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9th June 2022
The use of screening endoscopy in women before the age of 50 is associated with a 55% lower risk of being diagnosed with colorectal cancer (CRC) at age 55. This was the conclusion of a prospective cohort study of US women.
According to the International Agency for Research on Cancer, in 2020 there were almost 2 million colorectal cancer diagnoses and nearly one million deaths, making it the third most commonly diagnosed cancer type in the world. Although incidence rates among those of screening age have decreased, data from the US shows that among individuals under 50 years of age, the incidence rate has increased by approximately 2% between 2011 and 2016. According to the American Cancer Society, screening for CRC is associated with a significant reduction in CRC incidence and CRC-related mortality and have recommended that adults aged 45 years and older with an average risk of CRC should undergo regular screening. Furthermore, long-term follow studies suggest that screening endoscopy is associated with a reduced colorectal-cancer mortality. Nevertheless, there are limited data on the value of screening endoscopy in younger patients.
For the present study, the US researchers used data in the Nurses’ Health Study II, primarily because participants in this prospective registry were aged 26 to 45 at enrolment and this therefore provided an opportunity to examine any potential associations between the age of screening endoscopy and the development of CRC. Using 1991 as the baseline because this was the first year when questions about screening endoscopy were included, participants were asked in subsequent questionnaires if they had undergone sigmoidoscopy or colonoscopy in the past two years and the reason for this screening. The primary endpoint was overall CRC incidence although the researchers included the incidence of younger-onset CRC (diagnosed before age 55) and CRC mortality as secondary outcomes.
Screening endoscopy and development of colorectal cancer
A total of 111,801 women with a median of 36 years at enrolment were included in the analysis and followed for 26 years, during which time 519 incident cases of CRC were documented. Compared to women who underwent screening endoscopy age 50 or later, those who underwent a screen before 45 years of age were more likely to have a family history of CRC.
When compared to women who did not undergo screening endoscopy, the adjusted hazard ratios (HRs) for any CRC were 0.37 (95% CI 0.26 – 0.53) for women aged under 45 years, 0.43 (95% CI 0.29 – 0.62) for those 45 to 49 years of age and 0.46 (95% CI 0.30 – 0.69) for those 55 years and older. Hence there was a significantly lower risk of incident CRC when screening was started before the age of 45.
The authors calculated that the absolute reduction in the estimated cumulative incidence of CRC up to age 60 was 72 per 100,00 people if screening endoscopy was started between the ages of 45 to 49 compared to being performed between the ages of 50 to 54.
The risk of being diagnosed with CRC at age 55 was 55% lower if screening was started before the age of 45 (HR = 0.45, 95% CI 0.29 – 0.70) and equally lower (HR = 0.43) when started between the ages of 45 and 49.
The authors concluded that earlier screening endoscopy (before 50 years of age) was associated with a significantly lower risk of both CRC and a diagnosis before age 55.
Citation
Ma W et al. Age at Initiation of Lower Gastrointestinal Endoscopy and Colorectal Cancer Risk Among US Women JAMA Oncol 2022
6th May 2022
Globally, cancer of the colon and rectum (colorectal cancer) was diagnosed in 1.93 million people in 2020 and responsible for 916,000 deaths. Moreover, screening colonoscopy has been shown to be associated with a substantial decreased mortality risk. CT colonography (CTC) is a minimally invasive test that uses CT scans to check the colon and rectum. In a 2008 study, the authors concluded that CTC screening identified 90% of subjects with adenomas or cancers measuring 10 mm or more in diameter and that the results augmented published data on the role of CTC in screening patients with an average risk of colorectal cancer. However, to date, there is limited information on the sociodemographic factors that might influence uptake of CTC.
For the present investigation, the researchers turned to the National Health Interview Survey (NHIS), which is a nationally representative cross-sectional survey and used data collected in 2019. Included participants were aged 50 to 75 years of age and with no recorded history of colorectal cancer. In the NHIS survey, individuals were asked about whether or not they ever had a CTC and if they responded positively, when the scan had been performed. The researchers collected additional information on age, gender, ethnicity and employment status. They employed multiple variable logistic regression to evaluate predictors of CTC use.
