Systematic review of colorectal cancer screening guidelines for average-risk adults: Summarizing the current global recommendations

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.

Early onset colorectal cancer, not just the age: Data from a large health organization

Early onset colorectal cancer (EO-CRC) is increasing. We investigated the risk factors for ER-CRC compared to late onset colorectal cancer (LO-CRC). CRC patients between the years 1999 and 2021 were retrospectively evaluated. Data regarding demographics, comorbidities, malignancies, and mortality were collected. Data were retrieved using the MdClone platform from a large Health Maintenance Organization. The cohort was subdivided into EO-CRC (age ≤ 50 years) and LO-CRC (age ≥ 51 years) groups. 61,679 patients diagnosed with CRC were included in our analysis, 30,456 (49.4%) males, and 4891 (7.9%) Arabs, with an average age at diagnosis of 70.1 ± 13.1 years. 5561 (9%) patients were included in the EO-CRC group. Over the last decades, higher rates of EO-CRC were diagnosed compared to the previous decade, 9.8% vs 8.3%, p < 0.001. A higher percentage of EO-CRC patients were females (52.8% vs 50.4%), had a family history of CRC (9.9% vs 5.5%), were Arabs (18.7% vs 6.9%), and were smokers (32.7% vs 30.2%) compared to LO-CRC patients. Significantly lower rates of comorbidities such as ischemic heart disease, diabetes mellitus, hypertension, obesity, and iron deficiency anemia were found among EO-CRC patients, with a lower all-cause mortality (27.7% vs 63.1%, p < 0.001). 348 (6.3%) of the EO-CRC patients had another Lynch-related cancer until age 50 years compared to 45 (0.1%) at the LO-CRC. Young individuals with increased risk for CRC need special consideration and should be referred early for screening and endoscopic investigation, particularly those with a family history of CRC, smokers, and those of Arab ethnicity.

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.

Effectiveness of the Korean National Cancer Screening Program in Reducing Colorectal Cancer Mortality

BACKGROUND

Whether colorectal cancer (CRC) screening with a fecal immunochemical test (FIT) reduces mortality remains unclear. In South Korea, CRC screening with a FIT for individuals aged ≥ 50 years has been part of the Korean National Cancer Screening Program (KNCSP) since 2004. The aim of this study was to evaluate the effectiveness of the KNCSP in reducing CRC-specific mortality.

METHODS

We conducted a nested case-control study using cohort-based data derived from the KNCSP database. The cohort included 5,944,540 colorectal cancer-free individuals aged ≥ 50 years as of 2004. Individuals who died after CRC diagnosis were defined as cases (n = 29,992) and their sociodemographic characteristics were matched to those of the selected controls. The effects of screening exposure, frequency, and time interval on CRC-specific mortality were analyzed according to age group. Conditional logistic regression analysis was performed.

RESULTS

Compared with individuals who had never been screened, those who had ever been screened showed an OR of 0.74 (95% CI, 0.71-0.76) for CRC-specific mortality. CRC-specific mortality decreased as the number of screenings increased. Similar results were observed for those aged 50-79 years; however, the results for those aged 75-79 years were not statistically significant. Moreover, those aged ≥ 80 years had the opposite results.

CONCLUSIONS

CRC mass screening using FIT is effective for individuals aged 50-74 years; therefore, this study suggests that countries considering introducing national CRC screening implement FIT for those within this age range.

The efficacy and safety of precutting-endoscopic mucosal resection for colorectal tumors: a systematic review and meta-analysis

BACKGROUND

Several modified endoscopic mucosal resection (EMR) techniques have been reported for colorectal tumors. Precutting-EMR (PEMR) is a modification wherein a circumferential mucosal incision is made around a lesion to facilitate en bloc resection. This review compared the efficacy and safety of PEMR with conventional EMR for colorectal lesions.

METHODS

PubMed, Embase, Scopus, and Web of Science were searched for comparative studies available before February 15, 2024. This systematic review and meta-analysis were recorded in PROSPERO, identified as CRD42024509143.

RESULTS

Two hundred and eight studies underwent screening of which seven studies were found eligible. We found no significant difference in en bloc resection rates but complete resection rates were significantly better with PEMR. The duration of the procedure was significantly longer with PEMR as compared to EMR. There was no difference in the risk of delayed bleeding and recurrence between the two groups but the risk of perforation was significantly increased with PEMR.

CONCLUSIONS

The use of PEMR for colorectal lesions can improve complete resection rates, albeit at the cost of increased duration of the procedure and higher perforation rates compared to conventional EMR. PEMR may also have a tendency of better en bloc resection rates which needs to be confirmed by further studies.

Does Colonoscopy as a First Screening Test Still Make Sense?-Counterpoint

Colonoscopy has been widely regarded as the gold standard for its high diagnostic accuracy and preventive potential. However, its invasive nature, high cost, and suboptimal participation rates limit its utility at the population level. Non-invasive screening tests, notably the fecal immunochemical test (FIT) and multitarget stool DNA tests, present promising alternatives that may improve screening participation and reduce barriers to participation. Among these, FIT has demonstrated a consistent advantage in enhancing participation, which subsequently contributes to better long-term outcomes in CRC prevention. FIT-based two-step screening offers several practical advantages, including cost-effectiveness, non-invasiveness, and greater flexibility. Moreover, the quantitative nature of FIT allows for adjustable sensitivity thresholds and the ability of risk stratification, making it adaptable across diverse populations and scenarios. Through serial testing, FIT can increase cumulative detection rates over time. This approach facilitates the identification of high-risk individuals, allowing for more judicious use of colonoscopy resources and reducing unnecessary invasive procedures, especially among low-risk populations. Notably, evidence indicates that participation to FIT-based screening is consistently higher than to colonoscopy, which enhances the detection of early-stage cancers and advanced adenomas in the long run. Given the constraints of limited endoscopic capacity, the aging population, and the recent lowering of the recommended screening age due to the rising incidence of early-onset CRC, FIT emerges as a practical, flexible solution. The role of two-step FIT screening in improving participation and enabling risk-stratified, personalized approaches to CRC prevention is pivotal, advocating for its expanded integration into future screening paradigms.

Investigation of the expression level of methylated septin 9 gene and serological carcinoembryonic antigen to diagnose colorectal cancer. A meta-analysis study

Introduction

Colorectal cancer (CRC) is a rising threat, necessitating accurate early diagnosis.

Aim

This meta-analysis scrutinised methylated septin 9 (SEPT9) and carcinoembryonic antigen (CEA) in CRC.

Methods

From January 2012 to December 2022, databases including PubMed and Google Scholar were explored for English publications.

Results

The meta-analysis revealed SEPT9's superior diagnostic potential, boasting 71% sensitivity and 91% specificity, outshining CEA (49% and 53%). Notably, an 8-study analysis found a positive correlation between tumour grade and elevated CEA and SEPT9 levels, particularly in stages 3 and 4.

Conclusions

This meta-analysis supports SEPT9 as a potent CRC marker, urging its integration into diagnostic frameworks for enhanced precision and early intervention. The observed link between tumour grade and biomarker levels enhances clinical relevance. Implementing these findings promises improved CRC diagnosis precision, contributing to enhanced treatment outcomes and patient survival. Advocating for SEPT9's inclusion alongside traditional markers like CEA, this study pioneers more effective colorectal cancer management strategies.

Development of an algorithm combining blood-based biomarkers, fecal immunochemical test, and age for population-based colorectal cancer screening

BACKGROUND AND AIMS

Implementation of screening modalities has reduced the burden of colorectal cancer (CRC), but high false positive rates pose a major problem for colonoscopy capacity. We aimed to create a tailored screening algorithm that expands the fecal immunochemical test (FIT) with a blood specimen and current age to improve selection of individuals for diagnostic colonoscopy.

METHODS

In this prospective multicenter study, 8 blood-based biomarkers (carcinoembryonic antigen, ferritin, high-sensitivity C-reactive protein, human epididymis protein 4, Cyfra21-1, hepsin, interleukin 8, and osteoprotegerin) were investigated in 1977 FIT-positive individuals from the Danish national CRC screening program undergoing follow-up colonoscopy. Specimens were analyzed on Architect i2000, Architect c8000 (both from Abbott, Chicago, Ill, USA), or Luminex xMAP machines (MilliporeSigma, St. Louis, Mo, USA). FIT analyses and blood-based biomarker data were combined with clinical data (ie, age and colonoscopy findings) in a cross-validated logistic regression model (algorithm) benchmarked against a model solely using the FIT result (FIT model) applying different cutoffs for FIT positivity.

