The Norwegian Colorectal Cancer Prevention (NORCCAP) screening study: baseline findings and implementations for clinical work-up in age groups 50-64 years

BACKGROUND: Randomized controlled trials of sufficient power testing the long-term effect of screening for colorectal neoplasia only exist for faecal occult blood testing (FOBT). There is indirect evidence that flexible sigmoidoscopy (FS) may have a greater yield. The aim of this study was to determine the diagnostic yield of screening with FS or a combination of FS and FOBT in an average-risk population in an urban and combined urban and rural population in Norway. METHODS: 20,780 men and women (1:1), aged 50-64 years, were invited for once-only screening (FS only or a combination of FS and FOBT (1:1)) by randomization from the population registry. A positive FS was defined as a finding of any neoplasia or any polyp > or = 10 mm. A positive FS or FOBT qualified for colonoscopy. RESULTS: Overall attendance was 65%. Forty-one (0.3%) cases of CRC were detected. Any adenoma was found in 2208 (17%) participants and 545 (4.2%) had high-risk adenomas. There was no difference in diagnostic yield between the FS and the FS and FOBT group regarding CRC or high-risk adenoma. Work-up load comprised 2821 colonoscopies in 2524 (20%) screenees and 10% of screenees were recommended later colonoscopy surveillance. There were no severe complications at FS, but six perforations after therapeutic colonoscopy (1:336). CONCLUSIONS: The present study bodes well for future management of a national screening programme, provided that follow-up results reflect adequate proof of a net benefit. It is highly questionable whether the addition of once-only FOBT to FS will contribute to this effect.     

The Norwegian Colorectal Cancer Prevention (NORCCAP) Screening Study

Background: Randomized controlled trials of sufficient power testing the long-term effect of screening for colorectal neoplasia only exist for faecal occult blood testing (FOBT). There is indirect evidence that flexible sigmoidoscopy (FS) may have a greater yield. The aim of this study was to determine the diagnostic yield of screening with FS or a combination of FS and FOBT in an average-risk population in an urban and combined urban and rural population in Norway. Methods: 20,780 men and women (1:1), aged 50-64 years, were invited for once-only screening (FS only or a combination of FS and FOBT (1:1)) by randomization from the population registry. A positive FS was defined as a finding of any neoplasia or any polyp &#83 10 &#114 mm. A positive FS or FOBT qualified for colonoscopy. Results: Overall attendance was 65%. Forty-one (0.3%) cases of CRC were detected. Any adenoma was found in 2208 (17%) participants and 545 (4.2%) had high-risk adenomas. There was no difference in diagnostic yield between the FS and the FS and FOBT group regarding CRC or high-risk adenoma. Work-up load comprised 2821 colonoscopies in 2524 (20%) screenees and 10% of screenees were recommended later colonoscopy surveillance. There were no severe complications at FS, but six perforations after therapeutic colonoscopy (1:336). Conclusions: The present study bodes well for future management of a national screening programme, provided that follow-up results reflect adequate proof of a net benefit. It is highly questionable whether the addition of once-only FOBT to FS will contribute to this effect.     

Population-based surveillance by colonoscopy: effect on the incidence of colorectal cancer. Telemark Polyp Study I.

BACKGROUND: Most cases of colorectal cancer (CRC) develop from adenomas. Polypectomy is believed to reduce the incidence of CRC, but this effect has never been explored in prospective controlled studies. The aim of the present study was to evaluate the effect of polypectomy on colorectal cancer incidence in a population-based screening program. METHODS: In 1983, 400 men and women aged 50-59 years were randomly drawn from the population registry of Telemark, Norway. They were offered a flexible sigmoidoscopy and, if polyps were found, a full colonoscopy with polypectomy and follow-up colonoscopies in 1985 and 1989. A control group of 399 individuals was drawn from the same registry. In 1996 both groups (age, 63-72 years) were invited to have a colonoscopic examination. Hospital files and the files of The Norwegian Cancer Registry were searched to register any cases of CRC in the period 1983-96. RESULTS: At screening endoscopy 324 (81%) individuals attended in 1983 and 451 (71%) in 1996. From 1983 to 1996, altogether 10 individuals in the control group and 2 in the screening group were registered to have developed CRC (relative risk, 0.2; 95% confidence interval (CI), 0.03-0.95; P = 0.02). A higher overall mortality was observed in the screening group, with 55 (14%) deaths, compared with 35 (9%) in the control group (relative risk, 1.57; 95% CI, 1.03-2.4; P = 0.03). CONCLUSION: Endoscopic screening examination with polypectomy and follow-up was shown to reduce the incidence of CRC in a Norwegian normal population. The possible effect of screening on overall mortality should be addressed in larger studies.     

