Context: Current guidelines do not include an upper age cutoff for colorectal cancer screening with colonoscopy. Although the prevalence of colonic neoplasia increases with age, life expectancy decreases. Thus, the be...Context: Current guidelines do not include an upper age cutoff for colorectal cancer screening with colonoscopy. Although the prevalence of colonic neoplasia increases with age, life expectancy decreases. Thus, the benefit of screening colonoscopy in very elderly patients may be limited. Objective: To compare estimated life-years saved with screening colonoscopy in very elderly vs younger persons. Design, Setting, and Participants: Cross-sectional study conducted among 1244 asymptomatic individuals in 3 age groups (50-54 years [n = 1034], 75-79 years [n = 147], and ≥80 years [n = 63]) who underwent screening colonoscopy at a US teaching hospital and clinic. Main Outcome Measures: Prevalence of various tyes of colon neoplasia; estimated gain in life expectancy, calculated as life expectancy -(life expectancy during polyp lag time +life expectancy after colorectal cancer diagnosis); and comparison of mean gain in life expectancy across the 3 groups. Life expectancy and mortality data were derived from life tables, previous studies, and national databases. Results: The prevalence of neoplasia was 13.8%in the 50-to 54-year-old group, 26.5%in the 75-to 79-year-old group, and 28.6%in the group aged 80 years or older. Despite higher prevalence of neoplasia in elderly patients, mean extension in life expectancy was much lower in the group aged 80 years or older than in the 50-to 54-year-old group (0.13 vs 0.85 years). In sensitivity analysis, with longer polyp lag times the mean extension in life expectancy decreased more in the elderly than in the younger patients; alternatively, if it was assumed that a smaller proportion of adenomas progress to colorectal cancer, the mean extension in life expectancy decreased less in the elderly than in the younger patients. Conclusions: Even though prevalence of neoplasia increases with age, screening colonoscopy in very elderly persons (aged ≥80 years) results in only 15%of the expected gain in life expectancy in younger patients. Screening colonoscopy in very elderly patients should be performed only after careful consideration of potential benefits, risks, and patient preferences.展开更多
Background: Colonoscopic based surveillance is recommended for patients at increased risk of colorectal cancer. The appropriate interval between surveillance colonoscopies remains in debate, as is the “miss rate”for...Background: Colonoscopic based surveillance is recommended for patients at increased risk of colorectal cancer. The appropriate interval between surveillance colonoscopies remains in debate, as is the “miss rate”for colorectal cancer within such screening programmes. Aims: The main aim of this study was to determine whether a one-off interval faecal occult blood test (FOBT) facilitates the detection of significant neoplasia within a colonoscopic based surveillance programme. Secondary aims were to determine if invitees were interested in participating in interval screening, and to determine whether interval lesions were missed or whether they developed rapidly since the previous colonoscopy. Patients: Patients enrolled in a colonoscopic based screening programme due to a personal history of colorectal neoplasia or a significant family history. Methods: Patients within the screening programme were invited to performan immunochemical FOBT (Inform). A positive result was followed by colonoscopy; significant neoplasia was defined as colorectal cancer, adenomas either ≥10 mm or with a villous component, high grade dysplasia, or multiplicity (≥3 adenomas). Participation rates were determined for age, sex, and socioeconomic subgroups. Colonoscopy recall databases were examined to determine the interval between previous colonoscopy and FOBT offer, and correlations between lesion characteristics and interval time were determined. Results: A total of 785 of 1641 patients invited (47.8%) completed an Inform kit. Apositive result was recorded for 57 (7.3%). Fifty two of the 57 test positive patients completed colonoscopy; 14(1.8%of those completing the FOBT) had a significant neoplastic lesion. These consisted of six colorectal cancers and eight significant adenomas. Conclusions: A one off immunochemical faecal occult blood test within a colonoscopy based surveillance programme had a participation rate of nearly 50%and appeared to detect additional pathology, especially in patients with a past history of colonic neoplasia.展开更多
