Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology

Accuracy of in vivo optical diagnosis of colon polyp histology by narrow-band imaging in predicting colonoscopy surveillance intervals

BACKGROUND

The American Society for Gastrointestinal Endoscopy (ASGE) recently developed thresholds for the performance characteristics of technologies for real-time assessment of histology of diminutive (≤ 5 mm) colon polyps. Narrow-band imaging (NBI) has been shown to predict polyp histology with moderate to high accuracy in several studies.

OBJECTIVE

To determine whether in vivo optical diagnosis of polyp histology by using NBI can reach the 2 benchmarks set forth by the ASGE.

DESIGN

Retrospective analysis of data from 3 prospective clinical trials.

SETTING

Two tertiary referral centers.

PATIENTS

Subjects undergoing screening or surveillance colonoscopy.

INTERVENTIONS

In vivo optical diagnosis of polyp histology by using NBI.

MAIN OUTCOME MEASUREMENT

Accuracy in predicting colonoscopy surveillance intervals, negative predictive value (NPV) for diagnosing adenomatous histology in the rectosigmoid.

RESULTS

A total of 410 patients met the inclusion/exclusion criteria and had at least 1 polyp seen and resected during colonoscopy. Using in vivo optical diagnosis instead of histopathology for all diminutive polyps predicted the correct colonoscopy surveillance interval in 86% to 94% patients. When optical diagnosis was limited to diminutive polyps in the rectosigmoid only, the NPV for diagnosing adenomatous histology with NBI was 95%.

LIMITATIONS

Retrospective analysis from tertiary referral centers.

CONCLUSIONS

The threshold NPV for diagnosing adenomatous histology in diminutive rectosigmoid polyps recently set forth by the ASGE can be achieved by using NBI. The threshold accuracy rate for predicting surveillance interval recommendations can be reached by using NBI, but only if patients with 1 to 2 small adenomas without advanced features have a repeat colonoscopy in 10 years.

[The Alliance for the Prevention of Colorectal Cancer in Spain. A civil commitment to society]

Colorectal cancer (CRC) is the most common malignant tumor in Spain, when men and women are considered together, and the second leading cause of cancer death. Every week in Spain over 500 cases of CRC are diagnosed, and nearly 260 people die from the disease. Epidemiologic estimations for the coming years show a significant increase in the number of annual cases. CRC is a perfectly preventable tumor and can be cured in 90% of cases if detected in the early stages. Population-based screening programs have been shown to reduce the incidence of CRC and mortality from the disease. Unless early detection programs are established in Spain, it is estimated that in the coming years, 1 out of 20 men and 1 out of 30 women will develop CRC before the age of 75. The Alliance for the Prevention of Colorectal Cancer in Spain is an independent and non-profit organization created in 2008 that integrates patients' associations, altruistic non-governmental organizations and scientific societies. Its main objective is to raise awareness and disseminate information on the social and healthcare importance of CRC in Spain and to promote screening measures, early detection and prevention programs. Health professionals, scientific societies, healthcare institutions and civil society should be sensitized to this highly important health problem that requires the participation of all sectors of society. The early detection of CRC is an issue that affects the whole of society and therefore it is imperative for all sectors to work together.

Reflex immunohistochemistry and microsatellite instability testing of colorectal tumors for Lynch syndrome among US cancer programs and follow-up of abnormal results

PURPOSE

Immunohistochemistry (IHC) for MLH1, MSH2, MSH6, and PMS2 protein expression and microsatellite instability (MSI) are well-established tools to screen for Lynch syndrome (LS). Although many cancer centers have adopted these tools as reflex LS screening after a colorectal cancer diagnosis, the standard of care has not been established, and no formal studies have described this practice in the United States. The purpose of this study was to describe prevalent practices regarding IHC/MSI reflex testing for LS in the United States and the subsequent follow-up of abnormal results.

MATERIALS AND METHODS

A 12-item survey was developed after interdisciplinary expert input. A letter of invitation, survey, and online-survey option were sent to a contact at each cancer program. A modified Dillman strategy was used to maximize the response rate. The sample included 39 National Cancer Institute-designated Comprehensive Cancer Centers (NCI-CCCs), 50 randomly selected American College of Surgeons-accredited Community Hospital Comprehensive Cancer Programs (COMPs), and 50 Community Hospital Cancer Programs (CHCPs).

RESULTS

The overall response rate was 50%. Seventy-one percent of NCI-CCCs, 36% of COMPs, and 15% of CHCPs were conducting reflex IHC/MSI for LS; 48% of the programs used IHC, 14% of the programs used MSI, and 38% of the programs used both IHC and MSI. One program used a presurgical information packet, four programs offered an opt-out option, and none of the programs required written consent.

CONCLUSION

Although most NCI-CCCs use reflex IHC/MSI to screen for LS, this practice is not well-adopted by community hospitals. These findings may indicate an emerging standard of care and diffusion from NCI-CCC to community cancer programs. Our findings also described an important trend away from requiring written patient consent for screening.

Gender and ethnic differences in colorectal cancer screening embarrassment and physician gender preferences

PURPOSE/OBJECTIVES

To examine colorectal cancer (CRC) screening embarrassment among men and women from three ethnic groups and the associated physician gender preference by patient gender and ethnicity.

DESIGN

Cross-sectional, purposive sampling.

SETTING

Urban community in Brooklyn, NY.

SAMPLE

A purpose-derived, convenience sample of 245 European American, African American, and immigrant Jamaican men and women (aged 45-70 years) living in Brooklyn, NY.

METHODS

Participants provided demographics and completed a comprehensive measure of CRC screening embarrassment.

MAIN RESEARCH VARIABLES

Participant gender and ethnicity, physician gender, and CRC screening embarrassment regarding feces or the rectum and unwanted physical intimacy.

FINDINGS

As predicted, men and women both reported reduced fecal and rectal embarrassment and intimacy concern regarding same-gender physicians. As expected, Jamaicans reported greater embarrassment regarding feces or the rectum compared to European Americans and African Americans; however, in contrast to expectations, women reported less embarrassment than men. Interactions indicated that rectal and fecal embarrassment was particularly high among Jamaican men.

CONCLUSIONS

Men and women have a preference for same-gender physicians, and embarrassment regarding feces and the rectum shows the most consistent ethnic and gender variation.

IMPLICATIONS FOR NURSING

Discussing embarrassment and its causes, as well as providing an opportunity to choose a same-gender physician, may be promising strategies to reduce or manage embarrassment and increase CRC screening attendance.