Case-control study of screening colonoscopy in relatives of patients with colorectal cancer

OBJECTIVES: The efficacy of colonoscopic screening and polypectomy for the prevention of colorectal cancer (CRC) is well accepted but has never been documented in a prospective, controlled study. Screening by sigmoidoscopy has been found to reduce mortality from cancer of the rectum and distal colon. Case-control studies provide an alternative method for determining the efficacy of screening methods. METHODS: Between 1998 and 2000, a total of 40 subjects were found to have CRC (study group) and 160 had a normal colon (control group) among asymptomatic individuals participating in a screening colonoscopy program for a high-risk population of first-degree relatives of CRC patients. We compared these groups for screening by fecal occult blood testing, flexible sigmoidoscopy, barium enema, and colonoscopy in the 10-yr period before the index colonoscopy. RESULTS: Screening colonoscopy was performed in only 2.5% of the case subjects and 48.7% of controls (p < 0.0001), and all screening procedures in 12.5% and 73.7%, respectively (p < 0.0001). A statistically significant difference was also found for screening with fecal occult blood test, but not for flexible sigmoidoscopy or barium enema. Significant adenomatous polyps >1 cm in diameter were detected and removed in 19% of the control group within 10 yr of the index colonoscopy. Six (15%) of the patients in the study group died of CRC. CONCLUSIONS: Screening by colonoscopy can prevent progression to CRC from adenomatous polyps and may reduce the mortality associated with this devastating disease.     

Association between lifestyle and site-specific advanced colorectal lesions in screening with faecal immunochemical test and sigmoidoscopy

BackgroundLifestyle factors may help to identify individuals at high-risk for colorectal cancer (CRC).AimsTo examine the association between lifestyle, referral for follow-up colonoscopy and proximal neoplasia detection in CRC screening.MethodsIn this observational study, 14,832 individuals aged 50–74 years were invited to faecal immunochemical test (FIT) or sigmoidoscopy screening. Advanced lesions (AL), including advanced adenomas, advanced serrated lesions and CRC were divided according to location: distal-only, or proximal with or without distal AL. We collected information on smoking habit, body mass index and alcohol intake through a questionnaire.ResultsOut of 3,318 FIT and 2,988 sigmoidoscopy participants, 516 (16%) and 338 (11%), respectively, were referred for follow-up colonoscopy after a positive screening test. Two-hundred-and-fifty-six (4%) had distal-only and 119 (2%) proximal AL. In FIT participants, obesity and high alcohol intake were associated with proximal AL; odds ratio (95% confidence interval) 2.68 (1.36–5.26) and 2.16 (1.08–4.30), respectively. In sigmoidoscopy participants, current smoking was associated with proximal AL; 4.58 (2.24–9.38), and current smoking and obesity were associated with referral for colonoscopy; 2.80 (2.02–3.89) and 1.42 (1.01–2.00), respectively.ConclusionCurrent smoking, obesity and high alcohol intake were associated with screen-detected proximal colorectal AL. Current smoking and obesity were associated with referral for follow-up colonoscopy in sigmoidoscopy screening.     

Hyperplastic polyps seen at sigmoidoscopy are markers for additional adenomas seen at colonoscopy

Asymptomatic individuals undergoing screening flexible sigmoidoscopy were prospectively studied. Polyps were found in 185 subjects. The endoscopist recorded an opinion on the polyps' histology based on endoscopic appearance. No polyps were removed at sigmoidoscopy. All subjects with rectosigmoid polyps then underwent colonoscopy and polypectomy. Of them, 99 subjects (54%) had at least one rectosigmoid adenoma, 69 (37%) had only hyperplastic polyps, and 17 (9%) had other findings. The endoscopists' opinion of the histopathology of polyps at sigmoidoscopy was correct for 61% of the lesions. Of subjects with adenomatous rectosigmoid polyps, 29% had additional adenomas at more proximal sites. Proximal adenomas were found in 28% of patients with hyperplastic rectosigmoid polyps. Patients with rectosigmoid hyperplastic polyps had the same risk for additional proximal adenomas as patients with rectosigmoid adenomatous polyps.     