RESULTS

The cohort included individuals with CRC (n = 240), adenomas (n = 938), or no neoplastic lesions (n = 799). The cross-validated algorithm combining the 8 biomarkers, quantitative FIT result, and age performed superior to the FIT model in discriminating CRC versus non-CRC individuals (area under the receiver operating characteristic curve, 0.77 vs 0.67, respectively; P < .001). When discriminating individuals with either CRC or high- or medium-risk adenomas versus low-risk adenomas or clean colorectum, the areas under the receiver operating characteristic curve were 0.68 versus 0.64 for the algorithm and FIT model, respectively.

CONCLUSIONS

The algorithm presented here can improve patient allocation to colonoscopy, reducing colonoscopy burden without compromising cancer and adenoma detection rates or vice versa.

Pancreatic cancer screening is effective in individuals at risk with predisposing germline gene variants, but not in gene variant-negative familial pancreatic cancer families

OBJECTIVE

To evaluate the diagnostic yield of pancreatic cancer screening in individuals at risk (IAR) from familial pancreatic cancer (FPC) families with respect to the presence or absence of pathogenic germline variants predisposing to pancreatic adenocarcinoma (PDAC).

DESIGN

In a 20 years period, IAR from FPC families were enrolled in a prospective screening program of the national case collection for FPC of Germany, including magnet resonance imaging (MRI) and endoscopic ultrasound (EUS). The diagnostic yield was analyzed regarding significant pancreatic lesions such as PDAC, high-grade pancreatic-intraepithelial-neoplasia (PanIN3) and intraductal-papillary-mucinous-neoplasia (IPMN) with high-grade dysplasia. Screening results were compared between carriers of pathogenic variants and variant-negative IAR.

RESULTS

337 IAR, including 74 (22%) variant-carriers and 263 IAR of variant-negative FPC families (mean age 49; standard deviation [SD] + 8.9) were followed 64 (SD + 55) months. IAR underwent 5.1 (SD + 3.9) screening visits with 1733 MRI (5.1,SD + 3.9 per IAR) and 728 EUS (2.2,SD + 1.7 per IAR). In 12 (4%) cases, significant pancreatic lesions were detected, including 4 PDAC, 3 PanIN3 and 5 high-grade IPMN. Three of 4 IAR with PDAC died after a mean of 27 months postoperatively, and one IAR is alive without evidence of disease after 31 months. The diagnostic yield for significant lesions was 13.5% (10/74) for variant carriers compared to 0.8% (2/263) for IAR of variant-negative FPC families (p < 0.001). Logistic regression analysis revealed that a negative variant status was almost always accompanied by the absence of a significant lesion over time with a negative predictive value of 99.2% (95% CI 97.3%-99.9%).

CONCLUSION

The diagnostic yield seems to justify PDAC screening in IAR of FPC-families with pathogenic germline variants in PDAC predisposing genes, not in IAR of variant-negative families.

Diagnostic Performance of Faecal Immunochemical Testing (FIT) in Patients with Lynch Syndrome Scheduled for Colonoscopic Surveillance

BACKGROUND AND AIMS

Lynch syndrome (LS) carries a substantial lifetime risk of colorectal cancer which is currently mitigated by biennial colonoscopy surveillance. Paramount to the surveillance programme is the removal of adenomas before malignant transformation but there is an associated service burden and morbidity of repeated endoscopy. We investigated if faecal immunochemical testing (FIT) for faecal haemoglobin has the diagnostic performance to replace colonoscopy.

METHODS

In this retrospective cohort study, patients due to undergo planned surveillance for LS between November 2020 and April 2022 were sent two FIT kits prior to colonoscopy. Test diagnostic performance of colorectal cancer (CRC), advanced and non-advanced adenoma detection was calculated for single and double FIT strategies. A faecal-Hb of 10 µg Hb/g was considered positive.

RESULTS

In total, 78 patients, with 45 (57.7%) female, median age 52 years (IQR 41-63), completed at least one FIT and colonoscopy. The median time from FIT to colonoscopy was 47 days. A single FIT was positive in 7/30 cases of adenoma (2/3 advanced, 5/27 non-advanced). A total of 64 (82.1% of FIT1T returners) completed a second FIT. Using the greatest of the two FITs (FIT2TMAX) 8/26 (2/3 advanced, 4/23 non-advanced), patients with adenomas were identified. There were no cases of CRC. The sensitivity for adenoma detection was 23.3% and 23.1%, respectively.

CONCLUSIONS

In patients with LS awaiting colonoscopy, FIT has a low sensitivity for detecting adenomas and advanced adenomas. This is not improved by the addition of a second FIT test.

Contributions of early detection and cancer prevention to colorectal cancer mortality reduction by screening colonoscopy: a validated modeling study

BACKGROUND AND AIMS

Screening colonoscopy, recommended every 10 years, reduces mortality from colorectal cancer (CRC) by early detection of prevalent but undiagnosed CRC, as well as by removal of precursor lesions. The aim of this study was to assess the relative contribution of both components to total CRC mortality reduction over time.

METHODS

Using a validated multistate Markov model, we simulated hypothetical cohorts of 100,000 individuals aged 55 to 64 years with and without screening at baseline. Main outcomes included proportions of prevented CRC deaths arising from (asymptomatic) CRC already present at baseline and from newly developed CRC during 15 years of follow-up, and mortality rate ratios of screened versus nonscreened groups over time.

RESULTS

Early detection of prevalent cases accounted for 52%, 30%, and 18% of deaths prevented by screening colonoscopy within 5, 10, and 15 years, respectively. Relative reduction of mortality was estimated to be much larger for mortality from incident cancers than for mortality from cancers that were already present and detected early at screening endoscopy and for total CRC mortality (ie, 88% versus 67% and 79%, respectively, within 10 years from screening).

CONCLUSIONS

Reduction of CRC mortality mainly arises from early detection of prevalent cancers during the early years after screening colonoscopy, but prevention of incident cases accounts for the majority of prevented deaths in the longer run. Prevention of incident cases leads to sustained strong reduction of CRC mortality, possibly warranting an extension of screening intervals.

Colorectal Cancer Outcomes: A Comparative Review of Resource-Limited Settings in Low- and Middle-Income Countries and Rural America

Background/Objectives: Colorectal cancer remains a significant global health challenge, particularly in resource-limited settings where patient-centered outcomes following surgery are often suboptimal. Although more prevalent in low- and middle-income countries (LMICs), segments of the United States have similarly limited healthcare resources, resulting in stark inequities even within close geographic proximity. Methods: This review compares and contrasts colorectal cancer outcomes in LMICs with those in resource-constrained communities in rural America, utilizing an established implementation science framework to identify key determinants of practice for delivering high-quality colorectal cancer care. Results: Barriers and innovative, community-based strategies aimed at improving patient-centered outcomes for colorectal cancer patients in low resource settings are identified. We explore innovative approaches and community-based strategies aimed at improving patient-centered outcomes, highlighting the newly developed colorectal surgery fellowship in Sub-Saharan Africa as a model of innovation in this field. Conclusions: By exploring these diverse contexts, this paper proposes actionable solutions and strategies to enhance surgical care of colorectal cancer and patient outcomes, ultimately aiming to inform global health practices, inspire collaboration between LMIC and rural communities, and improve care delivery across various resource settings.

Combining FITs and HRFQ with colonoscopy improve the cost-effectiveness of a 9-year mass colorectal cancer screening program

BACKGROUND

Colorectal cancer (CRC) incidence has been increasing. Colonoscopy is still a gold standard method for its early diagnosis but using colonoscopy alone as a mass screening method is unrealistic. This study is to investigate whether combining fecal immunochemical test (FIT) and high-risk-factors questionnaire (HRFQ) with colonoscopy improve the cost-effectiveness of a mass CRC screening.

PATIENTS AND METHODS

CRC screening protocol combining FITs and HRFQ in the first stage and colonoscopy in the second stage was used in 50 villages/towns in 2007-2015. Residents aged 40-74 years were eligible for this free screening. A total of 160 210 (76.12%) participants completed first-stage screening, and 28 679 (17.90%) participants were defined as positive, among which 21 715 (75.72%) participants completed colonoscopy and were included in the final analysis. Outcomes were followed up until 2020.

RESULTS

The compliance was 76.12% and 75.72% in the first and second screening stage, respectively. A total of 252 CRC, 4033 adenoma, 1234 advanced neoplasm, and 5534 total neoplasm cases were detected in the screening. The positive predictive values of CRC, adenoma, advanced neoplasm, and total neoplasm were higher in FITs+ than those in the HRFQ+ population, respectively. A total of 64.60% and 43.42% total neoplasm cases were found in FITs+ and HRFQ+ (8.02% for both), respectively. The total colorectal neoplasm and CRC cases detected by combining HRFQ and FITs increased by 55.08% and 40.00%, respectively, and their increases were higher compared to HRFQ. The detection cost per any neoplasm by combining HRFQ and FITs was <$5331, while that by FITs and HRFQ alone was <$4570 and $5380, respectively.

