Bowel Cancer Screening Programme Research Articles

Interactions between folate metabolism-related nutrients and polymorphisms on colorectal cancer risk: a case-control study in the Basque country.

Folate-mediated one-carbon metabolism (FOCM) plays an important role in colorectal carcinogenesis. Previous studies have assessed the role of folate-mediated one-carbon metabolism (FOCM)-related gene-diet interaction in the aetiology of colorectal cancer (CRC), however, the results remained inconclusive. Thus, this study aimed to investigate dietary factors and genetic variants related to FOCM, as well as potential nutrient-gene and nutrient-lifestyle interactions, on CRC risk. This observational study included 229 patients diagnosed with CRC and 229 age- and sex-matched subjects as controls from a population-based bowel cancer screening program. Conditional logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (95%CI) for CRC risk. A Bonferroni-corrected threshold of α = 0.005 was considered significant, and P values less than 0.05 were considered to be suggestive of an association. After Bonferroni correction, a high dietary intake of betaine was associated with a decreased risk of CRC in the adjusted model (OR, 95% CI: 0.21, 0.10-0.40, P < 0.001). Two SNPs, rs1476413 and rs17824591, exhibited significant gene-diet interactions with total choline ad vitamin B12 intakes, respectively, in adjusted models (total choline, tertile 3 vs. 1, OR, 95% CI: 0.25, 0.11-0.66, Pinteraction = 0.012; vitamin B12, tertile 2 vs. tertile 1, OR, 95% CI: 2.48, 1.04-5.00, Pinteraction = 0.003). These findings suggest that betaine intake and interactions between some dietary factors and variants in MTHFR and MTHFD1 genes have an influence on CRC risk in the population studied. If these results are confirmed, specific nutritional intervention strategies could be designed.

The National Bowel Cancer Screening Programme: a service for the asymptomatic or a pathway acting as a safety net?

The National Bowel Cancer Screening Programme: a service for the asymptomatic or a pathway acting as a safety net?

National screening for colorectal cancer is associated with stage shift to earlier diagnosis.

Australia's National Bowel Cancer Screening Program consists of an immunohistochemical faecal occult blood test, targeting adults aged 50-74. Existing literature supports the principle of early detection of colorectal cancer (CRC) via national screening, but little is known about the association between colonoscopy or polypectomy rates and CRC stage over time. The aim of this study is to identify the longitudinal change to colonoscopy and polypectomy rates, and any stage shift associated with this screening program. A retrospective data-linkage study was performed using the Australian national health database (Medicare) to obtain colonoscopy and polypectomy rates between 1998 and 2017. A second prospective database of CRC resection specimens was analysed for this period. The cohort was divided based on time intervals related to the National Bowel Cancer Screening Program: pre-commencement 1998-2006 (Period A), immediately post-commencement 2007-2011 (Period B), and subsequent years 2012-2017 (Period C). Linear regression was used to test relation between annualized predictor and response variables. Annual colonoscopy rates doubled, and polypectomy rates tripled during the study (P < 0.001). Annual colonoscopy rate correlated to a lower T-stage (P = 0.038) and lower N-stage (P = 0.026), and there was a 7% increase in early CRC (stage I-II) in Period C (P < 0.001). Across the study period there was also a significant increase in right-sided tumours, and concurrent MMR deficiency and BRAF mutation. Polypectomy and colonoscopy rates increased after the introduction of the National Bowel Cancer screening program. There was a clinically significant shift to earlier CRC stage which manifested 5 years after its implementation.

Adenoma characteristics in the English Bowel Cancer Screening Programme.

