Endoscopic technological innovations for neoplasia detection in organized colorectal cancer screening programs: a systematic review and meta-analysis

Abstract

Many endoscopic technological innovations have claimed to increase the adenoma detection rate (ADR), but their role in population-based organized screening programs is debated. We searched PubMed, EMBASE, and Cochrane Library databases through January 2020 for randomized controlled trials (RCTs) evaluating the role of technological innovations in fecal immunochemical test (FIT)/fecal occult blood test+ subjects. The primary outcome was ADR, and secondary outcomes were advanced ADR, proximal colon ADR, mean adenoma per procedure (MAP), and cancer detection rate. We calculated pooled proportion rates (%) or risk ratio with 95% confidence interval (CI) and degree of heterogeneity (I2). Overall, 8 high quality RCTs met inclusion criteria with 3645 patients, 1813 (49.7%) in the intervention arm (advanced imaging, 3 studies; mechanical, 5 studies) and 1832 (50.3%) in the standard colonoscopy arm (mean age, 63.6 years). Pooled ADR was 56.5% (95% CI, 49.9%-62.9%) in the intervention arm and 55.9% (95% CI, 48.6%-63%) in the standard colonoscopy arm (relative risk [RR], 1.01; 95% CI, .93-1.10; I2= 50.4%). Similarly, no difference was observed for advanced imaging studies (RR, .95; 95% CI, .85-1.07; I2= 50.4%) or those with mechanical innovations (RR, 1.04; 95% CI, .92-1.17; I2= 69.49%). The pooled MAP was 1.5 in the intervention arm (95% CI, 1.2-1.8) and 1.5 in the standard colonoscopy (95% CI, 1.1-1.8), with no significant difference (unstandardized mean difference, .04; 95% CI, -.13 to .20; I2= 53.6%). No difference in advanced ADR, proximal colon ADR, or cancer detection was found. No significant publication bias was found. In our systematic review and meta-analysis, no technological improvement significantly increased detection rate of colorectal neoplasia in FIT+ subjects undergoing high-quality colonoscopy by high detectors, arguing against their implementation in organized programs.