Up-regulated miR-17 promotes cell proliferation, tumour growth and cell cycle progression by targeting the RND3 tumour suppressor gene in colorectal carcinoma

Emerging evidence indicates that the miR-17 family may have a causal role in human cancer tumorigenesis, but their specific effects on the occurrence of CRC (colorectal carcinoma) are still poorly understood. In the present study, we profiled CRC tissue samples by miRNA (microRNA) microarray and found that four members of the miR-17 family had higher expression in CRC tissues than in normal tissues. This finding was further validated by qRT-PCR (quantitative reverse transcription PCR). Transfecting CRC cells with an inhibitor of miR-17 lowered their ability to proliferate and induced G0/G1 arrest. We also confirmed that miR-17 exerted this function by directly targeting RND3 in vitro, and that the expression of miR-17 was negatively correlated with that of RND3 in CRC tissues and CRC cells. Moreover, miR-17 inhibition led to tumour growth suppression and up-regulation of RND3 expression in a nude mouse xenograft model. RND3 expression was found to be significantly lower in CRC tissues than in normal tissues and adenomas, indicating that RND3 may act as a tumour suppressor gene in CRC. In conclusion, the present study suggests that miR-17 plays an important role in CRC carcinogenesis by targeting RND3 and may be a therapeutic agent for CRC.

Colorectal cancer testing in the national Veterans Health Administration

BACKGROUND

Colorectal cancer (CRC) screening is a priority for the Veteran's Health Administration (VHA). Optimizing fecal occult blood testing (FOBT) is integral to CRC screening in health care systems.

AIMS

The purpose of this study was to characterize the utilization of CRC testing in a large integrated health care system (VHA), determine current rates of CRC testing by FOBT and examine factors associated with lack of FOBT card return.

METHODS

The VHA Office of Quality and Performance (OQP) collected data from a national sample of Veterans from October 2008 to September 2009. Rates and modality of CRC testing for eligible Veterans were calculated. Among those offered FOBT, bivariate analyses were performed to describe population characteristics by FOBT return. Logistic regression was used to determine factors independently associated with lack of FOBT return.

RESULTS

A total of 36,336 Veterans were included. On weighted analysis, 80.4% of Veterans received a form of CRC screening. The majority underwent colonoscopy in the prior 10 years (71.6%), followed by FOBT in the prior year (24.0%). A total of 31.0% did not return FOBT cards that were provided. Factors associated with a lack of FOBT return included: younger age, female gender, non-Caucasian race, living in the Northeast, current smoking and lack of influenza vaccination.

CONCLUSIONS

Overall rates of CRC screening in VHA are high. Systems-based practices within VHA likely play a role in successful CRC screening. CRC screening is most often via colonoscopy, followed by FOBT. Characteristics associated with non-adherence with FOBT may inform future quality improvement initiatives in health care systems.

Transparent cap-assisted colonoscopy versus standard adult colonoscopy: a systematic review and meta-analysis

BACKGROUND

Cap-assisted colonoscopy uses a transparent plastic hood attached to the tip of the colonoscope to flatten the semilunar folds and improve mucosal exposure. Several studies have examined the effect of cap-assisted colonoscopy on polyp detection, but the data are inconsistent.

OBJECTIVE

This study aimed to evaluate whether cap-assisted colonoscopy improves the yield of colorectal neoplasia detected compared with standard colonoscopy.

DATA SOURCES

A systematic search of the PubMed, MEDLINE, Embase, and Cochrane databases identified 12 studies that met the inclusion criteria for data extraction.

STUDY SELECTION

Publications that compared cap-assisted colonoscopy vs standard colonoscopy in adults in a prospective randomized controlled study were selected for review.

MAIN OUTCOME MEASURES

The primary outcomes used for meta-analysis were cecal intubation rate, cecal intubation time, and polyp detection rate. The analysis was performed using a fixed-effect model. Outcomes were calculated as odds ratios or standardized mean differences with 95% confidence intervals. The average polyp miss rate determined by tandem colonoscopy was also calculated.

RESULTS

The outcomes of 6185 patients were studied. Cap-assisted colonoscopy detected significantly more patients with polyps (OR 1.13; p = 0.030) and had a lower average polyp miss rate (12.2% vs 28.6%) than standard colonoscopy. Cap-assisted colonoscopy had a significantly higher cecal intubation rate than standard colonoscopy (OR 1.36; p = 0.020), whereas the time to cecal intubation (standard mean difference, 0.04 min; p = 0.280) was similar for the 2 colonoscope types.

CONCLUSIONS

Cap-assisted colonoscopy is associated with improved detection of colorectal neoplasia and higher cecal intubation rates than standard adult colonoscopy.

Serrated polyposis syndrome and the role of serrated polyps in colorectal cancer development

SUMMARY Serrated polyposis syndrome is characterized by the presence of multiple colorectal serrated polyps and is associated with an increased colorectal cancer risk. The mixture of distinct precursor lesion types and malignancies in serrated polyposis syndrome provides a unique model to study the recently proposed serrated neoplasia pathway. This pathway involves the progression of serrated polyps, that is, hyperplastic polyps, sessile serrated adenoma/polyps and/or traditional serrated adenomas, to colorectal cancer. The early genetic events of this route, as currently identified, are BRAF or KRAS mutations and an enhanced CPG island methylation status of multiple genes. There is evidence to suggest that a proportion of sporadic colorectal cancers originate from serrated polyps, which encompass molecular sequences of events such as hypermethylation of different genes and BRAF mutations. This review discusses the characteristics and clinical relevance of serrated polyps and provides an overview of the clinical aspects and treatment of serrated polyposis syndrome.

Preferência do paciente no rastreamento do câncer colorretal: uma comparação entre colonografia por tomografia computadorizada e colonoscopia

OBJETIVO: Avaliar o grau de aceitação do paciente submetido a colonografia por tomografia computadorizada (CTC) em comparação com a colonoscopia, quando realizadas para rastreamento de doença colorretal. MATERIAIS E MÉTODOS: Cinquenta pacientes com suspeita de doença colorretal foram submetidos a CTC e colonoscopia. Questionários foram aplicados antes e após a realização da CTC e após a colonoscopia. Graduou-se o desconforto esperado e experimentado antes e após a realização da CTC e da colonoscopia, bem como a preferência do paciente por exame. RESULTADOS: Em relação à CTC, antes de iniciar o exame 18% dos pacientes afirmaram esperar pouco desconforto, 78%, desconforto moderado e 4%, muito desconforto. Após a realização do exame, 72% dos pacientes relataram pouco desconforto, 26%, desconforto moderado e apenas um (2%) dos pacientes referiu muito desconforto. Após a realização da colonoscopia, 86% dos pacientes relataram preferência pela CTC. O grau de distensão colônica e a quantidade de fluido residual não influenciaram na preferência dos pacientes. CONCLUSÃO: Os pacientes preferiram a CTC à colonoscopia, não havendo relação estatística com o grau de distensão colônica na CTC e a eficiência do preparo intestinal.

