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Randel KR, Schult AL, Botteri E, Nawaz M, Nguyen DH, Holme Ø, Bretthauer M, Hoff G, de Lange T. Impact of inadequate bowel cleansing in sigmoidoscopy screening. Scand J Gastroenterol 2024:1-8. [PMID: 38850200 DOI: 10.1080/00365521.2024.2364213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 05/31/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND AND STUDY AIMS Long-time follow-up of sigmoidoscopy screening trials has shown reduced incidence and mortality of colorectal cancer (CRC), but inadequate bowel cleansing may hamper efficacy. The aim of this study was to assess the impact of bowel cleansing quality in sigmoidoscopy screening. PATIENTS AND METHODS Individuals 50 to 74 years old who had a screening sigmoidoscopy in a population-based Norwegian, randomized trial between 2012 and 2019, were included in this cross-sectional study. The bowel cleansing quality was categorised as excellent, good, partly poor, or poor. The effect of bowel cleansing quality on adenoma detection rate (ADR) and referral to colonoscopy was evaluated by fitting multivariable logistic regression models. RESULTS 35,710 individuals were included. The bowel cleansing at sigmoidoscopy was excellent in 20,934 (58.6%) individuals, good in 6580 (18.4%), partly poor in 7097 (19.9%) and poor in 1099 (3.1%). The corresponding ADRs were 17.0%, 16.6%, 14.5%, and 13.0%. Compared to participants with excellent bowel cleansing, those with poor bowel cleansing had an odds ratio for adenoma detection of 0.66 (95% confidence interval 0.55-0.79). We found substantial differences in the assessment of bowel cleansing quality among endoscopists. CONCLUSIONS Inadequate bowel cleansing reduces the efficacy of sigmoidoscopy screening, by lowering ADR. A validated rating scale and improved bowel preparation are needed to make sigmoidoscopy an appropriate screening method. Trial registration Clinicaltrials.gov (NCT01538550).
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Affiliation(s)
| | - Anna Lisa Schult
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, NIPH, Oslo, Norway
- Department of Medicine, Vestre Viken Hospital Trust Bærum, Gjettum, Norway
| | - Edoardo Botteri
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, NIPH, Oslo, Norway
- Department of Research, Cancer Registry of Norway, NIPH, Oslo, Norway
| | - Mobina Nawaz
- Department of Medicine, Vestre Viken Hospital Trust Bærum, Gjettum, Norway
| | | | - Øyvind Holme
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, NIPH, Oslo, Norway
- Department of Medicine, Sørlandet Hospital Trust, Kristiansand, Norway
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Michael Bretthauer
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Norway
| | - Geir Hoff
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, NIPH, Oslo, Norway
- Department of Research and Development, Telemark Hospital, Skien, Norway
| | - Thomas de Lange
- Department of Medicine and Emergencies, Mölndal, Sahlgrenska University Hospital, Region Västra Götaland, Sweden
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
- Department of Medical Research, Vestre Viken Hospital Trust, Bærum Hospital, Norway
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2
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Siau K, Pelitari S, Green S, McKaig B, Rajendran A, Feeney M, Thoufeeq M, Anderson J, Ravindran V, Hagan P, Cripps N, Beales ILP, Church K, Church NI, Ratcliffe E, Din S, Pullan RD, Powell S, Regan C, Ngu WS, Wood E, Mills S, Hawkes N, Dunckley P, Iacucci M, Thomas-Gibson S, Wells C, Murugananthan A. JAG consensus statements for training and certification in flexible sigmoidoscopy. Frontline Gastroenterol 2023; 14:181-200. [PMID: 37056324 PMCID: PMC10086722 DOI: 10.1136/flgastro-2022-102259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 10/04/2022] [Indexed: 01/28/2023] Open
Abstract
IntroductionJoint Advisory Group (JAG) certification in endoscopy is awarded when trainees attain minimum competency standards for independent practice. A national evidence-based review was undertaken to update standards for training and certification in flexible sigmoidoscopy (FS).MethodsA modified Delphi process was conducted between 2019 and 2020 with multisociety representation from experts and trainees. Following literature review and Grading of Recommendations, Assessment, Development and Evaluations appraisal, recommendation statements on FS training and certification were formulated and subjected to anonymous voting to obtain consensus. Accepted statements were peer-reviewed by national stakeholders for incorporation into the JAG FS certification pathway.ResultsIn total, 41 recommendation statements were generated under the domains of: definition of competence (13), acquisition of competence (17), assessment of competence (7) and postcertification support (4). The consensus process led to revised criteria for colonoscopy certification, comprising: (A) achieving key performance indicators defined within British Society of Gastroenterology standards (ie, rectal retroversion >90%, polyp retrieval rate >90%, patient comfort <10% with moderate-severe discomfort); (B) minimum procedure count ≥175; (C) performing 15+ procedures over the preceding 3 months; (D) attendance of the JAG Basic Skills in Lower gastrointestinal Endoscopy course; (E) satisfying requirements for formative direct observation of procedural skill (DOPS) and direct observation of polypectomy skill (SMSA level 1); (F) evidence of reflective practice as documented on the JAG Endoscopy Training System reflection tool and (G) successful performance in summative DOPS.ConclusionThe UK standards for training and certification in FS have been updated to support training, uphold standards in FS and polypectomy, and provide support to the newly independent practitioner.
