Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society

Effect of artificial intelligence-aided differentiation of adenomatous and non-adenomatous colorectal polyps at CT colonography on radiologists' therapy management

OBJECTIVES

Adenomatous colorectal polyps require endoscopic resection, as opposed to non-adenomatous hyperplastic colorectal polyps. This study aims to evaluate the effect of artificial intelligence (AI)-assisted differentiation of adenomatous and non-adenomatous colorectal polyps at CT colonography on radiologists' therapy management.

MATERIALS AND METHODS

Five board-certified radiologists evaluated CT colonography images with colorectal polyps of all sizes and morphologies retrospectively and decided whether the depicted polyps required endoscopic resection. After a primary unassisted reading based on current guidelines, a second reading with access to the classification of a radiomics-based random-forest AI-model labelling each polyp as "non-adenomatous" or "adenomatous" was performed. Performance was evaluated using polyp histopathology as the reference standard.

RESULTS

77 polyps in 59 patients comprising 118 polyp image series (47% supine position, 53% prone position) were evaluated unassisted and AI-assisted by five independent board-certified radiologists, resulting in a total of 1180 readings (subsequent polypectomy: yes or no). AI-assisted readings had higher accuracy (76% +/- 1% vs. 84% +/- 1%), sensitivity (78% +/- 6% vs. 85% +/- 1%), and specificity (73% +/- 8% vs. 82% +/- 2%) in selecting polyps eligible for polypectomy (p < 0.001). Inter-reader agreement was improved in the AI-assisted readings (Fleiss' kappa 0.69 vs. 0.92).

CONCLUSION

AI-based characterisation of colorectal polyps at CT colonography as a second reader might enable a more precise selection of polyps eligible for subsequent endoscopic resection. However, further studies are needed to confirm this finding and histopathologic polyp evaluation is still mandatory.

KEY POINTS

Question This is the first study evaluating the impact of AI-based polyp classification in CT colonography on radiologists' therapy management. Findings Compared with unassisted reading, AI-assisted reading had higher accuracy, sensitivity, and specificity in selecting polyps eligible for polypectomy. Clinical relevance Integrating an AI tool for colorectal polyp classification in CT colonography could further improve radiologists' therapy recommendations.

Body mass index and colorectal cancer screening among cancer survivors: the role of sociodemographic characteristics

We examined the association between body mass index (BMI) and guideline-concordant colorectal cancer (CRC) screening utilization among cancer survivors while considering the role of sociodemographic characteristics using a representative sample of the United States. We conducted a cross-sectional analysis utilizing data from the 2022 and 2020 Behavioral Risk Factor Surveillance System. Our outcome of interest was guideline-concordant CRC screening utilization and our exposure of interest was BMI. We performed weighted descriptive statistics and multivariable logistic regression analysis to examine the mentioned associations. Among 44,244 eligible cancer survivors, those who were overweight (84%) had the greatest CRC screening use, followed by those who were obese (81.3%), and underweight/normal weight (79.2%; p values < 0.001). Multivariable logistic regression analysis revealed those who were overweight or obese compared to underweight/normal weight had 1.2-1.3-fold increased odds of having guideline-concordant CRC screening (overweight: OR: 1.27; 95% CI: 1.09-1.49; obese: OR: 1.18; 95% CI: 1.00-1.39). Our subpopulation analyses within the levels of BMI showed that females who were overweight (OR: 0.83; 95% CI: 0.69-1.00) and non-Hispanic other (NHO) survivors who were underweight/normal weight (OR: 0.47; 95% CI: 0.24-0.91) were 17%-53% less likely to be screened for CRC. Our findings indicate that BMI was positively associated with guideline-concordant CRC screening use among cancer survivors. However, female survivors who were obese and NHO survivors who were underweight/normal weight were less likely to be screened for CRC. Cancer survivorship care that integrates weight management and specific sociodemographic characteristics has potential for improving CRC screening adherence.

Potential for enhancing efficacy of screening colonoscopy by lowering starting ages and extending screening intervals: A modelling study for Germany

Studies aimed to evaluate the expected impact of alternative screening strategies are essential for optimizing colorectal cancer (CRC) screening offers, but such studies are lacking in Germany, where two screening colonoscopies (CS) 10 years apart are offered for men from age 50 and women from age 55. Our aim was to explore whether and to what extent the efficacy of utilizing two CS could be enhanced by alternative starting ages and screening intervals. We modeled the expected numbers of CRC cases, CRC deaths, years of potential life lost (YPLL), and disability-adjusted life years (DALYs) due to CRC in hypothetical cohorts of 100,000 men and women aged 45-85 using COSIMO, a validated Markov-based multi-state simulation model. Modeled strategies included combinations of starting ages (45/50/55/60) and CS (10/15/20 years). For men, CRC deaths could be slightly reduced by extending the interval to 15 years, with a second CS at 65. YPLL and DALYs would be reduced by decreasing starting age to 45 when combined with a 15-year screening interval. For women, use of two CS at ages 50 and 65 would reduce all CRC burden parameters compared to the current earliest-use offer at 55 and 65 years. Our results suggest that lowering the starting age of screening colonoscopy to 45 for men and 50 for women, combined with extending the CS screening interval to 15 years would have the potential to enable significant reductions in years of potential life lost, and disability-adjusted life years compared to current screening offers in Germany.

Long-Term Effectiveness Associated With Fecal Immunochemical Testing for Early-Age Screening

Importance

The rising incidence of young-onset colorectal cancer (CRC) has prompted health policymakers to consider lowering the recommended starting age for screening. However, population-based evidence supporting the long-term effectiveness of early-age screening remains limited.

Objective

To evaluate whether initiating fecal immunochemical test (FIT) screening at ages 40 to 49 years, rather than at the currently recommended age of 50 years, reduces CRC incidence and mortality.

Design, Setting, and Participants

This study analyzed a community-based screening cohort of Taiwanese residents aged 40 to 49 years, categorized into 4 subcohorts based on participation in early screening (age 40 to 49 years) and continuation of nationwide regular screening (50 years and older). The cohort was followed up until 2019 to compare CRC incidence and mortality across subcohorts. To mitigate self-selection bias, a delayed screening design and efficient propensity score matching was used, restricting analyses to participants attending regular screening. To validate the findings, an extended nonadherence adjustment was applied to all 4 subcohorts. Data were collected from January 2001 to December 2019, and data were analyzed from January 2021 to December 2024.

Exposures

Biennial FIT screening was initiated for the early screening group at ages 40 to 49 years and for the regular screening group at age 50 years, with follow-up continuing under Taiwan's national screening program.

Main Outcomes and Measures

Primary outcomes were CRC incidence and mortality rates, reported as cases per 100 000 person-years, with adjusted relative risks (aRRs) comparing early vs regular screening groups.

Results

Of 263 125 included participants, 146 796 (55.8%) were female. A total of 39 315 participated in early and regular screening, and 223 810 participated in regular screening only. The early screening group exhibited lower CRC incidence (26.1 [95% CI, 22.3-29.9] vs 42.6 [95% CI, 40.5-44.7] per 100 000 person-years) and mortality (3.2 [95% CI, 1.9-4.6] vs 7.4 [95% CI, 6.5-8.2] per 100 000 person-years). In propensity score-matched analyses, early screening significantly reduced CRC incidence (aRR, 0.79; 95% CI, 0.67-0.94) and mortality (aRR, 0.61; 95% CI, 0.38-0.98). Findings were consistent in the extended nonadherence adjustment model, showing a 25% reduction in incidence (aRR, 0.75; 95% CI, 0.72-0.77) and a 34% reduction in mortality (aRR, 0.66; 95% CI, 0.62-0.71).

Conclusions and Relevance

This study found that initiating FIT screening at age 40 to 49 years was associated with further reduction in CRC mortality and incidence compared with starting screening at age 50 years. These results provide strong empirical support for lowering the CRC screening age, with substantial public health implications.

Circulating Tumor DNA in Addition to Fecal Immunochemical Test in a Dual-Test Colorectal Cancer Screening Approach

BACKGROUND

Early detection is paramount when reducing incidence and mortality of colorectal cancer (CRC). Current population-based screening programs primarily use fecal immunochemical test (FIT) to allocate individuals for colonoscopy although low specificity challenges colonoscopy capacities. We aimed to assess the potential of circulating tumor (ct)DNA markers for early CRC detection in a dual-test CRC screening approach among FIT positive individuals.

METHODS

Plasma samples from 774 FIT positive (≥100 ng Hemoglobin/mL) individuals from the Danish CRC screening program were analyzed for hypermethylated DNA in the genes Branched Chain Amino-acid Transaminase 1 (BCAT1), Ikaros-Family Zinc Finger transcription 1 (IKZF1), and Interferon Regulator Factor 4 (IRF4). Multivariate logistic regression models were generated adding the ctDNA markers and age to the FIT value. The dual-test approach was benchmarked to FIT at specific thresholds.

RESULTS

The dual-test approach improved CRC detection compared to the FIT alone (AUC of 87.2 [95% CI, 82.9-91.4] vs AUC of 72.5 [95% CI, 67.0-77.9]). This was also seen when adding advanced adenomas to the outcome resulting in AUCs of 71.8 [95% CI, 67.8-75.8] for the dual-test approach compared to 65.5 [95% CI, 61.3-69.7] for the FIT model alone. Benchmarking the dual-test approach at FIT cut-offs between 100 and 600 ng Hb/mL showed a potential for either reducing the colonoscopy requirement by up to 56% or increasing CRC detection by up to 28%.

CONCLUSIONS

As increasing FIT cutoff will decrease CRC detection rate, application of the ctDNA panel can increase the sensitivity and specificity in a dual-test approach among asymptomatic individuals.

Cancer Screening in Women

Cancer is the second leading cause of death in US women. Lung cancer has the highest mortality rate in the United States, followed by breast cancer, colorectal cancer, and pancreatic cancer. The incidence of new cancer cases per year in the United States is highest for breast cancer, followed by lung cancer, colorectal cancer, and uterine cancer. Cancer incidence and mortality rates are higher for many under-resourced communities. Cancers with effective screening programs include lung, breast, colorectal and cervical cancers. Clinicians should offer screening for these cancers to all women who meet criteria.

