Colorectal cancer screening in countries of European Council outside of the EU-28

Why is early detection of colon cancer still not possible in 2023?

Colorectal cancer (CRC) screening is a fundamental tool in the prevention and early detection of one of the most prevalent and lethal cancers. Over the years, screening, particularly in those settings where it is well organized, has succeeded in reducing the incidence of colon and rectal cancer and improving the prognosis related to them. Despite considerable advancements in screening technologies and strategies, the effectiveness of CRC screening programs remains less than optimal. This paper examined the multifaceted reasons behind the persistent lack of effectiveness in CRC screening initiatives. Through a critical analysis of current methodologies, technological limitations, patient-related factors, and systemic challenges, we elucidated the complex interplay that hampers the successful reduction of CRC morbidity and mortality rates. While acknowledging the advancements that have improved aspects of screening, we emphasized the necessity of addressing the identified barriers comprehensively. This study aimed to raise awareness of how important CRC screening is in reducing costs for this disease. Screening and early diagnosis are not only important in improving the prognosis of patients with CRC but can lead to an important reduction in the cost of treating a disease that is often diagnosed at an advanced stage. Spending more sooner can mean saving money later.

Long-term trends in the burden of colorectal cancer in Europe over three decades: a joinpoint regression and age-period-cohort analysis

Background

The burden of colorectal cancer (CRC) in Europe is at a high level, but the epidemiological features have not yet been systematically studied. This study aimed to provide a timely and reliable assessment of the burden and trends of CRC in Europe to provide a scientific basis for its prevention and treatment.

Methods

We analyzed data on CRC in 44 European countries between 1990 and 2019 from the Global Burden of Disease study (GBD) 2019. In addition, the joinpoint regression model was applied to reflect temporal trends. The age-period-cohort model was constructed to explore age, period, and birth cohort effects that influence the risk of morbidity and mortality.

Results

In Europe, new cases, disability-adjusted life years (DALYs) and deaths of CRC rose by 70.01%, 22.88% and 38.04% from 1990 to 2019, respectively. The age-standardized incidence rate (ASIR) has increased, while age-standardized DALY rate and age-standardized mortality rate (ASMR) have declined. We found that men experienced a significantly higher CRC burden than women. Age-period-cohort analysis showed that the risk of incidence and mortality increased with age and time; and it was lower in the later-born cohort than the earlier-born cohort.

Conclusion

ASIR for CRC in Europe generally trended upwards from 1990 to 2019, stabilizing in recent years but still at a high level. CRC burden varied considerably in different countries. There was a pronounced gender difference in CRC burden, and middle-aged and older men should be a priority population for CRC prevention and treatment.

Should we screen for colorectal cancer in people aged 75 and over? A systematic review - collaborative work of the French geriatric oncology society (SOFOG) and the French federation of digestive oncology (FFCD)

BACKGROUND

We have done a systematic literature review about CRC Screening over 75 years old in order to update knowledge and make recommendations.

METHODS

PUBMED database was searched in October 2021 for articles published on CRC screening in the elderly, and generated 249 articles. Further searches were made to find articles on the acceptability, efficacy, and harms of screening in this population, together with the state of international guidelines.

RESULTS

Most benefit-risk data on CRC screening in the over 75 s derived from simulation studies. Most guidelines recommend stopping cancer screening at the age of 75. In private health systems, extension of screening up to 80-85 years is, based on the life expectancy and the history of screening. Screening remains effective in populations without comorbidity given their better life-expectancy. Serious adverse events of colonoscopy increase with age and can outweigh the benefit of screening. The great majority of reviews concluded that screening between 75 and 85 years must be decided case by case.

CONCLUSION

The current literature does not allow Evidence-Based Medicine propositions for mass screening above 75 years old. As some subjects over 75 years may benefit from CRC screening, we discussed ways to introduce CRC screening in France in the 75-80 age group. IRB: An institutional review board composed of members of the 2 learned societies (SOFOG and FFCD) defined the issues of interest, followed the evolution of the work and reviewed and validated the report.

Colorectal Cancer: A Systematic Review of the Current Situation and Screening in North and Central Asian Countries

The prevalence of colorectal cancer (CRC) is increasing in the past few decades. A significant proportion of this increase is from low to middle income countries (LMIC). CRC prevalence is also increasing in North and Central Asian Countries (NCAC). Screening for colorectal cancer has decreased CRC mortality but data regarding screening practices in NCAC is limited.  A literature search was conducted in PubMed/Medline, Embase and Cochrane for current colorectal cancer screening practices in NCAC. Incidence and mortality rates were derived from public health agency websites to calculate age-standardized CRC mortality-to-incidence ratios. Web-based online break-point testing defined as statistical major changes in CRC mortality trends was completed. Among the 677 screened studies, 37 studies met the criteria for inclusion for review. CRC screening in NCAC is not organized, although most countries have cancer registries. The data availability is scarce, and most data is prior to 2017. Most studies are observational. There is minimal data about colonoscopy preparations, adenoma detection and complications rates. The polyp detection rates (PDRs) and adenoma detection rates (ADRs) seem low to optimal in this region. Commonly measured outcomes include participation rate, fecal immunochemical tests (FIT) positivity rate and cost-benefit measures. Lower mortality-to-incidence ratios is seen in countries with screening programs. Kazakhstan and Lithuania with screening programs have achieved breakpoint suggesting major changes in CRC mortality trends. Data about CRC screening varies widely within NCAC. High human developmental index (HDI) countries like Lithuania and Estonia have higher incidence of CRC and mortality. Seven NCAC have CRC screening programs with most utilizing non-invasive methods for screening. Data collection is regional and not organized. The ADR and PDR are low to optimal in this region and cancer detection rates are comparable to other high-income countries (HIC). CRC detection rate is 0.05% for screening in Kazakhstan and 0.2% for screening in Lithuania. Very limited information is available on the actual cost and logistics of implementing a CRC screening program. All NCAC have a cancer registry, with some having a high-quality registry showing national coverage with good validity and completeness. Establishing guideline-based registries and increasing screening efficacy could improve CRC outcomes in NCAC.

Numerical modelling of WNT/β-catenin signal pathway in characterization of EMT of colorectal carcinoma cell lines after treatment with Pt(IV) complexes

BACKGROUND AND OBJECTIVE

Colorectal cancer (CRC) is at the top of the most common cancer types in the world, with significant mortality rates among both men and women. Deregulation of Wnt/β-catenin pathway and cell-cell junctions' components, acquisition of invasive phenotype, epithelial-mesenchymal transition (EMT) and invasion are important for development and progression of colorectal cancer. Numerical simulation presents method for estimation of the Wnt pathway via its individual components in cells, thus providing information about EMT, migratory and invasive potential. By using this numerical model, the effectiveness of treatment in EMT suppression can be assessed. Furthermore, the model can be adapted to ``every'' cell type, application time or duration of treatment can be also modified.

METHODS

We characterized colorectal cancer (CRC) cell lines (HCT-116, SW-480) from the aspect of EMT, via markers β-catenin and E-cadherin using numerical modeling. To confirm the numerical model, cells were treated with sublethal concentrations of platinum(IV) complexes and their ligands. We confirmed β-catenin regulated expression of mesenchymal markers: N-cadherin, Vimentin and MMP-9, and decreased E-cadherin expression. Treatment-induced changes were determined in the protein expression of tested markers and results showed cell-specific responses. Molecular docking was performed to investigate exact effects of treatments on E-cadherin and β-catenin in cell-cell junctions and individually in tested cells.

RESULTS

The application of the numerical model via β-catenin and E-cadherin (experimentally measured), is largely valid for the categorization of EMT progression in cells. This numerical modeling better characterizes cells with single cell migration, higher expression of mesenchymal markers, and advanced mesenchymal phenotype like HCT-116 cell line. The model was validated for the treatments and results show HCT-116 cells as more sensitive to applied compounds, among which ligands were more potent in reducing migration and invasiveness. Anti-migratory/invasive effects were due to increased E-cadherin, cytoplasmic β-catenin expression and suppressed mesenchymal markers. In silico methods showed higher affinity of tested chemicals towards free β-catenin, which is the key for regulation of migratory/invasive potential.

CONCLUSIONS

Our study shows that, no matter individual properties of cell lines and EMT degree, de novo formation of intercellular junctions stands in the basis of anti-migratory/invasive process.