Confocal endomicroscopy of colorectal polyps

Confocal laser endomicroscopy (CLE) is one of several novel methods that provide real-time, high-resolution imaging at a micron scale via endoscopes. CLE has the potential to be a disruptive technology in that it can change the current algorithms that depend on biopsy to perform surveillance of high-risk conditions. Furthermore, it allows on-table decision making that has the potential to guide therapy in real time and reduce the need for repeated procedures. CLE and related technologies are often termed “virtual biopsy” as they simulate the images seen in traditional histology. However, the imaging of living tissue allows more than just pragmatic convenience; it also allows imaging of living tissue such as active capillary circulation, cellular death, and vascular and endothelial translocation, thus extending beyond what is capable in traditional biopsy. Immediate potential applications of CLE are to guide biopsy sampling in Barrett's esophagus and inflammatory bowel disease surveillance, evaluation of colorectal polyps, and intraductal imaging of the pancreas and bile duct. Data on these applications is rapidly emerging, and more is needed to clearly demonstrate the optimal applications of CLE. In this paper, we will focus on the role of CLE as applied to colorectal polyps detected during colonoscopy.

CT colonography without cathartic preparation: positive predictive value and patient experience in clinical practice

OBJECTIVE

To determine the positive predictive value (PPV) for polyps ≥ 6 mm detected at CT colonography (CTC) performed without cathartic preparation, with low-dose iodine faecal tagging regimen and to evaluate patient experience.

METHODS

1920 average-risk patients underwent CTC without cathartic preparation. Faecal tagging was performed by diatrizoate meglumine and diatrizoate sodium at a total dose of 60 ml (22.2 g of iodine).The standard interpretation method was primary 3D with 2D problem solving. We calculated per-patient and per-polyp PPV in relation to size and morphology. All colonic segments were evaluated for image quality (faecal tagging, amount of liquid and solid residual faeces and luminal distension). Patients completed a questionnaire before and after CTC to assess preparation and examination experience.

RESULTS

Per-polyp PPV for detected lesions of ≥ 6 mm, 6-9 mm, ≥ 10 mm and ≥ 30 mm were 94.3%, 93.1%, 94.7% and 98%, respectively. Per-polyp PPV, according to lesion morphology, was 94.6%, 97.3% and 85.1% for sessile, pedunculated and flat polyps, respectively. Per-patient PPV was 92.8%. Preparation without frank cathartics was reported to cause minimal discomfort by 78.9% of patients.

CONCLUSION

CTC without cathartic preparation and low-dose iodine faecal tagging may yield high PPVs for lesions ≥ 6 mm and is well accepted by patients.

KEY POINTS

• Computed tomographic colonography (CTC) without cathartic preparation is well accepted by patients • Cathartic-free faecal tagging CTC yields high positive predictive values • CTC without cathartic preparation could improve uptake of colorectal cancer screening.

Epigenetic alteration of microRNAs in feces of colorectal cancer and its clinical significance

MicroRNAs regulate target gene expression through translation repression or mRNA decay, and they are emerging as important modulators in cellular pathways. Previous studies have shown the occurrence of epigenetically modified miRNAs in colorectal cancer (CRC), identifying these miRNA methylation signatures may provide candidate markers for the detection of malignant colonocytes. Fecal-based tests are widely adopted as noninvasive methods for CRC diagnosis, thus several studies have attempted to use miRNAs from feces as CRC markers. This article evaluates a recently published study investigating the usefulness of epigenetically silenced miRNAs in fecal specimens, including miR-34b/c and miR-148a, as potential markers for CRC screening and prognosis.

Trends in colorectal cancer incidence rates in the United States by tumor location and stage, 1992-2008

BACKGROUND

Results from case-control studies outside the United States have been conflicted about the efficacy of colonoscopy for reducing cancer risk in the right colon. To contribute to this discourse from an alternative perspective, we analyzed high-quality surveillance data to report on recent trends in population-based colorectal cancer incidence rates by tumor location in the United States.

METHODS

Data from cancer registries in the Surveillance, Epidemiology, and End Results Program were analyzed to examine colorectal cancer incidence trends from 1992 through 2008 among individuals aged ≥ 50 years (n = 267,072). Joinpoint regression analysis was used to quantify annual percent change in age-standardized rates by tumor location and disease stage.

RESULTS

Incidence rates for right-sided colon tumors decreased annually by 2.6% (95% CI: 2.0-3.2) since 1999 in men and 2.3% (CI: 1.6-3.0) since 2000 in women, after remaining stable during the previous seven/eight years. Incidence rates for left-sided tumors were generally decreasing from 1992 to 2008 in both sexes. Beginning in 1999/2000, substantial, almost identical annual declines occurred for late-stage disease in both the right and left colon: 3.9% (CI: 3.1-4.8) and 4.2% (CI: 3.5-4.9), respectively, in men; and 3.3% (CI: 2.5-4.1) and 3.3% (CI: 2.8-3.8) in women.

CONCLUSION

Large declines in the incidence of right-sided colon tumors among individuals 50 years and older began around 2000.

IMPACT

Increased colonoscopy utilization during the past decade may have contributed to a reduction in risk for cancers in both the right and left colorectum in the United States.

Investigating the relationship between virtual cystoscopy image quality and CT slice thickness

OBJECTIVE

To investigate the effect of reconstruction slice thickness on image quality at CT virtual cystoscopy (VC).

METHODS

Pelvic CT examinations in bladder cancer patients were reconstructed at different slice thicknesses (0.6-5 mm) and intervals, and resulting VC images assessed. Quality indicators were ridging, holes, floaters and dimpling artefacts, tumour definition, and an overall score, ranked 1 (best) to 7 (worst). CT number and standard deviation (SD) for bladder contents and bladder wall were recorded. The mean SD was used as a measure of noise, and the contrast-to-noise ratio (CNR) was calculated as the CT number difference between them divided by the average image noise. The mean CNR across the three levels was used for analysis. Each qualitative image quality measure was compared with CT number, noise and CNR measurements.

RESULTS

Dimpling artefacts increased with thinner slice reconstruction and correlated with increased noise, often resulting in poor tumour definition. The best overall image quality score was seen for VC images reconstructed at 1.2 mm slice thickness, probably because of the competing effects of spatial resolution and CNR.

CONCLUSION

A slice thickness reconstruction <1.2 mm does not provide for better image quality at VC owing to the presence of increased noise.

