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This JAMA Patient Page describes Lynch syndrome, its risk factors and diagnosis, and its association with colorectal cancer and other specific cancers.
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Neoplasias Colorrectales Hereditarias sin Poliposis , Neoplasias Colorrectales Hereditarias sin Poliposis/genética , Neoplasias Colorrectales Hereditarias sin Poliposis/diagnóstico , HumanosRESUMEN
Importance: Early-onset colorectal cancer (EOCRC), defined as a diagnosis at younger than age 50 years, is increasing, and so-called red flag signs and symptoms among these individuals are often missed, leading to diagnostic delays. Improved recognition of presenting signs and symptoms associated with EOCRC could facilitate more timely diagnosis and impact clinical outcomes. Objective: To report the frequency of presenting red flag signs and symptoms among individuals with EOCRC, to examine their association with EOCRC risk, and to measure variation in time to diagnosis from sign or symptom presentation. Data Sources: PubMed/MEDLINE, Embase, CINAHL, and Web of Science were searched from database inception through May 2023. Study Selection: Studies that reported on sign and symptom presentation or time from sign and symptom presentation to diagnosis for patients younger than age 50 years diagnosed with nonhereditary CRC were included. Data Extraction and Synthesis: Data extraction and quality assessment were performed independently in duplicate for all included studies using Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guidelines. Joanna Briggs Institute Critical Appraisal tools were used to measure risk of bias. Data on frequency of signs and symptoms were pooled using a random-effects model. Main Outcomes and Measures: Outcomes of interest were pooled proportions of signs and symptoms in patients with EOCRC, estimates for association of signs and symptoms with EOCRC risk, and time from sign or symptom presentation to EOCRC diagnosis. Results: Of the 12â¯859 unique articles initially retrieved, 81 studies with 24â¯908â¯126 patients younger than 50 years were included. The most common presenting signs and symptoms, reported by 78 included studies, were hematochezia (pooled prevalence, 45% [95% CI, 40%-50%]), abdominal pain (pooled prevalence, 40% [95% CI, 35%-45%]), and altered bowel habits (pooled prevalence, 27% [95% CI, 22%-33%]). Hematochezia (estimate range, 5.2-54.0), abdominal pain (estimate range, 1.3-6.0), and anemia (estimate range, 2.1-10.8) were associated with higher EOCRC likelihood. Time from signs and symptoms presentation to EOCRC diagnosis was a mean (range) of 6.4 (1.8-13.7) months (23 studies) and a median (range) of 4 (2.0-8.7) months (16 studies). Conclusions and Relevance: In this systematic review and meta-analysis of patients with EOCRC, nearly half of individuals presented with hematochezia and abdominal pain and one-quarter with altered bowel habits. Hematochezia was associated with at least 5-fold increased EOCRC risk. Delays in diagnosis of 4 to 6 months were common. These findings highlight the need to identify concerning EOCRC signs and symptoms and complete timely diagnostic workup, particularly for individuals without an alternative diagnosis or sign or symptom resolution.
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Edad de Inicio , Neoplasias Colorrectales , Humanos , Neoplasias Colorrectales/diagnóstico , Neoplasias Colorrectales/epidemiología , Persona de Mediana Edad , Detección Precoz del Cáncer/métodos , Femenino , Adulto , Masculino , Diagnóstico Tardío/estadística & datos numéricosRESUMEN
BACKGROUND: Prompt detection of colorectal cancer (CRC) among individuals younger than age 50 years (early-onset CRC) is a clinical priority because of its alarming rise. METHODS: We conducted a matched case-control study of 5075 incident early-onset CRC among US commercial insurance beneficiaries (113 million adults aged 18-64 years) with 2 or more years of continuous enrollment (2006-2015) to identify red-flag signs and symptoms between 3 months to 2 years before the index date among 17 prespecified signs and symptoms. We assessed diagnostic intervals according to the presence of these signs and symptoms before and within 3 months of diagnosis. RESULTS: Between 3 months and 2 years before the index date, 4 red-flag signs and symptoms (abdominal pain, rectal bleeding, diarrhea, and iron deficiency anemia) were associated with an increased risk of early-onset CRC, with odds ratios (ORs) ranging from 1.34 to 5.13. Having 1, 2, or at least 3 of these signs and symptoms were associated with a 1.94-fold (95% confidence interval [CI] = 1.76 to 2.14), 3.59-fold (95% CI = 2.89 to 4.44), and 6.52-fold (95% CI = 3.78 to 11.23) risk (Ptrend < .001), respectively, with stronger associations for younger ages (Pinteraction < .001) and rectal cancer (Pheterogenity = .012). The number of different signs and symptoms was predictive of early-onset CRC beginning 18 months before diagnosis. Approximately 19.3% of patients had their first sign or symptom occur between 3 months and 2 years before diagnosis (median diagnostic interval = 8.7 months), and approximately 49.3% had the first sign or symptom within 3 months of diagnosis (median diagnostic interval = 0.53 month). CONCLUSIONS: Early recognition of red-flag signs and symptoms (abdominal pain, rectal bleeding, diarrhea, and iron-deficiency anemia) may improve early detection and timely diagnosis of early-onset CRC.
