Endoscopic Colorectal Cancer Screening Research Articles

When gold standards are not so golden: prevalence bias in randomized trials on endoscopic colorectal cancer screening

Randomized trials on the effectiveness of screening endoscopy in reducing colorectal cancer (CRC) risk have reported statistically significant, but rather modest reduction of CRC risk by the screening offer. However, risk estimates in these trials included substantial proportions of prevalent CRC cases which were early detected, but could not possibly have been prevented by screening. Thereby, a key principle of randomized prevention trials is violated that only “at risk” persons who do not yet have the disease one aims to prevent should be included in measures of preventive effects. Using recently published data from the Nordic-European Initiative on Colorectal Cancer (NordICC) trial as an example, we illustrate that approaches aimed to account for “prevalence bias” lead to effect estimates that are substantially larger than those reported in the trial and more in line with results from observational studies and real life settings. More rigorous methodological work is needed to develop effective and user-friendly tools to prevent or adjust for prevalence bias in future screening studies.

Quality of endoscopic screening for colorectal cancer in Italy: A national survey.

Colorectal cancer (CRC) is a major healthcare problem all over the world and screening is effective in reducing mortality and increasing survival. Since colonoscopy has a central role in faecal immunochemical test (FIT)-based CRC screening and surveillance, consistent quality measures are essential to ensure quality and outcomes. Nevertheless, screening modalities in clinical practice may differ according to the centers experience and the local availability of instrumentation and devices. to assess the quality of endoscopic screening for CRC and adherence to international guidelines across Gastroenterology Departments in Italy. All members of the Italian Society of Gastroenterology (SIGE) were invited to answer a web-based survey. Data from 64 hospitals from 17 Italian regions were analyzed. 32/64 (50.0%) were from northern, 12/64 (18.75%) from central and 20/64 (31.25%) from southern Italy. Each center is equipped with a median of 5.0 (3.5-7.0) endoscopists involved in CRC screening, 71.4% of which are gastroenterologists. After a positive FIT, most centers (93.8%) schedule a colonoscopy within 3 months. High-definition video endoscopy is routinely performed in 68.8% and chromoendoscopy in 53.1% of centers. Withdrawal time is ≥6min in 79.9% and cecal intubation rate is ≥90% in 94.4% of departments. Finally, in 92.7% of centers adenoma detection rate (ADR) overcome the minimum standard of 25%. Analyzing the data by regional areas, a significant higher number of median endoscopic examinations/year (6500 vs 4000 and 3000, respectively, p=0.024) and of endoscopists per center (6.5 vs 5.0 and 3.5, respectively, p<0.001) has been registered in the northern compared to central-southern centers. Data from this survey show adequacy and good quality of endoscopic screening for CRC in Italy, highlighting, at the same time, relevant deficiencies and a discrepancy in procedural attitudes between the different centers. These findings call for a urgent action to overcome the shortcomings, refine and homogenize the behaviour of all screening centers in the national territory and improve the outcomes.

Rectal neuroendocrine tumors: Current advances in management, treatment, and surveillance.

Rectal neuroendocrine neoplasms (r-NENs) are considered among the most frequent digestive NENs, together with small bowel NENs. Their incidence has increased over the past few years, and this is probably due to the widespread use of endoscopic screening for colorectal cancer and the advanced endoscopic procedures available nowadays. According to the current European Neuroendocrine Tumor Society (ENETS) guidelines, well-differentiated r-NENs smaller than 10 mm should be endoscopically removed in view of their low risk of local and distant invasion. R-NENs larger than 20 mm are candidates for surgical resection because of their high risk of distant spreading and the involvement of the muscularis propria. There is an area of uncertainty regarding tumors between 10 and 20 mm, in which the metastatic risk is intermediate and the endoscopic treatment can be challenging. Once removed, the indications for surveillance are scarce and poorly codified by international guidelines, therefore in this paper, a possible algorithm is proposed.

Effects of the Colorectal Cancer Control Program.