American Cancer Society Guidelines on nutrition and physical activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity

The American Cancer Society (ACS) publishes Nutrition and Physical Activity Guidelines to serve as a foundation for its communication, policy, and community strategies and, ultimately, to affect dietary and physical activity patterns among Americans. These Guidelines, published approximately every 5 years, are developed by a national panel of experts in cancer research, prevention, epidemiology, public health, and policy, and they reflect the most current scientific evidence related to dietary and activity patterns and cancer risk. The ACS Guidelines focus on recommendations for individual choices regarding diet and physical activity patterns, but those choices occur within a community context that either facilitates or creates barriers to healthy behaviors. Therefore, this committee presents recommendations for community action to accompany the 4 recommendations for individual choices to reduce cancer risk. These recommendations for community action recognize that a supportive social and physical environment is indispensable if individuals at all levels of society are to have genuine opportunities to choose healthy behaviors. The ACS Guidelines are consistent with guidelines from the American Heart Association and the American Diabetes Association for the prevention of coronary heart disease and diabetes, as well as for general health promotion, as defined by the 2010 Dietary Guidelines for Americans and the 2008 Physical Activity Guidelines for Americans.

Factors that influence cecal intubation rate during colonoscopy in deeply sedated patients

BACKGROUND AND AIM

The technical performance of colonoscopy performed in deeply sedated patients differs from that performed without sedation or under minimal to moderate sedation. The aim of this study is to evaluate the factors affecting cecal intubation during colonoscopy performed under deep sedation.

METHODS

A total of 5352 consecutive subjects who underwent a screening colonoscopy as part of a health check-up between January 2008 and December 2008 at an academic hospital were reviewed. All endoscopies were performed with deep sedation using combination propofol or propofol alone. Data collected included characteristics of the patients (age, gender, body mass index, bowel habits, history of abdominal or pelvic surgery, quality of bowel preparation, and presence/absence of colonic diverticula) and characteristics of the colonoscopists (experience level, colonoscopy procedure volume, and instrument handling method). These factors were analyzed to evaluate their impact on cecal intubation rates.

RESULTS

The crude cecal intubation rate was 98% and the adjusted cecal intubation rate was 98.3%. The mean cecal intubation time was 5.6 ± 3.2 min. Multivariate logistic regression analysis demonstrated that patient age greater than 60 years, constipation, poor colon preparation and a two-person colonoscopy procedure were independently associated with lower cecal intubation rates.

CONCLUSIONS

Colonoscopy performed under deep sedation by experienced colonoscopists results in high cecal intubation rates. Among the significant patient-related predictors influencing the cecal intubation, the quality of the bowel preparation was the only modifiable factor. When performed by experienced hands, the one-person method was associated with higher cecal intubation rates than the two-person method.

Quality evaluation of colonoscopy reporting and colonoscopy performance in daily clinical practice

BACKGROUND

Comprehensive monitoring of colonoscopy quality requires complete and accurate colonoscopy reporting.

OBJECTIVE

This study aimed to assess the compliance with colonoscopy reporting and to assess the quality of colonoscopy performance.

DESIGN

Consecutive colonoscopy reports were reviewed by hand. Four hundred reports were included from each department.

SETTING

Daily clinical practice in 12 Dutch endoscopy departments.

PATIENTS

Consecutive patients undergoing scheduled colonoscopy procedures.

MAIN OUTCOME MEASUREMENTS

Quality of reporting was assessed by using the American Society for Gastrointestinal Endoscopy criteria for colonoscopy reporting. Quality of colonoscopy performance was evaluated by using the cecal intubation rate and adenoma detection rate (ADR).

RESULTS

A total of 4800 colonoscopies were performed by 116 endoscopists: 70% by gastroenterologists, 16% by gastroenterology fellows, 10% by internists, 3% by nurse-endoscopists, and 1% by surgeons. The mean age of the patients was 59 years (standard deviation 16), and 47% were male. Reports contained information on indication, sedation practice, and extent of the procedure in more than 90%. Only 62% of the reports mentioned the quality of bowel preparation (range between departments 7%-100%); photographic documentation of the cecal landmarks was present in 71% (range 22%-97%). The adjusted cecal intubation rate was 92% (range 84%-97%). The ADR was 24% (range 13%-32%).

LIMITATIONS

Dependent on reports, no intervention in endoscopic practice. No analysis for performance per endoscopist.

CONCLUSION

Colonoscopy reporting varied significantly in clinical practice. Colonoscopy performance met the suggested standards; however, considerable variability between endoscopy departments was found. The results of this study underline the importance of the implementation of quality indicators and guidelines. Moreover, by continuous monitoring of quality parameters, the quality of both colonoscopy reporting and colonoscopy performance can easily be improved.

Use of family history in clinical guidelines for diabetes and colorectal cancer

BACKGROUND

Family history is a risk factor for many chronic diseases and as such is often incorporated into clinical practice guidelines.

PURPOSE

To assess the consistency of the use of family history in selected guidelines for colorectal cancer (CRC) and type 2 diabetes mellitus (T2DM) and to examine how these definitions influence their screening recommendations.

METHODS

Using a web-based search, guidelines issued between 2001 and 2011 from Australia, Canada, the United Kingdom, the U.S., and the WHO were reviewed. In total, 21 guidelines were found that included family history information (14 for CRC and seven for T2DM). For each guideline, the definition of family history and the way this definition influenced screening recommendations was recorded. Analyses were completed on May 2011.

RESULTS

Family history was defined most often as the presence of affected first-degree relatives; the number of such relatives and their ages at diagnosis were considered sometimes in making specific recommendations. The definition of family history and its impact on recommendations varied substantially, even for the same disease.

CONCLUSIONS

Despite the importance of family history as a risk factor for CRC and T2DM, its use in screening recommendations is inconsistent among guidelines from major organizations; however, differences do not appear large enough to prevent achieving consensus among the guidelines for each disease. More standardized recommendations for use of family history in CRC and T2DM screening guidelines could enhance their utility for prevention.

Genetic and epigenetic biomarkers of colorectal cancer

Cancer is a heterogeneous disease caused, in part, by genetic and epigenetic alterations. These changes have been explored in studies of the pathogenesis of colorectal cancer (CRC) and have led to the identification of many biomarkers of disease progression. However, the number of biomarkers that have been incorporated into clinical practice is surprisingly small. We review the genetic and epigenetic mechanisms of colorectal cancer and discuss molecular markers recommended for use in early detection, screening, diagnosis, determination of prognosis, and prediction of treatment outcomes. We also review important areas for future research.

Five year colorectal cancer outcomes in a large negative CT colonography screening cohort

OBJECTIVES

To assess the 5-year incidence of clinically presenting colorectal cancers following a negative CT colonography (CTC) screening examination, as few patient outcome data regarding a negative CTC screening result exist.

