The FOBT-Pos-Finger Followed By FOBT-6-Pack May Be a Viable Screening Policy for Colo Rectal Cancer
1
308 The FOBT-Pos-Finger Followed By FOBT-6-Pack May Be a Viable Screening Policy for Colo Rectal Cancer Shivani Jain, Stephen J. Sontag, Thomas G. Schnell, Jack Leya, Harish Bhatia Introduction: Screening for CRC using a single FOBT with stool from rectal exam (Finger-pos) is considered unacceptable. Two decades ago, it was our policy to ignore the Finger-pos and instead insure that all such pts returned a subsequent 6-pk. We now report the long-term results of our policy - the accepted medical standard at the time. Question: In Asx pts referred for GI w/u because of Finger-pos from routine rectal exam, what is the long-term outcome in those pts (a) who received a Flex Sig because of a subsequent 6-pk-neg versus (b) those who received a C-Scope because of a subsequent 6-pk-pos? Methods: Asx pts referred with Finger-pos were then given the 6-pk, with specific instructions as to its importance. FOBTwas not rehydrated and was considered pos if at least one of six windows was pos. Management was as follows: (a) If 6-pk-pos: C-Scope. (b) If 6-pk-neg: Flex Sig, with subsequent C-Scope only if adenomas found. Results: From 1985 to 1994, 230 Asx pts with finger-pos were referred for GI w/u. All 230 pts were given the 6-pk and all returned it (after f/u calls). 33/230 were 6-pk-pos and had C-scope; and 197/230 were 6-pk-neg and had Flex Sig. (A) Both groups: mean age at initial request: 65 years, and mean f/u: 11 years. (B) % with adenomas: 6-pk-pos Z 52%; 6-pk-neg Z19% (Diff 33%; CI: 15.6-49.7). (C) % with CRC: 6-pk-pos Z 24%; 6-pk-neg Z 2% (Diff 22%; CI: 10.3-38.8%). (D) All 12 pts with CRC were diagnosed within the first 3 months of request. (E) Median Survival 6.2 yrs for CRC and 13.7 yrs for non-CRC was significant (HR: 0.40; CI: 0.10 to 0.60). (F) 6-pk- result did not affect survival. (G) Only CRC predicted survival, however, no pts died from CRC. Conclusion: The 12X greater prevalence of CRC in 6-pk-pos pts vs 6-pk-neg pts and the detection of all CRC’s early in the w/u suggest that the finger-pos-FOBT followed by the 6-pk-FOBT may hold promise as a viable FOBTscreening policy. 309 Is American College of Radiology Recommendations for CT Colonography Reporting Suitable for Asia? Joseph J. Sung, Kelvin K. Tsoi, Yee Yu Pau, Bing-Yee Suen, Derek Luo, Simon S. NG Background: US Multi-Society Task Force on Colorectal Cancer Guideline recommends CT Colonography as a comparable screening modality for detection of cancer and polyps [Levin et al. Gastroenterol 2008]. ACR recommends that polyp ! 5 mm in size need not be reported and patients with 1 or 2 polyps 6-9 mm in size can be offered repeated CTC in 3 years without polypectomy [Zalis et al. Radiology 2005]. Aims: We aim to investigate the possibility of missing advanced colonic neoplasm (ACN) using these criteria in the Asian populations. Methods: Based the Asia Pacific Working Group (a consortium of 15 countries) database of 5747 subjects underwent colonoscopy for routine screening (nZ860), surveillance in patients with IBD or previous polypectomy (nZ206) and symptoms suggestive of bowel disorders that indicates colonoscopy (nZ4681), patients were classified by the size of the largest polyp and the number of polyps found in the colon. Results: Among 5747 subjects, polyps were found in 1695 subjects (29.5%) and complete histology and size available in 1620 (28.2%). The proportion with ACN was 3.7% (31/845) in 1-5 mm group, 11.8% (36/305) in 6-9 mm group and 64.0% (301/470) in the greater than 10 mm group. Using the ACR criteria, 31/368 (8.4%) ACN sized 1-5mm will not been reported and 32/368 (8.7%) ACN sized 6-9 mm will not be treated by polypectomy. 8.4%, 21.2% and 14.3% of entire population, persons age 50 or older and screening patients age 50 or older with ACN would be called normal. 