Manon van der Vlugt

Adherence to colorectal cancer screening: Four rounds of faecal immunochemical test-based screening

Background:The effectiveness of faecal immunochemical test (FIT)-based screening programs is highly dependent on consistent participation over multiple rounds. We evaluated adherence to FIT screening over four rounds and aimed to identify determinants of participation behaviour.Methods:A total of 23 339 randomly selected asymptomatic persons aged 50–74 years were invited for biennial FIT-based colorectal cancer screening between 2006 and 2014. All were invited for every consecutive round, except for those who had moved out of the area, passed the upper age limit, or had tested positive in a previous screening round. A reminder letter was sent to non-responders. We calculated participation rates per round, response rates to a reminder letter, and differences in participation between subgroups defined by age, sex, and socioeconomic status (SES).Results:Over the four rounds, participation rates increased significantly, from 60% (95% CI 60–61), 60% (95% CI 59–60), 62% (95% CI 61–63) to 63% (95% CI 62–64; P for trend<0.001) with significantly higher participation rates in women in all rounds (P<0.001). Of the 17 312 invitees eligible for at least two rounds of FIT screening, 12 455 (72%) participated at least once, whereas 4857 (28%) never participated; 8271 (48%) attended all rounds when eligible. Consistent participation was associated with older age, female sex, and higher SES. Offering a reminder letter after the initial invite in the first round increased uptake with 12%; in subsequent screening rounds this resulted in an additional uptake of up to 10%.Conclusions:In four rounds of a pilot biennial FIT-screening program, we observed a consistently high and increasing participation rate, whereas sending reminders remain effective. The substantial proportion of inconsistent participants suggests the existence of incidental barriers to participation, which, if possible, should be identified and removed.

Optical Diagnosis of Sessile Serrated Polyps: Bottleneck for the Optical Diagnosis Paradigm?

Background: Optical diagnosis of diminutive (1 to 5 mm) polyps could result in a more cost-effective colonoscopy practice. Previous optical diagnosis studies did not incorporate the differentiation of sessile serrated polyps (SSPs). This study aimed to evaluate the impact of optical diagnosis of diminutive SSPs on the overall performance of endoscopic polyp differentiation in daily colonoscopy practice. Methods: Endoscopy data were prospectively collected between 2011 and 2014 in a colonoscopy center. Each endoscopist reported a real-time optical diagnosis (SSP, adenoma or hyperplastic polyp) for all lesions in a structured colonoscopy reporting system, using narrow band imaging at their discretion. Study outcomes were accuracy of optical diagnosis, surveillance interval agreement and negative predictive value for diminutive rectosigmoid neoplastic histology based on the optical diagnosis of diminutive polyps compared to histopathology. Results: Of 2853 removed diminutive polyps, 202 (7.1%) were histologically proven SSPs. Optical diagnosis of diminutive SSPs was accurate in 24.4%. Diminutive SSPs determined 6.9% of postpolypectomy surveillance assignments. Inaccurate optical diagnosis of diminutive SSPs led to lower surveillance interval agreement (78.1% vs. 53.3%, P<0.01) and pooled negative predictive value per polyp (84.3% vs. 50.0%; P<0.01) in patients with diminutive SSPs when compared to patients without diminutive SSPs. Accurate endoscopic identification of diminutive SSPs improved from 0% in 2011 to 47% in 2014 (P=0.02). Conclusions: Endoscopic characterization of diminutive SSPs is difficult, impairing overall performance of optical diagnosis in patients with diminutive SSPs. Future optical diagnosis studies should use validated trainings and classification algorithms that include differentiation of SSPs.

Optical diagnosis of malignant colorectal polyps: is it feasible?