The diverse roles of the circadian clock in cancer

A growing part of the human population is affected by circadian misalignment caused by deregulated sleep, increased nighttime light exposure and erratic eating patterns. Thus, circadian rhythms are a key research area, with compelling links to cancer. Here, we review the circadian regulation of critical cellular processes, including immunity, metabolism, cell cycle control and DNA repair, under physiological homeostasis and in cancer. We discuss the divergent evidence indicating tissue-specific roles of the circadian clock in different cancer types and the potential link between circadian misalignment and early-onset cancers. Finally, we outline how understanding the circadian clock can improve cancer prevention and chronomedicine-based therapies.

Diagnostic value of genetic and epigenetic biomarker panels for colorectal cancer detection: a systematic review

PURPOSE

Exploration of effective screening methods is imperative to improve current screening for colorectal cancer (CRC). Our aim was to systematically search the literature to identify and assess the diagnostic accuracy of both genetic and epigenetic biomarker panels for CRC detection using liquid biopsies for circulating tumour DNA (ctDNA) from stool, blood, or urine.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) with searches in Medline, Embase, CENTRAL, and Web Of Science from inception up to March 20, 2025, using pre-defined keywords. Study quality assessment was performed using QUADAS-2 tool (Quality Assessment for Diagnostic Accuracy Studies 2). Primary and secondary outcomes were panel performance (sensitivity and specificity) for CRC, advanced precancerous lesions (APL), and staging of disease.

RESULTS

Forty-four studies were included. Exceptional performance for both CRC (sensitivity and specificity) and APL (sensitivity) was displayed by biomarker panels including methylated SDC2 with methylated SFRP1/2 (CRC: 91.5%/97.3%, APL: 89.2%) or methylated TFPI2 (CRC: 94.9%/98.1%, APL: 100%), and a 5-biomarker panel of mutational targets APC, Bat-26, KRAS, L-DNA, and p53 (CRC: 91.0%/93.0%, APL: 82.0%). Suboptimal APL sensitivities up to 57.0% were exhibited by Cologuard and variant panels (including KRAS, methylated BMP3, methylated NDRG4, FIT), and 47.8% for combinations including methylated SEPT9.

CONCLUSIONS

High-performance, candidate ctDNA biomarker panels with exceptional diagnostic accuracy for both CRC and APL have been identified. Further work should focus on the development of large-scale studies to justify their clinical implementation.

Profile of colorectal polyps in young patients: A retrospective study

There is an increased incidence of colorectal cancer in young patients, however, the relationship between polyp characteristics and histology is not clearly understood. This study aimed to investigate the prevalence of different histological types of polyps in young patients and risk factors associated with advanced histology. Young patients (aged <45) who underwent polypectomy at Sir Run Run Shaw Hospital (2015-2017, Zhejiang, China) and West China Xiamen Hospital (2023-2024, Xiamen, China) were included. A database of endoscopes was accessed to classify polyps according to endoscopic features. The distribution of polyps and the risk factors associated with advanced histology were reported. The detection rate of polyps among the young adults was 20%, with 47.6% of adenoma. Hyperplastic polyps were second only to tubular adenomas in frequency. Of the 2776 polyps, nearly 85% were sessile, 29.4% were located in the sigmoid colon, and 25.4% were located in the rectum. Among polyps, 87.3% were <10 mm in diameter. Histological features of advanced adenoma were found in 5.3% of patients. Of these, 30.4% occurred in polyps <10 mm. Furthermore, 69.6% were distributed in the distal colorectum. Multivariate logistic regression analysis demonstrated that polyp size and morphology were independent predictors of advanced adenomas. In young patients, polyps are mainly located in the distal colorectum, with tubular adenoma being the predominant type. Large size and pedunculated morphology were independent predictors of advanced polyp histology in young patients. Nearly one-third of the advanced histology cases were associated with small polyps. It is recommended that endoscopists resect all neoplastic polyps found during colonoscopy, especially pedunculated polyps, and submit them for histology.

Multi-target stool DNA and the Fecal Immunochemical Test: A Systematic Review and Meta-analysis on Test Performances

INTRODUCTION

Colorectal cancer (CRC) remains a leading cause of cancer death in the United States. Since the latest USPSTF update, additional studies examining the performance of the multi-target stool DNA (mt-sDNA) and the fecal immunochemical test (FIT) have been published. This analysis builds upon the USPSTF analysis by including recent studies on test performance.

METHODS

PubMed and Embase were searched for manuscripts published between December 4, 2019, and July 9, 2024, using colonoscopy as the reference standard. Double-blinded reviewers screened articles. Primary outcomes were test sensitivity and specificity for CRC, advanced neoplasia (AN), advanced precancerous lesions (APLs), and non-advanced precancerous lesions (NAPLs).

RESULTS

Of 4,320 citations screened, 41 new studies were identified. After combining with 14 studies from the previous USPSTF evidence review, 55 studies were analyzed. Forty-one studies reported the performance of FIT alone, ten of mt-sDNA alone, and four reported FIT and mt-sDNA. Of 14 studies evaluating mt-sDNA, two considered the next-generation mt-sDNA test's CRC sensitivity was 93.6% (95% CI:89.0-97.1) for next-generation mt-sDNA and 71.6% (95% CI:64.3-77.9) for FIT. Specificity was 91.6% (95% CI:89.2-93.7) for next-generation mt-sDNA and 96.3% (95% CI:95.4-97.0) for FIT. APL sensitivity was 22.2% (95% CI:20.6-24.0) for FIT and 45.6% (95% CI:40.8-50.4) for next-generation mt-sDNA.

DISCUSSION

This meta-analysis revealed that mt-sDNA has high sensitivity for detecting CRC and is more than twice as sensitive than FIT for detecting APL. The lifetime benefit and effectiveness of these tests should be further analyzed.

Impact of Digital Navigation on Screening Adherence With the Multi-Target Stool DNA Test

Background: Colorectal cancer (CRC) is the fourth most frequently diagnosed cancer and the second leading cause of cancer-related deaths in the United States. Screening can prevent CRC by detecting advanced precancerous lesions. Adherence to screening is crucial in reducing CRC disease burden; however, there is limited research on the impact of digital outreach screening uptake and adherence. Objective: This study evaluated the impact of different digital outreach channels on patient adherence to CRC screening with a multi-target stool DNA (mt-sDNA) test in a real-world setting. Methods: Patients were individuals aged 45 to 85 years with a valid mt-sDNA test order from Exact Sciences Laboratories, LLC (Jan. 1, 2023-Sept. 23, 2023). All patients received letters and phone calls; some received short message service (SMS), email, or both. Adherence and time to test return were compared across digital outreach categories stratified by patient characteristics. Multivariable regression evaluated the association of digital outreach methods with adherence and time to test return. Results: Among 2 425 308 patients (43.5% between 50 and 64 years, 58.2% female), digital SMS only (62.7%) was the most common outreach method. Overall adherence was 70.1%, with highest adherence in the digital SMS-plus-email group (72.9%). Mean time to test return from shipment of mt-sDNA kit to receipt of valid test was 25.8 days. In adjusted analyses, patients receiving digital SMS plus email had the highest odds of test return (odds ratio, 1.75; 95% confidence interval [CI], 1.73-1.78; P<.001) and had return times 8.7% shorter than the no-digital-outreach group (95% CI, 8.2-9.2; P<.001). Discussion: Among nationally insured individuals within the recommended age range for CRC screening, overall adherence to the mt-sDNA test was in the 70s, with the highest rates in the digital (SMS and email) outreach group and the lowest in the no-digital-outreach group. Conclusions: These findings highlight the importance of multichannel navigation in facilitating completion of CRC screening with the mt-sDNA test.

Burden and Cost of Gastrointestinal, Liver, and Pancreatic Diseases in the United States: Update 2024

BACKGROUND & AIMS

A contemporary report describing the burden and expenditures of gastrointestinal (GI) diseases can be helpful for policy makers, administrators, and researchers. Using the most recent data, we estimated the burden and costs associated with GI diseases in the United States.

METHODS

We generated estimates using data from the Rome Foundation Global Epidemiology Study 2017-2018 (symptoms), National Ambulatory Medical Care Survey 2019 and National Hospital Ambulatory Medical Care Survey 2019 (ambulatory visits), Nationwide Emergency Department Sample 2021 (emergency department visits), National Inpatient Sample 2021 (admissions), Kids' Inpatient Database 2019 (admissions), National Program of Cancer Registries 2001-2021 (cancer incidence), National Center for Health Statistics 2001-2021 (cancer mortality), Centers for Disease Control Wide-ranging Online Data for Epidemiologic Research 2021 (non-cancer mortality), MarketScan Commercial Claims and Encounters data 2002-2021 (endoscopy), MarketScan Medicare Supplemental data 2002-2021 (endoscopy), United Network for Organ Sharing Registry 2023 (transplant), Medical Expenditure Panel Survey 2021 (expenditures), and National Institutes of Health (NIH) 2012-2025 (research).

RESULTS

In 2021, GI health care expenditures totaled $111.8 billion. A GI diagnosis or symptom led to 14.5 million emergency department visits and 2.9 million hospital admissions. There were 315,065 new GI cancers diagnosed. GI diseases caused 281,413 deaths. In 2022, an estimated 23.5 million GI endoscopies were performed. In 2023, the NIH supported $3.6 billion for GI research, which represents 7.4% of the NIH budget.

CONCLUSION

GI diseases are responsible for a considerable and growing burden of health care use and costs. Funding innovative GI science and supporting the practice of GI medicine are critical to meeting the burden of GI illness.

The Old: Is There Any Role for Screening Colonoscopy after the Age of 75? The Surgeon's Perspective

Guidelines recommend individualized decision making for screening colonoscopy for colorectal cancer (CRC) in patients after the age of 75 years due to low additional benefits. That should be taken with a grain of salt, as these recommendations are based on expert opinion and simulation models which do not consider (1) the differences in pathogenesis and cancer biology of CRC in elderly; (2) the risks of colonoscopy in this patient population; (3) and the impact of new surgical and nonsurgical therapies for CRC. In this review, our goal is to bring a surgeon's perspective to understand the role of screening colonoscopy in patients older than 75 years.

