Adenoma characteristics in the English Bowel Cancer Screening Programme.

AIM: The English Bowel Cancer Screening Programme detects colorectal cancers and premalignant polyps in a faecal occult blood test-positive population. The aim of this work is to describe the detection rates and characteristics of adenomas within the programme, identify predictive factors influencing the presence or absence of carcinoma within adenomas and identify the factors predicting the presence of advanced colonic neoplasia in different colon segments. METHOD: The Bowel Cancer Screening System was retrospectively searched for polyps detected during colonoscopies between June 2006 and June 2012, at which time a guaiac test was being used. Data on size, location and histological features were collected, and described. Univariate and multivariate analyses were used to determine the significant factors influencing the development of carcinoma within an adenoma. RESULTS: A total of 229 419 polyps were identified; after exclusions 136 973 adenomas from 58 334 patients were evaluated. Over half were in the rectum or sigmoid colon. Subcentimetre adenomas accounted for 69.8% of the total. The proportion of adenomas containing advanced histological features increased with increasing adenoma size up to 35 mm, then plateaued. A focus of carcinoma was found in 2282 (1.7%) adenomas, of which 95.6% were located distally. Carcinoma was identified even in diminutive adenomas (0.1%). The proportion of adenomas containing cancer was significantly higher in women than men (2.0% vs. 1.5%, p < 0.001). CONCLUSION: This national, prospectively captured dataset adds robust information about histological features of adenomas that convey an increased risk for colorectal cancer, and identifies caecal adenomas, high-grade dysplasia, increasing adenoma size, distal location and female sex as independent risk factors associated with carcinoma.

Sustained colonoscopy quality improvement using a simple intervention bundle.

BACKGROUND: Unacceptable variation in colonoscopy quality exists. The Quality Improvement in Colonoscopy (QIC) study in 2011 improved quality by introducing an evidence-based "bundle" of measures into routine colonoscopy practice. The QIC bundle included: minimal cecal withdrawal time of ≥ 6 minutes; hyoscine butylbromide use; supine patient position for transverse colon examination; rectal retroflexion. Colonoscopy quality was measured by adenoma detection rate (ADR). The current study measured whether these effects led to a sustained change in practice 3 years following implementation. METHODS: This observational study collected data from eight hospital trusts (sites) in the United Kingdom for a 6-month period, 3 years following QIC bundle implementation. Use of the antispasmodic, hyoscine butylbromide, was measured as a marker of bundle uptake. Bundle effectiveness was measured by ADR change. Comparisons were made between data before and immediately after implementation of the bundle. RESULTS: 28 615 colonoscopies by 188 colonoscopists were studied. Hyoscine butylbromide use increased from 15.8 % pre-implementation to 47.4 % in the sustainability phase (P < 0.01) indicating sustained engagement with QIC measures. ADR was higher in the sustainability period compared with pre-intervention, but only reached statistical significance among the poorest-performing colonoscopists. CONCLUSIONS: The introduction of a simple, inexpensive, pragmatic intervention significantly changed practice over a sustained period, improving colonoscopy quality as measured by ADR, particularly in poorer performers. QIC demonstrates that an easy-to-implement quality improvement approach can deliver a sustained change in practice for many years post intervention.

Improved adenoma detection with Endocuff Vision: the ADENOMA randomised controlled trial.

