Colorectal Cancer Screening Based on Age and Gender: A Cost-Effectiveness Analysis

The Use of a Non-Invasive Biomarker for Colorectal Cancer Screening: A Comparative Cost-Effectiveness Modeling Study

This study aimed to examine the cost-effectiveness of fecal biomarker M3 panel compared to fecal immunochemical test (FIT) and colonoscopy in an Asian population. In a hypothetical population of 100,000 persons aged 50 years who received FIT yearly, M3 biomarker yearly, or colonoscopy every 10 years until the age of 75 years. Participants with positive FOBT or a result of "high risk" identified using the M3 biomarker are offered colonoscopy. We assumed surveillance colonoscopy is repeated every 3 years, and examined the treatment cost. A comparison of various outcome measures was conducted using Markov modelling. The incremental cost-effectiveness ratio (ICER) of FIT, M3 biomarker, and colonoscopy was USD108,176, USD133,485 and USD159,596, respectively. Comparing with FIT, the use of M3 biomarker could lead to significantly smaller total loss of cancer-related life-years (2783 vs. 5279); a higher number of CRC cases prevented (1622 vs. 146), a higher proportion of CRC cases prevented (50.2% vs. 4.5%), more life-years saved (2852 vs. 339), and cheaper total costs per life-year saved (USD212,553 vs. 773,894). The total costs per life-year saved is more affordable than that achieved by colonoscopy as a primary screening tool (USD212,553 vs. USD236,909). The findings show that M3 biomarkers may be more cost-effective than colonoscopy.

Cancer diagnostic tools to aid decision-making in primary care: mixed-methods systematic reviews and cost-effectiveness analysis

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.

Risk-stratified strategies in population screening for colorectal cancer

Colorectal cancer (CRC) screening has been demonstrated to reduce CRC incidence and mortality. However, besides such benefits, CRC screening is also associated with potential harmful effects. In an ideal world, screening would only be directed to the small proportion of the population that might potentially benefit. Risk‐based screening can be seen as a first step towards this ideal world, by redistributing screening resources from low‐risk to high‐risk individuals. In theory, this should result in scarce resources being used in individuals who benefit most, while intensity of screening is reduced in individuals who benefit less, hence improving the benefit‐harm ratio among all invitees. Available strategies that have been proposed for risk‐based CRC screening include using information on age, sex, prior screening history, lifestyle and/or genetic information. Implementation of risk‐based screening requires careful consideration of reliable risk prediction models, participation with screening and informed decision‐making. While it is important to recognise the limitations of current approaches, available evidence suggests that it might be feasible to start planning the introduction of tailored strategies within screening programmes. Implementing risk‐based screening based on age, sex and prior screening history alone would already represent a substantial improvement over current uniform screening approaches. We propose that it is time that screening programmes start there and continue striving towards more comprehensive approaches embedding primary prevention as an effective approach to lower risk for everyone.

Cost-effectiveness analysis of a community-based colorectal cancer screening program in Shanghai, China

OBJECTIVE

This study investigated the cost-effectiveness of a community-based colorectal cancer-screening program (C-CRCSP) in Shanghai, China, among the residents in the urban, suburban and rural areas.

METHODS

A Markov model was constructed to evaluate the cost-effectiveness of a 25-year annual C-CRCSP including 100 000 populations. Cost-effectiveness was determined by the incremental cost-effectiveness ratio (ICER); referring to either life-years gained, or quality-adjusted life-years (QALYs) gained. The threshold was gross domestic product per capita. Univariate and multivariate sensitivity analyses were performed to investigate the influence of compliance, prevalence, technological performance, medical cost and annual cost discount rate (3.5%) on ICER. A probabilistic sensitivity analysis evaluated the probability of the cost-effectiveness of C-CRCSP at different maximum acceptable ceiling ratios.

RESULTS

Compared with no screening, the C-CRCSP resulted in total gains of 7840 QALYs and 2210 life-years (LY), at a total cost of CNY 58.54 million; that is, the ICER were CNY 7460/QALYs and CNY 26650/LY. Stratifying by residency, the cumulative gains in QALYs and LY were estimated to be the lowest in the urban populations compared with the rural and suburban populations. The cost for the urban population was 3-fold and 6-fold that of the suburban and rural populations. The ICER for QALYs ranged from 2180 (rural) to 16 840 (urban).

CONCLUSION

The cost-effectiveness of a C-CRCSP in Shanghai was most favorable for the rural population, while the urban population benefits less in terms of QALYs. ICER could be enhanced by measures that increase compliance.

