Hepatocellular Carcinoma Surveillance Patterns and Outcomes in Patients With Cirrhosis

BACKGROUND & AIMS

Hepatocellular carcinoma (HCC) surveillance is associated with improved early detection and reduced mortality, although practice patterns and effectiveness vary in clinical practice. We aimed to characterize HCC surveillance patterns in a large, diverse cohort of patients with HCC.

METHODS

We conducted a retrospective cohort study of patients diagnosed with HCC between January 2008 and December 2022 at 2 large US health systems. We recorded imaging receipt in the year before HCC diagnosis: ultrasound plus α-fetoprotein (AFP), ultrasound alone, multiphasic contrast-enhanced computed tomography (CT)/magnetic resonance imaging (MRI), and no liver imaging. We used multivariable logistic and Cox regression analysis to compare early tumor detection, curative treatment receipt, and overall survival between surveillance strategies.

RESULTS

Among 2028 patients with HCC (46.7% Barcelona Clinic Liver Cancer stage A), 703 (34.7%) had ultrasound plus AFP, 293 (14.5%) had ultrasound alone, 326 (16.1%) had multiphasic CT/MRI, and 706 (34.8%) had no imaging in the year before HCC diagnosis. Over the study period, proportions without imaging were stable, whereas use of CT/MRI increased. Compared with no imaging, CT/MRI and ultrasound plus AFP, but not ultrasound alone, were associated with early stage HCC detection and curative treatment. Compared with ultrasound alone, CT/MRI and ultrasound plus AFP were associated with increased early stage detection.

CONCLUSIONS

HCC surveillance patterns vary in clinical practice and are associated with differing clinical outcomes. While awaiting data to determine if CT or MRI surveillance can be performed in a cost-effective manner in selected patients, AFP has a complementary role to ultrasound-based surveillance, supporting its adoption in practice guidelines.

Blood-based Migration Signature Biomarker Panel Discriminates Early Stage New Onset Diabetes related Pancreatic Ductal Adenocarcinoma from Type 2 Diabetes

BACKGROUND AND AIMS

While type 2 diabetes is a well-known risk factor for pancreatic ductal adenocarcinoma (PDAC), PDAC-induced new-onset diabetes (PDAC-NOD) is a manifestation of underlying PDAC. In this study, we sought to identify potential blood-based biomarkers for distinguishing PDAC-NOD from type 2 diabetes (T2DM) without PDAC.

MATERIALS AND METHODS

By ELISA analysis, a migration signature biomarker panel comprising tissue factor pathway inhibitor (TFPI), tenascin C (TNC-FNIII-C) and CA 19-9 was analyzed in plasma samples from 50 PDAC-NOD and 50 T2DM controls.

RESULTS

Both TFPI (area under the curve (AUC) 0.71) and TNC-FNIII-C (AUC 0.69) outperformed CA 19-9 (AUC 0.60) in distinguishing all stages of PDAC-NOD from T2DM controls. The combined panel showed an AUC of 0.82 (95% CI = 0.73-0.90) (p = 0.002). In the PDAC-NOD early stage II samples, the three biomarkers had an AUC of 0.84 (95% CI = 0.73-0.93) vs CA 19-9, AUC = 0.60, (95% CI = 0.45-0.73), which also improved significance (p = 0.0123).

CONCLUSION

The migration signature panel adds significantly to CA 19-9 to discriminate PDAC-NOD from T2DM controls and warrants further validation for high-risk group stratification.

A Liquid Biopsy Signature for the Early Detection of Gastric Cancer in Patients

BACKGROUND & AIMS

Diagnosing gastric cancer (GC) while the disease remains eligible for surgical resection is challenging. In view of this clinical challenge, novel and robust biomarkers for early detection thus improving prognosis of GC are necessary. The present study is to develop a blood-based long noncoding RNA (LR) signature for the early-detection of GC.

METHODS

The present 3-step study incorporated data from 2141 patients, including 888 with GC, 158 with chronic atrophic gastritis, 193 with intestinal metaplasia, 501 healthy donors, and 401 with other gastrointestinal cancers. The LR profile of stage I GC tissue samples were analyzed using transcriptomic profiling in discovery phase. The extracellular vesicle (EV)-derived LR signature was identified with a training cohort (n = 554) and validated with 2 external cohorts (n = 429 and n = 504) and a supplemental cohort (n = 69).

RESULTS

In discovery phase, one LR (GClnc1) was found to be up-regulated in both tissue and circulating EV samples with an area under the curve (AUC) of 0.9369 (95% confidence interval [CI], 0.9073-0.9664) for early-stage GC (stage I/II). The diagnostic performance of this biomarker was further confirmed in 2 external validation cohorts (Xi'an cohort, AUC: 0.8839; 95% CI: 0.8336-0.9342; Beijing cohort, AUC: 0.9018; 95% CI: 0.8597-0.9439). Moreover, EV-derived GClnc1 robustly distinguished early-stage GC from precancerous lesions (chronic atrophic gastritis and intestinal metaplasia) and GC with negative traditional gastrointestinal biomarkers (CEA, CA72-4, and CA19-9). The low levels of this biomarker in postsurgery and other gastrointestinal tumor plasma samples indicated its GC specificity.

CONCLUSIONS

EV-derived GClnc1 serves as a circulating biomarker for the early detection of GC, thus providing opportunities for curative surgery and improved survival outcomes.

Methods and biomarkers for early detection, prediction, and diagnosis of colorectal cancer

Colorectal cancer (CRC) is one of the most common digestive diseases worldwide. It has steadily ascended to the top three cancers in terms of incidence and mortality. The primary cause is the inability to diagnose it at an early stage. Therefore, early detection and diagnosis are essential for colorectal cancer prevention. Although there are now various methods for CRC early detection, in addition to recent developments in surgical and multimodal therapy, the poor prognosis and late detection of CRC still remain significant. Thus, it is important to investigate novel technologies and biomarkers to improve the sensitization and specification of CRC diagnosis. Here, we present some common methods and biomarkers for early detection and diagnosis of CRC, we hope this review will encourage the adoption of screening programs and the clinical use of these potential molecules as biomarkers for CRC early detection and prognosis.

Biomarkers in Lung Cancer Screening: a Narrative Review

Although when used as a lung cancer screening tool low-dose computed tomography (LDCT) has demonstrated a significant reduction in lung cancer related mortality, it is not without pitfalls. The associated high false positive rate, inability to distinguish between benign and malignant nodules, cumulative radiation exposure, and resulting patient anxiety have all demonstrated the need for adjunctive testing in lung cancer screening. Current research focuses on developing liquid biomarkers to complement imaging as non-invasive lung cancer diagnostics. Biomarkers can be useful for both the early detection and diagnosis of disease, thereby decreasing the number of unnecessary radiologic tests performed. Biomarkers can stratify cancer risk to further enrich the screening population and augment existing risk prediction. Finally, biomarkers can be used to distinguish benign from malignant nodules in lung cancer screening. While many biomarkers require further validation studies, several, including autoantibodies and blood protein profiling, are available for clinical use. This paper describes the need for biomarkers as a lung cancer screening tool, both in terms of diagnosis and risk assessment. Additionally, this paper will discuss the goals of biomarker use, describe properties of a good biomarker, and review several of the most promising biomarkers currently being studied including autoantibodies, complement fragments, microRNA, blood proteins, circulating tumor DNA, and DNA methylation. Finally, we will describe future directions in the field of biomarker development.

Prospective, Multi-Institutional, Real-Time Next-Generation Sequencing of Pancreatic Cyst Fluid Reveals Diverse Genomic Alterations That Improve the Clinical Management of Pancreatic Cysts

BACKGROUND & AIMS

Next-generation sequencing (NGS) of pancreatic cyst fluid is a useful adjunct in the assessment of patients with pancreatic cyst. However, previous studies have been retrospective or single institutional experiences. The aim of this study was to prospectively evaluate NGS on a multi-institutional cohort of patients with pancreatic cyst in real time.

METHODS

The performance of a 22-gene NGS panel (PancreaSeq) was first retrospectively confirmed and then within a 2-year timeframe, PancreaSeq testing was prospectively used to evaluate endoscopic ultrasound-guided fine-needle aspiration pancreatic cyst fluid from 31 institutions. PancreaSeq results were correlated with endoscopic ultrasound findings, ancillary studies, current pancreatic cyst guidelines, follow-up, and expanded testing (Oncomine) of postoperative specimens.

RESULTS

Among 1933 PCs prospectively tested, 1887 (98%) specimens from 1832 patients were satisfactory for PancreaSeq testing. Follow-up was available for 1216 (66%) patients (median, 23 months). Based on 251 (21%) patients with surgical pathology, mitogen-activated protein kinase/GNAS mutations had 90% sensitivity and 100% specificity for a mucinous cyst (positive predictive value [PPV], 100%; negative predictive value [NPV], 77%). On exclusion of low-level variants, the combination of mitogen-activated protein kinase/GNAS and TP53/SMAD4/CTNNB1/mammalian target of rapamycin alterations had 88% sensitivity and 98% specificity for advanced neoplasia (PPV, 97%; NPV, 93%). Inclusion of cytopathologic evaluation to PancreaSeq testing improved the sensitivity to 93% and maintained a high specificity of 95% (PPV, 92%; NPV, 95%). In comparison, other modalities and current pancreatic cyst guidelines, such as the American Gastroenterology Association and International Association of Pancreatology/Fukuoka guidelines, show inferior diagnostic performance. The sensitivities and specificities of VHL and MEN1/loss of heterozygosity alterations were 71% and 100% for serous cystadenomas (PPV, 100%; NPV, 98%), and 68% and 98% for pancreatic neuroendocrine tumors (PPV, 85%; NPV, 95%), respectively. On follow-up, serous cystadenomas with TP53/TERT mutations exhibited interval growth, whereas pancreatic neuroendocrine tumors with loss of heterozygosity of ≥3 genes tended to have distant metastasis. None of the 965 patients who did not undergo surgery developed malignancy. Postoperative Oncomine testing identified mucinous cysts with BRAF fusions and ERBB2 amplification, and advanced neoplasia with CDKN2A alterations.

CONCLUSIONS

PancreaSeq was not only sensitive and specific for various pancreatic cyst types and advanced neoplasia arising from mucinous cysts, but also reveals the diversity of genomic alterations seen in pancreatic cysts and their clinical significance.

Willingness to Pay for Down Syndrome Screening: A systematics Review

Background:Financial ability to pay has a unique role in the accessibility of health care services, which indicates the necessity of raising enough funds by governments. However, how much households are willing to pay (WTP) for receiving a particular service? And what factors influence their WTP? The current systematic review aimed to, firstly, review studies on the WTP for Down syndrome (DS) screening, and, secondly, to identify factors that affect WTP for DS screening. Methods:We systematically searched the Scopus, PubMed, Web of Sciences (ISI), and Embase databases to identify relevant studies from their inception to June 2020; the search strategy was updated on December 2021. Initially, 157 articles were identified, and 5 were found eligible for full-text review. In event of any disagreement, a third reviewer was used. Extracted WTPs were converted to US dollars in 2018 using exchange rate parity and the present value formula to make a comparison. The quality assessment of the selected studies was done using the "Lancsar and Louvier" and Smith checklist; also, vote counting was used to assess the influence of factors. Results:Five eligible studies, published from 2005 to 2020, were fully reviewed. All final studies were scored as good quality. The extracted WTPs varied from $169 to $1118 in UK and Canada, respectively. Income and information/knowledge about screening tests were the most frequently investigated factors. Education level, detection rate, women's age, cost, and family history were significantly associated with higher levels of WTP for DS screening. Conclusion:This study demonstrated a significant gap in WTP for DS screening in various countries. Women are WTP higher costs for tests with higher screenings. Also, a unique role was identified for income, occupation, information, and family history of DS in WTP for DS screening. In addition, a positive association was found for the variable of age.

