Colorectal Cancer Screening With the Multitarget Stool DNA Test

Performance of DNA methylation and blood-borne tumor indicators in detecting colorectal neoplasia and adenomas: a comparative study with the fecal occult blood test

Objectives

To evaluate the performance of stool methylated syndecan2 (mSDC2), methylated septin9 (mSEPT9), fecal occult blood test (FOBT), carcinoembryonic antigen (CEA), carbohydrate antigen 125 (CA125) and carbohydrate antigen 199 (CA199) in detecting colorectal neoplasia and adenomas.

Methods

Blood-borne CEA, CA125, and CA199 levels were measured by electrochemiluminescence. The SDC2 methylation was detected by Methylation Detection Kit for Human SDC2 Gene (Real time PCR), and the SEPT9 methylation was detected by the Septin9 Gene Methylation Detection Kit based on PCR fluorescent probe assay. The colonoscopy combined with tissue biopsy pathology was used as a validation criterion for colorectal neoplasia.

Results

In detecting colorectal neoplasia, the AUCs of mSDC2, FOBT and mSEPT9 were 0.935 (95% CI: 0.915-0.956, P<0.001), 0.824 (95% CI: 0.617-1.000, P<0.001) and 0.671 (95% CI: 0.511-0.831, P<0.001), respectively. The sensitivity of mSDC2, FOBT and mSEPT9 were 100.0%, 66.7% and 40.0%, respectively. But the AUC of CEA, CA125 and CA199 were not statistically significant for colorectal neoplasia (all P>0.05). The combined application of mSEPT9 and mSDC2 showed the best predictive performance (AUC: 0.956, 95% CI: 0.887~1.000). For adenomas, the AUC of FOBT was extremely low (AUC: 0.524, 95% CI: 0.502-0.545, P=0.004). The CEA, CA125, CA199, mSEPT9 and mSDC2 were not statistically significant in detecting adenomas (all P>0.05).

Conclusions

For individual tests, FOBT and mSDC2 are relatively better indicators for detecting colorectal neoplasia compared to mSEPT9, CEA, CA125 and CA199. The combined form of mSEPT9 and mSDC2 to detect colorectal neoplasia has good predictive performance. However, none of these indicators demonstrated significant predictive power for detecting adenomas in our study.

Barriers in early detection of colorectal cancer and exploring potential solutions

This editorial discusses the literature review article by Tonini and Zanni, the paper was published in January 2024, and the authors provided very interesting conclusions regarding existing barriers to the early diagnosis of colon cancer. Many cancers do not have identifiable precursors, or there are currently no screening tests to find them. Therefore, these cancers do not have preventive screening options. Early detection is crucial for reducing mortality rates by identifying cancer at an earlier stage through screening, as opposed to no screening. Colorectal cancer develops from precancerous lesions, which can be detected early and potentially prevented and cured. Early detection leads to improved survival rates, decreased complications, and reduced healthcare expenses. This editorial provides a brief description of the biology of colon cancer, emphasizing the contrast in outcomes between early detection and late detection. We also describe screening programs around the globe and examine the barriers in each program. Finally, we explore potential future solutions to enhance inclusion in screening programs and improve patient compliance.

Research progress on the correlation between intestinal flora and colorectal cancer

Colorectal cancer (CRC) is one of the most common gastrointestinal malignancies in the world. With the rapid pace of life and changes in diet structure, the incidence and mortality of CRC increase year by year posing a serious threat to human health. As the most complex and largest microecosystem in the human body, intestinal microecology is closely related to CRC. It is an important factor that affects and participates in the occurrence and development of CRC. Advances in next-generation sequencing technology and metagenomics have provided new insights into the ecology of gut microbes. It also helps to link intestinal flora with CRC, and the relationship between intestinal flora and CRC can be continuously understood from different levels. This paper summarizes the relationship between intestinal flora and CRC and its potential role in the diagnosis of CRC providing evidence for early screening and treatment of CRC.

Influence of Colorectal Cancer Risk Factors on Predictive Value of a Positive Multitarget Stool DNA Test

GOALS

We analyzed if the predictive value of multitarget stool-based DNA (mt-sDNA) varied when patients had pre-existing known colorectal cancer (CRC) risk factors.

BACKGROUND

mt-sDNA test is approved for CRC screening in average-risk patients. Whether patients with a personal history of adenomatous colon polyps or a family history of CRC (CRC risk factors) benefit from mt-sDNA testing is unknown.

