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Jury is in? Survival benefit with lap surgery for rectal cancer
, according to findings from a large meta-analysis.
The estimated 5-year OS rate for patients who underwent laparoscopic surgery was 76.2%, vs. 72.7% for those who had open surgery.
“The survival benefit of laparoscopic surgery is encouraging and supports the routine use of laparoscopic surgery for adult patients with rectal cancer in the era of minimally invasive surgery,” wrote the authors, led by Leping Li, MD, of the department of gastrointestinal surgery, Shandong (China) Provincial Hospital.
The article was published online in JAMA Network Open.
Surgery is an essential component in treating rectal cancer, but the benefits of laparoscopic vs. open surgery are not clear. Over the past 15 years, randomized clinical trials (RCTs) have shown comparable long-term outcomes for laparoscopic and open surgery. However, in most meta-analyses that assessed the evidence more broadly, researchers used an “inappropriate” method for the pooled analysis. Dr. Li and colleagues wanted to perform their own meta-analysis to more definitively understand whether the evidence on long-term outcomes supports or opposes the use of laparoscopic surgery for rectal cancer.
In the current study, the authors conducted an individual participant data meta-analysis using time-to-event data and focused on the long-term survival outcomes after laparoscopic or open surgery for adult patients with rectal cancer.
Ten articles involving 12 RCTs and 3,709 participants were included. In these, 2,097 patients were randomly assigned to undergo laparoscopic surgery, and 1,612 were randomly assigned to undergo open surgery. The studies covered a global population, with participants from Europe, North America, and East Asia.
In a one-stage analysis, the authors found that disease-free survival was slightly better among patients who underwent laparoscopic surgery, but the results were statistically similar (hazard ratio [HR], 0.92; P = .26).
However, when it came to OS, those who had undergone laparoscopic surgery fared significantly better (HR, 0.85; P = .02).
These results held up in the two-stage analysis for both disease-free survival (HR, 0.92; P = .25) and OS (HR, 0.85; P = .02). A sensitivity analyses conducted with large RCTs yielded similar pooled effect sizes for disease-free survival (HR, 0.91; P = .20) and OS (HR, 0.84; P = .03).
The authors highlighted several reasons why laparoscopic surgery may be associated with better survival. First, the faster recovery from the minimally invasive procedure could allow patients to begin adjuvant therapy earlier. In addition, the reduced stress responses and higher levels of immune function among patients undergoing minimally invasive surgery may contribute to a long-term survival advantage.
“These findings address concerns regarding the effectiveness of laparoscopic surgery,” the authors wrote. However, “further studies are necessary to explore the specific mechanisms underlying the positive effect of laparoscopic surgery on OS.”
No outside funding source was noted. The authors have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
, according to findings from a large meta-analysis.
The estimated 5-year OS rate for patients who underwent laparoscopic surgery was 76.2%, vs. 72.7% for those who had open surgery.
“The survival benefit of laparoscopic surgery is encouraging and supports the routine use of laparoscopic surgery for adult patients with rectal cancer in the era of minimally invasive surgery,” wrote the authors, led by Leping Li, MD, of the department of gastrointestinal surgery, Shandong (China) Provincial Hospital.
The article was published online in JAMA Network Open.
Surgery is an essential component in treating rectal cancer, but the benefits of laparoscopic vs. open surgery are not clear. Over the past 15 years, randomized clinical trials (RCTs) have shown comparable long-term outcomes for laparoscopic and open surgery. However, in most meta-analyses that assessed the evidence more broadly, researchers used an “inappropriate” method for the pooled analysis. Dr. Li and colleagues wanted to perform their own meta-analysis to more definitively understand whether the evidence on long-term outcomes supports or opposes the use of laparoscopic surgery for rectal cancer.
In the current study, the authors conducted an individual participant data meta-analysis using time-to-event data and focused on the long-term survival outcomes after laparoscopic or open surgery for adult patients with rectal cancer.
Ten articles involving 12 RCTs and 3,709 participants were included. In these, 2,097 patients were randomly assigned to undergo laparoscopic surgery, and 1,612 were randomly assigned to undergo open surgery. The studies covered a global population, with participants from Europe, North America, and East Asia.
In a one-stage analysis, the authors found that disease-free survival was slightly better among patients who underwent laparoscopic surgery, but the results were statistically similar (hazard ratio [HR], 0.92; P = .26).
However, when it came to OS, those who had undergone laparoscopic surgery fared significantly better (HR, 0.85; P = .02).
These results held up in the two-stage analysis for both disease-free survival (HR, 0.92; P = .25) and OS (HR, 0.85; P = .02). A sensitivity analyses conducted with large RCTs yielded similar pooled effect sizes for disease-free survival (HR, 0.91; P = .20) and OS (HR, 0.84; P = .03).
The authors highlighted several reasons why laparoscopic surgery may be associated with better survival. First, the faster recovery from the minimally invasive procedure could allow patients to begin adjuvant therapy earlier. In addition, the reduced stress responses and higher levels of immune function among patients undergoing minimally invasive surgery may contribute to a long-term survival advantage.
“These findings address concerns regarding the effectiveness of laparoscopic surgery,” the authors wrote. However, “further studies are necessary to explore the specific mechanisms underlying the positive effect of laparoscopic surgery on OS.”
No outside funding source was noted. The authors have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
, according to findings from a large meta-analysis.
The estimated 5-year OS rate for patients who underwent laparoscopic surgery was 76.2%, vs. 72.7% for those who had open surgery.
“The survival benefit of laparoscopic surgery is encouraging and supports the routine use of laparoscopic surgery for adult patients with rectal cancer in the era of minimally invasive surgery,” wrote the authors, led by Leping Li, MD, of the department of gastrointestinal surgery, Shandong (China) Provincial Hospital.
The article was published online in JAMA Network Open.
Surgery is an essential component in treating rectal cancer, but the benefits of laparoscopic vs. open surgery are not clear. Over the past 15 years, randomized clinical trials (RCTs) have shown comparable long-term outcomes for laparoscopic and open surgery. However, in most meta-analyses that assessed the evidence more broadly, researchers used an “inappropriate” method for the pooled analysis. Dr. Li and colleagues wanted to perform their own meta-analysis to more definitively understand whether the evidence on long-term outcomes supports or opposes the use of laparoscopic surgery for rectal cancer.
In the current study, the authors conducted an individual participant data meta-analysis using time-to-event data and focused on the long-term survival outcomes after laparoscopic or open surgery for adult patients with rectal cancer.
Ten articles involving 12 RCTs and 3,709 participants were included. In these, 2,097 patients were randomly assigned to undergo laparoscopic surgery, and 1,612 were randomly assigned to undergo open surgery. The studies covered a global population, with participants from Europe, North America, and East Asia.
In a one-stage analysis, the authors found that disease-free survival was slightly better among patients who underwent laparoscopic surgery, but the results were statistically similar (hazard ratio [HR], 0.92; P = .26).
However, when it came to OS, those who had undergone laparoscopic surgery fared significantly better (HR, 0.85; P = .02).
These results held up in the two-stage analysis for both disease-free survival (HR, 0.92; P = .25) and OS (HR, 0.85; P = .02). A sensitivity analyses conducted with large RCTs yielded similar pooled effect sizes for disease-free survival (HR, 0.91; P = .20) and OS (HR, 0.84; P = .03).
The authors highlighted several reasons why laparoscopic surgery may be associated with better survival. First, the faster recovery from the minimally invasive procedure could allow patients to begin adjuvant therapy earlier. In addition, the reduced stress responses and higher levels of immune function among patients undergoing minimally invasive surgery may contribute to a long-term survival advantage.
“These findings address concerns regarding the effectiveness of laparoscopic surgery,” the authors wrote. However, “further studies are necessary to explore the specific mechanisms underlying the positive effect of laparoscopic surgery on OS.”
No outside funding source was noted. The authors have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JAMA NETWORK OPEN
NeoChemo preserves rectum in half of patients with rectal cancer
Among patients with stage II or stage III rectal adenocarcinoma, organ preservation is achievable in up to half of patients who undergo total neoadjuvant chemotherapy (TNT), according to the results from a new randomized phase 2 trial.
The study included 324 patients from 18 centers who were randomized into one of two groups: induction chemotherapy followed by chemoradiotherapy (INCT-CRT) or chemoradiotherapy followed by consolidation chemotherapy (CRT-CNCT). Patients in both groups then underwent either total mesorectal excision (TME) or a watch-and-wait strategy, depending on tumor response.
“What the study shows is that the order of the chemo and the radiation dose doesn’t affect survival, but it seems to affect the probability of preserving the rectum. That data is consistent with other studies that have compared head-to-head chemotherapy followed by radiation versus radiation followed by chemotherapy. In addition, the survival rate for this study is no different from other prospective studies that included patients with similar-stage tumors selected by MRI. So the data suggest that you can probably avoid surgery in half of the patients with locally advanced rectal cancer and still achieve similar survival compared to patients treated with more conventional neoadjuvant treatments and mandatory surgery,” said lead author Julio Garcia-Aguilar, MD, PhD, in an interview.
“It is a significant shift in the treatment paradigm, that can potentially benefit half of the 50,000 rectal cancer patients diagnosed every year in the United States,” said Dr. Garcia-Aguilar, chief of colorectal surgery at Memorial Sloan Kettering Cancer Center, New York.
The study was published online in the Journal of Clinical Oncology.
Neoadjuvant CRT, TME, and adjuvant chemotherapy is an effective treatment strategy for locally advanced rectal adenocarcinoma, but the regimen can cause bowel, urinary, and sexual dysfunction. The majority of adverse effects from the therapy can be traced to surgery. In addition, some patients with distal rectal cancer often require a permanent colostomy.
TNT is a newer approach that delivers chemotherapy plus radiotherapy before surgery. It is designed to improve treatment compliance and eradicate micrometastases in advance of surgery.
After a median follow-up of 3 years, disease-free survival (76% in both groups) was similar to historical controls (75%). Both groups had similar rates of local recurrence-free survival (94% each) and distant metastasis–free survival (84% for INCT-CRT and 82% for CRT-CNCT).
Following TNT, 26% of patients were recommended for TME, including 28% in the INCT-CRT group and 24% in the CRT-CNCT group, and the rest offered watchful-waiting. Forty percent of those in the INCT-CRT group and 27% in the CRT-CNCT group who went on to watchful waiting had tumor regrowth. Of these combined 75 patients, 67 underwent successful salvage surgery.
In the intention-to-treat analysis, 53% of patients had a preserved rectum at 3 years (95% confidence interval, 45%-62%) in the CRT-CNCT group versus 41% in the INCT-CRT group (95% CI, 33%-50%; P = .01).
The new results reinforce other results and should contribute to shifting clinical practice, according to Dr. Garcia-Aguilar. “I think what we have learned is that rectal cancers respond to chemotherapy and radiation at a higher rate that we thought previously, but that the response takes time. That’s something that we use currently in an adaptive way to modify the treatment as we observe the tumor response,” he said.
The slow regrowth means that patients can be closely monitored without undue risk, but such an approach demands buy-in from the patient. “The patient needs to be compliant with a close surveillance protocol, because otherwise it can be a disaster. I think that’s really part of the message,” Dr. Garcia-Aguilar said.
Dr. Garcia-Aguilar has an ownership interest in Intuitive Surgical and has advised or consulted for Medtronic, Intuitive Surgical, and Johnson & Johnson.
Among patients with stage II or stage III rectal adenocarcinoma, organ preservation is achievable in up to half of patients who undergo total neoadjuvant chemotherapy (TNT), according to the results from a new randomized phase 2 trial.
The study included 324 patients from 18 centers who were randomized into one of two groups: induction chemotherapy followed by chemoradiotherapy (INCT-CRT) or chemoradiotherapy followed by consolidation chemotherapy (CRT-CNCT). Patients in both groups then underwent either total mesorectal excision (TME) or a watch-and-wait strategy, depending on tumor response.
“What the study shows is that the order of the chemo and the radiation dose doesn’t affect survival, but it seems to affect the probability of preserving the rectum. That data is consistent with other studies that have compared head-to-head chemotherapy followed by radiation versus radiation followed by chemotherapy. In addition, the survival rate for this study is no different from other prospective studies that included patients with similar-stage tumors selected by MRI. So the data suggest that you can probably avoid surgery in half of the patients with locally advanced rectal cancer and still achieve similar survival compared to patients treated with more conventional neoadjuvant treatments and mandatory surgery,” said lead author Julio Garcia-Aguilar, MD, PhD, in an interview.
“It is a significant shift in the treatment paradigm, that can potentially benefit half of the 50,000 rectal cancer patients diagnosed every year in the United States,” said Dr. Garcia-Aguilar, chief of colorectal surgery at Memorial Sloan Kettering Cancer Center, New York.
The study was published online in the Journal of Clinical Oncology.
Neoadjuvant CRT, TME, and adjuvant chemotherapy is an effective treatment strategy for locally advanced rectal adenocarcinoma, but the regimen can cause bowel, urinary, and sexual dysfunction. The majority of adverse effects from the therapy can be traced to surgery. In addition, some patients with distal rectal cancer often require a permanent colostomy.
TNT is a newer approach that delivers chemotherapy plus radiotherapy before surgery. It is designed to improve treatment compliance and eradicate micrometastases in advance of surgery.