The Young: Early-Onset Colon Cancer

Early-onset colorectal cancer (EO-CRC), characterized by diagnosis before the age of 50 years, has emerged as a significant healthcare challenge with increasing global incidence. While traditional risk factors such as family history and inherited syndromes contribute to EO-CRC, a substantial proportion of cases remain sporadic, necessitating further investigation into additional etiological factors. Molecular studies reveal heterogeneity in EO-CRC, with distinct mutational profiles compared to late-onset CRC. Clinical management presents unique considerations, including challenges in early detection and treatment strategies tailored to younger patients. Addressing EO-CRC requires a multidisciplinary approach integrating epidemiological, molecular, and clinical insights to improve prevention, diagnosis, and therapeutic outcomes. Emerging research avenues explore novel biomarkers and therapeutic targets, offering promise for advancing understanding and management of this disease in contemporary oncology practice.

When Should Colon Cancer Screening Begin? The Impact of Early-Onset Colorectal Cancer and the Reality of an Unscreened Older Population

BACKGROUND

Recent increases in colorectal cancer (CRC) incidence and mortality under age 50 have led the US to recommend starting screening at age 45 years instead of 50. Several other countries are now also reconsidering the age to start CRC screening.

AIMS

To aid decision makers in making an informed decision about lowering the starting age of CRC screening in their jurisdictions.

METHODS

In this article, we present the clinical and modeling evidence for the optimal age to start CRC screening and provide a checklist of considerations for decisions on age to start CRC screening.

RESULTS

Two observational studies showed that detection of advanced neoplasia in those aged 45-49 years undergoing colonoscopy was at least as high as in those aged 50-54 years. One Taiwanese study reported a 22% reduction in CRC incidence and a 39% reduction in CRC mortality from FIT screening in those 40-49 years compared to those 50 years and older. Nine modeling studies concluded that lowering the age to start screening to age 45 was cost-effective. However, lowering the start age can have negative spill-off effects, such as increased wait times for diagnostic colonoscopy for symptomatic individuals and decreased screening participation. In an effort to support decision making and prevent negative spill-off, the National Colorectal Cancer Screening Network in Canada proposed a Worksheet to determine the resource impact of earlier screening initiation.

CONCLUSIONS

Lowering the age to start CRC screening to 45 years likely leads to a reduction in CRC incidence and mortality but requires additional healthcare resources. Policy makers can use the worksheet to assess the expected increase and assess the feasibility within their jurisdictions.

Influencing factors of colonoscopy screening in first-degree relatives of hospitalized colorectal cancer patients and preliminary clinical practices to improve the compliance

Objectives

This study aimed to analyze the factors that influence colonoscopy screening in first-degree relatives (FDRs) of patients with colorectal cancer (CRC) and explore the feasibility to invite FDRs to undergo a colonoscopy to improve screening compliance.

Methods

Retrospective analysis based on a prospectively collected database of which FDRs of CRC patients who visited our center between April 2021 and October 2021 and received a questionnaire surgery. The questionnaire contained three aspects: demographic and lifestyle factors, health beliefs, and disease cognition. The FDRs were invited to undergo a colonoscopy and were followed-up by telephone regarding colonoscopy compliance one year later.

Results

In total, 303 FDRs from 256 patients with CRC were analyzed. Among them, 113 underwent colonoscopy, with a colonoscopy compliance rate of 37.3%. The results of the multivariate analysis showed that the FDRs who underwent colonoscopy were older (OR=2.32, p=0.006), had commercial insurance (OR=2.23, p=0.013), had multiple family members with CRC (OR=3.04, p=0.012), had higher cognition of CRC (OR=3.02, p=0.006), had high self-efficacy for disease screening (OR=1.14, p=0.026), and accepted colonoscopy appointment sheet to undergo colonoscopy screening (OR=4.51, p<0.001), which were influencing factors for CRC screening in FDRs.

Conclusion

This study found that FDRs who were ≥40 years old, had commercial insurance, had multiple family members with CRC, had higher cognition of CRC, had high self-efficacy for disease screening, and received a colonoscopy appointment while in the hospital were more willing to undergo colonoscopy screening. Studies could further validate the feasibility of this approach in the future.

CHOICE: A Comprehensive and Coordinated Colorectal Cancer Screening Program in a Large Urban Health System

OBJECTIVE

To develop a coordinated colorectal cancer (CRC) screening program within a large urban health system, with the ultimate goal of increasing system-wide screening rates of eligible patients and reducing no-show rates while increasing colonoscopy completion rates.

STUDY SETTING

A large urban academic health system comprising 8 hospitals and over 400 ambulatory practices.

STUDY DESIGN

The CHOICE Program combined patient navigation, electronic medical record (EMR) optimization, and system-wide practice changes to improve CRC screening completion by colonoscopy. The program incorporates provider and patient education, standardization of documentation and protocols, increased outreach by navigators, and streamlining of patient scheduling. The primary outcome is colonoscopy completion.

DATA COLLECTION

All health system patients between the ages of 45 and 75 and at average risk of CRC are the target population for the intervention. A review of screen-eligible patients' completion of colonoscopy was performed to assess program success.

PRINCIPAL FINDINGS

During a 2-year period (March 2022 to February 2024), 18,119 people were referred into the program, and 79% of scheduled patients completed the colonoscopy. The CHOICE program operationalized and standardized the CRC screening efforts of a large health system and offers a template that can be implemented or adapted by other hospital systems and provider networks.

The effect on colorectal cancer incidence and staging with population-based FOBT-screening in Sweden

AIM

To investigate colorectal cancer (CRC) incidence and stage of disease in the population invited vs. not invited to the guaiac-based Fecal Occult Blood (gFOBT) and Fecal Immunochemical Test (FIT) colorectal cancer screening program in Stockholm-Gotland, Sweden, 2008-2021, and to estimate the incidence rate by sex and localization in the colorectum.

METHODS

The study cohort consisted of all 60-69-years-old residents of the Stockholm-Gotland region 2008-2012 according to the population register. Screening with biennial gFOBT was successively implemented in the region by randomly inviting birth cohorts of the target group to different year of start of screening from 2008 and replaced by FIT with cut-off level 40 µg/g in women and 80 µg/g in men for a positive test in 2015. Record linkage was made to the National Cancer Register and to the Swedish Colorectal Cancer Register (SCRCR). The age-standardized CRC incidence ratio was compared in invited and non-invited during screening and in 70-75-year-olds and assessed overall and by sex, CRC stage and localization.

RESULTS

In total, 320,989 and 151,533 individuals were invited to a first screening and FIT round, and 5,972 CRCs were diagnosed. During screening, the overall age-adjusted incidence ratio for the gFOBT- and FIT-invited compared to the non-invited was 0.99 (95% CI 0.91-1.07) and 1.03 (95% CI 0.93-1.15), respectively. Post screening, 70-75 years of age, the overall incidence rate was 12% lower among the invited than the non-invited (RR 0.88, 95% CI 0.81-0.97). During FIT screening, the incidence for stage I and proximal CRC was 38 and 23% higher than in the non-invited (RR 1.38, 95% CI 1.09-1.76 and RR 1.23, 95% CI 1.02-1.48 respectively). The incidence post screening was 22% lower regarding stage I CRC, 13% lower in women, and 17% lower for distal CRCs as compared to the non-invited (RR 95% CI 0.78 0.63-0.95, 0.87 0.76-1.00 and 0.83 0.74-0.94 respectively).

CONCLUSION

In the Stockholm-Gotland program, the FIT screening significantly increased the incidence rate in early staged and proximal CRCs as compared to the uninvited, and the significant decrease in the overall CRC incidence post screening was mainly seen in distal, early staged CRCs in women.

Clinical analysis of lymphoma with malignant solid tumor simultaneously: a retrospective case series

This study aimed to investigate the clinical features and potential pathogenesis of lymphoma complicated with malignant solid tumors. Clinical data from 35 patients treated at Yantai Yuhuangding Hospital between January 2018 and March 2023 were retrospectively analyzed. Among 1726 lymphoma patients, 35 (2.03%) were found to have solid tumors, including 22 males and 13 females, with a median age of 62 years (range: 49-83 years). The lymphoma subtypes included 14 cases of diffuse large B-cell lymphoma (DLBCL), 8 cases of small lymphocytic lymphoma/chronic lymphocytic leukemia (SLL/CLL), 7 cases of marginal zone lymphoma (MZL), 3 cases of peripheral T-cell lymphoma (PTCL), 2 cases of follicular lymphoma (FL), and 1 case of Waldenström macroglobulinemia (WM). The solid tumors included 9 cases of papillary thyroid carcinoma (PTC), 8 cases of colorectal cancer (CRC), 7 cases of lung cancer (LC), 5 cases of gastric cancer (GC), 2 cases of prostate cancer (PCa), and 1 case each of breast cancer (BC), clear cell renal cell carcinoma (ccRCC), pharyngeal squamous cell carcinoma (PSCC), and bladder cancer (BLCA). Lymphoma with solid tumors is rare, often affecting elderly males. Non-Hodgkin's lymphoma, especially DLBCL, was the most common subtype, and PTC was the most frequent solid tumor. Clinicians should focus on these cases to improve diagnosis and treatment.

Evaluating the impact of hurricanes and the COVID-19 pandemic on colorectal cancer incidence in Puerto Rico: An interrupted time-series analysis

BACKGROUND

Major events, such as Hurricanes Irma and Maria and the coronavirus disease 2019 (COVID-19) pandemic disrupted Puerto Rico's health system. Lack of access to colorectal cancer (CRC) screening services may have impeded timely diagnosis. The authors examined the impact of these events on CRC incidence in Puerto Rico.

METHODS

The Puerto Rico Central Cancer Registry database allowed the authors to obtain CRC cases from 2012 to 2021. An interrupted time-series analysis was performed to examine changes in CRC incidence immediately after and during the periods after the hurricanes and the pandemic. Analysis periods included: pre-hurricanes, post-hurricanes, and post-COVID-19 lockdown restrictions.

RESULTS

We observed a level change of -8.3 CRC cases was observed in the month the hurricanes struck Puerto Rico, corresponding to an immediate decrease of 17.5%. After a slight upward trend, a second decline of 39.4 CRC cases was estimated after the COVID-19 lockdown restrictions, representing an immediate change of -24.2%. By the end of the study, the estimated numbers of patients with early stage CRC patients and those aged 50-75 years did not reach the expected numbers. In addition, CRC cases in patients with late-stage disease and in those aged younger than 50 years and aged 76 years and older exceeded the expected numbers.

CONCLUSIONS

Hurricanes Irma and Maria and the COVID-19 pandemic caused a decrease in CRC incidence in Puerto Rico. This analysis suggests that limited access to CRC screening services during these events likely hindered CRC diagnoses. To fully understand the long-term effects, monitoring of CRC trends will be necessary in the coming years.

