Colonoscopy in Romania

BACKGROUND: To date, colonoscopy is considered the gold standard for the investigation of the colon and also the gold standard method for colorectal cancer screening. AIM of this paper was to assess if and how is Romania prepared to cope with screening of colon cancer by means of colonoscopy. METHOD: We sent a study-type questionnaire addressed to all the centers in Romania known to perform digestive endoscopy and we inquired about the total number of colonoscopies and flexible sigmoidoscopies performed in 2003 (the questionnaire was sent to 43 centers). RESULTS: Thirty-eight centers responded to the question-naire. The total number of colonoscopies performed in Romania in 2003, obtained by collecting the data from the study centers, was 22,324. The number of sigmoidoscopies performed during the same period was 12,349. The ratio between the number of colonoscopies and sigmoidoscopies was 1.8/1. There were 106.3 colonoscopies /100,000 inhabitants. CONCLUSION: Considering the population of Romania (about 21 million inhabitants), the number of colonoscopies performed is insufficient for our country. The number of centers performing colonoscopy in Romania is also insufficient.     

Fecal occult blood and flexible sigmoidoscopy screening for colorectal cancer: modeling the impact on colonoscopy requirements and cancer detection rates

AiM: The aim of this study was to estimate the colonoscopy requirements and the likely impact of fecal occult blood and flexible sigmoidoscopy screening on the detection of colorectal cancer by using previously published data. METHODS: Fecal occult blood and flexible sigmoidoscopy screening programs were applied to the 2.04 million subjects aged 50-65 years, at a participation rate of 40%. The following strategies were evaluated: Fecal occult blood testing with colonoscopy follow up of all positive tests; flexible sigmoidoscopy with colonoscopy follow up of all adenomatous polyps; and flexible sigmoidoscopy with colonoscopy follow up of all adenomatous polyps > 10 mm in size. RESULTS: The fecal occult blood program detected 5.6% of all colorectal cancer cases at a rate of 2,914 colonoscopies/percentage of detection of colorectal cancer. The flexible sigmoidoscopy program detected 14% of all colorectal cancer cases at a rate of 8,160 colonoscopies/percentage of detection of colorectal cancer. The flexible sigmoidoscopy program with follow up of adenomatous polyps > 10 mm in size detected 13% of all colorectal cancer cases at a rate of 1,230 colonoscopies/percentage of detection of colorectal cancer. CONCLUSIONS: Flexible sigmoidoscopy screening followed by colonoscopic follow up of adenomatous polyps > 10 mm in size is the most efficient screening strategy in terms of colonoscopies generated and cases of colorectal cancer detected.     

Volume and yield of screening colonoscopy at a tertiary medical center after change in medicare reimbursement

OBJECTIVE: Starting July 1, 2001, Medicare began to reimburse for screening colonoscopy in asymptomatic adults older than 50 yr with no risk factors for colorectal cancer. We sought to determine the short-term impact of the change in Medicare reimbursement on the demand for and yield of screening colonoscopy at our tertiary institution. METHODS: Asymptomatic patients older than 50 referred for first screening colonoscopy after the change in Medicare reimbursement from July 1, 2001 to December 31, 2001 were compared with a similar cohort screened before Medicare coverage for a family history of cancer or polyps during the same months the previous year (July 1, 2000 to December 31, 2000). Patient demographics, number, size, location, and histology of polyps/cancers for these screening colonoscopies were collected. RESULTS: A total of 1282 colonoscopies were performed in our institution from July 1, 2001 to December 31, 2001, 257 (20%) for screening. During the same months in the previous year, 121 of 938 colonoscopies (12.9%) were for screening (p < 0.01). This was a 55% increase in the percentage of colonoscopies performed for screening, and a 112% increase in the number of screening colonoscopies. Patients screened after the change in Medicare reimbursement were on average 5 yr older compared with patients of the previous year (62 +/- 10 [mean +/- SD] vs 56 +/- 9 yr; p < 0.01). A total of 61 screening colonoscopies (24%) performed after the change in Medicare reimbursement had adenomatous lesions, compared with 25 (21%) screened for family history (p = ns). The number of adenomas 10 mm or larger or cancers did not differ significantly between the two groups (17 in 2001 vs 12 in 2000; p = ns). Age of 65 or older was associated with detection of adenomatous lesions (OR = 1.7; 95% CI = 1.01-2.9013). CONCLUSIONS: Since the change in Medicare reimbursement, there has been a significant increase in the number and proportion of colonoscopies performed for screening at our institution. Patients screened since this change are older, and the detection rate of neoplastic lesions is similar to those previously screened for a family history of colorectal cancer or polyps.     

