Is colonoscopy needed for the nonadvanced adenoma found on sigmoidoscopy?

doi:10.1016/S0016-5085(98)70132-5

Gastroenterology

Volume 115, Issue 3, September 1998, Pages 533-541

https://doi.org/10.1016/S0016-5085(98)70132-5 Get rights and content

Abstract

Background & Aims: The need for colonoscopy when small tubular adenomas with low-grade dysplasia are found on sigmoidoscopy is uncertain. The aim of this study was to examine the prevalence and characteristics of proximal adenomas in patients with distal adenomas. Methods: We studied 981 subjects with distal adenomas found on the index colonoscopy before randomization in the Polyp Prevention Trial. Results: Four hundred sixty patients (46.9%) had ≥1 distal adenoma that was pathologically advanced (villous component, high-grade dysplasia, or ≥1 cm); 21.5% (211 of 981) had any proximal adenoma; and 4.3% (42 of 981) (95% confidence interval [CI], 3.0–5.5) had an advanced proximal adenoma. A greater percentage of patients with an advanced distal adenoma (5.9%) (95% CI, 3.7–8.0) had an advanced proximal adenoma compared with those with a nonadvanced distal adenoma (2.9%) (95% CI, 1.4–4.3) (OR, 2.1; 95% CI, 1.1–4.3; P = 0.03). Not performing a colonoscopy in patients with a nonadvanced distal adenoma would have missed 36% (15 of 42) of the advanced proximal adenomas. Conclusions: Patients with an advanced distal adenoma are twice as likely to have an advanced proximal adenoma as patients with a nonadvanced distal adenoma. However, eschewing a colonoscopy in patients with a nonadvanced distal adenoma would result in not detecting a sizeable percentage of the prevalent advanced proximal adenomas. These data support performance of a colonoscopy in patients with a nonadvanced distal adenoma. Confirmation of these results in asymptomatic subjects undergoing screening sigmoidoscopy is advisable.

GASTROENTEROLOGY 1998;115:533-541

Section snippets

Study population

A detailed description of the determination of eligibility and randomization of participants in the PPT has been reported.⁴² Participants were recruited from academic and community hospitals in the vicinity of eight regional clinical centers: Bowman Gray School of Medicine, State University of New York at Buffalo, Edward Hines, Jr. Veterans Affairs Hospital, Kaiser Foundation Research Institute, Memorial Sloan-Kettering Cancer Center, University of Pittsburgh, University of Utah, and the Walter

Results

The derivation of the 981 patients used in this analysis is presented in Figure 1.

. Derivation of the sample.

Of the 2079 individuals enrolled in the PPT, 618 had previous adenomatous polyps and were excluded. Of the remaining 1461, 1123 had a confirmed distal adenoma. Additional 142 (12.6%) were excluded because of missing information. The missing data consisted of 137 patients with an adenoma of unknown size and 5 patients with an adenoma of unknown location (Figure 1).

In Table 1, the

Discussion

Adenomatous polyps are neoplastic precursors of colorectal cancer.³ The incidence of adenomatous polyps, however, far exceeds the incidence of colorectal cancer. Although data are limited, studies suggest that individuals without advanced distal adenomas, or adenomas with villous histology, high-grade dysplasia, or ≥1 cm in size, are at average risk for colorectal cancer.27, 31 This engenders an important question pertinent to screening for colorectal cancer: should individuals with a

