Colonoscopy Reduces Colorectal Cancer Incidence and Mortality in Patients With Non-Malignant Findings: A Meta-Analysis

Colonoscopy and polypectomy: beside age, size of polyps main factor for long-term risk of colorectal cancer in a screening population

PURPOSE

Despite national and international guideline recommendations, few studies have been conducted to estimate the impact of colonoscopy screening on long-term colorectal cancer incidence. Aim of this study was to determine the long-term impact of a full colonoscopy with polypectomy on colorectal cancer incidence in a large screening population.

METHODS

In this prospective observational cohort study, a total of 10,947 colonoscopy screening participants from within the scope of the Munich Cancer Registry were consecutively recruited from participating gastroenterology practices and their subsequent colorectal cancer incidence assessed. Predictive factors associated with colorectal cancer were also evaluated in univariate and multivariate analyses.

RESULTS

After a median follow-up of 14.24 years (95% CI [14.21-14.25]), 93 colorectal cancer cases were observed. This is equivalent to a truncated age-standardized rate of 69.0 (95% CI [43.3-94.7]) for male and 43.4 (95% CI [29.4-57.5]) for female participants (≥ 50 years at colonoscopy). The ratio of this observed to the expected rate from cancer registry data showed a 67% decrease in colorectal cancer incidence in the male and 65% in the female participants (p < 0.0001). In multivariate analysis of screening patients, age at screening (p < 0.0001) was the main predictive factor for colorectal cancer. In the subgroup with positive polyp findings, age (p < 0.0001) and the polyp size (p = 0.0002) were associated with colorectal cancer.

CONCLUSION

These results underline the significance of a full colonoscopy screening combined with polypectomy in reducing the total disease burden of colorectal cancer.

Will They Show? Predictors of Nonattendance for Scheduled Screening Colonoscopies at a Safety Net Hospital

BACKGROUND

Colonoscopy can reduce colorectal cancer-related mortality by up to 90% through early detection and polyp removal. Despite this, nonattendance rates for scheduled colonoscopies have been reported ranging from 4.1% to as high as 67% depending on the population studied.

AIM

The aim of the study was to measure the nonattendance rate for scheduled screening colonoscopy at a large safety net hospital and identify predictors of nonattendance within this patient population.

MATERIALS AND METHODS

This was a population-based study of 1186 adults who were scheduled to undergo screening colonoscopy at a safety net hospital as part of their routine preventative health program. Health systems variables were assessed including procedure time and scheduling patterns as well as patient-centered variables such as socioeconomic indicators and specific comorbid diagnoses. Associations with nonattendance were examined by univariate and multivariate logistic regression.

RESULTS

The overall rate of nonattendance for scheduled screening colonoscopy was 33%. A multivariate model was constructed to predict nonattendance revealing that private payer status [odds ratio (OR)=0.368, 95% confidence interval (CI): 0.225, 0.602] and prior colonoscopy (OR=0.371, 95% CI: 0.209, 0.656) were associated with greater attendance rates. Chronic obstructive pulmonary disease (OR=2.034, 95% CI: 1.239, 3.341), afternoon procedure time (OR=1.807, 95% CI: 1.137, 2.871), and a greater interval time between the date the colonoscopy was ordered and the date the colonoscopy was scheduled to occur (OR=1.005, 95% CI: 1.001, 1.009) were independently associated with nonattendance when controlling for age, sex, and race.

CONCLUSIONS

Specific predictors for scheduled screening colonoscopy nonattendance at a safety net hospital can be identified. These findings can be used to tailor community-based interventions to improve colorectal cancer screening rates.

APC Mutations Are Not Confined to Hotspot Regions in Early-Onset Colorectal Cancer

Simple Summary

Mutation of the APC gene is a common early event in colorectal cancer, however lower rates have been reported in younger cohorts of colorectal cancer patients. In sporadic cancer, mutations are typically clustered around a mutation cluster region, a narrowly defined hotspot within the APC gene. In this study we used a sequencing strategy aimed at identifying mutations more widely throughout the APC gene in patients aged 50 years or under. We found high rates of APC mutation in our young cohort that were similar to rates seen in older patients but the mutations we found were spread throughout the gene in a pattern more similar to that seen in inherited rather than sporadic mutations. Our study has implications both for the sequencing of the APC gene in early-onset colorectal cancer and for the etiology of this disease.

Abstract

While overall colorectal cancer (CRC) cases have been declining worldwide there has been an increase in the incidence of the disease among patients under 50 years of age. Mutation of the APC gene is a common early event in CRC but is reported at lower rates in early-onset colorectal cancer (EOCRC) than in older patients. Here we investigate the APC mutation status of a cohort of EOCRC patients in New Zealand using a novel sequencing approach targeting regions of the gene encompassing the vast majority of known APC mutations. Using this strategy we find a higher rate (72%) of APC mutation than previously reported in EOCRC with mutations being spread throughout the gene rather than clustered in hotspots as seen with sporadic mutations in older patients. The rate of mutations falling within hotspots was similar to those previously seen in EOCRC and as such our study has implications for sequencing strategies for EOCRC patients. Overall there were low rates of both loss of heterozygosity and microsatellite instability whereas a relatively high rate (40%) of APC promoter methylation was found, possibly reflecting increasing exposure of young people to pro-oncogenic lifestyle factors.

Integrated Imaging Methodology Detects Claudin-1 Expression in Premalignant Nonpolypoid and Polypoid Colonic Epithelium in Mice

OBJECTIVES

Conventional colonoscopy with white light illumination detects colonic adenomas based on structural changes alone and is limited by a high miss rate. We aim to demonstrate an integrated imaging strategy that combines wide-field endoscopy and confocal endomicroscopy in real time to visualize molecular expression patterns in vivo to detect premalignant colonic mucosa.

METHODS

A peptide specific for claudin-1 is labeled with Cy5.5 and administrated intravenously in genetically engineered mice that develop adenomas spontaneously in the distal colon. Wide-field endoscopy is used to identify the presence of nonpolypoid and polypoid adenomas. Anatomic landmarks are used to guide placement of a confocal endomicroscope with side-view optics to visualize claudin-1 expression patterns with subcellular resolution.

RESULTS

Wide-field fluorescence images show peak uptake in colon adenoma at ∼1 hour after systemic peptide administration, and lesion margins are clearly defined. Further examination of the lesion using a confocal endomicroscope shows dysplastic crypts with large size, elongated shape, distorted architecture, and variable dimension compared with normal. The mean fluorescence intensity is significantly higher for dysplasia than normal. Increased claudin-1 expression in dysplasia vs normal is confirmed ex vivo, and the binding pattern is consistent with the in vivo imaging results.

DISCUSSION

Wide-field endoscopy can visualize molecular expression of claudin-1 in vivo to localize premalignant colonic mucosa, and confocal endomicroscopy can identify subcellular feature to distinguish dysplasia from normal.

Brain metastases from primary colorectal cancer: is radiosurgery an effective treatment approach? Results of a multicenter study of the radiation and clinical oncology Italian association (AIRO)

OBJECTIVES

The prognosis of brain metastatic colorectal cancer patients (BMCRC) is poor. Several local treatments have been used, but the optimal treatment choice remains an unresolved issue. We evaluated the clinical outcomes of a large series of BMCRC patients treated in several Italian centers using stereotactic radiosurgery (SRS).

METHODS

185 BMCRC patients for a total of 262 lesions treated were evaluated. Treatments included surgery followed by post-operative SRS to the resection cavity, and SRS, either single-fraction, then hypofractionated SRS (HSRS). Outcomes was measured in terms of local control (LC), toxicities, brain distant failure (BDF), and overall survival (OS). Prognostic factors influencing survival were assed too.