CONCLUSIONS

Combining FITs and HRFQ with colonoscopy improve the cost-effectiveness of a mass CRC screening program. This protocol can be recommended for most populations, especially those in the countries and areas with high population density and low physician/population ratio.

Effect of fecal immunochemical test cut-off levels on adenoma detection rate: a systematic review and meta-analysis

BACKGROUND

Adenoma detection rate (ADR) is higher after a positive fecal immunochemical test (FIT) compared to direct screening colonoscopy.

OBJECTIVE

This meta-analysis evaluated how ADR, the rates of advanced adenoma detection (AADR), colorectal cancer detection (CDR), and sessile serrated lesion detection (SSLDR) are affected by different FIT positivity thresholds.

METHODS

We searched MEDLINE, EMBASE, CINAHL, and EBM Reviews databases for studies reporting ADR, AADR, CDR, and SSLDR according to different FIT cut-off values in asymptomatic average-risk individuals aged 50-74 years old. Data were stratified according to sex, age, time to colonoscopy, publication year, continent, and FIT kit type. Study quality, heterogeneity, and publication bias were assessed.

RESULTS

Overall, 4280 articles were retrieved and fifty-eight studies were included (277,661 FIT-positive colonoscopies; mean cecal intubation 96.3%; mean age 60.8 years; male 52.1%). Mean ADR was 56.1% (95% CI 53.4 - 58.7%), while mean AADR, CDR, and SSLDR were 27.2% (95% CI 24.4 - 30.1%), 5.3% (95% CI 4.7 - 6.0%), and 3.0% (95% CI 1.7 - 4.6%), respectively. For each 20 μg Hb/g increase in FIT cut-off level, ADR increased by 1.54% (95% CI 0.52 - 2.56%, p < 0.01), AADR by 3.90% (95% CI 2.76 - 5.05%, p < 0.01) and CDR by 1.46% (95% CI 0.66 - 2.24%, p < 0.01). Many detection rates were greater amongst males and Europeans.

CONCLUSIONS

ADRs in FIT-positive colonoscopies are influenced by the adopted FIT positivity threshold, and identified targets, importantly, proved to be higher than most current societal recommendations.

Screening of colorectal cancer: Methods and strategies

Colorectal cancer (CRC) has high incidence and mortality rates, and the emergence and application of CRC screening have helped us effectively control the occurrence and development of CRC. Currently, common international screening methods include tests based on feces and blood, and examination methods that allow for visualization, such as sigmoidoscopy and colonoscopy. Some methods have been widely used, whereas others such as multi-target stool RNA test are still being explored and developed, and are expected to become front-line screening methods for CRC in the future. The choice of screening method is affected by external conditions and the patients' situation, and the clinician must choose an appropriate strategy according to the actual situation and the patient's wishes. This article introduces various CRC screening methods and analyzes the factors relevant to the screening strategy.

Development and Effectiveness Evaluation of 360-Degree Virtual Reality-Based Educational Intervention for Adult Patients Undergoing Colonoscopy

Providing patients with accurate and organized information about colonoscopy, while reducing anxiety, is critical to the procedure's success. This study evaluated the impact of an immersive 360° virtual reality (VR)-based educational intervention for first-time adult colonoscopy patients regarding anxiety, attitudes, knowledge, compliance with bowel preparation, and bowel cleanliness. A quasi-experimental design with a non-equivalent control group and non-synchronized pretest-post-test clinical trial was conducted with 40 patients in the experimental group and 40 in the control group. The 360° VR intervention included two sessions: precautions before colonoscopy and the colonoscopy process. The control group received education through individual verbal explanations with written materials. The findings indicated that the VR intervention significantly improved patients' colonoscopy-related anxiety, attitudes, adherence to bowel preparation instructions, and bowel cleanliness. Utilizing 360° VR as an educational tool has the potential to enhance the effectiveness of educational programs by providing realistic information and engaging patients. These findings suggest that 360° VR has the capacity to enhance screening rates and clinical outcomes by reducing negative perceptions associated with colonoscopy. Furthermore, the application of this method can extend to diverse diagnostic testing-related nursing situations in clinical settings.

Immunotherapy-induced hepatitis in metastatic colorectal cancer: a systematic review and meta-analysis

Recent advances in immunotherapy using immune checkpoint inhibitors (ICIs) for various cancers have also highlighted a rise in immune-related adverse events, including hepatitis, potentially leading to the discontinuation of treatment. This study aimed to evaluate the prevalence of hepatitis in metastatic colorectal cancer (mCRC) patients undergoing different ICI therapies. An extensive search of PubMed, PubMed Central, and Google Scholar up to November 2023 identified relevant studies. After excluding non-English articles, case reports, reviews, ongoing trials, and studies combining other therapies, five studies qualified for inclusion. Data extraction and statistical analyses were performed using Excel and Comprehensive Meta-Analysis software, respectively. Results from a subgroup analysis indicated that the incidence of hepatitis was comparable among patients treated with PD-1 monotherapy, PDL-1 monotherapy, and combination PD-1 and CTLA-4 therapy, with rates of 2.6%, 2.2%, and 1.7% for any grade and 2.1%, 2.2%, and 1.7% for grade ≥3 hepatitis, respectively. Naive-treated mCRC patients exhibited higher hepatitis rates than those previously treated (3.2% vs 1.6% and 2.6% vs 1.6% for any grade and grade ≥3, respectively). This study underscores the similar risk of hepatitis across different ICI therapies, with an increased incidence in naive-treated mCRC patients.

A novel nomogram for the prediction of perforation during endoscopic submucosal dissection for colorectal neoplasms

BACKGROUND

High perforation risk hinders the widespread adoption of ESD for colorectal neoplasms. This study was performed to determine the risk factors of colorectal endoscopic submucosal dissection (ESD)-induced perforation and develop a predictive model.

METHODS

A total of 1046 colorectal neoplasms in 1011 patients were retrospectively enrolled from January 2011 to December 2021, in a single tertiary center as the derivation cohort. We identified independent risk factors for perforation using univariate analysis and multi-variate logistic regression. A nomogram was developed based on the logistic regression model and prospectively applied to 266 colorectal neoplasms as the validation cohort. The performance of the predictive model was evaluated with the receiver operating characteristic curve, calibration plot, and decision curve analysis.

RESULTS

Independent pre-operative factors for colorectal ESD-induced perforation were tumor located in the left colon [odds ratio (OR) 2.39, P = 0.040], size ≥ 40 mm (OR 3.36, P < 0.001), ≥2/3 circumference (OR 7.55, P = 0.004), located across folds (OR 6.26, P < 0.001), and laterally spreading tumor (non-granular type, OR 2.34, P = 0.029; granular type, OR 2.46, P = 0.021). The nomogram model incorporating the pre-operative factors performed well in both the derivation and validation cohorts (areas under the curve of 0.750 and 0.806, respectively). Decision curve analysis demonstrated that the clinical benefit of the nomogram was favorable.

CONCLUSIONS

The novel nomogram, developed and prospectively validated, incorporating tumor size, location, and morphology can successfully predict perforation during ESD for colorectal neoplasms.

Longer Interval Between First Colonoscopy With Negative Findings for Colorectal Cancer and Repeat Colonoscopy

Importance

For individuals without a family history of colorectal cancer (CRC), colonoscopy screening every 10 years is recommended to reduce CRC incidence and mortality. However, debate exists about whether and for how long this 10-year interval could be safely expanded.

Objective

To assess how many years after a first colonoscopy with findings negative for CRC a second colonoscopy can be performed.

Design, Setting, and Participants

This cohort study leveraged Swedish nationwide register-based data to examine CRC diagnoses and CRC-specific mortality among individuals without a family history of CRC. The exposed group included individuals who had a first colonoscopy with findings negative for CRC at age 45 to 69 years between 1990 and 2016. The control group included individuals matched by sex, birth year, and baseline age (ie, the age of their matched exposed individual when the exposed individual's first colonoscopy with findings negative for CRC was performed). Individuals in the control group either did not have a colonoscopy during the follow-up or underwent colonoscopy that resulted in a CRC diagnosis. Up to 18 controls were matched with each exposed individual. Individuals were followed up from 1990 to 2018, and data were analyzed from November 2022 to November 2023.

Exposure

A first colonoscopy with findings negative for CRC, defined as a first colonoscopy without a diagnosis of colorectal polyp, adenoma, carcinoma in situ, or CRC before or within 6 months after screening.

Main Outcomes and Measures

The primary outcomes were CRC diagnosis and CRC-specific death. The 10-year standardized incidence ratio and standardized mortality ratio were calculated to compare risks of CRC and CRC-specific death in the exposed and control groups based on different follow-up screening intervals.

