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Dai JY, Georg Luebeck E, Chang ET, Clarke CA, Hubbell EA, Zhang N, Duffy SW. Strong association between reduction of late-stage cancers and reduction of cancer-specific mortality in meta-regression of randomized screening trials across multiple cancer types. J Med Screen 2024:9691413241256744. [PMID: 38797981 DOI: 10.1177/09691413241256744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
BACKGROUND Late-stage cancer incidence has been proposed as an early surrogate for mortality in randomized controlled trials (RCTs) of cancer screening; however, its validity has not been systematically evaluated across screening RCTs of different cancers. METHODS We conducted a meta-regression analysis of cancer screening RCTs that reported both late-stage cancer incidence and cancer mortality. Based on a systematic literature review, we included 33 RCTs of screening programs targeting seven cancer types, including lung (n = 12), colorectal (n = 8), breast (n = 5), and prostate (n = 4), among others. We regressed the relative reduction of cancer mortality on the relative reduction of late-stage cancer incidence, inversely weighted for each RCT by the variance of estimated mortality reduction. RESULTS Across cancer types, the relative reduction of late-stage cancer incidence was linearly associated with the relative reduction of cancer mortality. Specifically, we observed this association for lung (R2 = 0.79 and 0.996 in three recent large trials), breast (R2 = 0.94), prostate (R2 = 0.98), and colorectal cancer (R2 = 0.75 for stage III/IV cancers and 0.93 for stage IV cancers). Trials with a 20% or greater reduction in late-stage cancers were more likely to achieve a significant reduction in cancer mortality. Our results also showed that no reduction of late-stage cancer incidence was associated with no or minimal reduction in cancer mortality. CONCLUSIONS Meta-regression of historical screening RCTs showed a strong linear association between reductions in late-stage cancer incidence and cancer mortality.
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Affiliation(s)
| | | | | | | | | | | | - Stephen W Duffy
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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2
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Webb AB, Berg CD, Castle PE, Crosby D, Etzioni R, Kessler LG, Menon U, Parmar M, Steele RJC, Sasieni PD. Considerations for using potential surrogate endpoints in cancer screening trials. Lancet Oncol 2024; 25:e183-e192. [PMID: 38697164 DOI: 10.1016/s1470-2045(24)00015-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 12/18/2023] [Accepted: 01/09/2024] [Indexed: 05/04/2024]
Abstract
The requirement of large-scale expensive cancer screening trials spanning decades creates considerable barriers to the development, commercialisation, and implementation of novel screening tests. One way to address these problems is to use surrogate endpoints for the ultimate endpoint of interest, cancer mortality, at an earlier timepoint. This Review aims to highlight the issues underlying the choice and use of surrogate endpoints for cancer screening trials, to propose criteria for when and how we might use such endpoints, and to suggest possible candidates. We present the current landscape and challenges, and discuss lessons and shortcomings from the therapeutic trial setting. It is hugely challenging to validate a surrogate endpoint, even with carefully designed clinical studies. Nevertheless, we consider whether there are candidates that might satisfy the requirements defined by research and regulatory bodies.
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Affiliation(s)
| | | | - Philip E Castle
- Division of Cancer Prevention and Division of Cancer Epidemiology and Genetics, US National Cancer Institute, Rockville, MD, USA
| | | | - Ruth Etzioni
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Larry G Kessler
- Department of Health Systems and Population Health (HSPOP), School of Public Health, University of Washington, Seattle, WA, USA
| | - Usha Menon
- Medical Research Council Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Mahesh Parmar
- Medical Research Council Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Robert J C Steele
- University of Dundee, Department of Surgery, Ninewells Hospital, Dundee, UK
| | - Peter D Sasieni
- The Cancer Research UK and King's College London Cancer Prevention Trials Unit, King's College London, London, UK; Wolfson Institute of Population Health, Queen Mary University of London, London, UK.
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3
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Shaukat A, Levin TR, Church TR. Screening for Colorectal Cancer in Asymptomatic Average-Risk Adults. Ann Intern Med 2024; 177:542-543. [PMID: 38621268 DOI: 10.7326/l24-0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/17/2024] Open
Affiliation(s)
| | | | - Timothy R Church
- University of Minnesota School of Public Health, Minneapolis, Minnesota
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4
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Bretthauer M, Wieszczy P, Løberg M, Kaminski MF, Werner TF, Helsingen LM, Mori Y, Holme Ø, Adami HO, Kalager M. Estimated Lifetime Gained With Cancer Screening Tests: A Meta-Analysis of Randomized Clinical Trials. JAMA Intern Med 2023; 183:1196-1203. [PMID: 37639247 PMCID: PMC10463170 DOI: 10.1001/jamainternmed.2023.3798] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 04/14/2023] [Indexed: 08/29/2023]
Abstract
Importance Cancer screening tests are promoted to save life by increasing longevity, but it is unknown whether people will live longer with commonly used cancer screening tests. Objective To estimate lifetime gained with cancer screening. Data Sources A systematic review and meta-analysis was conducted of randomized clinical trials with more than 9 years of follow-up reporting all-cause mortality and estimated lifetime gained for 6 commonly used cancer screening tests, comparing screening with no screening. The analysis included the general population. MEDLINE and the Cochrane library databases were searched, and the last search was performed October 12, 2022. Study Selection Mammography screening for breast cancer; colonoscopy, sigmoidoscopy, or fecal occult blood testing (FOBT) for colorectal cancer; computed tomography screening for lung cancer in smokers and former smokers; or prostate-specific antigen testing for prostate cancer. Data Extraction and Synthesis Searches and selection criteria followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline. Data were independently extracted by a single observer, and pooled analysis of clinical trials was used for analyses. Main Outcomes and Measures Life-years gained by screening was calculated as the difference in observed lifetime in the screening vs the no screening groups and computed absolute lifetime gained in days with 95% CIs for each screening test from meta-analyses or single randomized clinical trials. Results In total, 2 111 958 individuals enrolled in randomized clinical trials comparing screening with no screening using 6 different tests were eligible. Median follow-up was 10 years for computed tomography, prostate-specific antigen testing, and colonoscopy; 13 years for mammography; and 15 years for sigmoidoscopy and FOBT. The only screening test with a significant lifetime gain was sigmoidoscopy (110 days; 95% CI, 0-274 days). There was no significant difference following mammography (0 days: 95% CI, -190 to 237 days), prostate cancer screening (37 days; 95% CI, -37 to 73 days), colonoscopy (37 days; 95% CI, -146 to 146 days), FOBT screening every year or every other year (0 days; 95% CI, -70.7 to 70.7 days), and lung cancer screening (107 days; 95% CI, -286 days to 430 days). Conclusions and Relevance The findings of this meta-analysis suggest that current evidence does not substantiate the claim that common cancer screening tests save lives by extending lifetime, except possibly for colorectal cancer screening with sigmoidoscopy.
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Affiliation(s)
- Michael Bretthauer
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Department for Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Paulina Wieszczy
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Department for Transplantation Medicine, Oslo University Hospital, Oslo, Norway
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Magnus Løberg
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Department for Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Michal F. Kaminski
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Department for Transplantation Medicine, Oslo University Hospital, Oslo, Norway
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland
- Department of Cancer Prevention and Oncological Gastroenterology, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | | | - Lise M. Helsingen
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Department for Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Yuichi Mori
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Department for Transplantation Medicine, Oslo University Hospital, Oslo, Norway
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Øyvind Holme
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Department for Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Hans-Olov Adami
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Department for Transplantation Medicine, Oslo University Hospital, Oslo, Norway
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Mette Kalager
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Department for Transplantation Medicine, Oslo University Hospital, Oslo, Norway
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5
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Ding M, Yan J, Chao G, Zhang S. Application of artificial intelligence in colorectal cancer screening by colonoscopy: Future prospects (Review). Oncol Rep 2023; 50:199. [PMID: 37772392 DOI: 10.3892/or.2023.8636] [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: 02/21/2023] [Accepted: 07/07/2023] [Indexed: 09/30/2023] Open
Abstract
Colorectal cancer (CRC) has become a severe global health concern, with the third‑high incidence and second‑high mortality rate of all cancers. The burden of CRC is expected to surge to 60% by 2030. Fortunately, effective early evidence‑based screening could significantly reduce the incidence and mortality of CRC. Colonoscopy is the core screening method for CRC with high popularity and accuracy. Yet, the accuracy of colonoscopy in CRC screening is related to the experience and state of operating physicians. It is challenging to maintain the high CRC diagnostic rate of colonoscopy. Artificial intelligence (AI)‑assisted colonoscopy will compensate for the above shortcomings and improve the accuracy, efficiency, and quality of colonoscopy screening. The unique advantages of AI, such as the continuous advancement of high‑performance computing capabilities and innovative deep‑learning architectures, which hugely impact the control of colorectal cancer morbidity and mortality expectancy, highlight its role in colonoscopy screening.
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Affiliation(s)
- Menglu Ding
- The Second Affiliated Hospital of Zhejiang Chinese Medical University (The Xin Hua Hospital of Zhejiang Province), Hangzhou, Zhejiang 310000, P.R. China
| | - Junbin Yan
- The Second Affiliated Hospital of Zhejiang Chinese Medical University (The Xin Hua Hospital of Zhejiang Province), Hangzhou, Zhejiang 310000, P.R. China
| | - Guanqun Chao
- Department of General Practice, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, Zhejiang 310000, P.R. China
| | - Shuo Zhang
- The Second Affiliated Hospital of Zhejiang Chinese Medical University (The Xin Hua Hospital of Zhejiang Province), Hangzhou, Zhejiang 310000, P.R. China
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6
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Jordan B. [Does cancer screening really save lives ?]. Med Sci (Paris) 2023; 39:885-887. [PMID: 38018934 DOI: 10.1051/medsci/2023158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023] Open
Abstract
Systematic screening for specific cancers has been shown to reduce cancer-specific mortality, but has not demonstrated an effect on all-cause mortality. This paradox is due to minor but frequent risks of screening bearing on a large population, and also to the small beneficial effect expected even if screening is highly efficient. Upcoming multicancer detection approaches should allow a better detection of the effect (if any) of screening on all-cause mortality.
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Affiliation(s)
- Bertrand Jordan
- Biologiste, généticien et immunologiste, Président d'Aprogène (Association pour la promotion de la Génomique), 13007 Marseille, France
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7
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Dalmat RR, Ziebell RA, Kamineni A, Phipps AI, Weiss NS, Breslau ES, Burnett-Hartman AN, Corley DA, Doria-Rose VP, Green BB, Halm EA, Levin TR, Schottinger JE, Chubak J. Risk of Colorectal Cancer and Colorectal Cancer Mortality Beginning One Year after a Negative Fecal Occult Blood Test, among Screen-Eligible 76- to 85-Year-Olds. Cancer Epidemiol Biomarkers Prev 2023; 32:1382-1390. [PMID: 37450838 PMCID: PMC10592334 DOI: 10.1158/1055-9965.epi-23-0265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 06/05/2023] [Accepted: 07/13/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Colorectal cancer screening is universally recommended for adults ages 45 to 75 years. Noninvasive fecal occult blood tests are effective screening tests recommended by guidelines. However, empirical evidence to inform older adults' decisions about whether to continue screening is sparse, especially for individuals with prior screening. METHODS This study used a retrospective cohort of older adults at three Kaiser Permanente integrated healthcare systems (Northern California, Southern California, Washington) and Parkland Health. Beginning 1 year following a negative stool-based screening test, cumulative risks of colorectal cancer incidence, colorectal cancer mortality (accounting for deaths from other causes), and non-colorectal cancer mortality were estimated. RESULTS Cumulative incidence of colorectal cancer in screen-eligible adults ages 76 to 85 with a negative fecal occult blood test 1 year ago (N = 118,269) was 0.23% [95% confidence interval (CI), 0.20%-0.26%] after 2 years and 1.21% (95% CI, 1.13%-1.30%) after 8 years. Cumulative colorectal cancer mortality was 0.03% (95% CI, 0.02%-0.04%) after 2 years and 0.33% (95% CI, 0.28%-0.39%) after 8 years. Cumulative risk of death from non-colorectal cancer causes was 4.81% (95% CI, 4.68%-4.96%) after 2 years and 28.40% (95% CI, 27.95%-28.85%) after 8 years. CONCLUSIONS Among 76- to 85-year-olds with a recent negative stool-based test, cumulative colorectal cancer incidence and mortality estimates were low, especially within 2 years; death from other causes was over 100 times more likely than death from colorectal cancer. IMPACT These findings of low absolute colorectal cancer risk, and comparatively higher risk of death from other causes, can inform decision-making regarding whether and when to continue colorectal cancer screening beyond age 75 among screen-eligible adults.
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Affiliation(s)
- Ronit R. Dalmat
- Department of Epidemiology, University of Washington, Seattle, USA
| | - Rebecca A. Ziebell
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Amanda I. Phipps
- Department of Epidemiology, University of Washington, Seattle, USA
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Noel S. Weiss
- Department of Epidemiology, University of Washington, Seattle, USA
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Erica S. Breslau
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | | | - Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway Street, Oakland, CA, USA
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - V. Paul Doria-Rose
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | - Beverly B. Green
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
- Kaiser Permanente Bernard J Tyson School of Medicine, Department of Health Systems Science, Pasadena, CA
| | - Ethan A. Halm
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Theodore R. Levin
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway Street, Oakland, CA, USA
- Department of Gastroenterology, Kaiser Permanente Medical Center, Walnut Creek, CA USA
| | - Joanne E. Schottinger
- Kaiser Permanente Bernard J Tyson School of Medicine, Department of Health Systems Science, Pasadena, CA
| | - Jessica Chubak
- Department of Epidemiology, University of Washington, Seattle, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
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8
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Bresalier RS, Senore C, Young GP, Allison J, Benamouzig R, Benton S, Bossuyt PMM, Caro L, Carvalho B, Chiu HM, Coupé VMH, de Klaver W, de Klerk CM, Dekker E, Dolwani S, Fraser CG, Grady W, Guittet L, Gupta S, Halloran SP, Haug U, Hoff G, Itzkowitz S, Kortlever T, Koulaouzidis A, Ladabaum U, Lauby-Secretan B, Leja M, Levin B, Levin TR, Macrae F, Meijer GA, Melson J, O'Morain C, Parry S, Rabeneck L, Ransohoff DF, Sáenz R, Saito H, Sanduleanu-Dascalescu S, Schoen RE, Selby K, Singh H, Steele RJC, Sung JJY, Symonds EL, Winawer SJ. An efficient strategy for evaluating new non-invasive screening tests for colorectal cancer: the guiding principles. Gut 2023; 72:1904-1918. [PMID: 37463757 PMCID: PMC10511996 DOI: 10.1136/gutjnl-2023-329701] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 06/20/2023] [Indexed: 07/20/2023]
Abstract
OBJECTIVE New screening tests for colorectal cancer (CRC) are rapidly emerging. Conducting trials with mortality reduction as the end point supporting their adoption is challenging. We re-examined the principles underlying evaluation of new non-invasive tests in view of technological developments and identification of new biomarkers. DESIGN A formal consensus approach involving a multidisciplinary expert panel revised eight previously established principles. RESULTS Twelve newly stated principles emerged. Effectiveness of a new test can be evaluated by comparison with a proven comparator non-invasive test. The faecal immunochemical test is now considered the appropriate comparator, while colonoscopy remains the diagnostic standard. For a new test to be able to meet differing screening goals and regulatory requirements, flexibility to adjust its positivity threshold is desirable. A rigorous and efficient four-phased approach is proposed, commencing with small studies assessing the test's ability to discriminate between CRC and non-cancer states (phase I), followed by prospective estimation of accuracy across the continuum of neoplastic lesions in neoplasia-enriched populations (phase II). If these show promise, a provisional test positivity threshold is set before evaluation in typical screening populations. Phase III prospective studies determine single round intention-to-screen programme outcomes and confirm the test positivity threshold. Phase IV studies involve evaluation over repeated screening rounds with monitoring for missed lesions. Phases III and IV findings will provide the real-world data required to model test impact on CRC mortality and incidence. CONCLUSION New non-invasive tests can be efficiently evaluated by a rigorous phased comparative approach, generating data from unbiased populations that inform predictions of their health impact.
