Prevention by daily soluble aspirin of colorectal adenoma recurrence: 4-year results of the APACC randomised trial
Robert BenamouzigBernard UzzanJacques DeyraAntoine MartinBernard GirardJulian LittleStanislas Chaussade
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Abstract:
Background
Aspirin inhibits colorectal carcinogenesis. In a randomised double-blind placebo-controlled trial, daily soluble aspirin significantly reduced recurrence of colorectal adenomas at 1-year follow-up. In this study the results of daily intake of low-dose aspirin on polyp recurrence at 4-year follow-up are presented.Methods
272 patients (naive for chronic aspirin use) with colorectal adenomas were randomly assigned to treatment with lysine acetylsalicylate 160 mg/day (n=73) or 300 mg/day (n=67) or placebo (n=132) for 4 years. The primary endpoints were adenoma recurrence and adenomatous polyp burden at year 4, comparing aspirin at either dose with placebo. The same endpoints were also assessed at year 1 or 4 (last colonoscopy performed for each patient).Results
At the final year 4 colonoscopy the analysis included 185 patients (55 receiving aspirin 160 mg/day, 47 aspirin 300 mg/day and 83 placebo). There was no difference in the proportion of patients with at least one recurrent adenoma between patients receiving aspirin at either dose and those treated with placebo (42/102 (41%) vs 33/83 (40%); NS) or in the adenomatous polyp burden (3.1±5.8 mm vs 3.4±6.2 mm; NS). Also, the proportion of patients with at least one advanced recurrent adenoma did not differ (10/182 (10%) in the aspirin group vs 7/83 (7%) in the placebo group; NS).Conclusion
Daily low-dose aspirin decreased adenoma recurrence significantly at 1 year but not at year 4. This discrepancy might be explained by a differential effect of aspirin according to the natural history of the polyp.Trial Registration Number
NCT 00224679.Keywords:
Colorectal adenoma
Clinical endpoint
The usefulness of high definition colonoscopy plus i-scan (HD+i-SCAN) for average-risk colorectal cancer screening has not been fully assessed. The detection rate of adenomas and other measurements such as the number of adenomas per colonoscopy and the flat adenoma detection rate have been recognized as markers of colonoscopy quality. The aim of the present study was to compare the diagnostic performance of an HD+i-SCAN with that of standard resolution white-light colonoscope.This is a retrospective analysis of a prospectively collected screening colonoscopy database. A comparative analysis of the diagnostic yield of an HD+i-SCAN or standard resolution colonoscopy for average-risk colorectal screening was conducted.During the period of study, 155/163 (95.1%) patients met the inclusion criteria. The mean age was 56.9 years. Sixty of 155 (39%) colonoscopies were performed using a HD+i-SCAN. Adenoma-detection-rates during the withdrawal of the standard resolution versus HD+i-SCAN colonoscopies were 29.5% and 30% (p = n.s.). Adenoma/colonoscopy values for standard resolution versus HD+i-SCAN colonoscopies were 0.46 (SD = 0.9) and 0.72 (SD = 1.3) (p = n.s.). A greater number of flat adenomas were detected in the HD+i-SCAN group (6/60 versus 2/95) (p < .05). Likewise, serrated adenomas/polyps per colonoscopy were also higher in the HD+i-SCAN group.A HD+i-SCAN colonoscopy increases the flat adenoma detection rate and serrated adenomas/polyps per colonoscopy compared to a standard colonoscopy in average-risk screening population. HD+i-SCAN is a simple, available procedure that can be helpful, even for experienced providers. The performance of HD+i-SCAN and substantial prevalence of flat lesions in our average-risk screening cohort support its usefulness in improving the efficacy of screening colonoscopies.