Cost-Effectiveness of a Risk-Tailored Pancreatic Cancer Early Detection Strategy Among Patients With New-Onset Diabetes

BACKGROUND & AIMS

Screening for pancreatic ductal adenocarcinoma (PDAC) in asymptomatic adults is not recommended, however, patients with new-onset diabetes (NoD) have an 8 times higher risk of PDAC than expected. A novel risk-tailored early detection strategy targeting high-risk NoD patients might improve PDAC prognosis. We sought to evaluate the cost effectiveness of this strategy.

METHODS

We compared PDAC early detection strategies targeting NoD individuals age 50 years and older at various minimal predicted PDAC risk thresholds vs standard of care in a Markov state-transition decision model under the health care sector perspective using a lifetime horizon.

RESULTS

At a willingness to pay (WTP) threshold of $150,000 per quality-adjusted life-year, the early detection strategy targeting patients with a minimum predicted 3-year PDAC risk of 1% was cost effective (incremental cost-effectiveness ratio, $116,911). At a WTP threshold of $100,000 per quality-adjusted life-year, the early detection strategy at the 2% risk threshold was cost effective (incremental cost-effectiveness ratio, $63,045). The proportion of PDACs detected at local stage, costs of treatment for metastatic PDAC, utilities of local and regional cancers, and sensitivity of screening were the most influential parameters. Probabilistic sensitivity analysis confirmed that at a WTP threshold of $150,000, early detection at the 1.0% risk threshold was favored (30.6%), followed by the 0.5% risk threshold (20.4%) vs standard of care (1.7%). At a WTP threshold of $100,000, early detection at the 1.0% risk threshold was favored (27.3%) followed by the 2.0% risk threshold (22.8%) vs standard of care (2.0%).

CONCLUSIONS

A risk-tailored PDAC early detection strategy targeting NoD patients with a minimum predicted 3-year PDAC risk of 1.0% to 2.0% may be cost effective.

Dynamic Changes in Ultrasound Quality for Hepatocellular Carcinoma Screening in Patients With Cirrhosis

BACKGROUND & AIMS

Identifying patients in whom ultrasound may be inadequate to exclude the presence of hepatocellular carcinoma (HCC) can inform interventions to improve screening effectiveness. We aimed to characterize correlates of suboptimal ultrasound quality and changes in ultrasound quality over time in patients with cirrhosis undergoing HCC screening.

METHODS

We performed a retrospective cohort study of patients with cirrhosis who underwent ultrasound examination at 2 large health systems between July 2016 and July 2019. Exam adequacy was graded by radiologists using the LI-RADS Visualization Score (A, B, C); we evaluated changes in visualization over time among patients with >1 ultrasound exams. We performed multivariable logistic regression to identify characteristics associated with limited ultrasound visualization (scores B or C).

RESULTS

Of 2053 cirrhosis patients, 1685 (82.1%) had ultrasounds with score A, 262 (12.8%) had score B, and 106 (5.2%) had score C. Limited visualization was associated with alcohol-related or nonalcoholic fatty liver disease cirrhosis and presence of class II-III obesity. Among 1546 patients with >1 ultrasounds, 1129 (73.0%) had the same visualization score on follow-up (1046 score A, 60 score B, 23 score C). However, 255 (19.6%) of 1301 with score A at baseline had limited visualization when repeated (230 score B, 25 score C), and 130 (53.1%) of 245 patients with baseline limited visualization had good visualization when repeated.

CONCLUSIONS

Nearly 1 in 5 patients with cirrhosis had moderately-severely limited ultrasound visualization for HCC nodules, particularly those with obesity or alcohol-related or nonalcoholic fatty liver disease cirrhosis. Ultrasound quality can change between exams, including improvement in many patients with limited visualization.

A ratiometric electrochemical DNA-biosensor for detection of miR-141

A sensitive biosensor for the detection of miR-141 has been constructed. The DNA-biosensor is prepared by first immobilizing the thiolated methylene blue-labeled hairpin capture probe (MB-HCP) on two-layer nanocomposite film graphene oxide-chitosan@ polyvinylpyrrolidone-gold nanourchin modified glassy carbon electrode. We used the hematoxylin as an electrochemical auxiliary indicator in the second stage to recognize DNA hybridization via the square wave voltammetry (SWV) responses that record the accumulated hematoxylin on electrode surfaces. The morphology and chemical composition of nanocomposite was characterized using TEM, FE-SEM, and FT-IR techniques. The preparation stages of the DNA-biosensor were screened by electrochemical impedance spectroscopy and cyclic voltammetry. The proposed DNA-biosensor can distinguish miR-141 from a non-complementary and mismatch sequence. A detection limit of 0.94 fM and a linear range of 2.0 -5.0 × 10⁵ fM were obtained using SWV for miR-141 detection. The working potential for methylene blue and hematoxylin was -0.28 and + 0.15 V vs. Ag/AgCl, respectively. The developed biosensor can be successfully used in the early detection of non-small cell lung cancer (NSCLC) by directly measuring miR-141 in human plasma samples. This novel DNA-biosensor is of promise in early sensitive clinical diagnosis of cancers with miR-141 as its biomarker.

Predicting Pancreatic Cancer in the UK Biobank Cohort Using Polygenic Risk Scores and Diabetes Mellitus

BACKGROUND & AIMS

Diabetes mellitus (DM) is known to be associated with pancreatic ductal adenocarcinoma (PDAC), particularly new-onset DM (NODM). Others have developed polygenic risk scores (PRS) associated with PDAC risk. We aimed to compare the performance of these PRS in an independent cohort to determine if they can discriminate between NODM and long-standing DM patients with PDAC.

METHODS

Cases (1042) and matched cancer-free controls (10,420) were drawn from the UK Biobank. Five PRS models were calculated using single nucleotide polymorphisms (SNPs) from previous studies (Nakatochi, Galeotti, Molina, Jia, and Rashkin) and a combination of these. Regression models were used to assess the association between PDAC and PRS adjusted for ancestry, smoking, DM, waist circumference, and family history of digestive cancer. Receiver operator characteristic curves and area under the curve metrics (AUC) were used to assess the performance of each PRS for classifying PDAC risk.

RESULTS

The combined PRS model achieved the highest AUC (0.605), and significantly improved a clinical risk model in this cohort (AUC = 0.83; P = .0002). Individuals within the fifth quintile have a 2.74-fold increased risk of developing PDAC vs those in the first quintile (P < .001), and have a 3.05-fold increased risk of developing PDAC if they have DM vs those without DM (P < .001). The positive predictive value was 11.9% in participants without DM, 23.9% with long-standing DM, and 86.7% with NODM.

CONCLUSIONS

The PDAC-related common genetic variants are more strongly associated with DM. This PRS has the potential for targeting individuals with NODM for PDAC secondary screening measures.

Results of Compliant Participation in Five Rounds of Fecal Immunochemical Test Screening for Colorectal Cancer

BACKGROUND & AIMS

We investigated the magnitude and temporal patterns of the decreasing trend in main performance measures of fecal immunochemical test (FIT) screening for colorectal cancer (CRC) observed in second and subsequent rounds.

METHODS

We followed up 494,187 participants from the first round of a regional biennial FIT screening program in Italy (cut-off value for positivity, 20 μg hemoglobin/g feces) for 5 total rounds (2005-2016). At each round, only compliant participants were eligible. Performance measures from the first, third, fourth, and fifth rounds were compared with those from the second round (the first incidence round) using rate ratios from multivariate Poisson regression models and relative risk ratios from multinomial logistic regression models.

RESULTS

Between the second and the third rounds, a significant 20% to 30% decrease was found in the proportion of men with a positive FIT result (from 5.2% to 4.3%) and in detection rates of advanced adenoma (from 13.4 to 10.2 per 1000), CRC (from 1.7 to 1.4 per 1000), and advanced neoplasia (from 15.1 to 11.6 per 1000). Positive predictive values (PPVs) decreased by 10% or less between the second and third rounds. Detection rates and PPVs for adenoma stabilized by the fourth and fifth rounds. The PPVs for advanced adenoma, CRC, and advanced neoplasia decreased slightly in men and women by the fourth and fifth rounds. The detection rate of proximal colon cancer stabilized after the second round, whereas the detection rate of distal colon cancer decreased until the fourth round in men (from 0.7 to 0.3 per 1000), and the fifth round in women.

CONCLUSIONS

These findings support the notion that FIT screening prevents progression of a subset of advanced adenomas. Screening intensity could be modulated based on results from previous rounds, with a risk-based strategy.

Exploring Deep Transfer Learning Techniques for Alzheimer's Dementia Detection

Examination of speech datasets for detecting dementia, collected via various speech tasks, has revealed links between speech and cognitive abilities. However, the speech dataset available for this research is extremely limited because the collection process of speech and baseline data from patients with dementia in clinical settings is expensive. In this paper, we study the spontaneous speech dataset from a recent ADReSS challenge, a Cookie Theft Picture (CTP) dataset with balanced groups of participants in age, gender, and cognitive status. We explore state-of-the-art deep transfer learning techniques from image, audio, speech, and language domains. We envision that one advantage of transfer learning is to eliminate the design of handcrafted features based on the tasks and datasets. Transfer learning further mitigates the limited dementia-relevant speech data problem by inheriting knowledge from similar but much larger datasets. Specifically, we built a variety of transfer learning models using commonly employed MobileNet (image), YAMNet (audio), Mockingjay (speech), and BERT (text) models. Results indicated that the transfer learning models of text data showed significantly better performance than those of audio data. Performance gains of the text models may be due to the high similarity between the pre-training text dataset and the CTP text dataset. Our multi-modal transfer learning introduced a slight improvement in accuracy, demonstrating that audio and text data provide limited complementary information. Multi-task transfer learning resulted in limited improvements in classification and a negative impact in regression. By analyzing the meaning behind the AD/non-AD labels and Mini-Mental State Examination (MMSE) scores, we observed that the inconsistency between labels and scores could limit the performance of the multi-task learning, especially when the outputs of the single-task models are highly consistent with the corresponding labels/scores. In sum, we conducted a large comparative analysis of varying transfer learning models focusing less on model customization but more on pre-trained models and pre-training datasets. We revealed insightful relations among models, data types, and data labels in this research area.

Effects of Screening Compliance on Long-term Reductions in All-Cause and Colorectal Cancer Mortality

BACKGROUND & AIMS

Randomized trials have shown that biennial fecal occult blood test (FOBT) screening reduces mortality from colorectal cancer (CRC), but not overall mortality. Differences in benefit for men vs women, and by age, are unknown. We sought to evaluate long-term reduction in all-cause and CRC-specific mortality in men and women who comply with offered screening, and in different age groups, using individual participant data from 2 large randomized trials of biennial FOBT screening, compared with an intention to treat analysis.

METHODS

We updated the CRC and all-cause mortality from the Danish CRC screening trial (n = 61,933) through 30 years of follow up and pooled individual participant data with individual 30-year follow-up data from the Minnesota Colon Cancer Control trial (n = 46,551). We compared the biennial screening groups to usual care (controls) in individuals 50-80 years old using Kaplan Meier estimates of relative risks and risk differences, adjusted for study differences in age, sex, and compliance.

RESULTS

Through 30 years of follow up, there were 33,478 (71.9%) and 33,479 (72.2%) total deaths and 1023 (2.2%) and 1146 (2.5%) CRC deaths in the biennial screening (n = 46,553) and control groups (n = 46,358), respectively. Among compliers, biennial FOBT screening significantly reduced CRC mortality by 16% (relative risk [RR], 0.84; 95% CI, 0.74-0.96) and all-cause mortality by 2% (RR, 0.98; 95% CI, 0.97-0.99). Among compliers, the reduction in CRC mortality was larger for men (RR, 0.75; 95% CI, 0.62-0.90) than women (RR, 0.91; 95% CI, 0.75-1.09). The largest reduction in CRC mortality was in compliant men 60-69 years old (RR, 0.59; 95% CI, 0.42-0.81) and women 70 years and older (RR, 0.53; 95% CI, 0.30-0.94).

CONCLUSIONS

Long-term CRC mortality outcomes of screening among compliers using biennial FOBT are sustained, with a statistically significant reduction in all-cause mortality. The reduction in CRC mortality is greater in men than women-the benefit in women lags that of men by about 10 years.

