The Performance of Colorectal Cancer Screening in Brazil: The First Two Years of the Implementation Program in Barretos Cancer Hospital.

Colorectal cancer is the second most common cancer in Brazil. Yet, a nationally organized colorectal screening program is not implemented. Barretos Cancer Hospital (BCH) is one of the largest Brazilian institution that cares for underserved patients. BCH developed a fecal immunochemical test (FIT)-based organized colorectal cancer screening program to improve colorectal cancer outcomes.This study aims to present the quality/performance measures of the first 2 years of the FIT-based colorectal cancer screening program and its impact on the colorectal cancer disease stage. Between 2015 and 2017, a total of 6,737 individuals attending the Outpatient Department of Prevention or the Mobile Unit of BCH, which visits 18 cities of Barretos county, ages 50 to 65 years, were personally invited by a health agent/nurse practitioner. Exclusion criteria were personal history of colorectal cancer, adenomatous polyps, inflammatory bowel disease, and colonoscopy, or flexible sigmoidoscopy performed in the past 5 years. European Union (EU) guidelines for colorectal cancer screening programs were evaluated. Overall, 92.8% returned the FIT, with an inadequate examination rate of 1.5%. Among the 6,253 adequately tested, 12.5% had a positive result. The colonoscopy compliance and completion rates were 84.6 and 98.2%, respectively. The PPVs were 60.0%, 16.5%, and 5.6% for adenoma, advanced adenoma, and cancer, respectively. Stage distribution of screen-detected cancers shows earlier stages than clinically diagnosed colorectal cancer cancers reported at BCH and Brazilian cancer registries. Our colorectal cancer screening program achieved desirable quality metrics, aligned with the EU guidelines. The observed shift toward earlier colorectal cancer stages suggests an exciting opportunity to improve colorectal cancer-related cancers in Brazil.

Cap-assisted endoscopy increases ampulla of Vater visualization in high-risk patients.

BACKGROUND: Periampullary adenocarcinoma is a major clinical problem in high-risk patients including FAP population. A recent modification for visualizing the ampulla of Vater (AV) involves attaching a cap to the tip of the forward-viewing endoscope. Our aim was to compare the rates of complete visualization of AV using this cap-assisted endoscopy (CAE) approach to standard forward-viewing endoscopy (FVE). We also determined: (i) the rates of complications and additional sedation; (ii) the mean time required for duodenal examination; and (iii) the reproducibility among endoscopists performing this procedure. METHODS: We performed esophagogastroduodenoscopy for AV visualization in 102 > 18 years old using FVE followed by CAE. Video recordings were blinded and randomly selected for independent expert endoscopic evaluation. RESULTS: The complete visualization rate for AV was higher in CAE (97.0%) compared to FVE (51.0%) (p <  0.001). The additional doses of fentanyl, midazolam, and propofol required for CAE were 0.05, 1.9 and 36.3 mg. in 0.9, 24.5, and 77.5% patients, respectively. The mean time of duodenal examination for AV visualization was lower on CAE compared to FVE (1.41 vs. 1.95 min, p <  0.001). Scopolamine was used in 34 FVE and 24 CAE, with no association to AV complete visualization rates (p = 0.30 and p = 0.14). Three more ampullary adenomas were detected using CAE compared to FVE. Cap displacement occurred in one patient, and there was no observed adverse effect of the additional sedatives used. Kappa values for agreement between endoscopists ranged from 0.60 to 0.85. CONCLUSIONS: CAE is feasible, reproducible and safe, with a higher success rate for complete visualization compared to FVE. TRIAL REGISTRATION: ClinicalTrials.gov , NCT02867826 , 16 August 2016.

Comparison of a New-generation Fecal Immunochemical Test (FIT) With Guaiac Fecal Occult Blood Test (gFOBT) in Detecting Colorectal Neoplasia Among Colonoscopy-referral Patients.

