Strategies for Colorectal Cancer Screening

Utilization of molecular genetic approaches for colorectal cancer screening

The feasibility of population screening for colorectal cancer has been demonstrated in several studies. Most of these studies have considered individual characteristics, diagnostic approaches, epidemiological data, and socioeconomic factors. In this article, we comment on an editorial by Metaxas et al published in the recent issue of the journal. The authors emphasized the need to raise public awareness through health education programs and the possibility of using easily accessible non-invasive screening methods. Here, we focus on non-invasive molecular genetic approaches that can aid in colorectal cancer screening. On the one hand, we highlighted the use of tumor DNA/RNA markers directly for screening and, on the other hand, underline the use of polygenic risk assessment and hereditary predisposition to select individuals for more thorough cancer screening.

Does Colonoscopy as a First Screening Test Still Make Sense?-Counterpoint

Colonoscopy has been widely regarded as the gold standard for its high diagnostic accuracy and preventive potential. However, its invasive nature, high cost, and suboptimal participation rates limit its utility at the population level. Non-invasive screening tests, notably the fecal immunochemical test (FIT) and multitarget stool DNA tests, present promising alternatives that may improve screening participation and reduce barriers to participation. Among these, FIT has demonstrated a consistent advantage in enhancing participation, which subsequently contributes to better long-term outcomes in CRC prevention. FIT-based two-step screening offers several practical advantages, including cost-effectiveness, non-invasiveness, and greater flexibility. Moreover, the quantitative nature of FIT allows for adjustable sensitivity thresholds and the ability of risk stratification, making it adaptable across diverse populations and scenarios. Through serial testing, FIT can increase cumulative detection rates over time. This approach facilitates the identification of high-risk individuals, allowing for more judicious use of colonoscopy resources and reducing unnecessary invasive procedures, especially among low-risk populations. Notably, evidence indicates that participation to FIT-based screening is consistently higher than to colonoscopy, which enhances the detection of early-stage cancers and advanced adenomas in the long run. Given the constraints of limited endoscopic capacity, the aging population, and the recent lowering of the recommended screening age due to the rising incidence of early-onset CRC, FIT emerges as a practical, flexible solution. The role of two-step FIT screening in improving participation and enabling risk-stratified, personalized approaches to CRC prevention is pivotal, advocating for its expanded integration into future screening paradigms.

c-MET is an important marker for acid-driven metastasis and anti-immune in colorectal cancer

BACKGROUND

The tumor microenvironment plays an important role in cancer progression, especially acidic microenvironment which distinguish cancer from normal tissues and immune microenvironment. This study was the first to investigate whether acidic microenvironment affects colorectal metastasis through MET and the relationship between MET and immune microenvironment.

METHODS

We used TCGA and GEO databases to predict MET expression, its relationship with clinical features, and biological function it mediated, and validated its expression with clinical data, as well as to verify that MET mediates acidic microenvironment-induced colorectal cancer metastasis by inducing EMT at the cellular and animal levels. The TCGA database was also used to analyze the relationship between MET and immune cells, immune checkpoints and TMB in colorectal cancer, and to predict its value in prognosis and immunological treatment and targeted therapy in pan-cancer.

RESULTS

MET is highly expressed in colorectal cancer and is associated with metastasis and prognosis. Its biological function is mainly related to adhesion, cell cycle and fatty acid metabolism, and it can mediate acidic microenvironment to induce EMT and promote metastasis. According to immunoinfiltration analysis, MET expression is correlated with CD8 + T cells, DC, macrophages, Tregs, and TMB in CRC and were associated with the prognosis, immune checkpoint, and TMB of ACC, PRAD, LUAD respectively, in pan-cancer.

CONCLUSIONS

MET is an important contributor to acid-driven colorectal cancer metastasis and participates in immune escape of colorectal cancer. It is of great significance for the prognosis and immunotherapy of colorectal cancer and some other cancers.

Nonalcoholic fatty liver disease and colorectal cancer: a two-sample bidirectional Mendelian randomization analysis

OBJECTIVE

Observational studies suggest a connection between nonalcoholic fatty liver disease (NAFLD) and colorectal cancer (CRC) risk. It, however, remains unclear whether such a connection is causal. This study aims to examine the association between NAFLD and CRC using a two-sample bidirectional Mendelian randomization (MR) method.

METHODS

Summary statistics for NAFLD were obtained from four genome-wide association studies, including 8434 cases and 770 180 controls. Meanwhile, CRC and controls (1803 vs. 174 006) were collected from the FinnGen. The inverse variance weighted (IVW) method was used primarily, while sensitivity analyses were conducted via the weighted median, MR Egger method, simple mode, and weighted mode to enhance result reliability.

RESULTS

We found a positive correlation between NAFLD and CRC by IVW method in the forward MR analysis (odds ratio = 1.270, 95% confidence interval: 1.154-1.398, P = 1.092 × 10-6). Inverse MR analysis, however, suggested that CRC may not have a causal effect on NAFLD. Besides, we observed an absence of horizontal pleiotropy and heterogeneity in this MR analysis.

CONCLUSION

Our forward MR study found that NAFLD may increase CRC risk. In contrast, CRC may not have a causal relationship with NAFLD. This study provides genetic evidence supporting a cause-and-effect association between NAFLD and CRC.

Pathology-Driven Automation to Improve Updating Documented Follow-Up Recommendations in the Electronic Health Record After Colonoscopy

INTRODUCTION

Failure to document colonoscopy follow-up needs postpolypectomy can lead to delayed detection of colorectal cancer (CRC). Automating the update of a unified follow-up date in the electronic health record (EHR) may increase the number of patients with guideline-concordant CRC follow-up screening.

METHODS

Prospective pre-post design study of an automated rules engine-based tool using colonoscopy pathology results to automate updates to documented CRC screening due dates was performed as an operational initiative, deployed enterprise-wide May 2023. Participants were aged 45-75 years who received a colonoscopy November 2022 to November 2023. Primary outcome measure is rate of updates to screening due dates and proportion with recommended follow-up < 10 years. Multivariable log-binomial regression was performed (relative risk, 95% confidence intervals).

RESULTS

Study population included 9,824 standard care and 19,340 intervention patients. Patients had a mean age of 58.6 ± 8.6 years and were 53.4% female, 69.6% non-Hispanic White, 13.5% non-Hispanic Black, 6.5% Asian, and 4.6% Hispanic. Postintervention, 46.7% of follow-up recommendations were updated by the rules engine. The proportion of patients with a 10-year default follow-up frequency significantly decreased (88.7%-42.8%, P < 0.001). The mean follow-up frequency decreased by 1.9 years (9.3-7.4 years, P < 0.001). Overall likelihood of an updated follow-up date significantly increased (relative risk 5.62, 95% confidence intervals: 5.30-5.95, P < 0.001).

DISCUSSION

An automated rules engine-based tool has the potential to increase the accuracy of colonoscopy follow-up dates recorded in patient EHR. The results emphasize the opportunity for more automated and integrated solutions for updating and maintaining EHR health maintenance activities.

Projected Impact and Cost-Effectiveness of Novel Molecular Blood-Based or Stool-Based Screening Tests for Colorectal Cancer

BACKGROUND

Cell-free DNA blood tests (cf-bDNA) and next-generation stool tests could change colorectal cancer (CRC) screening.

OBJECTIVE

To estimate the clinical and economic impacts of novel CRC screening tests.

DESIGN

Cost-effectiveness analysis using MOSAIC (Model of Screening and Surveillance for Colorectal Cancer).

DATA SOURCES

Published data.

TARGET POPULATION

Average-risk persons.

TIME HORIZON

Ages 45 to 100 years.

PERSPECTIVE

Health sector.

INTERVENTION

Novel versus established CRC screening tests.

OUTCOME MEASURES

Incidence and mortality of CRC, quality-adjusted life-years (QALYs), costs.

RESULTS OF BASE-CASE ANALYSIS

For colonoscopy every 10 years, annual fecal immunochemical test (FIT), and triennial next-generation multitarget stool DNA, FIT-RNA, cf-bDNA (Guardant Shield), or cf-bDNA (Freenome), the relative rates (RRs) and 95% uncertainty intervals (UIs) versus no screening for CRC incidence were 0.21 (0.19 to 0.22), 0.29 (0.27 to 0.31), 0.33 (0.32 to 0.36), 0.32 (0.30 to 0.34), 0.58 (0.55 to 0.61) and 0.58 (0.55 to 0.60), respectively; the RRs for CRC death were 0.19 (0.17 to 0.20), 0.25 (0.23 to 0.27), 0.28 (0.27 to 0.30), 0.28 (0.26 to 0.30), 0.44 (0.42 to 0.47), and 0.46 (0.44 to 0.49), respectively. The cf-bDNA test (Shield; list price $1495) cost $89 600 ($74 800 to $102 300) per QALY gained versus no screening; alternatives were less costly and more effective.

RESULTS OF SENSITIVITY ANALYSIS

Incremental costs exceeded incremental benefits when novel test intervals were shortened to 2 or 1 years. The cf-bDNA test matched FIT's impact on CRC mortality at 1.35 (1.30 to 1.40)-fold FIT's uptake rate, assuming equal colonoscopy follow-up. If persons who accept colonoscopy or stool tests shifted to cf-bDNA, CRC deaths increased. This adverse effect was overcome if every 3 such substitutions were counterbalanced by cf-bDNA uptake by 2 or more persons refusing alternatives, assuming equal colonoscopy follow-up.

LIMITATION

Longitudinal test-specific participation patterns are unknown.

CONCLUSION

First-generation cf-bDNA tests may deliver net benefit or harm, depending on the balance between achieving screening in persons who decline alternatives versus substituting cf-bDNA for more effective alternatives.

PRIMARY FUNDING SOURCE

The Gorrindo Family Fund.

