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Terasawa T, Tadano T, Abe K, Sasaki S, Hosono S, Katayama T, Hoshi K, Nakayama T, Hamashima C. Single-round performance of colorectal cancer screening programs: a network meta-analysis of randomized clinical trials. BMC Med 2025; 23:110. [PMID: 39985068 PMCID: PMC11846209 DOI: 10.1186/s12916-025-03948-9] [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: 10/03/2024] [Accepted: 02/13/2025] [Indexed: 02/24/2025] Open
Abstract
BACKGROUND Demonstrating mortality reduction in new colorectal cancer (CRC) screening programs through randomized clinical trials (RCTs) is challenging. We systematically reviewed single-round program performance outcomes using a stepwise approach proposed by the World Endoscopy Organization CRC Screening Committee framework. METHODS The MEDLINE, EMBASE, Central, and Ichushi Web databases were searched until October 28, 2024, to find RCTs comparing guaiac-based and immunochemical fecal occult blood testing (gFOBT and FIT), flexible sigmoidoscopy (FS), computed tomographic colonography (CTC), and total colonoscopy (TCS). Paired reviewers screened studies, extracted data, and assessed bias risk. A Bayesian random-effects network meta-analysis was conducted, and the certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach. The primary outcome was advanced neoplasia (AN) detection, and the secondary outcomes were participation and colorectal cancer (CRC) detection, all during the first screening round. RESULTS Eighteen RCTs (437,072 invitees) were included. The risk of bias was low or raised some concerns for screening participation, but it was high for detection outcomes. In the network meta-analysis of 15 RCTs not allowing crossover, the FIT-based program had a higher AN detection rate than the gFOBT-based program (relative risk [RR] 2.48; 95% credible interval [CrI] 1.52-4.21; moderate certainty). AN detection rates were not different in the CTC- (RR 1.01; CrI 0.43-2.23; very low certainty) and TCS-based (RR 1.03; CrI 0.54-1.78; low certainty) programs compared with the FS-based program. All the visualization modality programs had higher AN detection rates than the FIT-based program (FS: RR 2.13 [CrI 1.38-3.77]; CTC 2.16 [1.11-4.51]; and TCS 2.19 [1.43-3.48]; all with low certainty). Low event rates precluded definitive conclusions regarding CRC detection (very low to low certainty). The TCS-based program had the worst participation rate (very low to low certainty). Comparative data allowing crossover were limited. CONCLUSIONS This is the first network meta-analysis that evaluates program-level initial performance indicators. FIT-based programs likely detect more AN cases than gFOBT-based programs, while FS-, CTC-, and TCS-based programs may outperform FIT. Due to limitations in first-round results, long-term outcomes should be assessed after 10-15 years.
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Affiliation(s)
- Teruhiko Terasawa
- Section of General Internal Medicine, Department of Emergency Medicine and General Internal Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan.
| | | | - Koichiro Abe
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Seiju Sasaki
- Center for Preventive Medicine, St. Luke's International Hospital Affiliated Clinic, Tokyo, Japan
| | - Satoyo Hosono
- Division of Cancer Screening Assessment and Management, National Cancer Center Institute for Cancer Control, Tokyo, Japan
| | - Takafumi Katayama
- Department of Statistics and Computer Science, College of Nursing Art and Science, University of Hyogo, Hyogo, Japan
| | - Keika Hoshi
- Center for Health Informatics Policy, National Institute of Public Health, Wako, Japan
| | - Tomio Nakayama
- Division of Cancer Screening Assessment and Management, National Cancer Center Institute for Cancer Control, Tokyo, Japan
| | - Chisato Hamashima
- Department of Nursing, Faculty of Medical Technology, Teikyo University, Tokyo, Japan
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Heisser T, Cardoso R, Niedermaier T, Hoffmeister M, Brenner H. Making colonoscopy-based screening more efficient: A "gateopener" approach. Int J Cancer 2023; 152:952-961. [PMID: 36214791 DOI: 10.1002/ijc.34317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 09/07/2022] [Accepted: 09/22/2022] [Indexed: 01/06/2023]
Abstract
Screening colonoscopy for early detection and prevention of colorectal cancer (CRC) is mostly used inefficiently. Here, we assessed the potential of an innovative approach to colonoscopy-based screening, by use of a single, low threshold fecal immunochemical test (FIT) as a "gateopener" for screening colonoscopy. Using COSIMO, a validated simulation model, we modeled scenarios including either direct invitation to screening colonoscopy or an alternative approach involving mailing a single ("gateopener") FIT along with an invitation to colonoscopy contingent on a FIT value above a low threshold yielding a 50% positivity rate (ie, every other pretest will be positive). Under plausible assumptions on screening offer adherence, we found that such "gateopener screening" (use of screening colonoscopy contingent on a positive, low threshold gateopener FIT) approximately doubled cancer detection rates vs conventional screening. In those spared from screening colonoscopy due to a negative gateopener FIT pretest, numbers needed to screen were 10-times higher vs those for individuals with a positive FIT, peaking in >2000 and >3800 (hypothetically) needed colonoscopies to detect one case of cancer in men and women, respectively. Gateopener screening resulted in 42%-51% and 59%-65% more prevented CRC cases and deaths, respectively. In summary, by directing colonoscopy capacities to those most likely to benefit, offering screening colonoscopy contingent on a "gateopener" low-threshold FIT would substantially enhance efficiency of colonoscopy screening.
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Affiliation(s)
- Thomas Heisser
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Medical Faculty Heidelberg, Heidelberg University, Heidelberg, Germany
| | - Rafael Cardoso
- Medical Faculty Heidelberg, Heidelberg University, Heidelberg, Germany.,Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Tobias Niedermaier
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Michael Hoffmeister
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany.,German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
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Jen GHH, Yen AMF, Hsu CY, Chiu HM, Chen SLS, Chen THH. Modelling the impacts of COVID-19 pandemic on the quality of population-based colorectal cancer screening. Prev Med 2021; 151:106597. [PMID: 34217416 PMCID: PMC8241682 DOI: 10.1016/j.ypmed.2021.106597] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/15/2021] [Accepted: 04/30/2021] [Indexed: 12/23/2022]
Abstract
COVID-19 pandemic has severely affected regular public health interventions including population-based cancer screening. Impacts of such screening delays on the changes in structure and screening process and the resultant long-term outcomes are unknown. It is therefore necessary to develop a systematic framework to assess theses impacts related to these components of quality. Using population-based cancer screening with fecal immunochemical test (FIT) as an illustration, the main analysis was to assess how various scenarios of screening delays were associated with the capacity for primary screening and full time equivalent (FTE) for colonoscopy and impact long-term outcomes based on a Markov decision tree model on population level. The second analysis was to quantify how the extent of COVID-19 epidemic measured by social distancing index affected capacity and FTE that were translated to delays with an exponential relationship. COVID-19 epidemic led to 25%, 29%, 34%, and 39% statistically significantly incremental risks of late cancer for the delays of 0.5-year, 1-year,1.5-year, and 2-year, respectively compared with regular biennial FIT screening. The corresponding statistically findings of four delayed schedules for death from colorectal cancer (CRC) were 26%, 28%, 29%, and 30%, respectively. The higher social distancing index led to a lower capacity of uptake screening and a larger reduction of FTE, resulting in longer screening delay and longer waiting time, which further impacted long-term outcomes as above. In summary, a systematic modelling approach was developed for demonstrating the strong impact of screening delays caused by COVID-19 epidemic on long-term outcomes illustrated with a Taiwan population-based FIT screening of CRC.
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Affiliation(s)
- Grace Hsiao-Hsuan Jen
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Amy Ming-Fang Yen
- School of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chen-Yang Hsu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan; Daichung Hospital, Miaoli, Taiwan
| | - Han-Mo Chiu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Sam Li-Sheng Chen
- School of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan.
| | - Tony Hsiu-Hsi Chen
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.
