Strategie di screening del cancro Colorettale - Gastrolearning®

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Strategie di screening del cancro Colorettale
Prof. C. Hassan - Università Cattolica Sacro Cuore (Roma).

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Strategie di screening del cancro Colorettale - Gastrolearning®

  1. 1. STRATEGIE DI SCREENING DEL CANCRO COLORETTALE C. Hassan
  2. 2. OPEN ISSUES • Who should be screened? • How should we screen?
  3. 3. THE PRESENT
  4. 4. AGE Age (years) 40-44 45-50 50-54 55-59 60-64 65-69 70-74 75-79 CRC incidence 13.3 27.6 55.1 97.0 153.4 226.9 318.6 412.0 /100,000 CRC mortality 4.6 9.6 19.0 34.4 55.4 85.6 125.9 171.9 /100,000 Lifeexpectancy 42 37 32 28 24 19 16 12
  5. 5. AGE
  6. 6. AGE
  7. 7. SEX
  8. 8. FAMILY HISTORY •At least one first-degree relative with CRC CRC RR 2.25 (95% CI:2-2.53)
  9. 9. FAMILY HISTORY •At least two first-degree relative with CRC •or one first-degree relative <45 ys CRC RR: 4.25 (95% CI:3.01-6.02)
  10. 10. EU GUIDELINES
  11. 11. EU GUIDELINES
  12. 12. OPEN ISSUES • Who should be screened? • How should we screen?
  13. 13. OPEN ISSUES • g-FOBT
  14. 14. 329,642 randomized subjects FU 12-17 yrs. -25% -13% -16% -16% RR 0.84 (0.78-0.90)
  15. 15. 5.3% 6.4% 33% 2.6% 1.7% 1.7%
  16. 16. INCIDENCE MORTALITY NS RR 0.91 (95% CI 84-98%)
  17. 17. MORTALITY -22-32% NS
  18. 18. EU GUIDELINES
  19. 19. OPEN ISSUES • g-FOBT • FIT
  20. 20. g-FOBT vs FIT •Advanced neoplasia detection rate
  21. 21. g-FOBT vs FIT •Cancer detection rate
  22. 22. FIT 1° round vs FIT 2° round
  23. 23. Effetto del test immunologico per la ricerca del sangue occulto fecale sull’incidenza del tumore al colon-retto. Ventura L1, Castiglione G., Grazzini G1, Mantellini P., Romeo G1, Buzzoni C1, Sacchettini C1, Rubeca T1, Zappa M1. 1. ISPO - Istituto per lo Studio e la Prevenzione Oncologica, Firenze -22% !
  24. 24. EU GUIDELINES
  25. 25. OPEN ISSUES • g-FOBT • FIT • FS
  26. 26. May 2010 The BIG BANG September 2011
  27. 27. UK FS ITT CRC incidence -23% SCORE -18% CRC mortality -31% -22%
  28. 28. UK FS PP CRC incidence -33% SCORE -31% CRC mortality -43% -38%
  29. 29. INCIDENCE REDUCTION IN THE DISTAL COLON By year from randomization SCORE TRIAL UK FLEXI-SCOPE TRIAL
  30. 30. EU GUIDELINES
  31. 31. OPEN ISSUES • g-FOBT • FIT • FS • OC
  32. 32. Variability in colonoscopy efficacy Cohort studies Author Population Endpoint Person-years Follow up CRC of follow up duration endpoint (years) reduction Winawer Post-Polypectomy Citarda Post-Polypectomy Robertson Post-Polypectomy Incidence Singh H Negative colon. Lakoff J Negative colon. Brenner H Negative colon. Incidence Rex Screening 8,401 14,211 10,786 5.9 10.5 3.7 76% 66% 5% Incidence 147,781 110,402§ 6,581 4.6 14 11.9 31% 55% 100% Incidence 10,492 14.7 48% Incidence Incidence Mortality
  33. 33. Variability in colonoscopy efficacy Case-control studies Author Population Endpoint CRC cases NoCRC endpoint CRC reduction controls Brenner H Brenner H Colonoscopy Incidence Neg. colonoscopy Incidence 1,688 380 Muller AD Baxter N Colonoscopy Colonoscopy 16,351 16,351 10,292 51,460 Incidence Mortality 1,932 485 77% 74% 45-49% 31%
  34. 34. OR 0.39 OR 1.07 [0.94─ 1.21] [0.34─ 0.45] 37%
  35. 35. HR 10 95% CI 1.4-87
  36. 36. Pick up the small (adenoma) not to miss the BIG (cancer)! ADR = -Miss Rate Ad. = -Miss Rate CRC
  37. 37. Predictors of interval CRC Author Study design Cohort Brenner H Case-control Cooper GS Cohort Baxter N Cohort Screening Endoscopy Biology predictors Kaminsky M Population Predictors Adenoma DR (<20%) NA Colonoscopy Incompleteness, FOBT+ Medicare Polyp DR (<24%), non-GI, OC Volume Colonoscopy Incompleteness, Polyp DR (<24%), non-GI specialty, Female sex, G3-G4 Proximal location Female sex