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Affiliation(s)
- Keith Siau
- Department of Gastroenterology, Royal Cornwall Hospital, Truro, UK
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Stavroula Pelitari
- Department of Gastroenterology, Royal Free London NHS Foundation Trust, London, UK
| | - Susi Green
- Department of Gastroenterology, University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - Brian McKaig
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Arun Rajendran
- Department of Gastroenterology, Hillingdon Hospitals NHS Foundation Trust, Uxbridge, UK
| | - Mark Feeney
- Department of Gastroenterology, Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - Mo Thoufeeq
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - John Anderson
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
| | - Vathsan Ravindran
- Department of Gastroenterology, St Mark's Hospital and Academic Institute Wolfson Unit for Endoscopy, Harrow, UK
| | - Paul Hagan
- Endoscopy, Royal Derby Hospital, Derby, UK
| | - Neil Cripps
- Colorectal Surgery, University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - Ian L P Beales
- University of East Anglia, Norwich, UK
- Department of Gastroenterology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | | | | | - Elizabeth Ratcliffe
- Department of Gastroenterology, Wrightington Wigan and Leigh NHS Foundation Trust, Wigan, UK
- Division of Diabetes, Endocrinology and Gastroenterology Faculty of Biology, Medicine and Health School of Medical Sciences, The University of Manchester, Manchester, UK
| | - Said Din
- Department of Gastroenterology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Rupert D Pullan
- Colorectal Surgery, Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - Sharon Powell
- Endoscopy, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Catherine Regan
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Wee Sing Ngu
- Colorectal Surgery, City Hospitals Sunderland NHS Foundation Trust, South Shields, UK
| | - Eleanor Wood
- Gastroenterology, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Sarah Mills
- Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
- Imperial College London, London, UK
| | - Neil Hawkes
- Department of Gastroenterology, Royal Glamorgan Hospital, Llantrisant, UK
| | - Paul Dunckley
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Marietta Iacucci
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
- Department of Gastroenterology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Siwan Thomas-Gibson
- Imperial College London, London, UK
- St Mark's Hospital and Academic Institute Wolfson Unit for Endoscopy, Harrow, UK
| | - Christopher Wells
- Department of Gastroenterology, North Tees and Hartlepool NHS Foundation Trust, Hartlepool, UK
| | - Aravinth Murugananthan
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
- Faculty of Health, Education and Life Sciences, Birmingham City University, Birmingham, UK
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3
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Kaminski MF, Robertson DJ, Senore C, Rex DK. Optimizing the Quality of Colorectal Cancer Screening Worldwide. Gastroenterology 2020; 158:404-417. [PMID: 31759062 DOI: 10.1053/j.gastro.2019.11.026] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 11/04/2019] [Accepted: 11/14/2019] [Indexed: 12/14/2022]
Abstract
Screening, followed by colonoscopic polypectomy (or surgery for malignant lesions), prevents incident colorectal cancer and mortality. However, there are variations in effective application of nearly every aspect of the screening process. Screening is a multistep process, and failure in any single step could result in unnecessary morbidity and mortality. Awareness of variations in operator- and system-dependent performance has led to detailed, comprehensive recommendations in the United States and Europe on how colonoscopy screening should be performed and measured. Likewise, guidance has been provided on quality assurance for nonprimary colonoscopy-based screening programs, including strategies to maximize adherence. Quality improvement is now a validated science, and there is clear evidence that higher quality prevents incident cancer and cancer death. Quality must be addressed at the levels of the system, provider, and individuals, to maximize the benefits of screening for any population. We review the important aspects of measuring and improving the quality of colorectal cancer screening.
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Affiliation(s)
- Michael F Kaminski
- Department of Gastroenterological Oncology, the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland; Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland; Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Douglas J Robertson
- Department of Veterans Affairs Medical Center, White River Junction, Vermont; The Geisel School of Medicine at Dartmouth and The Dartmouth Institute, Hanover, New Hampshire
| | - Carlo Senore
- Epidemiology and Screening Unit-CPO, University Hospital Città della Salute e della Scienza, Turin, Italy
| | - Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana.
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Wolf AMD, Fontham ETH, Church TR, Flowers CR, Guerra CE, LaMonte SJ, Etzioni R, McKenna MT, Oeffinger KC, Shih YCT, Walter LC, Andrews KS, Brawley OW, Brooks D, Fedewa SA, Manassaram-Baptiste D, Siegel RL, Wender RC, Smith RA. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin 2018; 68:250-281. [PMID: 29846947 DOI: 10.3322/caac.21457] [Citation(s) in RCA: 1115] [Impact Index Per Article: 185.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 04/23/2018] [Indexed: 12/11/2022] Open
Abstract
In the United States, colorectal cancer (CRC) is the fourth most common cancer diagnosed among adults and the second leading cause of death from cancer. For this guideline update, the American Cancer Society (ACS) used an existing systematic evidence review of the CRC screening literature and microsimulation modeling analyses, including a new evaluation of the age to begin screening by race and sex and additional modeling that incorporates changes in US CRC incidence. Screening with any one of multiple options is associated with a significant reduction in CRC incidence through the detection and removal of adenomatous polyps and other precancerous lesions and with a reduction in mortality through incidence reduction and early detection of CRC. Results from modeling analyses identified efficient and model-recommendable strategies that started screening at age 45 years. The ACS Guideline Development Group applied the Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria in developing and rating the recommendations. The ACS recommends that adults aged 45 years and older with an average risk of CRC undergo regular screening with either a high-sensitivity stool-based test or a structural (visual) examination, depending on patient preference and test availability. As a part of the screening process, all positive results on noncolonoscopy screening tests should be followed up with timely colonoscopy. The recommendation to begin screening at age 45 years is a qualified recommendation. The recommendation for regular screening in adults aged 50 years and older is a strong recommendation. The ACS recommends (qualified recommendations) that: 1) average-risk adults in good health with a life expectancy of more than 10 years continue CRC screening through the age of 75 years; 2) clinicians individualize CRC screening decisions for individuals aged 76 through 85 years based on patient preferences, life expectancy, health status, and prior screening history; and 3) clinicians discourage individuals older than 85 years from continuing CRC screening. The options for CRC screening are: fecal immunochemical test annually; high-sensitivity, guaiac-based fecal occult blood test annually; multitarget stool DNA test every 3 years; colonoscopy every 10 years; computed tomography colonography every 5 years; and flexible sigmoidoscopy every 5 years. CA Cancer J Clin 2018;68:250-281. © 2018 American Cancer Society.
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Affiliation(s)
- Andrew M D Wolf
- Associate Professor and Attending Physician, University of Virginia School of Medicine, Charlottesville, VA
| | - Elizabeth T H Fontham
- Emeritus Professor, Louisiana State University School of Public Health, New Orleans, LA
| | - Timothy R Church
- Professor, University of Minnesota and Masonic Cancer Center, Minneapolis, MN
| | - Christopher R Flowers
- Professor and Attending Physician, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA
| | - Carmen E Guerra
- Associate Professor of Medicine of the Perelman School of Medicine and Attending Physician, University of Pennsylvania Medical Center, Philadelphia, PA
| | - Samuel J LaMonte
- Independent retired physician and patient advocate, University of Washington and the Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Ruth Etzioni
- Biostatistician, University of Washington and the Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Matthew T McKenna
- Professor and Director, Division of Preventive Medicine, Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA
| | - Kevin C Oeffinger
- Professor and Director of the Duke Center for Onco-Primary Care, Durham, NC
| | - Ya-Chen Tina Shih
- Professor, Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Louise C Walter
- Professor and Attending Physician, University of California, San Francisco and San Francisco VA Medical Center, San Francisco, CA
| | - Kimberly S Andrews
- Director, Cancer Control Department, American Cancer Society, Atlanta, GA