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Brown JP, Wooldrage K, Kralj-Hans I, Wright S, Cross AJ, Atkin WS. Effect of once-only flexible sigmoidoscopy screening on the outcomes of subsequent faecal occult blood test screening. J Med Screen 2019; 26:11-18. [PMID: 30282520 PMCID: PMC6376653 DOI: 10.1177/0969141318785654] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 06/07/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To investigate the outcomes of biennial guaiac faecal occult blood test (gFOBT) screening after once-only flexible sigmoidoscopy (FS) screening. METHODS Between 1994 and 1999, as part of the UK FS Screening Trial (UKFSST), adults aged 55-64 were randomly allocated to an intervention group (offered FS screening) or a control group (not contacted). From 2006, a subset of UKFSST participants (20,895/44,041 intervention group; 41,497/87,149 control group) were invited to biennial gFOBT screening by the English Bowel Cancer Screening Programme. We analysed gFOBT uptake, test positivity, yield of colorectal cancer (CRC), and positive predictive value (PPV) for CRC, advanced adenomas (AAs), and advanced colorectal neoplasia (ACN: AA/CRC). RESULTS Uptake of gFOBT at first invitation was 1.9% lower (65.7% vs. 67.6%, p < 0.01) among intervention versus control group participants. Positivity was 0.4% lower (2.0% vs. 2.4%, p < 0.01) and CRC yield was 0.08% lower (0.19% vs. 0.27%, p = 0.14). PPVs were also lower in the intervention versus control group, at 10.3% vs. 12.3% ( p = 0.44) for CRC, 22.7% vs. 31.4% ( p < 0.01) for AA, and 33.0% vs. 43.7% ( p < 0.01) for ACN. Among those who refused FS ( n = 5532), gFOBT uptake at first invitation was 47.7%, CRC yield was 0.25%, and PPV for ACN was 46.2%. Among FS attenders ( n = 15,363), uptake was 72.2%, CRC yield was 0.18%, and PPV for ACN was 27.9%. CONCLUSIONS Uptake, positivity and PPV of gFOBT screening were reduced following prior offer of FS screening. However, a quarter of FS screened participants receiving a diagnostic examination after positive gFOBT were diagnosed with ACN.
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Affiliation(s)
- Jeremy P Brown
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Kate Wooldrage
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Ines Kralj-Hans
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Amanda J Cross
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Wendy S Atkin
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
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Tinmouth J, Vella ET, Baxter NN, Dubé C, Gould M, Hey A, Ismaila N, McCurdy BR, Paszat L. Colorectal Cancer Screening in Average Risk Populations: Evidence Summary. Can J Gastroenterol Hepatol 2016; 2016:2878149. [PMID: 27597935 PMCID: PMC5002289 DOI: 10.1155/2016/2878149] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 06/29/2016] [Indexed: 02/06/2023] Open
Abstract
Introduction. The objectives of this systematic review were to evaluate the evidence for different CRC screening tests and to determine the most appropriate ages of initiation and cessation for CRC screening and the most appropriate screening intervals for selected CRC screening tests in people at average risk for CRC. Methods. Electronic databases were searched for studies that addressed the research objectives. Meta-analyses were conducted with clinically homogenous trials. A working group reviewed the evidence to develop conclusions. Results. Thirty RCTs and 29 observational studies were included. Flexible sigmoidoscopy (FS) prevented CRC and led to the largest reduction in CRC mortality with a smaller but significant reduction in CRC mortality with the use of guaiac fecal occult blood tests (gFOBTs). There was insufficient or low quality evidence to support the use of other screening tests, including colonoscopy, as well as changing the ages of initiation and cessation for CRC screening with gFOBTs in Ontario. Either annual or biennial screening using gFOBT reduces CRC-related mortality. Conclusion. The evidentiary base supports the use of FS or FOBT (either annual or biennial) to screen patients at average risk for CRC. This work will guide the development of the provincial CRC screening program.
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Affiliation(s)
- Jill Tinmouth
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Emily T. Vella
- Program in Evidence-Based Care, Cancer Care Ontario, Hamilton, ON, Canada
| | - Nancy N. Baxter
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Catherine Dubé
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada
- Department of Medicine, Division of Gastroenterology, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada
| | - Michael Gould
- William Osler Health Centre, Etobicoke, ON, Canada
- Vaughan Endoscopy Clinic, Vaughan, ON, Canada
| | - Amanda Hey
- Northeast Cancer Centre Health Sciences North/Horizon Santé-Nord, Sudbury Outpatient Centre, Sudbury, ON, Canada
| | | | | | - Lawrence Paszat
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Parra-Pérez V, Watanabe-Yamamoto J, Nago-Nago A, Astete-Benavides M, Rodríguez-Ulloa C, Valladares-Álvarez G, Núñez-Calixto N, Yoza-Yoshidaira M, Gargurevich-Sánchez T, Pinto-Sánchez J, Niebuhr-Kakiuchi J, Uehara-Miyagusuku G, Rodríguez-Grandez J, Komazona-Sugajara R, Gutiérrez de Aranguren C. Factors related to advanced colorectal neoplasm at the Policlínico Peruano Japonés. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2015. [DOI: 10.1016/j.rgmxen.2015.08.009] [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: 10/23/2022] Open
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Parra-Pérez V, Watanabe-Yamamoto J, Nago-Nago A, Astete-Benavides M, Rodríguez-Ulloa C, Valladares-Álvarez G, Núñez-Calixto N, Yoza-Yoshidaira M, Gargurevich-Sánchez T, Pinto-Sánchez J, Niebuhr-Kakiuchi J, Uehara-Miyagusuku G, Rodríguez-Grandez J, Komazona-Sugajara R, Gutiérrez de Aranguren CF. Factors related to advanced colorectal neoplasm at the Policlínico Peruano Japonés. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2015; 80:239-47. [PMID: 26253888 DOI: 10.1016/j.rgmx.2015.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 06/14/2015] [Accepted: 06/25/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Identifying persons at high risk for advanced colorectal neoplasia can aid in the prevention of colon cancer. Previous studies have shown that some patients can present with proximal advanced neoplasia with no distal findings. AIMS To determine the factors related to advanced neoplasia and advanced proximal colorectal neoplasia in a Latin American population. MATERIAL AND METHODS A prospective, cross-sectional, observational, analytic study was conducted. It included patients that underwent colonoscopy at the Policlínico Peruano Japonés within the time frame of January and July 2012. Advanced neoplasia was defined as the presence of lesions ≥ 10mm with a villous component, high-grade dysplasia, or carcinoma. The splenic flexure was the limit between the proximal and distal colon. RESULTS A total of 846 patients were included in the study. Advanced neoplasia was detected in 108 patients (12.8%) and advanced proximal neoplasia in 55 patients (6.7%), 42 (76.4%) of whom had no neoplasia in the distal colon. Factors related to advanced neoplasia found in the multivariate analysis were age, at the intervals of 50-59 (p=0.019), 60-69 (p=0.016), and ≥ 70 years (0.002) and male sex (p=0.003). In the evaluation of advanced proximal neoplasia, the multivariate analysis identified the 60-69 year age interval (p=0.039) and advanced distal neoplasia (p=0.028) as factors related to advanced proximal disease. The ROC curve established the age cut-off point at 60 years for initially performing colonoscopy, rather than sigmoidoscopy. CONCLUSIONS Age and sex are related to advanced neoplasia, whereas age and advanced distal neoplasia are related to advanced proximal neoplasia.
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Affiliation(s)
- V Parra-Pérez
- Servicio de Gastroenterología, Policlínico Peruano Japonés, Lima, Perú.
| | | | - A Nago-Nago
- Servicio de Gastroenterología, Policlínico Peruano Japonés, Lima, Perú
| | | | - C Rodríguez-Ulloa
- Servicio de Gastroenterología, Policlínico Peruano Japonés, Lima, Perú
| | | | - N Núñez-Calixto
- Servicio de Gastroenterología, Policlínico Peruano Japonés, Lima, Perú
| | - M Yoza-Yoshidaira
- Servicio de Gastroenterología, Policlínico Peruano Japonés, Lima, Perú
| | | | - J Pinto-Sánchez
- Servicio de Gastroenterología, Policlínico Peruano Japonés, Lima, Perú
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Senore C, Inadomi J, Segnan N, Bellisario C, Hassan C. Optimising colorectal cancer screening acceptance: a review. Gut 2015; 64:1158-77. [PMID: 26059765 DOI: 10.1136/gutjnl-2014-308081] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 03/09/2015] [Indexed: 12/13/2022]
Abstract
The study aims to review available evidence concerning effective interventions to increase colorectal cancer (CRC) screening acceptance. We performed a literature search of randomised trials designed to increase individuals' use of CRC screening on PubMed, Embase, Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effects. Small (≤ 100 subjects per arm) studies and those reporting results of interventions implemented before publication of the large faecal occult blood test trials were excluded. Interventions were categorised following the Continuum of Cancer Care and the PRECEDE-PROCEED models and studies were grouped by screening model (opportunistic vs organised). Multifactor interventions targeting multiple levels of care and considering factors outside the individual clinician control, represent the most effective strategy to enhance CRC screening acceptance. Removing financial barriers, implementing methods allowing a systematic contact of the whole target population, using personal invitation letters, preferably signed by the reference care provider, and reminders mailed to all non-attendees are highly effective in enhancing CRC screening acceptance. Physician reminders may support the diffusion of screening, but they can be effective only for individuals who have access to and make use of healthcare services. Educational interventions for patients and providers are effective, but the implementation of organisational measures may be necessary to favour their impact. Available evidence indicates that organised programmes allow to achieve an extensive coverage and to enhance equity of access, while maximising the health impact of screening. They provide at the same time an infrastructure allowing to achieve a more favourable cost-effectiveness profile of potentially effective strategies, which would not be sustainable in opportunistic settings.
