Old vs new: Risk factors predicting early onset colorectal cancer

BACKGROUND Colorectal cancer(CRC)is the second leading cause of all cancer related deaths in the United States and Europe.Although the incidence has been decreasing for individuals’≥50,it has been on the rise for individuals<50.AIM To identify potential risk factors for early-onset CRC.METHODS A population-based cohort analysis using a national database,Explorys,screened all patients with an active electronic medical record from January 2012 to December 2016 with a diagnosis of CRC.Subgroups were stratified based on age(25–49 years vs≥50 years).Demographics,comorbidities,and symptom profiles were recorded and compared between both age groups.Furthermore,the younger group was also compared with a control group consisting of individuals aged 25-49 years within the same timeframe without a diagnosis of CRC.Twentydata points for CRC related factors were analyzed to identify potential risk factors specific to early-onset CRC.RESULTS A total of 68860 patients were identified with CRC,of which 5710(8.3%)were younger than 50 years old,with 4140(73%)between 40-49 years of age.Multivariable analysis was reported using odds ratio(OR)with 95%CI and demonstrated that several factors were associated with an increased risk of CRC in the early-onset group versus the later-onset group.These factors included:African-American race(OR 1.18,95%CI:1.09-1.27,P<0.001),presenting symptoms of abdominal pain(OR 1.82,95%CI:1.72-1.92,P<0.001),rectal pain(OR 1.50,95%CI:1.28-1.77,P<0.001),altered bowel function(OR 1.12,95%CI:1.05-1.19,P=0.0005),having a family history of any cancer(OR 1.78,95%CI:1.67-1.90,P<0.001),gastrointestinal(GI)malignancy(OR 2.36,95%CI:2.18-2.55,P<0.001),polyps(OR 1.41,95%CI:1.08-1.20,P<0.001),and obesity(OR 1.14,95%CI:1.08-1.20,P<0.001).Comparing the early-onset cohort versus the control group,factors that were associated with an increased risk of CRC were:male gender(OR 1.34,95%CI:1.27-1.41),P<0.001),Caucasian(OR 1.48,95%CI:1.40-1.57,P<0.001)and African-American race(OR 1.25,95%CI:1.17-1.35,P<0.001),presenting symptoms of abdominal pain(OR 4.73,95%CI:4.49-4.98,P<0.001),rectal pain(OR 7.48,95%CI:6.42-8.72,P<0.001),altered bowel function(OR 5.51,95%CI:5.19-5.85,P<0.001),rectal bleeding(OR 9.83,95%CI:9.12-10.6,P<0.001),weight loss(OR 7.43,95%CI:6.77-8.15,P<0.001),having a family history of cancer(OR 11.66,95%CI:10.97-12.39,P<0.001),GI malignancy(OR 28.67,95%CI:26.64-30.86,P<0.001),polyps(OR 8.15,95%CI:6.31-10.52,P<0.001),tobacco use(OR 2.46,95%CI:2.33-2.59,P<0.001),alcohol use(OR 1.71,95%CI:1.62-1.80,P<0.001),presence of colitis(OR 4.10,95%CI:3.79-4.43,P<0.001),and obesity(OR 2.88,95%CI:2.74-3.04,P<0.001).CONCLUSION Pending further investigation,these potential risk factors should lower the threshold of suspicion for early CRC and potentially be used to optimize guidelines for early screening.

