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Thiruvengadam NR, Solaimani P, Shrestha M, Buller S, Carson R, Reyes-Garcia B, Gnass RD, Wang B, Albasha N, Leonor P, Saumoy M, Coimbra R, Tabuenca A, Srikureja W, Serrao S. The Efficacy of Real-time Computer-aided Detection of Colonic Neoplasia in Community Practice: A Pragmatic Randomized Controlled Trial. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00225-8. [PMID: 38437999 DOI: 10.1016/j.cgh.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 02/12/2024] [Accepted: 02/13/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND & AIMS The use of computer-aided detection (CADe) has increased the adenoma detection rates (ADRs) during colorectal cancer (CRC) screening/surveillance in randomized controlled trials (RCTs) but has not shown benefit in real-world implementation studies. We performed a single-center pragmatic RCT to evaluate the impact of real-time CADe on ADRs in colonoscopy performed by community gastroenterologists. METHODS We enrolled 1100 patients undergoing colonoscopy for CRC screening, surveillance, positive fecal-immunohistochemical tests, and diagnostic indications at one community-based center from September 2022 to March 2023. Patients were randomly assigned (1:1) to traditional colonoscopy or real-time CADe. Blinded pathologists analyzed histopathologic findings. The primary outcome was ADR (the percentage of patients with at least 1 histologically proven adenoma or carcinoma). Secondary outcomes were adenomas detected per colonoscopy (APC), sessile-serrated lesion detection rate, and non-neoplastic resection rate. RESULTS The median age was 55.5 years (interquartile range, 50-62 years), 61% were female, 72.7% were of Hispanic ethnicity, and 9.1% had inadequate bowel preparation. The ADR for the CADe group was significantly higher than the traditional colonoscopy group (42.5% vs 34.4%; P = .005). The mean APC was significantly higher in the CADe group compared with the traditional colonoscopy group (0.89 ± 1.46 vs 0.60 ± 1.12; P < .001). The improvement in adenoma detection was driven by increased detection of <5 mm adenomas. CADe had a higher sessile-serrated lesion detection rate than traditional colonoscopy (4.7% vs 2.0%; P = .01). The improvement in ADR with CADe was significantly higher in the first half of the study (47.2% vs 33.7%; P = .002) compared with the second half (38.7% vs 34.9%; P = .33). CONCLUSIONS In a single-center pragmatic RCT, real-time CADe modestly improved ADR and APC in average-detector community endoscopists. (ClinicalTrials.gov number, NCT05963724).
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Affiliation(s)
- Nikhil R Thiruvengadam
- Division of Gastroenterology and Hepatology, Riverside University Health System, Moreno Valley, California; Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California.
| | - Pejman Solaimani
- Division of Gastroenterology and Hepatology, Riverside University Health System, Moreno Valley, California; Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California
| | - Manish Shrestha
- Division of Gastroenterology and Hepatology, Riverside University Health System, Moreno Valley, California; Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California
| | - Seth Buller
- Loma Linda University School of Medicine, Loma Linda, California
| | - Rachel Carson
- Division of Gastroenterology and Hepatology, Riverside University Health System, Moreno Valley, California; Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California
| | - Breanna Reyes-Garcia
- Division of Gastroenterology and Hepatology, Riverside University Health System, Moreno Valley, California; Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California
| | - Ronaldo D Gnass
- Department of Pathology, Riverside University Health System, Moreno Valley, California
| | - Bing Wang
- Department of Pathology, Loma Linda University School of Medicine, Loma Linda, California
| | - Natalie Albasha
- University of California Riverside School of Medicine, Riverside, California; Department of Medicine, Scripps Green Hospital, La Jolla, California
| | - Paul Leonor
- Division of Gastroenterology and Hepatology, Riverside University Health System, Moreno Valley, California; Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California
| | - Monica Saumoy
- Center for Digestive Health, Penn Medicine Princeton Medical Center, Plainsboro, New Jersey
| | - Raul Coimbra
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System, Moreno Valley, California; Department of Surgery, Riverside University Health System, Moreno Valley, California
| | - Arnold Tabuenca
- Department of Surgery, Riverside University Health System, Moreno Valley, California; Department of Surgery, University of California Riverside School of Medicine, Riverside, California
| | - Wichit Srikureja
- Division of Gastroenterology and Hepatology, Riverside University Health System, Moreno Valley, California; Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California
| | - Steve Serrao
- Division of Gastroenterology and Hepatology, Riverside University Health System, Moreno Valley, California; Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California
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Ladabaum U, Schoen RE, Meester R. NordICC's 10-Year Interim Results Are Unexpected and Inconsistent With Modeling Predictions. Gastroenterology 2024; 166:543-544. [PMID: 37783281 DOI: 10.1053/j.gastro.2023.09.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 10/04/2023]
Affiliation(s)
- Uri Ladabaum
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Robert E Schoen
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Reinier Meester
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California; Freenome, South San Francisco, California
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Vahdat V, Alagoz O, Chen JV, Saoud L, Borah BJ, Limburg PJ. Calibration and Validation of the Colorectal Cancer and Adenoma Incidence and Mortality (CRC-AIM) Microsimulation Model Using Deep Neural Networks. Med Decis Making 2023; 43:719-736. [PMID: 37434445 PMCID: PMC10422851 DOI: 10.1177/0272989x231184175] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 06/05/2023] [Indexed: 07/13/2023]
Abstract
OBJECTIVES Machine learning (ML)-based emulators improve the calibration of decision-analytical models, but their performance in complex microsimulation models is yet to be determined. METHODS We demonstrated the use of an ML-based emulator with the Colorectal Cancer (CRC)-Adenoma Incidence and Mortality (CRC-AIM) model, which includes 23 unknown natural history input parameters to replicate the CRC epidemiology in the United States. We first generated 15,000 input combinations and ran the CRC-AIM model to evaluate CRC incidence, adenoma size distribution, and the percentage of small adenoma detected by colonoscopy. We then used this data set to train several ML algorithms, including deep neural network (DNN), random forest, and several gradient boosting variants (i.e., XGBoost, LightGBM, CatBoost) and compared their performance. We evaluated 10 million potential input combinations using the selected emulator and examined input combinations that best estimated observed calibration targets. Furthermore, we cross-validated outcomes generated by the CRC-AIM model with those made by CISNET models. The calibrated CRC-AIM model was externally validated using the United Kingdom Flexible Sigmoidoscopy Screening Trial (UKFSST). RESULTS The DNN with proper preprocessing outperformed other tested ML algorithms and successfully predicted all 8 outcomes for different input combinations. It took 473 s for the trained DNN to predict outcomes for 10 million inputs, which would have required 190 CPU-years without our DNN. The overall calibration process took 104 CPU-days, which included building the data set, training, selecting, and hyperparameter tuning of the ML algorithms. While 7 input combinations had acceptable fit to the targets, a combination that best fits all outcomes was selected as the best vector. Almost all of the predictions made by the best vector laid within those from the CISNET models, demonstrating CRC-AIM's cross-model validity. Similarly, CRC-AIM accurately predicted the hazard ratios of CRC incidence and mortality as reported by UKFSST, demonstrating its external validity. Examination of the impact of calibration targets suggested that the selection of the calibration target had a substantial impact on model outcomes in terms of life-year gains with screening. CONCLUSIONS Emulators such as a DNN that is meticulously selected and trained can substantially reduce the computational burden of calibrating complex microsimulation models. HIGHLIGHTS Calibrating a microsimulation model, a process to find unobservable parameters so that the model fits observed data, is computationally complex.We used a deep neural network model, a popular machine learning algorithm, to calibrate the Colorectal Cancer Adenoma Incidence and Mortality (CRC-AIM) model.We demonstrated that our approach provides an efficient and accurate method to significantly speed up calibration in microsimulation models.The calibration process successfully provided cross-model validation of CRC-AIM against 3 established CISNET models and also externally validated against a randomized controlled trial.
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Affiliation(s)
- Vahab Vahdat
- Health Economics and Outcome Research, Exact Sciences Corporation, Madison, WI, USA
| | - Oguzhan Alagoz
- Departments of Industrial & Systems Engineering and Population Health Sciences, University of Wisconsin–Madison, Madison, WI, USA
| | - Jing Voon Chen
- Health Economics and Outcome Research, Exact Sciences Corporation, Madison, WI, USA
| | - Leila Saoud
- Health Economics and Outcome Research, Exact Sciences Corporation, Madison, WI, USA
| | - Bijan J. Borah
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| | - Paul J. Limburg
- Health Economics and Outcome Research, Exact Sciences Corporation, Madison, WI, USA
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Wilhelm C, Rebitschek FG. Medizinische Evidenz kompetent kommunizieren. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2023. [DOI: 10.1007/s00398-023-00568-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
ZusammenfassungWie alle Patienten in Deutschland sollen auch jene in der Herzchirurgie, soweit wie möglich, in die klinische Entscheidungsfindung eingebunden werden. Was möglich ist, hängt – neben Patientenvoraussetzungen – maßgeblich von den kommunikativen Fähigkeiten und Werkzeugen ab, die der beratende Arzt einsetzt, um informiertes Entscheiden auf Basis der besten verfügbaren medizinischen Erkenntnisse zu ermöglichen. Anhand von Schlüsselherausforderungen strukturiert dieser narrative Überblick Lösungsansätze für die Nutzung medizinischer Evidenz in Entscheidungsprozessen: unbestimmte Bezugsrahmen, relative Risiken, komplexe Informationen zu Entscheidungsoptionen bis hin zur Interpretation vorangehender diagnostischer Testergebnisse. Die dargestellten Lösungsansätze stellen in die Versorgung integrierbare Werkzeuge dar. Sie erfordern eine Kompetenzstärkung des Fachpersonals und qualitätsgesicherte medizinische Informationsangebote.
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Lu B, Wang L, Lu M, Zhang Y, Cai J, Luo C, Chen H, Dai M. Microsimulation Model for Prevention and Intervention of Coloretal Cancer in China (MIMIC-CRC): Development, Calibration, Validation, and Application. Front Oncol 2022; 12:883401. [PMID: 35530306 PMCID: PMC9072786 DOI: 10.3389/fonc.2022.883401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 03/24/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction A microsimulation model provides important references for decision-making regarding colorectal cancer (CRC) prevention strategies, yet such a well-validated model is scarce in China. Methods We comprehensively introduce the development of MIcrosimulation Model for the prevention and Intervention of Colorectal Cancer in China (MIMIC-CRC). The MIMIC-CRC was first constructed to simulate the natural history of CRC based on the adenoma-carcinoma pathway. The parameters were calibrated and validated using data from population-based cancer registry data and CRC screening programs. Furthermore, to assess the model’s external validity, we compared the model-derived results to outcome patterns of a sigmoidoscopy screening trial in the UK [UK Flexible Sigmoidoscopy Screening (UKFSS) trial]. Finally, we evaluated the application potential of the MIMIC-CRC model in CRC screening by comparing the 8 different strategies. Results We found that most of the model-predicted colorectal lesion prevalence was within the 95% CIs of observed prevalence in a large population-based CRC screening program in China. In addition, model-predicted sex- and age-specific CRC incidence and mortality were equivalent to the registry-based data. The hazard ratios of model-estimated CRC-related incidence and mortality for sigmoidoscopy screening compared to no screening were 0.60 and 0.51, respectively, which were comparable to the reported results of the UKFSS trial. Moreover, we found that all 8 strategies could reduce CRC incidence and mortality compared to no screening. Conclusions The well-calibrated and validated MIMIC-CRC model may represent a valid tool to assess the comparative effectiveness of CRC screening strategies and will be useful for further decision-making to CRC prevention.
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Affiliation(s)
- Bin Lu
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Le Wang
- Department of Cancer Prevention, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Cancer and Basic Medicine, Chinese Academy of Sciences, Hangzhou, China
| | - Ming Lu
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuhan Zhang
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie Cai
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chenyu Luo
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongda Chen
- Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Min Dai, ; Hongda Chen,
| | - Min Dai
- Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Min Dai, ; Hongda Chen,
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Cross AJ, Robbins EC, Saunders BP, Duffy SW, Wooldrage K. Higher Adenoma Detection Rates at Screening Associated With Lower Long-Term Colorectal Cancer Incidence and Mortality. Clin Gastroenterol Hepatol 2022; 20:e148-e167. [PMID: 32931959 PMCID: PMC8811539 DOI: 10.1016/j.cgh.2020.09.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 09/09/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Detection and removal of adenomas reduces colorectal cancer (CRC) risk. The impact of adenoma detection rates (ADRs) on long-term CRC incidence and mortality is unknown. We investigated this using data from the UK Flexible Sigmoidoscopy Screening Trial. METHODS Of 167,882 UK Flexible Sigmoidoscopy Screening Trial participants, 40,085 were in the intervention arm and underwent flexible sigmoidoscopy screening at 13 trial centers. The median follow-up time was 17 years. At each center, 1 endoscopist performed most flexible sigmoidoscopies. Multivariable logistic regression was used to classify centers into high-, intermediate-, and low-detector groups based on their main endoscopist's ADR. We calculated the incidence and mortality of distal and all-site CRC, and estimated hazard ratios (HRs) with 95% CIs using Cox regression. RESULTS Five, 4, and 4 centers, respectively, were classified into the high-detector, intermediate-detector, and low-detector groups. The average ADRs in each respective group were 15%, 12%, and 9%. Distal CRC incidence and mortality were reduced among those screened compared with controls in all groups, and effects of screening varied significantly by detector ranking, with larger reductions in incidence and mortality seen in the high-detector group (incidence: HR, 0.34; 95% CI, 0.27-0.42; mortality: HR, 0.22, 95% CI, 0.13-0.37) than in the low-detector group (incidence: HR, 0.55; 95% CI, 0.44-0.68; mortality: HR, 0.54; 95% CI, 0.34-0.86). Similar results were observed for all-site CRC, with larger effects seen in the high-detector (incidence: HR, 0.58; 95% CI, 0.50-0.67; mortality: HR, 0.52; 95% CI, 0.39-0.69) than in the low-detector group (incidence: HR, 0.72; 95% CI, 0.61-0.85; mortality: HR, 0.68; 95% CI, 0.51-0.92), although the heterogeneity was not statistically significant. CONCLUSIONS Higher ADRs at screening provide greater long-term protection against CRC incidence and mortality. Isrctn.org, number: ISRCTN28352761.
