Meta-analysis: adherence to colorectal cancer screening and the detection rate for advanced neoplasia, according to the type of screening test

A network-based analysis to identify a piRNA-target signature related to colorectal cancer prognosis: in silico and in vitro study

PURPOSE

Patients with colorectal cancer (CRC) are diagnosed in advanced stages and have worse overall survival. Also, this cancer incidence is rising in many countries. The aim of this study is to find piwi-interacting RNAs (piRNA) predicting the prognosis of patients with colorectal cancer, using bioinformatics and evaluating these results through RT-qPCR method.

METHODS

The target genes of piRNAs were predicted using miRDB and TargetRank databases. Protein-protein interaction (PPI) networks were constructed by STRING and were analyzed with Cytoscape software and the MCODE tool used for module construction. Expression levels of final selected piRNAs in 18 pairs of CRC tissue and adjacent normal tissue were measured by quantitative real-time reverse-transcription polymerase chain reaction (qRT-PCR).

RESULTS

Twenty CRC-related piRNAs and 980 target genes were included in this study. After PPI analysis 19 hub genes were identified. Then, the prognostic value of these hub genes was assessed via Kaplan-Meier survival analyses. This survival analysis indicated that the expression of six genes was significantly associated with overall survival of patients with CRC. These genes are targets of hsa-piR-487, hsa-piR-28944 and piR-hsa-8401. Also, the pathway analysis revealed the potential signal pathways of these piRNAs targets involved in CRC. RT-qPCR showed that hsa-piR-487 and hsa-piR-28944 expression significantly were down-regulated in CRC tumor tissues compared with the adjacent normal tissues (P < 0.05, P < 0.01).

CONCLUSION

It seems that hsa-piR-487 and hsa-piR-28944 can be considered as a potential biomarker for the diagnosis of CRC. However, it is still necessary to conduct studies with a higher statistical population and measure them in the serum of patients to confirm these results.

Single-round performance of colorectal cancer screening programs: a network meta-analysis of randomized clinical trials

BACKGROUND

Demonstrating mortality reduction in new colorectal cancer (CRC) screening programs through randomized clinical trials (RCTs) is challenging. We systematically reviewed single-round program performance outcomes using a stepwise approach proposed by the World Endoscopy Organization CRC Screening Committee framework.

METHODS

The MEDLINE, EMBASE, Central, and Ichushi Web databases were searched until October 28, 2024, to find RCTs comparing guaiac-based and immunochemical fecal occult blood testing (gFOBT and FIT), flexible sigmoidoscopy (FS), computed tomographic colonography (CTC), and total colonoscopy (TCS). Paired reviewers screened studies, extracted data, and assessed bias risk. A Bayesian random-effects network meta-analysis was conducted, and the certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach. The primary outcome was advanced neoplasia (AN) detection, and the secondary outcomes were participation and colorectal cancer (CRC) detection, all during the first screening round.

RESULTS

Eighteen RCTs (437,072 invitees) were included. The risk of bias was low or raised some concerns for screening participation, but it was high for detection outcomes. In the network meta-analysis of 15 RCTs not allowing crossover, the FIT-based program had a higher AN detection rate than the gFOBT-based program (relative risk [RR] 2.48; 95% credible interval [CrI] 1.52-4.21; moderate certainty). AN detection rates were not different in the CTC- (RR 1.01; CrI 0.43-2.23; very low certainty) and TCS-based (RR 1.03; CrI 0.54-1.78; low certainty) programs compared with the FS-based program. All the visualization modality programs had higher AN detection rates than the FIT-based program (FS: RR 2.13 [CrI 1.38-3.77]; CTC 2.16 [1.11-4.51]; and TCS 2.19 [1.43-3.48]; all with low certainty). Low event rates precluded definitive conclusions regarding CRC detection (very low to low certainty). The TCS-based program had the worst participation rate (very low to low certainty). Comparative data allowing crossover were limited.

CONCLUSIONS

This is the first network meta-analysis that evaluates program-level initial performance indicators. FIT-based programs likely detect more AN cases than gFOBT-based programs, while FS-, CTC-, and TCS-based programs may outperform FIT. Due to limitations in first-round results, long-term outcomes should be assessed after 10-15 years.

Endoscopic Screening and Surveillance of Gastrointestinal Cancer

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

Longitudinal retrospective study of real-world adherence to colorectal cancer screening before and after the COVID-19 pandemic in the USA

Introduction

At-home stool tests are an increasingly popular practice for colorectal cancer screening, especially when access to healthcare facilities is challenging. However, there is limited information about whether stool tests provide sufficient coverage when patients must undergo repeat testing. This study evaluates repeat preventative stool tests over 2 year periods in a healthcare system with 51 hospitals and over 1000 clinics across seven western US states, before and after the onset of the COVID-19 pandemic.

Methods

We conduct a real-world, observational, retrospective and longitudinal study based on electronic medical records. We measure the rate of repeat screening and mean delay in repeat screening among patients who receive an initial stool test. We estimate the changes in the likelihood of colorectal cancer screening using a Cox proportional hazard model.

Results

Our sample included 4 03 085 patients. The share of patients with an initial negative stool test who received a repeat screening ranged from 38% to 49% across different years. Among patients who received a repeat screening, there is a delay of 3 months on average. The volume of stool tests increased during the pandemic: the HR of screening after the onset of the pandemic to that before the pandemic was 1.18 (95% CI (1.15, 1.20), p<0.001).

Conclusions

Our findings show that less than 50% of patients received a repeat stool test, creating gaps in their screening coverage. The increase in stool tests during the pandemic is partly due to a substitution away from colonoscopies, underscoring the increasing importance of stool tests in CRC screening. Programmes that aim to increase CRC screening uptake should focus on repeated testing after an initial screening.

Effectiveness of the Korean National Cancer Screening Program in Reducing Colorectal Cancer Mortality

BACKGROUND

Whether colorectal cancer (CRC) screening with a fecal immunochemical test (FIT) reduces mortality remains unclear. In South Korea, CRC screening with a FIT for individuals aged ≥ 50 years has been part of the Korean National Cancer Screening Program (KNCSP) since 2004. The aim of this study was to evaluate the effectiveness of the KNCSP in reducing CRC-specific mortality.

METHODS

We conducted a nested case-control study using cohort-based data derived from the KNCSP database. The cohort included 5,944,540 colorectal cancer-free individuals aged ≥ 50 years as of 2004. Individuals who died after CRC diagnosis were defined as cases (n = 29,992) and their sociodemographic characteristics were matched to those of the selected controls. The effects of screening exposure, frequency, and time interval on CRC-specific mortality were analyzed according to age group. Conditional logistic regression analysis was performed.

RESULTS

Compared with individuals who had never been screened, those who had ever been screened showed an OR of 0.74 (95% CI, 0.71-0.76) for CRC-specific mortality. CRC-specific mortality decreased as the number of screenings increased. Similar results were observed for those aged 50-79 years; however, the results for those aged 75-79 years were not statistically significant. Moreover, those aged ≥ 80 years had the opposite results.

CONCLUSIONS

CRC mass screening using FIT is effective for individuals aged 50-74 years; therefore, this study suggests that countries considering introducing national CRC screening implement FIT for those within this age range.

Colorectal cancer screening using a multi-locus blood-based assay targeting circulating tumor DNA methylation: a cross-sectional study in an average-risk population

BACKGROUND

Effective screening for colorectal cancer (CRC) enables earlier diagnosis and intervention to improve patient survival.

METHODS

In this study, we prospectively conducted a blood-based CRC screening program for community residents in Hanjiang District, Yangzhou City, and evaluated the screening efficacy of a blood-based multi-locus DNA methylation assay (ColonAiQ). The ColonAiQ-positive rate and colonoscopy participation rate of the population, detection rate of intestinal lesions, and positive predictive value (PPV) of CRC and advanced adenoma (AA) were calculated, and the associated factors were explored.

RESULTS

A total of 105,285 participants were enrolled from January 2021 to December 2022, all of whom completed the ColonAiQ assay, yielding a positive rate of 6.42% (6759/105,285). The colonoscopy compliance rate was 48.56% (3282/6759). Intestinal lesions were detected in 1773 individuals (54.02%), including 63 cases of CRCs (predominately early-stage), 1195 adenomas (441 cases of AAs), 327 polyps, and 188 other benign lesions. CRC patients exhibited higher ColonAiQ scores and more positive loci compared to healthy individuals. The PPVs were 1.92% for CRC and 13.44% for AA. Among participants, 66,121 (62.8%) completed questionnaires graded by the Asia-Pacific Colorectal Screening score, with 12,139 (18.36%) classified in the high-risk tier. High-risk participants had a higher ColonAiQ-positive rate (11.07%) and PPVs for CRC (3.46%) and AA (22.18%). Factors associated with increased detection rates for CRC and AA included male gender, older age, a history of alcohol consumption, and prior polyps.

CONCLUSIONS

Our study demonstrated that ColonAiQ assay effectively identifies high-risk population. These findings strongly suggest that the ColonAiQ assay represents a promising strategy for the early detection of CRC and AA in individuals at average risk.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov (NCT05336539).

5-Hydroxymethylated Biomarkers in Cell-Free DNA Predict Occult Colorectal Cancer up to 36 Months Before Diagnosis in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial

PURPOSE

Using the prostate, lung, colorectal, and ovarian (PLCO) Cancer Screening Trial samples, we identified cell-free DNA (cfDNA) candidate biomarkers bearing the epigenetic mark 5-hydroxymethylcytosine (5hmC) that detected occult colorectal cancer (CRC) up to 36 months before clinical diagnosis.

MATERIALS AND METHODS

We performed the 5hmC-seal assay and sequencing on ≤8 ng cfDNA extracted from PLCO study participant plasma samples, including n = 201 cases (diagnosed with CRC within 36 months of blood collection) and n = 401 controls (no cancer diagnosis on follow-up). We conducted association studies and machine learning modeling to analyze the genome-wide 5hmC profiles within training and validation groups that were randomly selected at a 2:1 ratio.

