European Code against Cancer, 4th Edition: Cancer screening

The association between health literacy and cancer screening participation: A cross-sectional study across three organised screening programmes in Denmark

Objective

Health literacy may be related to non-participation in cancer screening, but there is limited understanding of its association with participation across all cancer screening programmes. This study aims to explore the associations between health literacy and advancing in participation in cancer screening programmes.

Methods

We conducted a cross-sectional study involving women aged 53-65 years residing in Denmark on 31 March 2018. Data utilised was from population registries and self-reported health literacy (HLS-EU-Q16) collected autumn 2017. Uni- and multivariate ordinal logistic regression models were employed to assess associations between health literacy levels and the likelihood of increased attendance in cancer screening programmes. Results were presented as odds ratios (ORs) with 95 % confidence intervals (CIs).

Results

Of the women included, 2668 (69.8 %) responded to the health literacy questionnaire. Among these, 53.3 % demonstrated adequate health literacy, 34.4 % had problematic, and 12.3 % inadequate. In total, 71.2 % attended three screening programmes, 20.1 % attended two, 6.2 % attended one, and 2.5 % attended none.There were no differences in the ORs for advancing in screening attendance when comparing problematic (OR = 1.18, 95 % CI: 0.97-1.42) or inadequate (OR = 0.96, 95 % CI: 0.74-1.26) health literacy levels with an adequate level.

Conclusions

Our study suggests that health literacy does not significantly influence cancer screening participation among the studied population in Denmark. Therefore, interventions aimed at increasing screening participation in this group should not only target health literacy but also focus on other aspects of non-participation.

Artificial intelligence utilization in cancer screening program across ASEAN: a scoping review

BACKGROUND

Cancer remains a significant health challenge in the ASEAN region, highlighting the need for effective screening programs. However, approaches, target demographics, and intervals vary across ASEAN member states, necessitating a comprehensive understanding of these variations to assess program effectiveness. Additionally, while artificial intelligence (AI) holds promise as a tool for cancer screening, its utilization in the ASEAN region is unexplored.

PURPOSE

This study aims to identify and evaluate different cancer screening programs across ASEAN, with a focus on assessing the integration and impact of AI in these programs.

METHODS

A scoping review was conducted using PRISMA-ScR guidelines to provide a comprehensive overview of cancer screening programs and AI usage across ASEAN. Data were collected from government health ministries, official guidelines, literature databases, and relevant documents. The use of AI in cancer screening reviews involved searches through PubMed, Scopus, and Google Scholar with the inclusion criteria of only included studies that utilized data from the ASEAN region from January 2019 to May 2024.

RESULTS

The findings reveal diverse cancer screening approaches in ASEAN. Countries like Myanmar, Laos, Cambodia, Vietnam, Brunei, Philippines, Indonesia and Timor-Leste primarily adopt opportunistic screening, while Singapore, Malaysia, and Thailand focus on organized programs. Cervical cancer screening is widespread, using both opportunistic and organized methods. Fourteen studies were included in the scoping review, covering breast (5 studies), cervical (2 studies), colon (4 studies), hepatic (1 study), lung (1 study), and oral (1 study) cancers. Studies revealed that different stages of AI integration for cancer screening: prospective clinical evaluation (50%), silent trial (36%) and exploratory model development (14%), with promising results in enhancing cancer screening accuracy and efficiency.

CONCLUSION

Cancer screening programs in the ASEAN region require more organized approaches targeting appropriate age groups at regular intervals to meet the WHO's 2030 screening targets. Efforts to integrate AI in Singapore, Malaysia, Vietnam, Thailand, and Indonesia show promise in optimizing screening processes, reducing costs, and improving early detection. AI technology integration enhances cancer identification accuracy during screening, improving early detection and cancer management across the ASEAN region.

Clinicopathological features of early-onset colorectal cancer in Japanese patients: a single-center retrospective study

BACKGROUND

The incidence of early-onset colorectal cancer (EoCRC), defined as CRC diagnosed at < 50 years of age, is increasing globally. However, only a few studies are reported from Japan, and the clinicopathological features of EoCRC in Japanese patients remain unknown.

METHODS

We retrospectively investigated consecutive Japanese patients who were pathologically diagnosed with invasive CRC at our hospital from January 2015 to December 2021. Patients were categorized into those who were diagnosed with CRC at < 50 years (early-onset group) and ≥ 50 years (late-onset group) of age. We compared the clinicopathological findings between the two groups.

RESULTS

The analysis included 731 patients. EoCRC was diagnosed in 46 patients　(6.3% of all patients). Of them, 41.3% demonstrated a positive fecal immunochemical test (FIT) for CRC screening as a diagnostic opportunity, which was significantly higher than that in the late-onset group (p = 0.032). Rectal cancer was significantly more prevalent in the early-onset group compared to the late-onset group (45.7% vs. 26.4%, p < 001). No significant difference in the rate of clinical stage at presentation was found between the two groups. Furthermore, patients with positive FIT were more likely diagnosed at an earlier stage.

CONCLUSIONS

EoCRC among Japanese patients tends to occur on the rectum and is more frequently diagnosed with FIT screening compared to late-onset CRC. Patients with advanced stage were diagnosed by symptoms, indicating the usefulness of FIT screening in diagnosing EoCRC at an early stage.

Endoscopic Screening and Surveillance of Gastrointestinal Cancer

Gastrointestinal (GI) cancer is a major health concern, contributing significantly to mortality rates in many regions, including Europe. It affects millions of people worldwide and leads to hundreds of thousands of deaths each year. Early detection and treatment through endoscopic methods play a vital role, providing less invasive and more affordable options compared to traditional surgical procedures. Targeted screening is vital for conditions such as Barrett's esophagus (BE), esophageal adenocarcinoma (EAC), gastric cancer (GC), ampullary carcinoma (AC), and colorectal cancer (CRC), particularly in high-risk populations. Endoscopic surveillance significantly reduces cancer incidence and improves survival rates, highlighting the importance of continuous advancements and updated guidelines to enhance screening efficacy and patient outcomes.

General practitioners may improve cervical screening equality in France

BACKGROUND

Vulnerable social groups have greater difficulty in accessing care and a lower quality of care. Health systems focused on primary care appear to be more effective, efficient and equitable. However, difficulties in accessing primary care are persisting. We focused on primary care screening for cervical cancer through Cervico-Uterine Smear (CUS), which has been shown to be effective in reducing disease incidence and mortality. In this study, we aimed to investigate the characteristics of women who undergo CUS according to the category of health professionals (general practitioners or gynaecologists) performing CUS and to analyse potential differences in access to care in terms of socioeconomic and geographical characteristics.

METHODS

This was a retrospective observational study based on data from the main health insurance schemes in France, allowing analysis of health care consumption according to socioeconomic levels and proximity to health care services. We included women aged 25 to 64 years in 2012 for whom CUS would be a relevant procedure (695,694). The sociodemographic and territorial indicators were age, geographical area deprivation, and the availability of gynaecological care. The analysis was performed using multinomial logistic regression.

RESULTS

A total of 202,271 (29%) patients underwent CUS; of whom 68% underwent CUS administered by gynaecologists and 28% were administered by general practitioners (GPs). However, inequalities in CUS screening rates were observed, with a decrease in the number of CUSs performed with increased age, a rural location, deprivation, and sparse health care provisions. Deprived people seemed less penalised by GPs.

