Prevalence and risk of colorectal adenoma in asymptomatic Koreans aged 40–49 years undergoing screening colonoscopy

Background and Aim: Colorectal cancer screening is recommended for average‐risk persons beginning at age 50. However, information about the incidence and risk factors of precursor adenoma in preceding decades is limited. The aim of this study was to determine the prevalence and risk factors of colorectal adenoma in persons aged 40–49 years and to compare the data with those aged 30–39 years and 50–59 years. Methods: A cross‐sectional study of 5254 asymptomatic subjects who underwent screening colonoscopy was conducted. Data were stratified by age into three groups: 608 aged 30–39 years, 1930 aged 40–49 years, and 2716 aged 50–59 years. Results: Prevalence of overall adenomas was 10.4% in the 30–39 years age group, 22.2% in the 40–49 years age group, and 32.8% in the 50–59 years age group. Advanced adenoma was found in 0.7% of the 30–39 years age group, 2.7% of the 40–49 years age group, and 4.1% of the 50–59 years age group. In the 40–49 years age group, male sex and current smoking habits showed associations with low‐risk adenoma after multiple adjustments. Moreover, male sex (odds ratio [OR] = 1.55, 95% confidence interval [CI]: 1.02–3.23), current smoking (OR = 1.58, 95%CI: 1.06–3.50), and family history of colorectal cancer (OR = 2.54, 95%CI: 1.16–5.56) were independent predictors of advanced adenoma in this age group. Conclusions: Prevalence of adenoma in subjects aged 40–49 years was higher than in previous studies. Male sex and current smoking habits along with a family history of colorectal cancer were associated with advanced adenoma in this age group.     

Potential for prevention: a cohort study of colonoscopies and removal of adenomas in a FIT-based colorectal cancer screening programme

Introduction: Evidence suggests that colorectal cancer (CRC) screening using guaiac faecal occult blood tests (gFOBT) reduces the CRC burden by facilitating timely removal of adenomas. Yet, the faecal immunochemical test (FIT) is being implemented in many countries. The aim of this study was to analyse the risk of having adenomas detected when invited for FIT-based screening as compared to those not yet invited.

Material and Methods: The study was designed as a register-based retrospective cohort study. The potential for prevention was estimated as number of individuals who had no adenomas, non-advanced adenomas, and advanced adenomas detected per 1000 invited/not yet invited individuals and the relative risk (RR) of each of the three outcomes.

Results: A total of 1,359,340 individuals were included, 29.6% of whom had been invited and 70.4% had not yet been invited to participate in CRC screening. Compared with the not yet invited population, the invited group had a RR of no adenomas of 2.28 (2.22–2.34) and a RR of advanced adenomas of 7.41 (6.93–7.91). The RR of colonoscopy was 2.93 (2.87–2.99) for the invited population compared with the not yet invited population.

Conclusion: The RR of having a colonoscopy was three times higher among those invited compared to those not yet invited for CRC screening and twice as often those who had been invited compared to those not yet invited had no adenomas detected. Still, the risk of advanced adenomas was more than seven times higher among the invited population, indicating that the screening programme holds great potential for reducing the CRC burden.

Abbreviations: CI: Confidence interval; CRC: Colorectal cancer; FIT: Faecal immunochemical test; ICD: International Classification of Disease; RR: Relative risk     

Colonoscopy surveillance for high risk polyps does not always prevent colorectal cancer