Cost-Effectiveness Analysis of Colorectal Cancer Screening: A Systematic Review

INTRODUCTION

Colorectal cancer (CRC) is a significant health problem with an increasing incidence worldwide. Screening is one of the ways, in which cases and deaths of CRC can be prevented. The objective of this systematic review was to evaluate the cost-effectiveness of the different CRC screening techniques and to specify the efficient technique from a cost-effectiveness perspective.

METHODS

The economic studies of CRC screening in general populations (average risk), aged 50 years and above were reviewed. Two reviewers independently reviewed the titles, abstracts, and full-texts of the studies in five databases: Cochrane, Embase, Scopus, Web of Science and PubMed. The disagreements between reviewers were resolved through the authors' consensus. The main outcome measures in this systematic review were the incremental cost-effectiveness ratio (ICER) of screening versus no-screening and then in comparison with other screening techniques. The ICER is defined by the difference in cost between two possible interventions, divided by the difference in their effect.

RESULTS

Eight studies were identified and retained for the final analysis. In this study, when screening techniques were compared to no-screening, all CRC screening techniques showed to be cost-effective. The lowest ICER calculated was $PPP -16265/quality-adjusted life-year (QALY) (the negative ICERs were between purchasing power parity in US dollar ($PPP) -16265/QALY to $PPP -1988/QALY, whereas the positive ICERs were between $PPP 1257/QALY to $PPP 55987/QALY). For studies comparing various screening techniques, there was great heterogeneity in terms of the structures of the analyses, leading to diverse conclusions about their incremental cost-effectiveness.

CONCLUSION

All CRC screening techniques were cost-effective, compared with the no-screening methods. The cost-effectiveness of the various screening techniques mainly was dependent on the context-specific parameters and highly affected by the framework of the cost-effectiveness analysis. In order to make the studies comparable, it is important to adopt a reference-based methodology for economic evaluation studies.

Cost-effectiveness analysis of colorectal cancer screening using colonoscopy, fecal immunochemical test, and risk score

BACKGROUND AND AIM

A risk-stratification score may be useful for colorectal cancer (CRC) screening, alongside screening colonoscopy (CS) and fecal immunochemical test (FIT). This study aimed to evaluate the effectiveness and cost-effectiveness of population-based CRC screening strategies using CS, FIT, and the Japanese CRC screening score.

METHODS

The effectiveness in quality-adjusted life years (QALYs), cost-effectiveness, and required number of CS procedures were evaluated for screening strategies with primary screening CS (strategy 1), FIT (strategy 2), and the risk score (strategy 3), using a simulation model analysis with two scenarios. In scenario 1, uptake rates for all tests were 60%. In scenario 2, uptake rates for FIT and a risk score were 40%, and those for screening CS and CS following a positive FIT or high risk score were 20% and 70%, respectively.

RESULTS

In scenario 1, strategy 1 gained the highest QALYs and required the highest cost. The incremental cost-effectiveness ratios per QALY gained for strategy 1 against the others were lower than 5 000 000 JPY. Strategy 1 required more than twice as many CS procedures as the other strategies. In scenario 2, strategy 3 had the highest QALYs and lowest cost, and strategy 1 had the lowest QALYs and highest cost.

CONCLUSIONS

Screening CS has the potential to be the most effective and cost-effective form of CRC screening, although it requires a large number of CS procedures. However, if non-invasive tests are preferred by recipients, other screening strategies, particularly those using the risk score, can be more effective and cost-effective.

Simulation modeling validity and utility in colorectal cancer screening delivery: A systematic review

OBJECTIVE

This study sought to assess the impact and validity of simulation modeling in informing decision making in a complex area of healthcare delivery: colorectal cancer (CRC) screening.

MATERIALS AND METHODS

We searched 10 electronic databases for English-language articles published between January 1, 2008, and March 1, 2019, that described the development of a simulation model with a focus on average-risk CRC screening delivery. Included articles were reviewed for evidence that the model was validated, and provided real or potential contribution to informed decision making using the GRADE EtD (Grading of Recommendations Assessment, Development, and Evaluation Evidence to Decision) framework.

RESULTS

A total of 43 studies met criteria. The majority used Markov modeling (n = 31 [72%]) and sought to determine cost-effectiveness, compare screening modalities, or assess effectiveness of screening. No study reported full model validation and only (58%) reported conducting any validation. Majority of models were developed to address a specific health systems or policy question; few articles report the model's impact on this decision (n = 39 [91%] vs. n = 5 [12%]). Overall, models provided evidence relevant to every element important to decision makers as outlined in the GRADE EtD framework.