CONCLUSIONS

Involvement of General Practitioners may improve cervical screening equality in France. The organisation of health systems around primary care may allow a better access to care and to account for the specific needs of deprived populations.

Systematic review of cost-effectiveness studies on cervical cancer screening across Europe

INTRODUCTION

Cervical cancer (CC) is a type of cancer with poor prognosis when diagnosed in advanced stage with a big socioeconomic burden. The incidence rates have wide variations among European countries depending on the implementation or not of screening, vaccination programs and the human development index (HDI). Most studies on cost-effectiveness of CC screening programs are carried out in countries with a high HDI, however more recent reviews of screening approaches are coming from countries with lower HDI aiming to identify the best screening strategies. Our study aims to identify which are the currently applied and most cost-effective strategies of CC screening in Europe.

MATERIALS AND METHODS

This is a systematic review conducted in three different databases (PubMed, Scopus and ScienceDirect) and reported following the PRISMA guidelines. General key terms for all databases were the following: cost-effectiveness, cervical cancer, screening, Europe. We included studies in English, Italian, Spanish and Bulgarian, published in the last 25 years, reporting data on cost-effectiveness of CC screening, costs and outcome measures. The methodological quality of the articles was evaluated with a standardized tool.

RESULTS

A total of 262 studies were identified and 22 studies were included in the final analysis. In 90.1 % of the economic studies, the new screening strategy was shown to be more cost-effective compared to the current one or compared to no screening. The optimal strategy mostly involved primary HPV testing, combined with cytology or as stand-alone screening technique. Several scenarios differing on starting age and periodicities for CC screening, combination of techniques and triage, were found to be cost-effective and below the willingness to pay (WTP) threshold. The methodology of all included studies was assessed from 10 to 11 on the JBI standardized tool and Drummond 11-point checklist.

CONCLUSION

Numerous cost-effective options for CC screening in different European countries were identified in this systematic review. HPV testing, with or without cytology, mainly starting at 30 years of age and repeated every 5 years or more was the most cost-effective technique. Future studies should focus on the most appropriate CC screening approach for each context and setting, also considering HPV vaccination in Europe.

Lack of social support, gender and colorectal cancer screening participation across Europe: How do screening programmes mitigate the effect of social support for men and women?

This study investigates how a lack of social support differentially affects men and women's colorectal cancer (CRC) screening participation, considering different screening strategies implemented across European countries. Although health sociology has stressed gender differences in social support and its effects on health behaviours, this was overlooked by cancer screening research. Using a data set of 65,961 women and 55,602 men in 31 European countries, we analysed the effect of social support variables on CRC screening uptake. We found that living alone and lower perceived social support were associated with lower screening uptake for both men and women. These effects were, however, stronger among men. Population-based screening programmes mitigated these effects, particularly for women, but not for men living alone. In countries with opportunistic screening programmes, social support variables remained associated with screening uptake. We conclude that cancer screening interventions should pay attention to social support and its gender-differentiated effects.

Application of CytoPath®Easy Vials in Cervical Cancer Screening: Self-Sampling Approach

Context

CytoPath®Easy kit (DiaPath S.p.A.) offers a major advantage compared to other commercially available kits available for the screening of cervical cancer, as it does not require additional equipment for sample processing. Using this methodology, collected epithelial cells are immersed in a preservative liquid before setting as a thin layer on a slide via gravity sedimentation.

Aims

To evaluate the suitability of the CytoPath®Easy kit for the processing of cervical samples, detection of pre-neoplastic lesions, and nucleic preservation and extraction for HR-HPV diagnosis.

Materials and Methods

A total of 242 self-sampled cervical specimens were utilized, with 192 collected in CytoPath®Easy vials and 50 collected and processed using the ThinPrepTM for comparative analysis. The samples underwent processing, Papanicolaou staining, and microscopic evaluation for morphological parameters. The extracted nucleic acids were assessed for purity and integrity, and the detection of high-risk human papillomavirus (HR-HPV) was carried out using the Alinitym HR HPV system kit (Abbott Laboratórios Lda).

Results

Both methods demonstrated effective performance, enabling the morphological assessment of the cervical epithelium. Statistical analysis indicated that ThinPrepTM yielded significantly better results in terms of cellularity. Conversely, CytoPath®Easy exhibited superior performance in terms of the quantity of extracted DNA and its degree of purification. Concerning the time consumed during processing, both methods were comparable, with the CytoPath®Easy methodology standing out for its cost-effectiveness, as it does not necessitate additional instruments and consumables.

Conclusions

The novel CytoPath®Easy methodology proves effective in preserving both nucleic acids and cell morphology characteristics, two crucial features for cervical cancer screening.

Cancer Screening: Present Recommendations, the Development of Multi-Cancer Early Development Tests, and the Prospect of Universal Cancer Screening

Cancer continues to pose a considerable challenge to global health. In the search for innovative strategies to combat this complex enemy, the concept of universal cancer screening has emerged as a promising avenue for early detection and prevention. In contrast to targeted approaches that focus on specific populations or high-risk individuals, universal screening seeks to cast a wide net to detect incipient malignancies in different demographic groups. This paradigm shift in cancer care underscores the importance of comprehensive screening programs that go beyond conventional boundaries. As our understanding of the complex molecular and genetic basis of cancer deepens, the need to develop comprehensive screening methods becomes increasingly apparent. In this article, we look at the rationale and potential benefits of universal cancer screening.

Cancer screening programs in South-east Asia and Western Pacific

BACKGROUND

The burden of cancer can be altered by screening. The field of cancer screening is constantly evolving; from the initiation of program for new cancer types as well as exploring innovative screening strategies (e.g. new screening tests). The aim of this study was to perform a landscape analysis of existing cancer screening programs in South-East Asia and the Western Pacific.

METHODS

We conducted an overview of cancer screening in the region with the goal of summarizing current designs of cancer screening programs. First, a selective narrative literature review was used as an exploration to identify countries with organized screening programs. Second, representatives of each country with an organized program were approached and asked to provide relevant information on the organizations of their national or regional cancer screening program.

RESULTS

There was wide variation in the screening strategies offered in the considered region with only eight programs identified as having an organized design. The majority of these programs did not meet all the essential criteria for being organized screening. The greatest variation was observed in the starting and stopping ages.

CONCLUSIONS

Essential criteria of organized screening are missed. Improving organization is crucial to ensure that the beneficial effects of screening are achieved in the long-term. It is strongly recommended to consider a regional cancer screening network.

The importance of cancer prevention policies to inform and guide preventative and screening measures for people with intellectual disabilities: The COST project "Cancer- Understanding Prevention in Intellectual Disabilities"

Cancer is a global public health problem, but its exact prevalence in people with intellectual disabilities is still uncertain. This population, with limited health skills and complex health needs, faces many challenges in cancer prevention, screening, timely diagnosis and treatment. Furthermore, they are often underrepresented in general cancer prevention and screening policies across Europe, leading to widened disparities in health outcomes and premature mortality. Thus, unified national and local policies are needed to reduce inequalities and promoting a pan-European inclusion of people with intellectual disabilities. Our goal is to raise public awareness of this issue, including the involvement of people with intellectual disabilities, and promote engagement from relevant stakeholders. The COST Action 'Cancer- Understanding Prevention in Intellectual Disabilities' (CUPID) project will address health inequalities faced by people with intellectual disabilities in relation to cancer, and support the development of policy recommendations specifically tailored to their unique cognitive and healthcare needs, having a positive long-term impact on quality of life.