| | - Otis W Brawley
- Chief Medical and Scientific Officer and Executive Vice President-Research, American Cancer Society, Atlanta, GA
| | - Durado Brooks
- Vice President, Cancer Control Interventions, Cancer Control Department, American Cancer Society, Atlanta, GA
| | - Stacey A Fedewa
- Strategic Director for Risk Factor Screening and Surveillance, American Cancer Society, Atlanta, GA
| | | | - Rebecca L Siegel
- Strategic Director, Surveillance Information Services, American Cancer Society, Atlanta, GA
| | - Richard C Wender
- Chief Cancer Control Officer, American Cancer Society, Atlanta, GA
| | - Robert A Smith
- Vice President, Cancer Screening, Cancer Control Department, American Cancer Society, Atlanta, GA
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Marzo-Castillejo M, Vela-Vallespín C, Bellas-Beceiro B, Bartolomé-Moreno C, Melús-Palazón E, Vilarrubí-Estrella M, Nuin-Villanueva M. Recomendaciones de prevención del cáncer. Actualización PAPPS 2018. Aten Primaria 2018; 50 Suppl 1:41-65. [PMID: 29866358 PMCID: PMC6837141 DOI: 10.1016/s0212-6567(18)30362-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Mercè Marzo-Castillejo
- Especialista en Medicina Familiar y Comunitaria y especialista en Medicina Preventiva y Salud Pública, Unitat de Suport a la Recerca de Costa de Ponent, IDIAP Jordi Gol, Direcció d'Atenció Primària Costa de Ponent, Institut Català de la Salut, Barcelona
| | - Carmen Vela-Vallespín
- Especialista en Medicina Familiar y Comunitaria, EAP Riu Nord i Riu Sud, Santa Coloma de Gramenet, SAP Barcelona Nord i Maresme-ICS, Unitat Docent Metropolitana Nord, Barcelona
| | - Begoña Bellas-Beceiro
- Especialista en Medicina Familiar y Comunitaria, Complejo Hospitalario Universitario de Canarias y Unidad Docente de Atención Familiar y Comunitaria La Laguna-Tenerife Norte, Servicio Canario de Salud, Santa Cruz de Tenerife
| | - Cruz Bartolomé-Moreno
- Especialista en Medicina Familiar y Comunitaria, Centro de Salud Goya de Zaragoza y Unidad Docente de Medicina Familiar y Comunitaria Sector Zaragoza I, Servicio Aragonés de Salud, Zaragoza
| | - Elena Melús-Palazón
- Especialista en Medicina Familiar y Comunitaria, Centro de Salud Actur Oeste, Zaragoza, y Unidad Docente de Medicina Familiar y Comunitaria Sector Zaragoza I, Servicio Aragonés de Salud, Zaragoza
| | - Mercè Vilarrubí-Estrella
- Especialista en Medicina Familiar y Comunitaria, Servicio de Gestión Clínica y Sistemas de Información, Dirección de Atención Primaria, Servicio Navarro de Salud, Pamplona
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6
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Labianca R, Merelli B. Screening and Diagnosis for Colorectal Cancer: Present and Future. TUMORI JOURNAL 2018. [DOI: 10.1177/548.6506] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | - Barbara Merelli
- Unit of Medical Oncology, Ospedali Riuniti di Bergamo, Italy
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7
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Rex DK, Boland CR, Dominitz JA, Giardiello FM, Johnson DA, Kaltenbach T, Levin TR, Lieberman D, Robertson DJ. Colorectal Cancer Screening: Recommendations for Physicians and Patients From the U.S. Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2017; 153:307-323. [PMID: 28600072 DOI: 10.1053/j.gastro.2017.05.013] [Citation(s) in RCA: 443] [Impact Index Per Article: 63.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This document updates the colorectal cancer (CRC) screening recommendations of the U.S. Multi-Society Task Force of Colorectal Cancer (MSTF), which represents the American College of Gastroenterology, the American Gastroenterological Association, and The American Society for Gastrointestinal Endoscopy. CRC screening tests are ranked in 3 tiers based on performance features, costs, and practical considerations. The first-tier tests are colonoscopy every 10 years and annual fecal immunochemical test (FIT). Colonoscopy and FIT are recommended as the cornerstones of screening regardless of how screening is offered. Thus, in a sequential approach based on colonoscopy offered first, FIT should be offered to patients who decline colonoscopy. Colonoscopy and FIT are recommended as tests of choice when multiple options are presented as alternatives. A risk-stratified approach is also appropriate, with FIT screening in populations with an estimated low prevalence of advanced neoplasia and colonoscopy screening in high prevalence populations. The second-tier tests include CT colonography every 5 years, the FIT-fecal DNA test every 3 years, and flexible sigmoidoscopy every 5 to 10 years. These tests are appropriate screening tests, but each has disadvantages relative to the tier 1 tests. Because of limited evidence and current obstacles to use, capsule colonoscopy every 5 years is a third-tier test. We suggest that the Septin9 serum assay (Epigenomics, Seattle, Wash) not be used for screening. Screening should begin at age 50 years in average-risk persons, except in African Americans in whom limited evidence supports screening at 45 years. CRC incidence is rising in persons under age 50, and thorough diagnostic evaluation of young persons with suspected colorectal bleeding is recommended. Discontinuation of screening should be considered when persons up to date with screening, who have prior negative screening (particularly colonoscopy), reach age 75 or have <10 years of life expectancy. Persons without prior screening should be considered for screening up to age 85, depending on age and comorbidities. Persons with a family history of CRC or a documented advanced adenoma in a first-degree relative age <60 years or 2 first-degree relatives with these findings at any age are recommended to undergo screening by colonoscopy every 5 years, beginning 10 years before the age at diagnosis of the youngest affected relative or age 40, whichever is earlier. Persons with a single first-degree relative diagnosed at ≥60 years with CRC or an advanced adenoma can be offered average-risk screening options beginning at age 40 years.
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Affiliation(s)
- Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana.
| | | | - Jason A Dominitz
- VA Puget Sound Health Care System, University of Washington, Seattle, Washington
| | | | | | - Tonya Kaltenbach
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | | | | | - Douglas J Robertson
- VA Medical Center, White River Junction, Vermont, and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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8
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Rex DK, Boland CR, Dominitz JA, Giardiello FM, Johnson DA, Kaltenbach T, Levin TR, Lieberman D, Robertson DJ. Colorectal Cancer Screening: Recommendations for Physicians and Patients from the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2017; 112:1016-1030. [PMID: 28555630 DOI: 10.1038/ajg.2017.174] [Citation(s) in RCA: 420] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This document updates the colorectal cancer (CRC) screening recommendations of the U.S. Multi-Society Task Force of Colorectal Cancer (MSTF), which represents the American College of Gastroenterology, the American Gastroenterological Association, and The American Society for Gastrointestinal Endoscopy. CRC screening tests are ranked in 3 tiers based on performance features, costs, and practical considerations. The first-tier tests are colonoscopy every 10 years and annual fecal immunochemical test (FIT). Colonoscopy and FIT are recommended as the cornerstones of screening regardless of how screening is offered. Thus, in a sequential approach based on colonoscopy offered first, FIT should be offered to patients who decline colonoscopy. Colonoscopy and FIT are recommended as tests of choice when multiple options are presented as alternatives. A risk-stratified approach is also appropriate, with FIT screening in populations with an estimated low prevalence of advanced neoplasia and colonoscopy screening in high prevalence populations. The second-tier tests include CT colonography every 5 years, the FIT-fecal DNA test every 3 years, and flexible sigmoidoscopy every 5 to 10 years. These tests are appropriate screening tests, but each has disadvantages relative to the tier 1 tests. Because of limited evidence and current obstacles to use, capsule colonoscopy every 5 years is a third-tier test. We suggest that the Septin9 serum assay (Epigenomics, Seattle, Wash) not be used for screening. Screening should begin at age 50 years in average-risk persons, except in African Americans in whom limited evidence supports screening at 45 years. CRC incidence is rising in persons under age 50, and thorough diagnostic evaluation of young persons with suspected colorectal bleeding is recommended. Discontinuation of screening should be considered when persons up to date with screening, who have prior negative screening (particularly colonoscopy), reach age 75 or have <10 years of life expectancy. Persons without prior screening should be considered for screening up to age 85, depending on age and comorbidities. Persons with a family history of CRC or a documented advanced adenoma in a first-degree relative age <60 years or 2 first-degree relatives with these findings at any age are recommended to undergo screening by colonoscopy every 5 years, beginning 10 years before the age at diagnosis of the youngest affected relative or age 40, whichever is earlier. Persons with a single first-degree relative diagnosed at ≥60 years with CRC or an advanced adenoma can be offered average-risk screening options beginning at age 40 years.
