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El Halabi J, Burke CA, Gault C, Mankaney G. An Unusual Case of Colorectal Polyposis. Am J Gastroenterol 2023; 118:1733. [PMID: 37335175 DOI: 10.14309/ajg.0000000000002372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 06/09/2023] [Indexed: 06/21/2023]
Affiliation(s)
- Jessica El Halabi
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Carol A Burke
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christopher Gault
- Department of Pathology, Virginia Mason Franciscan Health Hospital, Seattle, Washington, USA
| | - Gautam Mankaney
- Department of Gastroenterology and Hepatology, Virginia Mason Franciscan Health Hospital, Seattle, Washington, USA
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Sleiman J, Farha N, Beard J, Bena J, Morrison S, Milicia S, Heald B, Kalady MF, Church J, Liska D, Mankaney G, Burke CA. Incidence and prevalence of advanced colorectal neoplasia in Lynch syndrome. Gastrointest Endosc 2023; 98:412-419.e8. [PMID: 37031913 DOI: 10.1016/j.gie.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 02/24/2023] [Accepted: 04/04/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND AND AIMS Lynch syndrome (LS) is the most common hereditary cause of colorectal cancer (CRC) and endometrial cancer (EC). Although colonoscopy reduces CRC in LS, the protection is variable. We assessed the prevalence and incidence of neoplasia in LS during surveillance colonoscopy in the United States and factors associated with advanced neoplasia. METHODS Patients with LS undergoing ≥1 surveillance colonoscopy and with no personal history of invasive CRC or colorectal surgery were included. Prevalent and incident neoplasia was defined as occurring <6 months before and ≥6 months after germline diagnosis of LS, respectively. We assessed advanced adenoma (AA), CRC, and the impact of mismatch repair pathogenic variant (PV) and typical LS cancer history (personal history of EC and/or family history of EC/CRC) on outcome. RESULTS A total of 132 patients (inclusive of 112 undergoing prevalent and incident surveillance) were included. The median examination interval and duration of prevalent and incident surveillance was .88 and 1.06 years and 3.1 and 4.6 years, respectively. Prevalent and incident AA were detected in 10.7% and 6.1% and invasive CRC in 0% and 2.3% of patients. All incident CRC occurred in MSH2 and MLH1 PV carriers and only 1 (.7%) while under surveillance in our center. AAs were detected in both LS cancer history cohorts and represented in all PVs. CONCLUSIONS In a U.S. cohort of LS, advanced neoplasia rarely occurred over annual surveillance. CRC was diagnosed only in MSH2/MLH1 PV carriers. AAs occurred regardless of PV or LS cancer history. Prospective studies are warranted to confirm our findings.
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Affiliation(s)
- Joseph Sleiman
- Division of Gastroenterology, Hepatology and Nutrition at University of Pittsburgh School of Medicine, Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Natalie Farha
- Department of Gastroenterology, Hepatology and Nutrition
| | - Jonathan Beard
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - James Bena
- Department of Quantitative Health Science
| | | | - Susan Milicia
- Department of Colorectal Surgery; Sanford R. Weiss, M.D. Center for Hereditary Colorectal Neoplasia
| | - Brandie Heald
- Sanford R. Weiss, M.D. Center for Hereditary Colorectal Neoplasia; Department of Genomic Medical Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew F Kalady
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - James Church
- Department of Surgery, Division of Colorectal Surgery & Inflammatory Bowel Disease Center, Columbia University Medical Center, Herbert Irving Pavilion, New York, New York, USA
| | - David Liska
- Department of Colorectal Surgery; Sanford R. Weiss, M.D. Center for Hereditary Colorectal Neoplasia
| | - Gautam Mankaney
- Gastroenterology and Hepatology, Virginia Mason Franciscan Health, Seattle, Washington, USA
| | - Carol A Burke
- Department of Gastroenterology, Hepatology and Nutrition; Department of Colorectal Surgery; Sanford R. Weiss, M.D. Center for Hereditary Colorectal Neoplasia.
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Samadder NJ, Foster N, McMurray RP, Burke CA, Stoffel E, Kanth P, Das R, Cruz-Correa M, Vilar E, Mankaney G, Buttar N, Thirumurthi S, Turgeon DK, Sossenheimer M, Westover M, Richmond E, Umar A, Della'Zanna G, Rodriguez LM, Szabo E, Zahrieh D, Limburg PJ. Phase II trial of weekly erlotinib dosing to reduce duodenal polyp burden associated with familial adenomatous polyposis. Gut 2023; 72:256-263. [PMID: 35636921 PMCID: PMC9708943 DOI: 10.1136/gutjnl-2021-326532] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 05/14/2022] [Indexed: 01/27/2023]
Abstract
IMPORTANCE Patients with familial adenomatous polyposis (FAP) are at markedly increased risk for duodenal adenomas and cancer. Combination sulindac and erlotinib was previously shown to reduce duodenal polyp burden but was associated with a relatively high adverse event (AE) rate. OBJECTIVE To evaluate if a once weekly dosing schedule for erlotinib intervention improves the AE profile, while still providing efficacy with respect to reduced polyp burden, in participants with FAP. DESIGN, SETTING AND PARTICIPANTS Single-arm trial, enrolling 46 participants with FAP, conducted from October 2017 to September 2019 in eight academic cancer centres. EXPOSURES Participants self-administered 350 mg of erlotinib by mouth, one time per week for 6 months. MAIN OUTCOMES AND MEASURES Duodenal polyp burden (sum of polyp diameters) was assessed in the proximal duodenum by esophagogastroduodenoscopy performed at baseline and 6 months, with mean per cent change defined as the primary efficacy outcome of interest. Rate of grade 2-3 AEs was evaluated as a co-primary outcome. Secondary outcomes included changes in total duodenal polyp count, along with changes in lower gastrointestinal (GI) polyp burden and count (for participants examined by optional lower endoscopy). RESULTS Forty-six participants (mean age, 44.1 years (range, 18-68); women, 22 (48%)) were enrolled; 42 participants completed 6 months of intervention and were included in the per-protocol analysis. Duodenal polyp burden was significantly reduced after 6 months of weekly erlotinib intervention, with a mean per cent change of -29.6% (95% CI, -39.6% to -19.7%; p<0.0001). Similar results were observed in subgroup analyses defined by participants with advanced duodenal polyposis (Spigelman 3) at baseline (mean, -27%; 95% CI, -38.7% to -15.2%; p<0.0001). Post-intervention Spigelman stage was downstaged in 12% of the participants. Lower GI polyp number was also decreased after 6 months of intervention (median, -30.8%; IQR, -47.4% to 0.0%; p=0.0256). Grade 2 or 3 AEs were reported in 71.7% of subjects, with only two experiencing grade 3 toxicity at least possibly related to intervention. CONCLUSION In this single-arm, multi-centre trial of participants with FAP, erlotinib one time per week resulted in markedly lower duodenal polyp burden, and modestly reduced lower GI polyp burden, after 6 months of intervention. While AEs were still reported by nearly three-quarters of all participants, these events were generally lower grade and well-tolerated. These findings support further investigation of erlotinib as an effective, acceptable cancer preventive agent for FAP-associated GI polyposis. TRIAL REGISTRATION NUMBER NCT02961374.