Intelligent Wireless Capsule Endoscopy for the Diagnosis of Gastrointestinal Diseases

Through a wireless capsule endoscope (WCE) fitted with a miniature camera (about an inch), this study aims to examine the role of wireless capsule endoscopy (WCE) in the diagnosis, monitoring, and evaluation of GI (gastrointestinal) disorders. In a wearable belt recorder, a capsule travels through the digestive tract and takes pictures. It attempts to find tiny components that can be used to enhance the WCE. To accomplish this, we followed the steps below: Researching current capsule endoscopy through databases, designing and simulating the device using computers, implanting the system and finding tiny components compatible with capsule size, testing the system and eliminating noise and other problems, and analyzing the results. In the present study, it was shown that a spherical WCE shaper and a smaller WCE with a size of 13.5 diameter, a high resolution, and a high frame rate (8-32 fps) could help patients with pains due to the traditional capsules and provide more accurate pictures as well as prolong the battery life. In addition, the capsule can also be used to reconstruct 3D images. Simulation experiments showed that spherical endoscopic devices are more advantageous than commercial capsule-shaped endoscopic devices for wireless applications. We found that the sphere's velocity through the fluid was greater than the capsule's.

Shifting the Cancer Screening Paradigm: The Rising Potential of Blood-Based Multi-Cancer Early Detection Tests

Cancer remains a leading cause of death worldwide, partly owing to late detection which entails limited and often ineffective therapeutic options. Most cancers lack validated screening procedures, and the ones available disclose several drawbacks, leading to low patient compliance and unnecessary workups, adding up the costs to healthcare systems. Hence, there is a great need for innovative, accurate, and minimally invasive tools for early cancer detection. In recent years, multi-cancer early detection (MCED) tests emerged as a promising screening tool, combining molecular analysis of tumor-related markers present in body fluids with artificial intelligence to simultaneously detect a variety of cancers and further discriminate the underlying cancer type. Herein, we aim to provide a highlight of the variety of strategies currently under development concerning MCED, as well as the major factors which are preventing clinical implementation. Although MCED tests depict great potential for clinical application, large-scale clinical validation studies are still lacking.

Screening for colorectal cancer: awareness and adherence among Italian women

OBJECTIVE

To evaluate women's awareness about and attendance to colorectal cancer (CRC) screening programs in an area of Southern Italy, and to investigate related potential determinants.

METHODS

The survey was conducted among women through a self-administered questionnaire.

RESULTS

Overall, only 20.3% of respondents knew the three cancer screening tests offered to women and this knowledge, at the multivariate logistic regression analysis, resulted to be significantly higher in women who knew the two most common cancers in females, in those who were graduated, had a personal or family history of cancer, and had been informed about cancer prevention by physicians. Only 29.2% of women had ever undergone FOBT, 25% for screening purposes and, of these, 76.4% in the previous 2 years. Among those who had never undergone FOBT, 28.9% reported they had not been invited to attend, 34.5% that the test had not been prescribed by anyone, and 19.1% had no time to undergo. The results of the multivariate logistic regression model revealed that significant determinants of having undergone FOBT for screening purposes were having undergone mammography, having at least one chronic disease, not reporting alcohol consumption and having been informed about cancer screening by physicians.

CONCLUSION

Our findings have revealed a concerning low awareness about and adherence to CRC screening in women and have highlighted the fundamental role of healthcare workers and of enabling factors in the decision process. Interventions should be directed to increasing awareness, and to promote cancer prevention screening pathways more centered on women's health needs and convenience.

Colorectal Cancer Screening Program in Songjiang district, Shanghai between 2015 and 2017: Evaluation of participation rate and the associated factor

Little is known about the participation rate of newly implemented colorectal cancer (CRC) screening programs in China. Our goals were to identify factors associated with nonparticipation for CRC screening in Songjiang District, Shanghai. We analyzed individuals included in an observational cohort study from 4 towns (Xin Qiao, She Shan, Mao Gang, and Zhong Shan) in Songjiang District. The participation rate was calculated for the CRC screening program based on a fecal immunochemical test and a risk assessment questionnaire between 2015 and 2017 inclusive. Of the 27,130 individuals eligible for inclusion in this study, 20,863 (76.9%) participated in CRC screening at least once during 2015 and 2017. The factors linked with nonparticipation were; being male (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.82-0.93, P < .01), unmarried (OR 0.71, 95% CI 0.64-0.80, P < .01), having a high education level (middle school, OR 0.82, 95% CI 0.74-0.90, P < .01, high school or above, OR 0.64, 95% CI 0.57-0.73, P < .01), absence of chronic disease (OR 0.90, 95% CI 0.85-0.96, P < .01), and living in 2 out of the 4 towns covered (Xin Qiao, OR 0.72, 95% CI 0.66-0.78, P < .01, Zhong Shan, OR 0.29, 95% CI 0.26-0.31, P < .01). The current study revealed several associated factors with nonparticipation for the CRC screening in Songjiang district. These findings will help identify target populations that require an individualized approach to increase the participation rate.

Colorectal Cancer Screening with Computed Tomography Colonography: Single Region Experience in Kazakhstan

Background/Aims

The aim of our study was to determine the efficacy of computed tomography colonography (CTC) in screening for colorectal cancer (CRC).

Methods

A total of 612 females and 588 males aged 45 to 75 years were enrolled in CTC screening. CTC was performed following standard bowel preparation and colonic insufflation with carbon dioxide. The main outcomes were the detection rate of CRC and advanced adenoma (AA), prevalence of colorectal lesions in relation to socio-demographic and health factors, and overall diagnostic performance of CTC.

Results

Overall, 56.5% of the 1,200 invited subjects underwent CTC screening. The sensitivity for CRC and AA was 0.89 and 0.97, respectively, while the specificity was 0.71 and 0.99, respectively. The prevalence of CRC and AA was 3.0% (18/593) and 7.1% (42/593), respectively, with the highest CRC prevalence in the 66-75 age group (≥12 times; odds ratio [OR], 12.11; 95% confidence interval [CI], 4.45-32.92). CRC and AA prevalence were inversely correlated with Asian descent, physical activity, and negative fecal immunochemical test results (OR=0.43; 95% CI, 0.22-0.83; OR=0.16; 95% CI, 0.04-0.68; OR=0.5; 95% CI, 0.07-3.85, respectively).

Conclusions

Our study revealed high accuracy of CTC in diagnosing colonic neoplasms, good compliance with CTC screening, and high detection rate of CRC.

