Evaluating the Cost-Effective Use of Follow-Up Colonoscopy Based on Screening Findings and Age.

INTRODUCTION: Colorectal cancer (CRC), if not detected early, can be costly and detrimental to one's health. Colonoscopy can identify CRC early as well as prevent the disease. The benefit of screening colonoscopy has been established, but the optimal frequency of follow-up colonoscopy is unknown and may vary based on findings from colonoscopy screening and patient age. METHODS: A partially observed Markov process (POMP) was used to simulate the effects of follow-up colonoscopy on the development of CRC. The POMP uses adenoma and CRC growth models to calculate the probability of a patient having colorectal adenomas and CRC. Then, based on mortality, quality of life, and the costs associated with diagnosis, treatment, and surveillance of colorectal cancer, the overall costs and increase in quality-adjusted life years (QALYs) are calculated for follow-up colonoscopy scenarios. RESULTS: At the $100,000/QALY gained threshold, only one follow-up colonoscopy is cost-effective only after screening at age 50 years. The optimal follow-up is 8.5 years, which gives 84.0 QALYs gained/10,000 persons. No follow-up colonoscopy was cost-effective at the $50,000 and $75,000/QALY gained thresholds. The intervals were insensitive to the findings at screening colonoscopy. CONCLUSION: Follow-up colonoscopy is cost-effective following screening at age 50 years but not if screening occurs later. Following screening at age 50 years, the optimal follow-up interval is close to the currently recommended 10 years for an average risk screening but does not vary by colonoscopy result.

Assessment of sFRP4 as a bio-marker for predicting aggressiveness and recurrence of growth hormone-secreting pituitary adenomas.

The association of sFRP4 expression with aggressiveness and recurrence of growth hormone (GH)-secreting pituitary adenomas was investigated. Ten normal pituitary and 52 GH-secreting pituitary adenoma specimens were classified into three groups: normal pituitary (control) group, non-aggressive group, and aggressive group, according to preoperative evaluation by magnetic resonance imaging (MRI)/computed tomography (CT). Expression of sFRP4 was determined by quantitative real-time polymerase chain reaction (qRT-PCR), western blot analysis, and tissue microarrays, to assess the association between sFRP4 and aggressiveness. Follow-up information of all 52 patients was collected to evaluate the impact of sFRP4 expression on the recurrence/progression of GH-secreting pituitary adenomas. qRT-PCR results showed a lower level of sFRP4 mRNA in the aggressive group, as compared to that in the non-aggressive group (P=0.001). A similar trend was observed on western blot analysis for sFRP4 protein expression (P=0.004). On analysis by tissue microarrays, weak sFRP4 expression was detected in the aggressive group (10/15, 66.7%). Univariate analysis showed a significant relationship between low sFRP4 expression and aggressiveness (P=0.024). On multivariate analysis weak sFRP4 expression was found to be an independent factor of recurrence/progression (odds ratio: 0.063, P=0.026). Methylation of the sFRP4 promoter was increased in low sFRP4 staining group compared to that in the high sFRP4 staining group (P<0.001). In this study, weak sFRP4 expression appeared to predict aggressive behavior, and was associated with recurrence/progression of GH-secreting pituitary adenomas. Methylation of the sFRP4 promoter may account for the low sFRP4 expression.

Disparities in cervical cancer survival among Asian-American women.

PURPOSE: We compared overall survival and influencing factors between Asian-American women as a whole and by subgroup with white women with cervical cancer. METHODS: Cervical cancer data were from the Surveillance, Epidemiology, and End Results registry; socioeconomic information was from the Area Health Resource File. We used standard tests to compare characteristics between groups; the Kaplan-Meier method with log-rank test to assess overall survival and compare it between groups; and Cox proportional hazards models to determine the effect of race and other covariates on overall survival (with and/or without age stratification). RESULTS: Being 3.3 years older than white women at diagnosis (P < .001), Asian-American women were more likely to be in a spousal relationship, had more progressive disease, and were better off socioeconomically. Women of Filipino, Japanese, and Korean origin had similar clinical characteristics compared to white women. Asian-American women had higher 36- and 60-month survival rates (P = .004 and P = .013, respectively), higher overall survival rates (P = .049), and longer overall survival durations after adjusting for age and other covariates (hazard ratio = 0.77, 95% confidence interval: 0.68-0.86). Overall survival differed across age strata between the two racial groups. With the exception of women of Japanese or Korean origin, Asian-American women grouped by geographic origin had better overall survival than white women. CONCLUSIONS: Although Asian-American women, except those of Japanese or Korean origin, had better overall survival than white women, their older age at cervical cancer diagnosis suggests that they have less access to screening programs.

Combination aspirin and/or calcium chemoprevention with colonoscopy in colorectal cancer prevention: cost-effectiveness analyses.

