David Mansouri

The Impact of Age, Sex and Socioeconomic Deprivation on Outcomes in a Colorectal Cancer Screening Programme

Background Population-based colorectal cancer screening has been shown to reduce cancer specific mortality and is used across the UK. Despite evidence that older age, male sex and deprivation are associated with an increased incidence of colorectal cancer, uptake of bowel cancer screening varies across demographic groups. The aim of this study was to assess the impact of age, sex and deprivation on outcomes throughout the screening process. Methods A prospectively maintained database, encompassing the first screening round of a faecal occult blood test screening programme in a single geographical area, was analysed. Results Overall, 395 096 individuals were invited to screening, 204 139 (52%) participated and 6 079 (3%) tested positive. Of the positive tests, 4 625 (76%) attended for colonoscopy and cancer was detected in 396 individuals (9%). Lower uptake of screening was associated with younger age, male sex and deprivation (all p<0.001). Only deprivation was associated with failure to proceed to colonoscopy following a positive test (p<0.001). Despite higher positivity rates in those that were more deprived (p<0.001), the likelihood of detecting cancer in those attending for colonoscopy was lower (8% most deprived vs 10% least deprived, p = 0.003). Conclusion Individuals who are deprived are less likely to participate in screening, less likely to undergo colonoscopy and less likely to have cancer identified as a result of a positive test. Therefore, this study suggests that strategies aimed at improving participation of deprived individuals in colorectal cancer screening should be directed at all stages of the screening process and not just uptake of the test.

Temporal trends in mode, site and stage of presentation with the introduction of colorectal cancer screening: a decade of experience from the West of Scotland.

Background:Population colorectal cancer screening programmes have been introduced to reduce cancer-specific mortality through the detection of early-stage disease. The present study aimed to examine the impact of screening introduction in the West of Scotland.Methods:Data on all patients with a diagnosis of colorectal cancer between January 2003 and December 2012 were extracted from a prospectively maintained regional audit database. Changes in mode, site and stage of presentation before, during and after screening introduction were examined.Results:In a population of 2.4 million, over a 10-year period, 14 487 incident cases of colorectal cancer were noted. Of these, 7827 (54%) were males and 7727 (53%) were socioeconomically deprived. In the postscreening era, 18% were diagnosed via the screening programme. There was a reduction in both emergency presentation (20% prescreening vs 13% postscreening, P⩽0.001) and the proportion of rectal cancers (34% prescreening vs 31% pos-screening, P⩽0.001) over the timeframe. Within non-metastatic disease, an increase in the proportion of stage I tumours at diagnosis was noted (17% prescreening vs 28% postscreening, P⩽0.001).Conclusions:Within non-metastatic disease, a shift towards earlier stage at diagnosis has accompanied the introduction of a national screening programme. Such a change should lead to improved outcomes in patients with colorectal cancer.

The impact of aspirin, statins and ACE-inhibitors on the presentation of colorectal neoplasia in a colorectal cancer screening programme

Background:There is increasing evidence that aspirin, statins and ACE-inhibitors can reduce the incidence of colorectal cancer. The aim of the present study was to assess the impact of these medications on an individual’s risk of advanced neoplasia in a colorectal cancer screening programme.Methods:A prospectively maintained database of the first round of screening in our geographical area was analysed. The outcome measure was advanced neoplasia (cancer or intermediate or high risk adenomata).Results:Of the 4188 individuals who underwent colonoscopy following a positive occult blood stool test, colorectal pathology was present in 3043(73%). Of the 3043 patients with colorectal pathology, 1704(56%) had advanced neoplasia. Patients with advanced neoplasia were more likely to be older (OR 1.38; 95% CI 1.19–1.59) and male (OR 1.66; 95% CI 1.43–1.94) (both P<0.001). In contrast, those on aspirin (OR 0.68; 95% CI 0.56–0.83), statins (OR 0.65; 95% CI 0.55–0.78) or ACE inhibitors (OR 0.71; 95% CI 0.57–0.89) were less likely to have advanced neoplasia at colonoscopy (all P<0.05).Conclusion:In patients undergoing colonoscopy following a positive occult blood stool test with documented evidence of aspirin, statin or ACE-inhibitor usage, advanced neoplasia is less likely, suggesting that the usage of these medications may have a chemopreventative effect.

Screening for colorectal cancer: What is the impact on the determinants of outcome?

Colorectal cancer screening has been introduced across the UK following several large randomised control trials and a Cochrane review that have shown a reduction in cancer specific mortality with population based Faecal Occult Blood testing. This has been attributed to the detection of more early stage disease. It is well known that in addition to stage at presentation there are a variety of other key factors that determine a patients outcome following a diagnosis of colorectal cancer. For example there are tumour-related factors, such the presence of venous invasion and tumour necrosis, and also host-related factors, both in terms of demographic profile and an elevated circulating host inflammatory response that have been shown to be predictive of a poorer outcome. The present review summarises both the background behind the current screening programme and the observed and anticipated impact that colorectal cancer screening will have on the key determinants of outcome.

A comparison of tumour and host prognostic factors in screen-detected versus non screen-detected colorectal cancer: a contemporaneous study.