Incidence and localization of lymphoid follicles in early colorectal neoplasms

AIM： TO investigate the incidence and Iocalizations of lymphoid follicles （LFs） in early colorectal neoplasms in human beings. METHODS： From July 1992 to September 1999, a total of 1 324 early colorectal neoplasms were removed endoscopically or surgically at our hospital; 1 031 （77.9%） were available for analysis in this study. Localization of LFs was defined histologically： as submucosal LFs, if located under the muscularis mucosa; and as intramucosal LFs, if located across or over the muscularis RESULTS： Histologically, the materials included 903 intramucosal neoplasms and 128 submucosal cancers. Overall incidence of LFs was 27.2% （280/1 031）. The incidence of LFs was significantly higher in females （33.6% vs 24.9%, P = 0.0064）, the right-sided colon （32.2% vs 25.6%, P = 0.0403） and in flat or depressed type lesions （34.6% vs 25.2%, P〈O.O001） as compared to males, left-sided colon and protruding type lesions, respectively. The incidences of intramucosal neoplasms and submucosal cancers were 24.3% and 43.8%, respectively （P〈O.O001）. Localizations of LFs （intramucosal LF/submucosal LF） in depressed, flat, and protruding types were 1/24, 14/36, and 131/74, respectively. CONCLUSION： The incidence of LFs in early human colorectal neoplasms significantly differs by gender, location, macroscopic type, and histology. Moreover,localization significantly differs by macroscopic type.

Endoscopic submucosal dissection for colorectal neoplasms

Although endoscopic submucosal dissection(ESD) gains acceptance as one of the standard treatments for esophageal and stomach neoplasms in Japan,it is still in the developing stage for colorectal neoplasms.In terms of indications,little likelihood of nodal metastasis and technical resectability are principally considered.Some of intramucosal neoplasms,carcinomas with minute submucosal invasion,and carcinoid tumors,which are technically unresectable by conventional endoscopic treatments,may become good candidates for ESD,considering substantial risks and obtained benefits.ESD as a staging measure to obtain histological information of the invasion depth and lymphovascular infiltration is acceptable because preoperative prediction is difficult in some cases.In terms of techniques,advantages of ESD in comparison with other endoscopic treatments are to be controllable in size and shape,and to be resectable even in large and fibrotic neoplasms.The disadvantages may be longer procedure time,heavier bleeding,and higher possibility of perforation.However,owing to refinement of the techniques,invention of devices,and the learning curve,acceptable technical safety has been achieved.Colorectal ESD is very promising and become one of the standard treatments for colorectal neoplasms in the near future.

Approach to early-onset colorectal cancer:Clinicopathological,familial,molecular and immunohistochemical characteristics

AIM:To characterize clinicopathological and familial features of early-onset colorectal cancer(CRC) and compare features of tumors with and without microsatellite instability(MSI).METHODS:Forty-five patients with CRC aged 45 or younger were included in the study.Clinical information,a three-generation family history,and tumor samples were obtained.MSI status was analyzed and mismatch repair genes were examined in the MSI families.Tumors were included in a tissue microarray and an immunohistochemical study was carried out with a panel of selected antibodies.RESULTS:Early onset CRC is characterized by advanced stage at diagnosis,right colon location,low-grade of differentiation,mucin production,and presence of polyps.Hereditary forms represent at least 21% of cases.Eighty-one percent of patients who died during followup showed a lack of expression of cyclin E,which could be a marker of poor prognosis.β-catenin expression was normal in a high percentage of tumors.CONCLUSION:Early-onset CRC has an important familial component,with a high proportion of tumors showing microsatellite stable.Cyclin E might be a poor prognosis factor.

Optimization of colorectal cancer screening strategies: New insights

In this editorial,we discuss the article by Agatsuma et al.We concentrate specifically on the current routinely used screening tests recommended by society guidelines and delve into the significance of early diagnosis of colorectal cancer(CRC)and its substantial impact on both incidence and mortality rates.Screening is highly recommended,and an early diagnosis stands out as the most crucial predictor of survival for CRC patients.Therefore,it is essential to identify and address the barriers hindering adherence to screening measures,as these barriers can vary among different populations.Furthermore,we focus on screening strategy optimization by selecting high-risk groups.Patients with comorbidities who regularly visit hospitals have been diagnosed at an early stage,showing no significant difference compared to patients undergoing regular screening.This finding highlights the importance of extending screening measures to include patients with comorbidities who do not routinely visit the hospital.

Early-onset colorectal cancer:A sporadic or inherited disease?