Global Health 101

Global health is an evolving field that has been broadly defined as the promotion of health for all through transnational collaboration and research. It centers on the concepts of equity and collaboration. The focus of global health has recently undergone a major shift toward emphasizing the importance of a systems-based approach to healthcare delivery, which considers not only the target disease but also the many contextual factors, influencing the ability to deliver care equitably to a population to reduce the burden of any particular disease. Thus, an important global health delivery framework has been established to outline this inter- and multi-disciplinary systems-based to address major global health issues and improve health for all globally. The practice of global health, whether in research or in active intervention, necessitates guiding principles to ensure ethical conduct in the transnational partnerships and efforts to advance the field. With the introduction of the United Nations' Sustainable Development Goals in 2015, there has been a major shift in response to epidemiologic transition to focus on reducing the burden of noncommunicable diseases, including cancer, which disproportionately impact low-to-middle income countries. This is true for colorectal cancer, with care challenged by significant gaps in screening, early detection, and referral systems.

Colonoscopy Needs for Implementation of a Colorectal Cancer Screening Program in Ukraine

BACKGROUND

In Ukraine, there is no established colorectal cancer screening program. We aimed to project the number of screening colonoscopies needed for implementation of various CRC screening strategies in Ukraine.

METHODS

We modified a previously developed Markov microsimulation model to reflect the natural history of adenoma and CRC progression among average-risk 50-74-year-olds. We simulated colonoscopies needed for the following screening strategies: no screening, fecal occult blood test yearly, FOBT yearly with flexible sigmoidoscopy every 5 years, FS every 5 years, fecal immunohistochemistry test (FIT) yearly, or colonoscopy every 10 years. Assuming 80% screening adherence, we estimated colonoscopies required at 1 and 5 years depending on the implementation rate. In one-way sensitivity analyses, we varied implementation rate, screening adherence, sensitivity, and specificity.

RESULTS

Assuming an 80% screening adherence and complete implementation (100%), besides a no screening strategy, the fewest screening colonoscopies are needed with an FOBT program, requiring on average 6,600 and 26,800 colonoscopies per 100,000 persons at 1 and 5 years post-implementation, respectively. The most screening colonoscopies are required with a colonoscopy program, requiring on average 76,600 and 101,000 colonoscopies per 100,000 persons at 1 and 5 years post-implementation, respectively. In sensitivity analyses, the biggest driver of number of colonoscopies needed was screening adherence.

CONCLUSIONS

The number of colonoscopies needed and therefore the potential strain on the healthcare system vary substantially by screening test. These findings can provide valuable information for stakeholders on equipment needs when implementing a national screening program in Ukraine.

Calibrating Natural History of Cancer Models in the Presence of Data Incompatibility: Problems and Solutions

The calibration of cancer natural history models is often challenged by a lack of representative calibration targets, forcing modellers to rely on potentially incompatible datasets. Using a microsimulation colorectal cancer model as an example, the purposes of this paper are to (1) highlight the reasons for uncertainty in calibration targets, (2) illustrate practical and generalisable approaches for dealing with incompatibility in calibration targets, and (3) discuss the importance of future research in the area of incorporating uncertainty in calibration. The low quality of data and differences in populations, outcome definitions, and healthcare systems may result in incompatibility between the model and the data. Acknowledging reasons for data incompatibility allows assessment of the risk of incompatibility before calibrating the model. Only a few approaches are available to address data incompatibility, for instance addressing biases in calibration targets and their adjustment, relaxing the goodness-of-fit metric, and validation of the calibration targets to the data not used in the calibration. However, these approaches lack explicit comparison and validation, and so more research is needed to describe the nature and causes of indirect uncertainty (i.e. uncertainty that cannot be expressed in absolute quantitative forms) and identify methods for managing this uncertainty in healthcare modelling.

What can We Learn From High-Performing Screening Programs to Increase Bowel Cancer Screening Participation in Australia?

Background

Colorectal cancer (CRC) is the second most diagnosed cancer in men and women and second most common cause of cancer death in Australia; Australia’s CRC incidence and mortality are among the world’s highest. The Australian National Bowel Cancer Screening Program began in 2006; however, only 33% of those approached for the first time by the Program between 2018 and 2019 returned the kit. Of the 5.7 million kits sent during this period, only 44% were returned. Our aim was to identify practices and features of national bowel cancer screening programs in countries with similar programs but higher screening participation, to identify potential interventions for optimising Australian CRC screening participation.

Methods

We searched published and grey literature for CRC screening programs reporting at least 50% screening participation using postal invitation and free return of iFOBT home kits. Interviews were conducted with cancer registry staff and academic researchers, focused on participant and practitioner engagement in screening.

Results

National programs in Netherlands, Scotland, Denmark, and Finland reported over 50% screening participation rates for all invitation rounds. Shared characteristics include small populations within small geographic areas relative to Australia; relatively high literacy; a one-sample iFOBT kit; national registration systems for population cancer screening research; and screening program research including randomised trials of program features.

Conclusions

Apart from the one-sample kit, we identified no single solution to persistent Australian low uptake of screening. Research including randomised trials within the program promises to increase participation.

Impact

This screening program comparison suggests that within-program intervention trials will lead to increased Australian screening participation.

Colorectal cancer in adolescents and young adults with Lynch syndrome: a Danish register-based study

OBJECTIVE

To assess clinicopathological predictors and prognosis in early-onset colorectal cancer (CRC) in Lynch syndrome with comparison to patients diagnosed from age 40 and up.

DESIGN

National, retrospective register-based case-control study.

SETTING

Danish national hereditary CRC register.

PARTICIPANTS

Individuals with Lynch syndrome diagnosed with CRC from January 1950 to June 2020. The analysis was based on 215 early-onset CRCs diagnosed between 15 and 39 years of age and 574 CRCs diagnosed at age 40-88 years.

MAIN OUTCOME MEASURES

Clinical and histopathological characteristics and survival. Confounding variables were analysed by Cox analysis.

RESULTS

27.2% of the tumours in the Danish Lynch syndrome cohort were diagnosed under age 40. Disease-predisposing alterations in MLH1 and MSH2 were overrepresented in the age 15-39 cohort compared with patients diagnosed over age 40. CRCs diagnosed under age 40 showed an adverse stage distribution with 36.2% stage III-IV tumours compared with 25.8% in the over age 40 group. However, young patients diagnosed with early-stage tumours did have a significantly better prognosis compared with early-stage tumours in the older age group.

CONCLUSIONS

Early-onset CRC in Lynch syndrome is primarily linked to alterations in MLH1 and MSH2 and displays an adverse stage distribution. These observations serve as a reminder of surveillance, symptom awareness and rapid diagnostic handling of CRC in young adults with Lynch syndrome.

The role of anaerobic bacteria in the development and prevention of colorectal cancer: A review study

Colorectal cancer (CRC) is the third most frequently diagnosed cancer in both males and females in the Unites States. Colonoscopy is considered a safe method for screening this disorder; however, it can be challenging for patients. As research on microbiota, especially anaerobic microbiota, has expanded substantially, new links have been determined between anaerobic bacteria and CRC progression. These associations can be useful in screening CRC in the near future. This review discusses current research investigating the presence of anaerobic bacteria, including Bacteroides fragilis, Peptostreptococcus anaerobius, Clostridium septicum, Porphyromonas gingivalis, Fusobacterium nucleatum, and Parvimonas micra in CRC and presents an overview about their mechanisms of action. We also discuss the current anaerobic probiotics used for the treatment and prevention of CRC.

Incidence, mortality, survival, risk factor and screening of colorectal cancer: A comparison among China, Europe, and northern America

Colorectal cancer (CRC) is one of the most common malignancies worldwide. China, Europe and northern America account for more than half of the new CRC cases and associated deaths globally. This review summarizes the current status and temporal trends of CRC in China, Europe, and northern America. The potential primary preventive strategies and latest advances in CRC screening techniques and programs are discussed. Recently, the incidence and mortality of CRC in some European and northern American countries have decreased; conversely, CRC incidence and mortality continue to increase in China. The overall 5-year relative survival rate for CRC is similar between these regions, but there is considerable heterogeneity among European countries. Implementing population-based CRC screening programs can effectively address the growing disease burden. The effectiveness of nationwide CRC screening programs in these regions has been limited by relatively low coverage and participation rate. The deployment of state-of-the-art techniques and precise risk-adapted screening strategies incorporating effective risk prediction models and screening techniques may boost screening effectiveness. Our review provides novel foundations for the development and optimization of CRC preventive strategies.