Although colorectal cancer (CRC) screening is highly effective, screening rates lag far below recommended levels, particularly for low-income people. The Colorectal Cancer Control Program (CRCCP) funded $100 million in competitively awarded grants to 25 states from 2009-2015 to increase CRC screening rates among low-income, uninsured populations, in part by directly providing and paying for screening services. Using data from the 2001-2015 Behavioral Risk Factor Surveillance System (BRFSS) and a difference-in-differences strategy, we find no effects of CRCCP on the use of relatively cheap fecal occult blood tests (FOBT). We do, however, find that the CRCCP significantly increased the likelihood that uninsured 50-64-year-olds report ever having a relatively expensive endoscopic CRC screening (sigmoidoscopy or colonoscopy) by 2.9 percentage points, or 10.7%. These effects are larger for women, minorities, and individuals who did not undertake other types of preventive care. We do not find that the CRCCP led to significant changes in CRC cancer detection. Our results indicate that the CRCCP was effective at increasing CRC screening rates among the most vulnerable.

Adherence to Recommendations and Quality of Endoscopic Colorectal Cancer Surveillance in Long-Standing Ulcerative Colitis

Background: Long-standing ulcerative colitis has been associated with an increased risk of colorectal cancer (CRC). Current guidelines recommend endoscopic CRC screening after 8 years of disease duration. The objectives of our study were to assess the adherence to recommendations and the quality of endoscopic procedure in long-standing ulcerative colitis. Methods: This is a retrospective cohort study. We selected patients included in the Swiss IBD cohort with a disease duration of ≥8 years and an extension above the rectosigmoid junction. The complementary medical chart review focused on endoscopy and associated histological reports in 8 Swiss centers. Descriptive analyses focused on patients and their colonoscopies. Results: 309 colonoscopies were conducted among 116 patients with the following characteristics: women 47%, mean age at diagnosis 31 years, and pancolitis disease extent in 65.5% of cases; 38.8% of patients had a first screening colonoscopy <8 years, 13.8% between 8 and 10 years, and 47.4% >10 years. Cecal intubation was performed in 94.5% of cases, and bowel preparation was good to excellent in 61.5% of endoscopies. Chromoendoscopy was used in 7.4% of cases, and the mean withdrawal time was 16.4 min. Dysplasia was found in 6.2% of cases. Conclusion: Despite current international recommendations, a significant number of patients did not receive a proper endoscopic surveillance. An increased use of chromoendoscopy, monitoring of withdrawal time, and appropriate bowel preparation would increase the quality of CRC screening. The adherence to screening guidelines and endoscopic quality should be promoted and standardized.

Effects of Alternative Offers of Screening Sigmoidoscopy and Colonoscopy on Utilization and Yield of Endoscopic Screening for Colorectal Neoplasms: Protocol of the DARIO Randomized Trial.

