Average-risk Adults Research Articles

Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society.

In the United States, colorectal cancer (CRC) is the fourth most common cancer diagnosed among adults and the second leading cause of death from cancer. For this guideline update, the American Cancer Society (ACS) used an existing systematic evidence review of the CRC screening literature and microsimulation modeling analyses, including a new evaluation of the age to begin screening by race and sex and additional modeling that incorporates changes in US CRC incidence. Screening with any one of multiple options is associated with a significant reduction in CRC incidence through the detection and removal of adenomatous polyps and other precancerous lesions and with a reduction in mortality through incidence reduction and early detection of CRC. Results from modeling analyses identified efficient and model-recommendable strategies that started screening at age 45 years. The ACS Guideline Development Group applied the Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria in developing and rating the recommendations. The ACS recommends that adults aged 45 years and older with an average risk of CRC undergo regular screening with either a high-sensitivity stool-based test or a structural (visual) examination, depending on patient preference and test availability. As a part of the screening process, all positive results on noncolonoscopy screening tests should be followed up with timely colonoscopy. The recommendation to begin screening at age 45 years is a qualified recommendation. The recommendation for regular screening in adults aged 50 years and older is a strong recommendation. The ACS recommends (qualified recommendations) that: 1) average-risk adults in good health with a life expectancy of more than 10 years continue CRC screening through the age of 75 years; 2) clinicians individualize CRC screening decisions for individuals aged 76 through 85 years based on patient preferences, life expectancy, health status, and prior screening history; and 3) clinicians discourage individuals older than 85 years from continuing CRC screening. The options for CRC screening are: fecal immunochemical test annually; high-sensitivity, guaiac-based fecal occult blood test annually; multitarget stool DNA test every 3 years; colonoscopy every 10 years; computed tomography colonography every 5 years; and flexible sigmoidoscopy every 5 years. CA Cancer J Clin 2018;68:250-281. © 2018 American Cancer Society.

Advances in Faecal DNA Testing for Colorectal Cancer Screening: A Literature Review for Primary Care Providers

Recent epidemiological data gathered by the Centers for Disease Control and Prevention (CDC) suggest that colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the USA. Clinicians currently use five types of test to screen for CRC. Two of these five types, the DNA stool test and the faecal occult blood test, are non-invasive. The DNA stool test successfully detects both advanced neoplasias and non-advanced adenomas with more sensitivity than the faecal occult blood test. However, data suggest that it also generates more false-positive results. There is only one DNA stool test that has been approved by the U.S. Food and Drug administration (FDA): the approved Cologuard® (Exact Sciences, Madison, Wisconsin, USA) test. This test screens for nine different DNA biomarkers, one haemoglobin biomarker, and one β-actin. This article is a literature review of research on faecal DNA biomarkers conducted in the past 5 years from four large databases. Key findings include the ability to reach a sensitivity as high as 98% to detect abnormalities in the colon using a multi-target stool DNA-based assay. In comparison, the Cologuard offers 92% sensitivity and 87% specificity for all stages of CRC. Testing DNA biomarkers can serve as an adequate screen for cancer and adenomas in average-risk adults. Areas for further research include implementing studies to compare long-term health consequences for patients who receive colonoscopies versus DNA stool tests, finding ways to improve both the sensitivity and specificity of screening tests, and finding ways to improve the detection of those biomarkers most associated with CRC, including microRNA detection in the marking panel.

Systematic review of colorectal cancer screening guidelines for average-risk adults: Summarizing the current global recommendations.