Predictors of CTC utilisation
A total of 13,709 individuals with a mean age of 61.4 years (52.7% female) were included in the analysis, of whom, 70.3% were White, 10.4% Black and 12.1% Hispanic.
In total, only 1.4% of participants reported having previously undergone CTC and, of these, 39.9% had the procedure within the last 12 months.
When analysing the association between CTC use and ethnicity, Hispanic individuals were more than twice as likely to undergo CTC compared with White participants (OR = 2.67, 95% CI 1.66 – 4.29, p < 0.001). There was also a similarly higher use among Black individuals (OR = 2.47, 95% CI 1.60 – 3.82, p < 0.001) than White participants.
Among the other sociodemographic factors examined, only participants who reported that they worked in the last week were significantly less likely to have a CTC (OR = 0.61, 95% CI 0.40 – 0.94, p = 0.024).
One limitation recognised by the authors was how the study data were collected in 2019 prior to the COVID-19 pandemic and therefore they were unable to assess any potential impact on CTC uptake. They concluded that strategies improving access to CTC services could mitigate the observed racial disparities.
Citation
O’Connor B et al. Predictors of CT Colonography Use: Results From the 2019 National Health Interview Cross-Sectional Survey J Am Coll Radiol 2022
19th January 2022
The presence of neoplasia or precancerous lesions, have been identified after colorectal screening in patients aged 45 to 49 years of age, highlighting the need for lowering the age of such screening for average risk individuals. This was the finding from an examination of real-world outpatient colonoscopy data by a team from the Dr. Henry D. Janowitz Division of Gastroenterology, New York, US.
Colorectal cancer is a malignant tumour that forms in the tissues of the colon and is often grouped together with rectal cancer, due to the fact that these cancers share common features. During 2020 in Europe, colorectal cancer became the second most common cancer and the second highest cause of cancer death, accounting for 12.7% of all new cancer diagnoses and 12.4% of cancer deaths. Moreover, the importance of screening has been highlighted in a study which observed that the largest decreases in colorectal cancer mortality were seen in countries with long-standing screening programmes.
The incidence of early-onset colorectal cancer (i.e., cases in those aged under 50 years of age) has seen a world-wide increase, especially in high-income countries although the reasons behind this increase are uncertain. In addition, data suggests that the incidence of deaths due to early-onset colorectal cancer are also rising, had that these had increased by 1.3% annually between 2008 and 2017, in those aged younger than 50 years. Despite this, most screening programmes in Europe begin at 50 years of age.
But could there be an advantage from earlier screening and could this help identify those with neoplasia? This was the aim of the present study and the US team analysed data from a large and nationally representative set of outpatient colonoscopies to identify colorectal neoplasia among patients aged 18 to 54 years of age. They undertook a retrospective analysis of colonoscopy data and compared a ‘young onset group (defined as aged 18 to 49) with those aged 50 to 54 years.
Findings
A total of 562,559 colonoscopy procedures were included in the analysis, 145,998 of which were undertaken in those aged 18 – 44 years and 79,934 in those aged 45 – 49 years.
Among individuals aged 45 – 49, approximately 32% had any form of neoplasia, 7.5% had advanced premalignant lesions and 0.58% had colorectal cancer with a neoplasia present in 26.6% of those aged 40 to 44 years.
Discussing their findings, the authors stated that in a representative sample of patients under 50 years of age, the prevalence of any neoplasia among those aged 45 – 49 were almost as high as in those in the 50 to 54 year olds. They concluded that lowering the screening age to 45 will likely enable the detection of important pathology more frequently.
Citation
Trivedi PD et al. Prevalence and Predictors of Young-Onset Colorectal Neoplasia: Insights from a Nationally Representative Colonoscopy Registry Gastroenterology 2022
4th January 2022
Dietary supplements (DS) are used by 40% of adult patients diagnosed with either breast, prostate or colorectal cancer according to research by a team from the Department of Behavioural Science and Health, University College London, UK.