Revolutionizing prognostic predictions in colorectal cancer: Macrophage‑driven transcriptional insights from single‑cell RNA sequencing and gene co‑expression network analysis

Tumor-associated macrophages have become important biomarkers for cancer diagnosis, prognosis and therapy. The dynamic changes in macrophage subpopulations significantly impact the outcomes of cancer immunotherapy. Hence, identifying additional macrophage-related biomarkers is essential for enhancing prognostic predictions in colorectal cancer (CRC) immunotherapy. CRC single-cell RNA sequencing (scRNA-seq) data was obtained from the Gene Expression Omnibus (GEO) database. The data were processed, normalized and clustered using the 'Seurat' package. Cell types within each cluster were annotated using the 'SingleR' package. Weighted gene co-expression network analysis identified modules corresponding to specific cell types. A non-negative matrix factorization algorithm was employed to segregate different clusters based on the selected module. Differentially expressed genes (DEGs) were identified across various clusters and a prognostic model was constructed using lasso regression and Cox regression analyses. The robustness of the model was validated using The Cancer Genome Atlas (TCGA) database and GEO microarrays. Additionally, the prognosis, immune characteristics and response to immune checkpoint inhibitor (ICI) therapy were individually analyzed. The scRNA-seq data from GSE200997, consisting of 23 samples, were analyzed. Dimensionality reduction and cluster identification allowed the isolation of the primary myeloid cell subpopulations. The macrophage-related brown module was identified, which was further divided into two clusters. Using the DEGs from these clusters, a prognostic model was developed, comprising five macrophage-related genes. The robustness of the model was confirmed using microarray datasets GSE17536, GSE38832 and GSE39582, as well as TCGA cohort. Patients classified as high-risk by the present model exhibited poorer survival rates, lower tumor mutation burden, reduced microsatellite instability, lower tumor purity, more severe tumor immune dysfunction and exclusion, and less benefit from ICIs therapy compared with low-risk patients. The present prognostic model shows promise as a biomarker for risk stratification and predicting therapeutic efficacy in patients with CRC. However, further well-designed prospective studies are necessary to validate the findings.

Knowledge, practice, and attitudes regarding breast cancer self-examination among women of reproductive age in Saudi Arabia: a community-based study

Breast cancer is the second most common cancer among females worldwide and can often be detected at an early stage through breast self-examination (BSE). However, in many developing countries, most cases are diagnosed at advanced stages. This study aimed to assess the knowledge and practice of BSE among women of reproductive age in Saudi Arabia. This study adopted a community-based descriptive-analytical cross-sectional design. A stratified simple random sampling technique was used, with 50 participants from each region. Almost 500 Saudi women who fulfilled the inclusion criteria were enrolled in this study, and of these, 32.8% were within the age group of 20-29, 30.4% were within the age group of 30-39, and 32.8% were within the age group of more than 40 years. The overall knowledge score regarding BSE items among participants was 38%. Significant associations were found between breast cancer knowledge scores and demographic factors such as age group, educational level, marital status, region, and residence area (P < 0.05). Regarding knowledge of breast cancer risk factors, 48% of participants demonstrated poor knowledge, 43% had moderate knowledge, and only 9% had good knowledge. Effective prevention of breast cancer requires awareness and understanding of its risk factors. It is important for young women, starting from puberty, to be educated about potential changes in breast tissue and to receive proper training in BSE techniques from healthcare professionals.

Evaluation of the Relationship Between Colorectal Cancer Incidence and Colonoscopy: The Importance of Early Diagnosis

Objective The present study evaluated the relationship between the incidence of colorectal cancer and colonoscopy in Santa Catarina from 2018 to 2022.

Methods Observational study of ecological type, which includes all confirmed cases of CRC in the state of Santa Catarina from 2018 to 2022, across health macro-regions. The data were obtained from SINAN, through TABNET/DATASUS. The variables gender, age group, race, type of care, average cost per hospitalization, days of stay, deaths, and mortality rates were evaluated.

Results In the period from 2018 to 2022, there were more than 28,000 cases of CRC in the state of Santa Catarina, with the Grande Oeste region being responsible for the highest incidence throughout the studied period. The main age group is between 70 and 79 years old; As for gender, most cases are predominantly male; about race, white ethnicity is predominant; the nature of service is, for the most part, elective; the average value per hospital stay is 2,355.41; total hospital stay days are 120,924; the number of deaths is 1553 and the mortality rate is (5.44/100.00). Regarding colonoscopy, the largest number of colonoscopies performed was in Grande Florianópolis.

Conclusion There is a high incidence of CRC cases in the state of Santa Catarina. Males and those aged 70 to 79 are the most affected by CRC in Santa Catarina. The Grande Oeste region has a higher incidence of cases compared with other health macro-regions.

The miR-1269a/PCDHGA9/CXCR4/β-catenin pathway promotes colorectal cancer invasion and metastasis

BACKGROUND

Colorectal cancer (CRC) is the third most common cancer worldwide and the second leading cause of cancer-related death. This research focuses on investigating the impact and underlying molecular mechanisms of protocadherin gamma subfamily A, 9 (PCDHGA9) on the invasion and metastasis of CRC, aiming to identify more precise molecular markers for the diagnosis and prognosis of CRC.

METHODS

PCDHGA9 expression was detected using quantitative real-time quantitative polymerase chain reaction (RT-qPCR) in 63 pairs of colorectal cancer tissues. Differential gene expression from high-throughput sequencing was analyzed using ingenuity pathway analysis (IPA) to explore the biological functions of PCDHGA9 and its potential regulated genes. Bioinformatics tools were employed to explore potential upstream regulatory microRNAs of PCDHGA9. Dual-luciferase assays were performed to demonstrate the regulation between PCDHGA9 and miR-1269a. Protein mass spectrometry suggested an interaction between PCDHGA9 and HOXA1. JASPAR predicted that HOXA1 may act as a transcription factor of CXCR4. Coimmunoprecipitation, dual-luciferase assays, and nuclear-cytoplasmic fractionation experiments confirmed the molecular mechanism involving PCDHGA9, CXCR4, HOXA1, and β-catenin. Transwell, wound healing, and western blot assays were conducted to confirm the impact of PCDHGA9, miR-1269a, and CXCR4 on the invasion, metastasis, and epithelial-mesenchymal transition (EMT) functions of CRC cells in in vitro experiments. A whole-body fluorescence imaging system was used to evaluate the combined impact of miR-1269a and PCDHGA9 on the invasion and metastasis of CRC in in vivo experiments.

RESULTS

The expression of PCDHGA9 was found to be lower in CRC tissues compared with their corresponding adjacent tissues. Low expression of PCDHGA9 potentially correlated with worse prognosis and increased chances of invasion and metastasis in CRC. miR-1269a was highly expressed in CRC tissues and acted as a negative regulator for PCDHGA9, promoting invasion, migration, and EMT of CRC cells. PCDHGA9's interaction with HOXA1 downregulated CXCR4, a transcription factor, leading to accumulation of β-catenin and further promoting invasion, migration, and EMT of CRC cells.

CONCLUSIONS

PCDHGA9, acting as a tumor suppressor, is downregulated by miR-1269a. The low level of PCDHGA9 activates the Wnt/β-catenin pathway by releasing its interaction with HOXA1, promoting the expression of CXCR4, and causing invasion, migration, and EMT in CRC.

Use of stool DNA for colorectal cancer screening: a meta-analysis and systematic review

Colorectal cancer is the third most common malignancy in the USA and accounts for more than 1 million deaths worldwide with screening shown to reduce CRC mortality. This meta-analysis analyzed the use of stool DNA for screening average risk, asymptomatic subjects for colorectal cancer and advanced precancerous lesions and compared sDNA to FOBT tests (gFOBT and FIT). Eight studies were included from four different countries with a total of 39 665 subjects. Pooled sensitivity and specificity for sDNA for detecting CRC was 83.3% (95% CI: 60.8-94.2) and 92.4% (95% CI: 90.1-94.1), respectively, compared with FOBT, which had a lower sensitivity at 70.2% (95% CI: 45.5-86.9) but higher specificity 95.7% (95% CI: 95.1-96.2). Further analysis showed improved sensitivity of sDNA to 92.6% when only the studies employing sDNA tests that incorporate hemoglobin immunochemical test were used. Both sDNA and FOBT tests had low sensitivity for detecting advanced precancerous lesions. sDNA tests are sensitive and specific for the detection of CRC but show low sensitivity compared with colonoscopy for the detection of advanced precancerous lesions.

A nomogram of inflammatory indexes for preoperatively predicting the risk of lymph node metastasis in colorectal cancer

PURPOSE

To investigate the independent risk factors associated with the development of lymph node metastasis (LNM) in patients with colorectal cancer (CRC), focusing on preoperative systemic inflammatory indicators, and to construct a corresponding risk predictive model.

MATERIALS AND METHODS

The clinical data of 241 patients with CRC who underwent surgery after the first diagnosis between January 2012 and December 2017 at our hospital were reviewed. A best logistic regression model was constructed by Lasso regression for multivariate analysis, from which a Nomogram was derived. Using bootstrap to conduct internal validation. The model's predictive performance and clinical practicability were evaluated using the receiver operating characteristic curve (ROC) curve, calibration curve, and decision curve analysis (DCA). External validation was conducted using retrospective data from 170 patients who underwent surgery between January 2020 and May 2022 at another hospital.

RESULTS

Cross-validation indicated smoking history, neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), lymphocyte-monocyte ratio (LMR), fibrinogen-albumin ratio (FAR), and fecal occult blood (FOB) as variables with non-zero coefficients. These factors were included in the logistic regression, and multivariate analysis confirmed that smoking history, NLR, LMR, FAR, and FOB were independent risk factors (P < 0.05). The ROC and calibration curve of the original model and external validation indicated strong predictive power of the model. DCA suggested the model's favorable clinical utility.

CONCLUSIONS

The model constructed in this study has robust predictive performance and clinical utility for the preoperative determination of CRC LMN, offering significant for clinical decision-making in patients with CRC.

Population screening for colorectal cancer in Spain - A public health success with remaining challenges

The development of organized colorectal cancer screening programs in developed countries has led to a reduction in the incidence and mortality of this cancer. The implementation of the national screening program in Spain represents a major achievement in public health, aligning us with other European countries, but it still faces ongoing challenges. One of the main issues is the low participation rate of the eligible population, averaging 45%, with significant variation between autonomous communities. This requires allocating specific resources to overcome barriers that hinder participation. Another key aspect to improving the screening program is extending the screening age up to 74 years, in line with the recommendations of the European Union, as many member states are already doing.

Characterizing the Perceived Need for CRC Screening among the Elderly Living in Rural Areas in the Pacific Northwest US: Roles of Miscommunication, Experience of Discrimination, and Dependence

PURPOSE

Increasing the perceived need for CRC screening can facilitate undertaking CRC screening. This study aims to identify factors associated with the need for CRC screening in rural populations.

DESIGN

A cross-sectional online survey.

SETTING

The survey was conducted in June - September 2022 in the rural areas of Alaska, Idaho, Oregon, and Washington, US.

SUBJECTS

The subjects of this study were 250 adults (completion rate: 65%) aged 45-75 residing in rural Alaska, Idaho, Oregon, and Washington.

MEASURES

Perceived need for CRC screening, internet usage for health purposes, demographics, and intrapersonal, interpersonal, community, and environmental characteristics.