After a median follow-up of 3 years, disease-free survival (76% in both groups) was similar to historical controls (75%). Both groups had similar rates of local recurrence-free survival (94% each) and distant metastasis–free survival (84% for INCT-CRT and 82% for CRT-CNCT).
Following TNT, 26% of patients were recommended for TME, including 28% in the INCT-CRT group and 24% in the CRT-CNCT group, and the rest offered watchful-waiting. Forty percent of those in the INCT-CRT group and 27% in the CRT-CNCT group who went on to watchful waiting had tumor regrowth. Of these combined 75 patients, 67 underwent successful salvage surgery.
In the intention-to-treat analysis, 53% of patients had a preserved rectum at 3 years (95% confidence interval, 45%-62%) in the CRT-CNCT group versus 41% in the INCT-CRT group (95% CI, 33%-50%; P = .01).
The new results reinforce other results and should contribute to shifting clinical practice, according to Dr. Garcia-Aguilar. “I think what we have learned is that rectal cancers respond to chemotherapy and radiation at a higher rate that we thought previously, but that the response takes time. That’s something that we use currently in an adaptive way to modify the treatment as we observe the tumor response,” he said.
The slow regrowth means that patients can be closely monitored without undue risk, but such an approach demands buy-in from the patient. “The patient needs to be compliant with a close surveillance protocol, because otherwise it can be a disaster. I think that’s really part of the message,” Dr. Garcia-Aguilar said.
Dr. Garcia-Aguilar has an ownership interest in Intuitive Surgical and has advised or consulted for Medtronic, Intuitive Surgical, and Johnson & Johnson.
Among patients with stage II or stage III rectal adenocarcinoma, organ preservation is achievable in up to half of patients who undergo total neoadjuvant chemotherapy (TNT), according to the results from a new randomized phase 2 trial.
The study included 324 patients from 18 centers who were randomized into one of two groups: induction chemotherapy followed by chemoradiotherapy (INCT-CRT) or chemoradiotherapy followed by consolidation chemotherapy (CRT-CNCT). Patients in both groups then underwent either total mesorectal excision (TME) or a watch-and-wait strategy, depending on tumor response.
“What the study shows is that the order of the chemo and the radiation dose doesn’t affect survival, but it seems to affect the probability of preserving the rectum. That data is consistent with other studies that have compared head-to-head chemotherapy followed by radiation versus radiation followed by chemotherapy. In addition, the survival rate for this study is no different from other prospective studies that included patients with similar-stage tumors selected by MRI. So the data suggest that you can probably avoid surgery in half of the patients with locally advanced rectal cancer and still achieve similar survival compared to patients treated with more conventional neoadjuvant treatments and mandatory surgery,” said lead author Julio Garcia-Aguilar, MD, PhD, in an interview.
“It is a significant shift in the treatment paradigm, that can potentially benefit half of the 50,000 rectal cancer patients diagnosed every year in the United States,” said Dr. Garcia-Aguilar, chief of colorectal surgery at Memorial Sloan Kettering Cancer Center, New York.
The study was published online in the Journal of Clinical Oncology.
Neoadjuvant CRT, TME, and adjuvant chemotherapy is an effective treatment strategy for locally advanced rectal adenocarcinoma, but the regimen can cause bowel, urinary, and sexual dysfunction. The majority of adverse effects from the therapy can be traced to surgery. In addition, some patients with distal rectal cancer often require a permanent colostomy.
TNT is a newer approach that delivers chemotherapy plus radiotherapy before surgery. It is designed to improve treatment compliance and eradicate micrometastases in advance of surgery.
After a median follow-up of 3 years, disease-free survival (76% in both groups) was similar to historical controls (75%). Both groups had similar rates of local recurrence-free survival (94% each) and distant metastasis–free survival (84% for INCT-CRT and 82% for CRT-CNCT).
Following TNT, 26% of patients were recommended for TME, including 28% in the INCT-CRT group and 24% in the CRT-CNCT group, and the rest offered watchful-waiting. Forty percent of those in the INCT-CRT group and 27% in the CRT-CNCT group who went on to watchful waiting had tumor regrowth. Of these combined 75 patients, 67 underwent successful salvage surgery.
In the intention-to-treat analysis, 53% of patients had a preserved rectum at 3 years (95% confidence interval, 45%-62%) in the CRT-CNCT group versus 41% in the INCT-CRT group (95% CI, 33%-50%; P = .01).
The new results reinforce other results and should contribute to shifting clinical practice, according to Dr. Garcia-Aguilar. “I think what we have learned is that rectal cancers respond to chemotherapy and radiation at a higher rate that we thought previously, but that the response takes time. That’s something that we use currently in an adaptive way to modify the treatment as we observe the tumor response,” he said.
The slow regrowth means that patients can be closely monitored without undue risk, but such an approach demands buy-in from the patient. “The patient needs to be compliant with a close surveillance protocol, because otherwise it can be a disaster. I think that’s really part of the message,” Dr. Garcia-Aguilar said.
Dr. Garcia-Aguilar has an ownership interest in Intuitive Surgical and has advised or consulted for Medtronic, Intuitive Surgical, and Johnson & Johnson.
FROM JOURNAL OF CLINICAL ONCOLOGY
Early-onset colon cancer projected to double by 2030
from 7.9 to 12.9 cases in 2015 per 100,000 people. The reason for the increase isn’t well understood.
The findings were highlighted in a recent review article published online in the New England Journal of Medicine. “It’s a national phenomenon and it’s also occurring in other parts of the developed world. We’re used to seeing mostly older people who have this diagnosis. Now we’re seeing a lot of younger people with this disease. It’s rather alarming,” said author Frank Sinicrope, MD, a medical oncologist with Mayo Clinic, Rochester, Minn.
The trend contrasts with a decline in later-onset CRC likely attributable to increases in screening. As a result of the two trends, but especially the increased number of early-onset cases, the median age of diagnosis dropped from 72 in the early 2000s to 66 today.
“Although patients with early-onset colorectal cancer are more likely to have a hereditary syndrome than those who have later-onset disease, most cases are sporadic, with no identifiable cause. Furthermore, somatic mutational profiling of early-onset colorectal cancers has not revealed previously unidentified or actionable alterations to inform our understanding of the pathogenesis of these cancers or to guide treatment,” he wrote in the review.
“Early-onset colorectal cancers are most commonly detected in the rectum, followed by the distal colon; more than 70% of early-onset colorectal cancers are in the left colon at presentation,” he wrote in the review. Younger patients tend to be unfamiliar with CRC symptoms, which are often mistaken for benign conditions.
“We’ve moved the screening age down to 45, but that still is not going to capture a lot of these patients,” Dr. Sinicrope said. He estimates that 25% of rectal cancers and 10%-12% of colon cancers diagnosed in the next 10 years will be early onset.
Although the direct cause of the increased incidence isn’t clear, Dr. Sinicrope suggested it may reflect changing dietary habits and rising obesity among adolescents. “The sugar-containing beverages, the processed sugar and a lot of red meat in the diet and refined grains … reflect changes in the diet over the last 50 years. We may now be seeing the end result of many of these dietary changes that have occurred,” he said, calling for a greater emphasis on plant-based diets, which promote a healthier gut microbiome that may reduce CRC risk. Western-style diets can change the gut microbiome leading to inflammation which increases the risk of CRC.
Most patients with early CRC present with advanced disease in the left colon. And, pathogenic germline variants are present in one in six patients – half of which are associated with Lynch syndrome which increases the risk for CRC.
Dr. Sinicrope highlighted the need for more risk-based intervention, which in turn requires a better knowledge of family history.
“We need to do better job to risk stratify, and that will help us figure out who’s best to target our screening efforts toward,” Dr. Sinicrope said. He pointed out guidelines from the U.S. Multi-Society Task Force on Colorectal Cancer and the American Cancer Society that can help physicians identify patients who might benefit from earlier screening. The American Cancer Society recommends that CRC screening be conducted at 45 years for average-risk individuals.
“The best screening test is the one that the patient will do,” Dr. Sinicrope said.
from 7.9 to 12.9 cases in 2015 per 100,000 people. The reason for the increase isn’t well understood.
The findings were highlighted in a recent review article published online in the New England Journal of Medicine. “It’s a national phenomenon and it’s also occurring in other parts of the developed world. We’re used to seeing mostly older people who have this diagnosis. Now we’re seeing a lot of younger people with this disease. It’s rather alarming,” said author Frank Sinicrope, MD, a medical oncologist with Mayo Clinic, Rochester, Minn.
The trend contrasts with a decline in later-onset CRC likely attributable to increases in screening. As a result of the two trends, but especially the increased number of early-onset cases, the median age of diagnosis dropped from 72 in the early 2000s to 66 today.
“Although patients with early-onset colorectal cancer are more likely to have a hereditary syndrome than those who have later-onset disease, most cases are sporadic, with no identifiable cause. Furthermore, somatic mutational profiling of early-onset colorectal cancers has not revealed previously unidentified or actionable alterations to inform our understanding of the pathogenesis of these cancers or to guide treatment,” he wrote in the review.
“Early-onset colorectal cancers are most commonly detected in the rectum, followed by the distal colon; more than 70% of early-onset colorectal cancers are in the left colon at presentation,” he wrote in the review. Younger patients tend to be unfamiliar with CRC symptoms, which are often mistaken for benign conditions.
“We’ve moved the screening age down to 45, but that still is not going to capture a lot of these patients,” Dr. Sinicrope said. He estimates that 25% of rectal cancers and 10%-12% of colon cancers diagnosed in the next 10 years will be early onset.
Although the direct cause of the increased incidence isn’t clear, Dr. Sinicrope suggested it may reflect changing dietary habits and rising obesity among adolescents. “The sugar-containing beverages, the processed sugar and a lot of red meat in the diet and refined grains … reflect changes in the diet over the last 50 years. We may now be seeing the end result of many of these dietary changes that have occurred,” he said, calling for a greater emphasis on plant-based diets, which promote a healthier gut microbiome that may reduce CRC risk. Western-style diets can change the gut microbiome leading to inflammation which increases the risk of CRC.
Most patients with early CRC present with advanced disease in the left colon. And, pathogenic germline variants are present in one in six patients – half of which are associated with Lynch syndrome which increases the risk for CRC.
Dr. Sinicrope highlighted the need for more risk-based intervention, which in turn requires a better knowledge of family history.
“We need to do better job to risk stratify, and that will help us figure out who’s best to target our screening efforts toward,” Dr. Sinicrope said. He pointed out guidelines from the U.S. Multi-Society Task Force on Colorectal Cancer and the American Cancer Society that can help physicians identify patients who might benefit from earlier screening. The American Cancer Society recommends that CRC screening be conducted at 45 years for average-risk individuals.
“The best screening test is the one that the patient will do,” Dr. Sinicrope said.
from 7.9 to 12.9 cases in 2015 per 100,000 people. The reason for the increase isn’t well understood.
The findings were highlighted in a recent review article published online in the New England Journal of Medicine. “It’s a national phenomenon and it’s also occurring in other parts of the developed world. We’re used to seeing mostly older people who have this diagnosis. Now we’re seeing a lot of younger people with this disease. It’s rather alarming,” said author Frank Sinicrope, MD, a medical oncologist with Mayo Clinic, Rochester, Minn.
The trend contrasts with a decline in later-onset CRC likely attributable to increases in screening. As a result of the two trends, but especially the increased number of early-onset cases, the median age of diagnosis dropped from 72 in the early 2000s to 66 today.
“Although patients with early-onset colorectal cancer are more likely to have a hereditary syndrome than those who have later-onset disease, most cases are sporadic, with no identifiable cause. Furthermore, somatic mutational profiling of early-onset colorectal cancers has not revealed previously unidentified or actionable alterations to inform our understanding of the pathogenesis of these cancers or to guide treatment,” he wrote in the review.
“Early-onset colorectal cancers are most commonly detected in the rectum, followed by the distal colon; more than 70% of early-onset colorectal cancers are in the left colon at presentation,” he wrote in the review. Younger patients tend to be unfamiliar with CRC symptoms, which are often mistaken for benign conditions.
“We’ve moved the screening age down to 45, but that still is not going to capture a lot of these patients,” Dr. Sinicrope said. He estimates that 25% of rectal cancers and 10%-12% of colon cancers diagnosed in the next 10 years will be early onset.
Although the direct cause of the increased incidence isn’t clear, Dr. Sinicrope suggested it may reflect changing dietary habits and rising obesity among adolescents. “The sugar-containing beverages, the processed sugar and a lot of red meat in the diet and refined grains … reflect changes in the diet over the last 50 years. We may now be seeing the end result of many of these dietary changes that have occurred,” he said, calling for a greater emphasis on plant-based diets, which promote a healthier gut microbiome that may reduce CRC risk. Western-style diets can change the gut microbiome leading to inflammation which increases the risk of CRC.
Most patients with early CRC present with advanced disease in the left colon. And, pathogenic germline variants are present in one in six patients – half of which are associated with Lynch syndrome which increases the risk for CRC.
Dr. Sinicrope highlighted the need for more risk-based intervention, which in turn requires a better knowledge of family history.
“We need to do better job to risk stratify, and that will help us figure out who’s best to target our screening efforts toward,” Dr. Sinicrope said. He pointed out guidelines from the U.S. Multi-Society Task Force on Colorectal Cancer and the American Cancer Society that can help physicians identify patients who might benefit from earlier screening. The American Cancer Society recommends that CRC screening be conducted at 45 years for average-risk individuals.
