Articles
16 December 2003

Using Risk for Advanced Proximal Colonic Neoplasia To Tailor Endoscopic Screening for Colorectal Cancer

Publication: Annals of Internal Medicine
Volume 139, Number 12

Abstract

Background:

Colonoscopic screening for colorectal cancer has been suggested because sigmoidoscopy misses nearly half of persons with advanced proximal neoplasia.

Objective:

To create a clinical index to stratify risk for advanced proximal neoplasia and to identify a subgroup with very low risk in which screening sigmoidoscopy alone might suffice.

Design:

Cross-sectional study.

Setting:

A company-based program of screening colonoscopy for colorectal cancer.

Patients:

Consecutive persons 50 years of age or older undergoing first-time screening colonoscopy between September 1995 and June 2001.

Measurements:

A clinical index with 3 variables was created from information on the first 1994 persons. Points were assigned to categories of age, sex, and distal findings. Risk for advanced proximal neoplasia (defined as an adenoma 1 cm or larger or one with villous histology, severe dysplasia, or cancer) was measured for each score. The index was tested on the next 1031 persons from the same screening program.

Results:

Of 1994 persons, 67 (3.4%) had advanced proximal neoplasia. A low-risk subgroup comprising 37% of the cohort had scores of 0 or 1 and a risk of 0.68% (95% CI, 0.22% to 1.57%). Among the validation group of 1031 persons, risk for advanced proximal neoplasia in the low-risk subgroup (comprising 47% of the cohort) was 0.4% (upper confidence limit of 1.49%). Application of this index detected 92% of persons with advanced proximal neoplasms and, if applied following screening sigmoidoscopy, could reduce the need for colonoscopy by 40%. The marginal benefit of colonoscopy among low-risk persons was small: To detect 7 additional persons with advanced proximal neoplasia, 1217 additional colonoscopies would be required.

Conclusions:

This clinical index stratifies the risk for advanced proximal neoplasia and identifies a subgroup at very low risk. If it is validated in other cohorts or groups, the index could be used to tailor endoscopic screening for colorectal cancer.

Get full access to this article

View all available purchase options and get full access to this article.

