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Landy R, Katki HA, Huang WY, Wang D, Thomas M, Qu F, Freedman ND, Loftfield E, Shi J, Peters U, Hsu L, Schoen RE, Berndt SI. Evaluating the Use of Environmental and Polygenic Risk Scores to Inform Colorectal Cancer Risk-Based Surveillance Intervals. Clin Transl Gastroenterol 2024; 15:e00782. [PMID: 39733276 PMCID: PMC11671055 DOI: 10.14309/ctg.0000000000000782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2024] [Accepted: 10/06/2024] [Indexed: 12/14/2024] Open
Abstract
INTRODUCTION United States Multi-Society Task Force colonoscopy surveillance intervals are based solely on adenoma characteristics, without accounting for other risk factors. We investigated whether a risk model including demographic, environmental, and genetic risk factors could individualize surveillance intervals under an "equal management of equal risks" framework. METHODS Using 14,069 individuals from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial who had a diagnostic colonoscopy following an abnormal flexible sigmoidoscopy, we modeled the risk of colorectal cancer, considering the diagnostic colonoscopy finding, baseline risk factors (e.g., age and sex), 19 lifestyle and environmental risk factors, and a polygenic risk score for colorectal cancer. Ten-year absolute cancer risks for each diagnostic colonoscopy finding (advanced adenomas [N = 2,446], ≥3 non-advanced adenomas [N = 483], 1-2 non-advanced adenomas [N = 4,400], and no adenoma [N = 7,183]) were used as implicit risk thresholds for recommended surveillance intervals. RESULTS The area under the curve for the model including colonoscopy findings, baseline characteristics, and polygenic risk score was 0.658. Applying the equal management of equal risks framework, 28.2% of individuals with no adenoma and 42.7% of those with 1-2 non-advanced adenomas would be considered high risk and assigned a significantly shorter surveillance interval than currently recommended. Among individuals who developed cancer within 10 years, 52.4% with no adenoma and 48.3% with 1-2 non-advanced adenomas would have been considered high risk and assigned a shorter surveillance interval. DISCUSSION Using a personalized risk-based model has the potential to identify individuals with no adenoma or 1-2 non-advanced adenomas, who are higher risk and may benefit from shorter surveillance intervals.
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Affiliation(s)
- Rebecca Landy
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Hormuzd A. Katki
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Wen-Yi Huang
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Difei Wang
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Minta Thomas
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Flora Qu
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Neal D. Freedman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Erikka Loftfield
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Jianxin Shi
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Ulrike Peters
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Li Hsu
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Robert E. Schoen
- Departments of Medicine and Epidemiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sonja I. Berndt
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
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Stevens ER, Nagler A, Monina C, Kwon J, Olesen Wickline A, Kalkut G, Ranson D, Gross SA, Shaukat A, Szerencsy A. Pathology-Driven Automation to Improve Updating Documented Follow-Up Recommendations in the Electronic Health Record After Colonoscopy. Clin Transl Gastroenterol 2024; 15:e00785. [PMID: 39665587 PMCID: PMC11671091 DOI: 10.14309/ctg.0000000000000785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2024] [Accepted: 10/23/2024] [Indexed: 12/13/2024] Open
Abstract
INTRODUCTION Failure to document colonoscopy follow-up needs postpolypectomy can lead to delayed detection of colorectal cancer (CRC). Automating the update of a unified follow-up date in the electronic health record (EHR) may increase the number of patients with guideline-concordant CRC follow-up screening. METHODS Prospective pre-post design study of an automated rules engine-based tool using colonoscopy pathology results to automate updates to documented CRC screening due dates was performed as an operational initiative, deployed enterprise-wide May 2023. Participants were aged 45-75 years who received a colonoscopy November 2022 to November 2023. Primary outcome measure is rate of updates to screening due dates and proportion with recommended follow-up < 10 years. Multivariable log-binomial regression was performed (relative risk, 95% confidence intervals). RESULTS Study population included 9,824 standard care and 19,340 intervention patients. Patients had a mean age of 58.6 ± 8.6 years and were 53.4% female, 69.6% non-Hispanic White, 13.5% non-Hispanic Black, 6.5% Asian, and 4.6% Hispanic. Postintervention, 46.7% of follow-up recommendations were updated by the rules engine. The proportion of patients with a 10-year default follow-up frequency significantly decreased (88.7%-42.8%, P < 0.001). The mean follow-up frequency decreased by 1.9 years (9.3-7.4 years, P < 0.001). Overall likelihood of an updated follow-up date significantly increased (relative risk 5.62, 95% confidence intervals: 5.30-5.95, P < 0.001). DISCUSSION An automated rules engine-based tool has the potential to increase the accuracy of colonoscopy follow-up dates recorded in patient EHR. The results emphasize the opportunity for more automated and integrated solutions for updating and maintaining EHR health maintenance activities.
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Affiliation(s)
- Elizabeth R. Stevens
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
- Department of Health Informatics, NYU Langone Health, New York, New York, USA
| | - Arielle Nagler
- Department of Dermatology, NYU Langone Health, New York, New York, USA
| | - Casey Monina
- Medical Center Information Technology, NYU Langone Health, New York, New York, USA
| | - JaeEun Kwon
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | | | - Gary Kalkut
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - David Ranson
- Medical Center Information Technology, NYU Langone Health, New York, New York, USA
| | - Seth A. Gross
- Division of Gastroenterology and Hepatology, NYU Langone Health, New York, New York, USA
| | - Aasma Shaukat
- Division of Gastroenterology and Hepatology, NYU Langone Health, New York, New York, USA
| | - Adam Szerencsy
- Department of Health Informatics, NYU Langone Health, New York, New York, USA
- Medical Center Information Technology, NYU Langone Health, New York, New York, USA
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
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Larsen PT, Jørgensen SF, Hagemann-Madsen R, Rasmussen M, Andersen B, Njor SH. Detection of colorectal cancer and advanced neoplasia during first surveillance interval after detection of adenomas in fecal immunochemical test cancer screening: a nationwide study. Endoscopy 2024; 56:853-861. [PMID: 38955210 DOI: 10.1055/a-2343-5700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
BACKGROUND Adenoma surveillance guidelines are based on non-fecal immunochemical test (FIT)-based screening settings. However, colorectal cancer (CRC) risk may be different in FIT-positive screening populations. We evaluated the CRC and advanced adenoma risk within the recommended surveillance periods in the Danish FIT-based CRC screening program for participants with intermediate or high risk adenomas according to 2010 European guidelines. Furthermore, we estimated CRC risk for those who were not recommended surveillance according to European Society of Gastrointestinal Endoscopy (ESGE) 2020 guidelines. METHODS Using nationwide health registries, we identified 17 936 FIT-screening participants from 2014-2017 with adenomas undergoing surveillance (high risk 1 year, intermediate risk 3 years). Participants with a follow-up examination were included (N = 10 068). Relative risk (RR) of CRC and advance adenoma was compared between intermediate and high risk groups and between intermediates who were recommended surveillance (S) or no surveillance (NS) according to 2020 ESGE guidelines. RESULTS During surveillance, CRC occurred in 0.59% of the high risk group and 1.11% of the intermediate risk group (RR 0.53 [95%CI 0.34-0.84]). The high risk group had a 24% increased risk of advanced adenoma. CRC occurred in 1.69% of the intermediateNS group and 0.87% of the intermediateS group (RR 1.94 [95%CI 1.18-3.21]), and RR for advanced adenoma was 1.19 (95%CI 1.03-1.37). CONCLUSION CRC detection was lower among participants rated at higher risk at initial CRC screening. Findings at first screen-derived colonoscopy might not be as good a predictor of CRC risk in a FIT-positive screening population.
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Affiliation(s)
- Pernille T Larsen
- University Research Clinic for Cancer screening, Randers Regional Hospital, Randers NØ, Denmark
- Department of Clinical Medicine, Aarhus University Faculty of Health Sciences, Aarhus, Denmark
| | - Susanne F Jørgensen
- Department of Data, Innovation and Research, Lillebaelt Hospital - University Hospital of Southern Denmark, Vejle, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | | | - Morten Rasmussen
- Digestive Disease Center, Bispebjerg Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Berit Andersen
- University Research Clinic for Cancer Screening, Randers Regional Hospital, Randers NØ, Denmark
- Department of Clinical Medicine, Aarhus University Faculty of Health Sciences, Aarhus, Denmark
| | - Sisse H Njor
- Department of Data, Innovation and Research, Lillebaelt Hospital - University Hospital of Southern Denmark, Vejle, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Clinical Medicine, Aarhus University Faculty of Health Sciences, Aarhus, Denmark
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Polychronidis G, He MM, Vithayathil M, Knudsen MD, Wang K, Song M. Risk of colorectal neoplasia after removal of conventional adenomas and serrated polyps: a comprehensive evaluation of risk factors and surveillance use. Gut 2024; 73:1675-1683. [PMID: 38839270 DOI: 10.1136/gutjnl-2023-331729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 05/20/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Surveillance colonoscopy after polyp removal is recommended to prevent subsequent colorectal cancer (CRC). It is known that advanced adenomas have a substantially higher risk than non-advanced ones, but optimal intervals for surveillance remain unclear. DESIGN We prospectively followed 156 699 participants who had undergone a colonoscopy from 2007 to 2017 in a large integrated healthcare system. Using multivariable Cox proportional hazards regression we estimated the subsequent risk of CRC and high-risk polyps, respectively, according to index colonoscopy polyps, colonoscopy quality measures, patient characteristics and the use of surveillance colonoscopy. RESULTS After a median follow-up of 5.3 years, we documented 309 CRC and 3053 high-risk polyp cases. Compared with participants with no polyps at index colonoscopy, those with high-risk adenomas and high-risk serrated polyps had a consistently higher risk of CRC during follow-up, with the highest risk observed at 3 years after polypectomy (multivariable HR 5.44 (95% CI 3.56 to 8.29) and 8.35 (95% CI 4.20 to 16.59), respectively). Recurrence of high-risk polyps showed a similar risk distribution. The use of surveillance colonoscopy was associated with lower risk of CRC, with an HR of 0.61 (95% CI 0.39 to 0.98) among patients with high-risk polyps and 0.57 (95% CI 0.35 to 0.92) among low-risk polyps. Among 1548 patients who had high-risk polyps at both index and surveillance colonoscopies, 65% had their index polyps in the proximal colon and 30% had index and interval polyps in the same segments. CONCLUSION Patients with high-risk polyp findings were at higher risk of subsequent CRC and high-risk polyps and may benefit from early surveillance within 3 years. The subsite distribution of the index and recurrent high-risk polyps suggests the contribution of incomplete resection and missed lesions to the development of interval neoplasia.
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Affiliation(s)
- Georgios Polychronidis
- Department of Epidemiology, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- Department of General,Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Study Centre of the German Surgical Society, German Surgical Society/Heidelberg University Hospital, Heidelberg, Germany
| | - Ming-Ming He
- Department of Epidemiology, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- State Key Laboratory of Oncology in South China, Department of Medical Oncology, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Mathew Vithayathil
- Department of Epidemiology, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- Imperial College Healthcare NHS Trust, London, UK
| | - Markus D Knudsen
- Department of Epidemiology, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
- Department of Transplantation Medicine, Division of Surgery,Inflammatory Diseases and Transplantation, Oslo University Hospital, Oslo, Norway
| | - Kai Wang
- Department of Epidemiology, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Mingyang Song
- Department of Epidemiology, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
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Adán Merino L, Mora Soler AM, Ponferrada Díaz Á. [Surveillance recommendations after endoscopic resection of colorectal polyps]. Med Clin (Barc) 2024; 163:143-148. [PMID: 38849270 DOI: 10.1016/j.medcli.2024.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 06/09/2024]
Affiliation(s)
- Luisa Adán Merino
- Servicio de Aparato Digestivo, Hospital Universitario Infanta Leonor, Madrid, España.
| | - Ana María Mora Soler
- Servicio de Aparato Digestivo, Hospital Universitario Infanta Leonor, Madrid, España
| | - Ángel Ponferrada Díaz
- Servicio de Aparato Digestivo, Hospital Universitario Infanta Leonor, Madrid, España
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He D, Wang K, Zhang Y, Jiang X, Chen H, Chen J, Liu D, Li G, Hu J, He X. Risk of advanced neoplasia after removal of colorectal adenomas with high-grade dysplasia. Surg Endosc 2024; 38:3783-3798. [PMID: 38806955 PMCID: PMC11219408 DOI: 10.1007/s00464-024-10898-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 05/02/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Many studies reported the presence of adenomas with high-grade dysplasia (HGD) at index colonoscopy increased the incidence of advanced neoplasia (AN) and colorectal cancer (CRC) following. However, the conclusion remains obscure due to lack of studies on the specific population of adenomas with HGD. This study aimed to assess the long-term risk of AN and CRC after removal of adenomas with HGD. METHODS A total of 814 patients who underwent adenomas with HGD removal between 2010 and 2019 were retrospectively analyzed. The outcomes were the incidences of AN and CRC during surveillance colonoscopy. Cox proportional hazards models were utilized to identify risk factors associated with AN and CRC. RESULTS During more than 2000 person-years of follow-up, we found that AN and CRC incidence densities were 44.3 and 4.4 per 1000 person-years, respectively. The 10-year cumulative incidence of AN and CRC were 39.1% and 5.5%, respectively. In the multivariate model, synchronous low-risk polyps (HR 1.80, 95% CI 1.10-2.93) and synchronous high-risk polyps (HR 3.99, 95% CI 2.37-6.72) were risk factors for AN, whereas participation in surveillance colonoscopy visits (HR 0.56, 95% CI 0.36-0.88 for 1 visit; HR 0.10, 95% CI 0.06-0.19 for ≥ 2 visits) were associated with decreased AN incidence. Additionally, elevated baseline carcinoembryonic antigen (CEA) level (HR 10.19, 95% CI 1.77-58.59) was a risk factor for CRC, while participation in ≥ 2 surveillance colonoscopy visits (HR 0.11, 95% CI 0.02-0.56) were associated with decreased CRC incidence. Interestingly, for 11 patients who developed CRC after removal of adenomas with HGD, immunohistochemistry revealed that 8 cases (73%) were deficient mismatch repair CRCs. CONCLUSIONS Patients who have undergone adenoma with HGD removal are at higher risk of developing AN and CRC, while surveillance colonoscopy can reduce the risk. Patients with synchronous polyps, or with elevated baseline CEA level are considered high-risk populations and require more frequent surveillance.
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Affiliation(s)
- Degao He
- Department of Anorectal Surgery, Shenzhen Longhua District Central Hospital, Guanlan Avenue 187, Shenzhen, 518100, Guangdong, China.
- Department of General Surgery (Colorectal Surgery), The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China.
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China.