RESULTS

The median follow-up time was 33 months (range 3-183 months). Surgery plus SRS have been performed in 28 (10.7%) cases, SRS in 141 (53.8%), and HSRS in 93 (35.5%). 77 (41.6%) patients received systemic therapy. The main total dose and fractionation used were 24 Gy in single fraction or 24 Gy in three daily fractions. Local recurrence occurred in 32 (17.3%) patients. Median, 6 months,1-year-LC were 86 months (95%CI 36-86), 87.2% ± 2.8, 77.8% ± 4.1. Median,6 months,1-year-BDF were 23 months (95%CI 9-44), 66.4% ± 3.9, 55.3% ± 4.5. Median,6 months,1-year-OS were 7 months (95% CI 6-9), 52.7% ± 3.6, 33% ± 3.5. No severe neurological toxicity occurred. Stage at diagnosis, Karnofsky Performance Status (KPS), presence and number of extracranial metastases, and disease-specific-graded-prognostic-assessment (DS-GPA) score were observed as conditioning survival.

CONCLUSION

SRS/HSRS have proven to be an effective local treatment for BMCRC. A careful evaluation of prognostic factors as well as a multidisciplinary evaluation is a valid aid to manage the optimal therapeutic strategy for CTC patients with BMs.

ADVANCES IN KNOWLEDGE

The prognosis of BMCRC is poor. Several local treatments was used, but optimal treatment choice remains undefined. Radiosurgery has proven to be an effective local treatment for BMCRC. A careful evaluation of prognostic factors and a multidisciplinary evaluation needed.

Training a computer-aided polyp detection system to detect sessile serrated adenomas using public domain colonoscopy videos

Background  Colorectal cancer (CRC) is a major public health burden worldwide, and colonoscopy is the most commonly used CRC screening tool. Still, there is variability in adenoma detection rate (ADR) among endoscopists. Recent studies have reported improved ADR using deep learning models trained on videos curated largely from private in-house datasets. Few have focused on the detection of sessile serrated adenomas (SSAs), which are the most challenging target clinically. Methods  We identified 23 colonoscopy videos available in the public domain and for which pathology data were provided, totaling 390 minutes of footage. Expert endoscopists annotated segments of video with adenomatous polyps, from which we captured 509 polyp-positive and 6,875 polyp-free frames. Via data augmentation, we generated 15,270 adenomatous polyp-positive images, of which 2,310 were SSAs, and 20,625 polyp-negative images. We used the CNN AlexNet and fine-tuned its parameters using 90 % of the images, before testing its performance on the remaining 10 % of images unseen by the model. Results  We trained the model on 32,305 images and tested performance on 3,590 images with the same proportion of SSA, non-SSA polyp-positive, and polyp-negative images. The overall accuracy of the model was 0.86, with a sensitivity of 0.73 and a specificity of 0.96. Positive predictive value was 0.93 and negative predictive value was 0.96. The area under the curve was 0.94. SSAs were detected in 93 % of SSA-positive images. Conclusions  Using a relatively small set of publicly-available colonoscopy data, we obtained sizable training and validation sets of endoscopic images using data augmentation, and achieved an excellent performance in adenomatous polyp detection.

Comparison of Fentanyl versus Meperidine in Combination with Midazolam for Sedative Colonoscopy in Korea

Background/Aims

Combination of midazolam and opioids is used widely for endoscopic sedation. Compared with meperidine, fentanyl is reportedly associated with rapid recovery, turnover rate of endoscopy room, and quality of endoscopy. We compared fentanyl with meperidine when combined with midazolam for sedative colonoscopy.

Methods

A retrospective, cross-sectional, 1:2 matching study was conducted. Induction and recovery time were compared as the primary outcomes. Moreover, cecal intubation time, withdrawal time, total procedure time of colonoscopy, paradoxical reaction, adenoma detection rate, and adverse effect of midazolam or opioids were assessed as the secondary outcomes.

Results

A total of 129 subjects (43 fentanyl vs. 86 meperidine) were included in the analysis. The fentanyl group showed significantly more rapid induction time (4.5±2.7 min vs. 7.5±4.7 min, p<0.001), but longer recovery time (59.5±25.6 min vs. 50.3±10.9 min, p=0.030) than the meperidine group. In multivariate analysis, the induction time of the fentanyl group was 3.40 min faster (p<0.001), but the recovery time was 6.38 min longer (p=0.046) than that of the meperidine group. There was no difference in withdrawal time and adenoma detection rate between the two groups.

Conclusions

The fentanyl group had more rapid sedation induction time but longer recovery time than the meperidine group.

Is it disgusting or am I just easily disgusted? The relation between situational disgust, dispositional disgust, and colonoscopy intentions

OBJECTIVE

While early detection is an effective way to reduce mortality from colorectal cancer, screening rates are low. An underlying factor in screening completion failure may be experiences of disgust when learning about screening and/or dispositional disgust.

METHOD

Participants recruited via Amazon MTurk (N = 296) read information about colonoscopy and completed an online survey assessing both dispositional forms of disgust (i.e. trait disgust and disgust sensitivity) and situational forms, including state disgust and disgust associated with colonoscopy. Participants reported intentions to discuss colonoscopy with a provider and to prepare for and complete screening.

RESULTS

Greater state disgust and the degree to which one associated disgust with colonoscopy predicted lower screening, preparation and provider discussion intentions. By contrast, neither trait disgust nor disgust sensitivity was associated with intentions. Both disgust sensitivity and trait disgust moderated the state disgust to intentions relation.

CONCLUSIONS

This is one of few investigations of disgust examining the relation between specific types and colonoscopy intentions. Screening uptake may be improved by identifying specific components of disgust that have an effect on colonoscopy intentions. Future work focusing on the interplay between different disgust mechanisms as they relate to colonoscopy behaviour is important for intervention development.

The impact of sedation on quality metrics of colonoscopy: a single-center experience of 48,838 procedures

PURPOSE

Investigation of the role of sedation during colonoscopy is meaningful as the advantages of colonoscopy performing with sedation are still controversial.

METHODS

Medical records of patients who underwent colonoscopy in our institution were retrospectively analyzed. The sedation rate, adenoma detection rate (ADR), polyp detection rate (PDR), cecal intubation rate (CIR), iatrogenic colonic perforation rate (ICP) were calculated.

RESULTS

A total of 48,838 colonoscopies (24,498 in males) dated from July 2007 to February 2017 were analyzed. The median age was 50 years (range 16-85 years). An overall sedation rate was 80.38%. The PDR was 26.77%, and was not statistically different between colonoscopy with or without sedation (26.67% vs 27.22, p = 0.474). ADR was 12.9% regardless of applying sedation or not (13.0% vs 12.44%, p = 0.337). The CIR was 87.42% in all examinations with an adjusted CIR of 90.34%, and was higher when performed with sedation than without sedation (88.92% vs 80.64%, p < 0.0001). Five cases (0.01%) of ICP were reported, all of which occurred in patients under sedation.

CONCLUSIONS

The use of sedation is associated with increased CIR, but ADR and PDR remain unchanged with or without sedation. However, perforation rate, albeit very low, is significantly higher in sedated patients.

Determination of the Effectiveness of Informing With the Guidance of an Education Booklet in Patients Undergoing Colonoscopy-A Randomized Controlled Trial

PURPOSE

The aim of this study was to determine the effect of precolonoscopy information with the guidance of an education booklet on anxiety and bowel preparation adequacy in patients undergoing colonoscopy.

DESIGN

A randomized controlled study.

METHODS

The education group was informed face to face by the researcher with the guidance of the colonoscopy education booklet and provided the education booklet. The control group received usual care.

FINDINGS

The mean state and trait anxiety scores of the patients in the education group were found to be significantly lower than the control group. In the education group, the bowel preparation adequacy was determined to be higher compared with the control group.

CONCLUSIONS

Informing patients with the guidance of the education booklet before the colonoscopy decreased patients' state and trait anxiety levels and increased their bowel preparation adequacy.