Flexible sigmoidoscopy may be ineffective for secondary prevention of colorectal cancer in asymptomatic,average-risk men

Asymptomatic men (N=114) 50 years of age or older had screening for colorectal neoplasia with flexible sigmoidoscopy followed by colonoscopy regardless of the sigmoidoscopic result. Our study objective was to determine the prevalence of patients having isolated adenomatous polyps in a proximal colonic segment in the absence of a distal index neoplasm within reach of the sigmoidoscope. Through the combined use of sigmoidoscopy and colonoscopy, adenomatous polyps were detected in 47 of 114 individuals (41%). A total of 88 adenomas was found. Seventeen patients had isolated neoplasms in proximal colonic segments in the absence of distal adenomas. These patients represented 15% of screened subjects (17 of 114) and 20% of individuals who lacked adenomas on sigmoidoscopy (17 of 84). The majority of proximal neoplasms were small (<1.0 cm), tubular adenomas. Flexible sigmoidoscopy may be ineffective for screening asymptomatic men for neoplasia. However, it remains to be determined if a 20% miss rate (for those with a normal sigmoidoscopic examination) is significant and whether small proximal adenomas are worth finding.     

Prevalence of clinically important histology in small adenomas.

BACKGROUND & AIMS: The prevalence of advanced histology in small polyps has become a crucial issue in optimizing colorectal cancer screening strategies, especially in view of the advent of computed tomography colonography. We evaluated the prevalence of advanced histology in small and diminutive adenomas to clarify their clinical importance in terms of malignant potential. METHODS: Data were reviewed retrospectively from 3291 colonoscopies performed on asymptomatic patients found to have an adenoma on screening with flexible sigmoidoscopy a few weeks before the colonoscopy or who had a family history of colorectal cancer. All polyps were excised endoscopically and sent for pathology testing. Specimens with advanced histology were confirmed by a second reading. RESULTS: Of the 3291 colonoscopies performed, 1235 colonoscopies yielded a total of 1933 small or diminutive adenomatous polyps. Advanced histology including carcinoma was found in 10.1% of small (5-10 mm) adenomas and in 1.7% of diminutive adenomas (< or = 4 mm). Carcinoma was found in .9% of small adenomas, and 0% of diminutive adenomas. Of the 107 patients found to have polyps 2-10 mm with advanced histology, 100 (93%) were referred for colonoscopy because of an adenoma found on a recent screening with flexible sigmoidoscopy. Seven patients underwent colonoscopy for a positive family history of colon cancer; all 7 had a single affected first-degree relative older than age 50. CONCLUSIONS: Adenomas 5-10 mm in size harbor pathologically significant histology, and the need for removal of these lesions must be addressed to optimize colorectal cancer prevention.     

Effectiveness and patient tolerance of screening colonoscopy -- first results

BACKGROUND: In Germany screening colonoscopy was introduced into the national program on colorectal cancer prevention in October 2002 for asymptomatic subjects older than 55 years. It is the aim of this program to reduce the rate of mortality of colorectal cancer (CRC) during the next decade. Up to now no data are available concerning the outcome and patient tolerance of screening colonoscopy. METHODS: Patients were enrolled in the prospective study between October 2002 and June 2003. The diagnoses from colonoscopy and complications were recorded. A short interview provided information on individual family risks of CRC. During June 2003 all subjects were handed a questionnaire to evaluate their satisfaction and tolerance concerning screening colonoscopy. All subjects were offered sedation (Disoprivan: Propofol). RESULTS: A total of 1117 subjects (776 [69.5 %] female, 341 [30.5 %] male) underwent screening colonoscopy; age: 64.3 +/- 6.9 years. 1104 (98.8 %) requested sedation. In 1090 cases (97.6 %) colonoscopy was completed to the cecum (photographic documentation of cecal landmarks). A total of 11 patients had invasive cancer (1 %), 4 of these had adenomas containing invasive carcinoma. The stage was T1/N0 or T2/N0. A total of 138 (12.4 %) patients had 168 polypoid lesions, which were treated by complete polypectomy. 402 small polypoid lesions (< 0.5 cm) were only detected by biopsy. In this group 233 adenomas (20.9 %) were found. Complications were: 1 perforation and 4 haemorrhages after polypectomy. Patient tolerance was very high. 99.4 % of all subjects agreed to a control colonoscopy or recommended screening colonoscopy to their relatives and friends. CONCLUSION: Screening colonoscopy is an effective and well-accepted method in our unit for gastroenterology. The high prevalence of adenoma and invasive carcinoma suggests that screening colonoscopy should be provided for all persons at the age of 55, especially for men.     