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Affiliation(s)
- Amanda J Cross
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, United Kingdom.
| | - Emma C Robbins
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Brian P Saunders
- Wolfson Unit for Endoscopy, St Mark's Hospital, London, United Kingdom
| | - Stephen W Duffy
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University, London, United Kingdom
| | - Kate Wooldrage
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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DeYoreo M, Rutter CM, Ozik J, Collier N. Sequentially calibrating a Bayesian microsimulation model to incorporate new information and assumptions. BMC Med Inform Decis Mak 2022; 22:12. [PMID: 35022005 PMCID: PMC8756687 DOI: 10.1186/s12911-021-01726-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 12/17/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Microsimulation models are mathematical models that simulate event histories for individual members of a population. They are useful for policy decisions because they simulate a large number of individuals from an idealized population, with features that change over time, and the resulting event histories can be summarized to describe key population-level outcomes. Model calibration is the process of incorporating evidence into the model. Calibrated models can be used to make predictions about population trends in disease outcomes and effectiveness of interventions, but calibration can be challenging and computationally expensive. METHODS This paper develops a technique for sequentially updating models to take full advantage of earlier calibration results, to ultimately speed up the calibration process. A Bayesian approach to calibration is used because it combines different sources of evidence and enables uncertainty quantification which is appealing for decision-making. We develop this method in order to re-calibrate a microsimulation model for the natural history of colorectal cancer to include new targets that better inform the time from initiation of preclinical cancer to presentation with clinical cancer (sojourn time), because model exploration and validation revealed that more information was needed on sojourn time, and that the predicted percentage of patients with cancers detected via colonoscopy screening was too low. RESULTS The sequential approach to calibration was more efficient than recalibrating the model from scratch. Incorporating new information on the percentage of patients with cancers detected upon screening changed the estimated sojourn time parameters significantly, increasing the estimated mean sojourn time for cancers in the colon and rectum, providing results with more validity. CONCLUSIONS A sequential approach to recalibration can be used to efficiently recalibrate a microsimulation model when new information becomes available that requires the original targets to be supplemented with additional targets.
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Affiliation(s)
- Maria DeYoreo
- RAND Corporation, 1776 Main St., Santa Monica, CA, 90401, USA.
| | | | - Jonathan Ozik
- Argonne National Laboratory, Building 221, 9700 South Cass Avenue, Argonne, IL, 60439, USA
| | - Nicholson Collier
- Argonne National Laboratory, Building 221, 9700 South Cass Avenue, Argonne, IL, 60439, USA
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Rutter CM, Nascimento de Lima P, Lee JK, Ozik J. Too Good to Be True? Evaluation of Colonoscopy Sensitivity Assumptions Used in Policy Models. Cancer Epidemiol Biomarkers Prev 2021; 31:775-782. [PMID: 34906968 DOI: 10.1158/1055-9965.epi-21-1001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/13/2021] [Accepted: 11/23/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Models can help guide colorectal cancer (CRC) screening policy. While models are carefully calibrated and validated, there is less scrutiny of assumptions about test performance. METHODS We examined the validity of the CRC-SPIN model and colonoscopy sensitivity assumptions. Standard sensitivity assumptions, consistent with published decision analyses, assume sensitivity equal to 0.75 for diminutive adenomas (<6mm), 0.85 for small adenomas (6-10mm), 0.95 for large adenomas ( {greater than or equal to} 10mm), and 0.95 for preclinical cancer. We also selected adenoma sensitivity that resulted in more accurate predictions. Targets were drawn from the Wheat Bran Fiber study. We examined how well the model predicted outcomes measured over a three-year follow-up period, including: the number of adenomas detected, the size of the largest adenoma detected, and incident CRC. RESULTS Using standard sensitivity assumptions, the model predicted adenoma prevalence that was too low (42.5% versus 48.9% observed, with 95% confidence interval 45.3%-50.7%) and detection of too few large adenomas (5.1% versus 14.% observed, with 95% confidence interval 11.8%-17.4%). Predictions were close to targets when we set sensitivities to 0.20 for diminutive adenomas, 0.60 for small adenomas, 0.80 for 10-20mm adenomas, and 0.98 for adenomas 20mm and larger. CONCLUSIONS Colonoscopy may be less accurate than currently assumed, especially for diminutive adenomas. Alternatively, the CRC-SPIN model may not accurately simulate onset and progression of adenomas in higher-risk populations. IMPACT Misspecification of either colonoscopy sensitivity or disease progression in high-risk populations may impact the predicted effectiveness of CRC screening. When possible, decision analyses used to inform policy should address these uncertainties.
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Affiliation(s)
| | | | - Jeffrey K Lee
- Division of Research, Kaiser Permanente Northern California
| | - Jonathan Ozik
- Decision and Infrastructure Sciences Division, Argonne National Laboratory
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Evolving Evidence Supporting Use of Rectal Irrigation in the Management of Bowel Dysfunction: An Integrative Literature Review. J Wound Ostomy Continence Nurs 2021; 48:553-559. [PMID: 34781312 DOI: 10.1097/won.0000000000000816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Disorders of bowel function are prevalent, particularly among patients with spinal cord injuries and other neurological disorders. An individual's bowel control significantly impacts quality of life, as predictable bowel function is necessary to actively and independently participate in everyday activities. For many patients with bowel dysfunction, initial lifestyle adjustments and other conservative therapeutic interventions (eg, digital stimulation, oral laxatives, suppositories) are insufficient to reestablish regular bowel function. In addition to these options, rectal irrigation (RI) is a safe and effective method of standard bowel care that has been used for several decades in adults and children suffering from bowel dysfunction associated with neurogenic or functional bowel etiologies. Rectal irrigation is an appropriate option when conservative bowel treatments are inadequate. Unlike surgical options, RI can be initiated or discontinued at any time. This report summarizes the clinical, humanistic, and economic evidence supporting the use of RI in clinical practice, noting features (eg, practical considerations, patient education) that can improve patients' success with RI treatment.
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Koh P, Cole N, Evans HM, McFarlane J, Roberts AJ. Diagnostic utility of upper and lower gastrointestinal endoscopy for the diagnosis of acute graft-versus-host disease in children following stem cell transplantation: A 12-year experience. Pediatr Transplant 2021; 25:e14046. [PMID: 34076318 DOI: 10.1111/petr.14046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 03/30/2021] [Accepted: 04/29/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND Endoscopically obtained mucosal biopsies are the gold standard for diagnosing acute graft-versus-host disease of the gastrointestinal tract (GI-GVHD). There is no consensus on the ideal endoscopic approach in children. We aimed to ascertain which gastrointestinal sites and endoscopic approaches were most helpful for diagnosing acute GVHD and whether clinical symptoms can guide the endoscopic approach. METHOD A single-center retrospective review of all pediatric stem cell transplants (SCT) between January 1, 2007, and December 31, 2018. Of those with histologically diagnosed GI-GVHD, sensitivities of individual GI sites for making the diagnosis were calculated. Clinical symptoms were compared with GI site yielding diagnosis. RESULTS 216 allogeneic SCTs were performed in 199 patients. 37 of 52 suspected GI-GHVD cases underwent endoscopy. There was marked variability in the endoscopic approaches chosen. 82% of these cases had lower gastrointestinal symptoms. 21 cases had histologically proven GI-GVHD. 19 (90%) of these had GVHD of non-gastrointestinal sites; 10 (48%) had concurrent infections. The most-sensitive GI sites were the rectosigmoid and duodenum (86% and 76%, respectively). Overall sensitivity of upper GI endoscopy (UGIE) and lower GI endoscopy (LGIE) was 86% and 90%, respectively. There was no statistically significant association between clinical symptoms and site at which histological diagnosis was obtained. CONCLUSION We observed variability in the endoscopic approach used by clinicians. UGIE and sigmoidoscopy had high sensitivities for diagnosing GVHD, regardless of symptoms. LGIE had minimal additional diagnostic value. This would support a standardized approach with UGIE and sigmoidoscopy for all children with suspected GI-GVHD.
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Affiliation(s)
- Phoebe Koh
- Department of Paediatric Gastroenterology, Starship Child Health, Auckland, New Zealand
| | - Nyree Cole
- Stem Cell Transplant Unit, Starship Child Health Auckland, Auckland, New Zealand
| | - Helen M Evans
- Department of Paediatric Gastroenterology, Starship Child Health, Auckland, New Zealand.,Department of Paediatrics, University of Auckland, Auckland, New Zealand
| | - Jeannette McFarlane
- Department of Anatomical Pathology, Auckland City Hospital, Auckland, New Zealand
| | - Amin J Roberts
- Department of Paediatric Gastroenterology, Starship Child Health, Auckland, New Zealand.,Department of Paediatrics, University of Auckland, Auckland, New Zealand
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Medina-Lara A, Grigore B, Lewis R, Peters J, Price S, Landa P, Robinson S, Neal R, Hamilton W, Spencer AE. Cancer diagnostic tools to aid decision-making in primary care: mixed-methods systematic reviews and cost-effectiveness analysis. Health Technol Assess 2021; 24:1-332. [PMID: 33252328 DOI: 10.3310/hta24660] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Tools based on diagnostic prediction models are available to help general practitioners diagnose cancer. It is unclear whether or not tools expedite diagnosis or affect patient quality of life and/or survival. OBJECTIVES The objectives were to evaluate the evidence on the validation, clinical effectiveness, cost-effectiveness, and availability and use of cancer diagnostic tools in primary care. METHODS Two systematic reviews were conducted to examine the clinical effectiveness (review 1) and the development, validation and accuracy (review 2) of diagnostic prediction models for aiding general practitioners in cancer diagnosis. Bibliographic searches were conducted on MEDLINE, MEDLINE In-Process, EMBASE, Cochrane Library and Web of Science) in May 2017, with updated searches conducted in November 2018. A decision-analytic model explored the tools' clinical effectiveness and cost-effectiveness in colorectal cancer. The model compared patient outcomes and costs between strategies that included the use of the tools and those that did not, using the NHS perspective. We surveyed 4600 general practitioners in randomly selected UK practices to determine the proportions of general practices and general practitioners with access to, and using, cancer decision support tools. Association between access to these tools and practice-level cancer diagnostic indicators was explored. RESULTS Systematic review 1 - five studies, of different design and quality, reporting on three diagnostic tools, were included. We found no evidence that using the tools was associated with better outcomes. Systematic review 2 - 43 studies were included, reporting on prediction models, in various stages of development, for 14 cancer sites (including multiple cancers). Most studies relate to QCancer® (ClinRisk Ltd, Leeds, UK) and risk assessment tools. DECISION MODEL In the absence of studies reporting their clinical outcomes, QCancer and risk assessment tools were evaluated against faecal immunochemical testing. A linked data approach was used, which translates diagnostic accuracy into time to diagnosis and treatment, and stage at diagnosis. Given the current lack of evidence, the model showed that the cost-effectiveness of diagnostic tools in colorectal cancer relies on demonstrating patient survival benefits. Sensitivity of faecal immunochemical testing and specificity of QCancer and risk assessment tools in a low-risk population were the key uncertain parameters. SURVEY Practitioner- and practice-level response rates were 10.3% (476/4600) and 23.3% (227/975), respectively. Cancer decision support tools were available in 83 out of 227 practices (36.6%, 95% confidence interval 30.3% to 43.1%), and were likely to be used in 38 out of 227 practices (16.7%, 95% confidence interval 12.1% to 22.2%). The mean 2-week-wait referral rate did not differ between practices that do and practices that do not have access to QCancer or risk assessment tools (mean difference of 1.8 referrals per 100,000 referrals, 95% confidence interval -6.7 to 10.3 referrals per 100,000 referrals). LIMITATIONS There is little good-quality evidence on the clinical effectiveness and cost-effectiveness of diagnostic tools. Many diagnostic prediction models are limited by a lack of external validation. There are limited data on current UK practice and clinical outcomes of diagnostic strategies, and there is no evidence on the quality-of-life outcomes of diagnostic results. The survey was limited by low response rates. CONCLUSION The evidence base on the tools is limited. Research on how general practitioners interact with the tools may help to identify barriers to implementation and uptake, and the potential for clinical effectiveness. FUTURE WORK Continued model validation is recommended, especially for risk assessment tools. Assessment of the tools' impact on time to diagnosis and treatment, stage at diagnosis, and health outcomes is also recommended, as is further work to understand how tools are used in general practitioner consultations. STUDY REGISTRATION This study is registered as PROSPERO CRD42017068373 and CRD42017068375. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology programme and will be published in full in Health Technology Assessment; Vol. 24, No. 66. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Antonieta Medina-Lara
- Health Economics Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Bogdan Grigore
- Exeter Test Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Ruth Lewis
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
| | - Jaime Peters
- Exeter Test Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Sarah Price
- Primary Care Diagnostics, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Paolo Landa
- Health Economics Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Sophie Robinson
- Peninsula Technology Assessment Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Richard Neal
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - William Hamilton
- Primary Care Diagnostics, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Anne E Spencer
- Health Economics Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
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Robbins EC, Wooldrage K, Stenson I, Pack K, Duffy S, Weller D, Levin T, Conell C, Wright S, Nickerson C, Martin J, Cross AJ. Heterogeneity in colorectal cancer incidence among people recommended 3-yearly surveillance post-polypectomy: a validation study. Endoscopy 2021; 53:402-410. [PMID: 32814350 PMCID: PMC8007389 DOI: 10.1055/a-1217-0155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 06/12/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Colonoscopy surveillance is recommended for patients at increased risk of colorectal cancer (CRC) following adenoma removal. Low-, intermediate-, and high-risk groups are defined by baseline adenoma characteristics. We previously examined intermediate-risk patients from hospital data and identified a higher-risk subgroup who benefited from surveillance and a lower-risk subgroup who may not require surveillance. This study explored whether these findings apply in individuals undergoing CRC screening. METHODS This retrospective study used data from the UK Flexible Sigmoidoscopy Screening Trial (UKFSST), English CRC screening pilot (ECP), and US Kaiser Permanente CRC prevention program (KPCP). Screening participants (50 - 74 years) classified as intermediate-risk at baseline colonoscopy were included. CRC data were available through 2006 (KPCP) or 2014 (UKFSST, ECP). Lower- and higher-risk subgroups were defined using our previously identified baseline risk factors: higher-risk participants had incomplete colonoscopies, poor bowel preparation, adenomas ≥ 20 mm or with high-grade dysplasia, or proximal polyps. We compared CRC incidence in these subgroups and in the presence vs. absence of surveillance using Cox regression. RESULTS Of 2291 intermediate-risk participants, 45 % were classified as higher risk. Median follow-up was 11.8 years. CRC incidence was higher in the higher-risk than lower-risk subgroup (hazard ratio [HR] 2.08, 95 % confidence interval [CI] 1.07 - 4.06). Surveillance reduced CRC incidence in higher-risk participants (HR 0.35, 95 %CI 0.14 - 0.86) but not statistically significantly so in lower-risk participants (HR 0.41, 95 %CI 0.12 - 1.38). CONCLUSION As previously demonstrated for hospital patients, screening participants classified as intermediate risk comprised two risk subgroups. Surveillance clearly benefited the higher-risk subgroup.
