A simple scoring model for advanced colorectal neoplasm in asymptomatic subjects aged 40-49 years

Risk Factors for Early-onset Sporadic Colorectal Cancer in Male Veterans

Identifying risk factors for early-onset colorectal cancer (EOCRC) could help reverse its rising incidence through risk factor reduction and/or early screening. We sought to identify EOCRC risk factors that could be used for decisions about early screening. Using electronic databases and medical record review, we compared male veterans ages 35 to 49 years diagnosed with sporadic EOCRC (2008-2015) matched 1:4 to clinic and colonoscopy controls without colorectal cancer, excluding those with established inflammatory bowel disease, high-risk polyposis, and nonpolyposis syndromes, prior bowel resection, and high-risk family history. We ascertained sociodemographic and lifestyle factors, family and personal medical history, physical measures, vital signs, medications, and laboratory values 6 to 18 months prior to case diagnosis. In the derivation cohort (75% of the total sample), univariate and multivariate logistic regression models were used to derive a full model and a more parsimonious model. Both models were tested using a validation cohort. Among 600 cases of sporadic EOCRC [mean (SD) age 45.2 (3.5) years; 66% White], 1,200 primary care clinic controls [43.4 (4.2) years; 68% White], and 1,200 colonoscopy controls [44.7 (3.8) years; 63% White], independent risk factors included age, cohabitation and employment status, body mass index (BMI), comorbidity, colorectal cancer, or other visceral cancer in a first- or second-degree relative (FDR or SDR), alcohol use, exercise, hyperlipidemia, use of statins, NSAIDs, and multivitamins. Validation c-statistics were 0.75-0.76 for the full model and 0.74-0.75 for the parsimonious model, respectively. These independent risk factors for EOCRC may identify veterans for whom colorectal cancer screening prior to age 45 or 50 years should be considered.

PREVENTION RELEVANCE

Screening 45- to 49-year-olds for colorectal cancer is relatively new with uncertain uptake thus far. Furthermore, half of EOCRC occurs in persons < 45 years old. Using risk factors may help 45- to 49-year-olds accept screening and may identify younger persons for whom earlier screening should be considered. See related Spotlight, p. 479.

Colorectal Cancer Risk Assessment and Precision Approaches to Screening: Brave New World or Worlds Apart?

Current colorectal cancer (CRC) screening recommendations take a "one-size-fits-all" approach using age as the major criterion to initiate screening. Precision screening that incorporates factors beyond age to risk stratify individuals could improve on current approaches and optimally use available resources with benefits for patients, providers, and health care systems. Prediction models could identify high-risk groups who would benefit from more intensive screening, while low-risk groups could be recommended less intensive screening incorporating noninvasive screening modalities. In addition to age, prediction models incorporate well-established risk factors such as genetics (eg, family CRC history, germline, and polygenic risk scores), lifestyle (eg, smoking, alcohol, diet, and physical inactivity), sex, and race and ethnicity among others. Although several risk prediction models have been validated, few have been systematically studied for risk-adapted population CRC screening. In order to envisage clinical implementation of precision screening in the future, it will be critical to develop reliable and accurate prediction models that apply to all individuals in a population; prospectively study risk-adapted CRC screening on the population level; garner acceptance from patients and providers; and assess feasibility, resources, cost, and cost-effectiveness of these new paradigms. This review evaluates the current state of risk prediction modeling and provides a roadmap for future implementation of precision CRC screening.

Risk Stratification for Early-Onset Colorectal Cancer Using a Combination of Genetic and Environmental Risk Scores: An International Multi-Center Study

BACKGROUND

The incidence of colorectal cancer (CRC) among individuals aged younger than 50 years has been increasing. As screening guidelines lower the recommended age of screening initiation, concerns including the burden on screening capacity and costs have been recognized, suggesting that an individualized approach may be warranted. We developed risk prediction models for early-onset CRC that incorporate an environmental risk score (ERS), including 16 lifestyle and environmental factors, and a polygenic risk score (PRS) of 141 variants.