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Affiliation(s)
- Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Jason A Dominitz
- VA Puget Sound Health Care System, University of Washington, Seattle, Washington, USA
| | | | | | - Tonya Kaltenbach
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | | | | | - Douglas J Robertson
- VA Medical Center, White River Junction, Vermont, and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
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9
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Rex DK, Boland CR, Dominitz JA, Giardiello FM, Johnson DA, Kaltenbach T, Levin TR, Lieberman D, Robertson DJ. Colorectal cancer screening: Recommendations for physicians and patients from the U.S. Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc 2017; 86:18-33. [PMID: 28600070 DOI: 10.1016/j.gie.2017.04.003] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 04/06/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana, USA.
| | | | - Jason A Dominitz
- VA Puget Sound Health Care System, University of Washington, Seattle, Washington, USA
| | | | | | - Tonya Kaltenbach
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | | | | | - Douglas J Robertson
- VA Medical Center, White River Junction, Vermont, and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
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10
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Faulx AL, Lightdale JR, Acosta RD, Agrawal D, Bruining DH, Chandrasekhara V, Eloubeidi MA, Gurudu SR, Kelsey L, Khashab MA, Kothari S, Muthusamy VR, Qumseya BJ, Shaukat A, Wang A, Wani SB, Yang J, DeWitt JM. Guidelines for privileging, credentialing, and proctoring to perform GI endoscopy. Gastrointest Endosc 2017; 85:273-281. [PMID: 28089029 DOI: 10.1016/j.gie.2016.10.036] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 10/27/2016] [Indexed: 02/08/2023]
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11
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Ruco A, Walsh CM, Cooper MA, Rabeneck L. Training non-physicians to do endoscopy: Feasibility, effectiveness and cost-effectiveness. Best Pract Res Clin Gastroenterol 2016; 30:389-96. [PMID: 27345647 DOI: 10.1016/j.bpg.2016.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 04/12/2016] [Accepted: 04/28/2016] [Indexed: 01/31/2023]
Abstract
Colorectal cancer (CRC) is one of the most common cancers in women and men worldwide. Training non-physicians including nurses, nurse practitioners, and physician assistants to perform endoscopy can provide the opportunity to expand access to CRC screening as demand for endoscopic procedures continues to grow. A formal program, incorporating didactic instruction and hands-on practice in addition to oversight, is required to train non-physicians to perform endoscopy as safely and effectively as physicians. Additionally, the context in which the non-physician endoscopy program is organized will dictate key program characteristics including remuneration, participant recruitment and professional and legal considerations. This review explores the evidence in support of non-physician based endoscopy, potential challenges in implementing non-physician endoscopy and requirements for a high-quality program to support training and implementation.
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Affiliation(s)
- A Ruco
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - C M Walsh
- Division of Gastroenterology, Hepatology and Nutrition, SickKids Learning and Research Institutes, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Peadiatrics, University of Toronto, Canada
| | - M A Cooper
- Thunder Bay Regional Health Sciences Centre, Canada
| | - L Rabeneck
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Cancer Care Ontario, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
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Ormarsson OT, Asgrimsdottir GM, Loftsson T, Stefansson E, Kristinsson JO, Lund SH, Bjornsson ES. Clinical trial: free fatty acid suppositories compared with enema as bowel preparation for flexible sigmoidoscopy. Frontline Gastroenterol 2015; 6:278-283. [PMID: 26500756 PMCID: PMC4602256 DOI: 10.1136/flgastro-2014-100497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 09/09/2014] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES The purpose of this trial was to evaluate the efficacy and safety of recently developed suppositories containing free fatty acids as a bowel-cleansing agent prior to flexible sigmoidoscopy and compare them with Klyx (docusate sodium/sorbitol). DESIGN A controlled, non-inferiority, single-blind, randomised study on outpatients undergoing flexible sigmoidoscopy. SETTING Department of Gastroenterology, Landspitali-University Hospital and endoscopic clinic. PATIENTS 53 outpatients undergoing flexible sigmoidoscopy. INTERVENTION Participants were randomised to receive either free fatty acid suppositories (28) or a standard bowel preparation with Klyx enema (25). In the study group, two suppositories were administered the evening before as well as 2 h prior to the sigmoidoscopy. In the control group, Klyx enema (120 mL) was administered the evening before and repeated 2 h prior to the procedure. MAIN OUTCOME MEASUREMENTS Quality of the bowel cleansing, height of scope insertion and safety. RESULTS The mean height of scope insertion and bowel cleansing was 43 cm (SD=13.4) in the study group and 48 cm (SD=10.4) in the control group (NS). The investigating physicians were less satisfied with the bowel preparation in the study group compared with the control group with a difference of 20% (p<0.016). The amount of faeces noted in the rectum was similar in both groups with no significant difference (p<0.56). No serious side effects, toxic reaction or irritation were observed. CONCLUSIONS The suppositories are well tolerated with no significant side effects. The suppositories had distinct bowel emptying effect and as effective as Klyx in rectal cleansing. Although physician's satisfaction was slightly lower, the height of scope insertion was similar. TRIAL REGISTRATION NUMBER EudraCT nr.: 2010-018761-35.