Empowering cancer prevention with AI: unlocking new frontiers in prediction, diagnosis, and intervention

Artificial intelligence is rapidly changing our world at an exponential rate and its transformative power has extensively reached important sectors like healthcare. In the fight against cancer, AI proved to be a novel and powerful tool, offering new hope for prevention and early detection. In this review, we will comprehensively explore the medical applications of AI, including early cancer detection through pathological and imaging analysis, risk stratification, patient triage, and the development of personalized prevention approaches. However, despite the successful impact AI has contributed to, we will also discuss the myriad of challenges that we have faced so far toward optimal AI implementation. There are problems when it comes to the best way in which we can use AI systemically. Having the correct data that can be understood easily must remain one of the most significant concerns in all its uses including sharing information. Another challenge that exists is how to interpret AI models because they are too complicated for people to follow through examples used in their developments which may affect trust, especially among medical professionals. Other considerations like data privacy, algorithm bias, and equitable access to AI tools have also arisen. Finally, we will evaluate possible future directions for this promising field that highlight AI's capacity to transform preventative cancer care.

The role of health economic evidence in clinical practice guidelines for colorectal cancer: a comparative analysis across countries

Aim: Colorectal cancer (CRC) is among the most prevalent malignancies globally and causes massive resource consumption and economic burden. Health economic evidence (HEE) has been used in clinical practice guidelines (CPGs) for cancer to facilitate the rational allocation of health resources. However, in certain guideline development organizations, HEE is not yet utilized as a formal decision-making criterion. This study aimed to compare the discrepancies in the utilization of health economics as evidence in CRC CPGs across different countries and review specific features of economic evidence concerning the guidelines' applicability. Materials & methods: A systematic review was conducted using databases including Medline, Embase, CNKI, WanFang, and other guidelines databases to identify CPGs for CRC published in English or Chinese from January 2017 to September 2023. Data on the incorporation and application of HEE were extracted, and the method and quality of cost-effectiveness analysis (CEA) studies were evaluated. Descriptive analyses were used to summarize the results. Results: Out of 53 CPGs from 14 countries, most originated from the USA (n = 17 of 53 [32%]) and Canada (n = 9 of 53 [17%]). Sixty-eight percent (36/53) considered cost justification, and 57% (30/53) incorporated health economics studies as evidence. The included HEE cited in CPGs ranged from 1990 to 2021 and were not aligned with the countries in which the guidelines were issued. Among these CEA studies, 52% (26/50) were related to screening strategies, and 32% (16/50) pertained to treatment measures. The Markov model was the most frequently used (n = 27 of 50 [54%]). Based on the CHEQUE tool, the methodological quality of these CEA studies was inadequate in areas such as multiple data sources, approaches to select data sources, assessing the quality of data, and relevant equity or distribution. Conclusion: In summary, 57% of guidelines incorporated health economics studies as evidence, with a variation between different countries. The included HEE still had deficiencies in methodology and reporting quality. In the future, it is suggested that health economics research should use a standardized methodology and reporting approach to assist in clinical decision making.

Utilizing Quality Improvement Methodology to Address Disparities in Colorectal Cancer Screening Between Faculty and Resident Physicians

Health system data from a large academic medical center revealed a 14% lower rate of colorectal cancer (CRC) screening in resident patient panels compared to faculty patient panels. This resident-led quality improvement (QI) work identified causes for disparities in CRC screening and implemented an innovative panel management intervention to reduce CRC screening disparities. Analysis was conducted across two academic primary care clinics at a single institution. Residents engaged key stakeholders in the CRC screening process to identify causes for disparities and potential solutions in the CRC screening process. A novel interprofessional panel management protocol was implemented to guide residents on how to perform population health strategies to increase CRC screening and to streamline the navigation process. The effectiveness of each intervention in improving CRC screening was analyzed. After four months of protocol implementation, CRC screening for resident patient panels improved from 62 to 68% based on analysis done on a run chart. The difference in CRC screening between faculty and resident patient panels decreased from 14 to 10%, reducing the disparity by 29%. This interprofessional panel management protocol significantly increased the CRC screening rates among patients receiving primary care from resident physicians. This further highlights the importance of multipronged interventions to improve disparities in CRC screening and to improve overall screening rates.

Prevalence of colonoscopy-related adverse events in older adults aged over 65 years: a systematic review and meta-analysis

BACKGROUND

This study aims to assess the occurrence of colonoscopy-related adverse events (AEs) in adults aged over 65 years, as there has been a significant increase in the prevalence of colonoscopies among the elderly compared to two decades ago.

METHODS

A comprehensive search was conducted on 3 June 2024, using the PubMed, Embase, and Cochrane Library databases. Meta-analyses were performed using the generalized linear-mixed model, and the results were presented as pooled rates with relevant 95% confidence intervals (CIs).

RESULTS

We retrieved a total of 15 417 records and included 13 population-based studies. The overall rates of colonoscopy-related perforation and bleeding in the elderly population were 7.8 (95% CI 5.5-11.2; I2  = 94%) and 23.5 (95% CI 9.0-61.3; I2  = 100%) per 10 000 colonoscopies, respectively. The " > 80 years" group had a significantly higher risk of perforation (RR 2.55; 95% CI 1.15-5.66; I2  = 79%) and bleeding (RR 1.23; 95% CI 1.02-1.48; I2  = 0%) compared to the "65-80 years" group. For screening colonoscopies, the rates of perforation and bleeding were 8.5 (95% CI 7.1-10.2; I2  = 0%) and 27 (95% CI 9.0-81.0; I2  = 99%) per 10 000 colonoscopies, respectively. For diagnostic colonoscopies, the rates of perforation and bleeding were 18 (95% CI 16.2-20.0; I2  = 1%) and 16 (95% CI 8.1-31.3; I2  = 98%) per 10 000 colonoscopies, respectively. Compared to non-therapeutic colonoscopies, therapeutic procedures exhibited higher rates of both perforation (1.5 vs. 0.4 per 10 000 colonoscopies) and bleeding (7.1 vs. 0.5 per 10 000 colonoscopies). The prevalence of cardiopulmonary AEs in the elderly population is relatively high, although the definition used varies across different studies.

CONCLUSIONS

We conducted a comprehensive analysis on the prevalence of AEs related to colonoscopy in older adults. Overall, the AE rates remain low. However, we emphasize the importance of enhancing safety protocols to further minimize risks, ensuring that the benefits of colonoscopy continue to outweigh the risks, especially for patients over the age of 80.

Association Between Smoking Status and Prevalence of Advanced Outcomes in Patients With and Without Positive Stool Test Prior to Colonoscopy: Data from the New Hampshire Colonoscopy Registry

BACKGROUND AND AIMS

Our goal was to examine the association between smoking status (current, former, and never) and prevalence of advanced findings in patients with colonoscopy after a positive multi-target stool DNA test (mt-sDNA), patients with colonoscopy after a positive Fecal Immunochemical Test (FIT), and patients with colonoscopy only (no prior stool test).

METHODS

Our main outcome was prevalence of advanced lesions (any colorectal cancer (CRC), advanced adenoma, or advanced serrated polyp). We also looked at advanced adenomas and advanced serrated polyps separately. We performed logistic regressions comparing findings by smoking status within mt-sDNA + , FIT + , and colonoscopy-only patients, adjusting for age, sex, and CRC risk. We also performed logistic regressions within all current smokers comparing outcome odds between each screening method cohort.

RESULTS

Our sample included 967 mt-sDNA + , 498 FIT + , and 58,682 colonoscopy-only patients. Within the FIT + (OR = 2.46; 95%CI 1.16-5.26) and mt-sDNA + (OR = 1.65; 95%CI 1.05-2.59) groups, current smokers had higher odds of advanced serrated polyps than never-smokers (reference). In addition, FIT + current smokers (OR = 1.97; 95%CI 1.11-3.50) or mt-sDNA (OR = 3.27; 95%CI 2.25-4.74) current smokers had higher odds of advanced lesions than colonoscopy-only smokers (reference).

CONCLUSIONS

Within stool-test-positive patients, current smokers have higher odds of advanced serrated polyps than never-smokers, reinforcing the heightened importance of a follow-up colonoscopy in smokers with positive stool tests. We also found higher yields of advanced outcomes in FIT + and mt-sDNA + smokers vs. smokers who underwent colonoscopy without a prior stool test. Endoscopists need to be particularly vigilant in detecting advanced serrated polyps in patients who smoke and have a positive stool test.

Risk of Advanced Adenomas in Siblings Aged ≤ 50 Years of Patients with Early-Onset Colorectal Advanced Adenomas

PURPOSE

The risk of colorectal advanced adenomas (CAAs) and colorectal cancer (CRC) in siblings aged ≤ 50 of patients diagnosed with early-onset CAAs (E-CAAs), defined as having CAA at or below 50 years, is poorly understood. This study examined the risks of adenomas, CAA, and CRC in siblings aged ≤ 50 of patients diagnosed with E-CAA.

METHODS

This case-control study was conducted at a tertiary hospital in Vietnam. The participants included 96 cases who were siblings aged ≤ 50 of patients diagnosed with E-CAA. Controls were randomly selected from consecutive patients aged ≤ 50 who did not have siblings diagnosed with E-CAA. Controls were matched to cases in a 2:1 ratio for age, sex, and smoking status.

RESULTS

The mean age was similar between cases (40.9 ± 6.0 years) and controls (41.1 ± 6.0 years). Except for indications for colonoscopy, there were no significant differences in the baseline demographics between the two groups. A heightened risk of CAA was documented in cases compared with controls (odds ratio [OR] 6.33; 95% confidence interval [CI] 1.43-43.8; P = 0.018). This increased risk was more pronounced in males (OR 13.7; 95% CI 1.23-262; P = 0.006). Cases had higher risks of colorectal adenomas (OR 2.43; 95% CI 1.27-4.67; P = 0.009) and colorectal neoplasia (OR 2.33; 95% CI 1.24-4.40; P = 0.011) than those in controls.

CONCLUSION

Siblings aged ≤ 50 of patients diagnosed with E-CAA have an increased risk of adenomas, CAA, and colorectal neoplasia. CRC screening should be initiated early in these high-risk individuals.

