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Colonic Neoplasias Detection and Implications of the National Screening Programme
AGA Abstracts
(N = 886, PR = 4.9%; χ2 test p = 0.4). By logistic regression it was found that non advanced polyps, diverticula, hemorrhoids and other abnormalities all influenced false positive FIT results found. Conclusion Hemorrhoids are an infrequent cause of false positive FIT results. Even though many factors including hemorrhoids do influence false positive FIT results, the additional number of false positives caused by hemorrhoids only seems to be limited. Therefore, subjects known to have hemorrhoids might benefit equally from FIT based detection of colorectal neoplasia and a different screening approach may be unneeded for these individuals.
that we are missing adenomas behind these folds. Objective Assuming polyps are evenly distributed on the front and back of folds (cecal/anal), we attempted to document fold side distribution. An increased number of polyps/adenomas on the anal side vs. the cecal side would suggest polyps/adenomas missed on the cecal side of the fold. Methods We prospectively collected data on all outpatient colonoscopies performed at Walter Reed Army Medical Center from December 2009 - May 2010. An educational session instructed all endoscopists in this study on the data that needed to be collected. Quality indicators to include preparation quality, withdrawal time, cecal intubation rate, and adenoma detection rate were recorded. All endoscopists noted size, location in colon, and location in relation to colonic fold for all polyps identified. The histology of all polyps removed was retrieved at a later time. Results During this period, 1111 patients (56% male, 53% white, 56 years (18-91) median age (range)) underwent outpatient colonoscopy. Majority of patients (66%) had screening or surveillance colonoscopy. Quality indicators included 79% of bowel preparations were of good-to-excellent quality, 12 minute mean withdrawal time, 97% cecal intubation rate, and an appropriate adenoma detection rate (19% female, 25% male). Of 1092 polyps (560 adenomas) identified, 502 polyps (46%) were on a fold and 590 (54%) were not on a fold. Of the 502 polyps on a fold, 144 polyps (75 adenomas) were located on the tip of the fold and 358 polyps (192 adenomas) were distributed on either side of the folds. When comparing polyps and adenoma distribution on anal vs. cecal side; there were significantly more polyps (250 (70%) vs. 108 (30%), P<0.05) and adenomas (117 (61%) vs. 75 (39%), p<0.05) on the anal vs. cecal side. Conclusions The results of this study show fewer polyps and adenomas within the colon noted on the cecal side of the fold compared to the anal side of the fold. Based on the assumption that colonic polyps/adenomas are distributed evenly on either side of the fold, we may be missing 12% of polyps and 7% of adenomas behind these folds. This finding suggests that developing endoscopic technology and techniques to enhance cecal side polyp/adenoma detection may increase the yield of colonoscopy.
Su1159 Gastroenterologists Need to Address Anal Dysplasia Screening in High-Risk Populations Ross Cranston, Jonathan Baker, Darlene Maciak, Esther Elishaev, Ken S. Ho Background: Oncogenic human papillomavirus (HPV) associated anal cancer rates are approximately seventy times higher in HIV infected men who have sex with men (MSM) than in the general population. Anal cancer evolves in a step-wise manner from low-grade to high-grade dysplasia before microinvasion occurs, similar to that seen in the uterine cervix. Early detection of cellular abnormalities by anal cytology testing has been proposed as a screening method for high-risk individuals. Although sensitive (~80%) it has limited specificity and individuals with any cytologic abnormality are referred for high-resolution anoscopy (HRA) and biopsy, similar to cervical colposcopy, to map and define lesions histopathologically. High-grade anal dysplasia may subsequently be ablated by office based procedures in an attempt to obviate progression to cancer. Methods: HIV-positive MSM attending the Pittsburgh AIDS Center for Treatment were targeted for anal cytology screening, and those with any cytological abnormality were referred for HRA and biopsy of