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Neoplasias Colorrectales , Adulto , Humanos , Estudios de Casos y Controles , Neoplasias Colorrectales/diagnóstico , Neoplasias Colorrectales/epidemiología , Neoplasias Colorrectales/complicaciones , Dolor Abdominal/complicaciones , Diarrea/etiología , Detección Precoz del CáncerRESUMEN
Racial microaggressions, racially based remarks, or actions that negatively impact marginalized physicians of color (Black, Latino/a/x, and American Indian/Alaskan Natives) often go unaddressed. This article provides four strategies for how individuals and institutions can engage in anti-racism allyship: (1) be an upstander during microaggressions, (2) be a sponsor and advocate for physicians of color, (3) acknowledge academic titles and accomplishments, and (4) challenge the idea of a "standard fit" for academic faculty and research. Skills in academic allyship should be taught to all physicians throughout the educational continuum to mitigate feelings of isolation that racialized minority physicians frequently experience.
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The benefits of breastmilk and lactation are well established for both infants and women. National organizations recommend exclusively breastfeeding for the first 6 months of life and continued breastfeeding for the first 1-2 years of life. For physicians, childbearing years often coincide with key periods of training and their early career. Physician mothers have high rates of initiating breastfeeding but low success in maintaining breastfeeding. Breastfeeding discontinuation among physicians is a well-described, multifactorial issue that has persisted for decades. Reasons for discontinuation include inadequate access to pumping rooms, insufficient workplace and coworker support, and constrained schedules. Pumping is viewed as a burden to teammates and superiors, and physicians are often required to make up time spent pumping. Vague or absent policies to support breastfeeding by accreditation organizations and institutions create workplace conflict and impose additional stress on breastfeeding physicians, who devote significant time, energy, and mental reserves navigating clinical responsibilities, workplace relationships, and licensing requirements to pump. The authors propose several recommendations to improve the environment, support, and resources for breastfeeding physicians with a focus on what individuals, institutions, and professional organizations can do. Creating lactation policies that allow breastfeeding physicians equitable participation in the workplace is a matter of reproductive justice. Improving the collective awareness and support for breastfeeding trainees and physicians is a critical step in recruiting, retaining, and supporting women in medicine.
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Lactancia Materna , Madres , Lactante , Humanos , Femenino , Lugar de Trabajo , Promoción de la SaludRESUMEN
Metabolic syndrome may contribute to the rising incidence of multiple gastrointestinal (GI) cancers in recent birth cohorts. However, other than hepatocellular carcinoma, the association between nonalcoholic fatty liver disease (NAFLD) and risk of non-liver GI cancers is unexplored. We prospectively examined the associations of NAFLD risk with GI cancers among 319,290 participants in the UK Biobank (2006-2019). Baseline risk for NAFLD was estimated using the Dallas Steatosis Index, a validated prediction tool. Multivariable Cox models were used to estimate relative risks (RRs) and 95% confidence intervals (CIs) according to NAFLD risk categories: low (<20%), intermediate (20%-49%), and high (≥50%). We also examined the associations by age of cancer diagnosis (earlier onset [<60] vs. ≥60). A total of 273 incident liver cancer and 4789 non-liver GI cancer cases were diagnosed. Compared with individuals at low risk for NAFLD, those at high risk had 2.41-fold risk of liver cancer (RR = 2.41, 95% CI: 1.73-3.35) and 23% increased risk of non-liver GI cancers (RR = 1.23, 95% CI: 1.14-1.32) (all ptrend < 0.001). Stronger associations were observed for men and individuals who were obese (all pinteraction < 0.05). NAFLD-associated elevated risk was stronger for earlier-onset cancers. For each 25% increase in NAFLD risk, the RRs for earlier-onset cancers were 1.32 (95% CI: 1.05-1.66) for esophageal cancer, 1.35 (95% CI: 1.06-1.72) for gastric cancer, 1.34 (95% CI: 1.09-1.65) for pancreatic cancer, and 1.10 (95% CI: 1.01-1.20) for colorectal cancer. Conclusion: NAFLD risk was associated with an increased risk of liver and most GI cancers, especially those of earlier onset.