METHODS

Relying on risk score weights for ERS and PRS derived from studies of CRC at all ages, we evaluated risks for early-onset CRC in 3486 cases and 3890 controls aged younger than 50 years. Relative and absolute risks for early-onset CRC were assessed according to values of the ERS and PRS. The discriminatory performance of these scores was estimated using the covariate-adjusted area under the receiver operating characteristic curve.

RESULTS

Increasing values of ERS and PRS were associated with increasing relative risks for early-onset CRC (odds ratio per SD of ERS = 1.14, 95% confidence interval [CI] = 1.08 to 1.20; odds ratio per SD of PRS = 1.59, 95% CI = 1.51 to 1.68), both contributing to case-control discrimination (area under the curve = 0.631, 95% CI = 0.615 to 0.647). Based on absolute risks, we can expect 26 excess cases per 10 000 men and 21 per 10 000 women among those scoring at the 90th percentile for both risk scores.

CONCLUSIONS

Personal risk scores have the potential to identify individuals at differential relative and absolute risk for early-onset CRC. Improved discrimination may aid in targeted CRC screening of younger, high-risk individuals, potentially improving outcomes.

OUP accepted manuscript

Background

The uptake of colonoscopy is low in individuals at risk of colorectal cancer (CRC). We constructed a risk-prediction score (RPS) in a large community-based sample at high risk of CRC to enable more accurate risk stratification and to motivate and increase the uptake rate of colonoscopy.

Methods

A total of 12,628 participants classified as high-risk according to positivity of immunochemical fecal occult blood tests or High-Risk Factor Questionnaire underwent colonoscopy. Logistic regression was used to derive a RPS and analysed the associations of the RPS with colorectal lesions, giving odds ratios (ORs) and 95% confidence intervals (CIs).

Results

Of the participants, men (OR = 1.73, 95% CI = 1.58–1.90), older age (≥65 years; 1.41, 1.31–1.53), higher body mass index (≥28 kg/m²; 1.22, 1.07–1.39), ever smoking (1.47, 1.31–1.65), and weekly alcohol use (1.28, 1.09–1.52) were associated with a higher risk of colorectal lesions. We assigned 1 point to each of the above five risk factors and derived a RPS ranging from 0 to 5, with a higher score indicating a higher risk. Compared with a RPS of 0, a RPS of 1, 2, 3, and 4–5 showed a higher risk of colorectal lesions, with the OR (95% CI) being 1.50 (1.37–1.63), 2.34 (2.12–2.59), 3.58 (3.13–4.10), and 3.91 (3.00–5.10), respectively. The area under the receiver-operating characteristic curve of RPS in predicting colorectal lesions was 0.62.

Conclusions

Participants with an increase in the RPS of ≥1 point had a significantly higher risk of colorectal lesions, suggesting the urgency for measuring colonoscopy in this very high-risk group. High-risk strategies incorporating RPS may be employed to achieve a higher colonoscopy-uptake rate.

Risk prediction rule for advanced neoplasia on screening colonoscopy for average-risk individuals

BACKGROUND

In resource-limited countries, risk stratification can be used to optimize colorectal cancer screening. Few prospective risk prediction models exist for advanced neoplasia (AN) in true average-risk individuals.

AIM

To create and internally validate a risk prediction model for detection of AN in average-risk individuals.

METHODS

Prospective study of asymptomatic individuals undergoing first screening colonoscopy. Detailed characteristics including diet, exercise and medications were collected. Multivariate logistic regression was used to elucidate risk factors for AN (adenoma ≥1 cm, villous histology, high-grade dysplasia or carcinoma). The model was validated through bootstrapping, and discrimination and calibration of the model were assessed.

RESULTS

980 consecutive individuals (51% F; 49% M) were enrolled. Adenoma and AN detection rates were 36.6% (F 29%: M 45%; P < 0.001) and 5.1% (F 3.8%; M 6.5%) respectively. On multivariate analysis, predictors of AN [OR (95%CI)] were age [1.036 (1.00-1.07); P = 0.048], BMI [overweight 2.21 (0.98-5.00); obese 3.54 (1.48-8.50); P = 0.018], smoking [< 40 pack-years 2.01 (1.01-4.01); ≥ 40 pack-years 3.96 (1.86-8.42); P = 0.002], and daily red meat consumption [2.02 (0.92-4.42) P = 0.079]. Nomograms of AN risk were developed in terms of risk factors and age separately for normal, overweight and obese individuals. The model had good discrimination and calibration.

