Colorectal Cancer Screening Based on Age and Gender: A Cost-Effectiveness Analysis.

We evaluated whether age- and gender-based colorectal cancer screening is cost-effective.Recent studies in the United States identified age and gender as 2 important variables predicting advanced proximal neoplasia, and that women aged <60 to 70 years were more suited for sigmoidoscopy screening due to their low risk of proximal neoplasia. Yet, quantitative assessment of the incremental benefits, risks, and cost remains to be performed.Primary care screening practice (2008-2015).A Markov modeling was constructed using data from a screening cohort. The following strategies were compared according to the Incremental Cost Effectiveness Ratio (ICER) for 1 life-year saved: flexible sigmoidoscopy (FS) 5 yearly; colonoscopy 10 yearly; FS for each woman at 50- and 55-year old followed by colonoscopy at 60- and 70-year old; FS for each woman at 50-, 55-, 60-, and 65-year old followed by colonoscopy at 70-year old; FS for each woman at 50-, 55-, 60-, 65-, and 70-year old. All male subjects received colonoscopy at 50-, 60-, and 70-year old under strategies 3 to 5.From a hypothetical population of 100,000 asymptomatic subjects, strategy 2 could save the largest number of life-years (4226 vs 2268 to 3841 by other strategies). When compared with no screening, strategy 5 had the lowest ICER (US$42,515), followed by strategy 3 (US$43,517), strategy 2 (US$43,739), strategy 4 (US$47,710), and strategy 1 (US$56,510). Strategy 2 leads to the highest number of bleeding and perforations, and required a prohibitive number of colonoscopy procedures. Strategy 5 remains the most cost-effective when assessed with a wide range of deterministic sensitivity analyses around the base case.From the cost effectiveness analysis, FS for women and colonoscopy for men represent an economically favorable screening strategy. These findings could inform physicians and policy-makers in triaging eligible subjects for risk-based screening, especially in countries with limited colonoscopic resources. Future research should study the acceptability, feasibility, and feasibility of this risk-based strategy in different populations.

Screening strategies for colorectal cancer among patients with nonalcoholic fatty liver disease and family history.

Patients with nonalcoholic fatty liver disease (NAFLD) and family history of colorectal cancer (CRC) are at higher risks but how they should be screened remains uncertain. Hence, we evaluated the cost-effectiveness of CRC screening among patients with NAFLD and family history by different strategies. A hypothetical population of 100,000 subjects aged 40-75 years receive: (i) yearly fecal immunochemical test (FIT) at 50 years; (ii) flexible sigmoidoscopy (FS) every 5 years at 50 years; (iii) colonoscopy 10 yearly at 50 years; (iv) colonoscopy 10 yearly at 50 years among those with family history/NAFLD and yearly FIT at 50 years among those without; (v) colonoscopy 10 yearly at 40 years among those with family history/NAFLD and yearly FIT at 50 years among those without and (vi) colonoscopy 10 yearly at 40 years among those with family history/NAFLD and colonoscopy 10 yearly at 50 years among those without. The incremental cost-effectiveness ratio (ICER) was studied by Markov modeling. It was found that colonoscopy, FS and FIT reduced incidence of CRC by 49.5, 26.3 and 23.6%, respectively. Using strategies 4, 5 and 6, the corresponding reduction in CRC incidence was 29.9, 30.9 and 69.3% for family history, and 33.2, 34.7 and 69.8% for NAFLD. Compared with no screening, strategies 4 (US$1,018/life-year saved) and 5 (US$7,485) for family history offered the lowest ICER, whilst strategy 4 (US$5,877) for NAFLD was the most cost-effective. These findings were robust when assessed with a wide range of deterministic sensitivity analyses around the base case. These indicated that screening patients with family history or NAFLD by colonoscopy at 50 years was economically favorable.

Laparoscopic colorectal fellowship training programme : a 6-year experience in a university colorectal unit.

BACKGROUND: The aim of this study was to evaluate a structured training programme for laparoscopic colorectal surgery in a university colorectal unit over a 6-year period. METHODS: Data on patients who underwent laparoscopic colectomy between November 2004 and October 2010 were analyzed. Operations were performed either by the consultant colorectal surgeons or colorectal fellows. The effectiveness and safety of our structured training programme were evaluated. RESULTS: During the study period, 813 patients (478 men) with a median age 69 years (range 22-93) underwent laparoscopic colectomy. A total of 370 cases (45.5 %) were performed by four colorectal fellows. Overall, 674 patients (82.9 %) were classified as ASA I or II. The conversion rate was 3.7 %. The conversion rate, intra-operative blood loss, number of lymph nodes retrieved and post-operative recovery were similar between the two groups. When comparing with consultant group, the patients operated by fellows were: (1) significantly older; (2) more were operated on as emergency cases; (3) had pathologically less advanced tumours; (4) less patients with low rectal cancers. There were two surgical mortalities in this series. The morbidities between the two groups were similar. At the end of 3 years of training, the fellows had performed more than 85 cases of laparoscopic colectomies. The level of supervision decreased with increased experience. Finally, experienced fellows were able to supervise more junior colleagues on laparoscopic colectomies. CONCLUSIONS: Our results confirmed a structured training programme for laparoscopic colectomy is safe and effective. Reasonable results were achieved even though a high volume of cases were performed by surgical fellows.