DISCUSSION AND CONCLUSION

Simulation modeling contributes evidence that is considered valuable to decision making in CRC screening delivery, particularly in assessing cost-effectiveness and comparing screening modalities. However, the actual impact on decisions and validity of models is lacking in the literature. Greater validity testing, impact assessment, and standardized reporting of both is needed to understand and demonstrate the reliability and utility of simulation modeling.

Economic evaluations of screening strategies for the early detection of colorectal cancer in the average-risk population: A systematic literature review

Background

Colorectal cancer (CRC) screening has proven effective in reducing CRC mortality. This study aimed to systematically review, and evaluate the reporting quality, of the economic evidence regarding CRC screening in average-risk individuals.

Methods

Databases searched included Medline, EMBASE, National Health Service Economic Evaluation, Database of Abstracts of Reviews of Effects, Cost-Effectiveness Analysis registry, EconLit, and Health Technology Assessment database. Eligible studies were cost-effectiveness and cost-utility analyses comparing CRC screening strategies in average-risk individuals, published in English or Spanish, between January 2012 and November 2018. Reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

Results

Of 1,993 publications initially retrieved, 477 were excluded by duplicate review, 1,449 by title/abstract review, and 34 by full-text review. Finally, 33 publications were included in the qualitative synthesis. Most studies were conducted in Europe (36,4%), followed by United States (24,2%) and Asia (24,2%). The main screening modalities considered were fecal immunochemical tests (70%), colonoscopy (67%), guaiac fecal occult blood test (42%) and flexible sigmoidoscopy (30%). In most studies, CRC screening was deemed cost-effective compared to no screening. Sensitivity analyses indicated that cost of CRC screening tests, adherence to screening, screening test sensitivity, and cost of CRC treatment had the greatest impact on cost-effectiveness results across studies. The majority of studies (73%) adequately reported at least 50% of the items included in the CHEERS checklist. Least well reported items included setting, study perspective, discount rate, model choice, and methods to identify effectiveness data or to estimate resource use and costs.

Conclusions

CRC screening is an efficient alternative to no screening. Nevertheless, it is not possible to conclude which strategy should be preferred for population-based screening programs. Although we observed an overall good adherence to CHEERS recommendations, there is still room for improvement in economic evaluations reporting in this field.

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

BACKGROUND & AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

miR‑1273g‑3p promotes proliferation, migration and invasion of LoVo cells via cannabinoid receptor 1 through activation of ERBB4/PIK3R3/mTOR/S6K2 signaling pathway

MicroRNAs (miR) are important in various crucial cell processes including proliferation, migration and invasion. Dysregulation of miRNAs have been increasingly reported to contribute to colorectal cancer. However, the detailed biological function and potential mechanisms of miR‑1273g‑3p in colorectal cancer remain poorly understood. The expression levels of miR‑1273g‑3p in human colorectal cancer LoVo cell lines were detected via reverse transcription‑quantitative polymerase chain reaction (RT‑qPCR). The target genes of miR‑1273g‑3p were predicted by bioinformatics and verified by a luciferase reporter assay, RT‑qPCR and western blotting. The MTT, wound‑healing and Transwell assays were used to examine the biological functions of miR‑1273g‑3p in LoVo cells. The potential molecular mechanisms of miR‑1273g‑3p on LoVo cell proliferation, migration and invasion was detected by western blotting. The results of the present study demonstrated that miR‑1273g‑3p expression was extensively upregulated in LoVo cells compared with the normal colon epithelial NCM460 cell line. Further studies indicated that miR‑1273g‑3p inhibitor significantly suppressed LoVo cell proliferation, migration and invasion compared with inhibitor control. Following this, the cannabinoid receptor 1 (CNR1) was identified as a direct target gene of miR‑1273g‑3p. Knockdown of CNR1 restored the phenotypes of LoVo cells transfected with miR‑1273g‑3p inhibitor. Furthermore, the potential molecular mechanism of miR‑1273g‑3p on LoVo cell proliferation, migration and invasion may be mediated by activating the Erb‑B2 receptor tyrosine kinase 4 (ERBB4)/phosphoinositide‑3‑kinase regulatory subunit 3 (PIK3R3)/mechanistic target of rapamycin (mTOR)/S6 kinase 2 (S6K2) signaling pathway. These observations indicated that miR‑1273g‑3p promoted the proliferation, migration and invasion of LoVo cells via CNR1, and this may have occurred through activation of the ERBB4/PIK3R3/mTOR/S6K2 signaling pathway, suggesting that miR‑1273g‑3p may serve as a novel therapeutic target for the effective treatment of colorectal cancer.