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Affiliation(s)
- Orri Thor Ormarsson
- Department of Paediatric Surgery, Landspitali-University Hospital, Reykjavík, Iceland
| | | | | | - Einar Stefansson
- Department of Ophtalmology, Landspitali-University Hospital, Reykjavík, Iceland
| | | | - Sigrun Helga Lund
- Department of Public Health, University of Iceland, Reykjavik, Iceland
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Tárraga López PJ, Albero JS, Rodríguez-Montes JA. Primary and secondary prevention of colorectal cancer. CLINICAL MEDICINE INSIGHTS. GASTROENTEROLOGY 2014; 7:33-46. [PMID: 25093007 PMCID: PMC4116379 DOI: 10.4137/cgast.s14039] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 02/25/2014] [Accepted: 03/02/2014] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Cancer is a worldwide problem as it will affect one in three men and one in four women during their lifetime. Colorectal cancer (CRC) is the third most frequent cancer in men, after lung and prostate cancer, and is the second most frequent cancer in women after breast cancer. It is also the third cause of death in men and women separately, and is the second most frequent cause of death by cancer if both genders are considered together. CRC represents approximately 10% of deaths by cancer. Modifiable risk factors of CRC include smoking, physical inactivity, being overweight and obesity, eating processed meat, and drinking alcohol excessively. CRC screening programs are possible only in economically developed countries. However, attention should be paid in the future to geographical areas with ageing populations and a western lifestyle.19,20 Sigmoidoscopy screening done with people aged 55–64 years has been demonstrated to reduce the incidence of CRC by 33% and mortality by CRC by 43%. OBJECTIVE To assess the effect on the incidence and mortality of CRC diet and lifestyle and to determine the effect of secondary prevention through early diagnosis of CRC. METHODOLOGY: A comprehensive search of Medline and Pubmed articles related to primary and secondary prevention of CRC and subsequently, a meta-analysis of the same blocks are performed. RESULTS 225 articles related to primary or secondary prevention of CRC were retrieved. Of these 145 were considered valid on meta-analysis: 12 on epidemiology, 56 on diet and lifestyle, and over 77 different screenings for early detection of CRC. Cancer is a worldwide problem as it will affect one in three men and one in four women during their lifetime. There is no doubt whatsoever which environmental factors, probably diet, may account for these cancer rates. Excessive alcohol consumption and cholesterol-rich diet are associated with a high risk of colon cancer. A diet poor in folic acid and vitamin B6 is also associated with a higher risk of developing colon cancer with an overexpression of p53. Eating pulses at least three times a week lowers the risk of developing colon cancer by 33%, after eating less meat, while eating brown rice at least once a week cuts the risk of CRC by 40%. These associations suggest a dose–response effect. Frequently eating cooked green vegetables, nuts, dried fruit, pulses, and brown rice has been associated with a lower risk of colorectal polyps. High calcium intake offers a protector effect against distal colon and rectal tumors as compared with the proximal colon. Higher intake of dairy products and calcium reduces the risk of colon cancer. Taking an aspirin (ASA) regularly after being diagnosed with colon cancer is associated with less risk of dying from this cancer, especially among people who have tumors with COX-2 overexpression.16 Nonetheless, these data do not contradict the data obtained on a possible genetic predisposition, even in sporadic or non-hereditary CRC. CRC is susceptible to screening because it is a serious health problem given its high incidence and its associated high morbidity/mortality. CONCLUSIONS (1) Cancer is a worldwide problem. (2) A modification of diet and lifestyle could reduce morbidity and mortality. (3) Early detection through screening improves prognosis and reduces mortality.
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Affiliation(s)
- Pedro J Tárraga López
- Integrated Management, Hospital Universitario de Albacete, Albacete, Spain. ; University of Castille-La Mancha, Albacete, Spain
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Screening for Colorectal Cancer: When, how, and by Whom? CURRENT COLORECTAL CANCER REPORTS 2013. [DOI: 10.1007/s11888-012-0150-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Lee C, Koh SJ, Kim JW, Lee KL, Im JP, Kim SG, Kim JS, Jung HC, Kim BG. Incidental colonic 18F-fluorodeoxyglucose uptake: do we need colonoscopy for patients with focal uptake confined to the left-sided colon? Dig Dis Sci 2013; 58:229-35. [PMID: 22886593 DOI: 10.1007/s10620-012-2333-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 07/18/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND/AIMS Although access to [18F]2-fluoro-2-deoxyglucose (18F-FDG) positron emission tomography and computed axial tomography (PET/CT) for patients with malignancy has increased, little information is available on the suitability of PET/CT for diagnosis of advanced colonic neoplasms in oncology patients and on the clinical significance of incidental 18F-FDG focal uptake confined to the left-sided colon. METHODS Patients who underwent 18F-FDG PET/CT followed, within 90 days, by colonoscopy were identified. Case-control analysis was undertaken to determine whether focal 18F-FDG uptake confined to the left-sided colon was associated with advanced neoplasms in the right-sided colon. RESULTS One hundred ninety-five patients with colonic 18F-FDG uptake and 561 without colonic (18)F-FDG uptake were identified. Of the 195 patients with focal colonic 18F-FDG activity, 103 patients (52.8%) had 145 advanced colonic neoplasms, including 58 colon cancers and 11 metastatic cancers. In the detection of advanced colonic neoplasms, the sensitivity, specificity, positive predictive value, and negative predictive value of PET/CT were 54.4, 82.4, 46.9, and 86.3%, respectively. Overall accuracy was 76.2%. Ten (8.0%) of the 125 patients with focal 18F-FDG uptake confined to the left-sided colon had three colon cancers and seven advanced adenomas in the right-sided colon. Case-control analysis revealed that focal 18F-FDG uptake confined to the left-sided colon was associated with an advanced neoplasms in the right-sided colon (OR, 3.02; 95% CI, 1.12-8.13; P = 0.023). CONCLUSIONS Colonic focal (18)F-FDG uptake by oncology patients warrants endoscopic verification. Complete colon evaluation by colonoscopy is required, even for patients with focal 18F-FDG uptake confined to the left-sided colon.
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Affiliation(s)
- Changhyun Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea.
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van Dam L, Kuipers EJ, Steyerberg EW, van Leerdam ME, de Beaufort ID. The price of autonomy: should we offer individuals a choice of colorectal cancer screening strategies? Lancet Oncol 2013; 14:e38-46. [DOI: 10.1016/s1470-2045(12)70455-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Abstract
OBJECTIVES The development of a structured virtual reality (VR) training curriculum for colonoscopy using high-fidelity simulation. BACKGROUND Colonoscopy requires detailed knowledge and technical skill. Changes to working practices in recent times have reduced the availability of traditional training opportunities. Much might, therefore, be achieved by applying novel technologies such as VR simulation to colonoscopy. Scientifically developed device-specific curricula aim to maximize the yield of laboratory-based training by focusing on validated modules and linking progression to the attainment of benchmarked proficiency criteria. METHODS Fifty participants comprised of 30 novices (<10 colonoscopies), 10 intermediates (100 to 500 colonoscopies), and 10 experienced (>500 colonoscopies) colonoscopists were recruited to participate. Surrogates of proficiency, such as number of procedures undertaken, determined prospective allocation to 1 of 3 groups (novice, intermediate, and experienced). Construct validity and learning value (comparison between groups and within groups respectively) for each task and metric on the chosen simulator model determined suitability for inclusion in the curriculum. RESULTS Eight tasks in possession of construct validity and significant learning curves were included in the curriculum: 3 abstract tasks, 4 part-procedural tasks, and 1 procedural task. The whole-procedure task was valid for 11 metrics including the following: "time taken to complete the task" (1238, 343, and 293 s; P < 0.001) and "insertion length with embedded tip" (23.8, 3.6, and 4.9 cm; P = 0.005). Learning curves consistently plateaued at or beyond the ninth attempt. Valid metrics were used to define benchmarks, derived from the performance of the experienced cohort, for each included task. CONCLUSIONS A comprehensive, stratified, benchmarked, whole-procedure curriculum has been developed for a modern high-fidelity VR colonoscopy simulator.