The implementation of colorectal cancer screening interventions in low-and middle-income countries: a scoping review

BACKGROUND

Low- and middle-income countries (LMICs) experienced increasing rates of colorectal cancer (CRC) incidence in the last decade and lower 5-year survival rates compared to high-income countries (HICs) where the implementation of screening and treatment services have advanced. This review scoped and mapped the literature regarding the content, implementation and uptake of CRC screening interventions as well as opportunities and challenges for the implementation of CRC screening interventions in LMICs.

METHODS

We systematically followed a five-step scoping review framework to identify and review relevant literature about CRC screening in LMICs, written in the English language before February 2020. We searched Medline, Embase, Web of Science and Google Scholar for studies targeting the general, asymptomatic, at-risk adult population. The TIDieR tool and an implementation checklist were used to extract data from empirical studies; and we extracted data-informed insights from policy reviews and commentaries.

RESULTS

CRC screening interventions (n = 24 studies) were implemented in nine middle-income countries. Population-based screening programmes (n = 11) as well as small-scale screening interventions (n = 13) utilised various recruitment strategies. Interventions that recruited participants face-to-face (alone or in combination with other recruitment strategies) (10/15), opportunistic clinic-based screening interventions (5/6) and educational interventions combined with screening (3/4), seemed to be the strategies that consistently achieved an uptake of > 65% in LMICs. FOBT/FIT and colonoscopy uptake ranged between 14 and 100%. The most commonly reported implementation indicator was 'uptake/reach'. There was an absence of detail regarding implementation indicators and there is a need to improve reporting practice in order to disseminate learning about how to implement programmes.

CONCLUSION

Opportunities and challenges for the implementation of CRC screening programmes were related to the reporting of CRC cases and screening, cost-effective screening methods, knowledge about CRC and screening, staff resources and training, infrastructure of the health care system, financial resources, public health campaigns, policy commitment from governments, patient navigation, planning of screening programmes and quality assurance.

Colorectal cancer incidence and mortality after negative fecal immunochemical tests by age 70: A prospective observational study

Limited endoscopy capacity usually represents the main barrier to the extension of screening to subjects older than 70, given the high positivity rate in this age group. We assessed CRC incidence and mortality by number of previous negative fecal immunochemical tests (FIT) among subjects turning 70. We selected persons aged 70 years who had received their last screening invitation when they were 68 or 69 years old within the population-based screening program in the Veneto region of Italy. Subjects with a positive FIT were excluded. We calculated 10-year cumulative CRC incidence and mortality in cohorts of subjects having performed zero, one, two or three negative FITs over the last three screening rounds before turning 70. Out of 117 858 subjects included in the study (46.4% men), 33.7% had never participated in screening (zero negative FITs), 23.3% had had one-negative FIT, 20.1% two-negative FITs and 22.9% three negative FITs. The 10-year cumulative CRC incidence was 29.7 per 1000 subjects with zero FITs, and respectively, 14.5, 11.7 and 9.6 per 1000 subjects with one, two and three negative FITs. The corresponding figures for 10-year cumulative mortality were 9.3, 3.5, 2.2 and 2.1 per 1000 in the four study cohorts. Figures were roughly double for men than for women for all the study cohorts. In order to use more efficiently limited endoscopy resources, and to minimize the potential harms related to false positive results in the elderly, screening among people aged 70 to 74 might be restricted to those with zero previous negative FITs.

The Roadmap of Colorectal Cancer Screening

Colorectal cancer (CRC) is the third most common form of cancer in terms of incidence and the second in terms of mortality worldwide. CRC develops over several years, thus highlighting the importance of early diagnosis. National screening programs based on fecal occult blood tests and subsequent colonoscopy have reduced the incidence and mortality, however improvements are needed since the participation rate remains low and the tests present a high number of false positive results. This review provides an overview of the CRC screening globally and the state of the art in approaches aimed at improving accuracy and participation in CRC screening, also considering the need for gender and age differentiation. New fecal tests and biomarkers such as DNA methylation, mutation or integrity, proteins and microRNAs are explored, including recent investigations into fecal microbiota. Liquid biopsy approaches, involving novel biomarkers and panels, such as circulating mRNA, micro- and long-non-coding RNA, DNA, proteins and extracellular vesicles are discussed. The approaches reported are based on quantitative PCR methods that could be easily applied to routine screening, or arrays and sequencing assays that should be better exploited to describe and identify candidate biomarkers in blood samples.

Association of Colonic Diverticula with Colorectal Adenomas and Cancer

Background and Objectives: Conflicting evidence is reported regarding any association between colonic diverticula with colorectal adenomas or cancer. The present study aimed to evaluate, in a cohort of Caucasian patients, the association between colonic diverticula and colorectal polyps and cancer. Materials and Methods: All consecutive patients undergoing colonoscopy at our institution were included in the study. The presence and location of diverticula, polyps, and cancers were recorded. Histologically, polyps were classified as adenoma (with low or high dysplasia), hyperplastic, or inflammatory. The relative risk of the association of polyps and cancer with diverticula was assessed. Multiple logistic regression analyses, including age, sex, family history for colorectal cancer (CRC), and family history for diverticula, were carried out. Results: During the study period, 1490 patients were enrolled; 37.2% (n = 555) showed colonic diverticula or polyps or CRC (308 males, mean age 66 years). Particularly, 12.3% (n = 183) patients presented only diverticula, 13.7% (n = 204) only polyps or cancer, 11.3% (n = 168) both diseases, and 62.7% (n = 935) neither diverticula nor polyps and cancer. A total of 38 patients presented colorectal cancer, 17 of which had also diverticula. A significant increase in relative risk (RR 2.81, 95% CI 2.27-3.47, p < 0.0001) of colorectal adenoma and cancer in patients with colonic diverticula was found. At multivariate analysis, only diverticula resulted to be significantly associated with colorectal adenomas and cancer (Odds Ratio, OR 3.86, 95% CI 2.90-5.14, p < 0.0001). Conclusions: A significant association of colonic diverticula with colorectal adenoma or cancer was found. This implies that patients with colonic diverticula require a vigilant follow-up procedure for the prevention of colorectal cancer from those applicable to the general population.

Implementation of colorectal cancer screening interventions in low-income and middle-income countries: a scoping review protocol

INTRODUCTION

Colorectal cancer (CRC) imposes a significant global burden of disease. CRC survival rates are much lower in low-income and middle-income countries (LMICs). Screening tends to lead to an improvement in cancer detection and the uptake of available treatments and, in turn, to better chances of cancer survival. Most evidence on CRC screening interventions comes from high-income countries. The objective of this scoping review is to map the available literature on the implementation of CRC screening interventions in LMICs.

METHODS AND ANALYSIS

We will conduct a scoping review according to the framework proposed by Arksey and O'Malley (2005). We will search MEDLINE, EMBASE, Web of Science and Google Scholar using a combination of terms such as "colorectal cancer", "screening" and "low-middle-income countries". Studies of CRC screening interventions/programmes conducted in the general adult population in LMICs as well as policy reviews (of interventions in LMICs) and commentaries on challenges and opportunities of delivering CRC screening in LMICs, published in the English language before February 2020 will be included in this review. The title and abstract screen will be conducted by one reviewer and two reviewers will screen full-texts and extract data from included papers, independently, into a data charting template that will include criteria from an adapted template for intervention description and replication checklist and implementation considerations. The presentation of the scoping review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews guidance.

ETHICS AND DISSEMINATION

There are no ethical concerns. The results will be used to inform colorectal screening interventions in LMICs. We will publish the findings in a peer-reviewed journal and present them at relevant conferences.