AIMTo summarize and compare worldwide colorectal cancer (CRC) screening recommendations in order to identify similarities and disparities.METHODSA systematic literature search was performed using MEDLINE, EMBASE, Scopus, CENTRAL and ISI Web of knowledge identifying all average-risk CRC screening guideline publications within the last ten years and/or position statements published in the last 2 years. In addition, a hand-search of the webpages of National Gastroenterology Society websites, the National Guideline Clearinghouse, the BMJ Clinical Evidence website, Google and Google Scholar was performed.RESULTSFifteen guidelines were identified. Six guidelines were published in North America, four in Europe, four in Asia and one from the World Gastroenterology Organization. The majority of guidelines recommend screening average-risk individuals between ages 50 and 75 using colonoscopy (every 10 years), or flexible sigmoidoscopy (FS, every 5 years) or fecal occult blood test (FOBT, mainly the Fecal Immunochemical Test, annually or biennially). Disparities throughout the different guidelines are found relating to the use of colonoscopy, rank order between test, screening intervals and optimal age ranges for screening.CONCLUSIONAverage risk individuals between 50 and 75 years should undergo CRC screening. Recommendations for optimal surveillance intervals, preferred tests/test cascade as well as the optimal timing when to start and stop screening differ regionally and should be considered for clinical decision making. Furthermore, local resource availability and patient preferences are important to increase CRC screening uptake, as any screening is better than none.

Evaluation of Colorectal Cancer Screening in Federally Qualified Health Centers

Screening for colorectal cancer in average-risk adults is recommended beginning at age 50 years and continuing until age 75 years. This study was conducted to provide evidence for the effectiveness of an American Cancer Society grant program promoting colorectal cancer screening by implementing evidence-based interventions proven to increase screening rates. Analysis compared colorectal cancer screening rates in 77 grant-funded federally qualified health centers between 2013 and 2015 to those of a sample of 77 nonfunded federally qualified health centers selected using a genetic matching technique. The Uniform Data System from 2013 to 2015 provided data used in the analysis performed in 2016. Funded grantees differed significantly from nongrantees on several indicators at baseline. Genetic matching resulted in good-quality matched samples. Both matched samples increased colorectal cancer screening rates over time. Grantees increased their colorectal cancer screening rates significantly more than nongrantees, especially between 2013 and 2014, where funded federally qualified health centers increased by 9% and nonfunded federally qualified health centers increased by 3%. Across the 3 years, increases were 12% and 9%, respectively. The findings suggest grant funding was effective in promoting improvements in colorectal cancer screening rates in funded federally qualified health centers, and these improvements exceed those of nonfunded federally qualified health centers. Funding that results in targeted, intensive efforts supported by technical assistance and accountability for data and reporting, can result in improved system policies and practices that, in turn, can increase screening rates among uninsured and underserved populations.

555 Low Rates of Adverse Events and Low Utilization of Emergency Department or Outpatient Clinics Following Screening and Surveillance Colonoscopy Among Average Risk Adults

555 Low Rates of Adverse Events and Low Utilization of Emergency Department or Outpatient Clinics Following Screening and Surveillance Colonoscopy Among Average Risk Adults

Social networks as predictors of colorectal cancer screening in African Americans.

BackgroundEarly detection can reduce colorectal cancer (CRC) mortality by 15%–33%, and screening is widely recommended for average-risk adults beginning at age 50 years. Colorectal cancer mortality rates are higher in African Americans than in whites, while screening rates are somewhat lower. Individual social networks can reduce emotional and/or logistical barriers to health-promoting but distasteful procedures such as CRC screening. The aim of this study was to examine social network interactions, and their impact on CRC screening among African Americans. We hypothesized a positive association between social network index (SNI) scores and CRC screening.MethodsIn a community intervention trial with four arms, we previously demonstrated the efficacy of a small group educational intervention to promote CRC screening among African Americans. This intervention outperformed a one-on-one educational intervention, a reduced out-of-pocket expense intervention, and a control condition. In the present analysis, we compared the SNI scores for participants in the small group intervention cohort with a comparison group comprised of the other three cohorts. Social networks were assessed using the Social Network Index developed by Cohen.ResultsSmall group participants had a significantly higher network diversity score (Mean difference 0.71; 95% CI, 0.12–1.31; p=0.0017) than the comparison group. In the second component of the SNI score – the number of people talked to over a two week period – the small group intervention cohort also scored significantly higher than the comparison group. (Mean difference, 9.29; 95% CI, 3.963–14.6266; p=0.0004).ConclusionsThe findings suggest that social interaction and support was at least partially responsible for the relatively high post-intervention screening rate in the small group intervention participants. Education in small groups could foster strong social networks. Strong and positive network diversity and a large number of people in social networks may enhance CRC screening rates among African Americans.