Colorectal cancer is the third most common cancer diagnosed worldwide. Although epidemiology data show a marked variability around the world, its overall incidence rate shows a slow but steady decrease, mainly in developed countries. Conversely, early-onset colorectal cancer appears to display an opposite trend with an overall prevalence in United States and European Union ranging from 3.0% and 8.6%. Colorectal cancer has a substantial proportion of familial cases. In particular, early age at onset is especially suggestive of hereditary predisposition. The clinicopathological and molecular features of colorectal cancer cases show a marked heterogeneity not only between early- and late-onset cases but also within the early-onset group. Two distinct subtypes of early-onset colorectal cancers can be identified: a &#x0201c;sporadic&#x0201d; subtype, usually without family history, and an inherited subtype arising in the context of well defined hereditary syndromes. The pathogenesis of the early-onset disease is substantially well characterized in the inherited subtype, which is mainly associated to the Lynch syndrome and occasionally to other rare mendelian diseases, whereas in the &#x0201c;sporadic&#x0201d; subtype the origin of the disease may be attributed to the presence of various common/rare genetic variants, so far largely unidentified, displaying variable penetrance. These variants are thought to act cumulatively to increase the risk of colorectal cancer, and presumably to also anticipate its onset. Efforts are ongoing in the attempt to unravel the intricate genetic basis of this &#x0201c;sporadic&#x0201d; early-onset disease. A better knowledge of molecular entities and pathways may impact on family-tailored prevention and clinical management strategies.

Molecular approach to genetic and epigenetic pathogenesis of early-onset colorectal cancer

Colorectal cancer(CRC) is the third most frequent cancer type and the incidence of this disease is increasing gradually per year in individuals younger than 50 years old. The current knowledge is that early-onset CRC(EOCRC) cases are heterogeneous population that includes both hereditary and sporadic forms of the CRC. Although EOCRC cases have some distinguishing clinical and pathological features than elder age CRC, the molecular mechanism underlying the EOCRC is poorly clarified. Given the significance of CRC in the world of medicine, the present review will focus on the recent knowledge in the molecular basis of genetic and epigenetic mechanism of the hereditary forms of EOCRC, which includes Lynch syndrome, Familial CRC type X, Familial adenomatous polyposis, Mut YH-associated polyposis, Juvenile polyposis syndrome, Peutz-Jeghers Syndrome and sporadic forms of EOCRC. Recent findings about molecular genetics and epigenetic basis of EOCRC gave rise to new alternative therapy protocols. Although exact diagnosis of these cases still remains complicated, the present review paves way for better predictions and contributes to more accurate diagnostic and therapeutic strategies into clinical approach.

Use of blood-based biomarkers for early diagnosis and surveillance of colorectal cancer

Early screening for colorectal cancer(CRC) holds the key to combat and control the increasing global burden of CRC morbidity and mortality. However, the current available screening modalities are severely inadequate because of their high cost and cumbersome preparatory procedures that ultimately lead to a low participation rate. People simply do not like to have colonoscopies. It would be ideal, therefore, to develop an alternative modality based on blood biomarkers as the first line screening test. This will allow for the differentiation of the general population from high risk individuals. Colonoscopy would then become the secondary test, to further screen the high risk segment of the population. This will encourage participation and therefore help to reach the goal of early detection and thereby reduce the anticipated increasing global CRC incidence rate. A blood-based screening test is anappealing alternative as it is non-invasive and poses minimal risk to patients. It is easy to perform, can be repeated at shorter intervals, and therefore would likely lead to a much higher participation rate. This review surveys various blood-based test strategies currently under investigation, discusses the potency of what is available, and assesses how new technology may contribute to future test design.

