Incidence and recurrence rates of colorectal adenomas: a prospective study

Effects of Chinese herbal medicine on colorectal adenoma recurrence following polypectomy: a systematic review and meta-analysis

Objective

Preventing colorectal adenoma (CRA) recurrence after polypectomy is essential. However, the current evidence of Chinese herbal medicine (CHM) for CRA recurrence is still limited. This study aims to synthesize the effects of CHM as a prevention method for CRA recurrence.

Methods

Nine databases were searched up to May 2024. Randomised controlled trials identifying the preventive effects of CHM among people with CRA post-polypectomy were included. spreadsheets were used to collect and extract data. RevMan and STATA were used for data analysis. We performed subgroup and sensitivity analyses to explore potentially influencing variables.

Results

Twenty trials (2,325 participants) were included. The commonly used botanical drugs belonged to the categories of strengthening the spleen and anti-tumour metabolites. Compared to routine care (RC) alone, oral CHM plus RC significantly reduced the CRA recurrence rate at 12 months (RR 0.51, 95% CI [0.39, 0.67], I2 = 42%), 6 months (RR 0.44, 95% CI [0.36, 0.55], I2 = 0%), and 3 months (RR 0.46, 95% CI [0.22, 0.96], I2 = 0%) post-polypectomy. Compared to CHM placebo plus RC, San zi granule combined with RC significantly reduced CRA recurrence at 12 months post-polypectomy (RR 0.39, 95% CI [0.16, 0.93], I2 = 0%) and during the 2-year follow-up (RR 0.73, 95% CI [0.58, 0.90]). There were no significant differences between groups for treatment duration and syndromes. Additional analysis showed that oral CHM containing the botanical drugs of Si jun zi decoction plus RC reduced CRA recurrence at 12 months post-polypectomy with a low heterogeneity, compared to RC alone (RR 0.26, 95% CI [0.13, 0.54], I2 = 0%). Adverse events were similar in the above two comparisons.

Conclusion

Oral CHM combined with RC may reduce CRA recurrence and be well-tolerated. San zi granule and Si jun zi decoction may be representative prescriptions Experimental studies of the frequent botanical drugs have found anti-cancer effects that may account for the clinical findings. Future rigorous clinical trials are needed due to low-to-moderate certainty of evidence.

Systematic Review Registration

PROSPERO (CRD42023324197), https://www.crd.york.ac.uk/PROSPERO/view/CRD42023324197.

Derivation and validation of a nomogram incorporating modifiable lifestyle factors to predict development of colorectal adenomas after negative index colonoscopy

This retrospective cohort study aimed to identify baseline patient characteristics involving modifiable lifestyle factors that are associated with the development of colorectal adenomas, and establish and validate a nomogram for risk predictions among high-risk populations with negative index colonoscopy. A total of 83,076 participants who underwent an index colonoscopy at the Tianjin Union Medical Center between 2004 and 2019 were collected. According to meticulous inclusion and exclusion criteria, 249 subjects were enrolled and categorized into the primary and validation cohorts. Based on the primary cohort, we utilized the LASSO-Cox regression and the univariate/multivariate Cox proportional hazards (Cox-PH) regression parallelly to select variables, and incorporated selected variables into two nomogram models established using the multivariate Cox-PH regression. Comparison of the Akaike information criterion and the area under the receiver operating characteristic curve of the two models demonstrated that the nomogram model constituted by four covariates retained by the LASSO-Cox regression, including baseline age, body mass index, physical activity and family history of colorectal cancer (CRC) in first-degree relatives, performed better at predicting adenoma-free survival probabilities. Further validation including the concordance index, calibration plots, decision curve analysis and Kaplan-Meier survival curves also revealed good predictive accuracy, discriminating ability, clinical utility and risk stratification capacity of the nomogram model. Our nomogram will assist high-risk individuals with negative index colonoscopy to prevent colorectal adenoma occurrence and CRC morbidity with improved cost-effectiveness.

Association of the triglyceride-glucose index with the occurrence and recurrence of colorectal adenomas: a retrospective study from China

BACKGROUND

Resection of colorectal adenoma (CRA) prevents colorectal cancer; however, recurrence is common. We aimed to assess the association of the triglyceride-glucose (TyG) index with CRA occurrence and recurrence.

METHODS

Data from 3392 participants at a hospital in China from 2020 to 2022 were analyzed. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). A restricted cubic spline was used to fit TyG index dose‒response curves to recurrent adenomas. The discriminatory power of TyG index for predicting later recurrence was assessed with the area under the receiver operating characteristic (ROC) curve in 170 patients with a TyG index at initial adenoma diagnosis.

RESULTS

One thousand five hundred ninety-six adenoma and 1465 normal participants were included in the occurrence analysis, and 179 recurrent and 152 nonrecurrent participants were included in the recurrence analysis. The TyG mutation was an independent risk factor for CRA occurrence and recurrence. After adjusting for confounders, the risk of adenoma in the participants in Q2, Q3, and Q4 groups of TyG was 1.324 (95% CI 1.020-1.718), 1.349 (95% CI 1.030-1.765), and 1.445 (95% CI 1.055-1.980) times higher than that of the Q1, respectively, and the risk of recurrence in the Q3 and Q4 groups was 2.267 (95% CI 1.096-4.691) and 2.824 (95% CI 1.199-6.648) times in Q1 group. Multiple logistic regression showed that the highest quartile of the TyG index was associated with a greater risk of advanced adenoma recurrence (OR 4.456, 95% CI 1.157-17.164), two or more adenomas (OR 5.079, 95% CI 1.136-22.714 [after removal of TyG index extreme values]), and proximal colon or both adenomas (OR 3.043, 95% CI 1.186-7.810). Subgroup analysis revealed that the association was found to be present only in participants of all age groups who were either male or without obesity, hyperglycemia, hypertension, or dyslipidemia (p < 0.05). ROC curves illustrated that the TyG index had good predictive efficacy for identifying recurrence, especially for patients with two or more adenomas (AUC 0.777, 95% CI 0.648-0.907).

CONCLUSIONS

An increase in the TyG index is associated with an increased risk of adenoma occurrence and recurrence, with a stronger association with the latter.

Metachronous Colorectal Adenomas Occur Close to the Index Lesion

GOALS

The aim of this study is to assess the spatial relationship between index and metachronous colorectal adenoma location.

BACKGROUND

After the complete excision of a human sporadic colorectal adenoma, patients are at elevated risk of developing a further metachronous adenoma. Data regarding the occurrence site of a metachronous colorectal adenoma relative to the index adenoma are scarce.

STUDY

Prospectively maintained databases were interrogated to identify all colonoscopies and adenoma excisions performed over a 10-year period at a single university teaching hospital. Data for the colonic segments at which adenoma removal were reported at index and all subsequent colonoscopies were extracted and 2 allied data sets merged.

RESULTS

A total of 15,121 colonoscopies and 4759 polyp events were recorded. Four hundred fifty-two patients [296 male, 156 female, median (range) age 75 (32 to 100) y] developed at least 1 metachronous adenoma at follow-up colonoscopy. When single index events only are considered (ie, synchronous adenoma cases excluded), over 61% of metachronous adenomas were recorded in the same or an adjacent colonic segment. When the full span of the colon is considered, metachronous adenomas were more likely to occur in a section of the colon proximal to that of the index adenoma (41%±5%) than the same (39%±5%) or distal segment (20%±5%; P =0.006; 1-way χ 2 test).

CONCLUSIONS

A metachronous human sporadic colorectal adenoma is more likely to be found in the same colonic segment to that of the index adenoma or 1 immediately adjacent. These data suggest a shared origin of metachronous adenoma with preceding lesions, supporting the existence of precancerous fields.

Cancer-Associated Mutations in Normal Colorectal Mucosa Adjacent to Sporadic Neoplasia

INTRODUCTION:

Colorectal cancer arises in a multistep process of carcinogenesis from normal mucosa. The earliest precursor might be a morphologically inconspicuous precancerous field, harboring cancer-associated mutations.

METHODS:

We systematically analyzed genetic alterations in 77 tissue samples from 30 patients with sporadic colorectal neoplasms (18 large adenomas and 12 adenocarcinomas) and matched adjacent normal mucosa (N = 30), as well as normal rectal tissue (N = 17). We profiled mutations associated with colorectal cancer by targeted sequencing of 46 genetic loci using 157 custom amplicons and a median depth of 42,655 reads per loci.

