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Thiruvengadam NR, Solaimani P, Shrestha M, Buller S, Carson R, Reyes-Garcia B, Gnass RD, Wang B, Albasha N, Leonor P, Saumoy M, Coimbra R, Tabuenca A, Srikureja W, Serrao S. The Efficacy of Real-time Computer-aided Detection of Colonic Neoplasia in Community Practice: A Pragmatic Randomized Controlled Trial. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00225-8. [PMID: 38437999 DOI: 10.1016/j.cgh.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 02/12/2024] [Accepted: 02/13/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND & AIMS The use of computer-aided detection (CADe) has increased the adenoma detection rates (ADRs) during colorectal cancer (CRC) screening/surveillance in randomized controlled trials (RCTs) but has not shown benefit in real-world implementation studies. We performed a single-center pragmatic RCT to evaluate the impact of real-time CADe on ADRs in colonoscopy performed by community gastroenterologists. METHODS We enrolled 1100 patients undergoing colonoscopy for CRC screening, surveillance, positive fecal-immunohistochemical tests, and diagnostic indications at one community-based center from September 2022 to March 2023. Patients were randomly assigned (1:1) to traditional colonoscopy or real-time CADe. Blinded pathologists analyzed histopathologic findings. The primary outcome was ADR (the percentage of patients with at least 1 histologically proven adenoma or carcinoma). Secondary outcomes were adenomas detected per colonoscopy (APC), sessile-serrated lesion detection rate, and non-neoplastic resection rate. RESULTS The median age was 55.5 years (interquartile range, 50-62 years), 61% were female, 72.7% were of Hispanic ethnicity, and 9.1% had inadequate bowel preparation. The ADR for the CADe group was significantly higher than the traditional colonoscopy group (42.5% vs 34.4%; P = .005). The mean APC was significantly higher in the CADe group compared with the traditional colonoscopy group (0.89 ± 1.46 vs 0.60 ± 1.12; P < .001). The improvement in adenoma detection was driven by increased detection of <5 mm adenomas. CADe had a higher sessile-serrated lesion detection rate than traditional colonoscopy (4.7% vs 2.0%; P = .01). The improvement in ADR with CADe was significantly higher in the first half of the study (47.2% vs 33.7%; P = .002) compared with the second half (38.7% vs 34.9%; P = .33). CONCLUSIONS In a single-center pragmatic RCT, real-time CADe modestly improved ADR and APC in average-detector community endoscopists. (ClinicalTrials.gov number, NCT05963724).
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Affiliation(s)
- Nikhil R Thiruvengadam
- Division of Gastroenterology and Hepatology, Riverside University Health System, Moreno Valley, California; Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California.
| | - Pejman Solaimani
- Division of Gastroenterology and Hepatology, Riverside University Health System, Moreno Valley, California; Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California
| | - Manish Shrestha
- Division of Gastroenterology and Hepatology, Riverside University Health System, Moreno Valley, California; Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California
| | - Seth Buller
- Loma Linda University School of Medicine, Loma Linda, California
| | - Rachel Carson
- Division of Gastroenterology and Hepatology, Riverside University Health System, Moreno Valley, California; Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California
| | - Breanna Reyes-Garcia
- Division of Gastroenterology and Hepatology, Riverside University Health System, Moreno Valley, California; Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California
| | - Ronaldo D Gnass
- Department of Pathology, Riverside University Health System, Moreno Valley, California
| | - Bing Wang
- Department of Pathology, Loma Linda University School of Medicine, Loma Linda, California
| | - Natalie Albasha
- University of California Riverside School of Medicine, Riverside, California; Department of Medicine, Scripps Green Hospital, La Jolla, California
| | - Paul Leonor
- Division of Gastroenterology and Hepatology, Riverside University Health System, Moreno Valley, California; Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California
| | - Monica Saumoy
- Center for Digestive Health, Penn Medicine Princeton Medical Center, Plainsboro, New Jersey
| | - Raul Coimbra
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System, Moreno Valley, California; Department of Surgery, Riverside University Health System, Moreno Valley, California
| | - Arnold Tabuenca
- Department of Surgery, Riverside University Health System, Moreno Valley, California; Department of Surgery, University of California Riverside School of Medicine, Riverside, California
| | - Wichit Srikureja
- Division of Gastroenterology and Hepatology, Riverside University Health System, Moreno Valley, California; Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California
| | - Steve Serrao
- Division of Gastroenterology and Hepatology, Riverside University Health System, Moreno Valley, California; Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California
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Wang S, Yang Z, Sha F, Qi X, He Z, Szeto CH, Yang Z, Tang J. Prevalence of incidental colorectal cancer and polyps in autopsies of different populations: a systematic review with meta-regression analysis. Eur J Epidemiol 2023; 38:939-955. [PMID: 37634229 DOI: 10.1007/s10654-023-01041-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/11/2023] [Indexed: 08/29/2023]
Abstract
The colorectal cancer (CRC) and polyps incidentally found in autopsies represent the lesions that have not actually caused problems throughout the lifetime and thus may not need to be removed during screening. This study aimed to investigate the prevalence of incidental CRC (iCRC) and polyps in autopsies of different populations. A systematic search was performed on 19 August 2022 to identify autopsy studies that provided data on prevalence of iCRC, adenomatous polyps, hyperplastic polyps, and/or all polyps combined. The prevalence was pooled with the random-effects model. Subgroup and multivariable meta-regression analyses were conducted to investigate the heterogeneity. Forty-three eligible studies including 59,656 autopsies were identified, with 94% conducted before 1990 when CRC screening was uncommon or not available. The pooled prevalence was 0.7% (95% confidence interval [CI], 0.3-1.2%) for iCRC, 18.4% (95% CI, 13.3-24.1%) for adenomatous polyps, 16.4% (95% CI, 8.7-25.9%) for hyperplastic polyps, 26.3% (95% CI, 15.4-38.8%) for all polyps combined, and 29.9% (95% CI, 14.8-47.6%) for iCRC plus polyps. The prevalence of iCRC was higher (1.2%) in white-predominant populations but lower (0.4%) after excluding low-quality studies. Multivariable analyses showed that the prevalence of polyps was higher in white-predominant populations and higher-quality studies, increased with age, and showed a downward trend from "before 1975" through "after 1985". In conclusion, the prevalence of iCRC in autopsies was not low, considering the average lifetime risk of CRC, while incidental polyps were common. Both varied greatly in different populations. These findings may have implications when weighing the benefits and harms of screening.
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Affiliation(s)
- Shuting Wang
- JC School of Public Health and Primary Care, Faculty of Medicine, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Zhirong Yang
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
- Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Feng Sha
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| | - Zhonghu He
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Laboratory of Genetics, Peking University Cancer Hospital & Institute, Beijing, China
| | - Chun-Ho Szeto
- JC School of Public Health and Primary Care, Faculty of Medicine, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Zuyao Yang
- JC School of Public Health and Primary Care, Faculty of Medicine, the Chinese University of Hong Kong, Hong Kong SAR, China.
| | - Jinling Tang
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
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Bateman AC, Booth AL, Gonzalez RS, Shepherd NA. Microvesicular hyperplastic polyp and sessile serrated lesion of the large intestine: a biological continuum or separate entities? J Clin Pathol 2023:jcp-2023-208783. [PMID: 36927607 DOI: 10.1136/jcp-2023-208783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 03/07/2023] [Indexed: 03/18/2023]
Abstract
The range of lesions with a serrated appearance within the large intestine has expanded and become more complex over the last 30 years. The majority of these were previously known as metaplastic polyps but are today called hyperplastic polyps (HPs). HPs show two main growth patterns: microvesicular and goblet cell-rich. The former type shows morphological and molecular similarities (eg, BRAF mutations) to the more recently described sessile serrated lesion (SSL). In this review, we debate whether these lesions represent a biological spectrum or separate entities. Whichever view is held, microvesicular HPs and SSLs are distinct from the goblet cell-rich HP and the traditional serrated adenoma (TSA), which may themselves share molecular changes (eg, KRAS mutations), with the goblet cell-rich HP representing a precursor to the TSA. Both SSLs and the goblet cell-rich HP-TSA pathway are routes to colorectal cancer within the serrated pathway and overlaps between them can occur, for example, a (BRAF-mutated) TSA may arise from an SSL.
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Affiliation(s)
- Adrian C Bateman
- Department of Cellular Pathology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Adam L Booth
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Raul S Gonzalez
- Department of Pathology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Neil A Shepherd
- Gloucestershire Cellular Pathology Laboratory, Cheltenham, UK
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Thiruvengadam NR, Cote G, Gupta S, Rodrigues M, Schneider Y, Arain MA, Solaimani P, Serrao S, Kochman ML, Saumoy M. An Evaluation of Critical Factors for the Cost-Effectiveness of Real-Time Computer-Aided Detection: Sensitivity and Threshold Analyses Using a Microsimulation Model. Gastroenterology 2023; 164:906-920. [PMID: 36736437 DOI: 10.1053/j.gastro.2023.01.027] [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: 09/07/2022] [Revised: 01/19/2023] [Accepted: 01/22/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND The use of computer-aided detection (CAD) increases the adenoma detection rates (ADRs) during colorectal cancer (CRC) screening/surveillance. This study aimed to evaluate the requirements for CAD to be cost-effective and the impact of CAD on adenoma detection by endoscopists with different ADRs. METHODS We developed a semi-Markov microsimulation model to compare the effectiveness of traditional colonoscopy (mean ADR, 26%) to colonoscopy with CAD (mean ADR, 37%). CAD was modeled as having a $75 per-procedure cost. Extensive 1-way sensitivity and threshold analysis were performed to vary cost and ADR of CAD. Multiple scenarios evaluated the potential effect of CAD on endoscopists' ADRs. Outcome measures were reported in incremental cost-effectiveness ratios, with a willingness-to-pay threshold of $100,000/quality-adjusted life year. RESULTS When modeling CAD improved ADR for all endoscopists, the CAD cohort had 79 and 34 fewer lifetime CRC cases and deaths, respectively, per 10,000 persons. This scenario was dominant with a cost savings of $143 and incremental effectiveness of 0.01 quality-adjusted life years. Threshold analysis demonstrated that CAD would be cost-effective up to an additional cost of $579 per colonoscopy, or if it increases ADR from 26% to at least 30%. CAD reduced CRC incidence and mortality when limited to improving ADRs for low-ADR endoscopists (ADR <25%), with 67 fewer CRC cases and 28 CRC deaths per 10,000 persons compared with traditional colonoscopy. CONCLUSIONS As CAD is implemented clinically, it needs to improve mean ADR from 26% to at least 30% or cost less than $579 per colonoscopy to be cost-effective when compared with traditional colonoscopy. Further studies are needed to understand the impact of CAD on community practice.
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Affiliation(s)
- Nikhil R Thiruvengadam
- Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California.
| | - Gregory Cote
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon
| | - Shashank Gupta
- Department of Medicine, Loma Linda University Health, Loma Linda, California
| | - Medora Rodrigues
- Department of Medicine, Loma Linda University Health, Loma Linda, California
| | | | - Mustafa A Arain
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida
| | - Pejman Solaimani
- Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California
| | - Steve Serrao
- Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California
| | - Michael L Kochman
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Endoscopic Innovation, Research and Training, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Monica Saumoy
- Center for Digestive Health, Penn Medicine Princeton Medical Center, Plainsboro, New Jersey
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Li J, Zhang D, Wei Y, Chen K, Wu R, Peng K, Hou X, Li L, Huang C, Wang Y, Xun L, Xu H, Wang J, Chen Z, Shen M, Liu F. Colorectal Sessile Serrated Lesion Detection Using Linked Color Imaging: A Multicenter, Parallel Randomized Controlled Trial. Clin Gastroenterol Hepatol 2023; 21:328-336.e2. [PMID: 35390509 DOI: 10.1016/j.cgh.2022.03.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/10/2022] [Accepted: 03/17/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Linked color imaging (LCI) is a novel technology that improves the color differences between colorectal lesions and the surrounding mucosa. The present study aims to compare the detection of colorectal sessile serrated lesions (SSL) using LCI with white light imaging (WLI). METHOD A large-scale, multicenter, parallel prospective randomized controlled trial was conducted in 4 hospitals in China. The participants were randomly assigned to the LCI group and WLI group. The primary endpoint was the SSL detection rate (SDR). RESULTS A total of 884 patients were involved in the intention-to-treat analysis, with 441 patients in the LCI group and 443 patients in the WLI group. The total polyp detection rate, adenoma detection rate, and SDR were 51.8%, 35.7%, and 8.6%, respectively. The SDR was significantly higher in the LCI group than in the WLI group (11.3% vs 5.9%, P = .004). Furthermore, LCI significantly increased the number of polyps and adenomas detected per patient, when compared with WLI (P < .05). In addition, there was higher detection rate of diminutive and flat lesions in the LCI group (P < .05). Multivariate analysis revealed that LCI is an independent factor associated with SDR (hazard ratio, 1.990; 95% confidence interval, 1.203-3.293; P = .007), along with withdrawal time (hazard ratio, 1.157; 95% confidence interval, 1.060-1.263; P = .001) and operator experience (hazard ratio, 1.850; 95% confidence interval, 1.045-3.273; P = .035). CONCLUSIONS LCI is significantly superior to WLI for SSL detection, and may improve polyp and adenoma detection. LCI can be recommended as an appropriate method for routine inspection during colonoscopy (http://www.chictr.org.cn number, ChiCTR2000035705).
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Affiliation(s)
- Jun Li
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Di Zhang
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yunlei Wei
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Kan Chen
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ruijin Wu
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Kangsheng Peng
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaojia Hou
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lei Li
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Chao Huang
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yuxin Wang
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Linjuan Xun
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hongwei Xu
- Department of Gastroenterology, Kunshan Hospital of Traditional Chinese Medicine, Kunshan Affiliated Hospital of Yangzhou University, Kunshan, China
| | - Jianhua Wang
- Department of Gastroenterology, The First People's Hospital of Kunshan, Kunshan, China
| | - Zhirong Chen
- Department of Gastroenterology, Suzhou Municipal Hospital (Eastern), Suzhou Hospital Affiliated to Nanjing Medical University, Suzhou, China
| | - Ming Shen
- Department of Gastroenterology, Jiangyin Hospital of Traditional Chinese Medicine, Jiangyin Hospital Affiliated to Nanjing University of Chinese Medicine, Nanjing, China
| | - Feng Liu
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.
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Abstract
Colorectal cancer is the second leading cause of cancer-associated mortality, with a lifetime risk of approximately 4% to 5%. Colorectal cancer develops from the sequential acquisition of defined genetic mutations in the colonic epithelium. Tumorigenesis from normal tissue to cancer occurs largely through 3 pathways: the chromosomal instability pathway, the microsatellite instability pathway, and the sessile serrated pathway. Colorectal cancer incidence and mortality have decreased by approximately 35% since the beginning of screening programs in the 1990s, although other factors such as use of aspirin for coronary disease prevention and decreased smoking rates may also be important. In this review, we discuss the etiology, epidemiology, and histology of colorectal polyps and cancer.