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Affiliation(s)
- N Jewel Samadder
- Gastroenterology and Hepatology, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Nathan Foster
- Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan P McMurray
- Gastroenterology and Hepatology, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Carol A Burke
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Elena Stoffel
- Department of Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Priyanka Kanth
- Gastroenterology & Hepatology, University of Utah, Salt Lake City, Utah, USA
| | - Rohit Das
- Department of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Marcia Cruz-Correa
- Medicine, University of Puerto Rico, San Juan, Puerto Rico,Cancer Biology, UPR Comprehensive Cancer Center, San Juan, Puerto Rico
| | - E Vilar
- Clinical Cancer Prevention, UT MD Anderson Cancer Center, Houston, Texas, USA
| | - Gautam Mankaney
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Navtej Buttar
- Gastroenterology, Mayo Clinic, Rochester, Minnesota, Rochester, Minnesota, USA
| | - Selvi Thirumurthi
- Gastroenterology, Hepatology and Nutrition, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Danielle K Turgeon
- Medicine/Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Michelle Westover
- Gastroenterology & Hepatology, University of Utah, Salt Lake City, Utah, USA
| | - Ellen Richmond
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland, USA
| | - Asad Umar
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland, USA
| | - Gary Della'Zanna
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland, USA
| | - Luz M Rodriguez
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Eva Szabo
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland, USA
| | - David Zahrieh
- Gastroenterology and Hepatology, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Paul J Limburg
- Gastroenterology and Hepatology, Mayo Clinic Minnesota, Rochester, Minnesota, USA
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Shah RS, Mehta N, Burke CA, Mankaney G, Stevens T, Augustin T, Walsh MR, Bhatt A. Efficacy of endoscopic retrograde cholangiopancreatography in familial adenomatous polyposis patients after duodenectomy. DEN Open 2022; 2:e85. [PMID: 35310730 PMCID: PMC8828246 DOI: 10.1002/deo2.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 11/17/2021] [Accepted: 11/27/2021] [Indexed: 12/02/2022]
Abstract
Objectives Familial adenomatous polyposis (FAP) patients with Spigelman stage IV polyposis should be considered for prophylactic duodenectomy. Post‐surgical pancreaticobiliary complications occur and may require management via endoscopic retrograde cholangiopancreatography (ERCP). We aimed to assess the success and adverse events of ERCP in FAP patients after pancreas‐sparing duodenectomy (PSD) and pancreaticoduodenectomy (PD). Methods A retrospective review of FAP patients who underwent ERCP after PSD or PD from 1992 to 2020 at a quaternary referral center was completed. The technical success of ERCP was defined as the ability to identify the anastomosis and cannulate the duct. Post‐procedural adverse events were defined by bleeding, perforation, pancreatitis, or cholangitis. Clinical outcomes included the need for surgical intervention and recurrent pancreatitis after ERCP were assessed. Results Of 84 FAP patients with duodenectomy, 12 patients with PSD and two patients with PD underwent 17 ERCPs for pancreatic indications and five for biliary indications. The technical success of ERCP in patients with PSD and a single neoampullary complex for pancreatic (n = 6) and biliary (n = 5) indications was 100% but for those with PD (n = 2) or PSD reconstruction with pancreatic divisum or separate anastomoses (n = 3), it was 0%. Surgical intervention was required in 50% of patients with technically failed ERCP after PSD (2/4) and PD (1/2). There were no adverse events. Conclusions ERCP is expected to be therapeutically successful for biliary complications following PSD. Assessment and potential therapy for pancreatitis post‐PSD are best in the setting of a single neo‐ampullary complex rather than in PD or PSD with pancreatic divisum.
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Affiliation(s)
- Ravi S. Shah
- Department of Gastroenterology, Hepatology, and Nutrition Cleveland Clinic Cleveland USA
| | - Neal Mehta
- Department of Gastroenterology, Hepatology, and Nutrition Cleveland Clinic Cleveland USA
| | - Carol A. Burke
- Department of Gastroenterology, Hepatology, and Nutrition Cleveland Clinic Cleveland USA
| | - Gautam Mankaney
- Department of Gastroenterology, Hepatology, and Nutrition Cleveland Clinic Cleveland USA
| | - Tyler Stevens
- Department of Gastroenterology, Hepatology, and Nutrition Cleveland Clinic Cleveland USA
| | - Toms Augustin
- Department of Hepatobiliary Surgery Cleveland Clinic Cleveland USA
| | - Matthew R. Walsh
- Department of Hepatobiliary Surgery Cleveland Clinic Cleveland USA
| | - Amit Bhatt
- Department of Gastroenterology, Hepatology, and Nutrition Cleveland Clinic Cleveland USA
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Khare A, Burke CA, Heald B, O'Malley M, LaGuardia L, Milicia S, Cruise M, Eng C, Mankaney G. Endoscopic Findings in Patients With PTEN Hamartoma Tumor Syndrome Undergoing Surveillance. J Clin Gastroenterol 2022; 56:e183-e188. [PMID: 34231499 DOI: 10.1097/mcg.0000000000001580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/28/2021] [Indexed: 12/30/2022]
Abstract
GOALS AND BACKGROUND Phosphatase and tensin homolog hamartoma tumor syndrome (PHTS) is an inherited disorder that increases the risk for cancer in multiple organ systems, including breast, endometrial, thyroid, and the gastrointestinal tract. Surveillance is recommended however there lacks data to describe the change in polyposis phenotype and cancer incidence over surveillance. Our aim is to describe the polyposis phenotype and cancer incidence in PHTS patients undergoing endoscopic surveillance. STUDY PHTS patients, ages 17 through 89, who underwent at least 2 esophagogastroduodenoscopy (EGDs) or colonoscopies were identified. Number and sizes of polyps were noted, from which 5 categories were recreated. Incidence of colorectal and gastric cancer was evaluated. RESULTS Seventy patients were included. Patients were clustered and classified into 1 of 5 categories: no polyps, few small polyps (<1 cm, < 10 polyps), few large polyps (≥1 cm, < 10 polyps), many small polyps (<1 cm, ≥10 polyps), many large polyps (≥1 cm, ≥10 polyps). There was no significant difference in polyp number or size on EGD (P=0.47 and 0.83, respectively) or colonoscopy (P=0.49 and 0.10, respectively) over the surveillance period (4.8±3.9 y for stomach and 5.6±4.4 y for colon). The average interval between endoscopies was 28±24 months for EGDs and 29±23 months for colonoscopies. A stage II transverse colon adenocarcinoma and stage IV gastric adenocarcinoma were identified. Standardized incidence rates for gastric and colon cancers were 5427 (P=0.0002) and 353 (P=0.002), respectively. CONCLUSIONS PTHS individuals can be classified into polyposis phenotypes which do not change over an endoscopic surveillance period. Two cancers were associated with a large size polyp phenotype. Surveillance intervals should be determined by polyp size ≥1 cm and pathology.