lesions suspicious for high-grade dysplasia using standard colposcopic criteria. Areas with biopsy proven high-grade dysplasia were then ablated with either infrared coagulation or topical 80% trichloroacetic acid. Results: Of the 473 HIV-positive MSM who had anal cytology screening between 1-1-08 and 9-30-10, 404 had abnormal results (atypical squamous cells of undetermined significance (137), atypical squamous cells suggestive of high-grade (23), low grade squamous intraepithelial lesion (175), or high-grade squamous intraepithelial lesion (69)). Sixty men had no dysplasia and 9 men had persistent inadequate cytology samples after repeat testing. To date, 422 men have had HRA, including men with abnormal anal cytology and men referred for HRA without screening cytology due to a history of prior dysplasia. Their race demographic was 79% White, 18% Black and 3% Other; mean age was 46 years; mean CD4 lymphocyte count was 720 cells/μL and 277 men (66%) were taking antiretroviral therapy at the time of the initial visit. At first HRA, 282 (30%) men were diagnosed with high-grade anal dysplasia. Conclusions: In a population of HIV-positive MSM, both cytologic abnormalities and high-grade anal dysplasia are common. Over 1 million North Americans are infected with HIV and most will be co-infected with anal HPV. Due to the impact of combined antiretroviral therapy these individuals can now expect a life expectancy exceeding 40 years from their initial HIV diagnosis and are at high-risk of developing anal cancer. There is a pressing need to expand HRA services and gastroenterologists may be best placed to address this need.
Su1157 Females, Younger Persons and Persons With a Negative Family History More Often Have a False Positive FIT result Maaike Denters, Patrick M. Bossuyt, Marije Deutekom, Paul Fockens, Evelien Dekker Background and aims: Mass screening for colorectal cancer using the fecal immunohistochemical test (FIT) is a two-step screening method based on the identification of high risk individuals through the detection of blood in stool. A colonoscopy is offered to all persons with a positive test result only. A subset of persons with blood in stool will not have relevant abnormalities at colonoscopy. We aimed to identify factors associated with a false positive FIT result, using colonoscopy as the reference standard. Methods: Data were collected in a Dutch FIT based colorectal cancer screening pilot in the Amsterdam region. In 2008 asymptomatic persons aged 50 to 74 from a predefined target area were invited to participate in FIT screening. A single OC-sensor was used with a cut-off value of 50ngHb/ml. Family history of CRC, nicotine and alcohol use, visible blood in stool, changed bowel habits and known presence of haemorrhoids were recorded at the outpatient clinic by self report in all FIT positive persons prior to the colonoscopy. Positive predictive value (PPV) of FIT for advanced neoplasia was defined as the proportion of persons with at least one advanced adenoma or CRC at colonoscopy. Advanced adenoma was defined as any adenoma ≥10mm or an adenoma with a villous component >20% or high-grade dysplasia. Results: Patient history data and colonoscopy results were available for 373 FIT positives (52% male, median age 62, range 50 to 75). PPV for advanced neoplasia was higher in males than in females (51% in males versus 35% in females; p=0.002) and higher in older persons than in younger persons (54% in >69 years, 53% in 65-69 years, 40% in 60-64 years, 39% in 55-59 years and 32% in 50-54 years; p=0.05). PPV for advanced neoplasia was also higher in persons with a positive family history for CRC than in persons with a negative family history (62% versus 42%; p=0.03). No difference in PPV for advanced neoplasia was observed with regard to: visible blood in stool, changed bowel habits, known presence of haemorrhoids and nicotine and/or alcohol use. Conclusion: Females, younger persons and individuals with a negative family history for CRC are more likely to have a false positive FIT result at colonoscopy. In future screening programs, the combination of risk stratification and FIT result could be used as triage for follow-up investigations. Targeted follow-up after FITscreening could be offered to different persons according to their risk profile.
