data Sciences and the Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Douglas A. Corley
- Department of Gastroenterology, Kaiser Permanente San Francisco, San Francisco, CA,Division of Research, Kaiser Permanente Northern California, Oakland, CA
| |
Collapse
|