Uptake of a colorectal cancer screening blood test is higher than of a fecal test offered in clinic: A randomized trial

IntroductionColorectal cancer screening programs seek to maintain patient adherence to repeated tests over the duration of patients’ screening eligibility. This study compares uptake of an experimental blood test with that of a FIT for colorectal cancer screening in an office setting. MethodsThis small two-site randomized controlled trial (ClinicalTrials.gov, ID NCT02251782) assigned 413 average-risk adults overdue for screening in an integrated health system to one of two arms: Offer of a FIT versus offer of a blood test for colorectal cancer screening. The primary outcome was completion of the offered test within six weeks. Secondary outcomes were the proportion of participants with positive test results, and the proportion of participants with positive results who completed colonoscopy within 3 months of referral. Results99.5% (CI95: 97.3%-100%) of participants in the blood test arm and 88.1% (CI95: 83.0% − 91.8%) of participants in the FIT arm completed the offered test, a difference of 11.4% (CI95: 6.9% − 15.9%, p<.001). 16.5% of participants in the blood test arm and 1.7% of participants in the FIT arm had a positive test. 20 of 30 and 2 of 3 in the blood test and FIT arms, respectively, either scheduled or completed a colonoscopy within 3 months of the positive test result. ConclusionsUptake of a blood test was higher than that of a FIT among participants in a randomized controlled trial. A blood test may be a useful option for those hesitant to screen with currently available tests.

The Need for an Integrated Patient Navigation Pathway to Improve Access to Colonoscopy After Positive Fecal Immunochemical Testing: A Safety-Net Hospital Experience.

Colorectal cancer (CRC) is a leading cause of cancer-related deaths in the United States. Delays in access to colonoscopy following positive fecal immunochemical test (FIT) contribute to increased CRC incidence and mortality. To evaluate intervals from positive FIT result to receipt of colonoscopy among underserved safety-net populations. We retrospectively evaluated all average CRC risk adults who had positive FIT results from 2012 to 2015 at an ethnically diverse safety-net hospital system. Interval from positive FIT to receipt of colonoscopy was evaluated with Kaplan Meier methods and multivariate Cox proportional hazards models. Among 467 patients with positive FIT (48.4 % men, 39.5 % black, 22.5 % white, 17.4 % Asian, 9.7 % Hispanic, mean age 59.5 ± 9.8 years), mean time from positive FIT to receipt of colonoscopy was 220.5 days (SD 158.5). Compared to men, there was a trend towards longer time from FIT positive to colonoscopy among women (237.1 vs. 198.7 days, p = 0.07). No race/ethnicity-specific disparities in time to colonoscopy were observed. Compared to 2012-2013, there was a 27.2 % reduction in time from FIT positive to colonoscopy in 2014-2015 (173.9 vs. 238.8 days, p < 0.01). Among patients undergoing colonoscopy, 46.3 % had adenomatous polyps, 27.4 % had high risk adenomatous polyps, and 5.6 % had CRC. Among an ethnically diverse safety-net hospital system, improvements in access to colonoscopy after positive FIT were observed. However, patients still waited nearly 6 months from time of positive FIT to undergoing colonoscopy. Delays in receipt of colonoscopy are complex and reflect system-level and individual patient-level barriers.

Impact of a literacy-sensitive intervention on CRC screening knowledge, attitudes, and intention to screen.