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Affiliation(s)
- Emma C. Robbins
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, United Kingdom
| | - Kate Wooldrage
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, United Kingdom
| | - Iain Stenson
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, United Kingdom
| | - Kevin Pack
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, United Kingdom
| | - Stephen Duffy
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University, London, United Kingdom
| | - David Weller
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Theodore Levin
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States
| | - Carol Conell
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States
| | - Suzanne Wright
- Public Health England (PHE) Screening, Sheffield, United Kingdom
| | - Claire Nickerson
- Public Health England (PHE) Screening, Sheffield, United Kingdom
| | - Jessica Martin
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, United Kingdom
| | - Amanda J. Cross
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, United Kingdom
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13
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Randel KR, Schult AL, Botteri E, Hoff G, Bretthauer M, Ursin G, Natvig E, Berstad P, Jørgensen A, Sandvei PK, Olsen ME, Frigstad SO, Darre-Næss O, Norvard ER, Bolstad N, Kørner H, Wibe A, Wensaas KA, de Lange T, Holme Ø. Colorectal Cancer Screening With Repeated Fecal Immunochemical Test Versus Sigmoidoscopy: Baseline Results From a Randomized Trial. Gastroenterology 2021; 160:1085-1096.e5. [PMID: 33227280 DOI: 10.1053/j.gastro.2020.11.037] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 10/29/2020] [Accepted: 11/17/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND & AIMS The comparative effectiveness of sigmoidoscopy and fecal immunochemical testing (FIT) for colorectal cancer (CRC) screening is unknown. METHODS Individuals aged 50-74 years living in Southeast Norway were randomly invited between 2012 and 2019 to either once-only flexible sigmoidoscopy or FIT screening every second year. Colonoscopy was recommended after sigmoidoscopy if any polyp of ≥10 mm, ≥3 adenomas, any advanced adenomas, or CRC was found or, subsequent to, FIT >15 μg hemoglobin/g feces. Data for this report were obtained after complete recruitment in both groups and included 2 full FIT rounds and part of the third round. Outcome measures were participation, neoplasia detection, and adverse events. Age-standardized detection rates and age-adjusted odds ratios (ORs) were calculated. RESULTS We included 139,291 individuals: 69,195 randomized to sigmoidoscopy and 70,096 to FIT. The participation rate was 52% for sigmoidoscopy, 58% in the first FIT round, and 68% for 3 cumulative FIT rounds. Compared to sigmoidoscopy, the detection rate for CRC was similar in the first FIT round (0.25% vs 0.27%; OR, 0.92; 95% confidence interval [CI], 0.75-1.13) but higher after 3 FIT rounds (0.49% vs 0.27%; OR, 1.87; 95% CI, 1.54-2.27). Advanced adenoma detection rate was lower in the first FIT round compared to sigmoidoscopy at 1.4% vs 2.4% (OR, 0.57; 95% CI, 0.53-0.62) but higher after 3 cumulative FIT rounds at 2.7% vs 2.4% (OR, 1.14; 95% CI, 1.05-1.23). There were 33 (0.05%) serious adverse events in the sigmoidoscopy group compared to 47 (0.07%) in the FIT group (P = .13). CONCLUSIONS Participation was higher and more CRC and advanced adenomas were detected with repeated FIT compared to sigmoidoscopy. The risk of perforation and bleeding was comparable. Clinicaltrials.gov, Number: NCT01538550.
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Affiliation(s)
- Kristin R Randel
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway; Department of Research and Development, Telemark Hospital Trust, Skien, Norway; Institute of Health and Society, University of Oslo, Oslo, Norway.
| | - Anna L Schult
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway; Department of Medicine, Vestre Viken Hospital Trust Bærum, Gjettum, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Edoardo Botteri
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
| | - Geir Hoff
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway; Department of Research and Development, Telemark Hospital Trust, Skien, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Michael Bretthauer
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo; Norway Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Giske Ursin
- Cancer Registry of Norway, Oslo, Norway; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway; Department of Preventive Medicine, University of Southern California, Los Angeles, California
| | - Erik Natvig
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
| | - Paula Berstad
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
| | - Anita Jørgensen
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
| | | | - Marie Ek Olsen
- Department of Pathology, Østfold Hospital Trust, Grålum, Norway
| | - Svein Oskar Frigstad
- Department of Medicine, Vestre Viken Hospital Trust Bærum, Gjettum, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ole Darre-Næss
- Department of Medicine, Vestre Viken Hospital Trust Bærum, Gjettum, Norway
| | - Espen R Norvard
- Department of Pathology, Vestre Viken Hospital Trust Drammen, Drammen, Norway
| | - Nils Bolstad
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Hartwig Kørner
- Department of Gastrointestinal Surgery, Stavanger University Hospital Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Arne Wibe
- Norwegian University of Science and Technology; Department of Surgery, St. Olav's hospital, Trondheim University Hospital, Trondheim, Norway
| | - Knut-Arne Wensaas
- Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway
| | - Thomas de Lange
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Medical Research, Vestre Viken Hospital Trust Bærum, Gjettum, Norway; Department of Medicine, Sahlgrenska University Hospital-Mölndal, Sweden
| | - Øyvind Holme
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway; Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo; Department of Medicine, Sorlandet Hospital Trust, Kristiansand, Norway
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14
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Validity and Reliability of the Instruments to Measure Colorectal Cancer Screening Benefits and Barriers-Turkish Version. Cancer Nurs 2020; 45:E364-E373. [PMID: 33399288 DOI: 10.1097/ncc.0000000000000921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Perceptions of benefits and barriers are important determinants in understanding colorectal cancer screening (CRCS) behaviors. There is a need for standardized Turkish tools that measure the benefits and barriers of fecal occult blood test (FOBT) and colonoscopy (COL). OBJECTIVE The aim of this study was to assess the validity and reliability of the Turkish version of the "Instruments to Measure CRCS Benefits and Barriers." METHODS This methodological study was carried out in 2 stages in primary care and in 394 adults between the ages of 50 and 70 years. In the first stage, some items of the scales demonstrated low/unacceptable corrected item-total and factor loadings, and in the second stage, it was decided to add emoji-based facial scales, which include emoji expressions. RESULTS Results with the emoji-based facial scales included internal consistency coefficients of 0.85 for FOBT benefits, 0.79 for FOBT barriers, 0.84 for COL benefits, and 0.86 for COL barriers; the item-total correlations of FOBT varied between 0.39 and 0.73, whereas those of COL varied between 0.38 and 0.76. The factor loadings of all items were higher than 0.40. CONCLUSIONS The emoji-based facial scale for CRC Screening Benefits and Barriers is a valid and reliable tool for measuring the benefits and barriers perceptions of 50- to 70-year-old Turkish adults. IMPLICATIONS FOR PRACTICE The Instruments to Measure CRCS Benefits and Barriers-Turkish version can provide insights for nurses and healthcare professionals to understand individuals' perceived FOBT and COL benefits and barriers and to develop effective interventions to increase CRCS rates.
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15
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DeYoreo M, Lansdorp-Vogelaar I, Knudsen AB, Kuntz KM, Zauber AG, Rutter CM. Validation of Colorectal Cancer Models on Long-term Outcomes from a Randomized Controlled Trial. Med Decis Making 2020; 40:1034-1040. [PMID: 33078673 PMCID: PMC7665984 DOI: 10.1177/0272989x20961095] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Microsimulation models are often used to predict long-term outcomes and guide policy decisions regarding cancer screening. The United Kingdom Flexible Sigmoidoscopy Screening (UKFSS) Trial examines a one-time intervention of flexible sigmoidoscopy that was implemented before a colorectal cancer (CRC) screening program was established. Long-term study outcomes, now a full 17 y following randomization, have been published. We use the outcomes from this trial to validate 3 microsimulation models for CRC to long-term study outcomes. We find that 2 of 3 models accurately predict the relative effect of screening (the hazard ratios) on CRC-specific incidence 17 y after screening. We find that all 3 models yield predictions of the relative effect of screening on CRC incidence and mortality (i.e., the hazard ratios) that are reasonably close to the UKFSS results. Two of the 3 models accurately predict the relative reduction in CRC incidence 17 y after screening. One model accurately predicted the absolute incidence and mortality rates in the screened group. The models differ in their estimates related to adenoma detection at screening. Although high-quality screening results help to inform models, trials are expensive, last many years, and can be complicated by ethical issues and technological changes across the duration of the trial. Thus, well-calibrated and validated models are necessary to predict outcomes for which data are not available. The results from this validation demonstrate the utility of models in predicting long-term outcomes and in collaborative modeling to account for uncertainty.
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Affiliation(s)
| | | | - Amy B Knudsen
- Institute for Technology Assessment and Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Karen M Kuntz
- Department of Health Policy and Management, University of Minnesota, School of Public Health, Minneapolis, MN, USA
| | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, NY, USA
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16
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Temucin E, Nahcivan NO. The Effects of the Nurse Navigation Program in Promoting Colorectal Cancer Screening Behaviors: a Randomized Controlled Trial. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2020; 35:112-124. [PMID: 30470978 DOI: 10.1007/s13187-018-1448-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Although screening programs are known and recommended for the early detection of colorectal cancer (CRC), the screening rates for the fecal occult blood test (FOBT) and colonoscopy are very low among adult individuals. Navigation programs, also known as individualized counseling, have recently begun to be used for increasing screening rates. The purpose of this study was to compare the efficacy of the Nurse Navigation Program versus usual care on CRC screening participation and movement in stage of adoption for CRC screening and to examine perceived benefits of and barriers to CRC screening. This study was designed in line with a pre- and posttest two-group methodology. A total of 110 participants (55 nurse-navigated and 55 non-navigated patients) were studied. Data were collected using the following three tools: a sociodemographic information form, the Harvard Colorectal Cancer Risk Assessment Tool, and Instruments to Measure Colorectal Cancer Screening Benefits and Barriers. Following the Nurse Navigation Program, the FOBT (82 and 84%, respectively) and colonoscopy completion rates (15 and 22%, respectively) were significantly higher in the nurse-navigated group than in the non-navigated group at 3 and 6 months follow-up. Following the program, the benefit perceptions of the nurse-navigated group about CRC screening were improved, and their barrier perceptions were reduced. The results showed that the Nurse Navigation Program had significant effects on CRC screening behavior and health-related beliefs concerning CRC screening. Further assessment of the Nurse Navigation Program in different groups should be performed to observe its effects.
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Affiliation(s)
- Elif Temucin
- Nursing Faculty, Oncology Nursing Department, University of Health Sciences, Istanbul, Turkey.
| | - Nursen O Nahcivan
- Florence Nightingale Nursing Faculty, Public Health Nursing Department, Istanbul University, Istanbul, Turkey
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17
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Sun M, Wang Y, Sundquist J, Sundquist K, Ji J. Temporal Trends of Sex Disparity in Incidence and Survival of Colorectal Cancer: Variations by Anatomical Site and Age at Diagnosis. Clin Epidemiol 2020; 12:73-81. [PMID: 32021473 PMCID: PMC6983464 DOI: 10.2147/clep.s240006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 12/21/2019] [Indexed: 12/18/2022] Open
Abstract
Purpose The incidence of colorectal cancer (CRC) varies by age, sex, and anatomical subsite. Few studies have examined the temporal trends of age-specific sex disparity in incidence and survival by age at diagnosis and anatomical site. Patients and Methods The study was performed on all incident cases of CRC, using data derived from the nationwide Swedish Cancer Register between 1960 and 2014, including right-sided colon cancer (RCC), left-sided colon cancer (LCC), and rectal cancer. Male-to-female age-standardized incidence rate ratio (IRR) and male-to-female five-year survival rate ratio (SRR) were calculated as the main indicators. Furthermore, we performed joinpoint regression analyses to estimate average annual percentage change. Results The overall male-to-female IRR was 1.05 for RCC, 1.31 for LCC, and 1.66 for rectal cancer. Male-to-female IRR increased steadily for RCC by an average of 0.4% per year until the mid-1990s and then decreased gradually by an average of 1.0% per year. LCC patients showed an increase of 0.6% per year since the mid-1970s. For rectal cancer, a non-significant random fluctuation was noted during the study period. The temporal trends of male-to-female IRR varied by age at diagnosis. The male-to-female SRR was 0.87 for RCC, 0.88 for LCC, and 0.86 for rectal cancer, which remained relatively stable during the study period. Conclusion Sex disparity of CRC is age-, period-, and anatomical subsite-dependent. Further studies are needed to investigate the underlying contributing factors.
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Affiliation(s)
- Ming Sun
- Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden.,Beijing Key Laboratory of Clinical Epidemiology, School of Public Health, Capital Medical University, Beijing, People's Republic of China
| | - Youxin Wang
- Beijing Key Laboratory of Clinical Epidemiology, School of Public Health, Capital Medical University, Beijing, People's Republic of China
| | - Jan Sundquist
- Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden.,Department of Family Medicine and Community Health, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Center for Community-Based Healthcare Research and Education (CoHRE), Department of Functional Pathology, School of Medicine, Shimane University, Shimane, Japan
| | - Kristina Sundquist
- Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden.,Department of Family Medicine and Community Health, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Center for Community-Based Healthcare Research and Education (CoHRE), Department of Functional Pathology, School of Medicine, Shimane University, Shimane, Japan
| | - Jianguang Ji
- Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
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Steele RJC, Carey FA, Stanners G, Lang J, Brand J, Brownlee LA, Crichton EM, Winter JW, Phull PS, Mowat C, Strachan JA, Digan AM, Fraser CG. Randomized controlled trial: Flexible sigmoidoscopy as an adjunct to faecal occult blood testing in population screening. J Med Screen 2019; 27:59-67. [DOI: 10.1177/0969141319879955] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objectives Flexible sigmoidoscopy screening at around age 60 can reduce colorectal cancer incidence. Insufficient evidence exists on flexible sigmoidoscopy at age 60 in a population being offered biennial faecal occult blood test screening from age 50. This randomized controlled trial assessed if flexible sigmoidoscopy would be an effective adjunct to faecal occult blood test. Methods In the Scottish Bowel Screening Programme between June 2014 and December 2015, 51,769 individuals were randomized to be offered flexible sigmoidoscopy instead of faecal occult blood test at age 60 or to continue faecal occult blood test. Those not accepting flexible sigmoidoscopy and those with normal flexible sigmoidoscopy were offered faecal occult blood test. All with flexible sigmoidoscopy-detected neoplasia or a positive faecal occult blood test result were offered colonoscopy. Results Overall flexible sigmoidoscopy uptake was 17.8%, higher in men than women, and decreased with increasing deprivation (25.7% in the least to 9.2% in the most deprived quintile). In those who underwent flexible sigmoidoscopy, detection rate for colorectal cancer was 0.13%, for adenoma 7.27%, and for total neoplasia 7.40%. In those who underwent colonoscopy after a positive flexible sigmoidoscopy, detection rate for colorectal cancer was 0.28%, adenoma 8.66%, and total neoplasia 8.83%. On an intention to screen basis, there was no difference in colorectal cancer detection rate between the study and control groups. Adenoma and total neoplasia detection rate were significantly higher in the study group, with odds ratios of 5.95 (95%CI: 4.69–7.56) and 5.10 (95%CI: 4.09–6.35), respectively. Conclusions In a single screening round at age 60, there was low uptake and neoplasia detection rate. Flexible sigmoidoscopy detected significantly more neoplasia than faecal occult blood test alone.
