Colonoscopy and Sigmoidoscopy Use among the Average-Risk Population for Colorectal Cancer: A Systematic Review and Trend Analysis.

Monitoring population-level colonoscopy and sigmoidoscopy use is crucial to estimate the future burden of colorectal cancer and guide screening efforts. We conducted a systematic literature search on colonoscopy and sigmoidoscopy use, published between November 2016 and December 2018 in the databases PubMed and Web of Science to update previous reviews and analyze time trends for various countries. In addition, we used data from the German and European Health Interview Surveys and the National Health Interview Survey to explore recent time trends for Germany and the US, respectively. The literature search yielded 23 new articles: fourteen from the US and nine from Australia, Canada, England, Germany, Saudi Arabia, and South Korea. Colonoscopy use within 10 years was highest and, apart from the youngest age groups eligible for colorectal cancer screening, kept increasing to levels close to 60% in the US and Germany. A recent steep increase was also observed for South Korea. Limited data were available on sigmoidoscopy use; regional studies from the US suggest that sigmoidoscopy has become rarely used. Despite high uptake and ongoing increase in the US, Germany, and South Korea, use of colonoscopy and sigmoidoscopy has either remained low or essentially unknown for the majority of countries.

Occurrence of Distal Colorectal Neoplasia Among Whites and Blacks Following Negative Flexible Sigmoidoscopy: An Analysis of PLCO Trial.

BACKGROUND: It is unclear whether the higher rate of colorectal cancer (CRC) among non-Hispanic blacks (blacks) is due to lower rates of CRC screening or greater biologic risk. OBJECTIVE: We aimed to evaluate whether blacks are more likely than non-Hispanic whites (whites) to develop distal colon neoplasia (adenoma and/or cancer) after negative flexible sigmoidoscopy (FSG). DESIGN: We analyzed data of participants with negative FSGs at baseline in the Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial who underwent repeat FSGs 3 or 5 years later. Subjects with polyps or masses were referred to their physicians for diagnostic colonoscopy. We collected and reviewed the records of diagnostic evaluations. PARTICIPANTS: Our analytic cohort consisted of 21,550 whites and 975 blacks. MAIN MEASURES: We did a comparison by race (whites vs. blacks) in the findings of polyps or masses at repeat FSG, the follow-up of abnormal test results and the detection of colorectal neoplasia at diagnostic colonoscopy. KEY RESULTS: At the follow-up FSG examination, 304 blacks (31.2 %) and 4183 whites (19.4 %) had abnormal FSG, [adjusted relative risk (RR) = 1.00; 95 % confidence interval (CI), 0.90-1.10]. However, blacks were less likely to undergo diagnostic colonoscopy (76.6 % vs. 83.1 %; RR = 0.90; 95 % CI, 0.84-0.96). Among all included patients, blacks had similar risk of any distal adenoma (RR = 0.86; 95 % CI, 0.65-1.14) and distal advanced adenoma (RR = 1.01; 95 % CI, 0.60-1.68). Similar results were obtained when we restricted our analysis to compliant subjects who underwent diagnostic colonoscopy (RR = 1.01; 95 % CI, 0.80-1.29) for any distal adenoma and (RR = 1.18; 95 % CI, 0.73-1.92) for distal advanced adenoma. CONCLUSIONS: We did not find any differences between blacks and whites in the risk of distal colorectal adenoma 3-5 years after negative FSG. However, follow-up evaluations were lower among blacks.

Factors influencing colorectal cancer screening in rural southern Taiwan.

BACKGROUND: Colorectal cancer (CRC) is the most common cancer in Taiwan. Colorectal cancer screening can prevent or detect cancer early, but the acceptance rate in rural southern Taiwan is unknown. OBJECTIVE: The purpose of this study was to explore the prevalence of CRC screening and related factors in rural south Taiwan. METHODS: Cross-sectional study was conducted. Sample population was recruited from 2 rural areas in southern Taiwan. A structured questionnaire was completed by 635 participants. The following outcomes were studied: sociodemographic characteristics, knowledge of CRC screening, acceptance of CRC screening, and the reasons for having or not having CRC screening. RESULTS: The results indicated that 4.7% of the respondents had undergone a fecal occult blood test, 3.1% had undergone a sigmoidoscopy, and 2.7% had undergone a colonoscopy. For overall CRC screening, knowledge that CRC was the most common form of cancer was significant (P < .01). Among participants who knew that CRC was the most common form of cancer, the odds of undergoing CRC screening were 4.20-fold greater than among participants who did not know that CRC was the most common form of cancer (P < .01; confidence interval, 1.62-10.89). CONCLUSIONS: This study demonstrates that the acceptance of CRC screening among men remains higher than among women in rural southern Taiwan. Efforts to improve CRC screening in rural areas should focus on increasing community residents' knowledge about cancer incidence and prevention. IMPLICATIONS FOR PRACTICE: Colorectal cancer screening is a useful cancer prevention measure, and community health center nurses should assess and promote rural residents' acceptance for CRC screening.