Colonoscopy and sigmoidoscopy in patients aged eighty years or older

BACKGROUND: The demographic development will lead to an increase in endoscopic examinations in elderly patients. Indications, feasibility and therapeutic consequences following detection of pathologic findings are important assessing the relevance of endoscopy in geriatric patients. METHODS: We analyzed all colonoscopies and sigmoidoscopies which were performed between January 1995 and December 2000 in patients older than 80 years. The parameters indication, sedation, colonoscopy completion rate, endoscopic findings, therapeutic consequences and complications were evaluated. RESULTS: A total of 951 endoscopies in patients older than 80 years (781 colonoscopies, 170 sigmoidoscopies; mean age 84.3 years) were performed. The most frequent indications were: abdominal pain (n = 144; 15 %), bleeding (n = 115; 12 %), constipation (n = 97; 10 %), anemia (n = 85; 9 %), and history of polyps (n = 78; 8 %). Sedation was used in 183 examinations (19 %), mostly with midazolam (n = 179). Colonoscopy was completed successfully to the coecum in 71 %. 214 examinations were unremarkable (23 %). Frequent pathologic findings were: diverticular disease (n = 396; 42 %), polyps (n = 256; 27 %), and colorectal carcinoma (n = 75; 8 %). Curative surgery was possible in 55 % and palliative surgery in 9 % of patients with colorectal carcinoma, respectively. A complication was observed in six patients (0.6 %), four bleedings following polypectomy, one perforation after dilatation of a stenotic tumor, and one transient neurologic deficit. CONCLUSIONS: Endoscopy of the lower gastrointestinal tract is feasible in geriatric patients with a low rate of complications. The low number of normal findings and the frequent diagnosis of colorectal carcinoma were remarkable. In spite of old age more than half of the patients with carcinoma could be operated curatively emphasizing the importance of endoscopic investigations in this age group.     

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.     

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.     

Short- and long-term results of colonoscopic polypectomy in children

Eighty-four colorectal polyps of up to 3.3 cm in diameter were removed with the diathermy snare during 48 colonoscopies on 42 children, aged 2 to 18 years (mean, 7.4 years). Most polyps were juvenile and the majority were located in the sigmoid colon (55%) or rectum (37%). No complications related to medication, colonoscopy, or snare polypectomy were observed. The two presenting symptoms, rectal bleeding and anemia, disappeared soon after polypectomy in all but one patient with adenomatous polyposis coli, subsequently operated upon. Follow-up examinations, including total colonoscopy, performed 4 months to 7 years (mean, 25 months) later did not reveal abnormalities in any of the 37 children whose previously removed polyps were juvenile. The authors conclude that endoscopic snare polypectomy is an effective and safe treatment for colorectal polyps in the pediatric age group.     