STUDY

We reviewed charts for all positive mt-sDNA referrals between 2017 and 2021. Diagnostic colonoscopy adherence rates were calculated. In those who had colonoscopy, we compared detection rates for any colorectal neoplasia (CRN), multiple (3 or more) adenomas, sessile serrated polyps (SSP), advanced CRN, and CRC between patients with and without known CRC risk factors.

RESULTS

Of 1297 referrals for positive mt-sDNA, 1176 (91%) completed a diagnostic colonoscopy. The absence of neoplasia was noted in 27% of colonoscopy exams. When neoplasia was identified, findings were as follows: any CRN (73%), multiple adenomas (34%), SSP (23%), advanced CRN (33%), and CRC (2.5%). One or more CRC risk factors were present in 229 (19%) of cases. In the CRC risk factor subgroup, patients having a prior history of adenomatous polyps or a family history of CRC were no more likely to have any CRN, multiple adenomas, SSP, advanced CRN, or CRC compared to average-risk patients when mt-sDNA was positive.

CONCLUSIONS

In this real-world analysis of positive mt-sDNA referrals, adherence to subsequent diagnostic colonoscopy recommendations was high. The presence of pre-existing CRC risk factors did not affect the positive predictive value of mt-sDNA.

Interventions Increase Vaccination Rates in Inflammatory Bowel Disease and Rheumatoid Arthritis: A Systematic Review and Meta-Analysis

BACKGROUND

Patients with immune-mediated conditions such as IBD and RA are at risk for vaccine-preventable infections. Despite guideline recommendations, prior studies have shown suboptimal vaccination rates.

AIM

We conducted a systematic review and meta-analysis to compare the different interventions intended to increase vaccination rates.

METHODS

A systematic search was conducted of MEDLINE/PubMed, Embase, CINAHL, and Cochrane Library up to 2020 for studies with interventions intended to increase vaccination rates. We performed a random-effects meta-analysis to generate pooled odds ratios (ORs) to assess all interventions against no interventions. Our primary outcome was pneumococcal vaccination (PCV) rate.

RESULTS

Our review found 8580 articles, for which 15 IBD and 8 RA articles met the inclusion criteria; 21 articles were included in the analysis. PCV was the predominant vaccination (91%). In our analysis of patients with IBD, almost all interventions (patient-oriented, physician-oriented, or barrier-oriented) increased PCV uptake [OR, 4.74; 95% CI, 2.44-6.56, I2 = 90%] compared to no intervention. The greatest effect was seen in barrier-oriented studies [OR, 12.68; 95% CI, 2.21-72.62, I2 = 92%]. For RA data, all interventions had increased PCV uptake compared to no interventions (OR 2.74; 95% CI, 1.80-4.17, I2 = 95%).

CONCLUSION

Our data suggest that many different interventions can increase PCV rates. It appears that barrier-oriented interventions may have the greatest positive effect on increasing PCV uptake. However, clinicians should be encouraged to implement measures best suited to their practice. Future high-quality randomized controlled trials are needed to determine the best approach to optimize vaccination rates.

Epidemiology, risk factors, and prevention of colorectal cancer

Background: Colorectal cancer remains the fourth most common malignancy in Korea, and has been ranked as the third leading cause of cancer deaths in 2020. This study aims to describe the epidemiologic status of colorectal cancer in Korea, and provide basic data for effective primary and secondary prevention methods by summarizing risk factors and screening tools.Current Concepts: Although colorectal cancer incidence and mortality have decreased in recent years in Korea, it still poses a significant public health burden. From the early 1990s until the mid-2000s, the 5-year relative survival of patients with colorectal cancer in Korea continuously increased. This can be attributed to the successful introduction of the government-led screening program; development of improved surgical techniques, anticancer drugs, and adjuvant treatment; and advances medical resources and infrastructure along with economic growth. However, since the late 2000s, the improvement in survival has stagnated. The coronavirus disease 2019 outbreak has reduced hospital visits and screenings, which is assumed to cause delays in diagnosis, leading to a worse prognosis in the patients. To overcome these obstacles, it is essential to explore modifiable environmental risk factors and appropriate screening test methods in Korea.Discussion and Conclusion: Primary prevention through risk factor modification and secondary prevention using suitable screening programs can reduce the incidence and mortality rates of colorectal cancer.

Diagnostic accuracy of DNA-based SDC2 methylation test in colorectal cancer screening: a meta-analysis

Background

A growing body of research suggests that methylated genes can be used as early diagnostic markers for cancer. Some studies on methylated Syndecan 2 (SDC2) have shown that it has a great diagnostic ability in colorectal cancer. This meta-analysis was aimed to estimate the diagnostic performance of methylated SDC2 as a potential novel biomarker to screen for the colorectal cancer.

