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Invitations for screening colonoscopy reduces risk of colorectal cancer

27th October 2022

Inviting patients for screening colonoscopy has been found to be associated with a significantly lower 10-year risk of colorectal cancer

Patients who take up an invite for screening colonoscopy have a significantly reduced risk of developing colorectal cancer after 10 years according to the findings of a randomised trial by the NordICC study group.

In 2020, the World Health Organisation estimated that globally, there were 1.93 million cases of colorectal cancer and which resulted in 916,000 deaths. There are a variety of tests available for colorectal cancer screening and to date only the guaiac-based faecal occult blood test and sigmoidoscopy have been shown to reduce the incidence of colorectal cancer and its associated mortality in randomised trials. In addition to sigmoidoscopy, another endoscopic method is screening colonoscopy and which is considered to be the gold standard tool with a high sensitivity and specificity. However, to date, there are no large-scale randomised trials comparing the effectiveness of screening colonoscopy compared to no screening, to determine whether this impacts on the incidence of colorectal cancer.

In the present study, researchers created the Northern-European Initiative on Colorectal Cancer (NordICC) trial, which was a randomised trial investigating the effect of colonoscopy on colorectal cancer incidence and mortality. The trial enrolled individuals aged 55 to 64 who had not undergone previous screening and were randomised 1:2 to either an invitation to undergo screening colonoscopy or no invitation. The primary endpoint of the trial were the risks of colorectal cancer and death from the cancer after a 10 to 15 years, whereas the secondary endpoint was death from any cause.

Screening colonoscopy and cancer outcomes

A total of 84,585 individuals with a median age of 59 years (49.8% female) were enrolled, 28,220 of whom were invited for screening and who were followed-up for a median of 10 years. However, only 11,842 (42%) of participants accepted the invite and underwent screening.

The risk of colorectal cancer at 10 years was 0.98% in the invited group and 1.2% in the usual care (i.e., non-invited group), which was associated with an 18% lower risk of cancer (Risk ratio, RR = 0.82, 95% CI 0.70 – 0.93). However, the risk of colorectal cancer-related death was not significantly different between the groups (RR = 0.90, 95% CI 0.64 – 1.16). In addition, during the follow-up period, there was a similar level of death (11%) from any cause, in both groups.

The above data related to those who responded to the invite for screening but when researchers undertook a per-protocol analysis, i.e., assuming that all invitees underwent screening, the results were even more impressive. The risk of colorectal cancer at 10 years was reduced even further (RR = 0.69, 95% CI 0.55 – 0.83) as was the risk of colorectal cancer death (RR – 0.50, 95% CI 0.27 – 0.77).

The authors concluded that inviting patients for screening colonoscopy reduced the 10-year risk of colorectal cancer compared to those who were not screened.

Citation
Bretthauer M et al. Effect of Colonoscopy Screening on Risks of Colorectal Cancer and Related Death N Eng J Med 2022

Screening endoscopy before 50 associated with reduced risk of CRC diagnosis in women

9th June 2022

Screening endoscopy in women under 50 significantly reduces the risk of a colorectal cancer diagnosis at age 55 according to a US study

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

Neoplasia detected in a third of patients under 50 after colorectal screening

19th January 2022

Neoplasia (precancerous lesions) have been detected in a third of patients aged 45 to 49 years of age after colorectal screening

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 to 44 years and 79,934 in those aged 45 to49 years.

Among individuals aged 45 to 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 to 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.

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