Diagnostic yield and safety of colonoscopy in Israeli patients in an open access referral system

BACKGROUND: Open access endoscopy allows reference of patients for endoscopic procedures without prior gastrointestinal consultation, allowing the procedure to be more accessible. This practice is becoming increasingly widespread in the United States and other countries and has become commonplace in clinical practice in Israel. The objective of our study is to bring forward our experience with an open access referral system for colonoscopy and to measure the yield and safety of colonoscopy in this system. METHODS: Between January 2001 and September 2003, 10,866 colonoscopies were performed. Patient's charts were reviewed for the following data: demographics, indication for endoscopy, endoscopic and histopathologic findings, and complications. The practice guidelines of the American Society for Gastrointestinal Endoscopy were used to assess appropriateness of colonoscopy. RESULTS: 3533 pathologic findings were found, in 2978 colonoscopies. 2336 polyps were removed, including 18% hyperplastic, 26% tubular adenomata, 13% villous adenomata, 11% tubulovillous adenomata. Advanced disease was found in 41% of pathologic findings, 11% were invasive cancer. Rate of colonoscopies "generally indicated" according to American Society for Gastrointestinal Endoscopy guidelines was 78% with a rate of colonoscopies "generally not indicated" of 22%. Colonoscopy was completed successfully to the cecum in 93% of patients. 0.08% had serious complications during or immediately after colonoscopy. CONCLUSIONS: Our results suggest that open access colonoscopy is a reliable and safe method for screening average risk population. As colonoscopy is becoming the recommended screening model for colorectal cancer this attitude of performing screening in an open access system could both cut costs in the future and improve availability, in an aim to become common practice.     

Utilization of colonoscopy in the United States: results from a national consortium

BACKGROUND: To assess capacity for colonoscopy, we need to understand current utilization of colonoscopy in diverse clinical practice settings. The objective of this study was to determine the utilization of colonoscopy in diverse clinical practice settings. METHODS: The Clinical Outcomes Research Initiative (CORI) data repository, which receives endoscopy reports from 73 diverse adult practice sites in the United States was used. Colonoscopy reports from January 2000 to August 2002 were analyzed to determine the demographic characteristics of adult patients who received a colonoscopy and the procedure indication. The relationship of age, race, gender, and procedure indication was analyzed. RESULTS: Results of colonoscopies in 146,457 unique patients were analyzed. Of the reports, 68% came from nonacademic settings. Patients less than 50 years of age accounted for 20% of colonoscopies. The most common indications were rectal bleeding (33.6%), irritable bowel symptoms (23.8%), or screening because of a positive family history of colorectal cancer (22.4%) and screening with a primary colonoscopy or a fecal occult blood test (FOBT) (12.8%). In patients 50 years and older, asymptomatic screening (average-risk screening colonoscopy, positive family history, or FOBT positivity) accounted for 38.1% of all colonoscopies. Surveillance colonoscopy in patients with previous cancer or polyps accounted for 21.9% of colonoscopies performed in this age group. Differences in utilization were noted, based on gender and race. CONCLUSIONS: Colonoscopy utilization varies based on age, gender, and race. Colonoscopy often is performed in patients less than 50 years old for irritable bowel symptoms; rectal bleeding; or average-risk screening, for which benefits are uncertain. In patients older than 50 years, surveillance after polyp removal is a common indication and may be overused. Understanding utilization can lead to further study to determine outcomes, to optimize utilization, and to provide a basis for shifting limited resources.     

Colonoscopy practices, and colorectal cancer and polyp screening, as assessed in the French district of Isère from May to July in 2004

Background

A pilot program of organized screening for colorectal cancers was conducted in Isère, an administrative district in France. A fecal occult blood test (Hemoccult II^®) was proposed for all individuals aged greater than 50 years (women since 1991 and men since 2002), followed by colonoscopy for those testing positive. A prospective study was carried out from May to July in 2004 and compared with a similar study conducted in 1996. The goal was to investigate colonoscopy practices, especially the role of screening.

Methods

Gastroenterologists practising in Isère (n = 39/42 practitioners) completed a questionnaire including their patients’ age and gender, indications, methods and results for all colonoscopies performed in those aged greater than 20 years. Any tissue samples taken were sent away for histological evaluation.