RESULTS

We successfully obtained 5hmC profiles from these decades-old samples. A weighted Cox model of 32 5hmC-modified gene bodies showed a predictive detection value for CRC as early as 36 months before overt tumor diagnosis (training set AUC, 77.1% [95% CI, 72.2 to 81.9] and validation set AUC, 72.8% [95% CI, 65.8 to 79.7]). Notably, the 5hmC-based predictive model showed comparable performance regardless of sex and race/ethnicity, and significantly outperformed risk factors such as age and obesity (assessed as BMI). Finally, when splitting cases at median weighted prediction scores, Kaplan-Meier analyses showed significant risk stratification for CRC occurrence in both the training set (hazard ratio, [HR], 3.3 [95% CI, 2.6 to 5.8]) and validation set (HR, 3.1 [95% CI, 1.8 to 5.8]).

CONCLUSION

Candidate 5hmC biomarkers and a scoring algorithm have the potential to predict CRC occurrence despite the absence of clinical symptoms and effective predictors. Developing a minimally invasive clinical assay that detects 5hmC-modified biomarkers holds promise for improving early CRC detection and ultimately patient outcomes.

Colorectal cancer screening; colonoscopy and biopsy results in people undergoing colonoscopy due to positive fecal occult blood test

Objectives

Screening programs are important for the early detection of colorectal cancer, which is one of the causes of high morbidity and mortality. In this study, we investigated the colonoscopy results, the incidence of adenoma and cancer, and the relationship between test results and cancer in individuals with a positive fecal occult blood test for colorectal cancer screening.

Material and Methods

Within the scope of the colorectal cancer screening program, colonoscopy was requested for individuals aged 50-70 years who applied to our outpatient clinic with a positive fecal occult blood test. The results were collected and analyzed.

Results

The results of the colonoscopy could be obtained in only 237 (56.43%) of the 420 patients who were referred for a colonoscopy because of a positive fecal occult blood test. Colonoscopy results were normal in 15 (6.33%), benign anal disease in 64 (27%), benign colonic disease in 12 (5.06%) and polyp + adenocarcinoma in 146 (61.61%). Pathology results were benign polyp in 37 (15.61%), adenomatous polyp in 86 (36.29%) and adenocarcinoma in 23 (9.71%). Quantitative test results were higher in the adenomatous polyp + adenocarcinoma group and statistically significant (p= 0.03).

Conclusion

Individuals with positive fecal occult blood tests, especially those with high quantitative test results, should be encouraged to have a colonoscopy, and they should be warned about the high probability of adenomatous polyps and colorectal cancer.

Machine learning identifies cell-free DNA 5-hydroxymethylation biomarkers that detect occult colorectal cancer in PLCO Screening Trial subjects

Background

Colorectal cancer (CRC) is a leading cause of cancer-related mortality, and CRC detection through screening improves survival rates. A promising avenue to improve patient screening compliance is the development of minimally-invasive liquid biopsy assays that target CRC biomarkers on circulating cell-free DNA (cfDNA) in peripheral plasma. In this report, we identify cfDNA biomarker candidate genes bearing the epigenetic mark 5-hydroxymethylcytosine (5hmC) that diagnose occult CRC up to 36 months prior to clinical diagnosis using the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial samples.

Methods

Archived PLCO Trial plasma samples containing cfDNA were obtained from the National Cancer Institute (NCI) biorepositories. Study subjects included those who were diagnosed with CRC within 36 months of blood collection (i.e., case, n = 201) and those who were not diagnosed with any cancer during an average of 16.3 years of follow-up (i.e., controls, n = 402). Following the extraction of 3 - 8 ng cfDNA from less than 300 microliters plasma, we employed the sensitive 5hmC-Seal chemical labeling approach, followed by next-generation sequencing (NGS). We then conducted association studies and machine-learning modeling to analyze the genome-wide 5hmC profiles within training and validation groups that were randomly selected at a 2:1 ratio.

Results

Despite the technical challenges associated with the PLCO samples (e.g., limited plasma volumes, low cfDNA amounts, and long archival times), robust genome-wide 5hmC profiles were successfully obtained from these samples. Association analyses using the Cox proportional hazards models suggested several epigenetic pathways relevant to CRC development distinguishing cases from controls. A weighted Cox model, comprised of 32-associated gene bodies, showed predictive detection value for CRC as early as 24-36 months prior to overt tumor presentation, and a trend for increased predictive power was observed for blood samples collected closer to CRC diagnosis. Notably, the 5hmC-based predictive model showed comparable performance regardless of sex and self-reported race/ethnicity, and significantly outperformed risk factors such as age and obesity according to BMI (body mass index). Additionally, further improvement of predictive performance was achieved by combining the 5hmC-based model and risk factors for CRC.

Conclusions

An assay of 5hmC epigenetic signals on cfDNA revealed candidate biomarkers with the potential to predict CRC occurrence despite the absence of clinical symptoms or the availability of effective predictors. Developing a minimally-invasive clinical assay that detects 5hmC-modified biomarkers holds promise for improving early CRC detection and ultimately patient survival through higher compliance screening and earlier intervention. Future investigation to expand this strategy to prospectively collected samples is warranted.

A qualitative interview study on colorectal cancer screening in China

Background

The effectiveness of triage screening for colorectal cancer (CRC) is not fully achieved in Chinese populations, mainly due to low compliance to colonoscopy follow-up. This study aimed to collect viewpoints of experts in China on ongoing screening programs and emerging screening tests for CRC, which may help to improve effectiveness of CRC screening in the country.

Methods

We conducted 15 semi-structured interviews with experts involving CRC screening in China during October to November of 2020. Interview topics included personal characteristics, work context, opinions on ongoing screening programs, challenges and opportunities in optimization of screening strategies, and prospects for CRC screening in near future. To analyze the data, we used a generic qualitative research approach inspired by grounded theory, including open, axial, and selective coding.

Results

This analysis revealed a total of 83 initial categories, 37 subcategories and 10 main categories, which included 4 core categories of current modality for CRC screening, factors influencing screening effectiveness, optimization of CRC screening modality, and prospects for development of CRC screening. The results provide insight into the factors underlying the challenges of the ongoing CRC screening programs in China: the most important concern is the low compliance to colonoscopy, followed by the low specificity of the currently-used initial tests. The experts proposed to use quantitative instead of qualitative fecal immunochemical test (FIT), and optimize risk assessment tools to improve specificity of initial tests. Regarding the emerging screening tests, 9 of 15 experts did not think that the novel techniques are good enough to replace the current tests, but can be used complementarily in opportunistic screening for CRC.

Conclusion

The viewpoints of Chinese experts suggested that use quantitative FIT or optimize risk assessment tools may help to identify high-risk individuals of CRC more accurately, improve adherence to colonoscopy, and thus fully achieve the effectiveness of screening.

AGA Clinical Practice Update on Risk Stratification for Colorectal Cancer Screening and Post-Polypectomy Surveillance: Expert Review

DESCRIPTION

Since the early 2000s, there has been a rapid decline in colorectal cancer (CRC) mortality, due in large part to screening and removal of precancerous polyps. Despite these improvements, CRC remains the second leading cause of cancer deaths in the United States, with approximately 53,000 deaths projected in 2023. The aim of this American Gastroenterological Association (AGA) Clinical Practice Update Expert Review was to describe how individuals should be risk-stratified for CRC screening and post-polypectomy surveillance and to highlight opportunities for future research to fill gaps in the existing literature.

METHODS

This Expert Review was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPUC and external peer review through standard procedures of Gastroenterology. These Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: All individuals with a first-degree relative (defined as a parent, sibling, or child) who was diagnosed with CRC, particularly before the age of 50 years, should be considered at increased risk for CRC. BEST PRACTICE ADVICE 2: All individuals without a personal history of CRC, inflammatory bowel disease, hereditary CRC syndromes, other CRC predisposing conditions, or a family history of CRC should be considered at average risk for CRC. BEST PRACTICE ADVICE 3: Individuals at average risk for CRC should initiate screening at age 45 years and individuals at increased risk for CRC due to having a first-degree relative with CRC should initiate screening 10 years before the age at diagnosis of the youngest affected relative or age 40 years, whichever is earlier. BEST PRACTICE ADVICE 4: Risk stratification for initiation of CRC screening should be based on an individual's age, a known or suspected predisposing hereditary CRC syndrome, and/or a family history of CRC. BEST PRACTICE ADVICE 5: The decision to continue CRC screening in individuals older than 75 years should be individualized, based on an assessment of risks, benefits, screening history, and comorbidities. BEST PRACTICE ADVICE 6: Screening options for individuals at average risk for CRC should include colonoscopy, fecal immunochemical test, flexible sigmoidoscopy plus fecal immunochemical test, multitarget stool DNA fecal immunochemical test, and computed tomography colonography, based on availability and individual preference. BEST PRACTICE ADVICE 7: Colonoscopy should be the screening strategy used for individuals at increased CRC risk. BEST PRACTICE ADVICE 8: The decision to continue post-polypectomy surveillance for individuals older than 75 years should be individualized, based on an assessment of risks, benefits, and comorbidities. BEST PRACTICE ADVICE 9: Risk-stratification tools for CRC screening and post-polypectomy surveillance that emerge from research should be examined for real-world effectiveness and cost-effectiveness in diverse populations (eg, by race, ethnicity, sex, and other sociodemographic factors associated with disparities in CRC outcomes) before widespread implementation.