Colorectal cancer (CRC) screening rates remain low, especially among low-income populations. To determine if a CRC screening intervention (video, brochure) improves knowledge about CRC and CRC screening, attitudes toward screening, and intention to complete CRC screening among average-risk adults with different health literacy skills, seeking medical care at a Federally Qualified Health Center (FQHC). Average-risk adults (50 years or older) who were not within CRC screening guidelines completed face-to-face pre-and post-intervention interviews that focused on knowledge about CRC and CRC screening, attitudes toward CRC screening, and intention to complete CRC screening. Of the 270 participants, 64% were women, 72% were black/African American, 86% were not married, 79% had an annual household income of <$20,000, and 57% did not have health insurance. Reading levels by Rapid Estimate of Adult Literacy in Medicine health literacy test were: 3rd grade or lower, 17 participants (6.3%); 4th-6th grade, 27 (10.0%); 7th-8th grade, 101 (37.4 %); and high school, 125 (46.3%). CRC screening knowledge mean score improved, and perceived CRC susceptibility and self-efficacy to complete screening significantly increased, irrespective of health literacy (all P < .01). There were no significant changes in other attitudes or intention to complete screening. The study was conducted in a single FQHC, so the results may not be generalizable to other health centers or populations of low-income and minority patients. A CRC screening intervention improved CRC screening knowledge and attitudes across levels of health literacy and may be an important strategy for improving CRC screening in the primary care setting. National Cancer Institute K07 CA107079 (Ohio State University) and P30 CA016058 (Behavioral Measurement Shared Resource at The Ohio State University).

Patient Decision Aids for Colorectal Cancer Screening: A Systematic Review and Meta-analysis.

Decision aids prepare patients to make decisions about healthcare options consistent with their preferences. Helping patients choose among available options for colorectal cancer screening is important because rates are lower than screening for other cancers. This systematic review describes studies evaluating patient decision aids for colorectal cancer screening in average-risk adults and their impact on knowledge, screening intentions, and uptake. Sources included Ovid MEDLINE, Elsevier EMBASE, EBSCO CINAHL Plus, Ovid PsycINFO through July 21, 2015, pertinent reference lists, and Cochrane review of patient decisions aids. Reviewers independently selected studies that quantitatively evaluated a decision aid compared to one or more conditions or within a pre-post evaluation. Using a standardized form, reviewers independently extracted study characteristics, interventions, comparators, and outcomes. Analysis was conducted in August 2015. Twenty-three articles representing 21 trials including 11,900 subjects were eligible. Patients exposed to a decision aid showed greater knowledge than those exposed to a control condition (mean difference=18.3 of 100; 95% CI=15.5, 21.1), were more likely to be interested in screening (pooled relative risk=1.5; 95% CI=1.2, 2.0), and more likely to be screened (pooled relative risk=1.3; 95% CI=1.1, 1.4). Decision aid patients had greater knowledge than patients receiving general colorectal cancer screening information (pooled mean difference=19.3 of 100; 95% CI=14.7, 23.8); however, there were no significant differences in screening interest or behavior. Decision aids improve knowledge and interest in screening, and lead to increased screening over no information, but their impact on screening is similar to general colorectal cancer screening information.

Serrated polyps are detected at CT colonography: clinical observations over the past decade and results from CTC-based screening of average risk adults.

Serrated polyps are detected at CT colonography: clinical observations over the past decade and results from CTC-based screening of average risk adults.