BackgroundFlexible sigmoidoscopy and colonoscopy are recommended screening options for colorectal cancer (CRC). Despite colonoscopy being offered for CRC screening in Germany, the uptake of this offer has been very limited.ObjectiveThe objective of this study was to assess the potential for increasing use of endoscopic CRC screening and the detection of advanced colorectal neoplasms by offering the choice between use of flexible sigmoidoscopy and colonoscopy.MethodsThe DARIO study includes a cross-sectional study (part I), followed by a prospective 2-arm randomized controlled intervention trial (part II) with an associated biobank study (part III). Participation is possible in part I of the DARIO study only, parts I and II, or all 3 study parts. After obtaining informed consent from the municipalities, 12,000 people, aged 50-54 years, from the Rhine-Neckar region in Germany were randomly selected from residential lists of the responsible population registries and invited to complete a standardized questionnaire to investigate the nature, frequency, timing, and results of previous CRC screening and eventual diagnostic colonoscopies. In study part II participants from study part I with no colonoscopy in the preceding 5 years are randomized into 2 arms: arm A offering screening colonoscopy only, and arm B offering both options, either screening colonoscopy or screening sigmoidoscopy. The primary endpoint is the proportion of participants in whom colorectal neoplasms >0.5 cm are detected and removed at screening endoscopy. The secondary endpoints are the detection rate of any neoplasm and use of any endoscopic screening. Part III of the study will use samples from participants in study part II to construct a liquid and tissue biobank for the evaluation of less invasive methods of early detection of colon cancer and for the more detailed characterization of the detected neoplasms. Blood, urine, stool, and saliva samples are taken before the endoscopy. Tissue samples are obtained from the neoplasms removed during endoscopy.ResultsA total of 10,568 from 12,000 randomly selected women and men aged 50-54 years living in the Rhine-Neckar-Region of Germany have been invited for participation. The remaining 1432 (11.93%) could not be invited because they reached the age of 55 at the time of contact. Of those invited, 2785/10,568 (26.35%) participated in study part I; 53.60% (1493/2785) of these participants were female. Study parts II and III are ongoing.ConclusionsThis study will answer the question if alternative offers of either screening sigmoidoscopy or screening colonoscopy will increase utilization and effectiveness of endoscopic CRC screening compared with an exclusive offer of screening colonoscopy. In addition, alternative noninvasive screening tests will be developed and validated.Trial RegistrationGerman Clinical Trials Register DRKS00018932; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00018932International Registered Report Identifier (IRRID)DERR1-10.2196/17516

Factors to Improve Endoscopic Screening for Colorectal Cancer.

Colorectal cancer is one of the most sprayed cancers; the gold standard of diagnostic is a colonoscopy. The quality of this examination is depended on many factors, which includes doctors' experience. The purpose of this study is to establish the main factors affecting the completeness of colonoscopy in colorectal cancer screening. Endoscopists were questioned; descriptive statistics methods and logistic regression were used. The main factors that influence the quality of screening colonoscopy were identified: experience in colonoscopy, theoretical training, participation in the screening program, and number of annual colonoscopies. The calculated odds ratio for the selected dependent variable is calculated. The experience for more than 5years (p = 0.017) and at least 200 colonoscopies per year (p = 0.004) are the main factors that allow to perform complete colonoscopy in 90% or more of cases.

What Happened to Disparities in CRC Screening Among FFS Medicare Enrollees Following Medicare Modernization?

The Medicare Modernization Act of 2003, implemented in 2006, increased managed care options for seniors. It introduced insurance plans for prescription drug coverage for all Medicare beneficiaries, whether they were enrolled in FFS or managed care (Medicare Advantage) plans. The availability of drug coverage beginning in 2006 served to free up budgets for FFS Medicare enrollees that could be used to make copayments for colorectal cancer (CRC) screening using endoscopy (colonoscopy or sigmoidoscopy). In 2007, Medicare eliminated the copayments required by seniors for CRC screening by endoscopy. Later in 2008, CRC screening by colonoscopy became part of the gold standard for CRC screening. This legitimized its use and offered even further encouragement to seniors, who may have been reluctant to undergo the procedure because of the non-pecuniary risks associated with it. In addition, 37 CRC screening interventions occurred during this timeframe to enhance compliance with screening standards. Using multilevel analysis of individuals' endoscopy utilization, derived from 100% FFS Medicare claims, along with county-level market and contextual factors, we compare the periods before and after the MMA (2001-2005 to 2006-2009) to determine whether disparities in the utilization of endoscopic CRC screening occurred or changed over the decade. We examined Blacks, Asians, and Hispanics relative to Whites, and Females relative to Males (with race or ethnicity combined). We examined each state separately for evidence of disparities within states, to avoid confounding by geographic disparities. We expected that the net effect of the policy changes and the targeted interventions over the decade would be to increase CRC screening by endoscopy, reducing disparities. We saw improvements over time (reduced disparities relative to Whites) for Blacks and Hispanics residing in several states, and improvements over time for Females relative to Males in many states. For the vast majority of states, however, disparities persisted with Whites and Males exhibiting greater rates of utilization than other groups. States that undertook the interventions were more likely to have had improvements in disparities or positive disparities for women and minorities. While some gains were made over this time period, the gains were unevenly distributed across the USA and more work needs to be done to reduce remaining disparities.