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Affiliation(s)
- Carlo Senore
- Centro di Prevenzione Oncologica (CPO Piemonte), AOU Città della Salute e della Scienza, Turin, Italy
| | - John Inadomi
- Digestive Disease Center, University of Washington, Seattle, Washington, USA
| | - Nereo Segnan
- Centro di Prevenzione Oncologica (CPO Piemonte), AOU Città della Salute e della Scienza, Turin, Italy
| | - Cristina Bellisario
- Centro di Prevenzione Oncologica (CPO Piemonte), AOU Città della Salute e della Scienza, Turin, Italy
| | - Cesare Hassan
- Unit of Gastroenterology, Ospedale Nuovo Regina Margherita, Rome, Italy
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Stracci F, Zorzi M, Grazzini G. Colorectal cancer screening: tests, strategies, and perspectives. Front Public Health 2014; 2:210. [PMID: 25386553 PMCID: PMC4209818 DOI: 10.3389/fpubh.2014.00210] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 10/10/2014] [Indexed: 12/18/2022] Open
Abstract
Screening has a central role in colorectal cancer (CRC) control. Different screening tests are effective in reducing CRC-specific mortality. Influence on cancer incidence depends on test sensitivity for pre-malignant lesions, ranging from almost no influence for guaiac-based fecal occult blood testing (gFOBT) to an estimated reduction of 66–90% for colonoscopy. Screening tests detect lesions indirectly in the stool [gFOBT, fecal immunochemical testing (FIT), and fecal DNA] or directly by colonic inspection [flexible sigmoidoscopy, colonoscopy, CT colonography (CTC), and capsule endoscopy]. CRC screening is cost-effective compared to no screening but no screening strategy is clearly better than the others. Stool tests are the most widely used in worldwide screening interventions. FIT will soon replace gFOBT. The use of colonoscopy as a screening test is increasing and this strategy has superseded all alternatives in the US and Germany. Despite its undisputed importance, CRC screening is under-used and participation rarely reaches 70% of target population. Strategies to increase participation include ensuring recommendation by physicians, introducing organized screening and developing new, more acceptable tests. Available evidence for DNA fecal testing, CTC, and capsule endoscopy is reviewed.
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Affiliation(s)
- Fabrizio Stracci
- Public Health Section, Department of Experimental Medicine, University of Perugia , Perugia , Italy ; Regional Cancer Registry of Umbria , Perugia , Italy
| | | | - Grazia Grazzini
- Department of Screening, ISPO Cancer Prevention and Research Institute , Florence , Italy
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Massat NJ, Moss SM, Halloran SP, Duffy SW. Screening and Primary prevention of Colorectal Cancer: a Review of sex-specific and site-specific differences. J Med Screen 2013; 20:125-48. [DOI: 10.1177/0969141313501292] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Colorectal cancer (CRC) is the second commonest cancer in England. Incidence rates for colorectal adenomas and advanced colorectal neoplasia are higher in men than in women of all age groups. The male-to-female ratio for CRC incidence rates differs for different parts of the large bowel. Objective To summarize the current evidence on colorectal screening and prevention, focussing on potential differences in benefits between sexes and colorectal sites. Methods (i), We reviewed the evidence from randomized controlled trials (RCTs) of the impact of different screening approaches on CRC incidence and mortality, overall, for each sex separately, and for subsites of the large bowel. (ii) We reviewed studies comparing detection parameters for faecal immunochemical tests for haemoglobin (FIT) with guaiac FOBt (gFOBt). (iii) The role of aspirin in CRC prevention in the general population was reviewed using evidence from RCTs, with specific emphasis on the differences observed between sexes and lesion site. Results (i) Our intention-to-treat random-effects meta-analysis showed that once-only flexible sigmoidoscopy (FS) screening performed on average-risk individuals aged 55 + decreased CRC incidence by 18% and mortality by 28%, but sex-specific results were lacking. (ii) Modern quantitative FIT were superior to qualitative gFOBt in average-risk population screening in their ability to discriminate between individuals with and without colorectal neoplasia. Some recent FIT studies suggest varying operating characteristics in men and women. (iii) Evidence of an effect of aspirin on the incidence of CRC (in particular, proximal disease) in both sexes aged 40 and over at average-risk of CRC is emerging. Conclusions We encourage researchers of CRC screening and prevention to publish their results by sex where possible. Pilot studies should be undertaken before implementation of quantitative FIT in a national screening programme to establish the appropriate threshold. Finally, individual risk assessment for CRC and non-CRC events, will be necessary to make an informed decision on whether a patient should receive aspirin chemoprevention.
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Affiliation(s)
- Nathalie J Massat
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Sue M Moss
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Stephen P Halloran
- Royal Surrey County Hospital NHS Foundation Trust and the University of Surrey, Guildford, UK
| | - Stephen W Duffy
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
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11
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Holme Ø, Bretthauer M, Fretheim A, Odgaard‐Jensen J, Hoff G. Flexible sigmoidoscopy versus faecal occult blood testing for colorectal cancer screening in asymptomatic individuals. Cochrane Database Syst Rev 2013; 2013:CD009259. [PMID: 24085634 PMCID: PMC9365065 DOI: 10.1002/14651858.cd009259.pub2] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Colorectal cancer is the third most frequent cancer in the world. As the sojourn time for this cancer is several years and a good prognosis is associated with early stage diagnosis, screening has been implemented in a number of countries. Both screening with faecal occult blood test and flexible sigmoidoscopy have been shown to reduce mortality from colorectal cancer in randomised controlled trials. The comparative effectiveness of these tests on colorectal cancer mortality has, however, never been evaluated, and controversies exist over which test to choose. OBJECTIVES To compare the effectiveness of screening for colorectal cancer with flexible sigmoidoscopy to faecal occult blood testing. SEARCH METHODS We searched MEDLINE and EMBASE (November 16, 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 11) and reference lists for eligible studies. SELECTION CRITERIA Randomised controlled trials comparing screening with flexible sigmoidoscopy or faecal occult blood testing to each other or to no screening. Only studies reporting mortality from colorectal cancer were included. Faecal occult blood testing had to be repeated (annually or biennially). DATA COLLECTION AND ANALYSIS Data retrieval and assessment of risk of bias were performed independently by two review authors. Standard meta-analyses using a random-effects model were conducted for flexible sigmoidoscopy and faecal occult blood testing (FOBT) separately and we calculated relative risks with 95% confidence intervals (CI). We used a Bayesian approach (a contrast-based network meta-analysis method) for indirect analyses and presented the results as posterior median relative risk with 95% credibility intervals. We assessed the quality of evidence using GRADE. MAIN RESULTS We identified nine studies comprising 338,467 individuals randomised to screening and 405,919 individuals to the control groups. Five studies compared flexible sigmoidoscopy to no screening and four studies compared repetitive guaiac-based FOBT (annually and biennially) to no screening. We did not consider that study risk of bias reduced our confidence in our results. We did not identify any studies comparing the two screening methods directly. When compared with no screening, colorectal cancer mortality was lower with flexible sigmoidoscopy (relative risk 0.72; 95% CI 0.65 to 0.79, high quality evidence) and FOBT (relative risk 0.86; 95% CI 0.80 to 0.92, high quality evidence). In the analyses based on indirect comparison of the two screening methods, the relative risk of dying from colorectal cancer was 0.85 (95% credibility interval 0.72 to 1.01, low quality evidence) for flexible sigmoidoscopy screening compared to FOBT. No complications occurred after the FOBT test itself, but 0.03% of participants suffered a major complication after follow-up. Among more than 60,000 flexible sigmoidoscopy screening procedures and almost 6000 work-up colonoscopies, a major complication was recorded in 0.08% of participants. Adverse event data should be interpreted with caution as the reporting of adverse effects was incomplete. AUTHORS' CONCLUSIONS There is high quality evidence that both flexible sigmoidoscopy and faecal occult blood testing reduce colorectal cancer mortality when applied as screening tools. There is low quality indirect evidence that screening with either approach reduces colorectal cancer deaths more than the other. Major complications associated with screening require validation from studies with more complete reporting of harms
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Affiliation(s)
- Øyvind Holme
- Sorlandet Hospital KristiansandDepartment of MedicineServicebox 416KristiansandNorway4604
| | - Michael Bretthauer
- University of OsloInstitute of Health and Society, Dep. of Health Management and Health EconomicsPO Box 1089 BlindernOsloNorway0318
| | - Atle Fretheim
- Norwegian Knowledge Centre for the Health ServicesGlobal Health UnitOsloNorway
| | - Jan Odgaard‐Jensen
- Norwegian Knowledge Centre for the Health ServicesGlobal Health UnitOsloNorway
| | - Geir Hoff
- Telemark HospitalR&DUlefossvatnSkienNorway3710
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Garborg K, Holme Ø, Løberg M, Kalager M, Adami HO, Bretthauer M. Current status of screening for colorectal cancer. Ann Oncol 2013; 24:1963-72. [PMID: 23619033 DOI: 10.1093/annonc/mdt157] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Colorectal cancer (CRC) is a leading cause of cancer morbidity and mortality. A well-defined precursor lesion (adenoma) and a long preclinical course make CRC a candidate for screening. This paper reviews the current evidence for the most important tests that are widely used or under development for population-based screening. MATERIAL AND METHODS In this narrative review, we scrutinized all papers we have been aware of, and carried out searches in PubMed and Cochrane library for relevant literature. RESULTS Two screening methods have been shown to reduce CRC mortality in randomised trials: repetitive faecal occult blood testing (FOBT) reduces CRC mortality by 16%; once-only flexible sigmoidoscopy (FS) by 28%. FS screening also reduces CRC incidence (by 18%), FOBT does not. Colonoscopy screening has a potentially larger effect on CRC incidence and mortality, but randomised trials are lacking. New screening methods are on the horizon but need to be tested in large clinical trials before implementation in population screening. CONCLUSIONS FS screening reduces CRC incidence and CRC mortality by removal of adenomas; FOBT reduces CRC mortality by early detection of cancer. Several other tests are available, but none has been evaluated in randomised trials. Screening strategies differ considerably across countries.
