Outcome of 12‐month surveillance colonoscopy in high‐risk patients in the <scp>N</scp>ational <scp>H</scp>ealth <scp>S</scp>ervice <scp>B</scp>owel <scp>C</scp>ancer <scp>S</scp>creening <scp>P</scp>rogramme

Lee, Ta‐Jen; Nickerson, Claire; Af, Goddard; Rees, Colin; McNally, Richard J.Q.; Rutter,

doi:10.1111/codi.12278

Cited by 17 publications

(17 citation statements)

References 29 publications

(40 reference statements)

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“…The proportion of patients with no adenomas at follow-up surveillance was similar for Lee and colleagues 133 (49.2%) and Martínez and colleagues 134 (53.3%). We chose the estimate from the study by Martínez and colleagues, 134 as it was the larger study, and not only for high-risk patients.…”

Section: Surveillance Populationsupporting

confidence: 75%

“…We found several studies that reported the distribution of adenomas at follow-up surveillance for specific subgroups. For example, Lee and colleagues 133 reported the outcome of 12-month surveillance colonoscopy in high-risk patients (n = 1760) in the NHS Bowel Cancer Screening Programme. Martínez and colleagues 134 reported a pooled analysis of eight prospective studies comprising 9167 people with previously resected colorectal adenomas during a median follow-up of 4 years.…”

Section: Surveillance Populationmentioning

confidence: 99%

See 1 more Smart Citation

Virtual chromoendoscopy for the real-time assessment of colorectal polyps in vivo: a systematic review and economic evaluation

Picot

Rose

Cooper

et al. 2017

Health Technol Assess

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BackgroundCurrent clinical practice is to remove a colorectal polyp detected during colonoscopy and determine whether it is an adenoma or hyperplastic by histopathology. Identifying adenomas is important because they may eventually become cancerous if untreated, whereas hyperplastic polyps do not usually develop into cancer, and a surveillance interval is set based on the number and size of adenomas found. Virtual chromoendoscopy (VCE) (an electronic endoscopic imaging technique) could be used by the endoscopist under strictly controlled conditions for real-time optical diagnosis of diminutive (≤ 5 mm) colorectal polyps to replace histopathological diagnosis.ObjectiveTo assess the clinical effectiveness and cost-effectiveness of the VCE technologies narrow-band imaging (NBI), flexible spectral imaging colour enhancement (FICE) and i-scan for the characterisation and management of diminutive (≤ 5 mm) colorectal polyps using high-definition (HD) systems without magnification.DesignSystematic review and economic analysis.ParticipantsPeople undergoing colonoscopy for screening or surveillance or to investigate symptoms suggestive of colorectal cancer.InterventionsNBI, FICE and i-scan.Main outcome measuresDiagnostic accuracy, recommended surveillance intervals, health-related quality of life (HRQoL), adverse effects, incidence of colorectal cancer, mortality and cost-effectiveness of VCE compared with histopathology.Data sourcesElectronic bibliographic databases including MEDLINE, EMBASE, The Cochrane Library and Database of Abstracts of Reviews of Effects were searched for published English-language studies from inception to June 2016. Bibliographies of related papers, systematic reviews and company information were screened and experts were contacted to identify additional evidence.Review methodsSystematic reviews of test accuracy and economic evaluations were undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Meta-analyses were conducted, where possible, to inform the independent economic model. A cost–utility decision-analytic model was developed to estimate the cost-effectiveness of VCE compared with histopathology. The model used a decision tree for patients undergoing endoscopy, combined with estimates of long-term outcomes (e.g. incidence of colorectal cancer and subsequent morbidity and mortality) derived from University of Sheffield School of Health and Related Research’s bowel cancer screening model. The model took a NHS perspective, with costs and benefits discounted at 3.5% over a lifetime horizon. There were limitations in the data on the distribution of adenomas across risk categories and recurrence rates post polypectomy.ResultsThirty test accuracy studies were included: 24 for NBI, five for i-scan and three for FICE (two studies assessed two interventions). Polyp assessments made with high confidence were associated with higher sensitivity and endoscopists experienced in VCE achieved better results than those without experience. Two economic evaluations were included. NBI, i-scan and FICE are cost-saving strategies compared with histopathology and the number of quality-adjusted life-years gained was similar for histopathology and VCE. The correct surveillance interval would be given to 95% of patients with NBI, 94% of patients with FICE and 97% of patients with i-scan.LimitationsLimited evidence was available for i-scan and FICE and there was heterogeneity among the NBI studies. There is a lack of data on longer-term health outcomes of patients undergoing VCE for assessment of diminutive colorectal polyps.ConclusionsVCE technologies, using HD systems without magnification, could potentially be used for the real-time assessment of diminutive colorectal polyps, if endoscopists have adequate experience and training.Future workFuture research priorities include head-to-head randomised controlled trials of all three VCE technologies; more research on the diagnostic accuracy of FICE and i-scan (when used without magnification); further studies evaluating the impact of endoscopist experience and training on outcomes; studies measuring adverse effects, HRQoL and anxiety; and longitudinal data on colorectal cancer incidence, HRQoL and mortality.Study registrationThis study is registered as PROSPERO CRD42016037767.FundingThe National Institute for Health Research Health Technology Assessment programme.

