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Screening flexible sigmoidoscopy versus colonoscopy for reduction of colorectal cancer mortality

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Abstract

Purpose

Colonoscopy and flexible sigmoidoscopy are both recommended colorectal cancer (CRC) screening strategies, but their relative effectiveness is unclear. We sought to evaluate the ability of each of these two modalities to reduce CRC mortality.

Methods

We conducted a case-control study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Cases were persons aged 70–85 years who died of CRC and were matched to up to three non-CRC controls. Receipt of endoscopy was ascertained from Medicare claims and endoscopy indication assigned using a validated algorithm. Conditional logistic regression models were developed to estimate the association between screening colonoscopy or sigmoidoscopy and CRC mortality. We conducted secondary analyses by race, sex, and endoscopist characteristics, and with varying duration of the look-back period.

Results

In the initial analysis using all available look-back years, screening flexible sigmoidoscopy was associated with a 35% reduction in CRC mortality (OR 0.65, 95% CI 0.48, 0.89), while screening colonoscopy was associated with a 74% reduction (OR 0.26, 95% CI 0.23, 0.30). Sigmoidoscopy was not associated with any reduction in proximal CRC mortality. The association between colonoscopy and reduced CRC mortality was stronger in the distal than the proximal colon. Results were similar in analyses using a 5-year look-back period.

Conclusions

Screening colonoscopy was associated with greater reductions in CRC mortality than screening sigmoidoscopy, and with a greater reduction in the distal than the proximal colon. These results provide additional information on the relative benefits of screening for CRC with sigmoidoscopy and colonoscopy.

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References

  1. Wolf AMD, Fontham ETH, Church TR, Flowers CR, Guerra CE, LaMonte S, Etzioni R, McKenna M, Oeffinger KC, Shih YT, Walter LC, Andrews KS, Brawley OW, Brooks D, Fedewa SA, Manassaram-Baptiste D, Siegel RL, Wender RC, Smith RA (2018) Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin 68:250–281

    Article  PubMed  Google Scholar 

  2. Bibbins-Domingo K, Grossman DC, Curry SJ et al (2016) Screening for colorectal cancer: US preventive services task force recommendation statement. JAMA 315:2564–2575

    Article  CAS  Google Scholar 

  3. Rex DK, Boland CR, Dominitz JA et al (2017) Colorectal cancer screening: recommendations for physicians and patients from the U.S. multi-society task force on colorectal cancer. Am J Gastroenterol 112:1016–1030

    Article  PubMed  Google Scholar 

  4. Baxter NN, Goldwasser MA, Paszat LF, Saskin R, Urbach DR, Rabeneck L (2009) Association of colonoscopy and death from colorectal cancer. Ann Intern Med 150:1–8

    Article  PubMed  Google Scholar 

  5. Baxter NN, Warren JL, Barrett MJ, Stukel TA, Doria-Rose VP (2012) Association between colonoscopy and colorectal cancer mortality in a US cohort according to site of cancer and colonoscopist specialty. J Clin Oncol 30:2664–2669

    Article  PubMed  PubMed Central  Google Scholar 

  6. Nishihara R, Wu K, Lochhead P, Morikawa T, Liao X, Qian ZR, Inamura K, Kim SA, Kuchiba A, Yamauchi M, Imamura Y, Willett WC, Rosner BA, Fuchs CS, Giovannucci E, Ogino S, Chan AT (2013) Long-term colorectal-cancer incidence and mortality after lower endoscopy. N Engl J Med 369:1095–1105

    Article  CAS  PubMed  Google Scholar 

  7. Brenner H, Chang-Claude J, Seiler CM, Rickert A, Hoffmeister M (2011) Protection from colorectal cancer after colonoscopy: a population-based, case-control study. Ann Intern Med 154:22–30

    Article  PubMed  Google Scholar 

  8. Weiss NS (1998) Analysis of case-control studies of the efficacy of screening for cancer: how should we deal with tests done in persons with symptoms? Am J Epidemiol 147:1099–1102

    Article  CAS  PubMed  Google Scholar 

  9. Weiss NS, Doria-Rose VP (2009) The effectiveness of colonoscopy in reducing mortality from colorectal cancer. Ann Intern Med 150:817–818

    Article  PubMed  Google Scholar 

  10. Weiss NS, McKnight B, Stevens NG (1992) Approaches to the analysis of case-control studies of the efficacy of screening for cancer. Am J Epidemiol 135:817–823

    Article  CAS  PubMed  Google Scholar 

  11. Atkin WS, Edwards R, Kralj-Hans I, Wooldrage K, Hart AR, Northover JMA, Parkin DM, Wardle J, Duffy SW, Cuzick J (2010) Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet 375:1624–1633