Results

The study involved 2558 colonoscopies (54% female, 73% patients aged greater or equal to 50 years), an increase of 35% from 1996 to 2004. Of the patients referred, 50.0% were symptomatic (pain; bowel problems: 28.7%; rectal bleeding: 21.3%), 23.5% had colonic disease and 22.5% came from screening (3.1% had positive stool tests, 17.8% had a family history). Recommendations related to family history (update of the 1998 consensus conference: screening indicated for patients with a first-degree relative diagnosed with cancer or advanced polyps aged less than 60 years) were well applied in terms of relatedness (81%) but, in 52% of cases, the age was greater than 60 years. Colonoscopy was carried out in almost all cases (0.1% failure), with complications in 0.4% of the examinations. Of the 2558 colonoscopies performed, 10% revealed advanced polyps or cancer: 30% were following a positive test compared with 8% for symptoms and 6% with a family history. Multivariate analyses showed that polyps greater or equal to 10 mm or malignant tumors are 1.5 times more common in men than in women, and six times more frequently seen in patients having colonoscopy following a positive test for blood in stools than in those with a family history of colorectal cancer. The number of pathologies found increased significantly in those aged greater than 50 years.

Conclusion

This cross-sectional survey of colonoscopy practices in Isère shows an increase in the number of colonoscopies performed between 1996 and 2004. This increase is not explained by expansion of the screening program, which was the reason for only 3% of colonoscopies. However, the best diagnostic yield for advanced polyps or cancers was obtained in screened patients (30%).     

Withdrawal time in excellent or very poor bowel preparation qualities

AIM: To evaluate association(s) between withdrawal time and polyp detection in various bowel preparation qualities. METHODS: Retrospective cohort analysis of screening colonoscopies performed between January 2005 and June 2011 for patients with average risk of colorectal cancer. Exclusion criteria included patients with a personal history of adenomatous polyps or colon cancer, prior colonic resection, significant family history of colorectal cancer, screening colonoscopy after other abnormal screening tests such as flexible sigmoidoscopy or barium enema, and screening colonoscopies during in-patient care. All procedures were performed or directly supervised by gastroenterologists. Main measurements were number of colonic segments with polyps and total number of colonic polyps.RESULTS: Multivariate analysis of 8331 colonosco-pies showed longer withdrawal time was associated with more colonic segments with polyps in good(adjusted OR = 1.16; 95%CI: 1.13-1.19), fair(OR = 1.13; 95%CI: 1.10-1.17), and poor(OR = 1.18; 95%CI: 1.11-1.26) bowel preparation qualities. A higher number of total polyps was associated with longer withdrawal time in good(OR = 1.15; 95%CI: 1.13-1.18), fair(OR = 1.13; 95%CI: 1.10-1.16), and poor(OR = 1.20; 95%CI: 1.13-1.29) bowel preparation qualities. Longer withdrawal time was not associated with more colonic segments with polyps or greater number of colonic polyps in bowel preparations with excellent(OR = 1.07, 95%CI: 0.99-1.26; OR = 1.11, 95%CI: 0.99-1.24, respectively) and very poor(OR = 1.02, 95%CI: 0.99-1.12; OR = 1.05, 95%CI: 0.99-1.10, respectively) qualities.CONCLUSION: Longer withdrawal time is not associated with higher polyp number detected in colonoscopies with excellent or very poor bowel preparation quality.     

Different screening definitions have little impact on polypectomy rate estimates

BACKGROUND:

Polypectomy rate is a surrogate quality indicator for screening colonoscopy. Various methods for identifying screening colonoscopies have been used and it is unclear how different definitions affect the estimated polypectomy rate.

OBJECTIVE:

To estimate polypectomy rates and how they vary according to the definition of a screening colonoscopy, using patient- and endoscopist-reported indications.

METHODS:

A cross-sectional analysis of endoscopists and their patients 50 to 75 years of age who underwent colonoscopy was conducted. Based on questionnaire responses, four patient indications were derived: perceived screening; perceived nonscreening; medical history indicating nonscreening; and combination of the three indications. Endoscopist indication was derived from a questionnaire completed immediately after colonoscopy. Polypectomy status was obtained from provincial physician billing records. Polypectomy rates were computed, while accounting for physician and hospital level clustering, using all four patient indications, endoscopist indication, and the agreement between patient and endoscopist indications. The effect of indications on polypectomy rate was estimated adjusting for age, sex and family history of colorectal cancer.