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China.
| | - Kai Wang
- Department of Anaesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China
| | - Yanhong Zhang
- Department of General Surgery (Colorectal Surgery), The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China
| | - Xuefei Jiang
- Department of General Surgery (Institute of Gastroenterology), The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China
| | - Hao Chen
- Department of General Surgery (Colorectal Surgery), The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China
| | - Junguo Chen
- Department of General Surgery (Colorectal Surgery), The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China
| | - Danlin Liu
- Department of General Surgery (Colorectal Surgery), The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China
| | - Guanman Li
- Department of General Surgery (Colorectal Surgery), The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China
| | - Jiancong Hu
- Department of General Surgery (Endoscopic Surgery), The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China.
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China.
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China.
| | - Xiaosheng He
- Department of General Surgery (Colorectal Surgery), The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China.
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China.
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, 510655, Guangdong, China.
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Sullivan BA, Lieberman DA. Colon Polyp Surveillance: Separating the Wheat From the Chaff. Gastroenterology 2024; 166:743-757. [PMID: 38224860 DOI: 10.1053/j.gastro.2023.11.305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 01/17/2024]
Abstract
One goal of colorectal cancer (CRC) screening is to prevent CRC incidence by removing precancerous colonic polyps, which are detected in up to 50% of screening examinations. Yet, the lifetime risk of CRC is 3.9%-4.3%, so it is clear that most of these individuals with polyps would not develop CRC in their lifetime. It is, therefore, a challenge to determine which individuals with polyps will benefit from follow-up, and at what intervals. There is some evidence that individuals with advanced polyps, based on size and histology, benefit from intensive surveillance. However, a large proportion of individuals will have small polyps without advanced histologic features (ie, "nonadvanced"), where the benefits of surveillance are uncertain and controversial. Demand for surveillance will further increase as more polyps are detected due to increased screening uptake, recent United States recommendations to expand screening to younger individuals, and emergence of polyp detection technology. We review the current understanding and clinical implications of the natural history, biology, and outcomes associated with various categories of colon polyps based on size, histology, and number. Our aims are to highlight key knowledge gaps, specifically focusing on certain categories of polyps that may not be associated with future CRC risk, and to provide insights to inform research priorities and potential management strategies. Optimization of CRC prevention programs based on updated knowledge about the future risks associated with various colon polyps is essential to ensure cost-effective screening and surveillance, wise use of resources, and inform efforts to personalize recommendations.
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Affiliation(s)
- Brian A Sullivan
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, North Carolina; Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
| | - David A Lieberman
- Portland Veteran Affairs Medical Center, Portland, Oregon; Division of Gastroenterology and Hepatology, School of Medicine, Oregon Health and Science University, Portland, Oregon
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Baile-Maxía S, Jover R. Surveillance after colorectal polyp resection. Best Pract Res Clin Gastroenterol 2023; 66:101848. [PMID: 37852710 DOI: 10.1016/j.bpg.2023.101848] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/12/2023] [Accepted: 07/02/2023] [Indexed: 10/20/2023]
Abstract
Post-polypectomy surveillance has proven to reduce colorectal cancer (CRC) incidence in patients with high-risk polyps, but it implies a major burden on colonoscopy units. Therefore, it should be targeted to individuals with a higher risk. Different societies have published guidelines on surveillance after resection of polyps, with notable discrepancies among them, and many recommendations come from low-quality evidence based on surrogate measures, such as risk of advanced adenoma, and not CRC risk. In this review, we aimed to summarize the evidence supporting post-polypectomy surveillance, compare the recently updated major guidelines, and discuss the existing discrepancies on this topic. Briefly, patients with adenomas ≥10 mm or high-grade dysplasia and patients with serrated polyps ≥10 mm or dysplasia are generally considered to have an increased risk of metachronous CRC and require surveillance, whereas the indication of surveillance is not clearly established in patients without these high-risk features.
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Affiliation(s)
- Sandra Baile-Maxía
- Gastroenterology Department, Hospital General Universitario Dr. Balmis, Instituto de Investigación Biomédica ISABIAL, Universidad Miguel Hernández, Alicante, Spain
| | - Rodrigo Jover
- Gastroenterology Department, Hospital General Universitario Dr. Balmis, Instituto de Investigación Biomédica ISABIAL, Universidad Miguel Hernández, Alicante, Spain.
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Das TS, Rauch J, Shaukat A. Colorectal cancer screening-what does the recent NordICC trial mean for the U.S. population? Transl Gastroenterol Hepatol 2023; 8:40. [PMID: 38021363 PMCID: PMC10643301 DOI: 10.21037/tgh-23-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 08/10/2023] [Indexed: 12/01/2023] Open
Abstract
The incidence of colorectal cancer (CRC) has declined over time, though it remains a significant cause of morbidity and mortality in the U.S. It has the third highest incidence in incidence among all cancers and is the second leading cause of cancer death in both men and women. Screening reduces the incidence and mortality from CRC. There are several modalities for CRC screening, but the most common ones are a choice between a non-invasive stool-based test, such as fecal immunochemical testing (FIT) or an invasive endoscopic modality, such as colonoscopy. In the U.S. colonoscopy is the predominant CRC screening modality, with observational studies reporting large reductions in CRC incidence and mortality. Recently, a large randomized controlled trial (RCT) on effectiveness of colonoscopy reported smaller than expected reduction in CRC incidence and no reduction in CRC mortality with colonoscopy screening. Explanations of the lower than expected benefit include low uptake of colonoscopy, short follow-up for mortality endpoints and quality indicators (QIs) for some of the endoscopists participating in the screening colonoscopies. The findings of the study need to be taken in context with other literature on effectiveness of colonoscopy, with the overall message of reassuring patients of the benefits of screening, and colonoscopy. Here, we discuss the latest evidence on colonoscopy screening and it in the context of other screening modalities and the landscape.
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Affiliation(s)
- Taranika Sarkar Das
- Division of Gastroenterology, NYU Grossman School of Medicine, New York, NY, USA
| | - Jessica Rauch
- Division of Gastroenterology, NYU Grossman School of Medicine, New York, NY, USA
| | - Aasma Shaukat
- Division of Gastroenterology, NYU Grossman School of Medicine, New York, NY, USA
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Bonnington SN, Hungin APS, Nickerson C, Wright S, Sharp L, Rutter MD. Colorectal cancer and advanced adenoma incidence during post-polypectomy surveillance: a national cohort study in the English Bowel Cancer Screening Programme. Endoscopy 2023; 55:740-753. [PMID: 37185968 DOI: 10.1055/a-2060-0615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
BACKGROUND Improved colonoscopy quality has led to debate about whether all post-polypectomy surveillance is justified. We evaluated surveillance within the English Bowel Cancer Screening Programme (BCSP) to determine the yield of surveillance and identify predictive factors for surveillance outcome. METHODS We performed a retrospective cohort study of individuals undergoing post-polypectomy surveillance between July 2006 and January 2017. BCSP records were linked to the National Cancer Registration Database to identify interval-type post-colonoscopy colorectal cancers (CRCs). Advanced adenoma and CRC at surveillance were documented. CRC incidence was compared with the general population using standardized incidence ratios (SIRs). Predictors of advanced adenomas at first surveillance (S1), and CRC during follow-up, were identified. RESULTS 44 151 individuals (23 078 intermediate risk; 21 073 high risk) underwent 64 544 surveillance episodes. Advanced adenoma and CRC yields were, respectively, 10.0 % and 0.5 % at S1, 8.5 % and 0.4 % at S2, and 10.8 % and 0.4 % at S3. S1 yield was lowest in those with one index adenoma ≥ 10 mm (advanced adenoma 6.1 %; CRC 0.3 %). The SIR was 0.76 (95 %CI 0.66-0.88), accounted for by the intermediate risk group (intermediate risk SIR 0.61, 95 %CI 0.49-0.75; high risk SIR 0.95, 95 %CI 0.79-1.15). Adenoma multiplicity, presence of a large nonpedunculated adenoma, and greater villous component were associated with advanced adenoma at S1. Older age and multiplicity were significantly associated with CRC risk. CONCLUSION This large, national analysis found low levels of CRC in those undergoing surveillance and low advanced adenoma yield in most subgroups. Less intensive surveillance in some subgroups is warranted, and surveillance may be avoided in those with a single large adenoma.
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Affiliation(s)
- Stewart N Bonnington
- Gastroenterology, Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, North Shields, United Kingdom
| | - A Pali S Hungin
- Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | | | - Suzanne Wright
- NHS Cancer Screening Programmes, Sheffield, United Kingdom
| | - Linda Sharp
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Matthew D Rutter
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, United Kingdom
- Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, United Kingdom
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11
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Antonelli G. Endoscopic surveillance after resection of sessile serrated lesions: so far, so good? Endoscopy 2023; 55:737-739. [PMID: 37172937 DOI: 10.1055/a-2077-2364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Affiliation(s)
- Giulio Antonelli
- Gastroenterology and Digestive Endoscopy Unit, Ospedale dei Castelli Hospital, Ariccia, Rome, Italy
- Department of Anatomical, Histological, Forensic Medicine and Orthopedic Sciences, "Sapienza" University of Rome, Rome, Italy
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12
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Jodal HC, Wieszczy-Szczepanik P, Klotz D, Herfindal M, Barua I, Tag P, Helsingen LM, Refsum E, Holme Ø, Adami HO, Bretthauer M, Kalager M, Løberg M. A Comparison of Risk Classification Systems of Colorectal Adenomas: A Case-Cohort Study. Gastroenterology 2023; 165:483-491.e7. [PMID: 37146913 DOI: 10.1053/j.gastro.2023.04.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 04/14/2023] [Accepted: 04/23/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND & AIMS Because post-polypectomy surveillance uses a growing proportion of colonoscopy capacity, more targeted surveillance is warranted. We therefore compared surveillance burden and cancer detection using 3 different adenoma classification systems. METHODS In a case-cohort study among individuals who had adenomas removed between 1993 and 2007, we included 675 individuals with colorectal cancer (cases) diagnosed a median of 5.6 years after adenoma removal and 906 randomly selected individuals (subcohort). We compared colorectal cancer incidence among high- and low-risk individuals defined according to the traditional (high-risk: diameter ≥10 mm, high-grade dysplasia, villous growth pattern, or 3 or more adenomas), European Society of Gastrointestinal Endoscopy (ESGE) 2020 (high-risk: diameter ≥10 mm, high-grade dysplasia, or 5 or more adenomas), and novel (high-risk: diameter ≥20 mm or high-grade dysplasia) classification systems. For the different classification systems, we calculated the number of individuals recommended frequent surveillance colonoscopy and estimated number of delayed cancer diagnoses. RESULTS Four hundred and thirty individuals with adenomas (52.7%) were high risk based on the traditional classification, 369 (45.2%) were high risk based on the ESGE 2020 classification, and 220 (27.0%) were high risk based on the novel classification. Using the traditional, ESGE 2020, and novel classifications, the colorectal cancer incidences per 100,000 person-years were 479, 552, and 690 among high-risk individuals, and 123, 124, and 179 among low-risk individuals, respectively. Compared with the traditional classification, the number of individuals who needed frequent surveillance was reduced by 13.9% and 44.2%, respectively, and 1 (3.4%) and 7 (24.1%) cancer diagnoses were delayed using the ESGE 2020 and novel classifications. CONCLUSIONS Using the ESGE 2020 and novel risk classifications will substantially reduce resources needed for colonoscopy surveillance after adenoma removal.
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Affiliation(s)
- Henriette C Jodal
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway; Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway; Section of Oncology, Drammen Hospital, Vestre Viken Hospital Trust, Drammen, Norway.
| | - Paulina Wieszczy-Szczepanik
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway; Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Dagmar Klotz
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway; Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway; Department of Pathology, Oslo University Hospital, Oslo, Norway
| | - Magnhild Herfindal
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway; Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Ishita Barua
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway; Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Petter Tag
- Department of Medicine, Nordland Hospital Bodø, Bodø, Norway
| | - Lise M Helsingen
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway; Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Erle Refsum
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway; Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Øyvind Holme
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway; Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway; Department of Medicine, Sørlandet Hospital Kristiansand, Kristiansand, Norway
| | - Hans-Olov Adami
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway; Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway; Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Michael Bretthauer
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway; Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Mette Kalager
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway; Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway; Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Magnus Løberg
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway; Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
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13
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Juul FE, Garborg K, Nesbakken E, Løberg M, Wieszczy P, Cubiella J, Kalager M, Kaminski MF, Erichsen R, Adami HO, Ferlitsch M, Furholm SKB, Zauber AG, Quintero E, Bugajski M, Holme Ø, Dekker E, Jover R, Bretthauer M. Rates of repeated colonoscopies to clean the colon from low-risk and high-risk adenomas: results from the EPoS trials. Gut 2023; 72:951-957. [PMID: 36307178 PMCID: PMC11112405 DOI: 10.1136/gutjnl-2022-327696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 10/20/2022] [Indexed: 12/08/2022]
Abstract
OBJECTIVE High-quality colonoscopy (adequate bowel preparation, whole-colon visualisation and removal of all neoplastic polyps) is a prerequisite to start polyp surveillance, and is ideally achieved in one colonoscopy. In a large multinational polyp surveillance trial, we aimed to investigate clinical practice variation in number of colonoscopies needed to enrol patients with low-risk and high-risk adenomas in polyp surveillance. DESIGN We retrieved data of all patients with low-risk adenomas (one or two tubular adenomas <10 mm with low-grade dysplasia) and high-risk adenomas (3-10 adenomas, ≥1 adenoma ≥10 mm, high-grade dysplasia or villous components) in the European Polyp Surveillance trials fulfilling certain logistic and methodologic criteria. We analysed variations in number of colonoscopies needed to achieve high-quality colonoscopy and enter polyp surveillance by endoscopy centre, and by endoscopists who enrolled ≥30 patients. RESULTS The study comprised 15 581 patients from 38 endoscopy centres in five European countries; 6794 patients had low-risk and 8787 had high-risk adenomas. 961 patients (6.2%, 95% CI 5.8% to 6.6%) underwent two or more colonoscopies before surveillance began; 101 (1.5%, 95% CI 1.2% to 1.8%) in the low-risk group and 860 (9.8%, 95% CI 9.2% to 10.4%) in the high-risk group. Main reasons were poor bowel preparation (21.3%) or incomplete colonoscopy/polypectomy (14.4%) or planned second procedure (27.8%). Need of repeat colonoscopy varied between study centres ranging from 0% to 11.8% in low-risk adenoma patients and from 0% to 63.9% in high-risk adenoma patients. On the second colonoscopy, the two most common reasons for a repeat (third) colonoscopy were piecemeal resection (26.5%) and unspecified reason (23.9%). CONCLUSION There is considerable practice variation in the number of colonoscopies performed to achieve complete polyp removal, indicating need for targeted quality improvement to reduce patient burden. TRIAL REGISTRATION NUMBER NCT02319928.