The PATHFINDER Study: Assessment of the Implementation of an Investigational Multi-Cancer Early Detection Test into Clinical Practice

To examine the extent of the evaluation required to achieve diagnostic resolution and the test performance characteristics of a targeted methylation cell-free DNA (cfDNA)-based multi-cancer early detection (MCED) test, ~6200 participants ≥50 years with (cohort A) or without (cohort B) ≥1 of 3 additional specific cancer risk factors will be enrolled in PATHFINDER (NCT04241796), a prospective, longitudinal, interventional, multi-center study. Plasma cfDNA from blood samples will be analyzed to detect abnormally methylated DNA associated with cancer (i.e., cancer "signal") and a cancer signal origin (i.e., tissue of origin). Participants with a "signal detected" will undergo further diagnostic evaluation per guiding physician discretion; those with a "signal not detected" will be advised to continue guideline-recommended screening. The primary objective will be to assess the number and types of subsequent diagnostic tests needed for diagnostic resolution. Based on microsimulations (using estimates of cancer incidence and dwell times) of the typical risk profiles of anticipated participants, the median (95% CI) number of participants with a "signal detected" result is expected to be 106 (87-128). Subsequent diagnostic evaluation is expected to detect 52 (39-67) cancers. The positive predictive value of the MCED test is expected to be 49% (39-58%). PATHFINDER will evaluate the integration of a cfDNA-based MCED test into existing clinical cancer diagnostic pathways. The study design of PATHFINDER is described here.

Technological advances: Have they improved standards? Review of outcomes from the Welsh cervical screening programme

OBJECTIVES

Introduction of new technologies into cervical screening programmes has allowed more efficient programmes with less resources. We present an overview of screening technologies introduced into the Cervical Screening Wales programme and their evolution over time.

METHODS

Data from the programme's statistical report were used to evaluate its performance over a 17-year period between 2001/02 and 2017/18.

RESULTS

The introduction of liquid-based cytology has had a substantial impact on reducing inadequate sample rates and on increasing the positive predictive value of cytology. Inadequate rates have increased following the implementation of human papilloma virus testing as a triage test for cytology. Further knock-on effects on standard reporting ranges are expected following the introduction of human papilloma virus testing as the primary screening test. New performance standards have been introduced to better reflect the performance of the programme at a time when disease prevalence is expected to fall as women vaccinated against human papilloma virus reach screening age.

CONCLUSIONS

Improvements to this cervical cancer screening programme as illustrated through performance indicator ranges suggest a major role played by technology.

National Colorectal Cancer Screening Program in Lithuania: Description of the 5-Year Performance on Population Level

Simple Summary

The first Lithuanian analysis of colorectal cancer screening program is presented in our manuscript. We found that program is run with minimal expenses and still surpasses minimal requirements proposed by the European Union. Still the coverage is lower being 49.6% and must be improved.

Abstract

We aimed to report the results of the implementation of the National Colorectal Cancer (CRC) Screening Program covering all the country. The National Health Insurance Fund (NHIF) reimburses the institutions for performing each service; each procedure within the program has its own administrative code. Information about services provided within the program was retrieved from the database of NHIF starting from the 1 January 2014 to the 31 December 2018. Exact date and type of all provided services, test results, date and results of biopsy and histopathological examination were extracted together with the vital status at the end of follow-up, date of death and date of emigration when applicable for all men and women born between 1935 and 1968. Results were compared with the guidelines of the European Union for quality assurance in CRC screening and diagnosis. The screening uptake was 49.5% (754,061 patients) during study period. Participation rate varied from 16% to 18.1% per year and was higher among women than among men. Proportion of test-positive and test-negative results was similar during all the study period—8.7% and 91.3% annually. Between 9.2% and 13.5% of test-positive patients received a biopsy of which 52.3–61.8% were positive for colorectal adenoma and 4.6–7.3% for colorectal carcinoma. CRC detection rate among test-positive individuals varied between 0.93% and 1.28%. The colorectal cancer screening program in Lithuania coverage must be improved. A screening database is needed to systematically evaluate the impact and performance of the national CRC screening program and quality assurance within the program.

Tumor Infiltration by OX40+ Cells Enhances the Prognostic Significance of CD16+ Cell Infiltration in Colorectal Cancer

Objectives:

Analysis of tumor immune infiltration has been suggested to outperform tumor, node, metastasis staging in predicting clinical course of colorectal cancer (CRC). Infiltration by cells expressing OX40, a member of the tumor necrosis factor receptor family, or CD16, expressed by natural killer cells, monocytes, and dendritic cells, has been associated with favorable prognosis in patients with CRC. We hypothesized that assessment of CRC infiltration by both OX40+ and CD16+ cells might result in enhanced prognostic significance.

Methods:

Colorectal cancer infiltration by OX40 and CD16 expressing cells was investigated in 441 primary CRCs using tissue microarrays and specific antibodies, by immunohistochemistry. Patients’ survival was evaluated by Kaplan-Meier and log-rank tests. Multivariate Cox regression analysis, hazard ratios, and 95% confidence intervals were also used to evaluate prognostic significance of OX40+ and CD16+ cell infiltration.

Results:

Colorectal cancer infiltration by OX40+ and CD16+ cells was subclassified into 4 groups with high or low infiltration levels in all possible combinations. High levels of infiltration by both OX40+ and CD16+ cells were associated with lower pT stage, absence of peritumoral lymphocytic (PTL) inflammation, and a positive prognostic impact. Patients bearing tumors with high infiltration by CD16+ and OX40+ cells were also characterized by significantly longer overall survival, as compared with the other groups. These results were confirmed by analyzing an independent validation cohort.

Conclusions:

Combined infiltration by OX40+ and CD16+ immune cells is an independent favorable prognostic marker in CRC. The prognostic value of CD16+ immune cell infiltration is significantly improved by the combined analysis with OX40+ cell infiltration.

Performance indicators in breast cancer screening in the European Union: A comparison across countries of screen positivity and detection rates

Comparable performance indicators for breast cancer screening in the European Union (EU) have not been previously reported. We estimated adjusted breast cancer screening positivity rate (PR) and detection rates (DR) to investigate variation across EU countries. For the age 50-69 years, the adjusted EU-pooled PR for initial screening was 8.9% (cross-programme variation range 3.2-19.5%) while DR of invasive cancers was 5.3/1,000 (range 3.8-7.4/1,000) and DR of ductal carcinoma in situ (DCIS) was 1.3/1,000 (range 0.7-2.7/1,000). For subsequent screening, the adjusted EU-pooled PR was 3.6% (range 1.4-8.4%), the DR was 4.0/1,000 (range 2.2-5.8/1,000) and 0.8/1,000 (range 0.5-1.3/1,000) for invasive and DCIS, respectively. Adjusted performance indicators showed remarkable heterogeneity, likely due to different background breast cancer risk and awareness between target populations, and also different screening protocols and organisation. Periodic reporting of the screening indicators permits comparison and evaluation of the screening activities between and within countries aiming to improve the quality and the outcomes of screening programmes. Cancer Screening Registries would be a milestone in this direction and EU Screening Reports provide a fundamental contribution to building them.