RESULTS

Perceived need for CRC screening were negatively associated with patient-provider miscommunication (β = -.23, P < .001) and perceived discrimination (β = -.21, P < .001), cancer fatalism (β = -.16, P < .05), individualism (β = -.15, P < .05), and dependence on community (β = -.11, P < .05), but positively with compliance with social norms (β = .16, P < .05), trust in health care providers (β = .16, P < .05), knowledge about colorectal cancer (β = .12, P < .05).

CONCLUSIONS

Our study showed potential individual and situational characteristics that might help increase colorectal cancer screening. Future efforts might consider addressing discrimination in health care settings, improving patient-provider communication, and tailoring messaging to reflect the rural culture.

Determinants of early-onset colorectal cancer: a multicenter case-control study in Iran

BACKGROUND

We aimed to study the risk factors of early-onset colorectal cancer (CRC) incidence in the Iranian population. Early onset CRC in Iran is a relevant health issue that deserves further epidemiological efforts to be defined and controlled as far as possible. Early age screening of low-tract of the intestine would be particularly useful in families of colorectal cancer patients.

METHODS

We analyzed data from a multicenter hospital-based case-control study in Iran (The Iranian Study of Opium and Cancer). Sociodemographic and lifestyle information was collected using validated questionnaires. Multivariate logistic regressions estimated the odds ratios (OR) and 95% confidence intervals (CIs) for the association of early-onset CRC in individuals under the age of 50 and potential risk factors, including physical activity, socioeconomic status, body shape at age 15, dietary factors, vitamin D, cigarettes and waterpipe smoking, opium use and family history of CRC. Additionally, a subgroup analysis was conducted for individuals with a very young age of CRC onset (i.e. <35 years).

RESULTS

We analyzed data of 189 developed CRC below age 50 (99 colon and 90 rectum), and 66 patients under the age 35 (13 colon and 21 rectum). Early CRC was inversely associated with vegetables (OR, 0.59; 95% CI, 0.38-0.92 for 422-576 g/day) and vitamin D (OR, 0.49; 95% CI, 0.26-0.94), and positively associated with red meat intake (OR, 1.80; 1.15-2.83 per 25.65 g/day). Vegetables (OR, 0.51; 95% CI, 0.27-0.98 for 576 g/day), red meat (OR, 2.05; 95% CI, 1.11-3.79 for 25.65 g/day), vitamin D (OR, 0.29; 95% CI, 0.10-0.86) and opium use (OR, 2.61; 95% CI, 1.01-6.74) were associated with early rectum cancer. Results were heterogeneous by cancer site for high fruit and vegetables intakes and cigarette smoking. Family history was associated with CRC (OR, 3.16; 95% CI, 1.29-10.9) and rectum cancer (OR, 3.22; 95% CI, 1.24-14.4) in subjects younger than 35, and, to a lesser extent, with CRC and rectum cancer before age 50.

CONCLUSION

Early-onset CRC was related to the intake of vegetables, vitamin D and red meat in Iran. Early-onset rectum cancer was associated with regular opium use. Family history was associated with early CRC and early rectum cancer, particularly below the age of 35.

Validation of artificial intelligence-based bowel preparation assessment in screening colonoscopy (with video)

BACKGROUND AND AIMS

Accurate bowel preparation assessment is essential for determining colonoscopy screening intervals. Patients with suboptimal bowel preparation are at a high risk of missing >5 mm adenomas and should undergo an early repeat colonoscopy. In this study, we used artificial intelligence (AI) to evaluate bowel preparation and validated the ability of the system to accurately identify patients who are at high risk of having >5 mm adenomas missed due to inadequate bowel preparation.

METHODS

This prospective, single-center, observational study was conducted at the Eighth Affiliated Hospital, Sun Yat-sen University, from October 8, 2021, to November 9, 2022. Eligible patients who underwent screening colonoscopy were consecutively enrolled. The AI assessed bowel preparation using the e-Boston Bowel Preparation Scale (e-BBPS) while endoscopists made evaluations using BBPS. If both BBPS and e-BBPS deemed preparation adequate, the patient immediately underwent a second colonoscopy; otherwise, the patient underwent bowel re-cleansing before the second colonoscopy.

RESULTS

Among the 393 patients, 72 adenomas >5 mm in size were detected; 27 adenomas >5 mm in size were missed. In unqualified-AI patients, the >5 mm adenoma miss rate (AMR) was significantly higher than in qualified-AI patients (35.71% vs 13.19% [P = .0056]; odds ratio [OR], .2734 [95% CI, .1139-.6565]), as were the AMR (50.89% vs 20.79% [P < .001]; OR, .2532 [95% CI, .1583-.4052]) and >5 mm polyp miss rate (35.82% vs 19.48% [P = .0152]; OR, .4335 [95% CI, .2288-.8213]).

CONCLUSIONS

This study confirmed that patients classified as inadequate by AI exhibited an unacceptable >5 mm AMR, providing key evidence for implementing AI in guiding bowel re-cleansing and potentially standardizing future colonoscopy screening. (Clinical trial registration number: NCT05145712.).

Colorectal Cancer Screening and Management in Low- and Middle-Income Countries and High-Income Countries: A Narrative Review

Colorectal cancer (CRC) remains a leading global health challenge, being a highly prevalent cancer and a major cause of cancer-related deaths worldwide. The incidence of CRC varies significantly between high-income countries (HICs) and low- and middle-income countries (LMICs), with higher rates of incidence but lower mortality in HICs. Factors such as genetic predisposition, lifestyle, and dietary habits play significant roles in CRC development, with the Western diet and limited access to screening contributing to increased incidence. This review highlights disparities in CRC screening, management, and outcomes between HICs and LMICs, with HICs benefiting from advanced screening methods like colonoscopy and sigmoidoscopy, while LMICs face challenges due to limited healthcare infrastructure and resources. Tailored strategies, including low-cost screening options and community-based initiatives, are critical in LMICs to improve early detection and outcomes. Future directions for improving CRC care globally include telemedicine, artificial intelligence, and mobile health technologies to bridge access gaps, as well as personalized medicine to enhance treatment efficacy. Global collaboration and investment in healthcare infrastructure are necessary to reduce CRC-related mortality, particularly in resource-limited settings.

Enhancing Colorectal Cancer Screening with Droplet Digital PCR Analysis of Fusobacterium nucleatum in Fecal Immunochemical Test Samples

Fecal immunochemical test (FIT) followed by colonoscopy in positive cases is commonly used for population-based colorectal cancer screening. However, specificity of FIT for colorectal cancer is not ideal and has poor performance for advanced adenoma detection. Fecal Fusobacterium nucleatum (Fn) detection has been proposed as a potential noninvasive biomarker for colorectal cancer and advanced adenoma detection. We aimed to evaluate the diagnostic performance of Fn detection using droplet digital PCR (ddPCR) in FIT samples from individuals enrolled in a colorectal cancer screening program with colorectal adenoma or cancer. We evaluated Fn presence in DNA isolated from FIT leftover material of 300 participants in a colorectal cancer screening program using ddPCR. The Fn DNA amount was classified as Fn-low/negative and Fn-high, and the association with patients' clinicopathological features and accuracy measurements was calculated. Fn-high levels were more prevalent in FIT-positive (47.2%, n = 34 of 72) than FIT-negative samples (28.9%, n = 66 of 228; P < 0.04). Among FIT-positive samples, high Fn levels were significantly more frequent in patients with cancer (CA, n = 8) when compared to normal (NT, n = 16; P = 0.02), non-advanced adenomas (NAA, n = 36; P = 0.01), and advanced adenomas (AA, n = 12; P = 0.01). Performance analysis of Fn in FIT-positive samples for colorectal cancer detection yielded an AUC of 0.8203 [confidence interval (CI), 0.6464-0.9942], with high sensitivity (100%) and specificity of 50%. Concluding, we showed the feasibility of detecting Fn in FIT leftovers using the ultrasensitive ddPCR technique. Furthermore, we highlighted the potential use of Fn levels in fecal samples to ameliorate colorectal cancer detection. Prevention Relevance: Fusobacterium nucleatum detection by droplet digital PCR could prioritize the selection of fecal immunochemical test-positive individuals who might benefit the most from the colonoscopy procedure.

DNA methylation analysis of the SDC2, SEPT9 and VIM genes in fecal DNA for colorectal cancer diagnosis

BACKGROUND

Colorectal cancer is one of the most common cancers worldwide. DNA methylation sites may serve as a new gene signature for colorectal cancer diagnosis. The search for representative DNA methylation sites is urgently needed. This study aimed to systematically identify a methylation gene panel for colorectal cancer diagnosis via tissue and fecal samples.

METHODS

A total of 181 fecal and 50 tumor tissue samples were collected. They were obtained from 83 colorectal cancer patients and 98 healthy subjects. These samples were evaluated for DNA methylation of 9 target genes via quantitative bisulfite next-generation sequencing. We employed the rank-sum test to screen the colorectal cancer-specific methylation sites in the tissue and fecal cohorts. A data model was subsequently constructed and validated via the dedicated validation dataset.

RESULTS

Compared with the fecal and negative control samples, the colorectal cancer tissue samples presented significantly higher methylation rates for all the selected gene sites. The methylation rates of the tissue and preoperative fecal samples showed the same high and low rates at the same sites. After screening, a panel of 29 loci in the SDC2, SEPT9, and VIM genes proved to be reliable biomarkers for colorectal cancer diagnosis in fecal samples. Logistic regression models were then constructed and validated using this panel. The sensitivity of the model was 91.43% (95% CI = [89.69, 93.17]), the specificity was 100% (95% CI = [100,100]), and the AUC value is 99.31% (95% CI = [99,99.62]). The diagnostic accuracy of the model for stage I and stage II colorectal cancer was 100% (11/11) and 91.3% (21/23), respectively. Overall, this study confirms that the gene locus panel and the model can be used to diagnose colorectal cancer effectively through feces.

CONCLUSIONS

Our study identified a set of key methylation sites for colorectal cancer diagnosis from fecal samples, highlighting the importance of using tissue and fecal samples to accurately assess DNA methylation levels to screen for methylation sites, and developing an effective diagnostic model for colorectal cancer.

Nutrition and Selected Lifestyle Elements as a Tertiary Prevention in Colorectal Cancer Patients

BACKGROUND

Nutrition and lifestyle elements can significantly support the therapeutic process in colorectal cancer (CRC) patients, which is the basis for tertiary prevention. The study aimed to assess the nutritional strategies and lifestyle of CRC patients and to determine differences in these behaviors depending on gender and age.

METHODS

The study group included 202 CRC patients. The research was carried out in two hospitals and using the snowball method. The research tool was an original questionnaire. Data were processed in statistical programs. p < 0.05 was considered statistically significant.