Methods

Two independent researchers conducted a comprehensive literature search to identify all relevant studies on SDC2 methylation for the diagnosis of colorectal cancer from inception to March 1, 2021. By using STATA and Revman software, the data were analyzed using a Bivariate mixed model. The quality of each study was also evaluated.

Results

A total of 12 studies comprised of 1574 colorectal cancer patients and 1945 healthy people were included in our meta-analysis. Bivariate analysis showed a pooled sensitivity of 0.81 [95% confidence interval (CI) 0.74–0.86], specificity of 0.95 (95% CI 0.93–0.96), positive likelihood ratio of 15.29 (95% CI 10.83–21.60), and negative likelihood ratio of 0.21 (95% CI 0.15–0.27). The diagnostic odds ratio and the area under the summary ROC curve for diagnosing colorectal cancer were 74.42 (95% CI45.44–121.89) and 0.96 (95% CI 0.94–0.97), respectively. For adenomas, the pooled sensitivity and specificity were 0.47 (95% CI 0.34–0.61) and 0.95 (95% CI 0.92–0.97), respectively.

Conclusions

Our analysis revealed that methylated SDC2 could be considered as a potential novel biomarker to screen for colorectal cancer.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02395-7.

Evaluation of combined detection of multigene mutation and SDC2/SFRP2 methylation in stool specimens for colorectal cancer early diagnosis

PURPOSE

Molecular diagnostics of colorectal cancer (CRC) can be used as an auxiliary approach for patients recommended for colonoscopy, providing more CRC supplemental diagnosis options. This study investigated whether combined detection of KRAS/BRAF/APC mutation and SDC2/SFRP2 methylation can serve as auxiliary diagnostics in clinical management.

METHODS

KRAS/BRAF/APC mutation and SDC2/SFRP2 methylation in stool samples from healthy donors, patients with CRC, advanced adenoma (AA), non-advanced adenoma (NAA), or other gastroenterological diseases were evaluated using quantitative PCR (qPCR) or methylation-specific quantitative PCR (MSP). Test accuracy was determined by evaluating the tests' sensitivity, specificity, positive/negative predictive value (PPV/NPV), or positive/negative likelihood ratio (PLR/NLR).

RESULTS

The combined fecal KRAS/BRAF/APC mutation and SFRP2/SDC2 methylation detection test achieved a sensitivity of 88.57% with a PPV of 93.64% and a PLR of 7.10 for CRC patients. In comparison, the corresponding parameters for multigene mutation were 46.67%, 92.59%, and 36.26 and 83.81%, 93.94%, and 7.47, for DNA methylation, separately. The sensitivity of the combined test, gene mutation test, and DNA methylation test approach was 75%, 28.26%, and 72.83%. Furthermore, the specificity of this approach in the NAA group was 79.49%. Meanwhile, the overall diagnostic specificity for the combined test in NAA, healthy control, and interference groups was 88.42%. In addition, the sensitivity of the combined detection method increased with the disease stage in CRC patients and elevated along with the lesion size (≥ 1 cm) in AA patients.

CONCLUSION

Combined detection of fecal KRAS/BRAF/APC mutation and SFRP2/SDC2 methylation has potential application value for the auxiliary diagnosis of CRC and AA.

Gut Microbiota as Potential Biomarker and/or Therapeutic Target to Improve the Management of Cancer: Focus on Colibactin-Producing Escherichia coli in Colorectal Cancer

The gut microbiota is crucial for physiological development and immunological homeostasis. Alterations of this microbial community called dysbiosis, have been associated with cancers such colorectal cancers (CRC). The pro-carcinogenic potential of this dysbiotic microbiota has been demonstrated in the colon. Recently the role of the microbiota in the efficacy of anti-tumor therapeutic strategies has been described in digestive cancers and in other cancers (e.g., melanoma and sarcoma). Different bacterial species seem to be implicated in these mechanisms: F. nucleatum, B. fragilis, and colibactin-associated E. coli (CoPEC). CoPEC bacteria are prevalent in the colonic mucosa of patients with CRC and they promote colorectal carcinogenesis in susceptible mouse models of CRC. In this review, we report preclinical and clinical data that suggest that CoPEC could be a new factor predictive of poor outcomes that could be used to improve cancer management. Moreover, we describe the possibility of using these bacteria as new therapeutic targets.

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

AIM

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSION

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