Predictors of colorectal cancer following a negative colonoscopy in the Medicare population

Analysing 11 years of incidence trends, clinicopathological characteristics, and forecasts of colorectal cancer in young and old patients: a retrospective cross-sectional study in an Indonesian national referral hospital

OBJECTIVE

To obtain annual incidence trends, understand clinicopathological characteristics, and forecast the future burden of colorectal cancer (CRC) in Indonesia.

DESIGN

11-year retrospective cross-sectional study.

SETTING

A national referral hospital in Jakarta, Indonesia.

PARTICIPANTS

Data from 1584 eligible cases were recorded for trends and forecasting analyses; 433 samples were analysed to determine clinicopathological differences between young (<50 years) and old (≥50 years) patients.

METHODS

Trend analyses were done using Joinpoint software, expressed in annual percentage change (APC), and a regression analysis was executed to generate a forecasting model. Patients' characteristics were compared using χ2 or non-parametric tests.

MAIN OUTCOMES

Analysis of trends, forecasting model, and clinicopathological features between the age groups.

RESULTS

A significant increase in APC was observed among old patients (+2.38%) for CRC cases. Colon cancer increased remarkably (+9.24%) among young patients; rectal cancer trends were either stable or declining. The trend for right-sided CRC increased in the general population (+6.52%) and old patients (+6.57%), while the trend for left-sided CRC was stable. These cases are expected to be a significant health burden within the next 10 years. Patients had a mean age of 53.17±13.94, 38.1% were young, and the sex ratio was 1.21. Prominent characteristics were left-sided CRC, tumour size ≥5 cm, exophytic growth, adenocarcinoma, histologically low grade, pT3, pN0, inadequately dissected lymph nodes (LNs), LN ratio <0.05, no distant metastasis, early-stage cancer, no lymphovascular invasion, and no perineural invasion (PNI). Distinct features between young and old patients were found in the histological subtype, number of dissected LN, and PNI of the tumour.

CONCLUSIONS

Epidemiological trends and forecasting analyses of CRC cases in Indonesian patients showed an enormous increase in colon cancer in young patients, a particularly concerning trend. Additionally, young patients exhibited particular clinicopathological characteristics that contributed to disease severity.

Quality of Colonoscopy Performed in Rural Practice: Experience From the Clinical Outcomes Research Initiative and the Oregon Rural Practice-Based Research Network

PURPOSE

Colon cancer screening is effective. To complete screening in 80% of individuals over age 50 years by 2018 will require adequate colonoscopy capacity throughout the country, including rural areas, where colonoscopy providers may have less specialized training. Our aim was to study the quality of colonoscopy in rural settings.

METHODS

The Clinical Outcomes Research Initiative (CORI) and the Oregon Rural Practice-based Research Network (ORPRN) collaborated to recruit Oregon rural practices to submit colonoscopy reports to CORI's National Endoscopic Database (NED). Ten ORPRN sites were compared to non-ORPRN rural (n = 11) and nonrural (n = 43) sites between January 2009 and October 2011. Established colonoscopy quality measures were calculated for all sites.

RESULTS

No ORPRN physicians were gastroenterologists compared with 82% of nonrural physicians. ORPRN practices reached the cecum in 87.4% of exams compared with 89.3% of rural sites (P = .0002) and 90.9% of nonrural sites (P < .0001). Resected polyps were less likely to be retrieved (84.7% vs 91.6%; P < .0001) and sent to pathology (77.1% vs 91.3%; P < .0001) at ORPRN practices compared to nonrural sites. The overall polyp detection (39.0% vs 40.3%) was similar (P = .217) between ORPRN and nonrural practices. Of exams with polyps, the rate for largest polyp on exam 6-9 mm was 20.8% at ORPRN sites, compared to 26.8% at nonrural sites (P < .0001), and for polyps >9mm 16.6% vs 18.7% (P = .106).

CONCLUSION

ORPRN sites performed well on most colonoscopy quality measures, suggesting that high-quality colonoscopy can be performed in rural settings.