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Neoplasias Gastrointestinales , Neoplasias Hepáticas , Síndrome Metabólico , Enfermedad del Hígado Graso no Alcohólico , Masculino , Humanos , Enfermedad del Hígado Graso no Alcohólico/complicaciones , Síndrome Metabólico/complicaciones , Incidencia , Neoplasias Hepáticas/epidemiología , Neoplasias Gastrointestinales/epidemiologíaRESUMEN
Amyloidosis is a heterogeneous disease that can cause a wide array of nonspecific symptoms when the gastrointestinal (GI) tract is involved, including weight loss, early satiety, change in bowel habits with diarrhea, constipation, or alternating bowel pattern. Endoscopy with biopsy for Congo red staining establishes the diagnosis and fibril subtyping helps to guide targeted treatment options. Light chain amyloidosis is the most frequent subtype found throughout the GI tract. Transthyretin amyloidosis is most likely to be found on rectal biopsy. Management of the symptoms of GI tract involvement with amyloidosis relate to addressing the underlying symptom complex that is produced and generally abstracted from the management of severe forms of functional GI disorders. Attention to improving symptom management and nutrition status can improve quality of life in these patients.
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Neuropatías Amiloides Familiares , Enfermedades Gastrointestinales , Neuropatías Amiloides Familiares/complicaciones , Neuropatías Amiloides Familiares/diagnóstico , Neuropatías Amiloides Familiares/terapia , Endoscopía Gastrointestinal , Enfermedades Gastrointestinales/diagnóstico , Enfermedades Gastrointestinales/etiología , Enfermedades Gastrointestinales/terapia , Humanos , Calidad de VidaRESUMEN
Background and Aims: Early-onset colorectal cancer (CRC) is increasing in many developed countries. Type 2 diabetes mellitus has increased substantially in younger adults; however, its role in early-onset CRC remains unidentified. Methods: We conducted a claims-based nested case-control study using IBM MarketScan Commercial Database (2006-2015). Incident early-onset CRC diagnosed at ages 18-49 was identified by the International Classification of Diseases, ninth Revision, Clinical Modification diagnosis code, and the first coded diagnostic pathology date was assigned as the index date. Controls were frequency matched with cases. Type 2 diabetes, stratified by severity, was identified through International Classification of Diseases, ninth Revision, Clinical Modification using the Klabunde algorithm. Multivariable logistic regressions were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). Results: A total of 6001 early-onset CRC and 52,104 controls were included. Type 2 diabetes was associated with an increased risk of early-onset CRC (5.0% in cases vs 3.7% in controls; OR = 1.24, 95% CI: 1.09-1.41). The positive association was more pronounced for uncontrolled (OR = 1.37; 95% CI: 1.12-1.67) or complicated (OR = 1.59, 95% CI: 1.08-2.35) type 2 diabetes compared with controlled diabetes (OR = 1.13, 95% CI: 0.94-1.36). Conclusion: Individuals with type 2 diabetes have a higher risk of early-onset CRC, with stronger associations for uncontrolled diabetes and complicated diabetes. The rising prevalence of type 2 diabetes among younger adults may partially contribute to the increasing incidence of early-onset CRC.