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Affiliation(s)
- Robert JC Steele
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
- Scottish Bowel Screening Centre, NHS Tayside, Kings Cross Hospital, Dundee, UK
| | - Francis A Carey
- Department of Pathology, Ninewells Hospital and Medical School, Dundee, UK
| | - Greig Stanners
- Quality Indicators, NHS National Services Scotland, Glasgow, UK
| | - Jaroslaw Lang
- Quality Indicators, NHS National Services Scotland, Glasgow, UK
| | - Jess Brand
- National Specialist and Screening Services Directorate, Edinburgh, UK
| | - Linda A Brownlee
- Scottish Bowel Screening Centre, NHS Tayside, Kings Cross Hospital, Dundee, UK
| | - Emilia M Crichton
- Public Health Directorate, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Jack W Winter
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Perminder S Phull
- Department of Digestive Disorders, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Craig Mowat
- Department of Gastroenterology, NHS Tayside, Ninewells Hospital and Medical School, Dundee, UK
| | - Judith A Strachan
- Department of Blood Sciences and Scottish Bowel Screening Laboratory, NHS Tayside, Ninewells Hospital and Medical School, Dundee, UK
| | - Ann-Marie Digan
- Scottish Bowel Screening Centre, NHS Tayside, Kings Cross Hospital, Dundee, UK
| | - Callum G Fraser
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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19
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Jodal HC, Helsingen LM, Anderson JC, Lytvyn L, Vandvik PO, Emilsson L. Colorectal cancer screening with faecal testing, sigmoidoscopy or colonoscopy: a systematic review and network meta-analysis. BMJ Open 2019; 9:e032773. [PMID: 31578199 PMCID: PMC6797379 DOI: 10.1136/bmjopen-2019-032773] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Evaluate effectiveness, harms and burdens of faecal blood testing, sigmoidoscopy and colonoscopy screening for colorectal cancer over 15 years. DESIGN We performed an update of a Cochrane systematic review, and performed network meta-analysis comparing randomised trials evaluating colorectal cancer screening with guaiac faecal occult blood test (gFOBT) (annual, biennial), faecal immunochemical test (FIT) (annual, biennial), sigmoidoscopy (once-only) or colonoscopy (once-only) in a healthy population, aged 50-79 years. We conducted subgroup analysis on sex. Follow-up >5 years was required for analysis of colorectal cancer incidence and mortality. RESULTS 12 randomised trials proved eligible. Compared with no-screening, we found high certainty evidence for sigmoidoscopy screening slightly reducing colorectal cancer incidence (relative risk (RR) 0.76; 95% confidence interval (CI 0.70 to 0.83) and mortality (RR 0.74; 95% CI 0.69 to 0.80), while gFOBT screening had little or no difference on colorectal cancer incidence, but slightly reduced colorectal cancer mortality (annual: RR 0.69; 95% CI 0.56 to 0.86, biennial: RR 0.88; 95% CI 0.82 to 0.93). No screening test reduced mortality nor incidence by more than six per 1000 screened over 15 years. Sigmoidoscopy had a greater effect in men, for both colorectal cancer incidence (women: RR 0.86; 95% CI 0.81 to 0.92, men: RR 0.75, 95% CI 0.71 to 0.79), and mortality (women: RR 0.85; 95% CI 0.71 to 0.96, men: RR 0.67; 95% CI 0.61 to 0.75) (moderate certainty). CONCLUSIONS In a 15-year perspective, sigmoidoscopy reduces colorectal cancer incidence, while sigmoidoscopy, annual and biennial gFOBT all reduce colorectal cancer mortality. Sigmoidoscopy may reduce colorectal cancer incidence and mortality more in men than in women. PROSPERO REGISTRATION NUMBER CRD42018093401.
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Affiliation(s)
- Henriette C Jodal
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway
- Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
- Frontier Science Foundation, Boston, Massachusetts, USA
| | - Lise M Helsingen
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway
- Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
- Frontier Science Foundation, Boston, Massachusetts, USA
| | - Joseph C Anderson
- Veterans Affairs Medical Center, White River Junction, Vermont, USA
- The Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- University of Connecticut Health Center, Farmington, Connecticut, USA
| | - Lyubov Lytvyn
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Per Olav Vandvik
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway
| | - Louise Emilsson
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
- Vårdcentralen Värmlands Nysäter & Centre for Clinical Research, County Council of Värmland, Karlstad, Sweden
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20
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Thomas C, Whyte S, Kearns B, Chilcott JB. External Validation of a Colorectal Cancer Model Against Screening Trial Long-Term Follow-Up Data. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:1154-1161. [PMID: 31563258 DOI: 10.1016/j.jval.2019.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 06/19/2019] [Accepted: 06/27/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND The University of Sheffield School of Health and Related Research (ScHARR) Bowel Cancer Screening Model has been used previously to make decisions about colorectal cancer screening strategies in England. OBJECTIVES The objective of this study was to perform an external validation of the ScHARR model against long-term follow-up data about colorectal cancer (CRC) incidence and mortality reductions due to screening, from the Nottingham trial of guaiac faecal occult blood testing for CRC, and the UK Flexible Sigmoidoscopy Screening Trial. METHODS The ScHARR model was adapted prior to validation to reflect the setting of each trial in terms of population characteristics, details of screening and surveillance programs, uptake of screening, and further investigations and study follow-up. The impact of using current versus historical CRC incidence and mortality data in the validation was also examined by carrying out a series of analyses in which historical data from different years was included in the model. RESULTS The ScHARR model was able to predict CRC incidence and mortality rate/hazard ratios from both trials to well within the 95% confidence intervals in the observed data. While it was less accurate in predicting absolute incidence and mortality rates, modeling historical incidence and mortality data enabled these predictions to be improved considerably. CONCLUSION The ScHARR model is able to replicate the long-term relative benefit from screening observed in 2 large-scale UK-based screening trials and can therefore be considered to be an appropriate tool to facilitate decision making around the English bowel cancer screening program.
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Affiliation(s)
- Chloe Thomas
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, England, UK.
| | - Sophie Whyte
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, England, UK
| | - Benjamin Kearns
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, England, UK
| | - James B Chilcott
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, England, UK
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21
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Naber SK, Knudsen AB, Zauber AG, Rutter CM, Fischer SE, Pabiniak CJ, Soto B, Kuntz KM, Lansdorp-Vogelaar I. Cost-effectiveness of a multitarget stool DNA test for colorectal cancer screening of Medicare beneficiaries. PLoS One 2019; 14:e0220234. [PMID: 31483796 PMCID: PMC6726189 DOI: 10.1371/journal.pone.0220234] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 07/11/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND In 2014, the Centers for Medicare and Medicaid Services (CMS) began covering a multitarget stool DNA (mtSDNA) test for colorectal cancer (CRC) screening of Medicare beneficiaries. In this study, we evaluated whether mtSDNA testing is a cost-effective alternative to other CRC screening strategies reimbursed by CMS, and if not, under what conditions it could be. METHODS We use three independently-developed microsimulation models to simulate a cohort of previously unscreened US 65-year-olds who are screened with triennial mtSDNA testing, or one of six other reimbursed screening strategies. Main outcome measures are discounted life-years gained (LYG) and lifetime costs (CMS perspective), threshold reimbursement rates, and threshold adherence rates. Outcomes are expressed as the median and range across models. RESULTS Compared to no screening, triennial mtSDNA screening resulted in 82 (range: 79-88) LYG per 1,000 simulated individuals. This was more than for five-yearly sigmoidoscopy (80 (range: 71-89) LYG), but fewer than for every other simulated strategy. At its 2017 reimbursement rate of $512, mtSDNA was the most costly strategy, and even if adherence were 30% higher than with other strategies, it would not be a cost-effective alternative. At a substantially reduced reimbursement rate ($6-18), two models found that triennial mtSDNA testing was an efficient and potentially cost-effective screening option. CONCLUSIONS Compared to no screening, triennial mtSDNA screening reduces CRC incidence and mortality at acceptable costs. However, compared to nearly all other CRC screening strategies reimbursed by CMS it is less effective and considerably more costly, making it an inefficient screening option.
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Affiliation(s)
- Steffie K. Naber
- Erasmus MC, University Medical Center Rotterdam, Department of Public Health, Rotterdam, The Netherlands
| | - Amy B. Knudsen
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, United States of America
| | - Carolyn M. Rutter
- RAND Corporation, Santa Monica, California, United States of America
| | - Sara E. Fischer
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, United States of America
| | - Chester J. Pabiniak
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, United States of America
| | - Brittany Soto
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, United States of America
| | - Karen M. Kuntz
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Iris Lansdorp-Vogelaar
- Erasmus MC, University Medical Center Rotterdam, Department of Public Health, Rotterdam, The Netherlands
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22
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Smith FM, Pritchard DM, Wong H, Whitmarsh K, Hershman MJ, Sun Myint A. A cohort study of local excision followed by adjuvant therapy incorporating a contact X-ray brachytherapy boost instead of radical resection in 180 patients with rectal cancer. Colorectal Dis 2019; 21:663-670. [PMID: 30742736 DOI: 10.1111/codi.14584] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 01/27/2019] [Indexed: 12/21/2022]
Abstract
AIM Recent data have suggested near-equivalent oncological results when treating early rectal cancer by local excision followed by radio- ± chemotherapy rather than salvage radical surgery. The aim of this retrospective study was to assess the use of contact X-ray brachytherapy within this paradigm. METHOD All patients had undergone local excision and were referred to our radiotherapy centre for treatment with contact X-ray brachytherapy. Postoperative (chemo)radiotherapy was also given in their local hospital in most cases. Variables assessed were local excision method, postoperative therapy received, follow-up duration, disease-free survival, salvage surgery and stoma-free survival. RESULTS In total, 180 patients with a median age of 70 (range 36-99) years were assessed. Following local excision, pT stages were pT1 = 131 (72%), pT2 = 44 (26%), pT3 = 5 (2%). All patients received contact X-ray brachytherapy boosting at our centre and, in addition, 110 received chemoradiotherapy and 60 received radiotherapy alone. After a median follow-up of 36 months (range 6-48), 169 patients (94%) remained free of local recurrence. Of the 11 patients with local recurrence (three isolated nodal), five underwent salvage abdominoperineal excision. Eight patients developed distant disease, of whom five underwent metastasis surgery. At last included follow-up 173 (96%) patients were free of all disease and 170 (94%) were stoma free. CONCLUSIONS Contact therapy can be offered in addition to external beam radio (±chemo) therapy instead of radical surgery as follow-on treatment after local excision of early rectal cancer. This combination can provide equivalent outcomes to radical surgery. The added value of contact therapy should be formally assessed in a clinical trial.
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Affiliation(s)
- F M Smith
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - D M Pritchard
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK.,Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - H Wong
- Clatterbridge Cancer Centre, Bebington, UK
| | | | | | - A Sun Myint
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Clatterbridge Cancer Centre, Bebington, UK
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Bevan R, Blanks RG, Nickerson C, Saunders BP, Stebbing J, Tighe R, Veitch AM, Garrett W, Rees CJ. Factors affecting adenoma detection rate in a national flexible sigmoidoscopy screening programme: a retrospective analysis. Lancet Gastroenterol Hepatol 2019; 4:239-247. [PMID: 30655218 DOI: 10.1016/s2468-1253(18)30387-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 11/10/2018] [Accepted: 11/12/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND A national colorectal cancer screening programme started in England in 2013, offering one-off flexible sigmoidoscopy to all men and women aged 55 years in addition to the biennial faecal occult blood testing programme offered to all individuals aged 60-74 years. We analysed data from six pilot flexible sigmoidoscopy screening centres to examine factors affecting the adenoma detection rate (ADR). METHODS We did a retrospective analysis of flexible sigmoidoscopy screening procedures performed in individuals aged 55 years at six pilot sites in England as part of the National Health Service Bowel Scope Screening programme. ADR (number of procedures in which at least one adenoma was removed or biopsied, divided by total number of procedures) was calculated for each site and each endoscopist. Multiple regression models were used to examine the variation in ADR with withdrawal time and extent of examination, and the effect of other factors including comfort and bowel preparation on extent of examination. FINDINGS The analysis included 8256 procedures done between May 7, 2013, and May 6, 2014. The overall ADR was 9·1% (95% CI 8·5-9·8; 755 of 8256 procedures), varying from 7·4% (6·2-8·9) to 11·0% (9·1-13·4) by screening centre. The ADR was 11·5% (95% CI 10·6-12·5; 493 of 4299 procedures) in men and 6·6% (5·9-7·4; 262 of 3957 procedures) in women (p<0·0001). On multivariate analysis, factors associated with adenoma detection were male sex (relative risk 1·69, 95% CI 1·46-1·95; p<0·0001) and a withdrawal time from the splenic flexure of at least 3·25 min in negative procedures (1·22, 1·00-1·48; p=0·045). However, increasing the withdrawal time to 4·0 min or more did not increase the likelihood of adenoma detection (1·22, 0·99-1·51; p=0·057). Procedures not reaching the splenic flexure were associated with lower chance of adenoma detection (eg, 0·77, 0·66-0·91; p=0·0015 for procedures reaching the descending colon), but there was no additional benefit associated with reaching the transverse colon (0·83, 0·67-1·02; p=0·069). Women (0·83, 0·80-0·87; p<0·0001), individuals with adequate (0·79, 0·76-0·83; p<0·0001) or poor (0·58, 0·51-0·67; p<0·0001) bowel preparation (compared with good bowel preparation), and those with mild (0·82, 0·76-0·88; p<0·0001) or moderate or severe (0·58, 0·51-0·66; p<0·0001) discomfort (compared with no discomfort) were less likely to have a procedure reaching the splenic flexure. INTERPRETATION Key performance indicators for flexible sigmoidoscopy screening should be defined, including standards for insertion and withdrawal times, optimal depth, and bowel preparation. ADR could be improved by recommending a withdrawal time from the splenic flexure of at least 3·25 min (ideally 3·5-4·0 min). FUNDING None.
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Affiliation(s)
- Roisin Bevan
- North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees, UK.
| | - Roger G Blanks
- Cancer Epidemiology Unit, University of Oxford, Oxford, UK
| | | | | | - John Stebbing
- Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Richard Tighe
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | | | | | - Colin J Rees
- South Tyneside NHS Foundation Trust, South Shields, UK; Newcastle University, Newcastle-upon-Tyne, UK
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Brown JP, Wooldrage K, Kralj-Hans I, Wright S, Cross AJ, Atkin WS. Effect of once-only flexible sigmoidoscopy screening on the outcomes of subsequent faecal occult blood test screening. J Med Screen 2019; 26:11-18. [PMID: 30282520 PMCID: PMC6376653 DOI: 10.1177/0969141318785654] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 06/07/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To investigate the outcomes of biennial guaiac faecal occult blood test (gFOBT) screening after once-only flexible sigmoidoscopy (FS) screening. METHODS Between 1994 and 1999, as part of the UK FS Screening Trial (UKFSST), adults aged 55-64 were randomly allocated to an intervention group (offered FS screening) or a control group (not contacted). From 2006, a subset of UKFSST participants (20,895/44,041 intervention group; 41,497/87,149 control group) were invited to biennial gFOBT screening by the English Bowel Cancer Screening Programme. We analysed gFOBT uptake, test positivity, yield of colorectal cancer (CRC), and positive predictive value (PPV) for CRC, advanced adenomas (AAs), and advanced colorectal neoplasia (ACN: AA/CRC). RESULTS Uptake of gFOBT at first invitation was 1.9% lower (65.7% vs. 67.6%, p < 0.01) among intervention versus control group participants. Positivity was 0.4% lower (2.0% vs. 2.4%, p < 0.01) and CRC yield was 0.08% lower (0.19% vs. 0.27%, p = 0.14). PPVs were also lower in the intervention versus control group, at 10.3% vs. 12.3% ( p = 0.44) for CRC, 22.7% vs. 31.4% ( p < 0.01) for AA, and 33.0% vs. 43.7% ( p < 0.01) for ACN. Among those who refused FS ( n = 5532), gFOBT uptake at first invitation was 47.7%, CRC yield was 0.25%, and PPV for ACN was 46.2%. Among FS attenders ( n = 15,363), uptake was 72.2%, CRC yield was 0.18%, and PPV for ACN was 27.9%. CONCLUSIONS Uptake, positivity and PPV of gFOBT screening were reduced following prior offer of FS screening. However, a quarter of FS screened participants receiving a diagnostic examination after positive gFOBT were diagnosed with ACN.