RESULTS

Patients reported many behavioral-nutritional side effects. Half of them did not use a therapeutic diet (n = 101; 50.0%). The majority of patients declared that they ate three meals a day (57.4%). Fruits and vegetables were mainly eaten raw (69.3%). Almost a quarter of patients were not physically active at all (22.3%). Men chose to fry meat significantly more often than women (27.7% vs. 19.3%) (p = 0.003). The elderly consumed fast food significantly less often than middle-aged (88.5% vs. 72.3%) (p = 0.03).

CONCLUSIONS

Patients showed both pro- and anti-health activities. The findings revealed several noteworthy disparities in dietary habits and lifestyle choices based on gender and age, indicating that these factors can significantly influence the health management of CRC patients. The patients' behaviors should be constantly monitored and intensified, especially through regular consultations and educational meetings with an oncology dietitian for nutritional tertiary prevention of chronic disease.

Risk of colorectal neoplasia after removal of conventional adenomas and serrated polyps: a comprehensive evaluation of risk factors and surveillance use

BACKGROUND

Surveillance colonoscopy after polyp removal is recommended to prevent subsequent colorectal cancer (CRC). It is known that advanced adenomas have a substantially higher risk than non-advanced ones, but optimal intervals for surveillance remain unclear.

DESIGN

We prospectively followed 156 699 participants who had undergone a colonoscopy from 2007 to 2017 in a large integrated healthcare system. Using multivariable Cox proportional hazards regression we estimated the subsequent risk of CRC and high-risk polyps, respectively, according to index colonoscopy polyps, colonoscopy quality measures, patient characteristics and the use of surveillance colonoscopy.

RESULTS

After a median follow-up of 5.3 years, we documented 309 CRC and 3053 high-risk polyp cases. Compared with participants with no polyps at index colonoscopy, those with high-risk adenomas and high-risk serrated polyps had a consistently higher risk of CRC during follow-up, with the highest risk observed at 3 years after polypectomy (multivariable HR 5.44 (95% CI 3.56 to 8.29) and 8.35 (95% CI 4.20 to 16.59), respectively). Recurrence of high-risk polyps showed a similar risk distribution. The use of surveillance colonoscopy was associated with lower risk of CRC, with an HR of 0.61 (95% CI 0.39 to 0.98) among patients with high-risk polyps and 0.57 (95% CI 0.35 to 0.92) among low-risk polyps. Among 1548 patients who had high-risk polyps at both index and surveillance colonoscopies, 65% had their index polyps in the proximal colon and 30% had index and interval polyps in the same segments.

CONCLUSION

Patients with high-risk polyp findings were at higher risk of subsequent CRC and high-risk polyps and may benefit from early surveillance within 3 years. The subsite distribution of the index and recurrent high-risk polyps suggests the contribution of incomplete resection and missed lesions to the development of interval neoplasia.

Discovery and validation of colorectal cancer tissue-specific methylation markers: a dual-center retrospective cohort study

BACKGROUND AND PURPOSE

Early detection, diagnosis, and treatment of colorectal cancer and its precancerous lesions can significantly improve patients' survival rates. The purpose of this research is to identify methylation markers specific to colorectal cancer tissues and validate their diagnostic capability in colorectal cancer and precancerous changes by measuring the level of DNA methylation in stool samples.

METHOD

We analyzed samples from six cancer tissues and adjacent normal tissues and fecal samples from 758 participants, including 62 patients with interfering diseases. Bioinformatics databases were used to screen for candidate biomarkers for CRC, and quantitative methylation-specific PCR methods were applied for identification. The methylation levels of the candidate biomarkers in fecal and tissue samples were measured. Logistic regression and random forest models were built and validated using fecal sample data from one of the centers, and the independent or combined diagnostic value of the candidate biomarkers in fecal samples for CRC and precancerous lesions was analyzed. Finally, the diagnostic capability and stability of the model were validated at another medical center.

RESULTS

This study identified two colorectal cancer CpG sites with tissue specificity. These two biomarkers have certain diagnostic power when used individually, but their diagnostic value for colorectal cancer and colorectal adenoma is more significant when they are used in combination.

CONCLUSION

The results indicate that a DNA methylation biomarker combined diagnostic model based on two CpG sites, cg13096260 and cg12587766, has the potential for screening and diagnosing precancerous lesions and colorectal cancer. Additionally, compared to traditional diagnostic models, machine learning algorithms perform better but may yield more false-positive results, necessitating further investigation.

In vivo staging of colitis, adenoma and carcinoma in CRC progression by combination of H4R/DRD4-targeted fluorescent probes

Colorectal cancer (CRC) is the third most prevalent malignancy and the second leading cause of cancer-related mortality worldwide. Currently, CRC staging heavily relies on invasive surgical procedures for in vitro pathological analysis, which entails long detection cycles and increases the risk of metastasis. There is an urgent need for specific biomarkers to classify adenomas and cancers, while early in vivo staging detection could potentially reduce mortality and morbidity rates. This study focused on Type IV histamine receptor (H4R), which is highly expressed only in the inflammatory stage, and Dopamine receptor D4 (DRD4), which is highly expressed in colorectal adenoma and carcinoma stages. Fluorescent targeted molecular probes H4R-Cy5 and DRD4-M were constructed respectively. The in vitro cell level proves that H4R-Cy5 only has high specificity for RAW264.7 cells, and DRD4-M only has good affinity for HT29 cells. In inflammation-HT29 subcutaneous tumors, H4R-Cy5 and DRD4-M can target inflammation and tumor lesions respectively. In addition, this study is the first to combine the two probes to explore the feasibility of in vivo non-invasive staging on CRC mouse models. The results show that H4R-Cy5 can distinguish and identify the stages of inflammation in vivo, and the DRD4-M probe can accurately identify the stages of colorectal adenoma and carcinoma in vivo. The combination of these two probes can achieve precise non-invasive staging of colitis, adenoma and carcinoma, which is a major advance in the development of accurate diagnostic methods for colorectal precancerous lesions and has important implications for the selection of treatment strategies.

A Pressure Sensing Device to Assist in Colonoscopic Procedures to Prevent Perforation-A Case Study

Colonoscopy has a limited field of view because it relies solely on a small camera attached to the end of the scope and a screen displayed on a monitor. Consequently, the quality and safety of diagnosis and treatment depend on the experience and skills of the gastroenterologist. When a novice attempts to insert the colonoscope during the procedure, excessive pressure can sometimes be applied to the colon wall. This pressure can cause a medical accident known as colonic perforation, which the physician should prevent. We propose an assisting device that senses the pressure applied to the colon wall, analyzes the risk of perforation, and warns the physician in real time. Flexible pressure sensors are attached to the surface of the colonoscope shaft. These sensors measure pressure signals during a colonoscopy procedure. A simple signal processor is used to collect and process the pressure signals. In the experiment, a colonoscope equipped with the proposed device was inserted into a simulated colon made from a colon extracted from a pig. The processed data were visually communicated to the gastroenterologist via displays and light-emitting diodes (LEDs). The device helps the physician continuously monitor and prevent excessive pressure on the colon wall. In this experiment, the device appropriately generated and delivered warnings to help the physicians prevent colonic perforation. In the future, the device is to be improved, and more experiments will be performed in live swine models or humans to confirm its efficacy and safety.

Combining FITs and HRFQ with colonoscopy improve the cost-effectiveness of a 9-year mass colorectal cancer screening program

BACKGROUND

Colorectal cancer (CRC) incidence has been increasing. Colonoscopy is still a gold standard method for its early diagnosis but using colonoscopy alone as a mass screening method is unrealistic. This study is to investigate whether combining fecal immunochemical test (FIT) and high-risk-factors questionnaire (HRFQ) with colonoscopy improve the cost-effectiveness of a mass CRC screening.

PATIENTS AND METHODS

CRC screening protocol combining FITs and HRFQ in the first stage and colonoscopy in the second stage was used in 50 villages/towns in 2007-2015. Residents aged 40-74 years were eligible for this free screening. A total of 160 210 (76.12%) participants completed first-stage screening, and 28 679 (17.90%) participants were defined as positive, among which 21 715 (75.72%) participants completed colonoscopy and were included in the final analysis. Outcomes were followed up until 2020.

RESULTS

The compliance was 76.12% and 75.72% in the first and second screening stage, respectively. A total of 252 CRC, 4033 adenoma, 1234 advanced neoplasm, and 5534 total neoplasm cases were detected in the screening. The positive predictive values of CRC, adenoma, advanced neoplasm, and total neoplasm were higher in FITs+ than those in the HRFQ+ population, respectively. A total of 64.60% and 43.42% total neoplasm cases were found in FITs+ and HRFQ+ (8.02% for both), respectively. The total colorectal neoplasm and CRC cases detected by combining HRFQ and FITs increased by 55.08% and 40.00%, respectively, and their increases were higher compared to HRFQ. The detection cost per any neoplasm by combining HRFQ and FITs was <$5331, while that by FITs and HRFQ alone was <$4570 and $5380, respectively.

CONCLUSIONS

Combining FITs and HRFQ with colonoscopy improve the cost-effectiveness of a mass CRC screening program. This protocol can be recommended for most populations, especially those in the countries and areas with high population density and low physician/population ratio.

Risk of Cancers Proximal to the Colon in Fecal Immunochemical Test Positive Screenees in a Colorectal Cancer Screening Program

BACKGROUND & AIMS

In more than half of the colorectal cancer screening participants with a positive fecal immunochemical test (FIT) result, no advanced neoplasia (AN) is detected at colonoscopy. The positive FIT result could also be generated by cancers located proximal to the colon: upper gastrointestinal, oral cavity, nose, and throat cancers. We evaluated screenees' risk of being diagnosed with a cancer proximal to the colon within the 3 years and compared risks between those with a positive vs those with a negative FIT.

METHODS

Data of Dutch colorectal cancer screening participants who underwent biennial FIT-based screening 2014-2018 were collected from the national screening database and linked to the National Cancer Registry. Screenees were classified into 3 groups: FIT-positives with AN (FIT+/AN+), FIT-positives without AN (FIT+/AN-), and FIT-negatives (FIT-). We compared the cumulative incidence of cancers proximal to the colon in each group 3 years after FIT. A Cox regression analysis with left truncation and right censoring, using FIT positivity as time-dependent variable and stratified for sex, was performed to compare the hazard of cancers proximal to the colon in participants who were FIT-positive vs FIT-negative.

RESULTS

Three-year cumulative incidence of cancers proximal to the colon in FIT+/AN+ (n = 65,767), FIT+/AN- (n = 50,661), and FIT- (n = 1,831,647) screenees was 0.7%, 0.6%, and 0.4%, respectively (P < .001). FIT-positives were older and more frequently male than FIT-negatives (P < .001). Significantly more cancers proximal to the colon were detected among FIT-positives (P < .001; hazard ratio, 1.55; 95% CI, 1.44-1.67).