Role of CT colonoscopy for colorectal cancer screening in Indian population

Cancer as a cause of death is missed mostly in many parts of India. Mortality continues to rise from colorectal cancers that could well be prevented. Genetic, familial and dietary factors significantly account for increased risk of colorectal cancers. More so, large bowel origin of cancer, as a primary lesion or a source of distant metastases is undetected in a large number of patients in the absence of a complete work up. Even with metastatic disease, patients with colorectal cancer survive for many years unlike those having upper gastrointestinal cancers. Colorectal malignancy is potentially curable if detected early by several established screening methods. Today there is a range of options for CRC screening in the average-risk population, with current technology falling into 2 general categories: stool tests, which include tests for occult blood or exfoliated DNA; and structural exams, which include flexible sigmoidoscopy (FSIG), colonoscopy, double-contrast barium enema (DCBE) and computed tomographic colonography (CTC). Any one of these options applied in a systematic program of regular screening has the potential to significantly reduce deaths from CRC. Computerized tomographic scanning colonoscopy (CTC) is the least invasive outpatient procedure and not well recognized in India as a screening tool. CTC is a minimally invasive imaging examination of the entire colon and rectum and uses Multi detector CT scanner to acquire images and advanced 2-dimensional (2D) and 3-dimensional (3D)-image display techniques for interpretation. Clinical trials including large cohorts studies of CTC yielded promising results and paved the way for larger multicenter screening trials. CTC sensitivity and specificity for large (10 mm) polyps was found to be as high as 85% to 93% and 97% respectively. The majority of studies assessing the relative acceptability of CTC and conventional colonoscopy in patients who have undergone both tests on the same day have demonstrated a preference for CTC. Screening of average-risk adults with CTC should commence at age 50 years though the interval for repeat examination after a negative CTC has not been studied. However, screening may be limited to select groups in India because of our own limitations. Keywords: colorectal cancer; CT colonoscopy; MDCT; virtual colonoscopy; screening

Screening for Colorectal Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

Colorectal cancer (CRC) remains a significant cause of morbidity and mortality in the United States. To systematically review the effectiveness, diagnostic accuracy, and harms of screening for CRC. Searches of MEDLINE, PubMed, and the Cochrane Central Register of Controlled Trials for relevant studies published from January 1, 2008, through December 31, 2014, with surveillance through February 23, 2016. English-language studies conducted in asymptomatic populations at general risk of CRC. Two reviewers independently appraised the articles and extracted relevant study data from fair- or good-quality studies. Random-effects meta-analyses were conducted. Colorectal cancer incidence and mortality, test accuracy in detecting CRC or adenomas, and serious adverse events. Four pragmatic randomized clinical trials (RCTs) evaluating 1-time or 2-time flexible sigmoidoscopy (n = 458,002) were associated with decreased CRC-specific mortality compared with no screening (incidence rate ratio, 0.73; 95% CI, 0.66-0.82). Five RCTs with multiple rounds of biennial screening with guaiac-based fecal occult blood testing (n = 419,966) showed reduced CRC-specific mortality (relative risk [RR], 0.91; 95% CI, 0.84-0.98, at 19.5 years to RR, 0.78; 95% CI, 0.65-0.93, at 30 years). Seven studies of computed tomographic colonography (CTC) with bowel preparation demonstrated per-person sensitivity and specificity to detect adenomas 6 mm and larger comparable with colonoscopy (sensitivity from 73% [95% CI, 58%-84%] to 98% [95% CI, 91%-100%]; specificity from 89% [95% CI, 84%-93%] to 91% [95% CI, 88%-93%]); variability and imprecision may be due to differences in study designs or CTC protocols. Sensitivity of colonoscopy to detect adenomas 6 mm or larger ranged from 75% (95% CI, 63%-84%) to 93% (95% CI, 88%-96%). On the basis of a single stool specimen, the most commonly evaluated families of fecal immunochemical tests (FITs) demonstrated good sensitivity (range, 73%-88%) and specificity (range, 90%-96%). One study (n = 9989) found that FIT plus stool DNA test had better sensitivity in detecting CRC than FIT alone (92%) but lower specificity (84%). Serious adverse events from colonoscopy in asymptomatic persons included perforations (4/10,000 procedures, 95% CI, 2-5 in 10,000) and major bleeds (8/10,000 procedures, 95% CI, 5-14 in 10,000). Computed tomographic colonography may have harms resulting from low-dose ionizing radiation exposure or identification of extracolonic findings. Colonoscopy, flexible sigmoidoscopy, CTC, and stool tests have differing levels of evidence to support their use, ability to detect cancer and precursor lesions, and risk of serious adverse events in average-risk adults. Although CRC screening has a large body of supporting evidence, additional research is still needed.