“The best screening test is the one that the patient will do,” Dr. Sinicrope said.
FROM NEW ENGLAND JOURNAL OF MEDICINE
Jeopardy! champion’s parents sue doctors, hospital when patient dies after colectomy
Mr. Smith, who suffered from ulcerative colitis, underwent a colectomy on Jan. 15, 2021, at St. Rose Dominican Hospital–San Martin Campus in Las Vegas. At the time, the 24-year-old man was malnourished, extremely weak, and was having more than 10 bloody bowel movements a day, according to a Jan. 11, 2022, lawsuit filed by Smith’s parents.
The allegations state that, after the procedure, hospital staff did not provide Mr. Smith with anticoagulants and did not administer or suggest that Mr. Smith take anticoagulants upon his discharge on Jan. 19. On Jan. 29, 2021, Mr. Smith collapsed at home and his family called an ambulance. He was taken back to St. Rose where he died from bilateral pulmonary emboli.
Mr. Smith’s legal complaint claims that treatment by Smith’s surgeon, hospitalist, and nursing staff fell below the standard of care because they failed to administer anticoagulants following the surgery. After the surgery, Mr. Smith’s surgeon referenced “DVT/VTE prophylaxis/anticoagulation” in the record and another note read “already ordered,” according to Keith Beiermeister, MD, a colon and rectal surgeon retained by the Smiths’ attorney, Robert E. Murdock. However, the order section of the notes included no specific order for heparin or Lovenox (enoxaparin). A hospitalist who cared for Mr. Smith after the surgery also mentioned “DVT prophylaxis” in the progress notes, but the hospitalist did not order it nor ensure that anticoagulants were given, the lawsuit claims.
“In a surgery such as this, the standard of care requires both mechanical and chemical anticoagulation,” Dr. Beiermeister wrote in the complaint. “This is especially true after colectomy and with Brayden’s history. Anticoagulants and mechanical anticoagulation are needed to prevent emboli. The medical literature is clear that patients undergoing colorectal surgery as compared to general surgery have a significant increase in the risk of emboli. This is especially true with preexisting inflammation as is present in inflammatory bowel disease.”
A spokesman for St. Rose said the hospital does not comment on pending litigation.
Mr. Smith was a five-time Jeopardy! winner and gained national fame during his championship run. In a statement, Jeopardy! officials said the Jeopardy! family was “heartbroken by the tragic loss of Brayden Smith” and that he “will be missed.”
Surgeon must face second trial in stroke suit
A cardiovascular surgeon must face a second trial over claims that he performed an unnecessary surgery that caused a patient’s stroke, the Iowa Supreme Court has ruled.
William McGrew visited a Waterloo, Iowa, cardiovascular surgeon in 2014 after experiencing transient foggy vision in one eye. An ophthalmologist initially diagnosed Mr. McGrew with cataract, but he was referred to the surgeon to rule out other possibilities.
Because of Mr. McGrew’s age (69) and history of hypertension, the cardiovascular surgeon suspected carotid disease and recommended a CT angiogram to further investigate, according to a summary in the Iowa Supreme Court’s opinion.
The CT angiogram was performed at a local imaging center and read by a radiologist who interpreted it as showing 65% stenosis, or narrowing, of the right carotid artery. The surgeon did his own review and interpreted the results as showing 70% stenosis, according to court documents. The surgeon believed that McGrew was at significant risk for stroke and he recommended surgery, specifically a right carotid endarterectomy to remove the plaque from the right carotid artery. He advised McGrew of the surgery’s possible risks, the most common being a stroke.
The endarterectomy initially appeared successful, but the next morning, Mr. McGrew experienced facial droop and weakness on his left side. An MRI and CT scan showed that Mr. McGrew experienced a stroke on the right side of his brain. A CT angiogram showed that his right carotid artery was blocked. The surgeon performed another surgery to remove the carotid artery blockage, but the second surgery did not alleviate Mr. McGrew’s symptoms, according to court documents. Mr. McGrew remains wheelchair-bound, unable to move his left side, and requires nursing home care.
Mr. McGrew and his family later went to a neurologist who analyzed Mr. McGrew’s prior CT angiogram. He interpreted the angiogram as showing only 40% stenosis. The neurologist also asked a neuroradiologist to analyze the CT angiogram, and he assessed the stenosis at 32%. In his opinion, 40% stenosis was not significant to justify an endarterectomy, the neurologist told Mr. McGrew.
Mr. McGrew sued the surgeon and the radiologist in 2016, and later settled with the radiologist. The McGrews claimed that the surgeon negligently misinterpreted the CT angiogram and performed an ill-advised surgery that resulted in a stroke. The McGrews sought damages for pain and suffering, permanent loss of function, loss of income, past and future medical expenses, and loss of consortium.
At trial, attorneys for the surgeon asked the court to limit his and the radiologist’s testimonies, arguing that their opinions were not properly disclosed in expert reports. The trial court granted the motion, and jurors heard only a limited version of the testimony. In addition, some medical records were redacted. A jury found in the surgeon’s favor, deeming him not negligent.
The McGrews appealed. In a Jan. 21, 2022, opinion, the Iowa Supreme Court ruled that the trial court abused its discretion by not allowing the earlier testimonies. Justices said both the neurologist and the neuroradiologist should have been allowed to testify on the applicable standard of care. The district court also abused its discretion in preventing Mr. McGrew from introducing complete versions of the contemporaneous medical records, the court ruled.
Justices reversed the district court’s decision and remanded the case for a new trial.
Court: Patient must pay doc’s legal expenses
A patient must pay a physician about $20,000 in legal expenses after the patient’s malpractice suit was thrown out, an Arizona appeals court has ruled.
Scottsdale plastic surgeon Corwin Martin, MD, performed dental implant surgery on Penny Preszler in February 2012. Following the surgery, Ms. Preszler claimed numbness in her face and mouth, according to the appellate decision. She sued Dr. Martin and his practice for malpractice in 2015.
As the case continued, Ms. Preszler withdrew her first expert and disclosed a new expert. When Ms. Preszler’s second standard of care expert withdrew, she was given 30 days to disclose a new expert. When she failed to do so, Dr. Martin asked the court to dismiss the suit based on Ms. Preszler’s failure to disclose a proper standard of care expert.
She eventually presented a third expert, but Martin’s attorneys argued that the doctor was not a qualified expert under state law because he was board certified in periodontia, while Dr. Martin is board certified in oral and maxillofacial surgery. By this time, the case had gone on for 4 years.
When Ms. Preszler couldn’t come up with a fourth expert who was qualified, the court dismissed the case. The judge also awarded Dr. Martin $19,279.05 for expenses incurred in discovery related to Ms. Preszler’s first expert, attorneys’ fees, and expenses.
Ms. Preszler appealed, arguing that the periodontist was qualified to testify against Martin because he performed dental implant surgeries in the past without the board certification Dr. Martin obtained. In its Jan. 20, 2022, decision, a panel of the Arizona Court of Appeals upheld the decision, ruling that the expert was not qualified to opine. The patient must also pay the physician’s legal expenses as ordered by the lower court.
“[Ms.] Preszler has not shown the superior court abused its discretion in the award issued,” appellate judges wrote. “Three years after [Ms.] Preszler disclosed her first expert witness, that expert withdrew. [Dr.] Martin claimed substantial expenses relating to discovery addressing [Ms.] Preszler’s first expert, which were no longer beneficial given his withdrawal. ... [Ms.] Preszler has not shown that the expenses awarded to [Dr.] Martin were unreasonable or disproportionate to the time and costs expended regarding the withdrawn expert.”
A version of this article first appeared on Medscape.com.
Mr. Smith, who suffered from ulcerative colitis, underwent a colectomy on Jan. 15, 2021, at St. Rose Dominican Hospital–San Martin Campus in Las Vegas. At the time, the 24-year-old man was malnourished, extremely weak, and was having more than 10 bloody bowel movements a day, according to a Jan. 11, 2022, lawsuit filed by Smith’s parents.
The allegations state that, after the procedure, hospital staff did not provide Mr. Smith with anticoagulants and did not administer or suggest that Mr. Smith take anticoagulants upon his discharge on Jan. 19. On Jan. 29, 2021, Mr. Smith collapsed at home and his family called an ambulance. He was taken back to St. Rose where he died from bilateral pulmonary emboli.
Mr. Smith’s legal complaint claims that treatment by Smith’s surgeon, hospitalist, and nursing staff fell below the standard of care because they failed to administer anticoagulants following the surgery. After the surgery, Mr. Smith’s surgeon referenced “DVT/VTE prophylaxis/anticoagulation” in the record and another note read “already ordered,” according to Keith Beiermeister, MD, a colon and rectal surgeon retained by the Smiths’ attorney, Robert E. Murdock. However, the order section of the notes included no specific order for heparin or Lovenox (enoxaparin). A hospitalist who cared for Mr. Smith after the surgery also mentioned “DVT prophylaxis” in the progress notes, but the hospitalist did not order it nor ensure that anticoagulants were given, the lawsuit claims.
“In a surgery such as this, the standard of care requires both mechanical and chemical anticoagulation,” Dr. Beiermeister wrote in the complaint. “This is especially true after colectomy and with Brayden’s history. Anticoagulants and mechanical anticoagulation are needed to prevent emboli. The medical literature is clear that patients undergoing colorectal surgery as compared to general surgery have a significant increase in the risk of emboli. This is especially true with preexisting inflammation as is present in inflammatory bowel disease.”
A spokesman for St. Rose said the hospital does not comment on pending litigation.
Mr. Smith was a five-time Jeopardy! winner and gained national fame during his championship run. In a statement, Jeopardy! officials said the Jeopardy! family was “heartbroken by the tragic loss of Brayden Smith” and that he “will be missed.”
Surgeon must face second trial in stroke suit
A cardiovascular surgeon must face a second trial over claims that he performed an unnecessary surgery that caused a patient’s stroke, the Iowa Supreme Court has ruled.
William McGrew visited a Waterloo, Iowa, cardiovascular surgeon in 2014 after experiencing transient foggy vision in one eye. An ophthalmologist initially diagnosed Mr. McGrew with cataract, but he was referred to the surgeon to rule out other possibilities.
Because of Mr. McGrew’s age (69) and history of hypertension, the cardiovascular surgeon suspected carotid disease and recommended a CT angiogram to further investigate, according to a summary in the Iowa Supreme Court’s opinion.
The CT angiogram was performed at a local imaging center and read by a radiologist who interpreted it as showing 65% stenosis, or narrowing, of the right carotid artery. The surgeon did his own review and interpreted the results as showing 70% stenosis, according to court documents. The surgeon believed that McGrew was at significant risk for stroke and he recommended surgery, specifically a right carotid endarterectomy to remove the plaque from the right carotid artery. He advised McGrew of the surgery’s possible risks, the most common being a stroke.
The endarterectomy initially appeared successful, but the next morning, Mr. McGrew experienced facial droop and weakness on his left side. An MRI and CT scan showed that Mr. McGrew experienced a stroke on the right side of his brain. A CT angiogram showed that his right carotid artery was blocked. The surgeon performed another surgery to remove the carotid artery blockage, but the second surgery did not alleviate Mr. McGrew’s symptoms, according to court documents. Mr. McGrew remains wheelchair-bound, unable to move his left side, and requires nursing home care.
Mr. McGrew and his family later went to a neurologist who analyzed Mr. McGrew’s prior CT angiogram. He interpreted the angiogram as showing only 40% stenosis. The neurologist also asked a neuroradiologist to analyze the CT angiogram, and he assessed the stenosis at 32%. In his opinion, 40% stenosis was not significant to justify an endarterectomy, the neurologist told Mr. McGrew.
Mr. McGrew sued the surgeon and the radiologist in 2016, and later settled with the radiologist. The McGrews claimed that the surgeon negligently misinterpreted the CT angiogram and performed an ill-advised surgery that resulted in a stroke. The McGrews sought damages for pain and suffering, permanent loss of function, loss of income, past and future medical expenses, and loss of consortium.
At trial, attorneys for the surgeon asked the court to limit his and the radiologist’s testimonies, arguing that their opinions were not properly disclosed in expert reports. The trial court granted the motion, and jurors heard only a limited version of the testimony. In addition, some medical records were redacted. A jury found in the surgeon’s favor, deeming him not negligent.
The McGrews appealed. In a Jan. 21, 2022, opinion, the Iowa Supreme Court ruled that the trial court abused its discretion by not allowing the earlier testimonies. Justices said both the neurologist and the neuroradiologist should have been allowed to testify on the applicable standard of care. The district court also abused its discretion in preventing Mr. McGrew from introducing complete versions of the contemporaneous medical records, the court ruled.
Justices reversed the district court’s decision and remanded the case for a new trial.
Court: Patient must pay doc’s legal expenses
A patient must pay a physician about $20,000 in legal expenses after the patient’s malpractice suit was thrown out, an Arizona appeals court has ruled.
Scottsdale plastic surgeon Corwin Martin, MD, performed dental implant surgery on Penny Preszler in February 2012. Following the surgery, Ms. Preszler claimed numbness in her face and mouth, according to the appellate decision. She sued Dr. Martin and his practice for malpractice in 2015.