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Affiliation(s)
- Robert S Bresalier
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carlo Senore
- Epidemiology and screening unit, Centro di Riferimento per l'Epidemiologia e la Prevenzione Oncologica in Piemonte, Turin, Italy
| | - Graeme P Young
- Flinders Centre for Innovation in Cancer, Flinders University, Adelaide, South Australia, Australia
| | - James Allison
- Internal Medicine/Division of Gastroenterology, University of California San Francisco (UCSF), San Francisco, California, USA
| | - Robert Benamouzig
- Gastroenterology & Digestive Oncology Department, Hôpital Avicenne University Paris Nord La Sorbonne, Bobigny, France
| | - Sally Benton
- Department of Clinical Biochemistry and NHS Bowel Cancer Screening South of England Hub, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - Patrick M M Bossuyt
- Department of Epidemiology & Data Science, Amsterdam Public Health, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Luis Caro
- Carrera de especialista de Endoscopia Digestiva, Institución GEDYT (Gastroenterologia diagnostico y terapéutica), Buenos Aires, Argentina
| | - Beatriz Carvalho
- Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Han-Mo Chiu
- Department of Internal Medicine, College of Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Veerle M H Coupé
- Epidemiology and Data Science, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Willemijn de Klaver
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Clasine Maria de Klerk
- Department of Gastroenterology and Hepatology C2-310, Amsterdam UMC University of Amsterdam, Amsterdam, The Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology C2-115, Amsterdam University Medical Centres, Duivendrecht, The Netherlands
| | - Sunil Dolwani
- Dept of Gastroenterology, Division of Population Medicine, Cardiff University School of Medicine, Cardiff, UK
| | - Callum G Fraser
- Centre for Research into Cancer Prevention and Screening, University of Dundee School of Medicine, Dundee, UK
| | - William Grady
- Division of Translational Science and Therapeutics, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Lydia Guittet
- ERI3 Cancers & Populations, Normandie University, UNICAEN, Caen, France
| | - Samir Gupta
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | | | - Ulrike Haug
- Division of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology, Bremen, Germany
| | - Geir Hoff
- Department of Research, Telemark Hospital, Skien, Norway
- Department of CRC screening, Cancer Registry of Norway, Oslo, Norway
| | - Steven Itzkowitz
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Tim Kortlever
- Gastroenterology and Hepatology, Amsterdam University Medical Centres, Duivendrecht, The Netherlands
| | | | - Uri Ladabaum
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Beatrice Lauby-Secretan
- Section of Evidence Synthesis and Classification, International Agency for Research on Cancer, Lyon, France
| | - Mārcis Leja
- Institute of Clinical and Preventive Medicine, Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Bernard Levin
- Division of Cancer Prevention and Population Sciences, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Finlay Macrae
- Colorectal Medicine and Genetics, The University of Melbourne Department of Medicine Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Gerrit A Meijer
- Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Joshua Melson
- High-Risk Clinic for Gastrointestinal Cancers, University of Arizona Cancer Center Division of Gastroenterology, Banner University, Tucson, Arizona, USA
| | - Colm O'Morain
- Gastroenterology, Trinity College Dublin Faculty of Health Sciences, Dublin, Ireland
| | - Susan Parry
- National Bowel Screening Programme, National Screening Unit, Te Whatu Ora Health New Zealand, Auckland, New Zealand
- Department of Medicine, The University of Auckland, Auckland, New Zealand
| | - Linda Rabeneck
- Department of Medicine, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - David F Ransohoff
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Roque Sáenz
- Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago de Chile, Chile
| | - Hiroshi Saito
- Department of Gastroenterology, Aomori Prefectural Central Hospital, Aomori, Japan
| | | | - Robert E Schoen
- Departments of Medicine and Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kevin Selby
- Department of ambulatory Care, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Harminder Singh
- Internal Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | | | - Joseph J Y Sung
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Erin Leigh Symonds
- Department of Gastroenterology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Sidney J Winawer
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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9
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Kudelka MR, Gu W, Matsumoto Y, Ju T, Barnes II RH, Kardish RJ, Heimburg-Molinaro J, Lehoux S, Zeng J, Cohen C, Robinson BS, Shah KS, Chaikof EL, Stowell SR, Cummings RD. Targeting altered glycosylation in secreted tumor glycoproteins for broad cancer detection. Glycobiology 2023; 33:567-578. [PMID: 37216646 PMCID: PMC10426321 DOI: 10.1093/glycob/cwad035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/23/2023] [Indexed: 05/24/2023] Open
Abstract
There is an urgent need to develop new tumor biomarkers for early cancer detection, but the variability of tumor-derived antigens has been a limitation. Here we demonstrate a novel anti-Tn antibody microarray platform to detect Tn+ glycoproteins, a near universal antigen in carcinoma-derived glycoproteins, for broad detection of cancer. The platform uses a specific recombinant IgG1 to the Tn antigen (CD175) as a capture reagent and a recombinant IgM to the Tn antigen as a detecting reagent. These reagents were validated by immunohistochemistry in recognizing the Tn antigen using hundreds of human tumor specimens. Using this approach, we could detect Tn+ glycoproteins at subnanogram levels using cell lines and culture media, serum, and stool samples from mice engineered to express the Tn antigen in intestinal epithelial cells. The development of a general cancer detection platform using recombinant antibodies for detection of altered tumor glycoproteins expressing a unique antigen could have a significant impact on cancer detection and monitoring.
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Affiliation(s)
- Matthew R Kudelka
- Department of Biochemistry, Emory University School of Medicine, Atlanta, GA 30033, United States
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Wei Gu
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Yasuyuki Matsumoto
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Tongzhong Ju
- Department of Biochemistry, Emory University School of Medicine, Atlanta, GA 30033, United States
| | - Richard H Barnes II
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Robert J Kardish
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Jamie Heimburg-Molinaro
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Sylvain Lehoux
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Junwei Zeng
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Cynthia Cohen
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA 30033, United States
| | - Brian S Robinson
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA 30033, United States
| | - Kinjal S Shah
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA 30033, United States
| | - Elliot L Chaikof
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Sean R Stowell
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA 30033, United States
| | - Richard D Cummings
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
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Qaseem A, Harrod CS, Crandall CJ, Wilt TJ, Balk EM, Cooney TG, Cross JT, Fitterman N, Maroto M, Obley AJ, Tice J, Tufte JE, Shamliyan T, Yost J. Screening for Colorectal Cancer in Asymptomatic Average-Risk Adults: A Guidance Statement From the American College of Physicians (Version 2). Ann Intern Med 2023; 176:1092-1100. [PMID: 37523709 DOI: 10.7326/m23-0779] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023] Open
Abstract
DESCRIPTION The purpose of this updated guidance statement is to guide clinicians on screening for colorectal cancer (CRC) in asymptomatic average-risk adults. The intended audience is all clinicians. The population is asymptomatic adults at average risk for CRC. METHODS This updated guidance statement was developed using recently published and critically appraised clinical guidelines from national guideline developers since the publication of the American College of Physicians' 2019 guidance statement, "Screening for Colorectal Cancer in Asymptomatic Average-Risk Adults." The authors searched for national guidelines from the United States and other countries published in English using PubMed and the Guidelines International Network library from 1 January 2018 to 24 April 2023. The authors also searched for updates of guidelines included in the first version of our guidance statement. The Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument was used to assess the quality of eligible guidelines. Two guidelines were selected for adoption and adaptation by raters on the basis of the highest average overall AGREE II quality scores. The evidence reviews and modeling studies for these 2 guidelines were also used to synthesize the evidence of diagnostic test accuracy, effectiveness, and harms of CRC screening interventions and to develop our guidance statements. GUIDANCE STATEMENT 1 Clinicians should start screening for colorectal cancer in asymptomatic average-risk adults at age 50 years. GUIDANCE STATEMENT 2 Clinicians should consider not screening asymptomatic average-risk adults between the ages of 45 to 49 years. Clinicians should discuss the uncertainty around benefits and harms of screening in this population. GUIDANCE STATEMENT 3 Clinicians should stop screening for colorectal cancer in asymptomatic average-risk adults older than 75 years or in asymptomatic average-risk adults with a life expectancy of 10 years or less. GUIDANCE STATEMENT 4A Clinicians should select a screening test for colorectal cancer in consultation with their patient based on a discussion of benefits, harms, costs, availability, frequency, and patient values and preferences. GUIDANCE STATEMENT 4B Clinicians should select among a fecal immunochemical or high-sensitivity guaiac fecal occult blood test every 2 years, colonoscopy every 10 years, or flexible sigmoidoscopy every 10 years plus a fecal immunochemical test every 2 years as a screening test for colorectal cancer. GUIDANCE STATEMENT 4C Clinicians should not use stool DNA, computed tomography colonography, capsule endoscopy, urine, or serum screening tests for colorectal cancer.
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Affiliation(s)
- Amir Qaseem
- American College of Physicians, Philadelphia, Pennsylvania (A.Q., C.S.H.)
| | - Curtis S Harrod
- American College of Physicians, Philadelphia, Pennsylvania (A.Q., C.S.H.)
| | - Carolyn J Crandall
- David Geffen School of Medicine at UCLA, Los Angeles, California (C.J.C.)
| | - Timothy J Wilt
- Minneapolis VA Medical Center, Minneapolis, Minnesota (T.J.W.)
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11
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Zheng S, Schrijvers JJA, Greuter MJW, Kats-Ugurlu G, Lu W, de Bock GH. Effectiveness of Colorectal Cancer (CRC) Screening on All-Cause and CRC-Specific Mortality Reduction: A Systematic Review and Meta-Analysis. Cancers (Basel) 2023; 15:cancers15071948. [PMID: 37046609 PMCID: PMC10093633 DOI: 10.3390/cancers15071948] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/14/2023] [Accepted: 03/22/2023] [Indexed: 04/14/2023] Open
Abstract
(1) Background: The aim of this study was to pool and compare all-cause and colorectal cancer (CRC) specific mortality reduction of CRC screening in randomized control trials (RCTs) and simulation models, and to determine factors that influence screening effectiveness. (2) Methods: PubMed, Embase, Web of Science and Cochrane library were searched for eligible studies. Multi-use simulation models or RCTs that compared the mortality of CRC screening with no screening in general population were included. CRC-specific and all-cause mortality rate ratios and 95% confidence intervals were calculated by a bivariate random model. (3) Results: 10 RCTs and 47 model studies were retrieved. The pooled CRC-specific mortality rate ratios in RCTs were 0.88 (0.80, 0.96) and 0.76 (0.68, 0.84) for guaiac-based fecal occult blood tests (gFOBT) and single flexible sigmoidoscopy (FS) screening, respectively. For the model studies, the rate ratios were 0.45 (0.39, 0.51) for biennial fecal immunochemical tests (FIT), 0.31 (0.28, 0.34) for biennial gFOBT, 0.61 (0.53, 0.72) for single FS, 0.27 (0.21, 0.35) for 10-yearly colonoscopy, and 0.35 (0.29, 0.42) for 5-yearly FS. The CRC-specific mortality reduction of gFOBT increased with higher adherence in both studies (RCT: 0.78 (0.68, 0.89) vs. 0.92 (0.87, 0.98), model: 0.30 (0.28, 0.33) vs. 0.92 (0.51, 1.63)). Model studies showed a 0.62-1.1% all-cause mortality reduction with single FS screening. (4) Conclusions: Based on RCTs and model studies, biennial FIT/gFOBT, single and 5-yearly FS, and 10-yearly colonoscopy screening significantly reduces CRC-specific mortality. The model estimates are much higher than in RCTs, because the simulated biennial gFOBT assumes higher adherence. The effectiveness of screening increases at younger screening initiation ages and higher adherences.
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Affiliation(s)
- Senshuang Zheng
- Medical Center Groningen, Department of Epidemiology, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Jelle J A Schrijvers
- Medical Center Groningen, Department of Epidemiology, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Marcel J W Greuter
- Medical Center Groningen, Department of Radiology, University of Groningen, 9700 RB Groningen, The Netherlands
- Robotics and Mechatronics (RaM) Group, Technical Medical Centre, Faculty of Electrical Engineering Mathematics and Computer Science, University of Twente, 7522 NH Enschede, The Netherlands
| | - Gürsah Kats-Ugurlu
- Medical Center Groningen, Department of Pathology, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Wenli Lu
- Department of Epidemiology and Health Statistics, Tianjin Medical University, Tianjin 300070, China
| | - Geertruida H de Bock
- Medical Center Groningen, Department of Epidemiology, University of Groningen, 9700 RB Groningen, The Netherlands
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12
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Bright D, Hillier S, Song J, Huws DW, Greene G, Hodgson K, Akbari A, Griffiths R, Davies AR, Gjini A. Inequalities in colorectal cancer screening uptake in Wales: an examination of the impact of the temporary suspension of the screening programme during the COVID-19 pandemic. BMC Public Health 2023; 23:546. [PMID: 36949447 PMCID: PMC10031708 DOI: 10.1186/s12889-023-15345-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 02/28/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Response to the early stages of the COVID-19 pandemic resulted in the temporary disruption of cancer screening in the UK, and strong public messaging to stay safe and to protect NHS capacity. Following reintroduction in services, we explored the impact on inequalities in uptake of the Bowel Screening Wales (BSW) programme to identify groups who may benefit from tailored interventions. METHODS Records within the BSW were linked to electronic health records (EHR) and administrative data within the Secured Anonymised Information Linkage (SAIL) Databank. Ethnic group was obtained from a linked data method available within SAIL. We examined uptake for the first 3 months of invitations (August to October) following the reintroduction of BSW programme in 2020, compared to the same period in the preceding 3 years. Uptake was measured across a 6 month follow-up period. Logistic models were conducted to analyse variations in uptake by sex, age group, income deprivation quintile, urban/rural location, ethnic group, and clinically extremely vulnerable (CEV) status in each period; and to compare uptake within sociodemographic groups between different periods. RESULTS Uptake during August to October 2020 (period 2020/21; 60.4%) declined compared to the same period in 2019/20 (62.7%) but remained above the 60% Welsh standard. Variation by sex, age, income deprivation, and ethnic groups was observed in all periods studied. Compared to the pre-pandemic period in 2019/20, uptake declined for most demographic groups, except for older individuals (70-74 years) and those in the most income deprived group. Uptake continues to be lower in males, younger individuals, people living in the most income deprived areas and those of Asian and unknown ethnic backgrounds. CONCLUSION Our findings are encouraging with overall uptake achieving the 60% Welsh standard during the first three months after the programme restarted in 2020 despite the disruption. Inequalities did not worsen after the programme resumed activities but variations in CRC screening in Wales associated with sex, age, deprivation and ethnic group remain. This needs to be considered in targeting strategies to improve uptake and informed choice in CRC screening to avoid exacerbating disparities in CRC outcomes as screening services recover from the pandemic.
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Affiliation(s)
- Diana Bright
- Research and Evaluation Division, Knowledge and Research Directorate, Public Health Data, Public Health Wales, Floor 5, Number 2 Capital Quarter, Tyndall Street, Cardiff, CF10 4BZ, UK.
| | - Sharon Hillier
- Health Protection and Screening Services Directorate. Public Health Wales, Cardiff, Wales
| | - Jiao Song
- Communicable Disease Surveillance Centre. Public Health Wales, Cardiff, Wales
| | - Dyfed W Huws
- Research and Evaluation Division, Knowledge and Research Directorate, Public Health Data, Public Health Wales, Floor 5, Number 2 Capital Quarter, Tyndall Street, Cardiff, CF10 4BZ, UK
- Population Data Science, Faculty of Medicine, Health & Life Science, Swansea University Medical School, Swansea University, Swansea, Wales
| | - Giles Greene
- Research and Evaluation Division, Knowledge and Research Directorate, Public Health Data, Public Health Wales, Floor 5, Number 2 Capital Quarter, Tyndall Street, Cardiff, CF10 4BZ, UK
| | - Karen Hodgson
- Research and Evaluation Division, Knowledge and Research Directorate, Public Health Data, Public Health Wales, Floor 5, Number 2 Capital Quarter, Tyndall Street, Cardiff, CF10 4BZ, UK
| | - Ashley Akbari
- Population Data Science, Faculty of Medicine, Health & Life Science, Swansea University Medical School, Swansea University, Swansea, Wales
| | - Rowena Griffiths
- Population Data Science, Faculty of Medicine, Health & Life Science, Swansea University Medical School, Swansea University, Swansea, Wales
| | - Alisha R Davies
- Research and Evaluation Division, Knowledge and Research Directorate, Public Health Data, Public Health Wales, Floor 5, Number 2 Capital Quarter, Tyndall Street, Cardiff, CF10 4BZ, UK
| | - Ardiana Gjini
- Health Protection and Screening Services Directorate. Public Health Wales, Cardiff, Wales
- Cardiff University, Cardiff, UK
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13
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Bărbulescu LN, Mogoantă SȘ, Bărbulescu LF, Kamal C, Popa DL, Popa RT. A Pilot Colorectal Cancer Study Using Fecal Occult Blood Tests and Colonoscopy to Identify the Weaknesses of the Romanian Public Healthcare System before Implementing National Screening. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2531. [PMID: 36767908 PMCID: PMC9915351 DOI: 10.3390/ijerph20032531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/26/2023] [Accepted: 01/28/2023] [Indexed: 06/18/2023]
Abstract
The objective of this study is to investigate the feasibility of colorectal cancer (CRC) screening in the absence of a national screening program using the resources provided by the Romanian healthcare system. Study participants were recruited from adult patients (over 18 years old) registered with a general practitioner from an urban area over a period of 3 years (October 2019 to September 2022). Patients were recruited when they came for a consult at their family physician's office. The study excluded patients with a medical history of colorectal cancer. Written consent was obtained from the patients who agreed to participate. Patients who agreed to participate were recommended to undergo a fecal occult blood test (FOBT). For those with a positive FOBT result, a colonoscopy was recommended. The study identified a need and willingness of patients to participate in CRC screening when they were informed about it, especially when it involved a noninvasive test such as FOB. We did not anticipate the refusal to perform FOBT in the public healthcare system because the recommendation was made by a GP. We identified a deficit of specialists that can perform colonoscopies in the public healthcare system, insufficient health education, and a lack of dedicated pathways for screening.