Results

The sample included 110 074 individuals (65 147 females [59.2%]) in the exposed group and 1 981 332 (1 172 646 females [59.2%]) in the control group. The median (IQR) age for individuals in both groups was 59 (52-64) years. During up to 29 years of follow-up of individuals with a first colonoscopy with findings negative for CRC, 484 incident CRCs and 112 CRC-specific deaths occurred. After a first colonoscopy with findings negative for CRC, the risks of CRC and CRC-specific death in the exposed group were significantly lower than those in their matched controls for 15 years. At 15 years after a first colonoscopy with findings negative for CRC, the 10-year standardized incidence ratio was 0.72 (95% CI, 0.54-0.94) and the 10-year standardized mortality ratio was 0.55 (95% CI, 0.29-0.94). In other words, the 10-year cumulative risk of CRC in year 15 in the exposed group was 72% that of the 10-year cumulative risk of CRC in the control group. Extending the colonoscopy screening interval from 10 to 15 years in individuals with a first colonoscopy with findings negative for CRC could miss the early detection of only 2 CRC cases and the prevention of 1 CRC-specific death per 1000 individuals, while potentially avoiding 1000 colonoscopies.

Conclusions and Relevance

This cohort study found that for the population without a family history of CRC, the 10-year interval between colonoscopy screenings for individuals with a first colonoscopy with findings negative for CRC could potentially be extended to 15 years. A longer interval between colonoscopy screenings could be beneficial in avoiding unnecessary invasive examinations.

Colorectal cancer screening guidelines for average-risk and high-risk individuals: A systematic review

AIMS

This review aims to summarize the different colorectal cancer guidelines for average-risk and high-risk individuals from various countries.

METHODS

A comprehensive literature search regarding guidelines, consensus recommendations, or position statements about colorectal cancer screening published within the last 10 years (1st January 2012 to 27th August 2022), was performed at EBSCOhost, JSTOR, PubMed, ProQuest, SAGE, and ScienceDirect.

RESULTS

A total of 18 guidelines were included in this review. Most guidelines recommended screening between 45 and 75 years for average-risk individuals. Recommendations regarding colorectal cancer screening in high-risk individuals were more varied and depended on the risk factor. For high-risk individuals with a positive family history of colorectal cancer or advanced colorectal polyp, screening should begin at age 40. Some frequently suggested screening modalities in order of frequency are colonoscopy, FIT, and CTC. Furthermore, several screening intervals were suggested, including colonoscopy every 10 years for average-risk and every 5-10 years for high-risk individuals, FIT annually in average-risk and every 1-2 years in high-risk individuals, and CTC every five years for all individuals.

CONCLUSION

All individuals with average-risk should undergo colorectal cancer screening between 45 and 75. Meanwhile, individuals with higher risks, such as those with a positive family history, should begin screening at age 40. Several recommended screening modalities were suggested, including colonoscopy every 10 years in average-risk and every 5-10 years in high-risk, FIT annually in average-risk and every 1-2 years in high-risk, and CTC every five years.

Derivation and validation of a nomogram incorporating modifiable lifestyle factors to predict development of colorectal adenomas after negative index colonoscopy

This retrospective cohort study aimed to identify baseline patient characteristics involving modifiable lifestyle factors that are associated with the development of colorectal adenomas, and establish and validate a nomogram for risk predictions among high-risk populations with negative index colonoscopy. A total of 83,076 participants who underwent an index colonoscopy at the Tianjin Union Medical Center between 2004 and 2019 were collected. According to meticulous inclusion and exclusion criteria, 249 subjects were enrolled and categorized into the primary and validation cohorts. Based on the primary cohort, we utilized the LASSO-Cox regression and the univariate/multivariate Cox proportional hazards (Cox-PH) regression parallelly to select variables, and incorporated selected variables into two nomogram models established using the multivariate Cox-PH regression. Comparison of the Akaike information criterion and the area under the receiver operating characteristic curve of the two models demonstrated that the nomogram model constituted by four covariates retained by the LASSO-Cox regression, including baseline age, body mass index, physical activity and family history of colorectal cancer (CRC) in first-degree relatives, performed better at predicting adenoma-free survival probabilities. Further validation including the concordance index, calibration plots, decision curve analysis and Kaplan-Meier survival curves also revealed good predictive accuracy, discriminating ability, clinical utility and risk stratification capacity of the nomogram model. Our nomogram will assist high-risk individuals with negative index colonoscopy to prevent colorectal adenoma occurrence and CRC morbidity with improved cost-effectiveness.

Colorectal cancer and its attributable risk factors in East Asia, 1990-2030

BACKGROUND

The disease burden of colorectal cancer in East Asia has been at a high level. However, the epidemiological characteristics of the disease burden in this region have not been systematically studied.

METHOD

Data were obtained from the Global Burden of Disease 2019 program. Joinpoint analysis was used to identify long-term trends in mortality of colorectal cancer. Independent effects of age, period, and cohort were detected by the age-period-cohort model. The Bayesian age-period-cohort model was performed to predict the burden of colorectal cancer across East Asia by 2030.

RESULTS

From 1990 to 2019, the average annual percentage change (AAPC) showed upward trends in mainland China (1.05 [95% confidence interval (CI)], 0.82, 1.28) as well as Taiwan Province of China (1.81 [95% CI], 1.51, 2.10) but downward in Japan (-0.60 [95% CI], -0.70, -0.49) (P < 0.05). Attributable risk factors for colorectal cancer in East Asia remained stable over 30 years, while the risk of metabolic factors is noteworthy in the future. In the next decade, the age-standardized death rate (ASDR) of colorectal cancer in China was predicted to surpass that of Japan and South Korea in expectation.

CONCLUSION

The mortality of colorectal cancer is escalating in developing countries, while it is gradually declining in high-income countries across East Asia. Nonetheless, the disease burden of colorectal cancer in high-income countries remains substantial level.

Early-Onset Gastrointestinal Malignancies: An Investigation into a Rising Concern

There is growing recognition of early-onset gastrointestinal (GI) malignancies in young adults < 50 years of age. While much of the literature has emphasized colorectal cancer, these also include esophageal, gastric, liver, pancreatic, and biliary tract malignancies. Various factors, including lifestyle, hereditary, and environmental elements, have been proposed to explain the rising incidence of GI malignancies in the younger population. This review aims to provide an overview of the recent literature, including global trends and information regarding genetic and environmental risk factors.

The Role of Tumor Parenchymal and Stromal Ratios in Colorectal Cancer

Objective

To evaluate the implications and significant role of parenchymal and stromal ratio in colorectal cancer (CRC).

Materials and methods

In our review, we involved English studies from common databases such as Web of Science, Scopus, Google Scholar, PubMed, and the Cochrane Library using the following keywords "colorectal cancer", "tumor stromal ratio", "tumor parenchymal ratio", and "prognostic marker" till December 2023.

Results

The majority of CRC patients are usually diagnosed at late stages, which may lead to missing out on the chance to get radical therapy. Patients with unfavorable prognosis have epithelial malignant tumors with a high amount of stroma, more than 50% stroma, while tumors with a low amount of stroma, less than 50%, and abundant carcinoma tissue have a better prognosis.

Conclusion

Tumor-stromal ratio is a valuable, cheap, and fast modality that provides valuable prognostic data of colorectal carcinoma and other cancers.

European cancer mortality predictions for the year 2024 with focus on colorectal cancer

BACKGROUND

We predicted cancer mortality figures for 2024 for the European Union (EU), its five most populous countries, and the UK. We focused on mortality from colorectal cancer (CRC).

MATERIALS AND METHODS

Based on cancer death certification and population data from the World Health Organization and Eurostat databases from 1970 until the most available year, we predicted deaths and age-standardized rates (ASRs) for 2024 for all cancers and the 10 most common cancer sites. We fitted a linear regression to the most recent trend segment identified by the joinpoint model. The number of avoided deaths since the peak in 1988-2024 was estimated for all cancers and CRC.

RESULTS

We predicted 1 270 800 cancer deaths for 2024 in the EU, corresponding to ASRs of 123.2/100 000 men (-6.5% versus 2018) and 79.0/100 000 women (-4.3%). Since 1988, about 6.2 million cancer deaths have been avoided in the EU and 1.3 million in the UK. Pancreatic cancer displayed unfavorable predicted rates for both sexes (+1.6% in men and +4.0% in women) and lung cancer for women (+0.3%). The focus on CRC showed falls in mortality at all ages in the EU, by 4.8% for men and 9.5% for women since 2018. The largest declines in CRC mortality are predicted among those 70+ years old. In the UK, projected ASRs for CRC at all ages are favorable for men (-3.4% versus 2018) but not for women (+0.3%). Below age 50 years, CRC mortality showed unfavorable trends in Italy and the UK, in Poland and Spain for men, and in Germany for women.