BACKGROUND: Veterans Affairs (VA) Cooperative Study 380 showed that some advan ced colorectal neoplasias (i.e., adenomas at least 1 cm in diameter, villous ade nomas, adenomas with highgrade dysplasia, or cancer) in...BACKGROUND: Veterans Affairs (VA) Cooperative Study 380 showed that some advan ced colorectal neoplasias (i.e., adenomas at least 1 cm in diameter, villous ade nomas, adenomas with highgrade dysplasia, or cancer) in men would be missed wi th the use of flexible sigmoidoscopy but detected by colonoscopy. In a tandem st udy, we examined the yield of screening colonoscopy in women. METHODS: To determ ine the prevalence and location of advanced neoplasia, we offered colonoscopy to consecutive asymptomatic women referred for coloncancer screening. The diagno stic yield of flexible sigmoidoscopy was calculated by estimating the proportion of patients with advanced neoplasia whose lesions would have been identified if they had undergone flexible sigmoidoscopy alone. Lesions were considered detect able by flexible sigmoidoscopy if they were in the distal colon or if they were in the proximal colon in patients who had concurrent small adenomas in the dista l colon, a finding that would have led to colonoscopy. The results were compared with the results from VA Cooperative Study 380 for agematched men and women wit h negative fecal occultblood tests and no family history of colon cancer. RESU LTS: Colonoscopy was complete in 1463 women, 230 of whom (15.7 percent) had a fa mily history of colon cancer. Colonoscopy revealed advanced neoplasia in 72 wome n (4.9 percent). If flexible sigmoidoscopy alone had been performed, advanced ne oplasia would have been detected in 1.7 percent of these women (25 of 1463) and missed in 3.2 percent (47 of 1463). Only 35.2 percent ofwomen with advanced neop lasia would have had their lesions identified if they had undergone flexible sig moidoscopy alone, as compared with 66.3 percent of matched men from VA Cooperati ve Study 380 (P< 0.001). CON CLUSIONS: Colonoscopy may be the preferred method of screening for colorectal cancer in women.展开更多
Universal access to medical procedures is deemed an advantage of the Canadian health care system. The purposes of this prospective study were to determine the degree to which the practice of colon cancer screening by ...Universal access to medical procedures is deemed an advantage of the Canadian health care system. The purposes of this prospective study were to determine the degree to which the practice of colon cancer screening by colonoscopy differed among socioeconomic classes and to assess adherence to screening guidelines. Consecutive patients scheduled to undergo colonoscopy at a single center between August 2000 and August 2002 completed a questionnaire that determined patient characteristics and indications for the procedure. The patients were divided into two groups: screening patients, defined as individuals who indicated they were undergoing colonoscopy for screening purposes and were asymptomatic, and a control group, which comprised patients undergoing colonoscopy because of symptoms. Statistical analysis was performed to determine if patients in the screening group had different characteristics with respect to socioeconomic class, compared with the control group. A total of 1088 patients completed the questionnaire: 707 (65%) had colonoscopy because of symptoms, compared with 381 (35%) who underwent a screening examination. Mean age and marital status were similar in both groups. Of all colonoscopy procedures, there was a significantly greater proportion of men undergoing colonoscopy for screening purposes: 199 (52.2%) vs. 294 (41.6%) in the symptomatic group (p = 0.001). Based on the Cochran-Armitage test, patients in the screening group had significantly higher education levels (p = 0.004) and household incomes (p = 0.001). Income and education level, two indices of socioeconomic status, are statistically significantly higher in patients undergoing screening colonoscopy compared with those having colonoscopy for any other reason.展开更多
Context: Limited evidence exists to guide the optimal frequency of repeat endoscopic examination for colorectal cancer screening after a negative colonoscopy. Objective: To determine the duration and magnitude of the ...Context: Limited evidence exists to guide the optimal frequency of repeat endoscopic examination for colorectal cancer screening after a negative colonoscopy. Objective: To determine the duration and magnitude of the risk of developing colorectal cancer following performance of a negative colonoscopy. Design, Setting, and Patients: Population-based retrospective analysis of individuals whose colonoscopy evaluations did not result in a diagnosis of colorectal neoplasia. Patients who had been evaluated between April 1, 1989, and December 31, 2003, were identified using Manitoba Health’s physician billing claims database (N = 35 975). Standardized incidence ratios (SIRs) were calculated to compare colorectal cancer incidence in our cohort with colorectal cancer incidence in the provincial population. Stratified analysis