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Affiliation(s)
- Linda-Nicoleta Bărbulescu
- Doctoral School, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
- Cabinet Medical Dr Profir I Mirela SRL, 200145 Craiova, Romania
| | - Stelian-Ștefăniță Mogoantă
- Department of Surgery, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
- Department III of Surgery, University Emergency County Hospital, 200642 Craiova, Romania
| | | | - Constantin Kamal
- Department of Family Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Didi-Liliana Popa
- Department of Computers and Information Technology, University of Craiova, 200585 Craiova, Romania
- Doctoral School “Constantin Belea”, University of Craiova, 200585 Craiova, Romania
| | - Radu-Teodoru Popa
- Department of Computers and Information Technology, University of Craiova, 200585 Craiova, Romania
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14
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Kaalby L, Deding U, Al-Najami I, Berg-Beckhoff G, Bjørsum-Meyer T, Laurberg T, Shaukat A, Steele RJC, Koulaouzidis A, Rasmussen M, Kobaek-Larsen M, Baatrup G. Faecal haemoglobin concentrations are associated with all-cause mortality and cause of death in colorectal cancer screening. BMC Med 2023; 21:29. [PMID: 36691009 PMCID: PMC9872406 DOI: 10.1186/s12916-022-02724-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 12/28/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Colorectal cancer (CRC) screening reduces all-cause and CRC-related mortality. New research demonstrates that the faecal haemoglobin concentration (f-Hb) may indicate the presence of other serious diseases not related to CRC. We investigated the association between f-Hb, measured by a faecal immunochemical test (FIT), and both all-cause mortality and cause of death in a population-wide cohort of screening participants. METHODS Between 2014 and 2018, 1,262,165 participants submitted a FIT for the Danish CRC screening programme. We followed these participants, using the Danish CRC Screening Database and several other national registers on health and population, until December 31, 2018. We stratified participants by f-Hb and compared them using a Cox proportional hazards regression on all-cause mortality and cause of death reported as adjusted hazard ratios (aHRs). We adjusted for several covariates, including comorbidity, socioeconomic factors, demography and prescription medication. RESULTS We observed 21,847 deaths in the study period. Our multivariate analyses indicated an association relationship between increasing f-Hb and the risk of dying in the study period. This risk increased steadily from aHR 1.38 (95% CI: 1.32, 1.44) in those with a f-Hb of 7.1-11.9 μg Hb/g faeces to 2.20 (95% CI: 2.10, 2.30) in those with a f-Hb ≥60.0 μg Hb/g faeces, when compared to those with a f-Hb ≤7.0 μg Hb/g faeces. The pattern remained when excluding CRC from the analysis. Similar patterns were observed between incrementally increasing f-Hb and the risk of dying from respiratory disease, cardiovascular disease and cancers other than CRC. Furthermore, we observed an increased risk of dying from CRC with increasing f-Hb. CONCLUSIONS Our findings support the hypothesis that f-Hb may indicate an elevated risk of having chronic conditions if causes for the bleeding have not been identified. The mechanisms still need to be established, but f-Hb may be a potential biomarker for several non-CRC diseases.
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Affiliation(s)
- Lasse Kaalby
- Department of Surgery, Odense University Hospital, 5000, Odense, Denmark.
- Department of Clinical Research, University of Southern Denmark, 5000, Odense, Denmark.
| | - Ulrik Deding
- Department of Surgery, Odense University Hospital, 5000, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, 5000, Odense, Denmark
| | - Issam Al-Najami
- Department of Surgery, Odense University Hospital, 5000, Odense, Denmark
| | - Gabriele Berg-Beckhoff
- Unit for Health Promotion Research, Department of Public Health, University of Southern Denmark, 6700, Esbjerg, Denmark
- Unit for Health Research, Hospital South West Jutland, 6700, Esbjerg, Denmark
| | - Thomas Bjørsum-Meyer
- Department of Surgery, Odense University Hospital, 5000, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, 5000, Odense, Denmark
| | - Tinne Laurberg
- Steno Diabetes Centre Aarhus, Aarhus University Hospital, Aarhus, Denmark
| | - Aasma Shaukat
- GI Section, Minneapolis VA Medical Center and University of Minnesota, Minneapolis, MN, 55417, USA
- Division of Gastroenterology NYU Langone, New York, NY, 10016, USA
| | - Robert J C Steele
- Centre for Research into Cancer Prevention and Screening, University of Dundee School of Medicine, Dundee, DD1 9SY, UK
| | - Anastasios Koulaouzidis
- Department of Surgery, Odense University Hospital, 5000, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, 5000, Odense, Denmark
| | - Morten Rasmussen
- Digestive Disease Center, Bispebjerg University Hospital, 2400, Copenhagen, Denmark
| | - Morten Kobaek-Larsen
- Department of Surgery, Odense University Hospital, 5000, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, 5000, Odense, Denmark
| | - Gunnar Baatrup
- Department of Surgery, Odense University Hospital, 5000, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, 5000, Odense, Denmark
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15
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Reid MS, Paul HA, Mostoufi A, Robinson JL, Sadrzadeh SMH. Evaluation of the stability of fecal immunochemical test specimens. Clin Biochem 2022; 115:92-96. [PMID: 36470343 DOI: 10.1016/j.clinbiochem.2022.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 11/25/2022] [Accepted: 11/30/2022] [Indexed: 12/04/2022]
Abstract
Fecal immunochemical tests (FIT) are used to screen for colorectal cancer by detecting blood present in stool. Patients collect FIT specimens at home in a sampling kit and return them to the lab for testing. At our institution, patients are instructed to return their specimens to the laboratory within seven days from collection, which is shorter than the manufacturer stated room temperature (RT) stability of 15 days. The objective of this study was to assess and verify the stability of FIT specimens at RT and to determine if refrigerated storage improves stability. A series of experiments were performed with the OC-Sensor DIANA iFOB Test system between 2017 and 2019, using a positive clinical cut-off of 75 ng/mL (15 µg/g) hemoglobin (Hb). Specimens were collected and categorized based on their initially measured Hb concentration and had repeated measurements for up to 21 days following collection. FIT specimens were stored either at RT or refrigerated. Our results show that FIT specimens have reduced concentrations of Hb compared to baseline when stored at RT; refrigeration improved FIT specimen stability but did not completely prevent the reduction in Hb concentration. Additionally, specimens marginally above the cut-off (initial concentrations between 75 and 100 ng/mL (15-20 µg/g)) that were stored at RT showed 100% positivity on the day of collection (n=33), 63% on Day 3 (n=19), 46% on Days 4/5 (n=26), and 38% on Days 6/7 (n=26). Finally, specimens with Hb values near the clinical cut-off appear to be particularly susceptible to false negatives as a result of the reduction in Hb over time. Therefore, laboratories should verify the specifics of their FIT tests before offering it to patients to reduce false negatives.
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Affiliation(s)
- Michael S Reid
- Alberta Precision Laboratories, Diagnostic and Scientific Research Centre, 3535 Research Rd NW, Calgary, AB T2L 2K8, Canada; Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada.
| | - Heather A Paul
- Alberta Precision Laboratories, Diagnostic and Scientific Research Centre, 3535 Research Rd NW, Calgary, AB T2L 2K8, Canada; Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada.
| | - Arshia Mostoufi
- Department of Biological Sciences, University of Calgary, Calgary, AB, Canada.
| | - Jason L Robinson
- Alberta Precision Laboratories, Diagnostic and Scientific Research Centre, 3535 Research Rd NW, Calgary, AB T2L 2K8, Canada; Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada; Health PEI, Charlottetown, PEI, Canada.
| | - S M Hossein Sadrzadeh
- Alberta Precision Laboratories, Diagnostic and Scientific Research Centre, 3535 Research Rd NW, Calgary, AB T2L 2K8, Canada; Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada.
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16
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Sung JJY, Chiu HM, Lieberman D, Kuipers EJ, Rutter MD, Macrae F, Yeoh KG, Ang TL, Chong VH, John S, Li J, Wu K, Ng SSM, Makharia GK, Abdullah M, Kobayashi N, Sekiguchi M, Byeon JS, Kim HS, Parry S, Cabral-Prodigalidad PAI, Wu DC, Khomvilai S, Lui RN, Wong S, Lin YM, Dekker E. Third Asia-Pacific consensus recommendations on colorectal cancer screening and postpolypectomy surveillance. Gut 2022; 71:2152-2166. [PMID: 36002247 DOI: 10.1136/gutjnl-2022-327377] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 08/07/2022] [Indexed: 12/09/2022]
Abstract
The Asia-Pacific region has the largest number of cases of colorectal cancer (CRC) and one of the highest levels of mortality due to this condition in the world. Since the publishing of two consensus recommendations in 2008 and 2015, significant advancements have been made in our knowledge of epidemiology, pathology and the natural history of the adenoma-carcinoma progression. Based on the most updated epidemiological and clinical studies in this region, considering literature from international studies, and adopting the modified Delphi process, the Asia-Pacific Working Group on Colorectal Cancer Screening has updated and revised their recommendations on (1) screening methods and preferred strategies; (2) age for starting and terminating screening for CRC; (3) screening for individuals with a family history of CRC or advanced adenoma; (4) surveillance for those with adenomas; (5) screening and surveillance for sessile serrated lesions and (6) quality assurance of screening programmes. Thirteen countries/regions in the Asia-Pacific region were represented in this exercise. International advisors from North America and Europe were invited to participate.
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Affiliation(s)
| | - Han-Mo Chiu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | | | | | | | - Finlay Macrae
- The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | | | | | - Vui Heng Chong
- Raja Isteri Pengiran Anak Saleha Hospital, Brunei, Brunei Darussalam
| | - Sneha John
- Digestive Health, Endoscopy, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Jingnan Li
- Peking Union Medical College Hospital, Beijing, China
| | - Kaichun Wu
- Fourth Military Medical University, Xi'an, China
| | - Simon S M Ng
- The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | | | - Murdani Abdullah
- Division of Gastroenterology, Pancreatibiliar and Digestive Endoscopy. Department of Internal Medicine, Hospital Dr Cipto Mangunkusumo, Jakarta, Indonesia.,Human Cancer Research Center. IMERI. Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Nozomu Kobayashi
- Cancer Screening Center/ Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan.,Division of Screening Technology, National Cancer Center Institute for Cancer Control, Tokyo, Japan
| | - Masau Sekiguchi
- Cancer Screening Center/ Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan.,Division of Screening Technology, National Cancer Center Institute for Cancer Control, Tokyo, Japan
| | - Jeong-Sik Byeon
- University of Ulsan College of Medicine, Seoul, Korea (the Republic of)
| | - Hyun-Soo Kim
- Yonsei University, Seoul, Korea (the Republic of)
| | - Susan Parry
- National Bowel Screening Programme, New Zealand Ministry of Health, Auckland, New Zealand.,The University of Auckland, Auckland, New Zealand
| | | | | | | | - Rashid N Lui
- Division of Gastroenterology and Hepatology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, Hong Kong.,Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Sunny Wong
- Lee Kong Chian School of Medicine, Singapore
| | - Yu-Min Lin
- Shin Kong Wu Ho Su Memorial Hospital, Taipei, Taiwan
| | - E Dekker
- Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
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17
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Sung SY, Choi HH, Kim S, Park BR, Kim YK, Kim HK, Cho YS, Kim SW, Kim SS, Chae HS. Colonoscopy decreases mortality in colorectal cancer patients compared with fecal immunochemical test. J Gastroenterol Hepatol 2022; 37:1991-1997. [PMID: 35738218 DOI: 10.1111/jgh.15924] [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: 01/18/2022] [Revised: 06/03/2022] [Accepted: 06/18/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Colonoscopy and fecal immunochemical test (FIT) are commonly used screening methods for the detection of colorectal cancer (CRC), but their effects on survival have not been compared. We compared survival outcomes in patients with CRC according to the exposure history to colonoscopy or FIT before diagnosis of CRC. METHODS We performed a nationwide population-based retrospective cohort study using Korean national-insurance claims data. In total, 24 875 patients with CRC diagnosed in 2012 were included. The patients were divided into three groups in terms of examinations performed during the 10 years prior to CRC diagnosis: the colonoscopy group, the FIT group, and the never-screened group. Survival outcomes were compared among the three groups. The colonoscopy group and FIT group were matched using propensity score-matching method. RESULTS The cohort consisted of 9619 patients in the colonoscopy group, 6936 patients in the FIT group, and 8320 patients in the never-screened group. The 5-year overall survival rates were 74.1% in the colonoscopy group, 65.9% in the FIT group, and 59.6% in the never-screened group (P < 0.001). The adjusted hazard ratios for death were 0.56 (95% confidence interval [CI], 0.53-0.59) in the colonoscopy group and 0.78 (95% CI, 0.74-0.82) in the FIT group compared with the never-screened group. In the matched cohort, the adjusted hazard ratios for death was 0.76 (95% CI, 0.72-0.81) in the colonoscopy group compared with the FIT group. CONCLUSION Colonoscopy is a more effective method for reducing mortality in patients with CRC compared with FIT.
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Affiliation(s)
- Soo-Yoon Sung
- Department of Radiation Oncology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyun Ho Choi
- Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sukil Kim
- Department of Preventive Medicine and Public Health, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Bo Ram Park
- Big Data Department, National Health Insurance Service
| | - Young Ki Kim
- Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyung-Keun Kim
- Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young-Seok Cho
- Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Woo Kim
- Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung Soo Kim
- Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hiun-Suk Chae
- Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Castanon A, Parmar D, Massat NJ, Sasieni P, Duffy SW. Benefit of Biennial Fecal Occult Blood Screening on Colorectal Cancer in England: A Population-Based Case-Control Study. J Natl Cancer Inst 2022; 114:1262-1269. [PMID: 35575409 PMCID: PMC9468279 DOI: 10.1093/jnci/djac100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/23/2021] [Accepted: 05/06/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The English national bowel cancer screening program offering a guaiac fecal occult blood test began in July 2006. In randomized controlled trials of guaiac fecal occult blood test screening, reductions in mortality were accompanied by reductions in advanced stage colorectal cancer (CRC). We aimed to evaluate the effect of participation in the national bowel cancer screening program on stage-specific CRC incidence as a likely precursor of a mortality effect. METHODS In this population-based case-control study, cases were individuals diagnosed with CRC aged 60-79 years between January 1, 2012, and December 31, 2013. Two controls per case were matched on geographic region, gender, date of birth, and year of first screening invitation. Screening histories were extracted from the screening database. Conditional logistic regression with correction for self-selection bias was used to estimate odds ratios (odds ratios corrected for self-selection bias [cOR]) and 95% confidence intervals (CIs) by Duke stage, sex, and age. RESULTS 14 636 individuals with CRC and 29 036 without were eligible for analysis. The odds of CRC (any stage) were increased within 30 days of a screening test and decreased thereafter. No reduction in CRC (any stage) among screened individuals compared with those not screened was observed (cOR = 1.00, 95% CI = 0.89 to 1.15). However, screened individuals had lower odds of Duke stage D CRC (cOR = 0.68, 95% CI = 0.50 to 0.93). We estimate 435 fewer Duke D CRC by age 80 years in 100 000 people screened biennially between ages 60 and 74 years compared with an unscreened cohort. CONCLUSION The impact of colorectal screening on advanced CRC incidence suggests that the program will meet its aim of reducing mortality.