Background and study aims: As colorectal cancer screening programs are being implemented worldwide, an increasing number of early (T1) cancers are being diagnosed. These cancers should be recognized during colonoscopy because they require a specific therapeutic approach. Several studies have shown that Asian experts can reliably recognize T1 cancers during colonoscopy. In daily practice, however, accurate endoscopic diagnosis of T1 cancers still seems challenging. We evaluated the performance of optical diagnosis of T1 cancers by European colonoscopy experts, general gastroenterologists and gastrointestinal fellows. Patients and methods: We collected endoscopic images of 43 colonic lesions: 19 T1 cancers (excluding intramucosal carcinoma) and 24 benign polyps ranging from 7 mm to 30 mm in size. Seven colonoscopy experts, 7 general gastroenterologists, and 14 gastrointestinal fellows assessed these images. We calculated sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) and their 95 % confidence intervals for optical diagnosis of T1 cancers. Results: Overall sensitivity for correct diagnosis of T1 cancers was 60 % (95 % CI;45 – 72). Sensitivity was highest for experts (67 %: 95 %CI; 48 – 81), when compared to general gastroenterologists (53 %: 95 %CI; 37 – 69) and gastrointestinal fellows (59 %: 95 %CI;45 – 72). The overall NPV was 75 % (95 %CI;60 – 86); NPV was lowest for general gastroenterologists 72 % (95 %CI;57 – 83) vs 78 % (95 %CI;63 – 89) for experts and 75 % (95 %CI;60 – 85) for gastrointestinal fellows. Conclusions: In this image-based study, both sensitivity for the optical diagnosis of a T1 cancer and NPV for excluding a T1 cancer were insufficient. Experts performed best with a sensitivity of 67 % and a NPV of 78 %, while the performance of fellows in the last year of training was comparable to that of experts. Our study indicates that training for endoscopic diagnosis for T1 cancers is urgently needed to ensure optimal clinical practice for treatment of these lesions.

Acute Dysphagia: Don’t Wait and See

Department of Gastroenterology and Hepatology, and Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 Question: A 36-year-old Ghanese woman with an unremarkable medical history presented at our first aid department because of a sore throat and acute dysphagia after ingestion of pasta with dried fish. After triage, she was sent to her general practitioner, who inspected the oral cavity, which revealed no abnormalities and sent her home. Five days later, she presented again at her general practitioner with ongoing and progressive dysphagia accompanied by retrosternal pain and odynophagia. An ENT doctor was consulted, but no abnormalities were found in the oral cavity, hypopharynx, or larynx. Subsequently, we were consulted. Physical examination revealed no fever or other abnormalities. The laboratory results showed a C-reactive protein of 65.3 mg/L and leukocytes of 7.7 10/L. Diagnostic esophagogastroduodenoscopy was performed and showed an impacted structure in the distal esophagus (Figure A). Subsequently, a chest computed tomography (CT) was performed. Coronal (Figure B) and transversal (Figure C) CT images revealed a radiopaque structure with thickened esophageal wall and pleural fluid collection. What is the diagnosis and what would be the next step? Look on page 000 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. 101 102 103 104 105 106 107 Conflicts of interest The authors disclose no conflicts.

The accuracy of polyp assessment during colonoscopy in FIT-screening is not acceptable on a routine basis

Background: During colonoscopy, correct assessment of polyps is important. Recognition of early carcinomas is needed for tailor-made treatment and avoidance of unnecessary complications. Moreover, accurate diagnosis of diminutive lesions could result in a safe resect and discard strategy. We assessed the accuracy of polyp assessment by general endoscopists without specific training or experience in image-enhanced endoscopy during routine colonoscopies within a fecal immunochemical test (FIT)-based screening program. Methods: Data were collected in the third round of a FIT-based colorectal cancer screening pilot program. Patients diagnosed as FIT-positive (318) underwent colonoscopy using Olympus (160 and 180 series) endoscopes without magnification or routine use of (virtual) chromoendoscopy. Endoscopists received no special training. They made an on-site evaluation and classified detected polyps as hyperplastic, adenoma, carcinoma. Samples of resected lesions were sent for histopathology. Sensitivity and specificity were calculated. We differentiated for fellows and consultants. Results: In the 318 patients with a positive FIT-screening result, 683 lesions were detected; 564 lesions were included in the analyses. The pathologist classified these lesions as 141 hyperplastic polyps, 349 adenomas, 16 carcinomas, and 58 other. Sensitivity for diagnosis of adenomas was 88 % (95 %CI 84 – 91); specificity 49 % (95 %CI 42 – 55). Of the 16 colorectal carcinomas, endoscopists diagnosed four incorrectly (sensitivity 75 % [95 %CI 44 – 89]; specificity 99 % [95 %CI 98 – 100]), including three stage I cancers and one stage III cancer. There were no differences in accuracy of diagnosis that related to different sizes of lesions or the experience of the endoscopist. Conclusion: In a routine FIT-based screening setting and without specific training or routine use of (digital) chromoendoscopy, endoscopic prediction of the histopathology of colonic lesions is inaccurate when the procedure is performed by general endoscopists.

