• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
Crespi, there are conflicting data about efficacy of colonoscopy
 

Crespi, there are conflicting data about efficacy of colonoscopy

on

  • 767 views

 

Statistics

Views

Total Views
767
Views on SlideShare
763
Embed Views
4

Actions

Likes
0
Downloads
1
Comments
0

1 Embed 4

http://www.santeugenioroma.it 4

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    Crespi, there are conflicting data about efficacy of colonoscopy Crespi, there are conflicting data about efficacy of colonoscopy Presentation Transcript

    • There are conflicting data about the efficacy of colonoscopy… M.CRESPI,D.LISI
    • Efficacy of colonoscopy in reducing incidence of CRC
      • Results of two multi-center studies based on long-term follow-up of asymptomatic subjects after a colonoscopy with polypectomy
      • US National Polyp Study (prospective) - 76 %
      • Italian Multicenter Study (retrospective) - 66 %
      An alternative screening method But COMPLIANCE in general population is low
    • CRC after negative Colonoscopy in Canada f.u. of 45,985 subj (18,606 M – 27,379 F) for 229,090 pt/year Distal CRC Proximal CRC All CRC 0.71 239 170 F 0.59 220 130 M 0.44 118 52 F 0.44 136 60 M 0.99 107 106 F 0.88 74 65 M SIR Expected Observed
    • CRC risk despite surveillance CS in the Polyp Prevention Trial (PPT) >10y follow-up, >than 3 CS after index polypectomy Leung K GIE 2010 Only 36 % reduction in CRC incidence Advanced Adenoma at baseline CS is a strong risk predictor
    • Risk of CRC after negative colonoscopy Geul K et al, 2007 About 80% subjects with CRC between 50 – 58y have already one adenoma at 50y QUALITY of OC !? Fast-growing lesions !? 0.80 0.67 Right colon Singh 2009 0.16 0.55 Left colon Overall Ransohoff 2009 0.12 – 0.33 RR
    • Retrospective population based study on Colonoscopy and death from CRC Case/control study: 10,292 cases , 51,460 controls Baxter NN 2009 Complete colonoscopy OR left CRC 0.33 OR right CRC 0.99 Any advantage of CS over FS ? Are we talking about two Colons or two Cancers ??? Only a quality problem ?
    • In any case……
      • A good colonoscopy sometimes exists…..
      • Look at these data…
      • s
    • Risk of CRC and AA more than 10 y from a negative index colonoscopy German Colonoscopy Screening Program 2003 - 2010 Brenner H 2010 Are German endoscopists better ?!? Right Left Total 0.42 - 0.28 - 59.4 8.4 Expected - 0 CRC 25 Observed 0.82 AA Standardized Prevalence Ratio
    • Results of a large ecological study on colonoscopy coverage and CRC mortality / incidence in Ontario Rabeneck L AJG 2010 2,412,077 subj. (mean age 64y, female 53%) 14y follow-up (1993 – 2006) CRC Incidence 62,819 cases (2.6 %) Mortality 23,743 deaths (0.9 %) Result: for every 1% increase in Colonoscopy rate, 3% decrease in CRC mortality
    • Differences in protection against right/left sided CRC after a negative index CS ? Quality of CS (gastroent. Vs non-gastroent.?) Flat non polypoid lesions (more in right colon ?) Biology of proximal lesion (MSI and CIMP status ?) Why women worst ? (RR 0.99 vs 0.89 men)
    •  
    • Missed flat and depressed lesions Missed lesions on repeat colonoscopy Polypoid lesions 1.2% Flat lesions 16.7% Depressed lesions 13.6% Satosh et al. J Gastroenterol 2006
    • Pitfalls of standard colonoscopy
    • Significance of flat & depressed colonic lesions
      • Flat and depressed lesions are more likely to harbour HGD or beyond
      • Most (65-90%) flat and depressed lesion are located in the right colon
      • They are frequently MISSED !!
    • Submucosal invasion in cancerous colonic polyps Sbmucosal invasion - Submucosal invasion + 17% Flat depressed lesions Submucosal invasion - Submucosal invasion + Flat elevated lesions 0.8% Togashi et al; Annals of The Academy of Medicine of Singapore; 2003; (32 (2): 152-158
    • ABOUT CS
      • Colonoscopy is an operator dependent examination
      • A good colonoscopist has to be trained , certified , credentialed
      • The best colonoscopist has to be sufficiently slow , careful and compulsive during withdrawal
    • To consider….
      • In fact, screening is often perceived by patients as “insurance” against future cancer
      • Patients who submit to screening and surveillance colonoscopy do so with the hope and expectation of preventing occurrence and death , from colorectal cancer
      • In fact, reduction in CRC incidence by CS large studies averages just 50 %
    • Cecal intubation in Europe Note: a correct index is adjusted completion rate , excluding poor preparation or diseases 81.0 5145 60 Sweden 89.0 (69 – 98) 6004 21 centers in 10 EU countries EPAGE 76.9 9223 68 UK 82.6 12706 25 Italy, Lombardia 69.6 1245 33 Portugal Rate CS Num. Centers Country
    • Quality programs Colonoscopy practice in Italy Survey in 278 Endoscopy Units Data on 12,835 Colonoscopies Cecal intubation 82.6 %; Sedation (over 90 % only in 22% of centers) Serious complications 0.5 % Perforation 0.02% Bleeding 0.2 % Cardiopulm. 0.25% Polyp detection rate 27.3 % (in screen CS 24.2%) Screening CS 13.7 % (in 2004 survey in 18 centers: 16.1 %) Yes 84.3 % No 76.2 % Minoli G. et al. for AIGO 2006 - personal comunication
    • Low public compliance to screening colonoscopy (from Jack Tippit, Saturday Evening Post)
    • Miss rate of right sided CRC by colonoscopy in Ontario in usual clinical practice (1997 – 2001) CRC patients database: 4920 subjects Missed cancers: 4% by colonoscopy performed between 6 – 36 months before CRC diagnosis. (Byrd RL 1989: missed lesions: 3% ) CRC cannot be completely eliminated even with very intensive screening Bressler B et al 2004