The English Bowel Cancer Screening Programme detects colorectal cancers and premalignant polyps in a faecal occult blood test-positive population. The aim of this work is to describe the detection rates and characteristics of adenomas within the programme, identify predictive factors influencing the presence or absence of carcinoma within adenomas and identify the factors predicting the presence of advanced colonic neoplasia in different colon segments. The Bowel Cancer Screening System was retrospectively searched for polyps detected during colonoscopies between June 2006 and June 2012, at which time a guaiac test was being used. Data on size, location and histological features were collected, and described. Univariate and multivariate analyses were used to determine the significant factors influencing the development of carcinoma within an adenoma. A total of 229 419 polyps were identified; after exclusions 136 973 adenomas from 58 334 patients were evaluated. Over half were in the rectum or sigmoid colon. Subcentimetre adenomas accounted for 69.8% of the total. The proportion of adenomas containing advanced histological features increased with increasing adenoma size up to 35 mm, then plateaued. A focus of carcinoma was found in 2282 (1.7%) adenomas, of which 95.6% were located distally. Carcinoma was identified even in diminutive adenomas (0.1%). The proportion of adenomas containing cancer was significantly higher in women than men (2.0% vs. 1.5%, p < 0.001). This national, prospectively captured dataset adds robust information about histological features of adenomas that convey an increased risk for colorectal cancer, and identifies caecal adenomas, high-grade dysplasia, increasing adenoma size, distal location and female sex as independent risk factors associated with carcinoma.

Realized impact of COVID-19 related disruptions on the National Bowel Cancer Screening Program.

Colorectal cancer is the second most common cause of cancer mortality in Australia (1). The National Bowel Cancer Screening Program (NBCSP) aims to reduce mortality through early detection with a biennial faecal occult blood test for Australians aged 50-74 years (2). Modelling predicted COVID-19 would reduce participation and delay colonoscopies despite the NBCSP continuing during the pandemic (3). This study analyses the realized impact of COVID-19 related disruptions on the NBCSP and the effect on mortality. NBCSP participation, time to colonoscopy and annualized mortality were compared before and during COVID-19. The effect on mortality was determined using a validated microsimulation model (4, 5). From 1 January 2018 to 31 December 2019, 2 497 317 people participated in the NBCSP and 168 390 received a colonoscopy, compared to 2 490 265 and 162 573 from 1 January 2020 to 31 December 2021. Relative participation decreased 6 % and the proportion of colonoscopies performed within the recommended 120 days increased 14.5%. A disproportionally greater impact was observed outside major cities and in lower socioeconomic areas. An estimated 98-111 additional colorectal cancer deaths resulted from 3 % fewer colonoscopies performed during the pandemic. This study presents the most comprehensive analysis of the realized impact of COVID-19 on the NBCSP. Catch-up screening would be best targeted at Australians from rural and lower socioeconomic areas where participation remains low. Streamlined referral pathways and additional colonoscopy provisioning is required as less than two thirds of screen positive patients receive a colonoscopy within the recommended 120 days.

P371 Calprotectin Testing: A Methods Comparison Study

Abstract Background In conventional laboratory-based Enzyme Linked Immunosorbant Assays (ELISA) for calprotectin measurement, raw stool is returned to and manually processed by testing laboratories. The OCS-Pledia calprotectin test uses the same stool collection device as the OCS-Pledia FIT test used in the UK Bowel cancer screening programme. In brief, individuals sample their stool with a picker and transfer to a preprepared buffered diluent, which is then returned to the laboratory for fully automated analysis. We have previously shown that a stool concentration of &amp;gt;100ug/g measured using the IDK calprotectin ELISA was the optimal cut-off to distinguish IBS from IBD (sensitivity 86%, specificity 90%, positive predictive value 39%, negative predictive value 99%). We undertook a methods comparison study to report the stability, linearity and potential bias of the OCS-Pledia calprotectin assay compared with IDK ELISA. Methods 32 stool samples were collected from people with GI pathology, and homogenised. Samples were prepared for calprotectin testing using IDK and OCS-Pledia less than 4 hours from excretion (mean2.6 [SD]1.3 hrs). Samples were left at room temperature and further extracts taken at 6, 24, 48, 72, and 168 hours. Pairwise analysis of samples across the reporting range was undertaken and linearity and bias assayed by Pearson’s correlation and Bland-Altmann analysis, respectively. Results Calprotectin was stable over one week in both the OCS-Pledia buffered and the IDK ELISA unbuffered stool samples. However, OCS-Pledia results showed lower variance than that of the IDK ELISA, especially at later time points. There was a linear relationship between calprotectin measured with the OCS-Pledia and IDK-ELISA assays (R2=0.85; p&amp;lt;0.0001). The OCS-Pledia calprotectin assay has a positive bias across the reporting range. This led to 40 samples reading elevated calprotectin levels on OCS-Pledia but within normal range on IDK-ELISA. All 40 had colonic inflammation and therefore were false negative IDK-ELISA. Calprotectin concentrations of 600ug/g and 400ug/g measured using the OCS-Pledia assay were equivalent to concentrations of about 250ug/g and 100ug/g measured using the IDK ELISA. Conclusion OCS- Pledia assays for the measurement of calprotectin are likely to superseded conventional ELISAs because they are cheaper, easier to automate and do not involve laboratory staff pre-processing stool samples. Like conventional ELISA assays calprotectin is stable for at least one week. Clinicians will need to be aware, however, of the positive bias across the reporting range of calprotectin and adjust their positivity thresholds.