RESULTS:

A total of 2134 patients and 45 endoscopists were included. The proportion of colonoscopies classified as screening according to the nine indications ranged from 32.2% to 70.9%. Polypectomy rates ranged between 22.6% and 26.2% for screening colonoscopy, and between 27.1% and 30.8% for nonscreening colonoscopy. Adjusted ORs for indication ranged between 0.74 and 0.94.

DISCUSSION:

Although the proportion of colonoscopies identified as screening varied considerably among the indications, the estimated polypectomy rates were similar.

CONCLUSION:

The findings suggest that the way screening is defined does not greatly affect the estimates of polypectomy rate.     

A prospective, partly randomized study of the effectiveness of repeated examination of the colon after polypectomy and radical surgery for cancer

Results of 629 colonoscopies and 130 double-contrast examinations, performed during the first 2 years of a prospective, partly randomized cancer prophylactic programme, are reported. The patients were not more than 75 years old and had no previous diagnosis of adenoma or cancer. Repeated colonoscopy 3 months after polypectomy in 80 patients increased the chance of obtaining a complete colonoscopy from 70% to 86%, and the hepatic flexure was reached in a further 9%. Thirteen had polypectomy during the second colonoscopy. The gain in number of patients with adenomas was highest in those with sessile villous adenomas, carcinoma in situ, and mucosal carcinoma. Repeated colorectal examinations every 6 months in these resulted in recurrence rates of 13 of 33, 3 of 23, and 2 of 15 (18 months), respectively. The same figures for patients with stalked polyps, allocated to examination every 6 months, were 3 of 34, 1 of 21, and 2 of 14. Colonoscopy was also performed within 3 months of radical surgery for colorectal cancer, and 35 of 142 patients had polypectomy. Repeated examinations every 6 months resulted in recurrence rates for adenomas of 11 of 85, 3 of 46, and 1 of 34. One new cancer after 12 months could be treated radically. Five uncomplicated laparotomies were performed after the 629 colonoscopies because of perforation or bleeding.     

Impact of a CT colonography screening program on endoscopic colonoscopy in clinical practice

OBJECTIVE: The potential effect of CT colonography (CTC) on endoscopic colonoscopy (EC) has been the topic of much speculation. The aim of this study was to evaluate the impact of a CTC screening program on colonoscopy in clinical practice. METHODS: At our institution a third-party reimbursed CTC colorectal cancer (CRC) screening program was established in 2004. The number of CTC monthly exams performed, monthly EC total and screening exams performed, EC with polypectomy performed, and the number of referrals for EC screening exams requested were prospectively examined in the first 33 months after introduction of a CTC CRC screening program. RESULTS: The mean number of overall (378.5 vs 413.1) and screening (150.7 vs 162.9) colonoscopy exams performed per month did not change significantly after screening CTC was introduced. The mean number of monthly CTC exams performed rose significantly throughout the first year of the study from 39 initially to a peak of 147.6 cases per month but decreased slightly to 114.3 monthly exams at the end of 2006. A mean 10.0 patients per month were sent for EC after a positive CTC exam. The mean number of monthly colonoscopies with polypectomy remained constant after the introduction of CTC (197.0 vs 180.2). Monthly referrals for screening EC exams initially decreased but were unchanged 3 yr after institution of a CTC screening program (255.0 vs 253.5). CONCLUSIONS: (a) In our tertiary care center the initiation of a screening CTC program did not result in a decrease in the number of total colonoscopy exams, screening colonoscopy exams performed, nor requests for screening colonoscopy. (b) Only a small number of CTC exams were referred for EC with polypectomy, therefore a CTC screening program may not increase the overall number of therapeutic colonoscopies performed.     

