ACG Clinical Guidelines: Colorectal Cancer Screening 2021

Screening for Colorectal Cancer

Colorectal cancer remains the third leading cause of cancer death in the United States. Colorectal cancer screening allows for prevention and early detection of precancerous and cancerous lesions, and screening has been shown to be effective in preventing colorectal cancer deaths. Screening recommendations vary by patient risk profile. A variety of screening modalities exist.

Colorectal cancer screening guidelines for average-risk and high-risk individuals: A systematic review

AIMS

This review aims to summarize the different colorectal cancer guidelines for average-risk and high-risk individuals from various countries.

METHODS

A comprehensive literature search regarding guidelines, consensus recommendations, or position statements about colorectal cancer screening published within the last 10 years (1st January 2012 to 27th August 2022), was performed at EBSCOhost, JSTOR, PubMed, ProQuest, SAGE, and ScienceDirect.

RESULTS

A total of 18 guidelines were included in this review. Most guidelines recommended screening between 45 and 75 years for average-risk individuals. Recommendations regarding colorectal cancer screening in high-risk individuals were more varied and depended on the risk factor. For high-risk individuals with a positive family history of colorectal cancer or advanced colorectal polyp, screening should begin at age 40. Some frequently suggested screening modalities in order of frequency are colonoscopy, FIT, and CTC. Furthermore, several screening intervals were suggested, including colonoscopy every 10 years for average-risk and every 5-10 years for high-risk individuals, FIT annually in average-risk and every 1-2 years in high-risk individuals, and CTC every five years for all individuals.

CONCLUSION

All individuals with average-risk should undergo colorectal cancer screening between 45 and 75. Meanwhile, individuals with higher risks, such as those with a positive family history, should begin screening at age 40. Several recommended screening modalities were suggested, including colonoscopy every 10 years in average-risk and every 5-10 years in high-risk, FIT annually in average-risk and every 1-2 years in high-risk, and CTC every five years.

Colorectal Cancer Screening Among Individuals With a Substance Use Disorder: A Retrospective Cohort Study

Introduction

There is limited evidence on colorectal cancer screening among individuals with a substance use disorder. This study aims to investigate the association between personal history of a substance use disorder and colorectal cancer colonoscopy screening completion rates.

Methods

This retrospective cohort study analyzed 176,300 patients, of whom 171,973 had no substance use disorder and 4,327 had a substance use disorder diagnosis from electronic health record data (January 1, 2008-December 31, 2022) in a Midwestern healthcare system. Baseline was January 1, 2013, and a 10-year follow-up period ran through December 31, 2022. The outcome was receipt of colonoscopy in the 10-year follow-up period. Patients were aged 50-65 years at baseline, meaning that they were eligible for a colonoscopy through the entirety of the 10-year follow-up period. Covariates included demographics (age, race, and neighborhood SES), health services utilization, psychiatric and physical comorbidities, and prior colonoscopy or fecal occult blood testing. Entropy balancing was used to control for confounding in weighted log-binomial models calculating RR and 95% CIs.

Results

Patients were on average aged 57.1 (±4.5) years, 58.2% were female, 81.0% were White, and 16.9% were of Black race. The most prevalent comorbidities were obesity (29.6%) and hypertension (29.4%), followed by smoking/nicotine dependence (21.0%). The most prevalent psychiatric comorbidity was depression (6.4%), followed by anxiety disorder (4.5%). During the 10-year follow-up period, 40.3% of eligible patients completed a colorectal cancer colonoscopy screening test, and individuals with a substance use disorder diagnosis were significantly less likely to receive a colorectal cancer colonoscopy screening test both prior to and after controlling for confounding (RR=0.73; 95% CI=0.70, 0.77 and RR=0.81; 95% CI=0.74, 0.89, respectively). Results were not modified by sex, race, psychiatric comorbidity, or neighborhood SES.

Conclusions

Personal history of substance use disorder was independently associated with lower screening completion rates. Healthcare professionals should recognize unique barriers among individuals with substance use disorder and then address them individually as a multidisciplinary team in the outpatient setting to reduce this health disparity.

The effect of mailed outreach on FIT completion among patients aged 45-50 in a safety net healthcare system

PURPOSE

Colorectal cancer screening is recommended starting at age 45, but there has been little research on strategies to promote screening in patients younger than 50.

METHODS

An outreach program quasi-randomly assigned patients aged 45-50 without recent fecal immunochemical test (FIT), colonoscopy or contraindications to screening to two intervention arms: electronic outreach with email and text (electronic outreach only) versus electronic outreach plus mailed outreach with FIT, an instructional letter and a prepaid return envelope (mailed + electronic outreach). In response to known disparities in screening uptake, all Black patients were assigned to receive mailed + electronic outreach.

RESULTS

Among patients quasi-randomly assigned to an intervention (non-Black patients), the 180-day FIT completion rate was 18.8% in the electronic outreach only group (n = 1,318) and 25.0% in the mailed + electronic outreach group (n = 1,364) (difference 6.2% [95% CI 3.0, 9.4]). FIT completion was 16.6% among Black patients (n = 469), 8.4% (95% CI 4.1, 12.6) lower than among non-Black patients also assigned to mailed + electronic outreach.

CONCLUSION

Among patients aged 45-50, mailed + electronic outreach had a greater effect on FIT completion than electronic outreach alone. Crossover between intervention groups likely lead to an underestimation of the effect of mailed outreach.

The projected health and economic impact of increased colorectal cancer screening participation among Canadians by income quintile

OBJECTIVES

Disparities in colorectal cancer (CRC) screening uptake by socioeconomic status have been observed in Canada. We used the OncoSim-Colorectal model to evaluate the health and economic outcomes associated with increasing the participation rates of CRC screening programs to 60% among Canadians in different income quintiles.

METHODS

Baseline CRC screening participation rates were obtained from the 2017 Canadian Community Health Survey. The survey participants were categorized into income quintiles using their reported household income and 2016 Canadian Census income quintile thresholds. Within each quintile, the participation rate was the proportion of respondents aged 50-74 who reported having had a fecal test in the past two years. Using the OncoSim-Colorectal model, we simulated an increase in CRC screening uptake to 60% across income quintiles to assess the effects on CRC incidence, mortality, and associated economic costs from 2024 to 2073.

RESULTS

Increasing CRC screening participation rates to 60% across all income quintiles would prevent 69,100 CRC cases and 36,600 CRC deaths over 50 years. The improvement of clinical outcomes would also translate to increased person-years and health-adjusted person-years. The largest impact was observed in the lowest income group, with 22,200 cases and 11,700 deaths prevented over 50 years. Increased participation could lead to higher screening costs ($121 million CAD more per year) and lower treatments costs ($95 million CAD less per year), averaged over the period 2024-2073.

CONCLUSION

Increased screening participation will improve clinical outcomes across all income groups while alleviating associated treatment costs. The benefits of increased participation will be strongest among the lowest income quintile.

Global, regional, and national cancer burdens of respiratory and digestive tracts in 1990-2044: A cross-sectional and age-period-cohort forecast study

BACKGROUND

Understanding the current status and future trends of cancer burdens by systems provides important information for specialists, policymakers, and specific risk populations.

METHODS

The aim of this study was to compare the current and future cancer burdens of the gastrointestinal (GI) and respiratory tracts in terms of their magnitude and distribution. Data from a total of eight cancers of the digestive and respiratory tracts in the Global Burden of Disease (GBD) database were collected. The age-standardized incidence/death rates (ASIR/ASDRs), disability-adjusted life years (DALYs), and estimated annual percentage changes (EAPCs) were analyzed. Future trends were predicted with Bayesian age-period-cohort (BAPC) and NORDPRED models.

RESULTS

In 2019, there was a significant increase in DALY for both digestive and respiratory tract cancers compared to 1990. Meanwhile, ASIR increased slightly and ASDR decreased notably. In 2019, the global cancer burdens of respiratory and digestive tracts were 38568363.53 and 66912328.72 in DALY, 34.28 and 55.32 in ASIR, and 656.82 and 808.22 in ASDR per 100,000 population with changes of +54.63% and +43.93%, +2.92% and +5.65%, and -17.39% and -26.83% compared to those in 1990, respectively. Significant cross-regional differences in the cancer burdens were observed among the regions. Compared to four representative chronic diseases, the burden of cancers showed less remission and greater global inequalities. The burdens of both digestive and respiratory tract cancers were higher in males than in females in terms of the ASIR, ASDR, and DALY. The incidence and mortality rates of respiratory tract cancers were up to 3-4 times higher in males than in females, whereas the difference between male and female rates of digestive tract cancers was relatively smaller. The main risk factor associated with all kinds of digestive and respiratory tract cancers is tobacco, leading to 18.5 in ASDR and 3.38×107 in DALY for respiratory tract cancers; 8.29 in ASDR and 1.60×107 in DALY for digestive tract cancers, in 2019. Additionally, alcohol use contributes to most digestive and respiratory tract cancers (1.23/1.03 in ASDR and 1.60×106/2.57×106 in DALY for respiratory tract cancers; 4.19/3.82 in ASDR and 4.49×106/8.06×106 in DALY for digestive tract cancers), except for stomach cancer and tracheal, bronchus, and lung cancer. The cancer burdens of respiratory and digestive tracts are likely to decrease substantially between 2020 and 2044. For most metrics, except for the ASIR and male-to-female ratios of ASDR and ASDALY in digestive tract cancers, the worldwide variances of burden metrics have been decreasing in the past decades and will possibly maintain stable trends in the future.

CONCLUSIONS

The epidemiology of respiratory and GI tract cancers has common features and individual characteristics that are reflected in geography, age characteristics, and risk factors. Current epidemiological status, future trends, and the globalization of these disease burdens are important factors for making scientific planning of resources to minimize the cancer burden metrics and their cross-regional inequalities.