Comparison of Simulated Outcomes Between Stool- and Blood-Based Colorectal Cancer Screening Tests

The Centers for Medicare & Medicaid Services (CMS) recommend covering blood-based tests meeting proposed minimum performance thresholds for colorectal cancer (CRC) screening. Outcomes were compared between currently available stool-based screening tests and a hypothetical blood-based test meeting CMS minimum thresholds. Using the Colorectal Cancer and Adenoma Incidence and Mortality Microsimulation Model (CRC-AIM), outcomes were simulated for average-risk individuals screened between ages 45 and 75 years with triennial multitarget stool DNA (mt-sDNA), annual fecal immunochemical test (FIT), and annual fecal occult blood test (FOBT). Per CMS guidance, blood-based CRC screening was modeled triennially, with 74% CRC sensitivity and 90% specificity. Although not specified by CMS, adenoma sensitivity was set between 10% and 20%. Published adenoma and CRC sensitivity and specificity were used for stool-based tests. Adherence was set at (1) 100%, (2) 30%-70%, in 10% increments, and (3) real-world rates for stool-based tests (mt-sDNA = 65.6%; FIT = 42.6%; FOBT = 34.4%). Assuming perfect adherence, a blood-based test produced ≥19 lower life-years gained (LYG) than stool-based strategies. At the best-case scenario for blood-based tests (100% adherence and 20% adenoma sensitivity), mt-sDNA at real-world adherence achieved more LYG (287.2 vs. 297.1, respectively) with 14% fewer colonoscopies. At 100% blood-based test adherence and real-world mt-sDNA and FIT adherence, the blood-based test would require advanced adenoma sensitivity of 30% to reach the LYG of mt-sDNA (297.1) and ∼15% sensitivity to reach the LYG of FIT (258.9). This model suggests that blood-based tests with CMS minimally acceptable CRC sensitivity and low advanced adenoma sensitivity will frequently yield inferior outcomes to stool-based testing across a wide range of adherence assumptions.

Randomized Trial of Facilitated Adherence to Screening Colonoscopy vs Sequential Fecal-Based Blood Test

BACKGROUND & AIMS

Colorectal cancer (CRC) screening guidelines include screening colonoscopy and sequential high-sensitivity fecal occult blood testing (HSgFOBT), with expectation of similar effectiveness based on the assumption of similar high adherence. However, adherence to screening colonoscopy compared with sequential HSgFOBT has not been reported. In this randomized clinical trial, we assessed adherence and pathology findings for a single screening colonoscopy vs sequential and nonsequential HSgFOBTs.

METHODS

Participants aged 40-69 years were enrolled at 3 centers representing different clinical settings. Participants were randomized into a single screening colonoscopy arm vs sequential HSgFOBT arm composed of 4-7 rounds. Initial adherence to screening colonoscopy and sequential adherence to HSgFOBT, follow-up colonoscopy for positive HSgFOBT tests, crossover to colonoscopy, and detection of advanced neoplasia or large serrated lesions (ADN-SERs) were measured.

RESULTS

There were 3523 participants included in the trial; 1761 and 1762 participants were randomized to the screening colonoscopy and HSgFOBT arms, respectively. Adherence was 1473 (83.6%) for the screening colonoscopy arm vs 1288 (73.1%) for the HSgFOBT arm after 1 round (relative risk [RR], 1.14; 95% CI, 1.10-1.19; P ≤ .001), but only 674 (38.3%) over 4 sequential HSgFOBT rounds (RR, 2.19; 95% CI, 2.05-2.33). Overall adherence to any screening increased to 1558 (88.5%) in the screening colonoscopy arm during the entire study period and 1493 (84.7%) in the HSgFOBT arm (RR, 1.04; 95% CI, 1.02-1.07). Four hundred thirty-six participants (24.7%) crossed over to screening colonoscopy during the first 4 rounds. ADN-SERs were detected in 121 of the 1473 participants (8.2%) in the colonoscopy arm who were adherent to protocol in the first 12 months of the study, whereas detection of ADN-SERs among those who were not sequentially adherent (n = 709) to HSgFOBT was subpar (0.6%) (RR, 14.72; 95% CI, 5.46-39.67) compared with those who were sequentially adherent (3.3%) (n = 647) (RR, 2.52; 95% CI, 1.61-3.98) to HSgFOBT in the first 4 rounds. When including colonoscopies from HSgFOBT patients who were never positive yet crossed over (n = 1483), 5.5% of ADN-SERs were detected (RR, 1.50; 95% CI, 1.15-1.96) in the first 4 rounds.

CONCLUSIONS

Observed adherence to sequential rounds of HSgFOBT was suboptimal compared with a single screening colonoscopy. Detection of ADN-SERs was inferior when nonsequential HSgFOBT adherence was compared with sequential adherence. However, the greatest number of ADN-SERs was detected among those who crossed over to colonoscopy and opted to receive a colonoscopy. The effectiveness of an HSgFOBT screening program may be enhanced if crossover to screening colonoscopy is permitted.

CLINICALTRIALS

gov, Number: NCT00102011.

Impact of colorectal cancer screening on incidence, mortality and surgery rates: Evidences from programs based on the fecal immunochemical test in Italy

Fecal immunochemical tests (FIT) are among the most commonly used tests for colorectal cancer (CRC) screening programs worldwide. However, no randomised controlled trials have been carried out evaluating the impact of FIT-based screening programs (FIT-progr) on CRC incidence and mortality rates. Italian FIT-progr represent one of the most widespread and established experience worldwide. This paper reviews the evidence on the impact of FIT-progr on CRC incidence, tumor stage at diagnosis, mortality and surgery rates, deriving from Italian routine programs, i.e., outside the research setting. Unfortunately, the application of FIT-progr in Italy can be considered as an unplanned experimental model, due to the differences between Regions, both in health system management and adherence of the target population to the screening programs. The analysis of the manuscripts considered in the review, confirms that FIT-progr are effective in reducing CRC incidence and mortality rates and in improving the rate of endoscopic treatment of early invasive lesions. The review also highlights that FIT-progr are less performing for proximal colon than for distal colon and rectum.

Spectrum of Advanced Colorectal Neoplasia and Anticipated Yield of Average-Risk Screening in Veterans Under Age 50

The incidence of early onset colorectal cancer, or colorectal cancer (CRC) diagnosed before age 50, is increasing.¹ In response, multiple societal guidelines in the United States now recommend initiating CRC screening at age 45 in average-risk individuals (ie, those without high-risk clinical characteristics, such as bleeding, or iron deficiency anemia), inflammatory bowel disease, or family history of colorectal neoplasia.² The Veterans Health Administration (VHA) is the largest integrated health system in the United States and is contending with how best to expand CRC screening access to this younger population in the setting of limited colonoscopy resources. Understanding the rate and anatomic location of colorectal neoplasia in Veterans younger than age 50 can inform the expected yield of different screening modalities. Prior work has shown that individuals undergoing colonoscopy for low-risk diagnostic indications have equivalent risk of colorectal neoplasia as those undergoing average-risk screening.³ This study and a recent meta-analysis⁴ reported that 3.6% (95% confidence interval, 1.9%-6.7%) to 3.7% (95% confidence interval, 3.0%-4.7%) of average-risk individuals age 45-49 have advanced colorectal neoplasia (ACN), defined as an advanced polyp or carcinoma; however, data specific to the VHA population are lacking.

Colorectal Cancer: A Systematic Review of the Current Situation and Screening in North and Central Asian Countries

The prevalence of colorectal cancer (CRC) is increasing in the past few decades. A significant proportion of this increase is from low to middle income countries (LMIC). CRC prevalence is also increasing in North and Central Asian Countries (NCAC). Screening for colorectal cancer has decreased CRC mortality but data regarding screening practices in NCAC is limited.  A literature search was conducted in PubMed/Medline, Embase and Cochrane for current colorectal cancer screening practices in NCAC. Incidence and mortality rates were derived from public health agency websites to calculate age-standardized CRC mortality-to-incidence ratios. Web-based online break-point testing defined as statistical major changes in CRC mortality trends was completed. Among the 677 screened studies, 37 studies met the criteria for inclusion for review. CRC screening in NCAC is not organized, although most countries have cancer registries. The data availability is scarce, and most data is prior to 2017. Most studies are observational. There is minimal data about colonoscopy preparations, adenoma detection and complications rates. The polyp detection rates (PDRs) and adenoma detection rates (ADRs) seem low to optimal in this region. Commonly measured outcomes include participation rate, fecal immunochemical tests (FIT) positivity rate and cost-benefit measures. Lower mortality-to-incidence ratios is seen in countries with screening programs. Kazakhstan and Lithuania with screening programs have achieved breakpoint suggesting major changes in CRC mortality trends. Data about CRC screening varies widely within NCAC. High human developmental index (HDI) countries like Lithuania and Estonia have higher incidence of CRC and mortality. Seven NCAC have CRC screening programs with most utilizing non-invasive methods for screening. Data collection is regional and not organized. The ADR and PDR are low to optimal in this region and cancer detection rates are comparable to other high-income countries (HIC). CRC detection rate is 0.05% for screening in Kazakhstan and 0.2% for screening in Lithuania. Very limited information is available on the actual cost and logistics of implementing a CRC screening program. All NCAC have a cancer registry, with some having a high-quality registry showing national coverage with good validity and completeness. Establishing guideline-based registries and increasing screening efficacy could improve CRC outcomes in NCAC.

Clinical Effectiveness of Faecal Immunochemical Test in the Early Detection of Colorectal Cancer-An Umbrella Review

Introduction: The colorectal cancer prognosis depends on the stage of the neoplasm; therefore, its early detection plays an important role. The aim of the study is evaluation of the sensitivity, specificity, and clinical effectiveness of the faecal immunochemical test in the early colorectal cancer detection. Methods: The clinical analysis was based on the results of the studies included in a systematic review conducted in accordance with the Cochrane Collaboration guidelines. The following medical information sources were searched: Medline (via PubMed), Embase (via Ovid), The Cochrane Library. Results: From 241 citations, 13 studies were included in this review. All included studies had a low risk of bias. The faecal immunochemical test is highly specific in all analysed populations ranging from 85% to 97%. In most of the found studies, sensitivity is over 75%. The faecal immunochemical test screening also determines a reduction in death (10-59%) due to colorectal cancer. Conclusions: The faecal immunochemical test is an effective and cost-effective method of conducting population-wide colorectal cancer screening. It is an alternative or complementary to other screening tests, including colonoscopy.