Utilisation of Colorectal Cancer Screening Tests in European Countries by Type of Screening Offer: Results from the European Health Interview Survey

In the past two decades, an extensive rollout of colorectal cancer (CRC) screening programmes has been initiated in European countries with a large heterogeneity of screening offers. Using data from a population-based cross-sectional survey conducted between 2013 and 2016 in all European Union countries, we analysed the utilisation of faecal tests and colonoscopy among people aged 50–74 years and the factors associated with uptake by type of screening offer. We observed the highest utilisation of either test for countries with fully rolled out organised programmes with faecal tests (ranging from 29.7% in Croatia to 66.7% in the UK) and countries offering both faecal tests and colonoscopy (from 22.7% in Greece to 70.9% in Germany). Utilisation was very low for countries with no programme (from 6.3% in Romania to 30.5% in Norway). Younger age (50–54 years), longer time since last consultation with a doctor and a lifestyle score associated with increased CRC risk were significantly associated with lower test use, a pattern observed across all types of screening offers. Our results suggest that more countries should implement organised programmes with faecal immunochemical tests, in combination with alternative endoscopy offers where resources allow. Furthermore, there is a large potential for increasing screening use in Europe by better reaching the younger eligible individuals, those who have not been to the doctor recently and those at increased risk for CRC.

Understanding barriers and facilitators to participation in colorectal cancer screening: A French qualitative study

Based on the theory of social representations, this study aims to identify the main determinants to participation in colorectal cancer screening. Six focus groups (N = 29 participants belonging to the general population) were conducted, followed by a theoretical thematic analysis. Screening obstacles are a lack of test's accessibility, a low preoccupation for prevention and the negative image of colorectal cancer. Conversely, screening facilitators are the ease of the new test, being encouraged to get screened and appointment reminder. This study advances understanding of adherence to screening by addressing the beliefs and knowledge surrounding it.

Trends in colorectal cancer incidence in western Kazakhstan through the first decade of the screening implementation, 2009‒2018

Introduction The study is aimed to outline the vector of colorectal cancer incidence in the industrial Aktobe province of western Kazakhstan through the first decade of the screening implementation, 2009–2018.

Methods Rough incidence rates and annual percent changes were estimated for each age group at diagnosis, ethnicities, gender, residences, the disease stages and anatomic subsites (total N 1128) via regression analysis.

Results Within 2009–2018 colorectal cancer rates increased from 14.74 to 23.19, with annual percent changes of 4.69%. The most significant growth was traced in men compared to women, up to 28.39 by 2018, with annual percent changes 6.64% vs. 2.64% (p = 0.0009). Annual percent changes in Kazakhs reached 8.7%, whereas Slavic groups showed decline in the incidence, annual percent changes −4.3% (p = 0.002). Declining in rates was also observed in urban population compared to rural one, annual percent changes −3.3% vs. 17.6%, respectively. Patients aged 60–69 made 31% of all cases and showed the largest annual percent changes 9.37% (p = 0.002). Patients at Stage II made 61% of all observations, but general trend evidenced sharp growth in the group of Stage I (annual percent changes 28.91%, p < 0.0001).

Conclusion Overall, during the last decade colorectal cancer incidence increased 1.5 fold with expected further rise. However, the increment of Stage I portion by 2018 vs. advanced stages at diagnosis and the trend to decrease in rates among urban population inspire a definite assurance in potential efficiency of the screening program in long run. The next researches on colorectal cancer should include scenarios to reveal the role of disadvantaged environment in the region and consuming unhealthy ultra-processed food.

A Correlation Study of the Colorectal Cancer Statistics and Economic Indicators in Selected Balkan Countries

Colorectal cancer (CRC) is one of the most commonly diagnosed malignant neoplasms. The aim of the study was to evaluate and correlate most important epidemiological and economic indicators of CRC in 11 selected Balkan countries. The number of new CRC cases was 56,960, and the highest 5-year CRC prevalence was in Slovenia, Croatia, and Greece. Age-standardized CRC incidence rates were highest in Slovenia, Serbia, and Croatia, and age-standardized mortality rates were highest in Croatia, Serbia, and Bulgaria. Current Health Expenditure as % of Gross Domestic Product was the highest in Bosnia and Herzegovina and Serbia. The GDP per capita levels have shown positive correlation with the CRC incidence rate and prevalence. Absolute numbers of new and death-related CRC cases and 5-year prevalence in absolute numbers have shown strong positive correlation with GDP in million current US$. It has been shown that various economic indicators can be linked to the rate of incidence and prevalence of the CRC patients in the selected Balkan countries. Therefore, economic factors can influence the epidemiology of CRC, and heavy CRC burden in the Balkan region may be one of the indexes of the economic development.

Quantum dots as nanolabels for breast cancer biomarker HER2-ECD analysis in human serum

Early detection of cancer increases the possibility for an adequate and successful treatment of the disease. Therefore, in this work, a disposable electrochemical immunosensor for the front-line detection of the ExtraCellular Domain of the Human Epidermal growth factor Receptor 2 (HER2-ECD), a breast cancer biomarker, in a simple and efficient manner is presented. Bare screen-printed carbon electrodes were selected as the transducer onto which a sandwich immunoassay was developed. The affinity process was detected through the use of an electroactive label, core/shell CdSe@ZnS Quantum Dots, by differential pulse anodic stripping voltammetry in a total time assay of 2 h, with an actual hands-on time of less than 30 min. The proposed immunosensor responded linearly to HER2-ECD concentration within a wide range (10-150 ng/mL), showing acceptable precision and a limit of detection (2.1 ng/mL, corresponding to a detected amount (sample volume = 40 μL) of 1.18 fmol) which is about 7 times lower than the established cut-off value (15 ng/mL). The usefulness of the developed methodology was tested through the analysis of spiked human serum samples. The reliability of the presented biosensor for the selective screening of HER2-ECD was confirmed by analysing another breast cancer biomarker (CA15-3) and several human serum proteins.

Colorectal cancer screening behaviors of general surgeons and first-degree family members: a survey-based study

Background

Colorectal cancer (CRC) screening rates are low in the general population and among health care providers. The aim of this study was to evaluate the CRC screening practices of general surgeons who provide specialized diagnostic testing and CRC treatment and to examine the CRC screening behaviors of their first-degree family members.

Methods

A cross-sectional survey was conducted among general surgeons who attended the 21st National Surgical Congress in Turkey held from April 11th to 15th, 2018. The survey included items on demographics, screening-related attitude, CRC screening options, barriers to CRC screening, and surgeons’ annual volumes of CRC cases.

Results

A total of 530 respondents completed the survey. Almost one-third of the responding surgeons (29.4%, n = 156) were aged over 50 years, among whom approximately half (47.1%, n = 74) reported having undergone CRC screening and preferring a colonoscopy as the screening modality (78.4%). Among general surgeons aged 50 years and older, high-volume surgeons (≥25 CRC cases per year) were more likely to undergo screening compared with low-volume surgeons (< 25 CRC cases per year). The respondents aged below 50 years reported that 56.1% (n = 210) of their first-degree relatives were up-to-date with CRC screening, mostly with colonoscopy. Compared to low-volume surgeons aged below 50 years, high-volume surgeons’ first-degree relatives were more likely to be up-to-date with CRC screening.

Conclusion

The survey results demonstrated that routine screening for CRC among surgeons and/or their first-degree relatives is currently not performed at the desired level. However, high-volume surgeons are more likely to participate in routine screening.

The effect of knowledge and health beliefs about colorectal cancer on screening behaviour

AIMS AND OBJECTIVES

To determine the effect of the knowledge and health beliefs of individuals about colorectal cancer on their screening behaviour.

BACKGROUND

Colorectal cancer ranks third among the most common cancers both worldwide and in Turkey. Colorectal cancer plays an important role in cancer mortality but can be prevented by promoting healthy behaviour and participation in early screening programmes.

DESIGN

This descriptive study was completed with 114 women and 121 men.

METHODS

The study data were collected using the 'Data collection form' and 'Health Belief Model Scale for Protection from Colorectal Cancer'. Potential risk factors were investigated using logistic regression analyses. The AGREE checklist was completed.

RESULTS

The colorectal cancer screening tests were known by 23.0% of the subjects and 17% had undergone one of these tests. The score medians obtained from the confidence-benefit subscale of Health Belief Model Scale for Protection from Colorectal Cancer were found to be significantly higher in those who had undergone colorectal cancer screening. Logistic regression analysis revealed that having knowledge of the relevant tests was associated with undergoing colorectal cancer screening.