Longitudinal adherence to fecal occult blood testing impacts colorectal cancer screening quality.

OBJECTIVES: Existing cross-sectional quality measures for colorectal cancer (CRC) screening do not assess longitudinal adherence and thus may overestimate the quality of care. Our goal was to evaluate the adherence to repeated yearly fecal occult blood tests (FOBTs) in order to better understand the extent to which longitudinal adherence may impact screening quality. METHODS: This was a retrospective cohort analysis of 1,122,645 patients aged 50-75 years seen at any of the 136 Department of Veterans Affairs medical centers across the United States in 2000 and followed through 2005. The primary outcome was receipt of adequate CRC screening as defined by receipt of FOBTs in at least 4 out of 5 years or receipt of any number of FOBTs in addition to at least one colonoscopy, flexible sigmoidoscopy, or double-contrast barium enema. In a predefined subset of patients receiving exclusively FOBT, adherence with repeated testing was determined over the 5-year study period. RESULTS: Only 41.1% of men and 43.6% of women received adequate screening. Of the 384,527 men who received exclusively FOBT, 42.1% received a single FOBT, 26.0% received 2 tests, 17.8% received 3 tests, and only 14.1% were documented to have received at least 4 tests during the study period. Among the 10,469 female veterans receiving FOBT alone, rates were similar with only 13.7% completing at least 4 FOBTs in the 5-year study period. CONCLUSIONS: Adherence to repeated FOBT is low, suggesting that cross-sectional measurements of quality may overestimate the programmatic success of CRC screening.

Population-based prevalence estimates of history of colonoscopy or sigmoidoscopy: review and analysis of recent trends.

BACKGROUND: Lower GI endoscopy, such as colonoscopy or sigmoidoscopy, is thought to have a substantial impact on colorectal cancer incidence and mortality through detection and removal of precancerous lesions and early cancers. We aimed to review prevalence estimates of history of colonoscopy or sigmoidoscopy in the general population and to analyze recent trends. METHODS: A systematic review of the medical literature, including MEDLINE (1966 to August 2008) and EMBASE (1980 to August 2008), was undertaken, supplemented by searches of the European Health Interview & Health Examination Surveys database and bibliographies. Detailed age-specific and sex-specific prevalence estimates from the United States were obtained from the Behavioral Risk Factor Surveillance System surveys 2002, 2004, and 2006. RESULTS: The search yielded 55 studies that met our inclusion criteria. The majority of the reports (43) originated from the United States. Other countries of origin included Australia (2), Austria (2), Canada (5), France (1), Germany (1), and Greece (1). Estimates from the United States were generally increasing over time up to 56% (2006) for lifetime use of colonoscopy or sigmoidoscopy in people aged 50 years and older. Analysis of national survey data showed higher prevalences among men aged 55 years and older than for women of the same age. Prevalences were highest for people aged 70 to 79 years. CONCLUSION: Data from outside the United States were extremely limited. Prevalence estimates from the United States indicate that a considerable and increasing proportion of the population at risk has had at least 1 colonoscopy or sigmoidoscopy in their lives, although differences between age and sex groups persist. Prevalences of previous colonoscopy or sigmoidoscopy need to be taken into account in the interpretation of time trends in, and variation across, populations of colorectal cancer incidence and mortality.

Trends in colon cancer screening procedures in the US Medicare and Tricare populations: 1999-2001.

BACKGROUND: This study examined trends in the numbers of double contrast barium enemas, flexible sigmoidoscopies, and colonoscopies and trends in the choices of colorectal cancer screening service providers. METHODS: Descriptive statistics were used to examine Medicare and Tricare data for the years 1999 to 2001. RESULTS: The total volume of procedures increased 5% and 14%, respectively, in Tricare and Medicare. Tricare and Medicare, respectively, saw 32% and 33% reductions in barium enemas and 28% and 41% reductions in flexible sigmoidoscopies. Colonoscopies increased by 45% and 34% in Tricare and Medicare, respectively. Gastroenterologists provided the majority of colonoscopies for both groups each year. CONCLUSIONS: The volume of colonoscopies increased from 1999 to 2001 for both groups while the volumes of barium enemas and flexible sigmoidoscopies decreased. Gastroenterologists appear to be the preferred providers of colonoscopies.