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Affiliation(s)
- Frederik Emil Juul
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
- Clinical Effectiveness Research Group, Oslo University Hospital, Oslo, Norway
| | - Kjetil Garborg
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
- Clinical Effectiveness Research Group, Oslo University Hospital, Oslo, Norway
| | - Eugen Nesbakken
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
- Clinical Effectiveness Research Group, Oslo University Hospital, Oslo, Norway
| | - Magnus Løberg
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
- Clinical Effectiveness Research Group, Oslo University Hospital, Oslo, Norway
| | - Paulina Wieszczy
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
- Clinical Effectiveness Research Group, Oslo University Hospital, Oslo, Norway
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Joaquín Cubiella
- Gastroenterology, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Mette Kalager
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
- Clinical Effectiveness Research Group, Oslo University Hospital, Oslo, Norway
| | - Michael F Kaminski
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
- Clinical Effectiveness Research Group, Oslo University Hospital, Oslo, Norway
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland
- Maria Sklodowska-Curie National Research Institute of Oncology, Warszawa, Poland
| | - Rune Erichsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Surgery, Randers Regional Hospital, Randers, Denmark
| | - Hans-Olov Adami
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
- Clinical Effectiveness Research Group, Oslo University Hospital, Oslo, Norway
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Monika Ferlitsch
- Department of Internal Medicine III, Medical University of Vienna, Wien, Austria
| | - Siv K B Furholm
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Enrique Quintero
- Facultad de Medicina, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
| | - Marek Bugajski
- Maria Sklodowska-Curie National Research Institute of Oncology, Warszawa, Poland
| | - Øyvind Holme
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
- Clinical Effectiveness Research Group, Oslo University Hospital, Oslo, Norway
- Department of Gastroenterology, Sørlandet Sykehus HF, Kristiansand, Norway
| | - Evelien Dekker
- Dept of Gastroenterology and Hepatology C2-115, Amsterdam University Medical Centres, Duivendrecht, Netherlands
- Bergman Clinics IZA, Amsterdam, The Netherlands
| | - Rodrigo Jover
- Servicio de Medicina Digestiva, Hospital General Universitario de Alicante, Alicante, Valenciana, Spain
- Servicio de Medicina Digestiva, Hospital General Universitario Dr. Balmis, Universidad Miguel Hernández, Instituto de Investigación Sanitaria ISABIAL, Alicante, Spain
| | - Michael Bretthauer
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
- Clinical Effectiveness Research Group, Oslo University Hospital, Oslo, Norway
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Baile-Maxía S, Mangas-Sanjuán C, Ladabaum U, Hassan C, Rutter MD, Bretthauer M, Medina-Prado L, Sala-Miquel N, Pomares OM, Zapater P, Jover R. Risk Factors for Metachronous Colorectal Cancer or Advanced Adenomas After Endoscopic Resection of High-risk Adenomas. Clin Gastroenterol Hepatol 2023; 21:630-643. [PMID: 36549471 DOI: 10.1016/j.cgh.2022.12.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 11/24/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND & AIMS Among the characteristics of high-risk adenomas (HRAs), some may predict a higher risk of metachronous advanced lesions. Our aim was to assess which HRA characteristics are associated with high risk of metachronous colorectal cancer (CRC) or advanced adenomas (AAs). METHODS We systematically searched Pubmed, EMBASE, and Cochrane for cohort studies and clinical trials of CRC or AA incidence at surveillance stratified by baseline lesion size, histology, and multiplicity. We calculated pooled relative risks (RRs) using a random-effects model. Heterogeneity was assessed with the I2 statistic. RESULTS Fifty-five studies were included, with 936,540 patients with mean follow-up 5.4 ± 2.9 years. CRC incidence per 1000 person-years was 2.6 (2.1-3.0) for adenomas ≥20 mm, 2.7 (2.2-3.2) for high-grade dysplasia (HGD), 2.0 (1.8-2.3) for villous component, 0.8 (0.1-1.4) for ≥5 adenomas, 1.0 (0.7-1.2) for ≥3 adenomas. Metachronous CRC risk was higher in adenomas ≥20 mm vs 10 to 19 mm (RR, 2.08; 95% confidence interval [CI], 1.20-3.61), HGD vs low-grade dysplasia (RR, 2.89; 95% CI, 1.88-4.44), villous vs tubular (RR, 1.75; 95% CI, 1.33-2.31). No significant differences in CRC risk were found in ≥3 adenomas vs 1 to 2 (RR, 1.24; 95% CI, 0.84-1.83), nor in ≥5 adenomas vs 3 to 4 (RR, 0.79; 95% CI, 0.30-2.11). Compared with normal colonoscopy, RR for CRC risk was 2.61 (95% CI, 2.06-3.32) for ≥10mm, 6.62 (95% CI, 4.60-9.52) for HGD, 3.58 (95% CI, 2.24-5.73) for villous component, and 2.03 (95% CI, 1.40-2.94) for ≥3 adenomas. Similar trends were seen for metachronous AAs. CONCLUSION Metachronous CRC risk is highest in patients with baseline adenomas with ≥20 mm or HGD. Multiplicity does not seem to be associated with substantially higher CRC risk in the near term.
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Affiliation(s)
- Sandra Baile-Maxía
- Servicio de Medicina Digestiva, Hospital General Universitario Dr Balmis, Instituto de Investigación Biomédica ISABIAL, Universidad Miguel Hernández, Alicante, Spain
| | - Carolina Mangas-Sanjuán
- Servicio de Medicina Digestiva, Hospital General Universitario Dr Balmis, Instituto de Investigación Biomédica ISABIAL, Universidad Miguel Hernández, Alicante, Spain
| | - Uri Ladabaum
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Cesare Hassan
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; IRCCS Humanitas Research Hospital, Milan, Italy
| | - Matthew D Rutter
- North Tees and Hartlepool NHS Foundation Trust, Stockton-On-Tees, Cleveland, Yorkshire, United Kingdom; Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Michael Bretthauer
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway; Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Lucía Medina-Prado
- Servicio de Medicina Digestiva, Hospital General Universitario Dr Balmis, Instituto de Investigación Biomédica ISABIAL, Universidad Miguel Hernández, Alicante, Spain
| | - Noelia Sala-Miquel
- Servicio de Medicina Digestiva, Hospital General Universitario Dr Balmis, Instituto de Investigación Biomédica ISABIAL, Universidad Miguel Hernández, Alicante, Spain
| | - Oscar Murcia Pomares
- Servicio de Medicina Digestiva, Hospital General Universitario Dr Balmis, Instituto de Investigación Biomédica ISABIAL, Universidad Miguel Hernández, Alicante, Spain
| | - Pedro Zapater
- Clinical Pharmacology Department, Hospital General Universitario Dr Balmis, Instituto de Investigación Biomédica ISABIAL, CIBERehd, Alicante, Spain
| | - Rodrigo Jover
- Servicio de Medicina Digestiva, Hospital General Universitario Dr Balmis, Instituto de Investigación Biomédica ISABIAL, Universidad Miguel Hernández, Alicante, Spain.
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15
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Guo F, Edelmann D, Cardoso R, Chen X, Carr PR, Chang-Claude J, Hoffmeister M, Brenner H. Polygenic Risk Score for Defining Personalized Surveillance Intervals After Adenoma Detection and Removal at Colonoscopy. Clin Gastroenterol Hepatol 2023; 21:210-219.e11. [PMID: 35331942 DOI: 10.1016/j.cgh.2022.03.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/10/2022] [Accepted: 03/12/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Polygenic risk scores (PRSs) could help to define personalized colorectal cancer (CRC) screening strategies. The aim of this study was to evaluate whether a PRS, along with adenoma characteristics, could help to define more personalized and risk-adapted surveillance intervals. METHODS In a population-based, case-control study from Germany, detailed information on previous colonoscopies and a PRS based on 140 CRC-related, single-nucleotide polymorphisms was obtained from 4696 CRC cases and 3709 controls. Participants were classified as having low, medium, or high genetic risk according to tertiles of PRSs among controls. We calculated the absolute risk of CRC based on the PRS and colonoscopy history and findings. RESULTS We observed major variations of CRC risk according to the PRS, including among individuals with detection and removal of adenomas at colonoscopy. For instance, the estimated 10-year absolute risk of CRC for 50-year-old men and women with no polyps, for whom repeat screening colonoscopy is recommended after 10 years only, was 0.2%. Equivalent absolute risks were estimated for people with low-risk adenomas and low PRS. However, the same levels of absolute risk were reached within 3 to 5 years by those with low-risk adenomas and high PRS and with high-risk adenomas irrespective of the PRS. CONCLUSIONS Consideration of genetic predisposition to CRC risk, as determined by a PRS, could help to define personalized, risk-adapted surveillance intervals after detection and removal of adenomas at screening colonoscopy. However, whether the risk variation is strong enough to direct clinical risk stratification needs to be explored further.
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Affiliation(s)
- Feng Guo
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Dominic Edelmann
- Division of Biostatistics, German Cancer Research Center, Heidelberg, Germany
| | - Rafael Cardoso
- Division of Preventive Oncology, National Center for Tumor Diseases, German Cancer Research Center, Heidelberg, Germany; Medical Faculty Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Xuechen Chen
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany; Medical Faculty Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Prudence R Carr
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jenny Chang-Claude
- Division of Cancer Epidemiology, German Cancer Research Center, Heidelberg, Germany; Cancer Epidemiology Group, University Medical Center Hamburg-Eppendorf, University Cancer Center Hamburg, Hamburg, Germany
| | - Michael Hoffmeister
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany; Division of Preventive Oncology, National Center for Tumor Diseases, German Cancer Research Center, Heidelberg, Germany; German Cancer Consortium, German Cancer Research Center, Heidelberg, Germany.
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16
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Trivedi M, Mai D, Gupta S. Potential Impact of Extending Surveillance Intervals for Patients With 1-2 Low-Risk Adenomas. GASTRO HEP ADVANCES 2022; 2:298-300. [PMID: 39132662 PMCID: PMC11308823 DOI: 10.1016/j.gastha.2022.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/21/2022] [Indexed: 08/13/2024]
Affiliation(s)
- M. Trivedi
- Jennifer Moreno Veteran Affairs San Diego Healthcare System, San Diego, California
- University of California San Diego, Department of Internal Medicine, San Diego, California
| | - D. Mai
- Jennifer Moreno Veteran Affairs San Diego Healthcare System, San Diego, California
- University of California San Diego, Department of Internal Medicine, San Diego, California
| | - S. Gupta
- Jennifer Moreno Veteran Affairs San Diego Healthcare System, San Diego, California
- University of California San Diego, Division of Gastroenterology, San Diego, California
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17
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Cubiella J. Post-polypectomy surveillance: walking in the fog. Endoscopy 2022; 54:959-960. [PMID: 35668661 DOI: 10.1055/a-1849-2294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Joaquín Cubiella
- Department of Gastroenterology, Complexo Hospitalario Universitario de Ourense, Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEehd), Ourense, Spain
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18
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Bustamante-Balén M, García-Campos M, Lorenzo-Zúñiga V, Alonso-Lázaro N, Sanchez-Montes C, Argüello-Viudez L, Pons-Beltrán V. Impact of the European Society of Gastrointestinal Endoscopy 2020 guidelines on the number of scheduled post-polypectomy surveillance colonoscopies: Meeting presentations: Partial results of this research were published in abstract form at ESGE Days 2020. Endosc Int Open 2022; 10:E1238-E1244. [PMID: 36118644 PMCID: PMC9473806 DOI: 10.1055/a-1905-0155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 07/19/2022] [Indexed: 11/24/2022] Open
Abstract
Background and study aims In contrast with the European Society of Gastrointestinal Endoscopy (ESGE) 2013 and the US Multi-society Task Force (USMSTF) 2020 guidelines, the ESGE 2020 guideline considers patients with three to four adenomas < 10 mm or an adenoma with villous histology as low risk. The aim of this study was to quantify the influence of the application of the new ESGE 2020 guidelines, as opposed to the ESGE 2013 and USMSTF 2020 guidelines, on the number of scheduled colonoscopies, and to describe the main causes for changes in the surveillance intervals. Patients and methods A retrospective evaluation was conducted of a prospectively maintained fecal immunochemical test (FIT)-based regional colorectal cancer screening program database. Surveillance regimens following ESGE 2020, ESGE 2013, and USMSTF 2020 guidelines were compared. Results Overall, 1284 individuals with a positive FIT and undergoing colonoscopy were consecutively included. When applying the ESGE 2020 guidelines, 10.8 % of patients changed to a "no-surveillance" group (relative reduction in colonoscopies of 82.5 %). The main reason for these changes was considering three to four adenomas as low risk. The proportion of patients from the "3-year surveillance" group who moved to the "no-surveillance" group was lower when a sessile serrated lesion (SSL) was present (ESGE 2013, 32.0% vs 16.3 %; USMSTF 2020 17.2 % vs 6.8 %). Analyzing the 41 patients with SSLs who remained unchanged in the "no-surveillance" group, only in 15 (36.6 %) the cause was the presence of an SSL. Conclusions applying the new ESGE 2020 guidelines could reduce by 11 % the proportion of individuals being offered surveillance. SLLs have not a major influence on the change of surveillance intervals.