was performed to determine the duration of the reduced risk. Patients with a history of colorectal cancer prior to the index colonoscopy, inflammatory bowel disease, resective colorectal surgery, and lower gastrointestinal endoscopy within the 5 years before the index colonoscopy were excluded. Cohort members were followed up from the time of the index colonoscopy until diagnosis of colorectal cancer, death, out-migration from Manitoba, or end of the study period on December 31, 2003. Main Outcome Measure: Incidence of colorectal cancer. Results: A negative colonoscopy was associated with SIRs of 0.69 (95%confidence interval [CI], 0.59-0.81) at 6 months, 0.66 (95%CI, 0.56-0.78) at 1 year, 0.59 (95%CI, 0.48-0.72) at 2 years, 0.55 (95%CI, 0.41-0.73) at 5 years, and 0.28 (95%CI, 0.09-0.65) at 10 years. The proportion of colorectal cancer located in the right side of the colon was significantly higher in the colonoscopy cohort than the rate in the Manitoba population (47%vs 28%; P< .001). Conclusions: The risk of developing colorectal cancer remains decreased for more than 10 years following the performance of a negative colonoscopy. There is a need to improve the early detection rate of right-sided colorectal neoplasia in usual clinical practice.展开更多
Background and study aims: Screening colonoscopy with polypectomy has been shown to reduce the morbidity and mortality associated with colorectal cancer. However, there is a lack of large and systematic prospective st...Background and study aims: Screening colonoscopy with polypectomy has been shown to reduce the morbidity and mortality associated with colorectal cancer. However, there is a lack of large and systematic prospective studies of the complications of polypectomy. Patients and methods: Data on all snare polypectomies performed in 13 institutions (six hospitals and seven gastroenterology offices) were recorded prospectively during a 20-month period, including data on a 30-day follow-up period. The primary end points of the study were polypectomy complications, which were classed as “major" or “minor". Risk factors for complications were analyzed for both patient characteristics and polyp parameters. Results: A total of 3976 snare polypectomies in 2257 patients (mean age 64.5 years) were included in the study. The mean polyp size was 1.1 cm, and 72%were sessile. Complications occurred in 9.7%of patients (6.1%of polyps); 75%of these complications were minor; and the mortality rate was zero. Multivariate regression analysis revealed polyp size as the main risk factor, both for complications overall (odds ratio 6.56, 95%CI 4.45-9.67) and for major complications (odds ratio 31.01, 95%CI 7.53-128.1). Right-sided polyp location was a significant risk factor for major complications (odds ratio 2.40, 95%CI 1.34-4.28). Setting a cut-off value of 3%as an acceptable rate for major complications, polyps larger than 1 cm in the right colon or 2 cm in the left colon, and multiple polyps carried an increased risk. Conclusions: Colonoscopic polypectomy is associated with a 10%rate of complications, but three-quarters of these are of minor clinical significance. More than 90%of the complications can be managed conservatively if adequate endoscopic expertise is available. Guidelines for intensified follow-up after polypectomy should be based on the size, location, and number of a patient’spolyps.展开更多
PURPOSE:Data supporting an increased risk of colorectal cancer in patients with Crohn’s colitis are inconsistent.Despite this,clinical recommendations regarding colonoscopic screening and surveillance for patients wi...PURPOSE:Data supporting an increased risk of colorectal cancer in patients with Crohn’s colitis are inconsistent.Despite this,clinical recommendations regarding colonoscopic screening and surveillance for patients with Crohn’s colitis are extrapolated from chronic ulcerative colitis protocols.The primary aim of our study was to determine the incidence of dysplasia and carcinoma in pathology specimens of patients undergoing segmental or total colectomy for Crohn’s disease of the large bowel.In addition,we sought to identify risk factors associated with the development of dysplasia and carcinoma.METHODS:We performed a retrospective review of all patients operated on at our institution for Crohn’ s colitis between January 1992 and May 2004.Data were retrieved from patient charts,operative notes,and pathology reports.Logistic regression was used to model the probability of having dysplasia or adenocarcinoma.RESULTS:Two hundred twenty-two patients(138 females) who underwent surgical resection for the treatment of Crohn’s colitis were included in the study.Mean age at surgery was 41(range,15-82) years and the mean duration of disease was 10(range,0-53) years.There were five cases of dysplasia(2.3 percent) and six cases of adenocarcinoma(2.7 percent) .Three patients with dysplasia and one with adenocarcinoma were diagnosed on preoperative colonoscopy;while the other cases were discovered incidentally on pathologic examination of resected specimens.Factors associated with the presence of dysplasia or adenocarcinoma included older age at diagnosis(38.2 vs.30.3 years,P = 0.02) ,longer disease duration(16.0 vs.10.1 years,P = 0.05) ,and disease extent(90 percent extensive vs.59 percent limited,P = 0.05) .CONCLUSIONS:Patients with severe Crohn’s colitis requiring surgery are at significant risk for developing dysplasia and adenocarcinoma,particularly when diagnosed at an older age,after longer disease duration,and with more extensive colon involvement.展开更多