Mortality From Postscreening (Interval) Colorectal Cancers Is Comparable to That From Cancer in Unscreened Patients—A Randomized Sigmoidoscopy Trial

Endoscopic screening for colorectal cancer (CRC) is performed at longer time intervals than the fecal occult blood test or screenings for breast or prostate cancer. This causes concerns about interval cancers, which have been proposed to progress more rapidly. We compared outcomes of patients with interval CRCs after sigmoidoscopy screening vs outcomes of patients with CRC who had not been screened. We performed a secondary analysis of a randomized sigmoidoscopy screening trial in Norway with 98,684 participants (age range, 50-64 years) who were randomly assigned to groups that were (n= 20,552) or were not (n= 78,126) invited for sigmoidoscopy screening from 1999 through 2001; participants were followed up for a median 14.8 years. We compared CRC mortality and all-cause mortality between individuals who underwent screening and were diagnosed with CRC 30 days or longer after screening (interval cancer group, n= 163) and individuals diagnosed with CRC in the nonscreened group (controls, n= 1740). All CRCs in the control group were identified when they developed symptoms (clinically detected CRCs). Analyses were stratified by cancer site. We used Cox regression to estimate hazard ratio (HRs), adjusted for age and sex. Over the follow-up period, 43 individuals in the interval cancer group died from CRC; among controls, 525 died from CRC. CRC mortality (adjusted HR, 0.98; 95% confidence interval, 0.72-1.35; P= .92), rectosigmoid cancer mortality (adjusted HR, 1.10; 95% confidence interval, 0.63-1.92; P= .74), and all-cause mortality (adjusted HR, 0.99; 95% confidence interval, 0.76-1.27; P= .91) did not differ significantly between the interval cancer group and controls. In this randomized sigmoidoscopy screening trial, mortality did not differ significantly between individuals with interval CRCs and unscreened patients with clinically detected CRCs. ClinicalTrials.gov identifier: NCT00119912.

Diagnostic value of white light endoscopy and narrow band imaging for colorectal sessile serrated adenoma and hyperplastic polyp

Objective To differentiate colorectal sessile serrated adenoma (SSA) and large hyperplastic polyp (HP) with white light endoscopy and narrow band imaging. Methods Retrospective analysis was performed on the clinical data of 953 patients who underwent endoscopic screening for colorectal cancer at digestive endoscopy center of Peking Union Medical College Hospital from January 2015 to December 2015.Endoscopic features were compared with white light endoscopy and narrow band imaging between SSA and large HP in location, size, Paris classification, surface mucus, NICE classification and varicose microvascular vessel (VMV). Results A total of 28(2.9%) SSAs and 25(2.6%) HPs of diameter not less than 0.5 cm were detected in the total of 953 patients. Statistically significant difference was found in right hemi-colon, diameter not less than 1.0 cm and VMV in two groups(P<0.05). The sensitivities of the above three markers for SSA were 89.3%, 67.9% and 46.4% respectively. The specificities were 64.0%, 76.0% and 84.0% respectively. Diagnostic accuracies were 77.4%, 71.7% and 64.2% respectively. And the sensitivity, specificity and accuracy of three markers combined (at least two markers) were 75.0%, 88.0% and 81.1%, respectively. Conclusion SSA and large HP could be differentiated with a systemic consideration of lesion location, size, and surface of microvessels by using white light endoscopy and image-enhanced technique. Key words: Colonic polyps; Colonoscopy; Narrow band imaging; Sessile serrated adenoma; Hyperplastic polyp

Colonoscopy and Flexible Sigmoidoscopy in Colorectal Cancer Screening and Surveillance