Assessment of a Serum Microrna Risk Score for Colorectal Cancer among Participants of Screening Colonoscopy at Various Stages of Colorectal Carcinogenesis

We recently derived and validated a serum-based microRNA risk score (miR-score) which predicted colorectal cancer (CRC) occurrence with very high accuracy within 14 years of follow-up in a large population-based cohort. Here, we aimed to assess and compare the distribution of the miR-score among participants of screening colonoscopy at various stages of colorectal carcinogenesis. MicroRNAs (miRNAs) were profiled by quantitative-real-time-polymerase-chain-reaction in the serum samples of screening colonoscopy participants with CRC (n = 52), advanced colorectal adenoma (AA, n = 100), non-advanced colorectal adenoma (NAA, n = 88), and participants free of colorectal neoplasms (n = 173). The mean values of the miR-score were compared between groups by the Mann–Whitney U test. The associations of the miR-score with risk for colorectal neoplasms were evaluated using logistic regression analyses. MicroRNA risk scores were significantly higher among participants with AA than among those with NAA (p = 0.027) and those with CRC (p = 0.014), whereas no statistically significant difference was seen between those with NAA and those with no colorectal neoplasms (p = 0.127). When comparing adjacent groups, miR-scores were inversely associated with CRC versus AA and positively associated with AA versus NAA [odds ratio (OR), 0.37 (95% confidence interval (CI), 0.16–0.86) and OR, 2.22 (95% CI, 1.06–4.64) for the top versus bottom tertiles, respectively]. Our results are consistent with the hypothesis that a high miR-score may be indicative of an increased CRC risk by an increased tendency of progression from non-advanced to advanced colorectal neoplasms, along with a change of the miR-patterns after CRC manifestation.

Exosomal miRNAs as a Promising Source of Biomarkers in Colorectal Cancer Progression

Colorectal cancer (CRC) is the third most common type of cancer worldwide amongst males and females. CRC treatment is multidisciplinary, often including surgery, chemotherapy, and radiotherapy. Early diagnosis of CRC can lead to treatment initiation at an earlier stage. Blood biomarkers are currently used to detect CRC, but because of their low sensitivity and specificity, they are considered inadequate diagnostic tools and are used mainly for following up patients for recurrence. It is necessary to detect novel, noninvasive, specific, and sensitive biomarkers for the screening and diagnosis of CRC at earlier stages. The tumor microenvironment (TME) has an essential role in tumorigenesis; for example, extracellular vesicles (EVs) such as exosomes can play a crucial role in communication between cancer cells and different components of TME, thereby inducing tumor progression. The importance of miRNAs that are sorted into exosomes has recently attracted scientists’ attention. Some unique sequences of miRNAs are favorably packaged into exosomes, and it has been illustrated that particular miRNAs can be directed into exosomes by special mechanisms that occur inside the cells. This review illustrates and discusses the sorted and transported exosomal miRNAs in the CRC microenvironment and their impact on CRC progression as well as their potential use as biomarkers.

Adherence to colonoscopy in cascade screening of colorectal cancer: A systematic review and meta-analysis

BACKGROUND AND AIM

This study aims to systematically evaluate adherence to colonoscopy and related factors in cascade screening of colorectal cancer (CRC) among average-risk populations, which is crucial to achieve the effectiveness of CRC screening.

METHODS

We searched PubMed, Embase, Web of Science, and Cochrane Library for studies published in English up to October 16, 2020, and reporting the adherence to colonoscopy following positive results of initial screening tests. A random-effects meta-analysis was applied to estimate pooled adherence and 95% confidence intervals. Subgroup analysis and mixed-effects meta-regression analysis were performed to evaluate heterogeneous factors for adherence level.

RESULTS

A total of 245 observational and 97 experimental studies were included and generated a pooled adherence to colonoscopy of 76.6% (95% confidence interval: 74.1-78.9) and 80.4% (95% confidence interval: 77.2-83.1), respectively. The adherence varied substantially by calendar year of screening, continents, CRC incidence, socioeconomic status, recruitment methods, and type of initial screening tests, with the initial tests as the most modifiable heterogeneous factor for adherence across both observational (Q = 162.6, P < 0.001) and experimental studies (Q = 23.2, P < 0.001). The adherence to colonoscopy was at the highest level when using flexible sigmoidoscopy as an initial test, followed by using guaiac fecal occult blood test, quantitative or qualitative fecal immunochemical test, and risk assessment. The pooled estimate of adherence was positively associated with specificity and positive predictive value of initial screening tests, but negatively with sensitivity and positivity rate.

CONCLUSIONS

Colonoscopy adherence is at a low level and differs by study-level characteristics of programs and populations. Initial screening tests with high specificity or positive predictive value may be followed by a high adherence to colonoscopy.

Positive fecal immunochemical test results are associated with non-colorectal cancer mortality

BACKGROUND/AIMS

Studies have reported an association between fecal occult blood and increased all-cause, non-colorectal cancer (CRC) as well as CRC mortality. This study aimed to determine whether positive fecal immunochemistry test (FIT) results are associated with death from various causes in the South Korean population.

METHODS

Using the Korean National Cancer Screening Program database, we collected data on patients who underwent FIT between 2009 and 2011.

RESULTS

Of the 5,932,544 participants, 380,789 (6.4%) had positive FIT results. FIT-positive participants had a higher mortality rate than FIT-negative participants from CRC (1.33 and 0.21 per 1,000 person-years, p < 0.001, respectively) and non-CRC causes (10.40 and 7.50 per 1,000 person-years, p < 0.001, respectively). Despite adjusting for age, sex, smoking status, alcohol consumption habits, body mass index, comorbidity, and aspirin use, FIT positivity was associated with an increased risk of dying from all non-CRC causes (adjusted hazard ratio [aHR], 1.17; 95% confidence interval [CI], 1.15 to 1.18) and CRC (aHR, 5.61; 95% CI, 5.40 to 5.84). Additionally, FIT positivity was significantly associated with increased mortality from circulatory disease (aHR, 1.14; 95% CI, 1.11 to 1.17), respiratory disease (aHR, 1.14; 95% CI, 1.09 to 1.19), digestive disease (aHR, 1.57; 95% CI, 1.48 to 1.66), neuropsychological disease (aHR, 1.08; 95% CI, 1.01 to 1.16), blood and endocrine diseases (aHR, 1.10; 95% CI, 1.04 to 1.17), and external factors (aHR, 1.16; 95% CI, 1.11 to 1.20).

CONCLUSION

Positive FIT results are associated with an increased risk of mortality from CRC and various other chronic diseases, suggesting that it could be a predictor of mortality independent of its association with CRC.

A Global Evaluation of the Performance Indicators of Colorectal Cancer Screening with Fecal Immunochemical Tests and Colonoscopy: A Systematic Review and Meta-Analysis

(1) Background: To summarize the achievements of the performance indicators of colorectal cancer (CRC) screening programs that used the fecal immunochemical test (FIT) as a primary screening modality and colonoscopy as a subsequent confirmatory test. (2) Methods: PubMed, Ovid MEDLINE, Embase, and Cochrane were searched from inception to September 2020. We included original articles published in English, and performed hand searching for relevant national reports. We generated pooled achievement estimates of the performance indicators by "metaprop" (R software 3.6.3). Meta-regression analyses and subgroup analyses were also conducted. (3) Results: We included 93 studies involving nearly 90 million people-times. The participation rate ranged from 6.80% to 95.98%, which was associated with study type, continents, FIT number, age, and round. The pooled FIT invalid rate and positivity rate were 1.08% and 7.28%, respectively. The pooled estimates of FIT detection were 2.26% for adenoma, 1.26% for advanced adenoma, and 0.28% for CRC. In addition, only seven studies reported that their colonoscopy compliance rate reached 90% among 69 studies. The colonoscopy completion rate (21/40 studies > 95%) and the complication rate (18/27 studies < 0.5%) were acceptable. (4) Conclusions: Our findings could help to identify the areas that could be improved and finally optimize the CRC screening programs.

Impact of the Sessile Serrated Polyp Pathway on Predicted Colorectal Cancer Outcomes

Background and Aims

Approximately 20%-30% of colorectal cancers (CRCs) arise from the serrated polyp pathway. CRC screening options have differential sensitivity to detect sessile serrated polyps (SSPs). We used the Colorectal Cancer and Adenoma Incidence and Mortality Microsimulation Model (CRC-AIM) to assess how the detection of SSPs impacts predicted life years gained (LYG), CRC incidence, and CRC mortality with multitarget stool DNA (mt-sDNA) or fecal immunochemical test (FIT) screening.

Methods

A simulated cohort of average-risk US individuals underwent triennial mt-sDNA or annual FIT screening between ages 45-75 years. SSP-attributed CRCs were modeled at 0% (base case), 14.3%, 20%, and 30%, in combination with 4 adherence & attendance scenarios: S1: 100% stool-screening adherence/100% follow-up colonoscopy attendance after a positive stool test; S2: reported stool-screening adherence (mt-sDNA = 71%; FIT = 43%)/100% follow-up colonoscopy attendance; S3: reported stool-screening adherence/reported follow-up colonoscopy attendance (mt-sDNA = 72%; FIT = 47%); and S4: reported stool-screening adherence/72% follow-up colonoscopy attendance. Outcomes were per 1000 individuals. Sensitivity analyses used ranges of stool-screening adherence or follow-up attendance.

Results

At S1, S2, S3, and S4, LYG with FIT at the base case (0% SSP-attributed CRC) was 346.7, 279.3, 126.6, and 196.1, respectively, and with mt-sDNA was 324.6, 311.8, 215.8, and 215.8, respectively. Among the 4 adherence/attendance scenarios, modeling SSP-attributed CRCs decreased LYG by 4.9-20.9 with FIT and 2.0-5.1 with mt-sDNA. At S3 and 30% SSP-attributable CRCs, mt-sDNA had 95.1 more LYG, 21.5% greater CRC incidence reduction, and 22.2% greater CRC mortality reduction than FIT.