CONCLUSION

The prevalence of adenoma and AN in average-risk Lebanese individuals is similar to the West. Age, smoking, and BMI are important predictors of AN, with obesity being particularly powerful. Though external validation is needed, this model provides an important platform for improved risk-stratification for screening programs in regions where universal screening is not currently employed.

Value of routine test for identifying colorectal cancer from patients with nonalcoholic fatty liver disease

Background

Nonalcoholic fatty liver disease (NAFLD) is a risk factor for colorectal neoplasms. Our goal is to explore the relationship between NAFLD and colorectal cancer (CRC) and to analyze potential indicators for screening CRC in NAFLD based on clinical big data.

Methods

Demographic information and routine clinical indicators were extracted from Xiangya Medical Big Data Platform. 35,610 NAFLD cases without CRC (as group NAFLD-CRC), 306 NAFLD cases with CRC (as group NAFLD-NonCRC) and 10,477 CRC cases without NAFLD were selected and evaluated. The CRC incidence was compared between NAFLD population and general population by Chi-square test. Independent sample t-test was used to find differences of age, gender and routine clinical indicators in pairwise comparisons of NAFLD-CRC, NAFLD-NonCRC and nonNAFLD-CRC.

Results

NAFLD population had a higher CRC incidence than general population (7.779‰ vs 3.763‰, P < 0.001). Average age of NAFLD-CRC (58.79 ± 12.353) or nonNAFLD-CRC (59.26 ± 13.156) was significantly higher than NAFLD-nonCRC (54.15 ± 14.167, p < 0.001). But age had no significant difference between NAFLD-CRC and nonNAFLD-CRC (P > 0.05). There was no different gender distribution for three groups (P > 0.05). NAFLD-CRC had lower anaemia-related routine clinical indicators such as decrease of red blood cell count, mean hemoglobin content and hemoglobin than NAFLD-nonCRC (P < 0.05 for all). Anemia of NAFLD-CRC was typical but it might be slighter than nonNAFLD-CRC. More interestingly, NAFLD-CRC had distinct characteristics of leukocyte system such as lower white blood cell count (WBC) and neutrophil count (NEU_C) and higher basophil percentage (BAS_Per) than nonNAFLD-CRC and NAFLD-nonCRC (P < 0.05 for all). Compared with NAFLD-nonCRC, the change of WBC, BAS_Per and NEU_C in NAFLD-CRC was different from that in nonNAFLD-CRC. In addition, NAFLD-CRC had a higher level of low density lipoprotein (LDL) and high density lipoprotein (HDL), lower level of triglyceride (TG) and Albumin-to-globulin ratio (A/G) than NFLD-nonCRC (P < 0.05 for all).

Conclusions

NAFLD is associated with a high incidence of CRC. Age is an important factor for CRC and the CRC incidence increases with age. Anemia-related blood routine clinical indicators, leukocyte system and blood lipid indicators may be more important variables for identifying CRC in NAFLD. So blood routine test and liver function/blood lipid test are valuable for screening CRC in NAFLD.

Elevated serum triglyceride and low-density lipoprotein cholesterol promotes the formation of colorectal polyps

BACKGROUND

Hyperlipidaemia may be a potential risk factor for the occurrence of intestinal polyps. This study aimed to evaluate correlation between lipidaemia and the formation of colorectal polyps.

METHODS

One hundred and fourteen patients with colorectal polyps and forty-eight healthy controls were included in this study. Colonoscopies were performed for all patients and controls within 1 week before blood samples were taken. The concentrations of serum lipids and lipoproteins were measured simultaneously using an automatic biochemical analyser. The colorectal lesions were classified based on pathological characteristics, and four types were identified in the study: hyperplastic polyp (HP), tubular adenoma (TA), tubulovillous adenoma (TVA) and adenoma with high-grade dysplasia (A-HGD). Advanced adenoma was classified according to the number, size and histological type of polyps.