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Affiliation(s)
- Marco Bustamante-Balén
- Gastrointestinal Endoscopy Unit. Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Gastrointestinal Research Group. Health Research Institute (IISLaFe), Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Maria García-Campos
- Gastrointestinal Endoscopy Unit. Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | - Noelia Alonso-Lázaro
- Gastrointestinal Endoscopy Unit. Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Gastrointestinal Research Group. Health Research Institute (IISLaFe), Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Cristina Sanchez-Montes
- Gastrointestinal Endoscopy Unit. Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Gastrointestinal Research Group. Health Research Institute (IISLaFe), Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Lidia Argüello-Viudez
- Gastrointestinal Endoscopy Unit. Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Gastrointestinal Research Group. Health Research Institute (IISLaFe), Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Vicente Pons-Beltrán
- Gastrointestinal Endoscopy Unit. Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Gastrointestinal Research Group. Health Research Institute (IISLaFe), Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Medina-Prado L, Mangas-Sanjuan C, Baile-Maxía S, Martínez-Roca AA, Murcia Ó, Zarraquiños S, Rodríguez-Camacho E, Aginagalde AH, Álvarez-Urturi C, Valverde-Roig MJ, Zapater P, Bujanda L, Salas D, Portillo I, Pellisé M, Cubiella J, Jover R. Risk of Colorectal Cancer and Advanced Polyps One Year After Excision of High-Risk Adenomas. Dis Colon Rectum 2022; 65:1112-1120. [PMID: 34840293 DOI: 10.1097/dcr.0000000000002068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Patients with multiple or large adenomas are considered to be high-risk for metachronous colorectal cancer. OBJECTIVE Evaluate the risks of detecting colorectal cancer, advanced adenoma, and advanced serrated polyps at 1-year surveillance colonoscopy in patients with >5 adenomas or adenomas >20 mm. DESIGN Descriptive, retrospective, multicentric, cohort study. We calculated the absolute risk of developing colorectal cancer, advanced adenomas, and advanced serrated polyps at the 1-year surveillance colonoscopy. Potential risk factors for advanced neoplasia at follow-up were evaluated with univariable and multivariable logistic regression analyses. SETTINGS This study included data from a multicenter cohort colorectal cancer screening program, conducted from January 2014 to December 2015, based on fecal immunochemical tests in Spain. PATIENTS We included 2119 participants with at least 1 adenoma ≥20 mm or ≥5 adenomas of any size. MAIN OUTCOME MEASURES We calculated the absolute risk of developing colorectal cancer, advanced adenomas, and advanced serrated polyps at the 1-year surveillance colonoscopy. Potential risk factors for advanced neoplasia at follow-up were evaluated with univariable and multivariable logistic regression analyses. RESULTS At 1 year, participants displayed 6 colorectal cancers (0.3%), 228 advanced adenomas (10.5%), and 58 advanced serrated polyps (2.7%). The adjusted analysis identified 2 factors associated with advanced neoplasia: >5 adenomas (odds ratio 1.53; 95% CI: 1.15-2.03; p = 0.004) and polyps in a proximal location (OR 1.52; 95% CI: 1.15-2.02; p = 0.004). LIMITATIONS First, the sample size was relatively small compared to other studies with similar aims. Another limitation was the lack of a comparison group, which could have provided more practical results in terms of surveillance recommendations. CONCLUSIONS The colorectal cancer detection rate at a 1-year colonoscopy surveillance was low among patients classified at high risk of advanced neoplasia. The risk factors for advanced neoplasia were ≥5 adenomas and proximal polyps at baseline. See Video Abstract at http://links.lww.com/DCR/B820 . RIESGO DE CNCER COLORRECTAL Y DE PLIPOS AVANZADOS UN AO DESPUS DE LA RESECCIN DE ADENOMAS DE ALTO RIESGO ANTECEDENTES:Los pacientes con adenomas múltiples o grandes se consideran de alto riesgo para desarrollar cáncer colorrectal metacrónico.OBJETIVO:Evaluar los riesgos de detectar cáncer colorrectal, adenoma avanzado y pólipos serrados avanzados en la colonoscopia de seguimiento al año, en pacientes con un número mayor o igual a 5 adenomas o adenomas de 20 mm o más.DISEÑO:Estudio descriptivo, retrospectivo, multicéntrico, de cohortes. Calculamos el riesgo absoluto de desarrollar cáncer colorrectal, adenomas avanzados y pólipos serrados avanzados en la colonoscopia de vigilancia al año. Los factores de riesgo potenciales para el desarrollo de una neoplasia avanzada en el seguimiento, fueron evaluados mediante un análisis de regresión logística univariable y multivariable.AJUSTES:Este estudio incluyó datos de un programa de cribado de cáncer colorrectal de cohorte multicéntrico, realizado entre enero de 2014 y diciembre de 2015, con base en pruebas inmunoquímicas de materia fecal, en España.PACIENTES:Incluimos 2119 participantes con al menos un adenoma ≥20 mm o con cinco o más adenomas de cualquier tamaño.PRINCIPALES MEDIDAS DE RESULTADO:Calculamos el riesgo absoluto de desarrollar cáncer colorrectal, adenomas avanzados y pólipos serrados avanzados en la colonoscopia de vigilancia al año. Los potenciales factores de riesgo para desarrollar una neoplasia avanzada en el seguimiento, se evaluaron mediante un análisis de regresión logística univariable y multivariable.RESULTADOS:Al año se encontraron en los pacientes participantes, 6 cánceres colorrectales (0,3%), 228 adenomas avanzados (10,5%) y 58 pólipos serrados avanzados (2,7%). Mediante el análisis ajustado se identificaron dos factores asociados con el desarrollo de neoplasia avanzada: un número igual o mayor a 5 adenomas (razón de probabilidades 1,53; IC del 95%: 1,15-2,03; p = 0,004) y la presencia de pólipos en una ubicación proximal (razón de probabilidades 1,52; IC del 95%: 1,15-2,02; p = 0,004).LIMITACIONES:Primero, el tamaño de la muestra fue relativamente pequeño en comparación con otros estudios con objetivos similares. Otra limitación fue la falta de un grupo comparativo, que podría haber proporcionado resultados más prácticos, en términos de recomendaciones de vigilancia.CONCLUSIÓNES:La tasa de detección de cáncer colorrectal mediante una colonoscopia de vigilancia al año, fue baja entre los pacientes clasificados como de alto riesgo de neoplasia avanzada. Los factores de riesgo para desarrollar una neoplasia avanzada fueron; un número igual o mayor a 5 adenomas y la presencia de pólipos proximales en la colonoscopia inicial de base. Consulte Video Resumen en http://links.lww.com/DCR/B820 . ( Traducción-Eduardo Londoño-Schimmer ).
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Affiliation(s)
- Lucía Medina-Prado
- Servicio de Medicina Digestiva, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria ISABIAL, Alicante, Spain
| | - Carolina Mangas-Sanjuan
- Servicio de Medicina Digestiva, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria ISABIAL, Alicante, Spain
| | - Sandra Baile-Maxía
- Servicio de Medicina Digestiva, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria ISABIAL, Alicante, Spain
| | - Alejandro A Martínez-Roca
- Servicio de Medicina Digestiva, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria ISABIAL, Alicante, Spain
| | - Óscar Murcia
- Servicio de Medicina Digestiva, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria ISABIAL, Alicante, Spain
| | - Sara Zarraquiños
- Gastroenterology Department, Complexo Hospitalario de Ourense, Instituto de Investigación Biomédica Galicia Sur, Ourense, Spain
| | | | - Adrián Hugo Aginagalde
- Departamento de Medicina Preventiva y Salud Pública, Universidad del País Vasco / Euskal Herriko Unibertsitate (UPV/EHU), Subdirección de Calidad Asistencial e Innovación, Ministerio de Sanidad
| | | | - Maria J Valverde-Roig
- Oficina del Plan contra el Cáncer, Direcció General de Salut Pública i Addiccions, Valencia, Spain
| | - Pedro Zapater
- Clinical Pharmacology Department, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria ISABIAL, Alicante, Spain
| | - Luis Bujanda
- Gastroenterology Department, Instituto Biodonostia. CIBERehd, Universidad del País Vasco (UPV/EHU), San Sebastián, Spain
| | - Dolores Salas
- Oficina del Plan contra el Cáncer, Direcció General de Salut Pública i Addiccions, Valencia, Spain
| | - Isabel Portillo
- Departamento de Medicina Preventiva y Salud Pública, Universidad del País Vasco / Euskal Herriko Unibertsitate (UPV/EHU), Subdirección de Calidad Asistencial e Innovación, Ministerio de Sanidad
- The Basque Health Service, Colorectal Cancer Screening Program, Bilbao, Spain
| | - María Pellisé
- Gastroenterology Department, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Joaquín Cubiella
- Gastroenterology Department, Complexo Hospitalario de Ourense, Instituto de Investigación Biomédica Galicia Sur, Ourense, Spain
| | - Rodrigo Jover
- Servicio de Medicina Digestiva, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria ISABIAL, Alicante, Spain
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20
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Detection and Yield of Colorectal Cancer Surveillance in Adults with PTEN Hamartoma Tumour Syndrome. Cancers (Basel) 2022; 14:cancers14164005. [PMID: 36010998 PMCID: PMC9406787 DOI: 10.3390/cancers14164005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/12/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
Colorectal cancer surveillance (CCS) with colonoscopy every five years is advised for PTEN Hamartoma Tumour Syndrome (PHTS) patients aged ≥40 due to an increased colorectal cancer (CRC) risk. However, data to support CCS guidelines are scarce and available CRC risks are low (0-5% at age 50) and likely overestimated. We aimed to assess the detection and yield of CCS for PHTS patients without a CRC history. A retrospective cohort study including PHTS patients aged ≥40 with CCS at a PHTS expertise centre between 2011 and 2022. Adenomas with a ≥10 mm size, (tubulo)villous histology, or high-grade dysplasia were considered advanced. During 67 follow-up years, 37 patients (median age 47 years) underwent 61 colonoscopies. CCS yielded no CRCs. Adenomas were diagnosed in 13/37 (35%) patients during 23/100 colonoscopies (95% CI: 14-36), including one advanced adenoma. Baseline adenoma detection rates were similar to follow-up and higher in patients aged above 50 (50/100, 95% CI: 24-76) vs. age 50 or below (11/100, 95% CI: 3-30; p = 0.021). The low CRC and advanced adenoma yield allow for a more personalised surveillance program. Following our findings combined with literature on CRC risk and progression, we suggest starting CCS at age 40 with variable follow-up intervals between 1 and 10 years depending on previous colonoscopy findings.
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21
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Rosas US, Pan JY, Sundaram V, Su A, Fazal M, Dinh P, Ladabaum U. Adherence to Recommendations for Repeat Surveillance After Publication of New Postpolypectomy Guidelines. GASTRO HEP ADVANCES 2022; 2:132-143. [PMID: 39130145 PMCID: PMC11307611 DOI: 10.1016/j.gastha.2022.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/19/2022] [Indexed: 08/13/2024]
Abstract
Background and Aims The 2012 and 2020 US Multi-Society Task Force postpolypectomy guidelines have recommended progressively longer surveillance intervals for patients with low-risk adenomas (LRAs). These guidelines require data from past colonoscopies. We examined the impact of the 2012 guidelines for second surveillance on clinical practice, including the availability of prior colonoscopy data, with the aim of informing the implementation of the 2020 guidelines. Methods We identified surveillance colonoscopies at Stanford Health Care and the Palo Alto Veterans Affairs Health Care System in 3 periods: preguideline (March-August 2012), postguideline (January-June 2013), and delayed postguideline (July-September 2017). We collected data on the most recent previous colonoscopy, findings at the study entry surveillance colonoscopy, and recommendations for subsequent surveillance. Results Among 977 patients, the most recent prior colonoscopy data were available in 78% of preguideline, 78% of postguideline, and 61% of delayed postguideline cases (P < .001). The fraction of surveillance colonoscopy reports that deferred recommendations awaiting pathology increased from 6% to 11% in preguideline and postguideline to 59% in delayed postguideline cases (P < .001). Overall adherence to guidelines for subsequent surveillance was similar in all 3 periods (54%-67%; P = .089). In the postguideline and delayed postguideline periods combined, a 10-year subsequent surveillance interval was recommended in 0 of 29 cases with LRA followed by normal surveillance colonoscopy. Conclusion In patients undergoing surveillance, prior colonoscopy data were not always available and recommendations were often deferred awaiting pathology. Adherence to subsequent surveillance guidelines was suboptimal, especially for LRA followed by normal colonoscopy. Strategies addressing these gaps are needed to optimize implementation of the updated 2020 postpolypectomy guidelines.
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Affiliation(s)
- Ulysses S. Rosas
- Department of Medicine, Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jennifer Y. Pan
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
- Department of Medicine, Division of Gastroenterology and Hepatology, VA Palo Alto Health Care System, Palo Alto, California
| | - Vandana Sundaram
- Department of Medicine, Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
| | - Andrew Su
- Department of Medicine, Division of Digestive Diseases, UCLA, Los Angeles, California
| | - Muhammad Fazal
- Residency Program, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Philip Dinh
- Residency Program, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Uri Ladabaum
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
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22
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Doyle JB, Krigel A, Lebwohl B. Prevalence of Adenomas on Surveillance Colonoscopies for Patients with a History of Colonic Polyps of Unknown Histology. Dig Dis Sci 2022; 67:3239-3243. [PMID: 34156591 DOI: 10.1007/s10620-021-07108-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/09/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Guidelines for surveillance colonoscopy depend on polyp histology. When patients present to a new healthcare system and report a personal history of "colon polyps," however, information on polyp histology is frequently unavailable. AIMS To assess adenoma prevalence in patients with a history of colonic polyps of unknown histology and to compare it to patients undergoing either screening colonoscopy or surveillance colonoscopy for known adenomatous polyps. METHODS This cohort study evaluated colonoscopies of patients ≥ 50 years of age over a 14-year period at a single institution. The exposure of interest was colonoscopy indication, categorized into three groups: screening colonoscopy, surveillance colonoscopy for history of colonic polyp(s) of unknown histology, and surveillance colonoscopy for history of adenoma(s). The primary outcome was adenoma detection rate. Multivariable logistic regression was used to assess the association between colonoscopy indication and adenoma detection rate. RESULTS Of 31,856 colonoscopies, the adenoma prevalence was 26.1% for patients undergoing screening colonoscopy, 32.9% for patients with a history of polyps of unknown histology, and 41.9% for patients with a history of known adenomatous polyps. Relative to screening colonoscopies, there were higher odds of adenoma detection in surveillance colonoscopies for polyps of unknown histology (aOR compared to screening 1.42, 95% CI 1.30-1.55) and even higher odds among surveillance colonoscopies for a history of adenoma (aOR compared to screening 1.89, 95% CI 1.75-2.05). CONCLUSION The adenoma prevalence on surveillance colonoscopy for patients with polyps of unknown histology was higher than that of screening colonoscopies but lower than that of surveillance colonoscopies for patients with adenomatous polyps.
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Affiliation(s)
- John B Doyle
- Department of Medicine, Columbia University Medical Center, 180 Fort Washington Avenue, Suite 936, New York, NY, 10032, USA
| | - Anna Krigel
- Department of Medicine, Columbia University Medical Center, 180 Fort Washington Avenue, Suite 936, New York, NY, 10032, USA
| | - Benjamin Lebwohl
- Department of Medicine, Columbia University Medical Center, 180 Fort Washington Avenue, Suite 936, New York, NY, 10032, USA. .,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
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23
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Zgraggen A, Stoffel ST, Barbier MC, Marbet UA. Colorectal cancer surveillance by colonoscopy in a prospective, population-based long-term Swiss screening study - outcomes, adherence, and costs. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:761-778. [PMID: 35545112 PMCID: PMC9179214 DOI: 10.1055/a-1796-2471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Background
The success of colorectal cancer (CRC) screening depends mainly on screening quality, patient adherence to surveillance, and costs. Consequently, it is essential to assess the performance over time.
Methods
In 2000, a closed cohort study on CRC screening in individuals aged 50 to 80 was initiated in Uri, Switzerland. Participants who chose to undergo colonoscopy were followed over 18 years. We investigated the adherence to recommended surveillance and collected baseline characteristics and colonoscopy data. Risk factors at screening for the development of advanced adenomas were analyzed. Costs for screening and follow-up were evaluated retrospectively.
Results
1278 subjects with a screening colonoscopy were included, of which 272 (21.3%; 69.5% men) had adenomas, and 83 (6.5%) had advanced adenomas. Only 59.8% participated in a follow-up colonoscopy, half of them within the recommended time interval. Individuals with advanced adenomas at screening had nearly five times the risk of developing advanced adenomas compared to individuals without adenomas (24.3% vs. 5.0%, OR 4.79 CI 2.30–9.95). Individuals without adenomas developed advanced adenomas in 4.9%, including four cases of CRC; three of them without control colonoscopy. The villous component in adenomas smaller than 10 mm was not an independent risk factor. Costs for screening and follow-up added up to CHF 1’934’521 per 1’000 persons screened, almost half of them for follow-up examinations; 60% of these costs accounted for low-risk individuals.