OBJECTIVE: Low adenoma detection rates (ADR) are linked to increased postcolonoscopy colorectal cancer rates and reduced cancer survival. Devices to enhance mucosal visualisation such as Endocuff Vision (EV) may improve ADR. This multicentre randomised controlled trial compared ADR between EV-assisted colonoscopy (EAC) and standard colonoscopy (SC). DESIGN: Patients referred because of symptoms, surveillance or following a positive faecal occult blood test (FOBt) as part of the Bowel Cancer Screening Programme were recruited from seven hospitals. ADR, mean adenomas per procedure, size and location of adenomas, sessile serrated polyps, EV removal rate, caecal intubation rate, procedural time, patient experience, effect of EV on workload and adverse events were measured. RESULTS: 1772 patients (57% male, mean age 62 years) were recruited over 16 months with 45% recruited through screening. EAC increased ADR globally from 36.2% to 40.9% (P=0.02). The increase was driven by a 10.8% increase in FOBt-positive screening patients (50.9% SC vs 61.7% EAC, P<0.001). EV patients had higher detection of mean adenomas per procedure, sessile serrated polyps, left-sided, diminutive, small adenomas and cancers (cancer 4.1% vs 2.3%, P=0.02). EV removal rate was 4.1%. Median intubation was a minute quicker with EAC (P=0.001), with no difference in caecal intubation rate or withdrawal time. EAC was well tolerated but caused a minor increase in discomfort on anal intubation in patients undergoing colonoscopy with no or minimal sedation. There were no significant EV adverse events. CONCLUSION: EV significantly improved ADR in bowel cancer screening patients and should be used to improve colonoscopic detection. TRIAL REGISTRATION NUMBER: NCT02552017, Results; ISRCTN11821044, Results.

Expert opinions and scientific evidence for colonoscopy key performance indicators.

Colonoscopy is a widely performed procedure with procedural volumes increasing annually throughout the world. Many procedures are now performed as part of colorectal cancer screening programmes. Colonoscopy should be of high quality and measures of this quality should be evidence based. New UK key performance indicators and quality assurance standards have been developed by a working group with consensus agreement on each standard reached. This paper reviews the scientific basis for each of the quality measures published in the UK standards.

Are there biological differences between screen-detected and interval colorectal cancers in the English Bowel Cancer Screening Programme?

BACKGROUND: We measured biomarkers of tumour growth and vascularity in interval and screen-detected colorectal cancers (CRCs) in the English Bowel Cancer Screening Programme in order to determine whether rapid tumour growth might contribute to interval CRC (a CRC diagnosed between a negative guaiac stool test and the next scheduled screening episode). METHODS: Formalin-fixed, paraffin-embedded sections from 71 CRCs (screen-detected 43, interval 28) underwent immunohistochemistry for CD31 and Ki-67, in order to measure the microvessel density (MVD) and proliferation index (PI), respectively, as well as microsatellite instability (MSI) testing. RESULTS: Interval CRCs were larger (P=0.02) and were more likely to exhibit venous invasion (P=0.005) than screen-detected tumours. There was no significant difference in MVD or PI between interval and screen-detected CRCs. More interval CRCs displayed MSI-high (14%) compared with screen-detected tumours (5%). A significantly (P=0.005) higher proportion (51%) of screen-detected CRC resection specimens contained at least one polyp compared with interval CRC (18%) resections. CONCLUSIONS: We found no evidence of biological differences between interval and screen-detected CRCs, consistent with the low sensitivity of guaiac stool testing as the main driver of interval CRC. The contribution of synchronous adenomas to occult blood loss for screening requires further investigation.

Patient-derived measures of GI endoscopy: a meta-narrative review of the literature.

