Heterogeneity in colorectal cancer incidence among people recommended 3-yearly surveillance post-polypectomy: a validation study

Abstract

Background Colonoscopy surveillance is recommended for patients at increased risk of colorectal cancer (CRC) following adenoma removal. Low-, intermediate-, and high-risk groups are defined by baseline adenoma characteristics. We previously examined intermediate-risk patients from hospital data and identified a higher-risk subgroup who benefited from surveillance and a lower-risk subgroup who may not require surveillance. This study explored whether these findings apply in individuals undergoing CRC screening.

Methods This retrospective study used data from the UK Flexible Sigmoidoscopy Screening Trial (UKFSST), English CRC screening pilot (ECP), and US Kaiser Permanente CRC prevention program (KPCP). Screening participants (50 – 74 years) classified as intermediate-risk at baseline colonoscopy were included. CRC data were available through 2006 (KPCP) or 2014 (UKFSST, ECP). Lower- and higher-risk subgroups were defined using our previously identified baseline risk factors: higher-risk participants had incomplete colonoscopies, poor bowel preparation, adenomas ≥ 20 mm or with high-grade dysplasia, or proximal polyps. We compared CRC incidence in these subgroups and in the presence vs. absence of surveillance using Cox regression.

Results Of 2291 intermediate-risk participants, 45 % were classified as higher risk. Median follow-up was 11.8 years. CRC incidence was higher in the higher-risk than lower-risk subgroup (hazard ratio [HR] 2.08, 95 % confidence interval [CI] 1.07 – 4.06). Surveillance reduced CRC incidence in higher-risk participants (HR 0.35, 95 %CI 0.14 – 0.86) but not statistically significantly so in lower-risk participants (HR 0.41, 95 %CI 0.12 – 1.38).

Conclusion As previously demonstrated for hospital patients, screening participants classified as intermediate risk comprised two risk subgroups. Surveillance clearly benefited the higher-risk subgroup.

Publication History

Received: 17 October 2019

Accepted: 12 June 2020

Article published online:
19 August 2020

• References

• 1 Segnan N, Armaroli P, Bonelli L. et al. Once-only sigmoidoscopy in colorectal cancer screening: follow-up findings of the Italian Randomized Controlled Trial – SCORE. J Natl Cancer Inst 2011; 103: 1310-1322
• 2 Schoen RE, Pinsky PF, Weissfeld JL. et al. Colorectal-cancer incidence and mortality with screening flexible sigmoidoscopy. N Engl J Med 2012; 366: 2345-2357
• 3 Holme O, Loberg M, Kalager M. et al. Effect of flexible sigmoidoscopy screening on colorectal cancer incidence and mortality: a randomized clinical trial. JAMA 2014; 312: 606-615
• 4 Atkin W, Wooldrage K, Parkin DM. et al. Long term effects of once-only flexible sigmoidoscopy screening after 17 years of follow-up: the UK Flexible Sigmoidoscopy Screening randomised controlled trial. Lancet 2017; 389: 1299-1311
• 5 National Institute for Health and Care Excellence. Colorectal cancer prevention: colonoscopic surveillance in adults with ulcerative colitis, Crohn’s disease or adenomas Clinical guideline (CG118). Manchester: National Institute for Health and Care Excellence; 2011
• 6 Atkin WS, Valori R, Kuipers EJ. et al. European guidelines for quality assurance in colorectal cancer screening and diagnosis. First edition – Colonoscopic surveillance following adenoma removal. Endoscopy 2012; 44 (Suppl. 03) SE151-163
• 7 Lieberman DA, Rex DK, Winawer SJ. et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2012; 143: 844-857
• 8 Hassan C, Quintero E, Dumonceau JM. et al. Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2013; 45: 842-851
• 9 Atkin WS, Saunders BP. Surveillance guidelines after removal of colorectal adenomatous polyps. Gut 2002; 51 (Suppl. 05) V6-V9
• 10 van Stolk RU, Beck GJ, Baron JA. et al. Adenoma characteristics at first colonoscopy as predictors of adenoma recurrence and characteristics at follow-up. The Polyp Prevention Study Group. Gastroenterology 1998; 115: 13-18
• 11 Noshirwani KC, van Stolk RU, Rybicki LA. et al. Adenoma size and number are predictive of adenoma recurrence: implications for surveillance colonoscopy. Gastrointest Endosc 2000; 51: 433-437
• 12 Martínez ME, Sampliner R, Marshall JR. et al. Adenoma characteristics as risk factors for recurrence of advanced adenomas. Gastroenterology 2001; 120: 1077-1083
• 13 Winawer SJ, Zauber AG, O’Brien MJ. et al. Randomized comparison of surveillance intervals after colonoscopic removal of newly diagnosed adenomatous polyps. The National Polyp Study Workgroup. N Engl J Med 1993; 328: 901-906
• 14 Atkin W, Wooldrage K, Brenner A. et al. Adenoma surveillance and colorectal cancer incidence: a retrospective, multicentre, cohort study. Lancet Oncol 2017; 18: 823-834
• 15 Atkin W, Brenner A, Martin J. et al. The clinical effectiveness of different surveillance strategies to prevent colorectal cancer in people with intermediate-grade colorectal adenomas: a retrospective cohort analysis, and psychological and economic evaluations. Health Technol Assess 2017; 21: 1-536
• 16 Atkin WS, Edwards R, Kralj-Hans I. et al. Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet 2010; 375: 1624-1633
• 17 Atkin WS, Cook CF, Cuzick J. et al. Single flexible sigmoidoscopy screening to prevent colorectal cancer: baseline findings of a UK multicentre randomised trial. Lancet 2002; 359: 1291-1300
• 18 Alexander F, Weller D. Evaluation of the UK Colorectal Cancer Screening Pilot: Final Report. Edinburgh: UK CRC Screening Pilot Evaluation Team; 2003
• 19 UK Colorectal Cancer Screening Pilot Group. Results of the first round of a demonstration pilot of screening for colorectal cancer in the United Kingdom. BMJ 2004; 329: 133
• 20 Palitz AM, Selby JV, Grossman S. et al. The Colon Cancer Prevention Program (CoCaP): rationale, implementation, and preliminary results. HMO Pract 1997; 11: 5-12
• 21 Anderson JC, Butterly LF. Colonoscopy: quality indicators. Clin Transl Gastroenterol 2015; 6: e77
• 22 Brine S. Bowel screening to start at 50. London: Public Health England; 2018 https://www.gov.uk/government/news/bowel-screening-to-start-at-50 Accessed 21 January 2020
• 23 Bowel Cancer UK. We did it! Bowel cancer screening age to be lowered to 50 in England and Wales. 2018 https://www.bowelcanceruk.org.uk/news-and-blogs/news/we-did-it!-bowel-cancer-screening-age-to-be-lowered-to-50-in-england/ Accessed 21 January 2020
• 24 NHS Health Scotland. Bowel screening. 2019 http://www.healthscotland.scot/health-topics/screening/bowel-screening Accessed 21 January 2020
• 25 Ahmed S, Naumann D, Karandikar S. Differences in screening vs non-screening colonoscopy: scope for improvement?. Colorectal Dis 2016; 18: 903-909
• 26 Saunders BP, Fukumoto M, Halligan S. et al. Why is colonoscopy more difficult in women?. Gastrointest Endosc 1996; 43 : 124-126
• 27 Rees CJ, Koo S, Anderson J. et al. British Society of Gastroenterology Endoscopy Quality Improvement Programme (EQIP): overview and progress. Frontline Gastroenterol 2019; 10: 148-153