References

1.
Podolsky DK. Going the distancethe case for true colorectal-cancer screening [Editorial]. N Engl J Med. 2000;343:207-8. [PMID: 10900282]
2.
Detsky AS. Screening for colon cancercan we afford colonoscopy? [Editorial]. N Engl J Med. 2001;345:607-8. [PMID: 11529216]
3.
Lieberman DAWeiss DGBond JHAhnen DJGarewal HChejfec G. Use of colonoscopy to screen asymptomatic adults for colorectal cancer. Veterans Affairs Cooperative Study Group 380. N Engl J Med. 2000;343:162-8. [PMID: 10900274]
4.
Imperiale TFWagner DRLin CYLarkin GNRogge JDRansohoff DF. Risk of advanced proximal neoplasms in asymptomatic adults according to the distal colorectal findings. N Engl J Med. 2000;343:169-74. [PMID: 10900275]
5.
Ransohoff DFSandler RS. Clinical practice. Screening for colorectal cancer. N Engl J Med. 2002;346:40-4. [PMID: 11778002]
6.
Imperiale TFRansohoff DF. Screening for colorectal cancer [Letter]. N Engl J Med. 2000;343:1651-3.
7.
Rex DKLieberman DA. Feasibility of colonoscopy screening: discussion of issues and recommendations regarding implementation [Editorial]. Gastrointest Endosc. 2001;54:662-7. [PMID: 11677497]
8.
Byers TLevin BRothenberger DDodd GDSmith RA. American Cancer Society guidelines for screening and surveillance for early detection of colorectal polyps and cancer: update 1997. American Cancer Society Detection and Treatment Advisory Group on Colorectal Cancer. CA Cancer J Clin. 1997;47:154-60. [PMID: 9152173]
9.
Pignone MRich MTeutsch SMBerg AOLohr KN. Screening for colorectal cancer in adults at average risk: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137:132-41. [PMID: 12118972]
10.
Rex DKJohnson DALieberman DABurt RWSonnenberg A. Colorectal cancer prevention 2000: screening recommendations of the American College of Gastroenterology. American College of Gastroenterology. Am J Gastroenterol. 2000;95:868-77. [PMID: 10763931]
11.
Smith RAvon Eschenbach ACWender RLevin BByers TRothenberger D . American Cancer Society guidelines for the early detection of cancer: update of early detection guidelines for prostate, colorectal, and endometrial cancers. Also: update 2001testing for early lung cancer detection. CA Cancer J Clin. 2001;51:38-75. [PMID: 11577479]
12.
Winawer SJFletcher RHMiller LGodlee FStolar MHMulrow CD . Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology. 1997;112:594-642. [PMID: 9024315]
13.
Zarchy TErshoff D. Do characteristics of adenomas on flexible sigmoidoscopy predict advanced lesions on baseline colonoscopy? Gastroenterology. 1994;106:1501-4.
14.
Read TERead JDButterly LF. Importance of adenomas 5 mm or less in diameter that are detected by sigmoidoscopy. N Engl J Med. 1997;336:8-12. [PMID: 8970934]
15.
Schoen RECorle DCranston LWeissfeld JLLance PBurt R . Is colonoscopy needed for the nonadvanced adenoma found on sigmoidoscopy? The Polyp Prevention Trial. Gastroenterology. 1998;115:533-41. [PMID: 9721149]
16.
Wallace MBKemp JATrnka YMDonovan JMFarraye FA. Is colonoscopy indicated for small adenomas found by screening flexible sigmoidoscopy? Ann Intern Med. 1998;129:273-8. [PMID: 9729179]
17.
Levin TRPalitz AGrossman SConell CFinkler LAckerson L . Predicting advanced proximal colonic neoplasia with screening sigmoidoscopy. JAMA. 1999;281:1611-7. [PMID: 10235154]
18.
Braitman LEDavidoff F. Predicting clinical states in individual patients. Ann Intern Med. 1996;125:406-12. [PMID: 8702092]
19.
Konishi FMorson BC. Pathology of colorectal adenomas: a colonoscopic survey. J Clin Pathol. 1982;35:830-41. [PMID: 7107955]
20.
Hanley JAMcNeil BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology. 1982;143:29-36. [PMID: 7063747]
21.
Harrell FE JrLee KLMatchar DBReichert TA. Regression models for prognostic prediction: advantages, problems, and suggested solutions. Cancer Treat Rep. 1985;69:1071-77. [PMID: 4042087]
22.
Ruttimann UE. Statistical approaches to development and validation of predictive instruments. Crit Care Clin. 1994;10:19-35. [PMID: 8118728]
23.
Atkin WSCuzick JNorthover JMWhynes DK. Prevention of colorectal cancer by once-only sigmoidoscopy. Lancet. 1993;341:736-40. [PMID: 8095636]
24.
Atkin WSWhynes DK. Improving the cost-effectiveness of colorectal cancer screening [Editorial]. J Natl Cancer Inst. 2000;92:513-4. [PMID: 10749896]
25.
Fletcher RHFarraye FA. Screening flexible sigmoidoscopy: effectiveness is not enough [Editorial]. Gastroenterology. 1999;117:486-8. [PMID: 10419930]
26.
Selby JV. Targeting colonoscopy [Editorial]. Gastroenterology. 1994;106:1702-5.
27.
Lewis JDAsch DA. Barriers to office-based screening sigmoidoscopy: does reimbursement cover costs? Ann Intern Med. 1999;130:525-30. [PMID: 10075621]
28.
Levin TRPalitz AM. Flexible sigmoidoscopy: an important screening option for average-risk individuals. Gastrointest Endosc Clin N Am. 2002;12:23-40, vi. [PMID: 11916159]
29.
Stryker SJWolff BGCulp CELibbe SDIlstrup DMMacCarty RL. Natural history of untreated colonic polyps. Gastroenterology. 1987;93:1009-13. [PMID: 3653628]

Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 139Number 1216 December 2003
Pages: 959 - 965

