Colorectal cancer incidence is low in patients following a colonoscopy

Background/Aims

Colonoscopy has been proven a valuable tool in preventing colorectal cancer in controlled studies; we conducted a longitudinal confirmation study in everyday clinical practice.

Methods

In a retrospective study, we monitored the outcome of patients with a total colonoscopy at our hospital between 1994 and 2007. We analysed the data of in-house follow-up colonoscopies, a national person registry and the morphological tumour registry centralizing all histopathological data at a national level. Patients with a particular colorectal cancer risk were excluded.

Results

8950 patients were included in our study. 2032 (22.7%) patients had at least one colorectal adenoma at index colonoscopy. Adenoma prevalence was significantly higher in men than in women (27.9% vs. 17.4%, p < 0.001) and was increasing with age in both sexes. Patients were followed for a mean of 5.2 years and 19 had invasive colorectal cancer detected over 47,725 person years of follow-up. The incidence rate was 0.40 cases/1000 person years of follow-up (95% confidence interval, 0.25–0.62), and the standardized incidence ratio was 0.37 (95% confidence interval, 0.24–0.58).

Conclusion

Incidence rates of colorectal cancer are low in the follow-up of patients having undergone a total colonoscopy in everyday practice. After standard therapy of colorectal adenomas at colonoscopy, there is little evidence for excess colorectal cancer incidence in this subgroup.     

Racial Disparities in Incidence of Young-Onset Colorectal Cancer and Patient Survival

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Preoperative prevalence of Barrett's esophagus in esophageal adenocarcinoma: a systematic review.

BACKGROUND & AIMS: The public health impact of past screening and surveillance practices on the outcomes of Barrett's related cancers has not previously been quantified. Our purpose was to determine the prior prevalence of Barrett's esophagus in reported cases of incident adenocarcinoma undergoing resection, as an indirect measure of impact. METHODS: We performed a systematic review of the literature from 1966 to 2000. Studies were included if they reported: (1) the number of consecutive adenocarcinomas resected, and (2) the number of those resected who had a previously known diagnosis of Barrett's. We generated summary estimates using a random effects model. RESULTS: We identified and reviewed 752 studies. Twelve studies representing a total of 1503 unique cases of resected adenocarcinomas met inclusion criteria. Using a random effects model, the overall percentage of patients undergoing resection who had a prior diagnosis of Barrett's was 4.7% +/- 2.9%. CONCLUSIONS: The low prior prevalence (approximately 5%) of Barrett's esophagus in this study population provides indirect evidence to suggest that recent efforts to identify patients with Barrett's-whether through endoscopic screening or evaluation of symptomatic patients-have had minimal public health impact on esophageal adenocarcinoma outcomes. The potential benefits of endoscopic surveillance seem to have been limited to only a fraction of those individuals at risk. These data thus provide a clear and compelling rationale for the development of effective screening strategies to identify patients with Barrett's esophagus.     

Association of marital status with cardiovascular outcome in patients with breast cancer

BackgroundThe influences of marital status on cardiovascular death risk in patients with breast cancer remained unclear. This study aimed to evaluate the associations of different marital status with cardiovascular death risk in patients with breast cancer.MethodsA total of 182,666 female breast cancer patients were enrolled in this study from the Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2014, and was divided into two groups: married (N=107,043) and unmarried (N=75,623). A 1:1 propensity score matching (PSM) was applied to reduce inter-group bias between the two groups. Competing-risks model was used to assess the associations between different marital status and cardiovascular death risk in patients with breast cancer.ResultsAfter PSM, marital status was an independent predictor for cardiovascular death in patients with breast cancer. Unmarried condition was associated with increased cardiovascular death risk than married condition among breast cancer patients [unadjusted model: hazard ratio (HR) =2.012, 95% confidence interval (CI): 1.835–2.208, P<0.001; Model 1: HR =1.958, 95% CI: 1.785–2.148, P<0.001; Model 2: HR =1.954, 95% CI: 1.781–2.144, P<0.001; Model 3: HR =1.920, 95% CI: 1.748–2.107, P<0.001]. With the exception of separated condition (adjusted HR =0.886, 95% CI: 0.474–1.658, P=0.705), further unmarried subgroups analysis showed that the other three unmarried status were associated with increased cardiovascular death risk as follows: single (adjusted HR =1.623, 95% CI: 1.421–1.853, P<0.001), divorced (adjusted HR =1.394, 95% CI: 1.209–1.608, P<0.001), and widowed (adjusted HR =2.460, 95% CI: 2.227–2.717, P<0.001). In particularly, widowed condition showed the highest cardiovascular death risk in all 4 unmarried subgroups.ConclusionsUnmarried condition (e.g., single, divorced and widowed) was associated with elevated cardiovascular death risk compared with their married counterparts in patients with breast cancer, suggesting that more attention and humanistic care should be paid to unmarried breast cancer patients (especially the widowed patients) in the management of female breast cancer patients.     

