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Written by | Yan Xiaoliu
Source | "Medical Community" public number
.
" Michael Bretthauer, a Norwegian gastroenterologist and researcher, said
.
This statement is reflected
in many screening guidelines such as the American Cancer Society and the American Gastroenterological Association.
Because colorectal cancer evolved from intestinal polyps and adenomas
.
Colonoscopy can be detected and removed
early before it becomes malignant.
The risk of cancer is gone
.
But the latest study in the New England Journal of Medicine (NEJM) poured cold water
.
On October 9, local time, the magazine published an article by Michael Bresso of the University of Oslo and others, saying that colonoscopy can only reduce cancer risk by 18%, and does not significantly reduce mortality
.
"This is the first randomized trial on colonoscopy screening, and it's a milestone," said Samir Gupta, a gastroenterologist at the University of California, San Diego.
He was not involved in the aforementioned study
.
THAT, HE TOLD STAT, COULD RAISE A TROUBLING QUESTION
.
"Perhaps, colonoscopy screening is not as effective
as clinically thought.
It remains a good screening tool
.
But it may be time to reassess its gold-standard status
.
"
The conclusion of the article is surprising," Huang Liang, deputy chief physician of the Second District of Colorectal and Surgery at the Sixth Affiliated Hospital of Sun Yat-sen University, told the "medical community", "unable to figure out" some of the data of the study, and hoped to see further analysis and interpretation
.
What does the study say?
According to the World Health Organization's 2020 data, the global incidence of colorectal cancer has ranked third only to breast cancer and lung cancer, and the mortality rate is second
in the world.
Numerous studies have proven that screening is an effective means of
reducing colorectal cancer incidence and mortality.
Unfortunately, to date we have only fecal occult blood tests and sigmoidoscopy, which have been tested by the "pyramid of evidence" – randomized trials with positive results
.
According to STAT, the First Affiliated Hospital of Naval Medical University (formerly Shanghai Changhai Hospital) released a meta-analysis based on observational studies in 2016 that colonoscopy screening is of significant significance
.
However, a limitation of this analysis is that no randomized trials are available
.
NEJM's latest article may fill that gap.
The study included about 85,000 healthy people aged 55-64 years in many Nordic countries who had no history of
colorectal cancer screening.
Participants were randomized to a single colonoscopy screening group and a usual care control group
in a 1:2 ratio.
Its primary endpoint was to quantify the effect
of colonoscopy screening on cancer risk and associated mortality.
The secondary endpoint was all-cause mortality
.
NEJM's presentation is based on 10 years of follow-up data
.
Huang Liang said: "Simply put, the rate of colonoscopy screening is not high, and it has little impact on long-term survival
.
"
The results showed that the risk of colorectal cancer in the screening group and control group was 0.
98% and 1.
20%, respectively, and the former was reduced by 18%.
To prevent 1 case of colorectal cancer, 455 people
need to be screened.
NEJM
did not significantly differ
in the risk of colorectal cancer death between the two groups throughout the study period.
The screening group was 0.
28% and the control group was 0.
31%.
The risk of all-cause mortality was almost the same (11.
03% and 11.
04%, respectively).
"The reduction in the risk of death was lower than in other screening studies, and lower than expected
.
" By the "preset," the risk of death in the screening group should be 25 percent
lower than the control group by 15 years of follow-up, the article says.
How to see the 'depressing results' Jason Dominitz, executive director of the Virginia National Gastroenterology and Hepatology Program, released an accompanying editorial at NEJM, saying the aforementioned results
frustrating"
.
Earlier fecal occult blood tests were found to reduce the risk of
death by 15%.
A series of studies have also shown that sigmoidoscopy can reduce the risk of colorectal cancer by 18% to 26% and reduce mortality by 22% to 31%.
The sigmoidoscopy is about 60 centimeters long and cannot see the complete colon
.
"Colonoscopy covers the entire colorectal
.
We take it for granted that it will be no worse
than sigmoidoscopy.
The accompanying editorial reads
.
The article presents several possibilities
.
For example, "the study is not yet harvested," and screening takes longer to prove worthwhile
.
"Cancer treatment has advanced
by leaps and bounds over the past few decades.
The study was planned to be followed for 15 years
.
In the long run, the mortality rate will drop
significantly.
Another
notable detail is that only 42 percent of the subjects in the screening group actually had a colonoscopy
.