  38. 38. Adenoma Detection Rate dei Servizi di Endoscopia, per utilizzo di sessioni dedicate alle colonscopie di screening (%) 80% 70% 60% quinto quintile: ADR > 51,2% 50% 40% primo quintile: ADR < 38,6% R i c t D a m o n e d A 30% sessioni NON dedicate 20% sessioni dedicate 10% 0% 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64
  39. 39. Modello multilevel per Adenoma DR (LIVELLI: ENDOSCOPISTA, SERVIZIO DI ENDOSCOPIA E REGIONE) Parametro Odds Ratio 95%IC p value Caratteristiche del paziente Sesso del paziente Maschi 1,00 Femmine 0,58 0,56-0,60 <0,001 1,02 1,02-1,03 <0,001 Età del paziente Incremento di un anno Episodio di screening Primo 1,00 Successivi Preparazione intestinale 0,78 Colonscopia incompleta 2,49 Inadeguata 1,00 Adeguata 1,52 - 1,00 Cieco Sede raggiunta - 0,75-0,82 <0,001 - 2,29-2,67 <0,001 - 1,41-1,63 <0,001
  40. 40. Modello multilevel per Adenoma DR (LIVELLI: ENDOSCOPISTA, SERVIZIO DI ENDOSCOPIA E REGIONE) Parametro Odds Ratio 95%IC p value Caratteristiche dell’endoscopista Specializzazione Gastroenterologia 1,00 Altro 0,84 0,76-0,92 <0,001 Caratteristiche del Servizio Sedazione 1,00 31%-75% dei casi 1,17 0,89-1,54 0,270 >75% dei casi Sessioni dedicate ≤30% dei casi - 1,30 1,01-1,67 0,039 No 1,00 Sì 1,29 1,06-1,57 0,010
  41. 41. Adenoma Detection Rate in Servizi di endoscopia con diverse situazioni organizzative, per specialità dell’endoscopista (%) 60% 50% 40% 30% Gastroenterologia R i c t D a m o n e d A 20% Chirurgia e altre 10% 0% Sedazione occasionale, sessioni non dedicate Sedazione sistematica, sessioni non dedicate Sedazione occasionale, sessioni dedicate Sedazione sistematica, sessioni dedicate
  42. 42. EU GUIDELINES
  43. 43. CONCLUSIONS • g-FOBT likely to be replaced by FIT • FS likely to be added to g-FOBT/FIT • Colonoscopy implementation will be strictly related with its quality
  44. 44. OPEN ISSUES • Is there a variability in colonoscopy-related CRC prevention rate? • If any, is such variability related with ADR?
  45. 45. OPEN ISSUES • Are low-risk patients the same as average-risk?
  46. 46. Low-risk as average-risk?
  47. 47. Low-risk as average-risk?
  48. 48. Low-risk as average-risk? Low-risk = FP
  49. 49. Low-risk as average-risk?
  50. 50. Low-risk as average-risk? Risk reduction TP = >10 mm polypectomy -60/80% True FP = negative colonoscopy -30/70% TP = <10 mm polypectomy -0%
  51. 51. OPEN ISSUES • Are low-risk patients the same as average-risk? • Should we preclude a 1-year examination to intermediate risk subjects
  52. 52. Why 3-years in intermediate risk?
  53. 53. CRC risk 0.7%
  54. 54. Why 3-years in intermediate risk?
  55. 55. Why 3-years in intermediate risk?
  56. 56. Why 3-years in intermediate risk?
  57. 57. CCE-2 vs FIT •6% of subjects will result FIT+ •FIT PPV <30% •CCE-2 as triage in FIT+
  58. 58. SEX 50 60 70 80 45 Male 0.149% 0.869% 2.373% 45 Fem. 0.130% 0.663% 1.752% 3.434% 90 4.387% 5.717% 95+ 6.021% 4.983% 5.429%
  59. 59. CCE-2 vs FS •10-20% of subjects will result positive at FS •FS PPV <20% •CCE-2 as triage in FS+
  60. 60. SEX
  61. 61. FAMILY HISTORY •At least one first-degree relative with CRC CRC RR 2.25 (95% CI:2-2.53)
  62. 62. FAMILY HISTORY •At least two first-degree relative with CRC •or one first-degree relative <45 ys CRC RR: 4.25 (95% CI:3.01-6.02)
  63. 63. OPEN ISSUES • Who should be screened? • How should we screen?
  64. 64. THE PRESENT
  65. 65. AGE Age (years) 40-44 45-50 50-54 55-59 60-64 65-69 70-74 75-79 CRC incidence 13.3 27.6 55.1 97.0 153.4 226.9 318.6 412.0 /100,000 CRC mortality 4.6 9.6 19.0 34.4 55.4 85.6 125.9 171.9 /100,000 Lifeexpectancy 42 37 32 28 24 19 16 12
  66. 66. AGE
  67. 67. AGE
  68. 68. EU GUIDELINES
  69. 69. EU GUIDELINES
  70. 70. What did we learn from FS trials? No prevalent CRC -66% Prevalent CRC -33%
  71. 71. OPEN ISSUES • Who should be screened? • How should we screen?

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