Innovative Applications of Nanopore Technology in Tumor Screening: An Exosome-Centric Approach

Cancer remains one of the leading causes of death worldwide. Its complex pathogenesis and metastasis pose significant challenges for early diagnosis, underscoring the urgent need for innovative and non-invasive tumor screening methods. Exosomes, small extracellular vesicles that reflect the physiological and pathological states of their parent cells, are uniquely suited for cancer liquid biopsy due to their molecular cargo, including RNA, DNA, and proteins. However, traditional methods for exosome isolation and detection are often limited by inadequate sensitivity, specificity, and efficiency. Nanopore technology, characterized by high sensitivity and single-molecule resolution, offers powerful tools for exosome analysis. This review highlights its diverse applications in tumor screening, such as magnetic nanopores for high-throughput sorting, electrochemical sensing for real-time detection, nanomaterial-based assemblies for efficient capture, and plasmon resonance for ultrasensitive analysis. These advancements have enabled precise exosome detection and demonstrated promising potential in the early diagnosis of breast, pancreatic, and prostate cancers, while also supporting personalized treatment strategies. Additionally, this review summarizes commercialized products for exosome-based cancer diagnostics and examines the technical and translational challenges in clinical applications. Finally, it discusses the future prospects of nanopore technology in advancing liquid biopsy toward clinical implementation. The continued progress of nanopore technology not only accelerates exosome-based precision medicine but also represents a significant step forward in next-generation liquid biopsy and tumor screening.

Assessing Public Interest in Mammography, Computed Tomography Lung Cancer Screening, and Computed Tomography Colonography Screening Examinations Using Internet Search Data: Cross-Sectional Study

Background

The noninvasive imaging examinations of mammography (MG), low-dose computed tomography (CT) for lung cancer screening (LCS), and CT colonography (CTC) play important roles in screening for the most common cancer types. Internet search data can be used to gauge public interest in screening techniques, assess common screening-related questions and concerns, and formulate public awareness strategies.

Objective

This study aims to compare historical Google search volumes for MG, LCS, and CTC and to determine the most common search topics.

Methods

Google Trends data were used to quantify relative Google search frequencies for these imaging screening modalities over the last 2 decades. A commercial search engine tracking product (keywordtool.io) was used to assess the content of related Google queries over the year from May 1, 2022, to April 30, 2023, and 2 authors used an iterative process to agree upon a list of thematic categories for these queries. Queries with at least 10 monthly instances were independently assigned to the most appropriate category by the 2 authors, with disagreements resolved by consensus.

Results

The mean 20-year relative search volume for MG was approximately 10-fold higher than for LCS and 25-fold higher than for CTC. Search volumes for LCS have trended upward since 2011. The most common topics of MG-related searches included nearby screening locations (60,850/253,810, 24%) and inquiries about procedural discomfort (28,970/253,810, 11%). Most common LCS-related searches included CT-specific inquiries (5380/11,150, 48%) or general inquiries (1790/11,150, 16%), use of artificial intelligence or deep learning (1210/11,150, 11%), and eligibility criteria (1020/11,150, 9%). For CTC, the most common searches were CT-specific inquiries (1800/5590, 32%) or procedural details (1380/5590, 25%).

Conclusions

Over the past 2 decades, Google search volumes have been significantly higher for MG than for either LCS or CTC, although search volumes for LCS have trended upward since 2011. Knowledge of public interest and queries related to imaging-based screening techniques may help guide public awareness efforts.

Clinicopathological features of early-onset colorectal cancer in Japanese patients: a single-center retrospective study

BACKGROUND

The incidence of early-onset colorectal cancer (EoCRC), defined as CRC diagnosed at < 50 years of age, is increasing globally. However, only a few studies are reported from Japan, and the clinicopathological features of EoCRC in Japanese patients remain unknown.

METHODS

We retrospectively investigated consecutive Japanese patients who were pathologically diagnosed with invasive CRC at our hospital from January 2015 to December 2021. Patients were categorized into those who were diagnosed with CRC at < 50 years (early-onset group) and ≥ 50 years (late-onset group) of age. We compared the clinicopathological findings between the two groups.

RESULTS

The analysis included 731 patients. EoCRC was diagnosed in 46 patients　(6.3% of all patients). Of them, 41.3% demonstrated a positive fecal immunochemical test (FIT) for CRC screening as a diagnostic opportunity, which was significantly higher than that in the late-onset group (p = 0.032). Rectal cancer was significantly more prevalent in the early-onset group compared to the late-onset group (45.7% vs. 26.4%, p < 001). No significant difference in the rate of clinical stage at presentation was found between the two groups. Furthermore, patients with positive FIT were more likely diagnosed at an earlier stage.

CONCLUSIONS

EoCRC among Japanese patients tends to occur on the rectum and is more frequently diagnosed with FIT screening compared to late-onset CRC. Patients with advanced stage were diagnosed by symptoms, indicating the usefulness of FIT screening in diagnosing EoCRC at an early stage.

Colorectal cancer knowledge and screening awareness in Syria: a cross-sectional study

BACKGROUND

Colorectal cancer (CRC) is the third most common cancer globally, with rising incidence in developing countries due to lifestyle and dietary shifts. CRC often presents with late-stage symptoms, leading to higher mortality. Early detection through screening can significantly improve survival rates. In Syria, CRC is the second most common cancer, but screening rates remain low, especially following the decade-long war. This study aims to assess the knowledge of CRC and evaluate the awareness of CRC screening among Syrians to guide prevention and detection strategies.

METHODS

A cross-sectional online survey was conducted from September 27 to October 21, 2023, across six governorates: Damascus, Homs, Aleppo, Latakia, Hama, and Tartus, using a self-administered questionnaire distributed via social media. Statistical analysis was performed using SPSS v28.0, with a Chi-square test to explore differences in knowledge based on socio-demographical factors. Multicollinearity was assessed using the Variance Inflation Factor (VIF), and multinomial regression was performed to confirm relationships established by the Chi-square analysis.

RESULTS

The study included 772 participants, 42.6% of whom were aged 30-35 years. The majority were female (64.4%) and married (56.3%). Only 27.8% considered themselves informed about CRC. While 54.8% had heard of colonoscopy, only 15.4% had undergone the procedure. Significant knowledge gaps were identified, particularly regarding the link between adenocarcinoma polyps and CRC (29.9%), the role of diet (33.2%), and the protective effect of aspirin (17.7%). Individuals aged 50 and above demonstrated higher awareness levels, particularly in recognizing CRC's hereditary nature (p-value = 0.033) and the potential for cure (p-value = 0.012). Education and economic status were also strongly associated with better CRC knowledge, and males generally exhibited higher awareness than females.

CONCLUSION

This study highlights significant gaps in CRC knowledge and screening awareness among Syrians, emphasizing the need to integrate education and complimentary screening into national health policies. Targeted campaigns, nonprofit collaboration, and media engagement are essential to bridge these gaps. Future research should address limitations like sampling bias and the cross-sectional design through longitudinal and comparative studies to guide tailored interventions.

Colorectal cancer early screening: Dilemmas and solutions

Colorectal cancer (CRC) is a prevalent malignancy worldwide, posing a significant public health concern. Mounting evidence has confirmed that timely early screening facilitates the detection of incipient CRC, thereby enhancing patient prognosis. Obviously, non-participation of asymptomatic individuals in screening programs hampers early diagnosis and may adversely affect long-term outcomes for CRC patients. In this letter, we provide a comprehensive overview of the current status of early screening practices, while also thoroughly examine the dilemmas and potential solutions associated with early screening for CRC. In response to these issues, we proffer a set of recommendations directed at governmental authorities and the general public, which focus on augmenting financial investment, establishing standardized screening protocols, advancing technological capabilities, and bolstering public awareness campaigns. The importance of collaborative efforts from various stakeholders cannot be overstated in the quest to enhance early detection rates and alleviate the societal burden of CRC.

Regional patterns of early-onset colorectal cancer from the GEOCODE (Global Early-Onset COlorectal Cancer DatabasE)-European consortium: retrospective cohort study

BACKGROUND

The incidence of early-onset colorectal cancer is increasing, but in Europe this growth shows a heterogeneous pattern in different countries and regions.

METHODS

Patients from six countries who participated in the Global Early-Onset COlorectal Cancer DatabasE (GEOCODE)-Europe group were included. The inclusion criteria were patients with colorectal adenocarcinoma diagnosed between 18 and 49 years of age, between January 2010 and December 2017, with at least 3 years of follow-up. Patients with inherited colorectal cancer syndromes were excluded.

RESULTS

A total of 851 patients were included with almost equal sex distribution, most were diagnosed at age 39 years or older and 42% of patients were overweight or obese. Diagnoses were predominantly at later stages (62.5% stage III-IV) and tumours were predominantly located in the distal colon (76.9% left colon and rectum). Comparative analysis between countries demonstrated that the UK had a younger age at diagnosis and the Italian cohort had a higher prevalence of being overweight or obese. Patients from Luxembourg had more advanced stage diagnoses and those from The Netherlands had more polyps. Patients from the UK had a greater family history of colorectal cancer. Comparison of Mediterranean versus non-Mediterranean countries showed significant differences in the age at diagnosis and body mass index. The prevalence of early-onset colorectal cancer over the age of 40 years in Mediterranean versus non-Mediterranean countries was 71.4% versus 62.1% (P = 0.002), and early-onset colorectal cancer was diagnosed at a more advanced stage in Mediterranean countries versus non-Mediterranean countries (65.3% versus 54.7%; P = 0.033). Family history of colorectal cancer in a first-degree relative was more common in non-Mediterranean versus Mediterranean countries (19.1% versus 11.4%; P < 0.001).

CONCLUSION

This study highlights significant geographical disparities in the clinical, pathological and familial features of early-onset colorectal cancer across European countries.

Random forests algorithm using basic medical data for predicting the presence of colonic polyps

Background

Colorectal cancer is considered to be triggered by the malignant transformation of colorectal polyps. Early diagnosis and excision of colorectal polyps has been found to lower the mortality and morbidity associated with colorectal cancer.

Objective

The aim of this study is to offer a predictive model for the presence of colorectal polyps based on Random Forests machine learning algorithm, using basic patient information and common laboratory test results.

