Balancing early detection and over-screening: Evaluating colonoscopy's role in shaping colorectal cancer trends in Korea

Abstract

This study discusses the impact of the increasing use of colonoscopy on the trends of colorectal cancer (CRC) in Korea. Different views are raised on the research methods and conclusions of Kim et al. It emphasizes the need to carefully consider the balance between the benefits of early detection and the risks of over-screening. This letter also suggests directions for future research and policy considerations in the field of CRC screening and prevention in Korea.

Key Words: Colorectal cancer; Colonoscopy; Screening policies; Early detection; Over-screening; Artificial intelligence; Molecular biomarkers; Oncology research

Core Tip: This study meticulously examines the impact of increased colonoscopy use on colorectal cancer (CRC) trends in Korea, highlighting the critical balance between early detection and the risks of over-screening. It underscores the importance of age-specific screening guidelines and advocates for the integration of advanced technologies and personalized approaches in CRC screening strategies. The document emphasizes the need for ongoing research and policy development in the realm of CRC prevention and management, aligning with current trends in gastroenterology and oncology research.

TO THE EDITOR

Colorectal cancer (CRC) is a pressing global health issue[1], with South Korea experiencing a particularly notable increase in cases[2]. The crucial role of early detection in improving CRC survival rates can't be emphasized enough. Colonoscopy, an essential component of CRC screening, facilitates the early discovery and removal of precancerous growths, effectively reducing the risk of cancer development. The rising frequency of colonoscopies in Korea mirrors an enhanced awareness of CRC and a shift towards more proactive health measures[3,4]. This trend not only reflects a growing commitment to health management but also highlights the fundamental role of colonoscopy in combating CRC. The increased focus on early detection through colonoscopy represents a significant stride in public health, potentially leading to better outcomes for those at risk of this serious disease.

Recently, the key findings of the high-quality study titled “Trends in colorectal cancer incidence according to an increase in the number of colonoscopy cases in Korea”, published by Kim et al[5] on World Journal of Gastrointestinal Oncology, have revealed significant trends in the incidence of CRC across different age groups in Korea, correlating with the rising frequency of colonoscopy procedures. Notably, the incidence of CRC showed significant changes as colonoscopy use increased, suggesting that widespread screening influences CRC detection and management across various age groups. The research underscores the necessity of understanding these dynamics to optimize screening strategies and better address the increasing challenge of CRC. This highlights the shifting epidemiology of CRC and the critical role of preventive measures in different population segments.

ANALYZE AND CRITICALLY EVALUATE

The methodology of the study is robust, utilizing a retrospective cohort design to analyze the relationship between the number of colonoscopy procedures and the incidence of CRC in Korea. The large sample size and the extended duration of the study add strength to its findings. However, being a retrospective analysis, it may have inherent limitations like selection bias and the inability to establish causation[6].

In this study, we examined the impact of increased colonoscopy utilization on CRC trends in South Korea[7]. However, we recognize the limitations of generalizing these findings to populations with diverse healthcare systems and demographic profiles. South Korea's healthcare system exhibits notable differences compared to many other countries, particularly in resource allocation, insurance coverage, and public health awareness. These factors can significantly influence both the acceptance and effectiveness of colonoscopy screening. For example, research has shown that low-income and minority groups often participate in colonoscopy screening at considerably lower rates than other populations, potentially creating disparities in screening outcomes. Therefore, while our findings offer valuable insights specific to the South Korean context, they should be applied with caution in other countries or regions.

To address these limitations more effectively, we recommend that future research incorporate cross-national comparisons to assess the influence of varying healthcare systems, cultural contexts, and demographic characteristics on the effectiveness of colonoscopy screening. Additionally, targeted interventions for low-income and minority groups, coupled with the development of personalized screening strategies, can enhance acceptance and participation rates within these populations. By implementing such measures, we aim to achieve a more comprehensive understanding of colonoscopy screening's effectiveness across diverse populations, ultimately guiding the formulation of more impactful public health policies.

The findings of this study are substantial but must be interpreted with caution, as confounding factors such as lifestyle and dietary changes, along with advancements in diagnostic technology during the study period, may independently influence CRC incidence. These factors could also affect colonoscopy utilization. Consequently, controlling for confounding variables is crucial to ensure the validity and reliability of the results. Previous research has gathered detailed data on participants' lifestyle and dietary habits through questionnaires, covering aspects such as diet type, exercise frequency, and body mass index. The results revealed that a healthy diet (e.g., high-fiber intake) was associated with a lower risk of CRC, whereas obesity correlated with an increased risk[8].

In data analysis, researchers frequently employ multivariate regression models to adjust for confounding variables, incorporating lifestyle and dietary habits as covariates to evaluate their impact on the relationship between colonoscopy frequency and CRC incidence. Studies have demonstrated that, after accounting for lifestyle factors, the association between colonoscopy utilization and reduced CRC mortality becomes significantly stronger, underscoring the critical importance of controlling for confounding variables[9]. Additionally, to confirm the robustness of the findings, some studies have performed sensitivity analyses to assess the potential influence of variations in lifestyle and dietary patterns. For instance, a study involving individuals aged 50 years to 75 years reported an increase in colonoscopy screening rates from 47.7% in 2005 to 69.9% in 2021, highlighting the effectiveness of screening strategies and their vital role in reducing cancer incidence[10].

In summary, controlling for confounding factors and validating the robustness of results enable researchers to more thoroughly assess the relationship between colonoscopy frequency and CRC incidence, while offering readers a clear understanding of the research context and methodological framework. These efforts not only strengthen the credibility of the findings but also provide valuable insights for the development of future screening strategies.