基于Logistic回归和支持向量机的早发性结直肠癌风险预测模型

目的:通过Logis tic回归和支持向量机(SVM)探究早发性结直肠癌(EOCRC)和晚发性结直肠癌(LOCRC)的危险因素,建立针对不同年龄段人群的风险预测模型并比较预测效果。方法:选择2012—2022年诊断为结直肠癌患者,记录人口学特征、临床表现、既往史、家族史、生活方式、体格检查、实验室检查及病理诊断,分别建立风险预测模型,比较两模型的ROC曲线下面积(AUROC)、准确率、精确率、召回率、F1分数。结果:综合两模型结果,EOCRC风险与出现消化道出血、腹胀腹痛、大便习惯改变等临床表现、体重减轻、肿瘤标志物升高具有较强的正相关性,与婚姻状况、阑尾切除史、糖尿病史、血脂异常病史、结直肠癌家族史也存在较弱的正相关;LOCRC风险与婚姻状况、出现临床表现、体重减轻、血脂异常、肿瘤标志物升高具有较强的正相关性,与年龄、吸烟、阑尾切除史、结直肠癌家族史也存在一定的正相关性。两模型的AUROC、准确率、F1分数相差不大,但Logistic回归模型的精确率更高而SVM模型的召回率更高。结论:EOCRC和LOCRC的危险因素不完全相同,婚姻状况、吸烟、血脂异常、肿瘤家族史在EOCRC中的贡献低于在LOCRC中的贡献。相较Logistic回归,SVM能发现更多的结直肠癌危险因素,能尽可能多的找出结直肠癌的可能患者。

Fecal immunochemical test accuracy in average-risk colorectal cancer screening

AIM: To assess the fecal immunochemical test (FIT) accuracy for colorectal cancer (CRC) and advanced neoplasia (AN) detection in CRC screening.

早发性与晚发性结直肠癌临床特征比较及预后的分析

结直肠癌(colorectal cancer,CRC)是全球常见的消化系肿瘤,发病率位于世界第3,病死率位居世界第2,近年来结直肠癌总的发病率及病死率有所下降,但早发性结直肠癌(early-onset colorectal cancer,EOCRC)呈整体增长趋势.通常把<50岁诊断的结直肠癌定义为EOCRC,与晚发性结直肠癌(late-onset colorectal cancer,LOCRC)相比,其具有独特的临床特征,且预后较差.本文就EOCRC的临床特征及预后进行简要述评.

DNA 错配修复系统与早发结直肠癌的相关性研究

为探讨DNA错配修复(MMR)系统与早发性结直肠癌(EO-CRC)病理特征及其预后关系,收集189例EO-CRC肿瘤组织。通过免疫组化方法分为完整型组(pMMR)和缺陷型组(dMMR);基于Kaplan-Meier方法分析两组预后现状。研究结果显示,37例样本为dMMR,152例样本为pMMR。dMMR组中,MLH1和PMS2同时缺失最多(32.43%);dMMR组肿瘤位置大多发生于右半结肠(48.65%),pMMR组大多发生于直肠(58.55%);两组肿瘤尺寸大小和TNM分期均具有统计学意义(P<0.05);两组整体生存率具有统计学意义(Log-rank χ^(2)=4.19,P<0.05)。这表明,EO-CRC患者中dMMR组具有特殊的病理特征且预后更好,为EO-CRC患者的早期诊断和精准治疗提供参考。

Colorectal cancer patients in a tertiary hospital in Indonesia: Prevalence of the younger population and associated factors