As the case continued, Ms. Preszler withdrew her first expert and disclosed a new expert. When Ms. Preszler’s second standard of care expert withdrew, she was given 30 days to disclose a new expert. When she failed to do so, Dr. Martin asked the court to dismiss the suit based on Ms. Preszler’s failure to disclose a proper standard of care expert.
She eventually presented a third expert, but Martin’s attorneys argued that the doctor was not a qualified expert under state law because he was board certified in periodontia, while Dr. Martin is board certified in oral and maxillofacial surgery. By this time, the case had gone on for 4 years.
When Ms. Preszler couldn’t come up with a fourth expert who was qualified, the court dismissed the case. The judge also awarded Dr. Martin $19,279.05 for expenses incurred in discovery related to Ms. Preszler’s first expert, attorneys’ fees, and expenses.
Ms. Preszler appealed, arguing that the periodontist was qualified to testify against Martin because he performed dental implant surgeries in the past without the board certification Dr. Martin obtained. In its Jan. 20, 2022, decision, a panel of the Arizona Court of Appeals upheld the decision, ruling that the expert was not qualified to opine. The patient must also pay the physician’s legal expenses as ordered by the lower court.
“[Ms.] Preszler has not shown the superior court abused its discretion in the award issued,” appellate judges wrote. “Three years after [Ms.] Preszler disclosed her first expert witness, that expert withdrew. [Dr.] Martin claimed substantial expenses relating to discovery addressing [Ms.] Preszler’s first expert, which were no longer beneficial given his withdrawal. ... [Ms.] Preszler has not shown that the expenses awarded to [Dr.] Martin were unreasonable or disproportionate to the time and costs expended regarding the withdrawn expert.”
A version of this article first appeared on Medscape.com.
Mr. Smith, who suffered from ulcerative colitis, underwent a colectomy on Jan. 15, 2021, at St. Rose Dominican Hospital–San Martin Campus in Las Vegas. At the time, the 24-year-old man was malnourished, extremely weak, and was having more than 10 bloody bowel movements a day, according to a Jan. 11, 2022, lawsuit filed by Smith’s parents.
The allegations state that, after the procedure, hospital staff did not provide Mr. Smith with anticoagulants and did not administer or suggest that Mr. Smith take anticoagulants upon his discharge on Jan. 19. On Jan. 29, 2021, Mr. Smith collapsed at home and his family called an ambulance. He was taken back to St. Rose where he died from bilateral pulmonary emboli.
Mr. Smith’s legal complaint claims that treatment by Smith’s surgeon, hospitalist, and nursing staff fell below the standard of care because they failed to administer anticoagulants following the surgery. After the surgery, Mr. Smith’s surgeon referenced “DVT/VTE prophylaxis/anticoagulation” in the record and another note read “already ordered,” according to Keith Beiermeister, MD, a colon and rectal surgeon retained by the Smiths’ attorney, Robert E. Murdock. However, the order section of the notes included no specific order for heparin or Lovenox (enoxaparin). A hospitalist who cared for Mr. Smith after the surgery also mentioned “DVT prophylaxis” in the progress notes, but the hospitalist did not order it nor ensure that anticoagulants were given, the lawsuit claims.
“In a surgery such as this, the standard of care requires both mechanical and chemical anticoagulation,” Dr. Beiermeister wrote in the complaint. “This is especially true after colectomy and with Brayden’s history. Anticoagulants and mechanical anticoagulation are needed to prevent emboli. The medical literature is clear that patients undergoing colorectal surgery as compared to general surgery have a significant increase in the risk of emboli. This is especially true with preexisting inflammation as is present in inflammatory bowel disease.”
A spokesman for St. Rose said the hospital does not comment on pending litigation.
Mr. Smith was a five-time Jeopardy! winner and gained national fame during his championship run. In a statement, Jeopardy! officials said the Jeopardy! family was “heartbroken by the tragic loss of Brayden Smith” and that he “will be missed.”
Surgeon must face second trial in stroke suit
A cardiovascular surgeon must face a second trial over claims that he performed an unnecessary surgery that caused a patient’s stroke, the Iowa Supreme Court has ruled.
William McGrew visited a Waterloo, Iowa, cardiovascular surgeon in 2014 after experiencing transient foggy vision in one eye. An ophthalmologist initially diagnosed Mr. McGrew with cataract, but he was referred to the surgeon to rule out other possibilities.
Because of Mr. McGrew’s age (69) and history of hypertension, the cardiovascular surgeon suspected carotid disease and recommended a CT angiogram to further investigate, according to a summary in the Iowa Supreme Court’s opinion.
The CT angiogram was performed at a local imaging center and read by a radiologist who interpreted it as showing 65% stenosis, or narrowing, of the right carotid artery. The surgeon did his own review and interpreted the results as showing 70% stenosis, according to court documents. The surgeon believed that McGrew was at significant risk for stroke and he recommended surgery, specifically a right carotid endarterectomy to remove the plaque from the right carotid artery. He advised McGrew of the surgery’s possible risks, the most common being a stroke.
The endarterectomy initially appeared successful, but the next morning, Mr. McGrew experienced facial droop and weakness on his left side. An MRI and CT scan showed that Mr. McGrew experienced a stroke on the right side of his brain. A CT angiogram showed that his right carotid artery was blocked. The surgeon performed another surgery to remove the carotid artery blockage, but the second surgery did not alleviate Mr. McGrew’s symptoms, according to court documents. Mr. McGrew remains wheelchair-bound, unable to move his left side, and requires nursing home care.
Mr. McGrew and his family later went to a neurologist who analyzed Mr. McGrew’s prior CT angiogram. He interpreted the angiogram as showing only 40% stenosis. The neurologist also asked a neuroradiologist to analyze the CT angiogram, and he assessed the stenosis at 32%. In his opinion, 40% stenosis was not significant to justify an endarterectomy, the neurologist told Mr. McGrew.
Mr. McGrew sued the surgeon and the radiologist in 2016, and later settled with the radiologist. The McGrews claimed that the surgeon negligently misinterpreted the CT angiogram and performed an ill-advised surgery that resulted in a stroke. The McGrews sought damages for pain and suffering, permanent loss of function, loss of income, past and future medical expenses, and loss of consortium.
At trial, attorneys for the surgeon asked the court to limit his and the radiologist’s testimonies, arguing that their opinions were not properly disclosed in expert reports. The trial court granted the motion, and jurors heard only a limited version of the testimony. In addition, some medical records were redacted. A jury found in the surgeon’s favor, deeming him not negligent.
The McGrews appealed. In a Jan. 21, 2022, opinion, the Iowa Supreme Court ruled that the trial court abused its discretion by not allowing the earlier testimonies. Justices said both the neurologist and the neuroradiologist should have been allowed to testify on the applicable standard of care. The district court also abused its discretion in preventing Mr. McGrew from introducing complete versions of the contemporaneous medical records, the court ruled.
Justices reversed the district court’s decision and remanded the case for a new trial.
Court: Patient must pay doc’s legal expenses
A patient must pay a physician about $20,000 in legal expenses after the patient’s malpractice suit was thrown out, an Arizona appeals court has ruled.
Scottsdale plastic surgeon Corwin Martin, MD, performed dental implant surgery on Penny Preszler in February 2012. Following the surgery, Ms. Preszler claimed numbness in her face and mouth, according to the appellate decision. She sued Dr. Martin and his practice for malpractice in 2015.
As the case continued, Ms. Preszler withdrew her first expert and disclosed a new expert. When Ms. Preszler’s second standard of care expert withdrew, she was given 30 days to disclose a new expert. When she failed to do so, Dr. Martin asked the court to dismiss the suit based on Ms. Preszler’s failure to disclose a proper standard of care expert.
She eventually presented a third expert, but Martin’s attorneys argued that the doctor was not a qualified expert under state law because he was board certified in periodontia, while Dr. Martin is board certified in oral and maxillofacial surgery. By this time, the case had gone on for 4 years.
When Ms. Preszler couldn’t come up with a fourth expert who was qualified, the court dismissed the case. The judge also awarded Dr. Martin $19,279.05 for expenses incurred in discovery related to Ms. Preszler’s first expert, attorneys’ fees, and expenses.
Ms. Preszler appealed, arguing that the periodontist was qualified to testify against Martin because he performed dental implant surgeries in the past without the board certification Dr. Martin obtained. In its Jan. 20, 2022, decision, a panel of the Arizona Court of Appeals upheld the decision, ruling that the expert was not qualified to opine. The patient must also pay the physician’s legal expenses as ordered by the lower court.
“[Ms.] Preszler has not shown the superior court abused its discretion in the award issued,” appellate judges wrote. “Three years after [Ms.] Preszler disclosed her first expert witness, that expert withdrew. [Dr.] Martin claimed substantial expenses relating to discovery addressing [Ms.] Preszler’s first expert, which were no longer beneficial given his withdrawal. ... [Ms.] Preszler has not shown that the expenses awarded to [Dr.] Martin were unreasonable or disproportionate to the time and costs expended regarding the withdrawn expert.”
A version of this article first appeared on Medscape.com.
US Multi-Society Task Force lowers recommended CRC screening age
The U.S. Multi-Society Task Force on Colorectal Cancer (CRC) has lowered the recommended age to start CRC screening from 50 to 45 years of age for all average-risk individuals.
Although no studies have directly demonstrated the result of lowering the age of screening, lead author Swati G. Patel, MD, of University of Colorado Anschutz Medical Center, Aurora, and colleagues suggested that the increasing incidence of advanced CRC among younger individuals, coupled with the net benefit of screening, warrant a lower age threshold.
“Recent data ... show that CRC incidence rates in individuals ages 50 to 64 have increased by 1% annually between 2011 and 2016,” the authors wrote in Gastroenterology. “Similarly, CRC incidence and mortality rates in persons under age 50, termed early-age onset CRC (EAO-CRC), are also increasing.”
The task force of nine experts, representing the American Gastroenterological Association, the American College of Gastroenterology, and the American Society for Gastrointestinal Endoscopy, conducted a literature review and generated recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. In addition to recommending a lower age for initial screening, Dr. Patel and colleagues provided guidance for cessation of screening among older individuals.
Guidance for screening initiation
According to the authors, the present risk of CRC among younger individuals mirrors the historical risk for older individuals before screening was prevalent.
“The current CRC incidence rates in individuals ages 45 to 49 are similar to the incidence rates observed in 50-year-olds in 1992, before widespread CRC screening was performed,” they wrote.
Elevated rates among younger people have been disproportionately driven by rectal cancer, according to the authors. From 2006 to 2015, incidence of rectal cancer among Americans under 50 increased 1.7% per year, compared with 0.7% per year for colon cancer, based on data from the North American Association of Central Cancer Registries.
Associated mortality rates also increased, the authors noted. From 1999-2019, mortality from colon cancer among people 45-49 years increased from 6.4 to 6.6 deaths per 100,000 individuals, while deaths from rectal cancer increased from 1.3 to 1.7 per 100,000, according to the CDC. Concurrently, CRC-associated mortality rates among older individuals generally declined.
While these findings suggest a growing disease burden among the under-50-year age group, controlled data demonstrating the effects of earlier screening are lacking, Dr. Patel and colleagues noted. Still, they predicted that expanded screening would generate a net benefit.
“Although there are no CRC screening safety data for average-risk individuals [younger than] 50, there are ample data that colonoscopy for other indications (screening based on family history, symptom evaluation, etc.) is safer when comparing younger versus older individuals,” they wrote.
Supporting this claim, the authors cited three independently generated microsimulation models from the Agency for Healthcare Research and Quality that “showed a favorable balance of life-years gained compared with adverse events,” given 100% compliance.
Guidance for screening cessation
Like the situation with younger individuals, minimal data are available to determine the best time for screening cessation, according to the task force.
“There are no randomized or observational studies after 2017 that enrolled individuals over age 75 to inform the appropriate time to stop CRC screening,” the authors wrote. “In our search of 37 relevant articles, only one presented primary data for when to stop screening.”
This one available study showed that some individuals older than 74 do in fact gain benefit from screening,
“For example,” Dr. Patel and colleagues wrote, “women without a history of screening and no comorbidities benefitted from annual fecal immunochemical test (FIT) screening until age 90, whereas unscreened men with or without comorbidities benefited from annual FIT screening until age 88. Conversely, screening was not beneficial beyond age 66 in men or women with severe comorbidities.”
The task force therefore recommended personalized screening for individuals 76-85 years of age “based on the balance of benefits and harms and individual patient clinical factors and preferences.”
Screening for individuals 86 years and older, according to the task force, is unnecessary.
The authors disclosed relationships with Olympus America, Bayer Pharmaceuticals, Janssen Pharmaceuticals, and others.
This article was updated on Jan. 3, 2022.
The U.S. Multi-Society Task Force on Colorectal Cancer (CRC) has lowered the recommended age to start CRC screening from 50 to 45 years of age for all average-risk individuals.
Although no studies have directly demonstrated the result of lowering the age of screening, lead author Swati G. Patel, MD, of University of Colorado Anschutz Medical Center, Aurora, and colleagues suggested that the increasing incidence of advanced CRC among younger individuals, coupled with the net benefit of screening, warrant a lower age threshold.
“Recent data ... show that CRC incidence rates in individuals ages 50 to 64 have increased by 1% annually between 2011 and 2016,” the authors wrote in Gastroenterology. “Similarly, CRC incidence and mortality rates in persons under age 50, termed early-age onset CRC (EAO-CRC), are also increasing.”