BACKGROUND AND AIMS: GI endoscopy (GIE) is widely performed, with 1 in 3 people requiring an endoscopic procedure at some point. Patient experience of medical procedures is important, but, to date, experience measures of GIE are derived from clinician opinion rather than from patients themselves. In this meta-narrative review, the literature on methods of assessing patient experience in GIE is reported. METHODS: ScienceDirect, MEDLINE, Web of Knowledge, Web of Science, CINAHL, and PsycINFO were searched to November 2013 using meta-narrative standards. Search terms included those related to endoscopic procedures, combined with those related to patient experience. RESULTS: A total of 3688 abstracts were identified and reviewed for relevance. A total of 3549 were excluded, leaving 139 for full-text review. We subsequently included 48 articles. Three sub-groups of studies were identified--those developing original measures of endoscopy-specific patient experience (27 articles), those modifying existing measures (10 articles), and those testing existing measures for reliability or validity (11 articles). Most measures focused on pain, discomfort, anxiety, and embarrassment. Three studies explored wider aspects of experience, including preparation, unit organization, and endoscopist preference. Likert scales, visual analog scale scores, and questionnaires were used most commonly. The Global Rating Scale was validated for use in 2 studies, confirming that those domains cover all aspects of endoscopy experience. Other measures were modified to assess endoscopic experience, such as the modified Group Health Association of America survey (mGHAA-9) (modified by 5 studies). CONCLUSIONS: No patient-derived and validated endoscopy-specific experience measures were found. Patient-derived and validated experience measures should be developed and used to model optimal healthcare delivery.

Implementing a national flexible sigmoidoscopy screening program: results of the English early pilot.

BACKGROUND AND STUDY AIMS: Following the results of a major UK study showing that once-only flexible sigmoidoscopy (FSIG) screening significantly reduced colorectal cancer (CRC) incidence and mortality, an FSIG screening program in England was announced in late 2010. Three "early pilot" sites were selected in 2011 in Derby, South of Tyne, and Tees to assess the practicalities of the delivery of FSIG screening. PARTICIPANTS AND METHODS: Eligible people aged 55 from selected practices in the three early pilot areas received postal invitations to participate. The South of Tyne and Derby sites employed interactive models of screening invitation, while Tees used a simple invitation. Data were collected to assess uptake, process, and outcome. A self-completion participant satisfaction questionnaire was sent to all participants 1 month after attendance. RESULTS: A total of 4023 55-year-olds were invited to participate. Uptake was 29 %, with 1151 people screened over a 3-month period. Screening uptake differed by method of invitation: a simple approach was significantly more successful than an interactive one (32 % vs. 27 %, P = 0.0015). Uptake decreased significantly with increasing deprivation. Adenomas were found in 111 (9.8 %) of those screened and cancer in two. The procedure was rated "very" or "fairly" acceptable by 97 % of participants. Over 90 % of respondents said they would participate in future cancer screening and a similar proportion would recommend doing so to others. CONCLUSION: Delivery of an FSIG screening program to prevent CRC is feasible and should be implemented using a simple invitation system. The national Bowel Scope program subsequently commenced at pilot sites in May 2013, with full implementation planned by 2016.

Factors affecting adenoma detection rate in a national flexible sigmoidoscopy screening programme: a retrospective analysis.

