1
|
Fernandes C, Estevinho M, Marques Cruz M, Frazzoni L, Rodrigues PP, Fuccio L, Dinis-Ribeiro M. Adenoma detection rate by colonoscopy in real-world population-based studies: a systematic review and meta-analysis. Endoscopy 2024. [PMID: 39227020 DOI: 10.1055/a-2382-5795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2024]
Abstract
BACKGROUND Adenoma detection rate (ADR) is a quality indicator set at a minimum of 25% in unselected populations by the European Society of Gastrointestinal Endoscopy (ESGE). Nevertheless, a lack of pooled observational data resembling real-world practice limits support for this threshold. We aimed to perform a systematic review with meta-analysis to evaluate the pooled rates for conventional adenoma detection, polyp detection (PDR), cecal intubation, bowel preparation, and complications in population-based studies. METHODS The PubMed, Scopus, and Web of Science databases were searched until May 2023 for populational-based studies reporting overall ADR in unselected individuals. A random-effects model was used for meta-analysis. RESULTS 31 studies were included, comprising 3 644 561 subjects. A high quality of procedures was noticeable, with a high cecal intubation rate and low complication rate. The overall pooled ADR, PDR, and rate of cancer detection were 26.5% (95%CI 23.3% to 29.7%), 38.3% (95%CI 32.5% to 44.1%), and 2.7% (95%CI 1.5% to 3.9%), respectively. ADR varied according to indication: screening 33.3% (95%CI 24.5% to 42.2%), surveillance 42.9% (95%CI 36.9% to 49.0%), and diagnostic 24.7% (95%CI 19.5% to 29.9%), with subgroup analysis revealing rates of 34.4% (95%CI 22.0% to 40.5%) for post-fecal occult blood test and 26.6% (95%CI 22.6% to 30.5%) for primary colonoscopy screening. Diminutive conventional adenomas yielded a pooled rate of 59.9% (95%CI 43.4% to 76.3%). The pooled rate for overall serrated lesion detection was 12.4% (95%CI 8.8% to 16.0%). Male sex and higher age were significantly associated with an ADR above the benchmark. CONCLUSION This first meta-analysis relying on real-world observational studies supports the ESGE benchmark for ADR, while suggesting that different benchmarks might be used according to indication, sex, and age.
Collapse
Affiliation(s)
- Carlos Fernandes
- Programme in Health Data Science, University of Porto Faculty of Medicine, Porto, Portugal
| | - Manuela Estevinho
- Department of Gastroenterology, Vila Nova de Gaia Espinho Hospital Center, Vila Nova de Gaia, Portugal
- Department of Biomedicine, Unit of Pharmacology and Therapeutics, University of Porto Faculty of Medicine, Porto, Portugal
| | - Manuel Marques Cruz
- MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences, University of Porto Faculty of Medicine, Porto, Portugal
- CINTESIS@RISE, MEDCIDS, University of Porto Faculty of Medicine, Porto, Portugal
| | - Leonardo Frazzoni
- Gastroenterology and Endoscopy Unit, Forli-Cesena Hospitals, AUSL Romagna, Italy
| | | | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, Bologna, Italy
| | - Mário Dinis-Ribeiro
- Gastroenterology Department and PreCAM, RISE@CI-IPO (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto), Porto, Portugal
- Porto Comprehensive Cancer Center (Porto.CCC), Porto, Portugal
| |
Collapse
|
2
|
Abstract
In recommending and offering screening, health services make a health claim ('it's good for you'). This article considers ethical aspects of establishing the case for cancer screening, building a service programme, monitoring its operation, improving its quality and integrating it with medical progress. The value of (first) screening is derived as a function of key parameters: prevalence of the target lesion in the detectable pre-clinical phase, the validity of the test and the respective net utilities or values attributed to four health states-true positives, false positives, false negatives and true negatives. Decision makers as diverse as public regulatory agencies, medical associations, health insurance funds or individual screenees can legitimately come up with different values even when presented with the same evidence base. The main intended benefit of screening is the reduction of cause-specific mortality. All-cause mortality is not measurably affected. Overdiagnosis and false-positive tests with their sequelae are the main harms. Harms and benefits accrue to distinct individuals. Hence the health claim is an invitation to a lottery with benefits for few and harms to many, a violation of the non-maleficence principle. While a public decision maker may still propose a justified screening programme, respect for individual rights and values requires preference-sensitive, autonomy-enhancing educational materials-even at the expense of programme effectiveness. Opt-in recommendations and more 'consumer-oriented' qualitative research are needed.