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Section: Surveillance Populationsupporting

confidence: 75%

Section: Surveillance Populationmentioning

confidence: 99%

Virtual chromoendoscopy for the real-time assessment of colorectal polyps in vivo: a systematic review and economic evaluation

Picot

Rose

Cooper

et al. 2017

Health Technol Assess

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“…12% of men and 6.2% of women who undergo screening colonoscopy), are recommended to undergo surveillance colonoscopy 12 months from the screening colonoscopy. 98 Since 2013, the bowel scope programme has been rolled out across England, whereby, in addition to the biennial guaiac FOBt invitation, a single FS is offered to all individuals aged 55 years. 99 The presence of a colorectal adenoma of ≥ 10 mm in diameter, three or more small (i.e.…”

Section: The Nhs Bowel Cancer Screening Programmementioning

confidence: 99%

“…49 We expected the high ADRa at the 1-year surveillance colonoscopy of 'high-risk' individuals in the English BCSP compared with previous polyp-prevention trials. 98 The high ADRa in the seAFOod trial population of obese, male-predominant 'polyp formers' will also have been driven by the uniformly excellent colonoscopy quality in the BCSP, in which the ADRa figures prominently as an individual QA measure. 38,95,97 It is noteworthy that those previous aspirin RCTs with the highest placebo ADRa {47.1% [Aspirin and Folate Polyp-Prevention Study (AFPPS) 114 ] and 53.4% [APACC 115 ]} reported the smallest (statistically insignificant) risk reduction associated with aspirin (risk ratio 0.88 and 0.95, respectively) compared with the other two aspirin RCTs, 49 despite the overwhelming evidence for a CRC chemoprevention effect of aspirin.…”

Section: Colorectal Adenoma End Pointsmentioning

confidence: 99%

Eicosapentaenoic acid and/or aspirin for preventing colorectal adenomas during colonoscopic surveillance in the NHS Bowel Cancer Screening Programme: the seAFOod RCT

et al. 2019

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Background The omega-3 polyunsaturated fatty acid eicosapentaenoic acid (EPA) and aspirin both have proof of concept for colorectal cancer (CRC) chemoprevention, aligned with an excellent safety profile. Objectives The objectives were to determine whether or not EPA prevents colorectal adenomas, either alone or in combination with aspirin, and to assess the safety/tolerability of EPA, in the free fatty acid (FFA) form or as the triglyceride (TG), and aspirin. Design This was a randomised, blinded, placebo-controlled, 2 × 2 factorial trial. Setting The NHS Bowel Cancer Screening Programme (BCSP). Participants Patients (aged 55–73 years) identified as ‘high risk’ (i.e. those who have five or more colorectal adenomas of < 10 mm in size or three or more colorectal adenomas if one is ≥ 10 mm in size) at screening colonoscopy. Interventions The interventions were capsules containing 2000 mg of 99% EPA–FFA or 2780 mg of 90% EPA–TG (equivalent to 2000 mg of FFA) taken daily, or identical placebo capsules; and 300 mg of aspirin taken daily, or an identical placebo, enteric-coated tablet. Both were taken for ≈1 year until surveillance colonoscopy. All participants and staff were unaware of treatment allocation. Main outcome measures The primary outcome was the number of participants with one or more colorectal adenomas [adenoma detection rate (ADRa)] at surveillance colonoscopy. Outcomes were analysed for all participants with observable follow-up data by an ‘at-the-margins’ approach, adjusted for BCSP site and by the need for repeat baseline endoscopy. Secondary outcome measures – these included the number of colorectal adenomas per patient [mean adenomas per patient (MAP)], ‘advanced’ ADRa and colorectal adenoma location (right/left) and type (conventional/serrated). Results Between November 2011 and June 2016, 709 participants were randomised, with 707 providing data (80% male, mean age 65 years). The four treatment groups (EPA + aspirin, n = 177; EPA, n = 179; aspirin, n = 177; placebo, n = 176) were well matched for baseline characteristics. Tissue EPA levels and tolerability were similar for FFA and TG users. There was no evidence of any difference in ADRa between EPA users (62%) and non-users (61%) [risk difference –0.9%, 95% confidence interval (CI) –8.8% to 6.9%] or for aspirin users (61%) versus non-users (62%) (risk difference –0.6%, 95% CI –8.5% to 7.2%). There was no evidence of an interaction between EPA and aspirin for ADRa. There was no evidence of any effect on advanced ADRa of either EPA (risk difference –0.6%, 95% CI –4.4% to 3.1%) or aspirin (risk difference –0.3%, 95% CI –4.1% to 3.5%). Aspirin use was associated with a reduction in MAP [incidence rate ratio (IRR) 0.78, 95% CI 0.68 to 0.90), with preventative efficacy against conventional (IRR 0.82, 95% CI 0.71 to 0.94), serrated (IRR 0.46, 95% CI 0.25 to 0.87) and right-sided (IRR 0.73, 95% CI 0.61 to 0.88) lesions, but not left-sided (IRR 0.85, 95% CI 0.69 to 1.06) adenomas. There was evidence of chemopreventive efficacy of EPA on conventional (IRR 0.86, 95% CI 0.74 to 0.99) and left-sided (IRR 0.75, 95% CI 0.60 to 0.94) adenomas, but not on total MAP (IRR 0.91, 95% CI 0.79 to 1.05) or serrated (IRR 1.44, 95% CI 0.79 to 2.60) or right-sided (IRR 1.02, 95% CI 0.85 to 1.22) adenomas. EPA and aspirin treatment were well tolerated, with excess mild/moderate gastrointestinal (GI) adverse events (AEs) in the EPA alone group. There were six GI bleeding AEs. Conclusion EPA and aspirin treatment were not associated with a reduction in ADRa. However, both agents displayed evidence of chemopreventive efficacy, based on adenoma number reduction, which was specific to adenoma type and location, and is compatible with known anti-CRC activity of aspirin. Limitations Limitations of the trial included the failure to recruit to the target sample size of 853, and an unexpected switch of EPA formulation mid-trial. Future work A future objective should be to understand the mechanism(s) of action of EPA and aspirin using the trial biobank. Established trial infrastructure will enable future trials in the BCSP. Trial registration Current Controlled Trials ISRCTN05926847. Funding This project was funded by the Efficacy and Mechanism Evaluation (EME) programme, a MRC and NIHR partnership.