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Findings in the distal colorectum are not associated with proximal advanced serrated lesions
2015, Clinical Gastroenterology and Hepatology
Serrated lesions are an important contributor to colorectal cancer (CRC), notably in the proximal colon. Findings in the distal colorectum are markers of advanced proximal adenomatous neoplasia. However, it is not known whether they affect the odds of advanced proximal serrated lesions.
We performed a retrospective cross-sectional study of data from 1910 patients (59.3 ± 8.0 years, 53.8% female) who underwent an average-risk screening colonoscopy from August 2005 through April 2012 at Indiana University Hospital and an associated ambulatory surgery center. Colonoscopies were performed by an endoscopist with high rates of detection of adenomas and serrated polyps. Tissue samples of all serrated polyps (hyperplastic, sessile serrated adenoma/polyp [SSA/P], or traditional serrated adenoma) proximal to the sigmoid colon and serrated polyps >5 mm in the rectum or sigmoid colon were reviewed by a gastrointestinal pathologist and reclassified on the basis of World Health Organization criteria. Advanced serrated lesion (ASL) was defined as SSA/P with cytologic dysplasia, SSA/P ≥10 mm, or traditional serrated adenoma. Advanced conventional adenomatous neoplasia (ACN) was defined as tubular adenoma ≥10 mm, villous histology, high-grade dysplasia, or cancer. The prevalence of proximal ASL and ACN was calculated on the basis of distal colorectal findings. Multivariable logistic regression analysis was performed to determine the age-adjusted and sex-adjusted odds of advanced proximal adenomatous and serrated lesions. Secondary analyses were performed to examine the effect of variable ASL definitions.
Fifty-two patients (2.7%) had proximal ASL, and 99 (5.2%) had proximal ACN. Of the 52 patients with proximal ASL, 27 (52%) had no distal polyps. Of the 99 patients with proximal ACN, 40 (40%) had no distal polyps. Age and type of distal adenomas were significantly associated with proximal ACN. There were no significant associations between distal polyp type and proximal ASL. In secondary analyses, distal SSA/Ps (P = .008) but not distal hyperplastic polyps or conventional adenomas were associated with any proximal SSA/P.
The findings at flexible sigmoidoscopy that traditionally serve as indications for colonoscopy (conventional adenomas) are likely to be ineffective for detection of proximal ASL. This finding, plus the observation that most patients with proximal ASL have no distal polyps, favors screening colonoscopy over sigmoidoscopy, especially in the elderly. The observation that non-advanced distal SSA/Ps are associated with any proximal SSA/P warrants further study.
Identification of subjects at risk of proximal advanced neoplasia for colorectal cancer screening
2015, European Journal of Cancer
Citation Excerpt :
Yet another study conducted by Levin et al. demonstrated that age, family history and distal findings were predictors of PAN [32]. There are other studies which evaluated the predictors of colorectal neoplasia [33–36] with similar conclusions – yet the major objectives target at studying independent predictors only. Our study did not rely on distal findings as one of the predictive factors since its major research objective is to evaluate a cut-off score where FS could be used as an alternative screening tool among subjects who have not undergone either colonoscopy or FS before.
Flexible sigmoidoscopy (FS) and colonoscopy are two commonly used screening tools for colorectal cancer (CRC), and FS mainly detects distal lesions. Colonoscopy resource is limited, yet there is no definite evidence on when flexible sigmoidoscopy is suitable as a screening alternative. This study evaluated the optimal cut-off score from a validated risk stratification system which best predicts proximal advanced neoplasia (PAN) by comparing the sensitivity, specificity and relative risk of PAN according to various cut-off scores. 5819 asymptomatic subjects aged between 50 and 70 years (average age 57.7 years, standard deviation (SD) 4.9) received colonoscopy between 2008 and 2014 in Hong Kong. Their prevalence of PAN was evaluated according to a prediction tool for colorectal neoplasia based on age, gender, smoking status, family history of CRC, body mass index (BMI) and diabetes (ranging from 0 to 6). One binary logistic regression model was performed with PAN as the outcome variable and the risk score as the variable tested for association. In multivariate regression analysis, risk score ⩾3 was associated with significantly higher risk of PAN (3.4–9.1%; AOR = 3.18–8.09, p < 0.001) when compared with those scoring 0. Risk scores 0–2 were associated with either insignificant or lower risks of PAN compared to the overall risk. Applying FS for screening those who scored 0–2 and colonoscopy for those who scored ⩾3 led to a very small proportion of PAN being missed (1.60%), whilst maintaining a high level of specificity (81.9%). Clinicians may use this scoring system to inform subjects and facilitate their choice between colonoscopy and FS.
Tailoring colorectal cancer screening by considering risk of advanced proximal neoplasia
2012, American Journal of Medicine
Citation Excerpt :
Another candidate feature for tailoring is distal colorectal findings. An extensive literature supports a higher risk of advanced neoplasia in the proximal colon when distal neoplasia is present, with the magnitude of risk directly related to the degree or severity of distal neoplasia.17,20,22-25,37 Findings from this study provide further support for this literature and for using distal findings along with other factors to estimate the risk for advanced proximal neoplasia.