Sa1125 Despite Improved Access to Colonoscopy After Implementation of Fecal Immunochemical Testing (FIT) for Colorectal Cancer Screening in Average Risk Adults, Women and Hispanics Have Significantly Longer Waiting Times for Colonoscopy After Positive FIT

Sa1125 Despite Improved Access to Colonoscopy After Implementation of Fecal Immunochemical Testing (FIT) for Colorectal Cancer Screening in Average Risk Adults, Women and Hispanics Have Significantly Longer Waiting Times for Colonoscopy After Positive FIT

Abstract B94: Social networks as predictors of colorectal cancer screening in African Americans

Abstract Background: Early detection can reduce colorectal cancer (CRC) mortality by 15%–33%, and screening is widely recommended for average-risk adults beginning at age 50 years. However, African Americans have disproportionately low screening rates compared to whites. Factors that seem to facilitate CRC screening include higher income, higher education, older age, and male sex, strong social ties and supportive relationships. Individual social networks reduce emotional and/or logistical barriers to colorectal cancer screening participation. The aim of this study was to examine social network interactions, and its impact on colorectal cancer screening among African Americans. We hypothesized that a positive association is expected between social network index scores and colorectal cancer screening. Methods: Our preliminary published literature (Blumenthal Daniel S; Smith Selina A; Majett Charlye D; Alema-Mensah Ernest. A trial of 3 interventions to promote colorectal cancer screening in African Americans. Cancer, Feb2010;116(4): 922-9) showed that small groups (4-15 participants trained with CRC educational resources from the National Cancer Institute and the American Cancer Society) were significantly more likely to have CRC screening. Three hundred sixty-nine African-American men and women aged 50 years and above were enrolled in this randomized, controlled community intervention trial. Social networks were assessed using the Social Network Index (SNI) based on the index developed by Berkman (1979) [28]. The SNI consists of four domains: marriage or partnership, friends and relatives, religious activity, and voluntary associations. Categories were scored as follows: married (married = 1, widowed, divorced, separated, or never married = 0); contact with friends and relatives (≥156 contacts per year = 1, &amp;lt;156 contacts per year = 0); frequency of church or religious service attendance (attended four or more services per year = 1, attended less than four = 0); group (such as church groups, unions, fraternal or athletic groups, or school groups) participation (yes = 1, no = 0). Scores were summed for the four dichotomized variables with a range of 0 to 4. Scores of 0 and 1 indicate the fewest ties and a score of 4 the most ties. Cronbach's alpha for the SNI scale was 0.25 in this study. Descriptive statistics and bivariate analyses were run. T-test statistics was used to determine differences between the small group (intervention) and other groups (control, financial incentive and one on one). Results: There was a statistically significant difference in the network diversity among the groups. Small group participants had a higher network diversity score (Mean difference 0.71; 95% CI, 0.12-1.31; p=0.0017) compared to the other groups. Total number of people in social network score was significantly higher among the small group than the other groups (Mean difference, 9.29; 95% CI, 3.96-14.62; p=0.0004). Conclusions: Group education in small groups could foster strong social networks which may improve CRC screening rates among African Americans. Strong and positive network diversity and optimal number of people in social networks may enhance CRC screening rates. However, the screening rate of less than 35% in a group of individuals who participated in an educational program through multiple sessions over a period of several weeks indicated that there still are barriers to overcome. Citation Format: Ernest Alema-Mensah, Selina Smith, Mechelle Claridy, Victor Ede, Benjamin Ansa, Daniel Blumenthal. Social networks as predictors of colorectal cancer screening in African Americans. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B94.