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Bateman AC. The spectrum of serrated colorectal lesions-new entities and unanswered questions. Histopathology 2021; 78:780-790. [PMID: 33332664 DOI: 10.1111/his.14305] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Hyperplastic polyps (HPs) of the colon and rectum were historically thought not to be associated with an increased risk of development of colorectal cancer (CRC). The recognition of variants of serrated colorectal lesions that possessed relatively subtle but significant morphological differences from those of HPs and that could be associated with epithelial dysplasia and CRC led to the characterisation of sessile serrated lesions (SSLs) and traditional serrated adenomas (TSAs). These links were supported by the identification of genetic alterations that are commonly found in HPs, SSLs, TSAs, and CRC, e.g. BRAF and KRAS mutations. The 'serrated pathway' to CRC may progress faster than the traditional 'adenoma-carcinoma sequence', underlining the importance of identifying these lesions. The diagnostic histological criteria for SSLs have since been more clearly defined, in parallel with a drive to increase the recognition of these lesions at endoscopy. The existence of lesions showing overlapping morphological and molecular features with those of HPs, SSLs and TSAs has most recently been highlighted-including mucin-rich TSA, serrated tubulovillous adenoma, and those showing mixed histological features, e.g. comprising differing combinations of HP, SSL, and TSA. Morphological and molecular studies of this range of lesions are providing insights into the relationships of serrated colorectal lesions with each other and with CRC. This article provides an overview of the current understanding of serrated colorectal lesions, including a discussion of those with overlapping and mixed features.
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Affiliation(s)
- Adrian C Bateman
- Department of Cellular Pathology, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
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Meester RGS, van Herk MMAGC, Lansdorp-Vogelaar I, Ladabaum U. Prevalence and Clinical Features of Sessile Serrated Polyps: A Systematic Review. Gastroenterology 2020; 159:105-118.e25. [PMID: 32199884 PMCID: PMC8653879 DOI: 10.1053/j.gastro.2020.03.025] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 02/24/2020] [Accepted: 03/09/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Sessile serrated polyps (SSPs) could account for a substantial proportion of colorectal cancers. We aimed to increase clarity on SSP prevalence and clinical features. METHODS We performed a systematic review of MEDLINE, Web of Science, Embase, and Cochrane databases for original studies published in English since 2000. We included studies of different populations (United States general or similar), interventions (colonoscopy, autopsy), comparisons (world regions, alternative polyp definitions, adenoma), outcomes (prevalence, clinical features), and study designs (cross-sectional). Random-effects regression was used for meta-analysis where possible. RESULTS We identified 74 relevant colonoscopy studies. SSP prevalence varied by world region, from 2.6% in Asia (95% confidence interval [CI], 0-5.9) to 10.5% in Australia (95% CI, 2.8-18.2). Prevalence values did not differ significantly between the United States and Europe (P = .51); the pooled prevalence was 4.6% (95% CI, 3.4-5.8), and SSPs accounted for 9.4% of polyps with malignant potential (95% CI, 6.6-12.3). The mean prevalence was higher when assessed through high-performance examinations (9.1%; 95% CI, 4.0-14.2; P = .04) and with an alternative definition of clinically relevant serrated polyps (12.3%; 95% CI, 9.3-15.4; P < .001). Increases in prevalence with age were not statistically significant, and prevalence did not differ significantly by sex. Compared with adenomas, a higher proportion of SSPs were solitary (69.0%; 95% CI, 45.9-92.1; P = .08), with diameters of 10 mm or more (19.3%; 95% CI, 12.4-26.2; P = .13) and were proximal (71.5%; 95% CI, 63.5-79.5; P = .008). The mean ages for detection of SSP without dysplasia, with any or low-grade dysplasia, and with high-grade dysplasia were 60.8 years, 65.6 years, and 70.2 years, respectively. The range for proportions of SSPs with dysplasia was 3.7%-42.9% across studies, possibly reflecting different study populations. CONCLUSIONS In a systematic review, we found that SSPs are relatively uncommon compared with adenoma. More research is needed on appropriate diagnostic criteria, variations in detection, and long-term risk.
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Affiliation(s)
- Reinier G S Meester
- Department of Medicine, Stanford University, Stanford, California; Department of Public Health, Erasmus Medical Center University Medical Center, Rotterdam, The Netherlands.
| | - Marinika M A G C van Herk
- Department of Public Health, Erasmus Medical Center University Medical Center, Rotterdam, The Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus Medical Center University Medical Center, Rotterdam, The Netherlands
| | - Uri Ladabaum
- Department of Medicine, Stanford University, Stanford, California
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Barré S, Leleu H, Vimont A, Kaufmanis A, Gendre I, Taleb S, De Bels F. [Estimated impact of the current colorectal screening program in France]. Rev Epidemiol Sante Publique 2020; 68:171-177. [PMID: 32417153 DOI: 10.1016/j.respe.2020.04.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 03/13/2020] [Accepted: 04/29/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Colorectal cancer is the third most common cancer and the second most deadly in France. A Cochrane meta-analysis has confirmed the benefits of colorectal cancer screening. A nationwide colorectal screening program was set up in France in 2009 for medium-risk, asymptomatic people aged 50 to 74 years. It has been based, since 2015, on the Fecal Immunochemical Test. The participation rate for 2016-2017 was 34%, which is lower than the European objectives. The objective of this study was to evaluate the impact of the program at the current participation rate and at rates of 45% and 65%. METHODS The epidemiological impact of the program was estimated from the results of an individual simulation model adapted from the Microsimulation Screening Analysis Colon model, calibrated and transposed to the French context. An initial analysis was conducted to estimate the individual impact of screening and a second for the entire eligible population, at various participation rates. RESULTS The test is associated with a lifetime reduction in the risk of colorectal cancer of 24% for men and 21% for women, and a reduction in the risk of death from colorectal cancer of 51% and 43% respectively. At the current level of participation, the program reduces incidence by 5% and mortality by 14% compared to no organized screening. The impact would be reduced by an additional 3% and 8% for participation rates of 45% and 65% respectively. Similarly, mortality would decrease by an additional 8% and 22%. CONCLUSION These results confirm that in a population at medium risk for colorectal cancer, the organised programme is an effective strategy for reducing its incidence. They also confirm that the achievement of European objectives remains a key issue for improving the effectiveness of organized screening. An evolution of immunological test delivery modalities could help to achieve these participation objectives.
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Affiliation(s)
- S Barré
- Institut national du cancer, Boulogne-Billancourt, France
| | - H Leleu
- Public Health Expertise, Paris, France
| | - A Vimont
- Public Health Expertise, Paris, France
| | - A Kaufmanis
- Centre de coordination des dépistages des cancers - région Île-de-France, Paris, France
| | - I Gendre
- Centre de coordination des dépistages des cancers - région Grand-Est, Vandœuvre-lès-Nancy, France
| | - S Taleb
- Institut national du cancer, Boulogne-Billancourt, France.
| | - F De Bels
- Institut national du cancer, Boulogne-Billancourt, France
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Rex DK, Sullivan AW, Perkins AJ, Vemulapalli KC. Colorectal polyp prevalence and aspirational detection targets determined using high definition colonoscopy and a high level detector in 2017. Dig Liver Dis 2020; 52:72-78. [PMID: 31543411 DOI: 10.1016/j.dld.2019.08.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/23/2019] [Accepted: 08/14/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Colorectal adenoma prevalence can be determined by autopsy studies, or imaging studies such as colonoscopy. We describe the prevalence of colorectal adenomas determined by a single high detecting colonoscopist using high definition colonoscopes. METHODS We conducted a cross-sectional study of consecutive patients aged ≥18 years undergoing colonoscopy with a high level detector for the indications of screening, surveillance, and diagnostic reasons from December 29, 2016 to January 12, 2018. RESULTS During the study period, 1172 eligible patients underwent colonoscopy. Women comprised 55% (n = 646) and the majority (89%, n = 1038) were aged ≥50 years (mean age, 62.1 years). In persons aged ≥50 years undergoing screening, the prevalence of ≥1 conventional adenoma was 48.5% and ≥1 sessile serrated polyp was 15.3%. Diminutive polyps (1-5 mm in size) comprised three-quarters of all resected polyps (2236/2986). Among 246 patients (21%), 1050 hyperplastic appearing polyps were not resected from the recto-sigmoid. Adenoma prevalence was strongly associated with age and indication but serrated lesion prevalence was not. CONCLUSIONS The true prevalence of precancerous lesions in the colorectum determined by modern colonoscopy exceeds determination by autopsy studies. These data help define aspirational detection targets for colonoscopy. The economic burden associated with colonoscopic resection of tiny lesions is substantial.
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Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, United States.
| | - Andrew W Sullivan
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Anthony J Perkins
- Department of Biostatistics, Indiana University, Indianapolis, IN, United States
| | - Krishna C Vemulapalli
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, United States
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Meester RGS, Lansdorp-Vogelaar I, Winawer SJ, Zauber AG, Knudsen AB, Ladabaum U. High-Intensity Versus Low-Intensity Surveillance for Patients With Colorectal Adenomas: A Cost-Effectiveness Analysis. Ann Intern Med 2019; 171:612-622. [PMID: 31546257 PMCID: PMC8115352 DOI: 10.7326/m18-3633] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Surveillance of patients with colorectal adenomas has limited long-term evidence to support current practice. OBJECTIVE To compare the lifetime benefits and costs of high- versus low-intensity surveillance. DESIGN Microsimulation model. DATA SOURCES U.S. cancer registry, cost data, and published literature. TARGET POPULATION U.S. patients aged 50, 60, or 70 years with low-risk adenomas (LRAs) (1 to 2 small adenomas) or high-risk adenomas (HRAs) (3 to 10 small adenomas or ≥1 large adenoma) removed after screening with colonoscopy or fecal immunochemical testing (FIT). TIME HORIZON Lifetime. PERSPECTIVE Societal. INTERVENTION No further screening or surveillance, routine screening after 10 years, low-intensity surveillance (10 years after LRA removal and 5 years after HRA removal), and high-intensity surveillance (5 years after LRA removal and 3 years after HRA removal). OUTCOME MEASURES Colorectal cancer (CRC) incidence and incremental cost-effectiveness. RESULTS OF BASE-CASE ANALYSIS Without surveillance or screening, lifetime CRC incidence for patients aged 50 years was 10.9% after LRA removal and 17.2% after HRA removal at screening colonoscopy. Subsequent colonoscopic screening, low-intensity surveillance, or high-intensity surveillance decreased incidence by 39%, 46% to 48%, and 55% to 56%, respectively. Incidence of CRC and surveillance benefits were higher for adenomas detected at FIT screening and lower for older patients. High-intensity surveillance cost less than $30 000 per quality-adjusted life-year (QALY) gained compared with low-intensity surveillance. RESULTS OF SENSITIVITY ANALYSIS High-intensity surveillance cost less than $100 000 per QALY gained in most alternative scenarios for adenoma recurrence, CRC incidence, longevity, quality of life, screening ages, surveillance ages, test performance, disutilities, and cost. LIMITATION Few surveillance outcome data exist. CONCLUSION The model suggests that high-intensity surveillance as recommended in the United States provides modest but clinically relevant benefits over low-intensity surveillance at acceptable cost. PRIMARY FUNDING SOURCE National Cancer Institute.
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Affiliation(s)
- Reinier G S Meester
- Erasmus MC University Medical Center, Rotterdam, the Netherlands, and Stanford University, Stanford, California (R.G.M.)
| | | | - Sidney J Winawer
- Memorial Sloan Kettering Cancer Center, New York, New York (S.J.W., A.G.Z.)
| | - Ann G Zauber
- Memorial Sloan Kettering Cancer Center, New York, New York (S.J.W., A.G.Z.)
| | - Amy B Knudsen
- Massachusetts General Hospital, Boston, Massachusetts (A.B.K.)
| | - Uri Ladabaum
- Stanford University, Stanford, California (U.L.)
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12
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Buskermolen M, Cenin DR, Helsingen LM, Guyatt G, Vandvik PO, Haug U, Bretthauer M, Lansdorp-Vogelaar I. Colorectal cancer screening with faecal immunochemical testing, sigmoidoscopy or colonoscopy: a microsimulation modelling study. BMJ 2019; 367:l5383. [PMID: 31578177 PMCID: PMC6774435 DOI: 10.1136/bmj.l5383] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To estimate benefits and harms of different colorectal cancer screening strategies, stratified by (baseline) 15-year colorectal cancer risk. DESIGN Microsimulation modelling study using MIcrosimulation SCreening ANalysis-Colon (MISCAN-Colon). SETTING A parallel guideline committee (BMJ Rapid Recommendations) defined the time frame and screening interventions, including selection of outcome measures. POPULATION Norwegian men and women aged 50-79 years with varying 15-year colorectal cancer risk (1-7%). COMPARISONS Four screening strategies were compared with no screening: biennial or annual faecal immunochemical test (FIT) or single sigmoidoscopy or colonoscopy at 100% adherence. MAIN OUTCOME MEASURES Colorectal cancer mortality and incidence, burdens, and harms over 15 years of follow-up. The certainty of the evidence was assessed using the GRADE approach. RESULTS Over 15 years of follow-up, screening individuals aged 50-79 at 3% risk of colorectal cancer with annual FIT or single colonoscopy reduced colorectal cancer mortality by 6 per 1000 individuals. Single sigmoidoscopy and biennial FIT reduced it by 5 per 1000 individuals. Colonoscopy, sigmoidoscopy, and annual FIT reduced colorectal cancer incidence by 10, 8, and 4 per 1000 individuals, respectively. The estimated incidence reduction for biennial FIT was 1 per 1000 individuals. Serious harms were estimated to be between 3 per 1000 (biennial FIT) and 5 per 1000 individuals (colonoscopy); harms increased with older age. The absolute benefits of screening increased with increasing colorectal cancer risk, while harms were less affected by baseline risk. Results were sensitive to the setting defined by the guideline panel. Because of uncertainty associated with modelling assumptions, we applied a GRADE rating of low certainty evidence to all estimates. CONCLUSIONS Over a 15 year period, all screening strategies may reduce colorectal cancer mortality to a similar extent. Colonoscopy and sigmoidoscopy may also reduce colorectal cancer incidence, while FIT shows a smaller incidence reduction. Harms are rare and of similar magnitude for all screening strategies.