8.7%, 8.4% and 7.1% of these groups could have polypectomy delayed for at least three years. Conclusion: In total, around 1 in 6 ACN would be missed or delayed for treatment. Current criteria for CTC reporting will lead to substantial delay in management of ACN in Asian populations. No. of polyps &5 mm (%) 6-9 mm (%) S10 mm 1 to 2 Total no. polyps Adenoma ACN 717 377 (52.6) 24 (3.3) 286 248 (86.7) 32 (11.2) 446 270 (60.5) 283 (63.5) 3 or more Total no. polyps Adenoma ACN 128 88 (68.8) 7 (5.5) 19 17 (89.5) 4 (21.1) 24 23 (95.8) 18 (75.0) Advanced colonic neoplasm (ACN) included invasive cancer, high-grade dysplasia, villous, tubuolovillous. 310 Colonoscopy Versus Virtual Colonoscopy: A Systematic Review and Meta-Analysis of Patient Preference, Acceptance, and Satisfaction Otto Lin, Richard A. Kozarek Background: Many studies have assessed patient attitudes (preference, satisfaction and acceptance) towards computerized tomographic (CTC) or magnetic resonance colonography (MRC) versus conventional colonoscopy. We performed a meta- analysis of the published literature on this topic. Methods: We searched the MEDLINE databases up to October 2008 using a combination of relevant title/ abstract terms. We also searched the indices of abstracts in major gastroenterology and radiology journals, and performed a manual review of citations in all included articles. We reviewed the titles and abstracts of all retrieved studies, excluding many based on predefined criteria. Data were abstracted from the full text of included manuscripts by two blinded, independent investigators. Discrepancies were resolved by concurrent re-review of studies. We required eligible studies to be prospective, retrospective or cross-sectional designs directly comparing patient satisfaction with, acceptance of, or preference for colonoscopy versus CTC/MRC. Using the random effects model, we pooled data to arrive at summary measures. Extensive stratification analysis was performed. Results: 19 studies met inclusion criteria, totaling 5393 subjects. In 14 of these studies, patients preferred CTC/MRC over colonoscopy. Pooled data showed that 55.7% (95% confidence interval 48-62%) of patients preferred CTC vs. 31.3% (27-36%) who preferred colonoscopy (P!0.001). 6 studies reported satisfaction scores using various unvalidated scales, which we adjusted on to a scale of 1 to 10; the pooled adjusted satisfaction score for CTC was higher than that for colonoscopy, 6.5 vs. 4.8 (P!0.01). Stratification by procedure indication (screening vs. diagnostic), study objective (whether patient acceptance was a primary or secondary study objective), survey method (whether satisfaction scores were used as opposed to dichotomous preference queries), CTC technique or publication date, had no impact on results. However, stratification by journal type revealed that all 9 radiology papers reported higher preference for CTC, while 4 out of 10 gastroenterology or general medicine papers reported higher preference for colonoscopy (PZ0.03). Furthermore, 4 studies which featured limited bowel preparations for CTC all reported strong patient preference for CTC. Conclusions: Patients appear to prefer CTC/MRC over colonoscopy. However, most studies used unvalidated measurement methods to assess patient attitudes. Since patient acceptance is a ‘‘soft’’ outcome, it is easy for authorship and publication bias to affect reported results, as demonstrated by the discrepancy in radiology and gastroenterology study findings. 311 Randomized, Controlled Trial of the Use of Magnesium Citrate with Polyethylene Glycol Electrolyte Lavage Solution for Morning Colonoscopy Preparation Sin Sil Park Introduction: Large volume of polyethylene glycol electrolyte lavage solution (PEG-ELS) for bowel preparation before colonoscopy reduces patient’s tolerance and increase sleep disturbance in the patients undergoing morning colonoscopy. The aim of this study was to compare the tolerability and efficacy of three bowel preparation methods for morning colonoscopy: 4L of PEG-ELS; split-dose of PEG-ELS; and magnesium citrate plus 2L of PEG-ELS. Aims and Methods: This was a randomized, single-blinded, controlled study. Total 232 consecutive patients scheduled for outpatient elective colonoscopy were prospectively and randomly assigned to one of three preparations(Group 1(nZ79): 4L of PEG-ELS at 10PM; Group 2(nZ80): 2L of PEG-ELS at 8PM on the preceding day and 2L at 5AM on the