Conclusion

Incorporating SSPs and real-world adherence into the CRC-AIM modeling analyses yielded more practice-relevant estimates of CRC screening outcomes and should be applied in future studies to afford more appropriate assessment of comparative effectiveness estimates between guideline-endorsed screening options.

Evaluating behavioral economic interventions for promoting cancer screening uptake and adherence in targeted populations: a systematic review protocol

OBJECTIVE

The objective of this review is to determine the effectiveness of behavioral economic interventions for promoting uptake of and adherence to cancer screening recommended by guidelines.

INTRODUCTION

Cancer screening has been found to help reduce incidence of and mortality from advanced cancer. However, adherence to recommended cancer screening services is low in asymptomatic adults with average risk possibly due to systematic decision biases. The findings of this review will demonstrate whether interventions informed by behavioral economic insights can help improve uptake of and adherence to cancer screening.

INCLUSION CRITERIA

This review will consider studies that meet the following inclusion criteria: experimental, quasi-experimental, and analytical observational studies that i) evaluate the effects of behavioral economic interventions in adults eligible for guideline-recommended cancer screening, and that ii) report the number/percentage of individuals who used screening services; number/percentage of individuals who completed screening recommended by guidelines; participant self-reported intentions, choice, and satisfaction regarding the use of screening services; detection rates of early-stage cancers; use of early intervention for cancers; and cancer-related mortality.

METHODS

A systematic literature search will be performed by one reviewer. After removing duplicates, two reviewers will independently screen and appraise eligible studies according to the JBI methodology for systematic reviews of effectiveness. Five databases will be searched: CINAHL, the Cochrane Library, PsycINFO, PubMed, and Web of Science. Sources of gray literature and registered clinical trials will also be searched for potential studies. There will be no limits to publication date or language. Data synthesis will be conducted using meta-analysis and narrative synthesis where appropriate.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021258370.

Comparison of performance of two Stool DNA Tests and a Faecal Immunochemical Test in Detecting Colorectal Neoplasm: a Multicentre Diagnostic Study

BACKGROUND

The most widely used non-invasive screening tests for colorectal cancer (CRC) are faecal occult blood tests. Stool DNA test was developed in recent years. However, direct comparative analyses of these tests within the same population are still sparse.

METHODS

2842 participants who visited outpatient clinics or cancer screening centres were enrolled. Stool DNA test-I (KRAS, BMP3, NDRG4, and haemoglobin immunochemical tests), stool DNA test-II (SDC2 and SFRP2 tests) and FIT alone were performed and colonoscopy was used as the gold standard among 2240 participants. 42 and 302 participants had CRC and advanced adenomas (AA), respectively.

RESULTS

The sensitivity for CRC of stool DNA test-I, -II and FIT was 90.5%, 92.9% and 81.0%, respectively. The sensitivity for advanced neoplasm (CRC plus AA) of stool DNA test-I, -II and FIT was 34.9%, 42.2% and 25.9%, respectively. The specificity of stool DNA test-I, -II and FIT was 91.4%, 93.3% and 96.8%, respectively, among those with negative results on colonoscopy. When the specificity of FIT was adjusted to match that of stool DNA tests by changing the threshold, no significant difference was seen in the sensitivities among the 3 tests for detecting CRC. For advanced neoplasm, the sensitivity of FIT was higher than DNA test-I and similar to DNA test-II under the same specificities.

CONCLUSIONS

There was no significant advantage of the two stool DNA tests compared to FIT in detecting CRC or advanced neoplasm in this study.

IMPACT

Our findings do not support extensive use of stool DNA tests instead of FIT.

Cross-sectional adherence with the multi-target stool DNA test for colorectal cancer screening in a large, nationally insured cohort

PURPOSE

Colorectal cancer (CRC) is the second most deadly cancer in the USA. Early detection can improve CRC outcomes, but recent national screening rates (62%) remain below the 80% goal set by the National Colorectal Cancer Roundtable. Multiple options are endorsed for average-risk CRC screening, including the multi-target stool DNA (mt-sDNA) test. We evaluated cross-sectional mt-sDNA test completion in a population of commercially and Medicare-insured patients.

METHODS

Participants included individuals ages 50 years and older with commercial insurance or Medicare, with a valid mt-sDNA test shipped by Exact Sciences Laboratories LLC between January 1, 2018, and December 31, 2018 (n = 1,420,460). In 2020, we analyzed cross-sectional adherence, as the percent of successfully completed tests within 365 days of shipment date.

RESULTS

Overall cross-sectional adherence was 66.8%. Adherence was 72.1% in participants with Traditional Medicare, 69.1% in participants with Medicare Advantage, and 61.9% in participants with commercial insurance. Adherence increased with age: 60.8% for ages 50-64, 71.3% for ages 65-75, and 74.7% for ages 76 + years. Participants with mt-sDNA tests ordered by gastroenterologists had a higher adherence rate (78.3%) than those with orders by primary care clinicians (67.2%). Geographically, adherence rates were highest among highly rural patients (70.8%) and ordering providers in the Pacific region (71.4%).

CONCLUSIONS

Data from this large, national sample of insured patients demonstrate high cross-sectional adherence with the mt-sDNA test, supporting its role as an accepted, noninvasive option for average-risk CRC screening. Attributes of mt-sDNA screening, including home-based convenience and accompanying navigation support, likely contributed to high completion rates.

Multiple Biomarker-Combined Screening for Colorectal Cancer Based on Bisulfate Conversion-Free Detection of Fecal DNA Methylation

To evaluate the applicability of bisulfate conversion-free methylation assay based on enzyme digestion in fecal screening for colorectal cancer (CRC). Stool samples were collected from a total of 1142 participants with intestinal abnormalities, including 180 positive cases, 60 advanced adenomas, and 902 negative cases. DNA from reference cell lines and clinical samples was extracted and digested with an enzyme to detect the methylation of CRC markers SEPT9, SDC2, NDRG4, SFRP2, and BMP3 genes. Statistical analysis was then used to determine the ability of the markers, both individually and in combination, to detect CRC and adenoma. Our results showed that the enzyme digestion method could suitably detect DNA marker methylation in as low as 1% of the cell lines. BMP3 had a considerably low detection rate in all clinical samples, with only 6 positive cases detected out of 180 cancer samples. Our findings showed that the combination of SEPT9, SDC2, and SFRP2 had an area under the receiver operation curve of 0.937, sensitivity of 94.11%, and specificity of 89.21% for detecting CRC. Moreover, the detection sensitivity of adenoma can also reach 38.33%. After innovatively utilizing bisulfate conversion-free methylation assay for CRC screening, this study verified the potential clinical applicability of combining multiple biomarkers for CRC screening in a large number of samples.

A microRNA panel compared to environmental and polygenic scores for colorectal cancer risk prediction

Circulating microRNAs (miRNAs) could improve colorectal cancer (CRC) risk prediction. Here, we derive a blood-based miRNA panel and evaluate its ability to predict CRC occurrence in a population-based cohort of adults aged 50-75 years. Forty-one miRNAs are preselected from independent studies and measured by quantitative-real-time-polymerase-chain-reaction in serum collected at baseline of 198 participants who develop CRC during 14 years of follow-up and 178 randomly selected controls. A 7-miRNA score is derived by logistic regression. Its predictive ability, quantified by the optimism-corrected area-under-the-receiver-operating-characteristic-curve (AUC) using .632+ bootstrap is 0.794. Predictive ability is compared to that of an environmental risk score (ERS) based on known risk factors and a polygenic risk score (PRS) based on 140 previously identified single-nucleotide-polymorphisms. In participants with all scores available, optimism-corrected-AUC is 0.802 for the 7-miRNA score, while AUC (95% CI) is 0.557 (0.498-0.616) for the ERS and 0.622 (0.564-0.681) for the PRS.

The impact of 6 years of the National Colorectal Cancer Screening Program on colorectal cancer incidence and 5-year survival

We aimed to assess the impact of the first three rounds of the National Colorectal Cancer Screening Program (NCCSP) on CRC incidence and mortality in Slovenia. In NCCSP, we use two fecal immune tests (FITs) and if test is positive patient is referred to colonoscopy. From 2009, we invite Slovenian residents aged 50-69 years, one screening round takes 2 years. The response rate was from 56.9 to 59.9%. FIT was positive in 6.0-6.2% (more in older patients and in men; P < 0.05). The adenoma detection rate was >51.3% (more in men; P < 0.01). In NCCSP, 70.3% of all cancers diagnosed were in stages I and II, while 20.7% of all CRC were found in polyps resected during colonoscopies. Patients with positive first FIT have odds ratio 2.19 [95% confidence interval (CI), 2.06-2.32] for advanced neoplasia and cancer compared to patients with two negative FITs. The incidence rate for CRC has dropped significantly after 6 years in population and in men (P < 0.01) but not in women. Five-year CRC survival was 31.3% higher if cancer was diagnosed in NCCSP (P < 0.05). After 6 years of NCCSP, the incidence rate for CRC has dropped significantly (P < 0.01). Hazard ratio for death from CRC was 3.84 higher (95% CI, 3.36-4.40; P < 0.001) in patients with cancer detected outside the program.

Positive predictive value of fecal immunochemical test for high-risk colonic adenomas and carcinoma: A health maintenance organization cohort screening study in Lebanon

BACKGROUND AND STUDY AIMS

Fecal Immunochemical Test (FIT) is one of the leading modalities for colorectal cancer screening. Studies show that FIT is highly sensitive for the detection of colorectal cancer (CRC) but not similarly accurate for detection of pre-cancerous advanced adenomas (AA). We studied the performance metrics of FIT for the detection of CRC and AA in ahealth maintenance organization (HMO) cohort screening program.

PATIENTS AND METHODS

Retrospective cohort study of asymptomatic persons of screening age belonging to a HMO. Endoscopy and pathology reports of those who tested positive were used to calculate the positive predictive value (PPV) of FIT, and characterize endoscopic findings on colonoscopy.