BACKGROUND An increasing trend in colorectal cancer(CRC)occurring at younger ages has been observed worldwide,even though incidence is declining in the general population.Most currently available guidelines still recommend CRC screening for older populations,despite an alarming rise in early-onset CRC incidence.Risk stratification is necessary to further determine the population most at risk for early-onset CRC.However,epidemiological data on related clinical characteristics and potential risk factors,especially in developing countries,have not been widely reported.AIM To investigate the prevalence,demographics,clinicopathologic features,and associated factors of young-onset CRC patients in a tertiary hospital in Indonesia.METHODS Patients undergoing colonoscopy examination between 2008 and 2019,yielding a diagnosis of CRC were identified from medical records.The subjects were classified into two groups according to their age at diagnosis,namely early-onset(18-49 years old)and late-onset(≥50-years-old).Demographic data,characteristics,and risk factors of both onset age groups were evaluated using the chisquare and Fisher’s exact test.RESULTS Among 495 CRC patients confirmed by histopathology,205(41.4%)were classified as early-onset and 290(58.6%)as late-onset.Most subjects in the earlyonset CRC group were male(53.7%),with 89.8%displaying adenocarcinoma histopathology.A majority(78%)of the early-onset CRC patients had left-sided tumors,with the rectum(41%)and rectosigmoid(17.6%)being the most common sites.Abdominal pain was the most frequent symptom in the early-onset CRC patients(55.6%),which was significantly higher than that in the late-onset CRC patients(43.8%,P<0.05).Early-onset CRC cases were more likely to be underweight(34.6%vs 20.0%,P<0.001)compared to late-onset CRC cases.The proportion of subjects with suspected hereditary nonpolyposis colorectal cancer(HNPCC)was also higher in the early-onset CRC group than in the late-onset age group(9.3%vs 4.1%,P<0.05).However,no difference was observed in the parental or family histories of CRC cases.CONCLUSION Early-onset CRC patients were more likely to have abdominal pain,underweight status,and HNPCC suspicion than late-onset CRC patients.

Impact of colorectal cancer screening participation in remote northern Canada:A retrospective cohort study

BACKGROUND Screening provides earlier colorectal cancer(CRC)detection and improves outcomes.It remains poorly understood if these benefits are realized with screening guidelines in remote northern populations of Canada where CRC rates are nearly twice the national average and access to colonoscopy is limited.AIM To evaluate the participation and impact of CRC screening guidelines in a remote northern population.METHODS This retrospective cohort study included residents of the Northwest Territories,a northern region of Canada,age 50-74 who underwent CRC screening by a fecal immunohistochemical test(FIT)between January 1,2014 to March 30,2019.To assess impact,individuals with a screen-detected CRC were compared to clinically-detected CRC cases for stage and location of CRC between 2014-2016.To assess participation,we conducted subgroup analyses of FIT positive individuals exploring the relationships between signs and symptoms of CRC at the time of screening,wait-times for colonoscopy,and screening outcomes.Two sample Welch t-test was used for normally distributed continuous variables,Mann-Whitney-Wilcoxon Tests for data without normal distribution,and Chi-square goodness of fit test for categorical variables.A P value of<0.05 was considered to be statistically significant.RESULTS 6817 fecal tests were completed,meaning an annual average screening rate of 25.04%,843(12.37%)were positive,629 individuals underwent a follow-up colonoscopy,of which,24.48%had advanced neoplasia(AN),5.41%had CRC.There were no significant differences in stage,pathology,or location between screen-detected cancers and clinically-detected cancers.In assessing participation and screening outcomes,we observed 49.51%of individuals referred for colonoscopy after FIT were ineligible for CRC screening,most often due to signs and symptoms of CRC.Individuals were more likely to have AN if they had signs and symptoms of cancer at the time of screening,waited over 180 d for colonoscopy,or were indigenous[respectively,estimated RR 1.1895%CI of RR(0.89-1.59)];RR 1.523(CI:1.035,2.240);RR 1.722(CI:1.165,2.547)].CONCLUSION Screening did not facilitate early cancer detection but facilitated higher than anticipated AN detection.Signs and symptoms of CRC at screening,and long colonoscopy wait-times appear contributory.

Colorectal cancer screening from 45 years of age: Thesis, antithesis and synthesis

Colorectal cancer incidence and mortality in patients younger than 50 years are increasing, but screening before the age of 50 is not offered in Europe. Advancedstage diagnosis and mortality from colorectal cancer before 50 years of age are increasing. This is not a detection-bias effect;it is a real issue affecting the entire population. Three independent computational models indicate that screening from 45 years of age would yield a better balance of benefits and risks than the current start at 50 years of age. Experimental data support these predictions in a sex- and race-independent manner. Earlier screening is seemingly affordable, with minimal impediments to providing younger adults with colonoscopy. Indeed, the American Cancer Society has already started to recommend screening from 45 years of age in the United States. Implementing early screening is a societal and public health problem. The three independent computational models that suggested earlier screening were criticized for assuming perfect compliance. Guidelines and recommendations should be derived from well-collected and reproducible data, and not from mathematical predictions. In the era of personalized medicine, screening decisions might not be based solely on age, and sophisticated prediction software may better guide screening. Moreover, early screening might divert resources away from older individuals with greater biological risks. Finally, it is still unknown whether early colorectal cancer is part of a continuum of disease or a biologically distinct disease and, as such, it might not benefit from screening at all. The increase in early-onset colorectal cancer incidence and mortality demonstrates an obligation to take actions. Earlier screening would save lives, and starting at the age of 45 years may be a robust screening option.