BACKGROUND: A national colorectal cancer screening programme started in England in 2013, offering one-off flexible sigmoidoscopy to all men and women aged 55 years in addition to the biennial faecal occult blood testing programme offered to all individuals aged 60-74 years. We analysed data from six pilot flexible sigmoidoscopy screening centres to examine factors affecting the adenoma detection rate (ADR). METHODS: We did a retrospective analysis of flexible sigmoidoscopy screening procedures performed in individuals aged 55 years at six pilot sites in England as part of the National Health Service Bowel Scope Screening programme. ADR (number of procedures in which at least one adenoma was removed or biopsied, divided by total number of procedures) was calculated for each site and each endoscopist. Multiple regression models were used to examine the variation in ADR with withdrawal time and extent of examination, and the effect of other factors including comfort and bowel preparation on extent of examination. FINDINGS: The analysis included 8256 procedures done between May 7, 2013, and May 6, 2014. The overall ADR was 9·1% (95% CI 8·5-9·8; 755 of 8256 procedures), varying from 7·4% (6·2-8·9) to 11·0% (9·1-13·4) by screening centre. The ADR was 11·5% (95% CI 10·6-12·5; 493 of 4299 procedures) in men and 6·6% (5·9-7·4; 262 of 3957 procedures) in women (p<0·0001). On multivariate analysis, factors associated with adenoma detection were male sex (relative risk 1·69, 95% CI 1·46-1·95; p<0·0001) and a withdrawal time from the splenic flexure of at least 3·25 min in negative procedures (1·22, 1·00-1·48; p=0·045). However, increasing the withdrawal time to 4·0 min or more did not increase the likelihood of adenoma detection (1·22, 0·99-1·51; p=0·057). Procedures not reaching the splenic flexure were associated with lower chance of adenoma detection (eg, 0·77, 0·66-0·91; p=0·0015 for procedures reaching the descending colon), but there was no additional benefit associated with reaching the transverse colon (0·83, 0·67-1·02; p=0·069). Women (0·83, 0·80-0·87; p<0·0001), individuals with adequate (0·79, 0·76-0·83; p<0·0001) or poor (0·58, 0·51-0·67; p<0·0001) bowel preparation (compared with good bowel preparation), and those with mild (0·82, 0·76-0·88; p<0·0001) or moderate or severe (0·58, 0·51-0·66; p<0·0001) discomfort (compared with no discomfort) were less likely to have a procedure reaching the splenic flexure. INTERPRETATION: Key performance indicators for flexible sigmoidoscopy screening should be defined, including standards for insertion and withdrawal times, optimal depth, and bowel preparation. ADR could be improved by recommending a withdrawal time from the splenic flexure of at least 3·25 min (ideally 3·5-4·0 min). FUNDING: None.

Colorectal Cancer Screening-Who, How, and When?

Colorectal cancer (CRC) is the third most common cancer worldwide. It is amenable to screening as it occurs in premalignant, latent, early, and curable stages. PubMed, Cochrane Database of Systematic Reviews, and national and international CRC screening guidelines were searched for CRC screening methods, populations, and timing. CRC screening can use direct or indirect tests, delivered opportunistically or via organized programs. Most CRCs are diagnosed after 60 years of age; most screening programs apply to individuals 50-75 years of age. Screening may reduce disease-specific mortality by detecting CRC in earlier stages, and CRC incidence by detecting premalignant polyps, which can subsequently be removed. In randomized controlled trials (RCTs) guaiac fecal occult blood testing (gFOBt) was found to reduce CRC mortality by 13%-33%. Fecal immunochemical testing (FIT) has no RCT data comparing it to no screening, but is superior to gFOBt. Flexible sigmoidoscopy (FS) trials demonstrated an 18% reduction in CRC incidence and a 28% reduction in CRC mortality. Currently, RCT evidence for colonoscopy screening is scarce. Although not yet corroborated by RCTs, it is likely that colonoscopy is the best screening modality for an individual. From a population perspective, organized programs are superior to opportunistic screening. However, no nation can offer organized population-wide colonoscopy screening. Thus, organized programs using cheaper modalities, such as FS/FIT, can be tailored to budget and capacity.

The ADENOMA Study. Accuracy of Detection using Endocuff Vision™ Optimization of Mucosal Abnormalities: study protocol for randomized controlled trial.