A Randomized Trial Comparing the Bowel Cleansing Efficacy of Sodium Picosulfate/Magnesium Citrate and Polyethylene Glycol/Bisacodyl (The Bowklean Study)

Bowel cleansing is essential for a successful colonoscopy, but the ideal clearing agent and the volume have yet to be determined. A small-volume cleanser is important for patient compliance. This study aimed to compare the bowel cleansing efficacy, safety, tolerability, and acceptability of a 300-mL small-volume sodium picosulfate/magnesium citrate (PSMC) preparation-Bowklean with one 2-L polyethylene glycol (PEG)/bisacodyl-Klean-Prep/Dulcolax preparation under identical dietary recommendations. This multicenter, randomized, parallel-group, pre-specified noninferiority study enrolled 631 outpatients scheduled to undergo colonoscopy (Bowklean = 316 and Klean-Prep/Dulcolax = 315). After bowel preparation, an independent evaluator blinded to the subject's treatment allocation rated the quality of the colon cleansing. Efficacy was evaluated using the Aronchick Scale and Ottawa Bowel Preparation Scale (OPBS). Safety was assessed by monitoring adverse events. Tolerability and acceptability were measured via a patient questionnaire. Bowklean was non-interior to Klean-Prep/Dulcolax in overall colon cleansing but was associated with significantly better preparation quality. Notably, Bowklean was associated with significantly greater tolerability and acceptability of bowel preparations than Klean-Prep/Dulcolax. Safety profiles did not differ significantly between the groups. Our data indicate that Bowklean is a more effective and better-tolerated bowel cleansing preparation before colonoscopy than Klean-Prep/Dulcolax. Bowklean may therefore increase positive attitudes toward colonoscopies and participation rates.

Uptake of Colorectal Cancer Screening by Physicians Is Associated With Greater Uptake by Their Patients

BACKGROUND & AIMS

Physicians' own screening practices might affect screening in their patients. We conducted a population-based study to evaluate whether family physicians who underwent colorectal cancer testing were more likely to have patients who underwent colorectal cancer testing.

METHODS

We collected demographic and health care information on residents of Ontario, Canada from administrative databases; the sample was restricted to individuals at average risk of colorectal cancer who were 52-74 years old as of April 21, 2016. We obtained a list of all registered physicians in the province; physicians (n = 11,434) were matched with nonphysicians (n = 45,736) on age, sex, and residential location. Uptake of colorectal tests was defined by a record of a fecal occult blood test in the past 2 years, flexible sigmoidoscopy in the past 5 years, or colonoscopy in the past 10 years. Patients were assigned to family physicians based on billing claim frequency, and then the association between colorectal testing in family physicians and their patients was examined using a modified Poisson regression model.

RESULTS

Uptake of colorectal tests by physicians and nonphysicians (median age 60 years; 71% men) was 67.9% (95% confidence interval [CI], 67.0%-68.7%) and 66.6% (95% CI, 66.2%-67.1%), respectively. Physicians were less likely than nonphysicians to undergo fecal occult blood testing and were more likely to undergo colonoscopy; prevalence ratios were 0.44 (95% CI, 0.42-0.47) and 1.24 (95% CI, 1.22-1.26), respectively. Uptake of colorectal tests by family physicians was associated with greater uptake by their patients (adjusted prevalence ratio, 1.10; 95% CI, 1.08-1.12).

CONCLUSIONS

Approximately one-third of physicians and nonphysicians are overdue for colorectal cancer screening. Patients are more likely to be tested if their family physician has been tested. There is an opportunity for physicians to increase their participation in colorectal cancer screening, which could, in turn, motivate their patients to undergo screening.

Patient randomized trial of a targeted navigation program to improve rates of follow-up colonoscopy in community health centers

BACKGROUND

Colorectal cancer (CRC) screening by annual fecal immunochemical test (FIT) is an accessible and cost-effective strategy to lower CRC incidence and mortality. However, this mode of screening depends on follow-up colonoscopy after a positive FIT result. Unfortunately, nearly one-half of FIT-positive patients fail to complete this essential screening component. Patient navigation may improve follow-up colonoscopy adherence. To deliver patient navigation cost-effectively, health centers could target navigation to patients who are unlikely to complete the procedure on their own.

OBJECTIVES

The Predicting and Addressing Colonoscopy Non-adherence in Community Settings (PRECISE) clinical trial will validate a risk model of follow-up colonoscopy adherence and test whether patient navigation raises rates of colonoscopy adherence overall and among patients in each probability stratum (low, moderate, and high probability of adherence without intervention).

METHODS

PRECISE is a collaboration with a large community health center whose patient population is 37% Latino. Eligible patients will be aged 50-75, have an abnormal FIT result in the past month, and be due for a follow-up colonoscopy. Patients will be randomized to patient navigation or usual care. Primary outcomes will be colonoscopy completion within one year of a positive FIT result, cost, and cost-effectiveness. Secondary outcomes will include time to colonoscopy receipt, adequacy of bowel prep, and communication of results to primary care providers. Primary and secondary outcomes will be reported overall and by probability stratum.

DISCUSSION

This innovative clinical trial will test the effectiveness and financial feasibility of using a precision health intervention to improve CRC screening completion in community health centers.

TRIAL REGISTRATION

National Clinical Trial (NCT) Identifier: NCT03925883.

Identification of Differently Expressed Genes Associated With Prognosis and Growth in Colon Adenocarcinoma Based on Integrated Bioinformatics Analysis

Latest statistics showed that the morbidity and mortality of colon adenocarcinoma (COAD) ranked fourth and fifth, respectively, around the world. COAD was a heterogeneous disease, and the high rates of recurrence, metastasis, and drug resistance still posed great challenges for treatment, which needs to further develop therapeutic and prognostic targets. In this study, we got the top 3,075 differentially expressed genes (DEGs) and 1,613 potential prognostic genes by GEPIA 2 and identified 1,166 fitness genes in COAD based on genome-scale CRISPR-Cas9 knockout (GeCKO) screening data. Excluding the genes already reported in the literatures, a total of nine DEGs overlapping with prognostic and fitness genes were further analyzed. High expression of CCT6A, RHOQ, and RRP12 promoted COAD cell growth and were relative to lower survival rate of COAD patients, while high expression of UTP18, DDOST, YRDC, ACTG1, RFT1, and NLE1 also promoted COAD cell growth, but were relative to higher survival rate. In addition, CCT6A, UTP18, YRDC, RRP12, RFT1, NLE1, as well as DDOST were essential genes across pan-cancer including COAD cells, and ACTG1 and RHOQ were less essential genes in cancer cells. In a word, we discovered nine novel potential genes that could serve as anticancer targets and prognostic markers in COAD and its subtypes.

Co-registered photoacoustic and ultrasound imaging of human colorectal cancer

<p>Colorectal cancer is the second most common malignancy diagnosed globally. Critical gaps exist in diagnostic and surveillance imaging modalities for colorectal neoplasia. Although prior studies have demonstrated the capability of photoacoustic imaging techniques to differentiate normal from neoplastic tissue in the gastrointestinal tract, evaluation of deep tissue with a fast speed and a large field of view remains limited. To investigate the ability of photoacoustic technology to image deeper tissue, we conducted a pilot study using a real-time co-registered photoacoustic tomography (PAT) and ultrasound (US) system. A total of 23 <italic>ex vivo</italic> human colorectal tissue samples were imaged immediately after surgical resection. Co-registered photoacoustic images of malignancies showed significantly increased PAT signal compared to normal regions of the same sample. The quantitative relative total hemoglobin (rHbT) concentration computed from four optical wavelengths, the spectral features, such as the mean spectral slope, and 0.5-MHz intercept extracted from PAT and US spectral data, and image features, such as the first- and second-order statistics along with the standard deviation of the mean radon transform of PAT images, have shown statistical significance between untreated colorectal tumors and the normal tissue. Using either a logistic regression model or a support vector machine, the best set of parameters of rHbT and PAT intercept has achieved area-under-the-curve (AUC) values of 0.97 and 0.95 for both training and testing data sets, respectively, for prediction of histologically confirmed invasive carcinoma.</p>.