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Affiliation(s)
| | - Carol A Burke
- Gastroenterology, Hepatology, and Nutrition
- Colorectal Surgery
- Pathology and Laboratory Medicine Institute
| | - Brandie Heald
- Center for Personalized Genetic Healthcare
- Sanford R. Weiss, M.D. Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - Margaret O'Malley
- Colorectal Surgery
- Sanford R. Weiss, M.D. Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - Lisa LaGuardia
- Colorectal Surgery
- Sanford R. Weiss, M.D. Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - Susan Milicia
- Colorectal Surgery
- Sanford R. Weiss, M.D. Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - Michael Cruise
- Pathology and Laboratory Medicine Institute
- Sanford R. Weiss, M.D. Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - Charis Eng
- Genomic Medicine Institute
- Center for Personalized Genetic Healthcare
- Sanford R. Weiss, M.D. Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - Gautam Mankaney
- Gastroenterology, Hepatology, and Nutrition
- Sanford R. Weiss, M.D. Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgical Institute, Cleveland Clinic, Cleveland, OH
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Faisal MS, Burke CA, Liska D, Lightner AL, Leach B, O’Malley M, LaGuardia L, Click B, Achkar JP, Kalady M, Church JM, Mankaney G. Association of cancer with comorbid inflammatory conditions and treatment in patients with Lynch syndrome. World J Clin Oncol 2022; 13:49-61. [PMID: 35116232 PMCID: PMC8790302 DOI: 10.5306/wjco.v13.i1.49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 08/12/2021] [Accepted: 12/23/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Individuals with Lynch syndrome (LS) and hereditary non-polyposis colorectal cancer (HNPCC) are at increased risk of both colorectal cancer and other cancers. The interplay between immunosuppression, a comorbid inflammatory condition (CID), and HNPCC on cancer risk is unclear.
AIM To evaluate the impact of CIDs, and exposure to monoclonal antibodies and immunomodulators, on cancer risk in individuals with HNPCC.
METHODS Individuals prospectively followed in a hereditary cancer registry with LS/HNPCC with the diagnosis of inflammatory bowel disease or rheumatic disease were identified. We compared the proportion of patients with cancer in LS/HNPCC group with and without a CID. We also compared the proportion of patients who developed cancer following a CID diagnosis based upon exposure to immunosuppressive medications.
RESULTS A total of 21 patients with LS/HNPCC and a CID were compared to 43 patients with LS/HNPCC but no CID. Cancer occurred in 84.2% with a CID compared to 76.7% without a CID (P = 0.74) with no difference in age at first cancer diagnosis 45.5 ± 14.6 vs 43.8 ± 7.1 years (P = 0.67). LS specific cancers were diagnosed in 52.4% with a CID vs 44.2% without a CID (P = 0.54). Nine of 21 (42.9%) patients were exposed to biologics or immunomodulators for the treatment of their CID. Cancer after diagnosis of CID was seen in 7 (77.8%) of exposed individuals vs 5 (41.7%) individuals unexposed to biologics/immunomodulators (P = 0.18). All 7 exposed compared to 3/5 unexposed developed a LS specific cancer. The exposed and unexposed groups were followed for a median 10 years and 8.5 years, respectively. The hazard ratio for cancer with medication exposure was 1.59 (P = 0.43, 95%CI: 0.5-5.1).
CONCLUSION In patients with LS/HNPCC, the presence of a concurrent inflammatory condition, or use of immunosuppressive medication to treat the inflammatory condition, might not increase the rate of cancer occurrence in this limited study.