    Article  PubMed  Google Scholar 

  12. Schoen RE, Pinsky PF, Weissfeld JL, Yokochi LA, Church T, Laiyemo AO, Bresalier R, Andriole GL, Buys SS, Crawford ED, Fouad MN, Isaacs C, Johnson CC, Reding DJ, O'Brien B, Carrick DM, Wright P, Riley TL, Purdue MP, Izmirlian G, Kramer BS, Miller AB, Gohagan JK, Prorok PC, Berg CD, PLCO Project Team (2012) Colorectal-cancer incidence and mortality with screening flexible sigmoidoscopy. N Engl J Med 366:2345–2357

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Segnan N, Armaroli P, Bonelli L, Risio M, Sciallero S, Zappa M, Andreoni B, Arrigoni A, Bisanti L, Casella C, Crosta C, Falcini F, Ferrero F, Giacomin A, Giuliani O, Santarelli A, Visioli CB, Zanetti R, Atkin WS, Senore C, and the SCORE Working Group (2011) Once-only sigmoidoscopy in colorectal cancer screening: follow-up findings of the Italian randomized controlled trial--SCORE. J Natl Cancer Inst 103:1310–1322

    Article  PubMed  Google Scholar 

  14. Holme O, Loberg M, Kalager M et al (2014) Effect of flexible sigmoidoscopy screening on colorectal cancer incidence and mortality: a randomized clinical trial. JAMA. 312:606–615

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Holme O, Loberg M, Kalager M et al (2018) Long-term effectiveness of sigmoidoscopy screening on colorectal cancer incidence and mortality in women and men: a randomized trial. Ann Intern Med 168:775–782

    Article  PubMed  Google Scholar 

  16. Quintero E, Castells A, Bujanda L, Cubiella J, Salas D, Lanas Á, Andreu M, Carballo F, Morillas JD, Hernández C, Jover R, Montalvo I, Arenas J, Laredo E, Hernández V, Iglesias F, Cid E, Zubizarreta R, Sala T, Ponce M, Andrés M, Teruel G, Peris A, Roncales MP, Polo-Tomás M, Bessa X, Ferrer-Armengou O, Grau J, Serradesanferm A, Ono A, Cruzado J, Pérez-Riquelme F, Alonso-Abreu I, de la Vega-Prieto M, Reyes-Melian JM, Cacho G, Díaz-Tasende J, Herreros-de-Tejada A, Poves C, Santander C, González-Navarro A, COLONPREV Study Investigators (2012) Colonoscopy versus fecal immunochemical testing in colorectal-cancer screening. N Engl J Med 366:697–706

    Article  CAS  PubMed  Google Scholar 

  17. Bretthauer M, Kaminski MF, Loberg M et al (2016) Population-based colonoscopy screening for colorectal cancer: a randomized clinical trial. JAMA Intern Med 176:894–902

    Article  PubMed  PubMed Central  Google Scholar 

  18. Dominitz JA, Robertson DJ, Ahnen DJ, Allison JE, Antonelli M, Boardman KD, Ciarleglio M, del Curto BJ, Huang GD, Imperiale TF, Larson MF, Lieberman D, OʼConnor T, OʼLeary TJ, Peduzzi P, Provenzale D, Shaukat A, Sultan S, Voorhees A, Wallace R, Guarino PD (2017) Colonoscopy vs. fecal immunochemical test in reducing mortality from colorectal cancer (CONFIRM): rationale for study design. Am J Gastroenterol 112:1736–1746

    Article  PubMed  Google Scholar 

  19. Levin TR, Conell C, Shapiro JA, Chazan SG, Nadel MR, Selby JV (2002) Complications of screening flexible sigmoidoscopy. Gastroenterology 123:1786–1792

    Article  PubMed  Google Scholar 

  20. Brett AS (2014) Flexible sigmoidoscopy for colorectal cancer screening: more evidence, persistent ironies. JAMA 312:601–602

    Article  CAS  PubMed  Google Scholar 

  21. SEER Program Overview. Available from: http://healthcaredelivery.cancer.gov/seermedicare/overview/. Accessed June 1, 2018

  22. Ko CW, Dominitz JA, Neradilek M, Polissar N, Green P, Kreuter W, Baldwin LM (2014) Determination of colonoscopy indication from administrative claims data. Med Care 52:e21–e29

    Article  PubMed  PubMed Central  Google Scholar 

  23. Schenck AP, Klabunde CN, Warren JL, Peacock S, Davis WW, Hawley ST, Pignone M, Ransohoff DF (2008) Evaluation of claims, medical records, and self-report for measuring fecal occult blood testing among medicare enrollees in fee for service. Cancer Epidemiol Biomark Prev 17:799–804

    Article  Google Scholar 

  24. Weiss NS (1999) Case-control studies of the efficacy of screening tests designed to prevent the incidence of cancer. Am J Epidemiol 149:1–4

    Article  CAS  PubMed  Google Scholar 

  25. Kuntz KM, Lansdorp-Vogelaar I, Rutter CM, Knudsen AB, van Ballegooijen M, Savarino JE, Feuer EJ, Zauber AG (2011) A systematic comparison of microsimulation models of colorectal cancer: the role of assumptions about adenoma progression. Med Decis Mak 31:530–539