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“…A French study observed a 2.2-fold greater incidence of CRC amongst advanced adenoma patients compared with the general population,(17) whilst a large Dutch study concluded that excess CRC risk in adenoma patients was limited to the first few years of follow-up. (18) In addition, given the enhanced opportunity for polyp detection within bowel cancer screening programmes,(19, 20) the appropriate clinical management of patients following polypectomy is even more pertinent.…”

Section: Introductionmentioning

confidence: 99%

Colorectal Cancer Risk Following Adenoma Removal: A Large Prospective Population-Based Cohort Study

Coleman¹,

Loughrey

Murray³

et al. 2015

Cancer Epidemiology, Biomarkers &Amp; Prevention

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Background Randomised controlled trials have demonstrated significant reductions in colorectal cancer (CRC) incidence and mortality associated with polypectomy. However, little is known about whether polypectomy is effective at reducing CRC risk in routine clinical practice. The aim of this investigation was to quantify CRC risk following polypectomy in a large prospective population-based cohort study. Methods Patients with incident colorectal polyps between 2000 and 2005 in Northern Ireland (NI) were identified via electronic pathology reports received to the NI Cancer Registry (NICR). Patients were matched to the NICR to detect CRC and deaths up to 31st December 2010. CRC standardised incidence ratios (SIRs) were calculated and Cox proportional hazards modelling applied to determine CRC risk. Results During 44,724 person-years of follow-up, 193 CRC cases were diagnosed amongst 6,972 adenoma patients, representing an annual progression rate of 0.43%. CRC risk was significantly elevated in patients who had an adenoma removed (SIR 2.85; 95% CI: 2.61 to 3.25) compared with the general population. Male sex, older age, rectal site and villous architecture were associated with an increased CRC risk in adenoma patients. Further analysis suggested that not having a full colonoscopy performed at, or following, incident polypectomy contributed to the excess CRC risk. Conclusions CRC risk was elevated in individuals following polypectomy for adenoma, outside of screening programmes. Impact This finding emphasises the need for full colonoscopy and adenoma clearance, and appropriate surveillance, after endoscopic diagnosis of adenoma.

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Outcome of 12‐month surveillance colonoscopy in high‐risk patients in the National Health Service Bowel Cancer Screening Programme

Cited by 17 publications

References 29 publications

Virtual chromoendoscopy for the real-time assessment of colorectal polyps in vivo: a systematic review and economic evaluation

Virtual chromoendoscopy for the real-time assessment of colorectal polyps in vivo: a systematic review and economic evaluation

Eicosapentaenoic acid and/or aspirin for preventing colorectal adenomas during colonoscopic surveillance in the NHS Bowel Cancer Screening Programme: the seAFOod RCT

Colorectal Cancer Risk Following Adenoma Removal: A Large Prospective Population-Based Cohort Study

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