Co-registered photoacoustic and ultrasound imaging of human colorectal cancer

<p>Colorectal cancer is the second most common malignancy diagnosed globally. Critical gaps exist in diagnostic and surveillance imaging modalities for colorectal neoplasia. Although prior studies have demonstrated the capability of photoacoustic imaging techniques to differentiate normal from neoplastic tissue in the gastrointestinal tract, evaluation of deep tissue with a fast speed and a large field of view remains limited. To investigate the ability of photoacoustic technology to image deeper tissue, we conducted a pilot study using a real-time co-registered photoacoustic tomography (PAT) and ultrasound (US) system. A total of 23 <italic>ex vivo</italic> human colorectal tissue samples were imaged immediately after surgical resection. Co-registered photoacoustic images of malignancies showed significantly increased PAT signal compared to normal regions of the same sample. The quantitative relative total hemoglobin (rHbT) concentration computed from four optical wavelengths, the spectral features, such as the mean spectral slope, and 0.5-MHz intercept extracted from PAT and US spectral data, and image features, such as the first- and second-order statistics along with the standard deviation of the mean radon transform of PAT images, have shown statistical significance between untreated colorectal tumors and the normal tissue. Using either a logistic regression model or a support vector machine, the best set of parameters of rHbT and PAT intercept has achieved area-under-the-curve (AUC) values of 0.97 and 0.95 for both training and testing data sets, respectively, for prediction of histologically confirmed invasive carcinoma.</p>.

Computer-Assisted Flagging of Individuals at High Risk of Colorectal Cancer in a Large Health Maintenance Organization Using the ColonFlag Test

PURPOSE

To evaluate in a sample of adults who had been noncompliant with colorectal cancer (CRC) screening whether screening could be enhanced by an automated patient recall system based on identifying high-risk individuals using the ColonFlag test and an electronic medical record database.

METHODS

A total of 79,671 individuals who were determined to be noncompliant with current screening recommendations were identified in the Maccabi Health Services program in Israel. Their cancer risk was determined by ColonFlag using information on age, sex, and CBC results. Doctors of individuals who were flagged as high risk were notified and asked to follow up with their patients.

RESULTS

The ColonFlag identified 688 men and women who scored in the highest 0.87 percentile. Of these individuals, 254 had colonoscopies performed by Maccabi physicians, and 19 CRCs (7.5%) were found. An additional 15 cancers primarily identified outside of Maccabi were found through code matching.

CONCLUSION

The ColonFlag test is a rapid, efficient, and inexpensive test that can be applied to scan electronic medical records to identify individuals at high risk of CRC who would otherwise avoid screening.

Two Novel Long Noncoding RNAs - RP11-296E3.2 and LEF1-AS1can - Separately Serve as Diagnostic and Prognostic Bio-Markers of Metastasis in Colorectal Cancer

BACKGROUND Late diagnosis and metastasis are leading causes of the high mortality of colorectal cancer (CRC). Long noncoding RNAs (lncRNAs) have been reported to play a critical role in the development and progression of CRC. This study aimed to explore the clinical significance of 2 novel lncRNAs - RP11-296E3.2 and LEF1-AS1 - including their expression pattern, as well as diagnostic and prognostic values, for metastatic CRC patients. MATERIAL AND METHODS lncRNAs expression was examined in tissues (91 cases) and plasma (60 cases) from CRC patients by real-time quantitative PCR (qRT-PCR), and the correlations between its expression and clinicopathological features and diagnosis values in metastasis were analyzed. TCGA datasets were further used to analyze their utility in prediction of overall survival (OS) and disease-free survival (DFS). ATP-based tumor chemosensitivity assay (ATP-TCA) was used to evaluated tumor chemoresistance. RESULTS Compared with adjacent normal tissues, RP11-296E3.2 was significantly downregulated while LEF1-AS1 was significantly upregulated in cancer tissues (p=0.0143, p=0.0322, respectively). High levels of RP11-296E3.2 and LEF1-AS1 in tissues and plasma were correlated with tumor metastasis (p=0.0488, p=0.0252 in tissues, p=0.0331, p=0.1862 in plasma, respectively). Further analysis showed that RP11-296E3.2 sensitivity and specificity in diagnosis of CRC metastasis is better than CEA in plasma (0.690 and 0.621, and 0.621 and 0.500, respectively), and the OS of metastatic CRC patients with higher LEF1-AS1 expression levels in tissues was short (log-rank p<0.05). CONCLUSIONS Our findings suggest that RP11-296E3.2 and LEF1-AS1 could separately serve as potential novel diagnosis and prognostic markers for CRC metastasis.

Association of maternal prenatal folic acid intake with subsequent risk of autism spectrum disorder in children: A systematic review and meta-analysis

BACKGROUND

A number of studies have explored the link of antenatal folic acid (FA) intake with autism spectrum disorder (ASD) in children, with inconsistent findings. Therefore, we conducted a systematic review and meta-analysis of relevant studies to elucidate the actual association between maternal FA intake during the prenatal period and the risk of ASD in offspring.

METHODS

PubMed, EMBASE, PsycINFO, Scopus, Web of Science, and Cochrane Library were searched up to June 7, 2018, without language restriction. The random-effects model was applied to summarize results. The adjusted odds ratios (ORs) and hazard ratios (HRs) were pooled separately.

RESULTS

Eight observational studies (a total of 13 reports; 840,776 children and 7127 cases) were included. FA intake was mainly estimated from self-report of mothers or available databases. The results of overall analysis from 6 studies (9 reports) combined by OR and 2 studies (4 reports) presenting HR showed that the likelihoods of ASD in offspring whose mothers were prenatally exposed to FA did not vary significantly compared with those in offspring of mothers without such exposure (OR = 0.91, 95% CI: 0.73-1.13 and HR = 0.66, 95% CI: 0.38-1.17, respectively). Further analysis revealed that the primary outcome of the meta-analysis was stable regardless of the study design, and not unduly affected by any single report. Additionally, no publication bias was observed, and the findings of overall analysis were in agreement with those of subgroup analyses.

CONCLUSIONS

This study does not provide support for the association between maternal FA intake during the prenatal period and the reduced risk of ASD in children. However, in view of the types and limited number of studies in the literature, more investigation is needed to confirm the findings of this meta-analysis.

Molecular characterization of colorectal adenomas reveals POFUT1 as a candidate driver of tumor progression

Removal of colorectal adenomas is an effective strategy to reduce colorectal cancer (CRC) mortality rates. However, as only a minority of adenomas progress to cancer, such strategies may lead to overtreatment. The present study aimed to characterize adenomas by in‐depth molecular profiling, to obtain insights into altered biology associated with the colorectal adenoma‐to‐carcinoma progression. We obtained low‐coverage whole genome sequencing, RNA sequencing and tandem mass spectrometry data for 30 CRCs, 30 adenomas and 18 normal adjacent colon samples. These data were used for DNA copy number aberrations profiling, differential expression, gene set enrichment and gene‐dosage effect analysis. Protein expression was independently validated by immunohistochemistry on tissue microarrays and in patient‐derived colorectal adenoma organoids. Stroma percentage was determined by digital image analysis of tissue sections. Twenty‐four out of 30 adenomas could be unambiguously classified as high risk (n = 9) or low risk (n = 15) of progressing to cancer, based on DNA copy number profiles. Biological processes more prevalent in high‐risk than low‐risk adenomas were related to proliferation, tumor microenvironment and Notch, Wnt, PI3K/AKT/mTOR and Hedgehog signaling, while metabolic processes and protein secretion were enriched in low‐risk adenomas. DNA copy number driven gene‐dosage effect in high‐risk adenomas and cancers was observed for POFUT1, RPRD1B and EIF6. Increased POFUT1 expression in high‐risk adenomas was validated in tissue samples and organoids. High POFUT1 expression was also associated with Notch signaling enrichment and with decreased goblet cells differentiation. In‐depth molecular characterization of colorectal adenomas revealed POFUT1 and Notch signaling as potential drivers of tumor progression.

What's new?