BACKGROUND/AIM: The aim of the present study was to compare fecal immunochemical tests (FITs) for colorectal cancer (CRC) screening with the traditional guaiac-based FOB tests (gFOBT). MATERIALS AND METHODS: A cohort of 368 colonoscopy-referral patients were evaluated by i) the new-generation FIT: ColonView quick test (CV; Biohit Oyj, Finland) and ii) a conventional gFOBT HemoccultSENSA (HS; Beckman Coulter, USA). Three fecal samples were requested for both assays, and all subjects underwent diagnostic colonoscopy with biopsy confirmation. Sensitivity (SE), specificity (SP), positive predictive value (PPV), negative predictive value (NPV) and area under curve (AUC) were calculated for both tests using three endpoints: adenoma (A), advanced adenoma (AA) and adenocarcinoma (AC). RESULTS: Colonoscopy and biopsies disclosed normal mucosa in 90/378 (24.5%) subjects, early A in 108/368 (29.3%) cases, AA in 48/368 (13.0%) and AC in 37/368 (10.1%), and non-neoplastic conditions in the remaining 85 (30.3%). For the AC endpoint, the CV (Hb/Hp) test had 94.6% SE and 65.1% SP (AUC=0.799), while the HS test had SE of 75.7% and SP of 84.3% (AUC=0.800). For the A endpoint, the difference between CV and HS was even more pronounced; SE of 44.2% and 19.2%, respectively (p<0.0001). Hb and Hb/Hp complex of the CV test showed equal performance for all endpoints. CONCLUSION: Sensitivity (94.6%) of the ColonView quick test for the most reproducible endpoint (invasive CRC) far exceeded the pooled sensitivity (79%) estimated in a recent meta-analysis for 8 common FIT brands. As shown in a previous study, ColonView quick test is superior in SE to HemoccultSENSA test, making CV a perfect FIT for organized CRC screening.

Endoscopia digestiva alta na rede pública de saúde do Brasil: análise quantitativa por Estados e regiões do pais / Upper gastrointestinal endoscopy on the national health system of Brazil: quantitative analysis by states and regions of the country

Atualmente, a endoscopia digestiva alta (EDA) é um dos exames mais indicados para avaliar doenças do trato gastrointestinal. Considerando sua importância no diagnóstico e também na terapêutica de doenças do esôfago, estômago e duodeno, é de relevância a análise dos dados quantitativos desse exame no país, bem como calcular seu custo-benefício. O objetivo do presente estudo é avaliar o número de EDA realizadas pelo Sistema Único de Saúde (SUS) durante o período de janeiro de 2008 a dezembro de 2009 por estados e regiões do Brasil. Métodos: calculou-se o número de exames por 100 mil habitantes por ano, utilizando a população brasileira referente ao período de 2009, de acordo com o Instituto Brasileiro de Geografia e Estatística (IBGE). Para efeito de comparação utilizaram-se dados relativos a países com sistemas de saúde semelhantes ao SUS. Resultados: os estados onde mais se realizaram EDA foram: Piauí, Alagoas, Pernambuco, São Paulo e Paraíba; a região com maior número de EDA foi o Nordeste e a média nacional encontrada foi de 550 exames/100 mil habitantes/ano. Conclusão: quando se comparou a média nacional com países como Inglaterra, Holanda e Irlanda, notou-se que em nosso sistema público de saúde foi realizado a metade dos exames destes países.

Nowadays, Upper Gasrointestinal Endoscopy (UGE) is one of the most used procedures to evaluate disease of the Upper GI tract. Considering its diagnostic and therapeutic importance for esophageal, gastric and duodenal diseases, the analysis of Brazilian quantitative data, as well as the cost-effectiveness ratio, is of great importance. The objective of this report is to evaluate the number of UGE performed in the National Health System in the period from January, 2008 to December, 2009. Methodology: the rate of UGE per 100.000 habitants a year was calculated based on 2009 Brazilian population, according to the Brazilian Institute of Geography and Statistics. As comparison subjects, countries with health systems similar to Brazilian were used. Results: were obtained: more UGE were performed in Piauí, Alagoas, Pernambuco, São Paulo e Paraiba; the geographical region with more performed tests was the Northeastern, and the national overall was 550 UGE/100.000 habitants/ year. Conclusion: correlation of the latter figure to countries such as England, Netherlands or Ireland, shown that, in Brazil, there were performed half of UGE than in those countries.