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Purpose: Background and Aim: The adenoma detection rate is an independent predictor of the risk of interval colorectal cancer after screening colonoscopy. A number of techniques have been shown to maximize adenoma detection. We incorporated a comprehensive colonoscopy screening protocol that includes: 1. Ensuring a clean quality of colon preparation; 2. Cecal intubation in over 95%; 3. Colonoscope withdrawal time > 6 min; 4. Colonoscopy Screening Techniques for better adenoma detection (a. Use of a cap fitted endoscope to examine behind the folds; b. Patient position change to optimize distention of the colon; c. Eyes trained to detect flat lesions after looking at several flat lesions' images & videos). We have reported the effect of combining all these various techniques to maximize adenoma detection rate in 100 consecutive average risk patients (pts) undergoing screening colonoscopy previously. We report the adenoma detection rate in larger pool of 535 consecutive patients undergoing their first screening colonoscopy from 2009-2011. Methods: Endoscopist: Screening colonoscopy was performed by a single operator. Patients (pts): 535 consecutive patients undergoing screening colonoscopy from 2009-2011 were included in the study. Average risk pts: 495. Increased risk pts (Family history of colorectal cancer or polyps <60 years): 40. We used the comprehensive colonoscopy screening protocol to maximize adenoma detection in all patients during screening. Colonoscopy Report: The data was recorded in a structured colonoscopy report with well-defined fields to capture all the data. Main Outcome Measurements: We analyzed the adenoma detection rates. Results: Mean age: 58.3 ± 7.7; Sex: Men: Women: 220:315; BMI: 27.4 ± 5.4. Caucasians: 395(73.8%).The adenoma detection rate in screening population: 64.9%. The advanced adenoma detection rate (>1 cm adenoma or villous histology of any size or high grade dysplasia):14%.The multiple adenoma (≥ 3 adenomas) detection rate: 17%. The combined adenoma or proximal hyperplastic polyp detection rate: 69.7%. The proximal hyperplastic polyp detection rate: 15.3%. The serrated adenoma detection rate: 15%. The proximal hyperplastic polyp or serrated adenoma detection rate: 26.7%. See Table 1.Table: [1974] Prevalence of adenomas in 535 consecutive patients undergoing screening colonoscopies using a comprehensive colonoscopy screening protocolConclusion: Routine use of techniques to maximize adenoma detection result in persistent increase in adenoma detection rates, several fold higher than the adenoma detection rate set by the U.S Multi-Society Task Force on Colorectal Cancer (25% in men & 15% in women).
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BACKGROUND AND AIMS Colonoscopy is an excellent but imperfect modality for colorectal cancer screening and prevention. We studied the effects of a retractable transparent extension device on adenoma detection rate as well as on intubation and withdrawal times. METHODS Colonoscopy with or without the transparent retractable extension (TRE) was performed by one endoscopist. A subset of patients with colonic adenomas were randomized to repeat colonoscopy with or without a TRE device. Adenoma removal was done at the second colonoscopy. The principal outcome parameters were the cecal intubation time, withdrawal time, and the number, size, and location of adenomas detected. RESULTS The study was done in two parts. First, 835 patients underwent colonoscopy with or without the TRE. The patients' demographic characteristics, the indications for colonoscopy, the cecal intubation time and withdrawal time, and the proportion of patients with adenomas (29.0%vs 24.1%) (P= 0.11) were similar between the two techniques. The number of adenomas detected with the TRE was significantly higher than that without the extension (205 vs 150) (P= 0.04). Second, 60 patients with adenomas found at colonoscopy without the device were randomized to repeat colonoscopy within 3 months. Hood-assisted colonoscopy revealed 20% more adenomas than the initial procedure compared to a 4% increase without the hood (P= 0.029). CONCLUSIONS Colonoscopy with a TRE device improved the adenoma detection rate without affecting intubation and withdrawal times.
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Background Postcolonoscopy surveillance colonoscopy based on positive fecal occult blood testing (FOBT) is often performed, although its long-term efficacy has not been established. The aim of this study was to clarify the low potency of FOBT surveillance at short intervals after colonoscopy. Methods Colonoscopy was performed in 1308 average-risk patients, based on positive results of immunological FOBT [fecal immunological test (FIT)]. Patients were stratified according to the length of time since their last colonoscopy and their colonoscopy results [no adenoma or 1–2 small (<10 mm) adenomas]. Tumor detection rates were determined. Results The baseline patients characteristics did not differ between the groups. The advanced lesion detection rate (ALDR) among the patients who had never undergone a colonoscopy was 21.9% [95% confidence interval (CI), 19.1–25.0%]. Among the patients who had no adenoma detected in the previous colonoscopy within the past 5 years, the past 5–10 years and over 10 years, the ALDRs were 2.5% (95% CI, 1.0–5.5%), 4.1% (95% CI, 1.5–9.4%) and 9.3% (95% CI, 3.1–22.2%), respectively. Among the patients who had 1–2 small adenomas, the ALDRs were 7.4% (95% CI, 3.4–14.8%), 12.1% (95% CI, 4.2–27.9%) and 27.8% (95% CI, 12.2–51.2%), respectively. Invasive cancer was not observed in any patients within 5 years since the prior colonoscopy. Conclusion In average-risk patients whose prior colonoscopy detected no adenomas or low-risk adenomas, postcolonoscopy surveillance by FIT has a low positive predictive value within a 5-year interval.