Removal of colorectal adenomas is an effective strategy to reduce colorectal cancer (CRC) mortality rates. However, as only a minority of adenomas progress to cancer, such strategies may lead to overtreatment. While high‐risk adenomas, defined by specific DNA copy number aberrations, have an increased risk of progression, the mechanisms underlying colorectal adenoma‐to‐carcinoma progression remain unclear. This molecular characterization of colorectal adenomas, CRCs, and normal adjacent colon samples demonstrates that biological processes inherent to CRC are already more active in high‐risk adenomas compared to low‐risk adenomas. Moreover, the findings highlight POFUT1 and Notch signaling as potential drivers of colorectal tumor development.

Colonoscopy Indication Algorithm Performance Across Diverse Health Care Systems in the PROSPR Consortium

BACKGROUND

Despite the importance of characterizing colonoscopy indication for quality monitoring and cancer screening program evaluation, there is no standard approach to documenting colonoscopy indication in medical records.

METHODS

We applied two algorithms in three health care systems to assign colonoscopy indication to persons 50-89 years old who received a colonoscopy during 2010-2013. Both algorithms used standard procedure, diagnostic, and laboratory codes. One algorithm, the KPNC algorithm, used a hierarchical approach to classify exam indication into: diagnostic, surveillance, or screening; whereas the other, the SEARCH algorithm, used a logistic regression-based algorithm to provide the probability that colonoscopy was performed for screening. Gold standard assessment of indication was from medical records abstraction.

RESULTS

There were 1,796 colonoscopy exams included in analyses; age and racial/ethnic distributions of participants differed across health care systems. The KPNC algorithm's sensitivities and specificities for screening indication ranged from 0.78-0.82 and 0.78-0.91, respectively; sensitivities and specificities for diagnostic indication ranged from 0.78-0.89 and 0.74-0.82, respectively. The KPNC algorithm had poor sensitivities (ranging from 0.11-0.67) and high specificities for surveillance exams. The Area Under the Curve (AUC) of the SEARCH algorithm for screening indication ranged from 0.76-0.84 across health care systems. For screening indication, the KPNC algorithm obtained higher specificities than the SEARCH algorithm at the same sensitivity.

CONCLUSION

Despite standardized implementation of these indication algorithms across three health care systems, the capture of colonoscopy indication data was imperfect. Thus, we recommend that standard, systematic documentation of colonoscopy indication should be added to medical records to ensure efficient and accurate data capture.

Recent advances in colonoscopy

Colonoscopy continues to evolve as equipment and techniques improve. Traditionally, colonoscopy has focused on adenoma detection, characterisation and resection as the primary aims, and there has certainly been considerable activity over the last few years in terms of addressing these important issues. This review article not only will discuss progress made in these areas but also will focus on when to colonoscope in terms of introduction of faecal immunochemical testing, how to insert with the advent of water-assisted insertion, and how to withdraw using a bundle of evidence-based techniques to improve adenoma detection. In addition, the ramifications of failing to discover polyps and of post-colonoscopy colorectal cancer are highlighted.

LINC00668 promotes tumorigenesis and progression through sponging miR-188-5p and regulating USP47 in colorectal cancer

Long intergenic non-coding RNA No.668 (LINC00668) is implicated in the development of various malignancies. However, the role of LINC00668 and underlying mechanism in colorectal cancer (CRC) remains totally unknown. The expression pattern of LINC00668 in CRC cells were determined by qRT-PCR. CCK-8, EdU incorporation, flow cytometry, Transwell, and wound-healing assays were run to evaluate the functions of LINC00668 in CRC cells. Bioinformatics analyses were used to identify the LINC00668-specific binding with miRNAs that were screened by RNA pull-down. RNA immunoprecipitation and luciferase gene report assay were performed to confirm the interaction between miR-188-5p and LINC00668 in CRC cells. LINC00668 was significantly upregulated in CRC tissues and cells. Knockdown of LINC00668 suppressed cell proliferation and migration potential and induced cell apoptosis, but inhibition of miR-188-5p which was predicted to bind with LINC00668 reversed these effects. Furthermore, USP47 was a direct target of miR-188-5p, and overexpression of USP47 attenuated LINC00668 knockdown-induced tumor suppressive effects in CRC cells. Conclusively, our findings demonstrated that lncRNA LINC00668 acted as an oncogenic role in CRC cells by sponging miR-188-5p and upregulating USP47 and may represent a potential marker for CRC patients.

Impact of the supine position versus left horizontal position on colonoscopy insertion: a 2-center, randomized controlled trial

BACKGROUND AND AIMS

Colonoscopy insertion is painful for some patients and is one of the main barriers to screening colonoscopy. Few studies have assessed the impact of the supine position (SP) on colonoscopy insertion, especially for unsedated patients. The aim of this randomized controlled trial was to clarify this issue.

METHODS

Unsedated patients were randomized to SP or left horizontal position (LHP) as the starting position of colonoscopy insertion. The primary outcome measure was cecal intubation time (CIT), and the secondary outcome measures were descending colon intubation time (DIT), pain score of patients, difficulty score according to the endoscopist, and patients' acceptance of unsedated colonoscopy.

RESULTS

A total of 347 patients were randomized to the SP group (175) or the LHP group (172). The CIT in the SP group was significantly shorter than that in the LHP group (275.0 seconds [interquartile range (IQR), 234.0-328.5 seconds] versus 316.0 seconds [IQR, 261.0-370.0 seconds], P < .001). The DIT was also shorter in the SP group (64.5 seconds [IQR, 52.0-86.3 seconds] versus 74.0 seconds [IQR, 62.0-92.0 seconds], P = .001). Compared with the LHP, the SP had a lower pain score (3.3 versus 3.9, P = .002), a lower difficulty score (3.1 versus 3.7, P < .001), a lower frequency of position change (7.1% versus 38.0%, P < .001), and less need for abdominal compression (39.1% versus 45.5%, P = .02). SP was the only modifiable and independent factor identified to reduce CIT and pain score and improve patients' acceptance of unsedated colonoscopy.

CONCLUSIONS

As an economical and convenient method, SP can reduce CIT, ease pain, and improve patients' acceptance of unsedated colonoscopy. (Clinical trial registration number: NCT03289442.).

Post-colonoscopy colorectal cancer in Belgium: characteristics and influencing factors

Background and study aims  Post-colonoscopy colorectal cancer (PCCRC) is an important quality parameter of colonoscopy. Most studies have shown that the risk for colorectal cancer is reduced after an index colonoscopy for screening or diagnostic purposes with or without polypectomy. In this study, we aimed to quantify and describe PCCRC in Belgium, including the possible relationships with patient, physician, and colonoscopy characteristics. Patients and methods  Reimbursement data on colorectal related medical procedures from the Intermutualistic Agency (IMA-AIM) were linked with data on clinical and pathological staging of colorectal cancer (CRC) available at the Belgian Cancer Registry (BCR) over a period covering 9 years (2002 - 2010). Results  In total, 63 518 colorectal cancers were identified in 61 616 patients between 2002 and 2010. We calculated a mean PCCRC rate of 7.6 %. PCCRC was significantly higher in older people and correlated significantly with polyp detection rate and the number of resections and procedures performed per year per physician. Conditional observed survival, given still alive 3 years since first colonoscopy, for PCCRC was worse than for CRC. Older patients and patients with invasive carcinomas had a worse outcome. Conclusions  Although no quality register exists in Belgium, we were able to demonstrate that PCCRC in Belgium is directly related to the experience of the physician performing the procedure. In the absence of a quality register, utilization of population-based data sources proved to be a valuable tool to identify quality parameters.

G-EYE colonoscopy is superior to standard colonoscopy for increasing adenoma detection rate: an international randomized controlled trial (with videos)

BACKGROUND AND AIMS

Colorectal cancer (CRC) is largely preventable with routine screening and surveillance colonoscopy; however, interval cancers arising from precancerous lesions missed by standard colonoscopy still occur. An increased adenoma detection rate (ADR) has been found to be inversely associated with interval cancers. The G-EYE device includes a reusable balloon integrated at the distal tip of a standard colonoscope, which flattens haustral folds, centralizes the colonoscope's optics, and reduces bowel slippage. The insufflated balloon also aims to enhance visualization of the colon during withdrawal, thereby increasing the ADR.

