Development and validation of a scoring system for advanced colorectal neoplasm in young Korean subjects less than age 50 years

Performance of the Asia-Pacific Colorectal Screening score in stratifying the risk of advanced colorectal neoplasia: A meta-analysis and systematic review

BACKGROUND AND AIM

This study systematically reviewed and meta-analyzed the performance of the Asia-Pacific Colorectal Screening (APCS) score and its incorporation with the fecal immunochemical test (FIT) in stratifying the risk of advanced colorectal neoplasia (ACN).

METHODS

We systematically searched for relevant articles in 12 electronic databases and registers on October 20, 2021, and updated the search to September 1, 2023. Random-effect models were used to obtain the pooled performance statistics of the APCS score for ACN risk.

RESULTS

From the 101 records screened, 13 eligible studies in the Asia-Pacific region involving 69 762 subjects who had undergone colonoscopy were enrolled. The pooled prevalences of ACN in the average-risk (AR) tier (APCS 0-1), moderate-risk (MR) tier (APCS 2-3), and high-risk (HR) tier (APCS ≥ 4) groups were 0.9%, 3.1%, and 8.1%, respectively. Compared with the combined AR-MR group, the HR group was significantly associated with a higher ACN risk (pooled diagnostic odds ratio: 2.84, 95% confidence interval [CI]: 2.35-3.45, P < 0.001). The APCS score showed a sensitivity of 0.42 (95% CI: 0.40-0.44) and a specificity of 0.86 (95% CI: 0.85-0.86) for predicting the ACN risk, with a weighted area under the curve of 0.642 (95% CI: 0.610-0.657). The combination of the APCS score and FIT substantially improved ACN risk identification, demonstrating pooled diagnostic odds ratios of 4.02 (95% CI: 2.50-6.49) in the AR-MR groups and 5.44 (95% CI: 1.89-15.63) in the MR-HR groups.

CONCLUSIONS

The APCS score could effectively stratify the ACN risk in the Asia-Pacific population. Incorporating FIT further improves its performance in identifying high-risk subjects who should be prioritized for colonoscopy screenings.

Updated epidemiology of gastrointestinal cancers in East Asia

Globally, gastrointestinal cancers represent more than one-fourth of all cancer incidence and one-third of cancer-related mortality. Although there has been much progress in screening colorectal cancer, the prognosis of other gastrointestinal cancers tends to be poor. The highest burden of gastrointestinal cancers, including stomach, liver, oesophageal and gallbladder cancers, was observed in regions in East Asia. The increasing burden of gastrointestinal cancers in East Asian regions is related to population growth, ageing and the westernization of lifestyle habits in this region. Furthermore, the rising incidence of young-onset colorectal cancer is an emerging trend in East Asia. This Review provides a comprehensive and updated summary of the epidemiology of gastrointestinal cancers in East Asia, with emphasis on comparing their epidemiology in East Asia with that in Western regions, and highlights the major risk factors and implications for prevention. Overall, to optimally reduce the disease burden incurred by gastrointestinal cancers in East Asian regions, a concerted effort will be needed to modify unhealthy lifestyles, promote vaccination against the hepatitis virus, control Helicobacter pylori, liver fluke and hepatitis virus infections, increase the uptake rate of colorectal cancer screening, enhance detection of early cancers and their precursors, and improve cancer survivorship through an organized rehabilitation programme.

Is early-onset cancer an emerging global epidemic? Current evidence and future implications

Over the past several decades, the incidence of early-onset cancers, often defined as cancers diagnosed in adults <50 years of age, in the breast, colorectum, endometrium, oesophagus, extrahepatic bile duct, gallbladder, head and neck, kidney, liver, bone marrow, pancreas, prostate, stomach and thyroid has increased in multiple countries. Increased use of screening programmes has contributed to this phenomenon to a certain extent, although a genuine increase in the incidence of early-onset forms of several cancer types also seems to have emerged. Evidence suggests an aetiological role of risk factor exposures in early life and young adulthood. Since the mid-20th century, substantial multigenerational changes in the exposome have occurred (including changes in diet, lifestyle, obesity, environment and the microbiome, all of which might interact with genomic and/or genetic susceptibilities). However, the effects of individual exposures remain largely unknown. To study early-life exposures and their implications for multiple cancer types will require prospective cohort studies with dedicated biobanking and data collection technologies. Raising awareness among both the public and health-care professionals will also be critical. In this Review, we describe changes in the incidence of early-onset cancers globally and suggest measures that are likely to reduce the burden of cancers and other chronic non-communicable diseases.