BACKGROUND: Clinical and cohort studies have shown that low-dose aspirin and calcium are effective low-risk strategies for primary prevention of colorectal cancer (CRC). We compared the cost-effectiveness of aspirin and calcium chemoprevention used with colonoscopy for primary prevention of CRCs. METHODS: Markov chain Monte Carlo simulations for a population of 100,000 persons, with a colonoscopy compliance rate of 50%, were used for the analysis. If adenomas were detected, colonoscopy was repeated every 4 years until no adenomas were evident. Data sources included adenoma transition rates, initial adenoma and CRC incidences, and treatment complication rates from existing literature. Age-adjusted U.S. standard population mortality rates were used and costs were from Medicare reimbursement data. The target population was U.S. adults, undergoing CRC screening from ages 50 to 75 years. RESULTS: Outcomes included incremental cost-effectiveness ratios (ICER), life-years saved (LYS), and cancer-free years saved (CFYS). The ICER per LYS for colonoscopy alone dominated compared with no screening. Compared with colonoscopy alone, colonoscopies with aspirin (ICER = $12,950/LYS) or calcium (ICER = $13,041/LYS) were the next most cost-effective strategies. ICERs per CFYS were $3,061 and $2,317 for aspirin and calcium, respectively, when added to colonoscopy. Sensitivity analyses indicated that initial prevalence of adenomas was a main determinant of prevention cost-effectiveness. CONCLUSION: Low-dose aspirin or calcium supplementation may be beneficial when added to colonoscopy, for optimum CRC prevention, at small incremental costs. IMPACT: Cost-effectiveness analyses suggest that aspirin and calcium in combination with colonoscopies are cost-effective for CRC prevention in average-risk populations.

Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study).

OBJECTIVE: To investigate which perioperative treatment, ie, laparoscopic or open surgery combined with fast track (FT) or standard care, is the optimal approach for patients undergoing segmental resection for colon cancer. SUMMARY BACKGROUND DATA: Important developments in elective colorectal surgery are the introduction of laparoscopy and implementation of FT care, both focusing on faster recovery. METHODS: In a 9-center trial, patients eligible for segmental colectomy were randomized to laparoscopic or open colectomy, and to FT or standard care, resulting in 4 treatment groups. Primary outcome was total postoperative hospital stay (THS). Secondary outcomes were postoperative hospital stay (PHS), morbidity, reoperation rate, readmission rate, in-hospital mortality, quality of life at 2 and 4 weeks, patient satisfaction and in-hospital costs. Four hundred patients were required to find a minimum difference of 1 day in hospital stay. RESULTS: Median THS in the laparoscopic/FT group was 5 (interquar-tile range: 4-8) days; open/FT 7 (5-11) days; laparoscopic/standard 6 (4.5-9.5) days, and open/standard 7 (6-13) days (P < 0.001). Median PHS in the laparoscopic/FT group was 5 (4-7) days; open/FT 6 (4.5-10) days; laparoscopic/standard 6 (4-8.5) days and open/standard 7 (6-10.5) days (P < 0.001). Secondary outcomes did not differ significantly among the groups. Regression analysis showed that laparoscopy was the only independent predictive factor to reduce hospital stay and morbidity. CONCLUSIONS: Optimal perioperative treatment for patients requiring segmental colectomy for colon cancer is laparoscopic resection embedded in a FT program. If open surgery is applied, it is preferentially done in FT care. This study was registered under NTR222 (www.trialregister.nl).

Follow-up after colorectal polypectomy: a benefit-risk analysis of German surveillance recommendations.

OBJECTIVE: For colorectal screening patients a mean gain of life time was previously calculated of about 30-50 days. Different recommendations for recognising at-risk groups and defining surveillance intervals after an initial finding of colorectal adenomas have been published. However, no benefit-risk analysis regarding to specific long-term effects of follow-up has been reported to date. MATERIALS AND METHODS: A Markov model based on time-dependent transition possibilities was developed to perform a benefit-risk analysis of the risk-related surveillance recommendations based on the Erlangen Registry of Colorectal Polyps (ERCRP) in comparison with the recommendation of the German Society of Gastrointestinal Diseases and Nutrition (DGVS). The outcome was calculated for a 50-year-old patient with 30 years of follow-up after initial polypectomy. The data used in this model were taken from different sources, namely the ERCRP, the German Study Group of Colorectal Cancer, the German Statistical Yearbook, and from meta-analyses of studies reporting data on complications and sensitivity of colonoscopy. RESULTS: Patients under surveillance have a mean lifetime gain of 98 (ERCRP) and 110 (DGVS) days compared with those who do not come for surveillance. 84% and 94% of deaths from colorectal carcinoma (CRC) could be prevented if patients were followed up according to the recommendations of the ERCRP and the DGVS, respectively. Less colonoscopies are needed to prevent one death from CRC following the recommendations of the ERCRP (221) than those of the DGVS (283). The risk of death due to colonoscopy for patients during follow-up is about 0.05% lifetime risk. Sensitivity analysis showed the stability of the results under a wide range of reasonable variations of relevant parameters. In a pessimistic one-way sensitivity analysis regarding compliance, effectiveness was reduced to one third. CONCLUSION: Surveillance using colonoscopy is an effective tool for preventing CRC after colorectal polypectomy, especially if a good compliance is assumed. The effectiveness is higher following the recommendations of the DGVS, but more colonoscopies are needed.