RESULTS

Between 1995 and 2017, 3000 persons had screening fecal occult testing as part of their Employee Health Care plan. Of those, 150 had a positive qualitative FIT (cutoff 10 Âµg hemoglobin/g feces). All underwentcolonoscopy, and median time to colonoscopy was 27 days. 4 (2.6%) had carcinoma(2 stage IIIA and 2 stage IIIB), 106 (70.6%) had adenomas of which 40 (26.6% of the total cohort) had advanced adenomas (≥1 cm, villous features, or high-grade dysplasia) giving a PPV for AA and carcinoma of 29% and 3% respectively. When stratified by age, the PPV of AA; carcinoma was [50-59 (21.7%; 0.0%)], [60-69 (14.6%; 4.2%)], [70-79 (42.6%; 2.1%)], [80-89 (33.3%; 11.1%)].

CONCLUSION

The performance characteristics of FIT testing are acceptable for population screening in resource-limited settings. The resultsof this study are helpful when discussing expectations prior to colonoscopy in people with positive FIT.

A delay in colonoscopy after positive fecal tests leads to higher incidence of colorectal cancer: A systematic review and meta-analysis

BACKGROUND AND AIM

A delay in performing colonoscopies after positive fecal tests in a screening program may risk neoplastic progression. Our objective is to conduct a systematic review and meta-analysis to evaluate the effects of timing of a colonoscopy after a positive fecal test on the detection of colorectal cancer.

METHODS

Cochrane guidelines and PRISMA statement were followed for this review. Digital dissertation databases were searched from inception to June 1, 2020, and all studies reporting the detection rates of colorectal cancer on the basis of different time intervals between a positive fecal test and the post-test colonoscopy were included. We compared the detection rates of colorectal cancer (overall and advanced-stage) and advanced adenoma based on different time intervals.

RESULTS

A total of 361 637 patients from six observational studies were included for the analysis. The odds of detecting any colorectal cancer (odds ratio [OR] 1.58, 95% confidence interval [CI] 1.23-2.03, P < 0.001), advanced-stage colorectal cancer (OR 2.16, 95% CI 1.47-3.16, P < 0.001), or advanced adenomas (OR 1.17, 95% CI 1.06-1.28, P = 0.001) are significantly higher if the colonoscopies are performed after 6 months from a positive fecal test, compared with within 6 months. There was no significant difference in the detection rates based on a 1-month, a 2-month, or a 3-month cut-off.

CONCLUSIONS

A delay of colonoscopies beyond 6 months after positive fecal tests is associated with a higher odds of detecting colorectal cancer. A timely follow up of patients with positive fecal tests is warranted.

Lowering the colorectal cancer screening age improves predicted outcomes in a microsimulation model

AIMS

While most guidelines still recommend colorectal cancer (CRC) screening initiation at age 50 years in average-risk individuals, guideline-creating bodies are starting to lower the recommended age of initiation to 45 years to mitigate the trend of increasing CRC rates in younger populations. Using CRC-AIM, we modeled the impact of lowering the CRC screening initiation age, incorporating theoretical and reported adherence rates, for triennial multi-target stool DNA (mt-sDNA) or annual fecal immunochemical test (FIT) screening.

METHODS AND MATERIALS

Screening strategies were simulated for individuals without CRC at age 40 and screened from ages 50 to 75 or 45 to 75 years. Outcomes included CRC incidence, CRC mortality, and life-years gained (LYG) per 1000 individuals screened (compared with no screening). Models used theoretically perfect (100%) and previously reported (71% mt-sDNA; 43% FIT) adherence rates.

RESULTS

With perfect adherence, mt-sDNA and FIT resulted in 22.2 and 23.4 more predicted LYG, respectively, with screening initiation at age 45 versus 50 years; reported adherence resulted in 23.9 and 24.4 more LYG, respectively. With perfect adherence, screening initiation at age 45 versus 50 years resulted in 26.1 and 28.6 CRC cases, respectively, with mt-sDNA and 22.8 and 25.5 cases with FIT; with reported real-world adherence there were 28.5 and 31.2 cases, respectively, with mt-sDNA and 37.1 and 40.2 cases with FIT. Similar patterns were observed for CRC deaths. With screening initiation at age 45 and reported adherence, mt-sDNA averted 8.6 more CRC cases and 3.3 more deaths per 1000 individuals than FIT.

CONCLUSIONS

Estimated CRC screening outcomes improved by lowering the initiation age from 50 to 45 years. Incorporating reported adherence rates yields greater benefits from triennial mt-sDNA versus annual FIT screening.

Impact of Patient Adherence to Stool-Based Colorectal Cancer Screening and Colonoscopy Following a Positive Test on Clinical Outcomes

Colorectal cancer-screening models commonly assume 100% adherence, which is inconsistent with real-world experience. The influence of adherence to initial stool-based screening [fecal immunochemical test (FIT), multitarget stool DNA (mt-sDNA)] and follow-up colonoscopy (after a positive stool test) on colorectal cancer outcomes was modeled using the Colorectal Cancer and Adenoma Incidence and Mortality Microsimulation Model. Average-risk individuals without diagnosed colorectal cancer at age 40 undergoing annual FIT or triennial mt-sDNA screening from ages 50 to 75 were simulated. Primary analyses incorporated published mt-sDNA (71%) or FIT (43%) screening adherence, with follow-up colonoscopy adherence ranging from 40% to 100%. Secondary analyses simulated 100% adherence for stool-based screening and colonoscopy follow-up (S1), published adherence for stool-based screening with 100% adherence to colonoscopy follow-up (S2), and published adherence for both stool-based screening and colonoscopy follow-up after positive mt-sDNA (73%) or FIT (47%; S3). Outcomes were life-years gained (LYG) and colorectal cancer incidence and mortality reductions (per 1,000 individuals) versus no screening. Adherence to colonoscopy follow-up after FIT had to be 4%-13% higher than mt-sDNA to reach equivalent LYG. The theoretical S1 favored FIT versus mt-sDNA (LYG 316 vs. 297; colorectal cancer incidence reduction 68% vs. 64%; colorectal cancer mortality reduction 76% vs. 72%). The more realistic S2 and S3 favored mt-sDNA versus FIT (S2: LYG 284 vs. 245, colorectal cancer incidence reduction 61% vs. 50%, colorectal cancer mortality reduction 69% vs. 59%; S3: LYG 203 vs. 113, colorectal cancer incidence reduction 43% vs. 23%, colorectal cancer mortality reduction 49% vs. 27%, respectively). Incorporating realistic adherence rates for colorectal cancer screening influences modeled outcomes and should be considered when assessing comparative effectiveness. PREVENTION RELEVANCE: Adherence rates for initial colorectal cancer screening by FIT or mt-sDNA and for colonoscopy follow-up of a positive initial test influence the comparative effectiveness of these screening strategies. Using adherence rates based on published data for stool-based testing and colonoscopy follow-up yielded superior outcomes with an mt-sDNA versus FIT-screening strategy.

Cost-Effectiveness of Multitarget Stool DNA Testing vs Colonoscopy or Fecal Immunochemical Testing for Colorectal Cancer Screening in Alaska Native People

OBJECTIVE

To estimate the cost-effectiveness of multitarget stool DNA testing (MT-sDNA) compared with colonoscopy and fecal immunochemical testing (FIT) for Alaska Native adults.

PATIENTS AND METHODS

A Markov model was used to evaluate the 3 screening test effects over 40 years. Outcomes included colorectal cancer (CRC) incidence and mortality, costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). The study incorporated updated evidence on screening test performance and adherence and was conducted from December 15, 2016, through November 6, 2019.

RESULTS

With perfect adherence, CRC incidence was reduced by 52% (95% CI, 46% to 56%) using colonoscopy, 61% (95% CI, 57% to 64%) using annual FIT, and 66% (95% CI, 63% to 68%) using MT-sDNA. Compared with no screening, perfect adherence screening extends life by 0.15, 0.17, and 0.19 QALYs per person with colonoscopy, FIT, and MT-sDNA, respectively. Colonoscopy is the most expensive strategy: approximately $110 million more than MT-sDNA and $127 million more than FIT. With imperfect adherence (best case), MT-sDNA resulted in 0.12 QALYs per person vs 0.05 and 0.06 QALYs per person by FIT and colonoscopy, respectively. Probabilistic sensitivity analyses supported the base-case analysis. Under varied adherence scenarios, MT-sDNA either dominates or is cost-effective (ICERs, $1740-$75,868 per QALY saved) compared with FIT and colonoscopy.

CONCLUSION

Each strategy reduced costs and increased QALYs compared with no screening. Screening by MT-sDNA results in the largest QALY savings. In Markov model analysis, screening by MT-sDNA in the Alaska Native population was cost-effective compared with screening by colonoscopy and FIT for a wide range of adherence scenarios.

Determinants of Population-Based Cancer Screening Performance at Primary Healthcare Institutions in China

Background: For a decade, most population-based cancer screenings in China are performed by primary healthcare institutions. To assess the determinants of performance of primary healthcare institutions in population-based breast, cervical, and colorectal cancer screening in China. Methods: A total of 262 primary healthcare institutions in Tianjin participated in a survey on cancer screening. The survey consisted of questions on screening tests, the number of staff members and training, the introduction of the screening programs to residents, the invitation of residents, and the number of performed screenings per year. Logistic regression models were used to analyze the determinants of performance of an institution to fulfil the target number of screenings. Results: In 58% and 61% of the institutions between three and nine staff members were dedicated to breast and cervical cancer screening, respectively, whereas in 71% of the institutions ≥10 staff members were dedicated to colorectal cancer screening. On average 60% of institutions fulfilled the target number of breast and cervical cancer screenings, whereas 93% fulfilled the target number for colorectal cancer screening. The determinants of performance were rural districts for breast (OR = 5.16 (95%CI: 2.51–10.63)) and cervical (OR = 4.17 (95%CI: 2.14–8.11)) cancer screenings, and ≥3 staff members dedicated to cervical cancer screening (OR = 2.34 (95%CI: 1.09–5.01)). Conclusions: Primary healthcare institutions in China perform better in colorectal than in breast and cervical cancer screening, and institutions in rural districts perform better than institutions in urban districts. Increasing the number of staff members on breast and cervical cancer screening could improve the performance of population-based cancer screening.