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Affiliation(s)
- Maaike Buskermolen
- Erasmus MC, University Medical Center Rotterdam, Department of Public Health, Rotterdam, the Netherlands
| | - Dayna R Cenin
- Erasmus MC, University Medical Center Rotterdam, Department of Public Health, Rotterdam, the Netherlands
- Centre for Health Services Research, School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Lise M Helsingen
- Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
- Clinical Effecitveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway
- Frontier Science Foundation, Boston, MA, USA
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, ON, Canada
| | - Per Olav Vandvik
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ulrike Haug
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
- Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany
| | - Michael Bretthauer
- Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
- Clinical Effecitveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway
- Frontier Science Foundation, Boston, MA, USA
| | - Iris Lansdorp-Vogelaar
- Erasmus MC, University Medical Center Rotterdam, Department of Public Health, Rotterdam, the Netherlands
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13
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Crockett SD, Nagtegaal ID. Terminology, Molecular Features, Epidemiology, and Management of Serrated Colorectal Neoplasia. Gastroenterology 2019; 157:949-966.e4. [PMID: 31323292 DOI: 10.1053/j.gastro.2019.06.041] [Citation(s) in RCA: 169] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 06/07/2019] [Accepted: 06/15/2019] [Indexed: 12/11/2022]
Abstract
In addition to the adenoma to carcinoma sequence, colorectal carcinogenesis can occur via the serrated pathway. Studies have focused on clarification of categories and molecular features of serrated polyps, as well as endoscopic detection and risk assessment. Guidelines from the World Health Organization propose assigning serrated polyps to categories of hyperplastic polyps, traditional serrated adenomas, and sessile serrated lesions (SSLs). Traditional serrated adenomas and SSLs are precursors to colorectal cancer. The serrated pathway is characterized by mutations in RAS and RAF, disruptions to the Wnt signaling pathway, and widespread methylation of CpG islands. Epidemiology studies of serrated polyps have been hampered by inconsistencies in terminology and reporting, but the prevalence of serrated class polyps is 20%-40% in average-risk individuals; most serrated polyps detected are hyperplastic. SSLs, the most common premalignant serrated subtype, and are found in up to 15% of average-risk patients by high-detecting endoscopists. Variations in rate of endoscopic detection of serrated polyps indicate the need for careful examination, with adequate bowel preparation and sufficient withdrawal times. Risk factors for SSLs include white race, family history of colorectal cancer, smoking, and alcohol intake. Patients with serrated polyps, particularly SSLs and traditional serrated adenomas, have an increased risk of synchronous and metachronous advanced neoplasia. Surveillance guidelines vary among countries, but SSLs and proximal hyperplastic polyps require special attention in assignment of surveillance interval-especially in light of concerns regarding incomplete detection and resection.
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Affiliation(s)
- Seth D Crockett
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Centre, Nijmegen, The Netherlands
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14
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Buskermolen M, Gini A, Naber SK, Toes-Zoutendijk E, de Koning HJ, Lansdorp-Vogelaar I. Modeling in Colorectal Cancer Screening: Assessing External and Predictive Validity of MISCAN-Colon Microsimulation Model Using NORCCAP Trial Results. Med Decis Making 2018; 38:917-929. [PMID: 30343626 DOI: 10.1177/0272989x18806497] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Microsimulation models are increasingly being used to inform colorectal cancer (CRC) screening recommendations. MISCAN-Colon is an example of such a model, used to inform the Dutch CRC screening program and US Preventive Services Task Force guidelines. Assessing the validity of these models is essential to provide transparency regarding their performance. In this study, we tested the external and predictive validity of MISCAN-Colon. METHODS We validated MISCAN-Colon using the Norwegian Colorectal Cancer Prevention (NORCCAP) trial, a randomized controlled trial that examined the effectiveness of once-only flexible sigmoidoscopy (FS) screening. We simulated the study population and design of the NORCCAP trial in MISCAN-Colon and compared 10- to 12-year model-predicted hazard ratios (HRs) for overall and distal CRC incidence and mortality to those observed. In addition, we compared the numbers of screen-detected neoplasia. Finally, we predicted the trial's future results to allow for the assessment of predictive validity. RESULTS MISCAN-Colon predicted an HR for overall CRC incidence (0.85), distal CRC incidence (0.82), overall CRC mortality (0.68), and distal CRC mortality (0.62). These were within the limits of the 95% confidence intervals of the NORCCAP trial results. Similar results were observed for the number of screen-detected cancers. The model significantly underestimated the number of screen-detected adenomas. Model-predicted HRs for CRC incidence and mortality up to 15- to 17-year follow-up were 0.84 and 0.72, respectively. CONCLUSION Although the underestimation of screen-detected adenomas requires further investigation, MISCAN-Colon is able to make a valid replication of the CRC incidence and mortality reduction of an FS screening trial, which suggests that it can be considered a useful tool to support decision making on CRC screening.
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Affiliation(s)
- Maaike Buskermolen
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands (MB, AG, AKN, ETZ, HJdK, ILV)
| | - Andrea Gini
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands (MB, AG, AKN, ETZ, HJdK, ILV)
| | - Steffie K Naber
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands (MB, AG, AKN, ETZ, HJdK, ILV)
| | - Esther Toes-Zoutendijk
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands (MB, AG, AKN, ETZ, HJdK, ILV)
| | - Harry J de Koning
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands (MB, AG, AKN, ETZ, HJdK, ILV)
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands (MB, AG, AKN, ETZ, HJdK, ILV)
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15
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Meester RGS, Peterse EFP, Knudsen AB, de Weerdt AC, Chen JC, Lietz AP, Dwyer A, Ahnen DJ, Siegel RL, Smith RA, Zauber AG, Lansdorp‐Vogelaar I. Optimizing colorectal cancer screening by race and sex: Microsimulation analysis II to inform the American Cancer Society colorectal cancer screening guideline. Cancer 2018; 124:2974-2985. [PMID: 29846942 PMCID: PMC6055229 DOI: 10.1002/cncr.31542] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 02/15/2018] [Accepted: 02/18/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Colorectal cancer (CRC) risk varies by race and sex. This study, 1 of 2 microsimulation analyses to inform the 2018 American Cancer Society CRC screening guideline, explored the influence of race and sex on optimal CRC screening strategies. METHODS Two Cancer Intervention and Surveillance Modeling Network microsimulation models, informed by US incidence data, were used to evaluate a variety of screening methods, ages to start and stop, and intervals for 4 demographic subgroups (black and white males and females) under 2 scenarios for the projected lifetime CRC risk for 40-year-olds: 1) assuming that risk had remained stable since the early screening era and 2) assuming that risk had increased proportionally to observed incidence trends under the age of 40 years. Model-based screening recommendations were based on the predicted level of benefit (life-years gained) and burden (required number of colonoscopies), the incremental burden-to-benefit ratio, and the relative efficiency in comparison with strategies with similar burdens. RESULTS When lifetime CRC risk was assumed to be stable over time, the models differed in the recommended age to start screening for whites (45 vs 50 years) but consistently recommended screening from the age of 45 years for blacks. When CRC risk was assumed to be increased, the models recommended starting at the age of 45 years, regardless of race and sex. Strategies recommended under both scenarios included colonoscopy every 10 or 15 years, annual fecal immunochemical testing, and computed tomographic colonography every 5 years through the age of 75 years. CONCLUSIONS Microsimulation modeling suggests that CRC screening should be considered from the age of 45 years for blacks and for whites if the lifetime risk has increased proportionally to the incidence for younger adults. Cancer 2018;124:2974-85. © 2018 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society.
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Affiliation(s)
- Reinier G. S. Meester
- Department of Public HealthErasmus University Medical CenterRotterdamthe Netherlands
- Division of Gastroenterology and Hepatology, Department of MedicineStanford UniversityStanfordCalifornia
| | | | - Amy B. Knudsen
- Institute for Technology Assessment, Department of RadiologyMassachusetts General HospitalBostonMassachusetts
| | - Anne C. de Weerdt
- Department of Public HealthErasmus University Medical CenterRotterdamthe Netherlands
| | - Jennifer C. Chen
- Department of Epidemiology and BiostatisticsMemorial Sloan Kettering Cancer CenterNew YorkNew York
| | - Anna P. Lietz
- Institute for Technology Assessment, Department of RadiologyMassachusetts General HospitalBostonMassachusetts
| | - Andrea Dwyer
- University of Colorado Cancer CenterDenverColorado
- Fight Colorectal CancerSpringfieldMissouri
| | - Dennis J. Ahnen
- University of Colorado Cancer CenterDenverColorado
- Gastroenterology of the RockiesDenverColorado
| | - Rebecca L. Siegel
- Surveillance Information ServicesAmerican Cancer SocietyAtlantaGeorgia
| | - Robert A. Smith
- Cancer Control DepartmentAmerican Cancer SocietyAtlantaGeorgia
| | - Ann G. Zauber
- Department of Epidemiology and BiostatisticsMemorial Sloan Kettering Cancer CenterNew YorkNew York
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16
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Arrospide A, Idigoras I, Mar J, de Koning H, van der Meulen M, Soto-Gordoa M, Martinez-Llorente JM, Portillo I, Arana-Arri E, Ibarrondo O, Lansdorp-Vogelaar I. Cost-effectiveness and budget impact analyses of a colorectal cancer screening programme in a high adenoma prevalence scenario using MISCAN-Colon microsimulation model. BMC Cancer 2018; 18:464. [PMID: 29695234 PMCID: PMC5918894 DOI: 10.1186/s12885-018-4362-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 04/11/2018] [Indexed: 02/07/2023] Open
Abstract
Background The Basque Colorectal Cancer Screening Programme began in 2009 and the implementation has been complete since 2013. Faecal immunological testing was used for screening in individuals between 50 and 69 years old. Colorectal Cancer in Basque country is characterized by unusual epidemiological features given that Colorectal Cancer incidence is similar to other European countries while adenoma prevalence is higher. The object of our study was to economically evaluate the programme via cost-effectiveness and budget impact analyses with microsimulation models. Methods We applied the Microsimulation Screening Analysis (MISCAN)-Colon model to predict trends in Colorectal Cancer incidence and mortality and to quantify the short- and long-term effects and costs of the Basque Colorectal Cancer Screening Programme. The model was calibrated to the Basque demographics in 2008 and age-specific Colorectal Cancer incidence data in the Basque Cancer Registry from 2005 to 2008 before the screening begun. The model was also calibrated to the high adenoma prevalence observed for the Basque population in a previously published study. The multi-cohort approach used in the model included all the cohorts in the programme during 30 years of implementation, with lifetime follow-up. Unit costs were obtained from the Basque Health Service and both cost-effectiveness analysis and budget impact analysis were carried out. Results The goodness-of-fit of the model adaptation to observed programme data was evidence of validation. In the cost-effectiveness analysis, the savings from treatment were larger than the added costs due to screening. Thus, the Basque programme was dominant compared to no screening, as life expectancy increased by 29.3 days per person. The savings in the budget analysis appeared 10 years after the complete implementation of the programme. The average annual budget was €73.4 million from year 2023 onwards. Conclusions This economic evaluation showed a screening intervention with a major health gain that also produced net savings when a long follow-up was used to capture the late economic benefit. The number of colonoscopies required was high but remain within the capacity of the Basque Health Service. So far in Europe, no other population Colorectal Cancer screening programme has been evaluated by budget impact analysis. Electronic supplementary material The online version of this article (10.1186/s12885-018-4362-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Arantzazu Arrospide
- Gipuzkoa Primary Care - Integrated Health Care Organizations Research Unit, Alto Deba Integrated Health Care Organisation, Avda Navarra 16, 20500, Arrasate-Mondragón, Gipuzkoa, Spain. .,Health Services Research on Chronic Patients Network (REDISSEC), Arrasate - Mondragón, Gipuzkoa, Spain. .,Biodonostia Health Research Institute, Donostia - San Sebastian, Gipuzkoa, Spain.
| | - Isabel Idigoras
- Basque Country Colorectal Cancer Screening Programme, Basque Health Service, Bilbao, Bizkaia, Spain
| | - Javier Mar
- Gipuzkoa Primary Care - Integrated Health Care Organizations Research Unit, Alto Deba Integrated Health Care Organisation, Avda Navarra 16, 20500, Arrasate-Mondragón, Gipuzkoa, Spain.,Health Services Research on Chronic Patients Network (REDISSEC), Arrasate - Mondragón, Gipuzkoa, Spain.,Biodonostia Health Research Institute, Donostia - San Sebastian, Gipuzkoa, Spain.,Clinical Management Unit, Alto Deba Integrated Health Care Organisation, Arrasate - Mondragón, Gipuzkoa, Spain
| | - Harry de Koning
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Miriam van der Meulen
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Myriam Soto-Gordoa
- Gipuzkoa Primary Care - Integrated Health Care Organizations Research Unit, Alto Deba Integrated Health Care Organisation, Avda Navarra 16, 20500, Arrasate-Mondragón, Gipuzkoa, Spain.,Health Services Research on Chronic Patients Network (REDISSEC), Arrasate - Mondragón, Gipuzkoa, Spain.,Biodonostia Health Research Institute, Donostia - San Sebastian, Gipuzkoa, Spain
| | | | - Isabel Portillo
- Basque Country Colorectal Cancer Screening Programme, Basque Health Service, Bilbao, Bizkaia, Spain
| | | | - Oliver Ibarrondo
- Gipuzkoa Primary Care - Integrated Health Care Organizations Research Unit, Alto Deba Integrated Health Care Organisation, Avda Navarra 16, 20500, Arrasate-Mondragón, Gipuzkoa, Spain
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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17
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Lansdorp-Vogelaar I, Goede SL, Bosch LJ, Melotte V, Carvalho B, van Engeland M, Meijer GA, de Koning HJ, van Ballegooijen M. Cost-effectiveness of High-performance Biomarker Tests vs Fecal Immunochemical Test for Noninvasive Colorectal Cancer Screening. Clin Gastroenterol Hepatol 2018; 16:504-512.e11. [PMID: 28733262 PMCID: PMC5773413 DOI: 10.1016/j.cgh.2017.07.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 06/30/2017] [Accepted: 07/02/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Biomarker assays could increase the accuracy of noninvasive detection of colorectal cancer (CRC); fecal immunochemical tests (FITs) are estimated to miss 27%-47% of CRCs and 70%-80% of advanced adenomas per round of screening. We investigated the conditions under which biomarker screens would be cost-effective compared with FIT screens of average-risk individuals. METHODS We used the MISCAN-Colon microsimulation model to estimate the effects of various CRC screening test characteristics on life-years gained (LYG) and; age-specific all-cause mortality was based on the 2010 Dutch life tables. Simulated CRC incidence rate and CRC stage distribution were calibrated to observed data in The Netherlands from 1999 through 2003 (before opportunities for screening). Survival rates after diagnosis of CRC at an age younger than 75 years were based on CRC relative survival data from 1985 through 2004; survival for individuals diagnosed at an age of 75 years or older was adjusted to fit the observed age-increasing mortality/incidence ratio. We modeled FIT along with hypothetical biomarker tests with different test performance levels. For each biomarker test we calculated the maximum unit cost for the test to be cost-effective compared with FIT, assuming a willingness-to-pay threshold of €50,000 ($56,000) per LYG. RESULTS Biennial FIT screening of subjects 55-75 years old provided 84.9 LYG at a cost of €122,000 ($137,000) per 1000 participants. Considering a unit cost of €7 ($8) for FIT (including kit and analysis only, excluding organizational costs), a biomarker test that detects CRC with higher levels of specificity and sensitivity (100%) and advanced adenomas at a proportionally higher level of sensitivity (53%) should never exceed a cost of €51 ($57). The threshold cost could increase to more than €200 ($224) for high-performing biomarker tests in cases of limited colonoscopy capacity or higher uptake of this test. CONCLUSIONS By using the MISCAN-Colon microsimulation model to estimate effects of CRC screening tests, we found that for a biomarker test with increased overall performance to be cost-effective, it should not exceed 7-fold the unit cost of FIT. This maximum would increase substantially if colonoscopy becomes more expensive or scarce, or if the new test has higher screening uptake. These values could be used to estimate the added value of new biomarkers compared with current FIT screening.
