Zvi Alpern

Prevalence of Colorectal Neoplasia in Smokers

OBJECTIVES:Smoking has been linked with colorectal neoplasia. Previous colonoscopy screening studies have omitted smoking and have examined only gender, age, and family history. Our aim was to use a screening population to measure the prevalence of neoplasia in smokers, the anatomic location of these lesions, and the strength of this association relative to other risk factors.METHODS:Data collected from the charts of 1988 screening colonoscopy patients included colonic findings, histology, risk factors for colorectal neoplasia, and smoking pattern. Current smokers were defined as those who had smoked more than 10 pack-years and were currently smoking or who had quit within the past 10 yr. Our outcomes were any adenomatous lesion and significant colonic neoplasia, which included adenocarcinoma, high grade dysplasia, villous tissue, large (>1 cm) adenomas, and multiple (more than two) adenomas.RESULTS:Multivariate analysis revealed that current smokers were more likely to have any adenomatous lesion (odds ratio [OR] = 1.89; 95% CI = 1.42–2.51; p < 0.001) as well as significant neoplasia (OR = 2.26; 95% CI = 1.56–3.27; p < 0.001) than those who had never smoked. The increased risk for smokers was predominantly for left-sided neoplasia. The risk for significant neoplasia was greater for smokers than for patients with a family history of colorectal cancer (OR = 1.20; 95% CI = 0.75–1.92; p > 0.05).CONCLUSIONS:Smoking is a significant risk factor for colorectal neoplasia in a screening population, especially for significant left-sided lesions. In our sample population, smoking posed a greater risk than family history of colorectal cancer.

Prevalence and risk of colorectal neoplasia in consumers of alcohol in a screening population.

BACKGROUND AND AIMS:Although studies suggest a positive association between alcohol consumption and risk for colorectal neoplasia, the impact on screening has not been fully examined. It is also unclear whether all types of alcohol are associated with an increased risk. We performed a cross-sectional study to examine the impact of regular alcohol consumption on the detection of significant colorectal neoplasia in a screening population.METHODS:Data collected for 2,291 patients presenting for screening colonoscopy: known risk factors for colorectal neoplasia and alcohol drinking pattern. Our outcome was the endoscopic detection of significant colorectal neoplasia, which included adenocarcinoma, high-grade dysplasia, villous tissue, adenomas 1 cm or greater and multiple (>2) adenomas of any size.RESULTS:When compared to abstainers, we found an increased risk for significant neoplasia in those patients who consumed more than eight drinks of spirits alcohol (26.3%; OR = 2.53; 95% CI = 1.10–4.28; p < 0.01) and those who drank more than eight servings of beer per week (21.7%; OR = 2.43; 95% CI = 1.11–5.32; p= 0.02). Consuming one to eight glasses of wine per week was associated with a decreased risk for significant neoplasia (OR = 0.55; 95% CI = 0.34–0.87; p < 0.01).CONCLUSIONS:While there was a more than twofold increased risk of significant colorectal neoplasia in people who drink spirits and beer, people who drank wine had a lower risk. In our sample, people who drank more than eight servings of beer or spirits per week had at least a one in five chance of having significant colorectal neoplasia detected by screening colonoscopy.

Body mass index: a marker for significant colorectal neoplasia in a screening population.

Background and Aims Although some studies suggest a positive association between increasing body mass index (BMI) and risk for colorectal neoplasia, the impact on screening has not been examined. We performed a cross-sectional study to examine the association of BMI and colorectal neoplasia in a screening population. Methods Data collected for 2493 patients presenting for screening colonoscopy included known risk factors for colorectal neoplasia, demographic information, and lifestyle factors. Our outcome was the endoscopic detection of significant colorectal neoplasia which included adenocarcinoma, high-grade dysplasia, villous tissue, adenomas 1 cm or greater and multiple (>2) adenomas of any size. Results Overall, we observed an increased risk and prevalence for significant colorectal neoplasia in women as BMI increased (P value for trend <0.002). This relationship was the strongest for the women with a BMI ≥40 (odds ratios=4.26; 95% confidence intervals=2.00-9.11). There was no such relationship in our male population. Conclusions Increasing BMI, in our population, was associated with an increase risk for colorectal neoplasia in female patients. This study reinforces the importance of screening colonoscopy especially in obese women.

Predictors of proximal neoplasia in patients without distal adenomatous pathology

BACKGROUND:Previous colorectal cancer screening studies have observed that some patients may have advanced proximal neoplasia without distal findings. Since these studies have included only gender, age, and family history as risk factors, they are limited in their ability to identify predictors of isolated proximal neoplasia.METHODS:Data were collected from the charts of 1,988 patients who presented for colonoscopy. Information gathered included endoscopic findings, histology, known risk factors for colorectal neoplasia, and smoking pattern. Our main outcome was the presence of proximal adenomatous neoplasia in patients who had no distal adenomas. We defined significant neoplasia as adenocarcinoma, high-grade dysplasia, villous polyps, adenomas 1 cm or greater or more than two adenomas of any size.RESULTS:Fifty-five patients had isolated significant proximal neoplasia that would have been missed on a flexible sigmoidoscopy. While patients older than 60 yr had a greater risk for this neoplasia (odds ratio = 3.01: 95% CI = 1.66–4.23; p < 0.001), those who took a daily aspirin had a reduced risk (OR = 0.60; 95% CI = 0.30–0.88; p < 0.05). A family history of colorectal cancer increased the patients risk of having any adenomas (OR = 2.01; 95% CI = 1.33–3.40; p < 0.01) or villous tissue (OR = 2.03; 95% CI = 1.27–3.51; p < 0.05) in the proximal colon without distal findings. Smoking was associated with an increased risk of large (> 1 cm) isolated proximal tubular polyps (OR = 2.71; 95% CI = 1.64–4.46; p < 0.01) as well as isolated significant proximal neoplasia (OR = 2.30; 95% CI = 1.59–3.31; p < 0.01).CONCLUSIONS:Age greater than 60 yr, a history of at least 10 pack-years of smoking, and a family history of colorectal cancer increased the risk of finding significant proximal polyps in patients without distal pathology.