Materials and methods

164 patients were included in the study. The following data was collected: sex, residence, age, diabetes mellitus, body mass index, fasting blood glucose levels, hemoglobin, platelets, total, LDL and HLD cholesterol, triglycerides, serum glutamic-oxaloacetic transaminase, chronic gastritis, presence of colonic polyps at colonoscopy. 80% of patients were included in the training set for creating a Random forests algorithm, 20% were in the test set. External validation was performed on data from 42 patients. The performance of the Random Forests was compared with the performance of a generalized linear model (GLM) and support vector machine (SVM) built and tested on the same datasets.

Results

The Random Forest prediction model gave an AUC of 0.820 on the test set. The top five variables in order of importance were: body mass index, platelets, hemoglobin, triglycerides, glutamic-oxaloacetic transaminase. For external validation, the AUC was 0.79. GLM performance in internal validation was an AUC of 0.788, while for external validation AUC-0.65. For SVN, the AUC - 0.785 for internal validation and 0.685 for the external validation dataset.

Conclusions

A random forest prediction model was developed using patient's demographic data, medical history and common blood tests results. This algorithm can foresee, with good predictive power, the presence of colonic polyps.

Assessment of the frequency and risk factors for colorectal cancer in acromegaly

INTRODUCTION

Acromegaly is associated with a possible increased risk of neoplasias, like colorectal cancer (CRC), although magnitude of this risk is unclear.

OBJECTIVES

Evaluate frequency of colonic adenomatous polyps and CRC in patients with acromegaly at first and subsequent colonoscopies; correlate risk factors of CRC and disease activity of acromegaly with colonoscopy findings and analyze relationship of acromegaly as a risk factor for CRC and the best period for screening this neoplasia.

METHODS

Patients ≥18 years-old with acromegaly were included. A questionnaire involving characteristics of follow-up of acromegaly and risk factors of CRC was created. Biochemical and colonoscopic data were collected through medical records. Only full-length colonoscopies with satisfactory colonic preparation were included.

RESULTS

123 patients (77 women) were included (mean age at diagnosis of 43.1 years and mean follow-up of 13.7 years). In baseline colonoscopy, 80.5% had non-neoplastic findings, 14.6% non-advanced adenomas, 3.3% advanced adenomas and 1.6% CRC. At end of the study, 3 (2.4%) patients were diagnosed with CRC. No patient under 50 years had a neoplastic lesion on colonoscopy. We observed a positive statistically significant relationship between smoking (p = 0.026), age at diagnosis of acromegaly (p < 0.001), age at baseline colonoscopy (p = 0.002), and risk of adenomas and/or CRC at initial colonoscopy.

CONCLUSIONS

Smoking and advanced age were positively related to a higher risk of developing premalignant/malignant colonic lesions. Age ( > 50 years) was the most robust variable. Our data suggest that screening age for CRC in acromegaly should be reviewed.

Timely Completion of Direct Access Colonoscopy Is Noninferior to Office Scheduled for Screening and Surveillance

GOALS

We aimed to evaluate whether direct access colonoscopy (DAC) is noninferior to office-scheduled colonoscopy (OSC) for achieving successful colonoscopy.

BACKGROUND

DAC may improve access to colonoscopy. We developed an algorithm assessing eligibility, risk for inadequate preparation, and need for nursing/navigator assistance.

STUDY

This was a retrospective, single-center study of DAC and OSC patients from June 5, 2018, to July 31, 2019. Patients were 45 to 75 years old with an indication of screening or surveillance. A successful colonoscopy met 3 criteria: complete colonoscopy (cecum, anastomosis, or ileum), adequate preparation (Boston Score ≥2/segment), and performed <90 days from initial patient contact. Unsuccessful colonoscopy did not meet ≥1 criteria. Secondary end points included days to successful colonoscopy, preparation quality, polyp detection, and 10-year recall rate. Noninferiority against risk ratio value of 0.85 was tested using 1-sided alpha of 0.05.

RESULTS

A total of 1823 DAC and 828 OSC patients were eligible. DAC patients were younger, with a greater proportion of black patients and screening indications. For the outcome of successful colonoscopy, DAC was noninferior to OSC (DAC vs. OSC: 62.7% vs. 57.1%, RR 1.16, 95% LCL 1.09, P =0.001). For DAC, days to colonoscopy were fewer, and likelihood of 10-year recall after negative screening greater. Boston Score and polyp detection were similar for groups. Black patients were less likely to achieve successful colonoscopy; otherwise, groups were similar. For unsuccessful colonoscopies, proportionally more DAC patients canceled or no-showed while more OSC patients scheduled >90 days. DAC remained noninferior to OSC at 180 days.

CONCLUSIONS

DAC was noninferior to OSC for achieving successful colonoscopy, comparing similarly in quality and efficiency outcomes.

Adherence to mt-sDNA testing for colorectal cancer screening among new users in a US Black population

OBJECTIVE

Colorectal cancer (CRC) poses significant mortality risks, particularly among Black individuals, who experience the highest CRC incidence and mortality rates in the United States. This study examined adherence to multi-target stool DNA (mt-sDNA) testing in this population.

METHODS

This retrospective cohort analysis used Exact Sciences Laboratories (ESL)-linked claims data from January 2017 to December 2023 on Black patients in the United States aged 45 and older. High-risk individuals, those with payers other than commercial plans, managed care organizations, Medicare Advantage, Medicaid, or Medicare, and individuals with mt-sDNA prescriptions outside the study period were excluded. Adherence was defined as the percentage of patients returning the test kit with valid results within 365 days of shipment. Logistic regression analysis was used to identify factors associated with adherence.

RESULTS

Among 434,951 patients included in the study, the overall adherence to mt-sDNA testing was 62.0% (N = 266,981), with a mean time to adherence of 27.6 days (SD = 44.17). Females, older adults (76+ years), and non-metropolitan residents had higher adherence than males, younger adults, and metropolitan patients (all p < 0.001), respectively. Patients with orders from GI specialists had higher adherence than other prescribing clinicians (NP/PA: OR = 0.39, OB/GYN: OR = 0.54, Other: OR = 0.38, PCP: OR = 0.50; all p < 0.001). Digital outreach, especially SMS and email combination, was also associated with higher adherence (OR = 1.25, p < 0.001).

CONCLUSIONS

This large, national study found a 62.0% adherence rate to mt-sDNA testing among Black individuals. Higher adherence was associated with being female, older age, non-metropolitan residence, and digital outreach. While the findings highlight the promise of mt-sDNA, further research is needed to explore its full potential in improving CRC screening adherence across different demographic groups.

Participation and Yield in Multiple Rounds of Colorectal Cancer Screening Based on Fecal Immunochemical Test: A Systematic Review and Meta-Analysis

INTRODUCTION

The evidence on the cumulative participation and yield in multiple rounds of colorectal cancer (CRC) screening based on fecal immunochemical test is sparse. We aimed to assess the trends in participation and detection for advanced colorectal neoplasm under different screening intervals in multiround fecal immunochemical testing-based CRC screening by synthesizing the current available evidence.

METHODS

PubMed, Embase, and Cochrane were retrieved from January 1, 2002, to April 16, 2024, for potential eligible studies, and then, we synthesized participation and advanced colorectal neoplasm detection rates for each screening round, along with their respective 95% confidence intervals (CIs).

RESULTS

Nineteen studies involving a total of 2,296,071 individuals were included. As screening rounds increased, participation exhibited a gradual consistent increase, reaching 78.45% and 74.97% for annual and biennial screening strategies. For annual screening, the cumulative detection rates for 3 rounds were 1.38% (95% CI: 1.18%-1.63%), 1.95% (95% CI: 1.72%-2.21%), and 2.50% (95% CI: 2.29%-2.72%), respectively. For biennial screening, the cumulative detection rates for 4 rounds were 2.22% (95% CI: 1.22%-3.22%), 3.44% (95% CI: 2.06%-4.82%), 4.26% (95% CI: 2.70%-5.83%), and 5.10% (95% CI: 3.28%-7.29%), respectively. Notably, the per-round detection rate of advanced colorectal neoplasms declined yet as the screening progressed.

DISCUSSION

In population-based CRC screening programs, the participation exhibited a slow upward trend for both screening strategies, but the incremental benefits in CRC detection gradually diminished. Tailored strategies, such as extending intervals for individuals with multiple negative fecal immunochemical testing results, might optimize effectiveness and cost-efficiency in population-based CRC screening.

Diagnostic performance and clinical outcomes of computed tomography colonography in a sick inpatient population

PURPOSE

Though prior studies have proven CTC's efficacy in outpatients, its utility in the inpatient setting has not been studied. We evaluated the efficacy of a modified CTC protocol in the inpatient setting, primarily for patients awaiting organ transplantation.

METHODS

This retrospective study compared a group of inpatient CTCs from 2019 to 2021 and a randomly selected, age-matched 2:1 control group of outpatient CTCs. Both groups were assessed based on established criteria from literature.

RESULTS

10 % (63/652) of CTCs were performed in the inpatient setting, of which 29 were excluded, yielding 34 inpatient cases. 90 % (589/652) of CTCs were performed in the outpatient setting, from which 68 randomly selected, age-matched patients were selected as controls. Significantly more (24 %, 8/34) inpatients expired due to extracolonic causes (vs. 1 %, 1/68 outpatients, p < 0.05). 62 % (21/34) of inpatient CTCs were reported as diagnostic (vs. 74 %, 50/68 outpatient, p = 0.22). Significantly more inpatients (12 %, 4/34) than outpatients (1 %, 1/68) were unable to tolerate two imaging positions (p = 0.02). Subsequent colonoscopy was performed in 24 % (8/34) of inpatients, revealing pathologies including colonic polyps and non-bleeding ulcers. Inpatient CTCs had lower average quality scores, significant for one reviewer (p = 0.009-0.054). Inpatients had a larger number of segments with: >25 % residual fluid (1.22-1.28 inpatients vs. 0.60-0.73 outpatients, p = 0.003-0.026) and inadequate fluid tagging (1.10 inpatients vs. 0.49 outpatients, p = 0.046-0.0501). Distention was not significantly different between groups (p = 0.317-0.410).

CONCLUSION

Quality of inpatient CTC was inferior to outpatient CTCs across several metrics. 24 % undergoing inpatient CTC died of extracolonic causes within 22 months, and most did not have findings warranting intervention, questioning the value of this difficult exam in this patient population. Routine CT may be sufficient to exclude large or metastatic colonic lesions precluding transplant.