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Affiliation(s)
- Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands.
| | - S. Lucas Goede
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Linda J.W. Bosch
- Department of Pathology, VU University Medical Centre, Amsterdam, The Netherlands,Department of Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Veerle Melotte
- Department of Pathology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Beatriz Carvalho
- Department of Pathology, VU University Medical Centre, Amsterdam, The Netherlands,Department of Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Manon van Engeland
- Department of Pathology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Gerrit A. Meijer
- Department of Pathology, VU University Medical Centre, Amsterdam, The Netherlands,Department of Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Harry J. de Koning
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
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18
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van der Meulen MP, Lansdorp-Vogelaar I, Goede SL, Kuipers EJ, Dekker E, Stoker J, van Ballegooijen M. Colorectal Cancer: Cost-effectiveness of Colonoscopy versus CT Colonography Screening with Participation Rates and Costs. Radiology 2018; 287:901-911. [PMID: 29485322 DOI: 10.1148/radiol.2017162359] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Purpose To compare the cost-effectiveness of computed tomographic (CT) colonography and colonoscopy screening by using data on unit costs and participation rates from a randomized controlled screening trial in a dedicated screening setting. Materials and Methods Observed participation rates and screening costs from the Colonoscopy or Colonography for Screening, or COCOS, trial were used in a microsimulation model to estimate costs and quality-adjusted life-years (QALYs) gained with colonoscopy and CT colonography screening. For both tests, the authors determined optimal age range and screening interval combinations assuming a 100% participation rate. Assuming observed participation for these combinations, the cost-effectiveness of both tests was compared. Extracolonic findings were not included because long-term follow-up data are lacking. Results The participation rates for colonoscopy and CT colonography were 21.5% (1276 of 5924 invitees) and 33.6% (982 of 2920 invitees), respectively. Colonoscopy was more cost-effective in the screening strategies with one or two lifetime screenings, whereas CT colonography was more cost-effective in strategies with more lifetime screenings. CT colonography was the preferred test for willingness-to-pay-thresholds of €3200 per QALY gained and higher, which is lower than the Dutch willingness-to-pay threshold of €20 000. With equal participation, colonoscopy was the preferred test independent of willingness-to-pay thresholds. The findings were robust for most of the sensitivity analyses, except with regard to relative screening costs and subsequent participation. Conclusion Because of the higher participation rates, CT colonography screening for colorectal cancer is more cost-effective than colonoscopy screening. The implementation of CT colonography screening requires previous satisfactory resolution to the question as to how best to deal with extracolonic findings. © RSNA, 2018 Online supplemental material is available for this article.
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Affiliation(s)
- Miriam P van der Meulen
- From the Departments of Public Health (M.P.v.d.M., I.L.V., S.L.G., M.v.B.), Gastroenterology and Hepatology (E.J.K.), and Internal Medicine (E.J.K.), Erasmus Medical Centre, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Gastroenterology and Hepatology (E.D.) and Department of Radiology (J.S.), Academic Medical Center, Amsterdam, the Netherlands
| | - Iris Lansdorp-Vogelaar
- From the Departments of Public Health (M.P.v.d.M., I.L.V., S.L.G., M.v.B.), Gastroenterology and Hepatology (E.J.K.), and Internal Medicine (E.J.K.), Erasmus Medical Centre, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Gastroenterology and Hepatology (E.D.) and Department of Radiology (J.S.), Academic Medical Center, Amsterdam, the Netherlands
| | - S Lucas Goede
- From the Departments of Public Health (M.P.v.d.M., I.L.V., S.L.G., M.v.B.), Gastroenterology and Hepatology (E.J.K.), and Internal Medicine (E.J.K.), Erasmus Medical Centre, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Gastroenterology and Hepatology (E.D.) and Department of Radiology (J.S.), Academic Medical Center, Amsterdam, the Netherlands
| | - Ernst J Kuipers
- From the Departments of Public Health (M.P.v.d.M., I.L.V., S.L.G., M.v.B.), Gastroenterology and Hepatology (E.J.K.), and Internal Medicine (E.J.K.), Erasmus Medical Centre, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Gastroenterology and Hepatology (E.D.) and Department of Radiology (J.S.), Academic Medical Center, Amsterdam, the Netherlands
| | - Evelien Dekker
- From the Departments of Public Health (M.P.v.d.M., I.L.V., S.L.G., M.v.B.), Gastroenterology and Hepatology (E.J.K.), and Internal Medicine (E.J.K.), Erasmus Medical Centre, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Gastroenterology and Hepatology (E.D.) and Department of Radiology (J.S.), Academic Medical Center, Amsterdam, the Netherlands
| | - Jaap Stoker
- From the Departments of Public Health (M.P.v.d.M., I.L.V., S.L.G., M.v.B.), Gastroenterology and Hepatology (E.J.K.), and Internal Medicine (E.J.K.), Erasmus Medical Centre, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Gastroenterology and Hepatology (E.D.) and Department of Radiology (J.S.), Academic Medical Center, Amsterdam, the Netherlands
| | - Marjolein van Ballegooijen
- From the Departments of Public Health (M.P.v.d.M., I.L.V., S.L.G., M.v.B.), Gastroenterology and Hepatology (E.J.K.), and Internal Medicine (E.J.K.), Erasmus Medical Centre, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Gastroenterology and Hepatology (E.D.) and Department of Radiology (J.S.), Academic Medical Center, Amsterdam, the Netherlands
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Gini A, Zauber AG, Cenin DR, Omidvari AH, Hempstead SE, Fink AK, Lowenfels AB, Lansdorp-Vogelaar I. Cost Effectiveness of Screening Individuals With Cystic Fibrosis for Colorectal Cancer. Gastroenterology 2018; 154:556-567.e18. [PMID: 29102616 PMCID: PMC5823285 DOI: 10.1053/j.gastro.2017.10.036] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 10/12/2017] [Accepted: 10/26/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Individuals with cystic fibrosis are at increased risk of colorectal cancer (CRC) compared with the general population, and risk is higher among those who received an organ transplant. We performed a cost-effectiveness analysis to determine optimal CRC screening strategies for patients with cystic fibrosis. METHODS We adjusted the existing Microsimulation Screening Analysis-Colon model to reflect increased CRC risk and lower life expectancy in patients with cystic fibrosis. Modeling was performed separately for individuals who never received an organ transplant and patients who had received an organ transplant. We modeled 76 colonoscopy screening strategies that varied the age range and screening interval. The optimal screening strategy was determined based on a willingness to pay threshold of $100,000 per life-year gained. Sensitivity and supplementary analyses were performed, including fecal immunochemical test (FIT) as an alternative test, earlier ages of transplantation, and increased rates of colonoscopy complications, to assess if optimal screening strategies would change. RESULTS Colonoscopy every 5 years, starting at an age of 40 years, was the optimal colonoscopy strategy for patients with cystic fibrosis who never received an organ transplant; this strategy prevented 79% of deaths from CRC. Among patients with cystic fibrosis who had received an organ transplant, optimal colonoscopy screening should start at an age of 30 or 35 years, depending on the patient's age at time of transplantation. Annual FIT screening was predicted to be cost-effective for patients with cystic fibrosis. However, the level of accuracy of the FIT in this population is not clear. CONCLUSIONS Using a Microsimulation Screening Analysis-Colon model, we found screening of patients with cystic fibrosis for CRC to be cost effective. Because of the higher risk of CRC in these patients, screening should start at an earlier age with a shorter screening interval. The findings of this study (especially those on FIT screening) may be limited by restricted evidence available for patients with cystic fibrosis.
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Affiliation(s)
- Andrea Gini
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Dayna R. Cenin
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands,Faculty of Health Sciences, Curtin University, Perth, WA, Australia
| | - Amir-Houshang Omidvari
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Aliza K. Fink
- Cystic Fibrosis Foundation, Bethesda, MD, United States
| | - Albert B. Lowenfels
- Department of Surgery, New York Medical College, Valhalla, NY, United States,Department of Family Medicine, New York Medical College, Valhalla, NY, United States
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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20
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Naber SK, Kuntz KM, Henrikson NB, Williams MS, Calonge N, Goddard KA, Zallen DT, Ganiats TG, Webber EM, Janssens ACJ, van Ballegooijen M, Zauber AG, Lansdorp-Vogelaar I. Cost Effectiveness of Age-Specific Screening Intervals for People With Family Histories of Colorectal Cancer. Gastroenterology 2018; 154:105-116.e20. [PMID: 28964749 PMCID: PMC6104831 DOI: 10.1053/j.gastro.2017.09.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 08/18/2017] [Accepted: 09/18/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND & AIMS Relative risk of colorectal cancer (CRC) decreases with age among individuals with a family history of CRC. However, no screening recommendations specify less frequent screening with increasing age. We aimed to determine whether such a refinement would be cost effective. METHODS We determined the relative risk for CRC for individuals based on age and number of affected first-degree relatives (FDRs) using data from publications. For each number of affected FDRs, we used the Microsimulation Screening Analysis model to estimate costs and effects of colonoscopy screening strategies with different age ranges and intervals. Screening was then optimized sequentially, starting with the youngest age group, and allowing the interval of screening to change at certain ages. Strategies with an incremental cost effectiveness ratio below $100,000 per quality-adjusted life year were considered cost effective. RESULTS For people with 1 affected FDR (92% of those with a family history), screening every 3 years beginning at an age of 40 years is most cost effective. If no adenomas are found, the screening interval can gradually be extended to 5 and 7 years, at ages 45 and 55 years, respectively. From a cost-effectiveness perspective, individuals with more affected FDRs should start screening earlier and at shorter intervals. However, frequency can be reduced if no abnormalities are found. CONCLUSIONS Using a microsimulation model, we found that for individuals with a family history of CRC, it is cost effective to gradually increase the screening interval if several subsequent screening colonoscopies have negative results and no new cases of CRC are found in family members.
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Affiliation(s)
- Steffie K. Naber
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands,Corresponding author
| | - Karen M. Kuntz
- Department of Health Policy & Management, University of Minnesota, Minneapolis, MN, United States
| | | | - Marc S. Williams
- Genomic Medicine Institute, Geisinger Health System, Danville, PA, United States
| | - Ned Calonge
- The Colorado Trust, Denver, CO, United States
| | - Katrina A.B. Goddard
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, United States
| | - Doris T. Zallen
- Department of Science and Technology in Society, VirginiaTech, Blacksberg, VA, United States
| | - Theodore G. Ganiats
- Agency for Healthcare Research and Quality, Rockville, MD United States,Dr. Ganiats is a Senior Staff Fellow at the Agency for Healthcare Research and Quality (AHRQ). The views expressed are those of the author and no official endorsement by AHRQ, the U.S. Department of Health and Human Services, or the Federal government is intended or should be inferred.
| | - Elizabeth M. Webber
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, United States
| | | | - Marjolein van Ballegooijen
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ann G. Zauber
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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21
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Gini A, Zauber AG, Cenin DR, Omidvari AH, Hempstead SE, Fink AK, Lowenfels AB, Lansdorp-Vogelaar I. Cost-Effectiveness of Screening Individuals With Cystic Fibrosis for Colorectal Cancer. Gastroenterology 2017:S0016-5085(17)36715-X. [PMID: 29288655 DOI: 10.1053/j.gastro.2017.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Individuals with cystic fibrosis are at increased risk of colorectal cancer (CRC) compared to the general population, and risk is higher among those who received an organ transplant. We performed a cost-effectiveness analysis to determine optimal CRC screening strategies for patients with cystic fibrosis. METHODS We adjusted the existing Microsimulation Screening Analysis-Colon microsimulation model to reflect increased CRC risk and lower life expectancy in patients with cystic fibrosis. Modeling was performed separately for individuals who never received an organ transplant and patients who had received an organ transplant. We modeled 76 colonoscopy screening strategies that varied the age range and screening interval. The optimal screening strategy was determined based on a willingness to pay threshold of $100,000 per life-year gained. Sensitivity and supplementary analyses were performed, including fecal immunochemical test (FIT) as an alternative test, earlier ages of transplantation, and increased rates of colonoscopy complications, to assess whether optimal screening strategies would change. RESULTS Colonoscopy every 5 years, starting at age 40 years, was the optimal colonoscopy strategy for patients with cystic fibrosis who never received an organ transplant; this strategy prevented 79% of deaths from CRC. Among patients with cystic fibrosis who had received an organ transplant, optimal colonoscopy screening should start at an age of 30 or 35 years, depending on the patient's age at time of transplantation. Annual FIT screening was predicted to be cost-effective for patients with cystic fibrosis. However, the level of accuracy of the FIT in population is not clear. CONCLUSIONS Using a Microsimulation Screening Analysis-Colon microsimulation model, we found screening of patients with cystic fibrosis for CRC to be cost-effective. Due to the higher risk in these patients for CRC, screening should start at an earlier age with a shorter screening interval. The findings of this study (especially those on FIT screening) may be limited by restricted evidence available for patients with cystic fibrosis.
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Affiliation(s)
- Andrea Gini
- Department of Public Health, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Dayna R Cenin
- Department of Public Health, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands; Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Amir-Houshang Omidvari
- Department of Public Health, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | | | - Albert B Lowenfels
- Department of Surgery, New York Medical College, Valhalla, New York; Department of Family Medicine, New York Medical College, Valhalla, New York
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
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22
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East JE, Atkin WS, Bateman AC, Clark SK, Dolwani S, Ket SN, Leedham SJ, Phull PS, Rutter MD, Shepherd NA, Tomlinson I, Rees CJ. British Society of Gastroenterology position statement on serrated polyps in the colon and rectum. Gut 2017; 66:1181-1196. [PMID: 28450390 PMCID: PMC5530473 DOI: 10.1136/gutjnl-2017-314005] [Citation(s) in RCA: 177] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 03/31/2017] [Accepted: 04/03/2017] [Indexed: 02/07/2023]
Abstract
Serrated polyps have been recognised in the last decade as important premalignant lesions accounting for between 15% and 30% of colorectal cancers. There is therefore a clinical need for guidance on how to manage these lesions; however, the evidence base is limited. A working group was commission by the British Society of Gastroenterology (BSG) Endoscopy section to review the available evidence and develop a position statement to provide clinical guidance until the evidence becomes available to support a formal guideline. The scope of the position statement was wide-ranging and included: evidence that serrated lesions have premalignant potential; detection and resection of serrated lesions; surveillance strategies after detection of serrated lesions; special situations-serrated polyposis syndrome (including surgery) and serrated lesions in colitis; education, audit and benchmarks and research questions. Statements on these issues were proposed where the evidence was deemed sufficient, and re-evaluated modified via a Delphi process until >80% agreement was reached. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool was used to assess the strength of evidence and strength of recommendation for finalised statements. Key recommendation: we suggest that until further evidence on the efficacy or otherwise of surveillance are published, patients with sessile serrated lesions (SSLs) that appear associated with a higher risk of future neoplasia or colorectal cancer (SSLs ≥10 mm or serrated lesions harbouring dysplasia including traditional serrated adenomas) should be offered a one-off colonoscopic surveillance examination at 3 years (weak recommendation, low quality evidence, 90% agreement).