文摘Context: Current guidelines do not include an upper age cutoff for colorectal cancer screening with colonoscopy. Although the prevalence of colonic neoplasia increases with age, life expectancy decreases. Thus, the benefit of screening colonoscopy in very elderly patients may be limited. Objective: To compare estimated life-years saved with screening colonoscopy in very elderly vs younger persons. Design, Setting, and Participants: Cross-sectional study conducted among 1244 asymptomatic individuals in 3 age groups (50-54 years [n = 1034], 75-79 years [n = 147], and ≥80 years [n = 63]) who underwent screening colonoscopy at a US teaching hospital and clinic. Main Outcome Measures: Prevalence of various tyes of colon neoplasia; estimated gain in life expectancy, calculated as life expectancy -(life expectancy during polyp lag time +life expectancy after colorectal cancer diagnosis); and comparison of mean gain in life expectancy across the 3 groups. Life expectancy and mortality data were derived from life tables, previous studies, and national databases. Results: The prevalence of neoplasia was 13.8%in the 50-to 54-year-old group, 26.5%in the 75-to 79-year-old group, and 28.6%in the group aged 80 years or older. Despite higher prevalence of neoplasia in elderly patients, mean extension in life expectancy was much lower in the group aged 80 years or older than in the 50-to 54-year-old group (0.13 vs 0.85 years). In sensitivity analysis, with longer polyp lag times the mean extension in life expectancy decreased more in the elderly than in the younger patients; alternatively, if it was assumed that a smaller proportion of adenomas progress to colorectal cancer, the mean extension in life expectancy decreased less in the elderly than in the younger patients. Conclusions: Even though prevalence of neoplasia increases with age, screening colonoscopy in very elderly persons (aged ≥80 years) results in only 15%of the expected gain in life expectancy in younger patients. Screening colonoscopy in very elderly patients should be performed only after careful consideration of potential benefits, risks, and patient preferences.
文摘Background: Colonoscopic based surveillance is recommended for patients at increased risk of colorectal cancer. The appropriate interval between surveillance colonoscopies remains in debate, as is the “miss rate”for colorectal cancer within such screening programmes. Aims: The main aim of this study was to determine whether a one-off interval faecal occult blood test (FOBT) facilitates the detection of significant neoplasia within a colonoscopic based surveillance programme. Secondary aims were to determine if invitees were interested in participating in interval screening, and to determine whether interval lesions were missed or whether they developed rapidly since the previous colonoscopy. Patients: Patients enrolled in a colonoscopic based screening programme due to a personal history of colorectal neoplasia or a significant family history. Methods: Patients within the screening programme were invited to performan immunochemical FOBT (Inform). A positive result was followed by colonoscopy; significant neoplasia was defined as colorectal cancer, adenomas either ≥10 mm or with a villous component, high grade dysplasia, or multiplicity (≥3 adenomas). Participation rates were determined for age, sex, and socioeconomic subgroups. Colonoscopy recall databases were examined to determine the interval between previous colonoscopy and FOBT offer, and correlations between lesion characteristics and interval time were determined. Results: A total of 785 of 1641 patients invited (47.8%) completed an Inform kit. Apositive result was recorded for 57 (7.3%). Fifty two of the 57 test positive patients completed colonoscopy; 14(1.8%of those completing the FOBT) had a significant neoplastic lesion. These consisted of six colorectal cancers and eight significant adenomas. Conclusions: A one off immunochemical faecal occult blood test within a colonoscopy based surveillance programme had a participation rate of nearly 50%and appeared to detect additional pathology, especially in patients with a past history of colonic neoplasia.