Korean colonoscopy screening pilot study (K-cospi) for screening colorectal cancer: study protocol for the multicenter, community-based clinical trial

BACKGROUND

The Korean National Cancer Screening Program has been providing annual fecal immunochemical test for colorectal cancer (CRC) to adults aged 50 years and older since 2004. The Korean Colonoscopy Screening Pilot Study was developed to evaluate the effectiveness of colonoscopy screening for CRC incidence and mortality, screening-related complications, and acceptability of colonoscopy as a primary modality for the national CRC screening program.

METHODS

This study and its protocols have been approved by the Korean Public Institutional Review Board and the National Cancer Center Institutional Review Board. We obtain written informed consent from all participants. The target population is males and females aged 50-74 years living within the pilot sites. A total of 26,640 participants will be recruited for colonoscopy screening. Subjects who have been diagnosed with CRC, who are currently undergoing treatment for CRC, or who have undergone colonoscopy screening within the past 5 years are not allowed to participate. All participants need to complete baseline questionnaires. This pilot study is currently conducted by 104 endoscopists from 57 national cancer screening institutions (42 primary, 10 secondary, and 5 tertiary institutions) located in Goyang-si, Gimpo-si, and Paju-si. The number of endoscopists, medical institutions, and districts participating in the pilot study will be expanded, if necessary. Participating endoscopists at each medical institution perform colonoscopy and report the colonoscopy results to a centralized electronic case report system. We conduct a telephone survey after 7 days and 4 weeks post-colonoscopy to assess for procedure-related complications and satisfaction of the participants. In case of abnormal findings from colonoscopy screening, we track the results from follow-up diagnostic tests. Data from this pilot study will be linked to the diagnostic workup results, the Korean Cancer Registry, and death certificate data for analysis of the performance, long-term effects, and cost-effectiveness of colonoscopy.

DISCUSSION

The results will provide critical information to determine whether the introduction of colonoscopy as the primary modality of the Korean National Cancer Screening Program would be acceptable and feasible. Trial registration Korean Clinical Research Information Service registry, KCT0004142. Registered on 15 July 2019, http://cris.nih.go.kr/cris/en/search/search_result_st01.jsp?seq=16227.

Real-world cost-effectiveness of stool-based colorectal cancer screening in a Medicare population

AIM

Multiple screening strategies are guideline-endorsed for average-risk colorectal cancer (CRC). The impact of real-world adherence rates on the cost-effectiveness of non-invasive stool-based CRC screening strategies remains undefined.

METHODS

This cost-effectiveness analysis from the perspective of Medicare as a primary payer used the Colorectal Cancer and Adenoma Incidence and Mortality Microsimulation Model (CRC-AIM) to estimate cost and clinical outcomes for triennial multi-target stool DNA (mt-sDNA), annual fecal immunochemical test (FIT) and annual fecal occult blood test (FOBT) screening strategies in a simulated cohort of US adults aged 65 years, who were assumed to either be previously unscreened or initiating screening upon entry to Medicare. Reported real-world adherence rates for initial stool-based screening and colonoscopy follow up (after a positive stool test result) were defined as 71.1% and 73.0% for mt-sDNA, 42.6% and 47.0% for FIT, and 33.4% and 47.0% for FOBT, respectively. The incremental cost-effectiveness ratio using quality-adjusted life years (QALY) was defined as the primary outcome of interest; other cost and clinical outcomes were also reported in secondary analyses. Multiple sensitivity and scenario analyses were conducted.

RESULTS

When reported real-world adherence rates were included only for initial stool-based screening, mt-sDNA was cost-effective versus FIT ($62,814/QALY) and FOBT ($39,171/QALY); mt-sDNA also yielded improved clinical outcomes. When reported real-world adherence rates were included for both initial stool-based screening and follow-up colonoscopy (when indicated), mt-sDNA was increasingly cost-effective compared to FIT and FOBT ($31,725/QALY and $28,465/QALY, respectively), with further improved clinical outcomes.

LIMITATIONS

Results are based on real-world cross-sectional adherence rates and may vary in the context of other types of settings. Only guideline-recommended stool-based strategies were considered in this analysis.

CONCLUSION

Comparisons of the effectiveness and benefits of specific CRC screening strategies should include both test-specific performance characteristics and real-world adherence to screening tests and, when indicated, follow-up colonoscopy.

Estimating the impact of differential adherence on the comparative effectiveness of stool-based colorectal cancer screening using the CRC-AIM microsimulation model

BACKGROUND

Real-world adherence to colorectal cancer (CRC) screening strategies is imperfect. The CRC-AIM microsimulation model was used to estimate the impact of imperfect adherence on the relative benefits and burdens of guideline-endorsed, stool-based screening strategies.

METHODS

Predicted outcomes of multi-target stool DNA (mt-sDNA), fecal immunochemical tests (FIT), and high-sensitivity guaiac-based fecal occult blood tests (HSgFOBT) were simulated for 40-year-olds free of diagnosed CRC. For robustness, imperfect adherence was incorporated in multiple ways and with extensive sensitivity analysis. Analysis 1 assumed adherence from 0%-100%, in 10% increments. Analysis 2 longitudinally applied real-world first-round differential adherence rates (base-case imperfect rates = 40% annual FIT vs 34% annual HSgFOBT vs 70% triennial mt-sDNA). Analysis 3 randomly assigned individuals to receive 1, 5, or 9 lifetime (9 = 100% adherence) mt-sDNA tests and 1, 5, or 9 to 26 (26 = 100% adherence) FIT tests. Outcomes are reported per 1000 individuals compared with no screening.

RESULTS

Each screening strategy decreased CRC incidence and mortality versus no screening. In individuals screened between ages 50-75 and adherence ranging from 10%a-100%, the life-years gained (LYG) for triennial mt-sDNA ranged from 133.1-300.0, for annual FIT from 96.3-318.1, and for annual HSgFOBT from 99.8-320.6. At base-case imperfect adherence rates, mt-sDNA resulted in 19.1% more LYG versus FIT, 25.4% more LYG versus HSgFOBT, and generally had preferable efficiency ratios while offering the most LYG. Completion of at least 21 FIT tests is needed to reach approximately the same LYG achieved with 9 mt-sDNA tests.

CONCLUSIONS

Adherence assumptions affect the conclusions of CRC screening microsimulations that are used to inform CRC screening guidelines. LYG from FIT and HSgFOBT are more sensitive to changes in adherence assumptions than mt-sDNA because they require more tests be completed for equivalent benefit. At imperfect adherence rates, mt-sDNA provides more LYG than FIT or HSgFOBT at an acceptable tradeoff in screening burden.

Effectiveness of a mailed fecal immunochemical test outreach: a Medicare Advantage pilot study

BACKGROUND

Mailed fecal immunochemical test (FIT) outreach effectively increases colorectal cancer (CRC) screening but is underutilized. This pilot aimed to determine the use of FIT for CRC screening among Medicare Advantage enrollees when offered via mailed outreach and the factors associated with FIT return.

METHODS

Our pilot study included Medicare Advantage enrollees who were 50-75-years old, not up to date with CRC screening, and had a billable primary care encounter in the prior 3 years. Eligible patients received a letter containing information about CRC screening and a FIT kit, screening status by FIT was then assessed using the electronic health record.

RESULTS

Of the 1142 patients identified, 945 were eligible for outreach. On 12-month follow up, 29% of patients (n = 276) completed CRC screening via FIT, with a median return time of 140 days [interquartile range (IQR) 52-257]; 6% (n = 17) of the completed tests were positive, and 53% (n = 9) of patients have completed a diagnostic colonoscopy. Patients with primary encounter <12 months prior to mailed outreach were most likely to complete a FIT. Over the 12-month study period, CRC screening rates increased by 5% (63-68%).

CONCLUSIONS

Mailed FIT outreach in a Medicare Advantage population was feasible and led to a 5% increase in CRC screening completion. Our pilot revealed rare incorrect patient addresses and high lab discard rate; both important factors that were addressed prior to larger-scale implementation of a mailed FIT program. Further research is needed to understand the potential impact of multilevel interventions on CRC screening in this healthcare system.

Fecal DNA methylation markers for detecting stages of colorectal cancer and its precursors: a systematic review

Background

DNA methylation biomarkers in stool may have applications in early colorectal cancer (CRC) detection; however, their association with stages of CRC carcinogenesis or their performance in detecting various stages is unclear. We aimed to systematically review the evidence for DNA methylation markers in stool for risk stratification or detection of specific CRC stages, as well as precursors of CRC.

Methods

We conducted a systematic search in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched PubMed and ISI Web of Knowledge to identify relevant studies published until 14th January 2020. Two reviewers independently extracted data on study population characteristics, candidate genes, methylation measurement methods, odds ratios (ORs), overall and stage-specific sensitivities, specificities, areas under the receiver operating characteristics curve, and p-values for statistical significance for OR and for association of methylation levels with stage.

Results

Twenty-seven studies that reported stage-specific associations or performances of fecal DNA methylation markers for detecting colorectal neoplasms were identified. All studies used methylation-specific polymerase chain reaction for assessing methylation levels in the promoter or exon 1 regions of targeted genes. However, most studies were underpowered and limited by their case-control design. Furthermore, the stage-specific associations or sensitivities were validated for two markers (hypermethylation of GATA4 and VIM) only.

Conclusion

Methylation markers in stool may be useful for detection of CRC precursors or CRC staging, but promising candidate markers need to be validated in longitudinal studies on large screening populations, performing epigenome-wide analyses. Identification of stage-specific DNA methylation biomarkers in stool could boost current strategies towards early detection and enable different approaches to precision medicine for CRC.

Serum netrin-1 as a biomarker for colorectal cancer detection

BACKGROUND

Recent evidence support that netrin-1 involves in colorectal carcinogenesis.