Cost Effectiveness of Colorectal Cancer Screening Strategies in Middle- and High-Income Countries: A Systematic Review

BACKGROUND AND AIM

Colorectal cancer (CRC) is a significant global health burden, and screening can greatly reduce CRC incidence and mortality. Previous studies investigated the economic effects of CRC screening. We performed a systematic review to provide the cost-effectiveness of CRC screening strategies across countries with different income levels.

METHODS

We searched relevant scientific databases (PubMed, Embase, Ovid, Web of Science, Scopus) from January 1, 2010, to December 31, 2023. We selected English-language studies related to model-based economic evaluations of CRC screening strategies. Information such as the characters of screening tests, model characteristics, and key cost-effectiveness findings were collected. The net monetary benefit approach was used to compare the outcomes of various strategies.

RESULTS

A total of 56 studies were identified, including 46 from high-income countries (HICs), 6 from upper-middle-income countries (UMICs), and 4 from lower-middle-income countries (LMICs). Most annual fecal occult blood tests and fecal immunochemical tests were cost-saving, and colonoscopy every 10 years was cost-saving. Other strategies involving multitarget fecal FIT-DNA detection, computed tomography colonography, and flexible sigmoidoscopy were cost-effective compared with no screening. Newer strategies such as magnetic resonance colonography every 5 years, annual urine metabolomic tests, and fecal bacterial biomarkers were cost-effective compared with no screening.

CONCLUSION

In our updated review, we found that common CRC screening strategies and magnetic resonance colonography continued to be cost-effective compared with no screening. Areas for further development include accurately modeling the natural history of colorectal cancer and obtaining more evidence from UMICs and LMICs.

Revisiting the starting age of colorectal cancer screening for the average-risk Asian population: a cost-effectiveness analysis

BACKGROUND AND AIMS

One of the most prevalent and fatal tumors, colorectal cancer (CRC), has a significant impact on the use of healthcare services. Although Hong Kong's CRC screening program has been successful, it does not prioritize preventing early-onset CRC in people under age 50 years. This study aimed to assess the cost-effectiveness of different starting ages for CRC screening among an Asian population.

METHODS

We conducted a simulation study involving 100,000 individuals in Hong Kong who were screened using either the fecal immunochemical test (FIT) or colonoscopy as primary screening methods at ages 40, 45, and 50 until age 75. The performance of different strategies was evaluated based on life-years gained, and cost-effectiveness was measured using the incremental cost-effectiveness ratio (ICER).

RESULTS

The ICERs for initiating FIT screening at age 50, screening starting at age 45, and screening starting at age 40 were U.S. dollars (USD) 53,262, USD 67,892, and USD 86,554, respectively. For colonoscopy, the ICERs for initiating screening at ages 50, 45, and 40 were USD 267,669, USD 312,848, and USD 372,090, respectively. Overall, the FIT strategy was found to be less costly. At 70%, 80%, and 90% compliance rates, the FIT at age 45 gained 2135, 2296, and 2438 life-years, respectively, whereas colonoscopy at age 45 gained 2725, 2798, and 2855 life-years, respectively. With increased compliance rates, the FIT could save a similar number of life-years as colonoscopy with lower cost.

CONCLUSIONS

Initiating CRC screening at age 45 using the FIT in Hong Kong was determined to be a well-balanced and cost-effective strategy. This approach demonstrated a cost advantage over starting screening at age 40 and resulted in more lives saved compared with screening at age 50.

Prognostic Differences Between Early-Onset and Late-Onset Colorectal Cancer

Background and Objectives: Early-onset colorectal cancer (EO-CRC) has become a significant public health concern due to its alarming rise in incidence and the poor prognosis associated with this disease. The aim of our study was to identify epidemiological, clinical, and paraclinical characteristics that could explain the more aggressive evolution of EO-CRC compared to late-onset colorectal cancer (LO-CRC). Materials and Methods: We conducted a retrospective study over a two-year period, including 204 patients diagnosed with colorectal cancer (CRC). The patients were divided into two subgroups: those with EO-CRC and those with LO-CRC. Statistical analysis was performed using IBM SPSS Statistics, Version 29.0. Results: EO-CRC was identified in 11.3% of the patients included in the study. Compared to LO-CRC patients, EO-CRC patients exhibited a tendency for more distal tumor localization and a stenotic endoscopic appearance (43.5% vs. 29.3%). Regarding histopathological diagnosis, EO-CRC patients demonstrated a higher proportion of the mucinous histologic subtype (34.8% vs. 14.4%) and a significantly greater percentage of poorly differentiated tumors (39.1% vs. 14.5%; p = 0.010). Immunohistochemical results, available for a limited number of patients, revealed higher CDX2 positivity in LO-CRC patients (p = 0.012) and higher HER2 positivity in EO-CRC patients (p = 0.002). Smoking (p = 0.006) and hypertension (p = 0.002) were more prevalent in EO-CRC patients than in LO-CRC patients. Conclusions: Patients with EO-CRC exhibit distinct histopathological and molecular characteristics compared to those with LO-CRC, which may contribute to their poorer prognoses. The higher prevalence of the mucinous histological subtype, poor tumor differentiation, increased HER2 expression, and reduced CDX2 expression suggest potential molecular pathways driving the aggressive nature of EO-CRC. These findings highlight the need for tailored screening strategies and personalized therapeutic approaches in younger CRC patients. Future studies should further investigate the underlying mechanisms and potential biomarkers that could guide early diagnoses and targeted treatments.

Re-screening adherence to multi-target stool DNA test for colorectal cancer: real-world study in a large national population

PURPOSE

Adherence to colorectal cancer (CRC) re-screening is essential to maximize screening effectiveness. This study assessed adherence to a multi-target stool DNA (mt-sDNA) test among previous users in the USA across different payer types.

METHODS

Data from Exact Sciences Laboratories LLC (01/01/2023-12/31/2023) were used. Insured patients (45-85 years) who were shipped an mt-sDNA test during the data coverage period and had previously completed mt-sDNA screening with a negative result ≥ 2.5 years prior were included. Mt-sDNA re-screening adherence rate and mean time to test return were compared across payer types, and their associations with patient characteristics were assessed using multivariable regression models.

RESULTS

Of 793,567 patients (50-75 years: 89.0%; female: 62.0%), the re-screening adherence rate was 84.0% (from 66.5% for Medicaid to 90.2% for Medicare); mean (standard deviation) time to test return was 20.7 (20.8) days (from 19.2 [19.7] for Medicare to 22.4 [22.2] for Medicaid). Characteristics associated with higher likelihood of re-screening adherence included older ages (odds ratio [OR] = 1.25 and 1.11 for 65-75 and 76-85 years, respectively, relative to 45-49 years), living in a ZIP code with higher median household income (OR = 1.80 for > $200,000 relative to < $50,000), full digital outreach (OR = 1.84 relative to no digital outreach), and ≥ 3rd rounds of screening (OR = 2.44 relative to 2nd round of screening).

CONCLUSION

Adherence to CRC re-screening with mt-sDNA test was high across payer types, with sustained adherence in later rounds of screening. Strategies to improve re-screening rates in subgroups associated with lower re-screening adherence are warranted.

Single-round performance of colorectal cancer screening programs: a network meta-analysis of randomized clinical trials

BACKGROUND

Demonstrating mortality reduction in new colorectal cancer (CRC) screening programs through randomized clinical trials (RCTs) is challenging. We systematically reviewed single-round program performance outcomes using a stepwise approach proposed by the World Endoscopy Organization CRC Screening Committee framework.

METHODS

The MEDLINE, EMBASE, Central, and Ichushi Web databases were searched until October 28, 2024, to find RCTs comparing guaiac-based and immunochemical fecal occult blood testing (gFOBT and FIT), flexible sigmoidoscopy (FS), computed tomographic colonography (CTC), and total colonoscopy (TCS). Paired reviewers screened studies, extracted data, and assessed bias risk. A Bayesian random-effects network meta-analysis was conducted, and the certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach. The primary outcome was advanced neoplasia (AN) detection, and the secondary outcomes were participation and colorectal cancer (CRC) detection, all during the first screening round.

RESULTS

Eighteen RCTs (437,072 invitees) were included. The risk of bias was low or raised some concerns for screening participation, but it was high for detection outcomes. In the network meta-analysis of 15 RCTs not allowing crossover, the FIT-based program had a higher AN detection rate than the gFOBT-based program (relative risk [RR] 2.48; 95% credible interval [CrI] 1.52-4.21; moderate certainty). AN detection rates were not different in the CTC- (RR 1.01; CrI 0.43-2.23; very low certainty) and TCS-based (RR 1.03; CrI 0.54-1.78; low certainty) programs compared with the FS-based program. All the visualization modality programs had higher AN detection rates than the FIT-based program (FS: RR 2.13 [CrI 1.38-3.77]; CTC 2.16 [1.11-4.51]; and TCS 2.19 [1.43-3.48]; all with low certainty). Low event rates precluded definitive conclusions regarding CRC detection (very low to low certainty). The TCS-based program had the worst participation rate (very low to low certainty). Comparative data allowing crossover were limited.

CONCLUSIONS

This is the first network meta-analysis that evaluates program-level initial performance indicators. FIT-based programs likely detect more AN cases than gFOBT-based programs, while FS-, CTC-, and TCS-based programs may outperform FIT. Due to limitations in first-round results, long-term outcomes should be assessed after 10-15 years.

Colorectal Cancer Label-Free Impedimetric Immunosensor for Blood-Based Biomarker CCSP-2

Colorectal cancer (CRC) is one of the most treatable cancers, yet it ranks second in mortality worldwide. Early detection significantly impacts treatment outcomes, but early stage CRC often presents no symptoms or nonspecific symptoms. The current screening methods are invasive and lacks specificity, hindering widespread CRC screening efforts. This underscores the urgent need for improved CRC screening tools. In this study, a label-free impedimetric immunosensor for detecting colon cancer-secreted protein-2 (CCSP-2), which exhibits a mean 78-fold increase in primary colon cancers compared to normal mucosa, was developed. Our cost-effective and noninvasive electrochemical immunosensor for CCSP-2 biomarker detection aims to facilitate early diagnosis and monitoring of CRC. The designed immunosensor features a functionalized gold electrode (Au) modified with cysteine-modified recombinant protein G (RPGCys) to immobilize the CCSP-2 antibody (Ab), and bovine serum albumin (BSA) used to prevent sensor surface fouling. Electrochemical impedance spectroscopy (EIS) and cyclic voltammetry (CV) were employed to analyze the electrochemical response to the binding of CCSP-2 antigen (Ag) and Ab. The changes in relative charge transfer resistance (ΔR ct/R cti) with varying concentrations of Ag were plotted and a calibration curve was established between ΔR ct/R cti and logarithm of Ag concentration to assess sensor's sensitivity. The sensor demonstrated a linear response (R 2 = 0.95) within the range of 10-100 ng/μL, plateauing after 100 ng/μL, with a detection limit of 0.71 ng/μL. Statistical analysis of specificity and selectivity studies showed significant differences in Ag detection compared to blank and nonspecific protein BSA, both with and without cell extracts. This immunosensor effectively detects the CRC biomarker CCSP-2 with high sensitivity and specificity. Integrating this sensor with other sensors for serum CRC biomarkers present a promising approach for developing diagnostic and prognostic tools for CRC.