Su1160 Colonic Neoplasias Detection and Implications of the National Screening Programme Julius Spicak, Tomas Hucl, Marek Benes, Stepan Suchanek, Ondrej Urban, Vladimir Nosek, Miroslav Zavoral Introduction: The national colorectal cancer screening programme in the Czech Republic is based on FOBT and colonoscopy. The number of colonoscopies has been constantly increasing, reaching approximately 220 000 in a population of 10.5 million. Although the overall incidence of colorectal cancer is high throughout Europe, regional figures differ considerably, with the Czech Republic occupying the leading position. Each region should, therefore, monitor and evaluate all the related aspects and adapt rules of management accordingly. The aim of our multicenter prospective study was to analyze issues of the quality of colonoscopy, the incidence of colonic neoplasias, and the projection of screening. Results: A total of 2124 consecutive colonoscopies performed during 2010 at four distant tertiary centres for people older than 40 were analyzed. The occurrence rates of polyps, advanced adenomas, and carcinomas in the age groups of <45, 45-50, and > 50 years were 20.5%, 56.6%, and 54.4%; 9.4%, 10.0% and 31.1%; 1.0%, 2%, and 6.8% respectively. 59.9% of advanced neoplasias were potentially accessible by sigmoidoscopy. A total of 931 (43.8%) patients reported a positive family history. The occurrence rates of advanced adenomas and carcinomas were 6.8% and 2.1%, respectively, figures significantly lower than in other patients (44.6% and 8.5%, p≤0.05, respectively). The mean age in both groups was 47 and 63 years. In 245 patients coloscopy was done after positive FOBT, and in 320 as a primary screening method. The occurrence rate of advanced neoplasias after positive FOBT was significantly higher (21.2% vs. 14.7%, p≤0.05, respectively). The rates of caecum intubation, polyps, polyps >1 cm, and cancer detection in a subgroup of endoscopists with the highest number of colonoscopies were 93.9%, 72.1%, 24.1%, and 4.2%, significantly different from a subgroup of less experienced endospists (84.3%, 39.3%, 9.8%, and 1.1%, p≤0.05). Conclusions: The rate of neoplasias detected by colonoscopy in the Czech Republic is extremely high even in those under the age of 50, and the screening rules should be adapted accordingly. The proportion of people with a positive family history is high. The disproportionately low occurrence of neoplasias among them could be explained by their youth, suggesting they are well informed and seek screening early. The relatively young age of screened people indicates that the campaign should be focused more on those who are older. The Quality issues appear to be directly related to the experience of the endoscopist. Supported by the grant IGA - NS/9695
Su1158 Hemorrhoids Are an Infrequent Cause of False Positive Fecal Immunochemical Test Results Sietze T. Van Turenhout, Frank A. Oort, Jochim S. Terhaar sive Droste, René W. van der Hulst, Veerle M. Coupe, Anneke A. Bouman, Gerrit A. Meijer, Leo G. van Rossum, Chris J. Mulder Background Fecal immunochemical tests (FITs) are used for early detection of colorectal neoplasia. As FITs detect occult blood and not specifically colorectal cancer (CRC) or adenomas, they are hampered by false positive results. False positive tests consequently increase burden on colonoscopy capacity. As hemorrhoids are a plausible explanation for false positive FIT results, individuals with hemorrhoids might request a different screening strategy. Aims & Methods The aim of this study is to evaluate the association between hemorrhoids and false positive FIT results. Between June 2006 and October 2009, all subjects (≥18 years) scheduled for elective colonoscopy in five participating centers were invited to participate in this study. All individuals performed a FIT (OC sensor®) before bowel preparation and colonoscopy. FIT results were compared with colonoscopy as gold standard. Individuals without advanced neoplasia (CRC or advanced adenomas) were selected. Positivity rates in subjects in which hemorrhoids were the only abnormalities found at colonoscopy, were compared to subjects without any abnormalities. Logistic regression analysis was used to study factors influencing false positive FIT results. Results In the present study, 2855 patients were enrolled. False positive FIT results could be present in 2462 subjects in which no advanced neoplasia was found. Of these, 2123 did not and 339 did have hemorrhoids found at colonoscopy. At a cut-off value of 50ng/ml, the positivity rate (PR) in subjects in which hemorrhoids were the only abnormalities detected at colonoscopy (N = 134, PR = 6.7%) was not significantly different from the PR in individuals without any abnormalities
AGA Abstracts
S-418
(N = 886, PR = 4.9%; χ2 test p = 0.4). By logistic regression it was found that non advanced polyps, diverticula, hemorrhoids and other abnormalities all influenced false positive FIT results found. Conclusion Hemorrhoids are an infrequent cause of false positive FIT results. Even though many factors including hemorrhoids do influence false positive FIT results, the additional number of false positives caused by hemorrhoids only seems to be limited. Therefore, subjects known to have hemorrhoids might benefit equally from FIT based detection of colorectal neoplasia and a different screening approach may be unneeded for these individuals.