Use of flexible sigmoidoscopy to screen for colorectal cancer in HIV-infected patients 50 years of age and older

BACKGROUND: Although many patients with human immunodeficiency virus (HIV) infection are now living well beyond 50 years of age, there are no data available on colorectal cancer screening in this population. The aim of this study was to determine the utility of screening flexible sigmoidoscopy in patients with HIV. METHODS: Consecutive patients at average risk for colorectal cancer who were referred for screening flexible sigmoidoscopy were prospectively identified. A detailed medical history was obtained from all patients before flexible sigmoidoscopy, and colonoscopy was recommended for all subjects with positive sigmoidoscopic findings. RESULTS: A total of 2382 patients were enrolled in the study; 165 were HIV positive. The prevalence of neoplastic lesions (adenomas or adenocarcinomas) in the distal colon was significantly higher in HIV-infected patients than in control subjects (25.5% vs 13.1%, P<.001), and the odds of HIV-infected patients having a neoplastic lesion was significantly higher even after adjustment for potential confounding variables (odds ratio, 2.34; 95% confidence interval, 1.60-3.44). The prevalence of adenomas of any size (25.5% vs 12.9%, P<.001) and advanced neoplasia (7.3% vs 3.8%, P = .03) in the distal colon was significantly higher in HIV-infected patients. Among individuals with positive results on flexible sigmoidoscopy, proximal colonic neoplastic lesions on follow-up colonoscopy were more common in HIV-infected patients after adjustment for age, sex, and race/ethnicity (odds ratio, 1.88; 95% confidence interval, 1.02-3.46). CONCLUSIONS: Patients infected with HIV are more likely to have colonic neoplasms on screening flexible sigmoidoscopy than those without HIV, and these individuals should be offered colorectal cancer screening.     

Screening for colorectal cancer: the cost to find an advanced adenoma

OBJECTIVE: Cancer Care Ontario has recommended a program to screen for colorectal cancer using fecal occult blood testing (FOBT). Patients who test positive on FOBT will require further investigation. We examined the cost of finding an advanced adenoma in these patients using four different strategies. METHODS: Using decision analysis software (DATA 3.5, TreeAge Software, Boston, MA), we considered four strategies for evaluating patients referred for a positive FOBT: 1) flexible sigmoidoscopy to the splenic flexure, 2) flexible sigmoidoscopy with air contrast barium enema (ACBE), 3) virtual colonoscopy, and 4) colonoscopy. If an adenoma was found in any of the first three methods, colonoscopy and polypectomy were performed. An advanced adenoma was defined as a villous adenoma, tubular adenoma > or = 10 mm, high grade dysplasia, or cancer. Values for probabilities, test characteristics and costs ($CDN) were estimated from a MEDLINE literature review, local costs, and OHIP fee codes. Patients with adenomas identified as well as direct medical costs from a third party payer perspective were calculated. RESULTS: Assuming a probability of adenoma of 16.9%, the cost for each strategy (compared to no investigation) was as follows: flexible sigmoidoscopy to the splenic flexure, $226; flexible sigmoidoscopy with ACBE, $424; virtual colonoscopy, $597; and colonoscopy, $387. The cost to clear a patient of adenoma(s) was $1,930, $2,840, $3,681, and $2,290, respectively. Despite being most cost-effective, the sigmoidoscopy strategy was predicted to detect 69% of cases of advanced adenomas. The radiological strategies would be less expensive if ACBE cost less than $115 or virtual colonoscopy cost less than $291. The colonoscopy strategy was more cost-effective if the probability of an adenoma was > or = 33.5%. When the incremental costs were considered to investigate 1000 patients, virtual colonoscopy and sigmoidoscopy with ACBE were both more costly then colonoscopy, and neither detected as many cases of advanced adenomas. CONCLUSION: Improved access to colonoscopy seems to be the preferred approach to deal with increased referrals.     