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Affiliation(s)
- Alejandra Castanon
- Cancer Prevention Group, Faculty of Life Sciences & Medicine, School of Cancer & Pharmaceutical Sciences, King’s College London, London, UK
| | - Dharmishta Parmar
- Centre for Prevention, Detection and Diagnosis,Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Nathalie J Massat
- Centre for Prevention, Detection and Diagnosis,Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Peter Sasieni
- Cancer Prevention Group, Faculty of Life Sciences & Medicine, School of Cancer & Pharmaceutical Sciences, King’s College London, London, UK
| | - Stephen W Duffy
- Centre for Prevention, Detection and Diagnosis,Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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Thomas C, Mandrik O, Whyte S. Modelling cost-effective strategies for minimising socioeconomic inequalities in colorectal cancer screening outcomes in England. Prev Med 2022; 162:107131. [PMID: 35803353 DOI: 10.1016/j.ypmed.2022.107131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/17/2022] [Accepted: 06/27/2022] [Indexed: 11/18/2022]
Abstract
Colorectal cancer (CRC) incidence and mortality is higher in socioeconomically deprived groups for a variety of reasons, but is exacerbated by poorer screening uptake. However, many strategies for improving screening participation exist. This analysis aimed to model the impact of screening on CRC inequalities in England and then compare different strategies for increasing participation, to determine the most cost-effective methods for reducing screening-induced inequalities. An existing health economic model, Microsimulation Model in Cancer of the Bowel was adapted. Screening-eligible individuals were simulated to investigate the impact of screening on CRC inequalities. Following this, four strategies for promoting screening participation were compared: 1) annual re-invitation of screening non-participants; 2) a national media advertising campaign; 3) text message reminders for non-participants; 4) health promotion in deprived populations. Cost-effectiveness, CRC outcomes, resource impacts and effects on CRC inequalities were assessed. Inequalities analysis was based on age-standardised CRC mortality by socioeconomic group. Screening was found to be highly cost-effective but CRC inequalities increased as screening effectiveness improved. Annual re-invitation of non-participants was most cost-effective for promoting particiption (incremental cost-effectiveness ratio = £4404 per quality-adjusted life-year), reducing CRC mortality (11,129 deaths averted), and reducing screening-induced inequality (slope of inequalities reduced from 20.80 to 19.38), although it required 42% more screening kits to be sent out. Other strategies were cost-effective compared with screening alone, and improved CRC outcomes, but had varying impacts on inequalities. Whilst bowel cancer screening increases socioeconomic inequalities in CRC mortality, effective and cost-effective strategies are available for mitigating screening-induced inequalities.
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Affiliation(s)
- Chloe Thomas
- School of Health and Related Research, University of Sheffield, Regent Court, Sheffield S1 4DA, United Kingdom.
| | - Olena Mandrik
- School of Health and Related Research, University of Sheffield, Regent Court, Sheffield S1 4DA, United Kingdom
| | - Sophie Whyte
- School of Health and Related Research, University of Sheffield, Regent Court, Sheffield S1 4DA, United Kingdom
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20
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Cardoso R, Guo F, Heisser T, De Schutter H, Van Damme N, Nilbert MC, Tybjerg AJ, Bouvier AM, Bouvier V, Launoy G, Woronoff AS, Cariou M, Robaszkiewicz M, Delafosse P, Poncet F, Walsh PM, Senore C, Rosso S, Lemmens VEPP, Elferink MAG, Tomšič S, Žagar T, Lopez de Munain Marques A, Marcos-Gragera R, Puigdemont M, Galceran J, Carulla M, Sánchez-Gil A, Chirlaque MD, Hoffmeister M, Brenner H. Proportion and stage distribution of screen-detected and non-screen-detected colorectal cancer in nine European countries: an international, population-based study. Lancet Gastroenterol Hepatol 2022; 7:711-723. [PMID: 35561739 DOI: 10.1016/s2468-1253(22)00084-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/14/2022] [Accepted: 02/25/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND The effects of recently implemented colorectal cancer screening programmes in Europe on colorectal cancer mortality will take several years to be fully known. We aimed to analyse the characteristics and parameters of screening programmes, proportions of colorectal cancers detected through screening, and stage distribution in screen-detected and non-screen-detected colorectal cancers to provide a timely assessment of the potential effects of screening programmes in several European countries. METHODS We conducted this population-based study in nine European countries for which data on mode of detection were available (Belgium, Denmark, England, France, Italy, Ireland, the Netherlands, Slovenia, and Spain). Data from 16 population-based cancer registries were included. Patients were included if they were diagnosed with colorectal cancer from the year that organised colorectal cancer screening programmes were implemented in each country until the latest year with available data at the time of analysis, and if their age at diagnosis fell within the age groups targeted by the programmes. Data collected included sex, age at diagnosis, date of diagnosis, topography, morphology, clinical and pathological TNM information based on the edition in place at time of diagnosis, and mode of detection (ie, screen detected or non-screen detected). If stage information was not available, patients were not included in stage-specific analyses. The primary outcome was proportion and stage distribution of screen-detected versus non-screen detected colorectal cancers. FINDINGS 228 667 colorectal cancer cases were included in the analyses. Proportions of screen-detected cancers varied widely across countries and regions. The highest proportions (40-60%) were found in Slovenia and the Basque Country in Spain, where FIT-based programmes were fully rolled out, and participation rates were higher than 50%. A similar proportion of screen-detected cancers was also found for the Netherlands in 2015, where participation was over 70%, even though the programme had not yet been fully rolled out to all age groups. In most other countries and regions, proportions of screen-detected cancers were below 30%. Compared with non-screen-detected cancers, screen-detected cancers were much more often found in the distal colon (range 34·5-51·1% screen detected vs 26·4-35·7% non-screen detected) and less often in the proximal colon (19·5-29·9% screen detected vs 24·9-32·8% non-screen detected) p≤0·02 for each country, more often at stage I (35·7-52·7% screen detected vs 13·2-24·9% non-screen detected), and less often at stage IV (5·8-12·5% screen detected vs 22·5-31·9% non-screen detected) p<0·0001 for each country. INTERPRETATION The proportion of colorectal cancer cases detected by screening varied widely between countries. However, in all countries, screen-detected cancers had a more favourable stage distribution than cancers detected otherwise. There is still much need and scope for improving early detection of cancer across all segments of the colorectum, and particularly in the proximal colon and rectum. FUNDING Deutsche Krebshilfe.
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Affiliation(s)
- Rafael Cardoso
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases, Heidelberg, Germany; Medical Faculty Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Feng Guo
- Division of Clinical Epidemiology and Aging Research, DKFZ, Heidelberg, Germany
| | - Thomas Heisser
- Medical Faculty Heidelberg, University of Heidelberg, Heidelberg, Germany; Division of Clinical Epidemiology and Aging Research, DKFZ, Heidelberg, Germany
| | | | | | - Mef Christina Nilbert
- Danish Cancer Society Research Center, Copenhagen, Denmark; Hvidovre University Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | - Anne-Marie Bouvier
- Digestive Cancer Registry of Burgundy, Dijon, France, INSERM U1231, University Hospital of Dijon, French Network of Cancer Registries (FRANCIM), Dijon, France
| | - Véronique Bouvier
- Digestive Tumors Registry of Calvados, University Hospital of Caen, U1086 INSERM UCN - ANTICIPE, FRANCIM, Caen, France
| | - Guy Launoy
- Normandie University, UniCaen, INSERM ANTICIPE, Caen, France; University Hospital of Caen, Caen, France
| | - Anne-Sophie Woronoff
- Cancer Registry of Doubs, Centre Hospitalier Régional Universitaire Besançon (CHRU) Besançon, France
| | - Mélanie Cariou
- Digestive Tumors Registry of Finistère, CHRU Morvan, FRANCIM, Brest, France
| | | | | | | | | | | | - Stefano Rosso
- Piedmont Cancer Registry, University Hospital 'Città della Salute e della Scienza', Turin, Italy
| | - Valery E P P Lemmens
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, Netherlands; Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marloes A G Elferink
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, Netherlands
| | - Sonja Tomšič
- Slovenian Cancer Registry, Institute of Oncology, Ljubljana, Slovenia
| | - Tina Žagar
- Slovenian Cancer Registry, Institute of Oncology, Ljubljana, Slovenia
| | | | - Rafael Marcos-Gragera
- Epidemiology Unit and Girona Cancer Registry, Oncology Coordination Plan, Department of Health Government of Catalonia, Catalan Institute of Oncology, Girona, Spain; Descriptive Epidemiology, Genetics and Cancer Prevention Group, Biomedical Research Institute, Salt, Spain; Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiología y Salud Pública), Madrid, Spain
| | - Montse Puigdemont
- Epidemiology Unit and Girona Cancer Registry, Oncology Coordination Plan, Department of Health Government of Catalonia, Catalan Institute of Oncology, Girona, Spain; Descriptive Epidemiology, Genetics and Cancer Prevention Group, Biomedical Research Institute, Salt, Spain
| | - Jaume Galceran
- Tarragona Cancer Registry, Epidemiology and Prevention Cancer Service, Hospital Universitari Sant Joan de Reus, Pere Virgili Health Research Institute (IISPV), Reus, Spain
| | - Marià Carulla
- Tarragona Cancer Registry, Epidemiology and Prevention Cancer Service, Hospital Universitari Sant Joan de Reus, Pere Virgili Health Research Institute (IISPV), Reus, Spain
| | - Antonia Sánchez-Gil
- Department of Epidemiology, Regional Health Council, IMIB-Arrixaca, Murcia, Spain
| | - María-Dolores Chirlaque
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiología y Salud Pública), Madrid, Spain; Department of Epidemiology, Regional Health Council, IMIB-Arrixaca, Murcia, Spain; Department of Health and Social Sciences, Universidad de Murcia, Murcia, Spain
| | - Michael Hoffmeister
- Division of Clinical Epidemiology and Aging Research, DKFZ, Heidelberg, Germany
| | - Hermann Brenner
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases, Heidelberg, Germany; Division of Clinical Epidemiology and Aging Research, DKFZ, Heidelberg, Germany; German Cancer Consortium, DKFZ, Heidelberg, Germany.
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21
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Milton S, Emery JD, Rinaldi J, Kinder J, Bickerstaffe A, Saya S, Jenkins MA, McIntosh J. Exploring a novel method for optimising the implementation of a colorectal cancer risk prediction tool into primary care: a qualitative study. Implement Sci 2022; 17:31. [PMID: 35550164 PMCID: PMC9097304 DOI: 10.1186/s13012-022-01205-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 04/14/2022] [Indexed: 01/22/2023] Open
Abstract
Background We developed a colorectal cancer risk prediction tool (‘CRISP’) to provide individualised risk-based advice for colorectal cancer screening. Using known environmental, behavioural, and familial risk factors, CRISP was designed to facilitate tailored screening advice to patients aged 50 to 74 years in general practice. In parallel to a randomised controlled trial of the CRISP tool, we developed and evaluated an evidence-based implementation strategy. Methods Qualitative methods were used to explore the implementation of CRISP in general practice. Using one general practice in regional Victoria, Australia, as a ‘laboratory’, we tested ways to embed CRISP into routine clinical practice. General practitioners, nurses, and operations manager co-designed the implementation methods with researchers, focussing on existing practice processes that would be sustainable. Researchers interviewed the staff regularly to assess the successfulness of the strategies employed, and implementation methods were adapted throughout the study period in response to feedback from qualitative interviews. The Consolidated Framework for Implementation Research (CFIR) underpinned the development of the interview guide and intervention strategy. Coding was inductive and themes were developed through consensus between the authors. Emerging themes were mapped onto the CFIR domains and a fidelity checklist was developed to ensure CRISP was being used as intended. Results Between December 2016 and September 2019, 1 interviews were conducted, both face-to-face and via videoconferencing (Zoom). All interviews were transcribed verbatim and coded. Themes were mapped onto the following CFIR domains: (1) ‘characteristics of the intervention’: CRISP was valued but time consuming; (2) ‘inner setting’: the practice was open to changing systems; 3. ‘outer setting’: CRISP helped facilitate screening; (4) ‘individual characteristics’: the practice staff were adaptable and able to facilitate adoption of new clinical processes; and (5) ‘processes’: fidelity checking, and education was important. Conclusions These results describe a novel method for exploring implementation strategies for a colorectal cancer risk prediction tool in the context of a parallel RCT testing clinical efficacy. The study identified successful and unsuccessful implementation strategies using an adaptive methodology over time. This method emphasised the importance of co-design input to make an intervention like CRISP sustainable for use in other practices and with other risk tools. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01205-8.
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Affiliation(s)
- Shakira Milton
- Centre for Cancer Research, University of Melbourne, Melbourne, Australia. .,Department of General Practice, University of Melbourne, Melbourne, Australia.
| | - Jon D Emery
- Centre for Cancer Research, University of Melbourne, Melbourne, Australia.,Department of General Practice, University of Melbourne, Melbourne, Australia.,The Primary Care Unit, Institute of Public Health, University of Cambridge School of Clinical Medicine, Box 113, Cambridge Biomedical Campus, Cambridge, CB2 0SR, UK
| | - Jane Rinaldi
- University of Melbourne Shepparton Medical Centre, Melbourne Teaching Health Clinics Ltd, 49 Graham Street, Shepparton, VIC, 3630, Australia
| | - Joanne Kinder
- University of Melbourne Shepparton Medical Centre, Melbourne Teaching Health Clinics Ltd, 49 Graham Street, Shepparton, VIC, 3630, Australia
| | - Adrian Bickerstaffe
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Sibel Saya
- Centre for Cancer Research, University of Melbourne, Melbourne, Australia.,Department of General Practice, University of Melbourne, Melbourne, Australia
| | - Mark A Jenkins
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Jennifer McIntosh
- Department of General Practice, University of Melbourne, Melbourne, Australia.,HumaniSE Lab, Department of Software Systems and Cybersecurity, Monash University, Clayton, Victoria, Australia
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22
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Cao Z, Pan X, Yu H, Hua S, Wang D, Chen DZ, Zhou M, Wu J. A Deep Learning Approach for Detecting Colorectal Cancer via Raman Spectra. BME FRONTIERS 2022; 2022:9872028. [PMID: 37850174 PMCID: PMC10521640 DOI: 10.34133/2022/9872028] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 03/01/2022] [Indexed: 10/19/2023] Open
Abstract
Objective and Impact Statement. Distinguishing tumors from normal tissues is vital in the intraoperative diagnosis and pathological examination. In this work, we propose to utilize Raman spectroscopy as a novel modality in surgery to detect colorectal cancer tissues. Introduction. Raman spectra can reflect the substance components of the target tissues. However, the feature peak is slight and hard to detect due to environmental noise. Collecting a high-quality Raman spectroscopy dataset and developing effective deep learning detection methods are possibly viable approaches. Methods. First, we collect a large Raman spectroscopy dataset from 26 colorectal cancer patients with the Raman shift ranging from 385 to 1545 cm - 1 . Second, a one-dimensional residual convolutional neural network (1D-ResNet) architecture is designed to classify the tumor tissues of colorectal cancer. Third, we visualize and interpret the fingerprint peaks found by our deep learning model. Results. Experimental results show that our deep learning method achieves 98.5% accuracy in the detection of colorectal cancer and outperforms traditional methods. Conclusion. Overall, Raman spectra are a novel modality for clinical detection of colorectal cancer. Our proposed ensemble 1D-ResNet could effectively classify the Raman spectra obtained from colorectal tumor tissues or normal tissues.
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Affiliation(s)
- Zheng Cao
- RealDoctor AI Research Center, College of Computer Science and Technology, Zhejiang University, China
| | - Xiang Pan
- Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, China
| | - Hongyun Yu
- RealDoctor AI Research Center, College of Computer Science and Technology, Zhejiang University, China
| | - Shiyuan Hua
- Institute of Translational Medicine and the Cancer Institute of the Second Affiliated Hospital, Zhejiang University School of Medicine, China
| | - Da Wang
- Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, China
| | - Danny Z. Chen
- Department of Computer Science and Engineering, University of Notre Dame, USA
| | - Min Zhou
- Institute of Translational Medicine and the Cancer Institute of the Second Affiliated Hospital, Zhejiang University School of Medicine, China
| | - Jian Wu
- Second Affiliated Hospital School of Medicine, and School of Public Health, Zhejiang University, China
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23
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Lee B, Lin K, Liang PS. Effectiveness and Harms of Colorectal Cancer Screening Strategies. Gastrointest Endosc Clin N Am 2022; 32:215-226. [PMID: 35361332 DOI: 10.1016/j.giec.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Colorectal cancer screening incorporates various testing modalities. Factors including effectiveness, harms, cost, screening interval, patient preferences, and test availability should be considered when determining which test to use. Fecal occult blood testing and endoscopic screening have the most robust evidence, while newer blood- and imaging-based techniques require further evaluation. In this review, we compare the effectiveness, harms, and costs of the various screening strategies.
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Affiliation(s)
- Briton Lee
- Department of Medicine, NYU Langone Health, 550 First Avenue, NBV 16 North 30, New York, NY 10016, USA
| | - Kevin Lin
- Department of Medicine, NYU Langone Health, 550 First Avenue, NBV 16 North 30, New York, NY 10016, USA
| | - Peter S Liang
- Department of Medicine, NYU Langone Health, 550 First Avenue, NBV 16 North 30, New York, NY 10016, USA; Department of Medicine, VA New York Harbor Health Care System, 423 E 23rd Street, 11N, GI, New York, NY 10010, USA.
