Screening colonoscopy and risk of adverse events among individuals undergoing fecal immunochemical testing in a population-based program: A nested case-control study

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

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.

Longitudinal assessment of colonoscopy adverse events in the prospective Cooperative Studies Program no. 380 colorectal cancer screening and surveillance cohort

BACKGROUND AND AIMS

Data are limited regarding colonoscopy risk during long-term, programmatic colorectal cancer screening and follow-up. We aimed to describe adverse events during follow-up in a colonoscopy screening program after the baseline examination and examine factors associated with increased risk.

METHODS

Cooperative Studies Program no. 380 includes 3121 asymptomatic veterans aged 50 to 75 years who underwent screening colonoscopy between 1994 and 1997. Periprocedure adverse events requiring significant intervention were defined as major events (other events were minor) and were tracked during follow-up for at least 10 years. Multivariable odds ratios (ORs) were calculated for factors associated with risk of follow-up adverse events.

RESULTS

Of 3727 follow-up examinations in 1983 participants, adverse events occurred in 105 examinations (2.8%) in 93 individuals, including 22 major and 87 minor events (examinations may have had >1 event). Incidence of major events (per 1000 examinations) remained relatively stable over time, with 6.1 events at examination 2, 4.8 at examination 3, and 7.2 at examination 4. Examinations with major events included 1 perforation, 3 GI bleeds requiring intervention, and 17 cardiopulmonary events. History of prior colonoscopic adverse events was associated with increased risk of events (major or minor) during follow-up (OR, 2.7; 95% confidence interval, 1.6-4.6).

CONCLUSIONS

Long-term programmatic screening and surveillance was safe, as major events were rare during follow-up. However, serious cardiopulmonary events were the most common major events. These results highlight the need for detailed assessments of comorbid conditions during routine clinical practice, which could help inform individual decisions regarding the utility of ongoing colonoscopy follow-up.

A Comprehensive Metabolomics Analysis of Fecal Samples from Advanced Adenoma and Colorectal Cancer Patients

Accurate diagnosis of colorectal cancer (CRC) still relies on invasive colonoscopy. Noninvasive methods are less sensitive in detecting the disease, particularly in the early stage. In the current work, a metabolomics analysis of fecal samples was carried out by ultra-high-performance liquid chromatography–tandem mass spectroscopy (UPLC-MS/MS). A total of 1380 metabolites were analyzed in a cohort of 120 fecal samples from patients with normal colonoscopy, advanced adenoma (AA) and CRC. Multivariate analysis revealed that metabolic profiles of CRC and AA patients were similar and could be clearly separated from control individuals. Among the 25 significant metabolites, sphingomyelins (SM), lactosylceramides (LacCer), secondary bile acids, polypeptides, formiminoglutamate, heme and cytidine-containing pyrimidines were found to be dysregulated in CRC patients. Supervised random forest (RF) and logistic regression algorithms were employed to build a CRC accurate predicted model consisting of the combination of hemoglobin (Hgb) and bilirubin E,E, lactosyl-N-palmitoyl-sphingosine, glycocholenate sulfate and STLVT with an accuracy, sensitivity and specificity of 91.67% (95% Confidence Interval (CI) 0.7753–0.9825), 0.7 and 1, respectively.

Analysis of the Characteristics of Colonoscopy Perforation and Risk Factors for Failure of Endoscopic Treatment

Background: Many studies have been done regarding perforation after colonoscopy, but few studies analyzed the risk factors of endoscopic treatment failure after colonoscopy perforation. This study aimed to analyze the clinical characteristics and treatment plan of those patients with perforation after colonoscopy diagnosis and the treatment and risk factors of failure to endoscopic treatment.

Method: This was a retrospective observational study of patients who underwent colonoscopy examination and treatment at the Affiliated Hospital of Yangzhou University, from 04/2009 to 03/2020. The patients were grouped as perforation, treatment success, or failure (required laparoscopy or laparotomy).

Results: From April 2009 to March 2020, 43,470 patients were examined and treated with colonoscopy. There were 35 cases of intestinal perforation, for an incidence of 0.081%. Four patients had immediate surgical intervention (two patients with laparoscopic surgery and two with laparotomy surgery). Thirty-one (88.57%) patients underwent endoscopic treatment. Endoscopic treatment was successful in 20 patients and failed in 11. Compared with the failure group, the perforation size in the success group was smaller (7.60±4.85 vs. 14.4±7.03 mm, P=0.004), hospital stay was shorter (26.6±13.1 vs. 14.2±3.0, P=0.011), and hospitalization costs were lower (30,208±9506 vs. 23,053±6227 RMB, P=0.002). Multivariable logistic stepwise analysis showed that the absence of abdominal pain after therapeutic colonoscopy was independently associated with the success of endoscopic treatment.