A large proportion of fecal immunochemical test-positive participants in colorectal cancer screening is symptomatic

Background Symptomatic invitees are advised not to participate in colorectal cancer (CRC) screening but to directly consult their general practitioner (GP), because fecal immunochemical test (FIT) sensitivity for cancer is not optimal. This recommendation may not always be followed in daily practice. We evaluated how many FIT-positive participants had CRC-related symptoms and whether the presence of symptoms was associated with the presence and location of CRC/advanced neoplasia. Methods We prospectively collected data on CRC-related symptoms in all FIT-positive participants in the Dutch CRC screening program, referred to our endoscopy centers between 2014 and 2016, and evaluated whether symptoms were associated with detected CRC/advanced neoplasia at colonoscopy. Results Of 527 FIT-positive participants, 314 had advanced neoplasia, of which 41 had CRC. Overall, 246 (47%; 95% confidence interval (CI) 0.42–0.51) reported CRC-related symptoms. A change in bowel habits (odds ratio (OR) 2.86, CI 1.23–6.62) and visible blood in stool (OR 8.65, CI 2.34–32.0) were associated with the detection of CRC at colonoscopy. We did not observe significant associations between evaluated symptoms and advanced neoplasia. Conclusions A large proportion of FIT-positive screening participants have CRC-related symptoms. This suggests that current instructions do not retain symptomatic screening invitees from participation and awareness of CRC-related symptoms is inadequate.

Risk of Oral and Upper Gastrointestinal Cancers in Persons With Positive Results From a Fecal Immunochemical Test in a Colorectal Cancer Screening Program

BACKGROUND & AIMS European guidelines recommend screening for colorectal cancer (CRC) using the fecal immunochemical test (FIT), with follow‐up colonoscopies for individuals with positive test results. However, more than half of participants with positive results from the FIT are not found to have advanced neoplasia in the colonoscopy examination. Fecal occult blood might also come from the upper gastrointestinal (GI) tract, so perhaps we should consider esophagogastroduodenoscopy (EGD), to detect upper GI cancers. We aimed to determine how many individuals are found to have oral or upper GI cancers (oral cavity, throat, esophageal, gastric, or small bowel cancer) within 3 years after a positive or negative result from a FIT in a CRC screening program. METHODS We performed a retrospective analysis of data from a pilot study of 3 rounds of biennial FIT‐based screening for CRC in 2 regions in the west of the Netherlands, from 2006 through October 2012. Participants who developed oral or upper GI cancers were identified through linkage with the National Cancer Registry. We classified these cancers into 3 groups: those that developed in individuals with a positive result from a FIT but negative findings from colonoscopy (no advanced neoplasia), those that developed in individuals with a positive result from a FIT and a positive finding from colonoscopy (advanced neoplasia), and those that developed in individuals with negative results from a FIT. We compared oral and upper GI cancer incidence among groups. RESULTS Among 16,165 screening participants, linkage identified 52 persons who developed an oral or upper GI cancer within 3 years after a FIT. We found no significant difference in incidence values between individuals with a positive vs a negative FIT result: 8 cancers developed in individuals with a positive result from a FIT (0.37%; 95% CI, 0.19–0.76) and 44 developed in individuals with a negative result from a FIT (0.31%; 95% CI, 0.23–0.42) (P = .65). Of the 8 individuals with a positive result from a FIT and an oral or upper GI cancer, 6 were diagnosed after negative findings from colonoscopy and 2 after positive findings from colonoscopy. We found that only 0.14% of all persons with a positive result from a FIT were diagnosed with a gastric or esophageal cancer within 3 years. CONCLUSION In a study of individuals in the Netherlands undergoing screening for CRC by FIT, we found fewer than 1% of patients with a positive result from the FIT to receive a diagnosis of upper GI cancers within 3 years. Routine EGD investigation of individuals with positive results from a FIT and negative findings from colonoscopy is therefore not recommended. TrialRegister.nl, Number: NTR5385.