Risk of intestinal cancer in inflammatory bowel disease: a population-based study from olmsted county, Minnesota

BACKGROUND & AIMS: The risk for colorectal cancer in Crohn's disease and ulcerative colitis patients from the United States currently is unknown. We estimated the risk for small-bowel and colorectal cancer in a population-based cohort of 692 inflammatory bowel disease patients from Olmsted County, Minnesota, from 1940 to 2001. METHODS: The Rochester Epidemiology Project was used to identify cohort patients with colorectal and small-bowel cancer. The cumulative probability of cancer and standardized incidence ratios (SIR) were estimated using expected rates from Surveillance, Epidemiology, and End Results, white patients from Iowa, from 1973 to 2000, and Olmsted County, from 1980 to 1999. RESULTS: Colorectal cancer was observed in 6 ulcerative colitis patients vs 5.38 expected (SIR, 1.1; 95% confidence interval [CI], 0.4-2.4), but 4 of these occurred among those with extensive colitis or pancolitis (SIR, 2.4; 95% CI, 0.6-6.0). Six Crohn's disease patients (vs 3.2 expected) developed colorectal cancer (SIR, 1.9; 95% CI, 0.7-4.1). Three Crohn's disease patients developed small-bowel cancer vs 0.07 expected (SIR, 40.6; 95% CI, 8.4-118). CONCLUSIONS: The risk for colorectal cancer was not increased among ulcerative colitis patients overall, but appeared to be increased among those with extensive colitis. The colorectal cancer risk was increased slightly among Crohn's disease patients, who also had a 40-fold excess risk for small-bowel cancer.     

Cancer-attributable costs of diagnosis and care for persons with screen-detected versus symptom-detected colorectal cancer

BACKGROUND & AIMS: Colorectal cancer screening is effective and cost-effective, but little data from health plan settings are available inform decision-makers regarding direct economic implications of colorectal cancer screening programs. The purpose of this study was to compare the prediagnosis evaluation and first-year treatment costs of persons diagnosed with colorectal cancer, stratified by whether the cancer was detected by screening using fecal occult blood testing or evaluation of symptoms. METHODS: This retrospective study analyzed persons diagnosed with colorectal cancer from 1993 to 1999 in Group Health Cooperative, a large health maintenance organization in Washington state. Total health care costs during 3 months before and 12 months following diagnosis were compared for screen-detected versus symptom-detected individuals. RESULTS: During this time, 206 cancers were detected by screening and 717 by symptoms. In the 3 months before diagnosis, total costs were 7346 US dollars for persons with screen-detected versus 10,042 US dollars for those with symptom-detected cancer (P < 0.01). Stratified by stage, diagnosis costs were significantly lower for persons with stage B cancer (7282 US dollars vs. 11,682 US dollars ; P < 0.01) and nonsignificantly lower for other stages. A total of 53% of screen-detected cases were Dukes' stage A or in situ at diagnosis versus 30% of symptom-detected cases (P < 0.01). Overall costs were lower for the screen-detected group in the 12 months following diagnosis (22,369 US dollars vs. 29,471 US dollars; P < 0.01). CONCLUSIONS: Colorectal cancer screening can substantially reduce prediagnosis evaluation costs. These savings are of interest to health plans and should be factored into cost-effectiveness evaluations of screening programs.     