In addition to TNM stage there are adverse tumour and host factors, such as venous invasion and the presence of an elevated systemic inflammatory response (SIR), that influence the outcome in colorectal cancer. The present study aimed to examine how these factors varied in screen‐detected (SD) and nonscreen‐detected (NSD) tumours.

Flexible sigmoidoscopy following a positive faecal occult blood test within a bowel screening programme may reduce the detection of neoplasia.

Colorectal cancer screening using the faecal occult blood test (FOBt) detects a disproportionate number of left‐sided tumours. This study aims to examine the theoretical impact on neoplasia detection rates of a sigmoidoscopy‐first protocol in FOBt‐positive patients undergoing colonoscopy.

Factors associated with the efficacy of polyp detection during routine flexible sigmoidoscopy

Objective Flexible sigmoidoscopy reduces the incidence of colonic cancer through the detection and removal of premalignant adenomas. However, the efficacy of the procedure is variable. The aim of the present study was to examine factors associated with the efficacy of detecting polyps during flexible sigmoidoscopy. Design and patients Retrospective observational cohort study of all individuals undergoing routine flexible sigmoidoscopy in NHS Greater Glasgow and Clyde from January 2013 to January 2016. Results A total of 7713 patients were included. Median age was 52 years and 50% were male. Polyps were detected in 1172 (13%) patients. On multivariate analysis, increasing age (OR 1.020 (1.016–1.023) p<0.001), male sex (OR 1.23 (1.10–1.38) p<0.001) and the use of any bowel preparation (OR 3.55 (1.47–8.57) p<0.001) were associated with increasing numbers of polyps being detected. There was no significant difference in the number of polyps found in patients who had received an oral laxative preparation compared with an enema (OR 3.81 (1.57–9.22) vs 3.45 (1.43–8.34)), or in those who received sedation versus those who had not (OR 1.00 vs 1.04 (0.91–1.17) p=0.591). Furthermore, the highest number of polyps was found when the sigmoidoscope was inserted to the descending colon (OR 1.30 (1.04–1.63)). Conclusions Increasing age, male sex and the utilisation of any bowel preparation were associated with an increased polyp detection rate. However, the use of sedation or oral laxative preparation appears to confer no additional benefit. In addition, the results indicate that insertion to the descending colon optimises the efficacy of flexible sigmoidoscopy polyp detection.

Abstract A142: Pre-operative assessment of the tumor microenvironment of patients undergoing resection of colorectal cancer is feasible using colonoscopic biopsies

The tumor microenvironment (TME), comprising of the inflammatory cell infiltrate and tumor-associated stroma, is an important and potentially modifiable determinant of outcome in colorectal cancer (CRC). However, identifying patients who may benefit from therapy targeting the TME prior to surgery is problematic. The aim of the present study was to examine the clinical utility and prognostic value of assessment of the TME utilising colonoscopic tumor biopsies. Using an automated scoring system (nuclear h-score) the density of CD3 + T-lymphocytes was quantified in preoperative tumor biopsies of 120 patients undergoing elective resection of stage I-III CRC and compared to automated assessment and manual, semi-quantitative assessment (high vs. low) of CD3 + density within the TME of surgically resected tumor specimens. The tumor-associated stroma was measured in both biopsies and resected specimens using tumor stroma percentage (TSP) and classified as low ( 50%). The relationship with cancer-specific survival (CSS) was examined on univariate and multivariate analysis. The median h-score for CD3 + density in colonoscopic biopsies and resected specimens was 58 (interquartile range 33-83) and 22 (13-38). Automated assessment of CD3 + density in biopsies and resected specimens was significantly correlated ( r = 0.329, P + density and TSP, is feasible utilising colonoscopic tumor biopsies and may inform prognosis. This may allow for appropriate stratification of patients entering clinical trials targeting the tumor microenvironment of patients with colorectal cancer. Citation Format: James H. Park, David Mansouri, Clare Orange, Joanne Edwards, Paul G. Horgan, Donald C. McMillan, Campbell SD Roxburgh. Pre-operative assessment of the tumor microenvironment of patients undergoing resection of colorectal cancer is feasible using colonoscopic biopsies [abstract]. In: Proceedings of the Second CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; 2016 Sept 25-28; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2016;4(11 Suppl):Abstract nr A142.

The impact of aspirin and statin usage on the likelihood of advanced neoplasia at colonoscopy following a positive FOB screening test.

346 Background: There is increasing evidence that non-steroidal anti-inflammatory drugs, in particular aspirin, and statins can reduce the incidence and progression of colorectal cancer. However, studies examining this relationship within colorectal cancer screening are limited. Therefore the aim of the present study was to assess the impact of aspirin and statins on an individual’s risk of advanced neoplasia in a colorectal cancer screening programme. Methods: A prospectively maintained database of all patients in the first round of screening (April 2009 to March 2011) in our geographical was analysed. Medication usage was recorded prospectively at pre-colonoscopy assessment. The outcome measure was advanced neoplasia, which was defined as cancer or an intermediate or high risk adenomata (>2 polyps, or > 1 polyp >1cm). Results: 4,631 individuals underwent colonoscopy following a positive FOBt of which complete results were available for 4,188 (90%) pts. Overall, 657 (16%) were on aspirin, 880 (21%) were ...

Comment on Luo et al.: Diabetes mellitus and the incidence and mortality of colorectal cancer: a meta-analysis of 24 cohort studies

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