Yield of colonoscopy for advanced neoplasia in a population-based setting



Implementation of universal colonoscopic colorectal cancer (CRC) screening and surveillance is inappropriate and impossible. Risk stratification is needed for targeted screening.


Aim        

to assess factors associated with advanced colorectal neoplasia within a defined population.


Methods        

prospective recording of 2 cohorts composed of all consecutive diagnostic colonoscopic procedures performed by all the 34 endoscopists of the Haut-Rhin area: 1) an all indications (AI) cohort over a 3 month period and 2) a gFOBT cohort over a 3 year period within a CRC screening program with guaiac-based FOBT. Advanced neoplasia was defined as cancer or adenoma ≥ 10 mm, or with villous component or with high-grade dysplasia.


Results        

5568 colonoscopic procedures were recorded: 3185 in the gFOBT cohort in people aged 50 to 74 (men 54.7%) and 2383 in the AI cohort (mean age 58.9 y, men 48.1%). Overall, the advanced neoplasia rate was 31.0% in the gFOBT cohort and 12.5% in the AI cohort (p < 0.0001). In the latter, indications were symptoms (56.5%), screening (23.5%) and surveillance (20.0%). In the AI cohort, 1099 people (50.4%) had never had any previous colorectal examination. In this group, advanced neoplasia rates were not significantly different between people explored for symptoms (11.4%) and screening (10.6%). In the symptomatic group, abdominal pain and change in bowel habits had the lowest advanced neoplasia rate (6.0%). In the screening group, the advanced neoplasia rate was not significantly different between people with a family history of CRC, even in a first-degree relative < 60 y (9.2%) and without (19.4%). In both cohorts, the advanced neoplasia rate increased with age and was 1.9 time higher in men than in women. In the previously unexplored group of the AI cohort, the advanced neoplasia rate was low in women, similar in the 40-49 y and 50-59 y age groups (3.8% and 3.9%) and increased to 10.1% in the 60-69 y age group. It was respectively 8.5% and 21.3% in men in the 40-49 y and 50-59 y age groups. In the 40-59 y age group, men were four times as likely to have advanced neoplasia compared with women.


Conclusion        

in our population-based setting, gFOBT is by far the indication with the best yield for advanced neoplasia. Abdominal pain and change in bowel habits are the indications with the lowest yield, significantly lower than screening asymptomatic people. The yield for advanced neoplasia is not significantly influenced by a family history of CRC. The advanced neoplasia rate is about four times higher in men than in women in the 40-59 y age group and the recommended age at first screening should be postponed in women at least 10 years later than in men.



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