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Affiliation(s)
- James E East
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Wendy S Atkin
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Adrian C Bateman
- Department of Cellular Pathology, Southampton General Hospital, Southampton, UK
| | - Susan K Clark
- The Polyposis Registry, St. Mark's Hospital, London, UK
| | - Sunil Dolwani
- Cancer Screening, Prevention and Early Diagnosis Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Shara N Ket
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Simon J Leedham
- Gastrointestinal Stem-cell Biology Laboratory, Oxford Centre for Cancer Gene Research, Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Perminder S Phull
- Department of Digestive Disorders, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Matt D Rutter
- Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, Cleveland, UK
- School of Medicine, Durham University, Durham, UK
| | - Neil A Shepherd
- Gloucestershire Cellular Pathology Laboratory, Cheltenham General Hospital, Cheltenham, UK
| | - Ian Tomlinson
- Oxford Centre for Cancer Gene Research, Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Colin J Rees
- School of Medicine, Durham University, Durham, UK
- Department of Gastroenterology, South Tyneside NHS Foundation Trust, South Shields, UK
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23
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Herreros de Tejada A, González-Lois C, Santiago J. Serrated lesions and serrated polyposis syndrome. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 109:516-526. [PMID: 28530106 DOI: 10.17235/reed.2017.4065/2015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The serrated pathway has been shown to be an alternative colorectal carcinogenetic route potentially accounting for up to one third of all CRCs. Serrated lesions, particularly SSPs, have been a focus of research during the past few years. They have well-established histological and molecular characteristics that account for their potential carcinogenetic risk through the accumulation BRAF, KRAS and methylator profile (CpG) mutations. Their endoscopic identification and resection represent a challenge because of their specific characteristics, and the need for an adequate specimen for histological diagnosis. Knowledge of these lesions is key, as is the adoption of established criteria for their endoscopic description and histological diagnosis. SPS is the maximum expression of involvement by serrated lesions, is associated with increased risk for CRC, and requires attentive endoscopic follow-up, as well as family screening. While the exact etiopathogenic mechanism remains unknown, current research will likely provide us with appropriate answers in the not too distant future.
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Affiliation(s)
| | - Carmen González-Lois
- Anatomía Patológica, Hospital Universitario Puerta de Hierro Majadahonda, España
| | - José Santiago
- Digestivo, Hospital Universitario Puerta de Hierro Majadahonda, España
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24
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Meulen MPVD, Kapidzic A, Leerdam MEV, van der Steen A, Kuipers EJ, Spaander MCW, de Koning HJ, Hol L, Lansdorp-Vogelaar I. Do Men and Women Need to Be Screened Differently with Fecal Immunochemical Testing? A Cost-Effectiveness Analysis. Cancer Epidemiol Biomarkers Prev 2017; 26:1328-1336. [PMID: 28515110 DOI: 10.1158/1055-9965.epi-16-0786] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 02/24/2017] [Accepted: 05/04/2017] [Indexed: 11/16/2022] Open
Abstract
Background: Several studies suggest that test characteristics for the fecal immunochemical test (FIT) differ by gender, triggering a debate on whether men and women should be screened differently. We used the microsimulation model MISCAN-Colon to evaluate whether screening stratified by gender is cost-effective.Methods: We estimated gender-specific FIT characteristics based on first-round positivity and detection rates observed in a FIT screening pilot (CORERO-1). Subsequently, we used the model to estimate harms, benefits, and costs of 480 gender-specific FIT screening strategies and compared them with uniform screening.Results: Biennial FIT screening from ages 50 to 75 was less effective in women than men [35.7 vs. 49.0 quality-adjusted life years (QALY) gained, respectively] at higher costs (€42,161 vs. -€5,471, respectively). However, the incremental QALYs gained and costs of annual screening compared with biennial screening were more similar for both genders (8.7 QALYs gained and €26,394 for women vs. 6.7 QALYs gained and €20,863 for men). Considering all evaluated screening strategies, optimal gender-based screening yielded at most 7% more QALYs gained than optimal uniform screening and even resulted in equal costs and QALYs gained from a willingness-to-pay threshold of €1,300.Conclusions: FIT screening is less effective in women, but the incremental cost-effectiveness is similar in men and women. Consequently, screening stratified by gender is not more cost-effective than uniform FIT screening.Impact: Our conclusions support the current policy of uniform FIT screening. Cancer Epidemiol Biomarkers Prev; 26(8); 1328-36. ©2017 AACR.
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Affiliation(s)
| | - Atija Kapidzic
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Monique E van Leerdam
- Department of Medical Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Alex van der Steen
- Department of Public Health, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, the Netherlands.,Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Harry J de Koning
- Department of Public Health, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Lieke Hol
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, the Netherlands
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25
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Cao HL, Chen X, Du SC, Song WJ, Wang WQ, Xu MQ, Wang SN, Piao MY, Cao XC, Wang BM. Detection Rate, Distribution, Clinical and Pathological Features of Colorectal Serrated Polyps. Chin Med J (Engl) 2017; 129:2427-2433. [PMID: 27748334 PMCID: PMC5072254 DOI: 10.4103/0366-6999.191759] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Colorectal serrated polyp is considered as histologically heterogeneous lesions with malignant potential in western countries. However, few Asian studies have investigated the comprehensive clinical features of serrated polyps in symptomatic populations. The aim of the study was to evaluate the features of colorectal serrated polyps in a Chinese symptomatic population. Methods: Data from all consecutive symptomatic patients were documented from a large colonoscopy database and were analyzed. Chi-square test or Fisher's exact test and logistic regression analysis were used for the data processing. Results: A total of 9191 (31.7%) patients were detected with at least one colorectal polyp. The prevalence of serrated polyps was 0.53% (153/28,981). The proportions of hyperplastic polyp (HP), sessile serrated adenoma/polyp (SSA/P), and traditional serrated adenoma (TSA) of all serrated polyps were 41.2%, 7.2%, and 51.6%, respectively, which showed a lower proportion of HP and SSA/P and a higher proportion of TSA. Serrated polyps appeared more in males and elder patients while there was no significant difference in the subtype distribution in gender and age. The proportions of large and proximal serrated polyps were 13.7% (21/153) and 46.4% (71/153), respectively. In total, 98.9% (89/90) serrated adenomas were found with dysplasia. Moreover, 14 patients with serrated polyps were found with synchronous advanced colorectal neoplasia, and large serrated polyps (LSPs) (odds ratio: 3.446, 95% confidence interval: 1.010–11.750, P < 0.05), especially large HPs, might have an association with synchronous advanced neoplasia (AN). Conclusions: The overall detection rate of colorectal serrated polyps in Chinese symptomatic patient population was low, and distribution pattern of three subtypes is different from previous reports. Moreover, LSPs, especially large HPs, might be associated with an increased risk of synchronous AN.
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Affiliation(s)
- Hai-Long Cao
- Department of Gastroenterology and Hepatology, Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Xue Chen
- Department of Gastroenterology and Hepatology, Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Shao-Chun Du
- Department of Gastroenterology and Hepatology, Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Wen-Jing Song
- Department of Pathology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Wei-Qiang Wang
- Department of Gastroenterology and Hepatology, Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Meng-Que Xu
- Department of Gastroenterology and Hepatology, Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Si-Nan Wang
- Department of Gastroenterology and Hepatology, Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Mei-Yu Piao
- Department of Gastroenterology and Hepatology, Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Xiao-Cang Cao
- Department of Gastroenterology and Hepatology, Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Bang-Mao Wang
- Department of Gastroenterology and Hepatology, Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin 300052, China
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26
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Carballal S, Rodríguez-Alcalde D, Moreira L, Hernández L, Rodríguez L, Rodríguez-Moranta F, Gonzalo V, Bujanda L, Bessa X, Poves C, Cubiella J, Castro I, González M, Moya E, Oquiñena S, Clofent J, Quintero E, Esteban P, Piñol V, Fernández FJ, Jover R, Cid L, López-Cerón M, Cuatrecasas M, López-Vicente J, Leoz ML, Rivero-Sánchez L, Castells A, Pellisé M, Balaguer F. Colorectal cancer risk factors in patients with serrated polyposis syndrome: a large multicentre study. Gut 2016; 65:1829-1837. [PMID: 26264224 DOI: 10.1136/gutjnl-2015-309647] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 07/08/2015] [Accepted: 07/10/2015] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Serrated polyposis syndrome (SPS) is associated with an increased colorectal cancer (CRC) risk, although the magnitude of the risk remains uncertain. Whereas intensive endoscopic surveillance for CRC prevention is advised, predictors that identify patients who have high CRC risk remain unknown. We performed a multicentre nationwide study aimed at describing the CRC risk in patients with SPS and identifying clinicopathological predictors independently associated with CRC. DESIGN From March 2013 through September 2014, patients with SPS were retrospectively recruited at 18 Spanish centres. Data were collected from medical, endoscopy and histopathology reports. Multivariate logistic regression was performed to identify CRC risk factors. RESULTS In 296 patients with SPS with a median follow-up time of 45 months (IQR 26-79.7), a median of 26 (IQR 18.2-40.7) serrated polyps and 3 (IQR 1-6) adenomas per patient were detected. Forty-seven patients (15.8%) developed CRC at a mean age of 53.9±12.8, and 4 out of 47 (8.5%) tumours were detected during surveillance (cumulative CRC incidence 1.9%). Patients with >2 sessile serrated adenomas/polyps (SSA/Ps) proximal to splenic flexure and ≥1 proximal SSA/P with high-grade dysplasia were independent CRC risk factors (incremental OR=2, 95% CI 1.22 to 3.24, p=0.006). Patients with no risk factors showed a 55% decrease in CRC risk (OR=0.45, 95% CI 0.24 to 0.86, p=0.01). CONCLUSIONS Patients with SPS have an increased risk of CRC, although lower than previously published. Close colonoscopy surveillance in experienced centres show a low risk of developing CRC (1.9% in 5 years). Specific polyp features (SSA/P histology, proximal location and presence of high-grade dysplasia) should be used to guide clinical management.
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Affiliation(s)
- Sabela Carballal
- Gastroenterology Department, Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | | | - Leticia Moreira
- Gastroenterology Department, Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Luis Hernández
- Digestive Disease Section, Hospital Universitario de Móstoles, Madrid, Spain
| | - Lorena Rodríguez
- Gastroenterology Department, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | | | - Victoria Gonzalo
- Gastroenterology Department, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain
| | - Luis Bujanda
- Gastroenterology Department, Hospital Donostia/Instituto Biodonostia, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Universidad del País Vasco (UPV/EHU), San Sebastián, Spain
| | - Xavier Bessa
- Gastroenterology Department, Hospital del Mar, Barcelona, Spain
| | - Carmen Poves
- Gastroenterology Department, Hospital Clínico de San Carlos, Madrid, Spain
| | - Joaquin Cubiella
- Gastroenterology Department, Complexo Hospitalario Universitario de Ourense, Instituto de Investigación Biomédica Ourense, Pontevedra y Vigo, Ourense, Spain
| | - Inés Castro
- Gastroenterology Department, Complexo Hospitalario Universitario de Ourense, Instituto de Investigación Biomédica Ourense, Pontevedra y Vigo, Ourense, Spain
| | - Mariano González
- Gastroenterology Department, Hospital Puerta del Hierro, Madrid, Spain
| | - Eloísa Moya
- Gastroenterology Department, Hospital Universitario del Sureste, Arganda del Rey, Madrid, Spain
| | - Susana Oquiñena
- Gastroenterology Department, Complejo Hospitalario de Navarra, Navarra, Spain
| | - Joan Clofent
- Gastroenterology Department, Hospital de Sagunto, Sagunto, Valencia, Spain
| | - Enrique Quintero
- Gastroenterology Department, Hospital Universitario de Canarias, Tenerife, Spain
| | - Pilar Esteban
- Gastroenterology Department, Hospital Morales Meseguer, Murcia, Spain
| | - Virginia Piñol
- Gastroenterology Department, Hospital Josep Trueta, Girona, Spain
| | | | - Rodrigo Jover
- Gastroenterology Department, Hospital General de Alicante, Alicante, Spain
| | - Lucía Cid
- Gastroenterology Department, Complexo Hospitalario Universitario de Vigo, Instituto de Investigación Biomedica Ourense, Pontevedra, y Vigo, Vigo, Spain
| | - María López-Cerón
- Gastroenterology Department, Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Miriam Cuatrecasas
- Pathology Department, Centre for Biomedical Diagnosis, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Jorge López-Vicente
- Digestive Disease Section, Hospital Universitario de Móstoles, Madrid, Spain
| | - Maria Liz Leoz
- Gastroenterology Department, Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Liseth Rivero-Sánchez
- Gastroenterology Department, Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Antoni Castells
- Gastroenterology Department, Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - María Pellisé
- Gastroenterology Department, Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Francesc Balaguer
- Gastroenterology Department, Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
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Meester RG, Zauber AG, Doubeni CA, Jensen CD, Quinn VP, Helfand M, Dominitz JA, Levin TR, Corley DA, Lansdorp-Vogelaar I. Consequences of Increasing Time to Colonoscopy Examination After Positive Result From Fecal Colorectal Cancer Screening Test. Clin Gastroenterol Hepatol 2016; 14:1445-1451.e8. [PMID: 27211498 PMCID: PMC5028249 DOI: 10.1016/j.cgh.2016.05.017] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/15/2016] [Accepted: 05/02/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Delays in diagnostic testing after a positive result from a screening test can undermine the benefits of colorectal cancer (CRC) screening, but there are few empirical data on the effects of such delays. We used microsimulation modeling to estimate the consequences of time to colonoscopy after a positive result from a fecal immunochemical test (FIT). METHODS We used an established microsimulation model to simulate an average-risk United States population cohort that underwent annual FIT screening (from ages 50 to 75 years), with follow-up colonoscopy examinations for individuals with positive results (cutoff, 20 μg/g) at different time points in the following 12 months. Main evaluated outcomes were CRC incidence and mortality; additional outcomes were total life-years lost and net costs of screening. RESULTS For individuals who underwent diagnostic colonoscopy within 2 weeks of a positive result from an FIT, the estimated lifetime risk of CRC incidence was 35.5/1000 persons, and mortality was 7.8/1000 persons. Every month added until colonoscopy was associated with a 0.1/1000 person increase in cancer incidence risk (an increase of 0.3%/month, compared with individuals who received colonoscopies within 2 weeks) and mortality risk (increase of 1.4%/month). Among individuals who received colonoscopy examinations 12 months after a positive result from an FIT, the incidence of CRC was 37.0/1000 persons (increase of 4%, compared with 2 weeks), and mortality was 9.1/1000 persons (increase of 16%). Total years of life gained for the entire screening cohort decreased from an estimated 93.7/1000 persons with an almost immediate follow-up colonoscopy (cost savings of $208 per patient, compared with no colonoscopy) to 84.8/1000 persons with follow-up colonoscopies at 12 months (decrease of 9%; cost savings of $100/patient, compared with no colonoscopy). CONCLUSIONS By using a microsimulation model of an average-risk United States screening cohort, we estimated that delays of up to 12 months after a positive result from an FIT can produce proportional losses of up to nearly 10% in overall screening benefits. These findings indicate the importance of timely follow-up colonoscopy examinations of patients with positive results from FITs.