day of colonoscopy; Group 3(nZ73): magnesium citrate(250cc) at 8 PM on the preceding day and 2L of PEG-ELS at 5AM on the day of colonoscopy). Endoscopists were blinded to the types of preparation. The quality of bowel cleansing was rated using Aronchick scale (excellent, good, fair, poor, inadequate) and Ottawa scale. Tolerability and adverse effects of assigned preparation were evaluated by questionnaire completed by each patient before the procedure. Results: There were no differences in compliance and sleep disturbance among three groups (pZ0.504, pZ0.733). And compared with previous exam, the difference of sleep disturbance was not statistically significant (pZ0.075). But, the frequencies of nausea and abdominal distension were much higher in Group 1 and 2 than Group 3 (pZ0.002). The sum of symptom score (range 0-11) was also higher in Group 1 and 2 (p!0.0001). Satisfaction rates according to preparation method were 22.8%, 34.7% and 42.6% in Group 1, 2 and 3, respectively (pZ0.004). The willingness to choose the same preparation on the next colonoscopy was 48.1%, 62% and 93.2% (p!0.001). In Aronchick scale, bowel preparation of Group 1 was relatively poorer than Group 2 and 3 (p!0.001). The proportion of fair and poor bowel preparation was 48.1%, 23.8% and 24.7%, respectively. And only in Group 1, 7 patients showed inadequate bowel preparation. In Ottawa scale, Group 1 also showed poorer preparation in right colon preparation (p!0.001). But, there was no difference in Group 2 and Group 3 (pZ0.398). Conclusion: Preparatory split-dosed magnesium citrate plus 2L of PEG-ELS achieved the lowest symptom score and the highest satisfaction rate. In addition, bowel cleansing effect was superior to single-dosed 4L of PEG-ELS group and similar to split-dosed 4L of PEG-ELS group in morning colonoscopy. Abstracts AB102 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009 www.giejournal.org
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Transcript of The FOBT-Pos-Finger Followed By FOBT-6-Pack May Be a Viable Screening Policy for Colo Rectal Cancer
Abstracts
308
The FOBT-Pos-Finger Followed By FOBT-6-Pack May Be a Viable
Screening Policy for Colo Rectal CancerShivani Jain, Stephen J. Sontag, Thomas G. Schnell, Jack Leya,Harish BhatiaIntroduction: Screening for CRC using a single FOBTwith stool from rectal exam(Finger-pos) is considered unacceptable. Two decades ago, it was our policy to ignorethe Finger-pos and instead insure that all such pts returned a subsequent 6-pk. Wenow report the long-term results of our policy - the accepted medical standard at thetime. Question: In Asx pts referred for GI w/u because of Finger-pos from routinerectal exam, what is the long-term outcome in those pts (a) who received a Flex Sigbecause of a subsequent 6-pk-neg versus (b) those who received a C-Scope because ofa subsequent 6-pk-pos? Methods: Asx pts referred with Finger-pos were then giventhe 6-pk, with specific instructions as to its importance. FOBTwas not rehydrated andwas considered pos if at least one of six windows was pos. Management was as follows:(a) If 6-pk-pos: C-Scope. (b) If 6-pk-neg: Flex Sig, with subsequent C-Scope only ifadenomas found. Results: From 1985 to 1994, 230 Asx pts with finger-pos werereferred for GI w/u. All 230 pts were given the 6-pk and all returned it (after f/u calls).33/230 were 6-pk-pos and had C-scope; and 197/230 were 6-pk-neg and had Flex Sig.(A) Both groups: mean age at initial request: 65 years, and mean f/u: 11 years. (B) %with adenomas: 6-pk-pos Z 52%; 6-pk-neg Z19% (Diff 33%; CI: 15.6-49.7). (C) % withCRC: 6-pk-pos Z 24%; 6-pk-neg Z 2% (Diff 22%; CI: 10.3-38.8%). (D) All 12 pts withCRC were diagnosed within the first 3 months of request. (E) Median Survival 6.2 yrsfor CRC and 13.7 yrs for non-CRC was significant (HR: 0.40; CI: 0.10 to 0.60). (F) 6-pk-result did not affect survival. (G) Only CRC predicted survival, however, no pts diedfrom CRC. Conclusion: The 12X greater prevalence of CRC in 6-pk-pos pts vs 6-pk-negpts and the detection of all CRC’s early in the w/u suggest that the finger-pos-FOBTfollowed by the 6-pk-FOBT may hold promise as a viable FOBTscreening policy.