Conclusion
Our findings suggest that follow-up of screening colonoscopy should be reconsidered in Switzerland; in particular, long-term adherence is critical. Costs for follow-up could be substantially reduced by adopting less expensive long-term screening methods for low-risk individuals.
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Affiliation(s)
- Armin Zgraggen
- Kantonsspital Aarau AG, Division of Rheumatology, Aarau, Switzerland.,Division of Gastroenterology, Kantonsspital Uri, Altdorf, Switzerland
| | - Sandro Tiziano Stoffel
- Institute for Pharmaceutical Medicine, Universität Basel, Basel, Switzerland.,Research Department of Behavioural Sciences and Health, University College London, London, United Kingdom of Great Britain and Northern Ireland
| | | | - Urs Albert Marbet
- Division of Gastroenterology, Kantonsspital Uri, Altdorf, Switzerland
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24
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Kahi CJ, Myers LJ, Stump TE, Imler TD, Sherer EA, Larson J, Imperiale TF. Tailoring Surveillance Colonoscopy in Patients With Advanced Adenomas. Clin Gastroenterol Hepatol 2022; 20:847-854.e1. [PMID: 33775897 DOI: 10.1016/j.cgh.2021.03.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/06/2021] [Accepted: 03/23/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with advanced colorectal adenomas (AAs) are directed to undergo intensive surveillance. However, the benefit derived from surveillance may be outweighed by the risk of death from non-colorectal cancer (CRC) causes, leading to uncertainty on how best to individualize follow-up. The aim of this study was to derive a risk prediction model and risk index that estimate and stratify the risk for non-CRC cancer mortality (NCM) subsequent to diagnosis and removal of AA. METHODS We conducted a retrospective cohort study of veterans ≥40 years old who had colonoscopy for diagnostic or screening indications at 13 Veterans Affairs Medical Centers between 2002 and 2009 and had 1 or more AAs. The primary outcome was NCM using a fixed follow-up time period of 5 years. Logistic regression using the lasso technique was used to identify factors independently associated with NCM, and an index based on points from regression coefficients was constructed to estimate risk of 5-year NCM. RESULTS We identified 2943 veterans with AA (mean age [standard deviation] 63 [8.6] years, 98% male, 74% white), with an overall 5-year mortality of 16.7%, which was nearly all due to NCM (16.6%). Age, comorbidity burden, specific comorbid conditions, and hospitalization within the preceding year were independently associated with NCM. The risk prediction model had a goodness of fit (calibration) P value of .41 and c-statistic (discrimination) of 0.74 (95% confidence interval, 0.71-0.76). On the basis of comparable 5-year risks of NCM, the scores comprised 3 risk categories: low (score of 0-1), intermediate (score of 2-4), and high (score of ≥5), in which NCM occurred in 6.5%, 14.1%, and 33.2%, respectively. CONCLUSIONS We derived a risk prediction model that identifies veterans with advanced adenomas who are at high risk of NCM within 5 years, and who are thus unlikely to benefit from further surveillance.
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Affiliation(s)
- Charles J Kahi
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University, Indianapolis; Health Services Research & Development, Richard L. Roudebush VA Medical Center, Indianapolis; Indiana University School of Medicine, Indianapolis.
| | - Laura J Myers
- Health Services Research & Development, Richard L. Roudebush VA Medical Center, Indianapolis; Indiana University School of Medicine, Indianapolis
| | - Timothy E Stump
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis
| | | | - Eric A Sherer
- Health Services Research & Development, Richard L. Roudebush VA Medical Center, Indianapolis
| | - Jason Larson
- Health Services Research & Development, Richard L. Roudebush VA Medical Center, Indianapolis
| | - Thomas F Imperiale
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University, Indianapolis; Health Services Research & Development, Richard L. Roudebush VA Medical Center, Indianapolis; Indiana University School of Medicine, Indianapolis; The Regenstrief Institute, Indianapolis, Indiana
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25
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Ha J, Walker MJ, Myers LE, Ballard CJ, Imperiale TF. Yield and Risk Factors for Advanced Colorectal Neoplasia and Long-term Outcomes in Veterans With 3 or More Nonadvanced Adenomas. J Clin Gastroenterol 2022; 56:343-348. [PMID: 33935189 DOI: 10.1097/mcg.0000000000001553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/20/2021] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIMS Until recently, guidelines recommended a 3-year surveillance colonoscopy for persons with 3 to 10 nonadvanced adenomas (NAA). In this study, we quantify yield for metachronous advanced neoplasia (AN); attempt to identify risk factors for AN; and measure colorectal cancer (CRC) incidence and mortality. METHODS We used natural language processing to screen an existing data set for Veterans with 3 to 10 NAA. We manually reviewed colonoscopy and pathology reports to verify baseline findings and determine results of subsequent colonoscopy (sCY). Baseline features were extracted from the electronic medical record (EMR) and a national data set, CRC incidence was obtained from the Veterans Affairs cancer registry, and CRC mortality from the National Death Index through September 30, 2017. CRC incidence and mortality were compared between Veterans who did versus did not have sCY. RESULTS Natural language processing identified 3673 Veterans who potentially had 3 to 10 NAA, of which 1672 were excluded after EMR review. In the analytical cohort of 2001 subjects, 1178 (59%) had sCY at a mean (SD) follow-up of 4.3 (2.2) years. The sCY group was younger (mean age: 61 vs. 67 y; P<0.01) and were less likely to have diabetes (27% vs. 31%; P=0.02) and congestive heart failure (4% vs. 9%; P<0.01). sCY showed AN in 182 subjects (15.5%). Baseline features were no different between those with versus without metachronous AN. Subjects with sCY had a greater CRC incidence (n=7 vs. n=0; P=0.046), but there was no difference in CRC mortality (0 for both subgroups). CONCLUSIONS Among patients with 3 to 10 NAA on index colonoscopy who underwent sCY, AN was present in 15.5% at mean follow-up of 4.3 years. No risk factors for AN were identified. CRC incidence, but not CRC mortality, was higher among those with sCY.
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Affiliation(s)
| | - Megan J Walker
- Indiana University
- Roudebush VA Medical Center, Indianapolis, IN
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26
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Jodal HC, Klotz D, Herfindal M, Barua I, Tag P, Helsingen LM, Refsum E, Holme Ø, Adami HO, Bretthauer M, Kalager M, Løberg M. Long-term colorectal cancer incidence and mortality after adenoma removal in women and men. Aliment Pharmacol Ther 2022; 55:412-421. [PMID: 34716941 DOI: 10.1111/apt.16686] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/17/2021] [Accepted: 10/19/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Women and men with colorectal adenomas are at increased risk of colorectal cancer and colonoscopic surveillance is recommended. However, the long-term cancer risk remains unknown. AIMS To investigate colorectal cancer incidence and mortality after adenoma removal in women and men METHODS: We identified all individuals who had adenomas removed in Norway from 1993 to 2007, with follow-up through 2018. We calculated standardized incidence ratios (SIR) and incidence-based mortality ratios (SMR) with 95% confidence intervals (CI) for colorectal cancer in women and men using the female and male population for comparison. We defined high-risk adenomas as ≥2 adenomas, villous component, or high-grade dysplasia. RESULTS The cohort comprised 40 293 individuals. During median follow-up of 13.0 years, 1079 women (5.5%) and 866 men (4.2%) developed colorectal cancer; 328 women (1.7%) and 275 men (1.3%) died of colorectal cancer. Colorectal cancer incidence was more increased in women (SIR 1.64, 95% CI 1.54-1.74) than in men (SIR 1.12, 95% CI 1.05-1.19). Colorectal cancer mortality was increased in women (SMR 1.13, 95% CI 1.02-1.26) and reduced in men (SMR 0.79, 95% CI 0.71-0.89). Women with high-risk adenomas had an increased risk of colorectal cancer death (SMR 1.37, 95% CI 1.19-1.57); women with low-risk adenomas (SMR 0.90, 95% CI 0.76-1.07) and men with high-risk adenomas had a similar risk (SMR 0.89, 95% CI 0.76-1.04), while men with low-risk adenomas had reduced risk (SMR 0.70, 95% CI 0.59-0.84). CONCLUSIONS After adenoma removal, women had an increased risk of colorectal cancer death, while men had reduced risk, compared to the general female and male populations. Sex-specific surveillance recommendations after adenoma removal should be considered.
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Affiliation(s)
- Henriette C Jodal
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway.,Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Dagmar Klotz
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway.,Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.,Department of Pathology, Oslo University Hospital, Oslo, Norway
| | - Magnhild Herfindal
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway.,Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Ishita Barua
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway.,Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Petter Tag
- Department of Medicine, Nordland Hospital Bodø, Bodø, Norway
| | - Lise M Helsingen
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway.,Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Erle Refsum
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway.,Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Øyvind Holme
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway.,Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.,Department of Medicine, Sørlandet Hospital Kristiansand, Kristiansand, Norway
| | - Hans-Olov Adami
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway.,Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.,Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Michael Bretthauer
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway.,Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Mette Kalager
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway.,Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Magnus Løberg
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway.,Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
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27
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Jodal HC, Løberg M. Letter: towards gender-stratified colorectal cancer screening and surveillance? Authors' reply. Aliment Pharmacol Ther 2022; 55:506-507. [PMID: 35092055 DOI: 10.1111/apt.16764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Henriette C Jodal
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway.,Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Magnus Løberg
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway.,Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
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28
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Mann R, Gajendran M, Umapathy C, Perisetti A, Goyal H, Saligram S, Echavarria J. Endoscopic Management of Complex Colorectal Polyps: Current Insights and Future Trends. Front Med (Lausanne) 2022; 8:728704. [PMID: 35127735 PMCID: PMC8811151 DOI: 10.3389/fmed.2021.728704] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/27/2021] [Indexed: 12/16/2022] Open
Abstract
Most colorectal cancers arise from adenomatous polyps and sessile serrated lesions. Screening colonoscopy and therapeutic polypectomy can potentially reduce colorectal cancer burden by early detection and removal of these polyps, thus decreasing colorectal cancer incidence and mortality. Most endoscopists are skilled in detecting and removing the vast majority of polyps endoscopically during a routine colonoscopy. Polyps can be considered “complex” based on size, location, morphology, underlying scar tissue, which are not amenable to removal by conventional endoscopic polypectomy techniques. They are technically more challenging to resect and carry an increased risk of complications. Most of these polyps were used to be managed by surgical intervention in the past. Rapid advancement in endoscopic resection techniques has led to a decreasing role of surgery in managing these complex polyps. These endoscopic resection techniques do require an expert in the field and advanced equipment to perform the procedure. In this review, we discuss various advanced endoscopic techniques for the management of complex polyps.
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Affiliation(s)
- Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, CA, United States
- *Correspondence: Rupinder Mann
| | - Mahesh Gajendran
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Chandraprakash Umapathy
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Abhilash Perisetti
- Department of Gastroenterology and Hepatology, The University of Arkansas for Medical Sciences, Little Rock, AR, United States
- Interventional Oncology and Surgical Endoscopy (IOSE), Parkview Health, Fort Wayne, IN, United States
| | - Hemant Goyal
- The Wright Center for Graduate Medical Education, Scranton, PA, United States
| | - Shreyas Saligram
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Juan Echavarria
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
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29
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Helsingen LM, Kalager M. Colorectal Cancer Screening - Approach, Evidence, and Future Directions. NEJM EVIDENCE 2022; 1:EVIDra2100035. [PMID: 38319175 DOI: 10.1056/evidra2100035] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Colorectal Cancer ScreeningScreening for colorectal cancer is widespread and successful but screening programs across the globe differ in their recommendations. In this article, Helsingen and Kalager review the evidence for different approaches to colorectal cancer screening and propose a framework for the evaluation of screening programs going forward.
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Affiliation(s)
- Lise M Helsingen
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo
- Clinical Effectiveness Research Group, Oslo University Hospital, Oslo
| | - Mette Kalager
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo
- Clinical Effectiveness Research Group, Oslo University Hospital, Oslo
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30
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Post-polypectomy colonoscopy surveillance: Can we improve the diagnostic yield? GASTROENTEROLOGIA Y HEPATOLOGIA 2021; 45:474-487. [PMID: 34848307 DOI: 10.1016/j.gastrohep.2021.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/29/2021] [Accepted: 11/15/2021] [Indexed: 11/21/2022]
Abstract
Although adenomas and serrated polyps are the preneoplastic lesions of colorectal cancer, only few of them will eventually progress to cancer. This review provides a comprehensive overview of the present and future of post-polypectomy colonoscopy surveillance. Post-polypectomy surveillance guidelines have recently been updated and all share the aim towards more selective and less frequent surveillance. We have examined these current guidelines and compared the recommendations of each of them. To improve the diagnostic yield of post-polypectomy surveillance it is important to find predictors of metachronous polyps that better identify high-risk individuals of developing advanced neoplasia. For this reason, we have also conducted a literature review of the molecular biomarkers of metachronous advanced colorectal polyps. Finally, we have discussed future directions of post-polypectomy surveillance and identified possible strategies to improve the use of endoscopic resources with the COVID-19 pandemic.
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31
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Regueiro C, Almazán R, Portillo I, Besó M, Tourne-Garcia C, Rodríguez-Camacho E, Ono A, Gómez-Amorín Á, Cubiella J. Polyprev: Randomized, Multicenter, Controlled Trial Comparing Fecal Immunochemical Test with Endoscopic Surveillance after Advanced Adenoma Resection in Colorectal Cancer Screening Programs: A Study Protocol. Diagnostics (Basel) 2021; 11:diagnostics11091520. [PMID: 34573862 PMCID: PMC8465973 DOI: 10.3390/diagnostics11091520] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 08/13/2021] [Accepted: 08/17/2021] [Indexed: 01/05/2023] Open
Abstract
Colorectal cancer (CRC) screening programs have been implemented to reduce the burden of the disease. When an advanced colonic lesion is detected, clinical practice guidelines recommend endoscopic surveillance with different intervals between explorations. Endoscopic surveillance is producing a considerable increase in the number of colonoscopies, with a limited effect on the CRC incidence. Instead, participation in CRC screening programs based on the fecal immunochemical test (FIT) could be a non-inferior alternative to endoscopic surveillance to reduce 10-year CRC incidence. Based on this hypothesis, we have designed a multicenter and randomized clinical trial within the Spanish population CRC screening programs to compare FIT surveillance with endoscopic surveillance. We will include individuals aged from 50 to 65 years with complete colonoscopy and advanced lesions resected within the CRC screening programs. Patients will be randomly allocated to perform an annual FIT and colonoscopy if fecal hemoglobin concentration is ≥10 µg/g, or to perform endoscopic surveillance. On the basis of the non-superior CRC incidence, we will recruit 1894 patients in each arm. The main endpoint is 10-year CRC incidence and the secondary endpoints are diagnostic yield, participation, adverse effects, mortality and cost-effectiveness. Our results may modify the clinical practice after advanced colonic resection in CRC screening programs.