METHODS

Negative CTC screening patients (n = 1,050) in the University of Wisconsin Health system over a 14-month period were included. An electronic medical record (EMR) review was undertaken, encompassing provider, colonoscopy, imaging and histopathology reports. Incident colorectal cancers and other important GI tumours were recorded.

RESULTS

Of the 1,050 cohort (mean [±SD] age 56.9 ± 7.4 years), 39 (3.7%) patients were excluded owing to lack of follow-up within our system beyond the initial screening CTC. The remaining 1,011 patients were followed for an average of 4.73 ± 1.15 years. One incident colorectal adenocarcinoma represented a crude cancer incidence of 0.2 cancers per 1,000 patient years. EMR revealed 14 additional patients with clinically important GI tumours including: advanced adenomas (n = 11), appendiceal goblet cell carcinoid (n = 1), appendiceal mucinous adenoma (n = 1) and metastatic ileocolonic carcinoid (n = 1). All positive patients including the incident carcinoma are alive at the time of review.

CONCLUSIONS

Clinically presenting colorectal adenocarcinoma is rare in the 5 years following negative screening CTC, suggesting that current strategies, including non-reporting of diminutive lesions, are appropriate.

KEY POINTS

• CT colonography (CTC) screening is increasingly used to identify potential colorectal cancer. • Clinically presenting cancers are rare for 5 years following negative CTC screening. • The practice of setting a 6 mm polyp size threshold seems safe. • An interval of 5 years for routine CTC screening is appropriate.

Quantification of methylated markers with a multiplex methylation-specific technology

BACKGROUND

Aberrantly methylated genes represent important markers for cancer diagnosis. We describe a multiplex detection approach to efficiently quantify these markers for clinical applications such as colorectal cancer screening.

METHODS

Quantitative allele-specific real-time target and signal amplification (QuARTS) combines a polymerase-based target amplification with an invasive cleavage-based signal amplification. The fluorescence signal is detected in a fashion similar to real-time PCR. We measured the dynamic range and analytical sensitivity of multiplex QuARTS reactions with titrated plasmid DNA. We used the QuARTS technology to quantify methylated BMP3, NDRG4, VIM, and TFPI2 genes on 91 DNA samples extracted from colorectal tissues, including 37 cancers, 25 adenomas, and 29 healthy epithelia. The assays were designed in triplex format that incorporated ACTB as a reference gene. Percent methylation was calculated by dividing methylated strands over ACTB strands and multiplying by 100.

RESULTS

The QuARTS method linearly detected methylated or unmethylated VIM gene down to 10 copies. No cross-reactivity was observed when methylated assays were used to amplify 10(5) copies of unmethylated gene and vice versa. The multiplex assay detected methylated genes spiked in unmethylated genes at a 0.01% ratio and vice versa. At a diagnostic specificity cutoff of 95%, methylated BMP3, NDRG4, VIM, and TFPI2 detected 84%, 92%, 86%, and 92% of colorectal cancers and 68%, 76%, 76%, and 88% of adenomas, respectively.

CONCLUSIONS

The QuARTS technology provides a promising approach for quantifying methylated markers. The markers assayed highly discriminated colorectal neoplasia from healthy epithelia.

Risk prediction models for colorectal cancer: a review

Risk prediction models are important to identify individuals at high risk of developing the disease who can then be offered individually tailored clinical management, targeted screening and interventions to reduce the burden of disease. They are also useful for research purposes when attempting to identify new risk factors for the disease. In this article, we review the risk prediction models that have been developed for colorectal cancer and appraise their applicability, strengths, and weaknesses. We also discuss the factors to be considered for future development and improvement of models for colorectal cancer risk prediction. We conclude that there is no model that sufficiently covers the known risk factors for colorectal cancer that is suitable for assessment of people from across the full range of risk and that a new comprehensive model is needed.

Colonoscopist and primary care physician supply and disparities in colorectal cancer screening

OBJECTIVE. : To determine whether racial/ethnic disparities in colonoscopy use vary by physician availability. DATA SOURCE. : We used 100 percent Texas Medicare claims data for 2003-2007. STUDY DESIGN. : We identified beneficiaries aged 66-79 in 2007, examined racial/ethnic differences in colonoscopy use from 2003 to 2007, and estimated the percentage of white, black, and Hispanic beneficiaries who underwent colonoscopy by level of physician availability and area income. PRINCIPAL FINDINGS. : For the 974,879 beneficiaries, colonoscopy use was higher in whites (40.7 percent) compared to blacks (35.0 percent) and Hispanics (28.7 percent, p< .001). For whites, increasing availability of colonoscopists and primary care physicians (PCPs) was associated with higher colonoscopy use. For blacks and Hispanics, colonoscopy use was unchanged or decreased with increases in colonoscopist and PCP availability. In multilevel models, the odds of colonoscopy were 20 percent lower for blacks (OR 0.80, 95 percent CI 0.79-0.82) and 32 percent lower for Hispanics (OR 0.68, 95 percent CI 0.66-0.69) compared to whites; adjusting for availability of colonoscopists or PCPs did not attenuate racial/ethnic disparities. We found greater racial/ethnic disparities in areas with greater colonoscopist and PCP availability. CONCLUSIONS. : Greater area availability of colonoscopists and PCPs is associated with increased use of colonoscopy in whites but decreased use in minorities, resulting in larger racial/ethnic disparities.

Colonoscopist and primary care physician supply and disparities in colorectal cancer screening

OBJECTIVE. : To determine whether racial/ethnic disparities in colonoscopy use vary by physician availability. DATA SOURCE. : We used 100 percent Texas Medicare claims data for 2003-2007. STUDY DESIGN. : We identified beneficiaries aged 66-79 in 2007, examined racial/ethnic differences in colonoscopy use from 2003 to 2007, and estimated the percentage of white, black, and Hispanic beneficiaries who underwent colonoscopy by level of physician availability and area income. PRINCIPAL FINDINGS. : For the 974,879 beneficiaries, colonoscopy use was higher in whites (40.7 percent) compared to blacks (35.0 percent) and Hispanics (28.7 percent, p< .001). For whites, increasing availability of colonoscopists and primary care physicians (PCPs) was associated with higher colonoscopy use. For blacks and Hispanics, colonoscopy use was unchanged or decreased with increases in colonoscopist and PCP availability. In multilevel models, the odds of colonoscopy were 20 percent lower for blacks (OR 0.80, 95 percent CI 0.79-0.82) and 32 percent lower for Hispanics (OR 0.68, 95 percent CI 0.66-0.69) compared to whites; adjusting for availability of colonoscopists or PCPs did not attenuate racial/ethnic disparities. We found greater racial/ethnic disparities in areas with greater colonoscopist and PCP availability. CONCLUSIONS. : Greater area availability of colonoscopists and PCPs is associated with increased use of colonoscopy in whites but decreased use in minorities, resulting in larger racial/ethnic disparities.