AIM To determine the frequency and risk factors for colorectal cancer(CRC) development among individuals with resected advanced adenoma(AA)/traditional serrated adenoma(TSA)/advanced sessile serrated adenoma(ASSA). METHODS Data was collected from medical records of 14663 subjects found to have AA, TSA, or ASSA at screening or surveillance colonoscopy. Patients with inflammatory bowel disease or known genetic predisposition for CRC were excluded from the study. Factors associated with CRC developing after endoscopic management of high risk polyps were calculated in 4610 such patients who had at least one surveillance colonoscopy within 10 years following the original polypectomy of the incident advanced polyp. RESULTS84/4610(1.8%) patients developed CRC at the polypectomy site within a median of 4.2 years(mean 4.89 years), and 1.2%(54/4610) developed CRC in a region distinct from the AA/TSA/ASSA resection site within a median of 5.1 years(mean 6.67 years). Approximately, 30%(25/84) of patients who developed CRC at the AA/TSA/ASSA site and 27.8%(15/54) of patients who developed CRC at another site had colonoscopy at recommended surveillance intervals. Increasing age; polyp size; male sex; right-sided location; high degree of dysplasia; higher number of polyps resected; and piecemeal removal were associated with an increased risk for CRC developmentat the same site as the index polyp. Increasing age; right-sided location; higher number of polyps resected and sessile endoscopic appearance of the index AA/TSA/ASSA were significantly associated with an increased risk for CRC development at a different site. CONCLUSION Recognition that CRC may develop following AA/TSA/ASSA removal is one step toward improving our practice efficiency and preventing a portion of CRC related morbidity and mortality.     

The role of colonoscopy in screening persons with family history of colorectal cancer

Abstract First-degree relatives of colorectal cancer patients are at increased risk for developing colorectal neoplasms. In order to assess the potentiality of colonoscopy screening in this high-risk population, 213 asymptomatic family members (age range 30-69 years, mean 42.8 years) of those patients with colorectal cancer received colonoscopic examination at Chang-Gung Memorial Hospital from April 1992 to May 1994. Twenty-eight persons with 42 lesions (polyps or cancer) were identified, including 28 adenomas, nine hyperplastic polyps and five adenocarcinomas. The positive detection rate was 9.9% for adenoma and 2.3% for cancer. Colorectal neoplasms afflicted males more frequently than females (16.7 vs 5.7%, P < 0.05) and occurred less frequently in those < 40 years of age (5.5 vs 17.2%, P < 0.05). Forty-two per cent of the detected neoplastic lesions were beyond the reach of 60 cm flexible sigmoidoscopy and 36% of adenomas were < 0.5 cm in size and would be missed if patients were screened by air contrast barium enema. Cost analysis revealed that the charges of both screening colonoscopy and screening flexible sigmoidoscopy/air contrast barium enema were approximate. Colonoscopy also has a high acceptability and safety. It appears appropriate to use colonoscopy, rather than flexible sigmoidoscopy or air contrast barium enema, as an initial screening procedure for persons with a family history of colorectal cancer, especially those > 40 years of age.     

A modified colorectal screening score for prediction of advanced neoplasia: A prospective study of 5744 subjects

Background and Aim

We validated a modified risk algorithm based on the Asia‐Pacific Colorectal Screening (APCS) score that included body mass index (BMI) for prediction of advanced neoplasia.

Methods

Among 5744 Chinese asymptomatic screening participants undergoing a colonoscopy in Hong Kong from 2008 to 2012, a random sample of 3829 participants acted as the derivation cohort. The odds ratios for significant risk factors identified by binary logistic regression analysis were used to build a scoring system ranging from 0 to 6, divided into “average risk” (AR): 0; “moderate risk” (MR): 1–2; and “high risk” (HR): 3–6. The other 1915 subjects formed a validation cohort, and the performance of the score was assessed.

Results

The prevalence of advanced neoplasia in the derivation and validation cohorts was 5.4% and 6.0%, respectively (P = 0.395). Old age, male gender, family history of colorectal cancer, smoking, and BMI were significant predictors in multivariate regression analysis. A BMI cut‐off at > 23 kg/m² had better predictive capability and lower number needed to screen than that of > 25 kg/m². Utilizing the score developed, 8.4%, 57.4%, and 34.2% in the validation cohort were categorized as AR, MR, and HR, respectively. The corresponding prevalence of advanced neoplasia was 3.8%, 4.3%, and 9.3%. Subjects in the HR group had 2.48‐fold increased prevalence of advanced neoplasia than the AR group. The c‐statistics of the modified score had better discriminatory capability than that using predictors of APCS alone (c‐statistics = 0.65 vs 0.60).