CONCLUSION

FIT-positive screenees were at significantly increased risk of being diagnosed with a cancer proximal to the colon within 3 years after FIT, although the 3-year cumulative incidence was still less than 1%.

The Annual Cost of Cancer Screening in the United States

BACKGROUND

Cancer has substantial health, quality-of-life, and economic impacts. Screening may decrease cancer mortality and treatment costs, but the cost of screening in the United States is unknown.

OBJECTIVE

To estimate the annual cost of initial cancer screening (that is, screening without follow-up costs) in the United States in 2021.

DESIGN

Model using national health care survey and cost resources data.

SETTING

U.S. health care systems and institutions.

PARTICIPANTS

People eligible for breast, cervical, colorectal, lung, and prostate cancer screening with available data.

MEASUREMENTS

The number of people screened and associated health care system costs by insurance status in 2021 dollars.

RESULTS

Total health care system costs for initial cancer screenings in the United States in 2021 were estimated at $43 billion. Approximately 88.3% of costs were attributable to private insurance; 8.5% to Medicare; and 3.2% to Medicaid, other government programs, and uninsured persons. Screening for colorectal cancer represented approximately 64% of the total cost; screening colonoscopy represented about 55% of the total. Facility costs (amounts paid to facilities where testing occurred) were major drivers of the total estimated costs of screening.

LIMITATIONS

All data on receipt of cancer screening are based on self-report from national health care surveys. Estimates do not include costs of follow-up for positive or abnormal screening results. Variations in costs based on geography and provider or health care organization are not fully captured.

CONCLUSION

The $43 billion estimated annual cost for initial cancer screening in the United States in 2021 is less than the reported annual cost of cancer treatment in the United States in the first 12 months after diagnosis. Identification of cancer screening costs and their drivers is critical to help inform policy and develop programmatic priorities, particularly for enhancing access to recommended cancer screening services.

PRIMARY FUNDING SOURCE

None.

Outcomes of Robot-Assisted Versus Laparoscopic Surgery for Colorectal Cancer in Adults Aged 75 Years and Older: A Propensity Score-Matched Analysis of the US Nationwide Inpatient Sample

BACKGROUND

Robot-assisted surgery has been increasingly adopted in colorectal cancer resection.

OBJECTIVE

The study aimed to compare the inpatient outcomes of robot-assisted versus conventional laparoscopic colorectal cancer resection in patients aged 75 years and older.

DESIGN

A retrospective, population-based study.

SETTINGS

This study analyzed data from the United States Nationwide Inpatient Sample from 2005 to 2018.

PATIENTS

Patients with colorectal cancer aged 75 years and older and who underwent robot-assisted or conventional laparoscopic resection.

MAIN OUTCOME MEASURES

Postoperative complications, prolonged length of stay, and total hospital costs were assessed.

RESULTS

Data from 14,108 patients were analyzed. After adjustment, any postoperative complications (adjusted OR = 0.87; 95% CI, 0.77-0.99; p = 0.030) and prolonged length of stay (adjusted OR = 0.78; 95% CI, 0.67-0.91; p = 0.001) were significantly less in the robotic than the laparoscopic group. In addition, robotic surgery was associated with significantly higher total hospital costs (26.06 USD greater cost; 95% CI, 21.35-30.77 USD; p < 0.001).

LIMITATIONS

The analysis was limited by its retrospective and observational nature, potential coding errors, and the lack of intraoperative factors, such as operative time, laboratory measures, and information on surgeons' experience.

CONCLUSIONS

In the United States, in patients with colorectal cancer aged 75 years and older who were undergoing tumor resections, compared to conventional laparoscopic surgery, robotic surgery is associated with better inpatient outcomes in terms of complication rate and risk of prolonged length of stay. This finding is especially true among patients with colon cancer. However, robotic surgery is associated with higher total hospital costs. See Video Abstract .

RESULTADOS DE LA CIRUGA ASISTIDA POR ROBOT FRENTE A LA CIRUGA LAPAROSCPICA PARA EL CNCER COLORRECTAL EN ADULTOS AOS DE EDAD UN ANLISIS EMPAREJADO POR PUNTUACIN DE PROPENSIN DE LA MUESTRA NACIONAL DE PACIENTES HOSPITALIZADOS DE ESTADOS UNIDOS

ANTECEDENTES:La cirugía asistida por robot se ha adoptado cada vez más en la resección del cáncer colorrectal.OBJETIVO:El estudio tuvo como objetivo comparar los resultados hospitalarios de la resección del cáncer colorrectal asistida por robot versus la laparoscópica convencional en pacientes ≥ 75 años.DISEÑO:Estudio retrospectivo de base poblacional.AJUSTES:Este estudio analizó datos de la Muestra Nacional de Pacientes Hospitalizados de Estados Unidos de 2005 a 2018.PACIENTES:Pacientes con cáncer colorrectal ≥ 75 años y sometidos a resección laparoscópica convencional o asistida por robot.PRINCIPALES MEDIDAS DE RESULTADO:Se evaluaron las complicaciones posoperatorias, la duración prolongada de la estancia hospitalaria y los costos hospitalarios totales.RESULTADOS:Se analizaron datos de 14.108 pacientes. Después del ajuste, cualquier complicación posoperatoria (aOR = 0,87; IC del 95 %: 0,77-0,99, p = 0,030) y duración prolongada de la estancia hospitalaria (aOR = 0,78; IC del 95 %: 0,67-0,91, p = 0,001) fueron significativamente menores en el grupo robótico que el grupo laparoscópico. Además, la cirugía robótica se asoció con costos hospitalarios totales significativamente mayores ($26,06 USD mayor costo; IC 95%: 21,35-30,77 USD, p < 0,001).LIMITACIONES:El análisis estuvo limitado por su naturaleza retrospectiva y observacional, posibles errores de codificación y la falta de factores intraoperatorios como el tiempo operatorio, medidas de laboratorio e información sobre la experiencia de los cirujanos.CONCLUSIONES:En Estados Unidos, los pacientes con cáncer colorrectal ≥ 75 años que se sometieron a resecciones tumorales, en comparación con la cirugía laparoscópica convencional, la cirugía robótica se asocia con mejores resultados hospitalarios en términos de tasa de complicaciones y riesgo de estadía prolongada, especialmente entre pacientes con cáncer de colon. Sin embargo, la cirugía robótica se asocia a costes hospitalarios totales más elevados. (Traducción-Yesenia Rojas-Khalil ).

Colorectal cancer-specific microbiome in peripheral circulation and cancer tissues

Introduction

Accumulating evidence has supported that gut microbiota and metabolite profiles play indispensable roles in the pathogenesis of colorectal cancer (CRC), which ranks as the third most common cancer and the second leading cause of cancer-related deaths worldwide. However, alterations in tumoral or circulating microbiomes in CRC remain incompletely understood. It has been well-documented that tissue or serum microbiomes with low microbial biomass could be screened by use of 2bRAD sequencing for microbiome (2bRAD-M) at the species resolution.

Methods

In order to validate the microbial biomarkers distinguishing CRC and the variations in microorganisms present in serum and tumors, we performed 2bRAD-M to characterize the microbiomes in serum and cancer tissues of CRC patients with and without lymph node or liver metastasis.

Results

The composition of dominated microbiota in serum was different from that of tissue samples, while the microbial community composition of tumors was similar to that of the tumor-adjacent tissues. The analysis of α-diversity and β-diversity has revealed notable variations in serum microbiota diversities in CRC patients, particularly those with liver metastasis. Multiple CRC-specific microbial species, such as Moraxella A cinereus, Flavobacterium sp001800905, and Acinetobacter albensis, were identified in serum. Complicated functions and KEGG pathways were also confirmed in CRC according to the metastasis status.

Discussion

This study has found significant alterations in the microbial compositions and diversities in CRC and CRC-specific microbial species in both circulation and cancer tissues, which may serve as promising biomarkers for the screening, diagnosis and prognosis prediction of CRC. In particular, CRC-specific bacterial taxa are promising markers, holding transformative potentials in establishing personalized screening and risk stratification, refining much earlier non-invasive diagnostic approaches, and enhancing diagnostic sensitivity.

Dysbiosis promotes recurrence of adenomatous polyps in the distal colorectum

BACKGROUND

Colorectal polyps, which are characterized by a high recurrence rate, represent preneoplastic conditions of the intestine. Due to unclear mechanisms of pathogenesis, first-line therapies for non-hereditary recurrent colorectal polyps are limited to endoscopic resection. Although recent studies suggest a mechanistic link between intestinal dysbiosis and polyps, the exact compositions and roles of bacteria in the mucosa around the lesions, rather than feces, remain unsettled.

AIM

To clarify the composition and diversity of bacteria in the mucosa surrounding or 10 cm distal to recurrent intestinal polyps.

METHODS

Mucosal samples were collected from four patients consistently with adenomatous polyps (Ade), seven consistently with non-Ade (Pol), ten with current Pol but previous Ade, and six healthy individuals, and bacterial patterns were evaluated by 16S rDNA sequencing. Linear discriminant analysis and Student's t-tests were used to identify the genus-level bacteria differences between groups with different colorectal polyp phenotypes. Pearson's correlation coefficients were used to evaluate the correlation between intestinal bacteria at the genus level and clinical indicators.

RESULTS

The results confirmed a decreased level of probiotics and an enrichment of pathogenic bacteria in patients with all types of polyps compared to healthy individuals. These changes were not restricted to the mucosa within 0.5 cm adjacent to the polyps, but also existed in histologically normal tissue 10 cm distal from the lesions. Significant differences in bacterial diversity were observed in the mucosa from individuals with normal conditions, Pol, and Ade. Increased abundance of Gram-negative bacteria, including Klebsiella, Plesiomonas, and Cronobacter, was observed in Pol group and Ade group, suggesting that resistance to antibiotics may be one risk factor for bacterium-related harmful environment. Meanwhile, age and gender were linked to bacteria changes, indicating the potential involvement of sex hormones.

CONCLUSION

These preliminary results support intestinal dysbiosis as an important risk factor for recurrent polyps, especially adenoma. Targeting specific pathogenic bacteria may attenuate the recurrence of polyps.

Deep Learning-Based Reconstruction Improves the Image Quality of Low-Dose CT Colonography

RATIONALE AND OBJECTIVES

To evaluate the image quality of low-dose CT colonography (CTC) using deep learning-based reconstruction (DLR) compared to iterative reconstruction (IR).