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Affiliation(s)
- Cristina Regueiro
- Department of Gastroenterology, Instituto de Investigación Sanitaria Galicia Sur, Hospital Universitario de Ourense, 32005 Ourense, Spain;
- Correspondence:
| | - Raquel Almazán
- Conselleria de Sanidade, Dirección Xeral de Saúde Pública, 15704 Galicia, Spain; (R.A.); (E.R.-C.); (Á.G.-A.)
| | - Isabel Portillo
- Osakidetza Basque Health Service, Basque Country Colorectal Cancer Screening Programme, 48009 Bilbao, Spain;
- Biocruces Health Research Institute, Cancer Biomarker Area, 48903 Barakaldo, Spain
| | - María Besó
- Servicio de Promoción de la Salud y Prevención en el Entorno Sanitario, Dirección General de Salud Pública y Adicciones, 46021 Valencia, Spain;
| | - Carlos Tourne-Garcia
- Colon and Rectal Cancer Prevention Program, Directorate General for Public Health, Autonomous Government for Health, 30008 Mucia, Spain;
| | - Elena Rodríguez-Camacho
- Conselleria de Sanidade, Dirección Xeral de Saúde Pública, 15704 Galicia, Spain; (R.A.); (E.R.-C.); (Á.G.-A.)
| | - Akiko Ono
- Department of Gastroenterology, Hospital Clínico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain;
| | - Ángel Gómez-Amorín
- Conselleria de Sanidade, Dirección Xeral de Saúde Pública, 15704 Galicia, Spain; (R.A.); (E.R.-C.); (Á.G.-A.)
| | - Joaquín Cubiella
- Department of Gastroenterology, Instituto de Investigación Sanitaria Galicia Sur, Hospital Universitario de Ourense, 32005 Ourense, Spain;
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Waldmann E, Kammerlander A, Gessl I, Penz D, Majcher B, Hinterberger A, Trauner M, Ferlitsch M. New risk stratification after colorectal polypectomy reduces burden of surveillance without increasing mortality. United European Gastroenterol J 2021; 9:947-954. [PMID: 34343405 PMCID: PMC8498405 DOI: 10.1002/ueg2.12119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/08/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The 2020 postpolypectomy surveillance guideline update of European Society for Gastrointestinal Endoscopy defines a more restrictive group of individuals in need for surveillance 3 years after colonoscopy. AIM The aim of this cohort study was to validate the new guideline recommendation. METHODS Based on a national quality assurance program, we compared the 2020 risk group definition with the previous 2013 recommendations for their strength of association with (1) colorectal cancer death, and (2) all-cause death. RESULTS A total of 265,608 screening colonoscopies were included in the study. Mean age was 61.1 years (SD ±9.0), and 50.6% were women. During a mean follow-up of 59.3 months (SD ±35.0), 170 CRC deaths and 7723 deaths of any cause were identified. 62.4% of colonoscopies were negative and 4.9% were assigned to surveillance after 3 years according to the 2020 guidelines versus 10.4% following the 2013 guidelines, which corresponds to a relative reduction in colonoscopies by 47%. The strength of association with CRC mortality was markedly higher with the 2020 surveillance group as compared to the 2013 guidelines (HR 2.56, 95% CI 1.62-4.03 vs. HR 1.73, 95% CI 1.13-2.62), while the magnitude of association with CRC mortality for low risk individuals was lower (HR 1.17, 95% CI 0.83-1.63 vs. 1.25, 95% CI 0.88-1.76). CONCLUSIONS Adherence to the updated guidelines reduces the burden of surveillance colonoscopies by 47% while preserving the efficacy of surveillance in preventing CRC mortality.
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Affiliation(s)
- Elisabeth Waldmann
- Division for Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Quality Assurance Working Group, Austrian Society for Gastroenterology and Hepatology, Austria.,Department of Biostatistics, Harvard T.H. Chand School of Public Health, Boston, Massachusetts, USA
| | - Andreas Kammerlander
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Irina Gessl
- Quality Assurance Working Group, Austrian Society for Gastroenterology and Hepatology, Austria
| | - Daniela Penz
- Division for Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Quality Assurance Working Group, Austrian Society for Gastroenterology and Hepatology, Austria
| | - Barbara Majcher
- Division for Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Quality Assurance Working Group, Austrian Society for Gastroenterology and Hepatology, Austria
| | - Anna Hinterberger
- Division for Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Quality Assurance Working Group, Austrian Society for Gastroenterology and Hepatology, Austria
| | - Michael Trauner
- Division for Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Quality Assurance Working Group, Austrian Society for Gastroenterology and Hepatology, Austria
| | - Monika Ferlitsch
- Division for Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Quality Assurance Working Group, Austrian Society for Gastroenterology and Hepatology, Austria
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33
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Bhandari P, Longcroft-Wheaton G, Libanio D, Pimentel-Nunes P, Albeniz E, Pioche M, Sidhu R, Spada C, Anderloni A, Repici A, Haidry R, Barthet M, Neumann H, Antonelli G, Testoni A, Ponchon T, Siersema PD, Fuccio L, Hassan C, Dinis-Ribeiro M. Revising the European Society of Gastrointestinal Endoscopy (ESGE) research priorities: a research progress update. Endoscopy 2021; 53:535-554. [PMID: 33822332 DOI: 10.1055/a-1397-3005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND One of the aims of the European Society of Gastrointestinal Endoscopy (ESGE) is to encourage high quality endoscopic research at a European level. In 2016, the ESGE research committee published a set of research priorities. As endoscopic research is flourishing, we aimed to review the literature and determine whether endoscopic research over the last 4 years had managed to address any of our previously published priorities. METHODS As the previously published priorities were grouped under seven different domains, a working party with at least two European experts was created for each domain to review all the priorities under that domain. A structured review form was developed to standardize the review process. The group conducted an extensive literature search relevant to each of the priorities and then graded the priorities into three categories: (1) no longer a priority (well-designed trial, incorporated in national/international guidelines or adopted in routine clinical practice); (2) remains a priority (i. e. the above criterion was not met); (3) redefine the existing priority (i. e. the priority was too vague with the research question not clearly defined). RESULTS The previous ESGE research priorities document published in 2016 had 26 research priorities under seven domains. Our review of these priorities has resulted in seven priorities being removed from the list, one priority being partially removed, another seven being redefined to make them more precise, with eleven priorities remaining unchanged. This is a reflection of a rapid surge in endoscopic research, resulting in 27 % of research questions having already been answered and another 27 % requiring redefinition. CONCLUSIONS Our extensive review process has led to the removal of seven research priorities from the previous (2016) list, leaving 19 research priorities that have been redefined to make them more precise and relevant for researchers and funding bodies to target.
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Affiliation(s)
- Pradeep Bhandari
- Department of Gastroenterology, Portsmouth University Hospital NHS Trust, Portsmouth, UK
| | | | - Diogo Libanio
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
- Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, Porto, Portugal
| | - Pedro Pimentel-Nunes
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
- Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, Porto, Portugal
| | - Eduardo Albeniz
- Gastroenterology Department, Endoscopy Unit, Complejo Hospitalario de Navarra, Navarrabiomed-UPNA-IdiSNA, Pamplona, Spain
| | - Mathieu Pioche
- Gastroenterology Division, Edouard Herriot Hospital, Lyon, France
| | - Reena Sidhu
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Cristiano Spada
- Digestive Endoscopy and Gastroenterology, Fondazione Poliambulanza, Brescia, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, Ospedale dei Castelli, Ariccia, Rome, Italy
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Digestive Endoscopy Unit, IRCSS Humanitas Research Hospital, Milan, Italy
| | - Rehan Haidry
- Department of Gastroenterology, University College London Hospitals, London, UK
| | - Marc Barthet
- Department of Gastroenterology, Hôpital Nord, Assistance publique des hôpitaux de Marseille, Marseille, France
| | - Helmut Neumann
- Department of Medicine I, University Medical Center Mainz, Mainz, Germany
- GastroZentrum Lippe, Bad Salzuflen, Germany
| | - Giulio Antonelli
- Gastroenterology and Digestive Endoscopy Unit, Ospedale dei Castelli, Ariccia, Rome, Italy
- Nuovo Regina Margherita Hospital, Rome, Italy
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Rome, Italy
| | | | - Thierry Ponchon
- Gastroenterology Division, Edouard Herriot Hospital, Lyon, France
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Mario Dinis-Ribeiro
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
- Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, Porto, Portugal
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Winawer SJ, Zauber AG, O’Brien MJ, Geenen J, Waye JD. The National Polyp Study at 40: challenges then and now. Gastrointest Endosc 2021; 93:720-726. [PMID: 33010298 PMCID: PMC7887080 DOI: 10.1016/j.gie.2020.09.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 09/25/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Sidney J. Winawer
- Gastroenterology, Hepatology and Nutrition Service,
Department of Medicine, Memorial Sloan Kettering Cancer Center
| | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial
Sloan Kettering Cancer
| | - Michael J. O’Brien
- Department of Laboratory Pathology, Boston University
School of Medicine
| | - Joseph Geenen
- Department of Medicine, Medical College of Wisconsin
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35
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Wieszczy P, Waldmann E, Løberg M, Regula J, Rupinski M, Bugajski M, Gray K, Kalager M, Ferlitsch M, Kaminski MF, Bretthauer M. Colonoscopist Performance and Colorectal Cancer Risk After Adenoma Removal to Stratify Surveillance: Two Nationwide Observational Studies. Gastroenterology 2021; 160:1067-1074.e6. [PMID: 33065063 DOI: 10.1053/j.gastro.2020.10.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 10/04/2020] [Accepted: 10/07/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND AIMS Colonoscopy surveillance after adenoma removal is an increasing burden in many countries. Surveillance recommendations consider characteristics of removed adenomas, but not colonoscopist performance. We investigated the impact of colonoscopist performance on colorectal cancer risk after adenoma removal. METHODS We compared colorectal cancer risk after removal of high-risk adenomas, low-risk adenomas, and after negative colonoscopy for all colonoscopies performed by colonoscopists with low vs high performance quality (adenoma detection rate <20% vs ≥20%) in the Polish screening program between 2000 and 2011, with follow-up until 2017. Findings were validated in the Austrian colonoscopy screening program. RESULTS A total of 173,288 Polish colonoscopies were included in the study. Of 262 colonoscopists, 160 (61.1%) were low performers, and 102 (38.9%) were high performers; 11.1% of individuals had low-risk and 6.6% had high-risk adenomas removed at screening; 82.2% had no adenomas. During 10 years of follow-up, 443 colorectal cancers were diagnosed. For low-risk adenoma individuals, colorectal cancer incidence was 0.55% (95% confidence interval [CI] 0.40-0.75) with low-performing colonoscopists vs 0.22% (95% CI 0.14-0.34) with high-performing colonoscopists (hazard ratio [HR] 2.35; 95% CI 1.31-4.21; P = .004). For individuals with high-risk adenomas, colorectal cancer incidence was 1.14% (95% CI 0.87-1.48) with low-performing colonoscopists vs 0.43% (95% CI 0.27-0.69) with high-performing colonoscopists (HR 2.69; 95% CI 1.62-4.47; P < .001). After negative colonoscopy, colorectal cancer incidence was 0.30% (95% CI 0.27-0.34) for individuals examined by low-performing colonoscopists, vs 0.15% (95% CI 0.11-0.20) for high-performing (HR 2.10; 95% CI 1.52-2.91; P < .001). The observed trends were reproduced in the Austrian validation cohort. CONCLUSIONS Our results suggest that endoscopist performance may be an important contributor in addition to polyp characteristics in determining colorectal cancer risk after colonoscopy screening.
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Affiliation(s)
- Paulina Wieszczy
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland; Department of Oncological Gastroenterology and Department of Cancer Prevention, the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland; Department of Transplantation Medicine Oslo University Hospital, Oslo, Norway
| | - Elisabeth Waldmann
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria; Quality Assurance Working Group of the Austrian Society for Gastroenterology and Hepatology, Vienna, Austria; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Frontier Science Foundation, Boston, Brookline, Massachusetts
| | - Magnus Løberg
- Department of Transplantation Medicine Oslo University Hospital, Oslo, Norway; Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Jaroslaw Regula
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland; Department of Oncological Gastroenterology and Department of Cancer Prevention, the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
| | - Maciej Rupinski
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland; Department of Oncological Gastroenterology and Department of Cancer Prevention, the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
| | - Marek Bugajski
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland; Department of Oncological Gastroenterology and Department of Cancer Prevention, the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
| | - Kathryn Gray
- Frontier Science Foundation, Boston, Brookline, Massachusetts
| | - Mette Kalager
- Department of Transplantation Medicine Oslo University Hospital, Oslo, Norway; Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Monika Ferlitsch
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria; Quality Assurance Working Group of the Austrian Society for Gastroenterology and Hepatology, Vienna, Austria
| | - Michal F Kaminski
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland; Department of Oncological Gastroenterology and Department of Cancer Prevention, the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland; Department of Transplantation Medicine Oslo University Hospital, Oslo, Norway; Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Michael Bretthauer
- Department of Transplantation Medicine Oslo University Hospital, Oslo, Norway; Frontier Science Foundation, Boston, Brookline, Massachusetts; Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway.