Increasing bowel cancer screening using SMS in general practice: the SMARTscreen cluster randomised trial.

Australia has one of the highest incidences of colorectal cancer (CRC) worldwide. The Australian National Bowel Cancer Screening Program (NBCSP) is a best-practice, organised screening programme, but uptake is low (40.9%) and increasing participation could reduce morbidity and mortality associated with CRC. Endorsement by GPs is strongly associated with increasing screening uptake. This study (SMARTscreen) aimed to test whether a multi-intervention short message service (SMS) sent by general practices to 50-60-year-old patients who were due to receive the NBCSP kit would increase NBCSP uptake, by comparing it with usual care. A stratified cluster randomised controlled trial was undertaken, involving 21 Australian general practices in Western Victoria, Australia. For intervention practices, people due to receive the NBCSP kit within a 6-month study period were sent an SMS just before receiving the kit. The SMS included a personalised message from the person's general practice endorsing the kit, a motivational narrative video, an instructional video, and a link to more information. Control practices continued with usual care, comprising at-home testing with a faecal immunochemical test (FIT) through the NBCSP. The primary outcome was the between-arm percentage difference in uptake of FIT screening within 12 months from randomisation, which was estimated using generalised linear model regression. In total, 39.2% (1143/2914) of people in 11 intervention practices and 23.0% (583/2537) of people in 10 control practices had a FIT result in their electronic health records - a difference of 16.5% (95% confidence interval = 2.02 to 30.9). The SMS intervention increased NBCSP kit return in 50-60-year-old patients in general practice. This finding informed a larger trial - SMARTERscreen - to test this intervention in a broader Australian population.

The gut microbiota in adults with cystic fibrosis compared to colorectal cancer

BackgroundGut dysbiosis is implicated in colorectal cancer (CRC) pathogenesis. Cystic fibrosis (CF) is associated with both gut dysbiosis and increased CRC risk. We therefore compared the faecal microbiota from individuals with CF to CRC and screening samples. We also assessed changes in CRC-associated taxa before and after triple CF transmembrane conductance regulator (CFTR) modulator therapy. MethodsBacterial DNA amplification comprising V4 16S rRNA analysis was conducted on 84 baseline and 53 matched follow-up stool samples from adults with CF. These data were compared to an existing cohort of 430 CRC and 491 control gFOBT samples from the NHS Bowel Cancer Screening Programme. Data were also compared to 26 previously identified CRC-associated taxa from a published meta-analysis. ResultsFaecal CF samples had a lower alpha diversity and clustered distinctly from both CRC and control samples, with no clear clinical variables explaining the variation. Compared to controls, CF samples had an increased relative abundance in 6 of the 20 enriched CRC-associated taxa and depletion of 2 of the 6 taxa which have been reported as reduced in CRC. Commencing triple modulator therapy had subtle influence on the relative abundance of CRC-associated microbiota (n = 23 paired CF samples). ConclusionsCF stool samples were clearly dysbiotic, clustering distinctly from both CRC and control samples. Several bacterial shifts in CF samples resembled those observed in CRC. Studies assessing the impact of dietary or other interventions and the longer-term use of CFTR modulators on reducing this potentially pro-oncogenic milieu are needed.