Reproducibility and diagnostic value of Hemoccult-II test. A colonoscopic evaluation in asymptomatic patients

Inter-observer agreement rate in double readings of 246 Hemoccult-II tests was 0.88 (Kappa analysis). The slides were not rehydrated. The Hemoccult-II test was performed immediately before 748 total colonoscopies in asymptomatic patients after previous polypectomy or radical surgery for cancer to estimate the diagnostic value of the test in mass screening, accepting a higher prevalence of neoplasia in the study group but realizing that colonoscopy can only be performed in high-risk groups. Another purpose was to investigate the possibility of replacing colonoscopy with Hemoccult-II in surveillance after previous adenoma or cancer. The 79 colonoscopies after a positive test showed cancer in 3, adenomas in 13, and other intestinal pathology in 34 cases. The 669 colonoscopies after negative tests showed cancer in 1, adenomas in 67, and other pathology in 141 cases. In conclusion, the test cannot be used as a guideline for colonoscopy in follow-up programs for patients who have had adenomas, since it missed 84% of the new cases in the present series. The test does not exclude the presence of colorectal carcinoma, but the risk of cancer is probably several times less in patients with negative tests (1 of 669) than in patients with positive tests (3 of 79), which may justify the use of the Hemoccult-II test for mass screening in asymptomatic populations.     

Potential costs of flexible sigmoidoscopy-based colorectal cancer screening

BACKGROUND & AIMS: Increasing evidence shows that periodic screening by flexible sigmoidoscopy with appropriate referral of patients with adenomas to colonoscopy could substantially decrease colorectal cancer mortality rates. Estimates of the complete cost of such screening are needed. The aim of this study was to estimate the annual costs of periodic screening of Americans 50 years and older by flexible sigmoidoscopy with referral of subjects with adenomas to colonoscopy. METHODS: Cost analysis of flexible sigmoidoscopy, followed by colonoscopy as warranted, in U.S. population cohorts reaching age 50 each year from 1995 to 2010 was performed. Total yearly costs of repeat screening and surveillance examinations at American Cancer Society- recommended and other intervals were determined. RESULTS: With screening and surveillance intervals of 3 years, annual costs for the cohort of individuals turning 50 in 1995 would increase to $553 million by 2010. Annual costs for the entire population 50 years of age and older could increase by 2010 to nearly $20 billion. CONCLUSIONS: The cost of flexible sigmoidoscopy-based screening for colorectal cancer could vary as much as threefold depending on the protocol chosen. (Gastroenterology 1996 Dec;111(6):1411-7)     

Colon pathology detected after a positive screening flexible sigmoidoscopy: a prospective study in an ethnically diverse cohort

OBJECTIVES: Although the association between distal neoplasia on sigmoidoscopy and proximal colonic pathology on follow-up colonoscopy has been well-described, it is not known if these findings are consistent across ethnic groups. The aim of this study was to evaluate ethnic variations in the prevalence of proximal neoplasia on follow-up colonoscopy after a neoplastic lesion is found on sigmoidoscopy. METHODS: Consecutive asymptomatic patients at average-risk for colorectal cancer who were referred for screening flexible sigmoidoscopy were prospectively enrolled. Colonoscopy was recommended for all patients with a polyp on flexible sigmoidoscopy, regardless of size. Advanced neoplasms were defined as adenomas > or = 10 mm in diameter or any adenoma, regardless of size, with villous histology, high-grade dysplasia, or cancer. RESULTS: Among the 2,207 patients who had sigmoidoscopy, 970 were Caucasian, 765 were African American, 395 were Hispanic, and 77 were Asian. The prevalence of neoplasia in the distal colon was 12.6% in Caucasians, 11.2% in African Americans, 15.9% in Hispanics, and 24.7% in Asians (p = 0.002). Of the 290 patients with neoplastic lesions on sigmoidoscopy, follow-up colonoscopy identified neoplasms in the proximal colon in 63.9% of Caucasians, 59.3% of African Americans, 66.7% of Hispanics, and 26.3% of Asians (p = 0.01). Advanced neoplasms in the proximal colon were highest in African Americans (34.9%) and lowest in Asians (10.5%). CONCLUSIONS: In our study population, Asians demonstrated a higher prevalence of distal colonic neoplasia and a lower prevalence of proximal colonic neoplasia compared to non-Asians. Future studies should explore ethnic variation in colonic neoplasia prevalence and location since ethnic variation could lead to tailored colorectal cancer screening strategies.     