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36
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Schauer C, Plant A, Vandal AC, Claydon A. Outcomes Of Patients with Delayed Surveillance Colonoscopy. Intern Med J 2020; 52:1061-1069. [PMID: 33280217 DOI: 10.1111/imj.15146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 11/11/2020] [Accepted: 12/01/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Surveillance colonoscopy has been shown to be an effective tool for prevention of CRC in high-risk populations, if adhered to. We aimed to discover the sequelae of late surveillance in a cohort of patient's overdue for colonoscopy, in particular the development of colorectal cancer (CRC) or advanced adenoma (AA) within surveillance subgroups. METHOD We conducted a retrospective cohort study on all patients from the Bay of Plenty District Health Board region, New Zealand, placed on the colonoscopy surveillance waitlist from 2006 onwards who had their procedure completed between 1 November 2016 and 31 January 2018, when the total surveillance list was declared up-to-date. Patients with overdue surveillance, defined as done later than 90 days after the recommended due date were compared to patients who were done either early, or on time. RESULTS 786 patients were recorded as overdue for surveillance colonoscopy, and 386 were completed early or on time. The median time overdue was 22 months. Three cases (0.4%) of CRC were found in overdue patients compared to 4 cases (1%) for those done on time (adjusted p=0.24). There were 86 (11%) AA in patient's overdue compared to 27 (7%) in those not overdue (odds ratio (OR) 1.6, 95% confidence interval (CI) [1.0,2.5], p=0.04). Overdue status increased the expected risk of AA by approximately 60% (adjusted; 95% CI [1%,253%], p=0.04) or 19% per year overdue (95% CI [7%,32%], p=0.002). Surveillance of 248 low-risk post-polypectomy patients demonstrated 26/211 with AA in overdue patients compared to 2/37 (12.3% vs 5.4%, unadjusted p=0.23) for those done on time. Surveillance of 180 high-risk post-polypectomy patients identified 2 CRC's and 8/43 AA in those overdue, as compared to no CRC and 9/137 AA (18.6% vs 6.6%, OR 1.79 (95% CI [1.07,2.0], unadjusted p=0.03) in those done on time. CONCLUSION Whilst overdue surveillance is not predictive of increased CRC, it is associated with an increase in expected number of AA, particularly in patients having surveillance for previous high-risk polypectomy. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | - A Plant
- Gastroenterology Department, Tauranga Hospital, Bay of Plenty, District Health Board, Tauranga, New Zealand
| | - A C Vandal
- Ko Awatea, Counties Manukau District Health Board; Associate Professor, Faculty of Health and Environmental Sciences, Auckland University
| | - A Claydon
- Gastroenterology Department, Tauranga Hospital, Bay of Plenty, District Health Board, Tauranga, New Zealand
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37
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Lieberman D. Does Colon Surveillance After Polypectomy Prevent Colon Cancer and Save Lives? Clin Gastroenterol Hepatol 2020; 18:2876-2878. [PMID: 32289542 DOI: 10.1016/j.cgh.2020.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/03/2020] [Indexed: 02/07/2023]
Affiliation(s)
- David Lieberman
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon
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Pinsky PF, Schoen RE. Contribution of Surveillance Colonoscopy to Colorectal Cancer Prevention. Clin Gastroenterol Hepatol 2020; 18:2937-2944.e1. [PMID: 32017987 PMCID: PMC7549191 DOI: 10.1016/j.cgh.2020.01.037] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 01/16/2020] [Accepted: 01/24/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The contribution of surveillance colonoscopy, as opposed to that of initial colonoscopy examination, to prevention of colorectal cancer (CRC) is uncertain. We estimated the preventive effect of surveillance colonoscopy by applying the recently developed metric of adenoma dwell time avoided needed to prevent 1 CRC case (DTA). METHODS We followed subjects in the prostate, lung, colorectal and ovarian (PLCO) cancer screening trial who underwent colonoscopies following positive findings from sigmoidoscopies (colonoscopy cohort, n = 15,935) for CRC incidence for 10 years. The number and timing of adenomas removed during surveillance were measured in a subset (n = 3492) of patients and extrapolated to the entire cohort to estimate the total avoided adenoma dwell time. A previously determined DTA value of 612 dwell years was applied to estimate the number of CRC cases prevented by surveillance. Proportional reduction in CRC was computed as CP/(CO+CP), where CO and CP are observed and estimated prevented cases, respectively. RESULTS In the colonoscopy cohort of the PLCO, 2882 subjects had advanced adenomas (AAs), 572 had 3 or more non-advanced adenomas (NAA3+), 4496 had 1-2 non-advanced adenomas (NAA1-2), and 7985 had no adenoma (NA). The mean number of subsequent colonoscopy examinations over 10 years were 1.80 for subjects with AAs, 1.63 for subjects with NAA3+, and 1.46 for subjects with NAA1-2. Average years of avoided adenoma dwell time per subject were 4.0 for subjects with AAs, 5.5 for subjects with NAA3+, and 2.4 for subjects with NAA1-2. There were 56 cases of CRC in subjects with AAs, 4 cases of CRC in subjects with NAA3+, and 33 cases of CRC in subjects with NAA1-2. Estimated proportional reductions in CRC incidence were 25.0% in subjects with AAs (95% CI, 16%-34%), 34.4% in subjects with NAA1-2 (95% CI, 25%-40%), and 30.4% overall (in subjects with AAs, NAA3+, or NAA1-2; 95% CI, 25%-40%). Absolute CRC incidence reductions were 7.1 per 10,000 PY in subjects with AAs and 4.1 per 10,000 PY in subjects with NAA1-2. CONCLUSIONS Using the recently developed metric of DTA, we estimated that surveillance colonoscopy in the PLCO colonoscopy cohort during 10 years of follow up prevented 30% of CRC cases. Because the methodology for estimation is indirect, the true effect is uncertain.
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Affiliation(s)
- Paul F. Pinsky
- Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Robert E. Schoen
- Division of Gastroenterology, Hepatology and Nutrition, Departments of Medicine and Epidemiology, University of Pittsburgh, Pittsburgh, PA
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Djinbachian R, Iratni R, Durand M, Marques P, von Renteln D. Rates of Incomplete Resection of 1- to 20-mm Colorectal Polyps: A Systematic Review and Meta-Analysis. Gastroenterology 2020; 159:904-914.e12. [PMID: 32437747 DOI: 10.1053/j.gastro.2020.05.018] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 04/29/2020] [Accepted: 05/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Incomplete resection of neoplastic colorectal polyps can result in postcolonoscopy colorectal cancer. We performed a systematic review and meta-analysis to determine the incomplete resection rate (IRR) of colorectal polyps and associated factors. METHODS We searched MEDLINE, EMBASE, EBM Reviews, and CINAHL to identify full-text articles that reported IRRs of polyps 1 to 20 mm, published until March 2019. Exclusion criteria were studies of inflammatory bowel disease cohorts, referrals for difficult polypectomy, polyp sizes larger than 20 mm, and endoscopic submucosal resection and/or dissection as polypectomy approaches. IRRs were calculated based on findings from biopsies taken at polypectomy sites or assessments of margins of resected polyps. The primary outcome was IRR for snare removal of polyps 1 to 20 mm. Secondary outcomes included IRR for polyps 1 to 10 mm and 10 to 20 mm, IRR for hot and cold snare removal of polyps 1 to 10 mm and 10 to 20 mm, IRR of snare removal with or without submucosal injection, and IRR for forceps and cold snare removal of polyps 1 to 5 mm. RESULTS We identified 6148 reports and used 32 studies, with a total of 9282 polyps, in our quantitative analysis. The IRR for snare removal of polyps 1 to 20 mm was 13.8% (95% confidence interval [CI] 10.3-17.3; 13 studies, 5128 polypectomies). IRRs were 15.9% for snare removal of polyps 1 to 10 mm (95% CI 9.6-22.1; 9 studies, 2531 polypectomies) and 20.8% for snare removal of polyps 10 to 20 mm (95% CI 12.9-28.8; 6 studies, 412 polypectomies). The IRR for hot snare removal of polyps 1 to 10 mm was 14.2% (95% CI 5.2-23.2) vs 17.3% for cold snare polypectomy (95% CI 14.3‒20.3). The IRR for forceps removal of polyps 1 to 5 mm was 9.9% (95% CI 7.1-13.0) vs 4.4% for snare polypectomy (95% CI 2.9-6.1). CONCLUSIONS In a systematic review and meta-analysis, we found that colorectal polyps 1 to 20 mm are frequently incompletely resected, and that risk increases for polyps 10 mm or larger. There is no difference in IRRs of cold vs hot snares for polyps 1 to 10 mm. Snare polypectomy should be used over forceps for polyps 1 to 5 mm.
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Affiliation(s)
- Roupen Djinbachian
- Division of Internal Medicine, Montreal University Hospital Center (CHUM), Montreal, Canada; Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Ryma Iratni
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada; Faculty of Medicine, University of Montreal, Montreal, Canada
| | - Madeleine Durand
- Division of Internal Medicine, Montreal University Hospital Center (CHUM), Montreal, Canada; Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Paola Marques
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada; Bahia State University (UNEB), Salvador, Brazil
| | - Daniel von Renteln
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada; Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada.
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Meester RGS, van Herk MMAGC, Lansdorp-Vogelaar I, Ladabaum U. Prevalence and Clinical Features of Sessile Serrated Polyps: A Systematic Review. Gastroenterology 2020; 159:105-118.e25. [PMID: 32199884 PMCID: PMC8653879 DOI: 10.1053/j.gastro.2020.03.025] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 02/24/2020] [Accepted: 03/09/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Sessile serrated polyps (SSPs) could account for a substantial proportion of colorectal cancers. We aimed to increase clarity on SSP prevalence and clinical features. METHODS We performed a systematic review of MEDLINE, Web of Science, Embase, and Cochrane databases for original studies published in English since 2000. We included studies of different populations (United States general or similar), interventions (colonoscopy, autopsy), comparisons (world regions, alternative polyp definitions, adenoma), outcomes (prevalence, clinical features), and study designs (cross-sectional). Random-effects regression was used for meta-analysis where possible. RESULTS We identified 74 relevant colonoscopy studies. SSP prevalence varied by world region, from 2.6% in Asia (95% confidence interval [CI], 0-5.9) to 10.5% in Australia (95% CI, 2.8-18.2). Prevalence values did not differ significantly between the United States and Europe (P = .51); the pooled prevalence was 4.6% (95% CI, 3.4-5.8), and SSPs accounted for 9.4% of polyps with malignant potential (95% CI, 6.6-12.3). The mean prevalence was higher when assessed through high-performance examinations (9.1%; 95% CI, 4.0-14.2; P = .04) and with an alternative definition of clinically relevant serrated polyps (12.3%; 95% CI, 9.3-15.4; P < .001). Increases in prevalence with age were not statistically significant, and prevalence did not differ significantly by sex. Compared with adenomas, a higher proportion of SSPs were solitary (69.0%; 95% CI, 45.9-92.1; P = .08), with diameters of 10 mm or more (19.3%; 95% CI, 12.4-26.2; P = .13) and were proximal (71.5%; 95% CI, 63.5-79.5; P = .008). The mean ages for detection of SSP without dysplasia, with any or low-grade dysplasia, and with high-grade dysplasia were 60.8 years, 65.6 years, and 70.2 years, respectively. The range for proportions of SSPs with dysplasia was 3.7%-42.9% across studies, possibly reflecting different study populations. CONCLUSIONS In a systematic review, we found that SSPs are relatively uncommon compared with adenoma. More research is needed on appropriate diagnostic criteria, variations in detection, and long-term risk.
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Affiliation(s)
- Reinier G S Meester
- Department of Medicine, Stanford University, Stanford, California; Department of Public Health, Erasmus Medical Center University Medical Center, Rotterdam, The Netherlands.
| | - Marinika M A G C van Herk
- Department of Public Health, Erasmus Medical Center University Medical Center, Rotterdam, The Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus Medical Center University Medical Center, Rotterdam, The Netherlands
| | - Uri Ladabaum
- Department of Medicine, Stanford University, Stanford, California
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41
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Affiliation(s)
- Emma C Robbins
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, London, UK
| | - Kate Wooldrage
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, London, UK
| | - Amanda J Cross
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, London, UK
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Rutter MD, Bretthauer M, Hassan C, Jover R. Principles for Evaluation of Surveillance After Removal of Colorectal Polyps: Recommendations From the World Endoscopy Organization. Gastroenterology 2020; 158:1529-1533.e4. [PMID: 32240700 DOI: 10.1053/j.gastro.2019.12.052] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 12/26/2019] [Accepted: 12/31/2019] [Indexed: 12/25/2022]
Affiliation(s)
- Matthew D Rutter
- University Hospital of North Tees, Stockton on Tees, UK and, Northern Institute for Cancer Research, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | | | | | - Rodrigo Jover
- Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria ISABIAL, Alicante, Spain
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43
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Lee JK, Jensen CD, Levin TR, Doubeni CA, Zauber AG, Chubak J, Kamineni AS, Schottinger JE, Ghai NR, Udaltsova N, Zhao WK, Fireman BH, Quesenberry CP, Orav EJ, Skinner CS, Halm EA, Corley DA. Long-term Risk of Colorectal Cancer and Related Death After Adenoma Removal in a Large, Community-based Population. Gastroenterology 2020; 158:884-894.e5. [PMID: 31589872 PMCID: PMC7083250 DOI: 10.1053/j.gastro.2019.09.039] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/12/2019] [Accepted: 09/24/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS The long-term risks of colorectal cancer (CRC) and CRC-related death following adenoma removal are uncertain. Data are needed to inform evidence-based surveillance guidelines, which vary in follow-up recommendations for some polyp types. Using data from a large, community-based integrated health care setting, we examined the risks of CRC and related death by baseline colonoscopy adenoma findings. METHODS Participants at 21 medical centers underwent baseline colonoscopies from 2004 through 2010; findings were categorized as no-adenoma, low-risk adenoma, or high-risk adenoma. Participants were followed until the earliest of CRC diagnosis, death, health plan disenrollment, or December 31, 2017. Risks of CRC and related deaths among the high- and low-risk adenoma groups were compared with the no-adenoma group using Cox regression adjusting for confounders. RESULTS Among 186,046 patients, 64,422 met eligibility criteria (54.3% female; mean age, 61.6 ± 7.1 years; median follow-up time, 8.1 years from the baseline colonoscopy). Compared with the no-adenoma group (45,881 patients), the high-risk adenoma group (7563 patients) had a higher risk of CRC (hazard ratio [HR] 2.61; 95% confidence interval [CI] 1.87-3.63) and related death (HR 3.94; 95% CI 1.90-6.56), whereas the low-risk adenoma group (10,978 patients) did not have a significant increase in risk of CRC (HR 1.29; 95% CI 0.89-1.88) or related death (HR 0.65; 95% CI 0.19-2.18). CONCLUSIONS With up to 14 years of follow-up, high-risk adenomas were associated with an increased risk of CRC and related death, supporting early colonoscopy surveillance. Low-risk adenomas were not associated with a significantly increased risk of CRC or related deaths. These results can inform current surveillance guidelines for high- and low-risk adenomas.