BACKGROUND: Colonoscopy is the gold standard investigation for the diagnosis of bowel pathology and colorectal cancer screening. Adenoma detection rate is a marker of high quality colonoscopy and a high adenoma detection rate is associated with a lower incidence of interval cancers. Several technological advancements have been explored to improve adenoma detection rate. A new device called Endocuff Vision™ has been shown to improve adenoma detection rate in pilot studies. METHODS/DESIGN: This is a prospective, multicenter, randomized controlled trial comparing the adenoma detection rate in patients undergoing Endocuff Vision™-assisted colonoscopy with standard colonoscopy. All patients above 18 years of age referred for screening, surveillance, or diagnostic colonoscopy who are able to consent are invited to the study. Patients with absolute contraindications to colonoscopy, large bowel obstruction or pseudo-obstruction, colon cancer or polyposis syndromes, colonic strictures, severe diverticular segments, active colitis, anticoagulant therapy, or pregnancy are excluded. Patients are randomized according to site, age, sex, and bowel cancer screening status to receive Endocuff Vision™-assisted colonoscopy or standard colonoscopy on the day of procedure. Baseline data, colonoscopy, and polyp data including histology are collected. Nurse assessment of patient comfort and patient comfort questionnaires are completed post procedure. Patients are followed up at 21 days and complete a patient experience questionnaire. This study will take place across seven NHS Hospital Trusts: one in London and six within the Northern Region Endoscopy Group. A maximum of 10 colonoscopists per site will recruit a total of 1772 patients, with a maximum of four bowel screening colonoscopists permitted per site. DISCUSSION: This is the first trial to evaluate the adenoma detection rate of Endocuff Vision™ in all screening, surveillance, and diagnostic patient groups. This timely study will guide clinicians as to the role of Endocuff Vision™ in routine colonoscopy. STUDY REGISTRATION: ISRCTN11821044.

Surveillance colonoscopy in low-risk postpolypectomy patients: Is it necessary?

AIM: Patients who have had colorectal adenomas removed are at increased risk of developing colorectal cancer in the future. We sought to determine whether surveillance colonoscopy at 5 years in low-risk postpolypectomy patients is necessary and effective. METHOD: UK multicentre retrospective study. Patients diagnosed with 'low-risk' colorectal adenomas between April 2004 and April 2007 were identified and results of all subsequent lower gastrointestinal (GI) endoscopies were noted. Where no colonoscopy had been done at or after 5 years from the index investigation, patient details were cross-checked against hospital colorectal multidisciplinary team databases to ensure no colorectal cancer had been detected in the meantime. RESULTS: 641 patients were included. 131 patients (20.4%) had a 'per protocol' surveillance colonoscopy at 5 years. Of these, no patients were found to have colorectal cancer, 10 patients (7.6%) had advanced adenomas, 26 patients (19.8%) had non-advanced adenomas and 95 patients (72.5%) had no further adenomas. 510 patients (79.6%) did not have a surveillance colonoscopy at 5 years. Of these, 110 patients (17.2%) developed lower GI symptoms within 5 years of their index endoscopy and underwent a further lower GI endoscopy to investigate these symptoms. 3 colorectal cancers in 3 patients were found during these endoscopies and two further colorectal cancers were found at symptomatic colonoscopies at or after 5 years from index. CONCLUSIONS: Patients with low-risk adenomas should be risk profiled. Those with risk factors, such as two adenomas, male sex and advanced adenomas at index procedure should be offered 5-year surveillance colonoscopy.

Terminal ileal intubation and biopsy in routine colonoscopy practice.

This special report focuses on the current literature regarding the utility of terminal ileal (TI) intubation and biopsy. The authors reviewed the literature regarding the clinical benefit of TI intubation at the time of colonoscopy and also the evidence for TI intubation as a colonoscopy quality indicator. TI intubation is useful to identify ileal diseases such as Crohn's disease and additionally as a means of confirming colonoscopy completion when classical caecal landmarks are not confidently seen. Previous studies have demonstrated that TI intubation has variable yield but may be more useful in patients presenting with diarrhea. Reported rates of TI intubation at colonoscopy vary. The authors demonstrate that terminal ileoscopy is feasible in clinical practice and sometimes yields additional clinical information. Additionally it may be used as an indicator of colonoscopy completion. It may be particularly helpful when investigating patients with diarrhea, abnormalities seen on other imaging modalities and patients with suspected Crohn's disease. TIs reported as normal at endoscopy have a low yield when biopsied; however, biopsies from abnormal-looking TIs demonstrate a higher yield and have greater diagnostic value.

Ketamine as a possible cause of cirrhosis in a patient with chronic pain.