Conclusions

Incorporating BMI into the predictors of APCS score was found to improve risk prediction of advanced neoplasia and reduce colonoscopy resources.     

Metabolic syndrome is an independent risk factor for synchronous colorectal neoplasm in patients with gastric neoplasm

Background and Aim: There are no data on how metabolic syndrome (MetS) affects the prevalence of synchronous colorectal neoplasm (CRN) in gastric neoplasm (GN) patients. The aim of this study was to investigate a model for risk stratification for colorectal screening by evaluating the clinical characteristics of synchronous CRN in GN patients classified according to the presence of MetS. Methods: A cross‐sectional, case‐control study of 492 patients (368 males and 124 females) with GN, and 492 age‐matched healthy controls undergoing simultaneous upper endoscopy and colonoscopy, was conducted. Results: The GN group involved 446 patients without MetS, and 46 patients with MetS. In total, 177 (39.7%) and 28 (60.9%) synchronous CRN were detected in GN patients without MetS and with MetS, respectively (P = 0.006). A total of 143 (34.7%) synchronous colorectal adenomas were detected in GN patients without MetS, whereas 17 (48.6%) were detected in GN patients with MetS (P = 0.101), as well as more synchronous colorectal cancers (11.2% vs 37.9%, P < 0.001). A multivariate logistic regression analysis revealed that the presence of GN (OR = 1.54, 95% CI: 1.18–2.00, P = 0.001) and the presence of MetS (odds ratio = 1.82, 95% confidence interval: 1.19–2.78, P = 0.006) were significant independent risk factors associated with the prevalence of CRN. The frequency of synchronous CRN in GN patients with MetS was 1.96 times greater than that in the GN group without MetS. Conclusion: The risk of synchronous CRN is significantly increased by the presence of GN, especially in MetS patients. Screening for synchronous CRN is highly recommended for GN patients with MetS.     

Factors associated with patients’ decision on colorectal cancer screening

Cancer prevention and control are critical public health concerns. However, the screening uptake and referral rate for colorectal cancer (CRC) in Taiwan remain low. This study focused on the factors influencing whether a patient with a CRC diagnosis chooses to undergo referral follow-up.A cross-sectional research and used the Health Belief Model was method applied in this study. Variables such as demographic factors, CRC diagnosis-related knowledge factors, and health belief factors were employed to investigate the decisive factors that affect the health behavior of patients diagnosed with CRC who test positive on the fecal occult blood test. Study identified prospective participants in Daliao District, Kaohsiung City, Taiwan aged 50 to 75 years. A structured questionnaire was administered to the individuals, and 200 responded. The questionnaires of 100 who went for a referral group and 80 who did not a nonreferral group were analyzed. The questionnaire was reliable and valid, as determined through an expert evaluation and pretest, respectively.Among the 200 participants, T test indicated that those who underwent a referral were significantly more likely to be younger (Age [Mean ± SD] n: 62.7, 7.1%; Unreferred group: n: 65.1, 7.0%; Referred group: n:60.7, 6.6%; P ≤ .001), be more educated (P = .002), exercise more (P < .05), and have more family members with cancer (P = .001) or CRC (P < .05). Participants who underwent a referral also had significantly more knowledge (P < .001). Furthermore, those who underwent a referral had significantly perceived greater susceptibility (P < .05), greater benefits (P = .002), and lower barriers (P < .001) of screening; they also received greater encouragement to do so from sources (e.g., clinicians or the media) around them (P = .009).Age, education level, number of family members with cancer or CRC, exercise habits, knowledge of CRC, perceived susceptibility, perceived benefits, perceived barriers, and encouragement from others influence referral behavior. Government policy should focus on older patients and health education, especially in the mass media. Hospitals should also ensure the ease of referrals to lower perceived barriers.     