Since the invention of endoscopy in the 1800s, colonoscopy and flexible sigmoidoscopy have evolved into important tools in the diagnosis and treatment of lower gastrointestinal luminal diseases. These two modalities along with biochemical markers and widespread implementation of colorectal cancer (CRC) screening are responsible for the overall downtrend of CRC. However, this downward trend is not as robustly reflected in the right-sided CRC. It is thought that flat lesions in the right colon (sessile serrated polyp (SSA/P)), suboptimal colon preparation, differences in gender, and endoscopic techniques are some of the contributing factors accounting for this difference. In this review, we will summarize the most current literature and guidelines on CRC screening and surveillance. In addition, we will describe the recent advances in endoscopic CRC screening with emphasis on colonoscopy and flexible sigmoidoscopy and the changes they have brought to the CRC landscape in the US.

Medicare modernization and diffusion of endoscopy in FFS medicare

ObjectiveTo examine how FFS Medicare utilization of endoscopy procedures for colorectal cancer (CRC) screening changed after implementation of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) in 2006, which provided subsidized drug coverage and expanded the geographic availability of Medicare managed care plans across the US.Data Sources/Study Setting. Using secondary data from 100% FFS Medicare enrollees, we analyzed endoscopy utilization during two intervals, 2001-2005 and 2006-2009.Study designWe examined change in predictors of county-level endoscopy utilization rates based on a conceptual model of market supply and demand with spillovers from managed care practices. The equations for each period were estimated jointly in a spatial lag regression model that properly accounts for both place and time effects, allowing robust assessment of changes over time.Data collection/Extraction methodsAll Medicare FFS enrollees with both Parts A and B coverage who were age 65+, remained alive and living in the same state over the interval were included in the analyses. The later interval used a new cohort defined the same as the earlier interval. 100% Medicare denominator files were also used, providing county of address to use for county-level aggregation. The outcome variable was defined as county-level proportion of enrollees who ever used endoscopy over the interval.Principal findingsEndoscopy utilization by FFS Medicare increased, and became more accessible across the US. Medicare managed care plan spillovers onto FFS Medicare endoscopy utilization changed over time from a significant negative (restraining) effect in the early period to no significant effect by the later period.ConclusionsThe MMA eased budget constraints for seniors, making endoscopic CRC screening more affordable. The MMA policies also strengthened managed care business prospects, and enrollments in Medicare managed care escalated. The change in managed care spillover effects reflects the gradual acceptance of endoscopic CRC screening procedures, as they emerged as the gold standard during the period.

Predicting Incongruence between Self-reported and Documented Colorectal Cancer Screening in a Sample of African American Medicare Recipients

Assessments of colorectal cancer (CRC) screening rates typically rely on self-reported screening data, which are often incongruent with medical records. We used multilevel models to examine health-related, socio-demographic and psychological predictors of incongruent self-reports for CRC screening among Medicare-insured African Americans (N = 3,740). Results indicated that living alone decreased, and income increased, the odds of congruently self-reporting endoscopic CRC screening. Being male and having greater number of comorbidities decreased, and having less than a high school education increased, the odds of congruently self-reported fecal occult blood tests. Living alone, age and income had the most robust effects across classifications into one of four mutually exclusive categories defined by screening status (screened/unscreened) and congruence of self-reports. The results underscore the clinical importance of gathering socio-demographic data via patient interviews, and the relevance of these data for judging the veracity of self-reported CRC screenings behaviors.

Colonoscopy: quality indicators.

Effective endoscopic screening for colorectal cancer (CRC), one of the few preventable cancers, is dependent on the adequate detection and removal of potentially precancerous lesions. However, observed variation in colonoscopy performance in practice and outcomes has highlighted the need for consistent quality measures. Quality indicators or measures are tools that help to quantify health-care processes and can aid in providing high-quality health care. The primary colonoscopy quality indicator is the adenoma detection rate (ADR), which is defined as the proportion of an endoscopist's screening colonoscopies in which one or more adenomas have been detected. The risk of post-colonoscopy CRC is inversely correlated with an endoscopist's ADR. However, ADR is dependent on other quality measures, including cecal intubation rates, withdrawal times, and quality of bowel preparation. Achieving suggested benchmarks for these other quality measures will aid the endoscopist in achieving the recently updated ADR benchmark of 25% in their practice. In addition, beyond ensuring adequate ADRs, endoscopists should have high compliance rates with guideline-recommended and evidence-based screening and surveillance intervals. Compliance with quality measures will ensure effective and safe CRC prevention and better patient outcomes.