Application of machine-learning model to optimize colonic adenoma detection in India

AIMS

There is limited data on the prevalence and risk factors of colonic adenoma from the Indian sub-continent. We aimed at developing a machine-learning model to optimize colonic adenoma detection in a prospective cohort.

METHODS

All consecutive adult patients undergoing diagnostic colonoscopy were enrolled between October 2020 and November 2022. Patients with a high risk of colonic adenoma were excluded. The predictive model was developed using the gradient-boosting machine (GBM)-learning method. The GBM model was optimized further by adjusting the learning rate and the number of trees and 10-fold cross-validation.

RESULTS

Total 10,320 patients (mean age 45.18 ± 14.82 years; 69% men) were included in the study. In the overall population, 1152 (11.2%) patients had at least one adenoma. In patients with age > 50 years, hospital-based adenoma prevalence was 19.5% (808/4144). The area under the receiver operating curve (AUC) (SD) of the logistic regression model was 72.55% (4.91), while the AUCs for deep learning, decision tree, random forest and gradient-boosted tree model were 76.25% (4.22%), 65.95% (4.01%), 79.38% (4.91%) and 84.76% (2.86%), respectively. After model optimization and cross-validation, the AUC of the gradient-boosted tree model has increased to 92.2% (1.1%).

CONCLUSIONS

Machine-learning models may predict colorectal adenoma more accurately than logistic regression. A machine-learning model may help optimize the use of colonoscopy to prevent colorectal cancers.

TRIAL REGISTRATION

ClinicalTrials.gov (ID: NCT04512729).

Gastrointestinal Cancer Precursor Conditions and Their Detection

Gastrointestinal cancers are a leading cause of cancer morbidity and mortality. Many gastrointestinal cancers develop from cancer precursor lesions, which are commonly found in individuals with hereditary cancer syndromes. Hereditary cancer syndromes have advanced our understanding of cancer development and progression and have facilitated the evaluation of cancer prevention and interception efforts. Common gastrointestinal hereditary cancer syndromes, including their organ-specific cancer risk and surveillance recommendations, are reviewed in this article. The management of common gastroesophageal, pancreatic, and colonic precursor lesions is also discussed, regardless of their genetic background. Further research is needed to advance chemoprevention and immunoprevention strategies.

Reimagining Colorectal Cancer Screening: Innovations and Challenges with Dr. Aasma Shaukat

Colorectal cancer (CRC) currently ranks as the third most common cancer and the second leading cause of cancer-related deaths worldwide, posing a significant global health burden to the population. Recent studies have reported the emergence of a new clinical picture of the disease, with a notable increase in CRC rates in younger populations of <50 years of age. The American Cancer Society (ACS) now recommends CRC screening starting at age 45 for average-risk individuals. Dr. Aasma Shaukat's Keynote Conference highlights the critical need for updated screening strategies, with an emphasis on addressing the suboptimal adherence rates and the effective management of the growing burden of CRC. Lowering the adenoma detection screening age can facilitate early identification of adenomas in younger asymptomatic patients, altering the epidemiologic landscape. However, its implications may not be as profound unless a drastic shift in the age distribution of CRC is observed. Currently, various screening options are available in practice, including stool-based tests like multitarget stool DNA (mtDNA) tests, fecal immunochemical testing (FIT), and imaging-based tests. In addition to existing screening methods, blood-based tests are now emerging as promising tools for early CRC detection. These tests leverage innovative techniques along with AI and machine learning algorithms, aiding in tumor detection at a significantly earlier stage, which was not possible before. Medicare mandates specific criteria for national coverage of blood-based tests, including sensitivity ≥ 74%, specificity ≥ 90%, FDA approval, and inclusion in professional society guidelines. Ongoing clinical trials, such as Freenome, Guardant, and CancerSEEK, offer hope for further advancements in blood-based CRC screening. The development of multicancer early detection tests like GRAIL demonstrates a tremendous potential for detecting various solid tumors and hematologic malignancies. Despite these breakthroughs, the question of accessibility and affordability still stands. The ever-evolving landscape of CRC screening reflects the strength of the scientific field in light of an altered disease epidemiology. Lowering screening age along with the integration of blood-based tests with existing screening methods holds great potential in reducing the CRC-related burden. At the same time, it is increasingly important to address the challenges of adaptation of the healthcare system to this change in the epidemiologic paradigm.

Development and validation of a novel colonoscopy withdrawal time indicator based on YOLOv5

BACKGROUND AND AIM

The study aims to introduce a novel indicator, effective withdrawal time (WTS), which measures the time spent actively searching for suspicious lesions during colonoscopy and to compare WTS and the conventional withdrawal time (WT).

METHODS

Colonoscopy video data from 472 patients across two hospitals were retrospectively analyzed. WTS was computed through a combination of artificial intelligence (AI) and manual verification. The results obtained through WTS were compared with those generated by the AI system. Patients were categorized into four groups based on the presence of polyps and whether resections or biopsies were performed. Bland Altman plots were utilized to compare AI-computed WTS with manually verified WTS. Scatterplots were used to illustrate WTS within the four groups, among different hospitals, and across various physicians. A parallel box plot was employed to depict the proportions of WTS relative to WT within each of the four groups.

RESULTS

The study included 472 patients, with a median age of 55 years, and 57.8% were male. A significant correlation with manually verified WTS (r = 0.918) was observed in AI-computed WTS. Significant differences in WTS/WT among the four groups were revealed by the parallel box plot (P < 0.001). The group with no detected polyps had the highest WTS/WT, with a median of 0.69 (interquartile range: 0.40, 0.97). WTS patterns were found to be varied between the two hospitals and among senior and junior physicians.

CONCLUSIONS

A promising alternative to traditional WT for quality control and training assessment in colonoscopy is offered by AI-assisted computation of WTS.

Exploration of the application potential of serum multi-biomarker model in colorectal cancer screening

Analyzing blood lipid and bile acid profile changes in colorectal cancer (CRC) patients. Evaluating the integrated model's diagnostic significance for CRC. Ninety-one individuals with colorectal cancer (CRC group) and 120 healthy volunteers (HC group) were selected for comparison. Serum levels of total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and apolipoproteins (Apo) A1, ApoA2, ApoB, ApoC2, and ApoC3 were measured using immunoturbidimetric and colorimetric methods. Additionally, LC-MS/MS was employed to detect fifteen bile acids in the serum, along with six tumor markers: carcinoembryonic antigen (CEA), carbohydrate antigens (CA) 125, CA19-9, CA242, CA50, and CA72-4. Group comparisons utilized independent sample t-tests and Mann-Whitney U tests. A binary logistic regression algorithm was applied to fit the indicators and establish a screening model; the diagnostic accuracy of individual Indicators and the model was analyzed using receiver operating characteristic (ROC) curves. The CRC group showed significantly lower levels in eight serum lipid indicators and eleven bile acids compared to the HC group (P < 0.05). Conversely, serum levels of TG, CA19-9, and CEA were elevated (P < 0.05). Among the measured parameters, ApoA2 stands out for its strong correlation with the presence of CRC, showcasing exceptional screening efficacy with an area under the curve (AUC) of 0.957, a sensitivity of 85.71%, and a specificity of 93.33%. The screening model, integrating ApoA1, ApoA2, lithocholic acid (LCA), and CEA, attained an impressive AUC of 0.995, surpassing the diagnostic accuracy of individual lipids, bile acids, and tumor markers. CRC patients manifest noteworthy alterations in both blood lipids and bile acid profiles. A screening model incorporating ApoA1, ApoA2, LCA, and CEA provides valuable insights for detecting CRC.

An abdominal vibration combined with walking exercise (AVCWE) program for older patients with constipation: Development and feasibility study

BACKGROUND

Older patients with constipation are at higher risk for inadequate bowel preparation, but there are currently no targeted strategies. This study aims to develop an abdominal vibration combined with walking exercise (AVCWE) program and assess its feasibility among older patients with constipation.

METHODS

Phase I: Using the Delphi technique, eight experts across three professional fields were consulted to develop the AVCWE program. The experts evaluated and provided recommendations on demonstration videos and detailed descriptions of the preliminary protocol. Phase II: A single-arm feasibility study of the AVCWE program was conducted on 30 older patients with constipation undergoing colonoscopy at a tertiary hospital in China. A 10-point exercise program evaluation form and several open-ended questions were used to gather feedback from participants regarding the program. In both phases, content analysis was used to critically analyze and summarize qualitative suggestions for protocol modifications.

RESULTS

Based on feedback from the expert panel, the AVCWE program developed in Phase I included two procedures during laxative ingestion: at least 5,500 steps of walking exercise and two cycles of moderate-intensity abdominal vibration (each cycle consisted of 10 min of vibration and 10 min of rest). The feasibility study in Phase II showed high positive patient feedback scores for the program, ranging from 9.07 ± 0.74 to 9.73 ± 0.52.

CONCLUSION

The AVCWE program was developed by eight multidisciplinary experts and was well accepted by 30 older patients with constipation. Study participants believed that this program was simple, safe, appropriate, and helpful for their bowel preparation. The findings of this study may provide valuable information for optimizing bowel preparation in older patients with constipation.

Additional staining for lymphovascular invasion is associated with increased estimation of lymph node metastasis in patients with T1 colorectal cancer: Systematic review and meta-analysis

OBJECTIVES

Lymphovascular invasion (LVI) is a critical risk factor for lymph node metastasis (LNM), which requires additional surgery after endoscopic resection of T1 colorectal cancer (CRC). However, the impact of additional staining on estimating LNM is unclear. This systematic review aimed to evaluate the impact of additional staining on determining LNM in T1 CRC.