Patient-Reported Barriers Are Associated With Receipt of Hepatocellular Carcinoma Surveillance in a Multicenter Cohort of Patients With Cirrhosis

BACKGROUND

More than 20% of patients with cirrhosis do not receive semi-annual hepatocellular carcinoma (HCC) surveillance as recommended. Few studies have evaluated the effects of patient-level factors on surveillance receipt.

METHODS

We administered a telephone survey to a large cohort of patients with cirrhosis from 3 health systems (a tertiary care referral center, a safety-net health system, and Veterans Affairs) to characterize patient knowledge, attitudes, and perceived barriers of HCC surveillance. Multinomial logistic regression was performed to identify factors associated with HCC surveillance receipt (semi-annual and annual vs none) during the 12-month period preceding survey administration.

RESULTS

Of 2871 patients approached, 1020 (35.5%) completed the survey. Patients had high levels of concern about developing HCC and high levels of knowledge about HCC. However, patients had knowledge deficits, including believing surveillance was unnecessary when physical examination and laboratory results were normal. Nearly half of patients reported barriers to surveillance, including costs (28.9%), difficulty scheduling (24.1%), and transportation (17.8%). In the year before the survey, 745 patients (73.1%) received 1 or more surveillance examination; 281 received on-schedule, semi-annual surveillance and 464 received annual surveillance. Semi-annual HCC surveillance (vs none) was significantly associated with receipt of hepatology subspecialty care (odds ratio, 30.1; 95% CI, 17.5-51.8) and inversely associated with patient-reported barriers (odds ratio, 0.62; 95% CI, 0.41-0.94). Patterns of associations comparing annual vs no surveillance were similar although the magnitude of effects were reduced.

CONCLUSIONS

Patient-reported barriers such as knowledge deficits, costs, difficulty scheduling, and transportation are significantly associated with less frequent receipt of HCC surveillance, indicating a need for patient-centered interventions, such as patient navigation.

Development and Validation of the Asia-Pacific Proximal Colon Neoplasia Risk Score

BACKGROUND & AIMS

Patients found to be at high risk of advanced proximal neoplasia (APN) after flexible sigmoidoscopy screening should be considered for colonoscopy examination. We developed and validated a scoring system to identify persons at risk for APN.

METHODS

We collected data from 7954 asymptomatic subjects (age, 50-75 y) who received screening colonoscopy examinations at 14 sites in Asia. We randomly assigned 5303 subjects to the derivation cohort and the remaining 2651 to the validation cohort. We collected data from the derivation cohort on age, sex, family history of colorectal cancer, smoking, drinking, body mass index, medical conditions, and use of nonsteroidal anti-inflammatory drugs or aspirin. Associations between the colonoscopic findings of APN and each risk factor were examined using the Pearson χ² test, and we assigned each participant a risk score (0-15), with scores of 0 to 3 as average risk and scores of 4 or higher as high risk. The scoring system was tested in the validation cohort. We used the Cochran-Armitage test of trend to compare the prevalence of APN among subjects in each group.

RESULTS

In the validation cohort, 79.5% of patients were classified as average risk and 20.5% were classified as high risk. The prevalence of APN in the average-risk group was 1.9% and in the high-risk group was 9.4% (adjusted relative risk, 5.08; 95% CI, 3.38-7.62; P < .001). The score included age (61-70 y, 3; ≥70 y, 4), smoking habits (current/past, 2), family history of colorectal cancer (present in a first-degree relative, 2), and the presence of neoplasia in the distal colorectum (nonadvanced adenoma 5-9 mm, 2; advanced neoplasia, 7). The c-statistic of the score was 0.74 (95% CI, 0.68-0.79), and for distal findings alone was 0.67 (95% CI, 0.60-0.74). The Hosmer-Lemeshow goodness-of-fit test statistic was greater than 0.05, indicating the reliability of the validation set. The number needed to refer was 11 (95% CI, 10-13), and the number needed to screen was 15 (95% CI, 12-17).

CONCLUSIONS

We developed and validated a scoring system to identify persons at risk for APN. Screening participants who undergo flexible sigmoidoscopy screening with a score of 4 points or higher should undergo colonoscopy evaluation.

Advances in Screening, Early Diagnosis and Accurate Staging of Diabetic Neuropathy

The incidence of both type 1 and type 2 diabetes is increasing worldwide. Diabetic peripheral neuropathy (DPN) is among the most distressing and costly of all the chronic complications of diabetes and is a cause of significant disability and poor quality of life. This incurs a significant burden on health care costs and society, especially as these young people enter their peak working and earning capacity at the time when diabetes-related complications most often first occur. DPN is often asymptomatic during the early stages; however, once symptoms and overt deficits have developed, it cannot be reversed. Therefore, early diagnosis and timely intervention are essential to prevent the development and progression of diabetic neuropathy. The diagnosis of DPN, the determination of the global prevalence, and incidence rates of DPN remain challenging. The opinions vary about the effectiveness of the expansion of screenings to enable early diagnosis and treatment initiation before disease onset and progression. Although research has evolved over the years, DPN still represents an enormous burden for clinicians and health systems worldwide due to its difficult diagnosis, high costs related to treatment, and the multidisciplinary approach required for effective management. Therefore, there is an unmet need for reliable surrogate biomarkers to monitor the onset and progression of early neuropathic changes in DPN and facilitate drug discovery. In this review paper, the aim was to assess the currently available tests for DPN's sensitivity and performance.

Endoscopy for Gastric Cancer Screening Is Cost Effective for Asian Americans in the United States

BACKGROUND & AIMS

Endoscopic screening for gastric cancer is routine in some countries with high incidence and is associated with reduced gastric cancer-related mortality. Immigrants from countries of high incidence to low incidence of gastric cancer retain their elevated risk, but no screening recommendations have been made for these groups in the United States. We aimed to determine the cost effectiveness of different endoscopic screening strategies for noncardia gastric cancer, compared with no screening, among Chinese, Filipino, Southeast Asian, Vietnamese, Korean, and Japanese Americans.

METHODS

We generated a decision-analytic Markov model to simulate a cohort of asymptomatic 50-year-old Asian Americans. The cost effectiveness of 2 distinct strategies for endoscopic gastric cancer screening was compared with no screening for each group, stratified by sex. Outcome measures were reported in incremental cost-effectiveness ratios (ICERs), with a willingness-to-pay threshold of $100,000/quality-adjusted life-year (QALY). Extensive sensitivity analyses were performed.

RESULTS

Compared with performing no endoscopic gastric cancer screening, performing a 1-time upper endoscopy with biopsies, with continued endoscopic surveillance if gastric intestinal metaplasia was identified, was cost effective, whereas performing ongoing biennial endoscopies, even for patients with normal findings from endoscopy and histopathology, was not. The lowest ICERs were observed for Chinese, Japanese, and Korean Americans (all <$73,748/QALY).

CONCLUSIONS

Endoscopic screening for gastric cancer with ongoing surveillance of gastric preneoplasia is cost effective for Asian Americans ages 50 years or older in the United States. The lowest ICERs were for Chinese, Japanese, and Korean Americans (all <$73,748/QALY).

Validation of an Algorithm to Identify Patients at Risk for Colorectal Cancer Based on Laboratory Test and Demographic Data in Diverse, Community-Based Population

BACKGROUND & AIMS

Approximately 30%-40% of screening-eligible adults in the United States are not up to date with colorectal cancer (CRC) screening. We aimed to validate a predictive score, generated by a machine learning algorithm with common laboratory test data, to identify patients at high risk for CRC in a large, community-based, ethnically diverse cohort.

METHODS

We performed a nested case-control study using data from members of Kaiser Permanente Northern California (1996-2015). Cases were cohort members who received a complete blood cell count at ages 50-75 y, did not have a prior or current diagnosis of CRC diagnosis at the time of the blood cell count, and were subsequently diagnosed with CRC. We used data from the cohort to validate the ability of an algorithm that uses laboratory and demographic information to identify patients at increased risk for CRC. Test performance was evaluated using area under the receiver operating characteristic curve (AUROC) and odds ratios (OR) with 95% CI values to compare high (defined as 97% specificity or more) vs low scores.

RESULTS

A high score from the algorithm identified patients with a CRC diagnosis within the next 6 months with 35.4% sensitivity (95% CI, 33.8-36.7) and an AUROC of 0.78 (95% CI, 0.77-0.78). Patients with a high score had an increased risk of diagnosis with early-stage CRC (OR, 13.1; 95% CI, 11.8-14.3) and advanced stage CRC (OR, 24.8; 95% CI, 22.4-27.3) within the next 6 months. In patients with high scores, the ORs for proximal and distal cancers were 34.7 (95% CI, 31.5-37.7) and 12.1 (95% CI, 10.1-13.9), respectively. The algorithm's accuracy decreased with the time interval between blood test result and CRC diagnosis; performance did not differ by sex or race.

CONCLUSIONS

We validated a predictive model that uses complete blood cell count and demographic data to identify patients at high risk of CRC. The algorithm identified 3% of the population who require an investigation and identified 35% of patients who received a diagnosis of CRC within the next 6 months.

A nanobiosensor based on graphene oxide and DNA binding dye for multi-microRNAs detection

Multiplex assays for detection of biomarkers, provide advantageous analyses of different factors related to diagnoses of diseases. The Alzheimer’s disease (AD) is one of the most common disease in old people in societies which is increasing, significantly. A group of microRNAs (miRNAs) play an important role in developing the disease which can be considered as early stage biomarkers. Since, selective, sensitive, simple and rapid method for detection of these miRNAs in a single test is critical for early diagnosis and efficient therapy of the disease, herein, we report a sensitive fluorescence assay based on enzyme-free and isothermal hybridization chain reaction with SYBR Green and graphene oxide (GOX) for early detection of miR-137 and miR-142, as two Alzheimer’s biomarkers. Fluorescence spectrophotometry based on SYBR Green signal and GOX as the fluorescence quencher was used for detection and quantification of targets’ miRNAs and change in fluorescence intensity due to absence and presence of the targets was measured. The limit of detection in the newly designed nanobiosensor was achieved as 82 pM with a sensitive detection of the miRNAs from 0.05 to 5 nM, that is critical for detecting the biomarkers. Given the real range of concentrations of miRNAs in blood (from nanomolar to femtomolar values), the method holds great promise in dual and multiple targets detection due to its sensitivity, rapidness, inexpensive and specificity which provides a convenient detection method of Alzheimer’s in early stage.

Lower Adenoma Miss Rate of Computer-Aided Detection-Assisted Colonoscopy vs Routine White-Light Colonoscopy in a Prospective Tandem Study

BACKGROUND AND AIMS

Up to 30% of adenomas might be missed during screening colonoscopy-these could be polyps that appear on-screen but are not recognized by endoscopists or polyps that are in locations that do not appear on the screen at all. Computer-aided detection (CADe) systems, based on deep learning, might reduce rates of missed adenomas by displaying visual alerts that identify precancerous polyps on the endoscopy monitor in real time. We compared adenoma miss rates of CADe colonoscopy vs routine white-light colonoscopy.

METHODS

We performed a prospective study of patients, 18-75 years old, referred for diagnostic, screening, or surveillance colonoscopies at a single endoscopy center of Sichuan Provincial People's Hospital from June 3, 2019 through September 24, 2019. Same day, tandem colonoscopies were performed for each participant by the same endoscopist. Patients were randomly assigned to groups that received either CADe colonoscopy (n=184) or routine colonoscopy (n=185) first, followed immediately by the other procedure. Endoscopists were blinded to the group each patient was assigned to until immediately before the start of each colonoscopy. Polyps that were missed by the CADe system but detected by endoscopists were classified as missed polyps. False polyps were those continuously traced by the CADe system but then determined not to be polyps by the endoscopists. The primary endpoint was adenoma miss rate, which was defined as the number of adenomas detected in the second-pass colonoscopy divided by the total number of adenomas detected in both passes.