Colorectal cancer in the young,many questions,few answers

At a time where the incidence of colorectal cancer,a disease predominantly of developed nations,is showing a decline in those 50 years of age and older,data from the West is showing a rising incidence of this cancer in young individuals.Central to this has been the 75% increase in rectal cancer incidence in the last four decades.Furthermore,predictive data based on mathematical modelling indicates a 124 percent rise in the incidence of rectal cancer by the year 2030-a statistic that calls for collective global thought and action.While predominance of colorectal cancer(CRC) is likely to be in that part of the large bowel distal to the splenic flexure,which makes flexible sigmoidoscopic examination an ideal screening tool,the cost and benefit of mass screening in young people remain unknown.In countries where the incidence of young CRC is as high as 35% to 50%,the available data do not seem to indicate that the disease in young people is one of high red meat consuming nations only.Improvement in our understanding of genetic pathways in the aetiology of CRC,chiefly of the MSI,CIN and CIMP pathway,supports the notion that up to 30% of CRC is genetic,and may reflect a familial trait or environmentally induced changes.However,a number of other germline and somatic mutations,some of which remain unidentified,may play a role in the genesis of this cancer and stand in the way of a clear understanding of CRC in the young.Clinically,a proportion of young persons with CRC die early after curative surgery,presumably from aggressive tumour biology,compared with the majority in whom survival after operation will remain unchanged for five years or greater.The challenge in the future will be to determine,by genetic fingerprinting or otherwise,those at risk of developing CRC and the determinants of survival in those who develop CRC.Ultimately,prevention and early detection,just like for those over 50 years with CRC,will determine the outcome of CRC in young persons.At present,aside from those with an established familial tendency,there is no consensus on screening young persons who may be at risk.However,increasing awareness of this cancer in the young and the established benefit of prevention in older persons,must be a message that should be communicated with medical students,primary health care personnel and first contact doctors.The latter constitutes a formidable challenge.

Colorectal cancer in patients under 50 years of age:A retrospective analysis of two institutions' experience

AIM:To investigate the epidemiological characteristics of colorectal cancer(CRC)in patients under 50 years of age across two institutions.METHODS:Records of patients under age 50 years of age who had CRC surgery over a 16 year period were assessed at two institutions.The following documents where reviewed:admission notes,operative notes,and discharge summaries.The main study variables included:age,presenting symptoms,family history,tumor location,operation,stage/differentiation of disease,and post operative complications.Stage of disease was classified according to the American Joint Committee on Cancer TNM staging system:tumor depth;node status;and metastases.RESULTS:CRC was found in 180 patients under age50 years(87 females,93 males;mean age 41.4±6.2years).Young patients accounted for 11.2%of cases during a 6 year period for which the full data set wasavailable.Eight percent had a 1stdegree and 12%a 2nd degree family CRC history.Almost all patients(94%)were symptomatic at diagnosis;common symptoms included:bleeding(59%),obstruction(9%),and abdominal/rectal pain(35%).Evaluation was often delayed and bleeding frequently attributed to hemorrhoids.Advanced stage CRC(Stage 3 or 4)was noted in 53%of patients.Most tumors were distal to the splenic flexure(77%)and 39%involved the rectum.Most patients(95%)had segmental resections;6 patients had subtotal/total colectomy.Poorly differentiated tumors were noted in 12%and mucinous lesions in 19%of patients of which most had Stage 3 or 4 disease.Twenty-two patients(13%)developed recurrence and/or progression of disease to date.Three patients(ages 42,42and 49 years)went on to develop metachronous primary colon cancers within 3 to 4 years of their initial resection.CONCLUSION:CRC was common in young patients with no family history.Young patients with symptoms merit a timely evaluation to avoid presentation with late stage CRC.