METHODS

We searched five electronic databases. Outcomes were diagnostic odds ratio (DOR), assessed using hierarchical summary receiver operating characteristic curves, and interobserver agreement among pathologists for positive LVI, assessed using Kappa coefficients (κ). We performed a subgroup analysis of studies that simultaneously included a multivariable analysis for other risk factors (deep submucosal invasion, poor differentiation, and tumor budding).

RESULTS

Among the 64 studies (18,097 patients) identified, hematoxylin-eosin (HE) and additional staining for LVI had pooled sensitivities of 0.45 (95% confidence interval [CI] 0.32-0.58) and 0.68 (95% CI 0.44-0.86), specificities of 0.88 (95% CI 0.78-0.94) and 0.76 (95% CI 0.62-0.86), and DORs of 6.26 (95% CI 3.73-10.53) and 6.47 (95% CI 3.40-12.32) for determining LNM, respectively. In multivariable analysis, the DOR of additional staining for LNM (DOR 5.95; 95% CI 2.87-12.33) was higher than that of HE staining (DOR 1.89; 95% CI 1.13-3.16) (P = 0.01). Pooled κ values were 0.37 (95% CI 0.22-0.52) and 0.62 (95% CI 0.04-0.99) for HE and additional staining for LVI, respectively.

CONCLUSION

Additional staining for LVI may increase the DOR for LNM and interobserver agreement for positive LVI among pathologists.

GI genius endoscopy module: a clinical profile

INTRODUCTION

The identification of early-stage colorectal cancers (CRC) and the resection of pre-cancerous neoplastic lesions through colonoscopy allows to decrease both CRC incidence and mortality. However, colonoscopy miss rates up to 26% for adenomas and 9% for advanced adenomas have been reported. In recent years, artificial intelligence (AI) systems have been emerging as easy-to-use tools, potentially lowering the risk of missing lesions.

AREAS COVERED

This review paper focuses on GI Genius device (Medtronic Co. Minneapolis, MN, U.S.A.) a computer-assisted tool designed to assist endoscopists during standard white-light colonoscopies in detecting mucosal lesions.

EXPERT OPINION

Randomized controlled trials (RCTs) suggest that GI Genius is a safe and effective tool for improving adenoma detection, especially in CRC screening and surveillance colonoscopies. However, its impact seems to be less significant among experienced endoscopists and in real-world clinical scenarios compared to the controlled conditions of RCTs. Furthermore, it appears that GI Genius mainly enhances the detection of non-advanced, small polyps, but does not significantly impact the identification of advanced and difficult-to-detect adenoma. When using GI Genius, no complications were documented. Only a small number of studies reported an increased in withdrawal time or the removal of non-neoplastic lesions.

Uptake and detection rate of colorectal cancer screening with colonoscopy in China: A population-based, prospective cohort study

BACKGROUND

Colorectal cancer is the leading cause of cancer-related death worldwide. Colonoscopy is widely used as a screening test for detecting colorectal cancer in many countries. However, there is little evidence regarding the uptake and diagnostic yields of colonoscopy in population-based screening programs in countries with limited medical resources.

OBJECTIVE

We reported the uptake of colonoscopy and the detection of colorectal lesions and explored related factors based on a colorectal cancer screening program in China.

DESIGN

Individuals aged 45-74 years who were asymptomatic for colorectal cancer and had no history of colorectal cancer were recruited. An established risk score system was used to identify individuals at high risk for colorectal cancer, and they were subsequently recommended for colonoscopy.

SETTING

A population-based, prospective cohort study was implemented in 169 communities, 14 districts of Chongqing, Southwest China.

PARTICIPANTS

A total of 288,150 eligible participants were recruited from November 2013 to June 2021, and 41,315 participants were identified to be at high risk of colorectal cancer.

METHODS

Generalized linear mixed model was used to explore the individual and community structural characteristics associated with uptake of colonoscopy. Additionally, the detection rate of colorectal lesions under colonoscopy screening was also reported, and their associated factors were explored.

RESULTS

7859 subjects underwent colonoscopy, with an uptake rate of 19.02 % (95 % CI 18.64 %-19.40 %). Lower uptake rates were associated with older age, lower education, more physical activity, and structural characteristics, including residing in developing areas (OR 0.73, 95 % CI 0.69-0.78), residing more than 5 km from screening hospital (5-10 km: OR 0.85, 95 % CI 0.79-0.91; >10 km: OR 0.85, 95 % CI 0.80-0.91), and not being exposed to social media publicity (OR 0.63, 95 % CI 0.53-0.75). Overall, 8 colorectal cancers (0.10 %), 423 advanced adenomas (5.38 %), 820 nonadvanced adenomas (10.43 %), and 684 hyperplastic polyps (8.70 %) were detected, with an adenoma detection rate of 15.92 %. Several factors, including older age, male, current smoking and a family history of colorectal cancer, were positively related to colorectal neoplasms.

CONCLUSIONS

The uptake of colonoscopy for colorectal cancer screening was not optimal among a socioeconomically diverse high-risk population. The screening strategy should attempt to ensure equitable access to screening according to regional characteristics, and enhance the uptake of colonoscopy by recommended multifaceted interventions, which focus on individuals with poor compliance, select a closer screening hospital, and strengthen social media publicity at the structural level.

Considerations for using potential surrogate endpoints in cancer screening trials

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.

Demographic and clinical profile of patients undergoing colonoscopy at a tertiary care center in Nepal: a retrospective cross-sectional study

Background

Colonoscopy is widely used as a tool for diagnosis, screening and treatment of various pathologies in the rectum, colon, and terminal ileum. The aim of this study is to evaluate the demographic, clinical, and histological parameters of the records of patients undergoing colonoscopy at a tertiary care hospital in Nepal.

Materials and methods

This retrospective cross-sectional study included the hospital records of all patients who underwent colonoscopy from 2015 to 2019 in a tertiary care centre in Nepal.

Results

A total of 1255 records were included in the study. The mean and standard deviation of age were 43.8 and 19 years, respectively. Among the total study population, 61.9% were males and 38.1% were females. Common indications for colonoscopy included lower gastrointestinal bleeding (27.7%), altered bowel habit (26.9%) and persistent or recurrent abdominal pain (17.3%). Only 3% of the patients who underwent colonoscopy had inadequate bowel preparation. The overall diagnostic yield of colonoscopy was 57.5%. Findings during colonoscopy included colorectal polyp (19.4%), internal haemorrhoids (8.2%) and colitis (6.5%). Having an age of 50 or more years was significantly associated with the presence of colorectal adenocarcinoma (P=0.017, χ2 test) with an odds ratio of 2.35 (95% CI: 1.14, 4.89). Furthermore, having a female sex was found to be significantly associated with the presence of colorectal adenocarcinoma (P=0.012, χ2 test) with an odds ratio of 2.43 (95% CI: 1.19, 4.97).

Conclusion

In the authors' study, a smaller proportion of the colonoscopies was aimed at screening for colorectal carcinoma (CRC), when compared to studies in developed countries. The sex predisposition of CRC in the authors' study is in contrast to the global trend. The authors recommend conducting studies to determine the risk factors and need for CRC screening in the Nepalese population.

Determinants of early-onset colorectal cancer: a multicenter case-control study in Iran

BACKGROUND

We aimed to study the risk factors of early-onset colorectal cancer (CRC) incidence in the Iranian population. Early onset CRC in Iran is a relevant health issue that deserves further epidemiological efforts to be defined and controlled as far as possible. Early age screening of low-tract of the intestine would be particularly useful in families of colorectal cancer patients.

METHODS

We analyzed data from a multicenter hospital-based case-control study in Iran (The Iranian Study of Opium and Cancer). Sociodemographic and lifestyle information was collected using validated questionnaires. Multivariate logistic regressions estimated the odds ratios (OR) and 95% confidence intervals (CIs) for the association of early-onset CRC in individuals under the age of 50 and potential risk factors, including physical activity, socioeconomic status, body shape at age 15, dietary factors, vitamin D, cigarettes and waterpipe smoking, opium use and family history of CRC. Additionally, a subgroup analysis was conducted for individuals with a very young age of CRC onset (i.e. <35 years).

RESULTS

We analyzed data of 189 developed CRC below age 50 (99 colon and 90 rectum), and 66 patients under the age 35 (13 colon and 21 rectum). Early CRC was inversely associated with vegetables (OR, 0.59; 95% CI, 0.38-0.92 for 422-576 g/day) and vitamin D (OR, 0.49; 95% CI, 0.26-0.94), and positively associated with red meat intake (OR, 1.80; 1.15-2.83 per 25.65 g/day). Vegetables (OR, 0.51; 95% CI, 0.27-0.98 for 576 g/day), red meat (OR, 2.05; 95% CI, 1.11-3.79 for 25.65 g/day), vitamin D (OR, 0.29; 95% CI, 0.10-0.86) and opium use (OR, 2.61; 95% CI, 1.01-6.74) were associated with early rectum cancer. Results were heterogeneous by cancer site for high fruit and vegetables intakes and cigarette smoking. Family history was associated with CRC (OR, 3.16; 95% CI, 1.29-10.9) and rectum cancer (OR, 3.22; 95% CI, 1.24-14.4) in subjects younger than 35, and, to a lesser extent, with CRC and rectum cancer before age 50.

CONCLUSION

Early-onset CRC was related to the intake of vegetables, vitamin D and red meat in Iran. Early-onset rectum cancer was associated with regular opium use. Family history was associated with early CRC and early rectum cancer, particularly below the age of 35.