Collapse
Affiliation(s)
- Bernt-Peter Robra
- Institute for Social Medicine and Health Services Research, Otto-von-Guericke-University Magdeburg, Leipziger Str. 44, D-39140, Magdeburg, Germany.
| |
Collapse
|
3
|
Hoffmann S, Crispin A, Lindoerfer D, Sroczynski G, Siebert U, Mansmann U, Consortium FARKOR. Evaluating the effects of a risk-adapted screening program for familial colorectal cancer in individuals between 25 and 50 years of age: study protocol for the prospective population-based intervention study FARKOR. BMC Gastroenterol 2020; 20:131. [PMID: 32370777 PMCID: PMC7201550 DOI: 10.1186/s12876-020-01247-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 03/27/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Colorectal cancer (CRC) is the second most common malignant disease and the second most common cause of cancer death in Germany. Official CRC screening starts at age 50. As there is evidence that individuals with a family history of CRC have an increased risk of developing CRC before age 50, there are recommendations to start screening for this group earlier. This study aims to evaluate the clinical and economic effects of a risk-adapted screening program for CRC in individuals between 25 and 50 years of age with potentially increased familial CRC risk. METHODS FARKOR (Familiäres Risiko für das Kolorektale Karzinom) is a population-based prospective intervention study. All members of cooperating statutory health insurance companies between 25 and 50 years of age living in a model region in Germany (federal state of Bavaria, 3.5 million inhabitants in this age group) can participate in the program between October 2018 and March 2020. Recruitment takes place through physicians and through a public campaign. Additionally, insurances contact recently diagnosed CRC patients in order to encourage their relatives to participate in the program. Physicians assess a participant's familial history of CRC using a short questionnaire. All participants with a family history of CRC are invited to a shared decision making process to decide on further screening options consisting of either undergoing an immunological test for fecal occult blood or colonoscopy. Comprehensive data collection based on self-reported lifestyle information, medical documentation and health administrative databases accompanies the screening program. Longterm benefits, harms and the cost-effectiveness of the risk-adapted CRC screening program will be assessed by decision analytic modeling. DISCUSSION The data collected in this study will add important pieces of information that are still missing in the evaluation of the effects and the cost-effectiveness of a risk-adapted CRC screening strategy for individuals under 50 years of age. TRIAL REGISTRATION German Clinical Trials Register, DRKS-IDDRKS00015097.
Collapse
Affiliation(s)
- Sabine Hoffmann
- Department for Medical information Processing, Biometry, and Epidemiology, Ludwig-Maximilians University, Munich, D-81377 Germany
| | - Alexander Crispin
- Department for Medical information Processing, Biometry, and Epidemiology, Ludwig-Maximilians University, Munich, D-81377 Germany
| | - Doris Lindoerfer
- Department for Medical information Processing, Biometry, and Epidemiology, Ludwig-Maximilians University, Munich, D-81377 Germany
| | - Gaby Sroczynski
- Institute of Public Health, Medical Decision Making and HTA, UMIT - Private University for Health Sciences, Medical Informatics and Technology GmbH, Hall in Tirol, A-6060 Austria
| | - Uwe Siebert
- Institute of Public Health, Medical Decision Making and HTA, UMIT - Private University for Health Sciences, Medical Informatics and Technology GmbH, Hall in Tirol, A-6060 Austria
| | - Ulrich Mansmann
- Department for Medical information Processing, Biometry, and Epidemiology, Ludwig-Maximilians University, Munich, D-81377 Germany
- German Cancer Consortium (DKTK), Im Neuenheimer Feld 280, Heidelberg, D-69120 Germany
| | - FARKOR Consortium
- Department for Medical information Processing, Biometry, and Epidemiology, Ludwig-Maximilians University, Munich, D-81377 Germany
| |
Collapse
|
4
|
Abstract
This article explains some important concepts of screening and early detection. It also discusses under which circumstances screening is useful, who can profit from screening and which persons may be at risk from screening procedures. Before the introduction of a screening program, empirical studies on the effectiveness are necessary to evaluate whether a screening program could be successful.