Colonoscopic screening of first-degree relatives of patients with large adenomas: increased risk of colorectal tumors

BACKGROUND & AIMS: The risk of developing colorectal neoplasia is not well established among family members of individuals with large adenomas, and screening strategies remain under debate in this population. This study aimed at quantifying the risk of colorectal adenomas and cancers using colonoscopic screening in first-degree relatives of patients with large adenomas. METHODS: This case-control study was performed in 18 endoscopic units of French nonuniversity hospitals. A colonoscopy was offered to first-degree relatives of 306 index cases with adenomas > or =10 mm if they were alive, aged 40-75 years, and could be contacted by the index case. Among them, 168 were examined and matched for age, sex, and geographical area with 2 controls (n = 307). Controls were randomly selected from 1362 consecutive patients aged 40-75 years having undergone a colonoscopy for minor symptoms. RESULTS: The prevalence of large adenomas and cancers was 8.4% and 4.2%, in relatives and controls, respectively. Odds ratios (ORs) associated with a history of large adenomas in relatives were 2.27 (95% confidence interval [CI], 1.01-5.09) for cancers or large adenomas, 1.21 (95% CI, 0.68-2.15) for small adenomas, and 1.56 (95% CI, 0.96-2.53) for all colorectal neoplasia. The risk of large adenomas and cancers was higher in relatives of index cases younger than 60 years (OR, 3.82; 95% CI, 0.92-15.87) and when the index case had large distal adenomas (OR, 3.14; 95% CI, 1.27-7.73). CONCLUSIONS: First-degree relatives of patients with large adenomas are at increased risk of developing colorectal cancers or large adenomas. This result has implications for screening in this high-risk population.     

Beliefs, risk perceptions, and gaps in knowledge as barriers to colorectal cancer screening in older adults

OBJECTIVES: To assess beliefs and perceptions of risk about colorectal cancer (CRC) and gaps in knowledge about screening in adults aged 65 to 89.
DESIGN: A population-based survey.
SETTING: United States.
PARTICIPANTS: A total of 1,148 respondents with no history of CRC, representing an estimated population of 31.6 million persons, who were stratified according to screening behavior (up to date (n=457) vs not up to date (n=691)) and age (65–74 vs 75–89).
MEASUREMENTS: The Health Information National Trends Survey (2003) questionnaire.
RESULTS: An estimated 25% of adults aged 65 to 89 had not heard of the fecal occult blood test, 17% had not heard of sigmoidoscopy or colonoscopy, and 42% were not up to date with either screening modality. Not visiting a healthcare provider in the previous year, not knowing about tests available for colon cancer, perceiving the arrangements to be checked for detecting colon cancer to be difficult, and not having an opinion about it and its cost, were significantly associated with not being up to date (each P <.03). Persons who were not up to date were frequently unaware of the importance of CRC screening, and often reported lack of a provider's recommendation to be screened (>75%). Lack of knowledge and awareness were more prevalent in those aged 75 to 89 than those aged 65 to 74.
CONCLUSION: Lack of knowledge and awareness and the absence of a physician's recommendation to be tested might explain not being up to date with CRC screening in adults in these age groups. These findings suggest a potential value for better communication between older adults and their providers regarding screening for CRC, when appropriate.     

Microsatellite instability—a useful diagnostic tool to select patients at high risk for hereditary non-polyposis colorectal cancer: a study in different groups of patients with colorectal cancer