Prognostic factors for postoperative survival in melanoma patients with bone metastasis

Melanoma can spread to the bone by metastasis and is relevant to a poor outcome. However, because of the rarity of melanoma patients with bone metastasis, the prognostic postoperative survival factors of them have not been elucidated. The aim of this special population-based cohort was to elucidate the prognostic factors associated with postoperative survival. The Surveillance, Epidemiology, and End Results database was used to extract postoperative survival data relating to patients with melanoma and bone metastasis at diagnosis between 2010 and 2016, along with data on a range of potential postoperative prognostic factors. We then investigated the potential postoperative prognostic roles of these factors using a Cox regression model and the Kaplan-Meier analysis. In all, the Surveillance, Epidemiology, and End Results database included 186 cases. Regarding overall survival, the 1-, 3-, and 5-year overall survival rates for the entire cohort were 36.2%, 15.4%, and 9.5%, respectively. Regarding cancer-specific survival, the 1-, 3-, and 5-year cancer-specific survival rates were 42.0%, 23.2%, and 16.6%, respectively. Within a cohort of melanoma patients with bone metastasis after surgery, our analysis showed that a smaller tumor size and the lack of metastases at other sites were predictors of survival.     

Comparing risks and benefits of colorectal cancer screening in elderly patients

BACKGROUND & AIMS: In patients with limited life expectancy, the risks of colorectal cancer screening may outweigh the benefits. The aim of this study was to quantify risks and benefits of different screening strategies in elderly patients with varying life expectancies. METHODS: We examined risks and benefits of screening in patients aged 70-94 years with differing health status using 3 strategies: annual fecal occult blood tests, flexible sigmoidoscopy every 5 years, or colonoscopy every 10 years. We compared the number needed to screen to prevent one cancer-related death and the number needed to encounter one screening-related complication for different strategies. RESULTS: The potential benefit from screening varied widely with age, life expectancy, and screening modality. One cancer-related death would be prevented by screening 42 healthy men aged 70-74 years with colonoscopy, 178 healthy women aged 70-74 years with fecal occult blood tests, 431 women aged 75-79 years in poor health with colonoscopy, or 945 men aged 80-84 years in average health with fecal occult blood tests. Colonoscopy screening had the greatest benefit but the highest risk of complications. The potential for screening-related complications was greater than estimated benefit in some population subgroups aged 70 years and older. At all ages and life expectancies, the potential reduction in mortality from screening outweighed the risk of colonoscopy-related death. CONCLUSIONS: The potential benefits and risks of screening vary in elderly patients of different life expectancies. For any individual patient, the potential for harm from screening must be weighed against the likelihood of benefit, especially with shorter life expectancy.     

Risk of second primary cancer after treatment for esophageal cancer: a pooled analysis of nine cancer registries

The introduction of new treatments for esophageal cancer including surgery, chemotherapy, radiotherapy, or a combination of these modalities has not only improved patient survival, but may also increase the risk of the second primary cancers. The available evidence is conflicting with most risk estimates based on sparse numbers. Here we estimated standardized incidence ratios (SIRs) of second cancer among 24,557 esophageal cancer survivors (at least 2 months) in the Surveillance, Epidemiology, and End Results (SEER) Program between 1973 and 2007, who had been followed up for median 6.5 years (range 2 months-29.3 years). Second cancer risk was statistically significantly elevated (SIR = 1.34, 95% confidence interval [CI]= 1.25-1.42) among the survivors compared with the general population; the SIRs for cancers of oral and pharynx, stomach, small intestine, larynx, lung and bronchus, thyroid and prostate cancer were 8.64 (95% CI = 7.36-10.07), 2.87 (95% CI = 2.10-3.82), 3.80 (95% CI = 1.82-7.00), 3.19 (95% CI = 2.12-4.61), 1.68 (95% CI = 1.46-1.93), 2.50 (95% CI = 1.25-4.47), and 0.77 (95% CI = 0.65-0.90), respectively. Radiotherapy raised cancer risk of larynx (SIR = 3.98, 95% CI = 2.43-6.14) and thyroid (SIR = 3.57, 95% CI = 1.54-7.03) among all esophageal cancer survivors. For patients who had 5-9 years of follow up after radiotherapy, the SIR for lung cancer was 3.46 (95% CI = 2.41-4.82). Patients with esophageal cancer are at increased risks of second cancers of oral and pharynx, larynx, lung, and thyroid, while at a decreased risk for prostate cancer. These findings indicate that radiotherapy for esophageal cancer patients may increase risk of developing second cancers of larynx, lung, and thyroid. Thus, randomized clinical trials to address the association of radiotherapy and the risk of secondary cancer are warranted.     

