Gut: If this test is positive, the risk of death from colorectal cancer is doubled without colonoscopy!

Colorectal cancer (CRC) is the third most common malignant tumor in the world, and the number of deaths caused is the second highest among malignant tumors.

In 2020, 1.
9 million newly diagnosed CRC cases worldwide will cause approximately 930,000 deaths[1].

Early diagnosis and treatment through active screening can effectively reduce the mortality rate of CRC.

Colonoscopy is the core part of CRC screening.
Tissue biopsy can be taken at the same time as the examination, or early lesions can be removed under a microscope.
With pathological examination, it can be used as the "gold standard" for CRC diagnosis.

However, the relatively high cost, dietary restrictions before the examination, bowel preparation, and the pain and risk of complications during the examination are often prohibitive.

However, because of the painful examination and the risk of invasive procedures, can colonoscopy be delayed or even refused? the answer is negative.

Recently, a team led by Manuel Zorzi of the Veneto Tumor Registry of Italy published research results in the Gut journal[2].
After reviewing and analyzing the data of the Veneto Region CRC screening project for more than ten years, it was found that the fecal immunochemical test ( Among the participants with FIT positive, those who refused colonoscopy had twice the risk of death due to CRC as those who received timely colonoscopy.

Compared with the traditional guaiac fecal occult blood test (gFOBT), FIT is more sensitive and less susceptible to false positives due to interference from food, drugs and other factors.
It has gradually replaced gFOBT in practical applications and has become commonly used Non-invasive primary screening methods for CRC population.

The Veneto Region has implemented a colorectal cancer screening program since 2002.
The target population is residents aged 50-69 who receive FIT every 2 years.

The staff will call participants with positive FIT results (>20 micrograms of hemoglobin per gram of feces) to inform them of the FIT results and disease risk, suggest colonoscopy, and introduce preoperative visits and bowel preparations before endoscopy.
Wait for work. Both FIT and colonoscopy are free.

The above measures enabled 80% of FIT-positive participants to undergo colonoscopy within 3 months after FIT examination, of which 32.
4% were diagnosed as advanced tumors through colonoscopy (4.
6% for colorectal cancer, 27.
8% for progress Stage adenoma) [3].

Advanced colorectal tumor is not equal to colorectal cancer.
It refers to cancer or adenoma with at least one of the following characteristics: 1) Diameter ≥10mm; 2) With high-grade dysplasia; 3) The histology is villous or tubular villous (Image source: Gastroenterology) From January 1, 2004 to September 30, 2017, 11,270,93 people participated in this screening program and received one or more FITs, of which 113,008 people had at least one positive result.

1585 people were excluded from the study because they did not meet the conditions, and 111,423 people were eventually included in the study.

88013 people underwent colonoscopy through this screening program and were classified into the compliance group, and the remaining 23410 FIT-positive people were classified into the non-compliant group.

The researchers respectively calculated the cumulative incidence of CRC, the cumulative mortality of CRC, and the cumulative all-cause mortality of the above two groups and compared them.

3549 people (4.
03%) in the compliance group were diagnosed with CRC, and 882 people (3.
77%) in the non-compliance group were diagnosed with CRC.

Within one year after the FIT test was positive, the proportion of CRC patients diagnosed with CRC was 90.
1% in the compliance group and 62.
9% in the non-compliance group.
There was no statistical difference between the two groups in the proportion of CRC patients at the time of diagnosis.

The cumulative incidence of CRC of the two groups of participants, the green is the compliance group, the orange is the non-compliant group, the 10-year cumulative incidence of CRC in the compliance group is 44.
7/1000, and the non-compliant group is 54.
3/1000.

A few months after FIT, due to active screening, the cumulative incidence of CRC increased rapidly in the compliance group, but because colonoscopy can detect and remove precancerous lesions in time, the subsequent cumulative incidence of CRC decreased; the cumulative incidence of the non-compliant group in the first year The growth rate is slower, and then the diagnosis is usually due to the onset of symptoms, and the cumulative incidence rate is increasing rapidly.

Starting from the 6th year of follow-up, the cumulative incidence of CRC in the non-compliance group exceeded that of the compliance group! The cumulative mortality of CRC of the two groups of participants, green is the compliance group, orange is the non-compliant group, the 10-year cumulative death rate of CRC patients in the non-compliant group is 6.
8/1000, and the non-compliant group is 16.
0/1000.
The cumulative result of CRC in the non-compliant group The mortality rate was higher than that of the compliance group from the beginning of follow-up.
As the follow-up time prolonged, the difference between the two groups further widened.

During the entire follow-up period, the cumulative mortality of CRC in the non-compliant group was 103% higher than that in the compliant group! The all-cause mortality rate in the compliance group was 3.
97%, and the CRC mortality rate was 0.
38%; the all-cause mortality rate in the non-compliant group was 8.
52%, and the CRC mortality rate was 0.
72%.