CONCLUSIONS

Having knowledge on colorectal cancer screening tests increases the relevant confidence-benefit perception regarding the tests and the behaviour of participating in screening programmes. Regular training on colorectal cancer and early diagnosis should therefore be provided by healthcare professionals to both women and men aged 50-70 years to increase the rate of undergoing early screening tests.

RELEVANCE TO CLINICAL PRACTICE

Increasing the rate of early screening is among the responsibilities of health workers working in primary health centres. Therefore, problems that prevent individuals from participating in these programmes need to be identified. In this way, health workers will develop suggestions and initiatives that change the individual's health beliefs and increase motivation.

LncRNA MIR4435-2HG predicts poor prognosis in patients with colorectal cancer

Background

LncRNA MIR4435-2HG is observed in a variety of cancers, while its role in colorectal cancer is unknown. We aimed to demonstrate the relationship between MIR4435-2HG and colorectal cancer based on The Cancer Genome Atlas (TCGA) database.

Materials and Methods

Patients with colorectal cancer were collected from TCGA. We compared the expression of MIR4435-2HG in colorectal cancer and normal tissues with Wilcoxon rank sum test, and logistic regression was used to evaluate the relationship between MIR4435-2HG and clinicopathological characters. Moreover, Kaplan–Meier and Cox regression was performed to evaluate the correlation between MIR4435-2HG and survival rate. Gene set enrichment analysis (GSEA) was also conducted to annotate biological function of MIR4435-2HG.

Results

MIR4435-2HG level was elevated in colorectal cancer tissues. Increased level of MIR4435-2HG was significantly correlated with TNM stage (OR = 1.66 for T1/T2 vs. T3/T4; OR = 1.68 for N0 vs. N1/N2), stage (OR = 1.66 for stage 1/2 vs. stage 3/4), and carcinoembryonic antigen level before treatment (OR = 1.70 for <5 vs. ≥5) (all P-value <0.05). High MIR4435-2HG expression had a poorer progression-free survival (p = 0.048), and overall survival (OS) (P = 0.028), which were validated in the GSE92921 and GSE29621 datasets. MIR4435-2HG expression (P = 0.040, HR = 1.955 (95% CI [1.031–3.710])) was independently correlated with OS. GSEA demonstrated that the P38/MAPK pathway, the VEGF pathway, the cell adhesion molecules cams, the NOD-like receptor signaling pathway, the cell surface interactions at the vascular wall, and integrin cell surface interactions were differentially enriched in MIR4435-2HG high expression phenotype.

Conclusions

Increased MIR4435-2HG might be a potential biomarker for the diagnosis and prognosis of colorectal cancer. Moreover, MIR4435-2HG might participate in the development of colorectal cancer via the P38/MAPK and VEGF pathway.

Performance Characteristics of Fecal Immunochemical Tests for Colorectal Cancer and Advanced Adenomatous Polyps: A Systematic Review and Meta-analysis

BACKGROUND

Studies report inconsistent performance of fecal immunochemical tests (FITs) for colorectal cancer (CRC) and advanced adenomas.

PURPOSE

To summarize performance characteristics of FITs for CRC and advanced adenomas in average-risk persons undergoing screening colonoscopy (reference standard) and to identify factors affecting these characteristics.

DATA SOURCES

Ovid MEDLINE, PubMed, Embase, and the Cochrane Library from inception through October 2018; reference lists of studies and reviews.

STUDY SELECTION

Two reviewers independently screened records to identify published English-language prospective or retrospective observational studies that evaluated FIT sensitivity and specificity for colonoscopic findings in asymptomatic, average-risk adults.

DATA EXTRACTION

Two authors independently extracted data and evaluated study quality.

DATA SYNTHESIS

Thirty-one studies (120 255 participants; 18 FITs) were included; all were judged to have low to moderate risk of bias. Performance characteristics depended on the threshold for a positive result. A threshold of 10 µg/g resulted in sensitivity of 0.91 (95% CI, 0.84 to 0.95) and a negative likelihood ratio of 0.10 (CI, 0.06 to 0.19) for CRC, whereas a threshold of greater than 20 µg/g resulted in specificity of 0.95 (CI, 0.94 to 0.96) and a positive likelihood ratio of 15.49 (CI, 9.82 to 22.39). For advanced adenomas, sensitivity was 0.40 (CI, 0.33 to 0.47) and the negative likelihood ratio was 0.67 (CI, 0.57 to 0.78) at 10 µg/g, and specificity was 0.95 (CI, 0.94 to 0.96) and the positive likelihood ratio was 5.86 (CI, 3.77 to 8.97) at greater than 20 µg/g. Studies had low to high heterogeneity, depending on the threshold. Although several FITs had adequate performance, sensitivity and specificity for CRC for 1 qualitative FIT were 0.90 and 0.91, respectively, at its single threshold of 10 µg/g; positive and negative likelihood ratios were 10.13 and 0.11, respectively. Comparison of 3 FITs at 3 thresholds was inconclusive: CIs overlapped, and the comparisons were across rather than within studies.

LIMITATIONS

Only English-language studies were included. Incomplete reporting limited quality assessment of some evidence. Performance characteristics are for 1-time rather than serial testing.

CONCLUSION

Single-application FITs have moderate to high sensitivity and specificity for CRC, depending on the positivity threshold. Sensitivity of 1-time testing for advanced adenomas is low, regardless of the threshold.

PRIMARY FUNDING SOURCE

Department of Medicine, Indiana University School of Medicine.

Fecal immunochemical test in cancer screening - colonoscopy outcome in FIT positives and negatives

Objectives: Fecal immunochemical test (FIT) is used in colorectal cancer (CRC) screening, but evaluations of multiple sample strategies in colonoscopy screening cohorts are rare. The aim of this study was to assess accuracy of FIT for advanced neoplasia (AN) with two fecal samples in a colonoscopy screening cohort. Materials and methods: The study comprised 1155 participants of the colonoscopy arm in SCREESCO (Screening of Swedish Colons, NCT02078804), a randomized controlled study on CRC screening of 60-year-olds from the Swedish average-risk population. Participants provided two FIT samples prior to colonoscopy. First sample, mean of two, and any of the two samples above cut off level were assessed. Colonoscopy findings (CRC, advanced adenoma (AA), AN (CRC + AA) and adenoma characteristics) were evaluated in uni- and multivariable analysis in relation to FIT positivity (at ≥10 µg hemoglobin (Hb)/g). Results: Of 1155 invited, 806 (416 women, 390 men) participated. CRC, AA and non-AA were found in one (0.1%), 80 (9.9%) and 145 (18%), respectively. Sensitivity and specificity for AN were 20%/93%, 25%/92% and 26%/89% for first, mean of two and any of the two samples respectively at cut off level 10 µg/g, corresponding to 60 (74%)-65 (80%) participants with missed AN. The difference in sensitivity between screening strategies was non-significant. The specificity for first sample was significantly higher than for any of the two samples at cut off 10 µg/g (p = .02) and 20 µg/g (p = .04). FIT positivity in participants with adenoma was associated with pedunculated shape (p = .007) and high-risk dysplasia (p = .009). Conclusions: In an average-risk colonoscopy screening cohort of 60-year-olds, sensitivity for AN was modest and did not increase when using two samples instead of one. FIT predominantly detected adenomas with pedunculated shape and high-risk dysplasia, and participants with flat or broad based adenomas may thus be missed in screening.

Epidemiology of inflammatory bowel disease in the Republic of San Marino: The "EPIMICI - San Marino" study

BACKGROUND

The burden of Crohn's disease (CD) and ulcerative colitis (UC) has never been estimated in the Republic of San Marino, the third smallest nation of the world.

AIMS

To assess the occurrence and clinical features of CD and UC in San Marino during the last 35 years.

METHODS

We retrospectively evaluated the prevalence, incidence, and main clinical aspects of CD and UC from 1980 to 2014, crossing data from various sources.

RESULTS

Prevalence rates (per 100,000) on December 31, were 241 for CD (263 in males and 220 in females) and 311 for UC (370 in males and 255 in females). The specific incidence of UC steadily increased from 4.6 (95% CI: 1.5-10.6) in 1980-1984 to 12.4 (95% CI: 7.6-19.1) in 2010-2014; CD incidence showed a higher proportional increase, from 1.8 (95% CI: 0.2-6.6) in 1980-1984 to 17.9 (95% CI: 12.0-25.7) in 2010-2014. The main clinical features of CD and UC (activity and location at diagnosis, extra-intestinal manifestations, disease progression overtime, therapies, and hospitalizations) were analyzed.