Determinants of Participation and Detection Rate of Colorectal Cancer From a Population-Based Screening Program in China

Colorectal cancer (CRC) screening has been widely implemented in Europe and the USA. However, there is little evidence of participation and diagnostic yields in population-based CRC screening in China. The participation rate and detection of colorectal lesions in this program were reported and related factors were explored. The analysis was conducted in the context of the Cancer Screening Program in Urban China, which recruited 282,377 eligible participants aged 40–74 years from eight cities in Henan province from 2013 to 2019. A total of 39,834 participants were evaluated to be high risk for CRC by an established risk score system and were subsequently recommended for colonoscopy. Of 39,834 with high risk for CRC, 7,454 subjects undertook colonoscopy (participation rate of 18.71%). We found that 50–64 years, high level of education, marriage, former smoking, current alcohol drinking, low levels dietary intake of vegetables, high levels dietary intake of processed meat, lack of physical activity, fecal occult blood test positive result, history of colonic polyp, history of colorectitis, and family history of CRC were associated with increased participation of colonoscopy screening. Overall, 17 CRC (0.23%), 95 advanced adenoma (1.27%), 478 non-advanced adenomas dysplasia (6.41%), 248 hyperplastic polyp (3.33%), and 910 other benign lesions (12.21%) were detected. The findings from the study will provide important references for designing effective population-based CRC screening strategies in the future. Given the relatively low participation rate, there was room for improvement in the yield of CRC screening.

Key issues that need to be considered while revising the current annex of the European Council Recommendation (2003) on cancer screening

The 2003 European Council recommendation urging the Member States to introduce or scale up breast, cervical and colorectal cancer screening through an organized population-based approach has had a remarkable impact. We argue that the recommendation needs to be updated for at least two sets of reasons. First, some of the current clinical guidelines include new tests or protocols that were not available at the time of the Council document. Some have already been adopted by organized screening programs, such as newly defined age ranges for mammography screening, Human Papillomavirus (HPV)-based cervical cancer screening, fecal immunochemical test (FIT) and sigmoidoscopy for colorectal cancer screening. Second, the outcomes of randomized trials evaluating screening for lung and prostate cancer have been published recently and the balance between harms and benefits needs to be pragmatically assessed. In the European Union, research collaboration and networking to exchange and develop best practices should be regularly supported by the European Commission. Integration between primary and secondary preventive strategies through comprehensive approaches is necessary not only to maximize the reduction in cancer burden but also to control the rising trend of other noncommunicable diseases sharing the same risk factors.

A dynamic web-based decision aid to improve informed choice in organised breast cancer screening. A pragmatic randomised trial in Italy

Background

Improving the quality of information and communication is a priority in organised breast cancer screening and an ethical duty. Programmes must offer the information each woman is looking for, promoting informed decision-making. This study aimed to develop and evaluate a web-based dynamic decision aid (DA).

Methods

A pragmatic randomised trial carried out in six regional organised screening programmes recruited women at the first invitation receiving DA or a web-based standard brochure (SB). The primary outcome was informed choice measured on knowledge, attitudes, and intentions. Follow-up period: 7–10 days. Secondary outcomes included participation rate, satisfaction, decisional conflict, and acceptability of DA.

Results

Two thousand one hundred and nineteen women were randomised and 1001 completed the study. Respectively, 43.9% and 36.9% in the DA and SB reached the informed choice. The DA gave a 13-point higher proportion of women aware about overdiagnosis compared to SB (38.3% versus 25.2%, p < 0.0001). The percentage of women attending screening was the same: 84% versus 83%. Decisional conflict was significantly lower in the DA group (14.4%) than in the SB group (19.3%).

Conclusion

DA increases informed choice. Complete information including the pros, cons, controversies, and overdiagnosis–overtreatment issues boost a woman’s knowledge without reducing the rate of actual screening participation.

Clinical trial registration

ClinicalTrials.gov number NCT 03097653.

Geographic Inequalities in Breast Cancer in Italy: Trend Analysis of Mortality and Risk Factors

We calculated time trends of standardised mortality rates and risk factors for breast cancer (BC) from 1990 to 2016 for all women resident in Italy. The age-standardised mortality rate in Italy decreased from 4.2 in 1990 to 3.2 (×100,000) in 2016. While participation in organised screening programmes and age-standardised fertility rates decreased in Italy, screening invitation coverage and mammography uptake, the prevalence of women who breastfed and mean age at birth increased. Although southern regions had favourable prevalence of protective risk factors in the 1990s, fertility rates decreased in southern regions and increased in northern regions, which in 2016 had a higher rate (1.28 vs. 1.32 child per woman) and a smaller increase in women who breastfed (+4% vs. +30%). In 2000, mammography screening uptake was lower in southern than in northern and central regions (28% vs. 52%). However, the increase in mammography uptake was higher in southern (203%) than in northern and central Italy (80%), reducing the gap. Participation in mammographic screening programmes decreased in southern Italy (−10%) but increased in the North (6.6%). Geographic differences in mortality and risk factor prevalence is diminishing, with the South losing all of its historical advantage in breast cancer mortality.

Impact of chronic diseases on effect of breast cancer screening

Background

Although breast cancer screening reduces breast cancer mortality at the population level, subgroups of women may benefit differently. We investigated the impact of health status on the effect of breast cancer screening.

Methods

The study included 181 299 women invited in two population‐based screening programs in Denmark and 1 526 446 control subjects, followed from April 1981 to December 2014. Poisson regressions were used to compare the observed breast cancer mortality rate in women invited to screening with the expected rate in the absence of screening among women with and without chronic diseases. Chronic diseases were defined as any diagnosis in the Charlson Comorbidity Index during 4 years before the first invitation to screening.

Results

Almost 10% of women had chronic diseases before first invitation to screening. Whereas we observed a reduction in breast cancer mortality following invitation to screening of 28% (95% CI, 20% to 35%) among women without chronic diseases, only a 7% (95% CI, −39% to 37%) reduction was seen for women with chronic diseases (P‐value for interaction = .22). For participants, the reduction, corrected for selection bias, was 35% (95% CI 16% to 49%) for women without, and 4% (95% CI −146% to 62%) for women with chronic diseases (P‐value for interaction = .43).

Conclusion

Our data indicate a marginal effect of mammography screening on breast cancer mortality in women with chronic diseases. If our results are confirmed in other populations, the presence of chronic diseases will be an important factor to take into consideration in personalized screening.

Detection of high-risk human papillomavirus DNA in sentinel lymph nodes of patients with cervical cancer

The aim of the present study was to investigate the expression of human papillomavirus (HPV) DNA in sentinel lymph nodes (SLN) in patients with early-stage cervical cancer (CC). In addition, the present study compared the positive rate of SLNs metastasis detected by routine pathological examination, and investigated the value of HPV-DNA in the detection of early CC lymph node micrometastasis. Reverse transcription-quantitative PCR (RT-qPCR) was used in order to evaluate the HPV DNA detection in all CC samples [International Federation of Gynecology and Obstetrics (FIGO) stage IA2-IIA2]. The consistency of HPV-DNA was compared between primary lesions and SLNs. The positive rates of HPV-DNA were compared with pathological diagnosis of SLN metastasis, and the association between the positive expression of HPV-DNA in SLNs and the clinical and pathological parameters of patients with cervical cancer were analyzed. A total of 345 sentinel lymph nodes were detected in 100 patients with IA2-IIA2 CC. The positive rates of RT-qPCR and conventional histopathological detection of SLNs metastasis were 31.6% (109/345) and 12.8% (44/345), respectively (P<0.001). The positive expression of HPV-DNA in SLNs was associated with the clinical stage and tumor diameter (P<0.05), but not with patients' age, depth of cervical invasion, histological grade, lymphatic and vascular space invasion (LVSI), squamous cell carcinoma antigen (SCCAg) (P>0.05). The detection of HPV-DNA expression in pelvic lymph nodes of early CC may be used to improve the detection rate of micrometastasis, guide the postoperative adjuvant therapy more accurately and improve prognosis. Patients with positive HPV-DNA would require closer surveillance than those with negative HPV-DNA.