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Abstract Aim Patients with non‐advanced adenoma ( NAA ) underwent surveillance colonoscopy at intervals shorter than the interval recommended by the guidelines. We aimed to assess the incidence of recurrent advanced adenoma ( AA ) over a 5‐year period and to identify risk factors for recurrence. Method Patients with and without NAA identified at baseline colonoscopy who had had at least two colonoscopy examinations during the subsequent 5 years were included in the study. Data on the patients’ demographics and colorectal findings were extracted from a specially designed colonoscopy database. The primary outcome was the finding of recurrent AA formation. Multivariate analysis was used to identify factors that predict subsequent AA formation at surveillance colonoscopy. Results Among 43 155 colonoscopy procedures, 828 cases were identified with NAA (374) and without an adenoma (454). Forty‐eight (51.1%) of 94 received a follow‐up colonoscopy within 1 year due to an inadequate baseline colonoscopy. Patients with NAA at baseline had a low incidence of AA at an interval of 1−5 years which was not statistically different from patients without adenoma formation at the initial baseline colonoscopy (1.5% vs 2.2%, P = 0.51). The incidence of AA at follow‐up colonoscopy performed at 1−3 years and 3−5 years in patients with a baseline NAA was 1.7% and 1.4% ( P = 0.59). Age over 50 years and male gender were independent risk factors for AA recurrence within 5 years. Conclusion Surveillance colonoscopy within 5 years is of little benefit to patients who had an adequate polypectomy of an NAA at baseline. Too frequent reexamination due to concerns about AA recurrence should be avoided.
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AIM: Inadequate bowel preparation is associated with reduced adenoma detection. We sought to determine whether the adenoma miss rate during colonoscopy with inadequate preparation is significantly greater than the adenoma miss rate reported with tandem colonoscopy. METHODS: We reviewed records of all patients at our tertiary care center with an inadequately cleansed index colonoscopy between 2/1/2009-2/28/2010, who underwent repeat colonoscopy within 18 months. The primary endpoint was the overall adenoma miss rate. A two-sided test with alpha 0.05 had 80% power to distinguish an adenoma miss rate of about 33% compared to 22% reported with tandem colonoscopy. 910 patients had inadequate cleansing, and 127 met inclusion criteria including repeat colonoscopy within 18 months. RESULTS: The overall adenoma miss rate was significantly greater than reported with tandem colonoscopy (52% vs. 22%, p=0.001). Miss rates were higher for all adenoma size categories (57% vs. 26% for 1 year (OR=11.0, 95% CI: 5.81 to 20.9). CONCLUSION: The adenoma miss rate during colonoscopy with inadequate preparation is significantly higher than reported with tandem colonoscopy. Our findings support performing early repeat colonoscopy after inadequate preparation. © 2013 ACT. All rights reserved.
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Purpose: High definition (HD) colonoscopy has the potential to identify more polyps, especially flat lesions which could be missed during a standard (SD) colonoscopy. This advantage may be important in screening in high risk patients. Its utility in average risk screening colonoscopy in clinical practice is unclear. Methods: 378 consecutive patients undergoing average risk screening colonoscopy with two experienced gastroenterologists over a six month period in one endoscopy center were included. 207 patients were examined with a standard scope in the initial 3 months, and 177 patients with high definition scope in the later 3 months. Patients with personal history of polyps, family history of colorectal neoplasia, inflammatory bowel disease, and those referred for reasons other than screening were excluded. Results: Both groups were well matched, mean age (56 vs 56.6 yrs)and sex (female 66% vs 68%). A total of 77 (37%) patients had at least one polyp detected during standard colonoscopy vs 74 (43%) of patients with high definition colonoscopy. The adenoma detection rate was 18% with standard colonoscopy vs 24% with high definition colonoscopy. These differences were not statistically significant (polyp detection p = 0.11, adenoma detection p = 0.18). The adenoma detection rates varied between the two endoscopists (SD 30% vs 11%, HD 30% vs 19%). The endoscopist with the lower adenoma detection rate had a younger and more female (77% vs 48%) population. Conclusion: High definition colonoscopy did not significantly improve adenoma detection rates in our average risk screening colonoscopy population. The adenoma detection rate is likely to be influenced more by the population studied and operator technique, than by the use of high definition colonoscopy during screening.Table: Polyp detection by HD and SD colonoscopyTable: Distribution of Polyps
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