Survival from cancer appears to be increasing, with a 2018 global surveillance study finding that survival trends are generally increasing, even for some of the more lethal cancers. While evidence supporting various strategies aimed at reducing cancer risk in those living with and beyond cancer is rather limited, a 2018 report by the World Cancer Research fund and the American Institute for Cancer research, is clear in its view that ‘high-dose dietary supplements are not recommended for cancer prevention’, encouraging individuals to meet their nutritional needs through diet alone. Nevertheless, some data shows that cancer survivors tend to report a higher usage of DS than those with the disease.
For the current study, the authors sought to gain a better understanding the range of and reasons for, use of DS among survivors of breast, prostate and colorectal cancer. They undertook a cross-sectional survey using data from the Advancing Survival Cancer Outcomes Trial (ASCOT) and asked respondents with each of the three cancers, their thoughts about lifestyle and cancer, use of specific foods, e.g. fruits, vegetables, meat and high calorie foods together with information on the use of DS and any other non-prescribed treatments such as herbal extracts. Respondents were asked to express their views (using a Likert scale) on the perceived importance of supplements as an approach to prevent cancer reoccurrence.
Findings
A total of 1049 participants with mean age of 64.4 years (62.1% female) provided usable data for analysis. Breast cancer was the most common (54.4%) among respondents, followed by prostate (25.2%) and colorectal (20.4%). In addition, the majority were of white ethnicity (94%) and 68% had either no (34.9%) or at least one co-morbidity.
In total, 40% of respondents reported DS use, of whom, 32% believed that these supplements were important for a reduction in cancer recurrence. The most commonly used form of supplements were fish oils (13.1%), followed by calcium and vitamin D (9.1%) and multivitamin and minerals (8.2%).
Using regression analysis, the only factors significantly associated with DS use were meeting the requirements for fruit and vegetable intake (odds ratio, OR = 1.36, 95% CI 1.02 – 1.82, p = 0.039), a belief in the importance of supplements to prevent cancer recurrence (OR = 3.13, 95% CI 2.35 – 4.18, p < 0.001) and the absence of obesity (OR = 0.58, 95% CI 0.38 – 0.87, p = 0.010).
The authors concluded that DS use among cancer survivors was common and influenced by patient’s beliefs about recurrence. They added that further work was required to better understand the reasons for such beliefs and how best to provide appropriate supplement advice to those living with a cancer diagnosis.
Citation
Conway RE et al. Dietary supplement use by individuals living with and beyond breast, prostate, and colorectal cancer: A cross‐sectional survey Cancer 2021
10th December 2021
Colorectal cancer (CRC) is the second most common cause of cancer death among both men and women in Europe.1 CRC accounts for 13% of all cancers and is the most common digestive cancer, with over 375,000 newly diagnosed cases annually.2 Colorectal cancer is easier to treat when detected at early stages; when diagnosed at stage I, the overall 5-year survival rate is around 90%.3
Since the rollout of screening programmes across Europe, a steady decline in CRC mortality rates has been observed.4 However, this success has been halted since the start of the pandemic due to screening delays.
A primary tool in FIT-positives used for the screening, early diagnosis, and treatment of digestive cancers is endoscopy. Following the pandemic and multiple lockdowns, endoscopy has been one of the most heavily affected procedures, leading to a dramatic decrease of screening and surveillance procedures.5 A new analysis of NHS England data led by UCL researchers concluded an estimated endoscopy screening backlog of 476,000 recorded in January 2021.6 This delay is particularly problematic as bar an expected increase in overall survival, early detection also allows for minimally invasive surgery. This type of surgery results in a faster recovery for the patient, and is consequently cheaper for the healthcare system, which is essential in times of crisis to help relieve economic burdens.6
Prof Luigi Riccardiello, Research Committee Chair, United European Gastroenterology
Impact of screening delays
“The majority of diagnostic and treatment pathways utilised in the management of CRC have been severely affected by COVID, most notably demonstrated by the delays for CRC screening tests. Delays in screening are particularly problematic for CRC as the best outcomes are attained in those whose tumours are diagnosed at an early stage.7 Screening delays beyond 4-6 months have been shown to significantly increase advanced CRC cases and impact mortality if lasting beyond 12 months.8
We need to focus on implementing an unbroken prevention pathway and reorganising our efforts against high-impact disease, such as CRC, to prepare for future waves of COVID-19 or other pandemics.8 Moving forward we need to make sure to address the backlog of screenings that has accumulated, to avoid the risk of significant increases in deaths from colorectal cancer over the next few years.”