METHODS

In this randomized, controlled, international, multicenter study (11 centers), patients (aged ≥50 years) referred to colonoscopy for screening, surveillance, or changes in bowel habits were randomized to undergo either balloon-assisted colonoscopy by using an insufflated balloon during withdrawal or standard high-definition colonoscopy. The primary endpoint was the ADR.

RESULTS

One thousand patients were enrolled between May 2014 and September 2016 to undergo colonoscopy by experienced endoscopists; 803 were finally analyzed (standard colonoscopy n = 396; balloon-assisted colonoscopy n = 407). Baseline parameters were similar in both groups. Balloon-assisted colonoscopy provided a 48.0% ADR compared with 37.5% in the standard colonoscopy group (28% increase; P = .0027). Additionally, balloon-assisted colonoscopy provided for a significant increase in detection of advanced (P = .0033) flat adenomas (P < .0001) and sessile serrated adenomas/polyps (P = .0026).

CONCLUSION

Balloon-assisted colonoscopy yielded a higher ADR and increased the detection of advanced, flat, and sessile serrated adenomas/polyps when compared with standard colonoscopy. Improved detection by the G-EYE device could impact the quality of CRC screening by reducing miss rates and consequently reducing interval cancer incidence. (Clinical trial registration number: NCT01917513.).

Risk factors for severe complications of colonoscopy in screening programs

Severe complications (SC) in colonoscopy represent the most important adverse effect of colorectal cancer screening programs (CRCSP). The objective is to evaluate the risk factors for SC in colonoscopy indicated after a positive fecal occult blood test in population-based CRCSP. The SC (n = 161) identified from 48,730 diagnostic colonoscopies performed in a cohort of all the women and men invited from 2000 to 2012 in 6 CRCSP in Spain. A total of 318 controls were selected, matched for age, sex and period when the colonoscopy was performed. Conditional logistic regression models were estimated. The analysis was performed separately in groups: immediate-SC (same day of the colonoscopy); late-SC (between 1 and 30 days after); perforation; and bleeding events. SC occurred in 3.30‰ of colonoscopies. Prior colon disease showed a higher risk of SC (OR = 4.87). Regular antiplatelet treatment conferred a higher risk of overall SC (OR = 2.80) and late-SC (OR = 9.26), as did regular anticoagulant therapy (OR = 3.47, OR = 7.36). A history of pelvic-surgery or abdominal-radiotherapy was a risk factor for overall SC (OR = 5.03), immediate-SC (OR = 8.49), late-SC (OR = 4.65) and perforation (OR = 21.59). A finding of adenoma or cancer also showed a higher risk of overall SC (OR = 8.71), immediate-SC (OR = 12.67), late-SC (OR = 4.08), perforation (OR = 4.69) and bleeding (OR = 17.02). The risk of SC doesn't vary depending on the type of preparation or type of anesthesia. Knowing the clinical history of patients such as regular previous medication and history of surgery or radiotherapy, as well as the severity of the findings during the colonoscopy process could help to focus prevention measures in order to minimize SC in CRCSP.

Providers' Perceptions of Barriers to Optimal Communication With Patients During the Postcolonoscopy Experience

INTRODUCTION

Colonoscopy screening is an effective method of detecting and preventing colorectal cancer. Standard procedure for most colonoscopies (98%) is to use conscious sedation, which can cause short-term cognitive impairment postprocedure, including communication difficulties. In this study, we explored providers' (gastroenterology doctors and nurses) perceptions of the barriers to optimal communication with patients immediately following colonoscopy.

METHODS

We conducted interviews with 61 providers across 5 clinical configurations. Interviews were transcribed and coded with NVivo version 11 software.

RESULTS

Themes emerged regarding barriers to optimal provider-patient communication postcolonoscopy: patient barriers (sedation and patient characteristics), caregiver barriers, and system characteristics.

CONCLUSIONS

Providers' perceived barriers to communication are an important topic to study. They endorsed, in particular, interventions that target the postcolonoscopy time frame when patients may still be sedated, but providers must convey important discharge and follow-up instructions.

Interval colorectal cancer after colonoscopy

INTRODUCTION AND AIMS

Interval colorectal cancer (iCRC) can occur due to missed lesions or to a newly developed lesion. The present study aimed to assess the iCRC rate and its characteristics in our population and find possible explanations.

MATERIALS AND METHODS

A retrospective study was conducted on patients with colorectal cancer (CRC) diagnosed between January 2011 and January 2015 at our department. Demographics, endoscopic data, and tumor characteristics (location, histology, staging) were collected. We identified patients diagnosed with CCR who underwent colonoscopy at our department in the previous 10years and presented the disease (iCRC) before the date of their next recommended exam. The cases of iCRC were characterized and compared with other CRC cases. Possible explanations for the appearance of iCRC were analyzed.

RESULTS

A total of 266 patients presented with CRC, 61.7% were men, and mean patient age was 70.7years. We identified 10 patients with iCRC: 6 were men, and mean patient age was 71.1years. Mean time for iCRC diagnosis after index colonoscopy was 3.5±1.84years. Tumor was located in the right colon in 50% of the patients with iCRC and in 24.5% of the patients without iCRC (P=.091). More patients with iCRC had a family history of CRC (50%) than the patients with reference CRC (3.1%) (P=.000).

CONCLUSIONS

In our case series, 3.76% of all CRC were iCRC. There were no statistically significant differences between patients with or without iCRC, with the exception of family history of CRC.

Impact of fellowship training level on colonoscopy quality and efficiency metrics

BACKGROUND AND AIMS

Previous studies have described variable effects of fellow involvement on the adenoma detection rate (ADR), but few have stratified this effect by level of training. We aimed to evaluate the "fellow effect" on multiple procedural metrics including a newly defined adenoma management efficiency index, which may have a role in documenting colonoscopy proficiency for trainees. We also describe the impact of level of training on moderate sedation use.

METHODS

We performed a retrospective review of 2024 patients (mean age, 60.9 ± 10 years; 94% men) who underwent outpatient colonoscopy between June 2012 and December 2014 at our Veterans Affairs Medical Center. Colonoscopies were divided into 5 groups. The first 2 groups were first-year fellows in the first 6 months and last 6 months of the training year. Second- and third-year fellows and attending-only procedures accounted for 1 group each. We collected data on doses of sedatives used, frequency of adjunctive agent use, procedural times, and location, size, and histology of polyps. We defined the adenoma management efficiency index as average time required per adenoma resected during withdrawal.

RESULTS

Of the colonoscopies performed, 1675 involved a fellow and 349 were performed by the attending alone. There was no difference in ADR between fellows according to level of training (P = .8) or between fellows compared with attending-only procedures (P = .67). Procedural times decreased consistently during training and declined further for attending-only procedures. This translated into improvement in the adenoma management efficiency index (fellow groups by ascending level of training: 23.5 minutes vs 18.3 minutes vs 13.7 minutes vs 13.4 minutes vs attending group 11.7 minutes; P < .001). There was no difference in the average doses of midazolam and fentanyl used among fellow groups (P = .16 and P = .1, respectively). Compared with attending-only procedures, fellow involvement was associated with higher doses of fentanyl and midazolam and more frequent use of diphenhydramine and glucagon (P < .0001, P = .0002, P < .0001, and P = .01, respectively).

CONCLUSIONS

ADR was similar at different stages of fellowship training and comparable with the attending group. Efficiency of detecting and resecting polyps improved throughout training without reaching the attending level. Fellow involvement led to a greater use of moderate sedation, which may relate to a longer procedure duration and an evolving experience in endoscopic technique.

Endoscopic Screening in Asian Countries Is Associated With Reduced Gastric Cancer Mortality: A Meta-analysis and Systematic Review

BACKGROUND & AIMS

It is not clear how endoscopic screening for gastric cancer affects incidence or mortality. We performed a systematic review and meta-analysis to evaluate the relationship between endoscopic screening for gastric cancer and mortality and incidence.