RESULTS

The value of low-density lipoprotein cholesterol (LDL-C) was significantly higher in the group with advanced adenoma than in the controls (p < 0.05). Moreover, the LDL-C values in the HP and TA groups were higher when compared to that of controls (p < 0.05). Obesity, age, and increased TG and LDL-C were independent risk factors for the formation of colorectal polyps. The cut-off values of triglyceride (TG) and LDL-C to distinguish polyp patients from healthy controls were 0.96 mmol/L (AUC = 0.604, p = 0.036) and 3.05 mmol/L (AUC = 0.654, p = 0.002). The combined use of increased LDL-C and TG levels to distinguish polyp patients was effective, with a sensitivity of 50.0% and a specificity of 89.6% (AUC = 0.733, p < 0.01).

CONCLUSIONS

Colorectal polyps are more often found in obese and older patients. Increased LDL-C and TG were correlated with the occurrence of polyps. Combination of the two serum indicators was useful to assess risk of colorectal lesions, maybe more effective in screening hyperplastic polyp, tubular adenoma and advanced adenoma.

Colorectal carcinoma screening: Established methods and emerging technology

Colorectal carcinoma screening programs have shown success in lowering both the incidence and mortality rate of colorectal carcinoma at a population level, in part because this carcinoma is relatively slow growing and has an identifiable premalignant lesion. Still, many patients do not undergo the recommended screening for colorectal carcinoma, and of those who do, a subset may be over- or under-diagnosed by the currently available testing methods. The primary purpose of this article is to review the data regarding currently available colorectal cancer screening modalities, which include fecal occult blood testing, direct colonic visualization, and noninvasive imaging techniques. In addition, readers will be introduced to a variety of biomarkers that may serve as stand-alone or adjunct tests in the future. Finally, there is a brief discussion of the current epidemiologic considerations that public health officials must address as they create population screening guidelines. The data we provide as laboratory physicians and scientists are critical to the construction of appropriate recommendations that ultimately decrease the burden of disease from colorectal carcinoma.

Head-to-Head Comparison of the Performance of 17 Risk Models for Predicting Presence of Advanced Neoplasms in Colorectal Cancer Screening

OBJECTIVES

Many risk scores have been proposed to predict presence of advanced colorectal neoplasms, but a comprehensive comparison conducted in the same population is sparse. The aim of this study was to evaluate and directly compare the diagnostic performance of published risk prediction models for advanced colorectal neoplasms.

METHODS

Data were drawn from 2 cohorts of subjects undergoing screening colonoscopy in Germany, i.e., KolosSal (n = 16,195) and BliTz (n = 7,444). Absolute risks and relative risks were generated for the presence of at least 1 advanced neoplasm, taking the lowest risk group as the reference group. Performance of risk models was assessed by the area under the receiver operating characteristic curve (AUC) and compared by the net reclassification improvement.

RESULTS

The 2 cohorts included 1,917 (11.8%) and 848 (11.4%) participants with advanced neoplasm, respectively. Absolute risks were mostly between 5% and 10% among participants in the lowest risk group and between 15% and 20% among participants in the highest risk group, and relative risks mostly ranged from 2.0 to 4.0 across the risk models in both cohorts. The AUCs ranged from 0.58 to 0.65 in KolosSal and from 0.57 to 0.61 in BliTz for all risk scores. Compared to models with lower AUC, classification was significantly improved in most models with higher AUC.

DISCUSSION

Risk models for advanced colorectal neoplasms generally yielded modest discriminatory power, despite some variation in performance between models. Future studies should evaluate the performance of these risk models in racially diverse populations and investigate possible extensions, such as combination with polygenic risk scores.