Return to Work of Breast Cancer Survivors: Perspectives and Challenges for Occupational Physicians

Breast cancer is one of the most common diseases worldwide, mainly affecting the female gender. Considering the increase of breast cancer incidence and the decrease of mortality due to news diagnostic and therapeutic tools, the return to work issue after treatment is going to be very common in the next years. Occupational physicians therefore need to face the return to work and the fitness for work of workers previously diagnosed with breast cancer with a sufficient cultural and technical background. In addition to individual characteristics preceding the diagnosis, clinical outcome, lifestyles and occupational variables are the most impactful factors on return to work that need to be taken into account. The aim of this work is to analyze these factors and discuss the central role of occupational physicians in the decision-making process of returning to work in breast cancer survivors.

Alarming endoscopic data in young and older asymptomatic people: Results of an open access, unlimited age colonoscopic screening for colorectal cancer

There is a lack of a national organized screening program for colorectal cancer in Greece, and asymptomatic detection is usually the result of individual decisions. The collection of epidemiologic endoscopic data from a population of interest would therefore provide valuable information for future treatment guidance, especially during periods of economic austerity. The current cross-sectional study included 380 asymptomatic, average risk individuals undergoing screening colonoscopy for the first time, during the period of one year in a tertiary public hospital in Athens. Descriptive and analytic epidemiologic data were analyzed. The prevalence of adenomas and advanced lesions were compared between the younger and older cohort, and a regression model was applied for risk evaluation. The mean age of participants was 63 years, and 53% were male. A significant proportion of patients presented with polyps (51.5%) and 25% of them had lesions in the proximal colon. The prevalence of adenomas and advanced adenomas was 29.5 and 11.8%, respectively. Similar high prevalence rates of lesions were identified in the cohort of individuals <50 years of age and the older cohort (>50 years of age). Regression models identified age, number and size of polyps as the major risk factors for the detection of adenomas. The increase of advanced lesions in the older and younger cohort requires confirmation by larger studies. Overall, the results of the present study indicate the requirement for a well-organized screening colonoscopy program starting from as early as 40 years of age. This program may confer an additional endoscopic burden with socioeconomic consequences in a country with limited health resources.

Risk-Adapted Starting Age of Screening for Relatives of Patients With Breast Cancer

Importance

Breast cancer screening guidelines acknowledge the need for earlier screening for women at increased risk but provide limited guidance for women with a family history of breast cancer. A risk-adapted starting age of screening for relatives of patients with breast cancer may help supplement current screening guidelines.

Objective

To identify the risk-adapted starting age of breast cancer screening on the basis of a woman's detailed family history.

Design, Setting, and Participants

This nationwide cohort study analyzed data recorded in the Swedish family-cancer data sets. All women born from 1932 onward and with at least 1 known first-degree relative (FDR) were included (N = 5 099 172). Data from January 1, 1958, to December 31, 2015, were collected. Data were analyzed from October 1, 2017, to March 31, 2019.

Exposures

Family history of breast cancer in FDRs and second-degree relatives (SDRs).

Main Outcomes and Measures

Primary invasive breast cancer diagnosis and the age at which women with different constellations of family history attained the risk level at which breast screening is usually recommended.

Results

Of the 5 099 172 women included in the study, 118 953 (2.3%) received a diagnosis of primary invasive breast cancer. A total of 102 751 women (86.4%; mean [SD] age at diagnosis, 55.9 [11.1] years) did not have family history of breast cancer in FDRs and SDRs at the time of their diagnosis. Risk-adapted starting age of breast cancer screening varied by number of FDRs and SDRs with breast cancer diagnosis and the age at diagnosis of the FDRs. For example, for screening recommendation at age 50 years for the general population (2.2% 10-year cumulative risk), women with multiple affected FDRs, with the youngest affected relative receiving a diagnosis before age 50 years, reached the benchmark risk level at age 27 years. When the youngest relative received a diagnosis after age 50 years, however, this risk level was attained at age 36 years.

Conclusions and Relevance

This study identifies possible risk-based starting ages for breast cancer screening based on population-based registers. These results may serve as high-quality evidence to supplement current screening guidelines for relatives of patients with breast cancer.

Cost-Effectiveness of Colorectal Cancer Screening Strategies-A Systematic Review

BACKGROUND & AIMS

Widespread screening for colorectal cancer (CRC) has reduced its incidence and mortality. Previous studies investigated the economic effects of CRC screening. We performed a systematic review to provide up-to-date evidence of the cost effectiveness of CRC screening strategies by answering 3 research questions.

METHODS

We searched PubMed, National Institute for Health Research Economic Evaluation Database, Social Sciences Citation Index (via the Web of Science), EconLit (American Economic Association) and 3 supplemental databases for original articles published in English from January 2010 through December 2017. All monetary values were converted to US dollars (year 2016). For all research questions, we extracted, or calculated (if necessary), per-person costs and life years (LYs) and/or quality-adjusted LYs, as well as the incremental costs per LY gained or quality-adjusted LY gained compared with the baseline strategy. A cost-saving strategy was defined as one that was less costly and equally or more effective than the baseline strategy. The net monetary benefit approach was used to answer research question 2.

RESULTS

Our review comprised 33 studies (17 from Europe, 11 from North America, 4 from Asia, and 1 from Australia). Annual and biennial guaiac-based fecal occult blood tests, annual and biennial fecal immunochemical tests, colonoscopy every 10 years, and flexible sigmoidoscopy every 5 years were cost effective (even cost saving in most US models) compared to no screening. In addition, colonoscopy every 10 years was less costly and/or more effective than other common strategies in the United States. Newer strategies such as computed tomographic colonography, every 5 or 10 years, was cost effective compared with no screening.

CONCLUSIONS

In an updated review, we found that common CRC screening strategies and computed tomographic colonography continued to be cost effective compared to no screening. There were discrepancies among studies from different regions, which could be associated with the model types or model assumptions.

The influence of health systems on breast, cervical and colorectal cancer screening: an overview of systematic reviews using health systems and implementation research frameworks

Objectives

Screening for breast, cervical and colorectal cancer in an average-risk population is widely recommended in national and international guidelines although their implementation varies. Using a conceptual framework that draws on implementation and health systems research, we provide an overview of systematic literature reviews that address health system and service barriers or facilitators to effective cancer screening.

Methods

Using a systematic approach, we searched Cochrane Database of Systematic Reviews, Ovid Medline, Ovid Embase, Web of Science, PsychInfo and other internet sources. We included systematic reviews of screening interventions (i.e. targeting people at average risk) for breast, cervical and colorectal cancer. The analysis included 90 systematic reviews.

Results

This review identified a multitude of barriers and facilitators affecting the health system, the capabilities of individuals in the system and their intentions. A large proportion of the available evidence focused on uptake. The reviews demonstrated that health system factors influenced participation, as well as quality and effectiveness of the service provided. The barriers with the biggest impact were knowledge/education, mainly of clients but also providers (capability barriers) and beliefs and values (intention barriers) of the eligible population. These findings complement the usual focus on psychological and social barriers to informed participation by individuals that dominate the screening literature. The facilitators with the most supporting evidence were educational interventions (overcoming capability and intention barriers), invitation letters, reminders and appointments. These were mainly directed at eligible individuals and, to a lesser extent, to providers and healthcare professionals. Only a small number of reviews, mainly from Europe, specified organized, rather than opportunistic, screening programmes. In those, low participation was the most frequently cited barrier and invitation letters (including physician endorsement, phone calls and reminders to non-responders and healthcare professionals) were the most prevalent facilitators.

