The effect of attending a flexible sigmoidoscopic screening program on the prevalence of colorectal adenomas at 13-year follow-up.

OBJECTIVES: Understanding the epidemiology of colorectal adenomas is a prerequisite for designing follow-up programs after polypectomy. The aim of the study was to investigate the effect of polypectomy on the long-term prevalence of adenomas. METHODS: In 1983, a total of 799 men and women aged 50-59 yr were drawn from the general population register. Of these, 400 comprised a screening group and 399 a matched control group. The screenees were invited to undergo a once-only flexible sigmoidoscopy. Persons with polyps had a baseline colonoscopy with follow-ups in 1985 and 1989. In 1996, both the screenees and the controls were invited to a colonoscopic examination. RESULTS: In 1996, a total of 451 (71%) individuals attended. Adenomas were found in 78 (37%) individuals in the screening group and 103 (43%) in the control group, relative risk (95% confidence interval): 0.9 (0.7-1.1), p = 0.3, and high-risk adenomas (severe dysplasia, adenomas > or = 10 mm, villous components) were found in 16 (8%) and 32 (13%), respectively; relative risk (95% confidence interval): 0.6 (0.3-1.0), p = 0.07. CONCLUSIONS: There was no significant difference in adenoma prevalence between the group after the screening program and the controls after the usual care. There was a trend toward more high-risk adenomas in the control group. This suggests a very limited effect of one-time screening sigmoidoscopy with surveillance colonoscopy on the prevalence of adenomas, but a preventive effect on the development of high-risk adenomas consistent with the reported effect on cancer prevention.

Patient tolerance of colonoscopy without sedation during screening examination for colorectal polyps.

BACKGROUND: The administration of sedative drugs at colonoscopy has its drawbacks such as increases in the rate of complications and cost. Our aim was to study how individuals, drawn from a population registry and invited to undergo screening colonoscopy for colorectal polyps, experienced the procedure without conscious sedation. METHODS: Four hundred fifty-one individuals underwent the screening examination (median age 67 years, range 63 to 72). The cecum was intubated in 369 (82%). Fourteen days after the examination, 429 of the attendees received a questionnaire designed to evaluate their tolerance of the procedure. RESULTS: Four hundred nine participants (95%) replied.Twenty-one (5%) of these individuals found the examination very uncomfortable, 184 (45%) found it moderately uncomfortable, and 204 (50%) did not find it uncomfortable. A larger proportion of women than men, 110 (63%) versus 79 (41%), found the procedure very or moderately uncomfortable (p<0.001). Three hundred sixty-eight (90%) individuals stated that they would undergo repeat colonoscopy in 5 years. CONCLUSION: In this screening setting, routine use of conscious sedation did not seem to be necessary, as most participants found the examination to be only moderately uncomfortable or not at all uncomfortable. Colonoscopy without conscious sedation may, however, reduce the rate of intubation of the cecum and increase the risk of missing adenomas and cancers.

Flexible sigmoidoscopy or colonoscopy as a screening modality for colorectal adenomas in older age groups? Findings in a cohort of the normal population aged 63-72 years.

BACKGROUND: Most cases of colorectal cancer originate from adenomas. Removing adenomas has been shown to reduce the incidence of colorectal cancer. The design of cost effective endoscopic screening programmes requires a knowledge of the distribution of adenomas in different age groups. AIM: To investigate the distribution of colorectal adenomas in older age groups in the normal population. METHOD: A total of 356 men and women selected randomly from the population register were offered a colonoscopic screening examination to detect and remove polyps. RESULTS: In all, 241(68%) subjects, mean age 67.4 years (range 62-73), attended. The caecum was intubated in 193 (80%), and in this group 32 (38%) women and 51 (47%) men had adenomas. One hundred and ten (54%) of the adenomas and 11 (39%) of the "high risk adenomas" (adenomas larger than 10 mm in diameter, adenomas containing villous components, and adenomas with severe dysplasia) were found proximal to the sigmoid colon. In 36 (43%) of the subjects with adenomas, the adenomas were only found proximal to the sigmoid colon. Twenty two (11%) subjects had more than two adenomas. Of 203 adenomas discovered, 189 (93%) were less than 10 mm in diameter. CONCLUSION: More than half of the adenomas were localised proximal to the sigmoid colon, and, in nearly half of the adenoma bearing subjects examined, the adenoma was proximal to the descending colon. This indicates that a sigmoidoscopic screening examination in this age group would miss a substantial number of adenomas, but this may be acceptable as the vast majority of proximal adenomas do not progress to clinical cancer within the life expectancy of this age group.