Conclusions: Endoscopic treatment is logically the preferred modality for perforation management, leading to good recovery, shorter hospital stay, and lower costs of treatment. Postoperative abdominal pain is significantly related to the failure of endoscopic treatment.

Liquid Biopsy as a Source of Nucleic Acid Biomarkers in the Diagnosis and Management of Lynch Syndrome

Lynch syndrome (LS) is an autosomal dominant inherited cancer predisposition disorder, which may manifest as colorectal cancer (CRC), endometrial cancer (EC) or other malignancies of the gastrointestinal and genitourinary tract as well as the skin and brain. Its genetic cause is a defect in one of the four key DNA mismatch repair (MMR) loci. Testing of patients at risk is currently based on the absence of MMR protein staining and detection of mutations in cancer tissue and the germline, microsatellite instability (MSI) and the hypermethylated state of the MLH1 promoter. If LS is shown to have caused CRC, lifetime follow-up with regular screening (most importantly, colonoscopy) is required. In recent years, DNA and RNA markers extracted from liquid biopsies have found some use in the clinical diagnosis of LS. They have the potential to greatly enhance the efficiency of the follow-up process by making it minimally invasive, reproducible, and time effective. Here, we review markers reported in the literature and their current clinical applications, and we comment on possible future directions.

Colonoscopy-Related Adverse Events in Patients With Abnormal Stool-Based Tests: A Systematic Review of Literature and Meta-analysis of Outcomes

INTRODUCTION

Colorectal cancer (CRC) screening programs based on the fecal immunochemical test (FIT) and guaiac-based fecal occult blood (gFOBT) are associated with a substantial reduction in CRC incidence and mortality. We conducted a systematic review and comprehensive meta-analysis to evaluate colonoscopy-related adverse events in individuals with a positive FIT or gFOBT.

METHODS

A systematic and detailed search was run in January 2021, with the assistance of a medical librarian for studies reporting on colonoscopy-related adverse events as part of organized CRC screening programs. Meta-analysis was performed using the random-effects model, and the results were expressed for pooled proportions along with relevant 95% confidence intervals (CIs).

RESULTS

A total of 771,730 colonoscopies were performed in patients undergoing CRC screening using either gFOBT or FIT across 31 studies. The overall pooled incidence of severe adverse events in the entire patient cohort was 0.42% (CI 0.20-0.64); I2 = 38.76%. In patients with abnormal gFOBT, the incidence was 0.2% (CI 0.1-0.3); I2 = 24.6%, and in patients with a positive FIT, it was 0.4% (CI 0.2-0.7); I2 = 48.89%. The overall pooled incidence of perforation, bleeding, and death was 0.13% (CI 0.09-0.21); I2 = 22.84%, 0.3% (CI 0.2-0.4); I2 = 35.58%, and 0.01% (CI 0.00-0.01); I2 = 33.21%, respectively.

DISCUSSION

Our analysis shows that in colonoscopies performed after abnormal stool-based testing, the overall risk of severe adverse events, perforation, bleeding, and death is minimal.

Making decisions on your own: Self-administered decision aids about colorectal cancer screening - A systematic review and meta-analyses

OBJECTIVE

To provide a systematic review of self-administered decision aids (DAs) for citizens invited to participate in colorectal cancer screening synthesizing the effectiveness of self-administered DAs on informed choice or the components hereof; knowledge, attitudes, and participation.

METHODS

The literature search was undertaken in PubMed, CINAHL, PsycINFO, Embase and Scopus and last updated 19 March 2021. Results were presented by narrative synthesis, meta-analyses and vote counting based on direction of effect.

RESULTS

Fourteen studies of fair methodological quality were included. One study reported on informed choice and 13 studies reported on the components. Self-administered DAs increased participation and knowledge whereas it was inconclusive with regard to attitudes towards screening. The studies were very heterogeneous with different comparators, outcomes and means of measurement.

CONCLUSION

This systematic review showed a potential for self-administered DAs to support informed choice in colorectal cancer screening, especially by increasing knowledge.

PRACTICE IMPLICATIONS

It seems reasonable to consider informed choice to be one of the main outcomes of self-administered DAs. Yet there is a need for consensus on how to measure informed choice in cancer screening, especially a validated measurement of knowledge defining what constitutes 'adequate knowledge'.