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Affiliation(s)
- K Garborg
- Department of Medicine, Sørlandet Hospital, Kristiansand, Norway.
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13
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Hassan C, Giorgi Rossi P, Camilloni L, Rex DK, Jimenez-Cendales B, Ferroni E, Borgia P, Zullo A, Guasticchi G. Meta-analysis: adherence to colorectal cancer screening and the detection rate for advanced neoplasia, according to the type of screening test. Aliment Pharmacol Ther 2012; 36:929-40. [PMID: 23035890 DOI: 10.1111/apt.12071] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 08/01/2012] [Accepted: 09/14/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND A variety of tests have been proposed for colorectal cancer (CRC), giving rise to uncertainty regarding the optimal approach. The efficacy and effectiveness of different tests are related to both screened participation and the detection rate. AIM To perform a meta-analysis on adherence and detection rates of CRC screening tests. METHODS Relevant publications were identified by MEDLINE/EMBASE and other databases for the period 1999-2012. A previous systematic review was used for the period before 1966-1999. RCTs and controlled studies including a direct comparison of the uptake rates among different options for CRC screening were included. Adherence and detection rates for advanced neoplasia and cancer were extracted. Risk for bias was ascertained according to CONSORT guidelines. Forrest plots were produced based on random-effect models. RESULTS Fourteen studies provided data on 197 910 subjects. Endoscopic strategies were associated with a lower participation (RR: 0.67, 95% CI: 0.56, 0.80) rate, but a higher detection rate of advanced neoplasia (RR: 3.21, 95% CI: 2.38, 4.32) compared with faecal tests. FIT was superior to g-FOBT with regard to both adherence (RR: 1.16, 95% CI 1.03, 1.30) and detection of advanced neoplasia (RR: 2.28, 95% CI 1.68, 3.10) and cancer (RR: 1.96, 95% CI: 1.2, 3.2). CONCLUSION The superior accuracy of endoscopy compared with faecal tests minimised any impact of the participation rate in determining the detection rate of advanced neoplasia in a screening setting.
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Affiliation(s)
- C Hassan
- Laziosanità Agenzia di Sanità Pubblica, Regione Lazio, Rome, Italy.
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14
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Littlejohn C, Hilton S, Macfarlane GJ, Phull P. Systematic review and meta-analysis of the evidence for flexible sigmoidoscopy as a screening method for the prevention of colorectal cancer. Br J Surg 2012; 99:1488-500. [PMID: 23001715 DOI: 10.1002/bjs.8882] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2012] [Indexed: 12/18/2022]
Abstract
BACKGROUND Colorectal cancer is a significant cause of death. Removal of precancerous adenomas, and early detection and treatment of cancer, has been shown to reduce the risk of death. The aim of this review and meta-analysis was to determine whether flexible sigmoidoscopy (FS) is an effective population screening method for reducing mortality from colorectal cancer. METHODS MEDLINE (1946 to December 2012) and Embase (1980-2012, week 15) were searched for randomized clinical trials in which FS was used to screen non-symptomatic adults from a general population, and FS was compared with either no screening or any other alternative screening methods. Meta-analysis was carried out using a random-effects Mantel-Haenzsel model. RESULTS Twenty-four papers met the inclusion criteria, reporting results from 14 trials. Uptake of FS was usually lower than that for stool-based tests, although FS was more effective at detecting advanced adenoma and carcinoma. FS reduced the incidence of colorectal cancer after screening, and long-term mortality from colorectal cancer, compared with no screening in a selected population. Compared with stool-based tests in a general population, FS was associated with fewer interval cancers. CONCLUSION FS is efficacious at reducing colorectal cancer mortality compared with no screening. It is more effective at detecting advanced adenoma and carcinoma than stool-based tests. FS may be compromised by poorer uptake. Introduction of FS as a screening method should be done on a pilot basis in populations in which it is not currently used, and close attention should be paid to maximizing uptake. The relative risk of adverse events with FS compared with stool-based tests should be quantified, and its real-world effectiveness evaluated against the most effective stool-based tests.
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Affiliation(s)
- C Littlejohn
- NHS Grampian, Institute of Applied Health Sciences, University of Aberdeen, School of Medicine and Dentistry, Foresterhill, Aberdeen, UK.
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15
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Boltin D, Niv Y. Is There a Place for Screening Flexible Sigmoidoscopy? CURRENT COLORECTAL CANCER REPORTS 2012; 8:16-21. [DOI: 10.1007/s11888-011-0108-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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16
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Canadian guidelines for colorectal cancer screening. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2011; 25:479-81. [PMID: 21912757 DOI: 10.1155/2011/285926] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Decisions regarding colorectal cancer screening will continue to depend on local resources, which in some jurisdictions includes programmatic screening and individual patient preferences. I encourage gastroenterologists to participate in programmatic screening and assist in developing the colonoscopy quality assurance and improvement programs. Our involvement would ensure that we remain leaders in this area and that our expertise in quality in endoscopy is recognized. Finally, participation in programmatic screening should benefit endoscopic services by increasing resources to support higher colonoscopy volumes, shorter wait lists and continuing quality assurance.
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Abstract
The most rigorous and valid approach to evaluating cancer screening modalities is the randomized controlled trial (RCT). RCTs are major undertakings and the intricacies of trial design, operations, and management are generally underappreciated by the typical researcher. The purpose of this article is to inform the reader of the "nuts and bolts" of designing and conducting cancer screening RCTs. Following a brief introduction as to why RCTs are critical in evaluating screening modalities, we discuss design considerations, including the choice of design type and duration of follow-up. We next present an approach to sample-size calculations. We then discuss aspects of trial implementation, including recruitment, randomization, and data management. A discussion of commonly employed data analyses comes next, and includes methods for the primary analysis (comparison of cause-specific mortality rates between the screened and control arms for the cancer of interest), as well as for secondary endpoints such as sensitivity. We follow with a discussion of sequential monitoring and interim analysis techniques, which are used to examine the primary outcome while the trial is ongoing. We close with thoughts on lessons learned from past cancer screening RCTs and provide recommendations for future trials. Throughout the presentation we illustrate topics with examples from completed or ongoing RCTs, including the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial and the National Lung Screening Trial (NLST).
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Affiliation(s)
- Philip C Prorok
- Division of Cancer Prevention, National Cancer Institute, Bethesda, MD 20892, USA.
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Senore C, Malila N, Minozzi S, Armaroli P. How to enhance physician and public acceptance and utilisation of colon cancer screening recommendations. Best Pract Res Clin Gastroenterol 2010; 24:509-20. [PMID: 20833353 DOI: 10.1016/j.bpg.2010.06.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2010] [Revised: 05/17/2010] [Accepted: 06/18/2010] [Indexed: 01/31/2023]
Abstract
Colorectal Cancer (CRC) screening delivery is a multidisciplinary undertaking, aiming at reducing mortality from and incidence of CRC without adversely affecting the health status of participants. The adoption of a public health perspective involves commitment to ensure equity of access and sustainability of the program over time. We reviewed available evidence concerning predictors of CRC screening uptake and the impact of interventions to improve adoption of screening using conceptual frameworks defining the role of determinants of preventive behaviours and the reach and target of interventions. The results of this review indicate that policy measures aimed at supporting screening delivery, as well as organisational changes, influencing the operational features of preventive services, need to be implemented, in order to allow individual's motivation to be eventually realised. To ensure coverage and equity of access and to maximise the impact of the intervention, policies aimed at implementing organised programs should be adopted, ensuring that participation in screening and any follow-up assessment should not be limited by financial barriers. Participants and providers beliefs may determine the response to different screening modalities. To achieve the desired health impact, an active follow-up of people with screening abnormalities should be implemented, supported by the introduction of infrastructural changes and multidisciplinary team work, which can ensure sustainability over time of effective interventions. Continuous monitoring as well as the adoption of plans to evaluate for program effectiveness represent crucial steps in the implementation of a successful program.