The task force of nine experts, representing the American Gastroenterological Association, the American College of Gastroenterology, and the American Society for Gastrointestinal Endoscopy, conducted a literature review and generated recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. In addition to recommending a lower age for initial screening, Dr. Patel and colleagues provided guidance for cessation of screening among older individuals.
Guidance for screening initiation
According to the authors, the present risk of CRC among younger individuals mirrors the historical risk for older individuals before screening was prevalent.
“The current CRC incidence rates in individuals ages 45 to 49 are similar to the incidence rates observed in 50-year-olds in 1992, before widespread CRC screening was performed,” they wrote.
Elevated rates among younger people have been disproportionately driven by rectal cancer, according to the authors. From 2006 to 2015, incidence of rectal cancer among Americans under 50 increased 1.7% per year, compared with 0.7% per year for colon cancer, based on data from the North American Association of Central Cancer Registries.
Associated mortality rates also increased, the authors noted. From 1999-2019, mortality from colon cancer among people 45-49 years increased from 6.4 to 6.6 deaths per 100,000 individuals, while deaths from rectal cancer increased from 1.3 to 1.7 per 100,000, according to the CDC. Concurrently, CRC-associated mortality rates among older individuals generally declined.
While these findings suggest a growing disease burden among the under-50-year age group, controlled data demonstrating the effects of earlier screening are lacking, Dr. Patel and colleagues noted. Still, they predicted that expanded screening would generate a net benefit.
“Although there are no CRC screening safety data for average-risk individuals [younger than] 50, there are ample data that colonoscopy for other indications (screening based on family history, symptom evaluation, etc.) is safer when comparing younger versus older individuals,” they wrote.
Supporting this claim, the authors cited three independently generated microsimulation models from the Agency for Healthcare Research and Quality that “showed a favorable balance of life-years gained compared with adverse events,” given 100% compliance.
Guidance for screening cessation
Like the situation with younger individuals, minimal data are available to determine the best time for screening cessation, according to the task force.
“There are no randomized or observational studies after 2017 that enrolled individuals over age 75 to inform the appropriate time to stop CRC screening,” the authors wrote. “In our search of 37 relevant articles, only one presented primary data for when to stop screening.”
This one available study showed that some individuals older than 74 do in fact gain benefit from screening,
“For example,” Dr. Patel and colleagues wrote, “women without a history of screening and no comorbidities benefitted from annual fecal immunochemical test (FIT) screening until age 90, whereas unscreened men with or without comorbidities benefited from annual FIT screening until age 88. Conversely, screening was not beneficial beyond age 66 in men or women with severe comorbidities.”
The task force therefore recommended personalized screening for individuals 76-85 years of age “based on the balance of benefits and harms and individual patient clinical factors and preferences.”
Screening for individuals 86 years and older, according to the task force, is unnecessary.
The authors disclosed relationships with Olympus America, Bayer Pharmaceuticals, Janssen Pharmaceuticals, and others.
This article was updated on Jan. 3, 2022.
The U.S. Multi-Society Task Force on Colorectal Cancer (CRC) has lowered the recommended age to start CRC screening from 50 to 45 years of age for all average-risk individuals.
Although no studies have directly demonstrated the result of lowering the age of screening, lead author Swati G. Patel, MD, of University of Colorado Anschutz Medical Center, Aurora, and colleagues suggested that the increasing incidence of advanced CRC among younger individuals, coupled with the net benefit of screening, warrant a lower age threshold.
“Recent data ... show that CRC incidence rates in individuals ages 50 to 64 have increased by 1% annually between 2011 and 2016,” the authors wrote in Gastroenterology. “Similarly, CRC incidence and mortality rates in persons under age 50, termed early-age onset CRC (EAO-CRC), are also increasing.”
The task force of nine experts, representing the American Gastroenterological Association, the American College of Gastroenterology, and the American Society for Gastrointestinal Endoscopy, conducted a literature review and generated recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. In addition to recommending a lower age for initial screening, Dr. Patel and colleagues provided guidance for cessation of screening among older individuals.
Guidance for screening initiation
According to the authors, the present risk of CRC among younger individuals mirrors the historical risk for older individuals before screening was prevalent.
“The current CRC incidence rates in individuals ages 45 to 49 are similar to the incidence rates observed in 50-year-olds in 1992, before widespread CRC screening was performed,” they wrote.
Elevated rates among younger people have been disproportionately driven by rectal cancer, according to the authors. From 2006 to 2015, incidence of rectal cancer among Americans under 50 increased 1.7% per year, compared with 0.7% per year for colon cancer, based on data from the North American Association of Central Cancer Registries.
Associated mortality rates also increased, the authors noted. From 1999-2019, mortality from colon cancer among people 45-49 years increased from 6.4 to 6.6 deaths per 100,000 individuals, while deaths from rectal cancer increased from 1.3 to 1.7 per 100,000, according to the CDC. Concurrently, CRC-associated mortality rates among older individuals generally declined.
While these findings suggest a growing disease burden among the under-50-year age group, controlled data demonstrating the effects of earlier screening are lacking, Dr. Patel and colleagues noted. Still, they predicted that expanded screening would generate a net benefit.
“Although there are no CRC screening safety data for average-risk individuals [younger than] 50, there are ample data that colonoscopy for other indications (screening based on family history, symptom evaluation, etc.) is safer when comparing younger versus older individuals,” they wrote.
Supporting this claim, the authors cited three independently generated microsimulation models from the Agency for Healthcare Research and Quality that “showed a favorable balance of life-years gained compared with adverse events,” given 100% compliance.
Guidance for screening cessation
Like the situation with younger individuals, minimal data are available to determine the best time for screening cessation, according to the task force.
“There are no randomized or observational studies after 2017 that enrolled individuals over age 75 to inform the appropriate time to stop CRC screening,” the authors wrote. “In our search of 37 relevant articles, only one presented primary data for when to stop screening.”
This one available study showed that some individuals older than 74 do in fact gain benefit from screening,
“For example,” Dr. Patel and colleagues wrote, “women without a history of screening and no comorbidities benefitted from annual fecal immunochemical test (FIT) screening until age 90, whereas unscreened men with or without comorbidities benefited from annual FIT screening until age 88. Conversely, screening was not beneficial beyond age 66 in men or women with severe comorbidities.”
The task force therefore recommended personalized screening for individuals 76-85 years of age “based on the balance of benefits and harms and individual patient clinical factors and preferences.”
Screening for individuals 86 years and older, according to the task force, is unnecessary.
The authors disclosed relationships with Olympus America, Bayer Pharmaceuticals, Janssen Pharmaceuticals, and others.
This article was updated on Jan. 3, 2022.
FROM GASTROENTEROLOGY
Tracking adenomas per colonoscopy shows promise as quality measure
The number of adenomas per colonoscopy (APC) is inversely correlated with postcolonoscopy colorectal cancer (PCCRC), which supports use of APC as a new quality control measure, according to investigators.
Data from 138 endoscopists showed that patients screened by physicians with higher APCs had significantly lower rates of PCCRC, and an APC of 0.6 offered more protection than either an APC of 0.4 or an adenoma detection rate (ADR) of 25%, reported lead author Joseph C. Anderson, MD, of White River Junction VA Medical Center, Hanover, N.H., and colleagues.
“Unfortunately, APC has never been validated as a quality measure by demonstrating a reduction in PCCRC in exams performed by endoscopists with higher rates,” Dr. Anderson said at the annual meeting of the American College of Gastroenterology.
To this end, Dr. Anderson and colleagues reviewed data from the New Hampshire Colonoscopy Registry (NHCR), including 9,023 screening colonoscopies with a follow-up event 6-60 months after the initial exam. Procedures were conducted by 138 endoscopists in New Hampshire, Vermont, Massachusetts, and Maine.
Three quality measures were analyzed for associations with PCCRC: an APC of 0.4, an APC of 0.6, and an ADR of 25%. Hazard ratios were calculated for all PCCRCs, as well as PCCRCs diagnosed at first follow-up event. Rates were reported for two time periods: 6-36 months and 6-60 months.
From 6 to 60 months, 82 cases of PCCRC were diagnosed, among which 50 were diagnosed between 6 and 36 months.
For both periods, all three quality measures were significantly associated with reductions in PCCRC. The higher APC of 0.6, however, offered greater protection, reducing all PCCRCs by 71% and 61% in the shorter and longer period, respectively. In comparison, the lower APC of 0.4 reduced rates by 63% and 53%, while the ADR benchmark reduced rates by 62% and 42%.
These trends were maintained for PCCRCs diagnosed at first follow-up event. An APC of 0.6 was associated with respective reductions of 79% and 65% for the shorter and longer period, compared with 64% and 57% for the lower APC, and 67% and 49% for ADR.
Additional analysis clarified the relationship between APC level and likelihood of developing PCCRC. In terms of absolute risk, patients screened by an endoscopist with an APC greater than 0.6 had a 0.5% chance of developing PCCRC from 6 to 36 months, compared with 0.7% for an APC of 0.4-0.6, and 2.1% for an APC of less than 0.4 (P = .0001). This pattern held through 60 months, during which time an APC greater than 0.6 was associated with an absolute risk of PCCRC of 0.4%, compared with 0.7% for an APC of 0.4-0.6, and 1.6% for an APC less than 0.4 (P = .0001).
“Our novel data support the use of APC as a quality measure by demonstrating a reduction in PCCRC risk in exams performed by endoscopists with higher APCs,” Dr. Anderson concluded, noting that an APC of 0.6 appeared to offer more protection than an APC of 0.4. “I feel that ... APC as a quality measure, now that we’ve validated it, may be accepted because of its ability to differentiate endoscopists on their adenoma detection skills.”
According to Lawrence Hookey, MD, of Queen’s University, Kingston, Ont., “It’s an important study that will probably contribute to where we’re going forward.”
Dr. Lawrence, chair of the division and medical director of the endoscopy units at Kingston General and Hotel Dieu hospitals, said that APC may overcome the main concern with ADR – that endoscopists who find one adenoma may not be motivated to seek out as many as possible.
“The problem with ADR, in general, is that if you find one polyp, and if ADR is the stat you’re living by, then you don’t need to find any other polyps, and that obviously doesn’t do that patient a favor, necessarily,” Dr. Hookey said in an interview. “It does bring them back sooner for surveillance, but it doesn’t help remove the rest of the polyps that they have. And not that someone is going to find one polyp and turn off the light and pull the scope out, but you may not be looking as hard.”
APC mitigates this issue, he explained, because it determines “whether or not you’re truly clearing things out and getting rid of as many [polyps] as possible.”
Dr. Hookey said that APC is “probably the best” quality control measure on the horizon, and he suggested that more work is needed to determine the optimal benchmark figure, which should ideally be investigated through larger studies.
“I just want to see it in bigger groups,” he said.
The investigators and Dr. Hookey reported no conflicts of interest.
The number of adenomas per colonoscopy (APC) is inversely correlated with postcolonoscopy colorectal cancer (PCCRC), which supports use of APC as a new quality control measure, according to investigators.
Data from 138 endoscopists showed that patients screened by physicians with higher APCs had significantly lower rates of PCCRC, and an APC of 0.6 offered more protection than either an APC of 0.4 or an adenoma detection rate (ADR) of 25%, reported lead author Joseph C. Anderson, MD, of White River Junction VA Medical Center, Hanover, N.H., and colleagues.
“Unfortunately, APC has never been validated as a quality measure by demonstrating a reduction in PCCRC in exams performed by endoscopists with higher rates,” Dr. Anderson said at the annual meeting of the American College of Gastroenterology.
To this end, Dr. Anderson and colleagues reviewed data from the New Hampshire Colonoscopy Registry (NHCR), including 9,023 screening colonoscopies with a follow-up event 6-60 months after the initial exam. Procedures were conducted by 138 endoscopists in New Hampshire, Vermont, Massachusetts, and Maine.
Three quality measures were analyzed for associations with PCCRC: an APC of 0.4, an APC of 0.6, and an ADR of 25%. Hazard ratios were calculated for all PCCRCs, as well as PCCRCs diagnosed at first follow-up event. Rates were reported for two time periods: 6-36 months and 6-60 months.
From 6 to 60 months, 82 cases of PCCRC were diagnosed, among which 50 were diagnosed between 6 and 36 months.
For both periods, all three quality measures were significantly associated with reductions in PCCRC. The higher APC of 0.6, however, offered greater protection, reducing all PCCRCs by 71% and 61% in the shorter and longer period, respectively. In comparison, the lower APC of 0.4 reduced rates by 63% and 53%, while the ADR benchmark reduced rates by 62% and 42%.
These trends were maintained for PCCRCs diagnosed at first follow-up event. An APC of 0.6 was associated with respective reductions of 79% and 65% for the shorter and longer period, compared with 64% and 57% for the lower APC, and 67% and 49% for ADR.
Additional analysis clarified the relationship between APC level and likelihood of developing PCCRC. In terms of absolute risk, patients screened by an endoscopist with an APC greater than 0.6 had a 0.5% chance of developing PCCRC from 6 to 36 months, compared with 0.7% for an APC of 0.4-0.6, and 2.1% for an APC of less than 0.4 (P = .0001). This pattern held through 60 months, during which time an APC greater than 0.6 was associated with an absolute risk of PCCRC of 0.4%, compared with 0.7% for an APC of 0.4-0.6, and 1.6% for an APC less than 0.4 (P = .0001).