Multimodal Treatment of Metastatic Rectal Cancer in a Young Patient: Case Report and Literature Review

Metastatic colorectal cancer requires a multidisciplinary and individualized approach. Herein, we reported the case of a young woman diagnosed with metastatic rectal cancer who received an individualized multimodal treatment strategy that resulted in a remarkable survival. There were several particular aspects of this case, such as the early onset of the disease, the successful use of conversion therapy, the application of liquid biopsy to guide treatment, and the specific nature of the bone metastasis. To offer more insights for navigating such challenges in patients with metastatic colorectal cancer, we have conducted a literature review to find more data related to the particularities of this case. The incidence of early onset colorectal cancer is on the rise. Data suggests that it differs from older-onset colorectal cancer in terms of its pathological, epidemiological, anatomical, metabolic, and biological characteristics. Conversion therapy and surgical intervention provide an opportunity for cure and improve outcomes in metastatic colorectal cancer. It is important to approach each case individually, as every patient with limited liver disease should be considered as a candidate for secondary resection. Moreover, liquid biopsy has an important role in the individualized management of metastatic colorectal cancer patients, as it offers additional information for treatment decisions.

National Trends in the Incidence of Sporadic Malignant Colorectal Polyps in Young Patients (20-49 Years): An 18-Year SEER Database Analysis

Background and Objectives: Conflicting guidelines exist for initiating average-risk colorectal cancer screening at the age of 45 years. The United States Preventive Services Task Force (USPSTF) changed its guidelines in 2021 to recommend initiating screening at 45 years due to an increasing incidence of young-onset colorectal cancer. However, the American College of Physicians (ACP) recently recommended not screening average-risk individuals between 45 and 49 years old. We aim to study the national trends in the incidence of sporadic malignant polyps (SMP) in patients from 20 to 49 years old. Materials and Methods: We analyzed the Surveillance, Epidemiology, and End Results database (2000-2017) on patients aged 20-49 years who underwent diagnostic colonoscopy with at least a single malignant sporadic colorectal polyp. Results: Of the 10,742 patients diagnosed with SMP, 42.9% were female. The mean age of incidence was 43.07 years (42.91-43.23, 95% CI). Approximately 50% of malignant polyps were diagnosed between 45 and 49 years of age, followed by 25-30% between 40 and 45. There was an upward trend in malignant polyps, with a decreased incidence of malignant villous adenomas and a rise in malignant adenomas and tubulovillous adenomas. Conclusions: Our findings suggest that almost half of the SMPs under 50 years occurred in individuals under age 45, younger than the current screening threshold recommended by the ACP. There has been an upward trend in malignant polyps in the last two decades. This reflects changes in tumor biology, and necessitates further research and support in the USPSTF guidelines to start screening at the age of 45 years.

Timely Completion of Direct Access Colonoscopy Is Noninferior to Office Scheduled for Screening and Surveillance

GOALS

We aimed to evaluate whether direct access colonoscopy (DAC) is noninferior to office-scheduled colonoscopy (OSC) for achieving successful colonoscopy.

BACKGROUND

DAC may improve access to colonoscopy. We developed an algorithm assessing eligibility, risk for inadequate preparation, and need for nursing/navigator assistance.

STUDY

This was a retrospective, single-center study of DAC and OSC patients from June 5, 2018, to July 31, 2019. Patients were 45 to 75 years old with an indication of screening or surveillance. A successful colonoscopy met 3 criteria: complete colonoscopy (cecum, anastomosis, or ileum), adequate preparation (Boston Score ≥2/segment), and performed <90 days from initial patient contact. Unsuccessful colonoscopy did not meet ≥1 criteria. Secondary end points included days to successful colonoscopy, preparation quality, polyp detection, and 10-year recall rate. Noninferiority against risk ratio value of 0.85 was tested using 1-sided alpha of 0.05.

RESULTS

A total of 1823 DAC and 828 OSC patients were eligible. DAC patients were younger, with a greater proportion of black patients and screening indications. For the outcome of successful colonoscopy, DAC was noninferior to OSC (DAC vs. OSC: 62.7% vs. 57.1%, RR 1.16, 95% LCL 1.09, P=0.001). For DAC, days to colonoscopy were fewer, and likelihood of 10-year recall after negative screening greater. Boston Score and polyp detection were similar for groups. Black patients were less likely to achieve successful colonoscopy; otherwise, groups were similar. For unsuccessful colonoscopies, proportionally more DAC patients canceled or no-showed while more OSC patients scheduled >90 days. DAC remained noninferior to OSC at 180 days.

CONCLUSIONS

DAC was noninferior to OSC for achieving successful colonoscopy, comparing similarly in quality and efficiency outcomes.

Higher mortality risk from gynaecological neoplasms and non-Hodgkin's lymphoma in patients with systemic lupus erythematosus: an observational study from the Spanish National Registry

OBJECTIVE

To evaluate the impact of the different types of neoplasms and lineages on mortality of patients with SLE.

METHODS

Retrospective and observational comparison of the neoplasm-related deaths in patients with SLE and the general Spanish population reported in the Spanish Hospital Discharge Database. To determine the impact of SLE on the risk of dying from each neoplasm lineage, a binary logistic regression considering age, female sex, tobacco and alcohol consumption, was performed.

RESULTS

During 2016-2019, 139 531 in-hospital deaths from neoplasms were certified in Spain (91 in patients with SLE). Patients with SLE presented a lower mortality rate from solid organ neoplasms, (80.2% vs 91.1%, OR 0.393), linked to their lower risk of colorectal carcinoma (1.1% vs 10.8%, OR 0.110). By contrast, gynaecological neoplasms presented a higher risk (8.8% vs 3%, OR 3.039) in the deceased patients with SLE, associated with the higher frequency of vulvar neoplasms (2% vs 0.2%, OR 14.767) and cervical carcinomas (3.3% vs 0.5%, OR 3.809). Haematological neoplasm-related deaths were also more prevalent in patients with SLE (19.8% vs 8.9%, OR 2.546), mostly attributable to the higher proportion of deaths due to non-Hodgkin's lymphoma (11% vs 2.9%, OR 4.060) of B cell lineage (9.9% vs 2.5%, OR 4.133).

CONCLUSIONS

Patients with SLE present a higher risk of death from vulvar neoplasms, cervical carcinomas and B-cell non-Hodgkin's lymphoma in comparison with the general Spanish population. In addition to developing strategies that might help to attenuate their occurrence and impact, such as decreasing the immunosuppressive burden, specific early detection programmes for these conditions should be investigated and considered carefully.

Colorectal Cancer: Epidemiology, Risk Factors, and Prevention

Colorectal cancer (CRC) is the third most common cancer and the second most common cause of cancer mortality worldwide. There are disparities in the epidemiology of CRC across different populations, most probably due to differences in exposure to lifestyle and environmental factors related to CRC. Prevention is the most effective method for controlling CRC. Primary prevention includes determining and avoiding modifiable risk factors (e.g., alcohol consumption, smoking, and dietary factors) as well as increasing protective factors (e.g., physical activity, aspirin). Further studies, especially randomized, controlled trials, are needed to clarify the association between CRC incidence and exposure to different risk factors or protective factors. Detection and removal of precancerous colorectal lesions is also an effective strategy for controlling CRC. Multiple factors, both at the individual and community levels (e.g., patient preferences, availability of screening modalities, costs, benefits, and adverse events), should be taken into account in designing and implementing CRC screening programs. Health policymakers should consider the best decision in identifying the starting age and selection of the most effective screening strategies for the target population. This review aims to present updated evidence on the epidemiology, risk factors, and prevention of CRC.

Should we perform sigmoidoscopy for colorectal cancer screening in people under 45 years?

BACKGROUND

The strategy for preventing colorectal cancer is screening by colonoscopy, which offers a direct way for detection and removal of adenomatous polyps (APs). American College of Gastroenterology guidelines recommend that people aged ≥ 45 years should undergo colonoscopy; however, how to deal with people aged ≤ 45 years is still unknown.

AIM

To compare the prevalence of APs and high-grade neoplasia between the left and right colon in patients ≤ 45 years.

METHODS

A retrospective observational study was conducted at a single tertiary III hospital in China. This study included patients aged 18-45 years with undergoing initial colonoscopy dissection and pathological diagnosis AP or high-grade neoplasia between February 2014 and January 2021. The number of APs in the entire colon while screening and post-polypectomy surveillance in following 1-3 years were evaluated.

RESULTS

A total of 3053 cases were included. The prevalence of APs in the left and right colon was 55.0% and 41.6%, respectively (OR 1.7, 95%CI 1.6-2.4; P < 0.05). For APs with high-grade neoplasia, the prevalence was 2.7% and 0.9%, respectively (OR 3.0, 95%CI 2.0-4.6; P < 0.05). Therefore, the prevalence of APs and high-grade neoplasia in the left colon was significantly higher than in the right colon in patients aged ≤ 45 years. There were 327 patients who voluntarily participated in post-polypectomy surveillance in following 1-3 years, and APs were found in 216 cases (66.1%); 170 cases had 1-3 polyps (52.0%) and 46 cases had > 3 polyps (14.1%; OR 0.3, 95%CI 0.1-0.6; P < 0.05).

CONCLUSION

This study suggests that flexible sigmoidoscopy would be an optimal approach for initial screening in people aged ≤ 45 years and would be a more cost-effective and safe strategy.

The incidence of early onset colorectal cancer in Aotearoa New Zealand: 2000-2020

BACKGROUND

The incidence of early-onset colorectal cancer (EOCRC), diagnosed before age 50, has been rising in many countries in the past few decades. This study aims to evaluate this trend in Aotearoa New Zealand and assess its impact on Māori.

METHODS

Crude incidence and age-standardized incidence of colorectal cancer (CRC) was analyzed from all new cases from the Aotearoa New Zealand national cancer registry for the period 2000-2020. Trends were estimated by sex, ethnicity, age group and location of cancer and projections made to 2040.

