Screening for Colorectal Cancer in Personnel of an Academic Medical Center

The colorectal cancer (CRC) screening program in Israel offers the average-risk population fecal occult blood tests from the age of 50 years. Compliance, however, is very low, reaching only 6% of eligible persons in 2005. Our aim in this study was to describe the results of an improved CRC screening program directed at the in-house staff of Beilinson Hospital. All employees of Beilinson Hospital over age 50 years were sent a letter explaining the new CRC screening program and an accompanying questionnaire. Responders who reported a family history of CRC or related cancers or symptoms were offered colonoscopy; the remainder were offered sigmoidoscopy or, if they preferred, colonoscopy. Two hundred twenty of the 888 candidates (24.7%) completed the questionnaire, of whom 144 (16.2%) agreed to further investigation. These included 90 of 105 patients with a positive questionnaire and 20 of 115 with a negative questionnaire who underwent colonoscopy and 34 of 115 with a negative questionnaire who underwent sigmoidoscopy. The colonoscopy group included 26 of the 30 patients (86.6%) with a positive family history. Early-stage CRC was diagnosed in three patients (1.36%), all with a positive questionnaire. There were no pathologic findings on sigmoidoscopy. The sensitivity, specificity, and positive and negative predictive values of the questionnaire for identifying subjects with CRC or advanced adenoma were 100.00%, 18.86%, 2.27%, and 100.00%, respectively. In conclusion, using hospital facilities, we initiated a unique CRC screening program for employees. Our method may be applicable in other medical centers for the detection of adenomas and CRCs in the early, curative stages.     

Screening Colonoscopy for Colorectal Cancer in Asymptomatic People: A Meta-Analysis

Objective The preferred method for screening asymptomatic people for colorectal cancer (CRC) is colonoscopy, according to the new American guidelines. The aim of our study was to perform a meta-analysis of the prospective cohorts using total colonoscopy for screening this population for CRC. We looked for the diagnostic yield of the procedure as well as for its safety in a screening setting. Methods We included papers with more than 500 participants and only those reporting diagnostic yield of adenoma (and/or advanced adenoma) and CRC. Nested analysis were performed for secondary endpoints of complications and CRC stages when this information was available. All analyses were performed with StatDirect Statistical software, version 2.6.1 (). Results Our search yielded ten studies of screening colonoscopy conducted in asymptomatic people that met our inclusion criteria, with a total of 68,324 participants. Colonoscopy was complete and reached the cecum in 97% of the procedures. Colorectal cancer was found in 0.78% of the participants (95% confidence interval 0.13–2.97%). Stage I or II were found in 77% of the patients with CRC. Advanced adenoma was found in 5% of the cases (95% confidence interval 4–6%). Complications were rare and described in five cohorts. Perforation developed in 0.01% of the cases (95% confidence interval 0.006–0.02%) and bleeding in 0.05% (95% confidence interval 0.02–0.09%). Conclusions Our findings support the notion that colonoscopy is feasible and a suitable method for screening for CRC in asymptomatic people.     

Carbon Dioxide Insufflation Reduces Discomfort Due to Flexible Sigmoidoscopy in Colorectal Cancer Screening

Background: Flexible sigmoidoscopy is currently recommended as a screening modality for colorectal cancer. However, a substantial number of patients experience discomfort because of the procedure, possibly limiting compliance and thus screening success. During endoscopy, air is commonly used to insufflate the bowel. Carbon dioxide rather than air insufflation has been shown to reduce procedurerelated pain and discomfort in colonoscopy. The aim of the present study was to evaluate whether carbon dioxide insufflation reduces discomfort during and after flexible sigmoidoscopy for colorectal cancer screening. Methods: In a randomized, double-blinded design, 230 consecutive participants in a population-based flexible sigmoidoscopy colorectal cancer screening trial were assigned to have their examination performed with either carbon dioxide or air insufflation. Patients were asked to grade discomfort experienced both during and in the hours after the procedure on a visual analogue scale. Results: Carbon dioxide insufflation significantly reduced the amount of discomfort at 1, 3 and 6 h after the sigmoidoscopy. One hour after the examination, 84% of patients in the CO 2 group reported no discomfort, compared to 64% in the air group ( P = 0.006). No differences between the groups were observed during the examination. Conclusions: Carbon dioxide insufflation significantly reduced postexamination discomfort. The use of carbon dioxide rather than air insufflation may contribute to better public acceptance for flexible sigmoidoscopy screening.     