Ketamine has been typically administered in short-term, few doses in the clinical setting of acute pain. Its hallucinogenic side effects have made it popular as a recreational drug. Reports of urological, biliary and liver abnormalities have been reported, mainly in cases of abuse. It is now increasingly used for chronic pain conditions, and here we report liver abnormalities and ultimately cirrhosis in an adult on regular ketamine for chronic facial pain. Abnormal liver function tests were detected incidentally, and with no other cause for liver disease found, liver biopsy was performed. This showed fibrosis with incomplete cirrhosis.

Non-neoplastic findings at colonoscopy after positive faecal occult blood testing: data from the English Bowel Cancer Screening Programme.

BACKGROUND: The aim of the English Bowel Cancer Screening Programme (BCSP) is to diagnose early colorectal cancer and advanced adenomas. However, other findings are also reported at screening colonoscopy. Small studies demonstrate findings other than cancer or adenomas (non-neoplastic findings (NNF)) in 11-25%. OBJECTIVES AND SETTING: Describe the frequency and nature of NNF within the BSCP. METHODS: Data were obtained from the BCSP national database for all individuals undergoing colonoscopic investigation after positive faecal occult blood testing between August 2006 and November 2011. Data included demographics, smoking status, neoplastic findings and NNF. RESULTS: 121728 colonoscopies were analysed. ≥1 NNF were found in 26251 cases (21.6%). Diverticular disease (18875 cases) and haemorrhoids (7011) were the most frequently reported. Inflammatory bowel disease (IBD) was reported in 2152 cases. Individuals with a neoplastic diagnosis were less likely to have an NNF than those without (19.8% v 24.4%, p < 0.001). After adjustment for confounding using multivariable analysis, older age was still associated with a small but statistically significant risk of NNF. CONCLUSIONS: The BCSP generates a significant volume of NNF. A small proportion of individuals were found to have inflammatory bowel disease (IBD) - an important diagnosis with implications for long-term management. BCSP participants should be aware that findings other than neoplasia may be detected and the relevance of these findings to that individual is not known. Reporting of NNF varies between colonoscopists, and potential underreporting is a limitation of this study. Further study is required to establish the impact of NNF on primary and secondary care.

The National Health Service Bowel Cancer Screening Program: the early years.

The National Health Service Bowel Cancer Screening Program (NHS BCSP) was developed to improve outcomes from colorectal cancer, the third most frequent cancer and the second highest cause of cancer deaths in the UK. Screening pilot programs were developed after previous trials demonstrated a reduction in mortality with the use of fecal occult blood population screening. A successful pilot period led to the roll out of national biennial screening for all 60-69 year olds in 2006, and extended to 60-74 year olds in 2010. To the end of 2012, there have been over 16 million invitations to screening, with uptake of 55.35%. FOBt positivity was 2.08%. Almost 15,000 cancers have been identified; screen-detected cancers have been shown to be at an earlier stage than non-screen-detected, with 35% Dukes' stage A. The BCSP provides high quality colonoscopy with low adverse events rates. It is also a rich data source for research.

Review of the use of intralesional steroid injections in the management of ileocolonic Crohn's strictures.

Most patients with Crohn's disease present with either terminal ileal or colonic disease, with 70% requiring surgery by 10 years after diagnosis. Recurrent stricturing at the anastomotic site is common, often symptomatic and can require re-operation with its inherent risks. Balloon dilation has been shown to provide good symptom relief from such strictures. However, repeat dilations may be required, and further surgical intervention to an anastomotic stricture is needed in up to 30% of cases. Injection of corticosteroids has been suggested as an adjunct to dilation in order to improve outcomes. This paper reviews the current literature on the use of intralesional steroid injections following endoscopic balloon dilation of anastomotic and de novo Crohn's strictures. There have been only two randomised placebo controlled trials and five small non-controlled or retrospective studies. Study numbers vary from 10 to 29 patients. The two randomised trials conflict in their conclusions and numbers are small in these studies. Currently therefore, no firm support can be given to the routine use of intralesional steroid injections.