Population-based surveillance by colonoscopy: effect on the incidence of colorectal cancer. Telemark Polyp Study I.

BACKGROUND: Most cases of colorectal cancer (CRC) develop from adenomas. Polypectomy is believed to reduce the incidence of CRC, but this effect has never been explored in prospective controlled studies. The aim of the present study was to evaluate the effect of polypectomy on colorectal cancer incidence in a population-based screening program. METHODS: In 1983, 400 men and women aged 50-59 years were randomly drawn from the population registry of Telemark, Norway. They were offered a flexible sigmoidoscopy and, if polyps were found, a full colonoscopy with polypectomy and follow-up colonoscopies in 1985 and 1989. A control group of 399 individuals was drawn from the same registry. In 1996 both groups (age, 63-72 years) were invited to have a colonoscopic examination. Hospital files and the files of The Norwegian Cancer Registry were searched to register any cases of CRC in the period 1983-96. RESULTS: At screening endoscopy 324 (81%) individuals attended in 1983 and 451 (71%) in 1996. From 1983 to 1996, altogether 10 individuals in the control group and 2 in the screening group were registered to have developed CRC (relative risk, 0.2; 95% confidence interval (CI), 0.03-0.95; P = 0.02). A higher overall mortality was observed in the screening group, with 55 (14%) deaths, compared with 35 (9%) in the control group (relative risk, 1.57; 95% CI, 1.03-2.4; P = 0.03). CONCLUSION: Endoscopic screening examination with polypectomy and follow-up was shown to reduce the incidence of CRC in a Norwegian normal population. The possible effect of screening on overall mortality should be addressed in larger studies.

The psychologic effect of attending a screening program for colorectal polyps.

BACKGROUND: Participation in screening programs for malignant disease may have negative psychologic health effects that could outweigh the beneficial effects of the screening itself. The present study was designed to investigate the psychologic effect of attending a screening program for detection and removal of colorectal adenomas, which are precursors to colorectal cancer. METHOD: In 1983 a prospective. controlled screening study using flexible sigmoidoscopy to detect adenomas was started in Telemark County, Norway. Four hundred individuals were enrolled as a screening group and 399 as a control group. In 1996 survivors in both groups were invited to have a colonoscopic screening examination for detection and removal of polyps. Four hundred and fifty-one individuals (71%) attended; their mean age was 67.2 years (range, 63-72 years), and 48% were women. Fourteen days and 3 and 17 months after the examination the attendees received by mail a questionnaire composed of Goldberg's General Health Questionnaire (GHQ-28) and the Hospital Anxiety and Depression Scale (HADS). The questionnaire was also mailed to an age- and sex-matched group not enrolled in the endoscopic screening study. Four hundred and nine (95%), 395 (92%), and 389 (91%), respectively, returned the questionnaire. Of the controls 314 (70%) returned filled-in questionnaires. RESULTS: The scores for both GHQ-28 and HADS were lower, indicating a lower level of psychiatric morbidity among those attending the examination in 1996 than among the controls. There was a trend towards higher scores with increasing time after the examination in the screened group. CONCLUSION: During the first 17 months after screening the attendees, as a group, did not appear to have developed untoward psychologic effects as judged by HADS and GHQ questionnaires.

Doxepin and cimetidine in the treatment of duodenal ulcer: an open clinical and endoscopic study.

In an open clinical endoscopic study, 50 patients with duodenal ulcer showed no significant difference in ulcer healing during a 6-week treatment period with doxepin HCl (50 mg h.s.) versus cimetidine (1000 mg/day in divided doses). Possible tricyclic mechanisms of action in the treatment of peptic ulcer, e.g., histamine H2 blockade, are discussed.