Association of smoking and flat adenomas: results from an asymptomatic population screened with a high-definition colonoscope

BACKGROUND Flat adenomas represent a morphologically distinct class of polyps that may be difficult to detect, and little is known regarding risk factors for these lesions. Identification of risk factors for these lesions may aid in colorectal cancer (CRC) screening, because patients at risk for these lesions may require special imaging techniques. Smoking, an important risk factor for CRC, may be associated with molecular changes that increase the risk for flat adenomas. OBJECTIVE The aim of this study was to examine the association between smoking and flat adenomas. DESIGN Prospective cross-sectional study. SETTING University hospital endoscopy center. PATIENTS We enrolled asymptomatic patients presenting for CRC screening. INTERVENTIONS We screened patients with a high-definition (1080i signal) wide-angle (170 degrees field of view) Olympus 180-series colonoscope. We collected demographics, medication use, family history of CRC, diet history, and smoking history. MAIN OUTCOME MEASUREMENTS Polyp morphology, assessed by using the Japanese Research Society Classification (JRSC). RESULTS A total of 600 patients were enrolled. We observed that smoking was associated with having a flat adenoma of any size (adjusted odds ratio [OR], 2.53; 95% CI, 1.60-4.00), having only flat adenomas that were > or = 6 mm in diameter (adjusted OR, 3.84; 95% CI, 2.02-7.32), as well as flat advanced adenomas (adjusted OR, 2.81; 95% CI, 1.08-7.30). LIMITATIONS The study design may not account for some confounding variables and provides no information regarding smoking status at the time of initiation of flat adenomas. CONCLUSION Smoking was associated with flat adenomas in our population. Our findings may explain the earlier onset of CRC in smokers as well as the advanced stage with which they present, with compared with nonsmokers. Smokers may require screening with high-definition colonoscopes to detect flat adenomas.

Smokers as a high-risk group: data from a screening population.

Goal To determine the number of pack-years exposure associated with a 2-fold increase risk for significant colorectal neoplasia and to examine the risk of smoking in younger patients. Background Cigarette smoking has been shown to be a significant risk factor for colorectal neoplasia and may be used to stratify patients for screening or triaging of screening resources. However, more information is needed regarding the amount of exposure required to significantly increase by 2-fold an individuals risk for colorectal neoplasia. Methods Data collected for 2707 patients presenting for screening colonoscopy included tobacco use measured in pack-years and known risk factors for colorectal neoplasia. Our outcome was endoscopically detected significant colorectal neoplasia that included large (>1 cm) tubular adenomas, villous adenomas, multiple (3 or more) adenomas, high-grade dysplasia, and adenocarcinoma. Results Patients who smoked more than 30 pack-years were more than 2 times more likely to have significant colorectal neoplasia than patients who never smoked (odds ratio: 2.40; 95% confidence interval: 1.65-3.50). For patients aged 40 to 49 years, smokers were more likely than nonsmokers to have significant colorectal neoplasia (odds ratio: 2.71; 95% confidence interval: 1.05-6.97). Conclusions Patients who have smoked more than 30 pack-years had a more than 2-fold increase for significant colorectal neoplasia as compared with nonsmokers. The increased risk was also observed in younger patients. Our data have implications for screening guidelines.

Prevalence of significant proximal colorectal neoplasia in patients with large proximal hyperplastic polyps

Prevalence of significant proximal colorectal neoplasia in patients with large proximal hyperplastic polyps

Alcohol consumption and significant left-sided colorectal neoplasia in a screening population

Purpose: When screening for colorectal neoplasia, risk assessment is based on age and family history but not on factors such as behavior or lifestyle. Since previous studies have been inconclusive about the importance of alcohol as a risk factor for CRC, it remains unclear whether more intense screening is warranted in this population. To investigate this, we developed a cross-sectional study using screening colonoscopies to ascertain the prevalence and risk of colorectal neoplasia in patients who consumed varying types and amounts of alcohol. Methods: Screening colonoscopies were performed in 1988 asymptomatic patients. Age, weight, family history, alcohol use, diet, smoking history, level of education, and exercise were obtained for each patient. We divided alcohol beverages into spirits, beer and wine, which were then further subdivided by the number of drinks per week over the past 10 years. Significant left-sided lesions were defined as large ( 1cm), multiple ( 2) villous adenomas, high grade dysplasias or adenocarcinomas, distal to the splenic flexure. Results: Overall, patients who drank 9 or more glasses per week of spirits for more than 10 years (17.4%) were more likely than abstainers (6.1%) to develop significant left sided neoplastic lesions. A multivariate analysis was performed controlling for age, gender, family history and other lifestyle factors such as smoking. While patients who drank spirits had an increased risk, moderate wine drinking was associated with a reduction in neoplasia. Results are shown in the table below.

Anatomic location of significant colorectal neoplasia in male patients who smoke

Purpose: There is little data regarding anatomic distribution of significant adenomatous polyps (>1 cm) in smokers. Our aim was to determine if there is an association between smoking and the anatomic location of significant polyps.