prevalence of neoplasia and adr targets in 45 to 49 year-olds
TRANSCRIPT
Prevalence of Neoplasia and ADR targets in 45 to 49 year-olds
Aasma Shaukat MD MPHDirector GI Outcomes Research
Professor of Medicine and Population HealthNYU Grossman School of Medicine
2016
Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2016; 315(23): 2564-2575
• gFOBT• FIT• FIT-DNA• Flex Sig• Flex Sig +FIT• Colonoscopy• CT colonography• Sept9 DNA test
USPSTF Recommendations 2016
ACS Guidelines 2018• Qualified recommendation to lower screening age to 45
• Rising incidence of colon and rectal cancer in <50
• Based on modelling studies using MISCAN and SimCRC
Wolf AMD et al. Colorectal cancer screening for average‐risk adults: 2018 guideline update from the American Cancer Society. Cancer 2018. https://doi.org/10.3322/caac.21457
CRC Incidence
Siegel RL et al. J Natl Cancer Inst. 2017;109(8):27-32
CRC Incidence (1995-2016) in the US
American Cancer Society, Colorectal Cancer Facts and Figures 2020-2022. Atlanta: American Cancer Society 2020
CRC Mortality (1970-2017) in the US
American Cancer Society, Colorectal Cancer Facts and Figures 2020-2022. Atlanta: American Cancer Society 2020
Temporal changes Incidence of CRC
Siegel, R.L.,et al. Colorectal cancer statistics, 2020. CA A Cancer J Clin, 70: 145-164; J Natl Cancer Inst. 2017;109(8):27-32
APC: NHWs +1.3% AI/ANs +0.6% Blacks -1.6% Hispanics 0.0%
Birth cohort effect
Increasing CRC incidence is a real trend:Incidence and stage at diagnosis 1995-2015
Meester RGS et al. JAMA. 2019;321(19):1933-1934.
ACG Clinical Guidelines: Colorectal Cancer Screening 2021, The American Journal of Gastroenterology: 2021;116 :458-479
USPSTF Recommendations 2021
• Grade A or B recs are covered by Medicare
• Other payors follow Medicare11
Recommendation GRADE
Screen average risk men and women 50-75 A High certainty of substantial net benefit
Screen average risk men and women starting at age 45
B Moderate certainty of moderate net benefit
Individualize decision to screen 76-85 C Moderate certainty of small net benefit
US Preventive Services Task Force. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(19):1965–1977
Benefits of earlier age at screening
• Reduce CRC incidence and mortality in younger group with rising incidence
• Bring people earlier to screening, boost 50-to-55-year-olds getting screened
• Harms• Access• Resources• Disparities
Liang PS, et al. Potential Intended and Unintended Consequences of Recommending Initiation of Colorectal Cancer Screening at Age 45 Years. Gastroenterology. 2018 Aug 21. 10.1053/j.gastro.2018.08.019. Imperiale TF, et al. Lowering the Starting Age for Colorectal Cancer Screening to 45 Years: Who Will Come…and Should They? ClinGastroenterol Hepatol. 2018;16(10):1541-1544.
Benefits of earlier screening
US Preventive Services Task Force. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(19):1965-1977
Harms
US Preventive Services Task Force. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(19):1965–1977
Prevalence of Neoplasia and ADRs in 45-49??
What we Know
• Risk of adenoma increases with age
• Adenoma detection rate (ADR) is a validated quality indicator for screening colonoscopy.
• In the US, minimum benchmarks for screening colonoscopy for >=50years is 25%
?? What we don’t know
• Prevalence of AA, AN and
CRC in asymptomatic
<50 year olds
• Impact of lowering
screening age to 45 on
endoscopist ADR
Kaminski M et al. N Engl J Med 2010; 362:1795-1803; Corley DA et al. N Engl J Med 2014; 370:1298-1306; Rex DK, Schoenfeld PS, Cohen J, et al. Quality indicators for colonoscopy. Gastrointest Endosc 2015;81:31-53.
Prevalence of Neoplasia and ADRs in 45-49
Prevalence of Neoplasia in 45-49 year olds
Regula J et al. N Engl J Med 2006; 355:1863-1872
• National colonoscopy-based screening program for colorectal cancer in Poland
• N=50,148 participants 2000-2004• <50yo with family history CRC
Prevalence of Neoplasia in 45-49 year olds
Butterly LF et al. Colonoscopy Outcomes in Average-Risk Screening Equivalent Young Adults: Data From the New Hampshire Colonoscopy Registry. AJG 2021;116:171-179.