Prof Thomas Seufferlein, Editor in Chief of the German Journal of Gastroenterology
Varying CRC screening rates across Europe
“The health impacts of the pandemic relating to CRC seem to be inconsistent across Europe, mostly dependent on the healthcare systems in place for each country. In Germany, where colonoscopy screening is largely done within private practice, there were fewer screening delays reported during the second and third COVID-19 waves once all protective measures were established.9,10
It has been reported that only 14% of EU citizens aged between 50-74 years old have the opportunity to participate in formal population-based screening programme for CRC.4 Therefore, having a screening programme alone is not sufficient, it must also meet quality criteria in terms of invitations for every inhabitant and equal opportunities for all, awareness creation, repeat messages, and sensitivity to tone and style that will enhance citizen participation.4,8 EU member governments should look to urgently address both the implementation and reorganisation of screening programmes available, in a bid to improve both the coverage and overall quality of screenings.2”
Prof Evelien Dekker, Gastrointestinal Oncology
The role of pre-existing barriers
“Pre-existing barriers to screenings were still present throughout the pandemic and if anything were exacerbated.11 This includes patient barriers such as fear, where individuals who may have already been apprehensive to participate in for a screening were even more conscious throughout the pandemic, and thus the fear of getting COVID only compounded the issue of people not going for their screening. Therefore, moving forward we must focus on reassuring a patient with a positive FIT result that colonoscopy centers are safe and COVID-free areas. This will help foster individual compliance for screenings and prevent later stage diagnosis of CRC.
Additionally, there are health care provider and health system barriers, such as a lack of follow-up and screening costs, which would have been a larger cause for concern throughout the pandemic.11 Due to the overload on resources, its likely many providers were late in following up with individuals to get them in for screenings, which would have added to screening delays. Systems were also stretched in terms of budgets to keep up with the demands of COVID-19, and thus the screening costs may have acted as a barrier to ensuring prompt and speedy screenings for patients.
Lastly, but possibly most importantly, the significance of screening by FIT cannot be understated. According to the European guideline, this is the preferred screening test, triaging those that need colonoscopy and thus sparing the limited capacity for those who need it.
FIT-programmes are not only beneficial in reducing morbidity but also cost-effective and making best use of colonoscopy capacity, which is always essential, but especially during pandemic. It results in performing colonoscopy in those who need it most, and saving money needed for treating advanced stage cancers which can be reallocated for necessary COVID-care.”
References
4th October 2021
The research, which was conducted across multiple hospitals in Spain, compared data from the first year of the COVID-19 pandemic with data from the previous year. Of 1385 cases of CRC diagnosed over the two-year period, almost two thirds (868 cases, 62.7%) were diagnosed in the pre-pandemic year from 24,860 colonoscopies. By contrast, only 517 cases (37.3%) were diagnosed during the pandemic, which also saw a 27% drop in the number of colonoscopies performed, to 17,337
Those who were diagnosed with CRC between 15 March 2020 and 28 February 2021 were also older than in the pre-pandemic year, had more frequent symptoms, a greater number of complications and presented at a more advanced disease stage.
Experts say the fall is a consequence of the suspension of screening programmes and the postponement of non-urgent colonoscopy investigations during the pandemic. Fewer cancers were identified by CRC screening in the pandemic period, with just 22 (4.3%) cases found in comparison to 182 (21%) in the pre-pandemic year. During the pandemic, more patients were diagnosed through symptoms (81.2% of diagnoses) compared with the pre-pandemic year (69%).