This may limit the benefits of
screening.
"This indicates low
compliance among participants.
But why is it that when analyzing the screening group data, the 58% that is not checked is not removed? Can't figure it out
.
Huang Liang told the "medical community"
.
The University of Oslo research team may also be aware of this
.
They built mathematical models and performed calibration analyses, saying: "If more than 28,000 people in the screening group had colonoscopy, the risk of colorectal cancer and death in that group would have decreased by 31% and 50% respectively after 10 years
.
"
Huang Liang believes that this data is meaningful
.
"In terms of reducing cancer risk, the calibrated effect is similar to that of sigmoidoscopy and is still lower than expected
.
" The NEJM article reads
.
Michael Bressoe said in an interview that colonoscopy is expensive, time-consuming, and there are many unpleasant
preparations and procedures.
Its research may inspire public health policy makers and decision-makers to carefully choose the means of
recommendation.
"Many European countries support fecal occult blood tests for routine screening, which are cheap, readily available, and may have similar
results.
" Michael Bresso said
.
According to STAT, Samir Gupta, Jason Dominitz and other teams are conducting large randomized studies comparing colonoscopy with stool screening
.
Huang Liang's teacher, Department of Colorectal and Surgery, The Sixth Affiliated Hospital of Sun Yat-sen UniversityProfessor Ping's team also made discoveries
in stool screening.
The fecal DNA detection kit developed by him can achieve the early diagnosis of
colorectal cancer and adenomatous polyps by detecting the methylation status of human SDC2 gene in samples.
Previous clinical trials showed specificity of 97.
85%, sensitivity of 84.
22%, and overall agreement rate of 93.
65%.
Samir Gupta believes that the findings may not have a large impact
on individuals.
"What kind of screening people decide depends on personal preference
.
Someone is too busy to take time off for a colonoscopy
.
Then do fecal occult blood
.
The most important thing is to encourage people to look it up
.
Huang
Liang introduced that according to the "Chinese Guidelines for Colorectal Cancer Screening and Early Diagnosis and Treatment (2020)" (hereinafter referred to as the "Guidelines"), colonoscopy is the gold standard for colorectal cancer screening (strong recommendation, GRADE evidence grading: high) 1 high-quality test every 5 to 10 years is recommended (strong recommendation, GRADE evidence: high).
At the same time, fecal occult blood testing is recommended once a year (strongly recommended, GRADE evidence: medium).
"Our colonoscopy intervals are relatively conservative
.
This is due to the possibility of visual blindness and omissions
in the colonoscopy.
If the interval is more than 10 years, polyps and adenomas may progress to bowel cancer, delaying treatment
.
Huang Liang said
.
The Guidelines also define the starting age for
examination.
Because the incidence of colorectal cancer in China has increased since the age of 40, and has shown a significant upward trend
since the age of 50.
The Guidelines recommend colorectal cancer risk assessment from age 40 onwards and colorectal cancer screening
from age 40 for those who are at high risk.
The so-called "high-risk person" refers to those with family history, colorectal cancer history, intestinal adenoma history, 8-10 years long-term inflammatory bowel history, fecal occult blood test positive risk factors, and comprehensive age, gender, BMI, smoking, drinking and other assessment.
Source: [1] Effect of Colonoscopy Screening on Risks of Colorectal Cancer and Related Death.
NEJM.
October 9,2022.
DOI:10.
1056/ NEJMoa2208375[2]Understanding the Results of a Randomized Trial of Screening Colonoscopy.
NEJM.
October 9,2022.
DOI:10.
1056/NEJMe2211595 [3] In gold-standard trial,colonoscopy fails to reduce rate of cancer deaths.
STAT[4]If You Invite 455 People to Colonoscopy,You'll Stop One Case of Cancer.
Medpage Today[5]The Northern-European Initiative on Colorectal Cancer( NordICC).
clinicaltrials.
gov[6]Colonoscopy Reduces Colorectal Cancer Incidence and Mortality in Patients With Non-Malignant Findings:A Meta-Analysis.
Am J Gastroenterol.
2016 Mar; 111(3):355–365.
doi:10.
1038/ajg.
2015.
418[7]Guidelines for Colorectal Cancer Screening, Early Diagnosis and Treatment in China (2020, Beijing).
Chinese Journal of Oncology.
2021,43(01):16-38
Source: Medical Proofreader: Zang Hengjia Editor: Tian Dongliang
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