RESULTS:

Multiple mutations were found in colorectal neoplasms, most frequently in APC, KRAS, and TP53. In a subgroup of 11 of 30 patients, alterations were also detected in non-neoplastic mucosa. These mutations were divergent from those in matched neoplasms. The total alteration count and the allele frequency of mutations were higher in neoplasms compared with those in adjacent tissues. We found that younger patients (≤70 years) are less likely affected by mutations in non-neoplastic mucosa than older patients (>70 years, P = 0.013), although no association was found for other variables, including type, location and differentiation of neoplasia, and previous history of polyps.

DISCUSSION:

Our data show that cancer-associated mutations can be found in non-neoplastic tissues in a subgroup of patients with colorectal neoplasms. Further studies are needed to specify the risk of occurrence and recurrence of neoplasia in this patient population.

Outcomes at follow-up of negative colonoscopy in average risk population: systematic review and meta-analysis

OBJECTIVE

To review and summarise the evidence on the prevalence of colorectal adenomas and cancers at a follow-up screening colonoscopy after negative index colonoscopy, stratified by interval between examinations and by sex.

DESIGN

Systematic review and meta-analysis of all available studies.

DATA SOURCES

PubMed, Web of Science, and Embase. Two investigators independently extracted characteristics and results of identified studies and performed standardised quality ratings.

ELIGIBILITY CRITERIA

Studies assessing the outcome of a follow-up colonoscopy among participants at average risk for colorectal cancer with a negative previous colonoscopy (no adenomas).

RESULTS

28 studies were identified, including 22 cohort studies, five cross sectional studies, and one case-control study. Findings for an interval between colonoscopies of one to five, five to 10, and more than 10 years were reported by 17, 16, and three studies, respectively. Summary estimates of prevalences of any neoplasm were 20.7% (95% confidence interval 15.8% to 25.5%), 23.0% (18.0% to 28.0%), and 21.9% (14.9% to 29.0%) for one to five, five to 10, and more than 10 years between colonoscopies. Corresponding summary estimates of prevalences of any advanced neoplasm were 2.8% (2.0% to 3.7%), 3.2% (2.2% to 4.1%), and 7.0% (5.3% to 8.7%). Seven studies also reported findings stratified by sex. Summary estimates stratified by interval and sex were consistently higher for men than for women.

CONCLUSIONS

Although detection of any neoplasms was observed in more than 20% of participants within five years of a negative screening colonoscopy, detection of advanced neoplasms within 10 years was rare. Our findings suggest that 10 year intervals for colonoscopy screening after a negative colonoscopy, as currently recommended, may be adequate, but more studies are needed to strengthen the empirical basis for pertinent recommendations and to investigate even longer intervals.

STUDY REGISTRATION

Prospero CRD42019127842.

Colorectal Cancer Outcomes in a Large Negative Computed Tomography Colonography Screening Cohort

Introduction

At our institution, the most common cohort of individuals having computed tomography colonography (CTC) are those that require primary screening for colorectal cancer and were unable to tolerate or failed optical colonoscopy (OC). CTC is an efficient method for detecting polyps, masses, flat-lesions, and overt colorectal cancer, serving as a viable alternative to colonoscopy. This study follows patients with negative CTC results to evaluate the number of clinically significant lesions that may have been potentially missed by CTC. We suspect this number will be exceedingly low given the high sensitivity of this technique.

Methods

All patients with negative CTC screening (n = 509) in the Eastern Health Medical Health Region, located in Newfoundland and Labrador, Canada were included. An electronic medical record review was undertaken, encompassing provider, colonoscopy, imaging, and histopathology reports. Subjects were also checked through the Newfoundland Cancer Clinic Registry Database. All incidents of colorectal cancer were recorded.

Results

The study cohort comprised 509 subjects. These subjects were followed for an average of 7.88 years. Two colorectal adenocarcinomas in this cohort were identified representing a crude cancer incidence rate of 0.49 cancers per 1000 patient years, and a rate of 0.39% following a normal CTC.

Conclusions

Colorectal cancer presenting clinically is rare in the 7.88 years following a negative CTC, suggesting CTC is equally effective for colorectal screening compared to OC. Furthermore, current guidelines that recommend interval CTC screening every 5 years is conservative, and interval screening can likely be recommended over a longer time frame.

Can surveillance colonoscopy be discontinued in an elderly population with diminutive polyps?

OBJECTIVES

Surveillance colonoscopy after endoscopic resection (ER) for adenomatous polyps reduces the incidence and mortality of colorectal cancer (CRC). However, its significance in the elderly population is uncertain. The study aimed to determine whether surveillance colonoscopy should be discontinued in the elderly population.

METHODS

We enrolled 105 patients who underwent baseline colonoscopy between January 2004 and December 2009 and were subsequently followed-up over 5 years in our institution. All had diminutive colorectal polyps and were aged <80 years at baseline colonoscopy and ≥80 years at follow-up in May 2018. Patients who had undergone colectomy or who had inflammatory bowel disease, familial adenomatous polyposis, Lynch syndrome, and no diminutive polyps were excluded. The cumulative incidence of the target lesion was evaluated. Histopathological diagnoses included low-grade dysplasia (LGD), high-grade dysplasia (HGD), and carcinoma.

RESULTS

The target lesion was detected in 15% (16/105) of the patients. There was no invasive carcinoma; however, two HGDs were detected. There were three lesions that had increased from previously detected diminutive lesions, all of which were LGDs. There were no target lesions detected after 84 years of age, and the cumulative incidence was 0.20. The cumulative incidence was significantly higher in the group with HGD than in the group with no target lesions at baseline colonoscopy. There was no HGD after age 79 years, and the cumulative incidence was 0.019.

CONCLUSION

Surveillance colonoscopy for patients with diminutive polyps may be discontinued after age 79 years.

Single-cell genetic analysis of clonal dynamics in colorectal adenomas indicates CDX2 gain as a predictor of recurrence

Colorectal adenomas are common precancerous lesions with the potential for malignant transformation to colorectal adenocarcinoma. Endoscopic polypectomy provides an opportunity for cancer prevention; however, recurrence rates are high. We collected formalin-fixed paraffin-embedded tissue of 15 primary adenomas with recurrence, 15 adenomas without recurrence, and 14 matched pair samples (primary adenoma and the corresponding recurrent adenoma). The samples were analysed by array-comparative genomic hybridisation (aCGH) and single-cell multiplex interphase fluorescence in situ hybridisation (miFISH) to understand clonal evolution, to examine the dynamics of copy number alterations (CNAs) and to identify molecular markers for recurrence prediction. The miFISH probe panel consisted of 14 colorectal carcinogenesis-relevant genes (COX2, PIK3CA, APC, CLIC1, EGFR, MYC, CCND1, CDX2, CDH1, TP53, HER2, SMAD7, SMAD4 and ZNF217), and a centromere probe (CEP10). The aCGH analysis confirmed the genetic landscape typical for colorectal tumorigenesis, that is, CNAs of chromosomes 7, 13q, 18 and 20q. Focal aberrations (≤10 Mbp) were mapped to chromosome bands 6p22.1-p21.33 (33.3%), 7q22.1 (31.4%) and 16q21 (29.4%). MiFISH detected gains of EGFR (23.6%), CDX2 (21.8%) and ZNF217 (18.2%). Most adenomas exhibited a major clone population which was accompanied by multiple smaller clone populations. Gains of CDX2 were exclusively seen in primary adenomas with recurrence (25%) compared to primary adenomas without recurrence (0%). Generation of phylogenetic trees for matched pair samples revealed four distinct patterns of clonal dynamics. In conclusion, adenoma development and recurrence are complex genetic processes driven by multiple CNAs whose evaluations by miFISH, with emphasis on CDX2, might serve as a predictor of recurrence.

Effects of calcium on the incidence of recurrent colorectal adenomas: A systematic review with meta-analysis and trial sequential analysis of randomized controlled trials

BACKGROUND

Protective effects of calcium supplementation against colorectal adenomas have been documented in systematic reviews; however, the results have not been conclusive. Our objective was to update and systematically evaluate the evidence for calcium supplementation taking into consideration the risks of systematic and random error and to GRADE the evidence.

METHODS

The study comprised a systematic review with meta-analysis and trial sequential analysis (TSA) of randomized controlled trials (RCTs). We searched for RCTs published up until September 2016. Retrieved trials were evaluated using risk of bias. Primary outcome measures were the incidences of any recurrent adenomas and of advanced adenomas. Meta-analytic estimates were calculated with the random-effects model and random errors were evaluated with trial sequential analyses (TSAs).