Age-Specific Rates and Time-Courses of Gastrointestinal and Nongastrointestinal Complications Associated With Screening/Surveillance Colonoscopy

INTRODUCTION

The rates of serious cardiac, neurologic, and pulmonary events attributable to colonoscopy are poorly characterized, and background event rates are usually not accounted for.

METHODS

We performed a multistate population-based study using changepoint analysis to determine the rates and timing of serious gastrointestinal and nongastrointestinal adverse events associated with screening/surveillance colonoscopy, including analyses by age (45 to <55, 55 to <65, 65 to <75, and ≥75 years). Among 4.5 million persons in the Ambulatory Surgery and Services Databases of California, Florida, and New York who underwent screening/surveillance colonoscopy in 2005-2015, we ascertained serious postcolonoscopy events in excess of background rates in Emergency Department (SEDD) and Inpatient Databases (SID).

RESULTS

Most serious nongastrointestinal postcolonoscopy events were expected based on the background rate and not associated with colonoscopy itself. However, associated nongastrointestinal events predominated over gastrointestinal events at ages ≥65 years, including more myocardial infarctions plus ischemic strokes than perforations at ages ≥75 years (361 [95% confidence intervals {CI} 312-419] plus 1,279 [95% CI 1,182-1,384] vs 912 [95% CI 831-1,002] per million). At all ages, the observed-to-expected ratios for days 0-7, 0-30, and 0-60 after colonoscopy were substantially >1 for gastrointestinal bleeding and perforation, but minimally >1 for most nongastrointestinal complications. Risk periods ranged from 1 to 125 days depending on complication type and age. No excess postcolonoscopy in-hospital deaths were observed.

DISCUSSION

Although crude counts substantially overestimate nongastrointestinal events associated with colonoscopy, nongastrointestinal complications exceed bleeding and perforation risk in older persons. The inability to ascertain modifications to antiplatelet therapy was a study limitation. Our results can inform benefit-to-risk determinations for preventive colonoscopy.

Risks associated with colonoscopy in a population-based colon screening program: an observational cohort study

BACKGROUND

The risks associated with colonoscopy performed through the British Columbia Colon Screening Program (BCCSP) are not known. We aimed to determine the rate of colonoscopy-related serious adverse events within this program.

METHODS

For this prospective observational study, we used the BCCSP database to identify participants 50 to 74 years of age who had a positive result on fecal immunochemical testing (FIT) between Nov. 15, 2013, and Dec. 31, 2017, followed by colonoscopy. Unplanned medical events were recorded at the time of colonoscopy and 14 days later. We reviewed the unplanned events and defined them as serious adverse events if they resulted in death, hospital admission or intervention; we also classified them as probably, possibly or unlikely related to the colonoscopy. The primary outcome was the overall rate of serious adverse events; the secondary outcomes were 14-day post-colonoscopy rates of perforation, bleeding and death.

RESULTS

During the study period, a total of 96 192 colonoscopies were performed by 308 physicians at 50 sites. The median age of patients was 62 (10th-90th percentile 52-71) years, and 56% were male. Of these, 78 831 patients were contacted after the colonoscopy. Serious adverse events were deemed to have occurred in 350 colonoscopies (44 per 10 000, 95% confidence interval [CI] 39-50 per 10 000), with a number needed to harm of 225. Of the 332 (94.9%) serious adverse events that were probably or possibly related to colonoscopy, perforation occurred in 6 (95% CI 5-8) per 10 000 colonoscopies, bleeding in 26 (95% CI 22-30) per 10 000 colonoscopies and death in 3 (95% CI 1-10) per 100 000 colonoscopies.

INTERPRETATION

The rate of serious adverse events associated with colonoscopy in the BCCSP was in keeping with previous publications and met accepted benchmarks. The findings of this study inform stakeholders of the risks associated with colonoscopy in an FIT-based colon screening program.

Colonoscopy-Related Mortality in a Fecal Immunochemical Test-Based Colorectal Cancer Screening Program

BACKGROUND & AIMS

Many countries have introduced colorectal cancer (CRC) screening programs with fecal immunochemical tests (FITs), and follow-up colonoscopies for individuals with a positive FIT result. In order to make an informed decision to participate, individuals must be informed about the benefits and harms of FIT-based screening and subsequent colonoscopy. Colonoscopy-related fatal complications in FIT-based screening are understudied. We aimed to estimate the colonoscopy-related mortality in a national FIT-based CRC screening program.

