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Newcastle upon Tyne, United Kingdom

Rutter M.D.,University Hospital of North Tees | Rutter M.D.,Durham University | Rutter M.D.,Northern Region Endoscopy Group | Riddell R.H.,University of Toronto
Clinical Gastroenterology and Hepatology | Year: 2014

Surveillance for neoplasia in colitis is the most challenging diagnostic colonoscopic procedure. The detection and treatment of colorectal dysplasia in inflammatory bowel disease remain problematic to the point that unsuspected colorectal cancers (CRCs) are still identified. Excellent bowel preparation and use of high-resolution colonoscopes with chromoendoscopy facilitate the detection and characterization of subtle neoplasia. This approach is superior to taking random biopsy specimens and should be the standard of care for surveillance but requires adequate training. Suspicious lesions should be assessed carefully and described using objective terminology. The terms dysplasia-associated lesions/masses and flat dysplasia are best avoided because they may be open to misinterpretation. Most suspicious lesions detected during surveillance can be removed endoscopically, precluding the need for surgery. Nevertheless, endotherapy in colitis can be difficult as a result of underlying inflammation and scarring. Lesions that are not endoscopically resectable need to be removed surgically, although the possibility that some lesions might be amenable to local resection (including lymphadenectomy) rather than subtotal colectomy may need to be re-evaluated. Despite surveillance programs, patients still present clinically with CRC. This may occur because lesions are missed (possibly because of the failure to use optimal techniques), lesions are not adequately removed, patients fail to return for colonoscopy, or CRCs arise rapidly in mucosa that is minimally dysplastic and the CRCs are not recognized as being potentially invasive even on biopsy. Future advances in, for example, stool DNA assays, use of confocal endomicroscopy, or use of endoscopic ultrasound, may help in the identification of high-risk patients and the assessment of dysplastic lesions. © 2014 AGA Institute. Source

Geraghty J.,University of Liverpool | Butler P.,Bowel Cancer Screening Southern Programme Hub | Seaman H.,Bowel Cancer Screening Southern Programme Hub | Seaman H.,University of Surrey | And 9 more authors.
British Journal of Cancer | Year: 2014

Background: Colorectal neoplasia causes bleeding, enabling detection using Faecal Occult Blood tests (FOBt). The National Health Service (NHS) Bowel Cancer Screening Programme (BCSP) guaiac-based FOBt (gFOBt) kits contain six sample windows (or 'spots') and each kit returns either a positive, unclear or negative result. Test kits with five or six positive windows are termed 'abnormal' and the subject is referred for further investigation, usually colonoscopy. If 1-4 windows are positive, the result is initially 'unclear' and up to two further kits are submitted, further positivity leads to colonoscopy ('weak positive'). If no further blood is detected, the test is deemed 'normal' and subjects are tested again in 2 years' time. We studied the association between spot positivity % (SP%) and neoplasia.Methods:Subjects in the Southern Hub completing the first of two consecutive episodes between April 2009 and March 2011 were studied. Each episode included up to three kits and a maximum of 18 windows (spots). For each positivity combination, the percentage of positive spots out of the total number of spots completed by an individual in a single-screening episode was derived and named 'SP%'. Fifty-five combinations of SP can occur if the position of positive/negative spots on the same test card is ignored.The proportion of individuals for whom neoplasia was identified in Episode 2 was derived for each of the 55 spot combinations. In addition, the Episode 1 spot pattern was analysed for subjects with cancer detected in Episode 2.Results:During Episode 2, 284 261 subjects completed gFOBT screening and colonoscopies were performed on 3891 (1.4%) subjects. At colonoscopy, cancer was detected in 7.4% (n=286) and a further 39.8% (n=1550) had adenomas. Cancer was detected in 21.3% of subjects with an abnormal first kit (five or six positive spots) and in 5.9% of those with a weak positive test result.The proportion of cancers detected was positively correlated with SP%, with an R 2 correlation (linear) of 0.89. As the SP% increased from 11 to 100%, so the colorectal cancer (CRC) detection rate increased from 4 to 25%. At the lower SP%s, from 11to 25%, the CRC risk was relatively static at ∼4%. Above an SP% of 25%, every 10-percentage points increase in the SP%, was associated with an increase in cancer detection of 2.5%.Conclusions:This study demonstrated a strong correlation between SP% and cancer detection within the NHS BCSP. At the population level, subjects' cancer risk ranged from 4 to 25% and correlated with the gFOBt spot pattern.Some subjects with an SP% of 11% proceed to colonoscopy, whereas others with an SP% of 22% do not. Colonoscopy on patients with four positive spots in kit 1 (SP% 22%) would, we estimate, detect cancer in ∼4% of cases and increase overall colonoscopy volume by 6%. This study also demonstrated how screening programme data could be used to guide its ongoing implementation and inform other programmes. © 2014 Cancer Research UK. Source

