Eight years of colonoscopic bowel cancer screening in Germany: initial findings and projections

Triage May Improve Selection to Colonoscopy and Reduce the Number of Unnecessary Colonoscopies

Implementation of population screening for colorectal cancer by direct colonoscopy or follow-up colonoscopy after a positive fecal blood test has challenged the overall capacity of bowel examinations. Certain countries are facing serious colonoscopy capacity constraints, which have led to waiting lists and long time latency of follow-up examinations. Various options for improvement are considered, including increased cut-off values of the fecal blood tests. Results from major clinical studies of blood-based, cancer-associated biomarkers have, however, led to focus on a Triage concept for improved selection to colonoscopy. The Triage test may include subject age, concentration of hemoglobin in a feces test and a combination of certain blood-based cancer-associated biomarkers. Recent results have indicated that Triage may reduce the requirements for colonoscopy by around 30%. Such results may be advantageous for the capacity, the healthcare budgets and in particular, the subjects, who do not need an unnecessary, unpleasant and risk-associated bowel examination.

Quality of colonoscopy in an emerging country: A prospective, multicentre study in Russia

BACKGROUND

The quality of colonoscopy has been related to a higher risk of interval cancer, and this issue has been addressed extensively in developed countries. The aim of our study was to explore the main quality indicators of colonoscopy in a large emerging country.

METHODS

Consecutive patients referred for colonoscopy in 14 centres were prospectively included between July and October 2014. Before colonoscopy, several clinical and demographic variables were collected. Main quality indicators (i.e. caecal intubation rate, (advanced) adenoma detection rate, rate of adequate cleansing and sedation) were collected. Data were analysed at per patient and per centre level (only for those with at least 100 cases). Factors associated with caecal intubation rate and adenoma detection rate were explored at multivariate analysis.

RESULTS

A total of 8829 (males: 35%; mean age: 57 + 14 years) patients were included, with 11 centres enrolling at least 100 patients. Screening (including non-alarm symptoms) accounted for 59% (5188/8829) of the indications. Sedation and split preparation were used in 26% (2294/8829) and 25% (2187/8829) of the patients. Caecal intubation was achieved in 7616 patients (86%), and it was ≥85% in 8/11 (73%) centres. Adenoma detection rate was 18% (1550/8829), and it was higher than 20% in five (45%) centres, whilst it was lower than 10% in four (33%) centres. At multivariate analysis, age (OR: 1.020, 95% CI: 1.015-1.024), male sex (OR: 1.2, 95% CI: 1.1-1.3), alarm symptoms (OR: 1.8, 95% CI: 1.7-2), split preparation (OR: 1.4, 95% CI: 1.2-1.6), caecal intubation rate (OR: 1.6, 95% CI: 1.3-1.9) and withdrawal time measurement (OR: 1.2, 95% CI: 1.6-2.1) were predictors of a higher adenoma detection rate, while adequate preparation (OR: 3.4: 95% CI: 2.9-3.9) and sedation (OR: 1.3; 95% CI: 1.1-1.6) were the strongest predictors of caecal intubation rate.

CONCLUSIONS

According to our study, there is a substantial intercentre variability in the main quality indicators. Overall, the caecal intubation rate appears to be acceptable in most centres, whilst the overall level of adenoma detection appears low, with less than half of the centres being higher than 20%. Educational and quality assurance programs, including higher rates of sedation and split regimen of preparation, may be necessary to increase the key quality indicators.

Developments in Screening Tests and Strategies for Colorectal Cancer

BACKGROUND

Worldwide, colorectal cancer (CRC) is the third most common cancer in men and second most common in women. It is the fourth most common cause of cancer mortality. In the United States, CRC is the third most common cause of cancer and second most common cause of cancer mortality. Incidence and mortality rates have steadily fallen, primarily due to widespread screening.

METHODS

We conducted keyword searches on PubMed in four categories of CRC screening: stool, endoscopic, radiologic, and serum, as well as news searches in Medscape and Google News.

RESULTS

Colonoscopy is the gold standard for CRC screening and the most common method in the United States. Technological improvements continue to be made, including the promising "third-eye retroscope." Fecal occult blood remains widely used, particularly outside the United States. The first at-home screen, a fecal DNA screen, has also recently been approved. Radiological methods are effective but seldom used due to cost and other factors. Serum tests are largely experimental, although at least one is moving closer to market.

CONCLUSIONS

Colonoscopy is likely to remain the most popular screening modality for the immediate future, although its shortcomings will continue to spur innovation in a variety of modalities.