Cancer fear: facilitator and deterrent to participation in colorectal cancer screening.

Cancer fear has been associated with higher and lower screening uptake across different studies, possibly because different aspects of cancer fear have different effects on intentions versus behavior. The present study examined associations of three aspects of cancer fear with intention and uptake of endoscopic screening for colorectal cancer. A subsample of UK Flexible Sigmoidoscopy (FS) Trial participants received a baseline questionnaire that included three cancer fear items from a standard measure asking if: (i) cancer was feared more than other diseases, (ii) cancer worry was experienced frequently, and (iii) thoughts about cancer caused discomfort. Screening intention was assessed by asking participants whether, if invited, they would accept an invitation for FS screening. Positive responders were randomized to be invited or not in a 1:2 ratio. The behavioral outcome was clinic-recorded uptake. Control variables were age, gender, ethnicity, education, and marital status. The questionnaire return rate was 60% (7,971/13,351). The majority (82%) intended to attend screening; 1,920 were randomized to receive an invitation, and 71% attended. Fearing cancer more than other diseases (OR = 2.32, P < 0.01) and worrying a lot about cancer (OR = 2.34, P < 0.01) increased intentions to attend screening, but not uptake. Finding thoughts about cancer uncomfortable did not influence intention, but predicted lower uptake (OR = 0.72, P < 0.01). Different aspects of cancer fear have different effects on the decision and action processes leading to screening participation. Knowledge of the different behavioral effects of cancer fear may aid the design of effective public health messages.

Screening &amp; staging of colorectal cancer

In Europe, colorectal cancer (CRC) is the second most common cancer, and the second most common cause of death from cancer [1]. The vast majority of CRC develop from benign precursor lesions, so-called adenomatous polyps, which via the adenoma-carcinoma pathway may eventually transform into colon cancer. It has been shown that endoscopic removal of adenomas interrupts this pathway and subsequently reduces CRC incidence and cancer-related mortality. Thus endoscopic CRC screening programs have been instituted in many countries to reduced CRC cancer mortality. However, limited availability of colonoscopy and limited adherence of the population to colonoscopy-based screening programs is well documented. CT colonography (CTC) has evolved as an effective tool to detect small colorectal polyps, with a high sensitivity to diagnose adenomas ≥ 10 mm and advanced adenomas (with dysplasia) [2]. After negative screening CTC, clinically presenting CRC is rare in the 5 years following CTC [3]. Guidelines for staging of CRC have been developed by the European Society of Medical Oncology (ESMO) [4], which recommend MRI and/or endorectal ultrasound for local staging of rectal cancer (in order to decide which patients need neoadjuvant therapy). MRI is preferred in stenotic tumors or cancers in the upper third of the rectum. In patients with colon cancer, local staging (by CT) primarily seeks to exclude T4 disease with infiltration into other organs. Variability exists in different European countries regarding the use of contrast-enhanced MDCT of the abdomen and chest (to be preferred over chest X-ray) for evaluation of nodal disease and distant metastases. Assessment of lymph nodes based on size criteria alone has some limitations, because metastases can be found even in normal-sized lymph nodes [5,6]. FDG-PET is not recommended for staging [4]. It might be used for staging of patients with CT-detected synchronous liver metastases scheduled for liver surgery. However, a recent study showed that PET/CT in patients with potentially resectable liver metastases did not result in frequent change of management and did not improve overall survival [7]. CTC screening for CRC will be presented and CRC staging by MDCT and MRI will be highlighted.