CONCLUSIONS

Predicted cancer mortality rates remain favorable in the EU and the UK, mainly in males due to earlier smoking cessation compared to females, underlining the persisting major role of tobacco on cancer mortality in Europe. Attention should be paid to the predicted increases in CRC mortality in young adults.

Effectiveness of Colonoscopy Screening vs Sigmoidoscopy Screening in Colorectal Cancer

Importance

Randomized clinical screening trials have shown that sigmoidoscopy screening reduces colorectal cancer (CRC) incidence and mortality. Colonoscopy has largely replaced sigmoidoscopy for CRC screening, but long-term results from randomized trials on colonoscopy screening are still lacking.

Objective

To estimate the additional screening benefit of colonoscopy compared with sigmoidoscopy.

Design, Setting, and Participants

This comparative effectiveness simulation study pooled data on 358 204 men and women randomly assigned to sigmoidoscopy screening or usual care in 4 randomized sigmoidoscopy screening trials conducted in Norway, Italy, the US, and UK with inclusion periods in the years 1993 to 2001. The primary analysis of the study was conducted from January 19 to December 30, 2021.

Intervention

Invitation to endoscopic screening.

Main Outcomes and Measures

Primary outcomes were CRC incidence and mortality. Using pooled 15-year follow-up data, colonoscopy screening effectiveness was estimated assuming that the efficacy of colonoscopy in the proximal colon was similar to that observed in the distal colon in the sigmoidoscopy screening trials. The simulation model was validated using data from Norwegian participants in a colonoscopy screening trial.

Results

This analysis included 358 204 individuals (181 971 women [51%]) aged 55 to 64 years at inclusion with a median follow-up time ranging from 15 to 17 years. Compared with usual care, colonoscopy prevented an estimated 50 (95% CI, 42-58) CRC cases per 100 000 person-years, corresponding to 30% incidence reduction (rate ratio, 0.70 [95% CI, 0.66-0.75]), and prevented an estimated 15 (95% CI, 11-19) CRC deaths per 100 000 person-years, corresponding to 32% mortality reduction (rate ratio, 0.68 [95% CI, 0.61-0.76]). The additional benefit of colonoscopy screening compared with sigmoidoscopy was 12 (95% CI, 10-14) fewer CRC cases and 4 (95% CI, 3-5) fewer CRC deaths per 100 000 person-years, corresponding to percentage point reductions of 6.9 (95% CI, 6.0-7.9) for CRC incidence and 7.6 (95% CI, 5.7-9.6) for CRC mortality. The number needed to switch from sigmoidoscopy to colonoscopy screening was 560 (95% CI, 486-661) to prevent 1 CRC case and 1611 (95% CI, 1275-2188) to prevent 1 CRC death.

Conclusions and Relevance

The findings of this comparative effectiveness study assessing long-term follow-up after CRC screening suggest that there was an additional preventive effect on CRC incidence and mortality associated with colonoscopy screening compared with sigmoidoscopy screening, but the additional preventive effect was less than what was achieved by introducing sigmoidoscopy screening where no screening existed. The results probably represent the upper limit of what may be achieved with colonoscopy screening compared with sigmoidoscopy screening.

A qualitative interview study on colorectal cancer screening in China

Background

The effectiveness of triage screening for colorectal cancer (CRC) is not fully achieved in Chinese populations, mainly due to low compliance to colonoscopy follow-up. This study aimed to collect viewpoints of experts in China on ongoing screening programs and emerging screening tests for CRC, which may help to improve effectiveness of CRC screening in the country.

Methods

We conducted 15 semi-structured interviews with experts involving CRC screening in China during October to November of 2020. Interview topics included personal characteristics, work context, opinions on ongoing screening programs, challenges and opportunities in optimization of screening strategies, and prospects for CRC screening in near future. To analyze the data, we used a generic qualitative research approach inspired by grounded theory, including open, axial, and selective coding.

Results

This analysis revealed a total of 83 initial categories, 37 subcategories and 10 main categories, which included 4 core categories of current modality for CRC screening, factors influencing screening effectiveness, optimization of CRC screening modality, and prospects for development of CRC screening. The results provide insight into the factors underlying the challenges of the ongoing CRC screening programs in China: the most important concern is the low compliance to colonoscopy, followed by the low specificity of the currently-used initial tests. The experts proposed to use quantitative instead of qualitative fecal immunochemical test (FIT), and optimize risk assessment tools to improve specificity of initial tests. Regarding the emerging screening tests, 9 of 15 experts did not think that the novel techniques are good enough to replace the current tests, but can be used complementarily in opportunistic screening for CRC.

Conclusion

The viewpoints of Chinese experts suggested that use quantitative FIT or optimize risk assessment tools may help to identify high-risk individuals of CRC more accurately, improve adherence to colonoscopy, and thus fully achieve the effectiveness of screening.

Trends in colorectal cancer incidence according to an increase in the number of colonoscopy cases in Korea

BACKGROUND

The incidence of colorectal cancer (CRC) and preinvasive CRC (e.g., early colon cancer and advanced adenoma) is gradually increasing in several countries.

AIM

To evaluate the trend in incidence of CRC and preinvasive CRC according to the increase in the number of colonoscopies performed in Korea.

METHODS

This retrospective cohort study enrolled Korean patients from 2002 to 2020 to evaluate the incidence of CRC and preinvasive CRC, and assess the numbers of diagnostic colonoscopies and colonoscopic polypectomies. Colonoscopy-related complications by age group were also determined.

RESULTS

The incidence of CRC showed a rapid increase, then decreased after 2012 in the 50-75 year-age group. During the study period, the rate of incidence of preinvasive CRC increased at a similar level in patients under 50 and 50-75 years of age. Since 2009, the increase has been rapid, showing a pattern similar to the increase in colonoscopies. The rate of colonoscopic polypectomy in patients aged under 50 was similar to the rate in patients over 75 years of age after 2007. The rate of complications after colonoscopy and related deaths within 3 mo was high for those over 75 years of age.

CONCLUSION

The diagnosis of preinvasive CRC increased with the increase in the number of colonoscopies performed. As the risk of colonoscopy-related hospitalization and death is high in the elderly, if early lesions at risk of developing CRC are diagnosed and treated under or at the age of 75, colonoscopy-related complications can be reduced for those aged 76 years or over.

Risks, indications and technical aspects of colonoscopy in elderly or frail patients. Position paper of the Societat Catalana de Digestologia, the Societat Catalana de Geriatria i Gerontologia and the Societat Catalana de Medicina de Familia i Comunitaria

Colonoscopy (CS) is an invasive diagnostic and therapeutic technique, allowing the study of the colon. It is a safe and well tolerated procedure. However, CS is associated with an increased risk of adverse events, insufficient preparation and incomplete examinations in the elderly or frail patient (PEA/F). The objective of this position paper was to develop a set of recommendations on risk assessment, indications and special care required for CS in the PEA/F. It was drafted by a group of experts appointed by the SCD, SCGiG and CAMFiC that agreed on eight statements and recommendations, between them to recommend against performing CS in patients with advanced frailty, to indicate CS only if the benefits clearly outweigh the risks in moderate frailty and to avoid repeating CS in patients with a previous normal procedure. We also recommended against performing screening CS in patients with moderate or advanced frailty.

Detecting colorectal cancer using genetic and epigenetic biomarkers: screening and diagnosis

Colorectal cancer (CRC) is one of the most frequent types of cancer, with high incidence rates and mortality globally. The extended timeframe for developing CRC allows for the potential screening and early identification of the disease. Furthermore, studies have shown that survival rates for patients with cancer are increased when diagnoses are made at earlier stages. Recent research suggests that the development of CRC, including its precancerous lesion, is influenced not only by genetic factors but also by epigenetic variables. Studies suggest epigenetics plays a significant role in cancer development, particularly CRC. While this approach is still in its early stages and faces challenges due to the variability of CRC, it shows promise as a potential method for understanding and addressing the disease. This review examined the current evidence supporting genetic and epigenetic biomarkers for screening and diagnosis. In addition, we also discussed the feasibility of translating these methodologies into clinical settings. Several markers show promising potential, including the methylation of vimentin (VIM), syndecan-2 (SDC2), and septin 9 (SEPT9). However, their application as screening and diagnostic tools, particularly for early-stage CRC, has not been fully optimized, and their effectiveness needs validation in large, multi-center patient populations. Extensive trials and further investigation are required to translate genetic and epigenetic biomarkers into practical clinical use. biomarkers, diagnostic biomarkers.

Fecal Immunochemical Testing and the Risk of Advanced Colorectal Neoplasia: A Difference-In-Difference Analysis

PURPOSE

To evaluate the effectiveness of fecal immunochemical testing (FIT) in colorectal cancer screening.