Report on the Belgian consensus meeting on colorectal cancer screening.

Screening and prevention of colorectal cancer must be a public health priority. It is the most frequent malignancy in Europe, the second leading cause of cancer death, including Belgium where more than 6000 new cases occur per year. Various screening modalities, from non invasive to invasive are available and currently in use and they are all cost-effective in comparison with no screening. The decision as to which screening test to use should be made by the patient and clinician. Consensus documents prepared by the Belgian scientific community appear in this issue of Acta Gastroenterologica Belgica, summarizing the scientific evidence in favour as well as the limitations of fecal occult blood tests, flexible sigmoidoscopy, videocolonoscopy and virtual colonoscopy.

Flexible sigmoidoscopy as a screening test for colorectal cancer.

Flexible sigmoidoscopy (FS) is one of the screening modalities for colorectal cancer. The rationale for screening with flexible sigmoidoscopy is that it provides direct visualisation of the colon, and suspicious lesions can be biopsied. The most obvious disadvantage is that it examines only the lower third of the colon. The technical aspects of FS are sufficiently clear to enable us to define what FS can and cannot do. From the point of view of screening, FS clearly cannot completely exclude the presence of colon cancer in all asymptomatic people. A distinction must be made between screening the general population and testing the individual seeking screening. For the former, obtaining the greatest mortality benefit safely and at an acceptable cost to the nation is the crux of the matter. Recently published data indicate that FS is a cost-effective screening strategy, although colonoscopy and annual fecal occult blood test avert a greater number of cancer deaths. The results of randomised controlled trials of screening FS and colonoscopy, currently being conducted, will allow us to make a more accurate comparison with the established data regarding fecal occult blood test. In conclusion, flexible sigmoidoscopy every 5 years with or without FOBT is one of the screening methods recommended by major professional organizations. It identifies 50 to 70% of the advanced neoplasms, if any discovery of a distal neoplasia is followed up with a total examination of the colon by colonoscopy.

Colorectal cancer screening in primary care: the long and short of it.

Primary care physicians and physician extenders have been encouraged to perform sigmoidoscopy to improve compliance with screening and address the potential shortage of colonoscopists. A survey of primary care teaching programs reveals that sigmoidoscopy training is inconsistent and lacks minimum standards of competency. It would be helpful to know how many primary caregivers offer sigmoidoscopy in their practice and if they are deterred by insufficient resources and falling reimbursement. Colonoscopy is a more complete and efficient examination than sigmoidoscopy. Primary care physicians could be encouraged to promote colonoscopy if scheduling and patient instructions were easily available. It behooves colonoscopists to provide such assistance.

Patterns of use of flexible sigmoidoscopy, colonoscopy and gastroscopy: a population-based study in a Canadian province.

BACKGROUND & AIMS: Flexible sigmoidoscopy, colonoscopy and gastroscopy are important in the diagnosis and treatment of gastrointestinal (GI) diseases. Pressure on endoscopy resources is expected due to increased screening for GI cancers. The present study examined patterns of use of GI endoscopy in a Canadian province, Alberta, with universal health care insurance. METHODS: Data on physician payments from January 1, 1994 to March 31, 2002 were used to calculate age-sex adjusted rates and patterns of use. RESULTS: The gastroscopy rate increased by 17%, from 9.7 (95% CI 9.6 to 9.9) to 10.3 (95% CI 10.1 to 10.5). The colonoscopy rate increased by 105%, from 4.8 (95% CI 4.6 to 5.0) to 9.8 (95% CI 9.6 to 10.1). Flexible sigmoidoscopy rates declined by 10%, from 4.68 (95% CI 4.56 to 4.80) to 4.21 (95% CI 4.11 to 4.32). The increase in colonoscopy rates occurred in all age groups, whereas gastroscopy rates increased only in the older age groups. Regional variation in procedure rates was evident, but rural health regions did not have consistently lower rates than the large urban regions. A polypectomy was performed on 23.7% of male patients and 15.4% of female patients at time of colonoscopy. Rates of polypectomy for individual endoscopists ranged from 0% to 60%. CONCLUSIONS: There has been a marked increase in gastroscopy and colonoscopy rates, likely due to a broadening of indications rather than just increased use for cancer screening. Modest regional variation in rates exists, but there is no direct evidence of limited rural access to endoscopy. Reasonable polypectomy rates were seen but important variations between endoscopists exist.