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Affiliation(s)
- Muhammad S Faisal
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Carol A Burke
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH 44195, United States
| | - David Liska
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Brandie Leach
- Center for Personalized Genetic Healthcare, Genomic Medicine Institute, Cleveland, OH 44195, United States
| | - Margaret O’Malley
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Lisa LaGuardia
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Benjamin Click
- Department of Gastroenterology, Hepatology, & Nutrition, Cleveland Clinic, Cleveland, OH 44195, United States
| | - JP Achkar
- Center for Inflammatory Bowel Disease, Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Matthew Kalady
- Department of Colorectal Surgery, Ohio State University, Columbus, OH 43210, United States
| | - JM Church
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Gautam Mankaney
- Department of Gastroenterology and Hepatology, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
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Mankaney G, Cruise M, Burke CA. Finding the needle in a haystack: approach to detection of high-risk gastric lesions in familial adenomatous polyposis. Gastrointest Endosc 2021; 94:1043-1045. [PMID: 34598775 DOI: 10.1016/j.gie.2021.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/14/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Gautam Mankaney
- Department of Gastroenterology and Hepatology, Virginia Mason Franciscan Health, Seattle, Washington
| | - Michael Cruise
- Pathology and Laboratory Medicine Institute, Sanford R. Weiss MD Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Carol A Burke
- Department of Gastroenterology, Hepatology and Nutrition, Sanford R. Weiss MD Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA; Department of Colorectal Surgery, Sanford R. Weiss MD Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Monachese M, Mankaney G, El-Khider F, Rouphael C, Lopez R, Burke CA. Association between baseline hyperplastic polyps and metachronous serrated lesions. Gastrointest Endosc 2021; 93:1401-1407.e1. [PMID: 33316243 DOI: 10.1016/j.gie.2020.11.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/28/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Some data suggest that individuals with numerous, <10-mm, rectosigmoid hyperplastic polyps (HPs) are at average risk for the development of metachronous advanced adenomatous neoplasia. Guidelines suggest that these individuals do not need surveillance colonoscopy and should be followed akin to individuals with a normal colonoscopy. Less is known of the risk of metachronous neoplasia because of ≥1 HPs <10 mm proximal to the sigmoid colon. We compared the risk of metachronous neoplasia between individuals with small HPs and those with normal colonoscopy, specifically addressing the impact of location and number of HPs on risk. METHODS Colonoscopy and pathology reports from patients with ≥2 colonoscopies between 2004 and 2014 were reviewed. Exclusions included inpatients; age <40 or >75 years; and family or personal history of colorectal cancer, inflammatory bowel disease, previous colorectal surgery, or a previous colonoscopy with any adenoma, sessile serrated lesion (SSL), or HP ≥10 mm. The risk of metachronous neoplasia, including adenomas and SSLs, was compared in individuals with a normal index colonoscopy and those with <10-mm HPs stratified by location and number of HPs. RESULTS After exclusion, 1795 patients were included. At index colonoscopy, 82% (n = 1469) had a normal examination, 12% (219) had only 1, and 6% (107) had between 2 and 9 HPs <10 mm. Compared with patients with a normal index colonoscopy, patients with a proximal (odds ratio, 3.82; 95% confidence interval, 1.77-7.53) or distal HP (odds ratio, 2.23; 95% confidence interval, 1.18-4.00) had an increased risk of metachronous SSLs but not adenomas. CONCLUSIONS Patients with small proximal and distal HPs are at increased risk of metachronous SSLs. These preliminary findings warrant consideration during surveillance recommendations and future studies in larger cohorts.
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Affiliation(s)
- Marc Monachese
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gautam Mankaney
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease and Surgical Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Faris El-Khider
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease and Surgical Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Carol Rouphael
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease and Surgical Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rocio Lopez
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Carol A Burke
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease and Surgical Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Faisal MS, Burke CA, Achkar JP, Click B, O'Malley M, LaGuardia L, Milicia S, Leach B, Liska D, Church J, Kalady M, Mankaney G. Malignancy risk in individuals with familial adenomatous polyposis receiving biologics and immunomodulators. Fam Cancer 2021; 21:189-195. [PMID: 33822277 DOI: 10.1007/s10689-021-00250-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 03/29/2021] [Indexed: 12/19/2022]
Abstract
Clinicians may be hesitant to prescribe biologics or immunomodulators to individuals with familial adenomatous polyposis (FAP) and comorbid inflammatory disease (CID) because of increased cancer risk. Our aim was to compare the risk of malignancy in FAP individuals with inflammatory bowel (IBD) and/or rheumatic disease that received biologics/immunomodulators to those who did not. Individuals with FAP and CID were included in the study. We compared the incidence of cancer between individuals exposed to biologics/immunomodulators compared to unexposed from the date of diagnosis of comorbid disease till last follow up or death. Hazard ratio (HR) for cancer was computed using Cox regression model and compared by exposure status to biologic/immunomodulators. 25 individuals with FAP and a comorbid inflammatory disease were identified including 9 (36%) with IBD and 16 (64%) with rheumatic disease. 14 (56%) were exposed to a biologic and or immunomodulator. Median duration of biologic/immunomodulator exposure was 48 (2-180) months. 3 (21.4%) in the exposed group compared to 1 (9.1%) in the unexposed group developed cancer with a HR for exposure of 1.92 (CI 0.2-18.5, p = 0.57). Median duration of follow up after the diagnosis of inflammatory disease was 10 (5.5-17.0) years in the exposed and 6 (3.0-15.0) years in the unexposed group. In the exposed group, 1 patient developed gastric and 2 developed colon cancer. One unexposed patient developed medullary thyroid cancer. There is a possible trend of more cancers in the group that received biologics/immunomodulators-but given the small number of patients and p-value, there may be no difference at all. This preliminary finding warrants study in a larger cohort.
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Affiliation(s)
- Muhammad Salman Faisal
- Department of Internal Medicine, Cleveland Clinic Foundation, Lerner Research Institute, 2111 East 96th Street, Cleveland, OH, 44195, USA.
| | - Carol A Burke
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Foundation, Cleveland, USA
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, USA
- Sanford R. Weiss M.D. Center for Inherited Colorectal Neoplasia, Cleveland Clinic Foundation, Cleveland, USA
| | - Jean-Paul Achkar
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Foundation, Cleveland, USA
| | - Benjamin Click
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Foundation, Cleveland, USA
| | - Margaret O'Malley
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, USA
- Sanford R. Weiss M.D. Center for Inherited Colorectal Neoplasia, Cleveland Clinic Foundation, Cleveland, USA
| | - Lisa LaGuardia
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, USA
- Sanford R. Weiss M.D. Center for Inherited Colorectal Neoplasia, Cleveland Clinic Foundation, Cleveland, USA
| | - Susan Milicia
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, USA
- Sanford R. Weiss M.D. Center for Inherited Colorectal Neoplasia, Cleveland Clinic Foundation, Cleveland, USA
| | - Brandie Leach
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, USA
- Sanford R. Weiss M.D. Center for Inherited Colorectal Neoplasia, Cleveland Clinic Foundation, Cleveland, USA
| | - David Liska
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, USA
- Sanford R. Weiss M.D. Center for Inherited Colorectal Neoplasia, Cleveland Clinic Foundation, Cleveland, USA
| | - James Church
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, USA
- Sanford R. Weiss M.D. Center for Inherited Colorectal Neoplasia, Cleveland Clinic Foundation, Cleveland, USA
| | - Matthew Kalady
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, USA