Collapse
|
5
|
Stock C, Hoffmeister M, Birkner B, Brenner H. Inter-physician variation in follow-up colonoscopies after screening colonoscopy. PLoS One 2013; 8:e69312. [PMID: 23874941 PMCID: PMC3715496 DOI: 10.1371/journal.pone.0069312] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 06/07/2013] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND AND AIMS Surveillance is an integral part of the colorectal cancer (CRC) screening process. We aimed to investigate inter-physician variation in follow-up procedures after screening colonoscopy in an opportunistic CRC screening program. METHODS A historical cohort study in the German statutory health insurance system was conducted. 55,301 individuals who underwent screening colonoscopy in 2006 in Bavaria, Germany, and who were not diagnosed with CRC were included. Utilization of follow-up colonoscopies performed by the same physician (328 physicians overall) within 3 years was ascertained. Mixed effects logistic regression modelling was used to assess the effect of physicians and other potential predictors (screening result, age group, and sex) on re-utilization of colonoscopy. Physicians were grouped into quintiles according to individual effects estimated in a preliminary model. Predicted probabilities of follow-up colonoscopy by screening result and physician group were calculated. RESULTS The observed rate of follow-up colonoscopy was 6.2% (95% confidence interval: 5.9-6.4%), 18.6% (17.8-19.4%), and 37.0% (35.5-38.4%) after negative colonoscopy, low-risk adenoma and high-risk adenoma detection, respectively. All considered predictors were statistically significantly associated with follow-up colonoscopy. The predicted probabilities of follow-up colonoscopy ranged from 1.7% (1.4-2.0%) to 11.0% (10.2-11.7%), from 7.3% (6.2-8.5%) to 35.1% (32.6-37.7%), and from 17.9% (15.5-20.6%) to 56.9% (53.5-60.3%) in the 1(st) quintile (lowest rates of follow-up) and 5(th) quintile (highest rates of follow-up) of physicians after negative colonoscopy, low-risk adenoma and high-risk adenoma detection, respectively. CONCLUSIONS This study suggests substantial inter-physician variation in follow-up habits after screening colonoscopy. Interventions, including organizational changes in CRC screening should be considered to reduce this variation.
Collapse
Affiliation(s)
- Christian Stock
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | | | | | | |
Collapse
|
6
|
Spix C, Blettner M. Screening: part 19 of a series on evaluation of scientific publications. DEUTSCHES ARZTEBLATT INTERNATIONAL 2012; 109:385-90. [PMID: 22690254 DOI: 10.3238/arztebl.2012.0385] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Accepted: 01/24/2012] [Indexed: 01/10/2023]
Abstract
BACKGROUND The early detection of cancer and other diseases is generally considered beneficial, yet there is evidence that in some diseases screening may be of limited benefit. To clarify this issue, we present the statistical principles that underlie screening. Methods We define screening and discuss the conditions for its successful use. We give illustrative examples from among the currently recommended types of screening in Germany and from the recent medical literature, particularly with regard to mammography. RESULTS Certain specific conditions must be fulfilled for screening to be beneficial (usually measured by reduced mortality): The screening procedure must be of high quality, and the screening intervals must be well adapted to the distribution of the sojourn time. Alongside its benefits, screening can also cause harm, particularly to the many patients who are given a false positive test result. According to German law, potential participants are entitled to being given all information necessary to make an informed decision about screening. CONCLUSION Just like clinical interventions, screening programs should be evaluated before they are introduced or, at the latest, at the time of their introduction.
Collapse
Affiliation(s)
- Claudia Spix
- German Childhood Cancer Registry, Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg University Mainz, Germany.