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Affiliation(s)
- Carlo Senore
- AOU S Giovanni Battista - CPO Piemonte, SCDO Epidemiologia dei Tumori 2, Via S Francesco da Paola 31, 10123 Torino, Italy.
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Programas de cribado del cáncer colorrectal en la población de riesgo medio en la Unión Europea y España. GASTROENTEROLOGIA Y HEPATOLOGIA 2010; 33:111-8. [DOI: 10.1016/j.gastrohep.2009.03.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Accepted: 04/17/2009] [Indexed: 11/15/2022]
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Kato J, Morikawa T, Kuriyama M, Yamaji Y, Wada R, Mitsushima T, Yamamoto K. Combination of sigmoidoscopy and a fecal immunochemical test to detect proximal colon neoplasia. Clin Gastroenterol Hepatol 2009; 7:1341-6. [PMID: 19426835 DOI: 10.1016/j.cgh.2009.04.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Revised: 04/02/2009] [Accepted: 04/26/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The combination of sigmoidoscopy and a sensitive fecal occult blood test was recommended as one strategy for colorectal cancer screening by the US Preventive Services Task Force in 2008. However, there have been no studies to evaluate the sensitivity of a one-time screen that uses both flexible sigmoidoscopy and a fecal immunochemical test (FIT) to detect advanced colorectal neoplasia. METHODS We analyzed data from 21,794 asymptomatic persons who had undergone colonoscopy and a FIT. Analyses were performed with the following assumptions: colonoscopy would be performed for any positive FIT result; colonoscopy would be performed if the FIT result was negative and if advanced neoplasia was detected in the rectosigmoid (or plus descending) colon. The sensitivities and specificities of the combination of sigmoidoscopy and the FIT in detecting advanced neoplasia in the proximal colon were determined. RESULTS When colonoscopy was performed for a positive FIT result alone, for a positive sigmoidoscopy finding, and for a positive FIT result or sigmoidoscopy finding, the sensitivities in detection of advanced proximal neoplasia were 22.3%, 16.3%, and 31.7%, respectively. The sensitivities for detection of proximal invasive cancer were 58.3%, 8.3%, and 62.5%, respectively. CONCLUSIONS The combination of sigmoidoscopy and FIT can detect advanced proximal neoplasia better than either test alone. The incremental yield of advanced neoplasm detection by a screening program that uses both a FIT and sigmoidoscopy is approximately 10%. The FIT adds the most in terms of finding proximal cancers in a screening program that uses both tests. The combination of sigmoidoscopy and FIT is a viable and useful screening option.
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Affiliation(s)
- Jun Kato
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
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Abstract
Colorectal cancer (CRC) is the most common cancer in the Nordic countries after breast and prostate cancer. About 15,000 new cancers are diagnosed and more than 7000 patients will die from CRC in 2005. CRC fulfils most of the criteria for applying screening; the natural history is well known compared with many other cancers. CRC may be cured by detection at an early stage and even prevented by removal of possible precursors like adenomas. Faecal occult blood test is the only CRC screening modality that has been subjected to adequately sized randomised controlled trials (RCT) with long-term follow-up results, using Hemoccult-II. Sensitivity for strictly asymptomatic CRC is less than 30% for a single screening round, but programme sensitivity has been estimated to be more. Biennial screening with un-rehydrated Hemoccult-II slides has shown a CRC mortality reduction of 15-18% after approximately 10 years of follow-up in those targeted for screening. For those attending, the mortality reduction has been estimated at 23%. Denmark has decided to do feasibility studies to try to evaluate whether a population-based screening run by the community will have the same effect as has been demonstrated in the randomised trials. In Norway the government has accepted no formal population-based screening. In Finland, the Ministry of Social Affairs and Health made a recommendation in 2003 to the municipalities to run a randomised feasibility study with FOBT screening for colorectal cancer as a public health policy that is repeated every second year. In 2004 the first municipalities started. It has been claimed that today Sweden cannot afford CRC screening despite the potential mortality benefit. There is sufficient evidence for the efficacy of screening for colorectal cancer with fecal occult blood test every second year. There is, however, only little evidence on the effectiveness of screening when run as a public health service and there is insufficient knowledge of harmful effects and costs, even in RCTs.
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Affiliation(s)
- Matti Hakama
- Finnish Cancer Registry Institute for Statistical and Epidemiological Cancer research, Helsinki, Finland.
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Hoff G, Grotmol T, Skovlund E, Bretthauer M. Risk of colorectal cancer seven years after flexible sigmoidoscopy screening: randomised controlled trial. BMJ 2009; 338:b1846. [PMID: 19483252 PMCID: PMC2688666 DOI: 10.1136/bmj.b1846] [Citation(s) in RCA: 215] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2009] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine the risk of colorectal cancer after screening with flexible sigmoidoscopy. DESIGN Randomised controlled trial. SETTING Population based screening in two areas in Norway-city of Oslo and Telemark county (urban and mixed urban and rural populations). PARTICIPANTS 55 736 men and women aged 55-64 years. INTERVENTION Once only flexible sigmoidoscopy screening with or without a single round of faecal occult blood testing (n=13 823) compared with no screening (n=41 913). MAIN OUTCOME MEASURES Planned end points were cumulative incidence and mortality of colorectal cancer after 5, 10, and 15 years. This first report from the study presents cumulative incidence after 7 years of follow-up and hazard ratio for mortality after 6 years. RESULTS No difference was found in the 7 year cumulative incidence of colorectal cancer between the screening and control groups (134.5 v 131.9 cases per 100 000 person years). In intention to screen analysis, a trend towards reduced colorectal cancer mortality was found (hazard ratio 0.73, 95% confidence interval 0.47 to 1.13, P=0.16). For attenders compared with controls, a statistically significant reduction in mortality was apparent for both total colorectal cancer (hazard ratio 0.41, 0.21 to 0.82, P=0.011) and rectosigmoidal cancer (0.24, 0.08 to 0.76, P=0.016). CONCLUSIONS A reduction in incidence of colorectal cancer with flexible sigmoidoscopy screening could not be shown after 7 years' follow-up. Mortality from colorectal cancer was not significantly reduced in the screening group but seemed to be lower for attenders, with a reduction of 59% for any location of colorectal cancer and 76% for rectosigmoidal cancer in per protocol analysis, an analysis prone to selection bias. TRIAL REGISTRATION Clinical trials NCT00119912.
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Affiliation(s)
- Geir Hoff
- Norwegian Colorectal Cancer Prevention (NORCCAP) Centre, Cancer Registry of Norway, Montebello, NO-0310 Oslo, Norway.
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23
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Hoff G, Bretthauer M. Appointments timed in proximity to annual milestones and compliance with screening: randomised controlled trial. BMJ 2008; 337:a2794. [PMID: 19091759 PMCID: PMC2605613 DOI: 10.1136/bmj.a2794] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To investigate whether appointments for screening timed in proximity to annual milestones (birthdays, Christmas and New Year) may be used as a strategy to improve attendance for screening for colorectal cancer. DESIGN Randomised controlled trial. SETTING City of Oslo (urban) and Telemark county (urban and rural), Norway. PARTICIPANTS 12,960 screened adults (64.7% of those invited). MAIN OUTCOME MEASURE Attendance rates for each week and month of assigned appointment. RESULTS Attendance rates were significantly higher in December than the rest of the year (72.3% v 64.6%, P<0.001) in adults who received an invitation in the week of their birthday or were assigned to screening in the first or second week after their birthday (67.9% v 64.5%, P=0.007). This effect was most pronounced in the urban population of Oslo. In a multivariable logistic regression model, attendance improved in those who received an invitation in the week of their birthday or were assigned to screening in the first or second week after their birthday (odds ratio 1.15, 95% confidence interval 1.03 to 1.28) and those who were assigned to screening in December (odds ratio 1.45, 1.16 to 1.82). CONCLUSION Attendance rates for screening for colorectal cancer were higher in December and around attendees' birthdays, the latter particularly in an urban population. Compliance with screening programmes may therefore be improved by timing invitations in proximity to annual milestones. TRIAL REGISTRATION Clinical Trials NCT00119912.
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Affiliation(s)
- Geir Hoff
- Cancer Registry of Norway, Oslo, Norway.