Protective association of colonoscopy against proximal and distal colon cancer and patterns in interval cancer

BACKGROUND

The protective effect of colonoscopy against proximal colorectal cancer is variable and depends on the detection and complete removal of precancerous polyps.

OBJECTIVE

To estimate the efficacy of colonoscopy in a medical center with open-access screening colonoscopy since 1998.

DESIGN

Nested case-control study with incidence density sampling.

SETTING

University-affiliated Veterans Affairs Medical Center.

PATIENTS

Colorectal cancer (CRC) cases and control subjects selected from screening age patients matched by age, gender, and date of first primary care visit.

MAIN OUTCOME MEASUREMENT

Colonoscopy preceding the CRC diagnosis date.

RESULTS

A total of 20.2% of CRC cases had a colonoscopy in the preceding 10 years compared with 49.0% of control subjects (adjusted odds ratio [aOR], 0.20; 95% confidence interval [CI], 0.11-0.34). Colonoscopy was strongly associated with decreased odds of both distal CRC (aOR, 0.16; 95% CI, 0.07-0.34) and proximal CRC (aOR, 0.26; 95% CI, 0.11-0.58). The fraction of cases attributed to interval cancers was 10.5%. Missed lesions predominantly localized to the cecum and rectum, and recurrent lesions clustered in the hepatic flexure. Cecal intubation rate was 93% (98% in adequately prepped patients), and the adenoma detection rate was 45.2% in the control group.

LIMITATIONS

Single-center, retrospective case-control design.

CONCLUSION

In an open access colonoscopy program characterized by a high cecal intubation rate and adenoma detection rate, colonoscopy was strongly associated with reduced odds of both distal and proximal CRC. Among interval cancers, missed lesions clustered in the cecum and rectum and recurrent lesions in the hepatic flexure.

Post-colonoscopy colorectal cancer (PCCRC) rates vary considerably depending on the method used to calculate them: a retrospective observational population-based study of PCCRC in the English National Health Service

OBJECTIVE

Post-colonoscopy colorectal cancer (PCCRC) is a key quality indicator of colonoscopy. This study compares methods for defining PCCRC rates, proposes a new method of calculating them and quantifies them across the English National Health Service (NHS).

DESIGN

This retrospective observational population-based study involved all individuals with a first primary diagnosis of colorectal cancer made between 2001 and 2010 and treated in the English NHS. Previously published methods for deriving PCCRC rates were applied to the linked routine health data for this population to investigate the effect on the rate. A new method, based on the year of the colonoscopy rather than colorectal cancer diagnosis, was then used to calculate PCCRC rates.

RESULTS

Of 297,956 individuals diagnosed with colorectal cancer, a total of 94,648 underwent a colonoscopy in the 3 years prior to their diagnosis. The application of the published methods and exclusion criteria to the dataset produced significantly different PCCRC rates from 2.5% to 7.7%. The new method demonstrates that PCCRC rates within 3 years of colonoscopy (without exclusions) decreased in the English NHS over 8 years, falling from 10.6% to 7.3% for colonoscopies performed in 2001 and 2007 respectively.

CONCLUSIONS

The method used to determine PCCRC rates significantly affects findings with potential to substantially underestimate rates. To enable international benchmarking there needs to be a standardised method for defining PCCRC. This study proposes a new methodology using colonoscopy as a denominator and between 2001 and 2007 this method indicated an 8.6% PCCRC rate across the English NHS. It also demonstrated PCCRC rates have fallen over time.

Administrative Database Research Overestimates the Rate of Interval Colon Cancer

GOALS

Our study reexamines the prevalence of interval colorectal cancer (I-CRC) by manually reviewing CRC cases at a single institution.

BACKGROUND

In 2% to 8% of patients with CRC, diagnosis occurs during the interval 6 to 36 months after a cancer-free colonoscopy. Rates are often determined by linking the date of colonoscopy with cancer registry information.

STUDY

We examined all colonoscopies from 1993 to 2011. These examinations were linked with Pennsylvania Cancer Registry data. Matched charts were manually reviewed. We determined whether the CRC was "prevalent" or, for patients with a previous colonoscopy, whether they were interval or noninterval based on time from last colonoscopy. For interval cases, we identified "administrative errors" that could falsely increase the number of reported I-CRC.