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Affiliation(s)
- Reinier G.S. Meester
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Chyke A. Doubeni
- Department of Family Medicine and Community Health in the Perelman School of Medicine, Department of Epidemiology in the Perelman School of Medicine, and the Leonard Davis Institute of Health Economics and Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, PA, United States
| | | | - Virginia P. Quinn
- Kaiser Permanente Southern California, Research & Evaluation, Pasadena, CA, United States
| | - Mark Helfand
- Veterans Affairs Portland Healthcare System, Portland, OR, United States
| | - Jason A. Dominitz
- Veterans Affairs Puget Sound Healthcare System, Seattle, WA, United States,Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington, USA
| | | | | | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands
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28
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Knudsen AB, Zauber AG, Rutter CM, Naber SK, Doria-Rose VP, Pabiniak C, Johanson C, Fischer SE, Lansdorp-Vogelaar I, Kuntz KM. Estimation of Benefits, Burden, and Harms of Colorectal Cancer Screening Strategies: Modeling Study for the US Preventive Services Task Force. JAMA 2016; 315:2595-609. [PMID: 27305518 PMCID: PMC5493310 DOI: 10.1001/jama.2016.6828] [Citation(s) in RCA: 331] [Impact Index Per Article: 41.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE The US Preventive Services Task Force (USPSTF) is updating its 2008 colorectal cancer (CRC) screening recommendations. OBJECTIVE To inform the USPSTF by modeling the benefits, burden, and harms of CRC screening strategies; estimating the optimal ages to begin and end screening; and identifying a set of model-recommendable strategies that provide similar life-years gained (LYG) and a comparable balance between LYG and screening burden. DESIGN, SETTING, AND PARTICIPANTS Comparative modeling with 3 microsimulation models of a hypothetical cohort of previously unscreened US 40-year-olds with no prior CRC diagnosis. EXPOSURES Screening with sensitive guaiac-based fecal occult blood testing, fecal immunochemical testing (FIT), multitarget stool DNA testing, flexible sigmoidoscopy with or without stool testing, computed tomographic colonography (CTC), or colonoscopy starting at age 45, 50, or 55 years and ending at age 75, 80, or 85 years. Screening intervals varied by modality. Full adherence for all strategies was assumed. MAIN OUTCOMES AND MEASURES Life-years gained compared with no screening (benefit), lifetime number of colonoscopies required (burden), lifetime number of colonoscopy complications (harms), and ratios of incremental burden and benefit (efficiency ratios) per 1000 40-year-olds. RESULTS The screening strategies provided LYG in the range of 152 to 313 per 1000 40-year-olds. Lifetime colonoscopy burden per 1000 persons ranged from fewer than 900 (FIT every 3 years from ages 55-75 years) to more than 7500 (colonoscopy screening every 5 years from ages 45-85 years). Harm from screening was at most 23 complications per 1000 persons screened. Strategies with screening beginning at age 50 years generally provided more LYG as well as more additional LYG per additional colonoscopy than strategies with screening beginning at age 55 years. There were limited empirical data to support a start age of 45 years. For persons adequately screened up to age 75 years, additional screening yielded small increases in LYG relative to the increase in colonoscopy burden. With screening from ages 50 to 75 years, 4 strategies yielded a comparable balance of screening burden and similar LYG (median LYG per 1000 across the models): colonoscopy every 10 years (270 LYG); sigmoidoscopy every 10 years with annual FIT (256 LYG); CTC every 5 years (248 LYG); and annual FIT (244 LYG). CONCLUSIONS AND RELEVANCE In this microsimulation modeling study of a previously unscreened population undergoing CRC screening that assumed 100% adherence, the strategies of colonoscopy every 10 years, annual FIT, sigmoidoscopy every 10 years with annual FIT, and CTC every 5 years performed from ages 50 through 75 years provided similar LYG and a comparable balance of benefit and screening burden.
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Affiliation(s)
- Amy B Knudsen
- Institute for Technology Assessment, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Steffie K Naber
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - V Paul Doria-Rose
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
| | | | - Colden Johanson
- Institute for Technology Assessment, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts8Currently with Optum, Boston, Massachusetts
| | - Sara E Fischer
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Karen M Kuntz
- Department of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
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Moriichi K, Fujiya M, Okumura T. The efficacy of autofluorescence imaging in the diagnosis of colorectal diseases. Clin J Gastroenterol 2016; 9:175-83. [DOI: 10.1007/s12328-016-0658-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 05/23/2016] [Indexed: 02/06/2023]
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van der Meulen MP, Lansdorp-Vogelaar I, van Heijningen EMB, Kuipers EJ, van Ballegooijen M. Nonbleeding adenomas: Evidence of systematic false-negative fecal immunochemical test results and their implications for screening effectiveness-A modeling study. Cancer 2016; 122:1680-8. [PMID: 27061710 DOI: 10.1002/cncr.29952] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 01/07/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND If some adenomas do not bleed over several years, they will cause systematic false-negative fecal immunochemical test (FIT) results. The long-term effectiveness of FIT screening has been estimated without accounting for such systematic false-negativity. There are now data with which to evaluate this issue. METHODS The authors developed one microsimulation model (MISCAN [MIcrosimulation SCreening ANalysis]-Colon) without systematic false-negative FIT results and one model that allowed a percentage of adenomas to be systematically missed in successive FIT screening rounds. Both variants were adjusted to reproduce the first-round findings of the Dutch CORERO FIT screening trial. The authors then compared simulated detection rates in the second screening round with those observed, and adjusted the simulated percentage of systematically missed adenomas to those data. Finally, the authors calculated the impact of systematic false-negative FIT results on the effectiveness of repeated FIT screening. RESULTS The model without systematic false-negativity simulated higher detection rates in the second screening round than observed. These observed rates could be reproduced when assuming that FIT systematically missed 26% of advanced and 73% of nonadvanced adenomas. To reduce the false-positive rate in the second round to the observed level, the authors also had to assume that 30% of false-positive findings were systematically false-positive. Systematic false-negative FIT testing limits the long-term reduction of biennial FIT screening in the incidence of colorectal cancer (35.6% vs 40.9%) and its mortality (55.2% vs 59.0%) in participants. CONCLUSIONS The results of the current study provide convincing evidence based on the combination of real-life and modeling data that a percentage of adenomas are systematically missed by repeat FIT screening. This impairs the efficacy of FIT screening. Cancer 2016;122:1680-8. © 2016 American Cancer Society.
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Affiliation(s)
| | | | | | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands.,Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
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van Hees F, Zauber AG, van Veldhuizen H, Heijnen MLA, Penning C, de Koning HJ, van Ballegooijen M, Lansdorp-Vogelaar I. The value of models in informing resource allocation in colorectal cancer screening: the case of The Netherlands. Gut 2015; 64:1985-97. [PMID: 26063755 PMCID: PMC4672636 DOI: 10.1136/gutjnl-2015-309316] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 05/17/2015] [Indexed: 12/31/2022]
Abstract
In May 2011, the Dutch government decided to implement a national programme for colorectal cancer (CRC) screening using biennial faecal immunochemical test screening between ages 55 and 75. Decision modelling played an important role in informing this decision, as well as in the planning and implementation of the programme afterwards. In this overview, we illustrate the value of models in informing resource allocation in CRC screening using the role that decision modelling has played in the Dutch CRC screening programme as an example.
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Affiliation(s)
- Frank van Hees
- Department of Public Health, Erasmus MC, Rotterdam, the Netherlands
| | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Harriët van Veldhuizen
- Department of Quality Improvement, Erasmus MC, Rotterdam, the Netherlands from August 2014, before National Institute of Public Health and the Environment, Bilthoven, The Netherlands
| | | | - Corine Penning
- Department of Public Health, Erasmus MC, Rotterdam, the Netherlands
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van Hees F, Saini SD, Lansdorp-Vogelaar I, Vijan S, Meester RGS, de Koning HJ, Zauber AG, van Ballegooijen M. Personalizing colonoscopy screening for elderly individuals based on screening history, cancer risk, and comorbidity status could increase cost effectiveness. Gastroenterology 2015; 149:1425-37. [PMID: 26253304 PMCID: PMC4631390 DOI: 10.1053/j.gastro.2015.07.042] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 07/17/2015] [Accepted: 07/20/2015] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS Colorectal cancer (CRC) screening decisions for elderly individuals are often made primarily on the basis of age, whereas other factors that influence the effectiveness and cost effectiveness of screening are often not considered. We investigated the relative importance of factors that could be used to identify elderly individuals most likely to benefit from CRC screening and determined the maximum ages at which screening remains cost effective based on these factors. METHODS We used a microsimulation model (Microsimulation Screening Analysis-Colon) calibrated to the incidence of CRC in the United States and the prevalence of adenomas reported in autopsy studies to determine the appropriate age at which to stop colonoscopy screening in 19,200 cohorts (of 10 million individuals), defined by sex, race, screening history, background risk for CRC, and comorbidity status. We applied a willingness-to-pay threshold of $100,000 per quality-adjusted life-year (QALY) gained. RESULTS Less intensive screening history, higher background risk for CRC, and fewer comorbidities were associated with cost-effective screening at older ages. Sex and race had only a small effect on the appropriate age to stop screening. For some individuals likely to be screened in current practice (for example, 74-year-old white women with moderate comorbidities, half the average background risk for CRC, and negative findings from a screening colonoscopy 10 years previously), screening resulted in a loss of QALYs, rather than a gain. For some individuals unlikely to be screened in current practice (for example, 81-year-old black men with no comorbidities, an average background risk for CRC, and no previous screening), screening was highly cost effective. Although screening some previously screened, low-risk individuals was not cost effective even when they were 66 years old, screening some healthy, high-risk individuals remained cost effective until they reached the age of 88 years old. CONCLUSIONS The current approach to CRC screening in elderly individuals, in which decisions are often based primarily on age, is inefficient, resulting in underuse of screening for some and overuse of screening for others. CRC screening could be more effective and cost effective if individual factors for each patient are considered.
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Affiliation(s)
- Frank van Hees
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sameer D Saini
- Veteran Affairs Health Services Research and Development Center for Clinical Management Research, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sandeep Vijan
- Veteran Affairs Health Services Research and Development Center for Clinical Management Research, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Reinier G S Meester
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Harry J de Koning
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
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Abstract
BACKGROUND Many individuals have not received recommended colorectal cancer (CRC) screening before they become Medicare eligible at the age of 65. We aimed to estimate the long-term implications of increased CRC screening in the pre-Medicare population (50-64 y) on costs in the pre-Medicare and Medicare populations (65+ y). METHODS We used 2 independently developed microsimulation models [Microsimulation Screening Analysis Colon (MISCAN) and Simulation Model of CRC (SimCRC)] to project CRC screening and treatment costs under 2 scenarios, starting in 2010: "current trends" (60% of the population up-to-date with screening recommendations) and "enhanced participation" (70% up-to-date). The population was scaled to the projected US population for each year between 2010 and 2060. Costs per year were derived by age group (50-64 and 65+ y). RESULTS By 2060, the discounted cumulative total costs in the pre-Medicare population were $35.7 and $28.1 billion higher with enhanced screening participation, than in the current trends scenario ($252.1 billion with MISCAN and $239.5 billion with SimCRC, respectively). Because of CRC treatment savings with enhanced participation, cumulative costs in the Medicare population were $18.3 and $32.7 billion lower (current trends: $423.5 billion with MISCAN and $372.8 billion with SimCRC). Over the 50-year time horizon an estimated 60% (MISCAN) and 89% (SimCRC) of the increased screening costs could be offset by savings in Medicare CRC treatment costs. CONCLUSION Increased CRC screening participation in the pre-Medicare population could reduce CRC incidence and mortality, whereas the additional screening costs can be largely offset by long-term Medicare treatment savings.
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Haug U, Knudsen AB, Lansdorp-Vogelaar I, Kuntz KM. Development of new non-invasive tests for colorectal cancer screening: the relevance of information on adenoma detection. Int J Cancer 2015; 136:2864-74. [PMID: 25403937 PMCID: PMC4397119 DOI: 10.1002/ijc.29343] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 11/03/2014] [Indexed: 12/23/2022]
Abstract
Researchers are actively pursuing the development of a new non-invasive test (NIT) for colorectal cancer (CRC) screening as an alternative to fecal occult blood tests (FOBTs). The majority of pilot studies focus on the detection of invasive CRC rather than precursor lesions (i.e., adenomas). We aimed to explore the relevance of adenoma detection for the viability of an NIT for CRC screening by considering a hypothetical test that does not detect adenomas beyond chance. We used the Simulation Model of Colorectal Cancer (SimCRC) to estimate the effectiveness of CRC screening and the lifetime costs (payers' perspective) for a cohort of US 50-years-old persons to whom CRC screening is offered from age 50-75. We compared annual screening with guaiac and immunochemical FOBTs (with sensitivities up to 70 and 24% for CRC and adenomas, respectively) to annual screening with a hypothetical NIT (sensitivity of 90% for CRC, no detection of adenomas beyond chance, specificity and cost similar to FOBTs). Screening with the NIT was not more effective, but was 29-44% more costly than screening with FOBTs. The findings were robust to varying the screening interval, the NIT's sensitivity for CRC, adherence rates favoring the NIT, and the NIT's unit cost. A comparative modelling approach using a model that assumes a shorter adenoma dwell time (MISCAN-COLON) confirmed the superiority of the immunochemical FOBT over an NIT with no ability to detect adenomas. Information on adenoma detection is crucial to determine whether a new NIT is a viable alternative to FOBTs for CRC screening. Current evidence thus lacks an important piece of information to identify marker candidates that hold real promise and deserve further (large-scale) evaluation.
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Affiliation(s)
- Ulrike Haug
- Epidemiological Cancer Registry Baden-Wuerttemberg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Amy B. Knudsen
- Institute for Technology Assessment, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Karen M. Kuntz
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
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van der Steen A, Knudsen AB, van Hees F, Walter GP, Berger FG, Daguise VG, Kuntz KM, Zauber AG, van Ballegooijen M, Lansdorp-Vogelaar I. Optimal colorectal cancer screening in states' low-income, uninsured populations—the case of South Carolina. Health Serv Res 2015; 50:768-89. [PMID: 25324198 PMCID: PMC4450929 DOI: 10.1111/1475-6773.12246] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To determine whether, given a limited budget, a state's low-income uninsured population would have greater benefit from a colorectal cancer (CRC) screening program using colonoscopy or fecal immunochemical testing (FIT). DATA SOURCES/STUDY SETTING South Carolina's low-income, uninsured population. STUDY DESIGN Comparative effectiveness analysis using microsimulation modeling to estimate the number of individuals screened, CRC cases prevented, CRC deaths prevented, and life-years gained from a screening program using colonoscopy versus a program using annual FIT in South Carolina's low-income, uninsured population. This analysis assumed an annual budget of $1 million and a budget availability of 2 years as a base case. PRINCIPAL FINDINGS The annual FIT screening program resulted in nearly eight times more individuals being screened, and more important, approximately four times as many CRC deaths prevented and life-years gained than the colonoscopy screening program. Our results were robust for assumptions concerning economic perspective and the target population, and they may therefore be generalized to other states and populations. CONCLUSIONS A FIT screening program will prevent more CRC deaths than a colonoscopy-based program when a state's budget for CRC screening supports screening of only a fraction of the target population.