MATERIALS AND METHODS

Adults included in the study were divided into four groups according to body mass index (BMI). Routine-dose (RD: 120 kVp) CTC images were reconstructed with IR (RD-IR); low-dose (LD: 100kVp) images were reconstructed with IR (LD-IR) and DLR (LD-DLR). The subjective image quality was rated on a 5-point scale by two radiologists independently. The parameters for objective image quality included noise, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR). The Friedman test was used to compare the image quality among RD-IR, LD-IR and LD-DLR. The KruskalWallis test was used to compare the results among different BMI groups.

RESULTS

A total of 270 volunteers (mean age: 47.94 years ± 11.57; 115 men) were included. The effective dose of low-dose CTC was decreased by approximately 83.18% (5.18mSv ± 0.86 vs. 0.86mSv ± 0.05, P < 0.001). The subjective image quality score of LD-DLR was superior to that of LD-IR (3.61 ± 0.56 vs. 2.70 ± 0.51, P < 0.001) and on par with the RD- IR's (3.61 ± 0.56 vs. 3.74 ± 0.52, P = 0.486). LD-DLR exhibited the lowest noise, and the maximum SNR and CNR compared to RD-IR and LD-IR (all P < 0.001). No statistical difference was found in the noise of LD-DLR images between different BMI groups (all P > 0.05).

CONCLUSION

Compared to IR, DLR provided low-dose CTC with superior image quality at an average radiation dose of 0.86mSv, which may be promising in future colorectal cancer screening.

Development and validation of a novel colonoscopy withdrawal time indicator based on YOLOv5

BACKGROUND AND AIM

The study aims to introduce a novel indicator, effective withdrawal time (WTS), which measures the time spent actively searching for suspicious lesions during colonoscopy and to compare WTS and the conventional withdrawal time (WT).

METHODS

Colonoscopy video data from 472 patients across two hospitals were retrospectively analyzed. WTS was computed through a combination of artificial intelligence (AI) and manual verification. The results obtained through WTS were compared with those generated by the AI system. Patients were categorized into four groups based on the presence of polyps and whether resections or biopsies were performed. Bland Altman plots were utilized to compare AI-computed WTS with manually verified WTS. Scatterplots were used to illustrate WTS within the four groups, among different hospitals, and across various physicians. A parallel box plot was employed to depict the proportions of WTS relative to WT within each of the four groups.

RESULTS

The study included 472 patients, with a median age of 55 years, and 57.8% were male. A significant correlation with manually verified WTS (r = 0.918) was observed in AI-computed WTS. Significant differences in WTS/WT among the four groups were revealed by the parallel box plot (P < 0.001). The group with no detected polyps had the highest WTS/WT, with a median of 0.69 (interquartile range: 0.40, 0.97). WTS patterns were found to be varied between the two hospitals and among senior and junior physicians.

CONCLUSIONS

A promising alternative to traditional WT for quality control and training assessment in colonoscopy is offered by AI-assisted computation of WTS.

A Novel TGF-β-Related Signature for Predicting Prognosis, Tumor Microenvironment, and Therapeutic Response in Colorectal Cancer

The transforming growth factor beta (TGF-β) signaling plays a critical role in immune evasion and tumor progression. However, its modulatory influences on prognosis, tumor microenvironment (TME), and therapeutic efficacy remain unknown in colorectal cancer (CRC). We summarized TGF-β-related genes and comprehensively estimated their expression pattern in 2142 CRC samples from 9 datasets. Two distinct cluster patterns were divided and biological characteristics of each pattern were further analyzed. Then, to quantify the TGF-β cluster pattern of individual CRC patient, we generated the TGF-β score (TGFBscore) model based on TGF-β cluster pattern-relevant differentially expressed genes (DEGs). Subsequently, we conducted correlation analysis for TGFBscore and clinical prognosis, consensus molecular subtypes (CMSs), TME characteristics, liver metastasis, drug response, and immunotherapeutic efficacy in CRC. We illustrated transcriptional and genetic alterations of TGF-β-relevant genes, which were closely linked with carcinogenic pathways. We identified two different TGF-β cluster patterns, characterized by a high and a low TGFBscore. The TGFBscore-high group was significantly linked with worse patient survival, epithelial-mesenchymal transition (EMT) activation, liver metastasis tendency, and the infiltration of immunosuppressive cells (regulatory T cells [Tregs], M2 macrophages, cancer-associated fibroblasts [CAFs], and myeloid-derived suppressor cells [MDSCs]), while the TGFBscore-low group was linked with a survival advantage, epithelial phenotype, early CRC staging, and the infiltration of immune-activated cells (B cell, CD4 T cell, natural killer T [NKT] cell, and T helper 1 [Th1] cell). In terms of predicting drug response, TGFBscore negatively correlated (sensitive to TGFBscore-high group) with drugs targeting PI3K/mTOR, JNK and p38, RTK signaling pathways, and positively correlated (sensitive to TGFBscore-low group) with drugs targeting EGFR signaling pathway. Also, TGFBscore could predict the efficacy of different anti-tumor therapies. TGFBscore-low patients might benefit more from anti-PDL1 immunotherapy, adjuvant chemotherapy (ACT), and ERBB targeted therapy, whereas TGFBscore-high patients might benefit more from antiangiogenic targeted therapy. Our study constructed a novel TGF-β scoring model that could predict prognosis, liver metastasis tendency, and TME characteristics for CRC patients. More importantly, this work emphasizes the potential clinical utility of TGFBscore in evaluating the efficacy of chemotherapy, targeted therapy, and immunotherapy, guiding individualized precision treatment in CRC.

A proactive/reactive mass screening approach with uncertain symptomatic cases

We study the problem of mass screening of heterogeneous populations under limited testing budget. Mass screening is an essential tool that arises in various settings, e.g., the COVID-19 pandemic. The objective of mass screening is to classify the entire population as positive or negative for a disease as efficiently and accurately as possible. Under limited budget, testing facilities need to allocate a portion of the budget to target sub-populations (i.e., proactive screening) while reserving the remaining budget to screen for symptomatic cases (i.e., reactive screening). This paper addresses this decision problem by taking advantage of accessible population-level risk information to identify the optimal set of sub-populations for proactive/reactive screening. The framework also incorporates two widely used testing schemes: Individual and Dorfman group testing. By leveraging the special structure of the resulting bilinear optimization problem, we identify key structural properties, which in turn enable us to develop efficient solution schemes. Furthermore, we extend the model to accommodate customized testing schemes across different sub-populations and introduce a highly efficient heuristic solution algorithm for the generalized model. We conduct a comprehensive case study on COVID-19 in the US, utilizing geographically-based data. Numerical results demonstrate a significant improvement of up to 52% in total misclassifications compared to conventional screening strategies. In addition, our case study offers valuable managerial insights regarding the allocation of proactive/reactive measures and budget across diverse geographic regions.

Bioinformatics analysis and identification of cuproptosis-related long non-coding RNAs in colorectal cancer

OBJECTIVE

Identifying precise biomarkers for colorectal cancer (CRC) detection and management remains challenging. Here, we developed an innovative prognostic model for CRC using cuproptosis-related long non-coding RNAs (lncRNAs).

METHODS

In this retrospective study, CRC patient transcriptomic and clinical data were sourced from The Cancer Genome Atlas database. Cuproptosis-related lncRNAs were identified and used to develop a prognostic model, which helped categorize patients into high- and low-risk groups. The model was validated through survival analysis, risk curves, independent prognostic analysis, receiver operating characteristic curve analysis, decision curves, and nomograms. In addition, we performed various immune-related analyses. LncRNA expression levels were examined in normal human colorectal epithelial cells (FHC) and CRC cells (HCT-116) using quantitative polymerase chain reaction (qPCR).

RESULTS

Six cuproptosis-related lncRNAs were identified: ZKSCAN2-DT, AL161729.4, AC016394.1, AC007128.2, AL137782.1, and AC099850.3. The prognostic model distinguished between high-/low-risk populations, demonstrating excellent predictive ability for survival outcomes. Immunocorrelation analysis showed significant differences in immune cell infiltration and functions, immune checkpoint expression, and m6A methylation-related genes. The qPCR results showed significant upregulation of ZKSCAN2-DT, AL161729.4, AC016394.1, AC007128.2 in HCT-116 cells, while AL137782.1 and AC099850.3 expression patterns were significantly downregulated.

CONCLUSION

Cuproptosis-related lncRNAs can potentially serve as reliable diagnostic and prognostic biomarkers for CRC.

Effectiveness of colonoscopy, immune fecal occult blood testing, and risk-graded screening strategies in colorectal cancer screening

BACKGROUND

Colorectal cancer (CRC) is one of the most common malignant tumors, and early screening is crucial to improving the survival rate of patients. The combination of colonoscopy and immune fecal occult blood detection has garnered significant attention as a novel method for CRC screening. Colonoscopy and fecal occult blood tests, when combined, can improve screening accuracy and early detection rates, thereby facilitating early intervention and treatment. However, certain risks and costs accompany it, making the establishment of a risk classification model crucial for accurate classification and management of screened subjects.

AIM

To evaluate the feasibility and effectiveness of colonoscopy, immune fecal occult blood test (FIT), and risk-graded screening strategies in CRC screening.

METHODS

Based on the randomized controlled trial of CRC screening in the population conducted by our hospital May 2020 to May 2023, participants who met the requirements were randomly assigned to a colonoscopy group, an FIT group, or a graded screening group at a ratio of 1:2:2 (after risk assessment, the high-risk group received colonoscopy, the low-risk group received an FIT test, and the FIT-positive group received colonoscopy). The three groups received CRC screening with different protocols, among which the colonoscopy group only received baseline screening, and the FIT group and the graded screening group received annual follow-up screening based on baseline screening. The primary outcome was the detection rate of advanced tumors, including CRC and advanced adenoma. The population participation rate, advanced tumor detection rate, and colonoscopy load of the three screening programs were compared.

RESULTS

A total of 19373 subjects who met the inclusion and exclusion criteria were enrolled, including 8082 males (41.7%) and 11291 females (58.3%). The mean age was 60.05 ± 6.5 years. Among them, 3883 patients were enrolled in the colonoscopy group, 7793 in the FIT group, and 7697 in the graded screening group. Two rounds of follow-up screening were completed in the FIT group and the graded screening group. The graded screening group (89.2%) and the colonoscopy group (42.3%) had the lowest overall screening participation rates, while the FIT group had the highest (99.3%). The results of the intentional analysis showed that the detection rate of advanced tumors in the colonoscopy group was greater than that of the FIT group [2.76% vs 2.17%, odds ratio (OR) = 1.30, 95% confidence interval (CI): 1.01-1.65, P = 0.037]. There was no significant difference in the detection rate of advanced tumors between the colonoscopy group and the graded screening group (2.76% vs 2.35%, OR = 1.9, 95%CI: 0.93-1.51, P = 0.156), as well as between the graded screening group and the FIT group (2.35% vs 2.17%, OR = 1.09%, 95%CI: 0.88-1.34, P = 0.440). The number of colonoscopy examinations required for each patient with advanced tumors was used as an index to evaluate the colonoscopy load during population screening. The graded screening group had the highest colonoscopy load (15.4 times), followed by the colonoscopy group (10.2 times), and the FIT group had the lowest (7.8 times).