Chemopreventive effect of Myricetin, a natural occurring compound, on colonic chronic inflammation and inflammation-driven tumorigenesis in mice

Myricetin is a flavonoids compound extracted from edible myrica rubra. We aimed to evaluate the efficacy of Myricetin on colonic chronic inflammation and inflammation-driven tumorigenesis in mice. Myricetin was administrated by gavage for 4 consecutive weeks. Mice were sacrificed and the number of colonic polyps was counted. Myricetin significantly inhibited AOM/DSS-induced colitis and colorectal tumorigenesis. Myricetin prevented the incidence of colorectal tumorigenesis and reduced the size of colorectal polyps. Histopathologic analysis showed that Myricetin could attenuate the degree of colonic inflammation and colorectal tumorigenesis. Further analysis showed that Myricetin strongly reduced the levels of inflammatory factors TNF-α, IL-1β, IL-6, NF-κB, p-NF-κB, cyclooxygenase-2 (COX-2), PCNA and Cyclin D1 in the colonic tissues as analyzed by the assays of immunohistochemical staining, Western blotting and Q-RT-PCR. Our results demonstrated that Myricetin possesses the biological activities of chemoprevention colonic chronic inflammation and inflammation-driven tumorigenesis. We suggest that Myricetin could be developed as a promising chemopreventive drug for reducing the risk of colorectal cancer.

Colorectal cancer screening: Using evidence-based guidelines

Colorectal cancer is the third most common cancer diagnosed in men and women. There are multiple options for prevention and early detection. Evidence-based guidelines are available to select the best option based on personal and family history. NPs should utilize these guidelines in clinical practice to select the appropriate screening for their patients.

The association between CCND1 G870A polymorphism and colorectal cancer risk: A meta-analysis

BACKGROUND

CyclinD1 (CCND1) is a key cell cycle regulatory protein. A large number of epidemiological studies have assessed the potential correlation between the CCND1 G870A polymorphism and the risk of colorectal cancer (CRC), but their findings have been inconsistent. To obtain a more precise understanding of the association between the G870A polymorphism in the CCND1 gene and the CRC risk, we conducted a more comprehensive meta-analysis.

METHODOLOGY

We searched PubMed, Ovid, Springer, Weipu, China National Knowledge Infrastructure (CNKI), and Wanfang databases, covering all publications (the last search was updated on January 10, 2017). The pooled odds ratios (ORs) with 95% confidence intervals (CIs) were derived from a fixed effect or random effect model. Statistical analyses were performed using Review Manager 5.3 and STATA 10.0 software.

RESULTS

A total of 7276 CRC patients and 9667 controls from 27 publications were included in this meta-analysis. We found that compared with GG homozygote genetic model, AA, AG, AA + AG genetic models of the CCND1 G870A polymorphism were significantly associated with overall CRC risk (AA homozygote genetic model: OR = 1.28, 95% CI = 1.10-1.49; AG heterozygote genetic model: OR = 1.15, 95% CI = 1.06-1.25; AA homozygote + AG heterozygote genetic model: OR = 1.19, 95% CI = 1.07-1.33). Subgroup analyses by ethnicity and cancer location showed that A carriers were consistently associated with a significantly increased risk of CRC in all subsets of participants (Asian and Caucasian; colon cancer and rectal cancer). When stratified by study design, we found a significant association in hospital-based studies (HB), but no significant associations were found in either population-based studies (PB) or family-based studies (FB). According to subgroup analysis by cancer type, the risk of sporadic colorectal cancer (sCRC) and hereditary nonpolyposis colorectal cancer (HNPCC) were not correlated with the CCND1 G870A polymorphism, except AG (AG vs GG: OR = 1.30, 95% CI = 1.11-1.53).

CONCLUSIONS

This meta-analysis suggests that the CCND1 G870A polymorphism is associated with an increased risk of CRC, especially that A carriers may be a major risk factor for CRC.