METHODS

We conducted a prospective cohort study among 5,598 participants age 40-74 years between 2012 and 2020 in Tianjin, China. Inverse probability weighting was adopted to adjust for potential imbalanced factors between groups. A Cox proportional hazards model was used to estimate the weighted associations between FIT screening and advanced colorectal neoplasia. A difference-in-difference (DID) model was adopted to compare the incidence rates of advanced colorectal neoplasia between groups.

RESULTS

In DID analysis, the rate of incidence was reduced by 0.34 cases per person-years in the screening group as compared with the historical FIT screening group (rate ratio [RR], 0.08 [95% CI, 0.07 to 0.10]) and by 0.06 cases per person-years in the non-FIT screening group as compared with the historical non-FIT screening group (RR, 0.37 [95% CI, 0.29 to 0.48]; P < .001 for both comparisons), with a relative reduction of 0.28. Similar benefit effect from FIT screening was observed in sex and age subgroups.

CONCLUSION

FIT screening was associated with a reduction in incidence density from advanced colorectal neoplasia.

Long-term outcomes after endoscopic submucosal dissection for colorectal epithelial neoplasms in patients with severe comorbidities

Background and Aim

Long-term outcomes after endoscopic submucosal dissection (ESD) for colorectal epithelial neoplasms (CENs) in patients with severe comorbidities have not been clarified; the current study aimed to examine these long-term outcomes and compared them with those in patients with non-severe comorbidities.

Methods

We included 231 patients with CENs who underwent ESD between April 2005 and March 2023. Patients with comorbidities were categorized according to the American Society of Anesthesiologists Physical Status (ASA-PS). We conducted a propensity score-matched analysis and compared long-term outcomes of the two groups after ESD for CENs.

Results

Of the 156 patients enrolled in the study, 43 and 113 had severe (ASA-PS III) and non-severe (ASA-PS I/II) comorbidities, respectively. The 1:1 propensity score analysis matched 36 patients with severe comorbidities to 36 patients with non-severe comorbidities. After matching, there was no difference in the procedural outcomes of ESD between both groups. Regarding long-term outcomes, the 5-year overall survival rates after matching in the ASA-PS I/II and III groups were 100% and 73.5%, respectively, and patients in the ASA-PS III group exhibited significantly shorter overall survival than those in the ASA-PS I/II group (hazard ratio 7.209; 95% confidence interval 1.592-32.646; P = 0.010). No colorectal cancer-related deaths were noted in either group.

Conclusion

Overall survival after ESD for CENs was shorter in patients with severe comorbidities than in those with non-severe comorbidities. Clinicians should carefully determine whether the benefits of CEN resection with ESD outweigh the procedural risks in patients with severe comorbidities.

Assessing the Readability of Online Health Information for Colonoscopy - Analysis of Articles in 22 European Languages

Patients often search on the Internet information about different medical conditions and procedures. This study aimed to evaluate online health information on colonoscopy, focusing on quantity and comprehensibility of internet resources dedicated to the colonoscopy. This information could be used by European Union (EU) colorectal cancer (CRC) screening providers to address patient's unfilled educational needs, fear of colonoscopy, and other barriers that deter from CRC screening. The term "colonoscopy" translated into 22 official EU languages was searched using the Google search engine. For each translation, generated list of websites was assessed with Google Translate. The first 50 websites in each language were assessed for suitability. Records in other languages were excluded. Included websites were free, focused on patient education, and did not have password. Readability assessments were performed with Lix score. A total of 588 websites in Bulgarian, Croatian, Czech, Danish, Dutch, English, Estonian, Finnish, French, German, Greek, Hungarian, Italian, Latvian, Lithuanian, Polish, Portuguese, Romanian, Slovak, Slovenian, Spanish, and Swedish were evaluated. The overall mean Lix score was 56 ± 8 and was classified as very hard to comprehend. There were significant differences in mean Lix scores across the included languages (P<.001). There was not significant correlation (R2 = 0.1, P = 0.142) between Lix score and number of search hits. Although there was a wealth of online patient information on colonoscopy, the comprehensibility of the available information is low. Physician guidance to reliable resources could increase patient's willingness to undergo a screening colonoscopy.

Willingness to Pay for Colorectal Cancer Screening in Vietnam: Policy Implications From a Contingent Valuation Survey

OBJECTIVES

To determine the willingness to pay (WTP) for the fecal occult blood test (FOBT) and colonoscopy among the general population to provide evidence for policymakers in deciding whether to include them in the social health insurance benefit package and facilitate the pricing practice.

METHODS

The conventional double-bounded dichotomous choice contingent valuation survey was used to determine the WTP. We recruited 402 people aged 50 to 75 who came to 3 primary healthcare clinics in Hanoi from February 2019 to April 2019. The questionnaire was built based on the pilot research with a 5-bid design, that is, the starting bids of US $4.05, 6.75, 13.51, 21.01, and 36.47 for FOBT and US $21.01, 40.52, 54.03, 81.04, and 182.34 for colonoscopy. The data analysis was performed using the DCchoice package version 3.5.1. Cost in Vietnam dong is converted to 2022 US $using purchasing power parity method.

RESULTS

A total of 7.2% of participants refused to pay for FOBT and colonoscopy. Analysis of the univariate model showed that the mean and median WTP for FOBT were US $62.08 and 45.28. The mean and median WTP for colonoscopy were US $101.61 and 78.61. When adjusting the WTP value by related factors, the mean and median WTP estimates for FOBT were almost the same. The choice of WTP for FOBT and colonoscopy was statistically associated with several variables.

CONCLUSIONS

This study supports the inclusion of FOBT and colonoscopy into the social health insurance benefits package. This study also supports policymakers in pricing practice to optimize the uptake rate of colorectal cancer screening tests.

Improved stage and survival for patients in the Aotearoa New Zealand colorectal cancer screening program 2012-2019

BACKGROUND

Colorectal cancer (CRC) screening was introduced in Aotearoa New Zealand at Waitematā District Health Board (WDHB) in late 2011. This study reviewed patterns of disease, treatment received, and survival of patients with national bowel screening program (NBSP)-detected CRC versus non-NBSP patients at WDHB 2012-2019.

METHODS

Data collected retrospectively for all patients with adenocarcinoma of the colon or rectum at WDHB 2012-2019. Patient records were manually reviewed. Chi-square, Fisher's exact test and the Mann Whitney U-test used as appropriate. Kaplan-Meier and Cox proportional hazards regression modelling for survival analysis.

RESULTS

1667 patients included (360 NBSP and 1307 non-NBSP). 863 (51.8%) were male. Median age at diagnosis 73 years (range 21-100); NBSP patients were younger (median 68 vs. 76 years, P < 0.001). NBSP patients had significantly lower T, N, M and overall TNM stage than non-BSP patients. Median survival estimate on Kaplan-Meier analysis was 94 months for all patients. Statistically significant (P < 0.05) predictors of mortality on multi-variate regression analysis included increasing overall TNM stage compared with stage I (stage II HR 1.63 (95% CI 1.14-2.34), stage III HR 2.86 (95% CI 2.03-4.03), stage IV HR 7.73 (95% CI 5.59-10.68)), diagnosis within NBSP (HR 0.51 (95% CI 0.37-0.71)), increasing age in years (HR 1.03 (95% CI 1.02-1.03)), urgent/emergency surgery (HR 1.66 (95% CI 1.36-2.01)) and formal resection of primary tumour (HR 0.31 (95% CI 0.25-0.38)).

CONCLUSION

Patients diagnosed within the Aotearoa New Zealand NBSP were found to be younger and have earlier stage CRC. Diagnosis within the NBSP is an independent predictor of survival for patients with CRC.

Assessment of Psychosocial Correlates and Associated Factors of Colorectal Cancer Screening among Southwestern Saudi Population: A Cross-Sectional Study

Psychosocial correlates are one of the crucial determinants for the uptake of colorectal cancer (CRC) screening by the pre-eligible population. The present study aimed to identify the psychosocial correlates of colorectal cancer screening and determine their associated factors among the Saudi population in the Najran region, Saudi Arabia. Using a validated questionnaire, we assessed five constructs of psychosocial correlates of CRC screening among 790 participants aged 45 years and above. The five constructs were salience and coherence, cancer worries, perceived susceptibility, response efficacy, and social influence. Of the studied population, less than 50% agreed with most of the five constructs' statements, and 27.5% preferred to follow their family members' advice. Significantly higher mean scores (±SD) were identified for the male gender (7.38 ± 2.15, p = 0.027) and participants working in government sectors (7.60 ± 2.03, p = 0.027) in the cancer worries construct, while the mean (±SD) scores of perceived susceptibility were significantly higher among married participants (14.38 ± 4.10, p = 0.023) and smokers (14.95 ± 3.92, p = 0.041). Our survey results could help policymakers to implement focused health education programs for the pre-eligible population on the importance of the uptake of CRC screening. Furthermore, it is recommended to carry out exploratory mixed-method surveys in other regions of Saudi Arabia to understand the region's specific psychosocial correlates towards CRC screening.