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Background and Aims: The impact of sociodemographic factors on outcomes in patients with ulcerative colitis (UC) is not well studied. We characterized the association of race/ethnicity and insurance status with procedures, length of stay (LOS), mortality, and cost of care in a cohort of hospitalized patients with UC. Methods: Data from the National Inpatient Sample from 2016 to 2018 were used. Outcomes were analyzed using generalized estimating equations. All models included age, sex, income quartile, hospital diagnosis, hospital characteristics, and Elixhauser Comorbidity Index as well as the primary predictors. Results: A total of 34,814 patients were included. Black (adjusted odds ratio [aOR] 0.46, 95% confidence interval [0.39-0.55]) or Hispanic (aOR 0.74, [0.64-0.86]) patients had lower odds of colectomy than White patients. Patients with Medicare (aOR 0.54, [0.48-0.62), Medicaid (aOR 0.51, [0.45-0.58]), or no insurance (aOR 0.42, [0.35-0.50]) had lower odds of colectomy than privately insured patients. Black patients had higher mortality than White patients (aOR 1.38, [1.07-1.78]). Patients with Medicare or Medicaid had 5% ([1.01-1.09]) and 9% longer LOS ([1.05-1.13]), respectively, than privately insured patients, while uninsured patients had a 6% shorter LOS ([0.90-0.97]). Hispanic or Asian/Native American patients had 11% ([1.06-1.15]) and 13% ([1.07-1.20]) higher costs, respectively, than White patients. Uninsured patients had 11% lower hospitalization costs than privately insured patients ([0.85-0.94]). Conclusion: Hospitalized patients with UC differed significantly in rates of colectomy, mortality, LOS, and costs based on race/ethnicity and insurance status. Further research is needed to understand the cause of these differences and develop targeted solutions to reduce these inequities.
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OBJECTIVE: Factors that lead to metabolic dysregulation are associated with increased risk of early-onset colorectal cancer (CRC diagnosed under age 50). However, the association between metabolic syndrome (MetS) and early-onset CRC remains unexamined. DESIGN: We conducted a nested case-control study among participants aged 18-64 in the IBM MarketScan Commercial Database (2006-2015). Incident CRC was identified using pathologist-coded International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, and controls were frequency matched. MetS was defined as presence of ≥3 conditions among obesity, hypertension, hyperlipidaemia and hyperglycaemia/type 2 diabetes, based on ICD-9-CM and use of medications. Multivariable logistic regressions were used to estimate ORs and 95% CIs. RESULTS: MetS was associated with increased risk of early-onset CRC (n=4673; multivariable adjusted OR 1.25; 95% CI 1.09 to 1.43), similar to CRC diagnosed at age 50-64 (n=14 928; OR 1.21; 95% CI 1.15 to 1.27). Compared with individuals without a metabolic comorbid condition, those with 1, 2 or ≥3 conditions had a 9% (1.09; 95% CI 1.00 to 1.17), 12% (1.12; 95% CI 1.01 to 1.24) and 31% (1.31; 95% CI 1.13 to 1.51) higher risk of early-onset CRC (ptrend <0.001). No associations were observed for one or two metabolic comorbid conditions and CRC diagnosed at age 50-64. These positive associations were driven by proximal (OR per condition 1.14; 95% CI 1.06 to 1.23) and distal colon cancer (OR 1.09; 95% CI 1.00 to 1.18), but not rectal cancer (OR 1.03; 95% CI 0.97 to 1.09). CONCLUSIONS: Metabolic dysregulation was associated with increased risk of early-onset CRC, driven by proximal and distal colon cancer, thus at least in part contribute to the rising incidence of early-onset CRC.