RESULTS

Five randomized trials (2234 patients with a history of adenomas) were included. Two of the 5 trials showed either unclear or high risks of bias in most criteria. Meta-analysis of good quality RCTs suggest a moderate protective effect of calcium supplementation on recurrence of adenomas (relative risk [RR], 0.88 [95% CI 0.79-0.99]); however, its effects on advanced adenomas did not show statistical significance (RR, 1.02 [95% CI 0.67-1.55]). Subgroup analyses demonstrated a greater protective effect on recurrence of adenomas with elemental calcium dose ≥1600 mg/day (RR, 0.74 [95% CI 0.56-0.97]) compared to ≤1200 mg/day (RR, 0.84 [95% CI 0.73-0.97]). No major serious adverse events were associated with the use of calcium, but there was an increase in the incidence of hypercalcemia (P = .0095). TSA indicated a lack of firm evidence for a beneficial effect. Concerns with directness and imprecision rated down the quality of the evidence to "low."

CONCLUSION

The available good quality RCTs suggests a possible beneficial effect of calcium supplementation on the recurrence of adenomas; however, TSA indicated that the accumulated evidence is still inconclusive. Using GRADE-methodology, we conclude that the quality of evidence is low. Large well-designed randomized trials with low risk of bias are needed.

The clinical effectiveness of different surveillance strategies to prevent colorectal cancer in people with intermediate-grade colorectal adenomas: a retrospective cohort analysis, and psychological and economic evaluations

BACKGROUND

The UK guideline recommends 3-yearly surveillance for patients with intermediate-risk (IR) adenomas. No study has examined whether or not this group has heterogeneity in surveillance needs.

OBJECTIVES

To examine the effect of surveillance on colorectal cancer (CRC) incidence; assess heterogeneity in risk; and identify the optimum frequency of surveillance, the psychological impact of surveillance, and the cost-effectiveness of alternative follow-up strategies.

DESIGN

Retrospective multicentre cohort study.

SETTING

Routine endoscopy and pathology data from 17 UK hospitals (n = 11,944), and a screening data set comprising three pooled cohorts (n = 2352), followed up using cancer registries.

SUBJECTS

Patients with IR adenoma(s) (three or four small adenomas or one or two large adenomas).

PRIMARY OUTCOMES

Advanced adenoma (AA) and CRC detected at follow-up visits, and CRC incidence after baseline and first follow-up.

METHODS

The effects of surveillance on long-term CRC incidence and of interval length on findings at follow-up were examined using proportional hazards and logistic regression, adjusting for patient, procedural and polyp characteristics. Lower-intermediate-risk (LIR) subgroups and higher-intermediate-risk (HIR) subgroups were defined, based on predictors of CRC risk. A model-based cost-utility analysis compared 13 surveillance strategies. Between-group analyses of variance were used to test for differences in bowel cancer worry between screening outcome groups (n = 35,700). A limitation of using routine hospital data is the potential for missed examinations and underestimation of the effect of interval and surveillance.

RESULTS

In the hospital data set, 168 CRCs occurred during 81,442 person-years (pys) of follow-up [206 per 100,000 pys, 95% confidence interval (CI) 177 to 240 pys]. One surveillance significantly lowered CRC incidence, both overall [hazard ratio (HR) 0.51, 95% CI 0.34 to 0.77] and in the HIR subgroup (n = 9265; HR 0.50, 95% CI 0.34 to 0.76). In the LIR subgroup (n = 2679) the benefit of surveillance was less clear (HR 0.62, 95% CI 0.16 to 2.43). Additional surveillance lowered CRC risk in the HIR subgroup by a further 15% (HR 0.36, 95% CI 0.20 to 0.62). The odds of detecting AA and CRC at first follow-up (FUV1) increased by 18% [odds ratio (OR) 1.18, 95% CI 1.12 to 1.24] and 32% (OR 1.32, 95% CI 1.20 to 1.46) per year increase in interval, respectively, and the odds of advanced neoplasia at second follow-up increased by 22% (OR 1.22, 95% CI 1.09 to 1.36), after adjustment. Detection rates of AA and CRC remained below 10% and 1%, respectively, with intervals to 3 years. In the screening data set, 32 CRCs occurred during 25,745 pys of follow-up (124 per 100,000 pys, 95% CI 88 to 176 pys). One follow-up conferred a significant 73% reduction in CRC incidence (HR 0.27, 95% CI 0.10 to 0.71). Owing to the small number of end points in this data set, no other outcome was significant. Although post-screening bowel cancer worry was higher in people who were offered surveillance, worry was due to polyp detection rather than surveillance. The economic evaluation, using data from the hospital data set, suggested that 3-yearly colonoscopic surveillance without an age cut-off would produce the greatest health gain.

CONCLUSIONS

A single surveillance benefited all IR patients by lowering their CRC risk. We identified a higher-risk subgroup that benefited from further surveillance, and a lower-risk subgroup that may require only one follow-up. A surveillance interval of 3 years seems suitable for most IR patients. These findings should be validated in other studies to confirm whether or not one surveillance visit provides adequate protection for the lower-risk subgroup of intermediate-risk patients.

STUDY REGISTRATION

Current Controlled Trials ISRCTN15213649.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Dietary Inflammatory Index and Risk of Colorectal Adenoma Recurrence: A Pooled Analysis

No studies have evaluated the association between the dietary inflammatory index (DII) and colorectal adenoma recurrence. DII scores were calculated from a baseline food frequency questionnaire. Participants (n = 1727) were 40-80 years of age, enrolled in two Phase III clinical trials, who had ≥1 colorectal adenoma(s) removed within 6 months of study registration, and a follow-up colonoscopy during the trial. Multiple logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs). No statistically significant associations were found between DII and odds of colorectal adenoma recurrence [ORs (95% CIs) = 0.93 (0.73, 1.18) and 0.95 (0.73, 1.22)] for subjects in the second and third DII tertiles, respectively, compared to those in the lowest tertile (Ptrend = 0.72). No associations were found for recurrent colorectal adenoma characteristics, including advanced recurrent adenomas, large size, villous histology, or anatomic location. While our study did not support an association between a proinflammatory diet and colorectal adenoma recurrence, future studies are warranted to elucidate the role of a proinflammatory diet on the early stages of colorectal carcinogenesis.

A Review of Outcomes for Colorectal Adenomas

OBJECTIVES

Using data from former reports, this study reviews and analyzes the outcomes of tumor recurrence, tumor progression, and tumor-specific survival of patients with colorectal adenomas.

METHODS

Data were collected from 32 longitudinal studies of outcomes after the first diagnosis of colorectal adenoma and collected as individual patient results, that is, as failure times from the first tumor to the three outcomes. Altogether, there were 45,286 patients, including 22,148 for the outcome of additional adenomas, 23,796 for the outcome of progression to invasive carcinoma, and 2,602 for the outcome of disease-specific survival (some patients were available for more than one outcome).

RESULTS

In these data, the mean time to additional adenomas was 6 years, the mean time to invasive carcinoma was 15.9 years, and the mean tumor-specific survival time was 21.9 years.

CONCLUSIONS

Although greater than 50% of those with colorectal adenomas will have additional adenomas, few progress to invasive tumor or die of colorectal cancer.

Frequency of colonic adenomatous polyps in a tertiary hospital in Mumbai

INTRODUCTION

Incidence of colorectal carcinoma is increasing all over world. There is limited data on colorectal polyps from India. We evaluated the histomorphological features of colorectal polyps and determined risk stratification in adenomatous polyps.

METHODS

In 4970 consecutive colonoscopies, colorectal polyps were detected in 515 cases (10.3 %). Polyps were classified using standard histological criteria. Each polyp was evaluated for presence of dysplasia. Adenomatous polyps were classified as low-risk adenomas (1-2 tubular adenomas <10 mm) and high-risk adenomas characterized by villous histology, high-grade dysplasia, size ≥10 mm, or ≥3 adenomas.

RESULTS

Of 515 colorectal polyps, 270 (52.4 %) were adenomatous, followed by 78 (15.1 %) inflammatory, 78 (15.1 %) hyperplastic, 32 (6.2 %) hamartomatous polyps, 25 (4.8 %) benign epithelial polyps, 5 (0.9 %) cap polyps, 5 (0.9 %) lipomatous polyps, 3 (0.5 %) angiomatous polyps, 4 (0.7 %) lymphoid, and 15 (2.9 %) cases with adenocarcinoma masquerading as polyps. Mean (SD) age with colorectal polyps was 54.8 (33.0) years while for adenomatous polyps, 59.5 (14.8) years with male to female ratio of 2:1. Majority of adenomatous polyps 124 (45.9 %) were tubular adenomas present in rectosigmoid. High-grade dysplasia was found in 38 (14 %) adenomas. One hundred and fifty-five (57.4 %) were high risk of which majority were villous adenomas and nine (7.2 %) tubular adenomas.