Risk of Colorectal Cancer and Colorectal Cancer Mortality Beginning One Year after a Negative Fecal Occult Blood Test, among Screen-Eligible 76- to 85-Year-Olds

BACKGROUND

Colorectal cancer screening is universally recommended for adults ages 45 to 75 years. Noninvasive fecal occult blood tests are effective screening tests recommended by guidelines. However, empirical evidence to inform older adults' decisions about whether to continue screening is sparse, especially for individuals with prior screening.

METHODS

This study used a retrospective cohort of older adults at three Kaiser Permanente integrated healthcare systems (Northern California, Southern California, Washington) and Parkland Health. Beginning 1 year following a negative stool-based screening test, cumulative risks of colorectal cancer incidence, colorectal cancer mortality (accounting for deaths from other causes), and non-colorectal cancer mortality were estimated.

RESULTS

Cumulative incidence of colorectal cancer in screen-eligible adults ages 76 to 85 with a negative fecal occult blood test 1 year ago (N = 118,269) was 0.23% [95% confidence interval (CI), 0.20%-0.26%] after 2 years and 1.21% (95% CI, 1.13%-1.30%) after 8 years. Cumulative colorectal cancer mortality was 0.03% (95% CI, 0.02%-0.04%) after 2 years and 0.33% (95% CI, 0.28%-0.39%) after 8 years. Cumulative risk of death from non-colorectal cancer causes was 4.81% (95% CI, 4.68%-4.96%) after 2 years and 28.40% (95% CI, 27.95%-28.85%) after 8 years.

CONCLUSIONS

Among 76- to 85-year-olds with a recent negative stool-based test, cumulative colorectal cancer incidence and mortality estimates were low, especially within 2 years; death from other causes was over 100 times more likely than death from colorectal cancer.

IMPACT

These findings of low absolute colorectal cancer risk, and comparatively higher risk of death from other causes, can inform decision-making regarding whether and when to continue colorectal cancer screening beyond age 75 among screen-eligible adults.

Barriers and facilitators of colorectal cancer screening using the 5As framework: A systematic review of US studies

Despite clear evidence that regular screening reduces colorectal cancer (CRC) mortality and the availability of multiple effective screening options, CRC screening continues to be underutilized in the US. A systematic literature search of four databases - Ovid, Medline, EBSCHOhost, and Web of Science - was conducted to identify US studies published after 2017 that reported on barriers and facilitators to CRC screening adherence. Articles were extracted to categorize relevant CRC screening barriers or facilitators that were assessed against CRC screening outcomes using the 5As dimensions: Access, Affordability, Acceptance, Awareness, Activation. Sixty-one studies were included. Fifty determinants of screening within the 5As framework and two additional dimensions including Sociodemographics and Health Status were identified. The Sociodemographics, Access, and Affordability dimensions had the greatest number of studies included. The most common factor in the Access dimension was contact with healthcare systems, within the Affordability dimension was insurance, within the Awareness dimension was knowledge CRC screening, within the Acceptance dimension was health beliefs, within the Activation dimension was prompts and reminders, within the Sociodemographics dimension was race/ethnicity, and among the Health Status dimension was chronic disease history. Among all studies, contact with healthcare systems, insurance, race/ethnicity, age, and education were the most common factors identified. CRC screening barriers and facilitators were identified across individual, clinical, and sociocontextual levels. Interventions that consider multilevel strategies will most effectively increase CRC screening adherence.

Development and validation of colorectal cancer risk prediction tools: A comparison of models

BACKGROUND

Identification of individuals at elevated risk can improve cancer screening programmes by permitting risk-adjusted screening intensities. Previous work introduced a prognostic model using sex, age and two preceding faecal haemoglobin concentrations to predict the risk of colorectal cancer (CRC) in the next screening round. Using data of 3 screening rounds, this model attained an area under the receiver-operating-characteristic curve (AUC) of 0.78 for predicting advanced neoplasia (AN). We validated this existing logistic regression (LR) model and attempted to improve it by applying a more flexible machine-learning approach.

METHODS

We trained an existing LR and a newly developed random forest (RF) model using updated data from 219,257 third-round participants of the Dutch CRC screening programme until 2018. For both models, we performed two separate out-of-sample validations using 1,137,599 third-round participants after 2018 and 192,793 fourth-round participants from 2020 onwards. We evaluated the AUC and relative risks of the predicted high-risk groups for the outcomes AN and CRC.

RESULTS

For third-round participants after 2018, the AUC for predicting AN was 0.77 (95% CI: 0.76-0.77) using LR and 0.77 (95% CI: 0.77-0.77) using RF. For fourth-round participants, the AUCs were 0.73 (95% CI: 0.72-0.74) and 0.73 (95% CI: 0.72-0.74) for the LR and RF models, respectively. For both models, the 5% with the highest predicted risk had a 7-fold risk of AN compared to average, whereas the lowest 80% had a risk below the population average for third-round participants.

CONCLUSION

The LR is a valid risk prediction method in stool-based screening programmes. Although predictive performance declined marginally, the LR model still effectively predicted risk in subsequent screening rounds. An RF did not improve CRC risk prediction compared to an LR, probably due to the limited number of available explanatory variables. The LR remains the preferred prediction tool because of its interpretability.

Colorectal cancer: A health and economic problem

Colorectal Cancer (CRC) is the third most commonly diagnosed form of cancer and accounts for approximately 1.9 million cancer cases each year (10% of all new cancer cases globally). Incidence strongly increases with age and has been traditionally highest in Western, affluent countries, but it is rapidly increasing in many less developed countries and in younger generations in both developed and developing countries. With demographic aging, CRC will pose a rapidly increasing challenge for many societies, which underlines the need for major efforts on primary and secondary prevention. A number of effective screening options are available, and implementation of well-organized screening programs could have a major impact on lowering the future burden of the disease.

Incomplete resection of colorectal polyps of 4-20 mm in size when using a cold snare, and its associated factors

BACKGROUND : Cold snare polypectomy (CSP) is increasingly used for polypectomy and is recommended as the first-line modality for small (< 10 mm) polyps. This study aimed to evaluate incomplete resection rates (IRRs) when using CSP for colorectal polyps of 4-20 mm. METHODS : Adults (45-80 years) undergoing screening, surveillance, or diagnostic colonoscopy and CSP by one of nine endoscopists were included. The primary outcome was the IRR for colorectal polyps of 4-20 mm, defined as the presence of polyp tissue in marginal biopsies after resection of serrated polyps or adenomas. Secondary outcomes included the IRR for serrated polyps, ease of resection, and complications. RESULTS:  413 patients were included (mean age 63; 48 % women) and 182 polyps sized 4-20 mm were detected and removed by CSP. CSP required conversion to hot snare resection in < 1 % of polyps of < 10 mm and 44 % of polyps sized 10-20 mm. The IRRs for polyps < 10 mm and ≥ 10 mm were 18 % and 21 %. The IRR was higher for serrated polyps (26 %) compared with adenomas (16 %). The IRR was higher for flat (IIa) polyps (odds ratio [OR] 2.9, 95 %CI 1.1-7.4); and when resection was judged as difficult (OR 4.2, 95 %CI 1.5-12.1), piecemeal resection was performed (OR 6.6, 95 %CI 2.0-22.0), or visible residual polyp was present after the initial resection (OR 5.4, 95 %CI 2.0-14.9). Polyp location, use of a dedicated cold snare, and submucosal injection were not associated with incomplete resection. Intraprocedural bleeding requiring endoscopic intervention occurred in 4.7 %. CONCLUSIONS : CSP for polyps of 4-9 mm is safe and feasible; however, for lesions ≥ 10 mm, CSP failure occurs frequently, and the IRR remains high even after technical success. Incomplete resection was associated with flat polyps, visual residual polyp, piecemeal resection, and difficult polypectomies.

The Influence of the COVID-19 Pandemic on Colorectal Cancer Secondary Preventive Healthcare Measures

This study aims to assess the impact of SARS-CoV-2 on a population enrolled in a pilot colorectal screening program started by a family doctor in Romania. This observational retrospective study was spread over 43 months, respectively, from October 2019 to April 2023, and included 169 patients. The primary objective was to compare the pre-pandemic, pandemic, and post-pandemic periods to observe significant changes. The secondary objective was to study the correlation between vaccination against SARS-CoV-2 and participation in the study, especially in the age range class of interest-50-74 years. These data are important because Romanian Healthcare policymakers can use them to estimate the participation rate in a future national colorectal cancer screening and how to adjust and facilitate their communications with the targeted population. The rise of COVID-19 significantly negatively impacted the number of patients adhering to the pilot colorectal cancer screening and the number of test results during the pandemic period. However, in the post-pandemic period, the number of patients who joined the study, and the number of fecal occult blood tests was greater than expected (128.74%). We observed that screening participation was associated with vaccination (78.11% of patients had a complete COVID-19 vaccine scheme).