Impact of subsequent screening episodes on the positive predictive value for advanced neoplasia and on the distribution of anatomic subsites of colorectal cancer: A population-based study on behalf of the French colorectal cancer screening program

BackgroundThe anatomic distribution of advanced colorectal neoplasia is increasingly important for choosing screening strategies and treatment options. We sought to evaluate the impact of repeated screening on the positive predictive value (PPV) for advanced colorectal neoplasia (advanced adenoma, AA, and colorectal cancer, CRC) and their distribution according to anatomic subsite distribution in average-risk adults. MethodThe study included 98,031 men and women aged 50-74 who had a positive g-FOBT in 2010 and 2011 and underwent total colonoscopy. The PPV for detection of AA and CRC and the relative risks were determined with log-binomial models, and the distribution of anatomic subsites was estimated according to screening history. ResultThe median age was 61 years (62 years for participants with AA and 64 for those with CRC). The PPV for detection of advanced neoplasia was 24.5%, substantially higher in men than women (30.7% vs 17.7%), and it increased with age. It also fell at all screening episodes after the first. Subsequent screening episodes were associated with an increased RR for proximal AA (RR 1.13, 95% CI 1.16–1.20). Advancing age (RR 1.28, 95% CI 1.19–1.39 for every 10-year increase in age), female gender (RR 1.31, 95% CI 1.19–1.44), and subsequent screening (RR 1.15, 95% CI 1.04–1.27) were significantly and independently associated with detection of proximal adenocarcinoma. The latter was also detected at an advanced stage more often (RR, 1.24, 95% CI: 1.09–1.42). Early stages of invasive adenocarcinoma (stages I and II) was more likely to be detected in a subsequent than an initial screening (RR 1.07, 95% CI 1.01–1.13). ConclusionThis study found that subsequent screening episodes using g-FOBT were associated with an increase in the detection rate of proximal AA and CRC, especially among women. The more frequent detection of proximal invasive adenocarcinoma at an advanced stage in subsequent screenings suggests that some of these tumors may well not be real incident lesions, but are likely to include lesions that were missed on the previous screens. Although modest, the increase in the rate of detection of invasive adenocarcinoma at early (and more curable) stages from the first to subsequent screenings, together with this potential for missed diagnoses on initial screening and the increased detection rate for proximal or rectal AA in subsequent screening episodes, underlines the need to reinforce the population’s awareness of the importance of regular consistent screening, after negative results.

The Effect of Miralax-Gatorade Bowel Preparation Versus Golytely on Quality Indicators for Screening Colonoscopy

Introduction: Bowel preparation is a quality indicator for colonoscopy. Traditionally, Golytely/polyethylene glycol (PEG) has been the main bowel preparation but is not well tolerated by patients due to large volume and taste. Recently, Miralax/Gatorade (M-G) has been introduced as an option to obviate this problem. A meta-analysis concluded that the M-G preparation was inferior to PEG in quality while demonstrating no significant improvement in polyp detection. Our study was performed to examine adenoma detection rate (ADR), rate of one-year repeat colonoscopy due to poor bowel preparation, and rate of non-adherence to the USMSTF (United States Multi-Society Task Force) recommendation for surveillance resulting from suboptimal bowel preparation, given suggestions that low quality bowel preparations can lead to surveillance recommendations inconsistent with guidelines. Methods: Retrospective study examining the above mentioned parameters in 4 consecutive months in 2012, when there was a department-wide change in bowel preparation to M-G, compared with same 4 calendar months in 2011, when PEG was used. Split dosing was used for all patients. Results: 4094 colonoscopies were performed during the study period. After inclusion criteria (average risk adults between ages 50 and 65 years who had screening colonoscopies) and exclusion criteria were applied, 1690 cases remained for analysis. 785 colonoscopies were with M-G and 905 with PEG. There were no statistical differences in age, gender, narcotic usage, and diabetes between two groups. ADR for colonoscopies performed with M-G preparation was 30.5% versus 25.2% for PEG (p=0.02). Proportion of colonoscopies repeated sooner than recommended by USMSTF was 6.4% for M-G and 9.0% for PEG (p=0.05). Proportion of repeat colonoscopies within 1 year due to poor bowel preparation was 3.2% for M-G and 2.4% for PEG (p=0.35). Conclusion: Our retrospective analysis showed higher ADR for M-G compared with PEG. Low quality bowel preparations can result in surveillance recommendations inconsistent with society guidelines, thus adherence to guidelines may be considered a surrogate parameter for bowel preparation quality. In this study, there was a tendency for colonoscopies with PEG to have higher non-adherence to USMSTF recommendations but M-G with more repeat colonoscopies within a year due to poor bowel preparation, though both without statistical significance. More studies are needed to determine the optimal bowel preparation for colonoscopies.