Dr María José Domper Arnal, from the Service of Digestive Diseases, University Clinic Hospital and the Aragón Health Research Institute (IIS Aragón) in Zaragoza, Spain, and lead author of the study, commented “These are very worrying findings indeed – cases of colorectal cancer undoubtedly went undiagnosed during the pandemic. Not only were there fewer diagnoses, but those diagnosed tended to be at a later stage and suffering from more serious symptoms.”
There was a significant increase in the number of patients being diagnosed with serious complications – a sign of late-stage disease – with an increase in symptoms such as bowel perforation, abscesses, bowel obstruction and bleeding requiring hospital admission. These cases made up 10.6% pre-pandemic and 14.7% during the pandemic. The number of stage IV cancers being diagnosed rose during the pandemic year, with stage IV cases making up 19.9% of cases, in comparison to 15.9% in the previous year.
“Although these figures are across a population of 1.3 million in Spain, it’s highly likely that the same drop in diagnoses would have happened elsewhere across the globe where screening was stopped and surgeries postponed, especially in countries that were heavily impacted by COVID-19”, explained Dr Arnal.
“Colorectal cancer is often curable if it’s caught at an early stage. Our concern is that we’re losing the opportunity to diagnose patients at this early stage, and this will have a knock-on effect on patient outcomes and survival. We are likely to see this fall out for years to come.”
Source
Impact of the COVID-19 pandemic in the diagnosis and characteristics of colorectal cancer patients, presented at UEG Week Virtual 2021
27th August 2021
According to the World Cancer Research Fund, colorectal cancer (CRC) is the third most commonly cancer in men and the second most common cancer in women. Moreover, the most recent data from 2018, shows that worldwide, there were over 1.8 million new cases of CRC. The relationship between cancer and hypertension is uncertain although in a retrospective study of over 25,000 cancer patients, new onset hypertension was found in a third of individuals. This relationship might be related to the vascular endothelial growth factor (VEGF) proteins, which are mediators of angiogenesis and lymphangiogenesis in tumours and have been found to be elevated in patients with hypertension. It is conceivable therefore, that the use of anti-hypertensives may exert a protective effect in those with cancer. This was the theory behind a retrospective study of patients with CRC undertaken by a team from the University of Virginia, School of medicine, Virginia, US. They examined a Medicare database which contained patient demographic information for those with cancer. They focused on patients with CRC aged 65 years and older but excluded those with any stage of CRC prescribed anti-hypertensives prior to the cancer diagnosis. The researchers extracted data on the clinical characteristics of CRC including stage and tumour grade and examined adherence to anti-hypertensive therapy based on the proportion of days covered (PDC), which is a measure of adherence with values greater than 0.80 used to define patients who are adherent to their anti-hypertensive therapy. All classes of anti-hypertensives were included and the period of follow-up started 1 year after the initiation of blood pressure lowering therapy. The primary outcome was CRC-specific mortality and the team used hazard regression models to examine the association between the use of individual anti-hypertensives and mortality.
Findings
A total of 13,982 patients were included in the analysis. A range of factors were found to be associated with CRC mortality including male gender (hazard ratio, HR = 1.07, 95% CI 1.03 – 1.13) and interestingly, being single, rather than married (HR = 1.08). The use of anti-hypertensives was associated with a decreased CRC-specific mortality (HR = 0.79, 95% CI 0.75 – 0.83). Furthermore, there was a significant association between adherence to treatment (i.e., those with a PDC greater than 0.80 and decreased mortality (HR = 0.94, 95% CI 0.90 – 0.98). Among the different types of drugs, significant associations were found for only angiotensin enzyme converting enzyme inhibitors (HR = 0.84), beta-blockers (HR = 0.87) and thiazide diuretics (HR = 0.83).
In discussing these results, the authors were cautious that these novel findings would need to be researched further as a potential tool to improve cancer-related mortality. However, they concluded that anti-hypertensive medications might represent a promising pathway to supporting patients with CRC.
Citation
Balkrishnan R et al. Associations between initiating antihypertensive regimens on stage I–III colorectal cancer outcomes: A Medicare SEER cohort analysis. Cancer Med 2021
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