CONCLUSION

The most common colorectal polyps found during routine colonoscopy were 270 adenomatous (52.4 %) cases. Of these, 155 (57.4 %) adenomatous polyps were high-risk category. Population prevalence data of colonic polyps in general population beyond the age of 50 years needs to be obtained.

Calcium supplementation for the prevention of colorectal adenomas: A systematic review and meta-analysis of randomized controlled trials

AIM: To determine the efficacy of calcium supplementation in reducing the recurrence of colorectal adenomas.

METHODS: We conducted a systematic review and meta-analysis of published studies. We searched PubMed, Scopus, the Cochrane Library, the WHO International Clinical Trials Registry Platform, and the ClinicalTrials.gov website, through December 2015. Randomized, placebo-controlled trials assessing supplemental calcium intake for the prevention of recurrence of adenomas were eligible for inclusion. Two reviewers independently selected studies based on predefined criteria, extracted data and outcomes (recurrence of colorectal adenomas, and advanced or “high-risk” adenomas), and rated each trial’s risk-of-bias. Between-study heterogeneity was assessed, and pooled risk ratio (RR) estimates with their 95% confidence intervals (95%CI) were calculated using fixed- and random-effects models. To express the treatment effect in clinical terms, we calculated the number needed to treat (NNT) to prevent one adenoma recurrence. We also assessed the quality of evidence using GRADE.

RESULTS: Four randomized, placebo-controlled trials met the eligibility criteria and were included. Daily doses of elemental calcium ranged from 1200 to 2000 mg, while the duration of treatment and follow-up of participants ranged from 36 to 60 mo. Synthesis of intention-to-treat data, for participants who had undergone follow-up colonoscopies, indicated a modest protective effect of calcium in prevention of adenomas (fixed-effects, RR = 0.89, 95%CI: 0.82-0.96; random-effects, RR = 0.87, 95%CI: 0.77-0.98; high quality of evidence). The NNT was 20 (95%CI: 12-61) to prevent one colorectal adenoma recurrence within a period of 3 to 5 years. On the other hand, the association between calcium treatment and advanced adenomas did not reach statistical significance (fixed-effects, RR = 0.92, 95%CI: 0.75-1.13; random-effects, RR = 0.92, 95%CI: 0.71-1.18; moderate quality of evidence).

CONCLUSION: Our results suggest a modest chemopreventive effect of calcium supplements against recurrent colorectal adenomas over a period of 36 to 60 mo. Further research is warranted.

Surveillance colonoscopy in low-risk postpolypectomy patients: Is it necessary?

AIM

Patients who have had colorectal adenomas removed are at increased risk of developing colorectal cancer in the future. We sought to determine whether surveillance colonoscopy at 5 years in low-risk postpolypectomy patients is necessary and effective.

METHOD

UK multicentre retrospective study. Patients diagnosed with 'low-risk' colorectal adenomas between April 2004 and April 2007 were identified and results of all subsequent lower gastrointestinal (GI) endoscopies were noted. Where no colonoscopy had been done at or after 5 years from the index investigation, patient details were cross-checked against hospital colorectal multidisciplinary team databases to ensure no colorectal cancer had been detected in the meantime.

RESULTS

641 patients were included. 131 patients (20.4%) had a 'per protocol' surveillance colonoscopy at 5 years. Of these, no patients were found to have colorectal cancer, 10 patients (7.6%) had advanced adenomas, 26 patients (19.8%) had non-advanced adenomas and 95 patients (72.5%) had no further adenomas. 510 patients (79.6%) did not have a surveillance colonoscopy at 5 years. Of these, 110 patients (17.2%) developed lower GI symptoms within 5 years of their index endoscopy and underwent a further lower GI endoscopy to investigate these symptoms. 3 colorectal cancers in 3 patients were found during these endoscopies and two further colorectal cancers were found at symptomatic colonoscopies at or after 5 years from index.

CONCLUSIONS

Patients with low-risk adenomas should be risk profiled. Those with risk factors, such as two adenomas, male sex and advanced adenomas at index procedure should be offered 5-year surveillance colonoscopy.

Calcium intake and colorectal adenoma risk: dose-response meta-analysis of prospective observational studies

Evidence from randomized controlled trials suggests that calcium may protect against recurrence of colorectal adenomas, which could lead to the subsequent prevention of cancer. Yet the trials used only a large single dose and were of small sizes, and thus, knowledge of the dose-response relationship and influence on high-risk adenomas is limited. To address these issues, we conducted linear and nonlinear dose-response meta-analyses primarily based on prospective observational studies published up to July 2014 identified from PubMed and Embase. Summary relative risks (RRs) and 95% confidence intervals (CIs) were calculated for total and supplemental calcium intake, respectively, using a random-effects model. For total calcium intake, summary RR for each 300 mg/day increase was 0.95 (95% CI = 0.92-0.98; I(2)  = 45%; eight studies with 11,005 cases; range of intake = 333-2,229 mg/day). Evidence of nonlinearity was indicated: approximately, compared to 550 mg/day of total calcium intake, the summary RR was 0.92 (95% CI = 0.89-0.94) at 1,000 mg/day and 0.87 (95% CI = 0.84-0.90) at 1,450 mg/day (pnonlinearity  < 0.01). Associations were stronger for high-risk adenomas (≥1 cm in diameter, (tubulo)villous histology, dysplasia, or multiplicity): approximately, compared to 550 mg/day of total calcium intake, the summary RR was 0.77 (95% CI = 0.74-0.81) at 1,000 mg/day and reduced to 0.69 (95% CI = 0.66-0.73) at 1,450 mg/da (pnonlinearity  < 0.01). For supplemental calcium intake, summary RR of total adenoma risk for each 300 mg/day increase was 0.96 (95% CI = 0.93-0.99; I(2)  = 0%; three studies with 4,548 cases; range of supplementation = 0-1,366 mg/day). In conclusion, calcium intake may continue to decrease the risk of adenomas, particularly high-risk adenomas, over a wide range of calcium intake.

Factors predictive of high-risk adenomas at the third colonoscopy after initial adenoma removal

Evaluating predictive factors for high-risk adenomas at the third colonoscopy based on two prior colonoscopies may help evaluate high-risk adenoma at the third colonoscopy. We analyzed clinical data of 131 patients at Severance Hospital from January 1997 to January 2011. All of them underwent two subsequent colonoscopies after removal of adenomas during an initial colonoscopy. Among 20 patients with high-risk adenoma at the first and second colonoscopies, 10 (50%) patients had high-risk adenoma at the third colonoscopy. Among the 67 patients who had high-risk adenoma only once at the first or second colonoscopy, 15 (22.4%) patients had high-risk adenoma at the third colonoscopy but among the 44 patients without high-risk adenoma at the first and second colonoscopies, only 1 (2.3%) patient had high-risk adenoma at the third colonoscopy (P < 0.001). A multivariate time dependent covariate Cox regression analysis confirmed that high-risk adenoma at the first and/or second colonoscopy (HR, 9.56; 95% CI, 2.37-38.54; P = 0.002) was independent predictor of high-risk adenoma at the third colonoscopy. Given these findings, data from two prior colonoscopies, not one prior examination, may help identify high-risk populations at the third colonoscopy who require careful colonoscopic surveillance.

Dietary lifestyle and colorectal cancer onset, recurrence, and survival: myth or reality?

BACKGROUND AND PURPOSE

Interest in the possibility that diet might help to reduce the risk of colorectal cancer dates back to 1970 based on both the large variation in rates of specific cancers in different countries and the impressive changes observed in the incidence of cancer in migrants from low- to high-risk areas. Here, we report the state of art of literature data about this topic.

METHODS

Three sections have been separately considered: chemoprevention of first tumor onset, chemoprevention of recurrence after surgery, and chemoprevention of polyp recurrence in the course of the follow-up of subjects with elevated risk. A particular attention has been pointed to dietary factors and survival, whose relevance is showing a growing interest.

RESULTS

The relationship between diet and colorectal cancer has been extensively studied about the onset, sometimes with controversial results. Its influence on recurrence and survival has been examined in only few studies.

