Between July 2004 and April 2005, consecutive symptomatic patients undergoing colonoscopic examinations in 10 different Asian countries.
Setting
The location and the histologic features of all colonic neoplasms were recorded. Advanced neoplasm was defined as adenoma larger than 10 mm in size, with >25% villous features or with high-grade dysplasia or invasive carcinoma.
Main Outcome Measurements
The prevalence and the distribution of colorectal neoplasm and advanced neoplasm.
Results
A total of 5464 eligible patients underwent colonoscopy. Advanced neoplasm was found in 512 patients (9.4%). Factors associated with the presence of advanced neoplasm in this symptomatic Asian population included male sex (relative risk [RR] 1.52, 95% confidence interval [CI] 1.26-1.84), older age (RR 1.05, 95% CI 1.04-1.06), and ethnicity (P = .001). Advanced proximal neoplasm was detected in 136 patients (2.5%); 83 (61.0%) of the patients had normal distal colon. The RR of proximal advanced neoplasm was 2.5, 95% CI 1.7-3.7 in those with any adenoma in the distal colon compared with those with normal distal colon.
Limitations
Possible underrepresentation of some ethnic groups because of uneven ethnic group distribution and the lack of population-based registry.
Conclusions
This was the first multicenter colonoscopy survey that examined the characteristics of colorectal neoplasm in Asia. The results will have important implications on the planning for future colorectal cancer screening in this region.
Section snippets
Study population
This study was conducted between July 2004 and April 2005 in 17 endoscopy centers in 10 Asian countries (Appendix 1, available online at www.giejournal.org). All participating centers were secondary or tertiary referral endoscopy centers. We included consecutive symptomatic patients who were referred to these endoscopy centers for colonoscopy. Hence, patients included in this study were representative of the typical patients who were managed in the study centers. Patients who had previous
Patients
A total of 7290 patients had undergone colonoscopy in the study endoscopy centers during the study period. Fifty-four patients who were younger than 16 years old and 533 patients who had previous colonic examination were excluded (Fig. 1). The results of the 1204 asymptomatic individuals who underwent colonoscopy for screening purposes were not included in this study. Thirty-five white patients were also excluded in the analysis of this Asian study. The mean age (SD) of the 5464 symptomatic
Discussion
Colorectal cancer is increasing in Asian countries1, 2; however, there is a paucity of data from this region. Although the incidence of colorectal cancer may be derived from different cancer registries, including the GOLBOCAN,1 data on the precursor lesion, colorectal adenoma, are lacking. This multinational, multicenter, and multiracial study provided a glimpse on the epidemiology of colorectal neoplasm in Asia. This is the first prospective study to examine the epidemiology of colorectal
Acknowledgments
We would like to thank all members of the Asia Pacific Working Group on Colorectal Cancer, Professor William Chao, Professor Graeme Young, Miss Bing-yee Suen, and the staff of all participating endoscopy centers for their contribution to this study.
Some data suggest that individuals with numerous, <10-mm, rectosigmoid hyperplastic polyps (HPs) are at average risk for the development of metachronous advanced adenomatous neoplasia. Guidelines suggest that these individuals do not need surveillance colonoscopy and should be followed akin to individuals with a normal colonoscopy. Less is known of the risk of metachronous neoplasia because of ≥1 HPs <10 mm proximal to the sigmoid colon. We compared the risk of metachronous neoplasia between individuals with small HPs and those with normal colonoscopy, specifically addressing the impact of location and number of HPs on risk.
Colonoscopy and pathology reports from patients with ≥2 colonoscopies between 2004 and 2014 were reviewed. Exclusions included inpatients; age <40 or >75 years; and family or personal history of colorectal cancer, inflammatory bowel disease, previous colorectal surgery, or a previous colonoscopy with any adenoma, sessile serrated lesion (SSL), or HP ≥10 mm. The risk of metachronous neoplasia, including adenomas and SSLs, was compared in individuals with a normal index colonoscopy and those with <10-mm HPs stratified by location and number of HPs.