METHODS

Colonoscopy-related mortality within 30 days after colonoscopy was assessed by analysis of data from national endoscopy complication databases in the Netherlands, determining the excess 30-day rate of death in FIT-positive individuals undergoing colonoscopy vs FIT-negative individuals (based on data from the national screening database), and determining the rate of likely colonoscopy-related deaths based on registered causes of death by the Statistics Netherlands.

RESULTS

Between October 2013 and December 2017, 172,797 participants underwent colonoscopy after a positive result from a FIT in the Dutch national CRC screening program; 13,848 participants received a diagnosis of CRC. The reported fatal complication rate was 0.23 per 10,000 FIT-positive participants (or 1 per 43,199; 95% CI, 0.090 - 0.60) undergoing colonoscopy, whereas this was 0.91 per 10,000 FIT-positive participants (or 1 per 10,961; 95% CI, 0.44 - 1.38) according to the excess death rate. Likely colonoscopy-related causes of death were reported in 0.86 per 10,000 FIT-positive participants (or 1 per 11,236; 95% CI, 0.48 - 1.63) who underwent colonoscopy, of which 50% considered cardiovascular events.

CONCLUSIONS

Colonoscopy-related mortality within the Dutch FIT-based CRC screening program was estimated to range from 0.23 to 0.91 per 10,000 FIT-positive participants undergoing colonoscopy. These findings indicate underreporting of fatal complications in registries and a noteworthy incidence of fatal cardiovascular adverse events that requires further investigation. Nevertheless, the harm of FIT-based CRC screening is vastly outweighed by the benefits.

Adverse events of colonoscopy in a colorectal cancer screening program with fecal immunochemical testing: a population-based observational study

Background and study aims  The aim of this study was to assess adverse events (AEs) associated with colonoscopy in the French colorectal cancer screening program with fecal occult blood test (FOBT). Patients and methods  A retrospective cohort study was performed of all colonoscopies performed from 2015 to 2018 for a positive fecal immunochemical test (FIT) in patients aged 50 to 74 years within the screening program in progress in Alsace, part of the French program. AEs were recorded through prospective voluntary reporting by community gastroenterologists and retrospective postal surveys addressed to individuals screened. They were compared with those recorded in the previous program following colonoscopies performed from 2003 to 2014 for a positive guaiac-based FOBT (gFOBT). Results  Of 9576 colonoscopies performed for a positive FIT, 6194 (64.7 %) were therapeutic. Overall, 180 AEs were recorded (18.8 ‰, 95 % CI 16.1-21.5), 114 of them (11.9 ‰, 95 % CI 9.7-14.1) requiring hospitalization, 55 (5.7‰, 95 % CI 4.2-7.3) hospitalization > 24 hours, and eight (0.8 ‰, 95 % CI 0.3-1.4) surgery. The main complications requiring hospitalization were perforation (n = 18, 1.9 ‰, 95 % CI 1.0-2.7) and bleeding (n = 31, 3.2 ‰, 95 % CI 2.1-4.4). Despite a significant increase in several risk factors for complication, the rate of AEs remained stable between gFOBT and FIT programs. Overall, we observed one death (1/27,000 colonoscopies) and three splenic injuries. Conclusions  The harms of colonoscopy in a colorectal cancer screening program with FIT are more frequent than usually estimated. This study revealed six AEs requiring hospitalization > 24 hours (three bleeds, two perforations), one necessitating surgery, and 50 minor complications per 1000 colonoscopies.

Two-Person Colonoscopy as a Training Approach to Non-sedation Colonoscopy

BACKGROUND

Reported learning curves of colonoscopy vary from 94 to 275 cases and focus on one-person colonoscopy. Our aim was to evaluate the learning curve of two-person non-sedation colonoscopy for trainees in a single tertiary care hospital.

PATIENTS AND METHODS

We conducted a retrospective study in 1264 patients who underwent diagnostic or screening colonoscopies in a single institution from August 2012 to January 2013. Most of the patients (1174/1264) did not receive sedation during the procedure. All procedures were performed under two-person control. Two third-year residents who received previous colonoscopic training via a plastic model were the trainees.

RESULTS

In comparison to the performance of 5 staff members, the colonoscopic outcomes showed no significant differences in the completion rates (77.2% vs. 79.8%, P = .382), average polyp numbers (.9 ± 1.7 vs. 1.0 ± 1.8, P = .453), polyp detection rates (43.5% vs. 46.3%, P = .434), or intubation lengths (96.4 ± 29.3 vs. 96.3 ± 26.7 cm, P = .939). The total procedure times for the 2 groups were 17.2 ± 10.6 minutes (trainees) and 12.9 ± 7.8 minutes (staff) (P < .001).