that we are missing adenomas behind these folds. Objective Assuming polyps are evenly distributed on the front and back of folds (cecal/anal), we attempted to document fold side distribution. An increased number of polyps/adenomas on the anal side vs. the cecal side would suggest polyps/adenomas missed on the cecal side of the fold. Methods We prospectively collected data on all outpatient colonoscopies performed at Walter Reed Army Medical Center from December 2009 - May 2010. An educational session instructed all endoscopists in this study on the data that needed to be collected. Quality indicators to include preparation quality, withdrawal time, cecal intubation rate, and adenoma detection rate were recorded. All endoscopists noted size, location in colon, and location in relation to colonic fold for all polyps identified. The histology of all polyps removed was retrieved at a later time. Results During this period, 1111 patients (56% male, 53% white, 56 years (18-91) median age (range)) underwent outpatient colonoscopy. Majority of patients (66%) had screening or surveillance colonoscopy. Quality indicators included 79% of bowel preparations were of good-to-excellent quality, 12 minute mean withdrawal time, 97% cecal intubation rate, and an appropriate adenoma detection rate (19% female, 25% male). Of 1092 polyps (560 adenomas) identified, 502 polyps (46%) were on a fold and 590 (54%) were not on a fold. Of the 502 polyps on a fold, 144 polyps (75 adenomas) were located on the tip of the fold and 358 polyps (192 adenomas) were distributed on either side of the folds. When comparing polyps and adenoma distribution on anal vs. cecal side; there were significantly more polyps (250 (70%) vs. 108 (30%), P<0.05) and adenomas (117 (61%) vs. 75 (39%), p<0.05) on the anal vs. cecal side. Conclusions The results of this study show fewer polyps and adenomas within the colon noted on the cecal side of the fold compared to the anal side of the fold. Based on the assumption that colonic polyps/adenomas are distributed evenly on either side of the fold, we may be missing 12% of polyps and 7% of adenomas behind these folds. This finding suggests that developing endoscopic technology and techniques to enhance cecal side polyp/adenoma detection may increase the yield of colonoscopy.
Su1159 Gastroenterologists Need to Address Anal Dysplasia Screening in High-Risk Populations Ross Cranston, Jonathan Baker, Darlene Maciak, Esther Elishaev, Ken S. Ho Background: Oncogenic human papillomavirus (HPV) associated anal cancer rates are approximately seventy times higher in HIV infected men who have sex with men (MSM) than in the general population. Anal cancer evolves in a step-wise manner from low-grade to high-grade dysplasia before microinvasion occurs, similar to that seen in the uterine cervix. Early detection of cellular abnormalities by anal cytology testing has been proposed as a screening method for high-risk individuals. Although sensitive (~80%) it has limited specificity and individuals with any cytologic abnormality are referred for high-resolution anoscopy (HRA) and biopsy, similar to cervical colposcopy, to map and define lesions histopathologically. High-grade anal dysplasia may subsequently be ablated by office based procedures in an attempt to obviate progression to cancer. Methods: HIV-positive MSM attending the Pittsburgh AIDS Center for Treatment were targeted for anal cytology screening, and those with any cytological abnormality were referred for HRA and biopsy of lesions suspicious for high-grade dysplasia using standard colposcopic criteria. Areas with biopsy proven high-grade dysplasia were then ablated with either infrared coagulation or topical 80% trichloroacetic acid. Results: Of the 473 HIV-positive MSM who had anal cytology screening between 1-1-08 and 9-30-10, 404 had abnormal results (atypical squamous cells of undetermined significance (137), atypical