- Sanford R. Weiss M.D. Center for Inherited Colorectal Neoplasia, Cleveland Clinic Foundation, Cleveland, USA
| | - Gautam Mankaney
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Foundation, Cleveland, USA
- Sanford R. Weiss M.D. Center for Inherited Colorectal Neoplasia, Cleveland Clinic Foundation, Cleveland, USA
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Mehta NA, Shah RS, Yoon J, O'Malley M, LaGuardia L, Mankaney G, Bhatt A, Burke CA. Risks, Benefits, and Effects on Management for Biopsy of the Papilla in Patients With Familial Adenomatous Polyposis. Clin Gastroenterol Hepatol 2021; 19:760-767. [PMID: 32492482 DOI: 10.1016/j.cgh.2020.05.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 05/20/2020] [Accepted: 05/27/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Ampullary and duodenal cancer are the leading causes of death in patients with familial adenomatous polyposis (FAP) after colectomy has been performed. Risk of duodenal cancer is determined based on Spigelman stage (SS) of duodenal polyposis. Guidelines recommend endoscopic surveillance of the duodenum and visualization of the papilla to stage duodenal polyposis. There is no consensus on whether biopsies should be routinely collected from duodenal papilla and findings included in SS. Additionally, there are no data on the risk of pancreatitis after biopsy collection from papilla of patients with FAP. We studied the incidence of pancreatitis after biopsy of the papilla in patients with FAP and effects of biopsy findings on SS. METHODS We identified consecutive patients with FAP at a single center from January 2011 through December 2018 with ≥1 endoscopy with biopsy of the papilla. Patients with history of foregut surgery were excluded. We identified 273 patients with FAP who had biopsies collected from papilla over 792 EGDs, with 1-8 independent exams with biopsy per patient. We collected demographic, endoscopic, and histology data from patients and calculated SS with vs without biopsy findings. Post-procedural pancreatitis was defined by 2 of the following: abdominal pain, lipase level 3-fold the upper limit of normal, or radiography findings consistent with pancreatitis within 7 days of esophagogastroduodenoscopy (EGD). RESULTS Pancreatitis developed in 2 patients (0.73%): 1 after biopsy of a normal-appearing papilla and 1 after biopsy of an abnormal appearing papilla. Inclusions of biopsy data increased SS in 36 patients (13.2%), with consideration of prophylactic duodenectomy for 3.3%. CONCLUSIONS Pancreatitis after biopsy of the duodenal papilla is rare. Histology data obtained from biopsy of the papilla in patients with FAP can change SS and affect patient management.
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Affiliation(s)
- Neal A Mehta
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Ravi S Shah
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jiyoon Yoon
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Margaret O'Malley
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Sanford R. Weiss, MD Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lisa LaGuardia
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Sanford R. Weiss, MD Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gautam Mankaney
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Sanford R. Weiss, MD Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Amit Bhatt
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Sanford R. Weiss, MD Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Carol A Burke
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Sanford R. Weiss, MD Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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Kemp Bohan PM, Mankaney G, Vreeland TJ, Chick RC, Hale DF, Cindass JL, Hickerson AT, Ensley DC, Sohn V, Clifton GT, Peoples GE, Burke CA. Chemoprevention in familial adenomatous polyposis: past, present and future. Fam Cancer 2021; 20:23-33. [PMID: 32507936 PMCID: PMC7276278 DOI: 10.1007/s10689-020-00189-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 05/18/2020] [Indexed: 01/05/2023]
Abstract
Familial adenomatous polyposis (FAP) is a hereditary colorectal cancer syndrome characterized by colorectal adenomas and a near 100% lifetime risk of colorectal cancer (CRC). Prophylactic colectomy, usually by age 40, is the gold-standard therapy to mitigate this risk. However, colectomy is associated with morbidity and fails to prevent extra-colonic disease manifestations, including gastric polyposis, duodenal polyposis and cancer, thyroid cancer, and desmoid disease. Substantial research has investigated chemoprevention medications in an aim to prevent disease progression, postponing the need for colectomy and temporizing the development of extracolonic disease. An ideal chemoprevention agent should have a biologically plausible mechanism of action, be safe and easily tolerated over a prolonged treatment period, and produce a durable and clinically meaningful effect. To date, no chemoprevention agent tested has fulfilled these criteria. New agents targeting novel pathways in FAP are needed. Substantial preclinical literature exists linking the molecular target of rapamycin (mTOR) pathway to FAP. A single case report of rapamycin, an mTOR inhibitor, used as chemoprevention in FAP patients exists, but no formal clinical studies have been conducted. Here, we review the prior literature on chemoprevention in FAP, discuss the rationale for rapamycin in FAP, and outline a proposed clinical trial testing rapamycin as a chemoprevention agent in patients with FAP.
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Affiliation(s)
- Phillip M Kemp Bohan
- Department of Surgery, Brooke Army Medical Center, 3551 Roger Brooke Dr., Ft Sam Houston, TX, 78234, USA.
| | - Gautam Mankaney
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Timothy J Vreeland
- Department of Surgery, Brooke Army Medical Center, 3551 Roger Brooke Dr., Ft Sam Houston, TX, 78234, USA
| | - Robert C Chick
- Department of Surgery, Brooke Army Medical Center, 3551 Roger Brooke Dr., Ft Sam Houston, TX, 78234, USA
| | - Diane F Hale
- Department of Surgery, Brooke Army Medical Center, 3551 Roger Brooke Dr., Ft Sam Houston, TX, 78234, USA
| | - Jessica L Cindass
- Department of Surgery, Brooke Army Medical Center, 3551 Roger Brooke Dr., Ft Sam Houston, TX, 78234, USA
| | - Annelies T Hickerson
- Department of Surgery, Brooke Army Medical Center, 3551 Roger Brooke Dr., Ft Sam Houston, TX, 78234, USA
| | - Daniel C Ensley
- Department of Urology, Brooke Army Medical Center, Ft. Sam Houston, TX, USA
| | - Vance Sohn
- Department of Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, Tacoma, WA, USA
| | - G Travis Clifton
- Department of Surgery, Brooke Army Medical Center, 3551 Roger Brooke Dr., Ft Sam Houston, TX, 78234, USA
| | | | - Carol A Burke
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
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12
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Garg R, Singh A, Mohan BP, Mankaney G, Regueiro M, Chahal P. Underwater versus conventional endoscopic mucosal resection for colorectal lesions: a systematic review and meta-analysis. Endosc Int Open 2020; 8:E1884-E1894. [PMID: 33269325 PMCID: PMC7695518 DOI: 10.1055/a-1287-9621] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/21/2020] [Indexed: 12/11/2022] Open
Abstract
Background and study aims Underwater endoscopic mucosal resection (UEMR) for colorectal polyps has been reported to have good outcomes in recent studies. We conducted a systematic review and meta-analysis comparing the effectiveness and safety of UEMR to conventional EMR (CEMR). Methods A comprehensive search of multiple databases (through May 2020) was performed to identify studies that reported outcome of UEMR and CEMR for colorectal lesions. Outcomes assessed included incomplete resection, rate of recurrence, en bloc resection, adverse events (AEs) for UEMR and CEMR. Results A total of 1,651 patients with 1,704 polyps were included from nine studies. There was a significantly lower rate of incomplete resection (odds ratio [OR]: 0.19 (95 % confidence interval (CI), 0.05-0.78, P = 0.02) and polyp recurrence (OR: 0.41, 95 % CI, 0.24-0.72, P = 0.002) after UEMR. Compared to CEMR, rates overall complications (relative risk [RR]: 0.66 (95 % CI, 0.48-0.90) ( P = 0.008), and intra-procedural bleeding (RR: 0.59, 95 % CI, 0.41-0.84, P = 0.004) were significantly lower with UEMR. The recurrence rate was also lower for large non-pedunculated polyps ≥ 10 mm (OR 0.24, 95 % CI, 0.10-0.57, P = 0.001) and ≥ 20 mm (OR 0.14, 95 % CI, 0.02-0.72, P = 0.01). The rates of en bloc resection, delayed bleeding, perforation and post-polypectomy syndrome were similar in both groups ( P > 0.05). Conclusions In this systematic review and meta-analysis, we found that UEMR is more effective and safer than CEMR with lower rates of recurrence and AEs. UEMR use should be encouraged over CEMR.