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Affiliation(s)
- Jeremy P Brown
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Kate Wooldrage
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Ines Kralj-Hans
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Amanda J Cross
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Wendy S Atkin
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
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25
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Rapid review of factors associated with flexible sigmoidoscopy screening use. Prev Med 2019; 120:8-18. [PMID: 30597228 DOI: 10.1016/j.ypmed.2018.12.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 12/04/2018] [Accepted: 12/24/2018] [Indexed: 01/19/2023]
Abstract
Flexible sigmoidoscopy (FS) screening has been shown to reduce colorectal cancer (CRC) incidence and mortality among screened adults. The aim of this review was to identify patient-related factors associated with the screening test's use. We searched PubMed for studies that examined the association between FS screening use and one or more factors. To determine the eligibility of studies, we first reviewed titles, then abstracts, and finally the full paper. We started with a narrow search, which we expanded successively (by adding 'OR' terms) until the number of new publications eligible after abstract review was <1% of the total number of publications. We then abstracted factors from eligible papers and reported the number of times each was found to be positively or negatively associated with FS screening use. We identified 42 papers, most of which reported studies conducted in the United States of America (n = 21, 50%) and the United Kingdom (n = 13, 31%). Across studies, a wide range of factors were examined (n = 123), almost half of which were found to be associated with FS screening use at least once (n = 60). Sociodemographic and health and lifestyle factors that were frequently positively associated with FS screening use included: male gender, higher socioeconomic status and a family history of CRC. Frequently positively associated psychosocial factors included low perceived barriers and high perceived benefits. Findings suggest that future research should focus on developing a theoretical framework of cancer screening behaviour to allow a greater level of consistency and specificity in measuring key constructs.
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Picot J, Rose M, Cooper K, Pickett K, Lord J, Harris P, Whyte S, Böhning D, Shepherd J. Virtual chromoendoscopy for the real-time assessment of colorectal polyps in vivo: a systematic review and economic evaluation. Health Technol Assess 2019; 21:1-308. [PMID: 29271339 DOI: 10.3310/hta21790] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Current clinical practice is to remove a colorectal polyp detected during colonoscopy and determine whether it is an adenoma or hyperplastic by histopathology. Identifying adenomas is important because they may eventually become cancerous if untreated, whereas hyperplastic polyps do not usually develop into cancer, and a surveillance interval is set based on the number and size of adenomas found. Virtual chromoendoscopy (VCE) (an electronic endoscopic imaging technique) could be used by the endoscopist under strictly controlled conditions for real-time optical diagnosis of diminutive (≤ 5 mm) colorectal polyps to replace histopathological diagnosis. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of the VCE technologies narrow-band imaging (NBI), flexible spectral imaging colour enhancement (FICE) and i-scan for the characterisation and management of diminutive (≤ 5 mm) colorectal polyps using high-definition (HD) systems without magnification. DESIGN Systematic review and economic analysis. PARTICIPANTS People undergoing colonoscopy for screening or surveillance or to investigate symptoms suggestive of colorectal cancer. INTERVENTIONS NBI, FICE and i-scan. MAIN OUTCOME MEASURES Diagnostic accuracy, recommended surveillance intervals, health-related quality of life (HRQoL), adverse effects, incidence of colorectal cancer, mortality and cost-effectiveness of VCE compared with histopathology. DATA SOURCES Electronic bibliographic databases including MEDLINE, EMBASE, The Cochrane Library and Database of Abstracts of Reviews of Effects were searched for published English-language studies from inception to June 2016. Bibliographies of related papers, systematic reviews and company information were screened and experts were contacted to identify additional evidence. REVIEW METHODS Systematic reviews of test accuracy and economic evaluations were undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Meta-analyses were conducted, where possible, to inform the independent economic model. A cost-utility decision-analytic model was developed to estimate the cost-effectiveness of VCE compared with histopathology. The model used a decision tree for patients undergoing endoscopy, combined with estimates of long-term outcomes (e.g. incidence of colorectal cancer and subsequent morbidity and mortality) derived from University of Sheffield School of Health and Related Research's bowel cancer screening model. The model took a NHS perspective, with costs and benefits discounted at 3.5% over a lifetime horizon. There were limitations in the data on the distribution of adenomas across risk categories and recurrence rates post polypectomy. RESULTS Thirty test accuracy studies were included: 24 for NBI, five for i-scan and three for FICE (two studies assessed two interventions). Polyp assessments made with high confidence were associated with higher sensitivity and endoscopists experienced in VCE achieved better results than those without experience. Two economic evaluations were included. NBI, i-scan and FICE are cost-saving strategies compared with histopathology and the number of quality-adjusted life-years gained was similar for histopathology and VCE. The correct surveillance interval would be given to 95% of patients with NBI, 94% of patients with FICE and 97% of patients with i-scan. LIMITATIONS Limited evidence was available for i-scan and FICE and there was heterogeneity among the NBI studies. There is a lack of data on longer-term health outcomes of patients undergoing VCE for assessment of diminutive colorectal polyps. CONCLUSIONS VCE technologies, using HD systems without magnification, could potentially be used for the real-time assessment of diminutive colorectal polyps, if endoscopists have adequate experience and training. FUTURE WORK Future research priorities include head-to-head randomised controlled trials of all three VCE technologies; more research on the diagnostic accuracy of FICE and i-scan (when used without magnification); further studies evaluating the impact of endoscopist experience and training on outcomes; studies measuring adverse effects, HRQoL and anxiety; and longitudinal data on colorectal cancer incidence, HRQoL and mortality. STUDY REGISTRATION This study is registered as PROSPERO CRD42016037767. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Joanna Picot
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Micah Rose
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Keith Cooper
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Karen Pickett
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Joanne Lord
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Petra Harris
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Sophie Whyte
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Dankmar Böhning
- Southampton Statistical Sciences Research Institute (S3RI), Mathematical Sciences, University of Southampton, Southampton, UK
| | - Jonathan Shepherd
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
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Atkin W, Cross AJ, Kralj-Hans I, MacRae E, Piggott C, Pearson S, Wooldrage K, Brown J, Lucas F, Prendergast A, Marchevsky N, Patel B, Pack K, Howe R, Skrobanski H, Kerrison R, Swart N, Snowball J, Duffy SW, Morris S, von Wagner C, Halloran S. Faecal immunochemical tests versus colonoscopy for post-polypectomy surveillance: an accuracy, acceptability and economic study. Health Technol Assess 2019; 23:1-84. [PMID: 30618357 PMCID: PMC6340104 DOI: 10.3310/hta23010] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In the UK, patients with one or two adenomas, of which at least one is ≥ 10 mm in size, or three or four small adenomas, are deemed to be at intermediate risk of colorectal cancer (CRC) and referred for surveillance colonoscopy 3 years post polypectomy. However, colonoscopy is costly, can cause discomfort and carries a small risk of complications. OBJECTIVES To determine whether or not annual faecal immunochemical tests (FITs) are effective, acceptable and cost saving compared with colonoscopy surveillance for detecting CRC and advanced adenomas (AAs). DESIGN Diagnostic accuracy study with health psychology assessment and economic evaluation. SETTING Participants were recruited from 30 January 2012 to 30 December 2013 within the Bowel Cancer Screening Programme in England. PARTICIPANTS Men and women, aged 60-72 years, deemed to be at intermediate risk of CRC following adenoma removal after a positive guaiac faecal occult blood test were invited to participate. Invitees who consented and returned an analysable FIT were included. INTERVENTION We offered participants quantitative FITs at 1, 2 and 3 years post polypectomy. Participants testing positive with any FIT were referred for colonoscopy and not offered further FITs. Participants testing negative were offered colonoscopy at 3 years post polypectomy. Acceptibility of FIT was assessed using discussion groups, questionnaires and interviews. MAIN OUTCOME MEASURES The primary outcome was 3-year sensitivity of an annual FIT versus colonoscopy at 3 years for detecting advanced colorectal neoplasia (ACN) (CRC and/or AA). Secondary outcomes included participants' surveillance preferences, and the incremental costs and cost-effectiveness of FIT versus colonoscopy surveillance. RESULTS Of 8008 invitees, 5946 (74.3%) consented and returned a round 1 FIT. FIT uptake in rounds 2 and 3 was 97.2% and 96.9%, respectively. With a threshold of 40 µg of haemoglobin (Hb)/g faeces (hereafter referred to as µg/g), positivity was 5.8% in round 1, declining to 4.1% in round 3. Over three rounds, 69.2% (18/26) of participants with CRC, 34.3% (152/443) with AAs and 35.6% (165/463) with ACN tested positive at 40 µg/g. Sensitivity for CRC and AAs increased, whereas specificity decreased, with lower thresholds and multiple rounds. At 40 µg/g, sensitivity and specificity of the first FIT for CRC were 30.8% and 93.9%, respectively. The programme sensitivity and specificity of three rounds at 10 µg/g were 84.6% and 70.8%, respectively. Participants' preferred surveillance strategy was 3-yearly colonoscopy plus annual FITs (57.9%), followed by annual FITs with colonoscopy in positive cases (31.5%). FIT with colonoscopy in positive cases was cheaper than 3-yearly colonoscopy (£2,633,382), varying from £485,236 (40 µg/g) to £956,602 (10 µg/g). Over 3 years, FIT surveillance could miss 291 AAs and eight CRCs using a threshold of 40 µg/g, or 189 AAs and four CRCs using a threshold of 10 µg/g. CONCLUSIONS Annual low-threshold FIT with colonoscopy in positive cases achieved high sensitivity for CRC and would be cost saving compared with 3-yearly colonoscopy. However, at higher thresholds, this strategy could miss 15-30% of CRCs and 40-70% of AAs. Most participants preferred annual FITs plus 3-yearly colonoscopy. Further research is needed to define a clear role for FITs in surveillance. FUTURE WORK Evaluate the impact of ACN missed by FITs on quality-adjusted life-years. TRIAL REGISTRATION Current Controlled Trials ISRCTN18040196. FUNDING National Institute for Health Research (NIHR) Health Technology Assessment programme, NIHR Imperial Biomedical Research Centre and the Bobby Moore Fund for Cancer Research UK. MAST Group Ltd provided FIT kits.
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Affiliation(s)
- Wendy Atkin
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Amanda J Cross
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Ines Kralj-Hans
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Eilidh MacRae
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Carolyn Piggott
- Bowel Cancer Screening Programme Southern Hub, Guildford, UK
| | - Sheena Pearson
- Bowel Cancer Screening Programme Southern Hub, Guildford, UK
| | - Kate Wooldrage
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Jeremy Brown
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Fiona Lucas
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Aaron Prendergast
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Natalie Marchevsky
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Bhavita Patel
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Kevin Pack
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Rosemary Howe
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Hanna Skrobanski
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Robert Kerrison
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Nicholas Swart
- Department of Applied Health Research, University College London, London, UK
| | - Julia Snowball
- Bowel Cancer Screening Programme Southern Hub, Guildford, UK
| | - Stephen W Duffy
- Centre for Cancer Prevention, Wolfson Institute of Preventative Medicine, Queen Mary University, London, UK
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| | - Christian von Wagner
- Research Department of Behavioural Science and Health, University College London, London, UK
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Borowski DW, Cawkwell S, Zaidi SMA, Toward M, Maguire N, Garg DK, Gill TS. The NHS Bowel cancer screening programme achieves the anticipated survival improvement, but participation must be improved. Int J Health Care Qual Assur 2018; 31:106-115. [PMID: 29504872 DOI: 10.1108/ijhcqa-11-2016-0169] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Purpose The NHS Bowel cancer screening programme (NHSBCSP) aims to reduce colorectal cancer (CRC) cumulative mortality by up to 23 per cent; long-term outcomes at national level are not yet known. The purpose of this paper is to examine a local population of CRC patients of screening age for their characteristics and long-term survival in relation to their presentation, including through the NHSBCSP. Design/methodology/approach Retrospective analysis of a prospectively maintained CRC database for the years 2009-2014 in a single district hospital providing bowel cancer screening and tertiary rectal cancer services. Findings Of 528 CRC patients diagnosed in the screening age range, 144(27.3 per cent) presented through NHSBCSP, 308(58.3 per cent) electively with symptoms and 76(14.4 per cent) as emergency. NHSBCSP-diagnosed patients were younger (median 66 vs 68 and 69 years, respectively, p=0.001), had more often left-sided cancers (59(41.0 per cent) vs 82(26.6 per cent) and 24(31.6 per cent), respectively, p=0.001), more UICC-stage I (42(29.2 per cent) vs 49(15.9 per cent) and 2(2.6 per cent)), stage III (59(41.0 per cent) vs 106(34.4 per cent) and 20(26.3 per cent)) and less stage IV disease (8(5.6 per cent) vs 61(19.8 per cent) and 34 (44.7 per cent), respectively, p<0.001). Three-year overall survival was best for NHSBCSP and worst for emergency patients (87.5 per cent vs 69.0 per cent and 35.3 per cent, respectively, LogRank p<0.001). Originality/value Patients diagnosed within the NHSBCSP have improved outcome compared to both symptomatic elective and emergency presentations. A reduction in overall cumulative mortality in order of 25 per cent may well be achieved, but continuing high levels of emergency presentations and undetected right-sided disease emphasise need for further improvement in public participation in the NHSBCSP and research into more sensitive and acceptable alternative screening methods.
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29
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Bugajski M, Kaminski MF. Sigmoidoscopy: a shortcut to effective screening or a dead end? Lancet Gastroenterol Hepatol 2018; 4:82-83. [PMID: 30502932 DOI: 10.1016/s2468-1253(18)30410-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 11/23/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Marek Bugajski
- Department of Gastroenterological Oncology and Department of Cancer Prevention, The Maria Sklodowska-Curie Institute - Oncology Center, Warsaw, Poland; Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland
| | - Michal F Kaminski
- Department of Gastroenterological Oncology and Department of Cancer Prevention, The Maria Sklodowska-Curie Institute - Oncology Center, Warsaw, Poland; Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland; Institute of Health and Society, University of Oslo, Oslo, Norway.
