Population-based screening colonoscopy in Korea: balancing benefits and limitations.

Outcomes Associated With Colorectal Cancer After Population-Based Colonoscopy Screening: Results From a European Pragmatic Randomized Trial

Expectations for and challenges in population-based endoscopic gastric and colorectal cancer screening.

Lower Endoscopy and Prevention of Colon Cancer

Quality Measures for Colonoscopy: A Critical Evaluation

Optimizing Colorectal Cancer Screening by Getting FIT Right

Comparing Fecal Immunochemical Tests: Improved Standardization Is Needed

Colonoscopy is currently regarded as the gold standard and preferred method of screening for colorectal cancer (CRC). However, the benefit of colonoscopy screening may be blunted by low participation rates in population-based screening programs. Harmful effects of population-based colonoscopy screening may include complications induced by colonoscopy itself and by sedation, psychosocial distress, potential over-diagnosis, and socioeconomic burden. In addition, harmful effects of colonoscopy may increase with age and comorbidities. As the risk of adverse events in population-based colonoscopy screening may offset the benefit, the adverse events should be managed and monitored. To adopt population-based colonoscopy screening, consensus on the risks and benefits should be developed, focusing on potential harm, patient preference, socioeconomic considerations, and quality improvement of colonoscopy, as well as efficacy for CRC prevention. As suboptimal colonoscopy quality is a major pitfall of population-based screening, adequate training and regulation of screening colonoscopists should be the first step in minimizing variations in quality. Gastroenterologists should promote quality improvement, auditing, and training for colonoscopy in a population-based screening program.

Colonoscopy is currently regarded as the gold standard and preferred method of screening for colorectal cancer (CRC). However, the benefit of colonoscopy screening may be blunted by low participation rates in population-based screening programs. Harmful effects of population-based colonoscopy screening may include complications induced by colonoscopy itself and by sedation, psychosocial distress, potential over-diagnosis, and socioeconomic burden. In addition, harmful effects of colonoscopy may increase with age and comorbidities. As the risk of adverse events in population-based colonoscopy screening may offset the benefit, the adverse events should be managed and monitored. To adopt population-based colonoscopy screening, consensus on the risks and benefits should be developed, focusing on potential harm, patient preference, socioeconomic considerations, and quality improvement of colonoscopy, as well as efficacy for CRC prevention. As suboptimal colonoscopy quality is a major pitfall of population-based screening, adequate training and regulation of screening colonoscopists should be the first step in minimizing variations in quality. Gastroenterologists should promote quality improvement, auditing, and training for colonoscopy in a population-based screening program.

Colonoscopy is currently regarded as the gold standard and preferred method of screening for colorectal cancer (CRC). However, the benefit of colonoscopy screening may be blunted by low participation rate in population-based screening program. Harmful effects of population-based colonoscopy screening may include complications induced by colonoscopy itself and by sedation, psychosocial distress, potential over-diagnosis and socioeconomic burden. In addition, harmful effect of colonoscopy may increase with age and comorbidity. As the adverse event risk in population-based colonoscopy screening may offset benefit of the screening colonoscopy, the adverse events associated with screening colonoscopy should be well managed and monitored. To adopt population-based colonoscopy screening, consensus for the risk and benefits of screening colonoscopy should be formed for its potential harms, patient preference, socioeconomic considerations, quality improvement of colonoscopy as well as its efficacy for CRC prevention. As the suboptimal colonoscopy quality is a major pitfall of population-based colonoscopy screening, adequate training and provider regulation for screening colonoscopists should be the first step to minimize the variation of quality between colonoscopists. Gastroenterologists should lead quality improvement, auditing, and training associated with colonoscopy in a population-based colonoscopy screening program.