History

Published online: 16 December 2003
Published in issue: 16 December 2003

Keywords

Authors

Affiliations

Thomas F. Imperiale, MD
From Indiana University School of Medicine, Indiana University, Roudebush Veterans Affairs Medical Center, The Regenstrief Institute, Inc., Indianapolis Gastroenterology Research Foundation, and Eli Lilly and Co., Inc., Indianapolis, Indiana; and University of North Carolina, Chapel Hill, Chapel Hill, North Carolina.
David R. Wagner, MS
From Indiana University School of Medicine, Indiana University, Roudebush Veterans Affairs Medical Center, The Regenstrief Institute, Inc., Indianapolis Gastroenterology Research Foundation, and Eli Lilly and Co., Inc., Indianapolis, Indiana; and University of North Carolina, Chapel Hill, Chapel Hill, North Carolina.
Ching Y. Lin, BS
From Indiana University School of Medicine, Indiana University, Roudebush Veterans Affairs Medical Center, The Regenstrief Institute, Inc., Indianapolis Gastroenterology Research Foundation, and Eli Lilly and Co., Inc., Indianapolis, Indiana; and University of North Carolina, Chapel Hill, Chapel Hill, North Carolina.
Gregory N. Larkin, MD
From Indiana University School of Medicine, Indiana University, Roudebush Veterans Affairs Medical Center, The Regenstrief Institute, Inc., Indianapolis Gastroenterology Research Foundation, and Eli Lilly and Co., Inc., Indianapolis, Indiana; and University of North Carolina, Chapel Hill, Chapel Hill, North Carolina.
James D. Rogge, MD
From Indiana University School of Medicine, Indiana University, Roudebush Veterans Affairs Medical Center, The Regenstrief Institute, Inc., Indianapolis Gastroenterology Research Foundation, and Eli Lilly and Co., Inc., Indianapolis, Indiana; and University of North Carolina, Chapel Hill, Chapel Hill, North Carolina.
David F. Ransohoff, MD
From Indiana University School of Medicine, Indiana University, Roudebush Veterans Affairs Medical Center, The Regenstrief Institute, Inc., Indianapolis Gastroenterology Research Foundation, and Eli Lilly and Co., Inc., Indianapolis, Indiana; and University of North Carolina, Chapel Hill, Chapel Hill, North Carolina.
Grant Support: In part by grant K24 DK 02756 from the National Institute of Diabetes and Digestive and Kidney Disorders (Dr. Imperiale).
Disclosures: At the time of data collection, Mr. Wagner was responsible for the Indianapolis Gastroenterology Research Foundation portion of the Eli Lilly colorectal cancer program, and a portion of his salary was paid by funds received from Lilly for program management.
Corresponding Author: Thomas F. Imperiale, MD, The Regenstrief Institute, Inc., 1050 Wishard Boulevard, Indianapolis, IN 46202.
Current Author Addresses: Dr. Imperiale: The Regenstrief Institute, Inc., 1050 Wishard Boulevard, Indianapolis, IN 46202.
Ms. Lin: 6931 Middlebranch Avenue, Canton, OH 44721.
Dr. Rogge: Indianapolis Gastroenterology Research Foundation, 8051 South Emerson 200, Indianapolis, IN 46237.
Dr. Ransohoff: CB 7080, 4103 Bioinformatics Building, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7080.
Mr. Wagner: Med Institute, 1400 Cumberland Avenue, West Lafayette, IN 47906.
Dr. Larkin: Eli Lilly and Co., Lilly Corporate Center, DC 2111, Indianapolis, IN 46285.
Author Contributions: Conception and design: T.F. Imperiale, D.R. Wagner, D.F. Ransohoff.
Analysis and interpretation of the data: T.F. Imperiale, D.R. Wagner, C.Y. Lin, D.F. Ransohoff.
Drafting of the article: T.F. Imperiale, D.F. Ransohoff.
Critical revision of the article for important intellectual content: T.F. Imperiale, D.R. Wagner, G.N. Larkin, J.D. Rogge, D.F. Ransohoff.
Final approval of the article: T.F. Imperiale, J.D. Rogge, D.F. Ransohoff.
Provision of study materials or patients: D.R. Wagner, G.N. Larkin, J.D. Rogge.
Statistical expertise: T.F. Imperiale.
Obtaining of funding: T.F. Imperiale.
Administrative, technical, or logistic support: D.R. Wagner, C.Y. Lin, G.N. Larkin.
Collection and assembly of data: T.F. Imperiale, D.R. Wagner, C.Y. Lin.

Metrics & Citations

Metrics

Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. For an editable text file, please select Medlars format which will download as a .txt file. Simply select your manager software from the list below and click Download.

For more information or tips please see 'Downloading to a citation manager' in the Help menu.

Format





Download article citation data for:
Thomas F. Imperiale, David R. Wagner, Ching Y. Lin, et al. Using Risk for Advanced Proximal Colonic Neoplasia To Tailor Endoscopic Screening for Colorectal Cancer. Ann Intern Med.2003;139:959-965. [Epub 16 December 2003]. doi:10.7326/0003-4819-139-12-200312160-00005

View More

Get Access

Login Options:
Purchase

You will be redirected to acponline.org to sign-in to Annals to complete your purchase.

Access to EPUBs and PDFs for FREE Annals content requires users to be registered and logged in. A subscription is not required. You can create a free account below or from the following link. You will be redirected to acponline.org to create an account that will provide access to Annals. If you are accessing the Free Annals content via your institution's access, registration is not required.

Create your Free Account

You will be redirected to acponline.org to create an account that will provide access to Annals.

View options

PDF/ePub

View PDF/ePub

Related in ACP Journals

Full Text

View Full Text

Media

Figures

Other

Tables

Share

Share

Copy the content Link

Share on social media