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24
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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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25
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Fawns-Ritchie C, Miller CB, van der Pol M, Douglas E, Bell D, O'Carroll RE, Deary IJ. Psychological correlates of free colorectal cancer screening uptake in a Scottish sample: a cross-sectional observational study. BMJ Open 2022; 12:e042210. [PMID: 35105557 PMCID: PMC8808413 DOI: 10.1136/bmjopen-2020-042210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 01/12/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Colorectal cancer (CRC) screening uptake in Scotland is 56%. This study examined whether psychological factors were associated with CRC screening uptake. DESIGN Cross-sectional observational study. SETTING This study used data from the Healthy AGeing In Scotland (HAGIS) pilot study, a study designed to be representative of Scottish adults aged 50 years and older. PARTICIPANTS 908 (505 female) Scottish adults aged 50-80 years (mean age=65.85, SD=8.23), who took part in the HAGIS study (2016-2017). PRIMARY AND SECONDARY OUTCOME MEASURES Self-reported participation in CRC screening was the outcome measure. Logistic regression was used to test whether scores on measures of health literacy, cognitive ability, risk aversion, time preference (eg, present oriented or future oriented) and personality were associated with CRC screening when these psychological factors were entered individually and simultaneously in the same model. RESULTS Controlling for age, age-squared, sex, living arrangement, and sex*living arrangement, a one-point increase in risk aversion (OR=0.66, 95% CI 0.51 to 0.85) and present orientation (OR=0.86, 95% CI 0.80 to 0.94) was associated with reduced odds of screening. Higher scores on health literacy (OR per one-point increase=1.20, 95% CI 1.09 to 1.31), cognitive ability (OR per SD increase=1.51, 95% CI 1.25 to 1.81) and the intellect personality trait (OR per one-point increase=1.05, 95% CI 1.01 to 1.09) were associated with increased odds of screening. Higher risk aversion was the only psychological variable that was associated with CRC screening participation when all psychological variables were entered in the same model and remained associated with CRC screening when additionally adjusting for deprivation and education. A backward elimination model retained two psychological variables as correlates of CRC screening: risk aversion and cognitive ability. CONCLUSION Individuals who are more risk averse are less likely to participate in free, home CRC screening.
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Affiliation(s)
| | | | | | - Elaine Douglas
- Division of Economics, University of Stirling, Stirling, UK
| | - David Bell
- Division of Economics, University of Stirling, Stirling, UK
| | | | - Ian J Deary
- Department of Psychology, The University of Edinburgh, Edinburgh, UK
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26
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Mendis S, Hong W, Ananda S, Faragher I, Jones I, Croxford M, Steel M, Jalali A, Gard G, To YH, Lee M, Kosmider S, Wong R, Tie J, Gibbs P. Biology and Clinical Implications of Fecal Occult Blood Test (FOBT) Screen-Detected Colorectal Cancer. JNCI Cancer Spectr 2022; 6:6502287. [PMID: 35699496 PMCID: PMC8857921 DOI: 10.1093/jncics/pkab100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 07/11/2021] [Accepted: 11/11/2021] [Indexed: 12/24/2022] Open
Abstract
Abstract
Background
Fecal occult blood test (FOBT) based screening for colorectal cancer (CRC) reduces mortality, with earlier stage at diagnosis a prominent feature. Other characteristics of FOBT screen-detected cancers and any implications for clinical management have not been well explored.
Methods
We examined a multi-site clinical registry to compare the characteristics and outcomes of FOBT screen-detected CRC via the Australian National Bowel Cancer Screening Program (NBCSP), which is offered biennially to 50-74 year olds, and age matched non-screen detected cases in the same registry. All statistical tests were 2-sided. Odds Ratios were calculated using the Baptista-Pike method and Hazard Ratios via the log-rank method.
Results
Of 7,153 registry patients diagnosed June 1, 2006 to June 30, 2020, 4142 (57.9%) were aged between 50-74 years old. Excluding 406 patients with non-NBCSP screen-detected cancers and 35 patients with unknown method of detection, 473 (12.8%) were screen-detected via the NBCSP and 3228 (87.2%) were non screen-detected. Screen-detected patients were younger (mean age= 62.4 vs 64.2 years, P<.001) and more medically fit (Odds Ratio [OR] for ASA score 1-2 = 1.91, 95% confidence interval [CI] = 1.51 to 2.41, P<.001). Pathologic characteristics within each stage favoured the screen-detected cases. Stage III screen-detected colon cancers were more likely to receive adjuvant therapy (OR = 3.58, 95% CI = 1.52 to 8.36, P=.002). Screen-detected patients had superior relapse free (HR = 0.41, 95% CI = 0.29 to 0.60, P<.001) and overall survival (HR = 0.22, 95% CI = 0.15 to 0.35, P<.001), which was maintained in matched stage comparisons and multivariate analysis.
Conclusions
Beyond stage at diagnosis multiple other factors associated with a favourable outcome are observed in FOBT screen-detected CRC. Given the substantial stage by stage differences in survival outcomes, if independently confirmed, individualised adjuvant therapy and surveillance strategies could be warranted for FOBT screen-detected cancers.
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Affiliation(s)
- Shehara Mendis
- Personalised Oncology Division, Walter & Eliza Hall Institute, Parkville, VIC, Australia
- Department of Medical Oncology, Sunshine Hospital, Western Health, St Albans, VIC, Australia
| | - Wei Hong
- Personalised Oncology Division, Walter & Eliza Hall Institute, Parkville, VIC, Australia
- Faculty of Medicine & Health Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - Sumitra Ananda
- Personalised Oncology Division, Walter & Eliza Hall Institute, Parkville, VIC, Australia
- Department of Medical Oncology, Sunshine Hospital, Western Health, St Albans, VIC, Australia
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Parkville, VIC, Australia
| | - Ian Faragher
- Department of Colorectal Surgery, Footscray Hospital, Western Health, Footscray, VIC, Australia
| | - Ian Jones
- Department of Colorectal Surgery, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Surgery, The University of Melbourne, Parkville, VIC, Australia
| | - Matthew Croxford
- Department of Colorectal Surgery, Footscray Hospital, Western Health, Footscray, VIC, Australia
| | - Malcolm Steel
- Department of Colorectal Surgery, Box Hill Hospital, Eastern Health, Box Hill, VIC, Australia
| | - Azim Jalali
- Personalised Oncology Division, Walter & Eliza Hall Institute, Parkville, VIC, Australia
- Department of Medical Oncology, Sunshine Hospital, Western Health, St Albans, VIC, Australia
| | - Grace Gard
- Personalised Oncology Division, Walter & Eliza Hall Institute, Parkville, VIC, Australia
- Department of Medical Oncology, Sunshine Hospital, Western Health, St Albans, VIC, Australia
| | - Yat Hang To
- Personalised Oncology Division, Walter & Eliza Hall Institute, Parkville, VIC, Australia
- Faculty of Medicine & Health Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - Margaret Lee
- Personalised Oncology Division, Walter & Eliza Hall Institute, Parkville, VIC, Australia
- Department of Medical Oncology, Sunshine Hospital, Western Health, St Albans, VIC, Australia
- Department of Medical Oncology, Eastern Health, Box Hill, VIC, Australia
- Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia
| | - Suzanne Kosmider
- Department of Medical Oncology, Sunshine Hospital, Western Health, St Albans, VIC, Australia
| | - Rachel Wong
- Personalised Oncology Division, Walter & Eliza Hall Institute, Parkville, VIC, Australia
- Department of Medical Oncology, Eastern Health, Box Hill, VIC, Australia
- Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia
| | - Jeanne Tie
- Personalised Oncology Division, Walter & Eliza Hall Institute, Parkville, VIC, Australia
- Department of Medical Oncology, Sunshine Hospital, Western Health, St Albans, VIC, Australia
- Faculty of Medicine & Health Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - Peter Gibbs
- Personalised Oncology Division, Walter & Eliza Hall Institute, Parkville, VIC, Australia
- Department of Medical Oncology, Sunshine Hospital, Western Health, St Albans, VIC, Australia
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Parkville, VIC, Australia
- The Royal Melbourne Hospital, Parkville, VIC, Australia
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27
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Ghajari H, Sadeghi A, Khodakarim S, Zali M, Nazari SSH. Designing a Predictive Model for Colorectal Neoplasia Diagnosis Based on Clinical and Laboratory Findings in Colonoscopy Candidate Patients. J Gastrointest Cancer 2021; 53:880-887. [PMID: 34851503 DOI: 10.1007/s12029-021-00737-4] [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] [Accepted: 10/17/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Health authorities have expanded two strategies to diminish CRC-related influence: CR screening and improve diagnostic process in symptomatic patients. The aim of the current study is to design a predictive model to identify the most important risk factors that can efficiently predict patients who have high risk of colorectal neoplasia. METHOD A cross-sectional study was constructed to include all patients who had positive test for FIT or had one or more risk factors for colorectal cancer based on the guidelines of detecting high-risk groups for colorectal cancer in Iran. Multivariable binary logistic regression model was constructed for prediction of colorectal neoplasia. We used sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratio to check the accuracy. The Hosmer-Lemeshow test, chi-square test, and p value were used to determine the precision of model. RESULT Following an AIC stepwise selection model, only nine potential variables, namely gender, watery diarrhea, IBD, abdominal pain, melena, body mass index, depression drug, anti-inflammatory drug, and age, were found to be a predictor of colorectal neoplasia. The best cut-point probability in the final model was 0.27 and results of sensitivity and specificity, based on maximizing these two criteria, were 66% and 62%, respectively. CONCLUSION Overall, our model prediction was comparable with other risk prediction models for colorectal cancer. It had a modest discriminatory power to distinguish an individual's neoplasia colorectal risk.
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Affiliation(s)
- H Ghajari
- Department of Epidemiology, School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - A Sadeghi
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - S Khodakarim
- Department of Biostatistics, Faculty of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - M Zali
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - S S Hashemi Nazari
- Safety Promotion and Injury Prevention Research Center, Department of Epidemiology, School of Public Health, Shahid Beheshti University of Medical Sciences, Chamran Highway, Daneshjoo Blvd, 198353-5511, Velenjak Tehran, PC, Iran
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28
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Breekveldt ECH, Lansdorp-Vogelaar I, Toes-Zoutendijk E, Spaander MCW, van Vuuren AJ, van Kemenade FJ, Ramakers CRB, Dekker E, Nagtegaal ID, Krul MF, Kok NFM, Kuhlmann KFD, Vink GR, van Leerdam ME, Elferink MAG. Colorectal cancer incidence, mortality, tumour characteristics, and treatment before and after introduction of the faecal immunochemical testing-based screening programme in the Netherlands: a population-based study. Lancet Gastroenterol Hepatol 2021; 7:60-68. [PMID: 34822762 DOI: 10.1016/s2468-1253(21)00368-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND In 2014, a population-based colorectal cancer (CRC) screening programme was stepwise implemented in the Netherlands comprising faecal immunochemical testing once every 2 years, with a cutoff value for positivity of 47 μg haemoglobin per g faeces. We aimed to assess CRC incidence, mortality, tumour characteristics, and treatment before and after introduction of this screening programme. METHODS We did a retrospective, observational, population-based study in the Netherlands and gathered CRC incidence data from the Netherlands Cancer Registry from Jan 1, 2010, to Dec 31, 2019, in people aged 55 years or older. Patients with a CRC diagnosis between Jan 1, 2014, and Dec 31, 2018, in the Netherlands Cancer Registry were linked with the nationwide registry of histopathology and cytopathology (PALGA) to identify mode of detection (ie, screening-detected vs clinically detected). We calculated age-standardised CRC incidence rates and used data from Statistics Netherlands to calculate CRC-related mortality in 2010-19. We compared localisation, stage distribution, and treatment of screening-detected CRCs with clinically detected CRCs diagnosed in 2014-18 in patients aged 55-75 years. FINDINGS Between Jan 1, 2010, and Dec 31, 2019, 125 215 CRCs were diagnosed in individuals aged 55 years or older and were included in the analyses for CRC incidence. Before the introduction of the screening programme, the age-standardised CRC incidence rate was 214·3 per 100 000 population in 2013 in people aged 55 years or older. After the introduction of the screening programme, this rate initially increased to 259·2 per 100 000 population in 2015, and subsequently decreased to 181·5 per 100 000 population in 2019. Age-standardised incidence rates for advanced CRCs (stage III and IV) were 117·0 per 100 000 population in 2013 and increased to 122·8 per 100 000 population in 2015; this rate then decreased to 94·7 per 100 000 population in 2018. Age-standardised CRC mortality decreased from 87·5 deaths per 100 000 population in 2010 to 64·8 per 100 000 population in 2019. Compared with clinically detected CRCs, screening-detected CRCs were more likely to be located in the left side of the colon (48·6% vs 35·2%) and to be detected at an early stage (I or II; 66·7% vs 46·2%). Screening-detected CRCs were more likely to be treated by local excision compared with clinically detected CRCs, and this finding persisted when stage I CRCs were analysed separately. INTERPRETATION After introduction of this national screening programme, a decrease in overall and advanced-stage CRC incidence was observed. In view of this observation, together with the observed shift to detection at earlier stages and more screening-detected CRCs being treated by local excision, we might cautiously conclude that, in the long-term, faecal immunochemical testing-based screening could ultimately lead to a decrease in CRC-related morbidity and mortality. FUNDING None.
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Affiliation(s)
- Emilie C H Breekveldt
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands; Department of Gastroenterology and Hepatology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands.
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Esther Toes-Zoutendijk
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Anneke J van Vuuren
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Folkert J van Kemenade
- Department of Pathology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Christian R B Ramakers
- Department of Clinical Chemistry, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre-Location AMC, Amsterdam, Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Myrtle F Krul
- Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Niels F M Kok
- Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Koert F D Kuhlmann
- Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Geraldine R Vink
- Department of Medical Oncology, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, Netherlands
| | - Monique E van Leerdam
- Department of Gastroenterology and Hepatology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands; Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, Netherlands
| | - Marloes A G Elferink
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, Netherlands
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Zhou RC, Wang PZ, Li YY, Zhang Y, Ma MJ, Meng FY, Liu C, Yang XY, Lv M, Zuo XL, Li YQ. Quality Improvement of Sample Collection Increases the Diagnostic Accuracy of Quantitative Fecal Immunochemical Test in Colorectal Cancer Screening: A Pilot Study. Front Med (Lausanne) 2021; 8:762560. [PMID: 34765625 PMCID: PMC8575757 DOI: 10.3389/fmed.2021.762560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 09/22/2021] [Indexed: 01/02/2023] Open
Abstract
Objective: The diagnostic efficiency of the quantitative fecal immunochemical test (qFIT) has large variations in colorectal cancer (CRC) screening. We aimed to explore whether the practical sample collection operant training could improve the diagnostic accuracy of the qFIT in CRC screening. Methods: Moderate-/high-risk individuals aged 50–75 years old were invited to participate in a prospective observational study between July 2020 and March 2021. Participants took a qFIT sample without fecal sample collection operant training in advance and then completed another qFIT sample after the operant training. The primary outcome was the sensitivity and specificity of the qFITs for CRC and advanced colorectal neoplasia (ACRN). The secondary outcome was the difference in the area under the curves (AUCs) and the concentrations of the fecal hemoglobin (Hb) between the qFIT without and after the operant training. Results: Out of 913 patients, 81 (8.9%) patients had ACRN, including 25 (2.7%) patients with CRC. For CRC, the sensitivities of the qFIT without and after the operant training at 10 μg/g were 80.4 and 100.0%, respectively, and the specificities were 90.1 and 88.4%, respectively. For ACRN, the sensitivities were 49.4 and 69.1% and the specificities were 91.7 and 91.3%, respectively. The AUC of the qFIT after the operant training was significantly higher than that without the operant training for CRC (p = 0.027) and ACRN (p = 0.001). After the operant training, the concentration of the fecal Hb was significantly higher than that without the operant training (p = 0.009) for ACRN, but there was no significant difference for CRC (p = 0.367). Conclusion: Practical sample collection operant training improves the diagnostic accuracy of the qFIT, which increases the detection of the low concentrations of fecal Hb. Improving the quality of the sample collection could contribute to the diagnostic efficiency of the qFIT in CRC screening.