CONCLUSION

A hierarchical screening strategy based on CRC risk assessment is feasible for screening for CRC in the population. It can be used as an effective supplement to traditional colonoscopy and FIT screening programs.

Screening of colorectal cancer: Methods and strategies

Colorectal cancer (CRC) has high incidence and mortality rates, and the emergence and application of CRC screening have helped us effectively control the occurrence and development of CRC. Currently, common international screening methods include tests based on feces and blood, and examination methods that allow for visualization, such as sigmoidoscopy and colonoscopy. Some methods have been widely used, whereas others such as multi-target stool RNA test are still being explored and developed, and are expected to become front-line screening methods for CRC in the future. The choice of screening method is affected by external conditions and the patients' situation, and the clinician must choose an appropriate strategy according to the actual situation and the patient's wishes. This article introduces various CRC screening methods and analyzes the factors relevant to the screening strategy.

Role of sex steroids in colorectal cancer: pathomechanisms and medical applications

Given that the colon represents the most extensive hormone-responsive tissue in the human body, it prompts a compelling inquiry into whether the progression of its cancer is intimately linked to hormonal dynamics. Consequently, the interplay between sex steroids - a pivotal constituent of hormones - and colorectal cancer has increasingly captivated scientific interest. Upon a comprehensive review of pertinent literature both domestically and internationally, this study delineates the present landscape of three pivotal steroids - estrogen, progestin, and androgen - in the context of colorectal cancer. More specifically, this investigation probes into the potential utility of these steroids in providing therapeutic interventions, diagnostic insights, and prognostic indicators. Furthermore, this study also delves into the mechanistic pathways through which sex steroid interventions exert influence on colorectal cancer. It was discovered that the trio of sex steroid hormones partakes in an array of biological processes, thereby influencing the onset and progression of colorectal cancer. In conclusion, this study posits that a profound interconnection exists between colorectal cancer and sex steroids, suggesting that elucidating the targets of their action mechanisms could unveil novel avenues for the diagnosis and prevention of colorectal cancer.

Results of Implementation of Amyloidosis Screening for Patients Undergoing Carpal Tunnel Release

PURPOSE

Many patients with amyloidosis undergo carpal tunnel release (CTR) before amyloidosis diagnosis and before developing cardiac or other serious disease manifestations. The purposes of this study were to examine if our patient population had a similar prevalence of positive amyloidosis diagnoses to that in prior studies and to describe the results of implementing a screening program for amyloidosis.

METHODS

We retrospectively reviewed the biopsy results and subsequent interventions for all patients who underwent screening tenosynovial biopsy during CTR from March 2020 through December 2021. Amyloid screening was offered to patients who met the criteria for increased risk of disease using an appropriateness screening algorithm.

RESULTS

Seventy-five (48%) of 156 patients who underwent CTR met the eligibility criteria for amyloidosis testing. Of the 62 patients who agreed to undergo tenosynovial biopsy, 14 had amyloid-positive biopsy specimens (10 men and 4 women). All patients with positive tenosynovial biopsies had bilateral carpal tunnel syndrome and wild-type transthyretin amyloid subtype. One patient was diagnosed and started treatment for otherwise asymptomatic cardiac amyloidosis.

CONCLUSIONS

The incidence of amyloid-positive tenosynovial biopsy results from CTR was 22.5% in patients using the criteria from an appropriateness screening algorithm, which was higher than previously reported. Implementation of a screening program for patients undergoing CTR requires a multidisciplinary approach and may result in early diagnosis and lifesaving interventions for patients with amyloidosis.

TYPE OF STUDY/LEVEL OF EVIDENCE

Differential diagnosis/symptom prevalence study, II.

Performance of OC-Auto Micro 80 Fecal Immunochemical Test in an Integrated Academic-Community Health System

GOALS

We aimed to determine the performance of the OC-Auto Micro 80 fecal immunochemical test (FIT) in an average-risk population receiving care in an integrated, academic-community health system.

BACKGROUND

The FIT is the most used colorectal cancer (CRC) screening test worldwide. However, many Food and Drug Administration-cleared FIT products have not been evaluated in clinical settings.

STUDY

We performed a retrospective cohort study of patients (50 to 75 y old) in the University of Washington Medicine health care system who were screened for CRC by OC-Auto Micro 80 FIT between March 2016 and September 2021. We used electronic health records to extract patient-level and clinic-level factors, FIT use, colonoscopy, and pathology findings. The primary outcomes were the FIT positivity rate and neoplasms detected at colonoscopy. Secondary outcomes were FIT positivity by sex and safety-net versus non-safety-net clinical settings.

RESULTS

We identified 39,984 FITs completed by 26,384 patients; 2411 (6.0%) had a positive FIT result (>100 ng/mL of hemoglobin in buffer), and 1246 (51.7%) completed a follow-up colonoscopy. The FIT positive rate was 7.0% in men and 5.2% in women ( P <0.01). Among those who completed a colonoscopy after an abnormal FIT result, the positive predictive value for CRC, advanced adenoma, and advanced neoplasia was 3.0%, 20.9%, and 23.9%, respectively.

CONCLUSIONS

In a retrospective analysis of a large heterogeneous population, the OC-Auto Micro 80 FIT for CRC screening demonstrated a positivity rate of 6.0% and a positive predictive value for CRC of 3.0%.

Leveraging a realistic synthetic database to learn Shape-from-Shading for estimating the colon depth in colonoscopy images

Colonoscopy is the choice procedure to diagnose, screening, and treat the colon and rectum cancer, from early detection of small precancerous lesions (polyps), to confirmation of malign masses. However, the high variability of the organ appearance and the complex shape of both the colon wall and structures of interest make this exploration difficult. Learned visuospatial and perceptual abilities mitigate technical limitations in clinical practice by proper estimation of the intestinal depth. This work introduces a novel methodology to estimate colon depth maps in single frames from monocular colonoscopy videos. The generated depth map is inferred from the shading variation of the colon wall with respect to the light source, as learned from a realistic synthetic database. Briefly, a classic convolutional neural network architecture is trained from scratch to estimate the depth map, improving sharp depth estimations in haustral folds and polyps by a custom loss function that minimizes the estimation error in edges and curvatures. The network was trained by a custom synthetic colonoscopy database herein constructed and released, composed of 248400 frames (47 videos), with depth annotations at the level of pixels. This collection comprehends 5 subsets of videos with progressively higher levels of visual complexity. Evaluation of the depth estimation with the synthetic database reached a threshold accuracy of 95.65%, and a mean-RMSE of 0.451cm, while a qualitative assessment with a real database showed consistent depth estimations, visually evaluated by the expert gastroenterologist coauthoring this paper. Finally, the method achieved competitive performance with respect to another state-of-the-art method using a public synthetic database and comparable results in a set of images with other five state-of-the-art methods. Additionally, three-dimensional reconstructions demonstrated useful approximations of the gastrointestinal tract geometry. Code for reproducing the reported results and the dataset are available at https://github.com/Cimalab-unal/ColonDepthEstimation.

Comparative Effectiveness and Cost-Effectiveness of Colorectal Cancer Screening With Blood-Based Biomarkers (Liquid Biopsy) vs Fecal Tests or Colonoscopy

BACKGROUND & AIMS

Colorectal cancer (CRC) screening is highly effective but underused. Blood-based biomarkers (liquid biopsy) could improve screening participation.

METHODS

Using our established Markov model, screening every 3 years with a blood-based test that meets minimum Centers for Medicare & Medicaid Services' thresholds (CMSmin) (CRC sensitivity 74%, specificity 90%) was compared with established alternatives. Test attributes were varied in sensitivity analyses.

RESULTS

CMSmin reduced CRC incidence by 40% and CRC mortality by 52% vs no screening. These reductions were less profound than the 68%-79% and 73%-81%, respectively, achieved with multi-target stool DNA (Cologuard; Exact Sciences) every 3 years, annual fecal immunochemical testing (FIT), or colonoscopy every 10 years. Assuming the same cost as multi-target stool DNA, CMSmin cost $28,500/quality-adjusted life-year gained vs no screening, but FIT, colonoscopy, and multi-target stool DNA were less costly and more effective. CMSmin would match FIT's clinical outcomes if it achieved 1.4- to 1.8-fold FIT's participation rate. Advanced precancerous lesion (APL) sensitivity was a key determinant of a test's effectiveness. A paradigm-changing blood-based test (sensitivity >90% for CRC and 80% for APL; 90% specificity; cost ≤$120-$140) would be cost-effective vs FIT at comparable participation.

CONCLUSIONS

CMSmin could contribute to CRC control by achieving screening in those who will not use established methods. Substituting blood-based testing for established effective CRC screening methods will require higher CRC and APL sensitivities that deliver programmatic benefits matching those of FIT. High APL sensitivity, which can result in CRC prevention, should be a top priority for screening test developers. APL detection should not be penalized by a definition of test specificity that focuses on CRC only.

Prediction and analysis of albumin-bilirubin score combined with liver function index and carcinoembryonic antigen on liver metastasis of colorectal cancer

BACKGROUND

Colorectal cancer (CRC) is a common malignant tumor, and liver metastasis is one of the main recurrence and metastasis modes that seriously affect patients' survival rate and quality of life. Indicators such as albumin bilirubin (ALBI) score, liver function index, and carcinoembryonic antigen (CEA) have shown some potential in the prediction of liver metastasis but have not been fully explored.

AIM

To evaluate its predictive value for liver metastasis of CRC by conducting the combined analysis of ALBI, liver function index, and CEA, and to provide a more accurate liver metastasis risk assessment tool for clinical treatment guidance.

METHODS

This study retrospectively analyzed the clinical data of patients with CRC who received surgical treatment in our hospital from January 2018 to July 2023 and were followed up for 24 months. According to the follow-up results, the enrolled patients were divided into a liver metastasis group and a nonliver metastasis group and randomly divided into a modeling group and a verification group at a ratio of 2:1. The risk factors for liver metastasis in patients with CRC were analyzed, a prediction model was constructed by least absolute shrinkage and selection operator (LASSO) logistic regression, internal validation was performed by the bootstrap method, the reliability of the prediction model was evaluated by subject-work characteristic curves, calibration curves, and clinical decision curves, and a column graph was drawn to show the prediction results.