RESULTS

The adenoma miss rate was significantly lower with CADe colonoscopy (13.89%; 95% CI, 8.24%-19.54%) than with routine colonoscopy (40.00%; 95% CI, 31.23%-48.77%, P<.0001). The polyp miss rate was significantly lower with CADe colonoscopy (12.98%; 95% CI, 9.08%-16.88%) than with routine colonoscopy (45.90%; 95% CI, 39.65%-52.15%) (P<.0001). Adenoma miss rates in ascending, transverse, and descending colon were significantly lower with CADe colonoscopy than with routine colonoscopy (ascending colon 6.67% vs 39.13%; P=.0095; transverse colon 16.33% vs 45.16%; P=.0065; and descending colon 12.50% vs 40.91%, P=.0364).

CONCLUSIONS

CADe colonoscopy reduced the overall miss rate of adenomas by endoscopists using white-light endoscopy. Routine use of CADe might reduce the incidence of interval colon cancers. chictr.org.cn study no: ChiCTR1900023086.

Magnetic Resonance Imaging With Extracellular Contrast Detects Hepatocellular Carcinoma With Greater Accuracy Than With Gadoxetic Acid or Computed Tomography

BACKGROUND & AIMS

Computed tomography (CT) and magnetic resonance imaging (MRI) are used to detect hepatocellular carcinoma (HCC). We performed a prospective study to compare the diagnostic performance of CT, MRI with extracellular contrast agents (ECA-MRI), and MRI with hepatobiliary agents (HBA-MRI) in the detection of HCC using the liver imaging reporting and data system (LI-RADS).

METHODS

We studied 125 participants (102 men; mean age, 55.3 years) with chronic liver disease who underwent CT, ECA-MRI, or HBA-MRI (with gadoxetic acid) before surgery for a nodule initially detected by ultrasound at a tertiary center in Korea, from November 2016 through February 2019. We collected data on major features and assigned LI-RADS categories (v2018) from CT and MRI examinations. We then compared the diagnostic performance for LR-5 for each modality alone, and in combination.

RESULTS

In total, 163 observations (124 HCCs, 13 non-HCC malignancies, and 26 benign lesions; mean size, 20.7 mm) were identified. ECA-MRI detected HCC with 83.1% sensitivity and 86.6% accuracy, compared to 64.4% sensitivity and 71.8% accuracy for CT (P < .001) and 71.2% sensitivity (P = .005) and 76.5% accuracy for HBA-MRI (P = .005); all technologies detected HCC with 97.4% specificity. Adding CT to either ECA-MRI (89.2% sensitivity, 91.4% accuracy; both P < .05) or HBA-MRI (82.8% sensitivity, 86.5% accuracy; both P < .05) significantly increased its diagnostic performance in detection of HCC compared with the MRI technologies alone. ECA-MRI identified arterial phase hyperenhancement in a significantly higher proportion of patients (97.6%) than CT (81.5%; P < .001) or HBA-MRI (89.5%; P = .002). ECA-MRI identified non-peripheral washout in 79.8% of patients, vs 74.2% of patients for CT and 73.4% of patients for HBA-MRI (differences not significant). ECA-MRI identified enhancing capsules in 85.5% of patients, vs 33.9% for CT (P < .001) and 41.4% for HBA-MRI (P < .001).

CONCLUSION

In a prospective study of patients with chronic liver disease and a nodule detected by ultrasound, ECA-MRI detected HCC with higher levels of sensitivity and accuracy than CT or HBA-MRI, based on LI-RADS. Diagnostic performance was best when CT was used in combination with MRI compared with MRI alone.

Efficacy of Real-Time Computer-Aided Detection of Colorectal Neoplasia in a Randomized Trial

BACKGROUND & AIMS

One-fourth of colorectal neoplasias are missed during screening colonoscopies; these can develop into colorectal cancer (CRC). Deep learning systems allow for real-time computer-aided detection (CADe) of polyps with high accuracy. We performed a multicenter, randomized trial to assess the safety and efficacy of a CADe system in detection of colorectal neoplasias during real-time colonoscopy.

METHODS

We analyzed data from 685 subjects (61.32 ± 10.2 years old; 337 men) undergoing screening colonoscopies for CRC, post-polypectomy surveillance, or workup due to positive results from a fecal immunochemical test or signs or symptoms of CRC, at 3 centers in Italy from September through November 2019. Patients were randomly assigned (1:1) to groups who underwent high-definition colonoscopies with the CADe system or without (controls). The CADe system included an artificial intelligence-based medical device (GI-Genius, Medtronic) trained to process colonoscopy images and superimpose them, in real time, on the endoscopy display a green box over suspected lesions. A minimum withdrawal time of 6 minutes was required. Lesions were collected and histopathology findings were used as the reference standard. The primary outcome was adenoma detection rate (ADR, the percentage of patients with at least 1 histologically proven adenoma or carcinoma). Secondary outcomes were adenomas detected per colonoscopy, non-neoplastic resection rate, and withdrawal time.

RESULTS

The ADR was significantly higher in the CADe group (54.8%) than in the control group (40.4%) (relative risk [RR], 1.30; 95% confidence interval [CI], 1.14-1.45). Adenomas detected per colonoscopy were significantly higher in the CADe group (mean, 1.07 ±1.54) than in the control group (mean 0.71 ± 1.20) (incidence rate ratio, 1.46; 95% CI, 1.15-1.86). Adenomas 5 mm or smaller were detected in a significantly higher proportion of subjects in the CADe group (33.7%) than in the control group (26.5%; RR, 1.26; 95% CI, 1.01-1.52), as were adenomas of 6 to 9 mm (detected in 10.6% of subjects in the CADe group vs 5.8% in the control group; RR, 1.78; 95% CI, 1.09-2.86), regardless of morphology or location. There was no significant difference between groups in withdrawal time (417 ± 101 seconds for the CADe group vs 435 ± 149 for controls; P = .1) or proportion of subjects with resection of non-neoplastic lesions (26.0% in the CADe group vs 28.7% of controls; RR, 1.00; 95% CI, 0.90-1.12).

CONCLUSIONS

In a multicenter, randomized trial, we found that including CADe in real-time colonoscopy significantly increases ADR and adenomas detected per colonoscopy without increasing withdrawal time. ClinicalTrials.gov no: 04079478.

Absence of Iodine Staining Associates With Progression of Esophageal Lesions in a Prospective Endoscopic Surveillance Study in China

BACKGROUND & AIMS

Chromoendoscopy with iodine staining is used to identify esophageal squamous dysplasia and esophageal squamous cell carcinomas (ESCCs)-absence of staining indicates suspicious regions of dysplasia. However, screening detects precancerous lesions (mild and moderate dysplasia) that do not require immediate treatment; it is a challenge to which lesions are at risk for progression. We investigated the association between absence of iodine staining at chromoendoscopy screening and lesion progression using 6 years of follow-up data from a population-based randomized controlled trial in China. We then constructed and validated a model to calculate risk of progression to severe dysplasia, carcinoma in situ, or ESCC.

METHODS

We collected data from 1468 participants (45-69 years old) who were either negative for iodine staining at a baseline chromoendoscopy or found to have mild or moderate dysplasia in histologic analysis of biopsies in the Endoscopic Screening for Esophageal Cancer study in China, from January 2012 through September 2016; 788 of these participants were re-examined by endoscopy after a median interval of 4.2 years (development cohort). We investigated the association between absence of iodine staining and progression of esophageal lesions using Cox prediction models, considering corresponding baseline pathology findings and patient answers to a comprehensive questionnaire. Patients who did not receive a follow-up examination (n = 680) was used as the validation cohort; outcome events in these patients were identified by annual door to door active interviews or linkage with local electronic registry data. The primary outcome was incident esophageal severe dysplasia, carcinoma in situ, or ESCC.

RESULTS

In the development cohort, 11 lesions that did not stain with iodine but were classified as not dysplastic in the histology analysis were found to be severe dysplasia, carcinoma in situ, or ESCC at the follow-up evaluation. These lesions accounted for 39.3% of all progressed lesions (n = 28). In the validation cohort, 6 patients with lesions did not stain with iodine but were classified as not dysplastic by histology had a later diagnosis of ESCC, determined from medical records; these patients accounted for 50.0% of all patients with lesion progression (n = 12) until the closing date of this study. We developed a model based on patient age, body mass index, pathology findings, and baseline iodine staining to calculate risk for severe dysplasia, carcinoma in situ, or ESCC. It identified patients for severe dysplasia, carcinoma in situ, or ESCC in the development set with an area under the curve of 0.868 (95% CI, 0.817-0.920) and in the validation set with an area under the curve of 0.850 (95% CI, 0.748-0.952). Almost no cases would be missed if subjects determined to be high or intermediate-high risk subjects by the model were included in surveillance.

CONCLUSIONS

Absence of iodine staining at baseline chromoendoscopy identifies esophageal lesions at risk of progression with a high level of sensitivity. A model that combines results of iodine chromoendoscopy with other patient features identifies patients at risk of lesion progression with greater accuracy than histologic analysis of baseline biopsies.

Gene Variants That Affect Levels of Circulating Tumor Markers Increase Identification of Patients With Pancreatic Cancer

BACKGROUND & AIMS

Levels of carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9), and cancer antigen 125 (CA-125) in blood are used as markers to determine the response of patients with cancer to therapy, but are not used to identify patients with pancreatic cancer.

METHODS

We obtained blood samples from 504 patients undergoing pancreatic surveillance from 2002 through 2018 who did not develop pancreatic cancer and measured levels of the tumor markers CA19-9, CEA, CA-125, and thrombospondin-2. Single-nucleotide polymorphisms (SNPs) in FUT3, FUT2, ABO, and GAL3ST2 that have been associated with levels of tumor markers were used to establish SNP-defined ranges for each tumor marker. We also tested the association between additional SNPs (in FUT6, MUC16, B3GNT3, FAM3B, and THBS2) with levels of tumor markers. To calculate the diagnostic specificity of each SNP-defined range, we assigned the patients under surveillance into training and validation sets. After determining the SNP-defined ranges, we determined the sensitivity of SNP-adjusted tests for the tumor markers, measuring levels in blood samples from 245 patients who underwent resection for pancreatic ductal adenocarcinoma (PDAC) from 2010 through 2017.

RESULTS

A level of CA19-9 that identified patients with PDAC with 99% specificity had 52.7% sensitivity. When we set the cut-off levels of CA19-9 based on each SNP, the test for CA19-9 identified patients with PDAC with 60.8% sensitivity and 98.8% specificity. Among patients with FUT3 alleles that encode a functional protein, levels of CA19-9 greater than the SNP-determined cut-off values identified 66.4% of patients with PDAC, with 99.3% specificity. In the validation set, levels of CEA varied among patients with vs without SNP in FUT2, by blood group, and among smokers vs nonsmokers; levels of CA-125 varied among patients with vs without the SNP in GAL3ST2. The use of the SNPs to define the ranges of CEA and CA-125 did not significantly increase the diagnostic accuracy of the assays for these proteins. Combining data on levels of CA19-9 and CEA, CA19-9 and CA-125, or CA19-9 and thrombospondin-2 increased the sensitivity of detection of PDAC, but slightly reduced specificity.

CONCLUSIONS

Including information on SNPs associated with levels of CA19-9, CEA, and CA-125 can improve the diagnostic accuracy of assays for these tumor markers in the identification of patients with PDAC. Clinicaltrials.gov no: NCT02000089.

Diagnostic Yield of One-Time Colonoscopy vs One-Time Flexible Sigmoidoscopy vs Multiple Rounds of Mailed Fecal Immunohistochemical Tests in Colorectal Cancer Screening

BACKGROUND & AIMS

We compared the diagnostic yields of colonoscopy, flexible sigmoidoscopy, and fecal immunochemical tests (FITs) in colorectal cancer (CRC) screening.