“Our novel data support the use of APC as a quality measure by demonstrating a reduction in PCCRC risk in exams performed by endoscopists with higher APCs,” Dr. Anderson concluded, noting that an APC of 0.6 appeared to offer more protection than an APC of 0.4. “I feel that ... APC as a quality measure, now that we’ve validated it, may be accepted because of its ability to differentiate endoscopists on their adenoma detection skills.”
According to Lawrence Hookey, MD, of Queen’s University, Kingston, Ont., “It’s an important study that will probably contribute to where we’re going forward.”
Dr. Lawrence, chair of the division and medical director of the endoscopy units at Kingston General and Hotel Dieu hospitals, said that APC may overcome the main concern with ADR – that endoscopists who find one adenoma may not be motivated to seek out as many as possible.
“The problem with ADR, in general, is that if you find one polyp, and if ADR is the stat you’re living by, then you don’t need to find any other polyps, and that obviously doesn’t do that patient a favor, necessarily,” Dr. Hookey said in an interview. “It does bring them back sooner for surveillance, but it doesn’t help remove the rest of the polyps that they have. And not that someone is going to find one polyp and turn off the light and pull the scope out, but you may not be looking as hard.”
APC mitigates this issue, he explained, because it determines “whether or not you’re truly clearing things out and getting rid of as many [polyps] as possible.”
Dr. Hookey said that APC is “probably the best” quality control measure on the horizon, and he suggested that more work is needed to determine the optimal benchmark figure, which should ideally be investigated through larger studies.
“I just want to see it in bigger groups,” he said.
The investigators and Dr. Hookey reported no conflicts of interest.
The number of adenomas per colonoscopy (APC) is inversely correlated with postcolonoscopy colorectal cancer (PCCRC), which supports use of APC as a new quality control measure, according to investigators.
Data from 138 endoscopists showed that patients screened by physicians with higher APCs had significantly lower rates of PCCRC, and an APC of 0.6 offered more protection than either an APC of 0.4 or an adenoma detection rate (ADR) of 25%, reported lead author Joseph C. Anderson, MD, of White River Junction VA Medical Center, Hanover, N.H., and colleagues.
“Unfortunately, APC has never been validated as a quality measure by demonstrating a reduction in PCCRC in exams performed by endoscopists with higher rates,” Dr. Anderson said at the annual meeting of the American College of Gastroenterology.
To this end, Dr. Anderson and colleagues reviewed data from the New Hampshire Colonoscopy Registry (NHCR), including 9,023 screening colonoscopies with a follow-up event 6-60 months after the initial exam. Procedures were conducted by 138 endoscopists in New Hampshire, Vermont, Massachusetts, and Maine.
Three quality measures were analyzed for associations with PCCRC: an APC of 0.4, an APC of 0.6, and an ADR of 25%. Hazard ratios were calculated for all PCCRCs, as well as PCCRCs diagnosed at first follow-up event. Rates were reported for two time periods: 6-36 months and 6-60 months.
From 6 to 60 months, 82 cases of PCCRC were diagnosed, among which 50 were diagnosed between 6 and 36 months.
For both periods, all three quality measures were significantly associated with reductions in PCCRC. The higher APC of 0.6, however, offered greater protection, reducing all PCCRCs by 71% and 61% in the shorter and longer period, respectively. In comparison, the lower APC of 0.4 reduced rates by 63% and 53%, while the ADR benchmark reduced rates by 62% and 42%.
These trends were maintained for PCCRCs diagnosed at first follow-up event. An APC of 0.6 was associated with respective reductions of 79% and 65% for the shorter and longer period, compared with 64% and 57% for the lower APC, and 67% and 49% for ADR.
Additional analysis clarified the relationship between APC level and likelihood of developing PCCRC. In terms of absolute risk, patients screened by an endoscopist with an APC greater than 0.6 had a 0.5% chance of developing PCCRC from 6 to 36 months, compared with 0.7% for an APC of 0.4-0.6, and 2.1% for an APC of less than 0.4 (P = .0001). This pattern held through 60 months, during which time an APC greater than 0.6 was associated with an absolute risk of PCCRC of 0.4%, compared with 0.7% for an APC of 0.4-0.6, and 1.6% for an APC less than 0.4 (P = .0001).
“Our novel data support the use of APC as a quality measure by demonstrating a reduction in PCCRC risk in exams performed by endoscopists with higher APCs,” Dr. Anderson concluded, noting that an APC of 0.6 appeared to offer more protection than an APC of 0.4. “I feel that ... APC as a quality measure, now that we’ve validated it, may be accepted because of its ability to differentiate endoscopists on their adenoma detection skills.”
According to Lawrence Hookey, MD, of Queen’s University, Kingston, Ont., “It’s an important study that will probably contribute to where we’re going forward.”
Dr. Lawrence, chair of the division and medical director of the endoscopy units at Kingston General and Hotel Dieu hospitals, said that APC may overcome the main concern with ADR – that endoscopists who find one adenoma may not be motivated to seek out as many as possible.
“The problem with ADR, in general, is that if you find one polyp, and if ADR is the stat you’re living by, then you don’t need to find any other polyps, and that obviously doesn’t do that patient a favor, necessarily,” Dr. Hookey said in an interview. “It does bring them back sooner for surveillance, but it doesn’t help remove the rest of the polyps that they have. And not that someone is going to find one polyp and turn off the light and pull the scope out, but you may not be looking as hard.”
APC mitigates this issue, he explained, because it determines “whether or not you’re truly clearing things out and getting rid of as many [polyps] as possible.”
Dr. Hookey said that APC is “probably the best” quality control measure on the horizon, and he suggested that more work is needed to determine the optimal benchmark figure, which should ideally be investigated through larger studies.
“I just want to see it in bigger groups,” he said.
The investigators and Dr. Hookey reported no conflicts of interest.
FROM ACG 2021
'Deep learning' AI shows benefit in colonoscopy in U.S. population
Adenoma miss rates were significantly lower with the use of an artificial intelligence (AI)–based computer-aided detection (CADe) system than with high-definition white light (HDWL), according to a new prospective, multicenter, single-blind randomized study based on data from more than 200 colonoscopies.
Missed adenomas can be generally categorized as adenomas fully obscured from the visual field or those appearing partly or fully in the visual field but missed by an endoscopist, wrote Jeremy R. Glissen Brown, MD, of Harvard Medical School, Boston, and colleagues. While retrospective and prospective studies in China, Italy, and Japan have shown that deep-learning CADe improves adenoma identification during colonoscopy, there have been no prospective U.S. studies on CADe in a diverse population, they noted.
In the study published in Clinical Gastroenterology and Hepatology, the researchers reviewed data from 223 adults aged 22 years and older who underwent screening colonoscopies across four U.S. academic medical centers between 2019 and 2020. The procedure indication was primary colorectal cancer screening for 59.6% of the patients and postpolypectomy surveillance for 40.4%. Among this cohort, 45.3% (101) were female, 67.7% (151) were White, and 21% (133) were African American. Participants were randomized to receive either CADe colonoscopy first or HDWL colonoscopy first; the patients immediately underwent the other procedure in tandem fashion from the same endoscopist.
The primary outcome of the study was adenoma miss rate (AMR), defined as “the number of histologically confirmed adenomas detected during the second colonoscopy in either arm divided by the total number of adenomas detected during both procedures.” Sessile serrated lesion (SSL) miss rates and adenomas per colonoscopy (APC) were secondary outcomes.
Overall, the primary outcome of AMR was significantly lower in the CADe-first group, compared with the HDWL-first group (20.12% vs. 31.25%; P = .0247), with an odds ratio of 1.8048 (95% CI, 1.0780-3.0217). The CADe-first group yielded a lower SSL miss rate, compared with the HDLW-first group (7.14% vs. 42.11%; P = .0482), as well as a lower polyp miss rate (20.70% vs. 33.71%; P = .0007). The first-pass number of APC was significantly higher in the CADe-first group, compared with the HDWL-first group (1.19 [SD 2.03] vs. 0.90 [SD 1.55]; P = .0323). In addition, the first-pass adenoma detection rate (ADR) was not significantly different in the CADe-first group, compared with the HDWL-first group (50.44% vs. 43.64%; P = .3091), and the median withdrawal time was significantly shorter with CADe, compared with HDWL (9.5 minutes vs. 8.5 minutes; P = .0098).
There were no significant observable differences between the two groups regarding missed adenomas arranged by size or location. Moreover, there were no significant differences in miss rates for hyperplastic polyps or advanced adenomas. Factors significantly associated with missed adenomas included being in the HDLW-first group, age 65 years or younger, and the right colon vs. other locations. No immediate adverse events occurred in either group.
According to the researchers, while previous studies in China and Italy have shown increased ADR using CADe systems, these results are not generalizable to the U.S. population for several reasons, notably the studies’ inclusion of colonoscopy indications other than colorectal cancer screening and surveillance. Though the present study showed a significantly lower AMR with CADe, it still represents missed adenomas. The researchers note: “In the present study, in which CADe detected 285 polyps, there were only three false negatives (defined as polyps that were visualized by the endoscopist but not by the CADe system). Overall, this suggests that the ‘missed polyps’ in the CADe arm may have been obscured behind folds rather than in the visual field.” They added, “Further research is needed on combining CADe technologies with mucosal exposure devices, as the benefits of these tools for polyp detection may be additive.”
The study findings were limited by several factors, including the inability to detect a difference in overall ADR, the limited generalizability of the tandem study design to real-world practice, the inclusion of only experienced endoscopists, and the use of a second monitor that may have impacted gaze patterns, the researchers noted. However, the results represent the first examination of deep-learning CADe in a diverse U.S. population and showed a decrease in adenoma miss rates and decreased miss rates for polyps and SSLs, compared with HDWL. Based on these findings, the authors concluded CADe “has the potential to decrease inter-provider variability in colonoscopy quality by reducing adenoma miss rate even in experienced providers.”
Reducing miss rates matters
“Missed adenomas can be associated with the development of interval colorectal cancer, so whether novel technologies such as artificial intelligence-based computer-aided polyp detection system can decrease adenoma miss rate is of interest,” said Atsushi Sakuraba, MD, of the University of Chicago, in an interview.
Dr Sakuraba said he was not surprised by the current study findings, as several pilot and randomized studies have shown the benefits of AI-based polyp detection systems. As for how the AI-assisted technology might improve practice, he said it may be a valuable addition. “Adenoma miss rate was significantly lower with an AI-based polyp detection system, so it might lead to decreased colorectal cancer,” he explained. “Various methods to improve adenoma detection should complement each other.
Dr. Sakuraba also commented that additional research is needed outside of academic centers, noting “further studies in the community setting involving various endoscopists are required to confirm generalizability.”
Lead author Dr. Glissen Brown had no financial conflicts to disclose. This was an investigator-initiated study, with research software and study funding provided by Wision. Dr. Sakuraba disclosed collaborative research with Fuji film, which was not involved in this study.
Adenoma miss rates were significantly lower with the use of an artificial intelligence (AI)–based computer-aided detection (CADe) system than with high-definition white light (HDWL), according to a new prospective, multicenter, single-blind randomized study based on data from more than 200 colonoscopies.
Missed adenomas can be generally categorized as adenomas fully obscured from the visual field or those appearing partly or fully in the visual field but missed by an endoscopist, wrote Jeremy R. Glissen Brown, MD, of Harvard Medical School, Boston, and colleagues. While retrospective and prospective studies in China, Italy, and Japan have shown that deep-learning CADe improves adenoma identification during colonoscopy, there have been no prospective U.S. studies on CADe in a diverse population, they noted.
In the study published in Clinical Gastroenterology and Hepatology, the researchers reviewed data from 223 adults aged 22 years and older who underwent screening colonoscopies across four U.S. academic medical centers between 2019 and 2020. The procedure indication was primary colorectal cancer screening for 59.6% of the patients and postpolypectomy surveillance for 40.4%. Among this cohort, 45.3% (101) were female, 67.7% (151) were White, and 21% (133) were African American. Participants were randomized to receive either CADe colonoscopy first or HDWL colonoscopy first; the patients immediately underwent the other procedure in tandem fashion from the same endoscopist.
The primary outcome of the study was adenoma miss rate (AMR), defined as “the number of histologically confirmed adenomas detected during the second colonoscopy in either arm divided by the total number of adenomas detected during both procedures.” Sessile serrated lesion (SSL) miss rates and adenomas per colonoscopy (APC) were secondary outcomes.
Overall, the primary outcome of AMR was significantly lower in the CADe-first group, compared with the HDWL-first group (20.12% vs. 31.25%; P = .0247), with an odds ratio of 1.8048 (95% CI, 1.0780-3.0217). The CADe-first group yielded a lower SSL miss rate, compared with the HDLW-first group (7.14% vs. 42.11%; P = .0482), as well as a lower polyp miss rate (20.70% vs. 33.71%; P = .0007). The first-pass number of APC was significantly higher in the CADe-first group, compared with the HDWL-first group (1.19 [SD 2.03] vs. 0.90 [SD 1.55]; P = .0323). In addition, the first-pass adenoma detection rate (ADR) was not significantly different in the CADe-first group, compared with the HDWL-first group (50.44% vs. 43.64%; P = .3091), and the median withdrawal time was significantly shorter with CADe, compared with HDWL (9.5 minutes vs. 8.5 minutes; P = .0098).