309
Is American College of Radiology Recommendations for CT
Colonography Reporting Suitable for Asia?Joseph J. Sung, Kelvin K. Tsoi, Yee Yu Pau, Bing-Yee Suen, Derek Luo,Simon S. NGBackground: US Multi-Society Task Force on Colorectal Cancer Guidelinerecommends CT Colonography as a comparable screening modality for detection ofcancer and polyps [Levin et al. Gastroenterol 2008]. ACR recommends that polyp !5 mm in size need not be reported and patients with 1 or 2 polyps 6-9 mm in size canbe offered repeated CTC in 3 years without polypectomy [Zalis et al. Radiology 2005].Aims: We aim to investigate the possibility of missing advanced colonic neoplasm(ACN) using these criteria in the Asian populations. Methods: Based the Asia PacificWorking Group (a consortium of 15 countries) database of 5747 subjects underwentcolonoscopy for routine screening (nZ860), surveillance in patients with IBD orprevious polypectomy (nZ206) and symptoms suggestive of bowel disorders thatindicates colonoscopy (nZ4681), patients were classified by the size of the largestpolyp and the number of polyps found in the colon. Results: Among 5747 subjects,polyps were found in 1695 subjects (29.5%) and complete histology and size availablein 1620 (28.2%). The proportion with ACN was 3.7% (31/845) in 1-5 mm group, 11.8%(36/305) in 6-9 mm group and 64.0% (301/470) in the greater than 10 mm group.Using the ACR criteria, 31/368 (8.4%) ACN sized 1-5mm will not been reported and32/368 (8.7%) ACN sized 6-9 mm will not be treated by polypectomy. 8.4%, 21.2% and14.3% of entire population, persons age 50 or older and screening patients age 50 orolder with ACN would be called normal. 8.7%, 8.4% and 7.1% of these groups couldhave polypectomy delayed for at least three years. Conclusion: In total, around 1 in 6ACN would be missed or delayed for treatment. Current criteria for CTC reportingwill lead to substantial delay in management of ACN in Asian populations.
No. of polyps &5 mm (%) 6-9 mm (%) S10 mm
AB102 GAS
TROINTESTINA L ENDOSCOPY Volume 691 to 2
Total no. polypsAdenoma ACN717 377 (52.6)24 (3.3)
286 248(86.7) 32 (11.2)
446 270(60.5) 283 (63.5)
3 or more
Total no. polypsAdenoma ACN128 88 (68.8)7 (5.5)
19 17 (89.5)4 (21.1)
24 23 (95.8)18 (75.0)
Advanced colonic neoplasm (ACN) included invasive cancer, high-grade dysplasia,villous, tubuolovillous.