• NHCR 2004-2018• Diagnostic colonoscopy (abdominal
pain, constipation in <50 year olds)
Prevalence of Neoplasia in 45-49 year olds
*unpublished data; Liang P et al. manuscript in preparation
• GIQuIC Registry• 2010-2020• >2 million colonoscopies• Screening indication
Advanced neoplasia* Advanced adenoma/CRC*
Age N n Prevalence PR (95% CI) n Prevalence PR (95% CI)
45-49 129,173 7,034 5.4% 0.88 (0.86-0.90) 5,256 4.1% 0.85 (0.83-0.88)
50-54 1,324,334
82,383 6.2% REF 63,132 4.8% REF
55-59 673,143 47,074 7.0% 1.12 (1.11-1.14) 37,293 5.5% 1.16 (1.15-1.18)
Neoplasia and ADRs by age groups:
Karsenti D et al. World J Gastroenterol. 2019; 25(4): 447–456.
• Single Center in France• All indications by age• Year 2016• 30 Endoscopists• 45-49 (n=515), 50* (n=4436)
Neoplasia and ADRs by age groups:
Karsenti D et al. World J Gastroenterol. 2019; 25(4): 447–456.
ADRs by age groups:• Multiple endoscopy centers in MN• 223,572 average risk screening colonoscopies• 99 Endoscopists• 2014-2019
Shaukat A et al. Adenoma detection Rates for 45-49 year old screening population. Gastroenterology 2021 (accepted)
45-49 year old
n=4841
50-54 year old
n=58,914
p-value
(compared to 45-
49 )
50-75 year old
N=159,817
p-value
(compar
ed to 45-
49
Overall ADR 28.4%
(27.1%, 29.6%)
31.1% (30.7%,
31.4%)
<0.001 35.6% (35.4%,
35.8%)
<0.001
ADR in men 34.8% (32.9, 36.8) 38.3% (37.7, 38.9) <0.001 43.0% (42.6, 43.3) <0.001
ADR in women 22.6% (21.0, 22.4) 24.4% (23.9, 24.9) 0.001 29.0% (28.7, 29.3) <0.001
APC 0.44 (0.41, 0.46) 0.49 (0.48, 0.49) <0.001 0.59 (0.58, 0.59) <0.001
AN detection rate 3.28% (2.58, 3.97) 3.43% (3.23, 3.64) 0.68 3.5%, (3.3, 3.6) 0.56
CRC detected 3 32 0.91 110 0.81
ADRs by age groups:• Modelled the effect of proportion of 45-49 yr olds that
constitute the total screening colonoscopy population
Shaukat A et al. Adenoma detection Rates for 45-49 year old screening population. Gastroenterology 2021 (accepted)
45-49 year old as proportion of
total (%)
Overall ADR (%)
5% 35.2%
10% 34.9%
25% 33.8%
50% 32.0%
75% 30.1%
ADRs by age groups:
Bilal M and Shaukat A et al. Adenoma detection Rates for 45-49 year old screening population. Abstract ACG 2021
• GIQuIC registry US• 45-75 yr olds Screening
Colonoscopy • 2014-2020• >2 million exams• 814 Endoscopists
45-49 years 50-54 years 50-75 years
Overall Mean (SD) ADR 28.63 (10.34) 31.87 (9.34) 36.32 (9.78)
Endoscopist n 814 814 814Total procedures 47,213 1,014,193 2,759,326
Mean (SD) ADR in men 32.91 (10.74) 36.98 (9.96) 41.50 (9.89)Endoscopist n 219 219 219
Total procedures 9,928 470,146 1,270,382Mean (SD) ADR in women 22.84 (9.87) 25.57 (8.48) 30.10 (9.18)
Endoscopist n 321 321 321Total procedures 16,372 529,084 1,477,418
Summary• Rising trend of advanced neoplasia and CRC in 45-49 age group• Prevalence rates of neoplasia in 45-49 year olds similar to 50-54
olds (AD 0-5%) and lower than 55+ year olds • ADRs lower than thank for 50-55 year olds (AD 3%-7%)• With 45-49 year old added to screening pool:
– ADR will depend on proportion of screenees 45-49– ADR per endoscopist lower but above benchmarks
• More to come as data accumulate with new recommendations