squamous cells suggestive of high-grade (23), low grade squamous intraepithelial lesion (175), or high-grade squamous intraepithelial lesion (69)). Sixty men had no dysplasia and 9 men had persistent inadequate cytology samples after repeat testing. To date, 422 men have had HRA, including men with abnormal anal cytology and men referred for HRA without screening cytology due to a history of prior dysplasia. Their race demographic was 79% White, 18% Black and 3% Other; mean age was 46 years; mean CD4 lymphocyte count was 720 cells/μL and 277 men (66%) were taking antiretroviral therapy at the time of the initial visit. At first HRA, 282 (30%) men were diagnosed with high-grade anal dysplasia. Conclusions: In a population of HIV-positive MSM, both cytologic abnormalities and high-grade anal dysplasia are common. Over 1 million North Americans are infected with HIV and most will be co-infected with anal HPV. Due to the impact of combined antiretroviral therapy these individuals can now expect a life expectancy exceeding 40 years from their initial HIV diagnosis and are at high-risk of developing anal cancer. There is a pressing need to expand HRA services and gastroenterologists may be best placed to address this need.
Su1157 Females, Younger Persons and Persons With a Negative Family History More Often Have a False Positive FIT result Maaike Denters, Patrick M. Bossuyt, Marije Deutekom, Paul Fockens, Evelien Dekker Background and aims: Mass screening for colorectal cancer using the fecal immunohistochemical test (FIT) is a two-step screening method based on the identification of high risk individuals through the detection of blood in stool. A colonoscopy is offered to all persons with a positive test result only. A subset of persons with blood in stool will not have relevant abnormalities at colonoscopy. We aimed to identify factors associated with a false positive FIT result, using colonoscopy as the reference standard. Methods: Data were collected in a Dutch FIT based colorectal cancer screening pilot in the Amsterdam region. In 2008 asymptomatic persons aged 50 to 74 from a predefined target area were invited to participate in FIT screening. A single OC-sensor was used with a cut-off value of 50ngHb/ml. Family history of CRC, nicotine and alcohol use, visible blood in stool, changed bowel habits and known presence of haemorrhoids were recorded at the outpatient clinic by self report in all FIT positive persons prior to the colonoscopy. Positive predictive value (PPV) of FIT for advanced neoplasia was defined as the proportion of persons with at least one advanced adenoma or CRC at colonoscopy. Advanced adenoma was defined as any adenoma ≥10mm or an adenoma with a villous component >20% or high-grade dysplasia. Results: Patient history data and colonoscopy results were available for 373 FIT positives (52% male, median age 62, range 50 to 75). PPV for advanced neoplasia was higher in males than in females (51% in males versus 35% in females; p=0.002) and higher in older persons than in younger persons (54% in >69 years, 53% in 65-69 years, 40% in 60-64 years, 39% in 55-59 years and 32% in 50-54 years; p=0.05). PPV for advanced neoplasia was also higher in persons with a positive family history for CRC than in persons with a negative family history (62% versus 42%; p=0.03). No difference in PPV for advanced neoplasia was observed with regard to: visible blood in stool, changed bowel habits, known presence of haemorrhoids and nicotine and/or alcohol use. Conclusion: Females, younger persons and individuals with a negative family history for CRC are more likely to have a false positive FIT result at colonoscopy. In future screening programs, the combination of risk stratification and FIT result could be used as triage for follow-up investigations. Targeted follow-up after FITscreening could be offered to different persons according to their risk profile.