| | | |
Collapse
|
7
|
Kolligs FT, Crispin A, Munte A, Wagner A, Mansmann U, Göke B. Risk of advanced colorectal neoplasia according to age and gender. PLoS One 2011; 6:e20076. [PMID: 21629650 PMCID: PMC3101231 DOI: 10.1371/journal.pone.0020076] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Accepted: 04/22/2011] [Indexed: 12/16/2022] Open
Abstract
Background Colorectal cancer (CRC) is one of the leading causes of cancer related morbidity and death. Despite the fact that the mean age at diagnosis of CRC is lower in men, screening by colonoscopy or fecal occult blood test (FOBT) is initiated at same age in both genders. The prevalence of the common CRC precursor lesion, advanced adenoma, is well documented only in the screening population. The purpose of this study was to assess the risk of advanced adenoma at ages below screening age. Methods and Findings We analyzed data from a census of 625,918 outpatient colonoscopies performed in adults in Bavaria between 2006 and 2008. A logistic regression model to determine gender- and age-specific risk of advanced neoplasia was developed. Advanced neoplasia was found in 16,740 women (4.6%) and 22,684 men (8.6%). Male sex was associated with an overall increased risk of advanced neoplasia (odds ratio 1.95; 95% confidence interval, CI, 1.91 to 2.00). At any age and in any indication group, more colonoscopies were needed in women than in men to detect advanced adenoma or cancer. At age 75 14.8 (95% CI, 14.4–15.2) screening, 18.2 (95% CI, 17.7–18.7) diagnostic, and 7.9 (95% CI, 7.6–8.2) colonoscopies to follow up on a positive FOBT (FOBT colonoscopies) were needed to find advanced adenoma in women. At age 50 39.0 (95% CI, 38.0–40.0) diagnostic, and 16.3 (95% CI, 15.7–16.9) FOBT colonoscopies were needed. Comparable numbers were reached 20 and 10 years earlier in men than in women, respectively. Conclusions At any age and independent of the indication for colonoscopy, men are at higher risk of having advanced neoplasia diagnosed upon colonoscopy than women. This suggests that starting screening earlier in life in men than in women might result in a relevant increase in the detection of asymptomatic preneoplastic and neoplastic colonic lesions.
Collapse
Affiliation(s)
- Frank T Kolligs
- Department of Medicine II, University of Munich, Munich, Germany.
| | | | | | | | | | | |
Collapse
|
8
|
Luboldt W, Volker T, Wiedemann B, Zöphel K, Wehrmann U, Koch A, Toussaint T, Abolmaali N, Middendorp M, Aust D, Kotzerke J, Grünwald F, Vogl TJ, Luboldt HJ. Detection of relevant colonic neoplasms with PET/CT: promising accuracy with minimal CT dose and a standardised PET cut-off. Eur Radiol 2010; 20:2274-85. [PMID: 20503051 PMCID: PMC2914265 DOI: 10.1007/s00330-010-1772-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2009] [Revised: 02/16/2010] [Accepted: 02/19/2010] [Indexed: 12/21/2022]
Abstract
Objective: To determine the performance of FDG-PET/CT in the detection of relevant colorectal neoplasms (adenomas ≥10 mm, with high-grade dysplasia, cancer) in relation to CT dose and contrast administration and to find a PET cut-off. Methods: 84 patients, who underwent PET/CT and colonoscopy (n = 79)/sigmoidoscopy (n = 5) for \documentclass[12pt]{minimal}
\usepackage{amsmath}
\usepackage{wasysym}
\usepackage{amsfonts}
\usepackage{amssymb}
\usepackage{amsbsy}
\usepackage{mathrsfs}
\usepackage{upgreek}
\setlength{\oddsidemargin}{-69pt}
\begin{document}$${\left( {{\hbox{79}} \times {\hbox{6}} + {\hbox{5}} \times {\hbox{2}}} \right)} = {\hbox{484}}$$\end{document} colonic segments, were included in a retrospective study. The accuracy of low-dose PET/CT in detecting mass-positive segments was evaluated by ROC analysis by two blinded independent reviewers relative to contrast-enhanced PET/CT. On a per-lesion basis characteristic PET values were tested as cut-offs. Results: Low-dose PET/CT and contrast-enhanced PET/CT provide similar accuracies (area under the curve for the average ROC ratings 0.925 vs. 0.929, respectively). PET demonstrated all carcinomas (n = 23) and 83% (30/36) of relevant adenomas. In all carcinomas and adenomas with high-grade dysplasia (n = 10) the SUVmax was ≥5. This cut-off resulted in a better per-segment sensitivity and negative predictive value (NPV) than the average PET/CT reviews (sensitivity: 89% vs. 82%; NPV: 99% vs. 98%). All other tested cut-offs were inferior to the SUVmax. Conclusion: FDG-PET/CT provides promising accuracy for colorectal mass detection. Low dose and lack of iodine contrast in the CT component do not impact the accuracy. The PET cut-off SUVmax ≥ 5 improves the accuracy.
Collapse
|