PERSONAL INSIGHTS AND PERSPECTIVES

In this study, we examined the critical role of colonoscopy in CRC screening, acknowledging that its prominence as the primary screening tool may overshadow the potential contributions of other effective methods and emerging technologies. To provide a more comprehensive perspective on CRC screening, we expanded our discussion to encompass broader strategies, including non-invasive tests, artificial intelligence (AI) technologies, and the integration of molecular biomarkers.

Non-invasive screening methods, such as fecal immunochemical testing (FIT) and multi-target stool DNA testing (mt-sDNA), have shown high sensitivity and specificity in detecting CRC. Research indicates that FIT is more cost-effective than mt-sDNA testing, with both methods yielding comparable patient outcomes. This suggests that non-invasive tests can significantly enhance screening participation rates, particularly among individuals hesitant to undergo invasive procedures[11].

The application of AI technologies in colonoscopy is advancing rapidly, offering transformative potential. AI algorithms can analyze endoscopic images to enhance the detection rates of adenomas and polyps, thereby minimizing the risk of missed diagnoses. Notably, studies have demonstrated that AI-assisted endoscopy significantly improves the detection of small and flat lesions, which are frequently overlooked in conventional procedures[12,13].

The integration of molecular biomarkers presents new opportunities for personalized screening. By analyzing specific biomarkers in blood or stool samples, it becomes possible to achieve early cancer detection and provide tailored guidance for subsequent treatment. These innovative approaches and emerging technologies not only improve screening efficiency but also optimize resource utilization and reduce unnecessary healthcare expenditures[14].

The widespread adoption of colonoscopy has significantly advanced the early detection of CRC but has also raised concerns regarding over-screening. This can result in unnecessary medical procedures, heightened patient anxiety, and increased healthcare costs[15,16]. Therefore, it is crucial to develop screening guidelines tailored to age and regional characteristics[17,18]. These guidelines should aim to balance the benefits of early detection in high-risk populations with the potential risks and costs of over-screening in low-risk groups. Additionally, careful consideration is required when applying these strategies to healthcare settings or populations with differing demographic characteristics.

Policymakers need clear and actionable recommendations to facilitate the effective implementation of age-specific and region-specific screening guidelines. First, healthcare providers should be equipped with training and educational resources to ensure they fully understand and adhere to the new guidelines. Furthermore, standardized screening processes must be developed to guarantee that all eligible patients have equitable access to appropriate screening. Implementing patient navigation systems can also play a critical role in helping individuals overcome barriers to screening, such as language difficulties or distrust in the healthcare system.

Effective data monitoring and evaluation mechanisms are essential for the successful implementation of screening guidelines. Policymakers should establish robust systems to track screening rates across various regions and population groups, leveraging this data to refine and optimize screening strategies. This evidence-driven approach not only ensures the identification of populations most in need of intervention but also enhances the efficiency of resource allocation, enabling more targeted and impactful healthcare delivery.

Finally, policymakers should work closely with local health departments and community organizations to develop and implement personalized health education campaigns aimed at increasing public awareness about the importance of CRC screening. Engaging communities in these efforts not only fosters greater acceptance of screening programs but also significantly boosts overall participation rates.

These specific recommendations highlight the critical need for developing comprehensive and personalized screening strategies. Such strategies should be customized to address individual risk factors and align with regional healthcare contexts, while also ensuring their applicability and effectiveness across diverse settings. By adopting this approach, public health policies can achieve greater impact and play a significant role in reducing the incidence of CRC.

CURRENT RESEARCH TRENDS AND FUTURE DIRECTIONS

The study's findings correlate with the current trends in gastroenterology and oncology research, emphasizing the criticality of early detection in managing CRC[19,20]. It suggests a future research trajectory focusing on personalized screening strategies that account for individual risk factors like genetics, lifestyle, and family history. There is also a growing interest in employing advanced technologies, such as AI and molecular biomarkers, for more precise and earlier detection of CRC. For instance, recent research has demonstrated that AI models can assist in reading histopathologic tissue images, reducing variability among doctors and improving diagnostic accuracy in CRC screening. Additionally, studies have shown that AI-guided care can play a pivotal role in improving screening, diagnosis, and treatment strategies for CRC patients. While these approaches could transform CRC screening by enhancing efficiency and minimizing invasiveness, challenges such as resource allocation, technological adoption, and patient acceptance remain. For example, the need for substantial computational resources and the integration of AI tools into clinical workflows can pose significant hurdles. Moreover, patient acceptance of AI-driven diagnostic tools may vary, necessitating efforts to build trust and ensure transparency in AI applications. Addressing these aspects will be crucial to realizing the full potential of AI and molecular biomarkers in CRC screening.

CONCLUSION AND OUTLOOK

This study on CRC trends in Korea, in the context of increasing colonoscopy use, is pivotal for the broader landscape of CRC prevention and screening. It underscores the need for ongoing research to refine screening strategies, balancing the benefits of early detection with the risks of over-screening. The study highlights the importance of personalized medicine and technological advancements in enhancing CRC screening efficacy. It calls for researchers and policymakers to continue developing targeted, evidence-based approaches to CRC prevention.

The research provides crucial insights into understanding and optimizing CRC screening strategies, emphasizing the role of early detection in improving CRC management. The findings show significant changes in CRC incidence across various age groups in Korea as colonoscopy use increased, revealing the potential impact of widespread screening on CRC detection and management. The study stresses the importance of formulating age-specific screening guidelines that balance early detection benefits with over-screening risks and costs.

In line with current trends in gastroenterology and oncology research, the study suggests future research focusing on personalized screening strategies and the application of advanced technologies like AI and molecular biomarkers. These developments promise to revolutionize CRC screening, making it more efficient and less invasive, while also addressing over-screening challenges.

CONCLUSION

Overall, the study emphasizes the necessity of continued research and policy development to further improve CRC prevention and screening methods.