BACKGROUND: Clinical diagnosis of hereditary non-polyposis colorectal cancer (HNPCC) is based on a typical family history. As molecular genetic testing is predominantly restricted to these families, gene carriers not meeting the clinical criteria may be missed. AIMS: To examine the value of microsatellite instability (MSI) as a tool to increase the likelihood for uncovering a mismatch repair germline mutation in patients with colorectal cancer and to identify a genotype-phenotype relation in families with verified mutations. METHODS: Systematic search for germline mutations (hMSH2 and hMLH1 genes) was performed in 96 patients: 57 fulfilled the Amsterdam criteria (group 1) and 12 the looser HNPCC criteria (group 2). Seventeen patients showed familial clustering of cancers (group 3) and 10 patients under 50 years had sporadic cancer (group 4), the latter of whom all exhibited MSI+ tumours. RESULTS: A similar proportion of germline mutations was found in patients who fulfilled the clinical criteria of HNPCC and had MSI+ tumours (groups 1 and 2; 15/39) compared with patients who did not meet these clinical criteria but who had MSI+ tumours (groups 3 and 4; 8/27 patients). Affected relatives of patients with hMLH1 mutations showed a significantly higher frequency of colorectal cancer but a lower frequency of endometrium cancer than those with hMSH2 mutations. CONCLUSIONS: MSI in tumour tissue is a useful criterion for selecting patients who should be tested for germline mutations in the mismatch repair genes hMSH2 and hMLH1 irrespective of their family history. Among carriers of hMSH2 mutations the tumour spectrum was broader than among carriers of hMLH1 mutations.     

Depressed‐type submucosal invasive colorectal cancer in a patient with Lynch syndrome diagnosed using short‐interval colonoscopy

Although regular colonoscopy surveillance is recommended for patients with Lynch syndrome (LS) who underwent partial colectomy, the appropriate interval has not been determined. We report a case of colorectal cancer (CRC) detected by short‐interval surveillance colonoscopy (SC) in a patient with LS having a past history of partial colectomy. A 65‐year‐old man underwent sigmoidectomy for advanced CRC. His family history revealed that his two younger brothers had CRC in their twenties and thirties, respectively, and the patient met with the criteria in the Revised Bethesda Guidelines. After confirming the loss of MSH2 protein expression in the primary tumor, subsequent genetic testing showed germline mutation with a large deletion of exon 7–14 in the MSH2 gene, indicating a diagnosis of LS. After the diagnosis of LS, the patient underwent annual SC. Three years after the initial surgery, superficial submucosal invasive cancer was detected. Subsequently, SC after a 6‐month interval revealed a deep submucosal invasive cancer (7 mm in diameter). Although additional surgery was recommended, considering his comorbidities, regular SC rather than colectomy was selected. Even shorter‐interval SC carried out within a year is not sufficient to detect endoscopically resectable tumors in some high‐risk LS cases.     

A health‐risk appraisal model and endoscopic mass screening for esophageal cancer in Japanese men

A strong association between inactive aldehyde dehydrogenase‐2 (ALDH2) and risk of esophageal cancer has been demonstrated in East Asian drinkers. An alcohol flushing questionnaire asking about past and current tendency for facial flushing to occur after drinking a glass (≈180 mL) of beer predicts the presence of inactive ALDH2 among Japanese aged 40 years or older with a sensitivity and specificity of approximately 90%. We invented a health‐risk appraisal (HRA) model that makes it possible to identify Japanese men who are at high risk for esophageal cancer based on their past and current alcohol flushing tendency, drinking, smoking, and intake of vegetables and fruits. Between 2008 and 2009, 2221 Japanese men aged 50 years or older filled out the HRA questionnaire before undergoing a screening examination by upper gastrointestinal endoscopy at five medical facilities. The endoscopic examination resulted in a diagnosis of esophageal cancer in 19 subjects, and 117 (5.27%) subjects had an HRA score ≥11. The proportion of subjects with an HRA score ≥11 was higher in the 50–69 age group (6.11–6.88%) than in 70–89 age group (2.84–2.86%). The esophageal cancer detection rate was 4.27% among the subjects with an HRA score ≥11 and only 0.67% among the other subjects. Based on a receiver operating characteristic curve analysis, when an HRA score of ≥9 was used for subjects aged 50–69 years and of ≥8 for those aged 70–89 years as the cutoff value to select individuals with a high risk for esophageal cancer, its sensitivity and false‐positive rate was 52.6% and 15.2%, respectively, and the cancer detection rate was 2.91% in the high‐risk group, as opposed to 0.48% in the other group. In conclusion, the high detection rates for esophageal cancer in the high‐risk groups encouraged screening based on our HRA model in larger Japanese populations.