Spatial variability in socio-demographic factors affecting participation in the Australian national bowel cancer screening program

ObjectivesThe objective of this paper is to analyse the socio-demographic and spatial patterns associated with bowel cancer screening in Australia. Despite the importance of screening in reducing mortality via early intervention, it remains the case that overall screening rates are uneven between different socio-demographic groups and geographic regions. Notwithstanding this, there is limited knowledge in Australia regarding the interplay between socio-demographics and geography in relation to bowel cancer screening. Thus, this paper explores the socio-demographic and spatial patterns of screening participation across Australian regions to better inform public health policy and programs. Study designThis is a nationwide ecological study based on aggregate spatial data. MethodsAn ecological study is conducted using bowel cancer screening rates and selected socio-demographic data measured at the Statistical Area 3 level. Geographically weighted regression software is used to conduct global and spatial regression analysis. ResultsThe global regression results show that higher rates of screening participation were associated with employment/education disengagement and volunteering while in contrast, lower rates of participation were associated with higher rates of indigenous populations, people with chronic health conditions, and people with poor English skills. Considering the spatial analysis, the analysis shows that once the spatial non-stationarity in the data is considered the influence of the variables shown to be significant in the global model, has significant spatial variability. ConclusionFrom a public health perspective, addressing shortfalls in bowel cancer screening participation is an important priority. In order to understand differences in participation rates it is important to consider both socio-demographic factors as well as the geographic or spatial distribution of these factors.

A discrete choice experiment to understand public preferences and priorities for risk-stratified bowel cancer screening programmes in the UK

ObjectivePublic acceptability of bowel cancer screening programmes must be maintained, including if risk stratification is introduced. We aimed to describe and quantify preferences for different attributes of risk-stratified screening programmes amongst the UK population, focussing on who to invite for bowel screening. MethodsWe conducted a discrete choice experiment (DCE) including the following attributes: risk factors used to estimate bowel cancer risk (age plus/minus sex, lifestyle factors and genetics); personalisation of risk feedback; risk stratification strategy plus resource implications; default screening in the case of no risk information; number of deaths prevented by screening; and number experiencing physical harm from screening. We used the results of conditional logit regression models to estimate the importance of each attribute, willingness to trade-off between the attributes, and preferences for different programmes using contemporary risk scores and models. Results1196 respondents completed the survey, generating 21,528 DCE observations. Deaths prevented was the most influential attribute on respondents' decision-making (contributing to 58.8% of the choice), followed by harms experienced (15.9%). For every three additional deaths prevented, respondents were willing to accept an additional screening harm per 100,000 people. Risk factors and risk stratification strategy contributed to just 11.1% and 3.6% of the choice, respectively. Although the influence on decision-making was small, respondents favoured more personalised feedback. ConclusionsBowel cancer screening programmes that improve cancer outcomes, particularly by preventing more deaths amongst those screened, are most preferred by the public. Optimising risk prediction models, developing public communication, and readying infrastructure should be prioritised for implementation.

Management of pT1 CRC detected on the colorectal cancer screening programme (Basque Country. Spain)