RESULTS

Between 2000 and 2020, there were a total of 56,761 cases of CRC diagnosed in Aotearoa New Zealand, 3,702 of these being EOCRC, with age-standardized incidence decreasing significantly (P = 8.2 × 10- 80) from 61.0 to 47.3 cases per 100,000. EOCRC incidence increased on average by 26% per decade (incidence rate ratio (IRR) 1.26, p = < 0.0001) at all sites (proximal colon, distal colon and rectum), while the incidence in those aged 50-79 years decreased on average by 18% per decade (IRR 0.82, p = < 0.0005), again across all sites. There was no significant average change in CRC incidence in those over 80 years. In Māori, there was no significant change in age-standardized incidence. There was however a significant increase in crude incidence rates (IRR 1.28, p = < 0.0005) driven by significant increases in EOCRC (IRR1.36, p = < 0.0005). By 2040, we predict the incidence of EOCRC will have risen from 8.00 to 14.9 per 100,000 (6.33 to 10.00 per 100,000 in Māori). However, due to the aging population an estimated 43.0% of all CRC cases will be diagnosed in those over 80 years of age (45.9% over 70 years of age in Māori).

CONCLUSION

The age-standardized incidence of CRC from 2000 to 2020 decreased in Aotearoa New Zealand, but not for Māori. The incidence of EOCRC over the same period continues to rise, and at a faster rate in Māori. However, with the ageing of the population in Aotearoa New Zealand, and for Māori, CRC in the elderly will continue to dominate case numbers.

Clinicopathologic and endoscopic features of sessile serrated lesions and conventional adenomas: a large inpatient population-based study in China

Objectives

Sessile serrated lesions (SSLs) are precursors of sporadic colorectal cancer (CRC) and have distinct characteristics compared with conventional adenomas (CAs). Several lifestyle and environmental factors may play critical roles in the development of advanced lesions. Our aim is to describe the features of SSLs and CAs and further explore risk factors for advanced lesions.

Methods

This is an observational study that collected demographic, endoscopic, and histological data from the China-Japan Friendship Hospital among the inpatient population with pathologically reported as SSL or CA between 2015 and 2022. We analyzed the clinicopathology and endoscopic differences between SSL alone, CA alone, and synchronous SSL+CA groups, and identified risk factors using multiple regression analysis.

Results

A total of 9236 polyps from 6598 patients were included in the cohort. Patients with SSL+CA were more likely to be older (p=0.008), while individuals with SSL alone had a higher proportion of early-onset polyps (p<0.001), and SSLs were more common in advanced polyps than CAs (p<0.001). A greater proportion of advanced polyps in the SSL and CA groups were diagnosed as Yamada III, Yamada IV, and laterally spreading tumor (p=0.002, p<0.001, respectively), and multiple SSLs and CAs were more represented in nonadvanced polyps than in advanced polyps. In multiple regression analysis, older patients were more likely to develop advanced SSLs (aOR 1.05, 95% CI 1.02-1.09, p=0.005).

Conclusion

SSLs and CAs have diverse demographic, endoscopic, and histological characteristics, and their advanced lesions share different risk factors, which advances the understanding of the etiology and progression of SSLs.

Prevalence and risk factors of colorectal neoplasia in individuals aged 40-49 years: Findings from screening program in China

BACKGROUND AND AIM

The incidence of colorectal cancer (CRC) in individuals under 50 is increasing worldwide. We conducted an analysis of colonoscopy findings in high-risk individuals under 50 in the CRC screening program in Tianjin, China, to determine the detection rate and risk factors of advanced adenomas (AA), advanced colorectal neoplasia (ACN), colorectal neoplasia (CN).

METHODS

Our study investigated individuals aged 40-49 who underwent CRC screening and completed colonoscopy, 2012-2020, while the 50-54 age group served as a control. We compared the detection rates of AA, ACN, and CN among three age groups using univariate and multivariable logistic regression analyses, and investigated the risk factors associated with AA, ACN, and CN among individuals aged 40-49.

RESULTS

We found a gradual increase in the detection rate of AA, ACN, and CN among individuals aged 40-54. The detection rates for AA (OR 0.58; 95% CI 0.41-0.81), ACN (OR 0.58; 95% CI 0.43-0.77), and CN (OR 0.64; 95% CI 0.56-0.74) were lower in individuals aged 40-44 compared to 45-49. The detection rates of AA (OR 1.08; 95% CI 0.87-1.34) and ACN (OR 1.12; 95% CI 0.93-1.35) in individuals aged 45-49 were comparable with 50-54. Besides, lifestyle factors, BMI, and FIT are not associated with the detection rates of AA, ACN, and CN among individuals aged 40-49.

CONCLUSIONS

Our study reveals screening data in individuals under 50, indicating comparable detection rates of AA and ACN in individuals aged 45-49 and 50-54. These findings provide valuable data support for optimizing the optimal age to initiate screening.

Endoscopic features with associated histological and molecular alterations in serrated polyps with dysplasia: Retrospective analysis of a tertiary case series

BACKGROUND

Serrated polyps are incompletely understood lesions and include serrated sessile lesion (SSL) without or with dysplasia and traditional serrated adenoma (TSA).

AIMS

We investigated prevalence and characteristics of serrated lesions, especially SSL with dysplasia (mixed polyps).

METHODS

This retrospective study analyzed data from consecutive patients referred for colonoscopy at a tertiary care center. Endoscopic and histopathological characteristics of identified lesions were studied. SSLs with dysplasia were molecularly analyzed for mutations and microsatellite instability.

RESULTS

Among 1147 patients, a total of 436 polyps were found, including 288 adenomas (66.1 %) and 114 serrated lesions (SLDR 26.2 %). PDR was 34.5 % and ADR was of 30.2 %. Serrated lesions included 75 hyperplastic polyps (17.2 %), 24 SSLs without dysplasia (5.5 %), 6 SSLs with dysplasia (mixed polyps) (1.4 %) and 9 TSA (2.1 %). The mixed polyps were evaluated molecularly: these analyses found no KRAS mutation, a single NRAS mutation in one lesion, the Val600Glu BRAF mutation in four lesions in both their serrated non-dysplastic and dysplastic areas, and microsatellite instability in four lesions, limited to the dysplastic areas.

CONCLUSION

Our single-center experience confirms the high prevalence of serrated lesions, a part of which are SSL with dysplasia. These lesions seem to carry specific molecular alterations.

Single Versus Second Observer vs Artificial Intelligence to Increase the ADENOMA Detection Rate of Colonoscopy-A Network Analysis

BACKGROUND AND AIMS

Screening colonoscopy has significantly contributed to the reduction of the incidence of colorectal cancer (CRC) and its associated mortality, with adenoma detection rate (ADR) as the quality marker. To increase the ADR, various solutions have been proposed including the utilization of Artificial Intelligence (AI) and employing second observers during colonoscopies. In the interest of AI improving ADR independently, without a second observer, and the operational similarity between AI and second observer, this network meta-analysis aims at evaluating the effectiveness of AI, second observer, and a single observer in improving ADR.

METHODS

We searched the Medline, Embase, Cochrane, Web of Science Core Collection, Korean Citation Index, SciELO, Global Index Medicus, and Cochrane. A direct head-to-head comparator analysis and network meta-analysis were performed using the random-effects model. The odds ratio (OR) was calculated with a 95% confidence interval (CI) and p-value < 0.05 was considered statistically significant.

RESULTS

We analyzed 26 studies, involving 22,560 subjects. In the direct comparative analysis, AI demonstrated higher ADR (OR: 0.668, 95% CI 0.595-0.749, p < 0.001) than single observer. Dual observer demonstrated a higher ADR (OR: 0.771, 95% CI 0.688-0.865, p < 0.001) than single operator. In network meta-analysis, results were consistent on the network meta-analysis, maintaining consistency. No statistical difference was noted when comparing AI to second observer. (RR 1.1 (0.9-1.2, p = 0.3). Results were consistent when evaluating only RCTs. Net ranking provided higher score to AI followed by second observer followed by single observer.

CONCLUSION

Artificial Intelligence and second-observer colonoscopy showed superior success in Adenoma Detection Rate when compared to single-observer colonoscopy. Although not statistically significant, net ranking model favors the superiority of AI to the second observer.

Public effect of the 2022 Colorectal Cancer Awareness Campaign delivered through a metaverse platform

PURPOSE

The Korean Society of Coloproctology has been conducting Colorectal Cancer Awareness Campaign, also known as the Gold Ribbon Campaign, every September since 2007. The 2022 campaign was held through a metaverse platform targeting the younger age group under the slogan of raising awareness of early-onset colorectal cancer (CRC). This study aimed to analyze the impact of the 2022 campaign on a metaverse platform.

METHODS

Anonymized survey data were collected from participants in the metaverse campaign from September 1 to 15, 2022. The satisfaction score of the participants was evaluated by sex, age group, and previous campaign participation status.

RESULTS

During the campaign, 2,770 people visited the metaverse. Among them, 455 people participated in the survey (response rate, 16.4%). Approximately 95% of the participants reported being satisfied with the information provided by the campaign, understood the necessity of undergoing screening for and prevention of early-onset CRC, and were familiar with the structure of the metaverse. The satisfaction score for campaign information tended to decrease as the participants' age increased. When the participants' overall level of satisfaction with the metaverse platform was assessed, teenagers scored particularly lower than the other age groups. The satisfaction scores for CRC information provided in the metaverse, as well as the scores for recognizing the seriousness and necessity of screening for early-onset CRC, indicated a high positive tendency (P<0.001).

CONCLUSION

Most of the 2022 Gold Ribbon Campaign participants were satisfied with the metaverse platform. Medical society should pay attention to increasing participation in and satisfaction with future public campaigns.