Progress in cancer screening over a decade: results of cancer screening from the 1987, 1992, and 1998 National Health Interview Surveys.

BACKGROUND: Screening to detect cancer early, an increasingly important cancer control activity, cannot be effective unless it is widely used. METHODS: Use of Pap smears, mammography, fecal occult blood tests (FOBTs), sigmoidoscopy, and digital rectal examination (DRE) was evaluated in the 1987, 1992, and 1998 National Health Interview Surveys. Levels and trends in screening use were examined by sex, age, and racial/ethnic group. The effects of income, educational level, and health care coverage were examined within age groups. Logistic regression analyses of 1998 data were used to develop a parsimonious, policy-relevant model. RESULTS: Use of all screening modalities increased over the period examined; for mammography and DRE, the increase was more rapid in the first half of the decade; for the Pap test and sigmoidoscopy, the increase was more rapid in the second half of the decade. Levels of colorectal cancer screening (both sigmoidoscopy and FOBTs) in 1998 were less than the level that prevailed a decade earlier for mammography. Patterns of change for all screening modalities differed between age, sex, and racial/ethnic groups, but prevalence of use during the study, within recommended time intervals, was consistently lower among groups with lower income and less education. Logistic regression analyses indicated that insurance coverage and, to a greater extent, usual source of care had strong independent associations with screening usage when age, sex, racial/ethnic group, and educational level were taken into account. CONCLUSIONS: While cancer screening is generally increasing in the United States, usage is relatively low for colorectal cancer screening and among groups that lack health insurance or a usual source of care.

The nurse practitioner endoscopist.

Most upper and lower gastrointestinal endoscopies in Great Britain and Ireland are performed by surgeons, physicians or radiologists. Since the introduction of the 'nurse endoscopist' by the British Society of Gastroenterology Working Party, few centres in the UK have adopted this policy. We have reviewed the anxiety about nurse practitioner endoscopists among patients and physicians. Finally, the role and future of the nurse practitioner endoscopist in the UK is discussed.

Trends in use of barium enema examination, colonoscopy, and sigmoidoscopy: is use commensurate with risk of disease?

PURPOSE: To assess replacement of barium enema examination with colonoscopy in relation to age- and sex-related risk factors, place of service, physician specialty, and cost. MATERIALS AND METHODS: Between 1985 and 1992, 894,777 insurance claims for barium enema examination and lower gastrointestinal endoscopy were retrospectively examined. Changes in use were investigated. Use of proctosigmoidoscopy and flexible sigmoidoscopy, two office-based endoscopic procedures, was also examined. RESULTS: Use of diagnostic colonoscopy increased from 191 to 406 services per 100,000 persons; colonoscopy with biopsy, from 77 to 183 services; and colonoscopy with lesion removal, from 77 to 202 services. Barium enema examination use declined from 929 to 511 services per 100,000 persons; diagnostic proctosigmoidoscopy, from 854 to 193 services; and diagnostic flexible sigmoidoscopy, from 656 to 620 services. Increases in use of colonoscopy in patients aged younger than 40 years were greater than overall increases. CONCLUSION: Colonoscopy has been replacing barium enema examination as the initial colorectal examination since 1985. Increased use of colonoscopy in patients with lower risk of neoplasia suggests that indications have become overly broad.

Changes in diagnostic investigation and improved detection of colon cancer, Manitoba 1964-1984.

Detection of colon cancer has improved in Manitoba over the last 20 years with decreases in diagnostic delay and failure. Between 1981 and 1984 diagnostic delay, resulting from initial false-negative examinations, occurred in 5.7% of patients. Diagnostic failure, because all investigations were negative in patients found to have cancer of the colon within one year, was 0.66%, compared with 9.5% and 5.8% respectively between 1964 and 1969. In the intervening time double-contrast barium examinations and colonoscopy were introduced and became more widely used, with a corresponding decline in single-contrast examinations. The mortality rate in the general population was unchanged despite an increased incidence, while 1980 survival rates suggested that women cancer patients were living longer than previously as well as longer than their male counterparts.