Abstract Background The Bowel Cancer Screening Programme (BCSP) started in 2009 with faecal immunochemical test (FIT, with cut-off 20µg/g faeces) every 2 years (for 50-69 year- olds). 2.518.715 people were invited until 2021. Participation rate was 70.4% with 5.3% positive rate and 92.7% adherence to colonoscopy. Colorectal cancer (CRC) detection rate was 2.28 ‰ with 70.6% found in initial stage. The PT1 (stage I) represented 40% of the total cancer detected (4,050 in the overall period). Objectives To compare the characteristics and management of pT1 CRC. Methods Retrospective cohort study including pT1 CRC Stage I diagnosed after colonoscopy in positive FIT from 2009-2017. Variables: sex, age groups, endoscopic and surgical treatment, CRC recurrence and survival. Chi-square, Logistic Regression, SPSS v.23. Results Of the 1,523 CRC detected, 585 were detected as pT1 and I stage (38.4%). 73.4% in men and by age group 59% over 60 years-old. 48.5% were treated with surgery and 51.5% with endoscopic resection. No significant differences were found adjusted by sex and age regardless of treatment. In 57.6% of patients under surgery, CRC was not reported by pathological analysis. All cases followed up by colonoscopy with variability in the number of surveillances over time. 4.1% (24) had CRC recurrence with 87% detected in the surveillance, no significant differences regardless of the treatment. 1.5% (9) died due to CRC progression. Conclusions Apart from the high number of CRC detected in early stages by the screening Programme, an important number of cases are reported as pT1 CRC. Endoscopic resection is one of the treatments of choice without significant impact either in recurrence of neoplasia or mortality. However, surgical procedure shows overtreatment because of the high number of cases without CRC after the procedure. Therefore, endoscopic resection could be the main choice to treat pT1 CRC. Key messages • Endoscopic resection is one of the treatment of choice without impact in recurrence for the pT1 CRC detected through the BCSP. • The Basque BCSP obtains excellent participation rate, reflected in early detection and treatment of pre and malignant lesions.

Implementation of risk stratification within bowel cancer screening: a community jury study exploring public acceptability and communication needs

BackgroundPopulation-based cancer screening programmes are shifting away from age and/or sex-based screening criteria towards a risk-stratified approach. Any such changes must be acceptable to the public and communicated effectively. We aimed to explore the social and ethical considerations of implementing risk stratification at three different stages of the bowel cancer screening programme and to understand public requirements for communication.MethodsWe conducted two pairs of community juries, addressing risk stratification for screening eligibility or thresholds for referral to colonoscopy and screening interval. Using screening test results (where applicable), and lifestyle and genetic risk scores were suggested as potential stratification strategies. After being informed about the topic through a series of presentations and discussions including screening principles, ethical considerations and how risk stratification could be incorporated, participants deliberated over the research questions. They then reported their final verdicts on the acceptability of risk-stratified screening and what information should be shared about their preferred screening strategy. Transcripts were analysed using codebook thematic analysis.ResultsRisk stratification of bowel cancer screening was acceptable to the informed public. Using data within the current system (age, sex and screening results) was considered an obvious next step and collecting additional data for lifestyle and/or genetic risk assessment was also preferable to age-based screening. Participants acknowledged benefits to individuals and health services, as well as articulating concerns for people with low cancer risk, potential public misconceptions and additional complexity for the system. The need for clear and effective communication about changes to the screening programme and individual risk feedback was highlighted, including making a distinction between information that should be shared with everyone by default and additional details that are available elsewhere.ConclusionsFrom the perspective of public acceptability, risk stratification using current data could be implemented immediately, ahead of more complex strategies. Collecting additional data for lifestyle and/or genetic risk assessment was also considered acceptable but the practicalities of collecting such data and how the programme would be communicated require careful consideration.

Pivot to prevent bowel cancer: Reflections on adapting an Aboriginal bowel cancer screening awareness program to a digital call to action-A commentary.

The Sydney Local Health District (SLHD) Health Promotion Unit was awarded a Cancer Institute NSW grant to raise awareness of bowel cancer and promote the National Bowel Cancer Screening Program (NBCSP) among Aboriginal communities in SLHD. The COVID-19 pandemic thwarted initial plans for face-to-face workshops and plans pivoted to digital products and dissemination of messages on a range of communication platforms. The coronavirus (COVID-19) pandemic provided staff with the freedom, flexibility, and ability to be creative in ways not possible prior to the pandemic and ultimately ended up with a superior product with a reach further than anticipated. A more comprehensive suite of digital resources addressing barriers to bowel cancer screening in the Aboriginal community was produced that is able to be used more broadly. These resources have reached a much larger population group through websites, social media, as well as TV and radio advertisements, and have the potential to be used and adapted in other local health districts and states across Australia. Adapting an Aboriginal bowel cancer screening awareness program to a digital platform is a promising approach. SO WHAT?: COVID-19 provided an opportunity to create new long-lasting partnerships and to be creative beyond the scope of the original grant. This in turn produced a product with a reach further than anticipated that can also be built on and sustained.