There were no significant observable differences between the two groups regarding missed adenomas arranged by size or location. Moreover, there were no significant differences in miss rates for hyperplastic polyps or advanced adenomas. Factors significantly associated with missed adenomas included being in the HDLW-first group, age 65 years or younger, and the right colon vs. other locations. No immediate adverse events occurred in either group.
According to the researchers, while previous studies in China and Italy have shown increased ADR using CADe systems, these results are not generalizable to the U.S. population for several reasons, notably the studies’ inclusion of colonoscopy indications other than colorectal cancer screening and surveillance. Though the present study showed a significantly lower AMR with CADe, it still represents missed adenomas. The researchers note: “In the present study, in which CADe detected 285 polyps, there were only three false negatives (defined as polyps that were visualized by the endoscopist but not by the CADe system). Overall, this suggests that the ‘missed polyps’ in the CADe arm may have been obscured behind folds rather than in the visual field.” They added, “Further research is needed on combining CADe technologies with mucosal exposure devices, as the benefits of these tools for polyp detection may be additive.”
The study findings were limited by several factors, including the inability to detect a difference in overall ADR, the limited generalizability of the tandem study design to real-world practice, the inclusion of only experienced endoscopists, and the use of a second monitor that may have impacted gaze patterns, the researchers noted. However, the results represent the first examination of deep-learning CADe in a diverse U.S. population and showed a decrease in adenoma miss rates and decreased miss rates for polyps and SSLs, compared with HDWL. Based on these findings, the authors concluded CADe “has the potential to decrease inter-provider variability in colonoscopy quality by reducing adenoma miss rate even in experienced providers.”
Reducing miss rates matters
“Missed adenomas can be associated with the development of interval colorectal cancer, so whether novel technologies such as artificial intelligence-based computer-aided polyp detection system can decrease adenoma miss rate is of interest,” said Atsushi Sakuraba, MD, of the University of Chicago, in an interview.
Dr Sakuraba said he was not surprised by the current study findings, as several pilot and randomized studies have shown the benefits of AI-based polyp detection systems. As for how the AI-assisted technology might improve practice, he said it may be a valuable addition. “Adenoma miss rate was significantly lower with an AI-based polyp detection system, so it might lead to decreased colorectal cancer,” he explained. “Various methods to improve adenoma detection should complement each other.
Dr. Sakuraba also commented that additional research is needed outside of academic centers, noting “further studies in the community setting involving various endoscopists are required to confirm generalizability.”
Lead author Dr. Glissen Brown had no financial conflicts to disclose. This was an investigator-initiated study, with research software and study funding provided by Wision. Dr. Sakuraba disclosed collaborative research with Fuji film, which was not involved in this study.
Adenoma miss rates were significantly lower with the use of an artificial intelligence (AI)–based computer-aided detection (CADe) system than with high-definition white light (HDWL), according to a new prospective, multicenter, single-blind randomized study based on data from more than 200 colonoscopies.
Missed adenomas can be generally categorized as adenomas fully obscured from the visual field or those appearing partly or fully in the visual field but missed by an endoscopist, wrote Jeremy R. Glissen Brown, MD, of Harvard Medical School, Boston, and colleagues. While retrospective and prospective studies in China, Italy, and Japan have shown that deep-learning CADe improves adenoma identification during colonoscopy, there have been no prospective U.S. studies on CADe in a diverse population, they noted.
In the study published in Clinical Gastroenterology and Hepatology, the researchers reviewed data from 223 adults aged 22 years and older who underwent screening colonoscopies across four U.S. academic medical centers between 2019 and 2020. The procedure indication was primary colorectal cancer screening for 59.6% of the patients and postpolypectomy surveillance for 40.4%. Among this cohort, 45.3% (101) were female, 67.7% (151) were White, and 21% (133) were African American. Participants were randomized to receive either CADe colonoscopy first or HDWL colonoscopy first; the patients immediately underwent the other procedure in tandem fashion from the same endoscopist.
The primary outcome of the study was adenoma miss rate (AMR), defined as “the number of histologically confirmed adenomas detected during the second colonoscopy in either arm divided by the total number of adenomas detected during both procedures.” Sessile serrated lesion (SSL) miss rates and adenomas per colonoscopy (APC) were secondary outcomes.
Overall, the primary outcome of AMR was significantly lower in the CADe-first group, compared with the HDWL-first group (20.12% vs. 31.25%; P = .0247), with an odds ratio of 1.8048 (95% CI, 1.0780-3.0217). The CADe-first group yielded a lower SSL miss rate, compared with the HDLW-first group (7.14% vs. 42.11%; P = .0482), as well as a lower polyp miss rate (20.70% vs. 33.71%; P = .0007). The first-pass number of APC was significantly higher in the CADe-first group, compared with the HDWL-first group (1.19 [SD 2.03] vs. 0.90 [SD 1.55]; P = .0323). In addition, the first-pass adenoma detection rate (ADR) was not significantly different in the CADe-first group, compared with the HDWL-first group (50.44% vs. 43.64%; P = .3091), and the median withdrawal time was significantly shorter with CADe, compared with HDWL (9.5 minutes vs. 8.5 minutes; P = .0098).
There were no significant observable differences between the two groups regarding missed adenomas arranged by size or location. Moreover, there were no significant differences in miss rates for hyperplastic polyps or advanced adenomas. Factors significantly associated with missed adenomas included being in the HDLW-first group, age 65 years or younger, and the right colon vs. other locations. No immediate adverse events occurred in either group.
According to the researchers, while previous studies in China and Italy have shown increased ADR using CADe systems, these results are not generalizable to the U.S. population for several reasons, notably the studies’ inclusion of colonoscopy indications other than colorectal cancer screening and surveillance. Though the present study showed a significantly lower AMR with CADe, it still represents missed adenomas. The researchers note: “In the present study, in which CADe detected 285 polyps, there were only three false negatives (defined as polyps that were visualized by the endoscopist but not by the CADe system). Overall, this suggests that the ‘missed polyps’ in the CADe arm may have been obscured behind folds rather than in the visual field.” They added, “Further research is needed on combining CADe technologies with mucosal exposure devices, as the benefits of these tools for polyp detection may be additive.”
The study findings were limited by several factors, including the inability to detect a difference in overall ADR, the limited generalizability of the tandem study design to real-world practice, the inclusion of only experienced endoscopists, and the use of a second monitor that may have impacted gaze patterns, the researchers noted. However, the results represent the first examination of deep-learning CADe in a diverse U.S. population and showed a decrease in adenoma miss rates and decreased miss rates for polyps and SSLs, compared with HDWL. Based on these findings, the authors concluded CADe “has the potential to decrease inter-provider variability in colonoscopy quality by reducing adenoma miss rate even in experienced providers.”
Reducing miss rates matters
“Missed adenomas can be associated with the development of interval colorectal cancer, so whether novel technologies such as artificial intelligence-based computer-aided polyp detection system can decrease adenoma miss rate is of interest,” said Atsushi Sakuraba, MD, of the University of Chicago, in an interview.
Dr Sakuraba said he was not surprised by the current study findings, as several pilot and randomized studies have shown the benefits of AI-based polyp detection systems. As for how the AI-assisted technology might improve practice, he said it may be a valuable addition. “Adenoma miss rate was significantly lower with an AI-based polyp detection system, so it might lead to decreased colorectal cancer,” he explained. “Various methods to improve adenoma detection should complement each other.
Dr. Sakuraba also commented that additional research is needed outside of academic centers, noting “further studies in the community setting involving various endoscopists are required to confirm generalizability.”
Lead author Dr. Glissen Brown had no financial conflicts to disclose. This was an investigator-initiated study, with research software and study funding provided by Wision. Dr. Sakuraba disclosed collaborative research with Fuji film, which was not involved in this study.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
Concordance of DNA Repair Gene Mutations in Paired Primary Prostate Cancer Samples and Metastatic Tissue or Cell-free DNA
Importance
DNA damage response repair (DDR) gene mutations represent actionable alterations that can guide precision medicine strategies in men with advanced prostate cancer (PC). However, acquisition of contemporary tissue samples for molecular testing can be a barrier to deploying precision medicine approaches. We hypothesized that DDR alterations represent truncal events in PC and that primary tissue would reflect mutations found in cell-free circulating tumor (ctDNA) and/or metastatic tissue. OBJECTIVE: To assess concordance in DDR gene alterations between primary PC and metastases or ctDNA specimens.
Methods
Patients were included if a DDR pathway mutation was detected in metastatic tissue or ctDNA and primary tissue sequencing was available for comparison. Sequencing data from three cohorts were analyzed: (1) FoundationOne; (2) University of Washington (UW-OncoPlex or SU2C/PCF International Dream Team sequencing pipelines); and (3) University of Washington rapid autopsy series. Only pathogenic somatic mutations were included and we required 30 days between primary tumor tissue and ctDNA/ metastatic tissue acquisition. Clonal hematopoiesis of indeterminant potential (CHIP) and germline events were adjudicated by an expert molecular pathologist and excluded. DDR gene mutations detected in primary prostate tissue matched with metastatic tissue and/or ctDNA findings.
Results
Paired primary and ctDNA/metastatic samples were sequenced from 72 individuals with known DDR alterations. After excluding ctDNA studies where only CHIP and/or germline events (N=21) were observed, 51 subjects remained and were included in the final analysis. The median time from acquisition of primary tissue to acquisition of ctDNA or tumor tissue was 55 months (range: 5-193 months). Concordance in DDR gene mutation status across samples was 84% (95% CI: 71-92%). Rates of concordance between metastatic-primary and ctDNAprimary pairs were similar when CHIP cases were excluded. BRCA2 reversion mutations associated with resistance to PARP inhibitors and platinum chemotherapy were detected in ctDNA from two subjects.
Discussion
Primary prostate tissue accurately reflected the mutational status of actionable DDR genes in metastatic tissue, consistent with DDR alterations being truncal in most cases. After excluding likely CHIP events, ctDNA profiling accurately captured these DDR mutations, while also detecting reversion alterations that may suggest resistance mechanisms.
Importance
DNA damage response repair (DDR) gene mutations represent actionable alterations that can guide precision medicine strategies in men with advanced prostate cancer (PC). However, acquisition of contemporary tissue samples for molecular testing can be a barrier to deploying precision medicine approaches. We hypothesized that DDR alterations represent truncal events in PC and that primary tissue would reflect mutations found in cell-free circulating tumor (ctDNA) and/or metastatic tissue. OBJECTIVE: To assess concordance in DDR gene alterations between primary PC and metastases or ctDNA specimens.
Methods
Patients were included if a DDR pathway mutation was detected in metastatic tissue or ctDNA and primary tissue sequencing was available for comparison. Sequencing data from three cohorts were analyzed: (1) FoundationOne; (2) University of Washington (UW-OncoPlex or SU2C/PCF International Dream Team sequencing pipelines); and (3) University of Washington rapid autopsy series. Only pathogenic somatic mutations were included and we required 30 days between primary tumor tissue and ctDNA/ metastatic tissue acquisition. Clonal hematopoiesis of indeterminant potential (CHIP) and germline events were adjudicated by an expert molecular pathologist and excluded. DDR gene mutations detected in primary prostate tissue matched with metastatic tissue and/or ctDNA findings.
Results
Paired primary and ctDNA/metastatic samples were sequenced from 72 individuals with known DDR alterations. After excluding ctDNA studies where only CHIP and/or germline events (N=21) were observed, 51 subjects remained and were included in the final analysis. The median time from acquisition of primary tissue to acquisition of ctDNA or tumor tissue was 55 months (range: 5-193 months). Concordance in DDR gene mutation status across samples was 84% (95% CI: 71-92%). Rates of concordance between metastatic-primary and ctDNAprimary pairs were similar when CHIP cases were excluded. BRCA2 reversion mutations associated with resistance to PARP inhibitors and platinum chemotherapy were detected in ctDNA from two subjects.
Discussion
Primary prostate tissue accurately reflected the mutational status of actionable DDR genes in metastatic tissue, consistent with DDR alterations being truncal in most cases. After excluding likely CHIP events, ctDNA profiling accurately captured these DDR mutations, while also detecting reversion alterations that may suggest resistance mechanisms.
Importance
DNA damage response repair (DDR) gene mutations represent actionable alterations that can guide precision medicine strategies in men with advanced prostate cancer (PC). However, acquisition of contemporary tissue samples for molecular testing can be a barrier to deploying precision medicine approaches. We hypothesized that DDR alterations represent truncal events in PC and that primary tissue would reflect mutations found in cell-free circulating tumor (ctDNA) and/or metastatic tissue. OBJECTIVE: To assess concordance in DDR gene alterations between primary PC and metastases or ctDNA specimens.
Methods
Patients were included if a DDR pathway mutation was detected in metastatic tissue or ctDNA and primary tissue sequencing was available for comparison. Sequencing data from three cohorts were analyzed: (1) FoundationOne; (2) University of Washington (UW-OncoPlex or SU2C/PCF International Dream Team sequencing pipelines); and (3) University of Washington rapid autopsy series. Only pathogenic somatic mutations were included and we required 30 days between primary tumor tissue and ctDNA/ metastatic tissue acquisition. Clonal hematopoiesis of indeterminant potential (CHIP) and germline events were adjudicated by an expert molecular pathologist and excluded. DDR gene mutations detected in primary prostate tissue matched with metastatic tissue and/or ctDNA findings.