    Article  Google Scholar 

  26. SEER-Medicare: Summary Table of Available Medicare Data for Cancer & Non-cancer Cases. 2017. Available from: https://healthcaredelivery.cancer.gov/seermedicare/medicare/table.html. Accessed June 1, 2018

  27. Economic Research Service. Rural-Urban Continuum Codes: United States Department of Agriculture; 2013. Available from: http://www.ers.usda.gov/data-products/rural-urban-continuum-codes.aspx. Accessed June 29, 2018

  28. NCI Comorbidity Index Overview Bethesda, MD: National Cancer Institute. Available from: https://healthcaredelivery.cancer.gov/seermedicare/considerations/comorbidity.html. Accessed May 4, 2018

  29. Ko CW, Dominitz JA, Green P, Kreuter W, Baldwin LM (2010) Specialty differences in polyp detection, removal, and biopsy during colonoscopy. Am J Med 123:528–535

    Article  PubMed  Google Scholar 

  30. Ko CW, Dominitz JA, Green P, Kreuter W, Baldwin LM (2010) Utilization and predictors of early repeat colonoscopy in Medicare beneficiaries. Am J Gastroenterol 105:2670–2679

    Article  PubMed  Google Scholar 

  31. Weiss NS, Dhillon PK, Etzioni R (2004) Case-control studies of the efficacy of cancer screening: overcoming bias from nonrandom patterns of screening. Epidemiology 15:409–413

    Article  PubMed  Google Scholar 

  32. Brenner H, Hoffmeister M, Stegmaier C, Brenner G, Altenhofen L, Haug U (2007) Risk of progression of advanced adenomas to colorectal cancer by age and sex: estimates based on 840,149 screening colonoscopies. Gut 56:1585–1589

    Article  PubMed  PubMed Central  Google Scholar 

  33. Atkin W, Wooldrage K, Parkin DM, Kralj-Hans I, MacRae E, Shah U, Duffy S, Cross AJ (2017) Long term effects of once-only flexible sigmoidoscopy screening after 17 years of follow-up: the UK flexible sigmoidoscopy screening randomised controlled trial. Lancet 389:1299–1311

    Article  PubMed  PubMed Central  Google Scholar 

  34. Kahi CJ, Pohl H, Myers LJ, Mobarek D, Robertson DJ, Imperiale TF (2018) Colonoscopy and colorectal cancer mortality in the veterans affairs health care system: a case-control study. Ann Intern Med 168:481–488

    Article  PubMed  Google Scholar 

  35. Doubeni CA, Corley DA, Quinn VP, Jensen CD, Zauber AG, Goodman M, Johnson JR, Mehta SJ, Becerra TA, Zhao WK, Schottinger J, Doria-Rose VP, Levin TR, Weiss NS, Fletcher RH (2018) Effectiveness of screening colonoscopy in reducing the risk of death from right and left colon cancer: a large community-based study. Gut 67:291–298

    Article  PubMed  Google Scholar 

  36. Corley DA, Jensen CD, Marks AR, Zhao WK, Lee JK, Doubeni CA, Zauber AG, de Boer J, Fireman BH, Schottinger JE, Quinn VP, Ghai NR, Levin TR, Quesenberry CP (2014) Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med 370:1298–1306

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  37. Kaminski MF, Regula J, Kraszewska E, Polkowski M, Wojciechowska U, Didkowska J, Zwierko M, Rupinski M, Nowacki MP, Butruk E (2010) Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med 362:1795–1803

    Article  CAS  PubMed  Google Scholar 

  38. Boroff ES, Gurudu SR, Hentz JG, Leighton JA, Ramirez FC (2013) Polyp and adenoma detection rates in the proximal and distal colon. Am J Gastroenterol 108:993–999

    Article  PubMed  Google Scholar 

  39. Francis DL, Rodriguez-Correa DT, Buchner A, Harewood GC, Wallace M (2011) Application of a conversion factor to estimate the adenoma detection rate from the polyp detection rate. Gastrointest Endosc 73:493–497

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA

    Cynthia W. Ko

  2. Division of Gastroenterology, University of Washington, 356424, Seattle, WA, 98105, USA

    Cynthia W. Ko

  3. National Cancer Institute, National Institutes of Health, Bethesda, MD, USA

    V. Paul Doria-Rose & Lindsey Enewold

  4. Information Management Services, Inc., Calverton, MD, USA

    Michael J. Barrett

  5. Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA

    Aruna Kamineni

  6. Department of Epidemiology, University of Washington, Seattle, WA, USA

    Noel S. Weiss

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  1. Cynthia W. Ko
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Correspondence to Cynthia W. Ko.

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Ko, C.W., Doria-Rose, V.P., Barrett, M.J. et al. Screening flexible sigmoidoscopy versus colonoscopy for reduction of colorectal cancer mortality. Int J Colorectal Dis 34, 1273–1281 (2019). https://doi.org/10.1007/s00384-019-03300-7

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