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Affiliation(s)
| | - Amy B Knudsen
- Center for Colon Cancer Research, University of South CarolinaColumbia, SC
| | - Frank van Hees
- Institute for Technology Assessment, Department of Radiology, Massachusetts General HospitalBoston, MA
| | - Gailya P Walter
- Bureau of Community Health and Chronic Disease Prevention, South Carolina Department of Health and Environmental ControlColumbia, SC
| | - Franklin G Berger
- Bureau of Community Health and Chronic Disease Prevention, South Carolina Department of Health and Environmental ControlColumbia, SC
| | - Virginie G Daguise
- Division of Health Policy and Management, School of Public Health, University of MinnesotaMinneapolis, MN
| | - Karen M Kuntz
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer CenterNew York, NY
| | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer CenterNew York, NY
| | | | - Iris Lansdorp-Vogelaar
- Institute for Technology Assessment, Department of Radiology, Massachusetts General HospitalBoston, MA
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East JE, Vieth M, Rex DK. Serrated lesions in colorectal cancer screening: detection, resection, pathology and surveillance. Gut 2015; 64:991-1000. [PMID: 25748647 DOI: 10.1136/gutjnl-2014-309041] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 02/12/2015] [Indexed: 12/13/2022]
Affiliation(s)
- James E East
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
| | - Michael Vieth
- Institute of Pathology, Klinikum Bayreuth, Bayreuth, Germany
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana, USA
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Abdeljawad K, Vemulapalli KC, Kahi CJ, Cummings OW, Snover DC, Rex DK. Sessile serrated polyp prevalence determined by a colonoscopist with a high lesion detection rate and an experienced pathologist. Gastrointest Endosc 2015; 81:517-24. [PMID: 24998465 DOI: 10.1016/j.gie.2014.04.064] [Citation(s) in RCA: 132] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 04/29/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND The prevalence of sessile serrated adenomas and/or polyps (SSA/Ps) is uncertain. OBJECTIVE To determine the prevalence of SSA/Ps and SSA/Ps with cytologic dysplasia (SSA/P-CD) by using a colonoscopist with a high lesion detection rate and an expert in serrated lesion pathology. DESIGN Retrospective screening colonoscopy study. SETTING Academic endoscopy unit. PATIENTS A total of 1910 average risk, asymptomatic patients aged ≥50 years underwent screening colonoscopy between August 2005 and April 2012 by a single colonoscopist with a high lesion detection rate. INTERVENTIONS Slides of all lesions in the serrated class proximal to the sigmoid colon and all rectal and sigmoid colon serrated lesions >5 mm in size were reviewed by an experienced GI pathologist. MAIN OUTCOME MEASUREMENTS Prevalence of SSA/Ps, defined as the proportion of patients with ≥1 SSA/P. RESULTS There were 1910 patients, of whom 389 had 656 lesions in the serrated class. Review by the experienced GI pathologist determined a prevalence of SSA/Ps without cytologic dysplasia of 7.4% and SSA/Ps-CD of 0.6% (total SSA/P prevalence 8.1%). SSA/Ps and SSA/Ps-CD comprised 5.6% and 0.3%, respectively, of all resected polyps. The mean size of SSA/Ps was 7.13 mm (standard deviation [SD] 4.66), and 51 of 77 (66.2%) polyps ≥10 mm in the serrated class were SSA/Ps. LIMITATIONS Retrospective design. CONCLUSION A colonoscopist with a high lesion detection rate and an experienced pathologist identified a high prevalence (8.1%) of SSA/Ps in a screening population. SSA/Ps are more common than previously believed.
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Affiliation(s)
- Khaled Abdeljawad
- Department of Medicine, Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Krishna C Vemulapalli
- Department of Medicine, Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Charles J Kahi
- Department of Medicine, Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA; Richard L. Roudebush Veterans Affairs Medical Center, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Oscar W Cummings
- Department of Pathology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dale C Snover
- Department of Pathology, Fairview Southdale Hospital, Edina, Minnesota and Department of Laboratory Medicine and Pathology, the University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Douglas K Rex
- Department of Medicine, Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Epidemiology of goblet cell and microvesicular hyperplastic polyps. Am J Gastroenterol 2014; 109:1922-32. [PMID: 25350766 DOI: 10.1038/ajg.2014.325] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 09/02/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Serrated polyps compromise both typical hyperplastic polyps as well as sessile serrated adenomas and dysplastic serrated polyps. Hyperplastic polyps exhibit two histological patterns: microvesicular hyperplastic polyps (MVHPs) and goblet cell hyperplastic polyps (GCHPs). MVHPs and GCHPs differ in their molecular signature. MVHPs have been frequently found to have the BRAF(V600E) mutation as well as aberrant methylation. In contrast, GCHPs have been associated with the KRAS mutation (KRAS-mut), which are infrequently seen in dysplastic serrated sessile adenomas. The particular risk factors that are associated with development of the types of hyperplastic polyps have not been previously studied. The purpose of this study is to characterize the associations between particular risk factors and the development of goblet cell or microvesicular hyperplastic polyps. METHODS We conducted a cross-sectional analysis of 3,543 asymptomatic, mostly average risk patients 50 and 79 years of age undergoing open-access screening colonoscopy between March 2005 and January 2012. Each patient was given a survey regarding 25 reputed risk factors for colorectal neoplasia and the responses were correlated with findings at colonoscopy. Associations between putative risk factors for colorectal neoplasia and MVHPs and GSHPs were examined using multiple logistic regression. RESULTS MVHPS and GCHPs were identified in 5.3% and 8.7% of patients, respectively. The results of the statistical analysis indicate that a history of smoking greater than 20 years is associated with an increased risk of MVHPs (P<0.005) and GCHPs (P<0.005). An elevated BMI >30 kg/m(2) was also associated with the presence of MVHP at colonoscopy (P<0.005). Blacks and Asians appear to be protected from the development of MVHPs. In contrast, there was a positive association with the presence of GCHP at colonoscopy in blacks. CONCLUSIONS The study suggests that the development of the distinct histological types of hyperplastic polyps are associated with distinct modifiable and non-modifiable lifestyle factors.
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van Hees F, Zauber AG, Klabunde CN, Goede SL, Lansdorp-Vogelaar I, van Ballegooijen M. The appropriateness of more intensive colonoscopy screening than recommended in Medicare beneficiaries: a modeling study. JAMA Intern Med 2014; 174:1568-76. [PMID: 25133641 PMCID: PMC4416697 DOI: 10.1001/jamainternmed.2014.3889] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Many Medicare beneficiaries undergo more intensive colonoscopy screening than recommended. Whether this is favorable for beneficiaries and efficient from a societal perspective is uncertain. OBJECTIVE To determine whether more intensive colonoscopy screening than recommended is favorable for Medicare beneficiaries (ie, whether it results in a net health benefit) and whether it is efficient from a societal perspective (ie, whether the net health benefit justifies the additional resources required). DESIGN, SETTING, AND PARTICIPANTS Microsimulation modeling study of 65-year-old Medicare beneficiaries at average risk for colorectal cancer (CRC) and with an average life expectancy who underwent a screening colonoscopy at 55 years with negative results. INTERVENTIONS Colonoscopy screening as recommended by guidelines (ie, at 65 and 75 years) vs scenarios with a shorter screening interval (5 or 3 instead of 10 years) or in which screening was continued to 85 or 95 years. MAIN OUTCOMES AND MEASURES Quality-adjusted life-years (QALYs) gained (measure of net health benefit); additional colonoscopies required per additional QALY gained and additional costs per additional QALY gained (measures of efficiency). RESULTS Screening previously screened Medicare beneficiaries more intensively than recommended resulted in only small increases in CRC deaths prevented and life-years gained. In comparison, the increases in colonoscopies performed and colonoscopy-related complications experienced were large. As a result, all scenarios of more intensive screening than recommended resulted in a loss of QALYs, rather than a gain (ie, a net harm). The only exception was shortening the screening interval from 10 to 5 years, which resulted in 0.7 QALYs gained per 1000 beneficiaries. However, this scenario was inefficient because it required no less than 909 additional colonoscopies and an additional $711 000 per additional QALY gained. Results in previously unscreened beneficiaries were slightly less unfavorable, but conclusions were identical. CONCLUSIONS AND RELEVANCE Screening Medicare beneficiaries more intensively than recommended is not only inefficient from a societal perspective; often it is also unfavorable for those being screened. This study provides evidence and a clear rationale for clinicians and policy makers to actively discourage this practice.
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Affiliation(s)
- Frank van Hees
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Carrie N Klabunde
- Health Services and Economics Branch, Applied Research Program, National Cancer Institute, Bethesda, Maryland
| | - S Luuk Goede
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
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van Hees F, Habbema JDF, Meester RG, Lansdorp-Vogelaar I, van Ballegooijen M, Zauber AG. Should colorectal cancer screening be considered in elderly persons without previous screening? A cost-effectiveness analysis. Ann Intern Med 2014; 160:750-9. [PMID: 24887616 PMCID: PMC4109030 DOI: 10.7326/m13-2263] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The U.S. Preventive Services Task Force recommends against routine screening for colorectal cancer (CRC) in adequately screened persons older than 75 years but does not address the appropriateness of screening in elderly persons without previous screening. OBJECTIVE To determine at what ages CRC screening should be considered in unscreened elderly persons and to determine which test is indicated at each age. DESIGN Microsimulation modeling study. DATA SOURCES Observational and experimental studies. TARGET POPULATION Unscreened persons aged 76 to 90 years with no, moderate, and severe comorbid conditions. TIME HORIZON Lifetime. PERSPECTIVE Societal. INTERVENTION One-time colonoscopy, sigmoidoscopy, or fecal immunochemical test (FIT) screening. OUTCOME MEASURES Quality-adjusted life-years gained, costs, and costs per quality-adjusted life-year gained. RESULTS OF BASE-CASE ANALYSIS In unscreened elderly persons with no comorbid conditions, CRC screening was cost-effective up to age 86 years. Screening with colonoscopy was indicated up to age 83 years, sigmoidoscopy was indicated at age 84 years, and FIT was indicated at ages 85 and 86 years. In unscreened persons with moderate comorbid conditions, screening was cost-effective up to age 83 years (colonoscopy indicated up to age 80 years, sigmoidoscopy at age 81 years, and FIT at ages 82 and 83 years). In unscreened persons with severe comorbid conditions, screening was cost-effective up to age 80 years (colonoscopy indicated up to age 77 years, sigmoidoscopy at age 78 years, and FIT at ages 79 and 80 years). RESULTS OF SENSITIVITY ANALYSES Results were most sensitive to assuming a lower willingness to pay per quality-adjusted life-year gained. LIMITATION Only persons at average risk for CRC were considered. CONCLUSION In unscreened elderly persons CRC screening should be considered well beyond age 75 years. A colonoscopy is indicated at most ages. PRIMARY FUNDING SOURCE National Cancer Institute.
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Affiliation(s)
- Frank van Hees
- From Erasmus University Medical Center, Rotterdam, the Netherlands, and Memorial Sloan Kettering Cancer Center, New York, New York
| | - J. Dik F. Habbema
- From Erasmus University Medical Center, Rotterdam, the Netherlands, and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Reinier G. Meester
- From Erasmus University Medical Center, Rotterdam, the Netherlands, and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Iris Lansdorp-Vogelaar
- From Erasmus University Medical Center, Rotterdam, the Netherlands, and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marjolein van Ballegooijen
- From Erasmus University Medical Center, Rotterdam, the Netherlands, and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ann G. Zauber
- From Erasmus University Medical Center, Rotterdam, the Netherlands, and Memorial Sloan Kettering Cancer Center, New York, New York
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La Nauze R, Suzuki N, Saunders B, Clark S, Thomas-Gibson S. The endoscopist's guide to serrated polyposis. Colorectal Dis 2014; 16:417-25. [PMID: 24702773 DOI: 10.1111/codi.12475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 10/10/2013] [Indexed: 01/14/2023]
Abstract
AIM Serrated polyposis is a condition of the colon characterized by multiple serrated polyps. This review aims to provide a practical guide to the day-to-day management of serrated polyposis, including diagnosis, endoscopic identification of serrated polyps, surveillance, the role of endoscopic and surgical management and the screening of family members. METHOD The literature was searched using PubMed and MEDLINE databases for the terms "serrated polyp", "serrated polyposis" and "hyperplastic polyposis". English-language abstracts were read and the full article was retrieved if relevant to the review. Expert opinion from the authors was also sought. RESULTS Advances in our knowledge of the molecular pathways involved in serrated polyposis and an improved clinical picture of the disease from retrospective studies have led to better understanding of its pathogenesis and natural history. However, there are still areas not answered by the literature, and hence empirical management or expert opinion has to be followed. CONCLUSION Improvements in our understanding of serrated polyposis, together with improvements in endoscopic equipment and technique, have enabled the endoscopist to be at the forefront of managing this condition from diagnosis to endoscopic surveillance and control of the polyps.
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Affiliation(s)
- R La Nauze
- The Wolfson Unit for Endoscopy, St Mark's Hospital, Harrow, London, UK; Department of Gastroenterology, Alfred Hospital, Melbourne, Victoria, Australia
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Yamada A, Minamiguchi S, Sakai Y, Horimatsu T, Muto M, Chiba T, Boland CR, Goel A. Colorectal advanced neoplasms occur through dual carcinogenesis pathways in individuals with coexisting serrated polyps. PLoS One 2014; 9:e98059. [PMID: 24849572 PMCID: PMC4029807 DOI: 10.1371/journal.pone.0098059] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 04/25/2014] [Indexed: 01/27/2023] Open
Abstract
Background Individuals with serrated polyps (SP) are at higher risk for synchronous colorectal advanced neoplasms (AN) and cancers. However, it remains unclear whether there is a unique involvement of the serrated pathway and/or the classical adenoma-carcinoma sequence in this setting. Methods Colorectal ANs, which include tubular adenomas ≥10 mm, adenomas with villous histology, high-grade intraepithelial neoplasms, and cancers, were collected retrospectively. The groups included ANs with (AN+SP) or without (AN-only) coexisting SPs. Clinicopathological findings were compared between groups. BRAF and KRAS mutations in ANs and SPs, and methylation levels at long interspersed element-1 (LINE-1) in adjacent mucosa were determined by pyrosequencing. Results Seventy-five ANs from 40 patients in the AN+SP group, and 179 ANs from 119 patients in the AN-only group were analyzed. There were no significant differences in clinicopathological findings between the two groups, except that intraepithelial neoplasia in the AN+SP group was more likely to be located in the right colon (P = 0.018). BRAF mutations were significantly more frequent in the AN+SP group (P = 0.003), while KRAS mutations showed no significant differences between groups (P = 0.142). The majority of high-grade intraepithelial neoplasms in both groups showed a contiguous component of conventional adenoma. Individuals with large and right-sided SPs had significantly more conventional adenomas compared to those without such SPs (P = 0.027 and P = 0.031, respectively). Adjacent mucosa from individuals with multiple and large SPs showed significantly lower methylation levels at LINE-1 compared to individuals without such associated SPs (P = 0.049 and P = 0.015, respectively). Conclusion Our data suggest that both the adenoma-carcinoma sequence and the serrated pathway are operational in individuals with coexisting ANs and SPs. The reduced methylation levels at LINE-1 in the background mucosa suggest the possibility of an underlying ‘field defect’.