CONCLUSIONS

Literature data are convincing for a protective role on the onset of preneoplastic and neoplastic lesions for some foods such as fibers, vitamin A and D, folic acid, calcium, antioxidants, and promising perspectives for some substances such as phyto-estrogens. Less evidence-based data are available on the possibility to avoid the recurrence of the disease or to affect its mortality with dietary habits. Future perspectives will be directed be not only to identify new dietary style able to prevent the onset of neoplastic lesion of the colon but also to realize an effective chemoprevention.

Dietary supplement use is not associated with recurrence of colorectal adenomas: a prospective cohort study

Diet and lifestyle influence colorectal adenoma recurrence. The role of dietary supplement use in colorectal adenoma recurrence remains controversial. In this prospective cohort study, we examined the association between dietary supplement use, total colorectal adenoma recurrence and advanced adenoma recurrence. Colorectal adenoma cases (n = 565) from a former case-control study, recruited between 1995 and 2002, were prospectively followed until 2008. Adenomas with a diameter of ≥1 cm and/or (tubulo)villous histology and/or with high grade dysplasia and/or ≥3 adenomas detected at the same colonic examination were considered advanced adenomas. Hazard ratios (HRs) and 95% confidence intervals (CIs) for dietary supplement users (use of any supplement during the past year) compared to nonusers and colorectal adenoma recurrence were calculated using stratified Cox proportional hazard models for counting processes and were adjusted for age, sex, educational level and number of colonoscopies during follow-up. Robust sandwich covariance estimation was used to adjust for the within subject correlation. A number of 165 out of 565 adenoma patients had at least one colorectal adenoma recurrence during a median person-time of 5.4 years and of these, 37 patients had at least one advanced adenoma. One-third of the total study population (n = 203) used a dietary supplement. Compared to no use, dietary supplement use was neither statistically significantly associated with total colorectal adenoma recurrence (HR = 1.03; 95% CI 0.79-1.34) nor with recurrent advanced adenomas (HR = 1.59; 95% CI 0.88-2.87). This prospective cohort study did not suggest an association between dietary supplement use and colorectal adenoma recurrence.

Awareness of surveillance recommendations among patients with colorectal adenomas

BACKGROUND & AIMS

The efficacy of colorectal cancer screening programs depends on the rate of attendance at surveillance colonoscopy examinations. Increasing patients' awareness about the importance of surveillance might improve attendance, but it is not clear how much they know about their follow-up recommendations. We assessed the awareness of patients with adenomas about their surveillance recommendations.

METHODS

Ten endoscopy departments provided access to their colonoscopy database for quality assurance; 2 datasets were obtained. We analyzed data from 4000 colonoscopies (400 per department) performed on patients with adenomas. All the patients were mailed a survey to determine how much information they had about their colonoscopy results and their follow-up recommendations. Data from 549 patients were included in the analysis. We also assessed surveillance attendance among 500 patients (50 per department) who had adenomas removed.

RESULTS

Of the patients analyzed, 85% recalled retrieval of polyps during their colonoscopy, and 85% recalled whether they needed surveillance or not. The indication for surveillance was recalled by 69% of patients (range between departments, 55%-83%; P < .01). Factors that were associated with awareness of recommendations were younger age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.06-1.09), treatment by a gastroenterologist (OR, 5.53; 95% CI, 3.28-9.32), and presence of 3 or more adenomas (OR, 2.97; 95% CI, 1.29-6.85). Attendance among patients with adenomas varied among departments, from 60% to 89% (P < .01), and was not associated with awareness of patients about their recommendations per department (P = .59).

CONCLUSIONS

Not enough patients (only 85%) who receive colonoscopies are aware of their results or surveillance recommendations. Although awareness of findings and recommendations did not correlate with follow-up attendance, patients should be better informed about findings and their need for surveillance.

Adenoma incidence decreases under the effect of polypectomy

AIM: To investigate whether, under the influence of polypectomy, the incidence of adenoma decreases with age.

METHODS: Consecutive patients with colonic adenomas identified at index colonoscopy were retrospectively selected if they had undergone three or more complete colonoscopies, at least 24 mo apart. Patients who had any first-degree relative with colorectal cancer were excluded. Data regarding number of adenomas at each colonoscopy, their location, size and histological classification were recorded. The monthly incidence density of adenomas after the index examination was estimated for the study population, by using the person-years method. Baseline adenomas were excluded from incidence calculations but their characteristics were correlated with recurrence at follow-up, using the χ² test.

RESULTS: One hundred and fifty-six patients were included (109 male, mean age at index colonoscopy 56.8 ± 10.3 years), with follow-up that ranged from 48 to 232 mo. No significant correlations were observed between the number, the presence of villous component, or the size of adenomas at index colonoscopy and the presence of adenomas at subsequent colonoscopies (P = 0.49, 0.12 and 0.78, respectively). The incidence of colonic adenomas was observed to decay from 1.4% person-months at the beginning of the study to values close to 0%, at 12 years after index colonoscopy.

CONCLUSION: Our results suggest the sporadic formation of adenomas occurs within a discrete period and that, when these adenomas are removed, all neoplasia-prone clones may be extinguished.

[Standardized and structured histopathological evaluation of colorectal polyps: a practical checklist against the background of the new WHO classification]

Gastroenterologists removing colorectal polyps expect standardized and well-structured pathological reports, providing them with all relevant data for the further clinical management of the patient. Over the last year, a task force of clinicians and pathologists has developed a checklist to improve and harmonize endoscopic and pathological reporting of colorectal polyps. This checklist concentrates more on concrete recommendations from evidence-based guidelines and established international classifications for daily practice rather than detailed molecular pathological pathways of carcinogenesis. These recommendations are based on the current S3 guidelines for colorectal cancer (the chapter entitled "Management of colorectal polyps"), the histomorphological consensus manuscript of the GI working group of the German Society for Pathology, as well as the current WHO classification for tumors of the digestive system.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

KEY POINTS

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

Prognostic significance of high-grade dysplasia in colorectal adenomas

AIM

Colonoscopy to detect and remove polyps has contributed to a reduction in colorectal carcinoma. Three-year follow up is recommended for patients considered to be at high risk (at least three adenomas, adenoma ≥ 1 cm, villous or high-grade features). Our study focused on patients diagnosed with high-grade dysplasia with regard to initial management and follow up.

METHOD

A search of patients who had had endoscopic removal of a high-grade adenoma was carried out. Patients with the following were excluded: follow up of < 1 year, polyposis syndromes, prior colon cancer and a diagnosis of adenocarcinoma within 6 months following initial diagnosis.

RESULTS

Eighty-three patients treated between 1999 and 2007 for high-grade dysplasia (HGD) in a colorectal adenoma were identified. Over a median follow-up period of 4 years, 53 (64%) developed further adenomatous polyps. Among these, 7% had an adenoma with HGD or an adenocarcinoma. In all these patients, the initial high-grade adenoma was > 1 cm in diameter. Initial follow-up colonoscopy was performed on average 7 months following the initial diagnosis. Ten per cent of patients underwent prophylactic segmental resection, and 6% received argon laser therapy.

CONCLUSION

The study demonstrates that patients who have a colorectal adenoma > 1 cm with HGD may be at high risk of developing further adenomas with HGD or carcinoma. Close follow up is warranted.

Strategies for colon cancer prevention

Colorectal cancer (CRC) is common and is associated with a considerable mortality. Morbidity and thereby mortality can be reduced by using different prevention strategies such as lifestyle interventions and chemoprevention. Endoscopic surveillance of high-risk individuals and population-based endoscopic screening of average-risk individuals enables detection and removal of premalignant lesions (adenomas) as well as presymptomatic detection of cancer. Implementation of cancer detection tests such as fecal occult blood tests (FOBTs) is another strategy to reduce cancer mortality by early detection of CRC. Personalized management, based on estimates of the individual risk using information concerning environmental factors, lifestyle, family history, personality, social background and phenotype in combination with a variety of biomarkers such as genotype, will become more important as a strategy to optimize CRC prevention in the future.

Endoscopic and histopathologic predictors of recurrence of colorectal adenoma on lowering the miss rate

BACKGROUND/AIMS

Although colorectal adenoma is reported to recur frequently, this may result from missing it at baseline. However, few studies of recurrence have considered the miss rate. This study evaluated the recurrence rate prospectively and clinical predictors of recurrence in colorectal adenoma after lowering the miss rate.