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Abstract
Although there are several methods available for colon cancer screening, none is optimal. This article reviews methods for screening, including fecal occult blood tests, flexible sigmoidoscopy, colonoscopy, CT colonography, capsule endoscopy, and double contrast barium enema. A simple, inexpensive, noninvasive, and relatively sensitive screening test is needed to identify people at risk for developing advanced adenomas or colorectal cancer who would benefit from colonoscopy. It is hoped that new markers will be identified that perform better. Until then we fortunately have a variety of screening strategies that do work.
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Affiliation(s)
- Jack S Mandel
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Room 430, Atlanta, GA 30322, USA.
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Q&A on diagnosis, screening and follow-up of colorectal neoplasia. Dig Liver Dis 2008; 40:85-96. [PMID: 18055285 DOI: 10.1016/j.dld.2007.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2007] [Revised: 09/08/2007] [Accepted: 09/19/2007] [Indexed: 12/11/2022]
Abstract
The impressive and brisk evolution of medical science prevents many physicians from a thorough update on all the research fields. Colorectal cancer diagnosis, screening and follow-up is well known to require a multi-disciplinary approach, as it is faced by several specialties such as primary care physicians, gastroenterologists, non-gastroenterologist internists, radiologists and surgeons. To address this issue in a mutual perspective, we focused on the main points of the epidemiology, diagnosis, screening and follow-up of colorectal neoplasia by using a simple "Question & Answers" structure.
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Matarese VG, Feo CV, Pezzoli A, Trevisani L, Brancaleoni M, Gullini S. Colonoscopy surveillance in asymptomatic subjects with increased risk for colorectal cancer: clinical evaluation and cost analysis of an Italian experience. Eur J Cancer Prev 2007; 16:292-7. [PMID: 17554201 DOI: 10.1097/01.cej.0000236242.48242.48] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The aim of this study was three-fold: (a) to present a surveillance plan for colorectal cancer prevention with colonoscopy, focused on first-degree relatives of colorectal cancer patients in the province of Ferrara (Italy); (b) to analyse the cost of colonoscopy at the University Hospital of Ferrara; and (c) to analyse the cost of the surveillance plan in our province. In January 2000, in the province of Ferrara, following a campaign of public sensitization, a plan of surveillance with colonoscopy was started, addressing the population at an increased risk for colorectal cancer (i.e. over 45-year-old first-degree relatives of patients with either colorectal cancer or adenomatous polyps revealed before 60 years of age). In addition, we estimated the cost of colonoscopy both at the University Hospital of Ferrara and of the surveillance plan. Between January 2000 and October 2003, 585 individuals at increased risk were interviewed. Five hundred and forty-four (94%) accepted to undergo a colonoscopy. By October 2003, 439 (81%) colonoscopies had been performed. Colonoscopy was normal in 330 individuals (75%). In 109 individuals (25%), 144 lesions were found: 35 patients (32%) had hyperplastic polyps, 66 (61%) had adenomas, and eight (7%) adenocarcinomas (six Dukes A, one Dukes B, and one Dukes C stage). Out of a total of 101 adenomas, 68 were tubular adenomas (67%), 24 tubulo-villous adenomas (24%), and nine adenomas with high-grade dysplasia (9%). The cost of colonoscopy at our hospital and the costs of the surveillance plan amounted to euro 130.84 (euro 169.57 with single biopsy) and euro 43,103.66 (euro 42 310.34/year), respectively. These data show (a) the efficacy of colonoscopy in the early diagnosis of colorectal cancer and premalignant lesions in first-degree relatives of colorectal cancer patients; (b) the low cost of colonoscopy at the centre performing the surveillance; and (c) the feasibility of screening and surveillance programmes for colorectal cancer prevention.
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Abstract
Colorectal cancer screening reduces mortality in individuals 50 years and older. Each of the screening tests currently available has advantages and limitations, and there is no consensus as to which test or combination of tests is best. What is clear, however, is that the rates of colorectal cancer screening remain low. This review summarizes the clinical evidence supporting colorectal cancer screening in the average risk population and in high risk groups, discusses the advantages and disadvantages of the available screening tests, outlines the currently recommended guidelines for screening based on risk category, and discusses new and emerging technologies for colorectal cancer screening.
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Affiliation(s)
- J P Heiken
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri 63110, USA.
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Maciosek MV, Solberg LI, Coffield AB, Edwards NM, Goodman MJ. Colorectal cancer screening: health impact and cost effectiveness. Am J Prev Med 2006; 31:80-9. [PMID: 16777546 DOI: 10.1016/j.amepre.2006.03.009] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2005] [Revised: 03/15/2006] [Accepted: 03/17/2006] [Indexed: 01/28/2023]
Abstract
BACKGROUND Colorectal cancer is the second leading cause of cancer-related death in the United States, yet recommended screenings are not delivered to most people. This assessment of colorectal cancer screening's value to the U.S. population is part of the update to a 2001 ranking of recommended clinical preventive services found in the accompanying article. This article describes the burden of disease prevented and cost-effectiveness as a result of offering patients a choice of colorectal cancer screening tools. METHODS Methods used were designed to ensure consistent estimates across many services and are described in more detail in the companion articles. In a secondary analysis, the authors also estimated the impact of increasing offers for colorectal cancer screening above current levels among the current cross-section of adults aged 50 and older. RESULTS If a birth cohort of 4 million were offered screening at recommended intervals, 31,500 deaths would be prevented and 338,000 years of life would be gained over the lifetime of the birth cohort. In the current cross-section of people aged 50 and older, 18,800 deaths could be prevented each year by offering all people in this group screening at recommended intervals. Only 58% of these deaths are currently being prevented. In year 2000 dollars, the cost effectiveness of offering patients aged 50 and older a choice of colorectal cancer screening options is $11,900 per year of life gained. CONCLUSIONS Colorectal cancer screening is a high-impact, cost-effective service used by less than half of persons aged 50 and older.
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Nozaki R, Murata R, Tanimura S, Ohwan T, Ogata S, Yamada K, Takano M. COMMUNITY-BASED MASS SCREENING FOR COLORECTAL CANCER BY A COMBINATION OF FECAL OCCULT BLOOD TESTING AND FLEXIBLE SIGMOIDOSCOPY. Dig Endosc 2006. [DOI: 10.1111/j.1443-1661.2006.00591.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Nicholson FB, Barro JL, Atkin W, Lilford R, Patnick J, Williams CB, Pignone M, Steele R, Kamm MA. Review article: Population screening for colorectal cancer. Aliment Pharmacol Ther 2005; 22:1069-77. [PMID: 16305720 DOI: 10.1111/j.1365-2036.2005.02695.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Colorectal cancer is a common cancer and common cause of death. The mortality rate from colorectal cancer can be reduced by identification and removal of cancer precursors, adenomas, or by detection of cancer at an earlier stage. Pilot screening programmes have demonstrated decreased colorectal cancer mortality; as a result many countries are developing colorectal cancer screening programmes. The most common modalities being evaluated are faecal occult blood testing, flexible sigmoidoscopy and colonoscopy. Implementation of screening tests has been hampered by cost, invasiveness, availability of resources and patient acceptance. New technologies such at computed tomographic colonography and stool screening for molecular markers of neoplasia are in development as potential minimally invasive tools. This review considers who should be screened, which test to use and how often to screen.
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Huang CS, Lal SK, Farraye FA. Colorectal cancer screening in average risk individuals. Cancer Causes Control 2005; 16:171-88. [PMID: 15868457 DOI: 10.1007/s10552-004-4027-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2004] [Accepted: 09/30/2004] [Indexed: 02/07/2023]
Abstract
Colorectal cancer is the third leading type of cancer, and the second leading cause of cancer-related death in the United States. Prevention of colorectal cancer should be achievable by screening programs that detect adenomas in asymptomatic patients and lead to their removal. In this manuscript, we review the major screening modalities, the advantages and disadvantages of each approach, the data supporting their use, and various issues affecting the implementation of each test. Screening guidelines will be reviewed, and future techniques for colorectal cancer screening examined.
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Affiliation(s)
- Ismail Jatoi
- Department of Surgery, National Naval Medical Center, Uniformed Services University, Bethesda, MD, USA
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Abstract
Colorectal cancer (CRC) is one of the most common causes of cancer mortality in Western countries. Approximately six percent of the population will develop colorectal cancer during life. Individuals older than 50 years or with a family history for colorectal tumors as well as patients with an inflammatory bowel disease have an increased risk for CRC. A significant reduction of colorectal cancer mortality can be achieved by screening of asymptomatic patients and removal of premalignant adenomatous polyp precursors. Colonoscopy is recognized as the gold standard, but in future virtual colonoscopy might be a reasonable addition. Asymptomatic individuals with an average risk for CRC should be screened from the age of 50 and then every 10 years if the examination showed no pathological findings. When the individual or family history indicate a higher risk for a colorectal neoplasia, screening should begin at the age of 40 or 10 years before the earliest tumor occurrence in the family. Families with hereditary CRC require a special surveillance.