Quantifying the risk of advanced proximal colorectal neoplasia might allow tailoring of colorectal cancer screening, with colonoscopy for those at high risk and less invasive screening for very low-risk persons.
We analyzed findings from 10,124 consecutive adults aged ≥ 50 years who underwent screening colonoscopy to the cecum. We quantified the risk of advanced neoplasia (tubular adenoma ≥ 1 cm, a polyp with villous histology or high-grade dysplasia, or adenocarcinoma) both proximally (cecum to splenic flexure) and distally (descending colon to anus). The prevalence of advanced proximal neoplasia was quantified by age, gender, and distal findings.
The mean (standard deviation) age was 57.5 (6.0) years; 44% were women; 7835 (77%) had no neoplasia, and 1856 (18%) had 1 or more nonadvanced adenomas. Overall, 433 subjects (4.3%) had advanced neoplasia (267 distally, 196 proximally, 30 both), 33 (0.33%) of which were adenocarcinoma (18 distal, 15 proximal). The risk of advanced proximal neoplasia increased with age decade (1.13%, 2.00%, and 5.26%, respectively; P = .001) and was higher in men (relative risk [RR], 1.91; confidence interval [CI], 1.32-2.77). In women aged less than 70 years, the risk was 1.1% overall (vs 2.2% in men; RR, 1.98; CI, 1.42-2.76) and 0.86% in those with no distal neoplasia (vs 1.54% in men; RR, 1.81; CI, 1.20-2.74).
Risk of advanced proximal neoplasia is a function of age and gender. Women aged less than 60 to 70 years have a very low risk, particularly those with no distal adenoma. Sigmoidoscopy with or without occult blood testing may be sufficient and even preferable for screening these subgroups.
Body mass index increases risk for colorectal adenomas based on meta-analysis
2012, Gastroenterology
There have been inconsistent results published about the relationship between excess body weight, expressed as increased body mass index (BMI), and risk of colorectal adenoma (CRA). We conducted a meta-analysis to explore this relationship. We focused on whether the relationship varied based on the sex of the study subjects, study design, features of the polyps, or potential confounders, including alcohol use, nonsteroidal anti-inflammatory drug use, smoking, and exercise.
We identified studies by performing a literature search of Medline, EMBASE, and ISI Web of Science through July 31, 2011, and by searching the reference lists of pertinent articles. We analyzed 36 independent studies, which included 29,860 incident cases of CRA. Summary relative risks with their 95% confidence intervals (CIs) were calculated with a random-effects model. Between-study heterogeneity was assessed using Cochran's Q statistic and I² analyses.
Overall, a 5-unit increase in BMI (calculated as kg/m²) increased the risk for CRA (summary relative risk = 1.19; 95% CI: 1.13–1.26), although there was a high level of heterogeneity among studies (P_{heterogeneity} < .001; I² = 76.8%). Subgroup analyses revealed that the increased risk of CRA in obese individuals was independent of race, geographic location, study design, sex, adenoma progression, and confounders. The association between increased BMI and risk for CRA was stronger for colon than rectal adenoma.
Based on a meta-analysis, increased BMI increases the risk for colon but not rectal adenoma. Unlike colorectal cancer, there is no sex difference in the relationship between increased BMI and risk of CRA.
Colonic Polyps and Polyposis Syndromes
2010, Sleisenger and Fordtran’s Gastrointestinal and Liver Disease- 2 Volume Set: Pathophysiology, Diagnosis, Management, Expert Consult Premium Edition - Enhanced Online Features and Print
Colorectal cancer (CRC) screening using sigmoidoscopy followed by colonoscopy: A feasibility and efficacy study on a cancer institute based population
2006, Annals of Oncology
Background: Advanced distal neoplasia found at sigmoidoscopy could be the marker for more proximal lesions.
Patients and methods: In the setting of a screening clinic, subjects underwent flexible sigmoidoscopy. If no significant lesion was found, sigmoidoscopy was planned after 5 years. If an advanced neoplasia was found, colonoscopy was performed just after the first sigmoidoscopy and at 1, 3 and 5 years. If a non-advanced neoplasia was found, sigmoidoscopy was performed at 1, 3 and 5 years and followed by colonoscopy if advanced lesion was found.
Results: At first screening 1704/1912 (88%) subjects had a negative sigmoidoscopy, 104 (5.4%) had an advanced neoplasia, 96 (6%) had a non-advanced neoplasia and eight (0.4%) had invasive colorectal cancer (CRC). At follow-up examinations at 1, 3 and 5 years, among 170 subjects with advanced and non-advanced neoplasia, one developed invasive CRC and 47 (31.6%), advanced neoplasia. At 5 years, among 718 first negative sigmoidoscopies, 572 (80%) were confirmed negative and 97 (14%) had advanced neoplasia. Colorectal cancer status at 5 years could be checked for interval cancers in 97% of subjects and no CRC was diagnosed in subjects who did not attend sigmoidoscopy at 5 years. Comparison of the incidence of invasive CRC to the data of registries of the Netherlands and Luxembourg suggested that the incidence of CRC was decreased by 36%–46%. Seven of the nine CRCs were Duke's A and the two others were Duke's B and C.
Conclusions: Screening with sigmoidoscopy followed by colonoscopy in case of positive sigmoidoscopy leads to substantial decreases in the incidence of CRC. Most CRCs found are at an early, curable stage of their development.