OBJECTIVE

This study was to evaluate the performance of serum netrin-1 for detection of colorectal cancer (CRC) in both clinical/screening sets.

METHODS

A total of 115 consecutive patients with CRC and matched healthy controls were included in Clinical Set. Fifty subjects with CRC, 50 subjects with advanced adenoma (AA), and 150 matched control participants free of neoplasia were included in Screening Set.

RESULTS

In Clinical set, subjects with CRC presented higher levels of serum netrin-1 (513.9 ± 22.6 pg/mL) than controls (347.8 ± 20.3 pg/mL, p< 0.0001). Similar in Screening set, serum netrin-1 was higher in CRC (644.5 ± 37.0 pg/mL, both p< 0.0001), compared with controls (407.7 ± 14.8 pg/mL) and AA (416.5 ± 18.5 pg/mL). However, there was no difference between controls and AA (p= 0.752). Compared with the low netrin-1 group, the high group presented increased risk of CRC (Clinical set: OR = 4.300, p< 0.001; Screening set: OR = 7.731, p< 0.001). ROC curve of netrin-1 was developed to detect CRC (Clinical set: AUC 0.703; Screening set: AUC 0.759).

CONCLUSIONS

It suggests netrin-1 as a potential biomarker for CRC detection.

Efficacy and cost-effectiveness of fecal immunochemical test versus colonoscopy in colorectal cancer screening: a systematic review and meta-analysis

BACKGROUND AND AIMS

The fecal immunochemical test (FIT) and colonoscopy are the most commonly used strategies for colorectal cancer (CRC) screening worldwide. We aimed to compare their efficacy and cost-effectiveness in CRC screening in an average-risk population.

METHODS

PubMed, Embase, and National Health Services Economic Evaluation Database were searched. Risk ratio (RR) was used to evaluate the differences in detection rates of colorectal neoplasia between FIT and colonoscopy groups. A random-effects model was used to pool RRs. Incremental cost-effectiveness ratios (ICERs) were calculated to evaluate the cost-effectiveness of FIT versus colonoscopy.

RESULTS

Six randomized controlled trials and 17 cost-effectiveness studies were included. The participation rate in the FIT group was higher than that in the colonoscopy group (41.6% vs 21.9%). In the intention-to-treat analysis, FIT had a detection rate of CRC comparable with colonoscopy (RR, .73; 95% confidence interval, .37-1.42) and lower detection rates of any adenoma and advanced adenoma than 1-time colonoscopy. Most included cost-effectiveness studies showed that annual (13/15) or biennial (5/6) FIT was cost-saving (ICER < $0) or very cost-effective ($0 < ICER ≤ $25000/quality-adjusted life-year) compared with colonoscopy every 10 years.

CONCLUSIONS

FIT may be similar to 1-time colonoscopy in the detection rate of CRC, although it has lower detection rates of any adenoma and advanced adenoma than 1-time colonoscopy. Furthermore, annual or biennial FIT appears to be very cost-effective or cost-saving compared with colonoscopy every 10 years. These findings indicate, at least partly, that FIT is noninferior to colonoscopy in CRC screening in an average-risk population. Our findings should be treated with caution and need to be further confirmed.

Accuracy of colon capsule endoscopy for advanced neoplasia

BACKGROUND AND AIMS

Second-generation colon capsule endoscopy (CCE-2) has shown promising accuracy for the diagnosis of overall neoplasia. Advanced neoplasia (AN) represents the main target of colorectal cancer screening programs. Our aim was to assess the diagnostic accuracy of CCE-2 for the detection of AN in patients with a positive result for the fecal immunochemical test (FIT) who are undergoing screening.

METHODS

Patients aged 50 to 69 years with a positive result for the FIT in 4 population screening programs in Italy and Spain were enrolled. Screenees were asked to undergo CCE-2, followed by traditional colonoscopy (TC). TC was performed the same day or the following morning. Bowel preparation included a split-dose polyethylene glycol-based regimen, with sodium phosphate (NaP) with gastrografin as boosters. The CCE-2 video was read by an endoscopist blinded to the results of TC. The main outcomes were CCE-2 accuracy in terms of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for AN when using 2 different size thresholds for TC referral (ie, polyps ≥6 mm and ≥10 mm).

RESULTS

Two hundred twenty-two patients were enrolled, and 178 patients completed both CCE-2 and TC (87.7%). Overall, 59 cases of AN were detected at TC. CCE-2 sensitivity was 90%, specificity was 66.1%, PPV was 57.4%, and NPV was 92.9% for AN when using a 6-mm cut-off (TC referral rate, 52.8%) and 76.7%, 90.7%, 80.7%, and 88.4% when using a 10-mm cut-off (TC referral rate, 32%), respectively. CCE-2 detected that 8 of 9 already developed colorectal cancers. Among the 41 false positives at the 6-mm cut-off, 34 (82.9%) presented with a nonadvanced adenoma at TC. Mean transit time was 4 hours and 4 minutes, and ≥70% of patients excreted the capsule within 5 hours.

CONCLUSIONS

In an enriched disease setting, we showed the high sensitivity of CCE-2 for the diagnosis of AN at a 6-mm cut-off. The apparently low CCE-2 specificity is related to the choice of AN as the main outcome. (Clinical trial registration number: ISRCTN 62158762.).

[Knowledge, conduct and attitude before the European Code against Cancer by health professionals of primary care]

OBJECTIVE

To decide if Primary Care (PC) professionals know the European Code against Cancer (CECC) and if this relates to practice the recommendations with themselves and with their patients.

DESIGN

descriptive, observational study.

SETTING

Spanish Health Centers.

PARTICIPANTS

Health professionals.

INTERVENTIONS

self-administered questionnaire.

MAIN MEASUREMENTS

cancer protective and risk factors, screening for colorectal, breast, cervix and prostate cancer, level of knowledge of the ECAC.

RESULTS

1734 participants (10.5%), mean age 47.4 years (SD: 8.6), 71.5% female. 50.0% do not know the CECC; tutors (OR=1.61), assigned to the PAPPS (OR=1.51) and who have been working in AP for more time (OR=2.62) are the ones who know it most. 7.2% smoke and 79.1% drink alcohol. 64.1% presented normal weight and 19% performed physical activity. They avoid exposing themselves to the sun 52.7% and use protectors 53.8%. 85.2% have never had a colorectal screening, 11% never had a cytology, and 12% had a mammogram. There is a relationship between knowing the CECC and smoking (P<.001), overweight/obesity (P=.024), physical activity (P=.003), meat intake (P<.001), mammography (P<.001), cytology (P=.022), PSA (P=.045), as well as the promotion of their advice among patients.

CONCLUSIONS

The CECC is unknown by half of the AP professionals. The practice of its recommendations is uneven, with the prevalence of low smoking, and sun protection a little extended behavior. Those who know him are the ones who most practice his recommendations.

Effectiveness, benefit harm and cost effectiveness of colorectal cancer screening in Austria

BACKGROUND

Clear evidence on the benefit-harm balance and cost effectiveness of population-based screening for colorectal cancer (CRC) is missing. We aim to systematically evaluate the long-term effectiveness, harms and cost effectiveness of different organized CRC screening strategies in Austria.

METHODS

A decision-analytic cohort simulation model for colorectal adenoma and cancer with a lifelong time horizon was developed, calibrated to the Austrian epidemiological setting and validated against observed data. We compared four strategies: 1) No Screening, 2) FIT: annual immunochemical fecal occult blood test age 40-75 years, 3) gFOBT: annual guaiac-based fecal occult blood test age 40-75 years, and 4) COL: 10-yearly colonoscopy age 50-70 years. Predicted outcomes included: benefits expressed as life-years gained [LYG], CRC-related deaths avoided and CRC cases avoided; harms as additional complications due to colonoscopy (physical harm) and positive test results (psychological harm); and lifetime costs. Tradeoffs were expressed as incremental harm-benefit ratios (IHBR, incremental positive test results per LYG) and incremental cost-effectiveness ratios [ICER]. The perspective of the Austrian public health care system was adopted. Comprehensive sensitivity analyses were performed to assess uncertainty.

RESULTS

The most effective strategies were FIT and COL. gFOBT was less effective and more costly than FIT. Moving from COL to FIT results in an incremental unintended psychological harm of 16 additional positive test results to gain one life-year. COL was cost saving compared to No Screening. Moving from COL to FIT has an ICER of 15,000 EUR per LYG.

CONCLUSIONS

Organized CRC-screening with annual FIT or 10-yearly colonoscopy is most effective. The choice between these two options depends on the individual preferences and benefit-harm tradeoffs of screening candidates.

Colorectal Cancer Screening Modalities in Chinese Population: Practice and Lessons in Pudong New Area of Shanghai, China

Background: Parallel test of risk stratification and two-sample qualitative fecal immunochemical tests (FITs) are used to screen colorectal cancer (CRC) in Shanghai, China. This study was designed to identify an optimal initial screening modality based on available data. Methods: A total of 538,278 eligible residents participated in the program during the period of January 2013 to June 2017. Incident CRC was collected through program reporting system and by record linkage with the Shanghai Cancer Registry up to December 2017. Logistic regression model was applied to identify significant factors to calculate risk score for CRC. Cutoff points of risk score were determined based on Youden index and defined specificity. Sensitivity, specificity, and positive predictive values (PPVs) were computed to evaluate validity of assumed screening modalities. Results: A total of 446 CRC were screen-detected, and 777 interval or missed cases were identified through record linkage. The risk score system had an optimal cutoff point of 19 and performed better in detecting CRC and predicting long-term CRC risk than did the risk stratification. When using a cutoff point of 24, parallel test of risk score, and FIT were expected to avoid 56 interval CRCs with minimal decrease in PPV and increase in colonoscopy. However, the observed detection rates were much lower than those expected due to low compliance to colonoscopy. Conclusions: Risk score is superior to risk stratification used in the program, particularly when combined with FIT. Compliance to colonoscopy should be improved to guarantee the effectiveness of CRC screening in the population.