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Affiliation(s)
- Rajat Garg
- Department of Hospital Medicine, Cleveland Clinic, Ohio, United States
| | - Amandeep Singh
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, United States
| | - Babu P. Mohan
- Department of Inpatient Medicine, University of Arizona, Banner University Medical Center, Tucson, Arizona, United States
| | - Gautam Mankaney
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, United States
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, United States
| | - Prabhleen Chahal
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, United States
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13
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Heald B, Keel E, Marquard J, Burke CA, Kalady MF, Church JM, Liska D, Mankaney G, Hurley K, Eng C. Using chatbots to screen for heritable cancer syndromes in patients undergoing routine colonoscopy. J Med Genet 2020; 58:807-814. [PMID: 33168571 DOI: 10.1136/jmedgenet-2020-107294] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/03/2020] [Accepted: 09/11/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Hereditary colorectal cancer (HCRC) syndromes account for 10% of colorectal cancers but remain underdiagnosed. This feasibility project tested the utility of an artificial intelligence-based chatbot deployed to patients scheduled for colonoscopy to identify HCRC risk factors, educate participants about HCRC and obtain consent to genetic testing as an extension of genetic counselling of appropriate subjects. Genetic counsellor (GC) and genetic counselling assistant (GCA) time spent per subject was also measured. METHODS Patients scheduled for colonoscopy at Cleveland Clinic were invited via electronic medical record patient portal or letter prior to colonoscopy with a link to a chatbot administering the Colon Cancer Risk Assessment Tool (CCRAT) to screen for HCRC syndromes. Those with ≥1 positive response to a CCRAT question received chatbot-deployed genetic education and the option to receive genetic testing. An order for a 55-gene pan-cancer panel was placed for those consenting, and the subject had blood drawn on the day of colonoscopy. Results were disclosed by a GC or GCA by telephone. Subject demographics, progression through the chat, responses to CCRAT, personal and family history, genetic test results and communication with the subject were recorded. Descriptive statistics and two-tailed unpaired t-test and Fisher's exact test were used. RESULTS 506/4254 (11.9%) initiated and 487 (96.2%) completed the chat with the chatbot. 215 (44.1%) answered 'yes' to ≥1 CCRAT question and all completed pretest education. 129/181 (71.3%) subjects who consented completed testing, and 12 (9.3%) were found to have a germline pathogenic variant. Per subject, the GC spent a mean of 14.3 (SD 7.3) and the GCA a mean of 19.2 (SD 9.8) minutes. CONCLUSION The use of a chatbot in this setting was a novel and feasible method, with the potential of increasing genetic screening and testing in individuals at risk of HCRC syndromes.
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Affiliation(s)
| | - Emma Keel
- Cleveland Clinic, Cleveland, Ohio, USA
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14
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Bhatt A, Mankaney G, Burke CA. Approach to resection of adenomas of the papilla: Should familial adenomatous polyposis change the approach? Gastrointest Endosc 2020; 92:331-333. [PMID: 32703367 DOI: 10.1016/j.gie.2020.04.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 04/19/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Amit Bhatt
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gautam Mankaney
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Carol A Burke
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
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15
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Affiliation(s)
- Gautam Mankaney
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio; Sanford R. Weiss, MD, Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, Ohio.