Prevalence of Proximal Serrated Polyps and Conventional Adenomas in an Asymptomatic Average-Risk Screening Population

Background/Aims

Detection of proximal serrated polyps (PSPs) is increasingly recognized as a new qualitative target for colonoscopy. The aims of this study were to assess the detected prevalence of PSPs and synchronous adenomas in an asymptomatic average-risk screening cohort and to evaluate potential factors associated with detection of PSPs.

Methods

The study included 1,375 asymptomatic average-risk Korean patients (aged 50 years or older) who underwent screening colonoscopy. In total, 1,710 polyps were evaluated pathologically.

Results

The overall PSP detection rate (PSPDR) was low at 3.1%, despite high polyp (54.0%) and adenoma detection rates (ADRs, 43.5%). ADR did not correlate with PSPDR, but it was strongly correlated with PDR (r=0.810; p<0.001). Patients with PSPs were more likely to have longer withdrawal time and more proximal colon adenomas than patients without PSPs (adjusted odds ratio [OR], 1.19; 95% confidence interval [CI], 1.09 to 1.31; p<0.001) (adjusted OR, 2.03; 95% CI, 1.06 to 3.88; p=0.031, respectively).

Conclusions

The detected prevalence of PSPs was low (<5%) in an asymptomatic average-risk screening Korean population, despite the high prevalence of conventional adenomas. A longer mucosal inspection of the proximal colon may serve as a practical method to enhance detection of PSPs.     

The role of colonoscopy and flexible sigmoidoscopy in screening for Colorectal Carcinoma

Six hundred thirty-two patients were referred to the Colorectal Clinic from February 1983 to February 1986 for screening with the Pentax 65 cm flexible sigmoidoscope. Forty-nine of these patients (8 percent) had adenomatous polyps. There were 27 males and 22 females. The mean distance examined by the 65 cm flexible sigmoidoscope was 55 cm. Five patients were excluded from analysis, leaving 44 patients who underwent colonoscopy to the cecum. At the time of colonoscopy, 15 of the 44 patients (34 percent) had one or more adenomatous polyps beyond reach of the 65 cm flexible sigmoidoscope. The remaining 29 patients who underwent colonoscopy had no polyps beyond reach of the 65 cm flexible sigmoidoscope. Thirty adenomatous polyps, one invasive carcinoma of the ascending colon, and one hyperplastic polyp were found in these 15 patients. In summary, 34 percent of patients found to have adenomatous polyps within reach of the 65 cm flexible sigmoidoscope harbored one or more adenomatous polyps in the proximal colon at the time of colonoscopy. A positive 65 cm flexible sigmoidoscope examination requires colonoscopy to identify and remove proximal premalignant lesions, thereby aborting the polyp-cancer sequence.     

Flexible Sigmoidoscopy for Colorectal Cancer Screening in the Elderly

Data on performance characteristics of flexible sigmoidoscopy (FS) between age groups are limited. This study evaluates screening FS in subjects > or = 75 years of age (elderly) compared with ages 50-74 years (general screening population). Data were collected on patient characteristics, insertion depth, procedural difficulties, complications, and endoscopic findings. There was an increased rate of endoscopist-reported limitations (50.4% vs. 34.9%; P = 0.0001) and incomplete examinations (15.6% vs. 5.4%; P = 0.0001) in the elderly cohort relative to subjects aged 50-74. The complication rate (1.0% vs. 1.5%; P = 0.53), adenoma detection rate (7.2% vs. 5.6%; P = 0.213), and advanced adenoma detection rate (0.71% vs 0.65%; P = 0.86) were similar. More carcinomas were detected in the elderly (0.53% vs. 0.06%; P = 0.042). Factors associated with incomplete examinations in the elderly included age, female gender, and poor bowel preparation. Despite technical difficulties, FS in the elderly is safe and detects significant pathology.     

Population Screening for Colorectal Cancer Means Getting FIT: The Past,Present, and Future of Colorectal Cancer Screening Using the Fecal Immunochemical Test for Hemoglobin (FIT)

Fecal immunochemical tests for hemoglobin (FIT) are changing the manner in which colorectal cancer (CRC) is screened. Although these tests are being performed worldwide, why is this test different from its predecessors? What evidence supports its adoption? How can this evidence best be used? This review addresses these questions and provides an understanding of FIT theory and practices to expedite international efforts to implement the use of FIT in CRC screening.     

