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Juul FE, Cross AJ, Schoen RE, Senore C, Pinsky PF, Miller EA, Segnan N, Wooldrage K, Wieszczy-Szczepanik P, Armaroli P, Garborg KK, Adami HO, Hoff G, Kalager M, Bretthauer M, Holme Ø, Løberg M. Effectiveness of Colonoscopy Screening vs Sigmoidoscopy Screening in Colorectal Cancer. JAMA Netw Open 2024; 7:e240007. [PMID: 38421651 PMCID: PMC10905314 DOI: 10.1001/jamanetworkopen.2024.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/02/2024] [Indexed: 03/02/2024] Open
Abstract
Importance Randomized clinical screening trials have shown that sigmoidoscopy screening reduces colorectal cancer (CRC) incidence and mortality. Colonoscopy has largely replaced sigmoidoscopy for CRC screening, but long-term results from randomized trials on colonoscopy screening are still lacking. Objective To estimate the additional screening benefit of colonoscopy compared with sigmoidoscopy. Design, Setting, and Participants This comparative effectiveness simulation study pooled data on 358 204 men and women randomly assigned to sigmoidoscopy screening or usual care in 4 randomized sigmoidoscopy screening trials conducted in Norway, Italy, the US, and UK with inclusion periods in the years 1993 to 2001. The primary analysis of the study was conducted from January 19 to December 30, 2021. Intervention Invitation to endoscopic screening. Main Outcomes and Measures Primary outcomes were CRC incidence and mortality. Using pooled 15-year follow-up data, colonoscopy screening effectiveness was estimated assuming that the efficacy of colonoscopy in the proximal colon was similar to that observed in the distal colon in the sigmoidoscopy screening trials. The simulation model was validated using data from Norwegian participants in a colonoscopy screening trial. Results This analysis included 358 204 individuals (181 971 women [51%]) aged 55 to 64 years at inclusion with a median follow-up time ranging from 15 to 17 years. Compared with usual care, colonoscopy prevented an estimated 50 (95% CI, 42-58) CRC cases per 100 000 person-years, corresponding to 30% incidence reduction (rate ratio, 0.70 [95% CI, 0.66-0.75]), and prevented an estimated 15 (95% CI, 11-19) CRC deaths per 100 000 person-years, corresponding to 32% mortality reduction (rate ratio, 0.68 [95% CI, 0.61-0.76]). The additional benefit of colonoscopy screening compared with sigmoidoscopy was 12 (95% CI, 10-14) fewer CRC cases and 4 (95% CI, 3-5) fewer CRC deaths per 100 000 person-years, corresponding to percentage point reductions of 6.9 (95% CI, 6.0-7.9) for CRC incidence and 7.6 (95% CI, 5.7-9.6) for CRC mortality. The number needed to switch from sigmoidoscopy to colonoscopy screening was 560 (95% CI, 486-661) to prevent 1 CRC case and 1611 (95% CI, 1275-2188) to prevent 1 CRC death. Conclusions and Relevance The findings of this comparative effectiveness study assessing long-term follow-up after CRC screening suggest that there was an additional preventive effect on CRC incidence and mortality associated with colonoscopy screening compared with sigmoidoscopy screening, but the additional preventive effect was less than what was achieved by introducing sigmoidoscopy screening where no screening existed. The results probably represent the upper limit of what may be achieved with colonoscopy screening compared with sigmoidoscopy screening.