CONCLUSIONS

This study provides the first epidemiological report on CD and UC in San Marino, showing specific traits and overall higher prevalence and incidence rates than previously reported in neighbor Areas.

Risk Factors for Abdominal Aortic Aneurysm in Population-Based Studies: A Systematic Review and Meta-Analysis

Abdominal aortic aneurysm (AAA) represents an important public health problem with a prevalence between 1.3% and 12.5%. Several population-based randomized trials have evaluated ultrasound screening for AAA providing evidence of a reduction in aneurysm-related mortality in the screened population. The aim of our study was to perform a systematic review and meta-analysis of the risk factors for AAA. We conducted a systematic review of observational studies and we performed a meta-analysis that evaluated the following risk factors: gender, smoking habits, hypertension, coronary artery disease and family history of AAA. Respect to a previous a meta-analysis we added the funnel plot to examine the effect sizes estimated from individual studies as measure of their precision; sensitivity analysis to check the stability of study findings and estimate how the overall effect size would be modified by removal of one study; cumulative analysis to evaluate the trend between studies in relation to publication year. Abdominal aortic aneurysm prevalence is higher in smokers and in males. On the other hand, while diabetes is a risk factor for many cardiovascular diseases, it is not a risk factor for AAA. In addition, it is important to underline that all countries, where AAA screening was set up, had high income level and the majority belong to Western Europe (United Kingdom, Sweden, Italy, Poland, Spain and Belgium). Abdominal aortic aneurysm screening is fundamental for public health. It could avoid deaths, ruptures, and emergency surgical interventions if abdominal aortic aneurysm was diagnosed early in the population target for screening.

Colorectal Cancer in Ukraine: Regional Disparities and National Trends in Incidence, Management, and Mortality

Purpose

The incidence of colorectal cancer (CRC) is increasing worldwide, and the greatest increase is in low- to middle-income countries, such as Ukraine. Better knowledge of epidemiology of CRC in Ukraine is needed to understand how best to decrease the burden of disease.

Methods

The National Cancer Registry of Ukraine (NCRU) was queried for CRC incidence, mortality, stage, and treatment in Ukraine and assessed for regional variation from 1999 to 2015. Joinpoint analysis was used to analyze the trends.

Results

The incidence of colon cancer increased from 10.6 to 13.3 occurrences per 100,000, which provided an average annual percent change (AAPC) of 1.48 (95% CI, 1.3 to 1.7; P < .05). The incidence of rectal and anal cancers also increased from 9.9 to 11.5 occurrences per 100,000, which provided an AAPC of 1.0 (95% CI, 0.8 to 1.3; P < .05). Mortality remained the same (AAPC, 0.1; 95% CI, -0.3 to 0.2; P = .4). The proportion of patients who received cancer-specific treatment increased from 54.6% to 68.5% for colon cancer and from 61% to 74.4% for rectal and anal cancers. Overall, 34.5% of patients with colon cancer and 27.5% of patients with rectal cancer died within a year of diagnosis in 2015. Great regional variations in 1-year mortality and treatment received were identified.

Conclusion

The incidence of CRC in Ukraine is increasing. Despite stable mortality rates, many do not receive cancer-specific treatment, and a large proportion of patients die within a year of diagnosis. These findings illustrate the need to promote establishment of a screening program and to improve access to cancer-specific therapy in Ukraine.

An online self-test added to colorectal cancer screening can increase the effectiveness of familial cancer risk assessment without increasing distress

AIM

Most people who are at increased familial colorectal cancer (FCRC) risk are not identified, despite the need for enhanced surveillance colonoscopy for effective CRC prevention. An online self-test may enhance this identification. We assessed whether taking an online self-test to identify increased FCRC risk increases anxiety, distress or CRC risk perception in population-based CRC screening.

METHOD

After the precolonoscopy consultation, patients who had a positive immunohistochemical occult faecal blood test (iFOBT+) in population-based CRC screening were invited by email to take an online self-test at home which returned details of family history. Anxiety (STAI-DY), distress (HADS) and CRC risk perception were assessed immediately before and after taking the online self-test and 2 weeks later.

RESULTS

Of 250 participants invited, 177 (71%) completed the online self-test and psychological questionnaires and 153 (61%) completed questionnaires 2 weeks later. The median age was 65 years (range 61-75). The FCRC risk was increased in 17 participants (9.6%). Of these, 12 (6.8%) had a highly increased FCRC risk and may benefit from germline genetic testing for Lynch syndrome. In 7 of 17 participants (40%) the self-test obtained novel information on family history. Anxiety and distress levels were, and remained, below a clinically relevant level. Perception of CRC risk remained unchanged. Most participants (83%) would recommend the online self-test to others.

CONCLUSION

Of those with a iFOBT+, 9.6% had a previously unidentified increasedFCRC risk and require an enhanced surveillance colonoscopy instead of iFOBT. As screening for this risk did not increase anxiety or distress, and was highly acceptable, we recommend adding the online self-test to population-based CRC screening.

The Complex Puzzle of Interactions Among Functional Food, Gut Microbiota, and Colorectal Cancer

Colorectal cancer exerts a strong influence on the epidemiological panorama worldwide, and it is directly correlated to etiologic factors that are substantiated by genetic and environmental elements. This complex mixture of factors also has a relationship involving the structural dependence and composition of the gut microbiome, leading to a dysbacteriosis process that may evolve to serious modifications in the intestinal lining, eventually causing the development of a neoplasm. The gastrointestinal tract presents defense strategies and immunological properties that interfere in intestinal permeability, inhibiting the bacterial translocation, thus maintaining the integrity of intestinal homeostasis. The modulation of the intestinal microbiome and the extinction of risk factors associated with intestinal balance losses, especially of environmental factors, make cell and defense alterations impossible. This modulation may be conducted by means of functional foods in the diet, especially soluble fibers, polyunsaturated fatty acids, antioxidants and prebiotics that signal immunomodulatory effects in the intestinal microbiota, with preventive and therapeutic action for colorectal cancer. In summary, this review focuses on the importance of dietary modulation of the intestinal microbiota as an instrument for dysbacteriosis and, consequently, for the prevention of colorectal cancer, suggesting anticarcinogenic, and antiangiogenic properties. Among the intestinal modulating agents considered here are functional foods, especially flaxseed, oat and soy, composing a Bioactive Food Compound.

Developing a Self-Administered Decision Aid for Fecal Immunochemical Test-Based Colorectal Cancer Screening Tailored to Citizens With Lower Educational Attainment: Qualitative Study

BACKGROUND

Citizens with lower educational attainments (EA) take up colorectal cancer screening to a lesser degree, and more seldom read and understand conventional screening information than citizens with average EAs. The information needs of citizens with lower EA are diverse, however, with preferences ranging from wanting clear recommendations to seeking detailed information about screening. Decision aids have been developed to support citizens with lower EA in making informed decisions about colorectal cancer screening participation, but none embrace diverse information needs.

OBJECTIVE

The aim of this study was to develop a self-administered decision aid for participation in fecal immunochemical test-based colorectal cancer screening. The decision aid should be tailored to citizens with lower EA and should embrace diverse information needs.

METHODS

The Web-based decision aid was developed according to an international development framework, with specific steps for designing, alpha testing, peer reviewing, and beta testing the decision aid. In the design phase, a prototype of the decision aid was developed based on previous studies about the information needs of lower EA citizens and the International Patient Decision Aid Standards guidelines. Alpha testing was conducted using focus group interviews and email correspondence. Peer review was conducted using email correspondence. Both tests included both lower EA citizens and health care professionals. The beta testing was conducted using telephone interviews with citizens with lower EA. Data were analyzed using thematic analysis.

RESULTS

The developed decision aid presented information in steps, allowing citizens to read as much or as little as wanted. Values clarification questions were included after each section of information, and answers were summarized in a "choice-indicator" on the last page, guiding the citizens toward a decision about screening participation. Statistics were presented in both natural frequencies, absolute risk formats and graphically. The citizens easily and intuitively navigated around the final version of the decision aid and stated that they felt encouraged to think about the benefits and harms of colorectal cancer screening without being overloaded with information. They found the decision aid easy to understand and the text of suitable length. The health care professionals agreed with the citizens on most parts; however, concerns were raised about the length and readability of the text.