A population-based study of prevalence and adherence trends in average risk colorectal cancer screening, 1997 to 2008

BACKGROUND

Increasing colorectal cancer screening (CRCS) is important for attaining the Healthy People 2020 goal of reducing CRC-related morbidity and mortality. Evaluating CRCS trends can help identify shifts in CRCS, and specific groups that might be targeted for CRCS.

METHODS

We utilized medical records to describe population-based adherence to average-risk CRCS guidelines from 1997 to 2008 in Olmsted County, MN. CRCS trends were analyzed overall and by gender, age, and adherence to screening mammography (women only). We also carried out an analysis to examine whether CRCS is being initiated at the recommended age of 50.

RESULTS

From 1997 to 2008, the size of the total eligible sample ranged from 20,585 to 21,468 people. CRCS increased from 22% to 65% for women and from 17% to 59% for men (P < 0.001 for both) between 1997 and 2008. CRCS among women current with mammography screening increased from 26% to 74%, and this group was more likely to be adherent to CRCS than all other subgroups analyzed (P < 0.001).The mean ages of screening initiation were stable throughout the study period, with a mean age of 55 years among both men and women in 2008.

CONCLUSION

Although overall CRCS tripled during the study period, there is still room for improvement.

IMPACT

Working to decrease the age at first screening, exploration of gender differences in screening behavior, and targeting women adherent to mammography but not to CRCS seem warranted.

The impact of the quality of colon preparation on follow-up colonoscopy recommendations

OBJECTIVES

Published guidelines for timing of follow-up colonoscopy assume that the entire colon mucosa is visualized and provide no guidance in the case of poor preparations. We aimed to determine how preparation quality during screening colonoscopy affects gastroenterologists' recommendations on the timing of follow-up colonoscopy.

METHODS

Gastroenterologists were shown representative images of four colonoscopies with differing colon-preparation quality. For each set of images they were asked to recommend when a hypothetical patient with no polyps or malignancy on screening examination should return for a subsequent colonoscopy. For the same patient, gastroenterologists were asked to give recommendations based on a preparation-quality grading scale.

RESULTS

The survey was completed by 239 gastroenterologists. Nearly all recommended 10-year follow-up colonoscopy for the best-appearing preparation. For the three imperfect preparations there was considerable variability in recommendations; follow-up timing ranged from 1-2 days to 10 years for identical preparations. Similar variability was seen in recommendations based on a preparation-quality grading scale. Endoscopists generally recommended progressively shorter-interval follow-up as colon preparation worsened, with median recommended follow-up of 10, 5, 1, and 0.25 years for the four sets of images. No association was seen between personal demographics or practice characteristics and follow-up recommendations.

CONCLUSIONS

When colon preparation is imperfect, gastroenterologists provide highly variable recommendations regarding timing of follow-up colonoscopy.

Factors influencing colorectal cancer screening participation

Colorectal cancer (CRC) is a major health problem worldwide. Although population-based CRC screening is strongly recommended in average-risk population, compliance rates are still far from the desirable rates. High levels of screening uptake are necessary for the success of any screening program. Therefore, the investigation of factors influencing participation is crucial prior to design and launches a population-based organized screening campaign. Several studies have identified screening behaviour factors related to potential participants, providers, or health care system. These influencing factors can also be classified in non-modifiable (i.e., demographic factors, education, health insurance, or income) and modifiable factors (i.e., knowledge about CRC and screening, patient and provider attitudes or structural barriers for screening). Modifiable determinants are of great interest as they are plausible targets for interventions. Interventions at different levels (patient, providers or health care system) have been tested across the studies with different results. This paper analyzes factors related to CRC screening behaviour and potential interventions designed to improve screening uptake.

Validity of self-reported colorectal cancer test use in different racial/ethnic groups

OBJECTIVE

Prevalence of colorectal cancer (CRC) screening is ascertained by self-reported screening, yet little is known about the accuracy of this method across different racial/ethnic groups, particularly Hispanics. The purpose of this study was to compare the accuracy of CRC self-report measures across three racial/ethnic groups.

METHODS

During 2004 and 2005, 271 white, African-American and Hispanic participants were recruited from a primary care clinic in Southeast Texas, and their CRC testing history based on self-report and medical record (the 'gold standard') were compared.

RESULTS

Over-reporting was prevalent. Overall, up-to-date CRC test use was 57.6% by self-report and 43.9% by medical record. Racial/ethnic group differences were most pronounced for Hispanics in whom sensitivity was significantly lower for any up-to-date testing, fecal occult blood testing, flexible sigmoidoscopy and double contrast barium enema. There were no statistically significant differences across groups for over-reporting, specificity or concordance.

CONCLUSIONS

Self-report prevalence data are overestimating CRC test use in all groups; current measures are less sensitive in Hispanics.

Colorectal cancer screening disparities in Asian Americans and Pacific Islanders: which groups are most vulnerable?

BACKGROUND

Colorectal cancer (CRC) is a significant cause of mortality among Asian Americans and Pacific Islanders (AAPIs), yet studies have consistently reported lower CRC screening rates among AAPIs than among non-Latino Whites and African Americans. Moreover, existing research tends to aggregate AAPIs as one group when reporting CRC screening, masking the disproportionate burden in cancer screening that exists across AAPI groups.

METHODS

This study examines differences in CRC screening rates in both aggregated and disaggregated AAPI groups as compared with non-Latino Whites in order to identify the most vulnerable AAPI subgroups in terms of obtaining CRC screening. This study utilizes merged data from the 2001, 2003, and 2005 California Health Interview Survey (CHIS), specifically the data pertaining to adults aged 50 and older (n = 52,491) from seven AAPI groups (Chinese, Japanese, Korean, Filipino, South Asian, Vietnamese, and Pacific Islander) and non-Latino Whites. Andersen's Behavioral Model of Health Services Use was utilized to select potential confounders to racial/ethnic differences in CRC screening.

RESULTS

When AAPI groups were considered as an aggregate, their CRC screening rate (46.8%) was lower than that of non-Latino Whites (57.7%). When AAPI groups were disaggregated, further disparity was noted: Koreans (32.7%) showed the lowest CRC screening rate, whereas Japanese (59.8%) had the highest. When the influence of potential predisposing, enabling, and need confounders was adjusted, Koreans, Filipinos, and South Asians were found to have a lower likelihood than non-Latino Whites to undergo CRC screening. Comparisons among AAPI subgroups further revealed that Filipinos, Koreans, Pacific Islanders, and South Asians were less likely than Chinese, Japanese, and Vietnamese to receive CRC screening.