Colon, colorectal and all cancer incidence increase in the Young due to appendix reclassification

INTRODUCTION

Increases in colon and colorectal cancer incidence among adolescents and young adults (AYAs) have been reported progressively. Most of the increase may be due to an artifact caused by reclassifying appendiceal carcinoids/neuroendocrine tumor (NET) as malignant.

METHODS

Age-adjusted incidence and survival data were obtained from the Surveillance, Epidemiology, and End Results (SEER) SEER22 database.

RESULTS

In AYAs during 2000-2020, appendix cancer had an average annual percent change (AAPC) in incidence increase that in males was 3.7 times greater than the next most increasing cancer (AAPC12.8,95%CI: 10.9-14.6 vs AAPC3.4 [kidney] , 95%CI : 2.7-3.5) and correspondingly in females 2.9-fold greater (AAPC14.6,95%CI : 11.9-17.3 vs AAPC4.2 [pancreas], 95%CI : 3.6-4.8). From 2000-2009 to 2015-2020, appendix cancer incidence increased 17-,6.5-and 2.5-fold in children 0-14, AYAs 15-39, and adults 40-49 years of age, respectively. Carcinoid/NET accounted for 95%, 90% and 80% of appendix cancer increase in the three age groups, respectively. In 3,446 AYAs diagnosed during 2010-2020 with 'malignant' appendix NET, the 6-year cancer specific survival was 99.4% (95%CI , 99.0%to99.6%). From 2000-2009 to 2015-2020, colon carcinoma incidence in AYAs increased 61% with the appendix included, and only 11% with the appendix excluded.

CONCLUSIONS

Reclassification of appendix NET/carcinoids as malignant has artifactually increased the incidence of colon, colorectum, and all cancer in children and AYAs. Appendix NET/carcinoids are rarely fatal in < 40 year-olds and should not be considered as cancer and included in colorectal cancer analyses. To the extent that the appendix artifact occurs in 40-49 year-olds, recommendations for starting colorectal cancer screening earlier may be affected.\.

Trends in Early-Onset Colorectal Cancer in Singapore: Epidemiological Study of a Multiethnic Population

BACKGROUND

Colorectal cancer (CRC) incidence and mortality in those aged 50 years and above have decreased over the past 2 decades. However, there is a rising incidence of CRC among individuals under 50 years of age, termed early-onset colorectal cancer (EOCRC). Patients with EOCRC are diagnosed at an advanced stage and may be in more psychosocial, emotional, and financial distress.

OBJECTIVE

Our study examined the epidemiological shifts in CRC in Singapore, a multiethnic country.

METHODS

CRCs diagnosed at age 20 years and above were identified from the Singapore Cancer Registry (SCR) from 1968 to 2019. Patient characteristics included gender, ethnicity, and age of CRC diagnosis. Population information was obtained from the Department of Statistics Singapore (SingStat). Age-specific incidence rates (ASRs) and age-standardized incidence rates (ASIRs) were calculated. The cohort was divided into 3 age groups: 20-49, 50-64, and ≥65 years. Temporal trends in incidence rates were modeled with joinpoint regression. Birth cohort models were fitted using the National Cancer Institute (NCI) age-period-cohort analysis tool. Cancer-specific survival analysis was performed with the Cox proportional hazards model.

RESULTS

In total, 53,044 CRCs were included, and 6183 (11.7%) adults aged 20-49 years were diagnosed with EOCRC. The ASR of EOCRC rose from 5 per 100,000 population in 1968 to 9 per 100,000 population in 1996 at 2.1% annually and rose to 10 per 100,000 population in 2019 at 0.64% annually. The ASR for CRC among adults aged 50-64 years rose at 3% annually from 1968 to 1987 and plateaued from 1987, while the ASR for adults aged 65 years and above rose at 4.1% annually from 1968 to 1989 and 1.3% annually from 1989 to 2003 but decreased from 2003 onwards at 1% annually. The ASR of early-onset rectal cancer increased significantly at 1.5% annually. There was a continued rise in the ASR of EOCRC among males (annual percentage change [APC] 1.5%) compared to females (APC 0.41%). Compared to the 1950-1954 reference birth cohort, the 1970-1984 birth cohort had a significantly higher incidence rate ratio (IRR) of 1.17-1.36 for rectal cancer, while there was no significant change for colon cancer in later cohorts. There were differences in CRC trends across the 3 ethnic groups: Malays had a rapid and persistent rise in the ASR of CRC across all age groups (APC 1.4%-3%), while among young Chinese, only the ASR of rectal cancer was increasing (APC 1.5%). Patients with EOCRC had better survival compared to patients diagnosed at 65 years and above (hazard ratio [HR] 0.73, 95% CI 0.67-0.79, P<.001) after adjusting for covariates.

CONCLUSIONS

The rise in the incidence of rectal cancer among young adults, especially among Chinese and Malays, in Singapore highlights the need for further research to diagnose CRC earlier and reduce cancer-related morbidity and mortality.

Global burden of colorectal cancer attributable to metabolic risks from 1990 to 2021, with predictions to 2046

BACKGROUND

Metabolic risks are significant factors associated with colorectal cancer. This study aimed to assess global, regional and national burden for CRC attributable to metabolic risks from 1990 to 2021 and to predict mortality by 2046.

METHODS

Data from the Global Burden of Disease Study 2021 were used to quantify deaths, disability-adjusted life years (DALYs), and age-standardized rates of CRC due to metabolic risk factors, disaggregated by sex, age, region, country/territory, and sociodemographic index (SDI). The average annual percentage change (AAPC) was used to analyze temporal trends from 1990 to 2021. Metabolic risks include high fasting plasma glucose (FPG) and high body mass index (BMI). Future mortality trends up to 2046 were forecast using age-period-cohort models.

RESULTS

Globally, CRC deaths attributable to metabolic risks increased 2.47-fold, rising from 73,443 in 1990 to 181,689 in 2021. The global age-standardized mortality rates (ASMRs) and age-standardized rates of DALYs (ASDRs) of CRC attributable to high FPG and ASDRs attributable to high BMI increased from 1990 to 2021. The ASMRs and ASDRs of males was higher than that of females, with increasing trends. Central Europe had the highest ASMRs and ASDRs of CRC attributable to metabolic risks in 2021. Most regions and countries showed increasing trends in ASMR and ASDR for CRC due to metabolic risks, with Andean Latin America, Southeast Asia, and Cabo Verde increasing the most. High-SDI regions had the largest burden of CRC attributable to metabolic risks, while burden of other SDI regions have been significantly increased. A positive association was observed between SDI and age-standardized rates (ASMR: RFPG = 0.803, RBMI = 0.752; ASDR: RFPG = 0.812, RBMI = 0.756). By 2046, the ASMR of CRC attributable to high FPG was projected to remain stable and the ASMR due to high BMI was expected to see a slightly increase.

CONCLUSION

Colorectal cancer deaths and DALYs attributable to metabolic risk factors remain high, particularly in males and high-SDI regions. Further researches into the metabolic mechanisms of CRC and effective treatment strategies are needed.

Risk factors, prevention and screening of colorectal cancer: A rising problem

Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the second leading cause of cancer death worldwide. The leading risk factors for CRC include male gender, age over 50, family history, obesity, tobacco smoking, alcohol consumption, and unhealthy diet. CRC screening methods vary considerably between countries and depend on incidence, economic resources and healthcare structure. Important aspects of screening include adherence, which can vary significantly across ethnic and socioeconomic groups. Basic concepts of CRC screening include pre-stratification of patients by identifying risk factors and then using fecal immunochemical test or guaiac-based fecal occult blood test and/or colonoscopy or radiologic imaging techniques. Technological capabilities for CRC screening are rapidly evolving and include stool DNA test, liquid biopsy, virtual colonography, and the use of artificial intelligence. A CRC prevention strategy should be comprehensive and include active patient education along with targeted implementation of screening.

Assessing the Impact of Media Coverage of the NordICC Trial on Public Perspectives on Colonoscopy for Colorectal Cancer Screening

INTRODUCTION

Screening tests like colonoscopy can prevent colorectal cancer (CRC), yet their effectiveness is often questioned. The Nordic-European Initiative on Colorectal Cancer (NordICC) trial demonstrated that colonoscopy significantly reduces CRC incidence and mortality in per-protocol analysis. However, media coverage of the trial often focused on intention-to-screen findings that showed no change in mortality, possibly contributing to public confusion about colonoscopy benefits. This study aimed to assess whether such media articles undermined public perception and intent to undergo colonoscopic screening.

METHODS

We recruited a US nationally representative sample of unscreened adults aged 45 to 75 years at average CRC risk. Respondents were randomized 1:1 to read either a low-quality or high-quality article on NordICC, as rated by a panel of gastroenterologists. Before and after reading their article, participants reported whether they plan to be screened for CRC with a colonoscopy. Our primary outcome was a negative change in intent to undergo colonoscopic screening.

RESULTS

Among the 2013 participants who completed the survey, 1531 (76.1%) stated they planned to undergo colonoscopy or were undecided before reading the article. After reading the media report, 90 (12.0%) people in the low-quality article arm no longer planned to undergo colonoscopy versus 73 (9.3%) in the high-quality article arm; the difference was not statistically significant (P=0.08).

DISCUSSION

A widely promulgated article about NordICC rated as low-quality did not differentially impact attitudes towards colonoscopic CRC screening compared with another mainstream article rated as high-quality. Our study provides reassurance that most people will not summarily change health behaviors after reading a single article, regardless of perceived accuracy.