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^☆: Address requests for reprints to: Robert E. Schoen, M.D., M.P.H., Division of Gastroenterology and Hepatology, Mezzanine Level, C Wing, Pittsburgh University Hospital, 200 Lothrop Street, Pittsburgh, Pennsylvania 15213-2582. Fax: (412) 648-9378.

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Alimentary TractIs colonoscopy needed for the nonadvanced adenoma found on sigmoidoscopy?☆

Abstract

Section snippets

Study population

Results

Discussion

Gastroenterology

Gastroenterology

Gastroenterology

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Gastroenterology

Gastroenterology

Gastroenterology

Gastroenterology

Mayo Clin Proc

Mayo Clin Proc

Lancet

Gastroenterology

Gastroenterology

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Lancet

Gastroenterology

Gastroenterology

Lancet

Gastroenterology

The role of colonoscopy in the management of patients with colonic polyps

Gastrointest Endosc

How should we screen for colon cancer?

JAMA

Polyp guideline: diagnosis, treatment, and surveillance for patients with nonfamilial colorectal polyps

Ann Intern Med

Polyp guideline

Am J Gastroenterol

Small polyps found during fiberoptic sigmoidoscopy in asymptomatic patients

Ann Intern Med

Univariate and multivariate analyses of the relationship between adenocarcinoma and solitary and multiple adenomas in colorectal adenoma patients

Am J Cancer

Flexible sigmoidoscopy may be ineffective for secondary prevention of colorectal cancer in asymptomatic, average-risk men

Dig Dis Sci

Synchronous neoplasms in patients with diminutive colorectal adenomas

Cancer

Risk for colon adenomas in patients with rectosigmoid hyperplastic polyps

Ann Intern Med

Small rectosigmoid polyps as markers of proximal neoplasms

Dis Colon Rectum

Clinical significance of diminutive polyps of the rectum and sigmoid colon

Dis Colon Rectum

Alimentary Tract
Is colonoscopy needed for the nonadvanced adenoma found on sigmoidoscopy?☆