Impact of adenoma detection on the benefit of faecal testing vs. colonoscopy for colorectal cancer

Abstract

Colonoscopy quality, as measured by adenoma detection rates, varies widely across providers and is inversely related with patients’ post-colonoscopy cancer risk. This has unknown consequences for the benefits of faecal immunochemical testing (FIT) versus primary colonoscopy screening for colorectal cancer. Using an established microsimulation model, we predicted the lifetime colorectal cancer incidence and mortality benefits of annual FIT versus ten-yearly colonoscopy screening at differing ADR levels (quintiles; averages 15.3–38.7%), with colonoscopy performance assumptions estimated from community-based data on physician ADRs and patients’ post-colonoscopy risk of cancer. For patients receiving FIT screening with follow-up colonoscopy by physicians from the highest ADR quintile, simulated lifetime cancer incidence and mortality were 28.8 and 5.4 per 1000, respectively, versus 20.6 and 4.4 for primary colonoscopy screening (risk ratios, RR=1.40; 95% probability interval (PI), 1.19–1.71 for incidence, and RR=1.22; 95%PI, 1.02–1.54 for mortality). With every 5% point ADR decrease, lifetime cancer incidence was predicted to increase on average 9.0% for FIT versus 12.3% for colonoscopy, and mortality increased 9.9% versus 13.3%. In ADR quintile 1, simulated mortality was lower for FIT than colonoscopy screening (10.1 versus 11.8; RR=0.85; 95%PI, 0.83–0.90), while incidences were more similar. This suggests that relative cancer incidence and mortality reductions for FIT versus colonoscopy screening may differ by ADR, with fewer predicted deaths with colonoscopy screening in higher ADR settings and fewer deaths with annual FIT screening in lower ADR settings.

Once-only colonoscopy or two rounds of faecal immunochemical testing 2 years apart for colorectal cancer screening (SCREESCO): preliminary report of a randomised controlled trial

“…Detection of cancers was similar in the two intervention arms in the intention-to-screen and in the as-screened analysis, similar to the findings in the study by Quintero et al (1) but contrary to a Chinese study (6) where colonoscopy had a higher yield. However, polypectomy is the main effector in colorectal cancer prevention (22), and the different capacity of the SCREESCO study arms to find premalignant lesions is likely to have implications for the long term colorectal cancer mortality (23,24).…”

Adenoma Detection Rate Falls at the End of the Day in a Large Multi-site Sample

“…[5] In a recent modeling study by Meester at al, a 5% decrease in ADR was associated with a 12.3% and 13.3% increase in colorectal cancer incidence and mortality, respectively. [6] One potential driver of lower ADR is that, over the course of a day, an endoscopist may become fatigued and thereby detect fewer adenomas.…”

Effectiveness of Colorectal Cancer (CRC) Screening on All-Cause and CRC-Specific Mortality Reduction: A Systematic Review and Meta-Analysis

“…Nine simulation models were identified, including three Cancer Intervention and Surveillance Modeling Network (CISNET) CRC models (CRC Simulated Population Model for Incidence and Natural History (CRC-SPIN) [ 14 , 24 , 30 , 31 , 42 ], Simulation Model of Colorectal Cancer (SimCRC) [ 14 , 24 , 30 , 31 , 36 , 42 ] and MIcrosimulation SCreening ANalysis-Colon (MISCAN-Colon) [ 14 , 20 , 21 , 22 , 24 , 25 , 29 , 30 , 31 , 35 , 36 , 37 , 38 , 39 , 42 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 ]), adenoma and serrated pathway to colorectal cancer (ASCCA) [ 12 , 19 , 26 , 27 , 28 , 43 ], Microsimulation-based colon modelling open-source tool (CMOST) [ 23 , 41 ], Colorectal Cancer and Adenoma Incidence and Mortality Microsimulation Model (CRC-AIM) [ 40 , 44 , 68 , 69 ...…”

“…In the pooled analyses, gFOBT screening leads to a MR of 17% with 95% confidence intervals (95% CI) of 8–25% [ 17 ], and that FS results in a MR of 28% (95% CI: 20–35%) [ 15 , 16 ]. The model studies showed 24–79%, 8–84%, 25–56%, 16–94%, and 55–81% CRC-specific MRs on biennial fecal immunochemical tests (FIT), biennial gFOBT, single FS, 10-yearly colonoscopy, and 5-yearly FS screening, respectively [ 12 , 13 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ]. Adherence rates, adenoma detection rates and dwelling time were used in several model studies in the sensitivity analyses [ 10 , 13 , 19 , 23 , 40 , 41 , 44 ].…”

“…The following supporting information can be downloaded at: . References [ 13 , 20 , 21 , 22 , 23 , 24 , 25 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 60 , 62 , 63 , 64 , 70 , 74 , 75 , 94 , 95 ], Table S1: Literature search strategy; Box S1: Selection criteria for articles; Box S2: Qualitative assessment framework on model characteristics; Table S2: Subgroup analysis of RCTs (Intention-to-treat analyses); Table S3: Subgroup analysis of RCTs on CRC-specific mortality reduction by FOBT (Compliance-adjusted analysis); Table S4: Quality assessment of included models; Table S5: Characteristics of simulation models on biennial gFOBT screening from the age of 45 to 80; Table S6: Characteristics of simulation models on single FS screening from the age of 50 to 75; Table S7: Characteristics of simulation models on 10-yearly colonoscopy screening from the age of 55 to 75; Table S8: Characteristics of simulation models on 5-yearly flexible sigmoidoscopy (FS) screening from the age of 55...…”