[Comparative assessment of the results of different surgical treatments in patients with pituitary adenomas infiltrating the cavernous sinus]. / Sravnitel'naia otsenka rezul'tatov khirurgicheskogo lecheniia patsientov s adenomami gipofiza, infil'triruiushchimi kavernoznyi sinus, s primeneniem razlichnykh khirurgicheskikh metodik.

Benign pituitary tumors or adenomas are highly common, occasionally inclined to infiltrate the adjacent structures, the cavernous sinus in particular. Despite the fact that drug and radiation therapy are at present widely used treatments, surgical procedures remain highly topical. Different modifications of two basic surgical methods (transcranial intradural and transsphenoidal) that fail to completely remove a tumor from the cavernous sinus in most cases are mostly frequently used as before. Attempts to improve surgical procedures and introduction of current technologies have led to the emergence of an extradural method for tumor removal from the cavernous sinus and to the introduction of endoscopic monitoring during transsphenoidal operations. A strategy of two-stage removal of pituitary tumors has simultaneously been developed. The paper presents the results of surgical treatment of 297 patients with pituitary adenomas growing into the cavernous sinus, by using currently available procedures: transsphenoidal, transcranial intradural, and intra-extradural, and two-stage ones. The findings have confirmed that transsphenoidal removal of pituitary adenomas is the safest method. However, this method has a number of limitations in cases with tumor being grown into the cavernous sinus especially when there is a medial displacement of the intracavernous segment of the internal carotid artery. Moreover, secondary tumor nodes that may be removed by transcranial intradural access are a contraindication to its use. With this, attempts to remove a tumor from the cavernous sinus fail to ensure the desired completeness of removal from the cavernous sinus. The application of an intra-extradural access is the most adequate procedure for tumor removal from the cavernous sinus. The two-stage removal is the most adequate procedure in cases of simultaneously significant spread of a tumor intracranially and into the structures of the base of the skull.

Transsphenoidal microsurgical treatment of Cushing disease: postoperative assessment of surgical efficacy by application of an overnight low-dose dexamethasone suppression test.

OBJECT: Transsphenoidal adenomectomy with resection of a defined pituitary adenoma has been the treatment of choice for CD for the last 30 years. Surgical resection, however, may not always result in long-term remission of CD. This is particularly important in light of the high risk of morbidity and mortality in patients in the unsuccessfully treated cushingoid state. As such, it is interesting to identify prognostic factors that may predict the likelihood of long-term remission. METHODS: The authors review their series of 174 patients who have undergone transsphenoidal procedures for CD over a period of 20 years with minimum follow-up periods of 5 years. Selection of these patients was based on clinical, imaging, and laboratory criteria that included serum cortisol levels, loss of diurnal variation in serum cortisol levels, urinary free cortisol concentration, and results of a dexamethasone suppression test, petrosal sinus sampling, and corticotroph-releasing hormone stimulation tests as indicated. All patients who met the biochemical criteria underwent transsphenoidal microsurgery. The authors found an overall rate of remission of 74% at 5 years postoperatively. Patients in whom morning serum cortisol concentrations were lower than 3 microg/dl (83 nmol/L) on postoperative Day 3, following an overnight dexamethasone suppression test, had a 93% chance of remission at the 5-year follow-up examination. Patients with cortisol concentrations higher than this level uniformly failed to achieve long-term remission. CONCLUSIONS: Transsphenoidal microsurgery is an effective means of control for patients with adrenocorticotrophic hormone-producing microadenomas. Clinical outcome correlated well with the size of the tumor, as measured on preoperative imaging studies, and with postoperative morning cortisol levels following an overnight dexamethasone suppression test. Postoperative cortisol levels can be used as a useful prognostic indicator of the likelihood of future recurrence following transsphenoidal adenomectomy in CD.

Bronchogenic carcinoma and coexistent bronchioloalveolar cell adenomas. Assessment of radiologic detection and follow-up in 28 patients.

PURPOSE: Bronchioloalveolar cell adenomas (BAAs) have been described in up to 10% of patients with bronchogenic carcinoma. Their prognostic significance is unknown. The purpose of this study was to determine the prognostic implications of finding BAAs coexisting in specimens resected for primary bronchogenic carcinoma and to determine how frequently BAAs can be detected radiologically. METHODS: Follow-up information for a mean of 30 months was obtained on 28 patients with a single primary bronchogenic carcinoma and one or more coexistent BAAs. Preoperative chest radiographs (n=27) and CT scans (n=24) were retrospectively reviewed to assess the number of patients in whom BAAs could be detected radiologically. RESULTS: There was no significant difference between percentage survival of patients with a primary bronchogenic carcinoma and coexistent BAAs when compared with the percentage predicted survival of these patients based on their primary bronchogenic carcinoma alone. BAAs could be detected retrospectively in 1 of 27 (4%) preoperative radiographs and 11 of 24 (46%) CT scans. CONCLUSIONS: On standard preoperative imaging for bronchogenic carcinoma, BAAs were retrospectively detected in more than one third of patients in whom they were detected pathologically. However, the presence of coexistent BAAs with bronchogenic carcinoma does not affect short- and medium-term prognosis.