Colorectal Cancer Screening Prevalence,Perceived Barriers,and Preference for Screening Colonoscopy Among Hospitalized Women

Background:Barriers to colorectal cancer screening persist despite screening campaigns, especially among women. This study explores the prevalence, preferences, and barriers associated with colorectal cancer screening and evaluates the effect of an inpatient intervention (one-on-one bedside education and handout about colorectal cancer) on screening adherence among hospitalized women.Methods:A prospective intervention study among 510 hospitalized women, who are cancer-free (except for skin cancer) at enrollment, aged between 50 and 75 years was conducted at an academic center. Socio-demographic, family history, and medical comorbidities data were collected for all patients. A post-hospitalization follow-up survey determined the effect of inpatient intervention on colorectal cancer screening adherence. Unpaired t-test and chi-square tests were used to compare characteristics, perspectives, and preferences for screening among adherent and non-adherent groups.Results:Mean age was 60.5 years, 45% reported an annual household income of <$20 000, 36% of women were African American, 27% of women were overdue for colorectal cancer screening, and 33% never had a screening colonoscopy. The most frequently reported barriers to colorectal cancer screening were “I have other problems more important than getting a colonoscopy,” “No transportation to get to the test,” and “Not counseled by primary care provider.” Sixty-six percent of the non-adherent women would agree to have an inpatient screening colonoscopy if offered.Conclusion:A significant number of hospitalized women are non-adherent to colorectal cancer screening, while the educational intervention was partially successful in enhancing colorectal cancer screening, most hospitalized women remained non-adherent after hospitalization. A majority of these women were amenable to inpatient screening colonoscopy if offered during a hospital stay.     

Screening for colorectal cancer in average-risk populations

Screening average-risk populations for colorectal cancer can reduce the incidence and mortality of colorectal cancer. Effectiveness depends on programmatic adherence and quality. This review discusses the evidence supporting the use of currently available screening tests. The discussion specifically focuses on programmatic issues and highlights the importance of quality assurance in each program.     

Screening Preferences of Patients at Familial Risk of Colorectal Cancer

Our primary objective was to assess the screening preferences of patients at familial risk of colorectal cancer. Asymptomatic subjects aged 18–75 with a single first-degree relative diagnosed with colorectal cancer (n = 48) or polyps (n = 52) were asked to identify a preferred screening strategy, test features influencing their choice, and level of interest in decision-making after reviewing a decision aid describing the pros and cons of currently recommended screening tests. Although both groups preferred colonoscopy, 40% of subjects with a family history of colorectal cancer and 48% of those with a family history of polyps preferred alternative strategies. Accuracy was the most commonly identified test feature influencing test preference. Most subjects (66%) felt that selection of screening test should be a patient dominant or shared process. We conclude that patients at familial risk of colorectal cancer have distinct screening preferences that often vary from current recommendations.     

Using the Gastroscope for Incomplete Colonoscopy

PURPOSE Reports of virtual colonoscopy demonstrate sensitivity similar to that of conventional colonoscopy for polyps 5 mm or larger, suggesting the validity of its use for colorectal cancer screening. Critical to the success of either procedure is the ability to evaluate the entire colon. Cecal intubation rates during diagnostic or screening colonoscopies vary from 53 to 99 percent. We describe the added value of using a gastroscope to perform a colonoscopic examination that would otherwise result in an incomplete colonoscopy.METHODS From January 1, 2002 to December 31, 2002 a total of 1,979 colonoscopies were performed. A gastroscope was used in 1.3 percent (n = 26) of these colonoscopies in an effort to complete the index examination initially started with a standard or pediatric colonoscope. The success rate was defined as intubating proximal to the initial area of impasse and entering the cecum.RESULTS Cecal intubation was achieved in 62 percent of patients.CONCLUSIONS In patients with incomplete conventional colonoscopy, the gastroscope can usually advance through the initial area of impasse with a cecal intubation rate of 62 percent.Presented at The American Society of Colon and Rectal Surgeons Annual Meeting, Dallas, Texas, May 8 to 13, 2004.     