METHODS

A total of 30,007 asymptomatic persons, 50-74 years old, were invited for CRC screening in the Netherlands. Participants were assigned to groups that received 4 rounds of FIT (mailed to 15,046 participants), once-only flexible sigmoidoscopy (n = 8407), or once-only colonoscopy (n = 6600). Patients with positive results from the FIT (≥10 μg Hb/g feces) were referred for colonoscopy. Patients who underwent flexible sigmoidoscopy were referred for colonoscopy if they had a polyp of ≥10 mm; adenoma with ≥25% villous histology or high-grade dysplasia; sessile serrated adenoma; ≥3 adenomas; ≥20 hyperplastic polyps; or invasive CRC. The primary outcome was number of advanced neoplasia detected (diagnostic yield) by each test. Secondary outcomes were number of colonoscopies needed to detect advanced neoplasia and number of interval CRCs found during each primary screening test. Patients with interval CRCs were found through linkage with Netherlands Cancer Registry. Advanced neoplasia were defined as CRC, adenomas ≥ 10 mm, adenomas with high-grade dysplasia, or adenomas with a villous component of at least 25%.

RESULTS

The cumulative participation rate was significantly higher for FIT screening (73%) than for flexible sigmoidoscopy (31%; P < .001) or colonoscopy (24%; P < .001). The percentage of colonoscopies among invitees was higher for colonoscopy (24%) compared to FIT (13%; P < .001) or flexible sigmoidoscopy (3%; P < .001). In the intention to screen analysis, the cumulative diagnostic yield of advanced neoplasia was higher with FIT screening (4.5%; 95% CI 4.2-4.9) than with colonoscopy (2.2%; 95% CI, 1.8-2.6) or flexible sigmoidoscopy (2.3%; 95% CI, 2.0-2.7). In the as-screened analysis, the cumulative yield of advanced neoplasia was higher for endoscopic screening with colonoscopy (9.1%; 95% CI, 7.7-10.7) or flexible sigmoidoscopy (7.4%; 95% CI, 6.5-8.5) than with the FIT (6.1%; 95% CI, 5.7-6.6). All 3 screening strategies detected a similar proportion of patients with CRC. Follow-up times differed for each test (median 8.3 years for FIT and flexible sigmoidoscopy and 5.8 years for colonoscopy). Proportions of patients that developed interval CRC were 0.13% for persons with a negative result from FIT, 0.09% for persons with a negative result from flexible sigmoidoscopy, and 0.01% for persons with a negative result from colonoscopy.

CONCLUSIONS

Mailed multiple-round FITs detect significantly more advanced neoplasia, on a population level, compared with once-only flexible sigmoidoscopy or colonoscopy screening. Significantly fewer colonoscopies are required by individuals screened by multiple FITs. Trialregister.nl numbers: first round, NTR1096; second round and additional invitees, NTR1512; fourth round, NTR5874; COCOS trial NTR1829.

Lower Abnormal Fecal Immunochemical Test Cut-Off Values Improve Detection of Colorectal Cancer in System-Level Screens

BACKGROUND & AIMS

Noninvasive tests used in colorectal cancer screening, such as the fecal immunochemical test (FIT), are more acceptable but detect neoplasias with lower levels of sensitivity than colonoscopy. We investigated whether lowering the cut-off concentration of hemoglobin for designation as an abnormal FIT result increased the detection of advanced neoplasia in a mailed outreach program.

METHODS

We performed a prospective study of 17,017 uninsured patients, age 50 to 64 years, who were not current with screening and enrolled in a safety-net system in Texas. We reduced the cut-off value for an abnormal FIT result from 20 or more to 10 or more μg hemoglobin/g feces a priori. All patients with abnormal FIT results were offered no-cost diagnostic colonoscopy. We compared proportions of patients with abnormal FIT results and neoplasia yield for standard vs lower cut-off values, as well as absolute hemoglobin concentration distribution among 5838 persons who completed the FIT. Our primary aim was to determine the effects of implementing a lower hemoglobin concentration cut-off value on colonoscopy demand and yield, specifically colorectal cancer (CRC) and advanced neoplasia detection, compared with the standard, higher, hemoglobin concentration cut-off value.

RESULTS

The proportions of patients with abnormal FIT results were 12.3% at the 10 or more μg hemoglobin/g feces and 6.6% at the standard 20 or more μg hemoglobin/g feces cut-off value (P = .0013). Detection rates for the lower vs the standard threshold were 10.2% vs 12.7% for advanced neoplasia (P = .12) and 0.9% vs 1.2% for CRC (P = .718). The positive predictive values were 18.9% for the lower threshold vs 24.4% for the standard threshold for advanced neoplasia (P = .053), and 1.7% vs 2.4% for CRC (P = .659). The number needed to screen to detect 1 case with advanced neoplasia was 45 at the lower threshold compared with 58 at the standard threshold; the number needed to scope to detect 1 case with advanced neoplasia increased from 4 to 5. Most patients with CRC (72.7%) or advanced adenoma (67.3%) had hemoglobin concentrations of 20 or more μg/g feces. In the group with 10 to 19 μg hemoglobin/g feces, there were 3 patients with CRC (3 of 11; 27.3%) and 36 with advanced adenoma (36 of 110; 32.7%) who would not have been detected at the standard positive threshold (advanced neoplasia Pcomparison < .001). The proportion of patients found to have no neoplasia after an abnormal FIT result (false positives) was not significantly higher with the lower cut-off value (44.4%) than the standard cut-off value (39.1%) (P = .1103).

CONCLUSIONS

In a prospective study of 17,017 uninsured patients, we found that reducing the abnormal FIT result cut-off value (to ≥10 μg hemoglobin/g feces) might increase detection of advanced neoplasia, but doubled the proportion of patients requiring a diagnostic colonoscopy. If colonoscopy capacity permits, health systems that use quantitative FITs should consider lowering the abnormal cut-off value to optimize CRC detection and prevention. (ClinicalTrials.gov no: NCT01946282.).

Uptake of Colorectal Cancer Screening by Physicians Is Associated With Greater Uptake by Their Patients

BACKGROUND & AIMS

Physicians' own screening practices might affect screening in their patients. We conducted a population-based study to evaluate whether family physicians who underwent colorectal cancer testing were more likely to have patients who underwent colorectal cancer testing.

METHODS

We collected demographic and health care information on residents of Ontario, Canada from administrative databases; the sample was restricted to individuals at average risk of colorectal cancer who were 52-74 years old as of April 21, 2016. We obtained a list of all registered physicians in the province; physicians (n = 11,434) were matched with nonphysicians (n = 45,736) on age, sex, and residential location. Uptake of colorectal tests was defined by a record of a fecal occult blood test in the past 2 years, flexible sigmoidoscopy in the past 5 years, or colonoscopy in the past 10 years. Patients were assigned to family physicians based on billing claim frequency, and then the association between colorectal testing in family physicians and their patients was examined using a modified Poisson regression model.

RESULTS

Uptake of colorectal tests by physicians and nonphysicians (median age 60 years; 71% men) was 67.9% (95% confidence interval [CI], 67.0%-68.7%) and 66.6% (95% CI, 66.2%-67.1%), respectively. Physicians were less likely than nonphysicians to undergo fecal occult blood testing and were more likely to undergo colonoscopy; prevalence ratios were 0.44 (95% CI, 0.42-0.47) and 1.24 (95% CI, 1.22-1.26), respectively. Uptake of colorectal tests by family physicians was associated with greater uptake by their patients (adjusted prevalence ratio, 1.10; 95% CI, 1.08-1.12).

CONCLUSIONS

Approximately one-third of physicians and nonphysicians are overdue for colorectal cancer screening. Patients are more likely to be tested if their family physician has been tested. There is an opportunity for physicians to increase their participation in colorectal cancer screening, which could, in turn, motivate their patients to undergo screening.

Colorectal Cancer Incidence and Mortality After Removal of Adenomas During Screening Colonoscopies

BACKGROUND & AIMS

Recommendation of surveillance colonoscopy should be based on risk of colorectal cancer and death after adenoma removal. We aimed to develop a risk classification system based on colorectal cancer incidence and mortality following adenoma removal.

METHODS

We performed a multicenter population-based cohort study of 236,089 individuals (median patient age, 56 years; 37.8% male) undergoing screening colonoscopies with adequate bowel cleansing and cecum intubation at 132 centers in the Polish National Colorectal Cancer Screening Program, from 2000 through 2011. Subjects were followed for a median 7.1 years and information was collected on colorectal cancer development and death. We used recursive partitioning and multivariable Cox models to identify associations between colorectal cancer risk and patient and adenoma characteristics (diameter, growth pattern, grade of dysplasia, and number of adenomas). We developed a risk classification system based on standardized incidence ratios, using data from the Polish population for comparison. The primary endpoints were colorectal cancer incidence and colorectal cancer death.

RESULTS

We identified 130 colorectal cancers in individuals who had adenomas removed at screening (46.5 per 100,000 person-years) vs 309 in individuals without adenomas (22.2 per 100,000 person-years). Compared with individuals without adenomas, adenomas ≥20 mm in diameter and high-grade dysplasia were associated with increased risk of colorectal cancer (adjusted hazard ratios 9.25; 95% confidence interval [CI] 6.39-13.39, and 3.58; 95% CI 1.96-6.54, respectively). Compared with the general population, colorectal cancer risk was higher or comparable only for individuals with adenomas ≥20 mm in diameter (standardized incidence ratio [SIR] 2.07; 95% CI 1.40-2.93) or with high-grade dysplasia (SIR 0.79; 95% CI 0.39-1.41), whereas for individuals with other adenoma characteristics the risk was lower (SIR 0.35; 95% CI 0.28-0.44). We developed a high-risk classification based on adenoma size ≥20 mm or high-grade dysplasia (instead of the current high-risk classification cutoff of ≥3 adenomas or any adenoma with villous growth pattern, high-grade dysplasia, or ≥10 mm in diameter). Our classification system would reduce the number of individuals classified as high-risk and requiring intensive surveillance from 15,242 (36.5%) to 3980 (9.5%), without increasing risk of colorectal cancer in patients with adenomas (risk difference per 100,000 person-years, 5.6; 95% CI -10.7 to 22.0).

CONCLUSIONS

Using data from the Polish National Colorectal Cancer Screening Program, we developed a risk classification system that would reduce the number of individuals classified as high risk and require intensive surveillance more than 3-fold, without increasing risk of colorectal cancer in patients with adenomas. This system could optimize the use of surveillance colonoscopy.

Supplementary Anal Imaging by Magnetic Resonance Enterography in Patients with Crohn's Disease Not Suspected of Having Perianal Fistulas

BACKGROUND & AIMS

Few data are available to guide the use of anal imaging for patients with Crohn's disease (CD) who are not suspected of having perianal fistulas. We aimed to evaluate the role of anal imaging supplementary to magnetic resonance enterography (MRE) in these patients.

METHODS

In a prospective study, we added a round of anal MR imaging (MRI), collecting axial images alone, to MRE evaluation of 451 consecutive adults who were diagnosed with or suspected of having CD but not believed to have perianal fistulas. Images were examined for perianal tracts; if present, colorectal surgeons reexamined patients to identify external openings or perianal inflammation or abscess. Patients were followed and data were collected on dedicated treatment for perianal fistulas or abscess. We calculated the diagnostic yield for anal MRI, associated factors, and outcomes of MRI-detected asymptomatic perianal tracts.

RESULTS

A total of 440 patients (mean age, 29.6±8.9 years) met the inclusion criteria. Anal MRI revealed perianal tracts in 53 patients (12%; 95% CI, 9.3%-15.4%). Surgeons however did not identify any lesions that required treatment. The asymptomatic tracts were mostly single unbranched (83%), inter-sphincteric (72%), or had a linear dark signal at the tract margin (79%). Younger age at MRE, female sex, and CD activity index scores of 220-450 were independently associated with detection of perianal tracts. MRI detection of asymptomatic tracts was independently associated with later development of perianal fistulas or abscess that required treatment: 17.8% cumulative incidence at 37 months and an adjusted hazard ratio of 3.06 (95% CI, 1.01-9.27; P = .048).

CONCLUSIONS

In a prospective study of patients with CD, we found that adding anal MRI evaluation to MRE resulted in early identification of patients at risk for perianal complications.