Conclusion

Despite evidence of barriers and facilitators to screening participation and opportunistic screening, further health systems research covering the entire screening system for organized programmes is required.

Performance of colorectal cancer screening in the European Union Member States: data from the second European screening report

OBJECTIVE

To present comparative data about the performance of colorectal cancer (CRC) screening programmes in the European Union Member States (EU MSs).

DESIGN

Cross-sectional study. We analysed key performance indicators-participation rate, positivity rate (PR), detection rate (DR) and positive predictive value for adenomas and CRC-based on the aggregated quantitative data collected for the second EU screening report. We derived crude and pooled (through a random effects model) estimates to describe and compare trends across different MSs/regions and screening protocols.

RESULTS

Participation rate was higher in countries adopting faecal immunochemical test (FIT) (range: 22.8%-71.3%) than in those using guaiac faecal occult blood test (gFOBT) (range 4.5%-66.6%), and it showed a positive correlation (ρ=0.842, p<0.001) with participation in breast cancer screening in the same areas. Screening performance showed a large variability. Compliance with referral for colonoscopy (total colonoscopy (TC)) assessment ranged between 64% and 92%; TC completion rate ranged between 92% and 99%. PR and DR of advanced adenomas and CRC were higher in FIT, as compared with gFOBT programmes, and independent of the protocol among men, older subjects and those performing their first screening.

CONCLUSIONS

The variability in the results of quality indicators across population-based screening programmes highlights the importance of continuous monitoring, as well as the need to promote quality improvement efforts, as recommended in the EU guidelines. The implementation of monitoring systems, ensuring availability of data for the entire process, together with initiatives aimed to enhance reproducibility of histology and quality of endoscopy, represent a priority in screening programmes management.

Effect of a Single Aspirin Dose Prior to Fecal Immunochemical Testing on Test Sensitivity for Detecting Advanced Colorectal Neoplasms: A Randomized Clinical Trial

IMPORTANCE

Fecal immunochemical tests for hemoglobin are widely used for colorectal cancer (CRC) screening. Observational studies suggested that sensitivity of fecal immunochemical tests for detecting advanced neoplasms could be increased by acetylsalicylic acid (aspirin), especially among men.

OBJECTIVE

To evaluate the potential to increase sensitivity of fecal immunochemical tests by administering a single 300-mg oral aspirin dose 2 days before stool sampling.

DESIGN, SETTING, AND PARTICIPANTS

A randomized, placebo-controlled, double-blind trial was conducted in 14 gastroenterology practices and 4 hospitals in Germany, and included 2422 men and women aged 40 to 80 years scheduled for colonoscopy, with no recent use of aspirin or other drugs with antithrombotic effects (enrollment from June 2013 to November 2016, and final follow-up January 27, 2017).

INTERVENTIONS

Administration of a single tablet containing 300 mg of aspirin (n = 1208) or placebo (n = 1214) 2 days before fecal sampling for fecal immunochemical test.

MAIN OUTCOME AND MEASURES

The primary outcome was sensitivity of a quantitative fecal immunochemical test at 2 predefined cutoffs (10.2 and 17-μg Hb/g stool) for detecting advanced neoplasms (colorectal cancer or advanced adenoma).

RESULTS

Among 2422 randomized patients (mean [SD] age, 59.6 [7.9] years; 1219, 50%, men), 2134 were included in the analysis (78% for primary screening colonoscopy, 22% for diagnostic colonoscopy). Advanced neoplasms were identified in 224 participants (10.5%), including 8 participants (0.4%) with CRC and 216 participants (10.1%) with advanced adenoma. Sensitivity was 40.2% in the aspirin group and 30.4% in the placebo group (difference 9.8%, 95% CI, -3.1% to 22.2%, P = .14) at cutoff 10.2-μg Hb/g stool and 28.6% in the aspirin and 22.5% in the placebo group (difference 6.0%, 95% CI, -5.7% to 17.5%, P = .32) at cutoff 17-μg Hb/g stool.

CONCLUSIONS AND RELEVANCE

Among adults aged 40 to 80 years not using aspirin or other antithrombotic medications, administration of a single dose of oral aspirin prior to fecal immunochemical testing, compared with placebo, did not significantly increase test sensitivity for detecting advanced colorectal neoplasms at 2 predefined cutoffs of a quantitative fecal immunochemical test.

TRIAL REGISTRATION

Deutsches Register Klinischer Studien Identifier: DRKS00003252; EudraCT Identifier: 2011-005603-32/DE.

Comparative evaluation of novel screening strategies for colorectal cancer screening in China (TARGET-C): a study protocol for a multicentre randomised controlled trial

INTRODUCTION

Screening for colorectal cancer (CRC) is effective in reducing the disease burden. However, high-level evidence from randomised controlled trials on the effectiveness of CRC screening modalities is still lacking. We will conduct a large-scale multicentre randomised controlled trial in China to evaluate the effectiveness and cost-effectiveness of different CRC screening strategies.

METHODS AND ANALYSIS

20 000 eligible participants aged 50-74 years are enrolled in five provinces in China. After providing signed informed consent, the participants will be randomised into one of the three screening groups: (1) one-time colonoscopy (n=4000), (2) annual faecal immunochemical test (FIT) (n=8000) and (3) annual risk-adapted screening strategy (n=8000). The risk-adapted screening strategy will use an established CRC risk scoring system, the Asia-Pacific Colorectal Screening score. Participants at high risk of CRC will be referred for colonoscopy, while participants at low risk will be referred for an FIT. Information on clinical reports, epidemiological risk factors and health economic factors will be collected and stored in a web-based data management system. We will further request the participants to donate blood, faecal and saliva samples before conducting the colonoscopy. The primary outcome will be the detection rate of advanced colorectal neoplasia and the secondary outcomes will include the rates of CRC-related mortality, incidence of CRC, participation and complications. The study will last for at least 4 years and the cohort will be followed for 10 years to adequately answer the scientific questions.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of the National Cancer Center/Cancer Hospital, the Chinese Academy of Medical Sciences and Peking Union Medical College (18-013/1615). The results of the study will be submitted for publication in peer-reviewed journals and will be discussed by policy and decision makers.

TRIAL REGISTRATION NUMBER

ChiCTR1800015506.