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Affiliation(s)
- Ru-Chen Zhou
- Department of Gastroenterology, Qilu Hospital, Shandong University, Jinan, China.,Laboratory of Translational Gastroenterology, Qilu Hospital, Shandong University, Jinan, China.,Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI Tumor, Qilu Hospital, Shandong University, Jinan, China
| | - Pei-Zhu Wang
- Department of Gastroenterology, Qilu Hospital, Shandong University, Jinan, China.,Laboratory of Translational Gastroenterology, Qilu Hospital, Shandong University, Jinan, China.,Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI Tumor, Qilu Hospital, Shandong University, Jinan, China
| | - Yue-Yue Li
- Department of Gastroenterology, Qilu Hospital, Shandong University, Jinan, China.,Laboratory of Translational Gastroenterology, Qilu Hospital, Shandong University, Jinan, China.,Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI Tumor, Qilu Hospital, Shandong University, Jinan, China
| | - Yan Zhang
- Department of Gastroenterology, Qilu Hospital, Shandong University, Jinan, China.,Laboratory of Translational Gastroenterology, Qilu Hospital, Shandong University, Jinan, China.,Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI Tumor, Qilu Hospital, Shandong University, Jinan, China
| | - Ming-Jun Ma
- Department of Gastroenterology, Qilu Hospital, Shandong University, Jinan, China.,Laboratory of Translational Gastroenterology, Qilu Hospital, Shandong University, Jinan, China.,Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI Tumor, Qilu Hospital, Shandong University, Jinan, China
| | - Fan-Yi Meng
- Department of Gastroenterology, Qilu Hospital, Shandong University, Jinan, China.,Laboratory of Translational Gastroenterology, Qilu Hospital, Shandong University, Jinan, China.,Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI Tumor, Qilu Hospital, Shandong University, Jinan, China
| | - Chao Liu
- Department of Gastroenterology, Qilu Hospital, Shandong University, Jinan, China.,Laboratory of Translational Gastroenterology, Qilu Hospital, Shandong University, Jinan, China.,Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI Tumor, Qilu Hospital, Shandong University, Jinan, China
| | - Xiao-Yun Yang
- Department of Gastroenterology, Qilu Hospital, Shandong University, Jinan, China.,Laboratory of Translational Gastroenterology, Qilu Hospital, Shandong University, Jinan, China.,Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI Tumor, Qilu Hospital, Shandong University, Jinan, China
| | - Ming Lv
- Clinical Epidemiology Unit, Qilu Hospital, Shandong University, Jinan, China
| | - Xiu-Li Zuo
- Department of Gastroenterology, Qilu Hospital, Shandong University, Jinan, China.,Laboratory of Translational Gastroenterology, Qilu Hospital, Shandong University, Jinan, China.,Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI Tumor, Qilu Hospital, Shandong University, Jinan, China
| | - Yan-Qing Li
- Department of Gastroenterology, Qilu Hospital, Shandong University, Jinan, China.,Laboratory of Translational Gastroenterology, Qilu Hospital, Shandong University, Jinan, China.,Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI Tumor, Qilu Hospital, Shandong University, Jinan, China
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30
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Robbins EC, Cross AJ. Reply. Clin Gastroenterol Hepatol 2021; 19:2217-2218. [PMID: 34089851 DOI: 10.1016/j.cgh.2021.05.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 05/28/2021] [Accepted: 05/31/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Emma C Robbins
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Amanda J Cross
- Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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31
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Biccler J, Bollaerts K, Vora P, Sole E, Rodriguez LAG, Lanas A, Langley RE, Gabarró MS. Public health impact of low-dose aspirin on colorectal cancer, cardiovascular disease and safety in the UK - Results from micro-simulation model. IJC HEART & VASCULATURE 2021; 36:100851. [PMID: 34401469 PMCID: PMC8350404 DOI: 10.1016/j.ijcha.2021.100851] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 07/26/2021] [Indexed: 12/29/2022]
Abstract
Background Low-dose aspirin therapy reduces the risk of cardiovascular disease and may have a positive effect on the prevention of colorectal cancer. We evaluated the population-level expected effect of regular low-dose aspirin use on cardiovascular disease (CVD), colorectal cancer (CRC), gastrointestinal bleeding, symptomatic peptic ulcers, and intracranial hemorrhage, using a microsimulation study design. Methods We used individual-level state transition modeling to assess the impact of aspirin in populations aged 50–59 or 60–69 years old indicated for low-dose aspirin usage for primary or secondary CVD prevention. Model parameters were based on data from governmental agencies from the UK or recent publications. Results In the 50–59 years cohort, a decrease in incidence rates (IRs per 100 000 person years) of non-fatal CVD (-203 and −794) and fatal CVD (-97 and-381) was reported in the primary and secondary CVD prevention setting, respectively. The IR reduction of CRC (-96 and −93) was similar for primary and secondary CVD prevention. The IR increase of non-fatal (116 and 119) and fatal safety events (6 and 6) was similar for primary and secondary CVD prevention. Similar results were obtained for the 60–69 years cohort. Conclusions The decrease in fatal CVD and CRC events was larger than the increase in fatal safety events and this difference was more pronounced when low-dose aspirin was used for secondary compared to primary CVD prevention. These results provide a comprehensive image of the expected effect of regular low-dose aspirin therapy in a UK population indicated to use aspirin for CVD prevention.
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Affiliation(s)
- Jorne Biccler
- P95 Epidemiology and Pharmacovigilance, Leuven, Belgium
| | | | - Pareen Vora
- Bayer AG, Epidemiology, Integrated Evidence Generation, Berlin, Germany
| | - Elodie Sole
- P95 Epidemiology and Pharmacovigilance, Leuven, Belgium
| | | | - Angel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico, University of Zaragoza, Zaragoza, Spain.,CIBERehd. IIS Aragón, Zaragoza, Spain
| | - Ruth E Langley
- MRC Clinical Trials Unit, University College London, London, United Kingdom
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32
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Cardoso R, Zhu A, Guo F, Heisser T, Hoffmeister M, Brenner H. Incidence and Mortality of Proximal and Distal Colorectal Cancer in Germany. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:281-287. [PMID: 34180790 DOI: 10.3238/arztebl.m2021.0111] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 07/31/2020] [Accepted: 12/15/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND The use of colonoscopy has increased and colorectal cancer (CRC) incidence has decreased after the introduction of screening colonoscopy in Germany. However, it remains unknown to what extent progress has been achieved in the prevention of cancer in the proximal colon, distal colon, and rectum. METHODS We analyzed trends in CRC incidence (2000-2016) and mortality (2000-2018) in Germany by sex, age, and tumor location. RESULTS The age-standardized incidence of CRC declined by 22.4% (from 65.3 to 50.7 per 100 000) in men and by 25.5% (from 42.7 to 31.8 per 100 000) in women. CRC mortality declined by 35.8% (from 29.6 to 19.0 per 100 000) in men and by 40.5% (19.0 to 11.3 per 100 000) in women. Despite demographic changes, the annual numbers of CRC cases and deaths still decreased from about 60 400 to 58 300 and from around 28 700 to 24 200, respectively. The decline in incidence was greatest in groups aged ≥ 55 years. While the incidence of cancer in the distal colon and rectum decreased by 34.5% and 26.2%, respectively, in men and by 41.0% and 27.9% in women, the incidence of proximal colon cancer remained stable in men and decreased by only 7.0% in women. However, a major shift towards earlier stages was observed for the proximal cancers. CONCLUSION The results support the assumption that the increased use of colo - noscopy has contributed to substantial reductions in the incidence of distal CRC incidence and the mortality from cancers in the entire colon and rectum.
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Affiliation(s)
- Rafael Cardoso
- Division of Preventive Oncology, German Cancer Research Center and National Center for Tumor Diseases, Heidelberg; Faculty of Medicine Heidelberg, University of Heidelberg; Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg; German Cancer Consortium, German Cancer Research Center, Heidelberg
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What Should We Recommend for Colorectal Cancer Screening in Adults Aged 75 and Older? ACTA ACUST UNITED AC 2021; 28:2540-2547. [PMID: 34287279 PMCID: PMC8293045 DOI: 10.3390/curroncol28040231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 06/30/2021] [Accepted: 07/06/2021] [Indexed: 12/14/2022]
Abstract
The current recommendation to stop colorectal cancer screening for older adults is based on a lack of evidence due to systematic exclusion of this population from trials. Older adults are a heterogenous population with many available strategies for patient-centered assessment and decision-making. Evolutions in management strategies for colorectal cancer have made safe and effective options available to older adults, and the rationale to screen for treatable disease more reasonably, especially given the aging Canadian population. In this commentary, we review the current screening guidelines and the evidence upon which they were built, the unique considerations for screening older adults, new treatment options, the risks and benefits of increased screening and potential considerations for the new guidelines.
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34
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Tepeš B, Mlakar DN, Stefanovič M, Štabuc B, Grazio SF, Zakotnik JM. The impact of 6 years of the National Colorectal Cancer Screening Program on colorectal cancer incidence and 5-year survival. Eur J Cancer Prev 2021; 30:304-310. [PMID: 33369945 DOI: 10.1097/cej.0000000000000628] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We aimed to assess the impact of the first three rounds of the National Colorectal Cancer Screening Program (NCCSP) on CRC incidence and mortality in Slovenia. In NCCSP, we use two fecal immune tests (FITs) and if test is positive patient is referred to colonoscopy. From 2009, we invite Slovenian residents aged 50-69 years, one screening round takes 2 years. The response rate was from 56.9 to 59.9%. FIT was positive in 6.0-6.2% (more in older patients and in men; P < 0.05). The adenoma detection rate was >51.3% (more in men; P < 0.01). In NCCSP, 70.3% of all cancers diagnosed were in stages I and II, while 20.7% of all CRC were found in polyps resected during colonoscopies. Patients with positive first FIT have odds ratio 2.19 [95% confidence interval (CI), 2.06-2.32] for advanced neoplasia and cancer compared to patients with two negative FITs. The incidence rate for CRC has dropped significantly after 6 years in population and in men (P < 0.01) but not in women. Five-year CRC survival was 31.3% higher if cancer was diagnosed in NCCSP (P < 0.05). After 6 years of NCCSP, the incidence rate for CRC has dropped significantly (P < 0.01). Hazard ratio for death from CRC was 3.84 higher (95% CI, 3.36-4.40; P < 0.001) in patients with cancer detected outside the program.
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Affiliation(s)
- Bojan Tepeš
- AM DC Rogaška, Department of Gastroenterology, Rogaška Slatina
| | | | | | - Borut Štabuc
- University Clinical Center, Clinical department of Gastroenterology, Ljubljana, Slovenia
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35
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Kaalby L, Deding U, Kobaek-Larsen M, Havshoi ALV, Zimmermann-Nielsen E, Thygesen MK, Kroeijer R, Bjørsum-Meyer T, Baatrup G. Colon capsule endoscopy in colorectal cancer screening: a randomised controlled trial. BMJ Open Gastroenterol 2021; 7:bmjgast-2020-000411. [PMID: 32601101 PMCID: PMC7326244 DOI: 10.1136/bmjgast-2020-000411] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/07/2020] [Accepted: 05/31/2020] [Indexed: 02/06/2023] Open
Abstract
Introduction The use of capsule endoscopy has become an approved method in small bowel diagnostics, but the same level of integration is not seen in large bowel diagnostics. We will use colon capsule endoscopy (CCE) as a filter test in colorectal cancer (CRC) screening between the faecal immunochemical test (FIT) and colonoscopy. We aim to investigate the clinical performance, population acceptability, and economic implications of the procedure in a large-scale clinical trial. Methods and analysis We will randomly allocate 124 214 Danish citizens eligible for participation in the national CRC screening programme within the Region of Southern Denmark to either an intervention group or a control group. Prior to submitting a FIT, citizens randomised to the intervention group will be informed about their opportunity to undergo CCE, instead of colonoscopy, if the FIT is positive. Suspected cancers; >3 adenomas <10 mm in size, 1 adenoma >10 mm in size or >4 adenomas regardless of size, detected during CCE will generate an invitation to colonoscopy as per regular screening guidelines, whereas citizens with suspected low risk polyps will re-enter the biennial screening programme. Citizens with no CCE findings will be excluded from screening for 8 years. In the control group, citizens will follow standard screening procedures. Ethics and dissemination All participants must consent prior to capsule ingestion. All collected data will be handled and stored in accordance with current data protection legislation. Approvals from the regional ethics committee (ref. S-20190100) and the Danish data protection agency have been obtained (ref. 19/29858). Trial registration details The study has been registered with ClinicalTrials.gov under: NCT04049357.
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Affiliation(s)
- Lasse Kaalby
- Department of Surgery, Odense University Hospital, Svendborg, Denmark .,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ulrik Deding
- Department of Surgery, Odense University Hospital, Svendborg, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Morten Kobaek-Larsen
- Department of Surgery, Odense University Hospital, Svendborg, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Erik Zimmermann-Nielsen
- Department of Surgery, Odense University Hospital, Svendborg, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Marianne Kirstine Thygesen
- Department of Surgery, Odense University Hospital, Svendborg, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Rasmus Kroeijer
- Department of Surgery, Southwest Jutland Hospital Esbjerg, Esbjerg, Denmark
| | | | - Gunnar Baatrup
- Department of Surgery, Odense University Hospital, Svendborg, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Ionescu EM, Tieranu CG, Maftei D, Grivei A, Olteanu AO, Arbanas T, Calu V, Musat S, Mihaescu-Pintia C, Cucu IC. Colorectal Cancer Trends of 2018 in Romania-an Important Geographical Variation Between Northern and Southern Lands and High Mortality Versus European Averages. J Gastrointest Cancer 2021; 52:222-228. [PMID: 32152824 DOI: 10.1007/s12029-020-00382-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE In Romania, one of the highest rates for colorectal cancer (CRC) incidence and mortality in Europe was estimated based on data available in 2008. Ever since, consistent data are missing. In this article, we tried to estimate the general burden of CRC in our country. METHODS We collected data from all hospitalized recorded cases according to the ICD-10 revision (codes C18-C20), as both primary and secondary diagnoses, as reported by all the hospitals to the DRG National System, between 2016 and 2018. RESULTS There were 50,890 persons hospitalized with CRC. The prevalence of hospitalized colorectal cancer was 108.24/100,000 inhabitants in 2016, 113.09/100,000 inhabitants in 2017, and 116.83/100,000 inhabitants in 2018. Distal localization prevailed. We registered 34.13/100,000 deaths by CRC within the mentioned period of time, almost twofold higher than average European range. There are significant geographical differences regarding CRC prevalence and mortality, with higher rates in the Northern and Central Regions, and a very low prevalence and mortality in Bucharest and Southern provinces. CONCLUSION We note a high colorectal mortality rate in Romania, especially in the Northern and Central Regions, nearly double versus European ranges.
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Affiliation(s)
- Elena Mirela Ionescu
- Department of Gastroenterology, "Elias" Emergency University Hospital, 17th Blvd. Marasti, 011461, Bucharest, Romania
- Department of Gastroenterology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Cristian George Tieranu
- Department of Gastroenterology, "Elias" Emergency University Hospital, 17th Blvd. Marasti, 011461, Bucharest, Romania.
| | - Dana Maftei
- Department of Gastroenterology, "Elias" Emergency University Hospital, 17th Blvd. Marasti, 011461, Bucharest, Romania
| | - Adriana Grivei
- Department of Gastroenterology, "Elias" Emergency University Hospital, 17th Blvd. Marasti, 011461, Bucharest, Romania
| | - Andrei Ovidiu Olteanu
- Department of Gastroenterology, "Elias" Emergency University Hospital, 17th Blvd. Marasti, 011461, Bucharest, Romania
| | - Tudor Arbanas
- Department of Gastroenterology, "Elias" Emergency University Hospital, 17th Blvd. Marasti, 011461, Bucharest, Romania
- Department of Gastroenterology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Valentin Calu
- Department of Gastroenterology, "Elias" Emergency University Hospital, 17th Blvd. Marasti, 011461, Bucharest, Romania
- Department of Gastroenterology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Simona Musat
- The National School of Public Health, Management and Professional Development, Bucharest, Romania
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Keys MT, Serra-Burriel M, Martínez-Lizaga N, Pellisé M, Balaguer F, Sánchez A, Bernal-Delgado E, Castells A. Population-based organized screening by faecal immunochemical testing and colorectal cancer mortality: a natural experiment. Int J Epidemiol 2021; 50:143-155. [PMID: 33211822 DOI: 10.1093/ije/dyaa166] [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] [Accepted: 08/03/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Population-based organized screening programmes for colorectal cancer (CRC) are underway worldwide, with many based on the faecal immunochemical test (FIT). No clinical trials assessing FIT compared with no screening are planned, and few studies have assessed the population impact of such programmes. METHODS Before 2010, 11 out of 50 Spanish provinces initiated population-based organized screening programmes with FIT for an average-risk population aged 50-69 years. We used a quasi-experimental design across Spanish provinces between 1999 and 2016 to evaluate their impact on population age-standardized mortality and incidence rates due to CRC. Difference-in-differences and synthetic control analyses were performed to test for validation of statistical assumptions and to assess the dynamics of screening-associated changes in outcomes over time. RESULTS No differences in outcome trends between exposed (n = 11) and control (n = 36) provinces were observed for up to 7 years preceding the implementation of screening. Relative to controls, exposed provinces experienced a mean increase in age-standardized incidence of 10.08% [95% confidence interval (CI) (5.09, 15.07)] 2 years after implementation, followed by a reduction in age-standardized mortality rates due to CRC of 8.82% [95% CI (3.77, 13.86)] after 7 years. Results were similar for both women and men. No associated changes were observed in adjacent age bands not targeted by screening, nor for 10 other major causes of death in the exposed provinces. CONCLUSIONS FIT-based organized screening in Spain was associated with reductions in population colorectal cancer mortality. Further research is warranted in order to assess the replicability and external validity of our findings, and on gender-specific use of FIT in organized screening.