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     

A Community-Based Program of Colorectal Screening in an Asymptomatic Population: Evaluation of Screening Tests and Compliance

The incidence of colorectal cancer in Ashkenazi Jews is two to three times higher than in non-Ashkenazis. For a community colorectal screening program 1339 asymptomatic Ashkenazis over 40 yr old were asked to participate. Of these 1012 (75%) took Hemoccult II kits [fecal occult blood tests (FOBT)], and 614 (46%) personally returned them. Screenees were interviewed regarding family and personal medical history. Fourteen persons (2.3%) had positive tests, in whom colonoscopy revealed two with cancer (Dukes' B,C) and two with a greater than 2 cm polyp. The remaining 600 persons were invited for flexible sigmoidoscopy (FS) but only 287 (48%) appeared. The mean depth of insertion of the instrument was 50.3 cm (range 30-120), but was poorer for women. FS identified lesions in 28 (9.7%) persons: three had Dukes' A carcinomas and 25 had less than 2 cm adenomatous polyps. Significantly more women than men accepted FOBT, but among those completing FOBT, there was no difference by sex for use of FS. Middle-aged persons (50-69 yr) found screening more acceptable than young or older persons. Among screenees who agreed to undergo FS, a significantly larger fraction had a first relative with colon cancer, or a personal history of colon or female genital neoplasia, compared to those not agreeing to FS. There were no differences in screenees with relatives with noncolon cancer. Eighty-eight couples completed FOBT and were invited for FS. The decision whether or not to participate was made for both members in 81 (92%) couples. In conclusion, effective screening programs have to take into consideration compliance patterns of the target population.     

A prospective national study on colonoscopy and sigmoidoscopy in 2000 in France

AIM: The aim of this study was to evaluate the practice of colonoscopy and sigmoidoscopy in France in 2000. METHODS: A prospective study was conducted in November 2000 using questionnaires sent to all gastroenterologists practicing in France (N=2858) who were asked to reply to items concerning colonoscopies and sigmoidoscopies performed on two workdays chosen in advance. The response rate was 32.8%. Data were extrapolated to establish estimates for the entire year. RESULTS: An estimated 894000 colonoscopies and 115320 sigmoidoscopies were performed in 2000. Single-use material was used in 22.1% of the procedures. Indications for endoscopy were mainly hematochezia (21.6%), gastrointestinal symptoms (35%) and surveillance of patients with a history of previous polypectomy (15%). Colorectal cancer screening was the indication for 20% of colonoscopies. Abnormal findings were reported for 54.8% of the endoscopies (polyps for 287218 procedures and cancer for 32799). Failure was noted in 4.9% of colonoscopies. The complication rate was 0.48%. Most polyps were adenomas (64.4%) or hyperplasic polyps (28.1%). The overall estimated number of colonoscopies with polypectomy was 224133. CONCLUSION: In 2000 there was an increased rate of colonoscopy for colorectal cancer screening (20%) but an overall decrease (2.5%) in the total number of colonoscopies compared to 1999. Abnormal findings were disclosed by 54.8% of the procedures. Extrapolation from these data indicates that colonoscopic screening enabled the diagnosis of 32799 colorectal cancers.     

Patterns of use of flexible sigmoidoscopy, colonoscopy and gastroscopy: a population-based study in a Canadian province.

BACKGROUND & AIMS: Flexible sigmoidoscopy, colonoscopy and gastroscopy are important in the diagnosis and treatment of gastrointestinal (GI) diseases. Pressure on endoscopy resources is expected due to increased screening for GI cancers. The present study examined patterns of use of GI endoscopy in a Canadian province, Alberta, with universal health care insurance. METHODS: Data on physician payments from January 1, 1994 to March 31, 2002 were used to calculate age-sex adjusted rates and patterns of use. RESULTS: The gastroscopy rate increased by 17%, from 9.7 (95% CI 9.6 to 9.9) to 10.3 (95% CI 10.1 to 10.5). The colonoscopy rate increased by 105%, from 4.8 (95% CI 4.6 to 5.0) to 9.8 (95% CI 9.6 to 10.1). Flexible sigmoidoscopy rates declined by 10%, from 4.68 (95% CI 4.56 to 4.80) to 4.21 (95% CI 4.11 to 4.32). The increase in colonoscopy rates occurred in all age groups, whereas gastroscopy rates increased only in the older age groups. Regional variation in procedure rates was evident, but rural health regions did not have consistently lower rates than the large urban regions. A polypectomy was performed on 23.7% of male patients and 15.4% of female patients at time of colonoscopy. Rates of polypectomy for individual endoscopists ranged from 0% to 60%. CONCLUSIONS: There has been a marked increase in gastroscopy and colonoscopy rates, likely due to a broadening of indications rather than just increased use for cancer screening. Modest regional variation in rates exists, but there is no direct evidence of limited rural access to endoscopy. Reasonable polypectomy rates were seen but important variations between endoscopists exist.     

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.