CONCLUSION

These results highlight the importance of identifying differences in CRC screening behavior among disaggregated AAPI subgroups in order to help health professionals and policy-makers prioritize which AAPI subgroups need the most urgent interventions in terms of CRC screening promotion.

Colorectal cancer screening among primary care patients: does risk affect screening behavior?

Lifestyle factors including smoking, obesity, and diabetes can increase colorectal cancer (CRC) risk. Controversy exists regarding screening rates in individuals at increased CRC risk. To examine the effect of risk on CRC screening in primary care, cross-sectional data collected during January 2006-July 2007 from 720 participants in 24 New Jersey primary care practices were analyzed. Participants were stratified by risk: high (personal/family history of CRC, history of polyps, inflammatory bowel disease), increased (obesity, Type II diabetes, current/former smokers), and average. Outcomes were up-to-date with CRC screening, receiving a physician recommendation for screening, and recommendation adherence. Chi-square and generalized linear modeling were used to determine the effect of independent variables on risk group and risk group on outcomes. Thirty-seven percent of participants were high-risk, 46% increased-risk, and 17% average-risk. Age, race, insurance, education, and health status were related to risk. High-risk participants had increased odds of being up-to-date with screening (OR 3.14 95% CI 1.85-5.32) and adhering to physician recommendation (OR 7.18 95% CI 3.58-14.4) compared to average-risk. Increased-risk participants had 32% decreased odds of screening (OR 0.68, 95% CI 0.42-1.08). Low screening rates among increased-risk individuals highlight the need for screening interventions targeting these patients.

Sojourn time of preclinical colorectal cancer by sex and age: estimates from the German national screening colonoscopy database

The sojourn time of preclinical colorectal cancer is a critical parameter in modeling effectiveness and cost-effectiveness of colorectal cancer screening. For ethical reasons, it cannot be observed directly, and available estimates are based mostly on relatively small historic data sets that do not include differentiation by age and sex. The authors derived sex- and age-specific estimates (age groups: 55-59, 60-64, 65-69, 70-74, 75-79, and ≥80 years) of mean sojourn time, combining data from the German national screening colonoscopy registry (based on 1.88 million records) and data from population-based cancer registries (population base: 37.9 million people) for the years 2003-2006. Estimates of mean sojourn time were similar for both sexes and all age groups and ranged from 4.5 years (95% confidence interval: 4.1, 4.8) to 5.8 years (95% confidence interval: 5.3, 6.3) for the subgroups assessed. Sensitivity analyses indicated that mean sojourn time might be approximately 1.5 years longer if colorectal cancer prevalence in nonparticipants of screening colonoscopy is 20% lower than prevalence in participants or 1 year shorter if it exceeds the prevalence in participants by 20%. This study provides, for the first time, precise estimates of sojourn time by age and sex, and it suggests that sojourn times are remarkably consistent across age groups and in both sexes.

Promoting cancer screening within the patient centered medical home

While consensus has grown that primary care is the essential access point in a high-performing health care system, the current model of primary care underperforms in both chronic disease management and prevention. The Patient Centered Medical Home model (PCMH) is at the center of efforts to reinvent primary care practice, and is regarded as the most promising approach to addressing the burden of chronic disease, improving health outcomes, and reducing health spending. However, the potential for the medical home to improve the delivery of cancer screening (and preventive services in general) has received limited attention in both conceptualization and practice. Medical home demonstrations to date have included few evidence-based preventive services in their outcome measures, and few have evaluated the effect of different payment models. Decreasing use of hospitals and emergency rooms and an emphasis on improving chronic care represent improvements in effective delivery of healthcare, but leave opportunities for reducing the burden of cancer untouched. Data confirm that what does or does not happen in the primary care setting has a substantial impact on cancer outcomes. Insofar as cancer is the leading cause of death before age 80, the PCMH model must prioritize adherence to cancer screening according to recommended guidelines, and systems, financial incentives, and reimbursements must be aligned to achieve that goal. This article explores capacities that are needed in the medical home model to facilitate the integration of cancer screening and other preventive services. These capacities include improved patient access and communication, health risk assessments, periodic preventive health exams, use of registries that store cancer risk information and screening history, ability to track and follow up on tests and referrals, feedback on performance, and payment models that reward cancer screening.

Cultural, economic, and psychological predictors of colonoscopy in a national sample

BACKGROUND

Although colorectal cancer (CRC) is the second leading cause of cancer death among adults in the US and colonoscopy is efficacious in reducing morbidity and mortality from CRC, screening rates are sub-optimal. Understanding the socioeconomic, cultural, and health care context within which decisions about colonoscopy are made allows physicians to address patients' most salient beliefs and values and other constraints when making screening recommendations.

OBJECTIVE

To evaluate the direct and interactive effects of socioeconomics, health care variables, psychological characteristics, and cultural values on colonoscopy use.

DESIGN, SETTING, PARTICIPANTS

National survey completed between January-August 2009 in a random sample of African American, white, and Hispanic adults ages 50-75 without cancer (n = 582).

MAIN MEASURE

Self-reported colonoscopy use.

KEY RESULTS

Only 59% of respondents reported having a colonoscopy. The likelihood of colonoscopy increased with having health insurance (OR = 2.82, 95% CI = 1.24, 6.43, p = 0.004), and increasing age (OR = 1.40, 95% CI = 1.11, 1.77, p = 0.001). In addition, respondents with greater self-efficacy were more likely to have a colonoscopy (OR = 2.41, 95% CI = 1.35, 4.29, p = 0.003).

CONCLUSIONS

Programs that help patients to overcome access and psychological barriers to screening are needed.

Physician knowledge and appropriate utilization of computed tomographic colonography in colorectal cancer screening

GOALS

To assess physician understanding of computed tomographic colonography (CTC) in colorectal cancer (CRC) screening guidelines in a pilot study.

BACKGROUND

CTC is a sensitive and specific method of detecting colorectal polyps and cancer. However, several factors have limited its clinical availability, and CRC screening guidelines have issued conflicting recommendations.

STUDY

A web-based survey was administered to physicians at two institutions with and without routine CTC availability.

RESULTS

398 of 1655 (24%) participants completed the survey, 59% was from the institution with routine CTC availability, 52% self-identified as trainees, and 15% as gastroenterologists. 78% had no personal experience with CTC. Only 12% was aware of any current CRC screening guidelines that included CTC. In a multiple regression model, gastroenterologists had greater odds of being aware of guidelines (OR 3.49, CI 1.67-7.26), as did physicians with prior CTC experience (OR 4.81, CI 2.39-9.68), controlling for institution, level of training, sex, and practice type. Based on guidelines that recommend CTC, when given a clinical scenario, 96% of physicians was unable to select the appropriate follow-up after a CTC, which was unaffected by institution.