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Affiliation(s)
- Matthew T Keys
- Department of Public Health, Epidemiology, Biostatistics and Biodemography, University of Southern Denmark, Odense, Denmark.,Department of Economics, Center for Research in Health and Economics (CRES), Pompeu Fabra University, Barcelona, Spain
| | - Miquel Serra-Burriel
- Department of Economics, Center for Research in Health and Economics (CRES), Pompeu Fabra University, Barcelona, Spain
| | - Natalia Martínez-Lizaga
- Data Science in Health Services and Policy Research, Institute for Health Sciences in Aragón (IACS), Zaragoza, Spain.,Spanish Health Services Research Network on Chronic Diseases (REDISSEC), Zaragoza, Spain
| | - Maria Pellisé
- Department of Gastroenterology, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERehd, University of Barcelona, Barcelona, Spain
| | - Francesc Balaguer
- Department of Gastroenterology, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERehd, University of Barcelona, Barcelona, Spain
| | - Ariadna Sánchez
- Department of Gastroenterology, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERehd, University of Barcelona, Barcelona, Spain
| | - Enrique Bernal-Delgado
- Data Science in Health Services and Policy Research, Institute for Health Sciences in Aragón (IACS), Zaragoza, Spain.,Spanish Health Services Research Network on Chronic Diseases (REDISSEC), Zaragoza, Spain
| | - Antoni Castells
- Department of Gastroenterology, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERehd, University of Barcelona, Barcelona, Spain
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Semedo L, Lifford KJ, Edwards A, Seddon K, Brain K, Smits S, Dolwani S. Development and user-testing of a brief decision aid for aspirin as a preventive approach alongside colorectal cancer screening. BMC Med Inform Decis Mak 2021; 21:165. [PMID: 34016116 PMCID: PMC8139147 DOI: 10.1186/s12911-021-01523-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 05/09/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Several epidemiological and cohort studies suggest that regular low-dose aspirin use independently reduces the long-term incidence and risk of colorectal cancer deaths by approximately 20%. However, there are also risks to aspirin use, mainly gastrointestinal bleeding and haemorrhagic stroke. Making informed decisions depends on the ability to understand and weigh up benefits and risks of available options. A decision aid to support people to consider aspirin therapy alongside participation in the NHS bowel cancer screening programme may have an additional impact on colorectal cancer prevention. This study aims to develop and user-test a brief decision aid about aspirin to enable informed decision-making for colorectal screening-eligible members of the public. METHODS We undertook a qualitative study to develop an aspirin decision aid leaflet to support bowel screening responders in deciding whether to take aspirin to reduce their risk of colorectal cancer. The iterative development process involved two focus groups with public members aged 60-74 years (n = 14) and interviews with clinicians (n = 10). Interviews (n = 11) were used to evaluate its utility for decision-making. Analysis was conducted using a framework approach. RESULTS Overall, participants found the decision aid acceptable and useful to facilitate decision-making. They expressed a need for individualised risk information, more detail about the potential risks of aspirin, and preferred risk information presented in pictograms when offered different options. Implementation pathways were discussed, including the possibility of involving different clinicians in the process such as GPs and/or community pharmacists. A range of potentially effective timepoints for sending out the decision aid were identified. CONCLUSION An acceptable and usable decision aid was developed to support decisions about aspirin use to prevent colorectal cancer.
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Affiliation(s)
- Lenira Semedo
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Kate J Lifford
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Adrian Edwards
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Kathy Seddon
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Kate Brain
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Stephanie Smits
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Sunil Dolwani
- Division of Population Medicine, Cardiff University, Cardiff, UK.
- Department of Gastroenterology, University Hospital Llandough, Penlan Road, Penarth, Cardiff, CF64 2XX, UK.
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Head-to-head comparison of the test performance of self-administered qualitative vs. laboratory-based quantitative fecal immunochemical tests in detecting colorectal neoplasm. Chin Med J (Engl) 2021; 134:1335-1344. [PMID: 34039863 PMCID: PMC8183845 DOI: 10.1097/cm9.0000000000001524] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: Fecal immunochemical tests (FITs) are the most widely used non-invasive tests in colorectal cancer (CRC) screening. However, evidence about the direct comparison of the test performance of the self-administered qualitative a laboratory-based quantitative FITs in a CRC screening setting is sparse. Methods: Based on a CRC screening trial (TARGET-C), we included 3144 pre-colonoscopy fecal samples, including 24 CRCs, 230 advanced adenomas, 622 non-advanced adenomas, and 2268 participants without significant findings at colonoscopy. Three self-administered qualitative FITs (Pupu tube) with positivity thresholds of 8.0, 14.4, or 20.8 μg hemoglobin (Hb)/g preset by the manufacturer and one laboratory-based quantitative FIT (OC-Sensor) with a positivity threshold of 20 μg Hb/g recommended by the manufacturer were tested by trained staff in the central laboratory. The diagnostic performance of the FITs for detecting colorectal neoplasms was compared in the different scenarios using the preset and adjusted thresholds (for the quantitative FIT). Results: At the thresholds preset by the manufacturers, apart from the qualitative FIT-3, significantly higher sensitivities for detecting advanced adenoma were observed for the qualitative FIT-1 (33.9% [95% CI: 28.7–39.4%]) and qualitative FIT-2 (22.2% [95% CI: 17.7–27.2%]) compared to the quantitative FIT (11.7% [95% CI: 8.4–15.8%]), while at a cost of significantly lower specificities. However, such difference was not observed for detecting CRC. For scenarios of adjusting the positivity thresholds of the quantitative FIT to yield comparable specificity or comparable positivity rate to the three qualitative FITs accordingly, there were no significant differences in terms of sensitivity, specificity, positive/negative predictive values and positive/negative likelihood ratios for detecting CRC or advanced adenoma between the two types of FITs, which was further evidenced in ROC analysis. Conclusions: Although the self-administered qualitative and the laboratory-based quantitative FITs had varied test performance at the positivity thresholds preset by the manufacturer, such heterogeneity could be overcome by adjusting thresholds to yield comparable specificities or positivity rates. Future CRC screening programs should select appropriate types of FITs and define the thresholds based on the targeted specificities and manageable positivity rates.
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40
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Davidson KW, Barry MJ, Mangione CM, Cabana M, Caughey AB, Davis EM, Donahue KE, Doubeni CA, Krist AH, Kubik M, Li L, Ogedegbe G, Owens DK, Pbert L, Silverstein M, Stevermer J, Tseng CW, Wong JB. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA 2021; 325:1965-1977. [PMID: 34003218 DOI: 10.1001/jama.2021.6238] [Citation(s) in RCA: 716] [Impact Index Per Article: 238.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Colorectal cancer is the third leading cause of cancer death for both men and women, with an estimated 52 980 persons in the US projected to die of colorectal cancer in 2021. Colorectal cancer is most frequently diagnosed among persons aged 65 to 74 years. It is estimated that 10.5% of new colorectal cancer cases occur in persons younger than 50 years. Incidence of colorectal cancer (specifically adenocarcinoma) in adults aged 40 to 49 years has increased by almost 15% from 2000-2002 to 2014-2016. In 2016, 26% of eligible adults in the US had never been screened for colorectal cancer and in 2018, 31% were not up to date with screening. OBJECTIVE To update its 2016 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for colorectal cancer in adults 40 years or older. The review also examined whether these findings varied by age, sex, or race/ethnicity. In addition, as in 2016, the USPSTF commissioned a report from the Cancer Intervention and Surveillance Modeling Network Colorectal Cancer Working Group to provide information from comparative modeling on how estimated life-years gained, colorectal cancer cases averted, and colorectal cancer deaths averted vary by different starting and stopping ages for various screening strategies. POPULATION Asymptomatic adults 45 years or older at average risk of colorectal cancer (ie, no prior diagnosis of colorectal cancer, adenomatous polyps, or inflammatory bowel disease; no personal diagnosis or family history of known genetic disorders that predispose them to a high lifetime risk of colorectal cancer [such as Lynch syndrome or familial adenomatous polyposis]). EVIDENCE ASSESSMENT The USPSTF concludes with high certainty that screening for colorectal cancer in adults aged 50 to 75 years has substantial net benefit. The USPSTF concludes with moderate certainty that screening for colorectal cancer in adults aged 45 to 49 years has moderate net benefit. The USPSTF concludes with moderate certainty that screening for colorectal cancer in adults aged 76 to 85 years who have been previously screened has small net benefit. Adults who have never been screened for colorectal cancer are more likely to benefit. RECOMMENDATION The USPSTF recommends screening for colorectal cancer in all adults aged 50 to 75 years. (A recommendation) The USPSTF recommends screening for colorectal cancer in adults aged 45 to 49 years. (B recommendation) The USPSTF recommends that clinicians selectively offer screening for colorectal cancer in adults aged 76 to 85 years. Evidence indicates that the net benefit of screening all persons in this age group is small. In determining whether this service is appropriate in individual cases, patients and clinicians should consider the patient's overall health, prior screening history, and preferences. (C recommendation).
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Affiliation(s)
| | - Karina W Davidson
- Feinstein Institute for Medical Research at Northwell Health, Manhasset, New York
| | | | | | | | | | - Esa M Davis
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Alex H Krist
- Fairfax Family Practice Residency, Fairfax, Virginia
- Virginia Commonwealth University, Richmond
| | | | - Li Li
- University of Virginia, Charlottesville
| | | | | | - Lori Pbert
- University of Massachusetts Medical School, Worcester
| | | | | | - Chien-Wen Tseng
- University of Hawaii, Honolulu
- Pacific Health Research and Education Institute, Honolulu, Hawaii
| | - John B Wong
- Tufts University School of Medicine, Boston, Massachusetts
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Lin JS, Perdue LA, Henrikson NB, Bean SI, Blasi PR. Screening for Colorectal Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2021; 325:1978-1998. [PMID: 34003220 DOI: 10.1001/jama.2021.4417] [Citation(s) in RCA: 176] [Impact Index Per Article: 58.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Colorectal cancer (CRC) remains a significant cause of morbidity and mortality in the US. OBJECTIVE To systematically review the effectiveness, test accuracy, and harms of screening for CRC to inform the US Preventive Services Task Force. DATA SOURCES MEDLINE, PubMed, and the Cochrane Central Register of Controlled Trials for relevant studies published from January 1, 2015, to December 4, 2019; surveillance through March 26, 2021. STUDY SELECTION English-language studies conducted in asymptomatic populations at general risk of CRC. DATA EXTRACTION AND SYNTHESIS Two reviewers independently appraised the articles and extracted relevant study data from fair- or good-quality studies. Random-effects meta-analyses were conducted. MAIN OUTCOMES AND MEASURES Colorectal cancer incidence and mortality, test accuracy in detecting cancers or adenomas, and serious adverse events. RESULTS The review included 33 studies (n = 10 776 276) on the effectiveness of screening, 59 (n = 3 491 045) on the test performance of screening tests, and 131 (n = 26 987 366) on the harms of screening. In randomized clinical trials (4 trials, n = 458 002), intention to screen with 1- or 2-time flexible sigmoidoscopy vs no screening was associated with a decrease in CRC-specific mortality (incidence rate ratio, 0.74 [95% CI, 0.68-0.80]). Annual or biennial guaiac fecal occult blood test (gFOBT) vs no screening (5 trials, n = 419 966) was associated with a reduction of CRC-specific mortality after 2 to 9 rounds of screening (relative risk at 19.5 years, 0.91 [95% CI, 0.84-0.98]; relative risk at 30 years, 0.78 [95% CI, 0.65-0.93]). In observational studies, receipt of screening colonoscopy (2 studies, n = 436 927) or fecal immunochemical test (FIT) (1 study, n = 5.4 million) vs no screening was associated with lower risk of CRC incidence or mortality. Nine studies (n = 6497) evaluated the test accuracy of screening computed tomography (CT) colonography, 4 of which also reported the test accuracy of colonoscopy; pooled sensitivity to detect adenomas 6 mm or larger was similar between CT colonography with bowel prep (0.86) and colonoscopy (0.89). In pooled values, commonly evaluated FITs (14 studies, n = 45 403) (sensitivity, 0.74; specificity, 0.94) and stool DNA with FIT (4 studies, n = 12 424) (sensitivity, 0.93; specificity, 0.85) performed better than high-sensitivity gFOBT (2 studies, n = 3503) (sensitivity, 0.50-0.75; specificity, 0.96-0.98) to detect cancers. Serious harms of screening colonoscopy included perforations (3.1/10 000 procedures) and major bleeding (14.6/10 000 procedures). CT colonography may have harms resulting from low-dose ionizing radiation. It is unclear if detection of extracolonic findings on CT colonography is a net benefit or harm. CONCLUSIONS AND RELEVANCE There are several options to screen for colorectal cancer, each with a different level of evidence demonstrating its ability to reduce cancer mortality, its ability to detect cancer or precursor lesions, and its risk of harms.
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Affiliation(s)
- Jennifer S Lin
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Leslie A Perdue
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Nora B Henrikson
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Sarah I Bean
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Paula R Blasi
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
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Whelton SP, Berning P, Blumenthal RS, Marshall CH, Martin SS, Mortensen MB, Blaha MJ, Dzaye O. Multidisciplinary prevention and management strategies for colorectal cancer and cardiovascular disease. Eur J Intern Med 2021; 87:3-12. [PMID: 33610416 DOI: 10.1016/j.ejim.2021.02.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/09/2021] [Accepted: 02/06/2021] [Indexed: 02/06/2023]
Abstract
Colorectal cancer (CRC) and cardiovascular disease (CVD) are leading causes of morbidity and mortality worldwide. Their numerous shared and modifiable risk factors underscore the importance of effective prevention strategies for these largely preventable diseases. Conventionally regarded as separate disease entities, clear pathophysiological links and overlapping risk factors represent an opportunity for synergistic collaborative efforts of oncologists and cardiologists. In addition, current CRC treatment approaches can exert cardiotoxicity and thus increase CVD risk. Given the complex interplay of both diseases and increasing numbers of CRC survivors who are at increased risk for CVD, multidisciplinary cardio-oncological approaches are warranted for optimal patient care from primary prevention to acute disease treatment and long-term surveillance.
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Affiliation(s)
- Seamus P Whelton
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Philipp Berning
- Department of Hematology and Oncology, University Hospital Muenster, Muenster, Germany
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Catherine Handy Marshall
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Seth S Martin
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Martin Bødtker Mortensen
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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Robbins EC, Cross AJ. Guaiac Fecal Occult Blood Tests and Mortality: A 30-Year Follow-up of Two Pooled Trials. Clin Gastroenterol Hepatol 2021; 19:892-894. [PMID: 32798704 DOI: 10.1016/j.cgh.2020.08.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Emma C Robbins
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Amanda J Cross
- Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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Effects of Screening Compliance on Long-term Reductions in All-Cause and Colorectal Cancer Mortality. Clin Gastroenterol Hepatol 2021; 19:967-975.e2. [PMID: 32634624 DOI: 10.1016/j.cgh.2020.06.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/29/2020] [Accepted: 06/06/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Randomized trials have shown that biennial fecal occult blood test (FOBT) screening reduces mortality from colorectal cancer (CRC), but not overall mortality. Differences in benefit for men vs women, and by age, are unknown. We sought to evaluate long-term reduction in all-cause and CRC-specific mortality in men and women who comply with offered screening, and in different age groups, using individual participant data from 2 large randomized trials of biennial FOBT screening, compared with an intention to treat analysis. METHODS We updated the CRC and all-cause mortality from the Danish CRC screening trial (n = 61,933) through 30 years of follow up and pooled individual participant data with individual 30-year follow-up data from the Minnesota Colon Cancer Control trial (n = 46,551). We compared the biennial screening groups to usual care (controls) in individuals 50-80 years old using Kaplan Meier estimates of relative risks and risk differences, adjusted for study differences in age, sex, and compliance. RESULTS Through 30 years of follow up, there were 33,478 (71.9%) and 33,479 (72.2%) total deaths and 1023 (2.2%) and 1146 (2.5%) CRC deaths in the biennial screening (n = 46,553) and control groups (n = 46,358), respectively. Among compliers, biennial FOBT screening significantly reduced CRC mortality by 16% (relative risk [RR], 0.84; 95% CI, 0.74-0.96) and all-cause mortality by 2% (RR, 0.98; 95% CI, 0.97-0.99). Among compliers, the reduction in CRC mortality was larger for men (RR, 0.75; 95% CI, 0.62-0.90) than women (RR, 0.91; 95% CI, 0.75-1.09). The largest reduction in CRC mortality was in compliant men 60-69 years old (RR, 0.59; 95% CI, 0.42-0.81) and women 70 years and older (RR, 0.53; 95% CI, 0.30-0.94). CONCLUSIONS Long-term CRC mortality outcomes of screening among compliers using biennial FOBT are sustained, with a statistically significant reduction in all-cause mortality. The reduction in CRC mortality is greater in men than women-the benefit in women lags that of men by about 10 years.