Su1160 Colonic Neoplasias Detection and Implications of the National Screening Programme Julius Spicak, Tomas Hucl, Marek Benes, Stepan Suchanek, Ondrej Urban, Vladimir Nosek, Miroslav Zavoral Introduction: The national colorectal cancer screening programme in the Czech Republic is based on FOBT and colonoscopy. The number of colonoscopies has been constantly increasing, reaching approximately 220 000 in a population of 10.5 million. Although the overall incidence of colorectal cancer is high throughout Europe, regional figures differ considerably, with the Czech Republic occupying the leading position. Each region should, therefore, monitor and evaluate all the related aspects and adapt rules of management accordingly. The aim of our multicenter prospective study was to analyze issues of the quality of colonoscopy, the incidence of colonic neoplasias, and the projection of screening. Results: A total of 2124 consecutive colonoscopies performed during 2010 at four distant tertiary centres for people older than 40 were analyzed. The occurrence rates of polyps, advanced adenomas, and carcinomas in the age groups of <45, 45-50, and > 50 years were 20.5%, 56.6%, and 54.4%; 9.4%, 10.0% and 31.1%; 1.0%, 2%, and 6.8% respectively. 59.9% of advanced neoplasias were potentially accessible by sigmoidoscopy. A total of 931 (43.8%) patients reported a positive family history. The occurrence rates of advanced adenomas and carcinomas were 6.8% and 2.1%, respectively, figures significantly lower than in other patients (44.6% and 8.5%, p≤0.05, respectively). The mean age in both groups was 47 and 63 years. In 245 patients coloscopy was done after positive FOBT, and in 320 as a primary screening method. The occurrence rate of advanced neoplasias after positive FOBT was significantly higher (21.2% vs. 14.7%, p≤0.05, respectively). The rates of caecum intubation, polyps, polyps >1 cm, and cancer detection in a subgroup of endoscopists with the highest number of colonoscopies were 93.9%, 72.1%, 24.1%, and 4.2%, significantly different from a subgroup of less experienced endospists (84.3%, 39.3%, 9.8%, and 1.1%, p≤0.05). Conclusions: The rate of neoplasias detected by colonoscopy in the Czech Republic is extremely high even in those under the age of 50, and the screening rules should be adapted accordingly. The proportion of people with a positive family history is high. The disproportionately low occurrence of neoplasias among them could be explained by their youth, suggesting they are well informed and seek screening early. The relatively young age of screened people indicates that the campaign should be focused more on those who are older. The Quality issues appear to be directly related to the experience of the endoscopist. Supported by the grant IGA - NS/9695
Su1158 Hemorrhoids Are an Infrequent Cause of False Positive Fecal Immunochemical Test Results Sietze T. Van Turenhout, Frank A. Oort, Jochim S. Terhaar sive Droste, René W. van der Hulst, Veerle M. Coupe, Anneke A. Bouman, Gerrit A. Meijer, Leo G. van Rossum, Chris J. Mulder Background Fecal immunochemical tests (FITs) are used for early detection of colorectal neoplasia. As FITs detect occult blood and not specifically colorectal cancer (CRC) or adenomas, they are hampered by false positive results. False positive tests consequently increase burden on colonoscopy capacity. As hemorrhoids are a plausible explanation for false positive FIT results, individuals with hemorrhoids might request a different screening strategy. Aims & Methods The aim of this study is to evaluate the association between hemorrhoids and false positive FIT results. Between June 2006 and October 2009, all subjects (≥18 years) scheduled for elective colonoscopy in five participating centers were invited to participate in this study. All individuals performed a FIT (OC sensor®) before bowel preparation and colonoscopy. FIT results were compared with colonoscopy as gold standard. Individuals without advanced neoplasia (CRC or advanced adenomas) were selected. Positivity rates in subjects in which hemorrhoids were the only abnormalities found at colonoscopy, were compared to subjects without any abnormalities. Logistic regression analysis was used to study factors influencing false positive FIT results. Results In the present study, 2855 patients were enrolled. False positive FIT results could be present in 2462 subjects in which no advanced neoplasia was found. Of these, 2123 did not and 339 did have hemorrhoids found at colonoscopy. At a cut-off value of 50ng/ml, the positivity rate (PR) in subjects in which hemorrhoids were the only abnormalities detected at colonoscopy (N = 134, PR = 6.7%) was not significantly different from the PR in individuals without any abnormalities
AGA Abstracts
S-418