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Affiliation(s)
- C Lamberti
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Bonn
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Evans RE, Brotherstone H, Miles A, Wardle J. Gender differences in early detection of cancer. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/j.jmhg.2004.12.012] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Segnan N, Senore C, Andreoni B, Arrigoni A, Bisanti L, Cardelli A, Castiglione G, Crosta C, DiPlacido R, Ferrari A, Ferraris R, Ferrero F, Fracchia M, Gasperoni S, Malfitana G, Recchia S, Risio M, Rizzetto M, Saracco G, Spandre M, Turco D, Turco P, Zappa M. Randomized Trial of Different Screening Strategies for Colorectal Cancer: Patient Response and Detection Rates. J Natl Cancer Inst 2005; 97:347-57. [PMID: 15741571 DOI: 10.1093/jnci/dji050] [Citation(s) in RCA: 147] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Although there is general consensus concerning the efficacy of colorectal cancer screening, there is a lack of agreement about which routine screening strategy should be adopted. We compared the participation and detection rates achievable through different strategies of colorectal cancer screening. METHODS From November 1999 through June 2001 we conducted a multicenter, randomized trial in Italy among a sample of 55-64 year olds in the general population who had an average risk of colorectal cancer. People with previous colorectal cancer, adenomas, inflammatory bowel disease, a recent (< or =2 years) colorectal endoscopy or fecal occult blood test (FOBT), or two first-degree relatives with colorectal cancer were excluded. Eligible subjects were randomly assigned, within the roster of their general practitioner, to 1) biennial FOBT (delivered by mail), 2) biennial FOBT (delivered by general practitioner or a screening facility), 3) patient's choice of FOBT or "once-only" sigmoidoscopy, 4) "once-only" sigmoidoscopy, or 5) sigmoidoscopy followed by biennial FOBT. An immunologic FOBT was used. Participation and detection rates of the strategies tested were compared using multivariable logistic regression models that adjusted for age, sex, and screening center. All statistical tests were two-sided. RESULTS Of 28 319 people sampled, 1637 were excluded and 26 682 were randomly assigned to a screening arm. After excluding undelivered letters (n = 427), the participation rates for groups 1, 2, 3, 4, and 5 were 30.1% (682/2266), 28.1% (1654/5893), 27.1% (970/3579), 28.1% (1026/3650), and 28.1% (3049/10 867), respectively. Of the 2858 subjects screened by FOBT, 122 (4.3%) had a positive test result, 10 (3.5 per 1000) had colorectal cancer, and 39 (1.4%) had an advanced adenoma. Among the 4466 subjects screened by sigmoidoscopy, 341 (7.6%) were referred for colonoscopy, 18 (4 per 1000) had colorectal cancer, and 229 (5.1%) harbored an advanced adenoma. CONCLUSIONS The participation rates were similar for sigmoidoscopy and FOBT. The detection rate for advanced neoplasia was three times higher following screening by sigmoidoscopy than by FOBT.
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Affiliation(s)
- Nereo Segnan
- Centro Prevenzione Oncologica Regione Piemonte and Azienda Sanitaria Ospedaliera S Giovanni Battista, Torino, Italy.
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Abstract
Both the incidence and the mortality from colorectal cancer can be substantially reduced by primary and secondary prevention. There are many screening tests for colorectal cancer, and any test should result in a reduction in colorectal cancer incidence and mortality. If the age-eligible population undergoes these screening tests, the burden of colorectal cancer should be substantially reduced. The scientific evidence related to secondary prevention, specifically screening of individuals at average risk for colorectal cancer, is presently reviewed.
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Affiliation(s)
- Jack S Mandel
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 30322, USA.
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Munk EM, Pedersen L, Floyd A, Nørgård B, Rasmussen HH, Sørensen HT. Inflammatory bowel diseases, 5-aminosalicylic acid and sulfasalazine treatment and risk of acute pancreatitis: a population-based case-control study. Am J Gastroenterol 2004; 99:884-8. [PMID: 15128355 DOI: 10.1111/j.1572-0241.2004.04123.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Patients with inflammatory bowel diseases are suggested to have an increased risk of acute pancreatitis. Although azathioprine and glucocorticoids are risk factors for acute pancreatitis, the relation is poorly understood, in particular the role of 5-aminosalicylic acid and sulfasalazine treatment. To clarify these relations, we conducted a population-based case-control study. METHODS We identified 1,590 incident cases of acute pancreatitis from the Hospital Discharge Registry of the North Jutland County of Denmark from 1991 to 2002, and selected 10 controls per case (N = 15,913) from the Central Personal Registry, matched by age and gender. Among cases and controls, we identified patients with inflammatory bowel diseases. Data on drug use were extracted from a Pharmaco-epidemiological Prescription Database. RESULTS Adjusted odds ratios for acute pancreatitis in patients with Crohn's disease and ulcerative colitis were 3.7 (95% confidence interval (CI), 1.9-7.6) and 1.5 (95% CI, 0.7-3.6), respectively. In all patients treated with 5-aminosalicylic acid and sulfasalazine the adjusted odds ratios for acute pancreatitis were 0.7 (95% CI, 0.4-2.2) and 1.5 (95% CI, 0.4-5.2), respectively. Restricted to patients with inflammatory bowel diseases only, the adjusted odds ratios for acute pancreatitis in patients exposed to 5-aminosalicylic acid and sulfasalazine were 0.7 (95% CI, 0.1-3.8) and 0.6 (95% CI, 0.1-6.7), respectively. CONCLUSION We found a nearly four-fold increased risk of acute pancreatitis in patients with Crohn's disease and a 1.5-fold increased risk for ulcerative colitis. In patients with inflammatory bowel diseases, the use of 5-aminosalicylic acid or sulfasalazine was not associated with increased risk of acute pancreatitis.
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Affiliation(s)
- Estrid Muff Munk
- Department of Clinical Epidemiology, Aarhus University Hospital, DK-8000 Aarhus C, Denmark
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Bretthauer M, Skovlund E, Grotmol T, Thiis-Evensen E, Gondal G, Huppertz-Hauss G, Efskind P, Hofstad B, Thorp Holmsen S, Eide TJ, Hoff G. Inter-endoscopist variation in polyp and neoplasia pick-up rates in flexible sigmoidoscopy screening for colorectal cancer. Scand J Gastroenterol 2003; 38:1268-74. [PMID: 14750648 DOI: 10.1080/00365520310006513] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The Norwegian Colorectal Cancer Prevention study is an ongoing flexible sigmoidoscopy (FS) screening trial for colorectal cancer. Twenty-one thousand average-risk individuals, aged 50-64 years, living in two separate areas in Norway were randomly drawn from the Population Registry and invited to once-only screening flexible sigmoidoscopy. Examinations were performed over 3 years, at 2 centres, by 8 different endoscopists, using the same type of equipment. The aim of the present study was to investigate possible differences between endoscopists in detecting individuals with polyps, adenomas and advanced lesions (adenomas with severe dysplasia and/or villous components and/or size larger than 9 mm and carcinoma) in flexible sigmoidoscopy screening. METHODS The present trial comprises data from 8822 individuals, aged 55-64 years, who have undergone a flexible sigmoidoscopy. In the study period, all lesions detected by the different endoscopists were registered. Tissue samples were taken from all lesions detected. RESULTS Detection rates varied significantly between endoscopists, ranging from 36.4% to 65.5% for individuals with any polyp, from 12.7% to 21.2% for any adenoma and from 2.9% to 5.0% for advanced lesions. In a multiple logistic regression model, the performing endoscopist was a strong independent predictor for detection of individuals with polyps (P < 0.001 ), adenomas (P < 0.001) and advanced lesions (P = 0.01). CONCLUSION Detection rates for colorectal lesions vary significantly between endoscopists in colorectal cancer screening. Establishing systems for monitoring performance in screening programmes is important. Supervised training and re-certification for endoscopists with poor performance should be considered.
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Affiliation(s)
- M Bretthauer
- NORCCAP Centres of Telemark Hospital, Skien, Norway.