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Wieszczy P, Kaminski MF, Løberg M, Bugajski M, Bretthauer M, Kalager M. Estimation of overdiagnosis in colorectal cancer screening with sigmoidoscopy and faecal occult blood testing: comparison of simulation models. BMJ Open 2021; 11:e042158. [PMID: 33853794 PMCID: PMC8054108 DOI: 10.1136/bmjopen-2020-042158] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To estimate overdiagnosis of colorectal cancer (CRC) for screening with sigmoidoscopy and faecal occult blood testing (FOBT). DESIGN Simulation study using data from randomised trials. SETTING Primary screening, UK, Norway PARTICIPANTS: 152 850 individuals from the Nottingham trial and 98 678 individuals from the Norwegian Colorectal Cancer Prevention (NORCCAP) trial. INTERVENTION CRC screening. OUTCOME MEASURE We estimated overdiagnosis using long-term data from two randomised trials: the Nottingham trial comparing FOBT screening every other year to no-screening, and the NORCCAP trial comparing once-only sigmoidoscopy screening to no-screening. To estimate the natural growth of adenomas to CRC, we used the following microsimulation models: (i) the Microsimulation Screening Analysis; (ii) the CRC Simulated Population model for Incidence and Natural history; (iii) the Simulation Model of Colorectal Cancer; (iv) a model derived by the German Cancer Research Center. We defined overdiagnosed cancers as the difference between the observed number of CRCs in the no-screening arm and the expected number of cancers in screening arm (sum of observed and prevented by adenoma removal). The amount of overdiagnosis is defined as the number of overdiagnosed cancers over the number of cancers observed in the no-screening arm. RESULTS Overdiagnosis estimates were highly dependent on model assumptions. For FOBT screening with 2354 cancers observed in control arm, four out of five models predicted overdiagnosis, range 2.0% (2400 cancers expected in screening) to 7.6% (2533 cancers expected in screening). For sigmoidoscopy screening with 452 cancers observed in control arm, all models predicted overdiagnosis, range 25.2% (566 cancers expected in screening) to 128.1% (1031 cancers expected in screening). CONCLUSIONS The amount of overdiagnosis estimated based on the microsimulation models varied substantially. Microsimulation models may not give reliable estimates of the preventive effect of adenoma removal, and should be used with caution to inform guidelines.
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Affiliation(s)
- Paulina Wieszczy
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Michal F Kaminski
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland
- Department of Cancer Prevention and Department of Oncological Gastroenterology, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Magnus Løberg
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway
- Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Marek Bugajski
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland
- Department of Cancer Prevention and Department of Oncological Gastroenterology, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Michael Bretthauer
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway
- Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Mette Kalager
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway
- Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
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Liang JQ, Wong SH, Szeto CH, Chu ESH, Lau HC, Chen Y, Fang J, Yu J, Sung JJY. Fecal microbial DNA markers serve for screening colorectal neoplasm in asymptomatic subjects. J Gastroenterol Hepatol 2021; 36:1035-1043. [PMID: 32633422 PMCID: PMC8247299 DOI: 10.1111/jgh.15171] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/04/2020] [Accepted: 07/03/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND AIM We have previously shown that fecal microbial markers might be useful for non-invasive diagnosis of colorectal cancer (CRC) and adenoma. Here, we assessed the application of microbial DNA markers, as compared with and in combination with fecal immunochemical test (FIT), in detecting CRC and adenoma in symptomatic patients and asymptomatic subjects. METHODS We recruited 676 subjects [210 CRC, 115 advanced adenoma (AA), 86 non-advanced adenoma, and 265 non-neoplastic controls], including 241 symptomatic and 435 asymptomatic subjects. Fecal abundances of Fusobacterium nucleatum, a Lachnoclostridium sp. m3, Bacteroides clarus, and Clostridium hathewayi were quantified by quantitative PCR. Combining score of the four microbial markers (4Bac) and diagnostic prediction were determined using our previously established scoring model and cutoff values and FIT with a cutoff of 100 ng Hb/mL. RESULTS 4Bac detected similar percentages of CRC [85.3% (95%CI: 79.2-90.2%) vs 84.9% (68.1-94.9%)] and AA [35.7% (12.8-64.9%) vs 38.6% (29.1-48.8%)], while FIT detected more CRC [72.1% (63.7-79.4%) vs 66.7% (48.2-82.0%)] and AA [28.6% (8.4-58.1%) vs 16.8% (10.1-25.6%)], in symptomatic vs asymptomatic subjects, respectively. Focusing on the asymptomatic cohort, 4Bac was more sensitive for diagnosing CRC and AA than FIT (P < 0.001), with lower specificity [83.3% (77.6-88.0%) vs 98.6% (96.0-99.7%)]. FIT failed to detect any non-advanced adenoma [0% (0.0-4.2%)] compared with 4Bac [41.9% (31.3-53.0%), P < 0.0001]. Combining 4Bac with FIT improved sensitivities for CRC [90.9% (75.7-98.1%)] and AA [48.5% (38.4-58.7%)] detection. CONCLUSION Quantitation of fecal microbial DNA markers may serve as a new test, stand alone, or in combination with FIT for screening colorectal neoplasm in asymptomatic subjects.
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Affiliation(s)
- Jessie Qiaoyi Liang
- Institute of Digestive Disease and Department of Medicine and Therapeutics, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, CUHK Shenzhen Research InstituteThe Chinese University of Hong KongHong Kong, China,Department of Microbiology, Faculty of MedicineThe Chinese University of Hong KongHong Kong, China
| | - Sunny H Wong
- Institute of Digestive Disease and Department of Medicine and Therapeutics, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, CUHK Shenzhen Research InstituteThe Chinese University of Hong KongHong Kong, China
| | - Chun Ho Szeto
- Institute of Digestive Disease and Department of Medicine and Therapeutics, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, CUHK Shenzhen Research InstituteThe Chinese University of Hong KongHong Kong, China
| | - Eagle SH Chu
- Institute of Digestive Disease and Department of Medicine and Therapeutics, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, CUHK Shenzhen Research InstituteThe Chinese University of Hong KongHong Kong, China
| | - Harry C Lau
- Institute of Digestive Disease and Department of Medicine and Therapeutics, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, CUHK Shenzhen Research InstituteThe Chinese University of Hong KongHong Kong, China
| | - Yingxuan Chen
- Division of Gastroenterology and Hepatology, Renji Hospital, School of MedicineShanghai Jiaotong UniversityShanghaiChina
| | - Jingyuan Fang
- Division of Gastroenterology and Hepatology, Renji Hospital, School of MedicineShanghai Jiaotong UniversityShanghaiChina
| | - Jun Yu
- Institute of Digestive Disease and Department of Medicine and Therapeutics, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, CUHK Shenzhen Research InstituteThe Chinese University of Hong KongHong Kong, China
| | - Joseph JY Sung
- Institute of Digestive Disease and Department of Medicine and Therapeutics, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, CUHK Shenzhen Research InstituteThe Chinese University of Hong KongHong Kong, China
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47
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ACG Clinical Guidelines: Colorectal Cancer Screening 2021. Am J Gastroenterol 2021; 116:458-479. [PMID: 33657038 DOI: 10.14309/ajg.0000000000001122] [Citation(s) in RCA: 296] [Impact Index Per Article: 98.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 12/02/2020] [Indexed: 12/11/2022]
Abstract
Colorectal cancer (CRC) is the third most common cancer in men and women in the United States. CRC screening efforts are directed toward removal of adenomas and sessile serrated lesions and detection of early-stage CRC. The purpose of this article is to update the 2009 American College of Gastroenterology CRC screening guidelines. The guideline is framed around several key questions. We conducted a comprehensive literature search to include studies through October 2020. The inclusion criteria were studies of any design with men and women age 40 years and older. Detailed recommendations for CRC screening in average-risk individuals and those with a family history of CRC are discussed. We also provide recommendations on the role of aspirin for chemoprevention, quality indicators for colonoscopy, approaches to organized CRC screening and improving adherence to CRC screening. CRC screening must be optimized to allow effective and sustained reduction of CRC incidence and mortality. This can be accomplished by achieving high rates of adherence, quality monitoring and improvement, following evidence-based guidelines, and removing barriers through the spectrum of care from noninvasive screening tests to screening and diagnostic colonoscopy. The development of cost-effective, highly accurate, noninvasive modalities associated with improved overall adherence to the screening process is also a desirable goal.
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Mo S, Wang H, Han L, Xiang W, Dai W, Zhao P, Pei F, Su Z, Ma C, Li Q, Wang Z, Cai S, Wang H, Liu R, Cai G. Fecal Multidimensional Assay for Non-Invasive Detection of Colorectal Cancer: Fecal Immunochemical Test, Stool DNA Mutation, Methylation, and Intestinal Bacteria Analysis. Front Oncol 2021; 11:643136. [PMID: 33718241 PMCID: PMC7947614 DOI: 10.3389/fonc.2021.643136] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 01/15/2021] [Indexed: 12/15/2022] Open
Abstract
Background Fecal immunochemical test (FIT), DNA mutation, DNA methylation, and microbial dysbiosis all showed promising in colorectal cancer (CRC) non-invasive detection. We assessed CRC detection with an assay combining all these strategies and investigated the effect of clinical features on the performance of this comprehensive test. Methods We performed a multidimensional analysis study using stool samples collected from 108 patients with CRC, 18 patients with colorectal adenoma, and 36 individuals with no evidence of colorectal disease. The multidimensional analysis of stool samples including FIT, stool DNA (sDNA) tests for three methylated genes (Septin9, NDRG4, BMP3) and three mutated genes (KRAS, BRAF, PI3KCA) using next generation sequencing as well as detection of stool bacteria level of Fusobacterium nucleatum and Parvimonas micra using qPCR method. We used a linear support vector classification model to analyze the data. Results The sensitivity of FIT alone was 69.4% for CRC and 11.1% for adenoma. Separately, the sensitivity of the detection of intestinal bacteria, DNA mutation, and DNA methylation for CRC was 58.3, 50.0, and 51.9%, respectively. The combination of FIT and sDNA tests had a sensitivity of 81.5% for CRC (AUC: 0.93, better than FIT alone, P = 0.017) and 27.8% for adenoma with 94.4% specificity. Sensitivity of the multidimensional test to detect CRC with stage II (84.6%) and III (91.9%) CRC was relatively higher (88.2%) than that of patients with stage I (60.0%) and stage IV (75.0%) (P = 0.024). The rate of CRC detection increased with tumor size (P = 0.008) and age (P = 0.04). Interestingly, the rate of CRC detection was higher in smoking persons than non-smokers with marginal significance (P = 0.08). Conclusions The multidimensional assay of stool samples combining FIT and stool DNA tests further improved the diagnostic sensitivity for CRC. This could provide new approach for improvement of CRC screening and further demonstrations are warranted.
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Affiliation(s)
- Shaobo Mo
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Hui Wang
- Department of Research and Development, Singlera Genomics (Shanghai) Ltd., Shanghai, China
| | - Lingyu Han
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wenqiang Xiang
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Weixing Dai
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Pengfei Zhao
- Department of Research and Development, Singlera Genomics (Shanghai) Ltd., Shanghai, China
| | - Fengchun Pei
- Department of Research and Development, Singlera Genomics (Shanghai) Ltd., Shanghai, China
| | - Zhixi Su
- Department of Research and Development, Singlera Genomics (Shanghai) Ltd., Shanghai, China
| | - Chengcheng Ma
- Department of Research and Development, Singlera Genomics (Shanghai) Ltd., Shanghai, China
| | - Qi Li
- Department of Medical Oncology and Cancer Institute, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zhimin Wang
- Shanghai-MOST Key Laboratory of Health and Disease Genomics, Chinese National Human Genome Center, Shanghai Industrial Technology Institute, Shanghai, China
| | - Sanjun Cai
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Cancer Institute, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, China
| | - Hao Wang
- Department of Colorectal Surgery, Chang Hai Hospital, Naval Medical University, Shanghai, China
| | - Rui Liu
- Department of Research and Development, Singlera Genomics (Shanghai) Ltd., Shanghai, China
| | - Guoxiang Cai
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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Koffijberg H, Degeling K, IJzerman MJ, Coupé VMH, Greuter MJE. Using Metamodeling to Identify the Optimal Strategy for Colorectal Cancer Screening. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:206-215. [PMID: 33518027 DOI: 10.1016/j.jval.2020.08.2099] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 08/07/2020] [Accepted: 08/18/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Metamodeling can address computational challenges within decision-analytic modeling studies evaluating many strategies. This article illustrates the value of metamodeling for evaluating colorectal cancer screening strategies while accounting for colonoscopy capacity constraints. METHODS In a traditional approach, the best screening strategy was identified from a limited subset of strategies evaluated with the validated Adenoma and Serrated pathway to Colorectal CAncer model. In a metamodeling approach, metamodels were fitted to this limited subset to evaluate all potentially plausible strategies and determine the best overall screening strategy. Approaches were compared based on the best screening strategy in life-years gained compared with no screening. Metamodel runtime and accuracy was assessed. RESULTS The metamodeling approach evaluated >40 000 strategies in <1 minute with high accuracy after 1 adaptive sampling step (mean absolute error: 0.0002 life-years) using 300 samples in total (generation time: 8 days). Findings indicated that health outcomes could be improved without requiring additional colonoscopy capacity. Obtaining similar insights using the traditional approach could require at least 1000 samples (generation time: 28 days). Suggested benefits from screening at ages <40 years require adequate validation of the underlying Adenoma and Serrated pathway to Colorectal CAncer model before making policy recommendations. CONCLUSIONS Metamodeling allows rapid assessment of a vast set of strategies, which may lead to identification of more favorable strategies compared to a traditional approach. Nevertheless, metamodel validation and identifying extrapolation beyond the support of the original decision-analytic model are critical to the interpretation of results. The screening strategies identified with metamodeling support ongoing discussions on decreasing the starting age of colorectal cancer screening.
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Affiliation(s)
- Hendrik Koffijberg
- Health Technology and Services Research Department, Technical Medical Centre, University of Twente, Enschede, The Netherlands.
| | - Koen Degeling
- Health Technology and Services Research Department, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Maarten J IJzerman
- Health Technology and Services Research Department, Technical Medical Centre, University of Twente, Enschede, The Netherlands; Centre for Cancer Research and Centre for Health Policy, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia; Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia; Department of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Veerle M H Coupé
- Decision Modeling Center, Department of Epidemiology and Data Science, Amsterdam UMC - location VUmc, Amsterdam, the Netherlands
| | - Marjolein J E Greuter
- Decision Modeling Center, Department of Epidemiology and Data Science, Amsterdam UMC - location VUmc, Amsterdam, the Netherlands
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50
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Gini A, Buskermolen M, Senore C, Anttila A, Novak Mlakar D, Veerus P, Csanádi M, Jansen EEL, Zielonke N, Heinävaara S, Széles G, Segnan N, de Koning HJ, Lansdorp-Vogelaar I. Development and Validation of Three Regional Microsimulation Models for Predicting Colorectal Cancer Screening Benefits in Europe. MDM Policy Pract 2021; 6:2381468320984974. [PMID: 33598546 PMCID: PMC7863172 DOI: 10.1177/2381468320984974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 11/18/2020] [Indexed: 12/22/2022] Open
Abstract
Background. Validated microsimulation models have been shown to be useful tools in providing support for colorectal cancer (CRC) screening decisions. Aiming to assist European countries in reducing CRC mortality, we developed and validated three regional models for evaluating CRC screening in Europe. Methods. Microsimulation Screening Analysis–Colon (MISCAN-Colon) model versions for Italy, Slovenia, and Finland were quantified using data from different national institutions. These models were validated against the best available evidence for the effectiveness of screening from their region (when available): the Screening for COlon REctum (SCORE) trial and the Florentine fecal immunochemical test (FIT) screening study for Italy; the Norwegian Colorectal Cancer Prevention (NORCCAP) trial and the guaiac fecal occult blood test (gFOBT) Finnish population-based study for Finland. When published evidence was not available (Slovenia), the model was validated using cancer registry data. Results. Our three models reproduced age-specific CRC incidence rates and stage distributions in the prescreening period. Moreover, the Italian and Finnish models replicated CRC mortality reductions (reasonably) well against the best available evidence. CRC mortality reductions were predicted slightly larger than those observed (except for the Florentine FIT study), but consistently within the corresponding 95% confidence intervals. Conclusions. Our findings corroborate the MISCAN-Colon reliability in supporting decision making on CRC screening. Furthermore, our study provides the model structure for an additional tool (EU-TOPIA CRC evaluation tool: http://miscan.eu-topia.org) that aims to help policymakers and researchers monitoring or improving CRC screening in Europe.
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Affiliation(s)
- Andrea Gini
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Maaike Buskermolen
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Carlo Senore
- SC Epidemiology, Screening, Cancer Registry, Città della Salute e della Scienza University Hospital, CPO, Turin, Italy
| | | | | | - Piret Veerus
- National Institute for Health Development, Tallinn, Estonia
| | | | - Erik E L Jansen
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nadine Zielonke
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | | | - Nereo Segnan
- SC Epidemiology, Screening, Cancer Registry, Città della Salute e della Scienza University Hospital, CPO, Turin, Italy
| | - Harry J de Koning
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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