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Lee BI, Hong SP, Kim SE, Kim SH, Kim HS, Hong SN, Yang DH, Shin SJ, Lee SH, Kim YH, Park DI, Kim HJ, Yang SK, Kim HJ, Jeon HJ. [Korean guidelines for colorectal cancer screening and polyp detection]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2012; 59:65-84. [PMID: 22387833 DOI: 10.4166/kjg.2012.59.2.65] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Colorectal cancer is the second most common cancer in males and the fourth most common in females in Korea. Since the most of colorectal cancer occur through the prolonged transformation of adenomas into carcinomas, early detection and removal of colorectal adenomas are one of the most effective methods to prevent colorectal cancer. Considering the increasing incidence of colorectal cancer and polyps in Korea, it is very important to establish Korean guideline for colorectal cancer screening and polyp detection. Korean Multi-Society Take Force developed the guidelines with evidence-based methods. Parts of the statements drawn by systematic reviews and meta-analyses. Herein we discussed the epidemiology of colorectal cancers and adenomas in Korea, optimal screening methods for colorectal cancer, and detection for adenomas including fecal occult blood tests, radiologic tests, and endoscopic examinations.
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Affiliation(s)
- Bo In Lee
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
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Lee BI, Hong SP, Kim SE, Kim SH, Kim HS, Hong SN, Yang DH, Shin SJ, Lee SH, Park DI, Kim YH, Kim HJ, Yang SK, Kim HJ, Jeon HJ. Korean guidelines for colorectal cancer screening and polyp detection. Clin Endosc 2012; 45:25-43. [PMID: 22741131 PMCID: PMC3363119 DOI: 10.5946/ce.2012.45.1.25] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2011] [Revised: 01/17/2012] [Accepted: 01/17/2012] [Indexed: 12/15/2022] Open
Abstract
Now colorectal cancer is the second most common cancer in males and the fourth most common cancer in females in Korea. Since most of colorectal cancers occur after the prolonged transformation of adenomas into carcinomas, early detection and removal of colorectal adenomas are one of the most effective methods to prevent colorectal cancer. Considering the increasing incidence of colorectal cancer and polyps in Korea, it is very important to establish Korean guideline for colorectal cancer screening and polyp detection. The guideline was developed by the Korean Multi-Society Take Force and we tried to establish the guideline by evidence-based methods. Parts of the statements were draw by systematic reviews and meta-analyses. Herein we discussed epidemiology of colorectal cancers and adenomas in Korea and optimal methods for screening of colorectal cancer and detection of adenomas including fecal occult blood tests, radiologic tests, and endoscopic examinations.
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Affiliation(s)
- Bo-In Lee
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
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Lee BI, Hong SP, Kim SE, Kim SH, Kim HS, Hong SN, Yang DH, Shin SJ, Lee SH, Kim YH, Park DI, Kim HJ, Yang SK, Kim HJ, Jeon HJ. Korean Guidelines for Colorectal Cancer Screening and Polyp Detection. Intest Res 2012. [DOI: 10.5217/ir.2012.10.1.67] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
Affiliation(s)
- Bo In Lee
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Sung Pil Hong
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seong-Eun Kim
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Se Hyung Kim
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Soo Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Noh Hong
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Dong-Hoon Yang
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Jae Shin
- Department of Internal Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Suck-Ho Lee
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Young-Ho Kim
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Il Park
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Jung Kim
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea
| | - Suk-Kyun Yang
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyo Jong Kim
- Department of Internal Medicine, Kyunghee University College of Medicine, Seoul, Korea
| | - Hae Jeong Jeon
- Department of Radiology, Konkuk University School of Medicine, Seoul, Korea
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Abstract
Colorectal cancer (CRC) is the third most common cause of cancer death worldwide and a major health problem. In this review, the different approaches for CRC screening will be outlined with emphasis on evidence-based medicine. Evidence from randomized trials on the effectiveness of CRC screening is summarized. Several screening tools for CRC are available. They can be categorized according to their mode of action: early detection tools such as the faecal occult blood test (FOBT) and cancer prevention tools such as flexible sigmoidoscopy and colonoscopy. Meta-analyses of randomized trials show that FOBT screening reduces CRC mortality by 16% (risk ratio 0.84; 95% confidence interval (CI) 0.78-0.9) compared with 30% (risk ratio 0.7; 95% CI 0.6-0.81) for flexible sigmoidoscopy screening. FOBT screening is cheap and noninvasive, but results in large numbers of false-positive tests and needs to be repeated frequently. Flexible sigmoidoscopy is more invasive, but is effective for once-only screening. Although colonoscopy screening is used in some countries, no randomized trials have been conducted to estimate its benefit, and therefore, it should not be recommended at the present time. Faecal occult blood test and flexible sigmoidoscopy are the two CRC screening tools that can be recommended as they have been proven to reduce CRC mortality. Colonoscopy has the potential to be superior to FOBT and flexible sigmoidoscopy, but needs to be evaluated in randomized trials before any recommendation can be provided.
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Affiliation(s)
- M Bretthauer
- Centre for Colorectal Cancer Screening, The Cancer Registry of Norway, Oslo University Hospital, Oslo, Norway.
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Pickhardt PJ, Durick NA, Pooler BD, Hassan C. Left-sided polyps detected at screening CT colonography: do we need complete optical colonoscopy for further evaluation? Radiology 2011; 259:429-34. [PMID: 21357518 DOI: 10.1148/radiol.11101702] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE To estimate the relative yield of therapeutic flexible sigmoidoscopy compared with complete optical colonoscopy for isolated left-sided polyps (≥6 mm in diameter) identified at screening computed tomographic (CT) colonography. MATERIALS AND METHODS This retrospective institutional review board-approved and HIPAA-compliant study included a review of CT colonographic screening results in 6570 consecutive asymptomatic adults (3551 women, 3019 men; mean age, 56.8 years ± 7.3 [standard deviation]). Of 887 (13.5%) patients with cases positive for nondiminutive polyps (≥6 mm), a subset of 171 patients met the inclusion criteria (a) of having left-sided-only lesions of 6 mm or larger identified at CT colonography (rectum-to-splenic flexure) and (b) of undergoing subsequent evaluation with complete optical colonoscopy. CT colonography-optical colonoscopy concordance and proximal-versus-distal diagnostic yield at optical colonoscopy were assessed. The 95% confidence intervals (CIs) were calculated for relevant results. RESULTS From the study group of 171 patients, a total of 234 left-sided lesions of 6 mm or larger were prospectively reported at CT colonography, of which 222 (94.9%; 95% CI: 91.3%, 97.0%) were confirmed as true-positive findings at optical colonoscopy. With optical colonoscopy, an additional 17 benign left-sided polyps of 6 mm or larger (13 small, four large) were found in 11 patients, resulting in a total left-sided yield of 239 nondiminutive lesions, including 137 small polyps (6-9 mm) and 102 large lesions (≥10 mm), 160 neoplasms, 82 advanced adenomas, and seven cancers. Evaluation of the colon proximal to the splenic flexure in this cohort yielded eight small and two large benign polyps in nine patients but no proximal cancers or histologically advanced lesions. CONCLUSION For patients with left-sided-only polyps detected at CT colonography, the additional yield of complete optical colonoscopy beyond the expected reach of flexible sigmoidoscopy is very low and may not justify the added costs, potential risks, and procedural time.