文摘BACKGROUND: Veterans Affairs (VA) Cooperative Study 380 showed that some advan ced colorectal neoplasias (i.e., adenomas at least 1 cm in diameter, villous ade nomas, adenomas with highgrade dysplasia, or cancer) in men would be missed wi th the use of flexible sigmoidoscopy but detected by colonoscopy. In a tandem st udy, we examined the yield of screening colonoscopy in women. METHODS: To determ ine the prevalence and location of advanced neoplasia, we offered colonoscopy to consecutive asymptomatic women referred for coloncancer screening. The diagno stic yield of flexible sigmoidoscopy was calculated by estimating the proportion of patients with advanced neoplasia whose lesions would have been identified if they had undergone flexible sigmoidoscopy alone. Lesions were considered detect able by flexible sigmoidoscopy if they were in the distal colon or if they were in the proximal colon in patients who had concurrent small adenomas in the dista l colon, a finding that would have led to colonoscopy. The results were compared with the results from VA Cooperative Study 380 for agematched men and women wit h negative fecal occultblood tests and no family history of colon cancer. RESU LTS: Colonoscopy was complete in 1463 women, 230 of whom (15.7 percent) had a fa mily history of colon cancer. Colonoscopy revealed advanced neoplasia in 72 wome n (4.9 percent). If flexible sigmoidoscopy alone had been performed, advanced ne oplasia would have been detected in 1.7 percent of these women (25 of 1463) and missed in 3.2 percent (47 of 1463). Only 35.2 percent ofwomen with advanced neop lasia would have had their lesions identified if they had undergone flexible sig moidoscopy alone, as compared with 66.3 percent of matched men from VA Cooperati ve Study 380 (P< 0.001). CON CLUSIONS: Colonoscopy may be the preferred method of screening for colorectal cancer in women.
文摘Universal access to medical procedures is deemed an advantage of the Canadian health care system. The purposes of this prospective study were to determine the degree to which the practice of colon cancer screening by colonoscopy differed among socioeconomic classes and to assess adherence to screening guidelines. Consecutive patients scheduled to undergo colonoscopy at a single center between August 2000 and August 2002 completed a questionnaire that determined patient characteristics and indications for the procedure. The patients were divided into two groups: screening patients, defined as individuals who indicated they were undergoing colonoscopy for screening purposes and were asymptomatic, and a control group, which comprised patients undergoing colonoscopy because of symptoms. Statistical analysis was performed to determine if patients in the screening group had different characteristics with respect to socioeconomic class, compared with the control group. A total of 1088 patients completed the questionnaire: 707 (65%) had colonoscopy because of symptoms, compared with 381 (35%) who underwent a screening examination. Mean age and marital status were similar in both groups. Of all colonoscopy procedures, there was a significantly greater proportion of men undergoing colonoscopy for screening purposes: 199 (52.2%) vs. 294 (41.6%) in the symptomatic group (p = 0.001). Based on the Cochran-Armitage test, patients in the screening group had significantly higher education levels (p = 0.004) and household incomes (p = 0.001). Income and education level, two indices of socioeconomic status, are statistically significantly higher in patients undergoing screening colonoscopy compared with those having colonoscopy for any other reason.
文摘Context: Limited evidence exists to guide the optimal frequency of repeat endoscopic examination for colorectal cancer screening after a negative colonoscopy. Objective: To determine the duration and magnitude of the risk of developing colorectal cancer following performance of a negative colonoscopy. Design, Setting, and Patients: Population-based retrospective analysis of individuals whose colonoscopy evaluations did not result in a diagnosis of colorectal neoplasia. Patients who had been evaluated between April 1, 1989, and December 31, 2003, were identified using Manitoba Health’s physician billing claims database (N = 35 975). Standardized incidence ratios (SIRs) were calculated to compare colorectal cancer incidence in our cohort with colorectal cancer incidence in the provincial population. Stratified analysis was performed to determine the duration of the reduced risk. Patients with a history of colorectal cancer prior to the index colonoscopy, inflammatory bowel disease, resective colorectal surgery, and lower gastrointestinal endoscopy within the 5 years before the index colonoscopy were excluded. Cohort members were followed up from the time of the index colonoscopy until diagnosis of colorectal cancer, death, out-migration from Manitoba, or end of the study period on December 31, 2003. Main Outcome Measure: Incidence of colorectal cancer. Results: A negative colonoscopy was associated with SIRs of 0.69 (95%confidence interval [CI], 0.59-0.81) at 6 months, 0.66 (95%CI, 0.56-0.78) at 1 year, 0.59 (95%CI, 0.48-0.72) at 2 years, 0.55 (95%CI, 0.41-0.73) at 5 years, and 0.28 (95%CI, 0.09-0.65) at 10 years. The proportion of colorectal cancer located in the right side of the colon was significantly higher in the colonoscopy cohort than the rate in the Manitoba population (47%vs 28%; P< .001). Conclusions: The risk of developing colorectal cancer remains decreased for more than 10 years following the performance of a negative colonoscopy. There is a need to improve the early detection rate of right-sided colorectal neoplasia in usual clinical practice.