Design,Organization and Management of a Controlled Population Screening Study for Detection of Colorectal Neoplasia: Attendance Rates in the NORCCAP Study (Norwegian Colorectal Cancer Prevention)

Background: In the past three decades, the incidence of colorectal cancer (CRC) in Norway has doubled, surpassing all other Nordic countries for both men and women to become the most frequently diagnosed cancer. A small-scale, randomized study on flexible sigmoidoscopy (FS) screening in Telemark, Norway, has shown a reduction in accumulated CRC incidence after 13 years. The aim of our study was to evaluate the effect on CRC mortality and morbidity by screen detection of CRC and removal of precursor lesions (polypectomy), and to test out the management and organization mimicking a countrywide screening service. A total of 13,823 men and women (1:1), age 55-64 years, were drawn randomly from the population registries in Oslo (urban) and the county of Telemark (mixed urban and rural) and invited to have a screening examination. The rest of the relevant age cohorts constituted the control groups. In the screening group, 535 individuals were excluded according to exclusion criteria, rendering 13,288 individuals eligible for screening examination. Methods: A once only screening model was used. In the screening group, individuals were randomized to have a once only FS or a combination of FS and faecal occult blood test (FOBT). Results: The overall attendance rate was 8,849 out of 13,288 (67%); 73% in Telemark and 60% in Oslo. Attendance for FS only was 68% and 65% for combined FS&FOBT. Conclusions: The present FS/FS&FOBT screening study obtained a high acceptance rate for both screening modalities. The attendance rate was stable throughout the trial, suggesting an acceptable model for management of future countrywide screening.     

结直肠癌筛查及其进展

结直肠癌(CRC)是最常见的恶性肿瘤之一,近年来我国CRC发病率总体呈现上升趋势,在消化系统恶性肿瘤中居第二位。CRC筛查可显著降低其发病率和死亡率,筛查方法多样,目前以免疫化学法粪便隐血试验(FIT)和结肠镜检查为基础的两步法筛查方案为多个国家的权威指南或共识所推荐,其他筛查方法可作为个体化的选择和补充。对于结直肠息肉超过10枚同时有CRC个人史或家族史,或结直肠息肉超过20枚的极高危人群,应行多基因种系突变检测。     

Colorectal Cancer Screening and Surveillance in the Elderly: Updates and Controversies

Colorectal cancer is common worldwide, and the elderly are disproportionately affected. Increasing age is a risk factor for the development of precancerous adenomas and colorectal cancer, thus raising the issue of screening and surveillance in older patients. Elderly patients are a diverse and heterogeneous group, and special considerations such as comorbid medical conditions, functional status and cognitive ability play a role in deciding on the utility of screening and surveillance. Colorectal cancer screening can be beneficial to patients, but at certain ages and under some circumstances the harm of screening outweighs the benefits. Increasing adverse events, poorer bowel preparation and more incomplete examinations are observed in older patients undergoing colonoscopy for diagnostic, screening and surveillance purposes. Decisions regarding screening, surveillance and treatment for colorectal cancer require a multidisciplinary approach that accounts not only for the patient’s age but also for their overall health, preferences and functional status. This review provides an update and examines the challenges surrounding colorectal cancer diagnosis, screening, and treatment in the elderly.     

Surveillance Colonoscopy in Individuals at Risk for Hereditary Nonpolyposis Colorectal Cancer: An Evidence-Based Review

Purpose Surveillance colonoscopy plays an important role in the management of asymptomatic patients known to carry and suspected of carrying hereditary nonpolyposis colorectal cancer gene mutations. Although the shortest interval between surveillance examinations may seem to offer the most benefit to patients, excessive use of this procedure may have unwanted consequences. This study was designed to evaluate the evidence and make recommendations regarding the optimal frequency of surveillance colonoscopy and the age at which to initiate surveillance based on the best available evidence. Methods MEDLINE was searched for all articles assessing surveillance colonoscopy from 1966 to 2004 by using the MESH terms “hereditary nonpolyposis colorectal cancer” and “screening.” The evidence was systematically reviewed and a critical appraisal of the evidence was performed. Results There are no randomized, controlled, clinical trials examining the frequency of surveillance colonoscopy in hereditary nonpolyposis colorectal cancer. Three cohort studies were identified for review. There is one cohort study of good quality that provides evidence that surveillance colonoscopy every three years in patients with hereditary nonpolyposis colorectal cancer reduces the risk of developing colorectal cancer and the risk of death. The two remaining cohort studies provide poor evidence on which to make a recommendation. Conclusions The best available evidence supports surveillance with complete colonoscopy to the cecum every three years in patients with hereditary nonpolyposis colorectal cancer (B recommendation). There is no evidence to support or refute more frequent screening. Further research is required to examine the potential harms and benefits of more frequent screening. However, given the potential for rapid progression from adenoma to carcinoma and missing lesions at colonoscopy, there is consensus that screening more frequently than every three years is required.