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Neoplasias del Colon/epidemiología , Síndrome Metabólico/epidemiología , Neoplasias del Recto/epidemiología , Adulto , Edad de Inicio , Estudios de Casos y Controles , Colon/patología , Comorbilidad , Bases de Datos Factuales , Diabetes Mellitus Tipo 2/epidemiología , Femenino , Humanos , Hiperglucemia/epidemiología , Hiperlipidemias/epidemiología , Hipertensión/epidemiología , Incidencia , Masculino , Persona de Mediana Edad , Obesidad/epidemiología , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: The association between withdrawal time and adenoma detection has been established; however, the effect of cecal insertion time on adenoma detection remains unclear. AIM: To determine the association between cecal insertion time and adenoma detection. METHODS: This study completed a retrospective analysis of data collected in 4 prospective randomized-controlled trials related to screening and surveillance colonoscopy at a single tertiary care from 2010 to 2016. The primary outcome was cecal insertion time and its association with mean number of adenomas per patient and adenoma detection rate (ADR). RESULTS: 1303 patients met inclusion criteria (average age 59.7 ± 8.7 years; 759 females (58.3%), and 763 Caucasians (58.6%). Mean cecal insertion time was significantly longer in patients who were female (p < 0.001), received moderate sedation (p = 0.001), had fellow involvement (p < 0.001), older (p = 0.002), and lower Boston bowel preparation scale (p < 0.001). Withdrawal time was found to increase as mean cecal insertion time increased (p < 0.001). The mean cecal insertion time was not different in patients with or without adenomas (p = 0.94). Cecal insertion time did not correlate with the mean number of adenomas or advanced adenomas per patient (p > 0.05), which was also true on Poisson regression analysis. Adenomas and advanced adenomas per patient were found to decrease when cecal insertion to withdrawal time ratios were greater than 1 (p < 0.001). CONCLUSIONS: Prolonged cecal insertion time was not associated with a decrease in ADR, mean number of adenomas or advanced adenomas per patient. When withdrawal times were longer than cecal insertion times, the number of adenomas and advanced adenomas detected per patient was significantly improved.
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Adenoma/diagnóstico , Neoplasias del Colon/diagnóstico , Colonoscopía/estadística & datos numéricos , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Ensayos Clínicos Controlados Aleatorios como Asunto , Estudios Retrospectivos , Factores de TiempoRESUMEN
BACKGROUND AND AIMS: Transmural drainage with double-pigtail plastic stents (DPPSs) was the mainstay of endoscopic therapy for symptomatic peripancreatic fluid collections (PPFCs) until the introduction of lumen-apposing covered self-expanding metal stents (LAMSs). Currently, there are limited data regarding the efficacy and adverse event rate of LAMSs compared with DPPSs. METHODS: A retrospective analysis of EUS-guided PPFC drainage at a single tertiary care center between 2008 and 2015 was performed. Patients were classified based on drainage method: DPPSs and LAMSs. Adverse event rates, unplanned endoscopic procedures/necrosectomies, and PPFC resolution within 6 months were recorded. Significant bleeding was defined as necessitating transfusion or requiring endoscopic treatment/radiographic embolization. Subsequent endoscopic procedures were defined as unplanned procedures; stent removals were excluded. RESULTS: A total of 103 patients met inclusion criteria (84 DPPSs, 19 LAMSs). PPFCs were classified as walled-off necrosis (WON) in 23 (14 DPPSs, 9 LAMSs). There were significantly more bleeding episodes in the LAMS group (4 [19%]: 2 splenic artery pseudo-aneurysms, 1 collateral vessel bleed, 1 intracavitary variceal bleed; P = .0003) than in the DPPS group (1 (1%]: stent erosion into the gastric wall). One perforation occurred in the DPPS group. Unplanned repeat endoscopy was more frequent in the LAMS group (10% vs 26%, P = .07). Among retreated LAMS patients in with WON, 5 (56%) had obstruction by necrotic debris. In patients for whom follow-up was available, 67 of 70 (96%) with DPPSs and 16 of 17 (94%) with LAMSs had resolution of PPFCs within 6 months (P = .78). CONCLUSIONS: DPPSs and LAMSs are effective methods for treatment of PPFCs. In our cohort, use of LAMSs was associated with significantly higher rates of procedure-related bleeding and greater need for repeat endoscopic intervention.