Progress and Challenges in Colorectal Cancer Screening and Surveillance

Background: Racial/ethnic minorities, low-income individuals and recent immigrants shoulder a disproportionate burden of colorectal cancer (CRC) mortality. In Florida, Blacks and Hispanics remain at an increased risk of colorectal cancer (CRC) compared to non-Hispanic Whites (NHW). In the Miami metropolitan area, this disparity is most prominent within the ethnic enclaves of Little Haiti and Hialeah, comprised predominately of Haitian and Hispanic Americans, respectively These communities experience an increased rate of late-stage CRC diagnosis relative to the state as a whole, largely due to lack of access to, and utilization of, CRC screening. Fecal immunochemical testing (FIT) has proved successful in addressing screening barriers for other medically-underserved communities. The present study represents a novel method for FIT delivery and uptake, particularly for the medically disenfranchished. Community Health Workers (CHWs), indigenous to Little Haiti and Hialeah, identified unscreened individuals, educated them about how to appropriately use FIT, and then provided them a postage-paid envelope to return completed tests to a laboratory for processing. Here we report preliminary acceptability and feasibility data for this approach. Methods: The FIT for Life screening program was available to all persons residing in Little Haiti and Hialeah 50 and 75 years old, who were unscreened or underscreened according to US Preventive Task Force recommendations, and considered average risk for CRC based on a brief screener. Our team worked closely with community partners to identify the CHWs, who ultimately were responsible for participant recruitment and intervention delivery. Following FIT return, a research assistant contacted participants to ask a series of questions in their language of preference about their perceived acceptability of FIT as a modality for CRC prevention. Any participant, identified as FIT positive was navigated to timely colonoscopy Results: To date, 221 participants (112 Hispanic, 109 Haitian) have been consented, received education on CRC screening, and were given the FIT kits. 92 Hispanics (82.1%) and 97 Haitians (88.9%) returned the FIT kits for processing. The test positive rate was 2.2% for Hispanics and 3.1% for Haitians. The mean quantity of blood in stool for positive tests was 896 ng/mL for Hispanics and 950 ng/mL for Haitians. The mean quantity of blood in stool for negative tests was 5.2 ng/mL for Hispanics and 4.8 ng/mL for Haitians. On follow-up clinical care, one Haitian participant was found to have an advanced stage CRC and a second did not want to undergo colonoscopy. Based on acceptability surveys, 100% of Hispanics and 90% of Haitians responded that they would use FIT again if offered for further screening; the same proportions would recommend the FIT with CHW method to friends and family members. Interestingly, 90.2% of Hispanics and only 5.0% of Haitians felt confident that FIT works as well as a CRC screening test that would be administered by a physician or nurse. Conclusion: The pairing of CHWs with CRC screening by FIT appears to be an effective approach to disease prevention that is highly acceptable to study participants. Further examination of whether this method is needed. We have begun collaborating with Federally Qualified Health Centers (FQHC) in Little Haiti and Hialeah to explore the sustainability of this approach and to ensure that participants are linked to a medical home for ongoing cancer prevention. Citation Format: Daniel Sussman, Monica Oriol, Martha Gonzalez, Heisy Asusta, Jose Ruiz, Dinah Trevil, Dorothy Parker, Erin Kobetz. FIT FOR LIFE: Increasing prevention and early detection of colorectal cancer for the medically disenfranchised. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr B46. doi:10.1158/1538-7755.DISP13-B46