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Affiliation(s)
- Perry J Pickhardt
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252, USA.
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Consensus en endoscopie digestive: préparation colique pour la coloscopie totale chez l’adulte. ACTA ACUST UNITED AC 2010. [DOI: 10.1007/s10190-010-0136-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Bretthauer M. Evidence for colorectal cancer screening. Best Pract Res Clin Gastroenterol 2010; 24:417-25. [PMID: 20833346 DOI: 10.1016/j.bpg.2010.06.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2010] [Revised: 06/21/2010] [Accepted: 06/23/2010] [Indexed: 01/31/2023]
Abstract
The incidence of colorectal cancer (CRC) has been increasing during the past decades, and the lifetime risk for CRC in industrialised countries is about 5%. CRC is a good candidate for screening, because it is a disease with high prevalence, has recognised precursors, and early treatment is beneficial. This paper outlines the evidence for efficacy from randomised trials for the most commonly used CRC screening tests to reduce CRC incidence and mortality in the average-risk population. Four randomised trials have investigated the effect of guaiac-based fecal occult blood screening on CRC mortality, with a combined CRC mortality risk reduction of 15-17% in an intention-to-screen analysis, and 25% for those people who attended screening. Flexible sigmoidoscopy screening has been evaluated in three randomised trials. The observed reduction in CRC incidence varied between 23 and 80%, and between 27 and 67% for CRC mortality, respectively (intention-to-screen analyses) in the trials with long follow-up time. No randomised trials exist in other CRC screening tools, included colonoscopy screening. FOBT and flexible sigmoidoscopy are the two CRC screening methods which have been tested in randomised trials and shown to reduce CRC mortality. These tests can be recommended for CRC screening.
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Affiliation(s)
- Michael Bretthauer
- Centre for Colorectal Cancer Screening, The Cancer Registry of Norway, Oslo University Hospital, PO Box 5313 Majorstuen, N-0304 Oslo, Norway.
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Quality assurance of endoscopy in colorectal cancer screening. Best Pract Res Clin Gastroenterol 2010; 24:451-64. [PMID: 20833349 DOI: 10.1016/j.bpg.2010.06.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Accepted: 06/23/2010] [Indexed: 01/31/2023]
Abstract
This chapter explores the concept of quality assurance of colorectal cancer screening. It argues that effective quality assurance is critical to ensure that the benefits of screening outweigh the harms. The three key steps of quality assurance, definition of standards, measurement of standards and enforcement of standards, are explained. Quality is viewed from the perspective of the patient and illustrated by following the path of patients accessing endoscopy within screening services. The chapter discusses the pros and cons of programmatic versus non-programmatic screening and argues that quality assurance of screening can and should benefit symptomatic services. Finally, the chapter emphasises the importance of a culture of excellence underpinned by continuous quality improvement and effective service leadership.
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Liang Z, Richards R. Virtual colonoscopy vs optical colonoscopy. EXPERT OPINION ON MEDICAL DIAGNOSTICS 2010; 4:159-169. [PMID: 20473367 PMCID: PMC2869208 DOI: 10.1517/17530051003658736] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
IMPORTANCE OF THE FIELD: The high prevalence of colon carcinoma combined with the low compliance of currently recommended screening guidelines explains the continued high mortality rate of colon cancer. Utilizing a strategy of virtual colonoscopy (VC) in asymptomatic patients over 50, with optical colonoscopy (OC) follow-up for removal of detected adenomatous polyps may result in lowering the colon cancer death rate. However, the screening potential of VC has not yet been widely recognized. Debates and doubts of its potential benefits have been frequently seen in the literature since VC was first reported in 1994. AREAS COVERED IN THIS REVIEW: This article reviews the currently available screening options and discuss their advantages and drawbacks. TAKE HOME MESSAGE: VC has many advantages over the existing screening options and its several drawbacks can be mitigated so that it would become a valuable screening modality. A strategy that utilizes VC for population-based screening over the age of 50 and OC for screening high-risk individuals and those with positive VC findings would result in a significantly reduced rate of colon cancer deaths.
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Affiliation(s)
- Zhengrong Liang
- IEEE Fellow, Professor of Radiology, Computer Science and Biomedical Engineering, School of Medicine, L4-120, Health Sciences Center, Stony Brook University, Stony Brook, NY 11794-8460, USA, (Tel): +1 631-444-7837, (Fax): +1 631-444-6450
| | - Robert Richards
- Associate Professor, Program Director - GI Fellowship, Department of Medicine/Gastroenterology, Health Science Center, Level 17, Room 060, Stony Brook University, Stony Brook, NY 11794-8173, USA, (Tel): +1 631-444-7623
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Maslekar S, Waudby P, Avery G, Monson JRT, Duthie GS. Quality assurance in flexible sigmoidoscopy: medical and nonmedical endoscopists. Surg Endosc 2009; 24:89-93. [PMID: 19688402 DOI: 10.1007/s00464-009-0553-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Revised: 04/18/2009] [Accepted: 04/28/2009] [Indexed: 01/13/2023]
Abstract
PURPOSE The clinical assessment of position in colon and hence completion during flexible sigmoidoscopy (FS) is believed to be inaccurate. The technique of applying endomucosal clips with follow-up X-ray has previously been used for establishing completion in colonoscopy. Furthermore, we have now trained non-healthcare professionals (non-medical endoscopists, NME) to perform FS, but there is no data on assessment of their performance of FS. We performed this study with the aims of determining accuracy of endoscopists' clinical impression regarding actual position of endoscope in colon during FS, comparing medical (ME) and NME in terms of clinical accuracy, and to determine role of endomucosal clips with follow-up X-rays in documenting completion and hence quality assurance. METHODS All patients undergoing elective FS, except those with surgical resection, were included, after ethics approval. During FS, endoscopist applied an endomucosal clip at most proximal bowel reached and endoscopists recorded their independent opinion about position of clip. Post procedure, all patients underwent an abdominal X-ray, reported by consultant radiologist, blinded to outcome of FS. X-ray results were compared with endoscopist findings. Complete FS was defined as one where descending colon was reached. RESULTS Fifty-one patients, with median age of 55 years, participated in study. The endoscopists were accurate in their assessment of position in colon in 38 patients (75%). The attending nurse was accurate in only 31% of cases. The crude and corrected completion rates were 73% and 84%, respectively. There was no correlation between length of endoscope and its position in colon. There were no differences between NME and ME in terms of clinical accuracy. CONCLUSION This study has shown that clinical impression of endoscopist during FS regarding position is not very accurate, implying need for regular quality assurance. The technique of applying endomucosal clips with follow-on abdominal X-ray is an excellent objective measure of quality assurance in FS. NME can perform FS with comparable completion rates and accuracy.