METHODS

We conducted a systematic search of PubMed and EMBASE for published cohort and case-control studies of adults without gastric cancer who underwent endoscopic screening at least once that included a comparator and reported outcomes of mortality or incidence through March 8, 2018. Two investigators independently reviewed the included studies and extracted relevant data. The effect estimate of interest was the relative risk (RR). We used a random effects model to combine RRs and 95% confidence intervals (Cis).

RESULTS

Our final analysis included 6 cohort studies and 4 nested case-control studies comprising 342,013 individuals, all from Asia. The combined result (RR, 0.60; 95% CI, 0.49-0.73) indicated that endoscopic screening was associated with a 40% RR reduction in gastric cancer mortality. We did not observe an association between endoscopic screening and incidence (RR, 1.14; 95% CI, 0.93-1.40). Subgroup analysis showed significant reductions in gastric cancer mortality after endoscopic screening compared with no screening (RR, 0.58; 95% CI, 0.48-0.70) or radiographic screening (RR, 0.33; 95% CI, 0.12-0.91). However, endoscopic screening did not significantly reduce mortality compared with expected deaths (RR, 0.67; 95% CI, 0.38-1.16).

CONCLUSIONS

In a systematic review and meta-analysis, we found that endoscopic screening may reduce the risk of death from gastric cancer and not affect incidence in Asian countries. Population-based prospective cohort studies are warranted to confirm our findings.

Comparison of efficacy of colonoscopy between the morning and afternoon: A systematic review and meta-analysis

OBJECTIVE

Colonoscopy performed in the afternoon, rather than morning, has been reported to be associated with lower rates of adenoma and polyp detection (ADR and PDR) and cecal intubation (CIR). This meta-analysis evaluated the efficacy of afternoon colonoscopy relative to morning colonoscopy.

METHODS

The databases MEDLINE, Web of Science, EMBASE, and the Cochrane Library were searched to identify potential relevant studies. The primary outcome was ADR and the secondary outcomes were CIR and PDR. The outcomes were estimated by relative risk (RR) and 95% confidence interval (CI) with a random effects model.

RESULTS

Sixteen studies with 38,063 participants met the inclusion criteria. The pooled analyses indicated that ADR (RR: 1.08, 95% CI: 1.00-1.17) and CIR (RR: 1.01, 95% CI: 1.00-1.02) were stable during the whole day. In subgroup analyses, the effect of full-day block or inferior bowel preparation were more prominent, reflected by a significant reduction of ADR (RR: 1.18, 95% CI: 1.09-1.28; RR: 1.12, 95% CI: 1.01-1.24) and CIR (RR: 1.08, 95% CI: 1.02-1.13; RR: 1.02, 95% CI: 1.01-1.03) in the afternoon, respectively.

CONCLUSIONS

Colonoscopy quality, as indicated by the ADR and CIR, is not affected by the time of day for procedures performed in block shifts. However, endoscopists' working full-day blocks and inferior bowel preparation are associated with a significant decrease in ADR and CIR in the afternoon.

Probing the colorectal cancer proteome for biomarkers: Current status and perspectives

Colorectal cancer (CRC) is one of the most prevalent malignancies worldwide. Biomarkers that can facilitate better clinical management of CRC are in high demand to improve patient outcome and to reduce mortality. In this regard, proteomic analysis holds a promising prospect in the hunt of novel biomarkers for CRC and in understanding the mechanisms underlying tumorigenesis. This review aims to provide an overview of the current progress of proteomic research, focusing on discovery and validation of diagnostic biomarkers for CRC. We will summarize the contributions of proteomic strategies to recent discoveries of protein biomarkers for CRC and also briefly discuss the potential and challenges of different proteomic approaches in biomarker discovery and translational applications.

Quality indicators for screening colonoscopies and colonoscopist performance and the subsequent risk of interval bowel cancer: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this systematic review is to assess the association between quality indicators related to the individual colonoscopist's performance and subsequent interval cancers in patients participating in bowel cancer screening programs, following the JBI approach.This systematic review of association will search all relevant literature on the subject to answer the following review questions.

Evaluation of Cancer-Associated DNA Copy Number Events in Colorectal (Advanced) Adenomas

About 5% of colorectal adenomas are estimated to progress to colorectal cancer. However, it is important to identify which adenomas actually carry a high risk of progression, because these serve as intermediate endpoints, for example, in screening programs. In clinical practice, adenomas with a size of ≥10 mm, villous component and/or high-grade dysplasia, called advanced adenomas, are considered high risk, although solid evidence for this classification is lacking. Specific DNA copy number changes are associated with adenoma-to-carcinoma progression. We set out to determine the prevalence of cancer-associated events (CAE) in advanced and nonadvanced adenomas. DNA copy number analysis was performed on archival tissues from three independent series of, in total, 297 adenomas (120 nonadvanced and 177 advanced) using multiplex ligation-dependent probe amplification or low-coverage whole-genome DNA sequencing. Alterations in two or more CAEs were considered to mark adenomas as high risk. Two or more CAEs were overall present in 25% (95% CI, 19.0-31.8) of advanced adenomas; 23% (11/48), 36% (12/33), and 23% (22/96) of the advanced adenomas in series 1, 2, and 3, respectively, and 1.7% (1/58) and 4.8% (3/62) of the nonadvanced adenomas, in series 1 and 2, respectively. The majority of advanced adenomas do not show CAEs, indicating that only a subset of these lesions is to be considered high risk. Nonadvanced adenomas have very low prevalence of CAEs, although those with CAEs should be considered high risk as well. Specific DNA copy number alterations may better reflect the true progression risk than the advanced adenoma phenotype. Cancer Prev Res; 11(7); 403-12. ©2018 AACR.

Readability of information on colonoscopy preparation on the internet

Background: The incidence of colorectal cancer (CRC) has decreased in recent years, due in large part to increased screening, particularly through colonoscopy. This study aimed to examine the level of readability of information on colonoscopy preparation written on 100 websites that were found via an internet search.

Methods: In this cross-sectional study, the content of the first 100 websites in English found via an internet search were analyzed using established readability scales. Websites were compared based on whether they had a commercial or non-commercial URL extension.

Results: The majority of websites were found to have information of a difficult reading level. Less than 10% of websites had an easy reading level. Readability did not differ significantly based on URL extension.

Conclusion: The information currently posted on the internet regarding preparation for colonoscopy is written at a difficult reading level. If information presented was both accurate and easier to read, it could benefit a greater proportion of the general public and help inform decisions about preparing for a colonoscopy.

Risk factors associated with longer cecal intubation time: a systematic review and meta-analysis

PURPOSE

Cecal intubation time (CIT) is an indicator for difficult colonoscopy which is associated with patients' unpleasant experience as well as increased risk of complications. Several studies have attempted to identify predictors for prolonged CIT but those studies tended to be small which gave rise to inconsistent and underpowered results. This systematic review and meta-analysis was conducted to summarize all available data.

METHODS

MEDLINE and EMBASE databases were searched through November 2017 for studies that investigated the factors for prolonged CIT. Only factors that were reported by at least three studies were included in the meta-analyses. Pooled mean difference (MD) and 95% confidence interval (CI) were calculated using random effects model. The between-study heterogeneity of effect size was quantified using the Q statistic and I².

RESULTS

A total of nine studies involving 7131 patients were included. A total of six factors were analyzed. Patients with older age (≥ 65 versus < 65), female sex (versus male), low body mass index (BMI) (< 25 versus ≥ 25 kg/m²), and poor bowel preparation (versus fair to good) had significantly longer CIT. The presence of diverticulosis and prior abdominal surgery were not significantly associated with prolonged CIT.

CONCLUSIONS

The current meta-analyses have demonstrated that old age, female sex, low BMI, and poor bowel preparation were the predictors for prolonged CIT.

Prevalence of appropriate colorectal cancer screening and preferences for receiving screening advice among people attending outpatient clinics

OBJECTIVE

To examine among people attending outpatient clinics aged 50-74 at average risk of colorectal cancer (CRC): 1) The proportion who report: a) faecal occult blood test (FOBT) within the past two years; and b) colonoscopy within the past five years, including the reasons for undergoing colonoscopy; 2) characteristics associated with under-screening; 3) For those who are under-screened, the proportion who are: a) willing to receive help and the acceptability of different methods of receiving help, and; b) unwilling to receive help and reasons for this.