After exclusion, 1795 patients were included. At index colonoscopy, 82% (n = 1469) had a normal examination, 12% (219) had only 1, and 6% (107) had between 2 and 9 HPs <10 mm. Compared with patients with a normal index colonoscopy, patients with a proximal (odds ratio, 3.82; 95% confidence interval, 1.77-7.53) or distal HP (odds ratio, 2.23; 95% confidence interval, 1.18-4.00) had an increased risk of metachronous SSLs but not adenomas.
Patients with small proximal and distal HPs are at increased risk of metachronous SSLs. These preliminary findings warrant consideration during surveillance recommendations and future studies in larger cohorts.
Further research is required to better understand the increases in incidence of colorectal cancer and to improve prevention, early detection, and treatment of this disease. Whereas colorectal cancer age-standardised death rates have stabilised or declined in many high-income countries, which historically had the highest burden of colorectal cancer in the world,7 the burden is increasing in most low-income and middle-income countries,8 possibly as a result of ageing populations, urbanisation, and increased prevalence of westernised lifestyle risk factors, such as alcohol consumption, obesity, smoking, and suboptimal diet.9,10 The global burden of colorectal cancer attributable to various modifiable risk factors has not been described elsewhere and is an important estimate to report because it has implications for policy making and prevention efforts.
Data about the global, regional, and country-specific variations in the levels and trends of colorectal cancer are required to understand the impact of this disease and the trends in its burden to help policy makers allocate resources. Here we provide a status report on the incidence, mortality, and disability caused by colorectal cancer in 195 countries and territories between 1990 and 2017.
Vital registration, sample vital registration, verbal autopsy, and cancer registry data were used to generate incidence, death, and disability-adjusted life-year (DALY) estimates of colorectal cancer at the global, regional, and national levels. We also determined the association between development levels and colorectal cancer age-standardised DALY rates, and calculated DALYs attributable to risk factors that had evidence of causation with colorectal cancer. All of the estimates are reported as counts and age-standardised rates per 100 000 person-years, with some estimates also presented by sex and 5-year age groups.
In 2017, there were 1·8 million (95% UI 1·8–1·9) incident cases of colorectal cancer globally, with an age-standardised incidence rate of 23·2 (22·7–23·7) per 100 000 person-years that increased by 9·5% (4·5–13·5) between 1990 and 2017. Globally, colorectal cancer accounted for 896 000 (876 300–915 700) deaths in 2017, with an age-standardised death rate of 11·5 (11·3–11·8) per 100 000 person-years, which decreased between 1990 and 2017 (−13·5% [–18·4 to −10·0]). Colorectal cancer was also responsible for 19·0 million (18·5–19·5) DALYs globally in 2017, with an age-standardised rate of 235·7 (229·7–242·0) DALYs per 100 000 person-years, which decreased between 1990 and 2017 (−14·5% [–20·4 to −10·3]). Slovakia, the Netherlands, and New Zealand had the highest age-standardised incidence rates in 2017. Greenland, Hungary, and Slovakia had the highest age-standardised death rates in 2017. Numbers of incident cases and deaths were higher among males than females up to the ages of 80–84 years, with the highest rates observed in the oldest age group (≥95 years) for both sexes in 2017. There was a non-linear association between the Socio-demographic Index and the Healthcare Access and Quality Index and age-standardised DALY rates. In 2017, the three largest contributors to DALYs at the global level, for both sexes, were diet low in calcium (20·5% [12·9–28·9]), alcohol use (15·2% [12·1–18·3]), and diet low in milk (14·3% [5·1–24·8]).
There is substantial global variation in the burden of colorectal cancer. Although the overall colorectal cancer age-standardised death rate has been decreasing at the global level, the increasing age-standardised incidence rate in most countries poses a major public health challenge across the world. The results of this study could be useful for policy makers to carry out cost-effective interventions and to reduce exposure to modifiable risk factors, particularly in countries with high incidence or increasing burden.
Identificar personas con alto riesgo de neoplasia avanzada colorrectal puede ayudar en la prevención de cáncer de colon. Por otro lado, estudios previos han observado que algunos pacientes pueden tener neoplasia avanzada proximal sin hallazgos distales.
Determinar los factores relacionados a neoplasia avanzada y neoplasia avanzada proximal colorrectal en una población latinoamericana.