Colorectal cancer screening from 45 years of age: Thesis, antithesis and synthesis

Colorectal cancer incidence and mortality in patients younger than 50 years are increasing, but screening before the age of 50 is not offered in Europe. Advanced-stage diagnosis and mortality from colorectal cancer before 50 years of age are increasing. This is not a detection-bias effect; it is a real issue affecting the entire population. Three independent computational models indicate that screening from 45 years of age would yield a better balance of benefits and risks than the current start at 50 years of age. Experimental data support these predictions in a sex- and race-independent manner. Earlier screening is seemingly affordable, with minimal impediments to providing younger adults with colonoscopy. Indeed, the American Cancer Society has already started to recommend screening from 45 years of age in the United States. Implementing early screening is a societal and public health problem. The three independent computational models that suggested earlier screening were criticized for assuming perfect compliance. Guidelines and recommendations should be derived from well-collected and reproducible data, and not from mathematical predictions. In the era of personalized medicine, screening decisions might not be based solely on age, and sophisticated prediction software may better guide screening. Moreover, early screening might divert resources away from older individuals with greater biological risks. Finally, it is still unknown whether early colorectal cancer is part of a continuum of disease or a biologically distinct disease and, as such, it might not benefit from screening at all. The increase in early-onset colorectal cancer incidence and mortality demonstrates an obligation to take actions. Earlier screening would save lives, and starting at the age of 45 years may be a robust screening option.

A Comparative Study Evaluating the Incidence of Colorectal Neoplasia(s) in Candidates for Bariatric Surgery by Screening Colonoscopy, 40-49 Versus 50-65 Years Old: a Preliminary Study

INTRODUCTION

Obesity and metabolic syndrome (MetS) are associated with colorectal neoplasia (CRN) and carcinoma (CRC). Whether such subjects must undergo screening colonoscopy (SC) earlier, is unknown. Incidences of CRNs in 40-49- versus 50-65-year-old bariatric patients were compared by SC. No prospective data on SC is available in morbidly obese/MetS.

MATERIAL AND METHODS

Surgical weight loss candidates over 39 years of age, asymptomatic, and average-risk for CRC offered SC. Those giving written informed consent were enrolled. Colonoscopies were done by the same surgeon. Smoking/drinking history, fasting blood glucose (FBG), insulin, C-peptide, triglyceride, high density lipoprotein, vitamin D, HbA1c, and insulin resistance parameters were recorded. CRN rate and the distribution of variables in patients 40-49 years of age were compared with 50-65. Student's t and Chi-square tests were used as appropriate. P < 0.05 was regarded as statistically significant.

RESULTS

Among 168 SCs, 47 had CRNs (27.9%). Including carcinoma, 15 had an advanced CRN (aCRN) (8.9% aCRN and 0.6% CRC). CRN rate was 35.6% in ≥ 50 years old whereas 22.1% in 40-49 (p = 0.053). aCRN rates (8.4% in 40-49 versus 9.6% in 50-65) were similar (p = 0.792). Metabolic parameters and smoking-drinking history were equally distributed between the groups except FBG and HbA1c as their mean levels were slightly higher in the 50-65 age group (p < 0.05).

CONCLUSIONS

Presented results warrant routine SC in the 40-49-year-old morbidly obese and/or MetS patient population with average risk, and in aged > 50, it certainly must be enforced and included in the preoperative check-list if not done before.

Risk Scores for Predicting Advanced Colorectal Neoplasia in the Average-risk Population: A Systematic Review and Meta-analysis

OBJECTIVES

A systematic review and meta-analysis was performed to summarize the available evidence on risk scores for predicting advanced colorectal neoplasia (advanced adenomas and cancer) in average-risk and asymptomatic populations undergoing screening colonoscopy.

METHODS

PubMed, EMBASE, and Web of Science databases were searched up to 28 March 2018. Studies that developed or validated a risk score to predict the risk of advanced colorectal neoplasia were included. Two reviewers independently extracted study characteristics including diagnostic performance indicators and assessed risk of bias and applicability in the included studies. Meta-analyses were conducted to determine the overall discrimination of risk scores evaluated by more than 1 study.