, No. 5 : 2009
310
Colonoscopy Versus Virtual Colonoscopy: A Systematic Review
and Meta-Analysis of Patient Preference, Acceptance, and
SatisfactionOtto Lin, Richard A. KozarekBackground: Many studies have assessed patient attitudes (preference, satisfactionand acceptance) towards computerized tomographic (CTC) or magnetic resonancecolonography (MRC) versus conventional colonoscopy. We performed a meta-analysis of the published literature on this topic. Methods: We searched theMEDLINE databases up to October 2008 using a combination of relevant title/abstract terms. We also searched the indices of abstracts in major gastroenterologyand radiology journals, and performed a manual review of citations in all includedarticles. We reviewed the titles and abstracts of all retrieved studies, excluding manybased on predefined criteria. Data were abstracted from the full text of includedmanuscripts by two blinded, independent investigators. Discrepancies wereresolved by concurrent re-review of studies. We required eligible studies to beprospective, retrospective or cross-sectional designs directly comparing patientsatisfaction with, acceptance of, or preference for colonoscopy versus CTC/MRC.Using the random effects model, we pooled data to arrive at summary measures.Extensive stratification analysis was performed. Results: 19 studies met inclusioncriteria, totaling 5393 subjects. In 14 of these studies, patients preferred CTC/MRCover colonoscopy. Pooled data showed that 55.7% (95% confidence interval48-62%) of patients preferred CTC vs. 31.3% (27-36%) who preferred colonoscopy(P!0.001). 6 studies reported satisfaction scores using various unvalidated scales,which we adjusted on to a scale of 1 to 10; the pooled adjusted satisfaction scorefor CTC was higher than that for colonoscopy, 6.5 vs. 4.8 (P!0.01). Stratification byprocedure indication (screening vs. diagnostic), study objective (whether patientacceptance was a primary or secondary study objective), survey method (whethersatisfaction scores were used as opposed to dichotomous preference queries), CTCtechnique or publication date, had no impact on results. However, stratification byjournal type revealed that all 9 radiology papers reported higher preference forCTC, while 4 out of 10 gastroenterology or general medicine papers reportedhigher preference for colonoscopy (PZ0.03). Furthermore, 4 studies whichfeatured limited bowel preparations for CTC all reported strong patient preferencefor CTC. Conclusions: Patients appear to prefer CTC/MRC over colonoscopy.However, most studies used unvalidated measurement methods to assess patientattitudes. Since patient acceptance is a ‘‘soft’’ outcome, it is easy for authorship andpublication bias to affect reported results, as demonstrated by the discrepancy inradiology and gastroenterology study findings.
311
Randomized, Controlled Trial of the Use of Magnesium Citrate
with Polyethylene Glycol Electrolyte Lavage Solution for
Morning Colonoscopy PreparationSin Sil ParkIntroduction: Large volume of polyethylene glycol electrolyte lavage solution(PEG-ELS) for bowel preparation before colonoscopy reduces patient’s toleranceand increase sleep disturbance in the patients undergoing morning colonoscopy.The aim of this study was to compare the tolerability and efficacy of three bowelpreparation methods for morning colonoscopy: 4L of PEG-ELS; split-dose ofPEG-ELS; and magnesium citrate plus 2L of PEG-ELS. Aims and Methods: This wasa randomized, single-blinded, controlled study. Total 232 consecutive patientsscheduled for outpatient elective colonoscopy were prospectively and randomlyassigned to one of three preparations(Group 1(nZ79): 4L of PEG-ELS at 10PM;Group 2(nZ80): 2L of PEG-ELS at 8PM on the preceding day and 2L at 5AM on theday of colonoscopy; Group 3(nZ73): magnesium citrate(250cc) at 8 PM on thepreceding day and 2L of PEG-ELS at 5AM on the day of colonoscopy). Endoscopistswere blinded to the types of preparation. The quality of bowel cleansing was ratedusing Aronchick scale (excellent, good, fair, poor, inadequate) and Ottawa scale.Tolerability and adverse effects of assigned preparation were evaluated byquestionnaire completed by each patient before the procedure. Results: Therewere no differences in compliance and sleep disturbance among three groups(pZ0.504, pZ0.733). And compared with previous exam, the difference of sleepdisturbance was not statistically significant (pZ0.075). But, the frequencies ofnausea and abdominal distension were much higher in Group 1 and 2 than Group 3(pZ0.002). The sum of symptom score (range 0-11) was also higher in Group 1 and2 (p!0.0001). Satisfaction rates according to preparation method were 22.8%,34.7% and 42.6% in Group 1, 2 and 3, respectively (pZ0.004). The willingness tochoose the same preparation on the next colonoscopy was 48.1%, 62% and 93.2%(p!0.001). In Aronchick scale, bowel preparation of Group 1 was relatively poorerthan Group 2 and 3 (p!0.001). The proportion of fair and poor bowel preparationwas 48.1%, 23.8% and 24.7%, respectively. And only in Group 1, 7 patients showedinadequate bowel preparation. In Ottawa scale, Group 1 also showed poorerpreparation in right colon preparation (p!0.001). But, there was no difference inGroup 2 and Group 3 (pZ0.398). Conclusion: Preparatory split-dosed magnesiumcitrate plus 2L of PEG-ELS achieved the lowest symptom score and the highestsatisfaction rate. In addition, bowel cleansing effect was superior to single-dosed 4Lof PEG-ELS group and similar to split-dosed 4L of PEG-ELS group in morningcolonoscopy.
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