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Contrasting Effectiveness and Cost-Effectiveness of Colorectal Cancer Screening Under Commercial Insurance vs. Medicare. Am J Gastroenterol 2018; 113:1836-1847. [PMID: 29904156 PMCID: PMC6768591 DOI: 10.1038/s41395-018-0106-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 04/09/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Most cost-effectiveness analyses of colorectal cancer (CRC) screening assume Medicare payment rates and a lifetime horizon. Our aims were to examine the implications of differential payment levels and time horizons for commercial insurers vs. Medicare on the cost-effectiveness of CRC screening. METHODS We used our validated Markov cohort simulation of CRC screening in the average risk US population to examine CRC screening at ages 50-64 under commercial insurance, and at ages 65-80 under Medicare, using a health-care sector perspective. Model outcomes included discounted quality-adjusted life-years (QALYs) and costs per person, and incremental cost/QALY gained. RESULTS Lifetime costs/person were 20-44% higher when assuming commercial payment rates rather than Medicare rates for people under 65. Most of the substantial clinical benefit of screening at ages 50-64 was realized at ages ≥65. For commercial payers with a time horizon of ages 50-64, fecal occult blood testing (FOBT) and fecal immunochemical testing (FIT) were cost-effective (<$61,000/QALY gained), but colonoscopy was costly (>$185,000/QALY gained). Medicare experienced substantial clinical benefits and cost-savings from screening done at ages <65, even if screening was not continued. Among those previously screened, continuing FOBT and FIT under Medicare was cost-saving and continuing colonoscopy was highly cost-effective (<$30,000/QALY gained), and initiating any screening in those previously unscreened was highly effective and cost-saving. CONCLUSIONS Modeling suggests that CRC screening is highly cost-effective over a lifetime even when considering higher payment rates by commercial payers vs. Medicare. Screening may appear relatively costly for commercial payers if only a time horizon of ages 50-64 is considered, but it is predicted to yield substantial clinical and economic benefits that accrue primarily at ages ≥65 under Medicare.
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Levin TR, Corley DA, Jensen CD, Schottinger JE, Quinn VP, Zauber AG, Lee JK, Zhao WK, Udaltsova N, Ghai NR, Lee AT, Quesenberry CP, Fireman BH, Doubeni CA. Effects of Organized Colorectal Cancer Screening on Cancer Incidence and Mortality in a Large Community-Based Population. Gastroenterology 2018; 155:1383-1391.e5. [PMID: 30031768 PMCID: PMC6240353 DOI: 10.1053/j.gastro.2018.07.017] [Citation(s) in RCA: 299] [Impact Index Per Article: 49.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/02/2018] [Accepted: 07/16/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Little information is available on the effectiveness of organized colorectal cancer (CRC) screening on screening uptake, incidence, and mortality in community-based populations. METHODS We contrasted screening rates, age-adjusted annual CRC incidence, and incidence-based mortality rates before (baseline year 2000) and after (through 2015) implementation of organized screening outreach, from 2007 through 2008 (primarily annual fecal immunochemical testing and colonoscopy), in a large community-based population. Among screening-eligible individuals 51-75 years old, we calculated annual up-to-date status for cancer screening (by fecal test, sigmoidoscopy, or colonoscopy), CRC incidence, cancer stage distributions, and incidence-based mortality. RESULTS Initiation of organized CRC screening significantly increased the up-to-date status of screening, from 38.9% in 2000 to 82.7% in 2015 (P < .01). Higher rates of screening were associated with a 25.5% reduction in annual CRC incidence between 2000 and 2015, from 95.8 to 71.4 cases/100,000 (P < .01), and a 52.4% reduction in cancer mortality, from 30.9 to 14.7 deaths/100,000 (P < .01). Increased screening was initially associated with increased CRC incidence, due largely to greater detection of early-stage cancers, followed by decreases in cancer incidence. Advanced-stage CRC incidence rates decreased 36.2%, from 45.9 to 29.3 cases/100,000 (P < .01), and early-stage CRC incidence rates decreased 14.5%, from 48.2 to 41.2 cases/100,000 (P < .04). CONCLUSIONS Implementing an organized CRC screening program in a large community-based population rapidly increased screening participation to the ≥80% target set by national organizations. Screening rates were sustainable and associated with substantial decreases in CRC incidence and mortality within short time intervals, consistent with early detection and cancer prevention.
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Affiliation(s)
- Theodore R. Levin
- Kaiser Permanente Medical Center, Walnut Creek, CA.,Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Joanne E. Schottinger
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Virginia P. Quinn
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jeffrey K. Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Wei K. Zhao
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Natalia Udaltsova
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Nirupa R. Ghai
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Alexander T. Lee
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | - Bruce H. Fireman
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Chyke A. Doubeni
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Buskermolen M, Gini A, Naber SK, Toes-Zoutendijk E, de Koning HJ, Lansdorp-Vogelaar I. Modeling in Colorectal Cancer Screening: Assessing External and Predictive Validity of MISCAN-Colon Microsimulation Model Using NORCCAP Trial Results. Med Decis Making 2018; 38:917-929. [PMID: 30343626 DOI: 10.1177/0272989x18806497] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Microsimulation models are increasingly being used to inform colorectal cancer (CRC) screening recommendations. MISCAN-Colon is an example of such a model, used to inform the Dutch CRC screening program and US Preventive Services Task Force guidelines. Assessing the validity of these models is essential to provide transparency regarding their performance. In this study, we tested the external and predictive validity of MISCAN-Colon. METHODS We validated MISCAN-Colon using the Norwegian Colorectal Cancer Prevention (NORCCAP) trial, a randomized controlled trial that examined the effectiveness of once-only flexible sigmoidoscopy (FS) screening. We simulated the study population and design of the NORCCAP trial in MISCAN-Colon and compared 10- to 12-year model-predicted hazard ratios (HRs) for overall and distal CRC incidence and mortality to those observed. In addition, we compared the numbers of screen-detected neoplasia. Finally, we predicted the trial's future results to allow for the assessment of predictive validity. RESULTS MISCAN-Colon predicted an HR for overall CRC incidence (0.85), distal CRC incidence (0.82), overall CRC mortality (0.68), and distal CRC mortality (0.62). These were within the limits of the 95% confidence intervals of the NORCCAP trial results. Similar results were observed for the number of screen-detected cancers. The model significantly underestimated the number of screen-detected adenomas. Model-predicted HRs for CRC incidence and mortality up to 15- to 17-year follow-up were 0.84 and 0.72, respectively. CONCLUSION Although the underestimation of screen-detected adenomas requires further investigation, MISCAN-Colon is able to make a valid replication of the CRC incidence and mortality reduction of an FS screening trial, which suggests that it can be considered a useful tool to support decision making on CRC screening.
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Affiliation(s)
- Maaike Buskermolen
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands (MB, AG, AKN, ETZ, HJdK, ILV)
| | - Andrea Gini
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands (MB, AG, AKN, ETZ, HJdK, ILV)
| | - Steffie K Naber
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands (MB, AG, AKN, ETZ, HJdK, ILV)
| | - Esther Toes-Zoutendijk
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands (MB, AG, AKN, ETZ, HJdK, ILV)
| | - Harry J de Koning
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands (MB, AG, AKN, ETZ, HJdK, ILV)
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands (MB, AG, AKN, ETZ, HJdK, ILV)
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Toes-Zoutendijk E, Kooyker AI, Elferink MA, Spaander MCW, Dekker E, Koning HJD, Lemmens VE, van Leerdam ME, Lansdorp-Vogelaar I. Stage distribution of screen-detected colorectal cancers in the Netherlands. Gut 2018; 67:1745-1746. [PMID: 29055907 DOI: 10.1136/gutjnl-2017-315111] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 09/20/2017] [Accepted: 10/08/2017] [Indexed: 01/31/2023]
Affiliation(s)
- Esther Toes-Zoutendijk
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Arthur I Kooyker
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Gastroenterology and Hepatology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Marloes A Elferink
- Department of Research, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam Medical Center, Rotterdam, The Netherlands
| | - Harry J de Koning
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Valery E Lemmens
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Research, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands
| | - Monique E van Leerdam
- Department of Gastroenterology and Hepatology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Martellucci J, Sturiale A, Bergamini C, Boni L, Cianchi F, Coratti A, Valeri A. Role of transanal irrigation in the treatment of anterior resection syndrome. Tech Coloproctol 2018; 22:519-527. [PMID: 30083782 DOI: 10.1007/s10151-018-1829-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 07/23/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Transanal irrigation(TAI) has been reported to be an inexpensive and effective treatment for low anterior resection syndrome(LARS). The aim of the present prospective study was to evaluate the use of TAI in patients with significant LARS symptoms at a single medical center. METHODS Patients who had low anterior resection for rectal cancer between April 2015 and May 2016 at the Careggi University Hospital were assessed for LARS using the LARS and the Memorial Sloan-Kettering Cancer Center Bowel Function Instrument (MSKCC BFI) questionnaires 30-40 days after surgery or ileostomy closure (if this was done). Quality of life was evaluated using a visual analog scale and the Short Form-36 Health Survey. All patients with LARS score of 30 or higher were included (early LARS) as were all patients with a LARS score of 30 or higher referred 6 months or longer after surgery performed elsewhere (chronic LARS) in the same study period. Study participants were trained to perform TAI using the Peristeen™ System for 6 months, followed by 3 months of enema therapy following a similar protocol. RESULTS Thirty-three patients were enrolled in the study. Six patients stopped the treatment. The 27 patients (19 early LARS and 8 chronic LARS) who completed the study had a significant decrease in the number of median daily bowel movements [baseline 7 (range 0-14); 6 months 1 (range 0-4); 9 months 4 (range 0-13)]. The median LARS Score fell from 35.1 (range 30-42) (baseline) to 12.2 (range 0-21) after 6 months (p < 0.0001) and then rose to 27 (range 5-39) after 3 months of enema therapy. There was no difference in LARS score decrease at 6 months between the patients with early and chronic LARS (22.5 and 23.9 respectively; p=0.7) and there were no predictors of score decrease. Four components of the SF-36 significantly improved during the TAI period. The MSKCC BFI score significantly improved in several domains. Twenty-three patients (85%) asked to continue the treatment with TAI after the study ended. CONCLUSIONS TAI appears to be an effective treatment for LARS and results in a marked improvement of continence and quality of life. Patients may be assessed and treated for LARS early after surgery since the treatment benefit is similar to that observed in patients with LARS diagnosed 6 months or longer after surgery. The potential rehabilitative role of TAI for LARS is promising and should be further investigated.
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Affiliation(s)
- J Martellucci
- General Emergency and Minimally Invasive Surgery, Careggi University Hospital, largo Brambilla 3, 50134, Florence, Italy.
| | - A Sturiale
- General Emergency and Minimally Invasive Surgery, Careggi University Hospital, largo Brambilla 3, 50134, Florence, Italy
| | - C Bergamini
- General Emergency and Minimally Invasive Surgery, Careggi University Hospital, largo Brambilla 3, 50134, Florence, Italy
| | - L Boni
- Clinical Trial Center, Careggi University Hospital, Florence, Italy
| | - F Cianchi
- General and Endocrine Surgery, Careggi University Hospital, Florence, Italy
| | - A Coratti
- Oncologic and Robotic Surgery, Careggi University Hospital, Florence, Italy
| | - A Valeri
- General Emergency and Minimally Invasive Surgery, Careggi University Hospital, largo Brambilla 3, 50134, Florence, Italy
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Labianca R, Merelli B. Screening and Diagnosis for Colorectal Cancer: Present and Future. TUMORI JOURNAL 2018. [DOI: 10.1177/548.6506] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | - Barbara Merelli
- Unit of Medical Oncology, Ospedali Riuniti di Bergamo, Italy
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Bevan R, Rutter MD. Colorectal Cancer Screening-Who, How, and When? Clin Endosc 2018; 51:37-49. [PMID: 29397655 PMCID: PMC5806924 DOI: 10.5946/ce.2017.141] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 10/20/2017] [Indexed: 12/17/2022] Open
Abstract
Colorectal cancer (CRC) is the third most common cancer worldwide. It is amenable to screening as it occurs in premalignant, latent, early, and curable stages. PubMed, Cochrane Database of Systematic Reviews, and national and international CRC screening guidelines were searched for CRC screening methods, populations, and timing. CRC screening can use direct or indirect tests, delivered opportunistically or via organized programs. Most CRCs are diagnosed after 60 years of age; most screening programs apply to individuals 50-75 years of age. Screening may reduce disease-specific mortality by detecting CRC in earlier stages, and CRC incidence by detecting premalignant polyps, which can subsequently be removed. In randomized controlled trials (RCTs) guaiac fecal occult blood testing (gFOBt) was found to reduce CRC mortality by 13%-33%. Fecal immunochemical testing (FIT) has no RCT data comparing it to no screening, but is superior to gFOBt. Flexible sigmoidoscopy (FS) trials demonstrated an 18% reduction in CRC incidence and a 28% reduction in CRC mortality. Currently, RCT evidence for colonoscopy screening is scarce. Although not yet corroborated by RCTs, it is likely that colonoscopy is the best screening modality for an individual. From a population perspective, organized programs are superior to opportunistic screening. However, no nation can offer organized population-wide colonoscopy screening. Thus, organized programs using cheaper modalities, such as FS/FIT, can be tailored to budget and capacity.
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Affiliation(s)
- Roisin Bevan
- Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, Durham, UK
| | - Matthew D Rutter
- Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, Durham, UK
- School of Medicine, Pharmacy and Health, Durham University, Durham, UK
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37
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Rombouts AJM, Al-Najami I, Abbott NL, Appelt A, Baatrup G, Bach S, Bhangu A, Garm Spindler KL, Gray R, Handley K, Kaur M, Kerkhof E, Kronborg CJ, Magill L, Marijnen CAM, Nagtegaal ID, Nyvang L, Peters FP, Pfeiffer P, Punt C, Quirke P, Sebag-Montefiore D, Teo M, West N, de Wilt JHW. Can we Save the rectum by watchful waiting or Trans Anal microsurgery following (chemo) Radiotherapy versus Total mesorectal excision for early REctal Cancer (STAR-TREC study)?: protocol for a multicentre, randomised feasibility study. BMJ Open 2017; 7:e019474. [PMID: 29288190 PMCID: PMC5770914 DOI: 10.1136/bmjopen-2017-019474] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 10/20/2017] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Total mesorectal excision (TME) is the highly effective standard treatment for rectal cancer but is associated with significant morbidity and may be overtreatment for low-risk cancers. This study is designed to determine the feasibility of international recruitment in a study comparing organ-saving approaches versus standard TME surgery. METHODS AND ANALYSIS STAR-TREC trial is a multicentre international randomised, three-arm parallel, phase II feasibility study in patients with biopsy-proven adenocarcinoma of the rectum. The trial is coordinated from Birmingham, UK with national hubs in Radboudumc (the Netherlands) and Odense University Hospital Svendborg UMC (Denmark). Patients with rectal cancer, staged by CT and MRI as ≤cT3b (up to 5 mm of extramural spread) N0 M0 can be included. Patients will be randomised to either standard TME surgery (control), organ-saving treatment using long-course concurrent chemoradiation or organ-saving treatment using short-course radiotherapy. For patients treated with an organ-saving strategy, clinical response to (chemo)radiotherapy determines the next treatment step. An active surveillance regime will be performed in the case of a complete clinical regression. In the case of incomplete clinical regression, patients will proceed to local excision using an optimised platform such as transanal endoscopic microsurgery or other transanal techniques (eg, transanal endoscopic operation or transanal minimally invasive surgery). The primary endpoint of this phase II study is to demonstrate sufficient international recruitment in order to sustain a phase III study incorporating pelvic failure as the primary endpoint. Success in phase II is defined as randomisation of at least four cases per month internationally in year 1, rising to at least six cases per month internationally during year 2. ETHICS AND DISSEMINATION The medical ethical committees of all the participating countries have approved the study protocol. Results of the primary and secondary endpoints will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN14240288, 20 October 2016. NCT02945566; Pre-results, October 2016.