Still Controversial: Early Detection and Screening for Breast Cancer in Brazil, 1950-2010s

Mammographic screening for breast cancer is a widely used public health approach, but is constantly a subject of controversy. Medical and historical research on this topic has been mainly conducted in Western Europe and North America. In Brazil, screening mammography has been an open topic of discussion and a challenge for health care and public health since the 1970s. Effectively, Brazilian public health agencies never implemented a nationwide population-based screening programme for breast cancer, despite the pressures of many specific groups such as advocacy associations and the implementation of local programmes. This article examines the complex process of incorporating mammography as a diagnostic tool and the debates towards implementing screening programmes in Brazil. We argue that debates about screening for breast malignancies, especially those conducted in the late twentieth and early twenty-first centuries, took place in a context of change and uncertainty in the Brazilian health field. These discussions were strongly affected both by tensions between the public and the private health care sectors during the formative period of a new Brazilian health system, and by the growing role of civil society actors. Our study investigates these tensions and their consequences. We use several medical sources that discussed the topic in Brazil, mainly specialised leading oncology journals published between 1950 and 2017, medical congress reports for the same period, books and theses, institutional documents and oral testimonies of health professionals, patients and associations collected in the framework of the 'The History of Cancer' project from the Oswaldo Cruz Foundation and Brazilian National Cancer Institute.

Early Detection and Preventive Intervention in Schizophrenia: From Fantasy to Reality

Scientific progress in understanding human disease can be measured by the effectiveness of its treatment. Antipsychotic drugs have been proven to alleviate acute psychotic symptoms and prevent their recurrence in schizophrenia, but the outcomes of most patients historically have been suboptimal. However, a series of findings in studies of first-episode schizophrenia patients transformed the psychiatric field's thinking about the pathophysiology, course, and potential for disease-modifying effects of treatment. These include the relationship between the duration of untreated psychotic symptoms and outcome; the superior responses of first-episode patients to antipsychotics compared with patients with chronic illness, and the reduction in brain gray matter volume over the course of the illness. Studies of the effectiveness of early detection and intervention models of care have provided encouraging but inconclusive results in limiting the morbidity and modifying the course of illness. Nevertheless, first-episode psychosis studies have established an evidentiary basis for considering a team-based, coordinated specialty approach as the standard of care for treating early psychosis, which has led to their global proliferation. In contrast, while clinical high-risk research has developed an evidence-based care model for decreasing the burden of attenuated symptoms, no treatment has been shown to reduce risk or prevent the transition to syndromal psychosis. Moreover, the current diagnostic criteria for clinical high risk lack adequate specificity for clinical application. What limits our ability to realize the potential of early detection and intervention models of care are the lack of sensitive and specific diagnostic criteria for pre-syndromal schizophrenia, validated biomarkers, and proven therapeutic strategies. Future research requires methodologically rigorous studies in large patient samples, across multiple sites, that ideally are guided by scientifically credible pathophysiological theories for which there is compelling evidence. These caveats notwithstanding, we can reasonably expect future studies to build on the research of the past four decades to advance our knowledge and enable this game-changing model of care to become a reality.

Association Between Cigarette Smoking and Alcohol Consumption and Sessile Serrated Polyps in Subjects 30 to 49 Years Old

BACKGROUND & AIMS

We investigated the prevalence of sessile serrated polyps (SSPs) and the association between SSP risk and modifiable lifestyle factors in asymptomatic young adults.

METHODS

We performed a cross-sectional study using a screening colonoscopy database of 13,618 asymptomatic subjects age 30 to 49 years, and 17,999 subjects age 50 to 75 years. We investigated risk factors of SSP by multivariable analyses of clinical data that included cigarette smoking and alcohol consumption.

RESULTS

In subjects age 30 to 49 years, the prevalence of SSP was 2.0% (275 of 13,618 individuals). Of all SSPs, 40.7% (112 of 275 SSPs) were large (≥10 mm). Smoking for 20 or more pack-years was associated with overall SSPs (odds ratio [OR], 1.87; 95% CI, 1.17-2.99) and large SSPs (OR, 3.03; 95% CI, 1.62-5.66). The association between anatomic location and 20 or more pack-years of smoking was stronger for distal SSPs than for proximal SSPs (OR, 2.71; 95% CI, 1.27-5.77 vs OR, 1.60; 95% CI, 1.00-2.54). Cessation of smoking for 5 years or more decreased the risk of SSPs (OR, 0.49; 95% CI, 0.28-0.86) and of large SSPs (OR, 0.23; 95% CI, 0.10-0.54). Alcohol consumption was associated with large SSPs. These findings were similar for subjects age 50 to 75 years.

CONCLUSIONS

In an analysis of a screening colonoscopy database, we found that in asymptomatic young adults, smoking and alcohol consumption were associated with any SSPs and large SSPs. Cessation of smoking decreased the risk of SSPs. Therefore, early lifestyle modification may be recommended for primary prevention of SSPs in young adults.

New and Recurrent Colorectal Cancers After Resection: a Systematic Review and Meta-analysis of Endoscopic Surveillance Studies

BACKGROUND & AIMS

Outcomes of endoscopic surveillance after surgery for colorectal cancer (CRC) vary with the incidence and timing of CRC detection at anastomoses or non-anastomoses in the colorectum. We performed a systematic review and meta-analysis to evaluate the incidence of CRCs identified during surveillance colonoscopies of patients who have already undergone surgery for this cancer.

METHODS

We searched PubMed, EMBASE, SCOPUS, and the Cochrane Central Register of Clinical Trials through January 1, 2018 to identify studies investigating rates of CRCs at anastomoses or other locations in the colorectum after curative surgery for primary CRC. We collected data from published randomized controlled, prospective, and retrospective cohort studies. Data were analyzed by multivariate meta-analytic models.

RESULTS

From 2373 citations, we selected 27 studies with data on 15,803 index CRCs for analysis (89% of patients with stage I-III CRC). Overall, 296 CRCs at non-anastomotic locations were reported over time periods of more than 16 years (cumulative incidence, 2.2% of CRCs; 95% confidence interval [CI], 1.8%-2.9%). The risk of CRC at a non-anastomotic location was significantly reduced more than 36 months after resection compared with before this time point (odds ratio for non-anastomotic CRCs at 36-48 months vs 6-12 months after surgery, 0.61; 95% CI, 0.37-0.98; P = .031); 53.7% of all non-anastomotic CRCs were detected within 36 months of surgery. One hundred and fifty-eight CRCs were detected at anastomoses (cumulative incidence of 2.7%; 95% CI, 1.9%-3.9%). The risk of CRCs at anastomoses was significantly lower 24 months after resection than before (odds ratio for CRCs at anastomoses at 25-36 months after surgery vs 6-12 months, 0.56; 95% CI, 0.32-0.98; P = .036); 90.8% of all CRCs at anastomoses were detected within 36 months of surgery.

CONCLUSIONS

After surgery for CRC, the highest risk of CRCs at anastomoses and at other locations in the colorectum is highest during 36 months after surgery-risk decreases thereafter. Patients who have undergone CRC resection should be evaluated by colonoscopy more closely during this time period. Longer intervals may be considered thereafter.

Developing a Comprehensive Evidence-Based Service Package for Toddlers with Autism in a Low Resource Setting: Early Detection, Early Intervention, and Care Coordination

Objective: The number of children with autism, who have many unmet needs, is increasing dramatically. However, the existing evidence shows that early identification and intervention are effective in reducing the later costs and burdens of autism spectrum disorder (ASD). Thus, the present study aimed to develop evidence-based services for children with autism in Iran to reduce its impacts on the affected children and their families and to decrease its burden on the society. Method : A 3-step study was conducted based on a modification of the Replicating Effective Programs (REP) framework (step 1: need assessment and situation analysis; step 2: identifying current evidence-based services; step 3: designing the first draft of the package and its core elements). Each step was conducted by a specific methodology. Results: By considering the obtained data, it was found that a package of services with 4 core components to respond to the perceived needs in Iran was needed: (1) early detection of at-risk children; (2) care coordination and facilitation of access to current services; (3) implementation of an evidence-based early intervention program; and (4) training interventionists using an effective educational framework based on evidence-based material. Conclusion: REP framework was used in the present study, which has been shown to be effective in adapting and implementing health care services. By considering the preconditions of REP, a comprehensive package of services, with 4 components was designed for toddlers with autism in Iran. The next step will be to study this package using a multicenter hybrid effectiveness-implementation randomized control trial.

Primary Care Provider Practice Patterns and Barriers to Hepatocellular Carcinoma Surveillance

BACKGROUND & AIMS

Low rates of hepatocellular carcinoma (HCC) surveillance are primarily due to provider-related process failures. However, few studies have evaluated primary care provider (PCP) practice patterns, attitudes, and barriers to HCC surveillance at academic tertiary care referral centers.

METHODS

We conducted a web-based survey of PCPs at 2 tertiary care referral centers (133 providers) from June 2017 through December 2017. The survey was adapted from pretested surveys and included questions about practice patterns, attitudes, and barriers to HCC surveillance. We used the Fisher exact and Mann-Whitney rank-sum tests to identify factors associated with adherence to HCC surveillance recommendations, for categoric and continuous variables, respectively.

RESULTS

We obtained a provider-level response rate of 75% and clinic-level response rate of 100% (133 providers). Whereas most PCPs performed HCC surveillance themselves, one-third deferred surveillance to subspecialists and referred patients to a hepatology clinic. Providers believed the combination of ultrasound and α-fetoprotein analysis to be highly effective for early stage tumor detection and reported using the combination for assessment of most patients. However, PCPs were more likely to use computed tomography- or magnetic resonance imaging-based surveillance for patients with nonalcoholic steatohepatitis or decompensated cirrhosis. Most providers believed HCC surveillance to be efficacious for early tumor detection and increasing survival. However, they desired increased high-quality evidence to characterize screening benefits and harms. Providers expressed notable misconceptions about HCC surveillance, including the role for measurement of liver enzyme levels in HCC surveillance and cost effectiveness of surveillance in patients without cirrhosis. They also reported barriers, including not being up to date on HCC surveillance recommendations, limited time in the clinic, and competing clinical concerns.

CONCLUSIONS

In a web-based survey, PCPs reported misconceptions and barriers to HCC surveillance. This indicates the need for interventions, including provider education, to improve HCC surveillance effectiveness in clinical practice.

Effect of I-scan Electronic Chromoendoscopy on Detection of Adenomas During Colonoscopy

BACKGROUND & AIMS

I-scan is an electronic chromoendoscopy technology that improves resolution of epithelial and mucosal surfaces and vessels. We performed a randomized controlled trial to compare detection of adenomas by i-scan vs standard high-definition white-light (HDWL) colonoscopy.

METHODS

From February 1 through December 31, 2017, 740 outpatients (50-75 years old) undergoing screening and surveillance for colorectal neoplasia were randomly assigned to groups that received colonoscopies with i-scan 1 (surface and contrast enhancement) or HDWL. When lesions and polyps were detected, endoscopists could switch between i-scan 1 and HDWL imaging to confirm their finding; polyps were collected and analyzed by histology. The primary outcome was adenoma detection rate (ADR, proportion of subjects with at least 1 adenoma of any size); secondary outcomes included detection of sessile serrated polyps and neoplasias, along with location, size, and morphology of polyps. We performed intent to treat and per-protocol analyses (on 357 patients evaluated by i-scan and 358 evaluated by HDWL colonoscopy) to assess the primary and secondary outcomes.

RESULTS

There were no differences in baseline characteristics between the groups. In the intent to treat analysis, the ADR was significantly higher in the i-scan 1 group (47.2%) than in the HDWL colonoscopy group (37.7%) (P = .01). In the per-protocol analysis, the ADR in the i-scan 1 group (47.6%) was also significantly higher than in the HDWL group (37.2%) (P = .005), but this effect was not consistent among all endoscopists. There was no difference between groups in detection of sessile serrated polyps. However, the rate of neoplasia detection was significantly higher in the i-scan 1 group (56.4%) than in the than the HDWL group (46.1%) (P = .005). In secondary analyses, the increase in ADR was associated with improved detection of diminutive flat adenomas in the right colon.

CONCLUSION

In a prospective randomized trial, higher proportions of patients with adenomas were identified in a group that underwent colonoscopy with i-scan 1 than in a group evaluated by HDWL colonoscopy. This effect was mainly due to improved detection of diminutive, flat right sided adenomas. I-scan 1 technology may benefit some endoscopists. ClinicalTrials.gov no: NCT02811419.