Colorectal endoscopic submucosal dissection from a Westernperspective:Today's promises and future challenges

Over the last few years, endoscopic submucosal dissection(ESD) has shown to be effective in the management of early colorectal neoplasms, particularly in Asian countries where the technique was born. In the Western world, its implementation has been slow and laborious. In this paper, the indications for ESD, its learning model, the available methods to predict the presence of deep submucosal invasion before the procedure and the published outcomes from Asia and Europe will be reviewed. Since ESD has several limitations in terms of learning achievement in the West, and completion of the procedure for the first cases is difficult in our part of the world, a short review on colorectal assisted ESD has been included. Finally, other endoscopic and surgical treatment modalities that are in competition with colorectal ESD will be summarized.

Balloon overtube-guided colorectal endoscopic submucosal dissection

AIM:To evaluate the usefulness of a balloon overtube to assist colorectal endoscopic submucosal dissection(ESD)using a gastroscope.METHODS:The results of 45 consecutive patients who underwent colorectal ESD were analyzed in a single tertiary endoscopy center.In preoperative evaluation of access to the lesion,difficulties were experienced in the positioning and stabilization of a gastroscope in 15 patients who were thus assigned to the balloonguided ESD group.A balloon overtube was placed with a gastroscope to provide an endoscopic channel to the lesion in cases with preoperatively identified difficulties related to accessibility.Colorectal ESD was performed following standard procedures.A submucosal fluid bleb was created with hyaluronic acid solution.A circumferential mucosal incision was made to marginate the lesion.The isolated lesion was finally excised from the deeper layers with repetitive electrosurgical dissections with needle knives.The success of colorectal ESD,procedural feasibility,and procedure-related complications were the main outcomes and measurements.RESULTS:The overall en bloc excision rate of colorectal ESD during this study at our institution was 95.6%.En bloc excision of the lesion was successfully achieved in 13 of the 15 patients(86.7%)in the balloon overtube-guided colorectal ESD group,which was comparable to the results of the standard ESD group with better accessibility to the lesion(30/30,100%,not statistically significant).CONCLUSION:Use of a balloon overtube can improve access to the lesion and facilitate scope manipulation for colorectal ESD.

Predictors of Low Colorectal Cancer Screening in an Urban Academic Family Practice

Purpose: The primary objective was to describe the specific socio-demographic variables that are associated with colorectal cancer (CRC) under-screening in an urban, inner city population. The secondary objective was to determine the overall proportion of eligible patients who are not appropriately screened. Methods: A retrospective chart review of patients eligible for average-risk CRC screening as per Ontario’s ColonCancerCheck program guidelines was conducted at an academic, inner city family health practice associated with St. Michael’s Hospital in Toronto, Ontario. Simple measures of association, including t-tests and chi-square tests, were used to determine the relationships between screening and demographic characteristics. Based on a type I error rate of 0.05 and an appropriate sample size, the calculated power for this study was 0.82. Results: A total of 200 patients were randomly selected;54% were male;the majority were non-immigrants (77.5%) and were employed or retired (76.5%). Fifty-five percent of screened patients were up to date as per guidelines;29.5% and 31% were up to date with a fecal occult blood test or a colonoscopy respectively. Individuals with psychiatric illness (p = 0.0005), with no history of prior cancer screening for other cancers (p = 0.0001), on disability or unemployed (p = 0.0010), or who were younger (p = 0.0062) were significantly less likely to undergo CRC screening. Conclusion: Colorectal cancer screening rates at this academic, urban family practice were very similar to province wide screening rates. Future studies should focus on group specific interventions to increase CRC screening uptake in low CRC screened populations.