| | - Carol Rouphael
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Carol A Burke
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio; Sanford R. Weiss, MD, Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, Ohio; Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
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16
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Mankaney G, Macaron C, Burke CA. Refining Risk Factors for Gastric Cancer in Patients With Lynch Syndrome to Optimize Surveillance Esophagogastroduodenoscopy. Clin Gastroenterol Hepatol 2020; 18:780-782. [PMID: 31606458 DOI: 10.1016/j.cgh.2019.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 10/01/2019] [Accepted: 10/03/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Gautam Mankaney
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Sanford R. Weiss MD Center for Hereditary Colorectal Neoplasia, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Carole Macaron
- Section of Gastroenterology, Department of Veterans Affairs, Louis Stokes Cleveland Medical Center, Cleveland, Ohio
| | - Carol A Burke
- Department of Gastroenterology, Hepatology and Nutrition, Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio; Sanford R. Weiss MD Center for Hereditary Colorectal Neoplasia, Cleveland Clinic Foundation, Cleveland, Ohio
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17
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Sarvepalli S, Garber A, Rothberg MB, Mankaney G, McMichael J, Morris-Stiff G, Vargo JJ, Rizk MK, Burke CA. Association of Adenoma and Proximal Sessile Serrated Polyp Detection Rates With Endoscopist Characteristics. JAMA Surg 2020; 154:627-635. [PMID: 30994911 DOI: 10.1001/jamasurg.2019.0564] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Research demonstrates adenoma detection rate (ADR) and proximal sessile serrated polyp detection rate (pSSPDR) are associated with endoscopist characteristics including sex, specialty, and years in practice. However, many studies have not adjusted for other risk factors associated with colonic neoplasia. Objective To assess the association between endoscopist characteristics and polyp detection after adjusting the factors included in previous studies as well as other factors. Design, Setting, and Participants This cohort study was conducted in the Cleveland Clinic health system with data from individuals undergoing screening colonoscopies between January 2015 and June 2017. The study analyzed data using methods from previous studies that have demonstrated significant associations between endoscopist characteristics and ADR or pSSPDR. Multilevel mixed-effects logistic regression was performed to examine 7 endoscopist characteristics associated with ADRs and pSSPDRs after controlling for patient demographic, clinical, and colonoscopy-associated factors. Exposures Seven characteristics of endoscopists performing colonoscopy. Main Outcomes and Measures The ADR and pSSPDR, with a hypothesis created after data collection began. Results A total of 16 089 colonoscopies were performed in 16 089 patients by 56 clinicians. Of these, 8339 patients were male (51.8%), and the median (range) age of the cohort was 59 (52-66) years. Analyzing the data by the methods used in 4 previous studies yielded an association between endoscopist and polyp detection; surgeons (OR, 0.49 [95% CI, 0.28-0.83]) and nongastroenterologists (OR, 0.50 [95% CI 0.29-0.85]) had reduced odds of pSSPDR, which was similar to results in previous studies. In a multilevel mixed-effects logistic regression analysis, ADR was not significantly associated with any endoscopist characteristic, and pSSPDR was only associated with years in practice (odds ratio, 0.86 [95% CI, 0.83-0.89] per increment of 10 years; P < .001) and number of annual colonoscopies performed (odds ratio, 1.05 [95% CI, 1.01-1.09] per 50 colonoscopies/year; P = .02). Conclusions and Relevance The differences in ADRs that were associated with 7 of 7 endoscopist characteristics and differences in pSSPDRs that were associated with 5 of 7 endoscopist characteristics in previous studies may have been associated with residual confounding, because they were not replicated in this analysis. Therefore, these characteristics should not influence the choice of endoscopist for colorectal cancer screening. However, clinicians further from their training and those with lower colonoscopy volumes have lower adjusted pSSPDRs and may need additional training to help increase pSSPDRs.
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Affiliation(s)
| | - Ari Garber
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - Michael B Rothberg
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio.,Department of Value Based Care, Cleveland Clinic, Cleveland, Ohio
| | - Gautam Mankaney
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - John McMichael
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - John J Vargo
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - Maged K Rizk
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - Carol A Burke
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
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Burke CA, Mankaney G, Sutton RA. In reply: Colorectal cancer screening. Cleve Clin J Med 2019; 86:776-777. [PMID: 31821143 DOI: 10.3949/ccjm.86c.12003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Carol A Burke
- Department of Gastroenterology and Hepatology Cleveland Clinic
| | - Gautam Mankaney
- Department of Gastroenterology and Hepatology Cleveland Clinic
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19
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Mankaney G, Rizk M, Sarvepalli S, Bongorno J, Garber A, Lopez R, McMichael J, Burke CA. Patient-Initiated Colonoscopy Scheduling Effectively Increases Colorectal Cancer Screening Adherence. Dig Dis Sci 2019; 64:2497-2504. [PMID: 30877609 DOI: 10.1007/s10620-019-05584-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 03/08/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM We identified patients without medical record evidence of up-to-date colorectal cancer (CRC) screening and sent an invitation letter to self-schedule a colonoscopy without requiring prior primary care or gastroenterologist consultation. The aim of the study was to evaluate the response rate to the letter and factors associated with colonoscopy completion. METHODS A computer algorithm invited patients not up to date with CRC screening, with an INR < 1.5, and living within 300 miles of the Cleveland Clinic main campus through a letter. Patients scheduled a colonoscopy through a dedicated phone line without any prior physician consultation. Clinical, demographic, and socioeconomic variables were extracted from the EMR through natural language algorithms. We analyzed the percentage of patients who completed a colonoscopy within 6 months of sending the letter and factors associated with colonoscopy completion. RESULTS A total of 145,717 letters were sent. 1451 patients were deceased and excluded from analysis. 3.8% (5442) of letter recipients completed a colonoscopy. The strongest factors associated with colonoscopy completion on multivariate analysis included family history of polyps (OR 3.1, 95% CI 2.3, 4.2) or CRC (OR 2.1, 95% CI 1.7, 2.5). Other factors included younger age, male gender, married status, closer distance to endoscopy center, number of visits in the year prior, statin use, and diabetes. There were no immediate procedural complications. CONCLUSIONS Patient-initiated colonoscopy in response to letter invitation for CRC screening is effective and safe with safeguards established a priori. Consultation with a gastroenterologist or primary care physician is not necessary prior to colonoscopy. To our knowledge, this is the first study to evaluate patient-initiated colonoscopy for CRC cancer screening.
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Affiliation(s)
- Gautam Mankaney
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgical Institute, The Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA.
| | - Maged Rizk
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgical Institute, The Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA
| | - Shashank Sarvepalli
- Department of Medicine, Digestive Disease and Surgical Institute, The Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA
| | - Jeannie Bongorno
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgical Institute, The Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA
| | - Ari Garber
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgical Institute, The Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA
| | - Rocio Lopez
- Department of Biostatistics, and Quantitative Health Sciences, Digestive Disease and Surgical Institute, The Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA
| | - John McMichael
- Department of General Surgery, Digestive Disease and Surgical Institute, The Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA
| | - Carol A Burke
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgical Institute, The Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA
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Monachese M, Mankaney G, Lopez R, O'Malley M, Laguardia L, Kalady MF, Church J, Shin J, Burke CA. Outcome of thyroid ultrasound screening in FAP patients with a normal baseline exam. Fam Cancer 2019; 18:75-82. [PMID: 30003385 DOI: 10.1007/s10689-018-0097-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Familial adenomatous polyposis (FAP) is a hereditary cancer syndrome associated with a substantial lifetime risk for colorectal cancer. The leading extra-colonic causes of cancer in FAP include duodenal and thyroid cancer (TC). Recent guidelines recommend annual thyroid ultrasound (TUS) screening beginning in the teenage years but the evidence to support the interval particularly in FAP patients with a normal baseline ultrasound is lacking. TUS results from FAP patients enrolled in a thyroid screening program from 2006 to 2016 and who had at least 2 TUS were reviewed. TUS findings were classified as normal, low (LR) or high risk (HR) for TC based on nodule characteristics as determined by American Thyroid Association (ATA) guidelines. We assessed the incidence of TC in patient with normal baseline TUS and factors associated with TC. 264 FAP patients were included. Baseline TUS was normal in 167, LR in 74, and HR in 24 patients. Patients were observed for a mean 4.8 years and underwent an average of 3 TUS. Patients with normal baseline TUS did not develop TC during the course of follow up of 5.1 years. TC developed in 6 patients (2.3%) all with baseline nodules; 5 in the LR group and 1 in the HR group. Factors associated with development of TC were presence of baseline nodule(s) and female sex. The development of TC in FAP patients in a TUS screening program with short term follow up is low and no FAP patient with a normal baseline TUS developed TC during observation. Annual TUS in patients with a normal baseline TUS may not be needed. Extending the screening interval to 2 years may be reasonable until nodules are detected.