CONCLUSIONS

We have developed a self-administered decision aid presenting information in steps. We involved both citizens and health care professionals to target the decision aid for citizens with lower EA. This decision aid represents a new way of communicating detailed information and may be able to enhance informed choices about colorectal cancer screening participation among citizens with lower EA.

An Analysis of Italian Nurses' Approach to Patients' Pain: A Nationwide Online Survey

Healthcare providers play a fundamental role in evaluating pain. Several issues about how nurses are educated remain unsolved. The aim of our study was to address how Italian nurses manage patients suffering from pain in daily practice. A cross-sectional survey was administered among Italian registered nurses. Data were collected using a 34-item questionnaire that had been previously validated during a pilot study. The lowest level of participation/education/information events was observed in the South (p=0.0001). A significant difference among the four areas was found in the department affiliation of responders (p=0.0001). Pain assessment at patients' admission was most frequent in the Northeast (32.9%), whereas the lowest frequency was found in the South (15.1%) (p=0.0001). The prevalence of nurses' knowledge of pain scales and their distribution in usual applications was similar in the Northwest and -east, and Central Italy, but lower in the South (p=0.0001). This study underlines the need for change in the clinical approach to pain treatment in healthcare. Pain assessment is a fundamental step for preparing individualized therapeutic plans, and nurses play a crucial role in improving the quality of life of suffering patients.

Socioeconomic and demographic inequalities in stage at diagnosis and survival among colorectal cancer patients: evidence from a Swiss population-based study

Socioeconomic inequalities in cancer stage at diagnosis and survival are important public health issues. This study investigates the association between socioeconomic position (SEP) and colorectal cancer (CRC) stage at diagnosis and survival in Switzerland, a European country with highest level of medical facilities and life expectancy. We used population-based CRC data from seven Swiss cantonal cancer registries 2001-2008 (N = 10,088) linked to the Swiss National Cohort (SNC). Follow-up information was available until the end of 2013. SEP was estimated based on education. The association between cancer stage and SEP was assessed using logistic regression models including cancer localization (colon/rectum), sex, age, civil status, urbanity of residence, language region, and nationality (Swiss/non-Swiss). Survival was analyzed using competing risk regressions reporting subhazard ratios (SHRs) for the risk of dying due to CRC. We observed a social gradient for later stage CRC with adjusted odds ratios (ORs) of 1.11 (95% CI: 0.97-1.19) and 1.28 (95% CI: 1.08-1.50) for middle and low SEP compared to high SEP. Further, single compared to married people had elevated odds of being diagnosed at later stages. Survival was lower in patients with CRC with low SEP in the unadjusted model (SHR: 1.18, 95% CI: 1.07-1.30). After adjustment for stage at diagnosis and further sociodemographic characteristics, significant survival inequalities by SEP disappeared but remained for non-Swiss compared to Swiss citizens and for patients living in nonurban areas compared to their urban counterparts. Swiss public health strategies should facilitate equal access to CRC screening and optimal CRC care for all social groups and in all regions of Switzerland.

Transplantation of placenta-derived multipotent cells in rats with dimethylhydrazine-induced colon cancer decreases survival rate

Transplantation of placenta-derived multipotent cells (PDMCs) is a promising treatment method for many diseases. However, the impact of PDMCs on colon cancer has not yet been studied. PDMCs were obtained from rat placentas by culturing tissue explants. Colon cancer was experimentally induced in male albino Wistar rats by administering 20 mg/kg dimethylhydrazine (DMH) once a week for 20 consecutive weeks. The administration of the PDMCs was performed at the 20th week after the first DMH injection. The number and size of each tumour lesion were calculated in the 5th week after transplantation. The tumour type was determined by standard histological methods. To study the engraftment of PDMCs in the body of rats, the cells were transduced with enhanced green fluorescent protein. Cell engraftment was determined by assessing the presence of EGFP by PCR and immunohistochemistry. Survival of all rats was monitored daily. Allogeneic transplantation of PDMCs to rats at middle phase of DMH-induced colon carcinogenesis did not significantly influence the number of neoplasms and the parameters of mean and total tumour area, but led to an increase in size of the most invasiveness tumours. Intravenous allogeneic transplantation of PDMCs reduced the survival rate of rats with colon cancer by 17 days. PDMCs from rats engrafted into tissues of the normal intestine, tumours, lungs, liver, and spleen of rats for five weeks after intravenous transplantation. These results suggest that intravenous allogeneic transplantation of PDMCs promotes colon cancer progression and has a negative impact on survival of rats.

Waiting for diagnostic colonoscopy: a qualitative exploration of screening participants' experiences in a FIT-based colorectal cancer screening program

BACKGROUND

Participants in population-based screening for colorectal cancer (CRC) may experience increased anxiety immediately after a positive screening test, but research in this area is limited. The objective of this study was to explore how screening participants experience a positive test result and cope with the pre-diagnostic waiting period in a CRC screening program.

MATERIALS AND METHODS

Screening participants with a positive fecal immunochemical test (FIT) result were identified in the Danish national CRC program before they attended diagnostic colonoscopy. Sixteen screening participants were selected for an interview in their own homes, using a semi-structured interview guide. Transcribed data were analyzed thematically.

RESULTS

The most prominent themes were symptom appraisal and communication strategies. Most participants attributed the positive FIT result showing blood in the stool to pre-existing non-malignant conditions but a few were very worried about the FIT result and the outcome of the colonoscopy. Communication strategies included discussions with family or friends about the positive FIT result and the upcoming colonoscopy, or containing information until the colonoscopy had provided the definitive diagnostic result. There was no apparent need for communication with health care professionals during the pre-diagnostic waiting period.

CONCLUSION

The pre-diagnostic waiting period between positive FIT result and colonoscopy in a population-based screening program may cause worry for some participants, potentially to require support, but most people consider it unconcerning. Screening providers should communicate to all screening participants in written form that negative emotional responses may occur after a positive screening result. This is particularly important in screening programs using self-sample kits without the presence of a health care professional to reassure the few participants who may experience significant anxiety.

Preoperative Midregional Pro-Adrenomedullin and High-Sensitivity Troponin T Predict Perioperative Cardiovascular Events in Noncardiac Surgery

OBJECTIVE

We evaluated the utility of preoperative midregional (MR) pro-adrenomedullin (proADM) and cardiac troponin T (TnT) for improved detection of patients at high risk for perioperative cardiac events and mortality after major noncardiac surgery.

SUBJECTS AND METHODS

This prospective, single-center, observational study enrolled 79 patients undergoing major noncardiac surgery. After initial clinical assessment (clinical history, physical examination, echocardiogram, blood tests, and chest X-ray), MR-proADM and high-sensitivity TnT (hsTnT) were measured within 48 h prior to surgery by immunoluminometric and electrochemiluminescence immunoassay. Patients were followed by the consulting physician until discharge or up to 14 days in the hospital after surgery. Perioperative cardiac events included myocardial infarction and development or aggravation of congestive heart failure. Data were compared between patients who developed target events and event-free patients.

RESULTS

Within 14 days of monitoring, 14 patients (17.72%) developed target events: 9 (11.39%) died and 5 (6.33%) developed cardiovascular events. The average age of the patients was 71.29 ± 6.62 years (range: 55-87). Sex, age, and hsTnT did not significantly differ between groups. MR- proADM concentration was higher in deceased patients (p = 0.01). The upper quartile of MR-proADM was associated with a fatal outcome (66.7 vs. 20.0%, p < 0.01) and with cardiovascular events (64.3 vs. 16.9%, p < 0.01). MR-proADM above the cutoff value (≥0.85) was associated with a fatal outcome (88.9 vs. 20.0%, p < 0.01) and cardiovascular events (71.4 vs. 28.6%, p < 0.01); this association was not observed for hsTnT.

CONCLUSION

Preoperative measurement of MR-proADM provides useful information for perioperative cardiac events in high-risk patients scheduled for noncardiac surgery.