832 Analysis of Surgical Outcomes and Survival Benefit of Simultaneous Resection of the Primary Colonic Tumour and Liver Metastasis – Experience of a UK Tertiary Centre Between 2013-2022

Abstract Introduction 22% of patients with colorectal cancer present with synchronous metastases. Traditionally, surgical management for these patients is performed separately although increasingly these are being done as simultaneous resections as supported by NICE, UK. Large-scale data to support this is limited and heterogeneous. Aim We aimed to analyse the experience of simultaneous resection at a UK tertiary centre with attention to surgical, oncological outcomes, and survival benefits. Method A prospective database between 2013-2022 was analysed, and clinical data were collared. Statistics performed using R. Results Ninety-six simultaneous resections were reviewed. 71% were left-sided including rectal and 29% were right-sided, while 69% and 31% of patients underwent minor and major liver resections respectively. The majority of cases were performed as open (77%), laparoscopic (16%), or converted to open (6.5%). 30-day mortality was 1% and morbidity rate was 55.4% (Clavien Dindo III 39.2%, IV 4%). Stoma formation rate was 34%. To date, 62% had recurrent disease, 55% received further chemotherapy and 29% had further resections. Median time to recurrence was 31.2 weeks. Median total survival was 34 months. Left-sided and minor liver resections tended towards improved survival, but this was non-significant; survival was significantly improved for those patients diagnosed via the bowel cancer screening program (BSCP). Conclusions Simultaneous resection of colorectal cancer and liver metastases is safe with low mortality and an acceptable morbidity rate. Overall survival of 34 months is promising with further analysis required into oncological strategies and improving uptake of the BSCP.

Trends in pathology diagnoses during 10 years of a colorectal cancer screening programme.

We report pathology findings from the first 10 years of the faecal-occult blood-based Northern Ireland Bowel Cancer Screening Programme, presenting summary data and trends in pathology diagnoses and clinicopathological features of screen-detected cancers. Data were analysed from a comprehensive polyp-level pathology database representing all endoscopy specimens from programme inception in 2010 until 2021. A total of 9800 individuals underwent 13 472 endoscopy procedures, yielding 25 967 pathology specimens and 32 119 diagnoses. Index specimen diagnoses (4.1%) and index colonoscopies (10.4%) yielded a diagnosis of colorectal cancer, representing 1045 cancers from 1020 individuals (25 with synchronous cancers). A further 13 index cancers were identified via computed tomography colonography; 65.3% of cancer diagnoses were in males; 41.7% were stage I, 23.1% stage II, 25.8% stage III and 1.8% stage IV (7.6% unstaged). Of 233 pT1 cancers diagnosed within local excision specimens, 79 (33.9%) had completion surgery. Ten-year trends showed a steady decline in the proportion of index colonoscopies that yielded a diagnosis of cancer (14.7% in year 1; 4.8% in year 11) or advanced colorectal polyp. There was a strong upward trend in diagnoses of sessile serrated lesions, which overtook hyperplastic polyps in proportions of total index diagnoses by the end of the study time-frame (8.7% compared to 8.5%). Over the first 10 years of a population colorectal cancer screening programme, 'real world' pathology data demonstrate success in the form of reduced diagnoses of cancer and advanced colorectal polyp with passage of successive screening rounds. Interesting trends with respect to serrated polyp diagnoses are also evident, probably related to pathologist and endoscopist behaviour.

Colorectal cancer incidence trends by tumour location among adults of screening-age in England: a population-based study.