Detection and treatment of synchronous lesions in colorectal cancer： The clinical implication of perioperative colonoscopy

AIM： To evaluate the clinical significance of preand intra-operative colonoscopy for the detection of synchronous lesions in colon cancer.
METHODS： Two hundred and sixty-five pre-operative and 51 intra-operative colonoscopic evaluations were performed in 316 colorectal cancer patients who underwent curative resection from January 2001 to June 2006. The incidence and characteristics of synchronous lesions and their influence on surgery were evaluated.
RESULTS： Two hundred and eighty-two synchronous lesions were detected in 124 （39.2%） of 316 patients including all lesions regardless of their histologic type. True adenomatous polyps were found in 91 （28.8%） of 326 patients, and 27 （5.4% of all patients） patients had synchronous colon cancers. The preoperative identification of synchronous lesions altered the planned surgery in 37 （14.0%） of 265 patients. In 18 patients among the surgically removed cases, the lesions were removed by extending the resection range. Further segmental resection or polypectomy through enterotomy was necessary in 29 patients. Nineteen （37.2%） of 52 intraoperative colonoscopy cases had synchronous lesions. Additional surgical procedures including segmental bowel resection and polypectomy with enterotomy were necessary in 7 （23.7%） of 52 intraoperative colonoscopy cases to remove the lesions.
CONCLUSION： Synchronous colorectal polyps or cancer are frequent and their preoperative detection is important for optimal surgical planning and treatment. Intraoperative colonoscopy is a useful option in cases where a preoperative colonoscopy is not feasible.     

The yield of lower endoscopy in patients with constipation: survey of a university hospital,a public county hospital,and a Veterans Administration medical center

BACKGROUND: The role of endoscopy in the evaluation of constipation is controversial. The aim of this study was to clarify the yield of lower endoscopy in patients with constipation. METHODS: Endoscopic databases from 3 diverse hospitals were searched for procedures with constipation as an indication. Detection of neoplasia was the main outcome of interest. RESULTS: Among 19,764 sigmoidoscopies or colonoscopies, constipation was a procedure indication for 563 patients (mean age 61 [16] years, 52% women); 58% had procedure indications in addition to constipation. Colorectal cancer was diagnosed in 8 (1.4%), adenomas in 82 (14.6%), and advanced lesions (cancer or adenoma with malignancy, high-grade dysplasia, villous features, or size > or = 10 mm) in 24 (4.3%). In the 358 patients who underwent colonoscopy, cancer was detected in 1.7%, adenomas in 19.6%, and advanced lesions in 5.9%. Two patients with cancer were less than 50 years of age. In as many as 6 patients with cancer, the tumor may have caused partial obstruction. CONCLUSIONS: The range of neoplasia in patients with constipation evaluated with lower endoscopy was comparable with what would be expected in asymptomatic subjects undergoing colorectal cancer screening. Although chronic constipation alone may not be an appropriate indication for lower endoscopy, age-appropriate colorectal cancer screening should be pursued when patients with constipation seek medical care.     

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.     

Colorectal neoplasia screening with virtual colonoscopy: when, at what cost, and with what national impact?

BACKGROUND & AIMS: When optimized, virtual colonoscopy may be highly sensitive for colorectal neoplasia. We evaluated the effectiveness and cost-effectiveness of virtual colonoscopy screening (VC) vs. colonoscopy screening (COLO) and the potential impact at the national level. METHODS: Using a Markov model, we estimated the clinical and economic consequences of VC and COLO from ages 50 to 80 years. Using census data, we made projections to the national level. RESULTS: In the best case considered (95%, 94%, and 87% sensitivity for colorectal cancer [CRC], polyps > or =10 mm, and polyps <10 mm), VC was nearly as effective as COLO. However, if test costs were equal, total cost per person was 15% greater for VC than COLO, making COLO dominant. When test cost for VC was < or =60% of test cost for COLO, the small benefit of COLO vs. VC cost >200,000 US dollars/incremental life-year. The greater the likelihood of being referred for colonoscopy after VC, the greater the advantage of COLO. With 75% screening adherence in the United States, VC and COLO could decrease CRC incidence by 46%-54%, with COLO requiring 6.9 million colonoscopies/yr, and VC, 3.2 million colonoscopies/yr, plus 5.4 million virtual colonoscopies/yr with VC. CONCLUSIONS: Even if screening test sensitivities were similar, COLO is likely to be preferred over VC unless virtual colonoscopy costs significantly less than colonoscopy. VC may be most appropriate in persons unlikely to need colonoscopy, such as those at low CRC risk. If VC were substituted for COLO, the demand on resources would shift from endoscopic to radiologic services, but would not diminish.     