A Systematic Review of Cost-Effectiveness Analyses of Colorectal Cancer Screening in Europe: Have Studies Included Optimal Screening Intensities?

OBJECTIVE

To assess the range of strategies analysed in European cost-effectiveness analyses (CEAs) of colorectal cancer (CRC) screening with respect to the screening intervals, age ranges and test cut-offs used to define positivity, to examine how this might influence what strategies are found to be optimal, and compare them with the current screening policies with a focus on the screening interval.

METHODS

We searched PubMed, Web of Science and Scopus for peer-reviewed, model-based CEAs of CRC screening. We included studies on average-risk European populations using the guaiac faecal occult blood test (gFOBT) or faecal immunochemical test (FIT). We adapted Drummond's ten-point checklist to appraise study quality.

RESULTS

We included 39 studies that met the inclusion criteria. Biennial screening was the most frequently used interval which was analysed in 37 studies. Annual screening was assessed in 13 studies, all of which found it optimally cost-effective. Despite this, 25 of 26 European stool-based programmes use biennial screening. Many CEAs did not vary the age range, but the 14 that did generally found broader ranges optimal. Only 11 studies considered alternative FIT cut-offs, 9 of which found lower cut-offs superior. Conflicts between current policy and CEA evidence are less clear regarding age ranges and cut-offs.

CONCLUSIONS

The existing CEA evidence indicates that the widely adopted biennial frequency of stool-based testing in Europe is suboptimal. It is likely that many more lives could be saved throughout Europe if programmes could be offered with more intensive annual screening.

The effect of numeric information about the likelihood of receiving a false negative or false positive result on people's attitudes towards colorectal cancer screening using faecal immunochemical testing (FIT)

OBJECTIVE

To examine the impact of numeric risk information about false negative (FN) and false positive (FP) rates in fecal immunochemical testing (FIT) on attitudes towards screening.

METHODS

102 people aged 45-55, living in the UK, read 6 hypothetical vignettes presented online about the use of FIT kits to detect colorectal cancer, in which information about FN and FP rates was systematically varied.

RESULTS

Numeric FN risk information reduced people's interest in screening, perception of screening effectiveness and lowered trust in screening compared to verbal FN information. Verbal FN information reduced perceptions of screening effectiveness and trust compared to no FN information. People with high subjective numeracy reported lower trust in screening following the provision of numeric FN information but numeracy did not moderate any other associations. FP information did not affect attitudes towards FIT testing.

CONCLUSION

Numeric FN risk information decreased people's perceptions of screening effectiveness and trust in the results of screening. While it influenced people's interest in screening, the effect was small.

PRACTICE IMPLICATIONS

Numeric FN information has a small effect on interest in screening and could promote informed decision making without affecting screening uptake.

Older Age at First Screening Colonoscopy is Associated With an Increased Risk of Colorectal Adenomas and Cancer

INTRODUCTION

The goal of colorectal cancer (CRC) screening is to detect precancerous polyps before cancer development or identification of cancer at an early stage. Guidelines have recommended screening colonoscopy to start at age 45. Our aim was to determine the impact of delays in performing the first screening colonoscopy on the risk of adenoma or CRC detection.

METHODS

We analyzed colonoscopy and histopathology data of average CRC risk patients who had their first screening colonoscopy between 2010 and 2017. Univariate and multivariable logistic regression was performed to determine the association between demographic variables and the risk of adenomas or CRC.

RESULTS

A total of 1155 average risk patients underwent their initial screening colonoscopy during the study period. Median age was 54 years (range of 45-87) and 58.2% were females. In multivariable analysis, older age at first screening colonoscopy was significantly associated with the detection of adenomatous polyps (odds ratio 1.05, 95% confidence interval 1.04-1.07, P <0.001) and CRC (odds ratio 1.11, 95% confidence interval 1.06-1.16, P <0.001). The association between age and risk of adenomatous polyps (F-test 35.43, P =0.0019) and CRC (F-test 36.94, P =0.0017) fit an exponential growth model. It was estimated that the detection rate doubled every 14.20 years and 4.75 years for adenomas and CRC, respectively.

CONCLUSION

We found that older age at the initial performance of a screening colonoscopy was associated with increased detection of adenomatous polyps and CRC. This work highlights the need for guideline adherence for the prevention of CRC development.

Is there a place for sigmoidoscopy in colorectal cancer screening? A systematic review and critical appraisal of cost-effectiveness models

INTRODUCTION

Screening for colorectal cancer (CRC) is effective in reducing both incidence and mortality. Colonoscopy and stool tests are most frequently used for this purpose. Sigmoidoscopy is an alternative screening measure with a strong evidence base. Due to its distinct characteristics, it might be preferred by subgroups. The aim of this systematic review is to analyze the cost-effectiveness of sigmoidoscopy for CRC screening compared to other screening methods and to identify influencing parameters.

METHODS

A systematic literature search for the time frame 01/2010-01/2023 was conducted using the databases MEDLINE, Embase, EconLit, Web of Science, NHS EED, as well as the Cost-Effectiveness Registry. Full economic analyses examining sigmoidoscopy as a screening measure for the general population at average risk for CRC were included. Incremental cost-effectiveness ratios were calculated. All included studies were critically assessed based on a questionnaire for modelling studies.

RESULTS

Twenty-five studies are included in the review. Compared to no screening, sigmoidoscopy is a cost-effective screening strategy for CRC. When modelled as a single measure strategy, sigmoidoscopy is mostly dominated by colonoscopy or modern stool tests. When combined with annual stool testing, sigmoidoscopy in 5-year intervals is more effective and less costly than the respective strategies alone. The results of the studies are influenced by varying assumptions on adherence, costs, and test characteristics.

CONCLUSION

The combination of sigmoidoscopy and stool testing represents a cost-effective screening strategy that has not received much attention in current guidelines. Further research is needed that goes beyond a narrow focus on screening technology and models different, preference-based participation behavior in subgroups.

A Scoring Method to Prioritize Fecal Occult Blood Testing as a First Step in Colorectal Cancer Screening in Resource-Limited Settings

This study aims to develop a scoring method that can be used by primary care physicians from remote areas or resource-limited settings to estimate the need for fecal occult blood testing (FOBT) as a first step in colorectal cancer screening. This method relies on several modifiable risk factors that can influence a positive FOBT, an indication of the presence of colorectal polyps, or even colorectal cancer. The scoring method considers, besides the age and gender of the patient, the body mass index (BMI), smoking status, and the diagnoses of diabetes mellitus (type 2 diabetes), dyslipidemia, and hypertension. It does not need any paraclinical exams, which is an advantage when access or material resources are limited. The retrospective study was spread over forty-three months, respectively, from October 2019 to April 2023, and included 112 patients. The score that we designed is a numerical value between 0 and 7. The values between 0 and 3 represent a smaller risk of a positive FOBT (9.68%), values 4 and 5 represent a medium risk (14.75%), while values 6 and 7 represent a greater risk (40%). Using this score, a physician can determine if a patient has a greater risk and recommend it to prioritize taking a FOB test.

Optimizing allocation of colorectal cancer screening hospitals in Shanghai: a geospatial analysis

Screening programmes are important for early diagnosis and treatment of colorectal cancer (CRC) but they are not equally efficient in all locations. Depending on which hospital people belong to, they often are not willing to follow up even after a positive result, resulting in a lower-than-expected overall detection rate. Improved allocation of health resources would increase the program's efficiency and assist hospital accessibility. A target population exceeding 70,000 people and 18 local hospitals were included in the investigation of an optimization plan based on a locationallocation model. We calculated the hospital service areas and the accessibility for people in communities to CRC-screening hospitals using the Huff Model and the Two-Step Floating Catchment Area (2SFCA) approach. We found that only 28.2% of the residents with initially a positive screening result had chosen followup with colonoscopy and significant geographical differences in spatial accessibility to healthcare services indeed exist. The lowest accessibility was found in the Southeast, including the Zhangjiang, Jichang and Laogang communities with the best accessibility mainly distributed near the city centre of Lujiazui; the latter also had relatively a high level of what is called "ineffective screening" as it represents wasteful resource allocation. It is recommended that Hudong Hospital should be chosen instead of Punan Hospital as the optimization, which can improve the service population of each hospital and the populations served per colonoscope. Based on our results, changes in hospital configuration in colorectal cancer screening programme are needed to achieve adequate population coverage and equitable facility accessibility. Planning of medical services should be based on the spatial distribution trends of the population served.