Strategie di screening del cancro Colorettale - Gastrolearning®

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Gastrolearning II modulo/1a lezione
Strategie di screening del cancro Colorettale
Prof. C. Hassan - Università Cattolica Sacro Cuore (Roma).

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  • 1. STRATEGIE DI SCREENING DEL CANCRO COLORETTALE C. Hassan
  • 2. OPEN ISSUES • Who should be screened? • How should we screen?
  • 3. THE PRESENT
  • 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. AGE
  • 6. AGE
  • 7. SEX
  • 8. FAMILY HISTORY •At least one first-degree relative with CRC CRC RR 2.25 (95% CI:2-2.53)
  • 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. EU GUIDELINES
  • 11. EU GUIDELINES
  • 12. OPEN ISSUES • Who should be screened? • How should we screen?
  • 13. OPEN ISSUES • g-FOBT
  • 14. 329,642 randomized subjects FU 12-17 yrs. -25% -13% -16% -16% RR 0.84 (0.78-0.90)
  • 15. 5.3% 6.4% 33% 2.6% 1.7% 1.7%
  • 16. INCIDENCE MORTALITY NS RR 0.91 (95% CI 84-98%)
  • 17. MORTALITY -22-32% NS
  • 18. EU GUIDELINES
  • 19. OPEN ISSUES • g-FOBT • FIT
  • 20. g-FOBT vs FIT •Advanced neoplasia detection rate
  • 21. g-FOBT vs FIT •Cancer detection rate
  • 22. FIT 1° round vs FIT 2° round
  • 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. EU GUIDELINES
  • 25. OPEN ISSUES • g-FOBT • FIT • FS
  • 26. May 2010 The BIG BANG September 2011
  • 27. UK FS ITT CRC incidence -23% SCORE -18% CRC mortality -31% -22%
  • 28. UK FS PP CRC incidence -33% SCORE -31% CRC mortality -43% -38%
  • 29. INCIDENCE REDUCTION IN THE DISTAL COLON By year from randomization SCORE TRIAL UK FLEXI-SCOPE TRIAL
  • 30. EU GUIDELINES
  • 31. OPEN ISSUES • g-FOBT • FIT • FS • OC
  • 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. 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. OR 0.39 OR 1.07 [0.94─ 1.21] [0.34─ 0.45] 37%
  • 35. HR 10 95% CI 1.4-87
  • 36. Pick up the small (adenoma) not to miss the BIG (cancer)! ADR = -Miss Rate Ad. = -Miss Rate CRC
  • 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. 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. 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. 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. 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. EU GUIDELINES
  • 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. OPEN ISSUES • Is there a variability in colonoscopy-related CRC prevention rate? • If any, is such variability related with ADR?
  • 45. OPEN ISSUES • Are low-risk patients the same as average-risk?
  • 46. Low-risk as average-risk?
  • 47. Low-risk as average-risk?
  • 48. Low-risk as average-risk? Low-risk = FP
  • 49. Low-risk as average-risk?
  • 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. OPEN ISSUES • Are low-risk patients the same as average-risk? • Should we preclude a 1-year examination to intermediate risk subjects
  • 52. Why 3-years in intermediate risk?
  • 53. CRC risk 0.7%
  • 54. Why 3-years in intermediate risk?
  • 55. Why 3-years in intermediate risk?
  • 56. Why 3-years in intermediate risk?
  • 57. CCE-2 vs FIT •6% of subjects will result FIT+ •FIT PPV <30% •CCE-2 as triage in FIT+
  • 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. CCE-2 vs FS •10-20% of subjects will result positive at FS •FS PPV <20% •CCE-2 as triage in FS+
  • 60. SEX
  • 61. FAMILY HISTORY •At least one first-degree relative with CRC CRC RR 2.25 (95% CI:2-2.53)
  • 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. OPEN ISSUES • Who should be screened? • How should we screen?
  • 64. THE PRESENT
  • 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. AGE
  • 67. AGE
  • 68. EU GUIDELINES
  • 69. EU GUIDELINES
  • 70. What did we learn from FS trials? No prevalent CRC -66% Prevalent CRC -33%
  • 71. OPEN ISSUES • Who should be screened? • How should we screen?