In the era of widespread endoscopy use, randomized trials may strongly underestimate the effects of colorectal cancer screening

ObjectivesAlthough randomized controlled trials (RCTs) are considered the most valid approach to evaluate screening effects, they also face a number of methodological challenges, including nonadherence and contamination. We aimed to quantify their potential impact in RCTs evaluating endoscopic screening for colorectal cancer (CRC). Study Design and SettingWe carried out model calculations using plausible levels of nonadherence and contamination. ResultsAssuming medium values of adherence (70%) and contamination, that is, use of lower gastrointestinal endoscopy other than the one offered for screening (30%), true reductions in CRC incidence or mortality of 70%, 50%, or 30% would be expected to be attenuated to reductions of 43%, 29%, and 16%, respectively, in intention-to-screen analyses. In case of low levels of adherence (50%) and high but realistic levels of contamination (50%), even more severe attenuation of screening effects to estimated reductions of 27%, 17%, and 9% would be expected. The estimates are only slightly modified in sensitivity analyses, additionally allowing for differential adherence and contamination according to CRC risk. ConclusionIn the era of widespread endoscopy use even outside the screening programs, RCTs may strongly underestimate the effects of CRC screening. Additional analyses accounting for nonadherence and contamination are crucial for disclosing the true screening effects.

Endoscopic colorectal cancer screening provides long-lasting effect.

Endoscopic colorectal cancer screening provides long-lasting effect.

Factors Explaining Racial/Ethnic Disparities in Rates of Physician Recommendation for Colorectal Cancer Screening

Physician recommendation plays a crucial role in receiving endoscopic screening for colorectal cancer (CRC). This study explored factors associated with racial/ethnic differences in rates of screening recommendation. Data on 5900 adults eligible for endoscopic screening were obtained from the National Health Interview Survey. Odds ratios of receiving an endoscopy recommendation were calculated for selected variables. Planned, sequenced logistic regressions were conducted to examine the extent to which socioeconomic and health care variables account for racial/ethnic disparities in recommendation rates. Differential rates were observed for CRC screening and screening recommendations among racial/ethnic groups. Compared with Whites, Hispanics were 34% less likely (P < .01) and Blacks were 26% less likely (P < .05) to receive this recommendation. The main predictors that emerged in sequenced analysis were education for Hispanics and Blacks and income for Blacks. After accounting for the effects of usual source of care, insurance coverage, and education, the disparity reduced and became statistically insignificant. Socioeconomic status and access to health care may explain major racial/ethnic disparities in CRC screening recommendation rates.

Asymptomatic colon cancer finding during open bariatric surgery in a 29-year-old female

Obesity is known as a primary condition for colon cancer development [ 1 Larsson S.C. Wolk A. Obesity and colon and rectal cancer risk: a meta-analysis of prospective studies. Am J Clin Nutr. 2007; 86: 556-565 PubMed Google Scholar , 2 Larsson S.C. Rutegård J. Bergkvist L. Wolk A. Physical activity, obesity, and risk of colon and rectal cancer in a cohort of Swedish men. Eur J Cancer. 2006; 42: 2590-2597 Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar , 3 Giovannucci E. Ascherio A. Rimm E.B. Colditz G.A. Stampfer M.J. Willett W.C. Physical activity, obesity, and risk for colon cancer and adenoma in men. Ann Intern Med. 1995; 122: 327-334 Crossref PubMed Scopus (824) Google Scholar ]. Hypochromic anemia is a frequent finding in obese patients; nonetheless, colon cancer must be suspected and excluded [ [4] Park H.W. Han S. Lee J.S. et al. Risk stratification for advanced proximal colon neoplasm and individualized endoscopic screening for colorectal cancer by a risk-scoring model. Gastrointest Endosc. 2012; 76: 818-828 Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar ]. Bariatric surgery is known as the most effective treatment for moderate and severe obesity [ [5] 2004 ASBS Consensus Conference on Surgery for Severe Obesity. Surg Obes Rel Dis 2005;1:297–381. Google Scholar ]. The authors report a case in which a colon cancer was found during bariatric surgery.