CONCLUSION

Trainees achieved acceptable outcomes over an 81-97 case learning curve under a two-person non-sedation colonoscopy technique, an approach with potential as a transition to single-operator colonoscopy.

Colonoscopy adverse events: are we getting the full picture?

INTRODUCTION

Colonoscopy adverse events (AEs) are commonly underreported and standardised reporting is rarely used. We aimed to investigate AEs associated with colonoscopy in a real world setting, using the American Society of Gastrointestinal Endoscopy (ASGE) lexicon.

METHODS

This retrospective cohort study of AEs related to outpatient colonoscopies performed in the North Denmark Region from 2015 to 2018 identified AEs from readmission within eight days or death within 30 days of colonoscopy. AEs were investigated in electronic health records and categorised, attributed and graded according to the ASGE lexicon.

RESULTS

Of 49,445 colonoscopies performed, 1141 were potentially associated with AEs (23.07‰). Electronic health record review left 489 AEs attributed to colonoscopy (9.9‰); categorised as cardiovascular (0.65‰), pulmonary (0.36‰), thromboembolic (0.10‰), instrumental incl. perforations (0.99‰), bleeding (3.07‰), infection (0.87‰), drug reactions (0.04‰), pain (2.00‰), integument (damage to skin/bones) (0.34‰) and other (1.62‰) AEs. Ten (0.20‰) AEs were fatal, but only one was procedure related (perforation). All shearing force perforations occurred in the sigmoid colon. Most polypectomy perforations occurred in the caecum (60%).

CONCLUSIONS

Colonoscopy carries important procedure and non-procedure related risks. Non-procedure related AEs are likely underreported. Better attention to patients with pre-existing diseases and further colonoscopist training may lower AE rates. A standardised colonoscopy AE reporting system is warranted.

Evaluation of colonoscopy data for colorectal polyps and associated histopathological findings

Background

Adenomas of colon and rectal are frequent colonoscopically found benign lesions. The aim of this study is to evaluate the incidence of polyps among patients referred for colonoscopy and associated histopathological findings.

Methods

In this retrospective study, patients referred for colonoscopy at Shahid Madani Hospital from were enrolled. The records of the patients were evaluated for demographic data, polyp status along with size and location and type and histopathological findings of the polyps. The data obtained were statistically analyzed using SPSSv22.

Results

Among 1600 patients who underwent colonoscopy, 260 were positive with polyps. The main symptom among these patients was lower gastrointestinal bleeding 44.2%. The average size of the polyps was 5.68 ± 2.66 and the incidence was significantly greatest among the age group of 51–65 years, p < 0.01. The commonest sites polyps were sigmoid and descending colon, 28.6% and 23.2%, respectively. Adenomatous polyps were the most frequent type, 58.3%. The morphology and pathology of the polyps were significantly associated with each other, p < 0.01.

Conclusion

Our study evaluates the retrospective data for polyp findings among colonoscopy patients. Early diagnosis of polyps can provide better therapeutic outcomes.

•

Adenomas of colon and rectal are frequent colonoscopically found benign lesions.

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Surveillance of colonoscopy could have been compromised since several physicians were included in the study.

Mortality and Rate of Hospitalization in a Colonoscopy Screening Program From a Randomized Health Services Study

BACKGROUND & AIMS

It is difficult to quantify adverse events related to screening colonoscopy due to lack of valid and adequately powered comparison groups. We compared mortality and rate of unplanned hospitalizations among subjects who underwent screening colonoscopies within the Polish Colonoscopy Screening Program (PCSP) vs unscreened matched controls in Poland.

METHODS

Persons 55-64 years old living in the area covered by the PCSP from 2012 through 2015 were assigned in a (1:1) to a group invited for screening colonoscopy (n = 338,477) or a matched group that would be invited 5 years later (controls, n = 338,557). All subjects in the screening group were assigned proposed screening colonoscopy dates (actual dates when invitees confirmed or rescheduled colonoscopy) and those in the control group were assigned virtual dates corresponding to the matched individuals from the screening group. In the screening group, 55,390 subjects (16.4%) underwent screening colonoscopy. Mortality and hospitalization data were obtained from National Registries. We compared mortality and rate of hospitalization between the groups for defined intervals before and after colonoscopy date. Hospitalizations were divided into related and unrelated to colonoscopy based on ICD codes by 3 specialists. Our primary aim was to compare mortality and hospitalization 6 weeks before and 30 days following the actual or virtual date of colonoscopy in the screening or control group.