Video-Based Assessments of Colonoscopy Inspection Quality Correlate With Quality Metrics and Highlight Areas for Improvement

BACKGROUND & AIMS

Adenoma detection rate (ADR) and serrated polyp detection rate (SDR) vary significantly among colonoscopists. Colonoscopy inspection quality (CIQ) is the quality with which a colonoscopist inspects for polyps and may explain some of this variation. We aimed to determine the relationship between CIQ and historical ADRs and SDRs in a cohort of colonoscopists and assess whether there is variation in CIQ components (fold examination, cleaning, and luminal distension) among colonoscopists with similar ADRs and SDRs.

METHODS

We conducted a prospective observational study to assess CIQ among 17 high-volume colonoscopists at an academic medical center. Over 6 weeks, we video-recorded >28 colonoscopies per colonoscopist and randomly selected 7 colonoscopies per colonoscopist for evaluation. Six raters graded CIQ using an established scale, with a maximum whole colon score of 75.

RESULTS

We evaluated 119 colonoscopies. The median whole-colon CIQ score was 50.1/75. Whole-colon CIQ score (r=0.71; P<.01) and component scores (fold examination r=0.74; cleaning r=0.67; distension r=0.77; all P<.01) correlated with ADR. Proximal colon CIQ score (r=0.67; P<.01) and component scores (fold examination r=0.71; cleaning r=0.62; distension r=0.65; all P<.05) correlated with SDR. CIQ component scores differed significantly between colonoscopists with similar ADRs and SDRs for most of the CIQ skills.

CONCLUSION

In a prospective observational study, we found CIQ and CIQ components to correlate with ADR and SDR. Colonoscopists with similar ADRs and SDRs differ in their performance of the 3 CIQ components-specific, actionable feedback might improve colonoscopy technique.

Examining Lung Cancer Screening Behaviors in the Primary Care Setting: A Mixed Methods Approach

While the National Lung Screening Trials (NLST) demonstrated the efficacy of low dose chest computed tomography (LDCT) for lung cancer early detection, utilization of LDCT remains suboptimal. The purpose of this formative study was to understand attitudes and beliefs among primary care clinicians regarding LDCT lung cancer screening as well as to assess gaps in knowledge to identify opportunities for reinforcing personalized lung cancer screening that is accessible and evidence-based. A 20-item closed and open-ended interview was conducted with a targeted group of primary care clinicians (38 respondents; 33 physicians and 5 NPs/PAs). Quantitative data were analyzed using descriptive statistics while qualitative data was analyzed thematically. Although 50.0% of clinicians characterized LDCT as "very effective", only 47.4% of clinicians reported that they frequently or often recommend LDCT as a lung cancer screening tool. Respondents were generally unconcerned with the high rate of false positive test results. The majority of clinicians were referring patients for LDCT based on smoking history, however other factors were also considered (e.g., health status, sex, family history, past medical history, and occupational exposures.) The majority of respondents were knowledgeable about the use of LDCT as a lung screening tool but were unsure about its effectiveness for lung cancer early detection. Some clinicians are recommending patients for LDCT based on factors which are inconsistent with evidence-based guidelines.

Racial and Ethnic Differences in Presentation and Outcomes of Hepatocellular Carcinoma

BACKGROUND & AIMS

Racial and ethnic minorities are reported to have higher mortality related to hepatocellular carcinoma (HCC) than non-Hispanic whites. However, it is not clear whether differences in tumor characteristics or liver dysfunction among racial or ethnic groups affect characterization of causes for this disparity. We aimed to characterize racial and ethnic differences in HCC presentation, treatment, and survival.

METHODS

We performed a retrospective study of patients diagnosed with HCC from January 2008 through July 2017 at 2 large health systems in the United States. We used multivariable logistic regression and Cox proportional hazard models to identify factors associated with receipt of curative therapy and overall survival.

RESULTS

Among 1117 patients with HCC (35.9% white, 34.3% black, 29.7% Hispanic), 463 (41.5%) were diagnosed with early stage HCC (Barcelona Clinic Liver Cancer stage 0/A) and 322 (28.8%) underwent curative treatment. Hispanic (odds ratio [OR], 0.75; 95% CI, 0.55-1.00) and black patients (OR, 0.74; 95% CI, 0.56-0.98) were less likely to be diagnosed with early stage HCC than white patients. Among patients with early stage HCC, Hispanics were less likely to undergo curative treatment than whites (OR, 0.58; 95% CI, 0.36-0.91). Black patients with early stage HCC were also less likely to undergo curative treatment than white patients, but this difference was not statistically significant (OR, 0.66; 95% CI, 0.43-1.03). Black and Hispanic patients had shorter median survival times than white patients (10.6 and 14.4 mo vs 16.3 mo). After adjusting for type of medical insurance, Child-Pugh class, Barcelona Clinic Liver Cancer stage, and receipt of HCC treatment, black patients had significantly higher mortality (hazard ratio, 1.12; 95% CI, 1.10-1.14) and Hispanic patients had lower mortality (hazard ratio, 0.83; 95% CI, 0.74-0.94) than white patients.

CONCLUSIONS

In a retrospective study of patients diagnosed with HCC, we found racial/ethnic differences in outcomes of HCC to be associated with differences in detection of tumors at early stages and receipt of curative treatment. These factors are intervention targets for improving patient outcomes and reducing disparities.

Information on Genetic Variants Does Not Increase Identification of Individuals at Risk of Esophageal Adenocarcinoma Compared to Clinical Risk Factors

We previously developed a tool that identified individuals who later developed esophageal adenocarcinoma (based on age, sex, body mass index, smoking status, and prior esophageal conditions) with an area under the curve of 0.80. In this study, we collected data from 329,463 individuals in the UK Biobank cohort who were tested for genetic susceptibility to esophageal adenocarcinoma (a polygenic risk score based on 18 recognized genetic variants). We found that after inclusion of this genetic information, the area under the curve for identification of individuals who developed esophageal adenocarcinoma remained at 0.80. Testing for genetic variants associated with esophageal adenocarcinoma therefore seems unlikely to improve identification of individuals at risk of esophageal adenocarcinoma.

Accuracy of the Narrow-Band Imaging International Colorectal Endoscopic Classification System in Identification of Deep Invasion in Colorectal Polyps

BACKGROUND & AIMS

T1 colorectal polyps with at least 1 risk factor for metastasis to lymph node should be treated surgically and are considered endoscopically unresectable. Optical analysis, based on the Narrow-Band Imaging International Colorectal Endoscopic (NICE) classification system, is used to identify neoplasias with invasion of the submucosa that require endoscopic treatment. We assessed the accuracy of the NICE classification, along with other morphologic characteristics, in identifying invasive polyps that are endoscopically unresectable (have at least 1 risk factor for metastasis to lymph node).

METHODS

We performed a multicenter, prospective study of data collected by 58 endoscopists, from 1634 consecutive patients (examining 2123 lesions) at 17 university and community hospitals in Spain from July 2014 through June 2016. All consecutive lesions >10 mm assessed with narrow-band imaging were included. The primary end point was the accuracy of the NICE classification for identifying lesions with deep invasion, using findings from histology analysis as the reference standard. Conditional inference trees were fitted for the analysis of diagnostic accuracy.

RESULTS

Of the 2123 lesions analyzed, 89 (4.2%) had features of deep invasion and 91 (4.3%) were endoscopically unresectable. The NICE classification system identified lesions with deep invasion with 58.4% sensitivity (95% CI, 47.5-68.8), 96.4% specificity (95% CI, 95.5-97.2), a positive-predictive value of 41.6% (95% CI, 32.9-50.8), and a negative-predictive value of 98.1% (95% CI, 97.5-98.7). A conditional inference tree that included all variables found the NICE classification to most accurately identify lesions with deep invasion (P < .001). However, pedunculated morphology (P < .007), ulceration (P = .026), depressed areas (P < .001), or nodular mixed type (P < .001) affected accuracy of identification. Results were comparable for identifying lesions that were endoscopically unresectable.

CONCLUSIONS

In an analysis of 2123 colon lesions >10 mm, we found the NICE classification and morphologic features identify those with deep lesions with >96% specificity-even in non-expert hands and without magnification. ClinicalTrials.gov number NCT02328066.

Modifiable Failures in the Colorectal Cancer Screening Process and Their Association With Risk of Death

BACKGROUND & AIMS

Colorectal cancer (CRC) deaths occur when patients do not receive screening or have inadequate follow-up of abnormal results or when the screening test fails. We have few data on the contribution of each to CRC-associated deaths or factors associated with these events.

METHODS

We performed a retrospective cohort study of patients in the Kaiser Permanente Northern and Southern California systems (55-90 years old) who died of CRC from 2006 through 2012 and had ≥5 years of enrollment before diagnosis. We compared data from patients with those from a matched cohort of cancer-free patients in the same system. Receipt, results, indications, and follow-up of CRC tests in the 10-year period before diagnosis were obtained from electronic databases and chart audits.

RESULTS

Of 1750 CRC deaths, 75.9% (n = 1328) occurred in patients who were not up to date in screening and 24.1% (n = 422) occurred in patients who were up to date. Failure to screen was associated with fewer visits to primary care physicians. Of 3486 cancer-free patients, 44.6% were up to date in their screening. Patients who were up to date in their screening had a lower risk of CRC death (odds ratio, 0.38; 95% confidence interval, 0.33-0.44). Failure to screen, or failure to screen at appropriate intervals, occurred in a 67.8% of patients who died of CRC vs 53.2% of cancer-free patients; failure to follow-up on abnormal results occurred in 8.1% of patients who died of CRC vs 2.2% of cancer-free patients. CRC death was associated with higher odds of failure to screen or failure to screen at appropriate intervals (odds ratio, 2.40; 95% confidence interval, 2.07-2.77) and failure to follow-up on abnormal results (odds ratio, 7.26; 95% confidence interval, 5.26-10.03).

CONCLUSIONS

Being up to date on screening substantially decreases the risk of CRC death. In 2 health care systems with high rates of screening, most people who died of CRC had failures in the screening process that could be rectified, such as failure to follow-up on abnormal findings; these significantly increased the risk for CRC death.

Diagnostic Yield From Screening Asymptomatic Individuals at High Risk for Pancreatic Cancer: A Meta-analysis of Cohort Studies

BACKGROUND & AIMS

There have been few studies of abdominal imaging screening of individuals at high risk for pancreatic cancer (based on family history or genetic variants). We performed a meta-analysis of prospective cohort studies to determine the diagnostic yield and outcomes of abdominal imaging screening for asymptomatic individuals at high risk.

METHODS

Through a systematic review of multiple electronic databases and conference proceedings through July 2017, we identified prospective cohort studies (>20 patients) of asymptomatic adults determined to be at high-risk of pancreatic cancer (lifetime risk >5%, including specific genetic-associated conditions) who were screened by endoscopic ultrasound (EUS) and/or magnetic resonance imaging (MRI) to detect pancreatic lesions. Our primary outcome was identification of high-risk pancreatic lesions (high-grade pancreatic intraepithelial neoplasia, high-grade dysplasia, or adenocarcinoma) at initial screening, and overall incidence during follow up. Summary estimates were reported as incidence rates per 100 patient-years.

RESULTS

We identified 19 studies comprising 7085 individuals at high risk for pancreatic cancer; of these, 1660 patients were evaluated by EUS and/or MRI. Fifty-nine high-risk lesions were identified (43 adenocarcinomas: 28 during the initial exam and 15 during follow-up surveillance) and 257 patients underwent pancreatic surgery. Based on our meta-analysis, the overall diagnostic yield screening for high-risk pancreatic lesions was 0.74 (95% CI, 0.33-1.14), with moderate heterogeneity among studies. The number needed to screen to identify 1 patient with a high-risk lesion was 135 (95% CI, 88-303). The diagnostic yield was similar for patients with different genetic features that increased risk, and whether patients were screened by EUS or MRI.