RESULTS

A total of 22 studies including 17 original risk scores were identified. Risk scores included a median number of 5 risk factors. Factors most commonly included were age, sex, family history in first-degree relatives, body mass index and smoking. The area under the receiver operating characteristic curve of risk scores ranged from 0.62 to 0.77 in the individual studies and from 0.61 to 0.70 in the meta-analyses.

CONCLUSIONS

Although the majority of available risk scores had relatively weak discriminatory power, they may be of some use for risk stratification in CRC screening. Rather than developing more risk scores based on environmental risk factors, future research should focus on exploring possibilities of enhancing predictive power by combining risk factor data with novel laboratory matters, such as polygenetic risk scores.

Changes in lecithin: cholesterol acyltransferase, cholesteryl ester transfer protein and paraoxonase-1 activities in patients with colorectal cancer

BACKGROUND

Previous studies revealed decreased level of high-density lipoprotein cholesterol (HDLC) as important factor for development of colorectal cancer (CRC). Quantity and structure of HDL particles depend on activities of lipid transfer proteins lecithin:cholesterol acyltransferase (LCAT) and cholesteryl ester transfer protein (CETP), but this topic is largely unexplored in CRC. The main objective of this study was to investigate activities of LCAT and CETP in patients with CRC. Additionally, we analyzed activity of paraoxonase-1 (PON-1), as a main carrier of HDL-antioxidant function.

MATERIALS AND METHODS

Ninety-nine CRC patients and 101 healthy individuals were included. LCAT and CETP activities were assessed by measuring rates of formation and transfer of cholesteryl esters. PON-1 paraoxonase and arylesterase activities were measured.

RESULTS

Lower levels of HDL-C (p < .001) were observed in cohort of patients, alongside with decreased LCAT (p < .050) and increased CETP activity (p < .050). Both PON-1 activities were diminished in CRC (p < .050 and p < .001 respectively). Univariate logistic regression singled out HDL-C level (OR = 0.218, p < .001), CETP activity (OR = 1.010, p < .01) and mass (OR = 0.994, p < .001) as possible markers of elevated CRC risk. CETP mass maintained its predictive significance when adjusted for traditional risk factors and level of oxidative stress (OR = 0.993, p < .001; OR = 0.982, p < .050, respectively).

CONCLUSION

Our results demonstrated increased CETP and decreased LCAT and PON-1 activities in CRC patients. In preliminary analysis CETP mass was identified as potential significant predictor of CRC development, suggesting that alterations in HDL-C levels, alongside with changes in HDL structure might have a role in carcinogenesis.

Individualized colorectal cancer screening based on the clinical risk factors: beyond family history of colorectal cancer

BACKGROUND AND AIMS

Individuals without a family history of colorectal cancer (CRC) are screened uniformly despite interpersonal risk. To assess individual risk, we examined the age-specific prevalence of advanced colorectal neoplasia (ACRN) according to clinical risk factors and fecal immunochemical test (FIT) results.

METHODS

Participants without a family history of CRC who underwent screening colonoscopies and FITs were included. Clinical risk factors for ACRN were identified by using a logistic regression model. Point scores were assigned to each associated factor based on a regression coefficient.

RESULTS

A total of 34,658 participants were included. Age, male sex, smoking, and obesity were identified as risk factors. One-, 2-, and 1-point scores were assigned to male sex, smoking, and obesity, respectively. The prevalence of ACRN in individuals with 0, 1, and ≥2 risk score points was 1.4%, 1.6%, and 2.9% among those aged 50 to 51 years and 3.1%, 5.5%, and 7.5% among those aged ≥66 years, respectively. Among FIT-positive individuals, the prevalence of ACRN was 11.0% and 21.2% in those aged between 50 and 51 years and those aged ≥66 years, respectively. Among FIT-negative individuals with ≥2 risk score points, the prevalence of ACRN was 2.5% and 6.0% among those aged 50 to 51 years and those aged ≥66 years, respectively.

CONCLUSION

If the clinical risk score is ≥2 points (persons with smoking history or obese men), early colonoscopy may be recommended, even with no family history of CRC. Additionally, FIT may be an appropriate initial screening modality for average-risk individuals if the clinical risk score is 0 to 1.