RESULTS

In the intent to treat analysis, overall there were no significant differences in mortality between the colonoscopy group and control group (0.22% vs 0.22%; risk difference less than .01%; 95% CI, decrease of 0.02% to 0.02%; P = .913). The overall rate of unplanned hospitalization was significantly higher for the colonoscopy group (2.39% vs 2.31% for the control group; risk difference, 0.08%; 95% CI, 0.01%-0.15%; P=.026) for the entire observation period. This was due to the higher rate of hospitalizations after screening (1.10% vs 1.01% for the control group; risk difference, 0.09%; 95% CI, 0.04%-0.14%; P < .001) including higher proportion of hospitalizations that were assessed as related to colonoscopy (0.24% vs 0.22% for the control group; risk difference, 0.02%; 95% CI, 0.00%-0.05%; P = .046). In the per-protocol analysis, the overall rate of hospitalizations did not differ significantly between control and screening colonoscopy groups (1.87% vs 1.90%; P=.709). However, screening colonoscopy did increase rates of related hospitalizations after the date of screening (from 0.14% to 0.31%; P < .001).

CONCLUSIONS

In an analysis of data from the PCSP, we found high-quality evidence that colonoscopy as a screening intervention does not increase mortality before or after colonoscopy. However, it may be associated with a small but significant increase in unplanned hospitalizations, especially after the colonoscopy is completed.

Should Flanders consider lowering its target age for colorectal cancer screening to 45-49?

INTRODUCTION

Colorectal cancer (CRC) screening generally starts screening by the age of 50 based on guidelines. Lately however, a U.S. guideline recommended to start CRC screening from age 45 and, very recently, two studies were published that addressed young-onset in Europe (in part) (Vuik et al., 2019; Araghi et al., 2019).

MATERIALS AND METHODS

Flemish CRC incidence and mortality data contextualise trend results for age groups under 50 and what the implications could be for practice.

RESULTS

CRC incidence rates showed considerable variability over a 12-year period without a clear increase in disease burden for the age group 45-49 in Flanders. In several age groups under 39 an increasing incidence trend was visible for both genders. Data was analysed in a period where no CRC screening was present in Flanders.

DISCUSSION

Decreasing the target age for the Flemish CRC screening does not seem to be straightforward and primary prevention should be considered more prominently.

Colonoscopy-related complications in a nationwide immunochemical fecal occult blood test-based colorectal cancer screening program

Background

The Danish national screening program for colorectal cancer (CRC) consists of an immunochemical fecal occult blood test (iFOBT) followed by colonoscopy. The Danish Colorectal Cancer Screening Database (DCCSD) records data on the incidence of hospital-registered complications after colonoscopy. However, the validity of these data is unknown, and the incidence of complications is potentially underreported.

Objective

To evaluate the validity of the colonoscopy complications registered in the DCCSD by using medical records as the reference. Further, to evaluate the incidence of complications leading to hospital contact.

Methods

Among 14,671 individuals with a positive iFOBT result and a colonoscopy procedure performed from March 3, 2014 to December 31, 2014, we selected 295 individuals for medical record review. We calculated sensitivity as the proportion of true complications registered in the DCCSD out of all complications found in the medical records, and the positive predictive value (PPV) as the number of true complications in the DCCSD out of all DCCSD-registered complications. On the basis of the medical record data, we calculated the incidence proportion of hospital-registered complications overall and by subtype.

Results

In total, we reviewed 286 records and found 102 individuals with at least one complication. The sensitivity of the DCCSD for any complication was 29.4% (95% CI: 20.8–39.3) and the PPV was 88.2% (95% CI: 72.6–96.7). On the basis of the medical record data, the incidence proportion of any complication after colonoscopy was 0.70% (95% CI: 0.57–0.84) and that of perforation or lesion was 0.10% (95% CI: 0.06–0.17); bleeding, 0.41% (95% CI: 0.31–0.53); post-polypectomy syndrome, 0.16% (95% CI: 0.10–0.24); and other medical complications, 0.04 (95% CI: 0.02–0.09).

Conclusion

The DCCSD has low sensitivity for complications, and improvements in data registration are warranted. The incidence proportion of any hospital-treated post-colonoscopy complication was 0.70% in 2014, which was the first year of the Danish national CRC screening program. This is within the range of complications reported by other studies.