Changes in the choice of colorectal cancer screening tests in primary care settings from 7,845 prospectively collected surveys.

PURPOSE: Colorectal cancer (CRC) is one of the leading causes of cancer mortality worldwide. This study examined factors influencing the choice of participants between colonoscopy and fecal immunochemical test (FIT) in a screening program and the impact of an unbiased educational session on influencing this decision. METHODS: Data from 7,845 participants who underwent screening between May 2008 and April 2011 was analyzed. Binary logistic regression and multinomial regression were performed to calculate the odds of selection of colonoscopy instead of FIT and the impact of the educational session on final participant choice, respectively. RESULTS: Of the 7,845 participants, 4,796 (61 %) underwent FIT and 3,049 (39 %) underwent colonoscopy. A significant number of participants changed their initial choice after the educational session, with 27.1 % changing to FIT from colonoscopy and 8 % changing from FIT to colonoscopy. Age, educational level, occupation, income, family history of CRC, perception of risk of CRC, and perceptions regarding CRC screening were significantly different among the groups choosing FIT and colonoscopy. Family history of CRC and high self-perception of CRC risk resulted in higher odds of choosing colonoscopy, whereas older age, single marital status, and negative perception of CRC screening resulted in lower odds. Perceptions of overall health status, occupation, low income, younger age, and negative perceptions of CRC screening were associated with higher odds of change in screening choice. CONCLUSIONS: Those at higher odds of changing CRC screening options should be supported with more detailed explanations by primary care physicians to secure a more informed and considered choice.

Digestive cancer management in Asia: position statements: a report on GI Oncology Summit in 2011.

BACKGROUND AND AIM: With the rising incidence of digestive cancers in the Asia Pacific region and the advancement in diagnosis, management and palliation in these conditions, the clinical burden on oncologists is ever increasing. This Summit meeting was called to discuss the optimal management of digestive cancers and the role of Gastroenterologists. METHOD: Experts from Asia Pacific countries in the fields of medical, oncologic, surgical and endoscopic management of cancers in the esophagus, stomach, colon/rectum and the liver reviewed the literature and their practice. 18 position statements were drafted, debated and voted. RESULTS: It was agreed that the burden on GI cancer is increasing. More research will be warranted on chemotherapy, chemoprevention, cost-effectiveness of treatment and nutrition. Cancer management guidelines should be developed in this region when more clinical data are available. In order to improve care to patients, a multi-disciplinary team coordinated by a "cancer therapist" is proposed. This cancer therapist can be a gastroenterologist, a surgeon or any related discipline who have acquired core competence training. This training should include an attachment in a center-of-excellence in cancer management for no less than 12 months. CONCLUSION: The management of GI cancer should be an integrated multi-disciplinary approach and training for GI cancer therapists should be provided for.

The learning curve for laparoscopic colectomy: experience of a surgical fellow in an university colorectal unit.

BACKGROUND: This study aimed to evaluate the learning curve for laparoscopic colectomy of a surgical fellow in an university colorectal unit using a structured training protocol. METHODS: This study analyzed the data from 100 consecutive patients who had laparoscopic colectomy performed by a surgical fellow between 11/2004 and 12/2007. The structured training protocol required the fellow to assist more than 40 laparoscopic colectomies before embarking on his first case. Rectosigmoidectomy was prioritized during the initial experience. Operative times were analyzed to represent the learning curve. Other outcome data including conversion and operative outcome were also evaluated. RESULTS: The following procedures were performed: 49 rectosigmoidectomies, 38 right colon resections, and 13 other resections. Median operative time was 150 min, and conversion rate was 1%. Overall postoperative morbidity rate was 28% (major morbidity 3%). Three patients required early reoperation. There was no operative death. Median hospital stay was 8 days. Operative times reached their lowest point at period of cases 45-50, and remained relatively stable afterwards. Comparing the first 50 and second 50 cases, the only difference observed was more frequent presence of a supervisor in the theater in the first 50 cases (74% versus 52%, p = 0.02), while the other parameters including types of procedures, postoperative recovery, hospital stay, and morbidity rate were not different. CONCLUSIONS: Our results indicated that laparoscopic colectomy training can be safely performed under a structured protocol. The surgeon can perform laparoscopic colectomies more independently after 50 cases, without jeopardizing the clinical outcome.