METHODS

The study population comprised 128 patients who underwent baseline colonoscopy with resection of colorectal adenomas. Re-examination to lower the miss rate was performed within 2 months. Follow-up colonoscopy to detect recurrence was done more than 1 year after removal.

RESULTS

The mean follow-up period was 35.1 months (range, 12 to 84 months). Thirty patients had a recurrent adenoma, for a recurrence rate of 23.4%. Older patients (over 60 years) had a two-fold greater risk of recurrence than younger patients (hazard ratio, 2.39; 95% confidence interval [CI], 1.16-4.90). Patients with three or four adenomas at baseline colonoscopy had a two-fold greater risk than those with one adenoma (hazard ratio, 2.44; 95% CI, 1.11-5.35). Patients with advanced adenoma had a two-fold greater risk than those with no advanced adenoma (hazard ratio, 2.88; 95% CI, 1.40-5.95). In multivariate analysis, only the presence of three or four adenomas independently predicted the recurrence of adenoma (hazard ratio, 3.19; 95% CI, 1.04-9.79).

CONCLUSIONS

The recurrence rate of colorectal adenoma corrected by lowering the miss rate was lower than reported rates. The presence of multiple adenomas on initial colonoscopy was an important predictor of recurrence.

Can calcium chemoprevention of adenoma recurrence substitute or serve as an adjunct for colonoscopic surveillance?

OBJECTIVES

The aim of this study was to examine the potential cost-effectiveness of calcium chemoprevention post-polypectomy as a substitute or adjunct for surveillance.

METHODS

We constructed a Markov model of post-polypectomy adenoma recurrence and colorectal cancer (CRC) development, calibrated to data from prospective chemoprevention trials of fiber, calcium, antioxidants, and aspirin. We modeled four scenarios for 50-year-old patients immediately after polypectomy: (i) natural history with no further intervention; (ii) elemental calcium 1,200 mg/day from age 50-80; (iii) surveillance colonoscopy from age 50-80 every 5 years, or 3 years for large adenoma; (iv) calcium + surveillance. Patients were followed up until age 100 or death.

RESULTS

Calcium was cost-effective compared to natural history ($49,900/life-year gained). However, surveillance was significantly more effective than calcium (18.729 versus 18.654 life-years/patient; 76 percent versus 14 percent reduction in CRC incidence) at an incremental cost of $15,900/life-year gained. Calcium + surveillance yielded a very small benefit (0.0003 incremental life-years/patient) compared with surveillance alone, at a substantial incremental cost of $3,090,000/life-year gained.

CONCLUSION

Post-polypectomy calcium chemoprevention is unlikely to be a reasonable substitute for surveillance. It may be cost-effective in patients unwilling or unable to undergo surveillance.

Combined laparoscopic-endoscopic resections of colorectal polyps: 10-year experience and follow-up

BACKGROUND

Large, colorectal polyps or those that are difficult to access may be unamenable to conventional snare polypectomy and may require surgical resection. This study was designed to evaluate the resection of such lesions by the use of combined laparoscopic-endoscopic resections (CLER).

METHODS

Patients who had received CLER for colorectal polyps between January 1997 and December 2006 were identified from a prospectively maintained database. Patients with biopsies consistent with invasive cancer were excluded from the combined approach. Baseline characteristics, surgical, pathological, postoperative, and follow-up data of patients and lesions were reviewed.

RESULTS

A total of 146 consecutive patients underwent CLER for 154 lesions, and 120 (82%) patients underwent local excision (i.e., laparoscopy-assisted endoscopic resection, endoscopy-assisted wedge resection, and endoscopy-assisted transluminal resection). Twenty-six (18%) patients received endoscopy-assisted segmental colon resection. Conversion rate was 5% and intraoperative complications occurred in two patients (1%). Major postoperative complications occurred in five patients (3%), necessitating surgical reintervention in four of them. Follow-up colonoscopy revealed metachronous adenomas in 33 patients, of which 8 patients showed macroscopic or microscopic characteristics of advanced lesions. One patient, who had been converted to open resection because of incomplete laparoscopic resection of an adenoma, developed relapse of the initial adenoma and was successfully treated with repeat CLER accounting for a local recurrence rate of 0.9%.

CONCLUSIONS

Combined laparoscopic-endoscopic resection is an efficient, safe, and minimally invasive alternative to open resection for selected patients with difficult polyps, but it should be restricted to benign disease.

Combined laparoscopic-endoscopic resections of colorectal polyps: 10-year experience and follow-up

BACKGROUND

Large, colorectal polyps or those that are difficult to access may be unamenable to conventional snare polypectomy and may require surgical resection. This study was designed to evaluate the resection of such lesions by the use of combined laparoscopic-endoscopic resections (CLER).

METHODS

Patients who had received CLER for colorectal polyps between January 1997 and December 2006 were identified from a prospectively maintained database. Patients with biopsies consistent with invasive cancer were excluded from the combined approach. Baseline characteristics, surgical, pathological, postoperative, and follow-up data of patients and lesions were reviewed.

RESULTS

A total of 146 consecutive patients underwent CLER for 154 lesions, and 120 (82%) patients underwent local excision (i.e., laparoscopy-assisted endoscopic resection, endoscopy-assisted wedge resection, and endoscopy-assisted transluminal resection). Twenty-six (18%) patients received endoscopy-assisted segmental colon resection. Conversion rate was 5% and intraoperative complications occurred in two patients (1%). Major postoperative complications occurred in five patients (3%), necessitating surgical reintervention in four of them. Follow-up colonoscopy revealed metachronous adenomas in 33 patients, of which 8 patients showed macroscopic or microscopic characteristics of advanced lesions. One patient, who had been converted to open resection because of incomplete laparoscopic resection of an adenoma, developed relapse of the initial adenoma and was successfully treated with repeat CLER accounting for a local recurrence rate of 0.9%.

CONCLUSIONS

Combined laparoscopic-endoscopic resection is an efficient, safe, and minimally invasive alternative to open resection for selected patients with difficult polyps, but it should be restricted to benign disease.

Identification of patients at increased risk for colorectal cancer in an open access endoscopy center

GOALS

To determine whether patients referred for open access endoscopy (OAE) are being appropriately identified as "increased risk" or "average risk" for colorectal cancer (CRC) by referring physicians.

BACKGROUND

OAE allows nongastroenterologists to schedule elective endoscopies without prior consultation with a gastroenterologist. It is unknown how accurately referring physicians identify CRC risk of such patients.

METHODS

We retrospectively reviewed the records of outpatients referred to a single OAE center for screening or surveillance colonoscopy from July 1, 2001 to November 8, 2002. Before colonoscopy, a 3-question tool was used to stratify each patient as average risk or increased risk for CRC. CRC risk assessment was compared with the referring physician's indication for colonoscopy. Chi-square testing was used to compare the incidence of neoplastic polyps between average risk and increased risk patients.

RESULTS

Two hundred eighty-eight patients met inclusion criteria. Referring physicians accurately identified 61% of 126 increased risk patients, including 13 of 19 patients (68%) with a personal history of CRC, 29 of 61 patients (48%) with a family history of CRC, 47 of 61 patients (77%) with a personal history of colonic polyps, and 0 of 8 patients (0%) who met clinical criteria for hereditary nonpolyposis colorectal cancer. Adenomatous polyps were found in 24% of average risk patients compared with 41% of increased risk patients (P<0.01).

CONCLUSIONS

In an OAE system, referring physicians often fail to correctly identify patients at increased risk for CRC. Our 3-question tool for risk assessment helps to better identify patients at increased risk of CRC and can be used by gastroenterologists to stratify patients referred for OAE.

Five-year risk of colorectal neoplasia after negative screening colonoscopy

BACKGROUND

The appropriate interval for endoscopic rescreening after a negative colonoscopic examination is uncertain.

METHODS

We identified persons with no adenomas on baseline screening colonoscopy who returned at 5 years for follow-up colonoscopy. Findings were categorized according to the most advanced lesion present: no polyp, a hyperplastic polyp, a tubular adenoma less than 1 cm in diameter, an advanced adenoma (a tubular adenoma > or = 1 cm in diameter or a polyp with villous histologic features or high-grade dysplasia), or a cancer.