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Enfermedades Pancreáticas/cirugía , Plásticos , Complicaciones Posoperatorias/epidemiología , Stents Metálicos Autoexpandibles , Adolescente , Adulto , Anciano , Endosonografía , Humanos , Persona de Mediana Edad , Pancreatitis Aguda Necrotizante/cirugía , Hemorragia Posoperatoria/epidemiología , Estudios Retrospectivos , Stents , Cirugía Asistida por Computador , Adulto JovenRESUMEN
Patient navigation (PN) increases screening colonoscopy completion in minority and uninsured populations. However, colonoscopy quality is under-reported in the setting of PN and quality indicators have often failed to meet benchmark standards. This study investigated screening colonoscopy quality indicators after year-one of a PN initiative targeting the medically uninsured. This was a retrospective analysis of 296 outpatient screening colonoscopies. Patients were 45 to 75 years of age with no history of bowel cancer, inflammatory bowel disease, or colorectal surgery. The screening colonoscopy quality indicators: adenoma detection rate (ADR), cecal intubation rate (CIR), and bowel preparation quality were compared in 89 uninsured Federally Qualified Health Center (FQHC) patients who received PN and 207 University Hospital patients who received usual care. The FQHC PN and University Hospital cohorts were similar in female sex (69% vs. 70%; p = 0.861) and African American race (61% vs. 61%; p = 0.920). The FQHC PN cohort was younger (57 years vs. 60 years; p < 0.001). There was no difference in ADR (33% vs. 32%; p = 0.971) or CIR (96% vs. 95%; p = 0.900) comparing the FQHC PN and University Hospital cohorts. The FQHC PN patients had a greater likelihood of an optimal bowel preparation on multivariate logistic regression (odds ratio 4.17; 95% confidence interval 1.07 to 16.20). Uninsured FQHC patients who received PN were observed to have intra-procedure quality indicators that exceeded bench-mark standards for high-quality screening colonoscopy and were equivalent to those observed in an insured University Hospital patient population.
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BACKGROUND AND AIMS: Colorectal screening (CRS) rates in minority and uninsured populations have increased through patient navigation (PN) interventions. However, patient knowledge of colonoscopy results and follow-up recommendations has not been described in an African American (AA) population or following PN. Our objectives were to determine patient knowledge of colonoscopy results and follow-up recommendations within an AA patient population and to compare post-colonoscopy knowledge among patients who received either PN or usual care. METHODS: This is a prospective observational study of patients who completed a screening colonoscopy in 2014. A semi-structured telephone survey was completed by 96 participants (69 % AA, 78 % female, and mean age 63 years). The survey assessed patient recall of polyp results and follow-up recommendations. Responses were compared with the medical record. RESULTS: Of 96 patients surveyed (response rate, 68 %), 83 % accurately reported if polyps were detected and 66 % accurately reported their recommended follow-up. The identification of adenomatous polyps on colonoscopy was a predictor of accurate recall of colonoscopy results and follow-up recommendations. Uninsured patients who completed PN (18 of 96) were more likely to accurately report polyp results (100 vs. 80 %; P = 0.036), but the rates of accurate follow-up recall were not statistically significant (44 vs. 71 %; P = 0.053) when compared to usual care patients. CONCLUSIONS: In an AA population, post-colonoscopy polyp recall rates were similar to those described in white populations. Uninsured patients who completed PN were more likely than insured usual care patients to accurately report the presence of polyps on colonoscopy.
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Negro o Afroamericano , Pólipos del Colon/diagnóstico , Colonoscopía , Navegación de Pacientes , Pólipos del Colon/etnología , Neoplasias Colorrectales , Femenino , Estudios de Seguimiento , Conocimientos, Actitudes y Práctica en Salud , Humanos , Cobertura del Seguro , Masculino , Persona de Mediana Edad , Pólipos , Estudios Prospectivos , Estados UnidosRESUMEN
Limited English proficient (LEP) patients are at risk of disparities in health and health care quality. These disparities can be mitigated by providing care in a language they understand. Undergraduate medical education provides an opportunity to stress that language barriers negatively impact the quality and safety of health care for LEP patients and to teach students how to overcome them. Because the preponderance of LEP patients in the USA is Spanish speaking, the majority of US medical schools have established medical Spanish coursework for interested students. However, 70 % of medical schools note significant obstacles to delivering this curriculum. The most commonly cited obstacles include a lack of time to deliver it, heterogeneous student skill levels, and insufficient faculty support. We also note that educators need to make sure not to propagate disparities and medical errors for LEP patients. We provide recommendations for establishing medical students' linguistic and cultural competence for the care Spanish-speaking limited English proficiency patients, with the caution that this instruction must be coupled with education as to when to call on an interpreter if participants are not fluent in Spanish at the end of the course.