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Affiliation(s)
- Frederik E. Juul
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
- Clinical Effectiveness Research Group, Oslo University Hospital, Oslo, Norway
| | - Amanda J. Cross
- Cancer Screening & Prevention Research Group, Department of Surgery & Cancer, Imperial College London, London, United Kingdom
| | - Robert E. Schoen
- Division of Gastroenterology, Hepatology and Nutrition, Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Carlo Senore
- University Hospital Città della Salute e della Scienza, Turin, Italy
| | - Paul F. Pinsky
- Division of Cancer Prevention, National Cancer Institute, Rockville, Maryland
| | - Eric A. Miller
- Division of Cancer Prevention, National Cancer Institute, Rockville, Maryland
| | - Nereo Segnan
- University Hospital Città della Salute e della Scienza, Turin, Italy
| | - Kate Wooldrage
- Cancer Screening & Prevention Research Group, Department of Surgery & Cancer, Imperial College London, London, United Kingdom
| | - Paulina Wieszczy-Szczepanik
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
- Clinical Effectiveness Research Group, Oslo University Hospital, Oslo, Norway
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Paola Armaroli
- University Hospital Città della Salute e della Scienza, Turin, Italy
| | - Kjetil K. Garborg
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
- Clinical Effectiveness Research Group, Oslo University Hospital, Oslo, Norway
| | - Hans-Olov Adami
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
- Clinical Effectiveness Research Group, Oslo University Hospital, Oslo, Norway
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Geir Hoff
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
- Department of Research and Development, Telemark Hospital Trust, Skien, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Mette Kalager
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
- Clinical Effectiveness Research Group, Oslo University Hospital, Oslo, Norway
| | - Michael Bretthauer
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
- Clinical Effectiveness Research Group, Oslo University Hospital, Oslo, Norway
| | - Øyvind Holme
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
- Clinical Effectiveness Research Group, Oslo University Hospital, Oslo, Norway
- Department of Medicine, Sorlandet Hospital Health Trust, Kristiansand, Norway
| | - Magnus Løberg
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
- Clinical Effectiveness Research Group, Oslo University Hospital, Oslo, Norway
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El Halabi J, Burke CA, Hariri E, Rizk M, Macaron C, McMichael J, Rothberg MB. Frequency of Use and Outcomes of Colonoscopy in Individuals Older Than 75 Years. JAMA Intern Med 2023; 183:513-519. [PMID: 37010845 PMCID: PMC10071394 DOI: 10.1001/jamainternmed.2023.0435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 02/03/2023] [Indexed: 04/04/2023]
Abstract
Importance The benefits from colorectal cancer (CRC) screening may take 10 to 15 years to accrue. Therefore, screening is recommended for older adults who are in good health. Objective To determine the number of screening colonoscopies done in patients older than 75 years with a life expectancy of fewer than 10 years, diagnostic yield, and associated adverse events within 10 days and 30 days of the procedure. Design This cross-sectional study with a nested cohort between January 2009 and January 2022 in an integrated health system assessed asymptomatic patients older than 75 years who underwent screening colonoscopy in the outpatient setting. Reports with incomplete data, any indication other than screening, patients who had a colonoscopy within the previous 5 years, and patients with a personal history of inflammatory bowel disease or CRC were excluded. Exposures Life expectancy based on a prediction model from previous literature. Main Outcomes and Measures The primary outcome was the percentage of screened patients who had limited (<10 years) life expectancy. Other outcomes included colonoscopy findings and adverse events that developed within 10 days and 30 days of the procedure. Results A total of 7067 patients older than 75 years were included. The median (IQR) age was 78 (77-79) years, 3967 (56%) were women, and 5431 (77%) were White with an average of 2 comorbidities (taken from a select group of comorbidities). The proportion of colonoscopies performed on patients with a life expectancy of fewer than 10 years aged 76 to 80 years was 30% in both sexes and increased with age-82% of men and 61% of women aged 81 to 85 years (71% total), and 100% of patients beyond the age of 85 years. Adverse events requiring hospitalizations were common at 10 days (13.58 per 1000) and increased with age, particularly among patients older than 85 years. The detection of advanced neoplasia varied from 5.4% among patients aged 76 to 80 years to 6.2% in those aged 81 to 85 years and 9.5% among patients older than 85 years (P = .02). Of the total population, 15 patients (0.2%) had invasive adenocarcinoma; among patients with a life expectancy of fewer than 10 years, 1 of 9 was treated, whereas 4 of 6 patients with a life expectancy of greater than or equal to 10 years were treated. Conclusions and Relevance In this cross-sectional study with a nested cohort, most screening colonoscopies performed in patients older than 75 years were in patients with limited life expectancy and associated with increased risk of complications. Colorectal cancer was exceedingly rare.