Innovative Disease Model: Zebrafish as an In Vivo Platform for Intestinal Disorder and Tumors

Colorectal cancer (CRC) is one of the world’s most common cancers and is the second leading cause of cancer deaths, causing more than 50,000 estimated deaths each year. Several risk factors are highly associated with CRC, including being overweight, eating a diet high in red meat and over-processed meat, having a history of inflammatory bowel disease, and smoking. Previous zebrafish studies have demonstrated that multiple oncogenes and tumor suppressor genes can be regulated through genetic or epigenetic alterations. Zebrafish research has also revealed that the activation of carcinogenesis-associated signal pathways plays an important role in CRC. The biology of cancer, intestinal disorders caused by carcinogens, and the morphological patterns of tumors have been found to be highly similar between zebrafish and humans. Therefore, the zebrafish has become an important animal model for translational medical research. Several zebrafish models have been developed to elucidate the characteristics of gastrointestinal diseases. This review article focuses on zebrafish models that have been used to study human intestinal disorders and tumors, including models involving mutant and transgenic fish. We also report on xenograft models and chemically-induced enterocolitis. This review demonstrates that excellent zebrafish models can provide novel insights into the pathogenesis of gastrointestinal diseases and help facilitate the evaluation of novel anti-tumor drugs.

Comparison of claims data on hospitalization rates and repeat procedures in patients receiving a bowel preparation prior to colonoscopy

OBJECTIVES

To evaluate outcomes of colorectal screening using sodium picosulfate and magnesium citrate compared with other prescription bowel-preparation agents. Primary endpoints were rates of procedure-associated hospitalizations, diagnosis at hospitalization, and rates of early repeat screenings.

METHODS

This retrospective cohort study identified patients using the Truven Health Analytics MarketScan databases, which contain fully adjudicated, de-identified, medical- and prescription-drug claims, as well as demographic and enrollment information for individuals with commercial, Medicaid, and Medicare supplemental insurance coverage. Patients who had a colonoscopy or sigmoidoscopy over a 3-year period were identified using International Classification of Diseases Clinical Modification procedure codes, recorded on claims from physicians and facilities. First, screening colonoscopy was identified for each patient, and the study was limited to those patients who could be observed for ≥6 months before and 3 months after the screening procedure. Total number of hospitalizations and rates of early repeat screenings were evaluated for all patients who received sodium picosulfate and magnesium citrate and compared with those who received other bowel-preparation agents. Individual prescription medications that could affect the outcome of the cleansing agent were identified; further evaluations were made to establish whether patients had comorbid conditions, such as chronic kidney disease, cardiovascular disease, or psychiatric illness. Statistical methods included descriptive statistics, two-tailed t-tests, and multivariate logistic regression.

RESULTS

A total of 566,628 procedures were identified in the MarketScan databases and included in the study. Sodium picosulfate and magnesium citrate performed well in terms of safety outcomes, with no hospitalizations due to diagnosis of hyponatremia, dehydration, or other fluid disorders in the 10 days after procedure. Early repeat rates among sodium picosulfate and magnesium citrate patients were comparable with rates observed for all other cleansing agents.

CONCLUSION

Outcomes of colorectal screening using sodium picosulfate and magnesium citrate were not significantly different compared with other prescription bowel-preparation agents.

The Epigenomics of Embryonic Pathway Signaling in Colorectal Cancer

Colorectal cancer (CRC) is the second-leading cause of cancer death in developed countries. While early detection (e.g., colonoscopy) generally yields excellent outcomes, metastatic and drug-resistant disease is uniformly fatal, and non-compliance for screening remains over 25%. Familial CRCs (10% of total cases) primarily include mutations in the gene APC. Somatic disease is linked to several environmental several risk factors, including mutations in WNT, KRAS, and TGFβ. To reflect the genesis/progression of CRC, a series of five discrete stages, from normal colon mucosa to fully invasive carcinoma, each regulated by specific “gatekeeper” genes, remains well-accepted after 20 years. However, many CRC tumors do not possess those particular mutations, suggesting alternative mechanisms. More recently, embryo-like “cancer stem cells” have been proposed to undergo self-renewal and drive tumorigenesis (and possibly, metastasis), as governed by specific “epigenomic” alterations. Here, we review recent literature describing possible mechanisms that underlie these phenotypes, including cancer “stemness,” believed by many to associate with the epithelial-to-mesenchymal transition (EMT). We further propose that the maintenance of undifferentiated phenotypes, by the activity of distinct transcription factors, facilitates chromatin remodeling and phenotypic plasticity. With that regard, we support recent assertions that EMT is not an “either/or” event, but rather a continuous spectrum of mesenchymal vs. epithelial phenotypes (in various degrees of aberrant differentiation/undifferentiation). Finally, we discuss possible methods of pharmacologically targeting such aberrant epigenomes, with regard to their possible relevance toward halting, or even reversing, colorectal cancer progression.