Estudio analítico, observacional, transversal y prospectivo. Se incluyó a pacientes sometidos a colonoscopia en el Policlínico Peruano Japonés entre enero y julio del 2012. Se definió neoplasia avanzada como la presencia de lesiones ≥ 10 mm en tamaño, con componente velloso o displasia de alto grado o carcinoma. El límite entre el colon proximal y distal fue el ángulo esplénico.
Se incluyó a 846 pacientes. Se detectó neoplasia avanzada en 108 pacientes (12.8%). Se detectó neoplasia avanzada proximal en 55 pacientes (6.7%), de los cuales 42 (76.4%) tuvieron el colon distal sin neoplasias. El análisis multivariado encontró como factores relacionados a neoplasia avanzada a la edad, en intervalos 50-59 (p = 0.019), 60-69 (p = 0.016) y ≥ 70 años (0.002) y el género masculino (p = 0.003). Al evaluar neoplasia avanzada proximal, el análisis multivariado encontró a la edad en intervalo de 60-69 años (p = 0.039) y la neoplasia avanzada distal (p = 0.028) como relacionados. La curva ROC estableció un corte de edad de 60 años para realizar colonoscopia de inicio en lugar de sigmoidoscopia.
La edad y el género están relacionados con neoplasia avanzada, mientras que la edad y la neoplasia avanzada distal están relacionadas a neoplasia avanzada proximal.
Identifying persons at high risk for advanced colorectal neoplasia can aid in the prevention of colon cancer. Previous studies have shown that some patients can present with proximal advanced neoplasia with no distal findings.
To determine the factors related to advanced neoplasia and advanced proximal colorectal neoplasia in a Latin American population.
A prospective, cross-sectional, observational, analytic study was conducted. It included patients that underwent colonoscopy at the Policlínico Peruano Japonés within the time frame of January and July 2012. Advanced neoplasia was defined as the presence of lesions ≥ 10 mm with a villous component, high-grade dysplasia, or carcinoma. The splenic flexure was the limit between the proximal and distal colon.
A total of 846 patients were included in the study. Advanced neoplasia was detected in 108 patients (12.8%) and advanced proximal neoplasia in 55 patients (6.7%), 42 (76.4%) of whom had no neoplasia in the distal colon. Factors related to advanced neoplasia found in the multivariate analysis were age, at the intervals of 50-59 (p = 0.019), 60-69 (p = 0.016), and ≥ 70 years (0.002) and male sex (p = 0.003). In the evaluation of advanced proximal neoplasia, the multivariate analysis identified the 60-69 year age interval (p = 0.039) and advanced distal neoplasia (p = 0.028) as factors related to advanced proximal disease. The ROC curve established the age cut-off point at 60 years for initially performing colonoscopy, rather than sigmoidoscopy.
Age and sex are related to advanced neoplasia, whereas age and advanced distal neoplasia are related to advanced proximal neoplasia.
2015, Best Practice and Research: Clinical Gastroenterology
Citation Excerpt :
Increasing screening rates and adherence could lead to a substantial decline in CRC incidence and mortality [17]. Some recognized risk factors for CRC include older age [18–20], male gender [18,20], current smoking [21–24], family history in first-degree relatives [18], obesity [25], certain Asian ethnicities like Japanese, Koreans and Chinese [3,26], as well as unhealthy lifestyle habits such as excessive alcohol drinking [21–24,27] and low consumption of vegetables and fruit [28]. Regular, long-term use of aspirin or non-steroidal anti-inflammatory Drugs (NSAIDs) was associated with a reduced risk of CRC, especially after 10 years of use [29–31].
The idea of targeted screening for colorectal cancer based on risk profiles originates from its benefits to improve detection yield and optimize screening efficiency. Clinically, it allows individuals to be more aware of their own risk and make informed decisions on screening choice. From a public health perspective, the implementation of risk stratification strategies may better justify utilization of colonoscopic resources, and facilitate resource-planning in the formulation of population-based screening programmes. There are several at-risk groups who should receive earlier screening, and colonoscopy is more preferred. This review summarizes the currently recommended CRC screening strategies among subjects with different risk factors, and introduces existing risk scoring systems. Additional genetic, epidemiological, and clinical parameters may be needed to enhance their performance to risk-stratify screening participants. Future research studies should refine these scoring systems, and explore the adaptability, feasibility, acceptability, and user-friendliness of their use in clinical practice among different population groups.