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Affiliation(s)
| | - Carol A. Burke
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Essa Hariri
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Maged Rizk
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Carole Macaron
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - John McMichael
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Michael B. Rothberg
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio
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Yeoh A, Mannalithara A, Ladabaum U. Cost-Effectiveness of Earlier or More Intensive Colorectal Cancer Screening in Overweight and Obese Patients. Clin Gastroenterol Hepatol 2023; 21:507-519. [PMID: 35940514 DOI: 10.1016/j.cgh.2022.07.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/18/2022] [Accepted: 07/20/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND & AIMS Overweight and obese persons have not only elevated rates of colorectal cancer (CRC), but also higher competing mortality and healthcare spending. We examined the cost-effectiveness of intensified CRC screening in overweight and obese persons. METHODS We adapted our validated decision analytic model of CRC screening to compare screening starting at 45 or 40 years of age instead of at 50 years of age, or shortening screening intervals, in women and men with body mass index (BMI) ranging from normal to grade III obesity. Strategies included colonoscopy every 10 years (Colo10) or every 5 years (Colo5), or annual fecal immunochemical test. RESULTS Without screening, sex-specific total CRC deaths were similar for persons with overweight or obesity I-III, reflecting the counterbalancing of higher CRC risk by lower life expectancy as BMI rises. For all BMI and sex groups, Colo10 starting at 45 years of age or FIT starting at 40 years of age were cost-effective at a threshold of $100,000 per quality-adjusted life year gained. Colo10 starting at 40 years of age was cost-effective only for men with obesity II-III, at $93,300 and $80,400 per quality-adjusted life year gained, respectively. Shifting Colo10 to earlier starting ages was always preferred over Colo5 starting at later ages. Results were robust in sensitivity analysis, including varying all-cause mortality, complication, and BMI-specific CRC risks. CONCLUSIONS CRC screening starting at 45 years of age with colonoscopy, or at 40 years of age with FIT, appears cost-effective for women and men across the range of BMI. In men with obesity II-III, who have the highest CRC but also all-cause mortality risks, colonoscopy starting at 40 years of age appears cost-effective. It remains to be decided whether BMI should be used as a single predictor or incorporated into a multivariable tool to tailor CRC screening.
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Affiliation(s)
- Aaron Yeoh
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Ajitha Mannalithara
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Uri Ladabaum
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California.
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Imperiale TF. Uptake of Colorectal Cancer Screening in 45 to 49 Year Olds: An Early-Inning View from the Endoscopy Suite. Clin Gastroenterol Hepatol 2022; 20:2722-2724. [PMID: 35870767 DOI: 10.1016/j.cgh.2022.07.014] [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: 06/24/2022] [Revised: 07/12/2022] [Accepted: 07/12/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Thomas F Imperiale
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Center for Health Information and Communication, Health Services Research and Development, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana; The Regenstrief Institute, Inc, Indianapolis, Indiana.
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Shiratori Y, Miller SD, Hutfless S. Editorial: seeing the light at the end of gastroscope-Complications after elective procedures are ready for NICE, bright decision aid tools. Aliment Pharmacol Ther 2022; 56:155-156. [PMID: 35689318 DOI: 10.1111/apt.16961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Yasutoshi Shiratori
- Division of Gastroenterology, Sherbrooke University Hospital, Sherbrooke, Quebec, Canada
| | - Steven D Miller
- Division of Gastroenterology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Susan Hutfless
- Division of Gastroenterology, Johns Hopkins University, Baltimore, Maryland, USA
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