Abstract
Randomized controlled trials (RCTs) have yielded varying estimates of the benefit of flexible sigmoidoscopy (FS) screening for colorectal cancer (CRC). Our objective was to more precisely estimate the effect of FS-based screening on the incidence and mortality of CRC by performing a meta-analysis of published RCTs. Medline and Embase databases were searched for eligible articles published between 1966 and 28 May 2012. After screening 3,319 citations and 29 potentially relevant articles, two reviewers identified five RCTs evaluating the effect of FS screening on the incidence and mortality of CRC. The reviewers independently extracted relevant data; discrepancies were resolved by consensus. The quality of included studies was assessed using criteria set out by the Evidence-Based Gastroenterology Steering Group. Random effects meta-analysis was performed. The five RCTs meeting eligibility criteria were determined to be of high methodologic quality and enrolled 416,159 total subjects. Four European studies compared FS to no screening and one study from the United States compared FS to usual care. By intention to treat analysis, FS-based screening was associated with an 18% relative risk reduction in the incidence of CRC (0.82, 95% CI 0.73-0.91, p<0.001, number needed to screen [NNS] to prevent one case of CRC = 361), a 33% reduction in the incidence of left-sided CRC (RR 0.67, 95% CI 0.59-0.76, p<0.001, NNS = 332), and a 28% reduction in the mortality of CRC (relative risk [RR] 0.72, 95% CI 0.65-0.80, p<0.001, NNS = 850). The efficacy estimate, the amount of benefit for those who actually adhered to the recommended treatment, suggested that FS screening reduced CRC incidence by 32% (p<0.001), and CRC-related mortality by 50% (p<0.001). Limitations of this meta-analysis include heterogeneity in the design of the included trials, absence of studies from Africa, Asia, or South America, and lack of studies comparing FS with colonoscopy or stool-based testing. This meta-analysis of randomized controlled trials demonstrates that FS-based screening significantly reduces the incidence and mortality of colorectal cancer in average-risk patients.
Highlights
Colorectal cancer (CRC) is the second leading cause of cancerrelated death in the United States [1]
Endoscopic screening for CRC in average-risk patients has been widely adopted in the United States [2,3] in accordance with multi-society and US Preventative Services Task Force (USPTF) guidelines [4,5]
A search for human studies published in these databases between 1966 and 28 May 2012 was performed using the exploded medical subject heading (MeSH) terms ‘‘(exp endoscopy OR exp sigmoidoscopy OR exp colonoscopy) AND AND.’’ The search was augmented by manual searches of reference lists from potentially relevant papers to identify any additional studies that may have been missed using the computer-assisted strategy
Summary
Colorectal cancer (CRC) is the second leading cause of cancerrelated death in the United States [1]. Endoscopic screening for CRC in average-risk patients has been widely adopted in the United States [2,3] in accordance with multi-society and US Preventative Services Task Force (USPTF) guidelines [4,5] These recommendations for endoscopic screening, are based on observational studies [6,7,8], such as cohort and case-control studies, which have the potential to inaccurately estimate the true effect of this intervention on the incidence and mortality of CRC. Our objective was to more precisely estimate the effect of FS-based screening on the incidence and mortality of CRC by performing a meta-analysis of published RCTs. Colorectal cancer (CRC) is the second leading cause of cancer-related death in the United States. The conflicting results with respect to the incidence and mortality of CRC in these studies have called into question the effectiveness of endoscopic screening
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