Results
Paired primary and ctDNA/metastatic samples were sequenced from 72 individuals with known DDR alterations. After excluding ctDNA studies where only CHIP and/or germline events (N=21) were observed, 51 subjects remained and were included in the final analysis. The median time from acquisition of primary tissue to acquisition of ctDNA or tumor tissue was 55 months (range: 5-193 months). Concordance in DDR gene mutation status across samples was 84% (95% CI: 71-92%). Rates of concordance between metastatic-primary and ctDNAprimary pairs were similar when CHIP cases were excluded. BRCA2 reversion mutations associated with resistance to PARP inhibitors and platinum chemotherapy were detected in ctDNA from two subjects.
Discussion
Primary prostate tissue accurately reflected the mutational status of actionable DDR genes in metastatic tissue, consistent with DDR alterations being truncal in most cases. After excluding likely CHIP events, ctDNA profiling accurately captured these DDR mutations, while also detecting reversion alterations that may suggest resistance mechanisms.
Methods of Identifying Real World mCRPC Patients from the Veterans Health Administration System
Purpose
Prostate cancer is the fifth leading cause of death in the United States. Genomic testing is essential to guide treatment decisions in patients with metastatic castration resistant prostate cancer (mCRPC), the most advanced stage of prostate cancer. However, identifying mCRPC patients from administrative data is challenging and hinders researchers’ ability to assess testing among these patients. This study aims to develop algorithms using structured data and unstructured data with Natural language processing (NLP) methods to identify veterans by disease stage and hormone sensitivity, and to assess patient characteristics as well as receipt of tumor NGS testing.
Methods
We used biopsy, pathology, and diagnosis codes, to identify veterans with newly diagnosed PC within the Veterans Health Administration (VA) from January 1, 2017 to December 31, 2020. We developed and deployed: 1. A structured algorithm that used medication and Prostate-Specific Antigen (PSA) data to assess hormone sensitivity. 2. NLP tools to extract disease stage and hormone sensitivity from clinical notes. We report descriptive statistics on patient demographics, clinical characteristics, disease status, androgen deprivation therapy (ADT), and receipt of tumor NGS testing.
Results
There were 42,485 veterans with newly diagnosed prostate cancer between 2017-2020. This represented ~0.18% of veterans served in the VA and consisted of Whites (57%), Blacks (33%), and others (10%). During the study period, 3,113 (7.3%) patients had documentation of assessment for intraductal carcinoma, 5,160 (12.1%) had ADT treatment, 1,481 (3.5%) had CRPC, and 3,246 (7.6%) had metastatic disease. Among the 42,485 veterans, 422 received tumor NGS testing within VA, and 300 of them had metastatic disease. NLP tool and structured data algorithm collectively showed that 38% of the 422 tumor NGS testing recipients had mCRPC. Among all newly diagnosed PC patients, White patients had highest rates of tumor-based testing (2.3%), then Native Hawaiians (1.7%), Asians and Blacks (1.2% each), compared to Native Americans (0.4%).
Implications
NLP tools alongside structured data algorithms successfully identified variables required to measure access to tumor NGS testing. Efforts to validate and apply this method is ongoing to assess receipt of precision prostate cancer care in VA.
Purpose
Prostate cancer is the fifth leading cause of death in the United States. Genomic testing is essential to guide treatment decisions in patients with metastatic castration resistant prostate cancer (mCRPC), the most advanced stage of prostate cancer. However, identifying mCRPC patients from administrative data is challenging and hinders researchers’ ability to assess testing among these patients. This study aims to develop algorithms using structured data and unstructured data with Natural language processing (NLP) methods to identify veterans by disease stage and hormone sensitivity, and to assess patient characteristics as well as receipt of tumor NGS testing.
Methods
We used biopsy, pathology, and diagnosis codes, to identify veterans with newly diagnosed PC within the Veterans Health Administration (VA) from January 1, 2017 to December 31, 2020. We developed and deployed: 1. A structured algorithm that used medication and Prostate-Specific Antigen (PSA) data to assess hormone sensitivity. 2. NLP tools to extract disease stage and hormone sensitivity from clinical notes. We report descriptive statistics on patient demographics, clinical characteristics, disease status, androgen deprivation therapy (ADT), and receipt of tumor NGS testing.
Results
There were 42,485 veterans with newly diagnosed prostate cancer between 2017-2020. This represented ~0.18% of veterans served in the VA and consisted of Whites (57%), Blacks (33%), and others (10%). During the study period, 3,113 (7.3%) patients had documentation of assessment for intraductal carcinoma, 5,160 (12.1%) had ADT treatment, 1,481 (3.5%) had CRPC, and 3,246 (7.6%) had metastatic disease. Among the 42,485 veterans, 422 received tumor NGS testing within VA, and 300 of them had metastatic disease. NLP tool and structured data algorithm collectively showed that 38% of the 422 tumor NGS testing recipients had mCRPC. Among all newly diagnosed PC patients, White patients had highest rates of tumor-based testing (2.3%), then Native Hawaiians (1.7%), Asians and Blacks (1.2% each), compared to Native Americans (0.4%).
Implications
NLP tools alongside structured data algorithms successfully identified variables required to measure access to tumor NGS testing. Efforts to validate and apply this method is ongoing to assess receipt of precision prostate cancer care in VA.
Purpose
Prostate cancer is the fifth leading cause of death in the United States. Genomic testing is essential to guide treatment decisions in patients with metastatic castration resistant prostate cancer (mCRPC), the most advanced stage of prostate cancer. However, identifying mCRPC patients from administrative data is challenging and hinders researchers’ ability to assess testing among these patients. This study aims to develop algorithms using structured data and unstructured data with Natural language processing (NLP) methods to identify veterans by disease stage and hormone sensitivity, and to assess patient characteristics as well as receipt of tumor NGS testing.
Methods
We used biopsy, pathology, and diagnosis codes, to identify veterans with newly diagnosed PC within the Veterans Health Administration (VA) from January 1, 2017 to December 31, 2020. We developed and deployed: 1. A structured algorithm that used medication and Prostate-Specific Antigen (PSA) data to assess hormone sensitivity. 2. NLP tools to extract disease stage and hormone sensitivity from clinical notes. We report descriptive statistics on patient demographics, clinical characteristics, disease status, androgen deprivation therapy (ADT), and receipt of tumor NGS testing.
Results
There were 42,485 veterans with newly diagnosed prostate cancer between 2017-2020. This represented ~0.18% of veterans served in the VA and consisted of Whites (57%), Blacks (33%), and others (10%). During the study period, 3,113 (7.3%) patients had documentation of assessment for intraductal carcinoma, 5,160 (12.1%) had ADT treatment, 1,481 (3.5%) had CRPC, and 3,246 (7.6%) had metastatic disease. Among the 42,485 veterans, 422 received tumor NGS testing within VA, and 300 of them had metastatic disease. NLP tool and structured data algorithm collectively showed that 38% of the 422 tumor NGS testing recipients had mCRPC. Among all newly diagnosed PC patients, White patients had highest rates of tumor-based testing (2.3%), then Native Hawaiians (1.7%), Asians and Blacks (1.2% each), compared to Native Americans (0.4%).
Implications
NLP tools alongside structured data algorithms successfully identified variables required to measure access to tumor NGS testing. Efforts to validate and apply this method is ongoing to assess receipt of precision prostate cancer care in VA.
Diagnosis of Prostate Cancer and Prostate-specific Antigen Level on Initial Prostate Biopsy: Does Race Matter?
Objective
To determine whether Black Veterans are at higher risk for prostate cancer diagnosis on their first prostate biopsy compared to non-Hispanic White (White) Veterans.
Background
Prostate-specific antigen (PSA) testing is widely used to screen for prostate cancer. Although men of African ancestry display an increased incidence of prostate cancer and more aggressive disease, specific PSA thresholds for biopsy referral have yet to be proposed for this population.
Methods
We used the VHA’s electronic medical record data to collect Veterans’ demographic and clinical characteristics including self-identified race/ethnicity, age, date of first prostate biopsy, PSA results, and prostate cancer diagnosis. Veterans’ ZIP code of residence was used to determine urban/rural status, income, and education. We estimated multivariable logistic regression models to predict the likelihood of prostate cancer diagnosis on the first biopsy using race, baseline PSA, age at first PSA test, age at initial biopsy, smoking status, use of statins, and socioeconomic factors as predictors. We calculated adjusted predicted probabilities of cancer detection on the first prostate biopsy from the logistic models at different PSA levels.
Results
We identified 246,056 White and 71,653 Black Veterans who underwent their first prostate biopsy through February 28, 2020 and who had no previous prostate cancer diagnosis or treatment prior to that biopsy. Black Veterans appeared to receive their first PSA test four years earlier and undergo their first prostate biopsy two years earlier than their White counterparts (median age of 57 vs. 61 and 63 vs. 65, respectively). After controlling for selected covariates, we found that Black Veterans were 52% more likely to be diagnosed with prostate cancer on their first prostate biopsy compared to White Veterans (OR 1.52, 95% CI 1.49-1.55). Our model indicated that a Black Veteran with a PSA of 4.0 ng/ml has an equivalent risk of prostate cancer detection as a White Veteran with a PSA of 9.7 ng/ml.
Implications
Our findings suggested that developing a risk-based PSA threshold for referral to prostate biopsy may lead to earlier diagnosis of clinically significant prostate cancer in a population of Veterans known to have an increased incidence and risk of aggressive disease.
Objective
To determine whether Black Veterans are at higher risk for prostate cancer diagnosis on their first prostate biopsy compared to non-Hispanic White (White) Veterans.
Background
Prostate-specific antigen (PSA) testing is widely used to screen for prostate cancer. Although men of African ancestry display an increased incidence of prostate cancer and more aggressive disease, specific PSA thresholds for biopsy referral have yet to be proposed for this population.
Methods
We used the VHA’s electronic medical record data to collect Veterans’ demographic and clinical characteristics including self-identified race/ethnicity, age, date of first prostate biopsy, PSA results, and prostate cancer diagnosis. Veterans’ ZIP code of residence was used to determine urban/rural status, income, and education. We estimated multivariable logistic regression models to predict the likelihood of prostate cancer diagnosis on the first biopsy using race, baseline PSA, age at first PSA test, age at initial biopsy, smoking status, use of statins, and socioeconomic factors as predictors. We calculated adjusted predicted probabilities of cancer detection on the first prostate biopsy from the logistic models at different PSA levels.
Results
We identified 246,056 White and 71,653 Black Veterans who underwent their first prostate biopsy through February 28, 2020 and who had no previous prostate cancer diagnosis or treatment prior to that biopsy. Black Veterans appeared to receive their first PSA test four years earlier and undergo their first prostate biopsy two years earlier than their White counterparts (median age of 57 vs. 61 and 63 vs. 65, respectively). After controlling for selected covariates, we found that Black Veterans were 52% more likely to be diagnosed with prostate cancer on their first prostate biopsy compared to White Veterans (OR 1.52, 95% CI 1.49-1.55). Our model indicated that a Black Veteran with a PSA of 4.0 ng/ml has an equivalent risk of prostate cancer detection as a White Veteran with a PSA of 9.7 ng/ml.
Implications
Our findings suggested that developing a risk-based PSA threshold for referral to prostate biopsy may lead to earlier diagnosis of clinically significant prostate cancer in a population of Veterans known to have an increased incidence and risk of aggressive disease.
Objective
To determine whether Black Veterans are at higher risk for prostate cancer diagnosis on their first prostate biopsy compared to non-Hispanic White (White) Veterans.
Background
Prostate-specific antigen (PSA) testing is widely used to screen for prostate cancer. Although men of African ancestry display an increased incidence of prostate cancer and more aggressive disease, specific PSA thresholds for biopsy referral have yet to be proposed for this population.
Methods
We used the VHA’s electronic medical record data to collect Veterans’ demographic and clinical characteristics including self-identified race/ethnicity, age, date of first prostate biopsy, PSA results, and prostate cancer diagnosis. Veterans’ ZIP code of residence was used to determine urban/rural status, income, and education. We estimated multivariable logistic regression models to predict the likelihood of prostate cancer diagnosis on the first biopsy using race, baseline PSA, age at first PSA test, age at initial biopsy, smoking status, use of statins, and socioeconomic factors as predictors. We calculated adjusted predicted probabilities of cancer detection on the first prostate biopsy from the logistic models at different PSA levels.
Results
We identified 246,056 White and 71,653 Black Veterans who underwent their first prostate biopsy through February 28, 2020 and who had no previous prostate cancer diagnosis or treatment prior to that biopsy. Black Veterans appeared to receive their first PSA test four years earlier and undergo their first prostate biopsy two years earlier than their White counterparts (median age of 57 vs. 61 and 63 vs. 65, respectively). After controlling for selected covariates, we found that Black Veterans were 52% more likely to be diagnosed with prostate cancer on their first prostate biopsy compared to White Veterans (OR 1.52, 95% CI 1.49-1.55). Our model indicated that a Black Veteran with a PSA of 4.0 ng/ml has an equivalent risk of prostate cancer detection as a White Veteran with a PSA of 9.7 ng/ml.
Implications
Our findings suggested that developing a risk-based PSA threshold for referral to prostate biopsy may lead to earlier diagnosis of clinically significant prostate cancer in a population of Veterans known to have an increased incidence and risk of aggressive disease.