Considering that the non-compliance group itself has a higher risk of death, this group of people should be encouraged to undergo colonoscopy to help save lives.

The results of this study show that if a positive FIT result occurs, colonoscopy should be performed as much as possible, otherwise it will significantly increase the risk of death from CRC.

At the same time, because FIT positive may already be a manifestation of advanced adenoma and CRC, colonoscopy can not only help to deal with precancerous lesions, but also assist in the diagnosis and subsequent treatment of advanced tumors.
This is from the initial follow-up of participants in the compliance group The rapid increase in the cumulative incidence of CRC can also be seen.

So when it comes to colonoscopy, you must not delay! The United States began to promote CRC screening in the last century.
In 2000, the colonoscopy screening rate for people over 50 years old nationwide was 20%, and it rose to 61% in 2018.
The incidence and mortality of CRC have also continued to decline since the 1980s[4 ].

A recent study by the Stanford University team suggested that the starting time of colonoscopy may be reduced from 50 to 45 years old [5].

The picture source of colonoscopy screening and CRC incidence changes in people over 50 years old in the United States can be seen in reference [4] Compared with the effective secondary prevention work in developed countries, although my country’s CRC screening work began in the 1970s, To date, the 5-year survival rate of CRC patients is still far lower than that of the United States, Japan and South Korea, and the early diagnosis rate of CRC is also significantly behind Japan and South Korea [6].

In 2012, my country launched the "Urban Cancer Early Diagnosis and Early Treatment Project".
It passed risk assessments in 16 provinces and initially screened out 180,000 people at high risk of CRC and recommended colonoscopy recommendations, but those who received colonoscopy eventually The proportion of participants is less than 14% [7].

In terms of raising public awareness and participation, our country’s prevention work still has a long way to go.

Do you now know the importance of colonoscopy? But don’t be afraid of it.
The "Expert Consensus on China's Early Colorectal Cancer Screening Process" [6] recommends that the target age for CRC screening is 50-75 years old.
High-risk groups directly receive high-quality colonoscopy, and non-high-risk groups The screening methods are: (1) FIT, the recommended screening cycle is once a year; (2) Fecal DNA testing, the recommended screening cycle is once every 1 to 3 years; (3) Colonoscopy, screening is recommended The cycle is high-quality colonoscopy once every 5-10 years.

If a colonoscopy result is negative, there is no need to suffer the pain of colonoscopy every year for physical examinations.

If readers or family members belong to the screening target group, please make an appointment! Singularity is hiring everyone! Everybody Hi~! We need fresh blood to inject new energy into the singularity.

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 References: [1] Global Cancer Observatory.
[(accessed on 21 January 2021)]; Available online: https://gco.
iarc.
fr/[2] Zorzi M, Battagello J, Selby K, et al.
Non- compliance with colonoscopy after a positive faecal immunochemical test doubles the risk of dying from colorectal cancer.
Gut.
2021;gutjnl-2020-322192.
doi:10.
1136/gutjnl-2020-322192[3] Zorzi M, Hassan C, Capodaglio G, et al.
Long-term performance of colorectal cancer screening programmes based on the faecal immunochemical test.
Gut.
2018;67(12):2124-2130.
doi:10.
1136/gutjnl-2017-314753 [4] Siegel RL, Miller KD, Goding Sauer A, et al.
Colorectal cancer statistics, 2020.
CA Cancer J Clin.
2020;70(3):145-164.
doi:10.
3322/caac.
21601[5] Sehgal M, Ladabaum U, Mithal A, Singh H, Desai M, Singh G.
Colorectal Cancer Incidence After Colonoscopy at Ages 45-49 or 50-54 Years.
Gastroenterology.
2021;S0016-5085(21)00402-9.
doi:10.
1053/j.
gastro.
2021.
02.
015[6] National Research Center for Clinical Medicine of Digestive Diseases (Shanghai), National Alliance of Gastrointestinal Early Cancer Prevention and Treatment Centers, Chinese Medical Association Digestive Medicine Chinese Journal of Microscopy, et al.
Expert consensus on screening procedures for early colorectal cancer in China (2019, Shanghai).
Chinese Medical Journal, 2019,99 (38): 2961-2970.
DOI: 10.
3760/cma.
j.
issn.
0376- 2491.
2019.
38.
001[7] Chen H, Li N, Ren J, et al.
Participation and yield of a population-based colorectal cancer screening programme in China.
Gut.
2019;68(8):1450-1457.
doi:10.
1136/ gutjnl-2018-317124 Source of head picture: Wikipedia Author of this articleResponsible editor of the first day of junior high school | Tan Shuo1136/gutjnl-2018-317124 Source of head picture: Wikipedia Author of this articleResponsible editor of the first day of junior high school | Tan Shuo1136/gutjnl-2018-317124 Source of head picture: Wikipedia Author of this articleResponsible editor of the first day of junior high school | Tan Shuo