RESULTS

Of 130 patients were enrolled in the modeling group and 65 patients were enrolled in the verification group out of the 195 patients with CRC who fulfilled the inclusion and exclusion criteria. Through LASSO regression variable screening and logistic regression analysis. The ALBI score, alanine aminotransferase (ALT), and CEA were found to be independent predictors of liver metastases in CRC patients [odds ratio (OR) = 8.062, 95% confidence interval (CI): 2.545-25.540], (OR = 1.037, 95%CI: 1.004-1.071) and (OR = 1.025, 95%CI: 1.008-1.043). The area under the receiver operating characteristic curve (AUC) for the combined prediction of CRLM in the modeling group was 0.921, with a sensitivity of 78.0% and a specificity of 95.0%. The H-index was 0.921, and the H-L fit curve had χ2 = 0.851, a P value of 0.654, and a slope of the calibration curve approaching 1. This indicates that the model is extremely accurate, and the clinical decision curve demonstrates that it can be applied effectively in the real world. We conducted internal verification of one thousand resamplings of the modeling group data using the bootstrap method. The AUC was 0.913, while the accuracy was 0.869 and the kappa consistency was 0.709. The combination prediction of liver metastasis in patients with CRC in the verification group had an AUC of 0.918, sensitivity of 85.0%, specificity of 95.6%, C-index of 0.918, and an H-L fitting curve with χ 2 = 0.586, P = 0.746.

CONCLUSION

The ALBI score, ALT level, and CEA level have a certain value in predicting liver metastasis in patients with CRC. These three criteria exhibit a high level of efficacy in forecasting liver metastases in patients diagnosed with CRC. The risk prediction model developed in this work shows great potential for practical application.

Mass Spectrometry Proteomics Characterization of Plasma Biomarkers for Colorectal Cancer Associated With Inflammation

Background

Colorectal cancer (CRC) prognosis is determined by the disease stage with low survival rates for advanced stages. Current CRC screening programs are mainly using colonoscopy, limited by its invasiveness and high cost. Therefore, non-invasive, cost-effective, and accurate alternatives are urgently needed.

Objective and design

This retrospective multi-center plasma proteomics study was performed to identify potential blood-based biomarkers in 36 CRC patients and 26 healthy volunteers by high-resolution mass spectrometry proteomics followed by the validation in an independent CRC cohort (60 CRC patients and 44 healthy subjects) of identified selected biomarkers.

Results

Among the 322 identified plasma proteins, 37 were changed between CRC patients and healthy volunteers and were associated with the complement cascade, cholesterol metabolism, and SERPIN family members. Increased levels in CRC patients of the complement proteins C1QB, C4B, and C5 as well as pro-inflammatory proteins, lipopolysaccharide-binding protein (LBP) and serum amyloid A4, constitutive (SAA4) were revealed for first time. Importantly, increased level of C5 was verified in an independent validation CRC cohort. Increased C4B and C8A levels were correlated with cancer-associated inflammation and CRC progression, while cancer-associated inflammation was linked to the acute-phase reactant leucine-rich alpha-2-glycoprotein 1 (LRG1) and ceruloplasmin. Moreover, a 4-protein signature including C4B, C8A, apolipoprotein C2 (APO) C2, and immunoglobulin heavy constant gamma 2 was changed between early and late CRC stages.

Conclusion

Our results suggest that C5 could be a potential biomarker for CRC diagnosis. Further validation studies will aid the application of these new potential biomarkers to improve CRC diagnosis and patient care.

Developing a Nomogram for Predicting Colorectal Cancer and Its Precancerous Lesions Based on Data from Three Non-Invasive Screening Tools, APCS, FIT, and sDNA

Purpose

This study aimed to develop and validate a nomogram for predicting positive colonoscopy results using the data from non-invasive screening strategies.

Methods

The volunteers participated in primary colorectal cancer (CRC) screenings using Asia-Pacific colorectal screening (APCS) scoring, faecal immunochemical testing (FIT) and stool deoxyribonucleic acid (sDNA) testing and underwent a colonoscopy. The positive colonoscopy results included CRC, advanced adenoma (AA), high-grade intraepithelial neoplasia (HGIN), and low-grade intraepithelial neoplasia (LGIN). The enrolled participants were randomly selected for training and validation sets in a 7:3 ratio. A model for predicting positive colonoscopy results was virtualized by the nomogram using logistic regression analysis.

Results

Among the 179 enrolled participants, 125 were assigned to training set, while 54 were assigned to validation set. After multivariable logistic regression was done, APCS score, FIT result, and sDNA result were all identified as the predictors for positive colonoscopy results. A model that incorporated the above independent predictors was developed and presented as a nomogram. The C-index of the nomogram in the validation set was 0.768 (95% CI, 0.644-0.891). The calibration curve demonstrated a good agreement between prediction and observation. The decision curve analysis (DCA) curve showed that the model achieved a net benefit across all threshold probabilities. The AUC of the prediction model for predicting positive colonoscopy results was much higher than that of the FIT + sDNA test scheme.

Conclusion

The nomogram for predicting positive colonoscopy results was successfully developed based on 3 non-invasive screening tools (APCS scoring, FIT and sDNA test).

Bias due to coarsening of time intervals in the inference for the effectiveness of colorectal cancer screening

BACKGROUND

Observational studies are frequently used to estimate the comparative effectiveness of different colorectal cancer (CRC) screening methods due to the practical limitations and time needed to conduct large clinical trials. However, time-varying confounders, e.g. polyp detection in the last screening, can bias statistical results. Recently, generalized methods, or G-methods, have been used for the analysis of observational studies of CRC screening, given their ability to account for such time-varying confounders. Discretization, or the process of converting continuous functions into discrete counterparts, is required for G-methods when the treatment and outcomes are assessed at a continuous scale.

DEVELOPMENT

This paper evaluates the interplay between time-varying confounding and discretization, which can induce bias in assessing screening effectiveness. We investigate this bias in evaluating the effect of different CRC screening methods that differ from each other in typical screening frequency.

APPLICATION

First, using theory, we establish the direction of the bias. Then, we use simulations of hypothetical settings to study the bias magnitude for varying levels of discretization, frequency of screening and length of the study period. We develop a method to assess possible bias due to coarsening in simulated situations.

CONCLUSIONS

The proposed method can inform future studies of screening effectiveness, especially for CRC, by determining the choice of interval lengths where data are discretized to minimize bias due to coarsening while balancing computational costs.

Exploring the role of m 6 A writer RBM15 in cancer: a systematic review

In the contemporary epoch, cancer stands as the predominant cause of premature global mortality, necessitating a focused exploration of molecular markers and advanced therapeutic strategies. N6-methyladenosine (m6A), the most prevalent mRNA modification, undergoes dynamic regulation by enzymes referred to as methyltransferases (writers), demethylases (erasers), and effective proteins (readers). Despite lacking methylation activity, RNA-binding motif protein 15 (RBM15), a member of the m6A writer family, assumes a crucial role in recruiting the methyltransferase complex (MTC) and binding to mRNA. Although the impact of m6A modifications on cancer has garnered widespread attention, RBM15 has been relatively overlooked. This review briefly outlines the structure and operational mechanism, and delineates the unique role of RBM15 in various cancers, shedding light on its molecular basis and providing a groundwork for potential tumor-targeted therapies.

Applying the healthcare failure mode and effects analysis approach to improve the quality of an organised colorectal cancer screening programme

OBJECTIVE

The first level of a colorectal cancer (CRC) screening process was systematically analysed using the Healthcare Failure Mode and Effects Analysis (HFMEA) approach by a multidisciplinary team aiming to improve the programme quality.

SETTING

The study was conducted at the Local Health Authority of Bologna, Northern Italy.

METHODS

Seven brainstorming sessions were conducted and all the activities performed were recorded on a FMEA worksheet consisting of individual records reporting the specific phases of the analysed process along with associated activities, possible failure modes, their causes and effects, the obtained risk priority numbers (RPNs) and the control measures to plan.

RESULTS

Twenty-three failure modes, 14 effects and 12 possible causes were identified. Nine failure modes were prioritised according to the RPN obtained; most resulted in possible false-negative faecal immunochemical test (FIT) results (66.7%), followed by sample loss (22.2%) and not reaching the entire target population (11.1%). This leads to 66.7% of corrective/preventive actions being applied to the phase of returning the stool sample by the citizen. For this phase reorganisation, the local pharmacies were involved not only as FIT kit delivery points but also as specimen collection and sending points to the laboratory. These organisational changes allowed the introduction of complete traceability of kits and specimens flow, as well as temperature control. A re-evaluation of the prioritised failure modes 6 months after launching the implemented screening process showed that HFMEA application decreased the risk of potential errors by 75.9%.

CONCLUSION

HFMEA application in CRC screening programme is a useful tool to reduce potential errors.

Polyketide synthase positive Escherichia coli one-time measurement in stool is not informative of colorectal cancer risk in a screening setting

Environmental factors like the pathogenicity island polyketide synthase positive (pks+) Escherichia coli (E. coli) could have potential for risk stratification in colorectal cancer (CRC) screening. The association between pks+ E. coli measured in fecal immunochemical test (FIT) samples and the detection of advanced neoplasia (AN) at colonoscopy was investigated. Biobanked FIT samples were analyzed for both presence of E. coli and pks+ E. coli and correlated with colonoscopy findings; 5020 CRC screening participants were included. Controls were participants in which no relevant lesion was detected because of FIT-negative results (cut-off ≥15 μg Hb/g feces), a negative colonoscopy, or a colonoscopy during which only a nonadvanced polyp was detected. Cases were participants with AN [CRC, advanced adenoma (AA), or advanced serrated polyp (ASP)]. Existing DNA isolation and quantitative polymerase chain reaction (qPCR) procedures were used for the detection of E. coli and pks+ E. coli in stool. A total of 4542 (90.2%) individuals were E. coli positive, and 1322 (26.2%) were pks+ E. coli positive. The prevalence of E. coli in FIT samples from individuals with AN was 92.9% compared to 89.7% in FIT samples of controls (p = 0.010). The prevalence of pks+ E. coli in FIT samples from individuals with AN (28.6%) and controls (25.9%) was not significantly different (p = 0.13). The prevalences of pks+ E. coli in FIT samples from individuals with CRC, AA, or ASP were 29.6%, 28.3%, and 32.1%, respectively. In conclusion, the prevalence of pks+ E. coli in a screening population was 26.2% and did not differ significantly between individuals with AN and controls. These findings disqualify the straightforward option of using a snapshot measurement of pks+ E. coli in FIT samples as a stratification biomarker for CRC risk. © 2024 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.