CONCLUSIONS

Most physicians have limited experience with CTC and are unaware of recent recommendations concerning CTC in CRC screening.

Examining stools for colon cancer prevention: what are we really looking for?

Fecal immunochemical testing (FIT) is superior to guiac-based testing if we are looking for blood in stools, as it has better one-time colorectal cancer sensitivity and specificity and better patient acceptance. In this issue of the journal, Cai and colleagues (beginning on page 1572) and Khalid-de Bakker and colleagues (beginning on page 1563) present new information about the one-time test performance of FIT. FIT will have a growing appeal to providers and health care systems as resources for clinical preventive services shrink and as incentives to expand colorectal screening rates increase, but there are good reasons to be cautious about the temptation to organize new FIT screening programs. Colorectal screening has two potential objectives: To find cancers in an earlier, more-treatable stage and to find and remove adenomas to prevent cancers from forming in the first place. Because most adenomas, even advanced adenomas, do not bleed, tests designed to identify occult blood in the stool are better for detecting colorectal cancer, whereas direct endoscopic visualization of the colorectum is better for prevention. Even if advanced adenomas did commonly bleed, low compliance with repeat annual testing will seriously erode the benefit of FIT.

Epidemiological study of colorectal adenoma and cancer in symptomatic patients in China between 1990 and 2009

OBJECTIVE

The best cure for colorectal cancer (CRC) lies on its early diagnosis and treatment. We aimed to provide the epidemiological features of advanced colorectal adenoma (A-CRA) and CRC in symptomatic patients and to determine whether the incidences of A-CRA and CRC increased simultaneously in China between 1990 and 2009.

METHODS

A total of 157,943 patients who had undergone a colonoscopy from 1990 to 2009 were enrolled, of which 6,777 patients had A-CRA and 3,503 had CRC. They were compared with controls in a stratified analysis. The detection rates of A-CRA and CRC in the 1990s and 2000s were also compared.

RESULTS

The detection rate of A-CRA increased 1.88-fold over the two decades, while that of CRC increased 0.66-fold. The percentages of patients with A-CRA and CRC who were elder than 50 years were significantly higher in the 2000s than those in the 1990s (P = 0.000). The changes of location of A-CRA and CRC during the two decades indicated a shift of lesions from the distal colon to proximal colon.

CONCLUSION

There was a significant increase in detection rate of A-CRA in the 2000s, but CRC did not increase at a similar speed. Our results indicated that the early detection and removal of colorectal adenoma in symptomatic patients might decrease the incidence of CRC.

Adherence to physician recommendation to colorectal cancer screening colonoscopy among Hispanics

BACKGROUND

Colorectal cancer (CRC) is the second most commonly diagnosed cancer among Hispanics in the United States (US), yet the use of CRC screening is low in this population. Physician recommendation has consistently shown to improve CRC screening.

OBJECTIVE

To identify the characteristics of Hispanic patients who adhere or do not adhere to their physician's recommendation to have a screening colonoscopy.

DESIGN

A cross-sectional study featuring face-to-face interviews by culturally matched interviewers was conducted in primary healthcare clinics and community centers in New York City.

PARTICIPANTS

Four hundred Hispanic men and women aged 50 or older, at average risk for CRC, were interviewed. Two hundred and eighty (70%) reported receipt of a physician's recommendation for screening colonoscopy and are included in this study.

MAIN MEASURES

Dependent variable: self report of having had screening colonoscopy.

INDEPENDENT VARIABLES

sociodemographics, healthcare and health promotion factors.

KEY RESULTS

Of the 280 participants, 25% did not adhere to their physician's recommendation. Factors found to be associated with non-adherence were younger age, being born in the US, preference for completing interviews in English, higher acculturation, and greater reported fear of colonoscopy testing. The source of colonoscopy recommendation (whether it came from their usual healthcare provider or not, and whether it occurred in a community or academic healthcare facility) for CRC screening was not associated with adherence.

CONCLUSIONS

This study indicates that potentially identifiable subgroups of Hispanics may be less likely to follow their physician recommendation to have a screening colonoscopy and thus may decrease their likelihood of an early diagnosis and prompt treatment. Raising physicians' awareness to such patients' characteristics could help them anticipate patients who may be less adherent and who may need additional encouragement to undergo screening colonoscopy.

Inter-observer variation in the histological diagnosis of polyps in colorectal cancer screening

AIM

To determine the inter-observer variation in the histological diagnosis of colorectal polyps.

METHODS AND RESULTS

Four hundred and forty polyps were randomly selected from a colorectal cancer screening programme. Polyps were first evaluated by a general (324 polyps) or expert (116 polyps) pathologist, and subsequently re-evaluated by an expert pathologist. Conditional agreement was reported, and inter-observer agreement was determined using kappa statistics. In 421/440 polyps (96%), agreement for their non-adenomatous or adenomatous nature was obtained, corresponding to a very good kappa value of 0.88. For differentiation of adenomas as non-advanced and advanced, consensus was obtained in 266/322 adenomas (83%), with a moderate kappa value of 0.58. For the non-adenomatous or adenomatous nature, both general and expert pathologists, and expert pathologists between each other, showed very good agreement {kappa values of 0.89 [95% confidence interval (CI) 0.83-0.95] and 0.86 (95% CI 0.73-0.98), respectively}. For categorization of adenomas as non-advanced and advanced, moderate agreement was found between general and expert pathologists, and between expert pathologists [kappa values of 0.56 (95% CI 0.44-0.67) and 0.64 (95% CI 0.43-0.85), respectively].

CONCLUSIONS

General and expert pathologists demonstrate very good inter-observer agreement for differentiating non-adenomas from adenomas, but only moderate agreement for non-advanced and advanced adenomas. The considerable variation in differentiating non-advanced and advanced adenomas suggests that more objective criteria are required for risk stratification in screening and surveillance guidelines.

Colorectal cancer screening: update for 2011

Colorectal cancer is the third most common cancer in the United States. Although mortality and incidence rates are declining in the United States, colorectal cancer screening remains underused. In addition, recent data suggest that colonoscopy, which is often considered the gold standard for colorectal cancer screening, is less protective for right-sided tumors, which are more likely to be flat or depressed and are more affected by an inadequate bowel preparation. Imaging technologies such as chromoendoscopy and narrow band imaging have been developed to improve delineation of suspicious lesions during colonoscopy. In addition, other new modalities such as computed tomography colonography (CTC), capsule endoscopy, fecal immunochemical tests, and fecal DNA tests may offer less invasive screening options for patients who decline colonoscopy.