Observational methods to assess the effectiveness of screening colonoscopy in reducing right colon cancer mortality risk: SCOLAR.

Screening colonoscopy's effectiveness in reducing risk of death from right colon cancers remains unclear. Methodological challenges of existing observational studies addressing this issue motivated the design of 'Effectiveness of Screening for Colorectal Cancer in Average-Risk Adults (SCOLAR)'. SCOLAR is a nested case-control study based on two large integrated health systems. This affords access to a large, well-defined historical cohort linked to integrated data on cancer outcomes, patient eligibility, test indications and important confounders. We found electronic data adequate for excluding ineligible patients (except family history), but not the detailed information needed for test indication assignment. The lessons of SCOLAR's design and implementation may be useful for future studies seeking to evaluate the effectiveness of screening tests in community settings.

Screening for cancer: advice for high-value care from the American College of Physicians.

Cancer screening is one approach to reducing cancer-related morbidity and mortality rates. Screening strategies vary in intensity. Higher-intensity strategies are not necessarily higher value. High-value strategies provide a degree of benefits that clearly justifies the harms and costs incurred; low-value screening provides limited or no benefits to justify the harms and costs. When cancer screening leads to benefits, an optimal intensity of screening maximizes value. Some aspects of screening practices, especially overuse and underuse, are low value. Screening strategies for asymptomatic, average-risk adults for 5 common types of cancer were evaluated by reviewing clinical guidelines and evidence syntheses from the American College of Physicians (ACP), U.S. Preventive Services Task Force, American Academy of Family Physicians, American Cancer Society, American Congress of Obstetricians and Gynecologists, American Gastroenterological Association, and American Urological Association. "High value" was defined as the lowest screening intensity threshold at which organizations agree about screening recommendations for each type of cancer and "low value" as agreement about not recommending overly intensive screening strategies. This information is supplemented with additional findings from randomized, controlled trials; modeling studies; and studies of costs or resource use, including information found in the National Cancer Institute's Physician Data Query and UpToDate. The ACP provides high-value care screening advice for 5 common types of cancer; the specifics are outlined in this article. The ACP strongly encourages clinicians to adopt a cancer screening strategy that focuses on reaching all eligible persons with these high-value screening options while reducing overly intensive, low-value screening.

Implementing a Multisite, Transdisciplinary Case-Control Study to Assess Effectiveness of Screening Colonoscopy for Preventing Death From Colorectal Cancer (SCOLAR)

Background/Aims: Colorectal cancer (CRC) is the second leading cause of cancer death in the United States. There is a need for observational studies that assess effectiveness of “screening” colonoscopy by carefully defining indication for exam. “Screening for Colorectal Cancer in Average-Risk Adults (SCOLAR),” is a transdisciplinary study to determine if colonoscopy is as effective as believed, filling a critical void in the evidence on effectiveness of CRC screening interventions in reducing the risk of death in real-world practice.