RESULTS

Over the study period, 43,661 colonoscopies were performed, with 1147 (2.6%) positive for CRC after excluding cases (n=52) in which patients had IBD, previous surgery, or nonadenocarcinoma malignancy. Prevalent CRCs totaled 1062 (92.6%). Noninterval CRCs (diagnosed over 36 mo from index colonoscopy) were present in 40 (3.5%). There remained 45 (3.9%) potential I-CRC cases. However, after manual review, 21 cases were found to be administrative errors. Therefore, the accurate proportion of colonoscopies that found an I-CRC was 2.1% (95% confidence interval, 1.5%-3.2%).

CONCLUSIONS

The prevalence of I-CRC at our institution before adjustment was comparable with previously reported rates. This proportion was 47% lower after adjusting for administrative errors placing our figure at the lower end of reported I-CRC incidence. Reported rates of I-CRC may be falsely elevated due to errors unique to merging administrative databases.

Positive correlation between endoscopist radiofrequency ablation volume and response rates in Barrett's esophagus

BACKGROUND

Radiofrequency ablation (RFA) has become an accepted form of endoscopic treatment for Barrett's esophagus (BE), yet reported response rates are variable. There are no accepted quality measures for performing RFA, and provider-level characteristics may influence RFA outcomes.

OBJECTIVE

To determine whether endoscopist RFA volume is associated with rates of complete remission of intestinal metaplasia (CRIM) after RFA in patients with BE.

DESIGN

Retrospective analysis of longitudinal data.

SETTING

Three tertiary-care medical centers.

PATIENTS

Patients with BE treated with RFA.

INTERVENTION RFA MAIN OUTCOME MEASUREMENTS

For each endoscopist, we recorded RFA volume, defined as the number of unique patients treated as well as corresponding CRIM rates. We calculated a Spearman correlation coefficient relating these 2 measures.

RESULTS

We identified 417 patients with BE treated with RFA who had at least 1 post-RFA endoscopy with biopsies. A total of 73% of the cases had pretreatment histology of high-grade dysplasia or adenocarcinoma. The procedures were performed by 7 endoscopists, who had a median RFA volume of 62 patients (range 20-188). The overall CRIM rate was 75.3% (provider range 62%-88%). The correlation between endoscopist RFA volume and CRIM rate was strong and significant (rho = 0.85; P = .014). In multivariable analysis, higher RFA volume was significantly associated with CRIM (P for trend .04).

LIMITATIONS

Referral setting may limit generalizability. Limited number of endoscopists analyzed.

CONCLUSION

Endoscopist RFA volume correlates with rates of successful BE eradication. Further studies are required to confirm these findings and to determine whether RFA volume is a valid predictor of treatment outcomes in BE.

Tests and investigations for colorectal cancer screening

Worldwide, colorectal (CRC) is the third most common form of cancer, after lung and breast cancer, and the fourth most common cause of cancer death, although in developed countries CRC incidence is higher and it accounts for an even higher proportion of cancer deaths. Successful treatment of early-stage CRC confers substantial survival advantage, and there is now overwhelming evidence that screening average-risk individuals for CRC reduces the incidence and disease-specific mortality. In spite of considerable research for new biomarkers for CRC, the detection of blood in faeces remains the most effective screening tool. The best evidence to date for population-based CRC screening comes from randomised-controlled trials that used a guaiac-based faecal occult blood test (gFOBt) as the first-line screening modality, whereby test-positive individuals are referred for follow-up investigations, usually colonoscopy. A major innovation in the last ten years or so has been the development of other more analytically sensitive and specific screening techniques for blood in faeces. The faecal immunochemical test for haemoglobin (FIT) confers substantial benefits over gFOBt in terms of analytical sensitivity, specificity and practicality and FIT are now recommended for CRC screening by the European guidelines for quality assurance in colorectal cancer screening and diagnosis. The challenge internationally is to develop high quality CRC screening programmes for which uptake is high. This is especially important for developing countries witnessing an increase in the incidence of CRC as populations adopt more westernised lifestyles. This review describes the tests available for CRC screening and how they are being used worldwide. The reader will gain an understanding of developments in CRC screening and issues that arise in choosing the most appropriate screening test (or tests) for organised population-based screening internationally and optimising the performance of the chosen test (or tests). Whilst a wide range of literature has been cited, this is not a systematic review. The authors provide FOBT CRC screening for a population of 14.6 million in the south of England and the senior author (SPH) was the lead author of the European guidelines for quality assurance in colorectal cancer screening and diagnosis and leads the World Endoscopy Organization Colorectal Cancer Committee's Expert Working Group on 'FIT for Screening'.