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Affiliation(s)
- Anouk J M Rombouts
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Issam Al-Najami
- Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Natalie L Abbott
- Radiotheraphy Trials Quality Assurance Group, Velindre Cancer Centre, Cardiff, UK
| | - Ane Appelt
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
- Leeds Cancer Centre, St. James' University Hospital, Leeds, UK
| | - Gunnar Baatrup
- Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Simon Bach
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Aneel Bhangu
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Karen-Lise Garm Spindler
- Department of Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Richard Gray
- Clinical Trial Services Unit, University of Oxford, Oxford, UK
| | - Kelly Handley
- Institue of Applied Health Research, University of Birmingham Clinical Trials Unit, Birmingham, UK
| | - Manjinder Kaur
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Ellen Kerkhof
- Department of Radiotherapy, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Laura Magill
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Corrie A M Marijnen
- Department of Radiotherapy, Leiden University Medical Center, Leiden, The Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lars Nyvang
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Femke P Peters
- Department of Radiotherapy, Leiden University Medical Center, Leiden, The Netherlands
| | - Per Pfeiffer
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Cornelis Punt
- Department of Medical Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - Philip Quirke
- Department of Pathology, School of Medicine, University of Leeds, Leeds, UK
| | - David Sebag-Montefiore
- Department of Clinical Oncology, Leeds Radiotherapy Research Group, University of Leeds, Leeds, UK
| | - Mark Teo
- Department of Clinical Oncology, Leeds Radiotherapy Research Group, University of Leeds, Leeds, UK
- Department of Clinical Oncology, Leeds Cancer Centre, St James University Hospital, Leeds, UK
| | - Nick West
- Department of Pathology, School of Medicine, University of Leeds, Leeds, UK
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
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The use of high definition colonoscopy versus standard definition: does it affect polyp detection rate? Surg Endosc 2017; 32:2676-2682. [DOI: 10.1007/s00464-017-5962-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 10/23/2017] [Indexed: 12/18/2022]
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Liu JY, Chen LD, Xu JB, Wu H, Ye JN, Zhang XH, Xie XY, Wang W, Lu MD. Transabdominal Ultrasound Colonography for Detection of Colorectal Neoplasms: Initial Clinical Experience. ULTRASOUND IN MEDICINE & BIOLOGY 2017; 43:2174-2181. [PMID: 28684185 DOI: 10.1016/j.ultrasmedbio.2017.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 05/04/2017] [Accepted: 05/21/2017] [Indexed: 06/07/2023]
Abstract
We investigated the feasibility of using ultrasound colonography (USC) to visualize the healthy colon and rectum and detect colorectal polyps. Eight healthy volunteers underwent USC after standard bowel preparation. The feasibility and image quality of USC in different segments were evaluated. Then, USC was conducted on eight patients with known colonic neoplasms using colonoscopy as the reference standard. For volunteers, USC examinations were successfully performed on four (50.0%) ascending, three (37.5%) transverse and eight (100%) descending colons, as well as all sigmoid colons and rectums. One of four (25.0%) ascending, two of eight (25.0%) descending and all sigmoid colons and rectums were well visualized and free of artifacts. For patients, colonoscopy revealed that eight patients had 17 neoplasms in the distal sigmoid colon and rectum, which included 3 lesions ≤5 mm, 3 lesions 6-9 mm and 11 lesions ≥10 mm. USC visualized 12 of 17 (70.6%) neoplasms. Lesion detection by USC was 0% (0/3), 33.3% (1/3) and 100% (11/11) for neoplasms ≤5, 6-9 mm and ≥10 mm in size. USC can visualize the sigmoid colon and rectum well and detect distal sigmoid and rectal neoplasms ≥10 mm in diameter.
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Affiliation(s)
- Jin-Ya Liu
- Department of Medical Ultrasonics, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Li-Da Chen
- Department of Medical Ultrasonics, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jian-Bo Xu
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Hui Wu
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jin-Ning Ye
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xin-Hua Zhang
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xiao-Yan Xie
- Department of Medical Ultrasonics, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Wei Wang
- Department of Medical Ultrasonics, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
| | - Ming-De Lu
- Department of Medical Ultrasonics, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; Department of Hepatobiliary Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Leclair-Visonneau L, Clairembault T, Coron E, Le Dily S, Vavasseur F, Dalichampt M, Péréon Y, Neunlist M, Derkinderen P. REM sleep behavior disorder is related to enteric neuropathology in Parkinson disease. Neurology 2017; 89:1612-1618. [PMID: 28887374 DOI: 10.1212/wnl.0000000000004496] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 07/17/2017] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To determine whether REM sleep behavior disorder (RBD) in Parkinson disease (PD) is associated with lesions and dysfunctions of the autonomic nervous system by evaluating enteric phosphorylated α-synuclein histopathology (PASH) and permeability. METHODS A total of 45 patients with PD were included in this cross-sectional study. RBD was diagnosed on the basis of a standardized clinical interview and confirmed by polysomnography. For each patient, 5 biopsies were taken at the junction between the sigmoid and descending colon during the course of a rectosigmoidoscopy. For the detection of enteric PASH, 2 colonic biopsies were analyzed by immunohistochemistry with antibodies against phosphorylated α-synuclein and PGP9.5 in 43 patients (2 patients were excluded because only 1 biopsy was available). The paracellular permeability and transcellular permeability were evaluated by measuring sulfonic acid and horseradish peroxidase flux, respectively, in the 3 remaining biopsies mounted in Ussing chambers. RESULTS Enteric PASH was more frequent in the subgroup of patients with PD with RBD compared to patients without RBD (18 of 28, 64.3%, vs 2 of 15, 13.3%, respectively, p < 0.01). No differences were observed in intestinal permeability between patients with PD with and without RBD. CONCLUSIONS Patients with PD and RBD have a greater frequency of synuclein pathology in the enteric nervous system, suggesting that RBD is associated with widespread synuclein neuropathology.
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Affiliation(s)
- Laurène Leclair-Visonneau
- From Inserm (L.L.-V., T.C., E.C., M.N., P.D.), U1235, Nantes; University Nantes (L.L.-V., T.C., E.C., Y.P., M.N., P.D.); Inserm (L.L.-V., E.C., S.L.D., F.V., P.D.), CIC-04; CHU Nantes (L.L.-V., Y.P.), Department of Clinical Neurophysiology; CHU Nantes (T.C., E.C., F.V., M.N.), Institut des Maladies de l'Appareil Digestif; CHU Nantes (M.D.), Plateforme de Biométrie, Département Promotion DRCI; and CHU Nantes (P.D.), Department of Neurology, France.
| | - Thomas Clairembault
- From Inserm (L.L.-V., T.C., E.C., M.N., P.D.), U1235, Nantes; University Nantes (L.L.-V., T.C., E.C., Y.P., M.N., P.D.); Inserm (L.L.-V., E.C., S.L.D., F.V., P.D.), CIC-04; CHU Nantes (L.L.-V., Y.P.), Department of Clinical Neurophysiology; CHU Nantes (T.C., E.C., F.V., M.N.), Institut des Maladies de l'Appareil Digestif; CHU Nantes (M.D.), Plateforme de Biométrie, Département Promotion DRCI; and CHU Nantes (P.D.), Department of Neurology, France
| | - Emmanuel Coron
- From Inserm (L.L.-V., T.C., E.C., M.N., P.D.), U1235, Nantes; University Nantes (L.L.-V., T.C., E.C., Y.P., M.N., P.D.); Inserm (L.L.-V., E.C., S.L.D., F.V., P.D.), CIC-04; CHU Nantes (L.L.-V., Y.P.), Department of Clinical Neurophysiology; CHU Nantes (T.C., E.C., F.V., M.N.), Institut des Maladies de l'Appareil Digestif; CHU Nantes (M.D.), Plateforme de Biométrie, Département Promotion DRCI; and CHU Nantes (P.D.), Department of Neurology, France
| | - Séverine Le Dily
- From Inserm (L.L.-V., T.C., E.C., M.N., P.D.), U1235, Nantes; University Nantes (L.L.-V., T.C., E.C., Y.P., M.N., P.D.); Inserm (L.L.-V., E.C., S.L.D., F.V., P.D.), CIC-04; CHU Nantes (L.L.-V., Y.P.), Department of Clinical Neurophysiology; CHU Nantes (T.C., E.C., F.V., M.N.), Institut des Maladies de l'Appareil Digestif; CHU Nantes (M.D.), Plateforme de Biométrie, Département Promotion DRCI; and CHU Nantes (P.D.), Department of Neurology, France
| | - Fabienne Vavasseur
- From Inserm (L.L.-V., T.C., E.C., M.N., P.D.), U1235, Nantes; University Nantes (L.L.-V., T.C., E.C., Y.P., M.N., P.D.); Inserm (L.L.-V., E.C., S.L.D., F.V., P.D.), CIC-04; CHU Nantes (L.L.-V., Y.P.), Department of Clinical Neurophysiology; CHU Nantes (T.C., E.C., F.V., M.N.), Institut des Maladies de l'Appareil Digestif; CHU Nantes (M.D.), Plateforme de Biométrie, Département Promotion DRCI; and CHU Nantes (P.D.), Department of Neurology, France
| | - Marie Dalichampt
- From Inserm (L.L.-V., T.C., E.C., M.N., P.D.), U1235, Nantes; University Nantes (L.L.-V., T.C., E.C., Y.P., M.N., P.D.); Inserm (L.L.-V., E.C., S.L.D., F.V., P.D.), CIC-04; CHU Nantes (L.L.-V., Y.P.), Department of Clinical Neurophysiology; CHU Nantes (T.C., E.C., F.V., M.N.), Institut des Maladies de l'Appareil Digestif; CHU Nantes (M.D.), Plateforme de Biométrie, Département Promotion DRCI; and CHU Nantes (P.D.), Department of Neurology, France
| | - Yann Péréon
- From Inserm (L.L.-V., T.C., E.C., M.N., P.D.), U1235, Nantes; University Nantes (L.L.-V., T.C., E.C., Y.P., M.N., P.D.); Inserm (L.L.-V., E.C., S.L.D., F.V., P.D.), CIC-04; CHU Nantes (L.L.-V., Y.P.), Department of Clinical Neurophysiology; CHU Nantes (T.C., E.C., F.V., M.N.), Institut des Maladies de l'Appareil Digestif; CHU Nantes (M.D.), Plateforme de Biométrie, Département Promotion DRCI; and CHU Nantes (P.D.), Department of Neurology, France
| | - Michel Neunlist
- From Inserm (L.L.-V., T.C., E.C., M.N., P.D.), U1235, Nantes; University Nantes (L.L.-V., T.C., E.C., Y.P., M.N., P.D.); Inserm (L.L.-V., E.C., S.L.D., F.V., P.D.), CIC-04; CHU Nantes (L.L.-V., Y.P.), Department of Clinical Neurophysiology; CHU Nantes (T.C., E.C., F.V., M.N.), Institut des Maladies de l'Appareil Digestif; CHU Nantes (M.D.), Plateforme de Biométrie, Département Promotion DRCI; and CHU Nantes (P.D.), Department of Neurology, France
| | - Pascal Derkinderen
- From Inserm (L.L.-V., T.C., E.C., M.N., P.D.), U1235, Nantes; University Nantes (L.L.-V., T.C., E.C., Y.P., M.N., P.D.); Inserm (L.L.-V., E.C., S.L.D., F.V., P.D.), CIC-04; CHU Nantes (L.L.-V., Y.P.), Department of Clinical Neurophysiology; CHU Nantes (T.C., E.C., F.V., M.N.), Institut des Maladies de l'Appareil Digestif; CHU Nantes (M.D.), Plateforme de Biométrie, Département Promotion DRCI; and CHU Nantes (P.D.), Department of Neurology, France
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Niedermaier T, Weigl K, Hoffmeister M, Brenner H. Diagnostic performance of flexible sigmoidoscopy combined with fecal immunochemical test in colorectal cancer screening: meta-analysis and modeling. Eur J Epidemiol 2017; 32:481-493. [DOI: 10.1007/s10654-017-0279-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 06/24/2017] [Indexed: 12/13/2022]
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Merkofer F, Biskup E. [Not Available]. PRAXIS 2017; 106:449-455. [PMID: 28443717 DOI: 10.1024/1661-8157/a002680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Zusammenfassung. Das Kolonkarzinom stellt mit jährlich ca. 4000 Erkrankungen die dritthäufigste Todesursache in der Schweiz dar. Die meisten Kolonkarzinome treten sporadisch auf und entwickeln sich aus Adenomen (Polypen), deren Latenzzeit auf über zehn Jahre geschätzt wird. Personen über 50 Jahre ohne Risikoprofil (z.B. ohne familiäre Belastung) können häufiger an einem Kolonkarzinom erkranken. Um diese Adenome frühzeitig zu entdecken und eine Progression in ein Karzinom zu verhindern, sind Screeningverfahren wichtig. Es gibt mehrere Screeningmethoden (Stuhluntersuchungen wie Hämoccult-Test, fäkaler immunologischer Test, fäkaler DNA Test und Endoskopien wie Rekto-/Sigmoidoskopie, Ileo-Koloskopie, Kapselendoskopie). Ebenso wichtig ist auch, dass Prävention betrieben wird, indem die Bevölkerung für das Screening auf ein Kolonkarzinom sensibilisiert wird und dieses vor allem bei der Risikopopulation durchgeführt wird.
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Affiliation(s)
| | - Ewelina Biskup
- 1 Klinik für Innere Medizin, Universitätsspital Basel
- 2 Shanghai University of Medicine and Health Sciences, College of Basic Medical Sciences, Shanghai, PRC
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Atkin W, Wooldrage K, Parkin DM, Kralj-Hans I, MacRae E, Shah U, Duffy S, Cross AJ. Long term effects of once-only flexible sigmoidoscopy screening after 17 years of follow-up: the UK Flexible Sigmoidoscopy Screening randomised controlled trial. Lancet 2017; 389:1299-1311. [PMID: 28236467 PMCID: PMC6168937 DOI: 10.1016/s0140-6736(17)30396-3] [Citation(s) in RCA: 232] [Impact Index Per Article: 33.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 02/01/2017] [Accepted: 02/02/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Colorectal cancer is the third most common cancer worldwide. Previous analyses have only reported follow-up after flexible sigmoidoscopy for a maximum of 12 years. We aimed to examine colorectal cancer incidence and mortality after a single flexible sigmoidoscopy screening and 17 years of follow-up. METHODS In this multicentre randomised trial (UK Flexible Sigmoidoscopy Screening Trial), done between Nov 14, 1994, and March 30, 1999, 170 432 eligible men and women, who had indicated on a previous questionnaire that they would probably attend screening if invited, were randomly assigned (1:2) to an intervention group (offered flexible sigmoidoscopy screening) or a control group (not contacted). Randomisation was done centrally in blocks of 12, and stratified by trial centre, general practice, and household type. The nature of the intervention did not allow the staff to be masked to arm of the trial; however, randomisation was done in batches so that the control group and participants not yet randomised were unaware of their allocation status. The primary outcomes were incidence and mortality of colorectal cancer. Hazard ratios (HRs) and 95% CIs for colorectal cancer incidence and mortality were estimated for intention-to-treat and per-protocol analyses. The trial is registered with ISRCTN, number 28352761. FINDINGS Our cohort analysis included 170 034 people: 112 936 in the control group and 57 098 in the intervention group, 40 621 (71%) of whom were screened and 16 477 (29%) were not screened. During screening and a median of 17·1 years' follow-up, colorectal cancer was diagnosed in 1230 individuals in the intervention group and 3253 in the control group, and 353 individuals in the intervention group versus 996 individuals in the control group died from colorectal cancer. In intention-to-treat analyses, colorectal cancer incidence was reduced by 26% (HR 0·74 [95% CI 0·70-0·80]; p<0·0001) in the intervention group versus the control group and colorectal cancer mortality was reduced by 30% (0·70 [0·62-0·79]; p<0·0001) in the intervention group versus the control group. In per-protocol analyses, adjusted for non-compliance, colorectal cancer incidence and mortality were 35% (HR 0·65 [95% CI 0·59-0·71]) and 41% (0·59 [0·49-0·70]) lower in the screened group. INTERPRETATION A single flexible sigmoidoscopy continues to provide substantial protection from colorectal cancer diagnosis and death, with protection lasting at least 17 years. FUNDING National Institute for Health Research Efficacy and Mechanism Evaluation.