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Affiliation(s)
- Jeffrey K. Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco, San Francisco, CA,Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Theodore R. Levin
- Division of Research, Kaiser Permanente Northern California, Oakland, CA.,Department of Gastroenterology, Kaiser Permanente Walnut Creek, Walnut Creek, CA
| | - Chyke A. Doubeni
- Department of Family Medicine, and the Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, MN
| | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington,Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington
| | - Aruna S. Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Joanne E. Schottinger
- Department of Quality and Clinical Analysis, Kaiser Permanente Southern California, Pasadena, CA
| | - Nirupa R. Ghai
- Department of Regional Clinical Effectiveness, Kaiser Permanente Southern California, Pasadena, CA
| | - Natalia Udaltsova
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Wei K. Zhao
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Bruce H. Fireman
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - E. John Orav
- Department of Biostatistics, Harvard University T.H. Chan School of Public Health, Boston, MA
| | - Celette Sugg Skinner
- Department of Population and Data Sciences and the Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ethan A. Halm
- Department of Population and Data Sciences and the Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Douglas A. Corley
- Department of Gastroenterology, Kaiser Permanente San Francisco, San Francisco, CA,Division of Research, Kaiser Permanente Northern California, Oakland, CA
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Gupta S, Lieberman D, Anderson JC, Burke CA, Dominitz JA, Kaltenbach T, Robertson DJ, Shaukat A, Syngal S, Rex DK. Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc 2020; 91:463-485.e5. [PMID: 32044106 PMCID: PMC7389642 DOI: 10.1016/j.gie.2020.01.014] [Citation(s) in RCA: 202] [Impact Index Per Article: 40.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Samir Gupta
- Veterans Affairs San Diego Healthcare System, San Diego, California; University of California-San Diego, Division of Gastroenterology La Jolla, California; Moores Cancer Center, La Jolla, California.
| | - David Lieberman
- Division of Gastroenterology, Department of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Joseph C Anderson
- Veterans Affairs Medical Center, White River Junction, Vermont; The Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; University of Connecticut Health Center, Farmington, Connecticut
| | - Carol A Burke
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - Jason A Dominitz
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | - Tonya Kaltenbach
- San Francisco Veterans Affairs Medical Center, San Francisco, California; University of California San Francisco, San Francisco, California
| | - Douglas J Robertson
- Veterans Affairs Medical Center, White River Junction, Vermont; The Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Aasma Shaukat
- Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota; University of Minnesota, Minneapolis, Minnesota
| | - Sapna Syngal
- Division of Gastroenterology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Cancer Genetics and Prevention, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Douglas K Rex
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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He X, Hang D, Wu K, Nayor J, Drew DA, Giovannucci EL, Ogino S, Chan AT, Song M. Long-term Risk of Colorectal Cancer After Removal of Conventional Adenomas and Serrated Polyps. Gastroenterology 2020; 158:852-861.e4. [PMID: 31302144 PMCID: PMC6954345 DOI: 10.1053/j.gastro.2019.06.039] [Citation(s) in RCA: 161] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/18/2019] [Accepted: 06/25/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic screening reduces incidence and mortality of colorectal cancer (CRC) because precursor lesions, such as conventional adenomas or serrated polyps, are removed. Individuals with polypectomies are advised to undergo colonoscopy surveillance to prevent CRC. However, guidelines for surveillance intervals after diagnosis of a precursor lesion, particularly for individuals with serrated polyps, vary widely, and lack sufficient supporting evidence. Consequently, some high-risk patients do not receive enough surveillance and lower-risk subjects receive excessive surveillance. METHODS We examined the association between findings from first endoscopy and CRC risk among 122,899 participants who underwent flexible sigmoidoscopy or colonoscopy in the Nurses' Health Study 1 (1990-2012), Nurses' Health Study 2 (1989-2013), or the Health Professionals Follow-up Study (1990-2012). Endoscopic findings were categorized as no polyp, conventional adenoma, or serrated polyp (hyperplastic polyp, traditional serrated adenoma, or sessile serrated adenoma, with or without cytological dysplasia). Conventional adenomas were classified as advanced (≥10 mm, high-grade dysplasia, or tubulovillous or villous histology) or nonadvanced, and serrated polyps were assigned to categories of large (≥10 mm) or small (<10 mm). We used a Cox proportional hazards regression model to calculate the hazard ratios (HRs) of CRC incidence, after adjusting for various potential risk factors. RESULTS After a median follow-up period of 10 years, we documented 491 incident cases of CRC: 51 occurred in 6161 participants with conventional adenomas, 24 in 5918 participants with serrated polyps, and 427 in 112,107 participants with no polyp. Compared with participants with no polyp detected during initial endoscopy, the multivariable HR for incident CRC in individuals with an advanced adenoma was 4.07 (95% confidence interval [CI] 2.89-5.72) and the HR for CRC in individuals with a large serrated polyp was 3.35 (95% CI 1.37-8.15). In contrast, there was no significant increase in risk of CRC in patients with nonadvanced adenomas (HR 1.21; 95% CI 0.68-2.16, P = .52) or small serrated polyps (HR 1.25; 95% CI 0.76-2.08; P = .38). CONCLUSIONS These findings provide support for guidelines that recommend repeat lower endoscopy within 3 years of a diagnosis of advanced adenoma and large serrated polyps. In contrast, patients with nonadvanced adenoma or small serrated polyps may not require more intensive surveillance than patients without polyps.
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Affiliation(s)
- Xiaosheng He
- Department of Colorectal Surgery, the Six Affiliated Hospital, Sun Yat-sen University, Guangzhou, P.R. China; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Dong Hang
- Department of Epidemiology and Biostatistics, Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China; Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Kana Wu
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jennifer Nayor
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts
| | - David A Drew
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Edward L Giovannucci
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Shuji Ogino
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Oncologic Pathology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts; Program in MPE Molecular Pathological Epidemiology, Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Andrew T Chan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Broad Institute of MIT and Harvard, Cambridge, Massachusetts; Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Mingyang Song
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
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46
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Affiliation(s)
- Linda Rabeneck
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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47
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Gupta S, Lieberman D, Anderson JC, Burke CA, Dominitz JA, Kaltenbach T, Robertson DJ, Shaukat A, Syngal S, Rex DK. Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2020; 115:415-434. [PMID: 32039982 PMCID: PMC7393611 DOI: 10.14309/ajg.0000000000000544] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Samir Gupta
- Veterans Affairs San Diego Healthcare System, San Diego, California
- University of California-San Diego, Division of Gastroenterology La Jolla, California
- Moores Cancer Center, La Jolla, California
| | - David Lieberman
- Division of Gastroenterology, Department of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Joseph C. Anderson
- Veterans Affairs Medical Center, White River Junction, Vermont
- The Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- University of Connecticut Health Center, Farmington, Connecticut
| | - Carol A. Burke
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - Jason A. Dominitz
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- University of Washington School of Medicine, Seattle, Washington
| | - Tonya Kaltenbach
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- University of California San Francisco, San Francisco, California
| | - Douglas J. Robertson
- Veterans Affairs Medical Center, White River Junction, Vermont
- The Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Aasma Shaukat
- Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota
- University of Minnesota, Minneapolis, Minnesota
| | - Sapna Syngal
- Division of Gastroenterology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Cancer Genetics and Prevention, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Douglas K. Rex
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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48
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Gupta S, Lieberman D, Anderson JC, Burke CA, Dominitz JA, Kaltenbach T, Robertson DJ, Shaukat A, Syngal S, Rex DK. Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2020; 158:1131-1153.e5. [PMID: 32044092 PMCID: PMC7672705 DOI: 10.1053/j.gastro.2019.10.026] [Citation(s) in RCA: 263] [Impact Index Per Article: 52.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Samir Gupta
- Veterans Affairs San Diego Healthcare System, San Diego, California; University of California-San Diego, Division of Gastroenterology La Jolla, California; Moores Cancer Center, La Jolla, California.
| | - David Lieberman
- Division of Gastroenterology, Department of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Joseph C Anderson
- Veterans Affairs Medical Center, White River Junction, Vermont; The Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; University of Connecticut Health Center, Farmington, Connecticut
| | - Carol A Burke
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - Jason A Dominitz
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | - Tonya Kaltenbach
- San Francisco Veterans Affairs Medical Center, San Francisco, California; University of California San Francisco, San Francisco, California
| | - Douglas J Robertson
- Veterans Affairs Medical Center, White River Junction, Vermont; The Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Aasma Shaukat
- Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota; University of Minnesota, Minneapolis, Minnesota
| | - Sapna Syngal
- Division of Gastroenterology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Cancer Genetics and Prevention, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Douglas K Rex
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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Lieberman D, Sullivan BA, Hauser ER, Qin X, Musselwhite LW, O'Leary MC, Redding TS, Madison AN, Bullard AJ, Thomas R, Sims KJ, Williams CD, Hyslop T, Weiss D, Gupta S, Gellad ZF, Robertson DJ, Provenzale D. Baseline Colonoscopy Findings Associated With 10-Year Outcomes in a Screening Cohort Undergoing Colonoscopy Surveillance. Gastroenterology 2020; 158:862-874.e8. [PMID: 31376388 DOI: 10.1053/j.gastro.2019.07.052] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 07/25/2019] [Accepted: 07/29/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Few studies have evaluated long-term outcomes of ongoing colonoscopic screening and surveillance in a screening population. We aimed to determine the 10-year risk for advanced neoplasia (defined as adenomas ≥10mm, adenomas with villous histology or high-grade dysplasia, or colorectal cancer [CRC]) and assessed whether baseline colonoscopy findings were associated with long-term outcomes. METHODS We collected data from the Department of Veterans Affairs Cooperative Studies Program Study on 3121 asymptomatic veterans (50-75 years old) who underwent a screening colonoscopy from 1994 through 1997 at 13 medical centers and were then followed for 10 years or until death. We included 1915 subjects with at least 1 surveillance colonoscopy and estimated cumulative incidence of advanced neoplasia by Kaplan-Meier curves. We then fit a longitudinal joint model to estimate risk of advanced neoplasia at each subsequent examination after baseline, adjusting for multiple colonoscopies within individuals. RESULTS Through 10 years of follow-up, there were 146 individuals among all baseline colonoscopy groups found to have at least 1 incident advanced neoplasia. The cumulative 10-year incidence of advanced neoplasia was highest among those with baseline CRC (43.7%; 95% CI 13.0%-74.4%), followed by those with baseline advanced adenoma (AA) (21.9%; 95% CI 15.7-28.1). The cumulative 10-year incidence of advanced neoplasia was 6.3% (95% CI 4.1%-8.5%) and 4.1% (95% CI 2.7%-5.4%) for baseline 1 to 2 small adenomas (<1cm, and without villous histology or high-grade dysplasia) and no neoplasia, respectively (log-rank P = .10). After adjusting for prior surveillance, the risk of advanced neoplasia at each subsequent examination was not significantly increased in veterans with 1 or 2 small adenomas at baseline (odds ratio 0.96; 95% CI 0.67-1.41) compared with veterans with no baseline neoplasia. CONCLUSIONS Baseline screening colonoscopy findings associate with advanced neoplasia within 10 years. Individuals with only 1 or 2 small adenomas at baseline have a low risk of advanced neoplasia over 10 years. Alternative surveillance strategies, could be considered for these individuals.
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Affiliation(s)
- David Lieberman
- VA Portland Health Care System, Portland, Oregon; Oregon Health & Science University, Portland, Oregon
| | - Brian A Sullivan
- Cooperative Studies Program Epidemiology Center, Durham VA Health Care System, Durham, North Carolina; Duke University, Durham, North Carolina
| | - Elizabeth R Hauser
- Cooperative Studies Program Epidemiology Center, Durham VA Health Care System, Durham, North Carolina; Duke University, Durham, North Carolina
| | - Xuejun Qin
- Cooperative Studies Program Epidemiology Center, Durham VA Health Care System, Durham, North Carolina; Duke University, Durham, North Carolina
| | - Laura W Musselwhite
- Cooperative Studies Program Epidemiology Center, Durham VA Health Care System, Durham, North Carolina; Duke University, Durham, North Carolina
| | - Meghan C O'Leary
- Cooperative Studies Program Epidemiology Center, Durham VA Health Care System, Durham, North Carolina
| | - Thomas S Redding
- Cooperative Studies Program Epidemiology Center, Durham VA Health Care System, Durham, North Carolina
| | - Ashton N Madison
- Cooperative Studies Program Epidemiology Center, Durham VA Health Care System, Durham, North Carolina
| | - A Jasmine Bullard
- Cooperative Studies Program Epidemiology Center, Durham VA Health Care System, Durham, North Carolina
| | - Reana Thomas
- Cooperative Studies Program Epidemiology Center, Durham VA Health Care System, Durham, North Carolina
| | - Kellie J Sims
- Cooperative Studies Program Epidemiology Center, Durham VA Health Care System, Durham, North Carolina
| | - Christina D Williams
- Cooperative Studies Program Epidemiology Center, Durham VA Health Care System, Durham, North Carolina; Duke University, Durham, North Carolina
| | - Terry Hyslop
- Cooperative Studies Program Epidemiology Center, Durham VA Health Care System, Durham, North Carolina; Duke University, Durham, North Carolina
| | - David Weiss
- Perry Point Cooperative Studies Program Coordinating Center, VA Maryland Health Care System, Perry Point, Maryland
| | - Samir Gupta
- San Diego VA Medical Center, San Diego, California; University of California San Diego, San Diego, California
| | - Ziad F Gellad
- Cooperative Studies Program Epidemiology Center, Durham VA Health Care System, Durham, North Carolina; Duke University, Durham, North Carolina
| | - Douglas J Robertson
- White River Junction VA Medical Center, White River Junction, Vermont; Dartmouth Geisel School of Medicine, Hanover, New Hampshire
| | - Dawn Provenzale
- Cooperative Studies Program Epidemiology Center, Durham VA Health Care System, Durham, North Carolina; Duke University, Durham, North Carolina.
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Wieszczy P, Kaminski MF, Franczyk R, Loberg M, Kobiela J, Rupinska M, Kocot B, Rupinski M, Holme O, Wojciechowska U, Didkowska J, Ransohoff D, Bretthauer M, Kalager M, Regula J. Colorectal Cancer Incidence and Mortality After Removal of Adenomas During Screening Colonoscopies. Gastroenterology 2020; 158:875-883.e5. [PMID: 31563625 DOI: 10.1053/j.gastro.2019.09.011] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 09/16/2019] [Accepted: 09/19/2019] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Paulina Wieszczy
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland; Department of Oncological Gastroenterology and Department of Cancer Prevention, the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland; Frontier Science Foundation, Boston, Massachusetts.
| | - Michal F Kaminski
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland; Department of Oncological Gastroenterology and Department of Cancer Prevention, the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland; Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo and Department of Transplantation Medicine Oslo University Hospital, Oslo, Norway
| | - Robert Franczyk
- Department of Oncological Gastroenterology and Department of Cancer Prevention, the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland; Department of Descriptive and Clinical Anatomy, Center of Biostructure Research, Medical University of Warsaw, Poland
| | - Magnus Loberg
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo and Department of Transplantation Medicine Oslo University Hospital, Oslo, Norway; Department of Transplantation Medicine and K. G. Jebsen Center for Colorectal Cancer Research, Oslo University Hospital, Oslo, Norway
| | - Jarek Kobiela
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Gdansk, Poland
| | - Maria Rupinska
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland; Department of Oncological Gastroenterology and Department of Cancer Prevention, the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
| | - Bartlomiej Kocot
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Maciej Rupinski
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland; Department of Oncological Gastroenterology and Department of Cancer Prevention, the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
| | - Oyvind Holme
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo and Department of Transplantation Medicine Oslo University Hospital, Oslo, Norway; Department of Medicine, Sorlandet Hospital Kristiansand, Kristiansand, Norway
| | - Urszula Wojciechowska
- National Cancer Registry of Poland, the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
| | - Joanna Didkowska
- National Cancer Registry of Poland, the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
| | - David Ransohoff
- Departments of Medicine and Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michael Bretthauer
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo and Department of Transplantation Medicine Oslo University Hospital, Oslo, Norway; Department of Transplantation Medicine and K. G. Jebsen Center for Colorectal Cancer Research, Oslo University Hospital, Oslo, Norway
| | - Mette Kalager
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo and Department of Transplantation Medicine Oslo University Hospital, Oslo, Norway; Department of Transplantation Medicine and K. G. Jebsen Center for Colorectal Cancer Research, Oslo University Hospital, Oslo, Norway
| | - Jaroslaw Regula
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland; Department of Oncological Gastroenterology and Department of Cancer Prevention, the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
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