Proximal and distal colorectal cancers (CRCs) exhibit different clinical, molecular and biological patterns. The aim of this study was to determine temporal trends in the age-standardized incidence rates (ASIRs) of proximal and distal CRC following the introduction of the English Bowel Cancer Screening Programme (BCSP) in 2006. The National Cancer Registration and Analysis Service database was used to identify incident cases of CRC among adults of screening age (60-74 years) between 2001 and 2017. ASIRs were calculated using the European Standard Population 2013 and incidence trends analysed by anatomical subsite (proximal, caecum to descending colon; distal, sigmoid to rectum), sex and Index of Multiple Deprivation (IMD) quintile using Joinpoint regression software. Between 2001 and 2017, 541 515 incident cases of CRC were diagnosed [236 167 proximal (43.6%) and 305 348 distal (56.4%)]. A marginal reduction in the proximal ASIR was noted from 2008 [annual percentage change (APC) -1.4% (95% CI -2.0% to -0.9%)] compared with a greater reduction in distal ASIR from 2011 to 2014 [APC -6.6% (95% CI -11.5% to -1.5%)] which plateaued thereafter [APC -0.5% (95% CI -3.2% to 2.2%)]. Incidence rates decreased more rapidly in men than women. Adults in IMD quintiles 4-5 experienced the greatest reduction in distal tumours [APC -3.5% (95% CI -4.3% to -2.7%)]. Following the introduction of the English BCSP, the incidence of CRC has subsequently reduced among adults of screening age, with this trend being most pronounced in distal tumours and in men. There is also evidence of a reduction in the deprivation gap for distal tumour incidence. Strategies to improve the detection of proximal tumours are warranted.

Colorectal polyp outcomes after participation in the seAFOod polyp prevention trial: Evidence of rebound elevated colorectal polyp risk after short-term aspirin use.

The seAFOod polyp prevention trial was a randomised, placebo-controlled, 2 × 2 factorial trial of aspirin 300 mg and eicosapentaenoic acid (EPA) 2000 mg daily in individuals who had a screening colonoscopy in the English Bowel Cancer Screening Programme (BCSP). Aspirin treatment was associated with a 20% reduction in colorectal polyp number at BCSP surveillance colonoscopy 12 months later. It is unclear what happens to colorectal polyp risk after short-term aspirin use. To investigate colorectal polyp risk according to the original trial treatment allocation, up to 6 years after trial participation. All seAFOod trial participants were scheduled for further BCSP surveillance and provided informed consent for the collection of colonoscopy outcomes. We linked BCSP colonoscopy data to trial outcomes data. In total, 507 individuals underwent one or more colonoscopies after trial participation. Individuals grouped by treatment allocation were well matched for clinical characteristics, follow-up duration and number of surveillance colonoscopies. The polyp detection rate (PDR; the number of individuals who had ≥1 colorectal polyp detected) after randomization to placebo aspirin was 71.1%. The PDR was 80.1% for individuals who had received aspirin (odds ratio [OR] 1.13 [95% confidence interval 1.02, 1.24]; p = 0.02). There was no difference in colorectal polyp outcomes between individuals who had been allocated to EPA compared with its placebo (OR for PDR 1.00 [0.91, 1.10]; p = 0.92). Individuals who received aspirin in the seAFOod trial demonstrated increased colorectal polyp risk during post-trial surveillance. Rebound elevated neoplastic risk after short-term aspirin use has important implications for aspirin cessation driven by age-related bleeding risk. ISRCTN05926847.

Economic impact of implementing optical diagnosis with a "resect and discard" strategy within the English Bowel Cancer Screening Programme: Findings from the DISCARD3 study.

Advances in endoscopic technology, such as narrow band imaging and high definition colonoscopes, offer the potential for optical diagnosis (OD) with a "resect and discard" (RD) strategy for diminutive (≤5mm) and small (6-9mm) colorectal polyps. This could help alleviate the huge cost and time burden required for histopathology. The aim of this study is to conduct an economic analysis of a RD strategy within the English Bowel Cancer Screening Programme (BCSP). A decision tree was designed to compare a RD strategy with standard histopathology for patients included in the DISCARD3 study and was extrapolated to a national BCSP patient cohort. Of the 525 patients in the DISCARD3 study, 354 were assessed for surveillance intervals (after excluding cases with colorectal cancer and at least one polyp >10 mm). 269/354 cases had polyps of which, 182 had only diminutive polyps, 77 had both small and diminutive polyps, and 10 had only small polyps. Surveillance interval concordance was 97.9% in patients with at least 1 diminutive polyp and 98.7% in patients with at least 1 diminutive or small polyp. In DISCARD3, a RD approach would reduce overall direct healthcare costs by £35,468.8 (-72.3%) for patients with diminutive polyps or by £42,666.2 (-75.0%) for patients with diminutive or small polyps. When extrapolated to the entire English BCSP, the annual savings are almost £2.4m for patients with diminutive polyps or £3.4m for patients with diminutive or small polyps, after adjusting for the costs of an OD quality assurance process (QAP). OD with a RD strategy for diminutive and small polyps during BCSP colonoscopy would offer substantial cost savings without adversly affecting surveillance interval concordance.