CONCLUSIONS

Based on meta-analysis, 135 patients at high-risk for pancreatic cancer must be screened to identify 1 patient with a high-risk pancreatic lesion. Further studies are needed to determine whether screening reduces mortality and is cost effectiveness for individuals at high-risk of pancreatic cancer.

A Learning Collaborative Approach Increases Specificity of Diagnosis of Acute Liver Failure in Pediatric Patients

BACKGROUND & AIMS

Many pediatric patients with acute liver failure (PALF) do not receive a specific diagnosis (such as herpes simplex virus or Wilson disease or fatty acid oxidation defects)-they are left with an indeterminate diagnosis and are more likely to undergo liver transplantation, which is contraindicated for some disorders. Strategies to facilitate complete diagnostic testing should increase identification of specific liver diseases and might reduce liver transplantation. We investigated whether performing recommended age-specific diagnostic tests (AS-DTs) at the time of hospital admission reduces the percentage PALFs with an indeterminate diagnosis.

METHODS

We performed a multinational observational cohort study of 658 PALF participants in the United States and Canada, enrolled at 10 medical centers, during 3 study phases from December 1999 through December 2014. A learning collaborative approach was used to implement AS-DT using an electronic medical record admission order set at hospital admission in phase 3 of the study. Data from 10 study sites participating in all 3 phases were compared before (phases 1 and 2) and after (phase 3) diagnostic test recommendations were inserted into electronic medical record order sets.

RESULTS

The percentage of subjects with an indeterminate diagnosis decreased significantly between phases 1-2 (48.0%) and phase 3 (to 30.8%) (P = .0003). The 21-day cumulative incidence rates for liver transplantation were significantly different among phase 1 (34.6%), phase 2 (31.9%), and phase 3 (20.2%) (P = .030). The 21-day cumulative incidence rates for death did not differ significantly among phase 1 (17.9%), phase 2 (11.9%), and phase 3 (11.3%) (P = .20).

CONCLUSIONS

In a multinational study of children with acute liver failure, we found that incorporating diagnostic test recommendations into electronic medical record order sets accessed at time of admission reduced the percentage with an indeterminate diagnosis that may have reduced liver transplants without increasing mortality. Widespread use of this approach could significantly enhance care of acute liver failure in children.

Effects of Organized Colorectal Cancer Screening on Cancer Incidence and Mortality in a Large Community-Based Population

BACKGROUND & AIMS

Little information is available on the effectiveness of organized colorectal cancer (CRC) screening on screening uptake, incidence, and mortality in community-based populations.

METHODS

We contrasted screening rates, age-adjusted annual CRC incidence, and incidence-based mortality rates before (baseline year 2000) and after (through 2015) implementation of organized screening outreach, from 2007 through 2008 (primarily annual fecal immunochemical testing and colonoscopy), in a large community-based population. Among screening-eligible individuals 51-75 years old, we calculated annual up-to-date status for cancer screening (by fecal test, sigmoidoscopy, or colonoscopy), CRC incidence, cancer stage distributions, and incidence-based mortality.

RESULTS

Initiation of organized CRC screening significantly increased the up-to-date status of screening, from 38.9% in 2000 to 82.7% in 2015 (P < .01). Higher rates of screening were associated with a 25.5% reduction in annual CRC incidence between 2000 and 2015, from 95.8 to 71.4 cases/100,000 (P < .01), and a 52.4% reduction in cancer mortality, from 30.9 to 14.7 deaths/100,000 (P < .01). Increased screening was initially associated with increased CRC incidence, due largely to greater detection of early-stage cancers, followed by decreases in cancer incidence. Advanced-stage CRC incidence rates decreased 36.2%, from 45.9 to 29.3 cases/100,000 (P < .01), and early-stage CRC incidence rates decreased 14.5%, from 48.2 to 41.2 cases/100,000 (P < .04).

CONCLUSIONS

Implementing an organized CRC screening program in a large community-based population rapidly increased screening participation to the ≥80% target set by national organizations. Screening rates were sustainable and associated with substantial decreases in CRC incidence and mortality within short time intervals, consistent with early detection and cancer prevention.

Lugol Chromoendoscopy Detects Esophageal Dysplasia With Low Levels of Sensitivity in a High-Risk Region of China

BACKGROUND & AIMS

Chromoendoscopy with Lugol dye is used to screen for early-stage esophageal squamous dysplasia (ESD) and esophageal cancer. However, the sensitivity with which Lugol chromoendoscopy detects ESD or esophageal cancer has not been fully assessed in large populations in China.

METHODS

From 2012 to 2016, a total of 15,264 residents in rural Hua County, Henan Province, which is a high-incidence area of esophageal cancer in China, were screened by Lugol chromoendoscopy. Biopsies were collected from endoscopically visualized lesions, identified before and after Lugol chromoendoscopy, and analyzed histologically. Biopsies were also collected from standard sites in the esophagus (28 and 33 cm distal to the incisors) if no abnormalities were found. We calculated the sensitivity with which Lugol chromoendoscopy detects esophageal dysplasia and carcinoma, using findings from biopsy analysis as the reference standard.

RESULTS

A total 586 participants were found by biopsy analysis to have ESD or more severe lesions. After endoscopy images were reviewed twice, Lugol chromoendoscopy sensitivity values for the detection of mild, moderate, and severe dysplasia, and esophageal cancer, were 45.9%, 55.3%, 87.0%, and 97.7%, respectively. ESDs were most frequently missed by Lugol chromoendoscopy in younger patients and men with moderate levels of dysplasia.

CONCLUSION

In a screening analysis of a general population in China, we found Lugol chromoendoscopy to identify individuals with ESD with lower levels of sensitivity (46%-87%) than previously believed, although it identified patients with esophageal cancer with almost 98% sensitivity. Prospective studies are needed to evaluate the clinical significance of esophageal lesions that are not detected by endoscopy.

Number of Adenomas Removed and Colorectal Cancers Prevented in Randomized Trials of Flexible Sigmoidoscopy Screening

BACKGROUND & AIMS

Screening for colorectal cancer (CRC) with sigmoidoscopy reduces CRC incidence by detecting and removing adenomas. The number needed to screen is a measure of screening efficiency, but is not directly associated with adenoma removal. We propose the following 2 new metrics for quantifying the relationship between adenoma removal and CRC prevented: number of adenomas needed to remove (NNR) and adenoma dwell time avoided (DTA).

METHODS

We collected data from 4 randomized trials of sigmoidoscopy screening (1 in the United States and 3 in Europe) to assess NNR and DTA. For each trial, NNR was computed as the number of adenomas removed from subjects in the intervention group, divided by the number of CRCs prevented. DTA was computed similarly but taking into account the timing of adenoma removal. Combined results across trials were assessed using standard meta-analytic techniques.

RESULTS

The estimated NNR for the PLCO (Prostate, Lung, Colorectal and Ovarian) trial was 74 (95% confidence interval [CI], 56-110), for the NORCCAP (Norwegian Colorectal Cancer Prevention) trial was 71 (95% CI, 44-174), for the SCORE (Screening for Colon Rectum) trial was 27 (95% CI, 14-135), and for the UKFSST (UK Flexible Sigmoidoscopy Screening Trial) was 36 (95% CI, 28-52). The combined estimate (meta-analysis) of NNR was 52 (95% CI, 36-93) assuming heterogeneity (P for heterogeneity = .014). DTA estimates among trials ranged from 278 to 730 years, with a combined estimate of 500 (95% CI, 344-833) years assuming heterogeneity (P for heterogeneity = .035), or 2 CRC cases prevented per 1000 adenoma dwell years avoided. The combined estimates of NNR and DTA restricted to advanced adenomas were 13 (95% CI, 9-22) and 122 (95% CI, 90-190) years, respectively.

CONCLUSIONS

We collected data from 4 randomized trials of sigmoidoscopy screening for CRC to develop metrics of endoscopic efficiency, NNR and DTA, which are directly linked to adenoma detection and removal. They can be used to compare screening among endoscopic modalities and to more precisely measure adenoma to carcinoma transition rates.

Yield of Colonoscopy After a Positive Result From a Fecal Immunochemical Test OC-Light

BACKGROUND & AIMS

The fecal immunochemical test (FIT) is widely used in colorectal cancer (CRC) screening. The OC-Light FIT is 1 of 2 FITs recommended for CRC screening by the Preventive Services Task Force guidelines. However, little is known about its ability to detect CRC in large average-risk populations.

METHODS

We performed a retrospective cohort study of patients (50-75 years old) in the San Francisco Health Network who were screened for CRC by OC-Light FIT from August 2010 through June 2015. Patients with a positive result were referred for colonoscopy. We used electronic health records to identify participants with positive FIT results, and collected results from subsequent colonoscopies and pathology analyses. The FIT positive rate was calculated by dividing the number of positive FIT results by the total number of FIT tests completed. The primary outcome was the positive rate from OC-Light FIT and yield of neoplasms at colonoscopy. Secondary outcomes were findings from first vs subsequent rounds of testing, and how these varied by sex and race.

RESULTS

We collected result from 35,318 FITs, performed on 20,886 patients; 2930 patients (8.3%) had a positive result, and 1558 patients completed the follow-up colonoscopy. A positive result from the FIT identified patients with CRC with a positive predictive value of 3.0%, and patients with advanced adenoma with a positive predictive value of 20.8%. The FIT positive rate was higher during the first round of testing (9.4%) compared to subsequent rounds (7.4%) (P < .01). The yield of CRC in patients with a positive result from the first round of the FIT was 3.7%, and decreased to 1.8% for subsequent rounds (P = .02).

CONCLUSIONS

In a retrospective analysis of patients in a diverse safety-net population who underwent OC-Light FIT for CRC screening, we found that approximately 3% of patients with a positive result from a FIT to have CRC and approximately 21% to have advanced adenoma.

Risk of Neoplastic Progression in Individuals at High Risk for Pancreatic Cancer Undergoing Long-term Surveillance

BACKGROUND & AIMS

Screening of individuals who have a high risk of pancreatic ductal adenocarcinoma (PDAC), because of genetic factors, frequently leads to identification of pancreatic lesions. We investigated the incidence of PDAC and risk factors for neoplastic progression in individuals at high risk for PDAC enrolled in a long-term screening study.

METHODS

We analyzed data from 354 individuals at high risk for PDAC (based on genetic factors of family history), enrolled in Cancer of the Pancreas Screening cohort studies at tertiary care academic centers from 1998 through 2014 (median follow-up time, 5.6 years). All subjects were evaluated at study entry (baseline) by endoscopic ultrasonography and underwent surveillance with endoscopic ultrasonography, magnetic resonance imaging, and/or computed tomography. The primary endpoint was the cumulative incidence of PDAC, pancreatic intraepithelial neoplasia grade 3, or intraductal papillary mucinous neoplasm with high-grade dysplasia (HGD) after baseline. We performed multivariate Cox regression and Kaplan-Meier analyses.

RESULTS

During the follow-up period, pancreatic lesions with worrisome features (solid mass, multiple cysts, cyst size > 3 cm, thickened/enhancing walls, mural nodule, dilated main pancreatic duct > 5 mm, or abrupt change in duct caliber) or rapid cyst growth (>4 mm/year) were detected in 68 patients (19%). Overall, 24 of 354 patients (7%) had neoplastic progression (14 PDACs and 10 HGDs) over a 16-year period; the rate of progression was 1.6%/year, and 93% had detectable lesions with worrisome features before diagnosis of the PDAC or HGD. Nine of the 10 PDACs detected during routine surveillance were resectable; a significantly higher proportion of patients with resectable PDACs survived 3 years (85%) compared with the 4 subjects with symptomatic, unresectable PDACs (25%), which developed outside surveillance (log rank P < .0001). Neoplastic progression occurred at a median age of 67 years; the median time from baseline screening until PDAC diagnosis was 4.8 years (interquartile range, 1.6-6.9 years).

CONCLUSIONS

In a long-term (16-year) follow-up study of individuals at high-risk for PDAC, we found most PDACs detected during surveillance (9/10) to be resectable, and 85% of these patients survived for 3 years. We identified radiologic features associated with neoplastic progression.