The objectives of this session are to: 1) review the new guidelines for average-risk colorectal cancer (CRC) screening; 2) review recent selected studies of CRC screening for currently recommended tests, and; 3) review recent decision analyses and a cost-effectiveness analysis on screening. Guidelines: Less than 2 years ago, colorectal cancer (CRC) screening guidelines were highly concordant and flexible. New guidelines issued by the American Cancer Society/American College of Radiology/Multisociety Task Force in March 2008 (1), the U.S. Preventive Services Task Force in November 2008 (2) and the American College of Gastroenterology in March 2009 (3) are now disparate, with two of three organizations implicitly or explicitly preferring colonoscopy despite the absence of published evidence supporting this preference. Two decision analyses, commissioned by the USPSTF, show four screening strategies with equivalence in CRC mortality reduction and life-years gained: colonoscopy every 10 years; a sensitive guaiac-based fecal occult blood test (FOBT) annually; fecal immunochemical testing (FIT) annually, and; the combination of flexible sigmoidoscopy every 5 years with a mid-interval sensitive FOBT or FIT. (4) Screening tests: For fecal DNA, a large screening study comparing a multi-component panel to Hemoccult II with colonoscopy as the reference standard showed that fecal DNA detected 52% of CRCs compared to 13% for Hemoccult II; the two tests had comparable specificity. Recent case-control studies of fecal DNA using somewhat different markers show a single application cancer sensitivity of 83–88% and specificity of 82%.(5) Yet another version of fecal DNA showed cancer sensitivity and specificity of 58% and 84%, respectively; sensitivity for adenomas 1 cm or larger was 46%.(6) The main issues limiting wider use of fecal DNA are its uncertain test interval and greater cost compared to other non-invasive tests. Computer tomographic colonography (CTC or “virtual colonoscopy”) continues to demonstrate good-to-excellent test characteristics for CRC and large (1 cm or larger) adenomas. The ACRIN trial reaffirmed CTC's test characteristics, and may have enhanced prospects for generalizability of test performance. (7) Ongoing issues for CTC include deciding on which CTC colonic findings should be reported and which should lead to colonoscopy (polyp size, number); radiation dose; the clinical and economic impact of extracolonic findings; cost-effectiveness of CTC; and whether it would increase population adherence to CRC screening. Immunochemical FOBTs (or FITs) were developed to enhance the test characteristics of guaiac-based tests. FITs use monoclonal or polyclonal antibodies to detect the intact portion of human hemoglobin and are specific for occult bleeding from a lower GI source. Several FITs are currently available for CRC screening as qualitative tests. Few studies of FITs use colonoscopy as a reference standard; the few that do show widely varying test characteristics for cancer and advanced adenomas, although these are generally better than those of guaiac-based FOBTs. (8) Studies comparing guaiac-based FOBTs with FITs show higher acceptance rates as well as higher detection rates for cancer and advanced adenomas. (9) The real potential of FITs may be in their use as quantitative tests, as data from Levi and colleagues (10) suggest, although more investigation is required to determine the optimal number of single-application tests and the threshold for a positive test. A recent cost-effectiveness analysis by Parekh and colleagues (11) suggests that, as CRC treatment costs increase, screening with FIT may be cost-saving. This analysis also showed that annually FIT screening dominated colonoscopy screening every ten years, meaning that it was both less costly and more effective, suggesting that annual FIT may be “better than” colonoscopy when FIT adherence is high. Until just a few months ago, the effectiveness of sigmoidoscopy was supported only by high-quality case-control studies. Seven-year interim findings from NORCCAP, one of 4 ongoing trials of sigmoidoscopy, were published earlier this year. (12) Study findings included no difference in cancer incidence (not unexpected given the relatively short follow-up); no difference in CRC mortality by intention-to-treat; and a 60% per protocol reduction in overall CRC mortality, including a 75% mortality reduction from recto-sigmoid cancer. Colonoscopy is currently the most “popular” CRC screening test, despite an absence of data demonstrating its superiority over other tests. Within gastroenterology, much attention is focused on monitoring the performance of colonoscopy through parameters such as the extent of examination (to the cecum and by which landmarks?); withdrawal time spent examining the mucosa; and adenoma detection rate. Evidence for the effectiveness of colonoscopy in reducing CRC incidence and mortality is indirect. Follow-up of the National Polyp Study cohort suggests a 76–90% reduction in CRC incidence when compared to 3 reference populations. (13) Kahi and colleagues compared the observed CRC rate in a cohort of screened persons with a median of 7 years follow-up and found a significant reduction in CRC incidence of 67% (95% CI, 38–90%) when compared with SEER data; CRC mortality was reduced by 65%, though this finding was not statistically significant. (14) The degree and duration of protection of colonoscopy from CRC has been questioned in two recent studies. In a population-based case-control study, Baxter and colleagues found that colonoscopy reduced CRC mortality by 37% overall. Colonoscopy reduced left-sided CRC mortality by 67%, but reduced right-sided mortality by just 1%, a non-significant result. (15) In a population-based retrospective cohort study, Lakoff and colleagues looked at risk of CRC after a “negative” colonoscopy, finding that colonoscopy was protective later and less consistently for the proximal colon than for the distal colon. (16) Both technical and biological factors may explain the apparent and relative ineffectiveness of colonoscopy in the right colon in the Baxter and Lakoff studies, respectively. What's coming? Future studies are expected on how colonoscopy can improve detection of adenomas; on FIT test performance, both qualitative and quantitative; on CT colonography performance and acceptance, the latter of which would be enhanced by use of a “virtual prep”; on test performance and logistics of fecal DNA; and on blood-based biomarkers for CRC/advanced adenomas. Finally, we might also expect tailoring of both screening and surveillance based on improved risk stratification. Citation Information: Cancer Prev Res 2010;3(1 Suppl):CN14-06.

Colon Cancer Screening Models: Lessons and Challenges

BACKGROUNDThe effectiveness of fecal immunochemical testing (FIT) in reducing colorectal cancer (CRC) mortality has not yet been fully assessed in a large, population-based service screening program.METHODSA prospective cohort study of the follow-up of approximately 5 million Taiwanese from 2004 to 2009 was conducted to compare CRC mortality for an exposed (screened) group and an unexposed (unscreened) group in a population-based CRC screening service targeting community residents of Taiwan who were 50 to 69 years old. Given clinical capacity, this nationwide screening program was first rolled out in 2004. In all, 1,160,895 eligible subjects who were 50 to 69 years old (ie, 21.4% of the 5,417,699 subjects of the underlying population) participated in the biennial nationwide screening program by 2009.RESULTSThe actual effectiveness in reducing CRC mortality attributed to the FIT screening was 62% (relative rate for the screened group vs the unscreened group, 0.38; 95% confidence interval, 0.35-0.42) with a maximum follow-up of 6 years. The 21.4% coverage of the population receiving FIT led to a significant 10% reduction in CRC mortality (relative rate, 0.90; 95% confidence interval, 0.84-0.95) after adjustments for a self-selection bias.CONCLUSIONSThis large, prospective Taiwanese cohort undergoing population-based FIT screening for CRC had the statistical power to demonstrate a significant CRC mortality reduction, although the follow-up time was short. Although such findings are informative for health decision makers, continued follow-up of this large cohort will be required to estimate the long-term impact of FIT screening if the covered population is expanded. Cancer 2015;121:3221–3229. © 2015 American Cancer Society.A significant reduction in colorectal cancer mortality resulting from fecal immunochemical testing is demonstrated by a large, population-based, nationwide service screening program with a maximum follow-up of 6 years. Although long-term follow-up of this nationwide service screening program is required, these findings are useful for convincing health decision makers that the continuous promotion of such a nationwide screening program is worthwhile.

COVID-19: An Opportunity to Reimagine Colorectal Cancer Diagnostic Testing—A New Paradigm Shift