The Role of Diet and Lifestyle in Early-Onset Colorectal Cancer: A Systematic Review

Simple Summary

This systematic review sifted through the exogenous dietary and lifestyle risk factors associated with early-onset colorectal cancer, going through the putative involvement of these exogenous risk factors in epigenetic and microbiota modifications. Given the burden of early-onset colorectal cancer and its globally increasing trend with scant literature on its pathogenesis, we believe it would be of benefit to highlight the importance of further systematic and large studies. Indeed, dietary and lifestyle modification could complement colorectal screening for early-onset colorectal cancer prevention.

Abstract

The incidence of early-onset colorectal cancer, defined as colorectal cancer occurring in young adults under the age of 50, is increasing globally. Knowledge of the etiological factors in young adults is far from complete. Questionable eoCRCs’ exogenous factors are represented by processed meat, sugary drinks, alcohol, Western dietary pattern, overweight and obesity, physical inactivity, and smoking, though with heterogeneous results. Therefore, we performed a systematic review to summarize the current evidence on the role of diet and lifestyle as eoCRC risk factors. We systematically searched PubMed, Scopus, and EMBASE up to July 2021, for original studies evaluating diet, alcohol, physical activity, BMI, and smoking in eoCRC and included twenty-six studies. Indeed, the exogenous factors could represent modifiable key factors, whose recognition could establish areas of future interventions through public health strategies for eoCRC primary prevention. Additionally, we discussed the role of additional non-modifiable risk factors, and of epigenetic regulation and microbiota as mediators of the eoCRC triggered by diet and lifestyle.

Risk prediction rule for advanced neoplasia on screening colonoscopy for average-risk individuals

BACKGROUND

In resource-limited countries, risk stratification can be used to optimize colorectal cancer screening. Few prospective risk prediction models exist for advanced neoplasia (AN) in true average-risk individuals.

AIM

To create and internally validate a risk prediction model for detection of AN in average-risk individuals.

METHODS

Prospective study of asymptomatic individuals undergoing first screening colonoscopy. Detailed characteristics including diet, exercise and medications were collected. Multivariate logistic regression was used to elucidate risk factors for AN (adenoma ≥1 cm, villous histology, high-grade dysplasia or carcinoma). The model was validated through bootstrapping, and discrimination and calibration of the model were assessed.

RESULTS

980 consecutive individuals (51% F; 49% M) were enrolled. Adenoma and AN detection rates were 36.6% (F 29%: M 45%; P < 0.001) and 5.1% (F 3.8%; M 6.5%) respectively. On multivariate analysis, predictors of AN [OR (95%CI)] were age [1.036 (1.00-1.07); P = 0.048], BMI [overweight 2.21 (0.98-5.00); obese 3.54 (1.48-8.50); P = 0.018], smoking [< 40 pack-years 2.01 (1.01-4.01); ≥ 40 pack-years 3.96 (1.86-8.42); P = 0.002], and daily red meat consumption [2.02 (0.92-4.42) P = 0.079]. Nomograms of AN risk were developed in terms of risk factors and age separately for normal, overweight and obese individuals. The model had good discrimination and calibration.

CONCLUSION

The prevalence of adenoma and AN in average-risk Lebanese individuals is similar to the West. Age, smoking, and BMI are important predictors of AN, with obesity being particularly powerful. Though external validation is needed, this model provides an important platform for improved risk-stratification for screening programs in regions where universal screening is not currently employed.