Rees C.J.,South Tyneside District General Hospital | Rees C.J.,Northern Region Endoscopy Group | Rees C.J.,Durham University | Bevan R.,South Tyneside District General Hospital | Bevan R.,Northern Region Endoscopy Group
Expert Review of Gastroenterology and Hepatology | Year: 2013

The National Health Service Bowel Cancer Screening Program (NHS BCSP) was developed to improve outcomes from colorectal cancer, the third most frequent cancer and the second highest cause of cancer deaths in the UK. Screening pilot programs were developed after previous trials demonstrated a reduction in mortality with the use of fecal occult blood population screening. A successful pilot period led to the roll out of national biennial screening for all 60-69 year olds in 2006, and extended to 60-74 year olds in 2010. To the end of 2012, there have been over 16 million invitations to screening, with uptake of 55.35%. FOBt positivity was 2.08%. Almost 15,000 cancers have been identified; screen-detected cancers have been shown to be at an earlier stage than non-screen-detected, with 35% Dukes' stage A. The BCSP provides high quality colonoscopy with low adverse events rates. It is also a rich data source for research. © 2013 Informa UK Ltd. Source

Lee T.J.W.,University Hospital of North Tees | Rees C.J.,South of Tyne Bowel Cancer Screening Center | Rees C.J.,Durham University | Rees C.J.,Northern Region Endoscopy Group | And 10 more authors.
Endoscopy | Year: 2014

Background and study aims: Adenoma detection is a key objective of colonoscopy, particularly in the context of colorectal cancer screening. The aim of this observational study was to identify the technical colonoscopy factors associated with adenoma detection. Patients and methods: The study analyzed data from the English Bowel Cancer Screening Programme. The indication for all colonoscopies was a positive fecal occult blood test. The relationships between the following colonoscopy factors and adenoma detection (one or more adenomas, advanced adenomas, right-sided adenomas, and total number of adenomas) were examined in multivariable analyses: bowel preparation quality, cecal intubation, withdrawal time, rectal retroversion, colonoscopist experience, antispasmodic use, sedation use, and start time of procedure. The following patient factors were controlled for: age, sex, body mass index, smoking, alcohol, deprivation, and geographical location. Results: A total of 31088 colonoscopies were analyzed. The following technical factors increased the relative risk of adenoma detection (P< 0.001 in multivariable analysis unless otherwise stated): cecal intubation, increased withdrawal time, higher quality bowel preparation, intravenous antispasmodic use, earlier procedure start time within a session (P= 0.018), and greater colonoscopist experience. Detection of advanced and right-sided adenomas also increased with these factors. Adenoma detection did not differ between sedated and unsedated colonoscopy (P= 0.143). Conclusion: This study demonstrated important associations between colonoscopy practice and adenoma detection. Use of intravenous antispasmodic was associated with increased adenoma detection. The effect of the start time of colonoscopy suggests that endoscopist fatigue may have a deleterious impact on adenoma detection. © Georg Thieme Verlag KG Stuttgart, New York. Source

Bevan R.,South Tyneside District Hospital | Bevan R.,Northern Region Endoscopy Group | Rubin G.,Durham University | Sofianopoulou E.,Durham University | And 4 more authors.
Endoscopy | Year: 2015

Background and study aims: Following the results of a major UK study showing that once-only flexible sigmoidoscopy (FSIG) screening significantly reduced colorectal cancer (CRC) incidence and mortality, an FSIG screening program in England was announced in late 2010. Three early pilot sites were selected in 2011 in Derby, South of Tyne, and Tees to assess the practicalities of the delivery of FSIG screening. Participants and methods: Eligible people aged 55 from selected practices in the three early pilot areas received postal invitations to participate. The South of Tyne and Derby sites employed interactive models of screening invitation, while Tees used a simple invitation. Data were collected to assess uptake, process, and outcome. A self-completion participant satisfaction questionnaire was sent to all participants 1 month after attendance. Results: A total of 4023 55-year-olds were invited to participate. Uptake was 29%, with 1151 people screened over a 3-month period. Screening uptake differed by method of invitation: a simple approach was significantly more successful than an interactive one (32% vs. 27%, P=0.0015). Uptake decreased significantly with increasing deprivation. Adenomas were found in 111 (9.8%) of those screened and cancer in two. The procedure was rated very or fairly acceptable by 97% of participants. Over 90% of respondents said they would participate in future cancer screening and a similar proportion would recommend doing so to others. Conclusion: Delivery of an FSIG screening program to prevent CRC is feasible and should be implemented using a simple invitation system. The national Bowel Scope program subsequently commenced at pilot sites in May 2013, with full implementation planned by 2016. © Georg Thieme Verlag KG Stuttgart · New York. Source

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