Overtreatment in nonmalignant lesions detected in a colorectal cancer screening program: a retrospective cohort study

Abstract

Background Although colorectal cancer (CRC) screening programs reduce CRC incidence and mortality, they are associated with risks in healthy subjects. However, the risk of overtreatment and overdiagnosis has not been determined yet. The aim of this study was to report the surgery rates in patients with nonmalignant lesions detected within the first round of a fecal immunochemical test (FIT) based CRC screening program and the factors associated with it. Methods We included in this analysis all patients with nonmalignant lesions detected between May 2013 and June 2019 in the Galician (Spain) CRC screening program. We calculated surgery rate according to demographic variables, the risk classification according to the colonoscopy findings (European guidelines for quality assurance), the endoscopist’s adenoma detection rate (ADR) classified into quartiles and the hospital’s complexity level. We determined which variables were independently associated with surgery rate and expressed the association as Odds Ratio and its 95% confidence interval (CI). Results We included 15,707 patients in the analysis with high (19.9%), intermediate (26.9%) low risk (23.3%) adenomas and normal colonoscopy (29.9%) detected in the analyzed period. Colorectal surgery was performed in 162 patients (1.03, 95% CI 0.87–1.19), due to colonoscopy complications (0.02, 95% CI 0.00–0.05) and resection of colorectal benign lesions (1.00, 95% CI 0.85–1.16). Median hospital stay was 6 days with 17.3% patients developing minor complications, 7.4% major complications and one death. After discharge, complications developed in 18.4% patients. In benign lesions, an endoscopic resection was performed in 25.4% and a residual premalignant lesion was detected in 89.9%. The variables independently associated with surgery in the multivariable analysis were age (≥60 years = 1.57, 95% CI 1.11–2.23), sex (female = 2.10, 95% CI 1.52–2.91), the European guidelines classification (high risk = 67.94, 95% CI 24.87–185.59; intermediate risk = 5.63, 95% CI 1.89–16.80; low risk = 1.43; 95% CI 0.36–5.75), the endoscopist’s ADR (Q4 = 0.44, 95% CI 0.28–0.68; Q3 = 0.44, 95% CI 0.27–0.71; Q2 = 0.71, 95% CI 0.44–1.14) and the hospital (tertiary = 0.54, 95% CI 0.38–0.79). Conclusions In a CRC screening program, the surgery rate and the associated complications in patients with nonmalignant lesions are low, and related to age, sex, endoscopic findings, endoscopist’s ADR and the hospital’s complexity.

Clinical Effectiveness of Faecal Immunochemical Test in the Early Detection of Colorectal Cancer—An Umbrella Review

“…The discernible difference between regions was based on the conducting of screening programmes (in regions without screening programmes, the surgery rates were higher) [ 61 , 62 ]. A different study, where surgery rates in patients with nonmalignant cancers had been analysed, showed the small value of the factor, and the surgical interventions had been performed mainly on the unresectable polyps [ 64 ].…”

Substratifying the risk of covert malignancy in significant rectal polyps: Outcomes from a specialist multidisciplinary team (MDT)

“…As a result, LNPCPs containing covert malignancy are often removed piecemeal in the UK [9]. Worse still, if lesions are "overcalled" on assessment, patients with benign polyps may be subjected to unnecessary resectional surgery [10].…”

Diffusion-Weighted MRI as a Quantitative Imaging Biomarker in Colon Tumors

“…Overtreatment of colorectal tumors is a well-known risk. Patients with non-malignant adenomas may undergo partial colectomy, when polypectomy or mucosectomy would be less costly, less demanding for the patient, and have a lower rate of complications [ 9 , 10 ]. On the other hand, colonic tumors with an endoscopically benign appearance, commonly polypoid, are often removed by polypectomy or mucosectomy.…”