Colorectal cancer and advanced adenoma incidence during post-polypectomy surveillance: a national cohort study in the English Bowel Cancer Screening Programme.

Improved colonoscopy quality has led to debate about whether all post-polypectomy surveillance is justified. We evaluated surveillance within the English Bowel Cancer Screening Programme (BCSP) to determine the yield of surveillance and identify predictive factors for surveillance outcome. We performed a retrospective cohort study of individuals undergoing post-polypectomy surveillance between July 2006 and January 2017. BCSP records were linked to the National Cancer Registration Database to identify interval-type post-colonoscopy colorectal cancers (CRCs). Advanced adenoma and CRC at surveillance were documented. CRC incidence was compared with the general population using standardized incidence ratios (SIRs). Predictors of advanced adenomas at first surveillance (S1), and CRC during follow-up, were identified. 44 151 individuals (23 078 intermediate risk; 21 073 high risk) underwent 64 544 surveillance episodes. Advanced adenoma and CRC yields were, respectively, 10.0 % and 0.5 % at S1, 8.5 % and 0.4 % at S2, and 10.8 % and 0.4 % at S3. S1 yield was lowest in those with one index adenoma ≥ 10 mm (advanced adenoma 6.1 %; CRC 0.3 %). The SIR was 0.76 (95 %CI 0.66-0.88), accounted for by the intermediate risk group (intermediate risk SIR 0.61, 95 %CI 0.49-0.75; high risk SIR 0.95, 95 %CI 0.79-1.15). Adenoma multiplicity, presence of a large nonpedunculated adenoma, and greater villous component were associated with advanced adenoma at S1. Older age and multiplicity were significantly associated with CRC risk. This large, national analysis found low levels of CRC in those undergoing surveillance and low advanced adenoma yield in most subgroups. Less intensive surveillance in some subgroups is warranted, and surveillance may be avoided in those with a single large adenoma.

Evaluating changes to home bowel cancer screening kits: an end-user perspective study

PurposeMany people do not participate in mail-out bowel cancer screening programs due to difficulties using the screening kit. The current study investigated the ways the screening kit could be modified to improve usability.Methods1,109 people evaluated 15 different screening kit modifications. Participants reported on how these kit modifications would affect their screening barriers, their future screening intentions, and how much they would recommend that the modification is made to the current screening kit used the program. All responses were given via an online survey conducted between April and December of 2021.ResultsSeventeen percent of previous NBCSP non-participators indicated that a one-sample test would increase their intention to participate. Recommendation ratings demonstrated higher levels of support for modifications that included providing a barcode naming label (M = 9.06, 95% CI [8.81, 9.31]), having a larger diameter opening of the collection tube (M = 8.42, 95% CI [8.10, 8.74]), and highlighting the expiry date on the kit packaging (M = 8.59, 95% CI [8.29, 8.89]). There were lower levels of support for modifications that reduced the size of the packaging the kit is sent in (M = 6.47, 95% CI [6.09, 6.85]), removed branding from kit packaging (M = 5.98, 95% CI [5.57, 6.39]), and removed the information booklet that comes with the screening kit (M = 5.25, 95% CI [4.78, 5.72]).ConclusionThese findings highlight multiple ways in which bowel cancer screening kits can be changed to increase usability for invitees of national bowel cancer screening programs. Findings have implications for all screening programs that use immunochemical-based bowel cancer screening kits.