Sessile serrated polyp detection rates after fecal immunochemical test or multitarget stool DNA test: Systematic review and meta-analysis

Background and study aims Published studies report a higher adenoma detection rate (ADR) for FIT-DNA as compared with FIT. Data are less replete about the performance of stool-based tests for sessile serrated polyp (SSP) detection. We performed a meta-analysis to evaluate the performance of FIT and FIT-DNA testing for SSP detection rate (SSPDR) in patients undergoing colonoscopy for follow up of positive noninvasive tests. Methods A comprehensive literature search of multiple databases (until September 2022) was performed to identify studies reporting SSPDR in patients with positive FIT or FIT-DNA tests. The outcome was overall colonoscopy detection of any SSPs and advanced serrated polyps (ASP: SSP ≥ 10 mm and/or dysplasia). Results Included were 482,405 patients (52.4% females) with a mean age of 62.3 ± 4.4 years from 23 studies. The pooled SSPDR for all positive stool-based tests was 5.3% and higher for FIT-DNA (15.0%, 95% confidence interval [CI] 8.3-25.7) versus FIT (4.1%, 95% CI 3.0-5.6; P = 0.0002). The overall pooled ASP detection rate was 1.4% (95% CI 0.81-2.3) and higher for FIT-DNA (3.8 %, 95% CI 1.7-8.6) compared with FIT (0.71%, 95% CI 0.36-1.4; P <0.01). SSPDR with FIT-DNA was also significantly higher than FIT when the FIT cutoff was >10 ug/g and in FIT-positive patients in studies conducted in North America ( P <0.05). Conclusions FIT-DNA outperformed FIT in both SSP and ASP detection including FIT with a lower threshold cutoff of >10 ug/g. Further comparative studies are needed to assess the impact of our findings on colorectal cancer reduction.

From No Disease to Stage IV Colon Cancer in Four Months: A Case Report

Colorectal cancer remains one of the most common cancers in the population. Meanwhile, steroids or other immunosuppressive drugs are usually given in rheumatological diseases as a treatment for flare-ups. Herein, we present the case of a 61-year-old female diagnosed with metastatic colorectal cancer merely four months following the commencement of glucocorticoid therapy for a recently diagnosed rheumatologic condition, despite a clear colorectal cancer screening colonoscopy conducted four months prior. The case report discusses the possible impact of corticosteroids on the fast disease progression of colorectal cancer and raises awareness regarding this potential risk.

Interventions to Improve Endoscopic Screening Adherence of Cancer in High-Risk Populations: A Scoping Review

Background

Colorectal, and gastric cancers have the second, and fourth mortality rates worldwide, respectively. Endoscopic screening is a crucial diagnostic tool for colorectal, and gastric cancers. Effective interventions can improve adherence to endoscopic screening in high-risk populations, which is important for cancer prevention and mortality reduction. This study aimed to identify interventions that could improve adherence to endoscopic screening for cancer in high-risk populations.

Methods

Combination keywords including colorectal cancer, gastric cancer, screening adherence, and interventions were used to search for articles in PubMed, Web of Science, Cochrane Library, and MEDLINE Complete. The review methodology was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-SCR).

Results

A total of 12 articles were included in this review: 9 randomized controlled trials(RCT) and 3 quasi-experimental studies(QEDs). Among the extracted studies, 11 were about colorectal cancer, and 1 was about gastric cancer. Most studies used lecture-based or Information Technology-based health education interventions. Narrative interventions have proven to be novel and effective approaches for promoting adherence to endoscopic screening. Health education interventions included cancer epidemiology, cancer risk factors, warning symptoms, and screening methods.

Conclusion

All interventions involved were effective in increasing individual knowledge of cancer-related endoscopic screening, willingness to undergo screening, and screening behaviors. These findings provide a reference for designing endoscopy-related cancer screening interventions.

Colorectal cancer screening at age 45 years in Israel: Cost-effectiveness and global implications

BACKGROUND

Colorectal cancer (CRC) incidence at ages <50 years is increasing worldwide. Screening initiation was lowered to 45 years in the United States. The cost-effectiveness of initiating CRC screening at 45 years in Israel was assessed with the aim of informing national policy and addressing internationally relevant questions.

METHODS

A validated CRC screening model was calibrated to Israeli data and examined annual fecal immunochemical testing (FIT) or colonoscopy every 10 years from 45 to 74 years (FIT45-74 or Colo45-74) versus from 50 to 74 years (FIT50-74 or Colo50-74). The addition of a fourth colonoscopy at 75 years was explored, subanalyses were performed by sex/ethnicity, and resource demands were estimated.

RESULTS

FIT50-74 and Colo50-74 reduced CRC incidence by 57% and 70% and mortality by 70% and 77%, respectively, versus no screening, with greater absolute impact in Jews/Other versus Arabs but comparable relative impact. FIT45-74 further reduced CRC incidence and mortality by an absolute 3% and 2%, respectively. With Colo45-74 versus Colo50-74, CRC cases and deaths increased slightly as three colonoscopies per lifetime shifted to 5 years earlier but mean quality-adjusted life-years gained (QALYGs) per person increased. FIT45-74 and Colo45-74 cost 23,800-53,900 new Israeli shekels (NIS)/QALYG and 110,600-162,700 NIS/QALYG, with the lowest and highest values among Jewish/Other men and Arab women, respectively. A fourth lifetime colonoscopy cost 48,700 NIS/QALYG. Lowering FIT initiation to 45 years with modest participation required 19,300 additional colonoscopies in the first 3 years.

CONCLUSIONS

Beginning CRC screening at 45 years in Israel is projected to yield modest clinical benefits at acceptable costs per QALYG. Despite different estimates by sex/ethnicity, a uniform national policy is favored. These findings can inform Israeli guidelines and serve as a case study internationally.

miRNA as a Biomarker for the Early Detection of Colorectal Cancer

MicroRNAs (miRNAs) are short, non-coding RNA segments that can be detected in a variety of clinical samples, including serum, stool, and urine. While miRNAs were initially known for their effect on post-translational gene expression, the last decade of research has shown them to be promising biomarkers for the detection of many types of cancer. This paper explores the use of miRNA detection as a tool for colorectal cancer (CRC) screening. We discuss the current state of miRNA detection, compare it to the existing CRC screening tools, and highlight the advantages and drawbacks of this approach from a clinical and logistical perspective. Our research finds that miRNA-based tests for CRC show great potential, but that widespread clinical adoption will be conditional on future research overcoming key hurdles.

Trends in Detection of Adenoma and Sessile Serrated Lesions Over a Decade in a Community-Based Healthcare System

INTRODUCTION

Adenoma detection rate (ADR) is an accepted benchmark for screening colonoscopy. Factors driving ADR and its relationship with sessile serrated lesions detection rate (SSLDR) over time remain unclear. We aim to explore patient, physician, and procedural influences on ADR and SSLDR trends.

METHODS

Using a large healthcare system in northern California from January 2010 to December 2020, a total of 146,818 screening colonoscopies performed by 33 endoscopists were included. ADR and SSLDR were calculated over time using natural language processing. Logistic regression was used to calculate the odd ratios of patient demographics, physician attributes, and procedural details over time.

RESULTS

Between 2010 and 2020, ADR rose from 19.4% to 44.4%, whereas SSLDR increased from 1.6% to 11.6%. ADR increased by 2.7% per year (95% confidence interval 1.9%-3.4%), and SSLDR increased by 1.0% per year (95% confidence interval 0.8%-1.2%). Higher ADR was associated with older age, male sex, higher body mass index, current smoker, higher comorbidities, and high-risk colonoscopy. By contrast, SSLDR was associated with younger age, female sex, white race, and fewer comorbidities. Patient and procedure characteristics did not significantly change over time ( P -interaction >0.05). Longer years in practice and male physician were associated with lower ADR and SSLDR in 2010, but significantly attenuated over time ( P -interaction <0.05).

DISCUSSION

Both ADR and SSLDR have increased over time. Patient and procedure factors did not significantly change over time. Male endoscopist and longer years in practice had lower initial ADR and SSLDR, but significantly lessened over time.

Applicability of Online Chat-Based Artificial Intelligence Models to Colorectal Cancer Screening

BACKGROUND

Over the past year, studies have shown potential in the applicability of ChatGPT in various medical specialties including cardiology and oncology. However, the application of ChatGPT and other online chat-based AI models to patient education and patient-physician communication on colorectal cancer screening has not been critically evaluated which is what we aimed to do in this study.

METHODS

We posed 15 questions on important colorectal cancer screening concepts and 5 common questions asked by patients to the 3 most commonly used freely available artificial intelligence (AI) models. The responses provided by the AI models were graded for appropriateness and reliability using American College of Gastroenterology guidelines. The responses to each question provided by an AI model were graded as reliably appropriate (RA), reliably inappropriate (RI) and unreliable. Grader assessments were validated by the joint probability of agreement for two raters.

RESULTS

ChatGPT and YouChat™ provided RA responses to the questions posed more often than BingChat. There were two questions that > 1 AI model provided unreliable responses to. ChatGPT did not provide references. BingChat misinterpreted some of the information it referenced. The age of CRC screening provided by YouChat™ was not consistently up-to-date. Inter-rater reliability for 2 raters was 89.2%.

CONCLUSION

Most responses provided by AI models on CRC screening were appropriate. Some limitations exist in their ability to correctly interpret medical literature and provide updated information in answering queries. Patients should consult their physicians for context on the recommendations made by these AI models.