Primary prevention: a need for concerted action

The burden of cancer is increasing worldwide, and Europe is no exception in this regard. Cancer incidence rate for men in 2018, excluding nonmelanoma skin cancers, averaged over the 40 UN-defined European countries has been estimated as 436/100 000. For women, the estimated incidence rate is 332.6/100 000. Although mortality rates are declining in most European countries, the total number of cancer deaths continues to rise due to an increase in the number of older people in the age range when the cancer typically occurs. The increase in incident cases and cancer deaths increases the pressure on healthcare infrastructure and related costs, thus presenting a challenge to health service sustainability in countries. In the general population, there remains a perception of an ever-increasing cancer risk. Hence, treatment alone is not a solution to address the cancer burden. At the same time, recent estimates of preventable fractions of cancer suggest that about half of all cancer cases could be prevented through rigorous implementation of successful prevention measures, among other actions, by following the cancer prevention recommendations of the European Code against Cancer. Smoking alone explains almost half of all preventable cancers, and the scattered way of implementing tobacco control in Europe with still increasing numbers of lung cancers in women demonstrates the gap between prevention potential and effectively implemented prevention. Cancer prevention clearly needs more resources, stronger support from decision-makers and society, and a solid network to better speak with one voice. The newly established 'Cancer Prevention Europe' (Forman et al., ) offers promising opportunities for the latter.

Cancer prevention policy in the EU: Best practices are now well recognised; no reason for countries to lag behind

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National Cancer Control Programmes (NCCPs) are key elements in cancer control.

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NCCPs’ role in national cancer policies of EU countries has grown significantly.

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Few quantitative assessments are available to evaluate success or failure of the implementation of NCCPs.

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Research on methodologies to better assess the effectiveness of cancer prevention policies should be enhanced.

Through the application of science to public health practice, National Cancer Control Programmes provide the framework for the development of policies on cancer control, with the ultimate goal of reducing cancer morbidity and mortality, and improving quality of life. In the last decade, a substantial number of Member States in the European Union (EU) have formulated and/or updated their National Cancer Control Programmes, Plans or Strategies including primary prevention (health promotion and environmental protection), secondary prevention (screening and early detection), integrated care and organization of services, and palliative care as main elements. Although tobacco control and population-based screening policies are examples of best practices that are gradually being implemented in most of the EU countries, there are still large regional differences in cancer burden arising from the wide variety of social determinants and other epidemiological factors, along with gaps in the policy and practical articulation of cancer control within the health systems. On the other hand, few quantitative assessments are available with regard to evaluating the success or failure of the implementation of these programmes, especially in terms of reducing cancer incidence or mortality. An EU framework to better assess of the effectiveness of cancer prevention policies and the factors triggering shortfall in best practices implementation seems imperative.

Colonoscopy as Part of Pre-Transplant Work-Up in Successful Kidney Transplant Candidates: Single-Center Experience and Review of Literature

Background

Screening colonoscopy is not obligatory in kidney pre-transplant work-up guidelines. According to recommendations, only transplant recipients over age 50 years should be screened. The aim of this study was to characterize endoscopic findings revealed as part of pre-transplant work-up.

Material/Methods

We retrospectively reviewed pre-transplant work-up charts of 434 adult patients who received a cadaveric donor kidney transplantation (KT) from 2012 to 2015. Endoscopic findings analysis with age subgroup (<50 and ≥50) analysis were performed.

Results

Out of 434 of patients that underwent KT, 29% have had a colonoscopy. In 75.6% of those, pathologies were found. Hemorrhoids were found in 33% and polyps in 30.7% of patients. Adenoma detection rate (ADR) was 18.1% (67.5% distal predominance). Advanced ADR was 10.2% (distal predominance). Diverticulosis was found in 28.3% of patients and ulcerative colitis was found in 2.4%. In age subgroup analysis, ADR was higher in patients ≥50 years compared to those <50 years (21.6% vs. 4%; p=0.041).

Conclusions

Colonoscopy as part of pre-transplant work-up enables removal of precancerous lesions and management of benign findings. All candidates meeting criteria for the general population should be screened. Patients under age 50 years could also benefit from colonoscopy as part of the pre-transplant work-up. Therefore, we suggest that baseline colonoscopy should be included in pre-transplant work-up guidelines for all patients, regardless of age. However, further studies are needed to confirm this recommendation.

The narrow path to organized LDCT lung cancer screening programs in Europe

A recent position statement by a group of European experts reviewed the current evidence for low-dose computed tomography (LDCT) lung cancer screening, based on the outcomes and screening performance of the published randomized trials and identified actions needed for eventual future implementation. After the National Lung Screening Trial (NLST) outcome publication, guidelines changed in USA and Canada, but there are still problems in real-world screening practice. In Europe any decision was postponed to the publication of the European randomized trial outcomes and recommendations continue to discourage screening for lung cancer in all member countries. The NELSON randomized controlled trial (RCT), the largest one in Europe, outcome results are still waited, whereas the MILD, DANTE, DLSCT and ITALUNG (all with small sample size) RCTs have published mortality and incidence data with adequate follow up. The implementation of an organized screening in Europe is conditioned by a health technology assessment process at European level. According with the European policy, confirmed in the recent European Cancer Code [2015], screening is transferred in current public-health practice according with evidence-based recommendations and based on organized, usually population-based, programs. Guidelines, standard indicators of performance, training of dedicated radiologists and professionals and a comprehensive quality assurance system is requested in European countries to implement nationally a public health screening program. Waiting the NELSON randomized trial results, key issues as modality for selection of high risk subjects and recruitment, integration of screening and smoking cessation, optimal screening regimen and related research on biomarkers should be assessed, discussed and reviewed. Informed decision making, promotion of primary prevention and integration of screening and smoking cessation are all essential components of a comprehensive risk reduction policy. The path to an Evidence-based screening practice is narrow and, in the absence of a well-established decision-making process, the risk of a spontaneous, uncontrolled use of LDCT screening or, on the other side, an oversight of the screening opportunity is high.

Thiopurines in Inflammatory Bowel Disease: New Findings and Perspectives

Thiopurines, available as azathioprine, mercaptopurine, and thioguanine, are immunomodulating agents primarily used to maintain corticosteroid-free remission in patients with inflammatory bowel disease. To provide a state-of-the-art overview of thiopurine treatment in inflammatory bowel disease, this clinical review critically summarises the available literature, as assessed by several experts in the field of thiopurine treatment and research in inflammatory bowel disease.

Time from breast cancer diagnosis to therapeutic surgery and breast cancer prognosis: A population-based cohort study

Theoretically, time from breast cancer diagnosis to therapeutic surgery should affect survival. However, it is unclear whether this holds true in a modern healthcare setting in which breast cancer surgery is carried out within weeks to months of diagnosis. This is a population- and register-based study of all women diagnosed with invasive breast cancer in the Stockholm-Gotland healthcare region in Sweden, 2001-2008, and who were initially operated. Follow-up of vital status ended 2014. 7,017 women were included in analysis. Our main outcome was overall survival. Main analyses were carried out using Cox proportional hazards models. We adjusted for likely confounders and stratified on mode of detection, tumor size and lymph node metastasis. We found that a longer interval between date of morphological diagnosis and therapeutic surgery was associated with a poorer prognosis. Assuming a linear association, the hazard rate of death from all causes increased by 1.011 (95% CI 1.006-1.017) per day. Comparing, for example, surgery 6 weeks after diagnosis to surgery 3 weeks after diagnosis, thereby confers a 1.26-fold increased hazard rate. The increase in hazard rate associated with surgical delay was strongest in women with largest tumors. Whilst there was a clear association between delays and survival in women without lymph node metastasis, the association may be attenuated in subgroups with increasing number of lymph node metastases. We found no evidence of an interaction between time to surgery and mode of detection. In conclusion, unwarranted delays to primary treatment of breast cancer should be avoided.