RESULTS

Baseline screening colonoscopy had identified 2436 persons with no adenomas; 1256 of them (51.6%) were rescreened a mean (+/-SD) of 5.34+/-1.34 years later. The mean age of this group at baseline was 56.7 years; 56.7% of its members were men. No cancers were found on rescreening (95% confidence interval [CI] for the detection rate, 0 to 0.24%). One or more adenomas were found in 201 persons (16.0%). A total of 19 advanced adenomas, of which 10 (52.6%) were distal to the splenic flexure, were found in 16 persons (1.3%). The risk of an advanced adenoma did not differ significantly between persons with no polyps at baseline and those with hyperplastic polyps at baseline (1.1% [12 of 1057] and 2.0% [4 of 199], respectively; P=0.30). Men were more likely than women to have any adenoma (tubular less than 1 cm in diameter or advanced) (relative risk, 1.88; 95% CI, 1.42 to 2.51) and to have an advanced adenoma (relative risk, 3.31; 95% CI, 1.02 to 10.8).

CONCLUSIONS

Among persons with no colorectal neoplasia on initial screening colonoscopy, the 5-year risk of colorectal cancer is extremely low. The risk of advanced adenoma is also low, although it is higher among men than among women. Our findings support a rescreening interval of 5 years or longer after a normal colonoscopic examination.

A comparative study of standard vs. high definition colonoscopy for adenoma and hyperplastic polyp detection with optimized withdrawal technique

BACKGROUND

Colonoscopy has a known miss rate for polyps and adenomas. High definition (HD) colonoscopes may allow detection of subtle mucosal change, potentially aiding detection of adenomas and hyperplastic polyps.

AIM

To compare detection rates between HD and standard definition (SD) colonoscopy.

METHODS

Prospective, cohort study with optimized withdrawal technique (withdrawal time >6 min, antispasmodic, position changes, re-examining flexures and folds). One hundred and thirty patients attending for routine colonoscopy were examined with either SD (n = 72) or HD (n = 58) colonoscopes.

RESULTS

Groups were well matched. Sixty per cent of patients had at least one adenoma detected with SD vs. 71% with HD, P = 0.20, relative risk (benefit) 1.32 (95% CI 0.85-2.04). Eighty-eight adenomas (mean +/- standard deviation 1.2 +/- 1.4) were detected using SD vs. 93 (1.6 +/- 1.5) with HD, P = 0.12; however more nonflat, diminutive (<6 mm) adenomas were detected with HD, P = 0.03. Twenty-three proximal hyperplastic polyps (0.32 +/- 0.58) were detected with SD vs. 31 (0.53 +/- 0.86) with HD, P = 0.35. Overall prevalence of proximal large (>9 mm) hyperplastic polyps was 7% (0.09 +/- 0.36).

CONCLUSIONS

High definition did not lead to a significant increase in adenoma or hyperplastic polyp detection, but may help where comprehensive lesion detection is paramount. High detection rates appear possible with either SD or HD, when using an optimized withdrawal technique.

Apoptosis in normal rectal mucosa, baseline adenoma characteristics, and risk of future adenomas

Low apoptosis in the normal rectal mucosa has been associated with colorectal adenomas in cross-sectional studies. It is unknown whether apoptosis can predict the occurrence of new adenomas. We evaluated whether apoptosis at baseline colonoscopy, as well as patient and adenoma characteristics, could predict future occurrence of adenomas. Study subjects were participants in the Diet and Health Study III, a cross-sectional study of adenoma risk factors between August 1998 and March 2000. At baseline, subjects underwent colonoscopy and provided normal rectal mucosal biopsies to evaluate apoptosis as well as information about diet and lifestyle. The present study includes 257 subjects who returned for follow-up colonoscopy between 2000 and 2005. Apoptosis, number of adenomas, size, and atypia at baseline colonoscopy were evaluated as predictors of new adenomas. Logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (95% CI). At baseline, low apoptosis was significantly associated with increased risk of adenomas (P = 0.0001). Compared with those in the lowest tertile, subjects with high apoptosis were less likely to have an adenoma at follow-up (crude OR, 0.25; 95% CI, 0.09-0.65; adjusted OR, 0.29; 95% CI, 0.08-1.06). Having three or more adenomas at baseline was associated with increased risk of new adenomas (crude OR, 2.46; 95% CI, 1.14-5.31; adjusted OR, 3.74; 95% CI, 1.01-13.83). This study suggests that lower apoptosis is associated with increased risk of future adenoma development. If confirmed in larger studies, apoptosis could potentially be used to identify patients at highest risk for developing new adenomas.

Importance of postpolypectomy surveillance and postpolypectomy compliance to follow-up screening--review of literature

INTRODUCTION

Approximately 150,000 people are diagnosed with colorectal cancer each year and 56,000 may die from it annually in the United States. Colorectal cancer is the second leading cause of cancer deaths in the USA and yet, when diagnosed at an early stage, it is one of the most preventable cancers. According to the US Preventive Services Task Force, initial screening for colorectal cancer is recommended in people above 50 years of age with average risk and earlier in people with a strong family history and other risk factors. Adenomatous polyps are considered as precursors of colorectal cancer. Removal of polyps and postpolypectomy surveillance reduces the overall mortality from colorectal cancer.

DISCUSSION

According to updated guidelines in 2006, a 3-year-follow-up colonoscopy is recommended in patients with adenomatous polyps>or=1 cm. An important factor in the surveillance and prevention of colorectal cancer in postpolypectomy patients is compliance with follow-up colonoscopy. In the present article, we provide an overview of the importance of postpolypectomy surveillance and summarize the compliance data for postpolypectomy surveillance. Compliance to postpolypectomy surveillance varies from one study to another and it should be expected that the compliance with follow-up would be low outside of clinical trials. Some measures that can improve patient compliance include patient education regarding a need of follow-up screening, reminder letters, and alerts in patient's charts.

CONCLUSION

In conclusion, effective surveillance screening with good patient compliance in postpolypectomy patients will contribute significantly in reducing colon cancer morbidity and mortality.

Five-year colon surveillance after screening colonoscopy

BACKGROUND & AIMS

Outcomes of colon surveillance after colorectal cancer screening with colonoscopy are uncertain. We conducted a prospective study to measure incidence of advanced neoplasia in patients within 5.5 years of screening colonoscopy.

METHODS

Three thousand one hundred twenty-one asymptomatic subjects, age 50 to 75 years, had screening colonoscopy between 1994 and 1997 in the Department of Veterans Affairs. One thousand one hundred seventy-one subjects with neoplasia and 501 neoplasia-free controls were assigned to colonoscopic surveillance over 5 years. Cohorts were defined by baseline findings. Relative risks for advanced neoplasia within 5.5 years were calculated. Advanced neoplasia was defined as tubular adenoma greater than > or =10 mm, adenoma with villous histology, adenoma with high-grade dysplasia, or invasive cancer.

RESULTS

Eight hundred ninety-five (76.4%) patients with neoplasia and 298 subjects (59.5%) without neoplasia at baseline had colonoscopy within 5.5 years; 2.4% of patients with no neoplasia had interval advanced neoplasia. The relative risk in patients with baseline neoplasia was 1.92 (95% CI: 0.83-4.42) with 1 or 2 tubular adenomas <10 mm, 5.01 (95% CI: 2.10-11.96) with 3 or more tubular adenomas <10 mm, 6.40 (95% CI: 2.74-14.94) with tubular adenoma > or =10 mm, 6.05 (95% CI: 2.48-14.71) for villous adenoma, and 6.87 (95% CI: 2.61-18.07) for adenoma with high-grade dysplasia.

CONCLUSIONS

There is a strong association between results of baseline screening colonoscopy and rate of serious incident lesions during 5.5 years of surveillance. Patients with 1 or 2 tubular adenomas less than 10 mm represent a low-risk group compared with other patients with colon neoplasia.

Non-compliance in surveillance for patients with previous resection of large (≥ 1 cm) colorectal adenomas

AIM: To assess the extent and reasons of non-compliance in surveillance for patients undergoing polypectomy of large (≥ 1 cm) colorectal adenomas.

METHODS: Between 1995 and 2002, colorectal adenomas ≥ 1 cm were diagnosed in 210 patients and subsequently documented at the Erlangen Registry of Colorectal Polyps. One hundred and fifty-eight patients (75.2%) could be contacted by telephone and agreed to be interviewed. Additionally, records were obtained from the treating physicians.

RESULTS: Fifty-four out of 158 patients (34.2%) neglected any surveillance. Reasons for non-compliance included lack of knowledge concerning surveillance intervals (45.8%), no symptoms (29.2%), fear of examination (18.8%) or old age/severe illness (6.3%). In a multivariate analysis, the factors including female gender (P = 0.036) and age > 62 years (P = 0.016) proved to be significantly associated with non-compliance in surveillance.