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Affiliation(s)
- Sushil Maslekar
- Academic Surgical Unit, Castle Hill Hospital, University of Hull, East Yorkshire, UK.
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Mahon SM. Prevention and Screening of Gastrointestinal Cancers. Semin Oncol Nurs 2009; 25:15-31. [DOI: 10.1016/j.soncn.2008.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Alonso-Coello P, Marzo-Castillejo M, Mascort JJ, Hervás AJ, Viña LM, Ferrús JA, Ferrándiz J, López-Rivas L, Rigau D, Solà I, Bonfill X, Piqué JM. [Clinical practice guideline on the management of rectal bleeding (update 2007)]. GASTROENTEROLOGIA Y HEPATOLOGIA 2009; 31:652-67. [PMID: 19174083 DOI: 10.1016/s0210-5705(08)75814-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Pablo Alonso-Coello
- Centro Cochrane Iberoamericano, Servicio de Epidemiología Clínica y Salud Pública (Universidad Autónoma de Barcelona), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Dioguardi N, Grizzi F, Fiamengo B, Russo C. Metrically measuring liver biopsy: A chronic hepatitis B and C computer-aided morphologic description. World J Gastroenterol 2008; 14:7335-44. [PMID: 19109867 PMCID: PMC2778117 DOI: 10.3748/wjg.14.7335] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To describe a quantitative analysis method for liver biopsy sections with a machine that we have named “Dioguardi Histological Metriser” which automatically measures the residual hepatocyte mass (including hepatocytes vacuolization), inflammation, fibrosis and the loss of liver tissue tectonics.
METHODS: We analysed digitized images of liver biopsy sections taken from 398 patients. The analysis with Dioguardi Histological Metriser was validated by comparison with semi-quantitative scoring system.
RESULTS: The method provides: (1) the metrical extension in two-dimensions (the plane) of the residual hepatocellular set, including the area of vacuoles pertinent to abnormal lipid accumulation; (2) the geometric measure of the inflammation basin, which distinguishes intra-basin space and extra-basin dispersed parenchymal leukocytes; (3) the magnitude of collagen islets, (which were considered truncated fractals and classified into three degrees of magnitude); and (4) the tectonic index that quantifies alterations (disorders) in the organization of liver tissue. Dioguardi Histological Metriser machine allows to work at a speed of 0.1 mm2/s, scanning a whole section in 6-8 min.
CONCLUSION: The results are the first standardized metrical evaluation of the geometric properties of the parenchyma, inflammation, fibrosis, and alterations in liver tissue tectonics of the biopsy sections. The present study confirms that biopsies are still valuable, not only for diagnosing chronic hepatitis, but also for quantifying changes in the organization and order of liver tissue structure.
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Papamichael D, Audisio R, Horiot JC, Glimelius B, Sastre J, Mitry E, Van Cutsem E, Gosney M, Köhne CH, Aapro M. Treatment of the elderly colorectal cancer patient: SIOG expert recommendations. Ann Oncol 2008; 20:5-16. [PMID: 18922882 DOI: 10.1093/annonc/mdn532] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Colorectal cancer (CRC) is one of the commonest malignancies of Western countries, with approximately half the incidence occurring in patients >70 years of age. Elderly CRC patients, however, are understaged, undertreated and underrepresented in clinical trials. The International Society of Geriatric Oncology created a task force with a view to assessing the potential for developing guidelines for the treatment of elderly (geriatric) CRC patients. A review of the evidence presented by the task force members confirmed the paucity of clinical trial data in elderly people and the lack of evidence-based guidelines. However, recommendations have been proposed on the basis of the available data and on the emerging evidence that treatment outcomes for fit, elderly CRC patients can be similar to those of younger patients. It is hoped that these will pave the way for formal treatment guidelines based upon solid scientific evidence in the future.
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Affiliation(s)
- D Papamichael
- Department of Medical Oncology, B.O. C. Oncology Centre, Nicosia, Cyprus.
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Canadian credentialing guidelines for flexible sigmoidoscopy. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2008; 22:115-9. [PMID: 18299727 DOI: 10.1155/2008/874796] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Levin B, Lieberman DA, McFarland B, Andrews KS, Brooks D, Bond J, Dash C, Giardiello FM, Glick S, Johnson D, Johnson CD, Levin TR, Pickhardt PJ, Rex DK, Smith RA, Thorson A, Winawer SJ. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology 2008; 134:1570-95. [PMID: 18384785 DOI: 10.1053/j.gastro.2008.02.002] [Citation(s) in RCA: 1419] [Impact Index Per Article: 88.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In the United States, colorectal cancer (CRC) is the third most common cancer diagnosed among men and women and the second leading cause of death from cancer. CRC largely can be prevented by the detection and removal of adenomatous polyps, and survival is significantly better when CRC is diagnosed while still localized. In 2006 to 2007, the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology came together to develop consensus guidelines for the detection of adenomatous polyps and CRC in asymptomatic average-risk adults. In this update of each organization's guidelines, screening tests are grouped into those that primarily detect cancer early and those that can detect cancer early and also can detect adenomatous polyps, thus providing a greater potential for prevention through polypectomy. When possible, clinicians should make patients aware of the full range of screening options, but at a minimum they should be prepared to offer patients a choice between a screening test that primarily is effective at early cancer detection and a screening test that is effective at both early cancer detection and cancer prevention through the detection and removal of polyps. It is the strong opinion of these 3 organizations that colon cancer prevention should be the primary goal of screening.
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Affiliation(s)
- Bernard Levin
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Gorin SS, Ashford AR, Lantigua R, Hajiani F, Franco R, Heck JE, Gemson D. Intraurban influences on physician colorectal cancer screening practices. J Natl Med Assoc 2007; 99:1371-1380. [PMID: 18229773 PMCID: PMC2575938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND Community social and economic resources influence colorectal (CRC) screening decisions by physicians and patients. The aim of this study is to systematically assess the differences in screening recommendations of primary care physicians within two urban communities that are distinct in socioeconomic characteristics. METHODS Two-hundred-sixty-four primary care community (i.e., not hospital-based) physicians were stratified by community. Using self-report questionnaires, we examined primary care physicians' CRC screening practices, knowledge of risk factors and perceived physician and patient barriers to screening, Physicians practicing in upper-socioeconomic status (SES) communities were compared with those of participants practicing in lower SES communities. RESULTS Physicians practicing in low-SES urban communities were significantly more likely to screen with fecal occult blood test than were physicians in upper-SES areas. Alternatively, upper-SES physicians were significantly more likely to recommend screening colonoscopy than were lower-SES physicians. The number of physicians (N=11) who screened for CRC using the double-contrast barium enema were few. CONCLUSIONS Community-level SES influences physician cancer screening practices. Further understanding of these relationships may guide the development of interventions targeted to specific neighborhoods within urban areas.
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Carl I, Mitchell M. Symptomatic hyperphosphataemia following phosphate enema in a healthy adult. THE ULSTER MEDICAL JOURNAL 2007; 76:172-3. [PMID: 17853649 PMCID: PMC2075585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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