Risk Factors Associated With Young-Onset Colorectal Adenomas and Cancer: A Systematic Review and Meta-Analysis of Observational Research

The risk of young-onset colorectal adenomas and cancer (yCRAC) in adults less than 50 years of age is increasing. We conducted a systematic review and meta-analysis of epidemiologic studies to identify lifestyle and clinical risk factors associated with yCRAC risk. We searched Medline, EMBASE, and Cochrane Database of Systematic Reviews for studies which: used an epidemiologic study design, involved individuals with yCRAC, evaluated at least 1 lifestyle or clinical factor, and applied multivariable regression approaches. We critically appraised the quality of included studies and calculated pooled measures of association (e.g. odds ratio [OR]) and 95% confidence intervals (CI) using random-effects models. We identified 499 articles in our search with 9 included in a narrative synthesis and 6 included in a meta-analysis. We found in the pooled analysis that smoking and alcohol consumption were lifestyle factors associated with yCRAC, as were clinical factors including obesity elevated blood glucose, elevated blood pressure, and elevated triglycerides. We identified lifestyle and clinical risk factors associated with risk of yCRAC, which have potential implications for informing preventive efforts and modifying screening to target at-risk populations.

Association between waist circumference and risk of colorectal neoplasia in normal-weight adults

BACKGROUND AND AIM

Abdominal obesity, measured using waist circumference (WC), is associated with the colorectal neoplasia (CRN) risk. We examined whether WC is associated with the CRN risk even in normal-weight individuals.

METHODS

A cross-sectional study was performed on asymptomatic normal-weight (body mass index 18.5-23 kg/m² ) individuals who underwent colonoscopy as health checkups.

RESULTS

Of 63 057 examinees, 30 498 were men (mean age, 41.1 years) and 32 559 were women (mean age, 41.7 years). The prevalence of overall CRN in WC quartiles 1, 2, 3, and 4 was 14.2%, 15.5%, 15.5%, and 18.7%, respectively, in men and 7.4%, 8.9%, 9.4%, and 11.5%, respectively, in women. The prevalence of advanced CRN (ACRN) in WC quartiles 1, 2, 3, and 4 was 1.5%, 1.3%, 1.6%, and 2.1%, respectively, in men and 1.0%, 1.3%, 1.2%, and 1.3%, respectively, in women. Among men, the overall CRN risk in quartile 4 (> 82 cm) was higher than that in quartiles 1, 2, and 3 (adjusted odds ratio, OR [95% confidence interval, CI], 1.22 [1.11-1.34], 1.12 [1.05-1.23], and 1.18 [1.07-1.29], respectively); the ACRN risk in quartile 4 was also higher than that in quartiles 1, 2, and 3 (adjusted OR [95% CI], 1.41 [1.09-1.81], 1.56 [1.19-2.03], and 1.50 [1.16-1.94], respectively). Among women, the overall CRN risk in quartile 4 (> 77 cm) was higher than that in quartiles 1 and 3; the ACRN risk was not different among all groups.

CONCLUSIONS

Even with a normal weight, a large WC was associated with the CRN risk, especially with the ACRN risk in men.

Prevalence and risk factors of colorectal cancer in Asia

Globally, colorectal cancer (CRC) is a substantial public health burden, and it is increasingly affecting populations in Asian countries. The overall prevalence of CRC is reported to be low in Asia when compared with that in Western nations, yet it had the highest number of prevalent cases. This review described the prevalence of CRC in Asia according to the International Agency for Research on Cancer from World Health Organization (WHO) database and summarized its major risk factors. Non-modifiable factors include genetic factors, ethnicity, age, gender, family history and body height; smoking, alcohol drinking, weight, Westernized diet, physical inactivity, chronic diseases and microbiota were involved in environmental factors. These risk factors were separately discussed in this review according to published literature from Asian countries. CRC screening has been playing an important role in reducing its disease burden. Some recommendations on its screening practices have been formulated in guidelines for Asia Pacific countries.