CONCLUSION: Efforts to increase compliance in surveillance are of utmost importance. This applies particularly to women’s compliance. Effective strategies for avoiding metachronous colorectal adenoma and cancer should focus on both the improvement in awareness and knowledge of patients and information about physicians for surveillance.

Repeat colonoscopy has a low yield even in symptomatic patients

BACKGROUND

In many regions, the demand for colonoscopy exceeds its availability. Patients undergoing repeat examinations comprise a significant proportion of those on waiting lists.

OBJECTIVE

To assess the yield of repeat colonoscopy in varied clinical settings.

DESIGN

Cohort study.

SETTING

Endoscopic database of an Australian tertiary referral hospital.

PATIENTS

Adults who had >/=2 colonoscopies between 1992 and 2004. Patients were excluded if the repeat procedure was for completion or for high-risk surveillance.

MAIN OUTCOME MEASUREMENTS

Yield for neoplasia by indication, interval to repeat examination, and appropriateness for surveillance (determined by National Australian guidelines).

RESULTS

A total of 4974 colonoscopies in 2075 patients were studied. The mean age was 63.1 years (range, 19.2-92.4 years). The mean number of examinations was 2.4 (range, 2-8), with a mean interval between examinations of 2.9 years. Colorectal cancer (CRC) was significantly more prevalent at initial colonoscopy compared with subsequent colonoscopies (7.9% vs 0.6%; prevalence ratio 14.2, 95% confidence interval [CI] 8.5-23.7, P < .001), as were advanced adenomas (15.3% vs 4.8%; prevalence ratio 3.2, 95% CI 2.6-3.9, P < .001). No CRCs were detected in symptomatic patients undergoing polyp surveillance examinations performed before the recommended interval.

LIMITATIONS

Retrospective design.

CONCLUSIONS

Yield of repeat colonoscopy is significantly lower than for initial colonoscopy, irrespective of indication. In symptomatic patients within a polyp surveillance program, the yield is negligible when a colonoscopy is performed before the recommended surveillance interval. The need for a repeat colonoscopy should be carefully considered, and patients who have never had a colonoscopy must take priority on waiting lists over those awaiting repeat examinations.

Folate metabolism polymorphisms influence risk of colorectal adenoma recurrence

Folate intake is inversely related to risk of developing colorectal neoplasia. Associations between risk of colorectal neoplasia and polymorphisms in genes coding for enzymes involved in folate metabolism have also been reported, suggesting a relationship between genotype and development of colorectal neoplasia. To further investigate the effects of folate metabolism genotypes on colorectal neoplasia, we genotyped 546 patients participating in a randomized controlled trial of folate supplementation for the prevention of colorectal adenoma recurrence. A significantly reduced risk of recurrence was observed in patients heterozygous for the MTRR A66G polymorphism [relative risk (RR), 0.64; 95% confidence interval (95% CI), 0.46-0.90] or heterozygous for the MTHFR A1298C polymorphism (RR, 0.71; 95% CI, 0.52-0.97). Furthermore, a significant reduction in recurrence risk was seen in MTRR A66G heterozygotes who received folate supplements but not in those who did not receive folate. Patients heterozygous for the MTHFR C677T polymorphism had a nonsignificant risk reduction (RR, 0.92; 95% CI, 0.69-1.23), as did patients with one or two variant alleles for the MTR A2756G polymorphism (RR, 0.82; 95% CI, 0.60-1.12). No influence on recurrence risk was observed for the TSER, TSER 3R G>C, and TS 1494del6 variants. These findings provide additional support for the hypothesis that germ line variants in folate metabolism genes influence the development of colorectal adenomas.

Incident rates of colonic neoplasia in older patients: when should we stop screening?

INTRODUCTION

Current guidelines endorse colon cancer screening every 5-10 years in patients over 50 years of age. However, there is no consensus regarding what age is appropriate to stop screening. The aim of this study was to characterize neoplasia occurrence/recurrence in a large cohort of patients > or =70 years of age undergoing colonoscopy.

METHODS

The Mayo Rochester endoscopic database was reviewed to determine the incidence of colonic neoplasia in patients > or =70 years undergoing two colonoscopies at least 12 months apart between January 1996 and December 2000. Patients were classified based on (i) age: 70-74, 75-79, > or =80 years; and (ii) polyp detection on initial examination, that is, subsequent examination for screening or surveillance.

RESULTS

Overall, 1353 patients underwent two colonoscopies at least 12 months apart (median interval 140 weeks) with removal of polyp on initial examination in 726 (53.7%) patients (surveillance cohort). On subsequent endoscopy, polyps > or =10 mm were detected in 54 (4.0%) and cancer in 13 (1.0%) patients. All age groups were well matched with respect to detection of neoplasia on index examination (P = 0.9) and polyp size on initial colonoscopy among the surveillance group (P = 0.9). Using a Cox proportional hazards model, adjusted hazard ratios (95% confidence interval [CI]) for neoplasia (polyps > or =10 mm) were: 2.0 (1.50-2.73, P < 0.0001) (surveillance vs screening), 1.33 (0.96-1.79, P = 0.08) (> or =80 vs 70-74), and 1.05 (0.78-1.38, P = 0.75) (75-79 vs 70-74). Adjusted hazard ratios for development of cancer were: 1.87 (1.03-3.97, P = 0.04) (surveillance vs screening), 1.73 (0.84-3.56, P = 0.13) (> or =80 vs 70-74), and 1.38 (0.71-2.77, P = 0.34) (75-79 vs 70-74).

CONCLUSIONS

Prior history of neoplasia remains a strong risk factor for colorectal neoplasia development in elderly patients and should be considered when deciding the need for continuing screening/surveillance. Incident neoplasia rates in a previously screened elderly population rise slowly with advancing age although cancer rates rise more sharply. Therefore, screening still retains a role in elderly patients; however, clinical judgment is still required to individualize screening practice. As the risk of competing comorbid illnesses continues to increase over time, the threshold to perform colon screening should increase accordingly.

Incident rates of colonic neoplasia according to age and gender: implications for surveillance colonoscopy intervals

INTRODUCTION

Current guidelines endorse surveillance colonoscopy at 3 to 5 years following initial detection of neoplasia. However, individual patients' risks may vary according to age and gender. This study aimed to characterize neoplasia recurrence in a large patient cohort undergoing surveillance colonoscopy.

METHODS

All patients undergoing two colonoscopies at least 12 months apart between 1996 and 2000, with detection and removal of a polyp on the index colonoscopy, were identified using our endoscopic database to determine the incidence of colonic neoplasia. Patients were classified according to age (<50, 50-64, 65-74, > or =75 years) and gender.

RESULTS

Overall, 1803 patients underwent two colonoscopies at least 12 months apart (median interval, 140 weeks) with removal of a polyp on initial examination. Polyps > or =5 mm were detected in 334 (19%) patients and polyps > or =10 mm in 105 (6%) on subsequent endoscopy. All age and gender groups were well matched with respect to size of polyp detected on initial colonoscopy (P = 0.2). Kaplan-Meier curves and a Cox proportional hazards model demonstrated similar rates of neoplasia recurrence for all patients irrespective of age and gender.

CONCLUSIONS

Similar rates of neoplasia recurrence were observed among patients of different gender and age groups on surveillance colonoscopy. From a health resource utilization perspective, these findings support current recommendations for similar surveillance intervals for patients regardless of age and gender.

Role of supplemental calcium in the recurrence of colorectal adenomas: a metaanalysis of randomized controlled trials

BACKGROUND

Colorectal adenomas are neoplastic growths that are important targets for chemoprevention. Dietary calcium is thought to play an important role in chemoprevention. However, the role of calcium supplementation for preventing recurrence of adenomas is controversial. We performed a systematic review and meta-analysis to study the role of calcium supplementation in preventing recurrence of adenomas.

METHODS

We searched electronic bibliographic databases (Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, CINAHL, EMBASE, and MEDLINE) and contacted authors to identify potentially eligible studies.

RESULTS

We identified three trials including 1,485 subjects with previously removed adenomas who were randomized to calcium versus placebo supplementation. The study endpoint was recurrence of adenomas at the end of 3-4 yr in 1,279 patients who completed the trials. We found that the recurrence of adenomas was significantly lower in subjects randomized to calcium supplementation (RR: 0.80, CI: 0.68, 0.93; p-value = 0.004).

CONCLUSIONS

This systematic review and meta-analysis suggest that calcium supplementation prevents recurrent colorectal adenomas.