Development of polyps and cancer in patients with a negative colonoscopy: a follow-up study of more than 20 years

Background. Adenomas are missed during colonoscopy. Aim. Assess the occurrence of colorectal cancer (CRC) and polyps in patients with a negative index colonoscopy (IC). Patients and Methods. All patients with a IC in 1992–1994, aged 40 and 60 years, were included. Exclusion criterion was presence of abnormalities, a family history, or surveillance. At the end of 2013 all records were studied in order to gather follow-up information. Results. 394 patients were included in four groups: group 1 patients who died, group 2 patients who were not in the hospital systems anymore, group 3 patients still visiting the hospital but not the department of gastroenterology, and group 4 patients undergoing new colonoscopies. In group 1, 2 patients died of CRC and 4 developed a polyp. No data were available from the patients in group 2. Patients in group 3 visited the outpatient clinics but did not undergo new colonoscopy. Patients in group 4 underwent additional colonoscopies. The yield was 35 patients polyps and three CRCs. Five patients (1.3%) developed CRC, and 39 (9%) developed a polyp. Conclusion. Given these results the number of potentially missed adenomas in IC is very low and the consequences of missed adenomas are highly exaggerated.

Potentially inappropriate screening colonoscopy in Medicare patients: variation by physician and geographic region

IMPORTANCE

Inappropriate use of colonoscopy involves unnecessary risk for older patients and consumes resources that could be used more effectively.

OBJECTIVES

To determine the frequency of potentially inappropriate colonoscopy in Medicare beneficiaries in Texas and to examine variation among physicians and across geographic regions.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used 100% Medicare claims data for Texas and a 5% sample from the United States from 2000 through 2009. We identified Medicare beneficiaries aged 70 years or older who underwent a colonoscopy from October 1, 2008, through September 30, 2009.

MAIN OUTCOME MEASURES

Colonoscopies were classified as screening in the absence of a diagnosis suggesting an indication for the procedure. Screening colonoscopy was considered potentially inappropriate on the basis of patient age or occurrence too soon after colonoscopy with negative findings. The percentage of patients undergoing potentially inappropriate screening colonoscopy was estimated for each colonoscopist and hospital service area.

RESULTS

A large percentage of colonoscopies performed in older adults were potentially inappropriate: 23.4% for the overall Texas cohort and 9.9%, 38.8%, and 24.9%, respectively, in patients aged 70 to 75, 76 to 85, or 86 years or older. There was considerable variation across the 797 colonoscopists in the percentages of colonoscopies performed that were potentially inappropriate. In a multilevel model including patient sex, race or ethnicity, number of comorbid conditions, educational level, and urban or rural residence, 73 colonoscopists had percentages significantly above the mean (23.9%), ranging from 28.7% to 45.5%, and 119 had percentages significantly below the mean (23.9%), ranging from 6.7% to 18.6%. The colonoscopists with percentages significantly above the mean were more likely to be surgeons, graduates of US medical schools, medical school graduates before 1990, and higher-volume colonoscopists than those with percentages significantly below the mean. Colonoscopist rankings were fairly stable over time (2006-2007 vs 2008-2009). There was also geographic variation across Texas and the United States, with percentages ranging from 13.3% to 34.9% in Texas and from 19.5% to 30.5% across the United States.

CONCLUSIONS AND RELEVANCE

Many colonoscopies performed in older adults may be inappropriate. The likelihood of undergoing potentially inappropriate colonoscopy depends in part on where patients live and what physician they see.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPACT

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