[Incidental findings in gastroscopy and colonoscopy]

For many specific and nonspecific gastrointestinal symptoms, endoscopic diagnostic procedures play an important role. Gastroscopy and colonoscopy are easily available diagnostic and interventional procedures with low risk. The technical development of gastrointestinal endoscopy has led to an improvement in diagnostics and therapy. In addition to frequent and expected findings, incidental findings may occur. The incidental findings can distinguish rare diseases of unexpected diagnoses. Rare diagnoses usually require an individualized therapy. Unexpected diagnoses can take place during (not properly detected) or after an endoscopy (overlooked or newly appeared) occur. This overview deals with the question of how to minimize unexpected diagnoses and how to diagnose and treat incidental findings.

Toll-like receptor genetic variants and colorectal cancer

Single-nucleotide polymorphisms in Toll-like receptor 5 (TLR5), encoding a sensor for flagellin, have been shown to influence cytokine responses to intestinal bacteria and to be associated with significant alterations in the survival of colorectal carcinoma (CRC) patients. These findings point to a link between TLRs and CRC that may have both therapeutic and prognostic/predictive implications.

The incidence of colorectal cancer is decreasing in the older age cohorts in the zaanstreek region in the Netherlands: an age-cohort effect

Introduction. Colorectal cancer (CRC) has a high incidence. Removal of adenomas, the precursor lesion, could be helpful in the prevention of cancer. Aim. To investigate the yearly incidence of CRC in consecutive years. Patients and Methods. All patients diagnosed with CRC in the years 1990 till 2010 were studied. Date of diagnosis, age at time of diagnosis, gender, and localisation of the tumour were assessed. Results. A total of 1575 incident CRC were diagnosed, 865 men (55%) and 710 women (45%). CRC occurred more often in men. In the course of the years, the occurrence of CRC increased. After exclusion of rectal cancer, the percentage of proximal cancer in the colon shows a trend towards increase in the consecutive years. In the twenty consecutive years, the population of the Zaanstreek region increased from 130.000 to 145.330. There was a significant increase of CRC in the age cohort 51-70 in the period of twenty years, while a significant decreasing incidence of cancer was seen in patients above 71 years. Conclusion. The decreasing incidence of colorectal cancer in the age cohorts above 71 years possibly reflects indirect evidence of an age-cohort effect due to removal of adenomas in these age cohorts earlier in life.

[Screening for colorectal cancer. Current evidence and novel developments]

CLINICAL ISSUE

Colorectal cancer is one of the leading causes of cancer-related morbidity and mortality. Screening has been demonstrated to reduce both the incidence and mortality of colorectal cancer. In addition to the large group with a normal risk level, two further risk groups need to be distinguished: increased family risk and hereditary colorectal cancer syndromes. STANDARD METHODS FOR SCREENING: The highest evidence for all screening tests has been demonstrated for guaiac-based fecal occult blood testing. Colonoscopy is a diagnostic and therapeutic tool and it serves as the reference standard for other tests in clinical studies.

INNOVATIONS

Fecal immunochemical tests have a higher sensitivity than guaiac-based tests. Several novel techniques are under development and could be adopted by screening programs in the future. Next to colonoscopy, computed tomography (CT) colonography and colon capsule endoscopy have the highest sensitivity for colorectal neoplasia. Molecular tests which are based on the detection of genetic and epigenetic changes of DNA released by the tumor into feces or blood have a high potential and could potentially replace occult blood tests in the future.

PRACTICAL RECOMMENDATIONS

Colonoscopy is the primary instrument for screening for colorectal neoplasia. Fecal occult blood testing should only be performed if colonoscopy is denied and CT colonography has not yet been approved for screening in Germany.

Screening: part 19 of a series on evaluation of scientific publications

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.

Incidence of colorectal cancer in Poland in 1999-2008

INTRODUCTION

Malignant neoplasm of the colon is one of the most common gastrointestinal cancers and takes the second place in terms of incidence in the world. In Asian countries compared with Western countries the incidence is a bit lower. In recent years in Poland there has been a disturbing increase in the incidence of this cancer, particularly in the voivodships Mazowieckie, Slaskie, and Wielkopolskie.

MATERIAL AND METHODS

Statistical data from the National Cancer Registry on the incidence of colorectal cancer in Poland in 1999-2008, including the provinces which are grouped into provinces of Eastern, Western and Central Poland. We analysed data on both men and women, with the division of colon cancer, rectal folds esico and rectum. The analysis took into account the recognized incidence in absolute numbers and age-standardized incidence rates.

RESULTS

The incidence of colon cancer in 1999 was 3438 cases among men and 3476 women, while in 2008 this number increased in both men and women and for men was 4763, and 4340 for women. In all Polish provinces, in 1999, 2165 men and 1719 women, and in 2008, 3188 men and 2150 women suffered from rectal cancer.

CONCLUSIONS

In the years 1999-2008 there was an increase in incidence of cancer of the colon. In Poland, there are territorial differences in the incidence of colorectal cancer described by the standardized incidence ratio. The incidence in Western and Central Poland is generally higher than for Eastern Poland. Probably, these differences have multiple bases.