文摘Background and study aims: Screening colonoscopy with polypectomy has been shown to reduce the morbidity and mortality associated with colorectal cancer. However, there is a lack of large and systematic prospective studies of the complications of polypectomy. Patients and methods: Data on all snare polypectomies performed in 13 institutions (six hospitals and seven gastroenterology offices) were recorded prospectively during a 20-month period, including data on a 30-day follow-up period. The primary end points of the study were polypectomy complications, which were classed as “major" or “minor". Risk factors for complications were analyzed for both patient characteristics and polyp parameters. Results: A total of 3976 snare polypectomies in 2257 patients (mean age 64.5 years) were included in the study. The mean polyp size was 1.1 cm, and 72%were sessile. Complications occurred in 9.7%of patients (6.1%of polyps); 75%of these complications were minor; and the mortality rate was zero. Multivariate regression analysis revealed polyp size as the main risk factor, both for complications overall (odds ratio 6.56, 95%CI 4.45-9.67) and for major complications (odds ratio 31.01, 95%CI 7.53-128.1). Right-sided polyp location was a significant risk factor for major complications (odds ratio 2.40, 95%CI 1.34-4.28). Setting a cut-off value of 3%as an acceptable rate for major complications, polyps larger than 1 cm in the right colon or 2 cm in the left colon, and multiple polyps carried an increased risk. Conclusions: Colonoscopic polypectomy is associated with a 10%rate of complications, but three-quarters of these are of minor clinical significance. More than 90%of the complications can be managed conservatively if adequate endoscopic expertise is available. Guidelines for intensified follow-up after polypectomy should be based on the size, location, and number of a patient’spolyps.
文摘PURPOSE:Data supporting an increased risk of colorectal cancer in patients with Crohn’s colitis are inconsistent.Despite this,clinical recommendations regarding colonoscopic screening and surveillance for patients with Crohn’s colitis are extrapolated from chronic ulcerative colitis protocols.The primary aim of our study was to determine the incidence of dysplasia and carcinoma in pathology specimens of patients undergoing segmental or total colectomy for Crohn’s disease of the large bowel.In addition,we sought to identify risk factors associated with the development of dysplasia and carcinoma.METHODS:We performed a retrospective review of all patients operated on at our institution for Crohn’ s colitis between January 1992 and May 2004.Data were retrieved from patient charts,operative notes,and pathology reports.Logistic regression was used to model the probability of having dysplasia or adenocarcinoma.RESULTS:Two hundred twenty-two patients(138 females) who underwent surgical resection for the treatment of Crohn’s colitis were included in the study.Mean age at surgery was 41(range,15-82) years and the mean duration of disease was 10(range,0-53) years.There were five cases of dysplasia(2.3 percent) and six cases of adenocarcinoma(2.7 percent) .Three patients with dysplasia and one with adenocarcinoma were diagnosed on preoperative colonoscopy;while the other cases were discovered incidentally on pathologic examination of resected specimens.Factors associated with the presence of dysplasia or adenocarcinoma included older age at diagnosis(38.2 vs.30.3 years,P = 0.02) ,longer disease duration(16.0 vs.10.1 years,P = 0.05) ,and disease extent(90 percent extensive vs.59 percent limited,P = 0.05) .CONCLUSIONS:Patients with severe Crohn’s colitis requiring surgery are at significant risk for developing dysplasia and adenocarcinoma,particularly when diagnosed at an older age,after longer disease duration,and with more extensive colon involvement.