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Affiliation(s)
- Atsushi Yamada
- Gastrointestinal Cancer Research Laboratory, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas, United States of America
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | - Yoshiharu Sakai
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takahiro Horimatsu
- Department of Experimental Therapeutics, Institute for Advancement of Clinical and Translational Science (iACT), Kyoto University Hospital, Kyoto, Japan
| | - Manabu Muto
- Department of Therapeutic Oncology, Kyoto University Hospital, Kyoto, Japan
| | - Tsutomu Chiba
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - C. Richard Boland
- Gastrointestinal Cancer Research Laboratory, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas, United States of America
- * E-mail: ;
| | - Ajay Goel
- Gastrointestinal Cancer Research Laboratory, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas, United States of America
- * E-mail: ;
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Limketkai BN, Lam-Himlin D, Arnold MA, Arnold CA. The cutting edge of serrated polyps: a practical guide to approaching and managing serrated colon polyps. Gastrointest Endosc 2013; 77:360-75. [PMID: 23410696 DOI: 10.1016/j.gie.2012.11.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 11/06/2012] [Indexed: 12/13/2022]
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Michalopoulos G, Tzathas C. Serrated polyps of right colon: guilty or innocent? Ann Gastroenterol 2013; 26:212-219. [PMID: 24714424 PMCID: PMC3959453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 04/09/2013] [Indexed: 11/21/2022] Open
Abstract
In recent years a lot of interest has been focused on a specific category of polyps, the so-called serrated polyps which until recently were categorized with the hyperplastic or mixed polyps and were thought to have no risk of malignant transformation. Recently though, the serrated pathway of carcinogenesis was discovered and destroyed this myth. It is believed that up to one third of all colorectal cancers arise through the serrated pathway; these cancers occur more often in the proximal colon and have specific molecular characteristics. Specific subtypes of serrated polyps (mainly the sessile serrated adenomas/polyps) are thought to be precursor lesions of these cancers. The prevention of these cancers is a challenge for gastroenterologists because their location and endoscopic characteristics renders them difficult to detect. Also, although there is a clear need for creating a specific post-polypectomy surveillance program for these lesions, to date there have been no guidelines for surveillance with a high level of evidence. In this article the main molecular, endoscopic, histological and epidemiologic characteristics of these lesions are presented, as well as recommendations for surveillance.
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Affiliation(s)
- George Michalopoulos
- Gastroenterology Department, Tzaneion General Hospital, Piraeus, Greece,
Correspondence to: George Michalopoulos, Gastroenterology Department, Tzaneion General Hospital, Piraeus, Greece, Zani and Afentouli 1, 18536 Piraeus, Greece, Tel.: +30 210 4592896, Fax: +30 210 4592897, e-mail:
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Blair V, Kahokehr A, Sammour T. Cancer in Māori: lessons from prostate, colorectal and gastric cancer and progress in hereditary stomach cancer in New Zealand. ANZ J Surg 2012; 83:42-8. [DOI: 10.1111/ans.12042] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2012] [Indexed: 01/26/2023]
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Corleto VD, Pagnini C, Cattaruzza MS, Zykaj E, Di Giulio E, Margagnoni G, Pilozzi E, D’Ambra G, Lamazza A, Fiori E, Ferri M, Masoni L, Ziparo V, Annibale B, Delle Fave G. Is proliferative colonic disease presentation changing? World J Gastroenterol 2012; 18:6614-9. [PMID: 23236236 PMCID: PMC3516210 DOI: 10.3748/wjg.v18.i45.6614] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 06/19/2012] [Accepted: 08/04/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the site, age and gender of cases of colorectal cancer (CRC) and polyps in a single referral center in Rome, Italy, during two periods.
METHODS: CRC data were collected from surgery/pathology registers, and polyp data from colonoscopy reports. Patients who met the criteria for familial adenomatous polyposis, hereditary non-polyposis colorectal cancer syndrome or inflammatory bowel disease were excluded from the study. Overlap of patients between the two groups (cancers and polyps) was carefully avoided. The χ2 statistical test and a regression analysis were performed.
RESULTS: Data from a total of 768 patients (352 and 416 patients, respectively, in periods A and B) who underwent surgery for cancer were collected. During the same time periods, a total of 1693 polyps were analyzed from 978 patients with complete colonoscopies (428 polyps from 273 patients during period A and 1265 polyps from 705 patients during period B). A proximal shift in cancer occurred during the latter years for both sexes, but particularly in males. Proximal cancer increased > 3-fold in period B compared to period A in males [odds ratio (OR) 3.31, 95%CI: 2.00-5.47; P < 0.0001). A similar proximal shift was observed for polyps, particularly in males (OR 1.87, 95%CI: 1.23-2.87; P < 0.0038), but also in females (OR 1.62, 95%CI: 0.96-2.73; P < 0.07).
CONCLUSION: The prevalence of proximal proliferative colonic lesions seems to have increased over the last decade, particularly in males.
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Knudsen AB, Hur C, Gazelle GS, Schrag D, McFarland EG, Kuntz KM. Rescreening of persons with a negative colonoscopy result: results from a microsimulation model. Ann Intern Med 2012; 157:611-20. [PMID: 23128861 PMCID: PMC3515652 DOI: 10.7326/0003-4819-157-9-201211060-00005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Persons with a negative result on screening colonoscopy are recommended to repeat the procedure in 10 years. OBJECTIVE To assess the effectiveness and costs of colonoscopy versus other rescreening strategies after an initial negative colonoscopy result. DESIGN Microsimulation model. DATA SOURCES Literature and data from the Surveillance, Epidemiology, and End Results program. TARGET POPULATION Persons aged 50 years who had no adenomas or cancer detected on screening colonoscopy. TIME HORIZON Lifetime. PERSPECTIVE Societal. INTERVENTION No further screening or rescreening starting at age 60 years with colonoscopy every 10 years, annual highly sensitive guaiac fecal occult blood testing (HSFOBT), annual fecal immunochemical testing (FIT), or computed tomographic colonography (CTC) every 5 years. OUTCOME MEASURES Lifetime cases of colorectal cancer, life expectancy, and lifetime costs per 1000 persons, assuming either perfect or imperfect adherence. RESULTS OF BASE-CASE ANALYSIS Rescreening with any method substantially reduced the risk for colorectal cancer compared with no further screening (range, 7.7 to 12.6 lifetime cases per 1000 persons [perfect adherence] and 17.7 to 20.9 lifetime cases per 1000 persons [imperfect adherence] vs. 31.3 lifetime cases per 1000 persons with no further screening). In both adherence scenarios, the differences in life-years across rescreening strategies were small (range, 30 893 to 30 902 life-years per 1000 persons [perfect adherence] vs. 30 865 to 30 869 life-years per 1000 persons [imperfect adherence]). Rescreening with HSFOBT, FIT, or CTC had fewer complications and was less costly than continuing colonoscopy. RESULTS OF SENSITIVITY ANALYSIS Results were sensitive to test-specific adherence rates. LIMITATION Data on adherence to rescreening were limited. CONCLUSION Compared with the currently recommended strategy of continuing colonoscopy every 10 years after an initial negative examination, rescreening at age 60 years with annual HSFOBT, annual FIT, or CTC every 5 years provides approximately the same benefit in life-years with fewer complications at a lower cost. Therefore, it is reasonable to use other methods to rescreen persons with negative colonoscopy results. PRIMARY FUNDING SOURCE National Cancer Institute.
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Affiliation(s)
- Amy B Knudsen
- Institute for Technology Assessment, Massachusetts General Hospital, 101 Merrimac Street, 10th Floor, Boston, MA 02114, USA.
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Haug U, Knudsen AB, Kuntz KM. How should individuals with a false-positive fecal occult blood test for colorectal cancer be managed? A decision analysis. Int J Cancer 2012; 131:2094-102. [PMID: 22307927 PMCID: PMC3693764 DOI: 10.1002/ijc.27463] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Accepted: 01/16/2012] [Indexed: 12/24/2022]
Abstract
Several industrialized nations recommend fecal occult blood testing (FOBT) to screen for colorectal cancer (CRC), but corresponding screening guidelines do not specify how individuals with a prior false-positive FOBT result (fpFOBT) should be managed in terms of subsequent CRC screening. Accordingly, we conducted a decision analysis to compare different strategies for managing such individuals. We used a previously developed CRC microsimulation model, SimCRC, to calculate life-years and the lifetime number of colonoscopies (as a measure of required resources) for a cohort of 50-year-olds to whom FOBT-based CRC screening is offered annually from 50 to 75 years. We compared three management strategies for individuals with a prior fpFOBT: (i) resume screening in 10 years with 10-yearly colonoscopy (SwitchCol_long); (ii) resume screening in 1 year with annual FOBT (ContinueFOBT_Short) and (iii) resume screening in 10 years (i.e., the recommended interval following a negative colonoscopy) with annual FOBT (ContinueFOBT_long). We performed sensitivity analyses on various parameters and assumptions. When using different management strategies for individuals with a prior fpFOBT, the variation in the number of life-years gained relative to no screening was <2%, whereas the variation in the lifetime number of colonoscopies was 23% (percentages are calculated as the maximum difference across strategies divided by the lowest number across strategies). The ContinueFOBT_long strategy showed the lowest lifetime number of colonoscopies per life-year gained even when key assumptions were varied. In conclusion, the ContinueFOBT_long strategy was advantageous regarding both clinical benefit and required resources. Specifying an appropriate management strategy for individuals with a prior fpFOBT may substantially reduce required resources within a FOBT-based CRC screening program without limiting its effectiveness.
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Affiliation(s)
- Ulrike Haug
- Division of Preventive Oncology, National Center for Tumor Diseases/German Cancer Research Center, DKFZ, Heidelberg, Germany.
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Rex DK, Ahnen DJ, Baron JA, Batts KP, Burke CA, Burt RW, Goldblum JR, Guillem JG, Kahi CJ, Kalady MF, O'Brien MJ, Odze RD, Ogino S, Parry S, Snover DC, Torlakovic EE, Wise PE, Young J, Church J. Serrated lesions of the colorectum: review and recommendations from an expert panel. Am J Gastroenterol 2012. [PMID: 22710576 DOI: 10.1038/aig.2012161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Serrated lesions of the colorectum are the precursors of perhaps one-third of colorectal cancers (CRCs). Cancers arising in serrated lesions are usually in the proximal colon, and account for a disproportionate fraction of cancer identified after colonoscopy. We sought to provide guidance for the clinical management of serrated colorectal lesions based on current evidence and expert opinion regarding definitions, classification, and significance of serrated lesions. A consensus conference was held over 2 days reviewing the topic of serrated lesions from the perspectives of histology, molecular biology, epidemiology, clinical aspects, and serrated polyposis. Serrated lesions should be classified pathologically according to the World Health Organization criteria as hyperplastic polyp, sessile serrated adenoma/polyp (SSA/P) with or without cytological dysplasia, or traditional serrated adenoma (TSA). SSA/P and TSA are premalignant lesions, but SSA/P is the principal serrated precursor of CRCs. Serrated lesions have a distinct endoscopic appearance, and several lines of evidence suggest that on average they are more difficult to detect than conventional adenomatous polyps. Effective colonoscopy requires an endoscopist trained in the endoscopic appearance of serrated lesions. We recommend that all serrated lesions proximal to the sigmoid colon and all serrated lesions in the rectosigmoid > 5 mm in size, be completely removed. Recommendations are made for post-polypectomy surveillance of serrated lesions and for surveillance of serrated polyposis patients and their relatives.
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Rex DK, Ahnen DJ, Baron JA, Batts KP, Burke CA, Burt RW, Goldblum JR, Guillem JG, Kahi CJ, Kalady MF, O’Brien MJ, Odze RD, Ogino S, Parry S, Snover DC, Torlakovic EE, Wise PE, Young J, Church J. Serrated lesions of the colorectum: review and recommendations from an expert panel. Am J Gastroenterol 2012; 107:1315-29; quiz 1314, 1330. [PMID: 22710576 PMCID: PMC3629844 DOI: 10.1038/ajg.2012.161] [Citation(s) in RCA: 792] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Serrated lesions of the colorectum are the precursors of perhaps one-third of colorectal cancers (CRCs). Cancers arising in serrated lesions are usually in the proximal colon, and account for a disproportionate fraction of cancer identified after colonoscopy. We sought to provide guidance for the clinical management of serrated colorectal lesions based on current evidence and expert opinion regarding definitions, classification, and significance of serrated lesions. A consensus conference was held over 2 days reviewing the topic of serrated lesions from the perspectives of histology, molecular biology, epidemiology, clinical aspects, and serrated polyposis. Serrated lesions should be classified pathologically according to the World Health Organization criteria as hyperplastic polyp, sessile serrated adenoma/polyp (SSA/P) with or without cytological dysplasia, or traditional serrated adenoma (TSA). SSA/P and TSA are premalignant lesions, but SSA/P is the principal serrated precursor of CRCs. Serrated lesions have a distinct endoscopic appearance, and several lines of evidence suggest that on average they are more difficult to detect than conventional adenomatous polyps. Effective colonoscopy requires an endoscopist trained in the endoscopic appearance of serrated lesions. We recommend that all serrated lesions proximal to the sigmoid colon and all serrated lesions in the rectosigmoid > 5 mm in size, be completely removed. Recommendations are made for post-polypectomy surveillance of serrated lesions and for surveillance of serrated polyposis patients and their relatives.
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Affiliation(s)
| | - Dennis J. Ahnen
- Staff Physician Denver VA Medical Center and Professor of Medicine, University of Colorado School of Medicine
| | | | | | - Carol A. Burke
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | - Randall W. Burt
- Division of Gastroenterology, Department of Internal Medicine, University of Utah School of Medicine
| | | | | | - Charles J. Kahi
- Indiana University School of Medicine; Richard L. Roudebush VA Medical Center
| | | | | | - Robert D. Odze
- Brigham and Womens Hospital, Department of Pathology, Harvard Medical School, Boston MA
| | - Shuji Ogino
- Department of Pathology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Susan Parry
- New Zealand Familial GI Cancer Registry, Auckland City Hospital, New Zealand; Department of Gastroenterology, Middlemore Hospital, Auckland, New Zealand
| | - Dale C. Snover
- Department of Pathology, Fairview Southdale Hospital, Edina, MN
| | - Emina Emilia Torlakovic
- Department of Laboratory Medicine and Pathobiology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Paul E. Wise
- Department of Surgery, Vanderbilt University Medical Center
| | - Joanne Young
- Cancer Council Queensland Senior Research Fellow, Laboratory Head, Familial Cancer Laboratory, Australia
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