Comparison of the characteristics of the CF-H290I and PCF-Q260JI colonoscopes in non-sedated patients with a history of abdominal or pelvic surgery: a randomized controlled study

BACKGROUND AND AIM

The purpose of this randomized controlled study was to compare the characteristics of the CF-H290I (high-definition) colonoscope with those of the PCF-Q260JI (high-resolution) colonoscope in non-sedated patients with a history of abdominal or pelvic surgery in an effort to help endoscopists to select more effectively and objectively between the various colonoscopes.

METHODS

A total of 397 patients who underwent colonoscopy at the Affiliated Wuxi People's Hospital of Nanjing Medical University, between August 2022 and October 2022 were randomized to a CF-H290I group (n = 198) or a PCF-Q260JI group (n = 199) using a computer-generated allocation method. We compared the adenoma detection rate (ADR), patient satisfaction with the examination, discomfort associated with colonoscopy including abdominal distension and pain, cecal intubation time, and patient willingness to undergo colonoscopy in the future between the CF-H290I and PCF-Q260JI groups.

RESULTS

There was no statistically significant difference in the overall ADR between the CF-H290I and PCF-Q260JI groups (81 [40.9%] vs 63 [31.7%], Z = 3.674, P = 0.055). However, the ADRs in the transverse colon and left colon were significantly higher in the CF-H290I group (22 [11.1%] vs 6 [3.0%], Z = 9.588, P = 0.002 and 57 [28.8%] vs 37 [18.6%], Z = 5.212, P = 0.017, respectively). More sessile serrated lesions were detected in the CF-H290I group (52 [26.3] vs 30 [15.1%], Z = 7.579, P = 0.006). Patient satisfaction with colonoscopy was better in the PCF-Q260JI group (8.91 ± 1.09 vs 8.51 ± 1.44, t = -3.158, P < 0.01) with less likelihood of discomfort (23 [11.6%] vs 41 [20.7%], Z = 6.144, P = 0.013), The number of patients willing to undergo colonoscopy in the future was significantly greater in the PCF-Q260JI group (168 [84.4%] vs 149 [75.3%], Z = 5.186, P = 0.023). The cecal intubation time was significantly shorter in the CF-H290I group (256.09 ± 155.70 s vs 315.64 ± 171.64 s, P = 0.004). There were no complications such as perforation or bleeding in either group.

CONCLUSION

The CF-H290I and PCF-Q260JI colonoscopes each have advantages when used in patients with a history of abdominal or pelvic surgery. The CF-H290I has higher ADRs in the transverse and left colon whereas the PCF-Q260JI is less painful and better accepted by patients. This study was approved by the Clinical Research Ethics Committee of Wuxi People's Hospital and was registered in the Chinese Clinical Trial Registry (ChiCTR2200063092).

Spatial mapping of colorectal cancer screening uptake and associated factors

OBJECTIVE

Over the past decades, it has been understood that the availability of screening tests has contributed to a steady decline in incidence of colorectal cancer (CRC). However, it is also seen that there is a geographic disparity in the use of such tests across small areas. The aim of this study is to examine small-area level barrier factors that may impact CRC screening uptake and to delineate coldspot (low uptake of screening) counties in Florida.

METHODS

Data on the percentages of county-level CRC screening uptakes in 2016 and county-level barrier factors for screening were obtained from the Florida Department of Health, Division of Public Health Statistics & Performance Management. Bayesian spatial beta models were used to produce posterior probability of deceedance to identify coldspots for CRC screening rates.

RESULTS

Unadjusted screening rates using sigmoidoscopy or colonoscopy test ranged from 56.8 to 85%. Bayesian spatial beta models were fitted to the proportion data. At an ecological level, we found that an increasing rate of CRC screening uptake for either of the test types (colon/rectum exam, stool-based test) was strongly associated with a higher health insurance coverage, and lower percentage of population that speak English less than very well (immigration) at county level. Eleven coldspot counties out of 67 total were also identified.

CONCLUSION

This study suggests that health insurance disparities in the use of CRC screening tests are an important factor that may need more attention for resource allocation and health policy targeting small areas with low uptake of screening.

Performance of the Asia-Pacific Colorectal Screening score in stratifying the risk of advanced colorectal neoplasia: A meta-analysis and systematic review

BACKGROUND AND AIM

This study systematically reviewed and meta-analyzed the performance of the Asia-Pacific Colorectal Screening (APCS) score and its incorporation with the fecal immunochemical test (FIT) in stratifying the risk of advanced colorectal neoplasia (ACN).

METHODS

We systematically searched for relevant articles in 12 electronic databases and registers on October 20, 2021, and updated the search to September 1, 2023. Random-effect models were used to obtain the pooled performance statistics of the APCS score for ACN risk.

RESULTS

From the 101 records screened, 13 eligible studies in the Asia-Pacific region involving 69 762 subjects who had undergone colonoscopy were enrolled. The pooled prevalences of ACN in the average-risk (AR) tier (APCS 0-1), moderate-risk (MR) tier (APCS 2-3), and high-risk (HR) tier (APCS ≥ 4) groups were 0.9%, 3.1%, and 8.1%, respectively. Compared with the combined AR-MR group, the HR group was significantly associated with a higher ACN risk (pooled diagnostic odds ratio: 2.84, 95% confidence interval [CI]: 2.35-3.45, P < 0.001). The APCS score showed a sensitivity of 0.42 (95% CI: 0.40-0.44) and a specificity of 0.86 (95% CI: 0.85-0.86) for predicting the ACN risk, with a weighted area under the curve of 0.642 (95% CI: 0.610-0.657). The combination of the APCS score and FIT substantially improved ACN risk identification, demonstrating pooled diagnostic odds ratios of 4.02 (95% CI: 2.50-6.49) in the AR-MR groups and 5.44 (95% CI: 1.89-15.63) in the MR-HR groups.

CONCLUSIONS

The APCS score could effectively stratify the ACN risk in the Asia-Pacific population. Incorporating FIT further improves its performance in identifying high-risk subjects who should be prioritized for colonoscopy screenings.

Population-based screening for colorectal cancer in Wuhan, China

Fecal DNA test has emerged as a non-invasive alternative for colorectal cancer (CRC) screening in average-risk population. However, there is currently insufficient evidence in China to demonstrate the effectiveness of population-based CRC screening using fecal DNA based test. Here, a large-scale real-world study for CRC screening was implemented in Wuhan, Hubei province, China. A total of 98,683 subjects aged between 45 and 60 years were screened by a fecal DNA test (ColoTect®) which detected methylation status of SDC2, ADHFE1, and PPP2R5C. Participants who tested positive were advised to receive diagnostic colonoscopy. 4449 (4.5%) subjects tested positive for fecal DNA test, and 3200 (71.9%) underwent colonoscopy. Among these, 2347 (73.3%) had abnormal colonoscopy findings, of which 1330 (56.7%) subjects received pathological diagnosis. Detection rates for CRC and advanced precancerous lesions were 1.3% and 2.3%, respectively. Detection rates for nonadvanced adenomas and polyps were 14.0% and 21.6%, respectively. 28.0% of all colonoscopies showed colorectal neoplasm but lack pathological diagnosis. 6.1% showed other abnormalities such as enteritis. In conclusion, preliminary real-world evidence suggested that fecal DNA tests had promising diagnostic yield in population-based CRC screening.

Clinical trial registration

https://www.chictr.org.cn/showproj.html?proj=192838, identifier ChiCTR2300070520.

ESR Essentials: Imaging in colorectal cancer-practice recommendations by ESGAR

Colorectal cancer (CRC) is a significant global health concern. Diagnostic imaging, using different modalities, has a pivotal role in CRC, from early detection (i.e., screening) to follow-up. The role of imaging in CRC screening depends on each country's approach: if an organized screening program is in place, the role of CT colonography (CTC) is limited to the study of either individuals with a positive stool test unwilling/unable to undergo colonoscopy (CC) or in patients with incomplete CC. Although CC is the most common modality to diagnose CRC, CRC can be also incidentally detected during a routine abdominal imaging examination or at the emergency room in patients presenting with intestinal occlusion/subocclusion or perforation. Staging is a crucial aspect of CRC management, guiding treatment decisions and providing valuable prognostic information. An accurate local staging is mandatory in both rectal and colon cancer to drive the appropriate therapeutic workflow. Important limitations of US, CT, and MR in N-staging can be partially solved by FDG PET/CT. Distant staging is usually managed by CT, with MR and FDG PET/CT which can be used as problem-solving techniques. Follow-up is performed according to the general recommendations of the oncological societies. CLINICAL RELEVANCE STATEMENT: It is essential to summarize each phase of colorectal cancer workup, differentiating the management for colon and rectal cancer supported by the main international guidelines and literature data, with the aim to inform the community on the best practice imaging in colorectal cancer. KEY POINTS: • Colorectal cancer is a prevalent disease that lends itself to imaging at each stage of detection and management. • Various imaging modalities can be used as adjuncts to, or in place of, direct visualization methods of screening and are necessary for evaluating metastatic disease. • Reevaluation of follow-up strategies should be considered depending on patients' individual risk of recurrence.

Efficacy and Safety of Thermal Ablation after Endoscopic Mucosal Resection: A Systematic Review and Network Meta-Analysis

(1) Background: Large colonic polyps during colonoscopy can be managed by Endoscopic mucosal resection (EMR). To decrease the polyp recurrence rate, thermal ablation methods like argon plasma coagulation (APC) and snare tip soft coagulation (STSC) have been introduced. We performed this network meta-analysis to assess the efficacy and safety of these modalities. (2) Methods: We performed a comprehensive literature review, through 5 January 2024, of databases including Embase, PubMed, SciELO, KCI, Cochrane Central, and Web of Science. Using a random effects model, we conducted a frequentist approach network meta-analysis. The risk ratio (RR) with 95% confidence interval (CI) was calculated. Safety and efficacy endpoints including rates of recurrence, bleeding, perforation, and post polypectomy syndrome were compared. (3) Results: Our search yielded a total of 13 studies with 2686 patients. Compared to placebo, both APC (RR: 0.33 CI: 0.20-0.54, p < 0.01) and STSC (RR: 0.27, CI: 0.21-0.34, p < 0.01) showed decreased recurrence rates. On ranking, STSC showed the lowest recurrence rate, followed by APC and placebo. Regarding individual adverse events, there was no statistically significant difference between either of the thermal ablation methods and placebo. (4) Conclusions: We demonstrated the efficacy and safety of thermal ablation after EMR for decreasing recurrence of adenoma.