Effectiveness of screening colonoscopy in a community-based study

In 2002 screening colonoscopy was introduced in Germany for the prevention of colorectal cancer (CRC) and CRC mortality. Individuals took part in a prospective study from October 2002 until September 2005 performed at a single centre for gastroenterology. Histopathological data, surgical-pathological stages and further follow-up events were recorded until 31st of December 2006. For screened individuals without symptoms, the data obtained were compared to those from age-matched patients who presented with clinical symptoms/signs and who underwent colonoscopy during the same period in time. A total of 5066 individuals underwent screening colonoscopy. In this group, colorectal cancer was detected in 46 individuals (0.9%). Endoscopic treatment was considered adequate for 21 cancers. In this group of 46 patients, 94.5% were classified into UICC stages I-II by pathological staging. In 504 screened individuals, colorectal polyps were detected (12.2%) and removed by polypectomy. Of these polyps, 16 were classified as cancer, 496 as adenomas and 1 as a carcinoid tumour. High grade dysplasia was noted in 41 polyps (8.3% of adenomas). In comparison, 4099 symptomatic patients underwent colonoscopy. In this group 100 cancers (2.4%) were detected. Advanced malignant tumours were noted in 39% of these; endoscopic treatment was feasible in 16% of the cancers. As of December 2006, cancer-related deaths were observed in 20% of symptomatic patients with CRC. Screening colonoscopy detects colorectal cancers in the early stages. Given the favourable prognosis in these stages, screening can reduce CRC-related mortality.     

Use, appropriateness, and diagnostic yield of screening colonoscopy: an international observational study (EPAGE)

BACKGROUND: Screening for colorectal cancer (CRC) has been shown to decrease mortality. OBJECTIVE: To examine determinants associated with having (1) a screening colonoscopy, (2) an appropriate indication for screening, and (3) a significant diagnosis at screening. DESIGN: Prospective observational study. SETTING: Twenty-one endoscopy centers from 11 countries. PATIENTS: Asymptomatic patients who underwent a colonoscopy for the purpose of detecting CRC and who did not have a history of polyps or CRC, a lesion observed at a recent barium enema or sigmoidoscopy, or a recent positive fecal occult blood test. INTERVENTION: Screening colonoscopy. MAIN OUTCOME MEASUREMENTS: Appropriateness according to the European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) criteria and significant diagnoses (cancer, adenomatous polyps, new diagnoses of inflammatory bowel disease, angiodysplasia). RESULTS: Of 5069 colonoscopies, 561 (11%) were performed for screening purposes. Patients were more likely to have a screening colonoscopy if they were aged 45 to 54 years (odds ratio [OR] 2.53, 95% confidence interval [CI] 1.60-3.99). Screening colonoscopies were appropriate, uncertain, and inappropriate in 26%, 60%, and 14% of cases, respectively. Eighty-one significant diagnoses were made, including 4 cancers. Significant diagnoses were more often made for uncertain/appropriate indications (OR 3.20, 95% CI 1.12-9.17) than for inappropriate indications. LIMITATIONS: Although data completeness was asked of all centers, it is possible that not all consecutive patients were included. Participating centers were a convenience sample and thus may not be representative. CONCLUSIONS: About 1 of 10 colonoscopies were performed for screening, preferentially in middle-aged individuals. A higher diagnostic yield in uncertain/appropriate indications suggests that the use of appropriateness criteria may enhance the efficient use of colonoscopy for screening.