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Affiliation(s)
- Marc Monachese
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Gautam Mankaney
- Department of Gastroenterology and Hepatology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA
| | - Rocio Lopez
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Margaret O'Malley
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
- Sanford R. Weiss MD Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, OH, USA
| | - Lisa Laguardia
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
- Sanford R. Weiss MD Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew F Kalady
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
- Sanford R. Weiss MD Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, OH, USA
| | - James Church
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
- Sanford R. Weiss MD Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, OH, USA
| | - Joyce Shin
- Sanford R. Weiss MD Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, OH, USA
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Carol A Burke
- Department of Gastroenterology and Hepatology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA.
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA.
- Sanford R. Weiss MD Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, OH, USA.
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Abstract
Colorectal cancer, the second most common type of cancer and cause of cancer-related deaths in the United States, can largely be prevented by screening. The 2 most used methods in the United States are colonoscopy and fecal immunochemical testing (FIT). FIT is noninvasive but must be done yearly for optimal performance and, if positive, must be followed by colonoscopy. Colonoscopy is invasive, operator-dependent, and more expensive, but it can detect and remove polyps during the same procedure. The choice of test depends on patient preference, family history, and the likelihood of compliance.
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Affiliation(s)
- Gautam Mankaney
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA. .,Clinical Instructor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | | | - Carol A Burke
- Vice Chair, Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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22
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Leone PJ, Mankaney G, Sarvapelli S, Abushamma S, Lopez R, Cruise M, LaGuardia L, O'Malley M, Church JM, Kalady MF, Burke CA. Endoscopic and histologic features associated with gastric cancer in familial adenomatous polyposis. Gastrointest Endosc 2019; 89:961-968. [PMID: 30597145 DOI: 10.1016/j.gie.2018.12.018] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 12/17/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Gastric cancer (GC) is a newly described cancer risk in Western patients with familial adenomatous polyposis (FAP). Little is known about clinical, endoscopic, and pathologic features associated with FAP-related GC. We compared these features in FAP patients with and without GC. METHODS FAP patients were identified through the David G. Jagelman Inherited Colorectal Cancer Registries Cologene database. FAP patients with GC and randomly selected FAP patients without GC who had undergone at least 2 EGDs were analyzed. Demographic, clinical, endoscopic, and pathologic features were compared. RESULTS Ten FAP patients with GC were identified, and 40 age-matched FAP control subjects were selected. No demographic differences were noted between patients and control subjects. All GC cases arose in the proximal stomach among gastric polyposis, with only 2 endoscopically visible. The prevalence of gastric polyposis was similar (100% vs 93%). Endoscopic features associated with GC included a carpeting of gastric polyps (100% vs 22.5%), solitary polyps >20 mm (100% vs 0%), and a polypoid mound of polyps (80% vs 0%; all P < .001). GC patients had a higher prevalence of gastric adenomas (30% vs 5%, P = .048) and polyps with high-grade dysplasia, including fundic gland polyps (50% vs 10%, P = .01) and pyloric gland adenomas (20% vs 0%, P = .037). CONCLUSIONS We identified endoscopic features and advanced pathology present in the stomachs of Western patients with FAP who developed GC. Upper GI surveillance in FAP should include the stomach and awareness of features associated with GC. Optimal approaches to treatment of gastric polyposis and methods of identification of early GC precursors in FAP are needed.
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Affiliation(s)
- Pamela J Leone
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gautam Mankaney
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Suha Abushamma
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rocio Lopez
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael Cruise
- Department of Pathology and Laboratory Medicine, Cleveland Clinic, Cleveland, Ohio, USA; Sanford R. Weiss MD Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lisa LaGuardia
- Sanford R. Weiss MD Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, Ohio, USA; Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Margaret O'Malley
- Sanford R. Weiss MD Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, Ohio, USA; Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - James M Church
- Sanford R. Weiss MD Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, Ohio, USA; Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Matthew F Kalady
- Sanford R. Weiss MD Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, Ohio, USA; Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Carol A Burke
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA; Sanford R. Weiss MD Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, Ohio, USA; Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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23
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Mankaney G, Burke CA. Personalizing guideline-driven cancer screening. Cleve Clin J Med 2019; 86:228-230. [PMID: 30951447 DOI: 10.3949/ccjm.86a.19037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Gautam Mankaney
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA. .,Clinical Instructor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Carol A Burke
- Vice Chair, Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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24
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Mankaney G, Burke CA, Cruise M, Church J, Wadhwa V, Chahal P, Vargo J, Bhatt A. Endoscopic Ultrasound Imaging Detection of Gastric Cancer in Familial Adenomatous Polyposis. Gastroenterology 2017; 153:353-354. [PMID: 28601481 DOI: 10.1053/j.gastro.2017.05.059] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 04/19/2017] [Accepted: 05/23/2017] [Indexed: 01/28/2023]
Affiliation(s)
- Gautam Mankaney
- Department of Gastroenterology and Hepatology, The Cleveland Clinic, Cleveland, Ohio
| | - Carol A Burke
- Department of Gastroenterology and Hepatology, The Cleveland Clinic, Cleveland, Ohio
| | - Michael Cruise
- Department of Pathology and Laboratory Medicine, The Cleveland Clinic, Cleveland, Ohio
| | - James Church
- Department of Colorectal Surgery, The Cleveland Clinic, Cleveland, Ohio
| | - Vaibhav Wadhwa
- Department of Gastroenterology and Hepatology, The Cleveland Clinic, Cleveland, Ohio
| | - Prabhleen Chahal
- Department of Gastroenterology and Hepatology, The Cleveland Clinic, Cleveland, Ohio
| | - John Vargo
- Department of Gastroenterology and Hepatology, The Cleveland Clinic, Cleveland, Ohio
| | - Amit Bhatt
- Department of Gastroenterology and Hepatology, The Cleveland Clinic, Cleveland, Ohio.
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