Would initiating colorectal cancer screening from age of 45 be cost-effective in Germany? An individual-level simulation analysis

Background

Colorectal cancer (CRC) screening has been shown to be effective and cost-saving. However, the trend of rising incidence of early-onset CRC challenges the current national screening program solely for people ≥50 years in Germany, where extending the screening to those 45-49 years might be justified. This study aims to evaluate the cost-effectiveness of CRC screening strategies starting at 45 years in Germany.

Method

DECAS, an individual-level simulation model accounting for both adenoma and serrated pathways of CRC development and validated with German CRC epidemiology and screening effects, was used for the cost-effectiveness analysis. Four CRC screening strategies starting at age 45, including 10-yearly colonoscopy (COL), annual/biennial fecal immunochemical test (FIT), or the combination of the two, were compared with the current screening offer starting at age 50 years in Germany. Three adherence scenarios were considered: perfect adherence, current adherence, and high screening adherence. For each strategy, a cohort of 100,000 individuals with average CRC risk was simulated from age 20 until 90 or death. Outcomes included CRC cases averted, prevented death, quality-adjusted life-years gained (QALYG), and total incremental costs considering both CRC treatment and screening costs. A 3% discount rate was applied and costs were in 2023 Euro.

Result

Initiating 10-yearly colonoscopy-only or combined FIT + COL strategies at age 45 resulted in incremental gains of 7-28 QALYs with incremental costs of €28,360-€71,759 per 1,000 individuals, compared to the current strategy. The ICER varied from €1,029 to €9,763 per QALYG, and the additional number needed for colonoscopy ranged from 129 to 885 per 1,000 individuals. Among the alternatives, a three times colonoscopy strategy starting at 45 years of age proves to be the most effective, while the FIT-only strategy was dominated by the currently implemented strategy. The findings remained consistent across probabilistic sensitivity analyses.

Conclusion

The cost-effectiveness findings support initiating CRC screening at age 45 with either colonoscopy alone or combined with FIT, demonstrating substantial gains in quality-adjusted life-years with a modest increase in costs. Our findings emphasize the importance of implementing CRC screening 5 years earlier than the current practice to achieve more significant health and economic benefits.

Feasibility and Colonoscopy Yield Using the Fecal Immunochemical Test (FIT)-Based Colorectal Cancer Screening in a Latin America Country

BACKGROUND & AIMS

Organized colorectal cancer (CRC) screening is not widely practiced in Latin America and the results of regional studies may help overcome barriers for implementation of national screening programs. We aimed to describe the implementation and findings of a fecal immunochemical test (FIT)-based program in Brazil.

METHODS

In a prospective population-based study, asymptomatic individuals (50-75 years old) from Sao Paulo city were invited to undergo FIT for CRC screening. Participants with positive FIT (≥10 μg Hb/g feces) were referred for colonoscopy. Subjects were classified into groups according to the presence of CRC, precursor lesions, and other benign findings, possibly related to bleeding.

RESULTS

Of a total of 9881 subjects, 7.8% had positive FIT and colonoscopy compliance was 68.9% (n = 535). Boston scale was considered adequate in 99% and cecal intubation rate was 99.4%. CRC was diagnosed in 5.9% of the cases, adenoma in 63.2%, advanced adenoma in 31.4%, and advanced neoplasia in 33.0%. Age was positively associated with CRC (P = .03). Higher FIT concentrations were associated with increased detection of CRC (P < .008), advanced adenoma (P < .001), and advanced neoplasia (P < .001).

CONCLUSIONS

Implementation of a FIT-based CRC screening program was feasible in a low-resource setting, and there was a high yield for neoplasia in individuals with a positive FIT. This approach could be used as a model to plan and disseminate organized CRC screening more broadly in Brazil and Latin America.

Colorectal Cancer Prevention: Is Chat Generative Pretrained Transformer (Chat GPT) ready to Assist Physicians in Determining Appropriate Screening and Surveillance Recommendations?

OBJECTIVE

To determine whether a publicly available advanced language model could help determine appropriate colorectal cancer (CRC) screening and surveillance recommendations.

BACKGROUND

Poor physician knowledge or inability to accurately recall recommendations might affect adherence to CRC screening guidelines. Adoption of newer technologies can help improve the delivery of such preventive care services.

METHODS

An assessment with 10 multiple choice questions, including 5 CRC screening and 5 CRC surveillance clinical vignettes, was inputted into chat generative pretrained transformer (ChatGPT) 3.5 in 4 separate sessions. Responses were recorded and screened for accuracy to determine the reliability of this tool. The mean number of correct answers was then compared against a control group of gastroenterologists and colorectal surgeons answering the same questions with and without the help of a previously validated CRC screening mobile app.

RESULTS

The average overall performance of ChatGPT was 45%. The mean number of correct answers was 2.75 (95% CI: 2.26-3.24), 1.75 (95% CI: 1.26-2.24), and 4.5 (95% CI: 3.93-5.07) for screening, surveillance, and total questions, respectively. ChatGPT showed inconsistency and gave a different answer in 4 questions among the different sessions. A total of 238 physicians also responded to the assessment; 123 (51.7%) without and 115 (48.3%) with the mobile app. The mean number of total correct answers of ChatGPT was significantly lower than those of physicians without [5.62 (95% CI: 5.32-5.92)] and with the mobile app [7.71 (95% CI: 7.39-8.03); P < 0.001].

CONCLUSIONS

Large language models developed with artificial intelligence require further refinements to serve as reliable assistants in clinical practice.

Significance of SDC2 and NDRG4 methylation in stool for colorectal cancer diagnosis

BACKGROUND

Recent studies have identified methylated SDC2 and NDRG4 in colorectal cancer (CRC), however, the diagnostic value of the combined two genes remains undefined. This study aims to investigate the methylation of SDC2 and NDRG4 in stool samples and their application in diagnosis of CRC.

METHODS

Five groups were enrolled in our study which consisted of CRC (n = 138), advanced adenomas (n = 27), polyp (n = 35), intestinal disease control (n = 150), and healthy individuals (n = 28). Methylation status of SDC2 and NDRG4 in fecal samples were tested with appropriate commercial kits. Primary data were collected and statistical analyses were performed.

RESULTS

The positive rates of both SDC2 and NDRG4 methylation in stool samples of CRC group were significantly higher (P < 0.001) than those of either group of advanced adenomas, or polyp, or intestinal disease or the healthy control. It was suggested that both methylated SDC2,NDRG4, SDC2/NDRG4 and age were independent risk factors for CRC. The sensitivity of SDC2 and NDRG4 for CRC diagnosis were 73.9 % and 63.0 %, respectively, while SDC2 combined with NDRG4 had a higher sensitivity of 85.5 %. The specificity of SDC2, NDRG4 and SDC2 combined with NDRG4 achieved 91.6 %, 88.3 % and 84.6 %, respectively. The AUC for methylated SDC2 and NDRG4 were 0.828 (95 % CI: 0.780-0.876) and 0.757 (95 % CI: 0.703-0.811), respectively. In contrast, SDC2 combined with NDRG4 improved the AUC to 0.850 (95 % CI: 0.807-0.893).

CONCLUSIONS

This research confirmed the significance of detection of SDC2 and NDRG4 methylation by using noninvasive samples of stool. More importantly, attributing to their high level and frequency of methylation in stool, SDC2 and NDRG4 could be promising biomarkers for stool-based method for screening and early diagnosis of CRC, especially when combined.

Uncovering a dose-response relationship between positive fecal immunochemical test (FIT) and all-cause, cardiovascular and cancer-related mortality

BACKGROUND

Fecal immunochemical test (FIT) is for colorectal cancer (CRC) screening. Its association with non-CRC mortality has been overlooked. Given the quantitative FIT values, its dose-response relationships with different causes of deaths and years of life shortened were assessed.

METHODS

This retrospective study included 546,214 adults aged ≥ 20 who attended a health surveillance program from 1994 to 2017 and were followed up until the end of 2020. FIT ≥ 20 μg Hb/g was defined as positive. The Cox model was used to assess adjusted hazard ratios (aHR).

RESULTS

Positive FIT was associated with increased all-cause mortality (aHR: 1.34, 95 % CI: 1.25-1.44) and all-cancer mortality (aHR: 1.71, 95 % CI: 1.55-1.89), with a reduction of life expectancy by 4 years. The association remained even with CRC excluded. With each 10 μg Hb/g increase in FIT above 20 μg Hb/g, life expectancy was reduced by one year, and mortality increased by 4 %. About 18.6 % of deaths with positive FIT were attributed to cardiovascular disease (CVD), followed by CRC (13.5 %) and upper gastrointestinal (GI) cancers (4.5 %). The all-cause mortality rate after excluding CRC for positive FIT was 3.56/1,000 person-year, comparable to the all-cause mortality rate of 3.69/1,000 person-year for hypertension.

CONCLUSION

Positive FIT was associated with increased mortality in a dose-response manner and shortened life expectancy by 4 years, an overlooked risk comparable to hypertension, even with CRC excluded. After a negative colonoscopy, subjects with positive FIT should undergo a workup on CVD risk factors and look for other upper GI cancers.