Colon cancer surgery in patients operated on an emergency basis

OBJECTIVE

to study the epidemiological profile of patients with colorectal cancer operated on an emergency basis at the Bonsucesso Federal Hospital.

METHODS

this is a retrospective study of patients operated between January 1999 and December 2012. We analyzed the following variables: age, gender, clinical data, TMN staging, tumor location, survival and types of surgery.

RESULTS

we evaluated 130 patients in the study period. The most frequent clinical picture was intestinal obstruction, in 78% of cases. Intestinal perforation was the surgical indication in 15%. The majority (39%) of the patients had advanced TNM staging, compared with 27% in the initial stage. There were 39 deaths (30%) documented in the period. The most common tumor site was the sigmoid colon (51%), followed by the ascending colon (16%). The curative intent was performed in most cases, with adjuvant treatment being performed in 40% of the patients. Distant metastases were found in 42% of the patients and 10% had documented disease recurrence. Disease-free survival at two and five years was 69% and 41%, respectively.

CONCLUSION

there was a high mortality rate and a low survival rate in colorectal cancer patients operated on urgently.

Placenta-derived multipotent cells have no effect on the size and number of DMH-induced colon tumors in rats

Transplantation of placenta-derived multipotent cells (PDMCs) is a promising approach for cell therapy to treat inflammation-associated colon diseases. However, the effect of PDMCs on colon cancer cells remains unknown. The aim of the present study was to characterize PDMCs obtained from human (hPDMCs) and rat (rPDMCs) placentas and to evaluate their impact on colon cancer progression in rats. PDMCs were obtained from human and rat placentas by tissue explant culturing. Stemness- and trophoblast-related gene expression was studied using reverse transcription-polymerase chain reaction (RT-PCR), and surface markers and intracellular proteins were detected using flow cytometry and immunofluorescence, respectively. Experimental colon carcinogenesis was induced in male albino Wistar rats by injecting 20 mg/kg dimethylhydrazine (DMH) once a week for 20 consecutive weeks. The administration of rPDMCs and hPDMC was performed at week 22 after the initial DMH-injection. All animals were sacrificed through carbon dioxide asphyxiation at week 5 after cell transplantation. The number and size of each tumor lesion was calculated. The type of tumor was determined by standard histological methods. Cell engraftment was determined by PCR and immunofluorescence. Results demonstrated that rPDMCs possessed the immunophenotype and differentiation potential inherent in MSCs; however, hPDMCs exhibited a lower expression of cluster of differentiation 44 and did not express trophoblast-associated genes. The data of the present study indicated that PDMCs may engraft in different tissues but do not significantly affect DMH-induced tumor growth during short-term observations.

Low-FODMAP Diet Improves Irritable Bowel Syndrome Symptoms: A Meta-Analysis

Irritable bowel syndrome (IBS) affects 7–15% of the general population. A recently devised dietary approach consists of restricting foods with highly fermentable oligo-, di-, and monosaccharides, and polyols (FODMAPs), which can trigger and/or exacerbate IBS symptoms. The aim of this study is to use meta-analysis to provide an update on the randomised control trials (RCTs) and cohort studies, and examine them separately in relation to diet type. Papers were selected using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart. Cohen’s d and odds ratios were used as a measure of effect size for RCTs. A random effects model was used to account for different sources of variation among studies. Heterogeneity was assessed using Q statistics, I², Tau, and Tau². Publication bias was analysed and represented by a funnel plot, and funnel plot symmetry was assessed with Egger’s test. The results showed that in the RCTs, the patients receiving a low-FODMAP diet experienced a statistically significant pain and bloating reduction compared with those receiving a traditional diet; as regards to stool consistency, there was no significant difference between treatments. A significant reduction in abdominal pain and bloating were described by patients receiving a low-FODMAP diet compared with those receiving a high-FODMAP diet. In cohort studies, pain and bloating were significantly reduced after treatment compared with the baseline diet. We conclude that there is evidence that a low-FODMAP diet could have a favourable impact on IBS symptoms, especially abdominal pain and bloating. However, it remains to be demonstrated whether a low-FODMAP diet is superior to conventional IBS diets, especially in the long term.

Low HtrA1 expression in patients with long‑standing ulcerative colitis and colorectal cancer

The association between inflammatory bowel disease (IBD) and colorectal cancer (CRC) is being increasingly investigated. HtrA1 overexpression inhibits cell growth and proliferation by influencing apoptosis, invasiveness and migration of tumour cells. In the present study, HtrA1 expression was analysed in 228 colon tissue samples from patients with CRC, adenoma with high-grade dysplasia (AHD), adenoma with low-grade dysplasia (ALD), ulcerative colitis of >10 year duration (UCL), ulcerative colitis of <5 year duration (UCS) and colonic diverticulitis (D), and was compared with its expression in normal colon tissues (NCTs) collected 5 cm from the CRC lesion and in healthy colon mucosa (HC), to establish whether HtrA1 can serve as a biomarker for these conditions. All tissue specimens came from Italian Caucasian subjects. The main finding of the present study was that HtrA1 expression was significantly reduced in CRC and UCL tissues compared with that observed in both NCT and HC samples and with tissues from the other patients. In particular, a similar HtrA1 expression was detected in the stromal compartment of UCL and CRC samples. In contrast, the HtrA1 level was significantly lower (p=0.0008) in UCL compared with UCS tissues, suggesting an inverse relationship between HtrA1 expression and ulcerative colitis duration. HtrA1 immunostaining in the stromal compartment of AHD and ALD tissues showed no differences compared with the HC tissues. No data are available on the immunohistochemical localization of HtrA1 in CRC or IBD. The present findings suggest that HtrA1 could serve as a marker to identify UCL patients at high risk of developing CRC.

Breast Cancer Screening Programmes across the WHO European Region: Differences among Countries Based on National Income Level

Breast cancer (BC) is the most frequent tumour affecting women all over the world. In low- and middle-income countries, where its incidence is expected to rise further, BC seems set to become a public health emergency. The aim of the present study is to provide a systematic review of current BC screening programmes in WHO European Region to identify possible patterns. Multiple correspondence analysis was performed to evaluate the association among: measures of occurrence; GNI level; type of BC screening programme; organization of public information and awareness campaigns regarding primary prevention of modifiable risk factors; type of BC screening services; year of screening institution; screening coverage and data quality. A key difference between High Income (HI) and Low and Middle Income (LMI) States, emerging from the present data, is that in the former screening programmes are well organized, with approved screening centres, the presence of mobile units to increase coverage, the offer of screening tests free of charge; the fairly high quality of occurrence data based on high-quality sources, and the adoption of accurate methods to estimate incidence and mortality. In conclusion, the governments of LMI countries should allocate sufficient resources to increase screening participation and they should improve the accuracy of incidence and mortality rates.

Role of Urinary Biomarkers in the Diagnosis of Adenoma and Colorectal Cancer: A Systematic Review and Meta-Analysis

The growing interest in enhancing and spreading colorectal cancer (CRC) screening has been stimulating the exploration of novel biomarkers with greater sensitivity and specificity than immunochemical faecal occult blood test (iFOBT). The present study provides i) a systematic review of the urinary biomarkers that have been tested to achieve early CRC diagnosis and assess the risk of colorectal adenoma and adenocarcinoma, and ii) a meta-analysis of the data regarding the urinary prostaglandin (PG) metabolite PGE-M. As regard to gene markers, we found significantly different percent methylation of the vimentin gene in CRC patients and healthy controls (HC) (p<0.0001). Respect to metabolism of nitrogenous bases, cytidine, 1-methyladenosine, and adenosine, have higher concentrations in CRC patients than in HC (respectively, p<0.01, p=0.01, and p<0.01). As regard to spermine we found that N1,N12 diacetyl spermine (DiAcSpm) and N1, N8 diacetylspermidine (DiAcSpd) were significantly higher in CRC than in HC (respectively p=0.01 and p<0.01). Respect to PGE-M, levels were higher in CRC than in those with multiple polyposis (p<0.006) and HC subjects (p<0.0004). PGE-M seems to be the most interesting and promising urinary marker for CRC and adenoma risk assessment and for CRC screening. In conclusion, evidence suggests that urinary biomarker could have a potential role as urinary biomarkers in the diagnosis of colorectal cancer. Particularly, PGE-M seems to be the most promising urinary marker for CRC early detection.