Application of machine learning approaches to predict the 5-year survival status of patients with esophageal cancer

BackgroundAccurate prognostic estimation for esophageal cancer (EC) patients plays an important role in the process of clinical decision-making. The objective of this study was to develop an effective model to predict the 5-year survival status of EC patients using machine learning (ML) algorithms.MethodsWe retrieved the information of patients diagnosed with EC between 2010 and 2015 from the Surveillance, Epidemiology, and End Results (SEER) Program, including 24 features. A total of 8 ML models were applied to the selected dataset to classify the EC patients in terms of 5-year survival status, including 3 newly developed gradient boosting models (GBM), XGBoost, CatBoost, and LightGBM, 2 commonly used tree-based models, gradient boosting decision trees (GBDT) and random forest (RF), and 3 other ML models, artificial neural networks (ANN), naive Bayes (NB), and support vector machines (SVM). A 5-fold cross-validation was used in model performance measurement.ResultsAfter excluding records with missing data, the final study population comprised 10,588 patients. Feature selection was conducted based on the χ² test, however, the experiment results showed that the complete dataset provided better prediction of outcomes than the dataset with removal of non-significant features. Among the 8 models, XGBoost had the best performance [area under the receiver operating characteristic (ROC) curve (AUC): 0.852 for XGBoost, 0.849 for CatBoost, 0.850 for LightGBM, 0.846 for GBDT, 0.838 for RF, 0.844 for ANN, 0.833 for NB, and 0.789 for SVM]. The accuracy and logistic loss of XGBoost were 0.875 and 0.301, respectively, which were also the best performances. In the XGBoost model, the SHapley Additive exPlanations (SHAP) value was calculated and the result indicated that the four features: reason no cancer-directed surgery, Surg Prim Site, age, and stage group had the greatest impact on predicting the outcomes.ConclusionsThe XGBoost model and the complete dataset can be used to construct an accurate prognostic model for patients diagnosed with EC which may be applicable in clinical practice in the future.     

The incidence of colorectal cancer following a negative screening sigmoidoscopy: implications for screening interval

BACKGROUND & AIMS: Current guidelines recommend a 5-year interval for colorectal cancer (CRC) screening by sigmoidoscopy. However, the optimal screening interval is uncertain. We estimated the annual incidence of distal and proximal CRC in the first 5 years following a negative sigmoidoscopy examination to gauge the potential benefit of rescreening in <5 years. METHODS: A cohort of 72,483 participants in the Colon Cancer Prevention program of Kaiser Permanente of Northern California (KP) was defined using computerized databases. Men and women aged 50 years and older who had a negative screening flexible sigmoidoscopy examination between 1994 and 1996 and were considered not to be at high risk for developing CRC were included. Subjects were censored at the time of diagnosis (for cases), death, termination of KP membership, or subsequent colon examination. RESULTS: Thirty cases of distal and 80 cases of proximal CRC occurred. Age-adjusted incidence rates of distal CRC ranged from a low of 2.8 per 100,000 person-years in the first year of follow-up to a high of 13.0 per 100,000 in the fourth year (rate difference, 10.2; 95% confidence interval, 1.1-19.3). However, for the entire follow-up period, incidence of distal CRC remained much lower than age-adjusted rates of 70.6 in the general population (Surveillance, Epidemiology, and End Results registry). The incidence of proximal CRC was also decreased modestly over population rates of disease. CONCLUSIONS: Screening by sigmoidoscopy more frequently than every 5 years would likely lead, at best, to only modest improvements as compared with a 5-year screening interval.