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Affiliation(s)
- Wendy Atkin
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK.
| | - Kate Wooldrage
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - D Maxwell Parkin
- Clinical Trial Service Unit, The Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
| | - Ines Kralj-Hans
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Eilidh MacRae
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Urvi Shah
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Stephen Duffy
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University, London, UK
| | - Amanda J Cross
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
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Abstract
Pediatric patients with either functional or organic bowel dysfunction may suffer from constipation and fecal incontinence and represent a complex group in whom management is often difficult. Many noninvasive and invasive treatments have been proposed, with variable efficacy and adverse effects. Transanal irrigation (TAI) is now an accepted alternative, in both children and adults, for bowel dysfunction that has not responded to conservative and medical therapies. There is, however, still some uncertainty about the use of TAI in pediatric populations. Hence, a group of specialists from different nations and pediatric disciplines, all with long-standing experience of bowel management in children, performed a literature search and had round table discussions to determine the best-practice use of TAI in the pediatric patient population. Based on these findings, this article provides best-practice recommendations on indications, patient selection, important considerations before treatment, patient and family training, treatment regimens, troubleshooting, and practical aspects of TAI. We conclude that careful patient selection, a tailored approach, directly supervised training, and sustained follow-up are key to optimize outcomes with TAI in children with functional or organic bowel dysfunction.
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Rees CJ, Thomas Gibson S, Rutter MD, Baragwanath P, Pullan R, Feeney M, Haslam N. UK key performance indicators and quality assurance standards for colonoscopy. Gut 2016; 65:1923-1929. [PMID: 27531829 PMCID: PMC5136732 DOI: 10.1136/gutjnl-2016-312044] [Citation(s) in RCA: 196] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 07/08/2016] [Accepted: 07/17/2016] [Indexed: 12/12/2022]
Abstract
Colonoscopy should be delivered by endoscopists performing high quality procedures. The British Society of Gastroenterology, the UK Joint Advisory Group on GI Endoscopy, and the Association of Coloproctology of Great Britain and Ireland have developed quality assurance measures and key performance indicators for the delivery of colonoscopy within the UK. This document sets minimal standards for delivery of procedures along with aspirational targets that all endoscopists should aim for.
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Affiliation(s)
- Colin J Rees
- Department of Gastroenterology, South Tyneside NHS Foundation Trust, South Shields, UK,Durham University School of Medicine, Pharmacy and Health,Northern Region Endoscopy Group
| | | | - Matt D Rutter
- Durham University School of Medicine, Pharmacy and Health,Northern Region Endoscopy Group,Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, UK
| | - Phil Baragwanath
- University Hospital of Coventry & Warwickshire NHS Trust, Coventry, UK
| | - Rupert Pullan
- South Devon Healthcare NHS Foundation Trust, Torquay, UK
| | - Mark Feeney
- South Devon Healthcare NHS Foundation Trust, Torquay, UK
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Rees CJ, Bevan R, Zimmermann-Fraedrich K, Rutter MD, Rex D, Dekker E, Ponchon T, Bretthauer M, Regula J, Saunders B, Hassan C, Bourke MJ, Rösch T. Expert opinions and scientific evidence for colonoscopy key performance indicators. Gut 2016; 65:2045-2060. [PMID: 27802153 PMCID: PMC5136701 DOI: 10.1136/gutjnl-2016-312043] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 09/08/2016] [Accepted: 09/11/2016] [Indexed: 12/12/2022]
Abstract
Colonoscopy is a widely performed procedure with procedural volumes increasing annually throughout the world. Many procedures are now performed as part of colorectal cancer screening programmes. Colonoscopy should be of high quality and measures of this quality should be evidence based. New UK key performance indicators and quality assurance standards have been developed by a working group with consensus agreement on each standard reached. This paper reviews the scientific basis for each of the quality measures published in the UK standards.
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Affiliation(s)
- Colin J Rees
- Department of Gastroenterology, South Tyneside District Hospital, South Shields, UK
| | - Roisin Bevan
- Department of Gastroenterology, North Tees University Hospital, Stockton-on-Tees, UK
| | | | - Matthew D Rutter
- Department of Gastroenterology, North Tees University Hospital, Stockton-on-Tees, UK
| | - Douglas Rex
- Department of Gastroenterology, Indiana University, Indianapolis, USA
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Thierry Ponchon
- Department of Gastroenterology and Hepatology, Edouard Herriot Hospital, Lyon University, Lyon, France
| | - Michael Bretthauer
- Department of Health Management and Health Economics and KG Jebsen Center for Colorectal Cancer Research, University of Oslo, Oslo, Norway
| | - Jaroslaw Regula
- Department of Gastroenterology, Medical Center for Postgraduate Education and the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
| | - Brian Saunders
- Department of Gastroenterology, St Mark's Hospital and Academic Institute, Harrow, UK
| | - Cesare Hassan
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
| | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, Sydney, Australia
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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van Jaarsveld CHM, Miles A, Edwards R, Wardle J. Marriage and cancer prevention: Does marital status and inviting both spouses together influence colorectal cancer screening participation? J Med Screen 2016; 13:172-6. [PMID: 17217605 DOI: 10.1177/096914130601300403] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives This study examined the influence of marital status and inviting both partners together on participation in colorectal cancer screening. Setting Data were from a subset of participants from the UK Flexible Sigmoidoscopy Trial (1996–1999). Methods Marital status was self-reported, and co-invitation of partner was obtained from the trial database. Screening intentions were assessed in 16,527 adults aged 55–64 years. Attendance was recorded in the 4130 respondents who were subsequently invited. Results Multivariate analyses, controlling for age and educational level, indicate that married (or cohabiting) people have more positive intentions (odds ratio [OR] 1.26; 95% confidence interval [CI] 1.14–1.38) and higher attendance rates at screening (OR = 1.23; 95% CI 1.04–1.45) than non-married people. After adjusting for the marriage effect, inviting partners together (co-invitation) significantly increased screening intentions among women (OR = 1.17; 95% CI 1.04–1.31) but not men (OR = 0.97; 95% CI 0.85–1.10). Co-invitation significantly increased attendance at screening in both genders (OR = 1.34; 95% CI 1.14–1.58). Conclusions In this age group, married adults are more likely to participate in colorectal cancer screening than the non-married, and inviting both members of a couple together further increases screening uptake. The positive effect of marriage was as strong for women as men.
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Affiliation(s)
- Cornelia H M van Jaarsveld
- Cancer Research UK Health Behaviour Unit, Department of Epidemiology and Public Health, University College London, Gower Street, London WC1E 6BT, UK
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McGregor LM, Skrobanski H, Miller H, Ritchie M, Berkman L, Morris S, Rees C, von Wagner C. Using Specialist Screening Practitioners (SSPs) to increase uptake of the Bowel Scope (Flexible Sigmoidoscopy) Screening Programme: a study protocol for a feasibility single-stage phase II trial. Pilot Feasibility Stud 2016; 2:54. [PMID: 27965871 PMCID: PMC5153869 DOI: 10.1186/s40814-016-0093-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 08/12/2016] [Indexed: 01/22/2023] Open
Abstract
Background The NHS Bowel Scope Screening (BSS) programme offers men and women aged 55 years a once-only flexible sigmoidoscopy (FS), a test that can help reduce colorectal cancer (CRC) incidence and mortality. However, the benefits of BSS are contingent on uptake. This National Institute for Health Research-funded single-stage phase II trial will test the feasibility of using patient navigation (PN), an intervention that offers support to patients to overcome barriers to healthcare, to increase BSS uptake within a socially deprived area of England. Methods/design All individuals invited for BSS at South Tyneside NHS Foundation Trust during the 6-month recruitment period will be invited to take part in the study. Consenting participants will be randomised to receive PN or usual care in a 2:1 ratio. PN involves non-attenders receiving a phone call from a Specialist Screening Practitioner (SSP) who will elicit reasons for non-attendance and offer educational, practical, and emotional support as needed. If requested by the patient, another appointment for BSS will then be arranged. We anticipate 30 % of participants will be non-attenders. Using A’Hern single-stage design, with 20 % significance level and 80 % power, at least 35 participants who receive PN need to subsequently attend for PN to be considered worthy of further investigation in a definitive trial. The primary outcome measure will be the number of participants in the PN group who re-book and attend their BSS appointment. A qualitative analysis of the PN transcripts, and interviews with the SSPs, will also be conducted, alongside a quantitative analysis of completed patient-reported experience questionnaires. An economic analysis will calculate the costs of delivering PN. Discussion This feasibility study will be instrumental in deciding whether to conduct the first definitive trial of PN in BSS in England. If PN is subsequently shown to be cost-effective at increasing uptake of BSS, NHS policies could be modified to implement PN as a standard service. The results will be disseminated in peer-reviewed journals and at scientific conferences. Trial registration International Standard Randomised Controlled Trial Number, ISRCTN13314752 Electronic supplementary material The online version of this article (doi:10.1186/s40814-016-0093-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lesley M McGregor
- Cancer Research UK Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London, WC1E 6BT UK
| | - Hanna Skrobanski
- Cancer Research UK Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London, WC1E 6BT UK
| | - Hayley Miller
- Gateshead Health NHS Foundation Trust, Queen Elizabeth Hospital, Queen Elizabeth Avenue, Sheriff Hill, Gateshead, Tyne and Wear NE9 6SX UK
| | - Mary Ritchie
- Gateshead Health NHS Foundation Trust, Queen Elizabeth Hospital, Queen Elizabeth Avenue, Sheriff Hill, Gateshead, Tyne and Wear NE9 6SX UK
| | | | - Stephen Morris
- Department of Applied Health Research, University College London, London, WC1E 6BT UK
| | - Colin Rees
- South Tyneside NHS Foundation Trust, South Tyneside District Hospital, Harton Lane, South Shields, Tyne and Wear NE34 0PL UK
| | - Christian von Wagner
- Cancer Research UK Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London, WC1E 6BT UK
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Tinmouth J, Vella ET, Baxter NN, Dubé C, Gould M, Hey A, Ismaila N, McCurdy BR, Paszat L. Colorectal Cancer Screening in Average Risk Populations: Evidence Summary. Can J Gastroenterol Hepatol 2016; 2016:2878149. [PMID: 27597935 PMCID: PMC5002289 DOI: 10.1155/2016/2878149] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 06/29/2016] [Indexed: 02/06/2023] Open
Abstract
Introduction. The objectives of this systematic review were to evaluate the evidence for different CRC screening tests and to determine the most appropriate ages of initiation and cessation for CRC screening and the most appropriate screening intervals for selected CRC screening tests in people at average risk for CRC. Methods. Electronic databases were searched for studies that addressed the research objectives. Meta-analyses were conducted with clinically homogenous trials. A working group reviewed the evidence to develop conclusions. Results. Thirty RCTs and 29 observational studies were included. Flexible sigmoidoscopy (FS) prevented CRC and led to the largest reduction in CRC mortality with a smaller but significant reduction in CRC mortality with the use of guaiac fecal occult blood tests (gFOBTs). There was insufficient or low quality evidence to support the use of other screening tests, including colonoscopy, as well as changing the ages of initiation and cessation for CRC screening with gFOBTs in Ontario. Either annual or biennial screening using gFOBT reduces CRC-related mortality. Conclusion. The evidentiary base supports the use of FS or FOBT (either annual or biennial) to screen patients at average risk for CRC. This work will guide the development of the provincial CRC screening program.
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Affiliation(s)
- Jill Tinmouth
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Emily T. Vella
- Program in Evidence-Based Care, Cancer Care Ontario, Hamilton, ON, Canada
| | - Nancy N. Baxter
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Catherine Dubé
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada
- Department of Medicine, Division of Gastroenterology, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada
| | - Michael Gould
- William Osler Health Centre, Etobicoke, ON, Canada
- Vaughan Endoscopy Clinic, Vaughan, ON, Canada
| | - Amanda Hey
- Northeast Cancer Centre Health Sciences North/Horizon Santé-Nord, Sudbury Outpatient Centre, Sudbury, ON, Canada
| | | | | | - Lawrence Paszat
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Abstract
BACKGROUND Treatment of early stage rectal cancer has excellent oncological results. To reduce treatment-related mortality and morbidity and improve functional results, a focus on local resections is increasingly important. OBJECTIVE The purpose of this study was to compare outcomes after transanal endoscopic microsurgery and total mesorectal excision for early stage rectal cancer (T1 + T2) in Norway. DESIGN This was an observational study based on prospective data from the Norwegian Colorectal Cancer Registry. SETTINGS The study was conducted as a national, population-based study. PATIENTS All 543 patients with T1 and 1593 patients with T2 rectal cancer without distant metastases that was treated by transanal endoscopic microsurgery or total mesorectal excision without radiochemotherapy during 2000-2009 were included. MAIN OUTCOME MEASURES The primary outcomes were 5-year relative survival and 5-year local recurrence rate. RESULTS Among 543 patients with T1 cancer, the 5-year overall survival rate was 65.3% after transanal endoscopic microsurgery versus 81.5% after total mesorectal excision (p = 0.012). Adjusted for age and sex there was no excess mortality for transanal endoscopic microsurgery (HR = 1.28 (95% CI, 0.8-1.9); p = 0.22). The 5-year relative survival rate was 96.8% after transanal endoscopic microsurgery versus 98.2% after total mesorectal excision (p = 0.603), and the 5-year local recurrence rate was 14.5% versus 1.4% (p < 0.001). Among 1593 patients with T2 cancer, 5-year overall survival was 42.1% versus 76.1% (p < 0.001), 5-year relative survival was 65.4% versus 93.9% (p < 0.001), and 5 year local recurrence rate was 11.4% versus 4.4% in the 2 groups. LIMITATIONS The study is limited by its observational design and that the 2 groups were different according to patient and tumor characteristics. Another limitation was the low number of transanal endoscopic microsurgery procedures. CONCLUSIONS Transanal endoscopic microsurgery had comparable 5-year relative survival to total mesorectal excision in T1 rectal cancer but inferior 5-year relative survival in T2 rectal cancer. Transanal endoscopic microsurgery was associated with higher local recurrence rates for both T1 and T2 tumors.
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