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Floyd A, Pedersen L, Nielsen GL, Thorlacius-Ussing O, Sorensen HT. Risk of acute pancreatitis in users of azathioprine: a population-based case-control study. Am J Gastroenterol 2003; 98:1305-8. [PMID: 12818274 DOI: 10.1111/j.1572-0241.2003.07459.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Azathioprine has been linked to subsequent acute pancreatitis in several case reports and small case series. We examined the risk for acute pancreatitis in users of azathioprine in North Jutland County, Denmark, with about 490,000 inhabitants. METHODS We identified patients with incident cases of acute pancreatitis from the Hospital Discharge Registry of the county from 1991-2000, and selected 10 controls per case, matched by age and sex, from the Central Personal Registry using incidence density sampling technique. All prescriptions of azathioprine within 90 days before admission were likewise collected from the population-based North Jutland Prescription Database. Data on potential confounders were extracted from registries. We used conditional logistic regression to adjust for confounding. RESULTS A total of 1,388 patients and 13,836 controls were included in the study. We found that 1,317 persons in the entire population redeemed a total of 15,811 prescriptions of azathioprine in the county. The incidence rate for acute pancreatitis among all users of azathioprine was one per 659 treatment year. The crude OR of having redeemed prescriptions for azathioprine within 90 days before admission for acute pancreatitis was 7.5 (95% CI = 2.6-21.6). After adjustment for gallstone disease, alcohol-related diseases, inflammatory bowel disease, and use of glucocorticoids, the OR increased to 8.4 (95% CI = 2.4-29.4). The population-attributable risk, which measures the proportion of all cases of pancreatitis that are attributable to the use of azathioprine in our study population, was 0.4%. CONCLUSIONS There was a substantially increased relative risk of acute pancreatitis in users of azathioprine.
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Affiliation(s)
- Andrea Floyd
- Department of Clinical Epidemiology at Aalborg University Hospital, Aalborg, Denmark
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Abstract
Colorectal cancer screening can prevent the development of colorectal cancer and reduce the risk for death. Screening recommendations include fecal occult blood testing, sigmoidoscopy, radiographic imaging of the colon, and colonoscopy. This article focuses on recommendations for average-risk individuals and discusses the potential benefits and limitations of each. High-risk individuals should be screened with colonoscopy. Cost-effectiveness analyses of colorectal cancer screening are summarized.
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Affiliation(s)
- David A Lieberman
- Division of Gastroenterology, Oregon Health & Science University, Portland VA Medical Center, Portland, Oregon, USA
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Triantafillidis JK, Cheracakis P, Merikas EG, Peros G. Acute pancreatitis may precede the clinical manifestations of Crohn's disease. Am J Gastroenterol 2003; 98:1210-1. [PMID: 12809859 DOI: 10.1111/j.1572-0241.2003.07436.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abstract
CONTEXT Screening for colorectal cancer clearly reduces colorectal cancer mortality, yet many eligible adults remain unscreened. Several screening tests are available, and various professional organizations have differing recommendations on which screening test to use. Clinicians are challenged to ensure that eligible patients undergo colorectal cancer screening and to guide patients in choosing what tests to receive. OBJECTIVE To critically assess the evidence for use of the available colorectal cancer screening tests, including fecal occult blood tests, sigmoidoscopy, colonoscopy, double-contrast barium enema, and newer tests, such as virtual colonoscopy and stool-based molecular screening. DATA SOURCES All relevant English-language articles were identified using PubMed (January 1966-August 2002), published meta-analyses, reference lists of key articles, and expert consultation. DATA EXTRACTION Studies that evaluated colorectal cancer screening in healthy individuals and assessed clinical outcomes were included. Evidence from randomized controlled trials was considered to be of highest quality, followed by observational evidence. Diagnostic accuracy studies were evaluated when randomized controlled trials and observational studies were not available or did not provide adequate evidence. Studies were excluded if they did not evaluate colorectal screening tests and if they did not evaluate average-risk individuals. DATA SYNTHESIS Randomized controlled trials have shown that fecal occult blood testing can reduce colorectal cancer incidence and mortality. Case-control studies have shown that sigmoidoscopy is associated with a reduction in mortality, and observational studies suggest colonoscopy is effective as well. Combining fecal occult blood testing and sigmoidoscopy may decrease mortality and can increase diagnostic yield. CONCLUSION The recommendation that all men and women aged 50 years or older undergo screening for colorectal cancer is supported by a large body of direct and indirect evidence. At present, the available evidence does not currently support choosing one test over another.
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Affiliation(s)
- Judith M E Walsh
- Division of General Internal Medicine, Department of Medicine, Women's Health Clinical Research Center, University of California San Francisco, Campus Box 1793, 1635 Divisadero Suite 600, San Francisco, CA 94115, USA.
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44
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Dickdarmkrebs in Deutschland. Internist (Berl) 2003. [DOI: 10.1007/s00108-002-0851-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Chorost MI, Datta R, Santiago RC, Lee B, Bollman J, Leitman IM, Ghosh BC. Colon cancer screening: Where have we come from and where do we go? J Surg Oncol 2003; 85:7-13. [PMID: 14696082 DOI: 10.1002/jso.20008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Levin TR. Flexible sigmoidoscopy for colorectal cancer screening: valid approach or short-sighted? Gastroenterol Clin North Am 2002; 31:1015-29, vii. [PMID: 12489275 DOI: 10.1016/s0889-8553(02)00053-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Flexible sigmoidoscopy is a safe, effective test that may be delivered feasibly on a large scale for mass colorectal cancer screening. Flexible sigmoidoscopy is 67% to 80% as sensitive as colonoscopy in a screening population, but is probably 10 to 20 times safer than colonoscopy in terms of complications. Several national guidelines recommend combining flexible sigmoidoscopy with fecal occult blood tests. There is limited evidence to support this practice, and the added benefit to an existing flexible sigmoidoscopy screening program although real, may be marginal. In the future, it is likely that flexible sigmoidoscopy screening among patients aged 50 to 65 will be supplemented with total colonic screening, using molecular-based fecal tests or virtual colonoscopy, after age 65.
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Affiliation(s)
- Theodore R Levin
- Gastroenterology Department, Kaiser Permanente Medical Center, 1425 S. Main Street, Medicine Station E, Walnut Creek, CA 94596, USA.
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47
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Swaroop VS, Larson MV. Colonoscopy as a screening test for colorectal cancer in average-risk individuals. Mayo Clin Proc 2002; 77:951-6. [PMID: 12233928 DOI: 10.4065/77.9.951] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Screening for colorectal cancer has become the standard of care and is currently recommended by most major health organizations, including the American Cancer Society. Randomized controlled trials using fecal occult blood testing as the screening strategy have shown a reduction in mortality due to colorectal cancer. However, colorectal cancer differs from other cancers in that a variety of screening tests have been approved and recommended by experts. The advantages and disadvantages of different screening tests have been the subject of intense debate. Colonoscopy has theoretical advantages over other screening tests, including direct visualization of the entire colon and, more importantly, removal of precancerous adenomatous lesions. This review discusses the advantages and disadvantages of colonoscopy as a screening test for colorectal cancer with regard to efficacy, cost-effectiveness, and patient compliance.
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Affiliation(s)
- Vege Santhi Swaroop
- Division of Area General Internal Medicine, Mayo Clinic, Rochester, Minn 55905, USA.
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Zheng S, Liu XY, Ding KF, Wang LB, Qiu PL, Ding XF, Shen YZ, Shen GF, Sun QR, Li WD, Dong Q, Zhang SZ. Reduction of the incidence and mortality of rectal cancer by polypectomy: a prospective cohort study in Haining County. World J Gastroenterol 2002; 8:488-92. [PMID: 12046076 PMCID: PMC4656427 DOI: 10.3748/wjg.v8.i3.488] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To reduce the incidence and mortality of rectal cancer and address the hypothesis that colorectal cancer often arise from precursor lesion (s), either adenomas or non-adenomatous polyps, by conducting a population-based mass screening for colorectal cancer in Haining County, Zhejiang, PRC.
METHODS: From 1977 to 1980, physicians screened the population of Haining County using 15 cm rigid endoscopy. Of over 240000 participants, 4076 of them were diagnosed with precursor lesions, either adenomas or non-adenomatous polyps, which were then removed surgically. All individuals with precursor lesions were followed up and reexamined by endoscopy every two to five years up to 1998.
RESULTS: After the initial screening, 953 metachronous adenomas and 417 non-adenomatous polyps were detected and removed from the members of this cohort. Further, 27 cases of colorectal cancer were detected and treated. Log-rank tests showed that the survival time among those cancer patients who underwent mass screening increased significantly compared to that of other colorectal cancer patients (P < 0.0001). According to the population-based cancer registry in Haining County, age-adjusted incidence and mortality of rectal cancer decreased by 41% and 29% from 1977-1981 to 1992-1996, respectively. Observed cumulative 20-year rectal cancer incidence was 31% lower than the expected in the screened group; the mortality due to rectal cancer was 18% lower than the expected in the screened group.
CONCLUSION: Mass screening for rectal cancer and precursor lesions with protocoscopy in the general population and periodical following-up with routine endoscopy for high-risk patients may decrease both the incidence and mortality of rectal cancer.
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Affiliation(s)
- Shu Zheng
- Cancer Institute, Zhejiang University, 88 Jiefang Road, HangZhou 310009, Zhejiang Province, China.
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Affiliation(s)
- H Strul
- Department of Gastroenterology, Tel-Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Israel
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