METHODS

Cross-sectional survey of 197 participants attending a major regional hospital in New South Wales, Australia. Multivariable logistic regression was used to determine correlates of under-screening.

RESULTS

A total of 59% reported either FOBT in the past two years or colonoscopy in the past five years. Of those reporting colonoscopy in the past five years, 21% were potentially over-screened. Males were more likely than females to be under-screened. Of those under-screened (41%), fewer than half were willing to receive screening advice. Conclusions and implications for public health: A significant proportion of people attending outpatient clinics are under-screened for CRC, with some people also over-screened. There is a need to explore strategies to overcome both under- and over-screening.

Barriers to Colorectal Cancer Screening in a Primary Care Setting in Turkey

Colorectal cancer (CRC) is the third most common form of cancer in men worldwide and the second most common in women. The purpose of this study was to determine both barriers established by primary health care providers (PHCPs) and barriers perceived by them and to produce solutions for achieving the desired results. A four-part questionnaire was administered to family physicians (FPs) and family health personnels (FHPs) in Samsun, Turkey on 01-15 May, 2016. Sixty-six percent of PHCPs were contacted. Data were evaluated as numbers and percentages, and statistical significance was analyzed using the Chi square and t tests. 478 PHCPs participated; 49.4 % were FPs and 50.6 % FHPs. Of the participants, 86.6 % stated that they performed CRC screening on patients. The level of participants knowing that screening should start at age 50 and conclude at age 70 was 49.7 %. The level of subjects requesting the fecal occult blood test (FOBT) at the correct intervals was 29.7 %, but only 6.9 % recommended colonoscopy at the correct intervals. Additionally, 18.2 % of subjects knew that the test used is immunochemical FOBT, and 60.5 % reported not using reminders. PHCPs' low levels of knowledge, awareness and advice compatible with guidelines concerning CRC screening may represent an obstacle to such screening. Barriers perceived by PHCPs include patients' inability to access definite medical information, deficiencies in the reminder system and patients' lack of interest in CRC screening. Additions to the screening program will be useful in overcoming barriers.

Precision Medicine for CRC Patients in the Veteran Population: State-of-the-Art, Challenges and Research Directions

Colorectal cancer (CRC) accounts for ~9% of all cancers in the Veteran population, a fact which has focused a great deal of the attention of the VA's research and development efforts. A field-based meeting of CRC experts was convened to discuss both challenges and opportunities in precision medicine for CRC. This group, designated as the VA Colorectal Cancer Cell-genomics Consortium (VA4C), discussed advances in CRC biology, biomarkers, and imaging for early detection and prevention. There was also a discussion of precision treatment involving fluorescence-guided surgery, targeted chemotherapies and immunotherapies, and personalized cancer treatment approaches. The overarching goal was to identify modalities that might ultimately lead to personalized cancer diagnosis and treatment. This review summarizes the findings of this VA field-based meeting, in which much of the current knowledge on CRC prescreening and treatment was discussed. It was concluded that there is a need and an opportunity to identify new targets for both the prevention of CRC and the development of effective therapies for advanced disease. Also, developing methods integrating genomic testing with tumoroid-based clinical drug response might lead to more accurate diagnosis and prognostication and more effective personalized treatment of CRC.

Public health impact of colonoscopy use on colorectal cancer mortality in Germany and the United States

BACKGROUND AND AIMS

Colonoscopy has been demonstrated to be effective in reducing colorectal cancer (CRC) incidence and mortality and has been widely used for primary CRC screening in Germany and the United States. We performed a population-based analysis to evaluate and compare the public health impact of recent colonoscopy use on CRC deaths among adults aged 55 to 79 years in Germany and the United States from 2008 to 2011.

METHODS

The epidemiologic metrics of attributable fraction and prevented fraction as well as the impact numbers were calculated using colonoscopy utilization data from nationally representative health surveys, relative risk estimates from medical literature, and CRC death registry data.

RESULTS

Overall, 36.6% (95% credible interval [CrI], 27.3%-45.5%) of CRC deaths in Germany were estimated to be attributable to nonuse of colonoscopy, compared with the U.S. estimates of 38.2% (95% CrI, 28.6%-47.1%) and 33.6% (95% CrI, 24.8%-42.2%) for years 2008 to 2009 and 2010 to 2011, respectively. The proportion of CRC deaths theoretically prevented by colonoscopy use within 10 years was 30.7% (95% CrI, 24.8%-35.7%) in Germany, whereas in the United States this proportion ranged from 29.0% (95% CrI, 23.4%-33.6%) for 2008 to 2009 to 33.9% (95% CrI, 27.4%-39.2%) for 2010 to 2011.

CONCLUSIONS

Recent colonoscopy use is likely to have prevented a considerable fraction of CRC mortality in both countries, and more deaths could be avoided by increasing colonoscopy use in the target population. Attributable and prevented fraction can provide valuable information on the public health impact of colonoscopy use and guide policymaking.

RECALAD. Patient care at National Health System Digestive Care Units - A pilot study, 2015

OBJECTIVES

To reach a situation diagnosis on the status of patient management at digestive care units (DCUs) in Spain.

MATERIAL AND METHODS

A cross-sectional descriptive study across DCUs in general acute care hospitals within the Spanish National Health System (data referred to 2015). The study variables were collected with a questionnaire including items on structure, services portfolio, activity, education, research, and good practice. Hospital discharge rates for digestive diseases were also assessed using the minimum basic data set (2005-2014).

RESULTS

Two hundred and nine hospitals invited, 55 responders (26.3%). Average discharges from hospital were 1,139 ± 653 per DCU/year, and 100 ± 66 per year per dedicated gastroenterologist. In 2014, admission rate to DCUs per 1,000 population and year was 280, with a mean stay of 7.4 days. The analysis of the MBDS for 2005-2014 reveals a progressive increase in the number of discharges (37% more in 2014 versus 2005), with a 28% decrease in hospital gross mortality rate (3.7% in 2014) and a slightly reduced (14%) mean stay (7.6 days in 2014). Considerable variability may be seen in structure, activity, and results indicators. Mortality and readmission rates, as well as mean stay, vary more than 100% amongst DCUs, and major dispersions also exist in frequentation and results amongst autonomous communities.

CONCLUSIONS

The RECALAD 2015 survey unveiled relevant aspects related to DCUs organization, structure, and management. The notable variability encountered likely reflects relevant differences in efficiency and productivity, and thus points out there is ample room for improvement.

Brain metastasis from colorectal cancer: a single center experience

Purpose

The detection rate of brain metastasis (BM) from colorectal cancer (CRC) is increasing. This study was designed to analyze the clinical features of BM and prognosis according to the therapeutic modalities.

Methods

A total of 19 cases were collected in this study between November 2008 and December 2015. We reviewed the patients' demographic data and the clinical features of BM retrospectively and investigated their prognostic significance.

Results

Nineteen patients included 8 male and 11 female patients. The median age at diagnosis of BM was 62.4 years (range, 32–83 years). The median interval between diagnosis of CRC and BM was 39 months (range, 0–98 months). Eighteen patients (94.7%) had extracranial metastasis at the diagnosis of BM. Lung was the most common site of extracranial metastasis in 14 patients (73.7%). Synchronous BMs were found at the diagnosis of primary CRC in 2 patients (10.5%). The location of primary CRC was the colon in 6 patients (31.6%) and the rectum in 13 patients (68.4%). At the diagnosis of BM, 10 patients (52.6%) had a solitary BM. The common neurologic symptoms were headache in 8 cases (42.1%) and ataxia in 6 cases (31.6%). The median survival after the diagnosis of BM was 3 months (range, 1–10 months). The patients who underwent surgery plus stereotactic radiosurgery (SRS) had an improved survival (range, 3–10 months) than the other patients (range, 1–6 months) (P = 0.016).

Conclusion

In patients with BM from CRC, surgical resection plus SRS might improve survival.