Report in English with a Dutch summary (KCE reports 45A)

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70 Screening for Colorectal Cancer KCE reports vol.45 advance. The response rate was 32.8%. Data were extrapolated to establish estimates for the entire year and are presented in Table 19 (not published, but downloadable slideshow from the SFED website 315). Table 19: Estimated complication rates of colonoscopies in France 2002 - 2003 Complication category Percentage Hemorrhage 0,28% Anesthetical problems 0,05% Perforation 0,07% Septicaemia 0,01% Other 0,06% TOTAL COMPLICATIONS (Nestimated = 4.962 / 1.041.953 colonoscopies) 0,47% Several factors might improve the quality (complication rates) and sensitivity (missing rates) of colonoscopy: (1) examiners should receive adequate training, (2) caecal intubation rates should be high, (3) caecal intubation should be verified by specific landmarks in all cases, (4) failure to reach the caecum should be followed by barium enema or virtual colonoscopy, and (5) meticulous examination would appear to improve sensitivity for cancer detection 316. Whether and when colonoscopy with negative findings has to be repeated is not well defined. To determine the duration and magnitude of the risk of developing colorectal cancer following performance of a negative colonoscopy Singh et al 317 performed a population-based retrospective analysis of individuals with neoplasia-negative colonoscopic evaluations. A cohort of 35.975 patients who had been evaluated between April 1, 1989, and December 31, 2003, were identified using Manitoba Health's physician billing claims database. Standardized incidence ratios (SIRs) were calculated to compare CRC incidence in the cohort with that in the general population of the same province. Stratified analysis was performed to determine the duration of the risk reduction. Patients with a history of CRC prior to the index colonoscopy, inflammatory bowel disease, resective colorectal surgery, and lower gastrointestinal endoscopy within the 5 years before the index colonoscopy were excluded. Cohort members were followed up from the time of the index colonoscopy until diagnosis of colorectal cancer, death, emigration from Manitoba, or end of the study period on December 31, 2003. Results are summarized in Table 20. Table 20: Standardized incidence ratios (SIR) after negative index colonoscopy versus control 317 Follow up time SIR 95% CI 6 months 0,69 0,59 - 0,81 1 year 0,66 0,56 - 0,78 2 years 0,59 0,48 - 0,72 5 years 0,55 0,41 - 0,73 10 years 0,28 0,09 - 0,65 The proportion of right sided CRC was significantly higher in the colonoscopy cohort than the rate in the Manitoba population (47% vs. 28%; P< 0,001). The study concluded that the risk of developing CRC remains decreased for more than 10 years following the performance of a negative colonoscopy and that there is a need to improve the early detection rate of right-sided colorectal neoplasia in usual clinical practice.
KCE reports vol.45 Screening for Colorectal Cancer 71 In a small population based case-control study in Germany 318; including 380 cases and 485 controls, detailed history and results of previous colonoscopies were obtained by interview and from medical records and adjusted relative risks of colorectal cancer among subjects with a previous negative colonoscopy compared with those without previous colonoscopy were estimated according to time since colonoscopy. Subjects with previous negative colonoscopy had a 74% lower risk of CRC than those without previous colonoscopy (OR 0,26; 95% CI 0,16 to 0,40). This low risk was seen even if the colonoscopy had been done up to 20 or more years previously. Particularly low risks were seen for rectosigmoid cancer (OR 0,13; 95% CI 0,04 to 0,43) and for rectal cancer (OR 0,19; 95% CI 0,09 to 0,39), and after a negative screening colonoscopy at ages 55 to 64 (OR 0,17; 95% CI 0,08 to 0,39) and 65 (OR 0,21; 95% CI 0,10 to 0,41). The authors concluded that subjects with negative findings at colonoscopy are at very low risk of colorectal cancer and might not need to undergo repeat colonoscopy for 20 years or more, if at all. The possibility of extending screening intervals to 20 years or more might reduce complications and increase the feasibility, compliance and cost-effectiveness of colonoscopy based screening programs. 5.4.4 Double contrast barium enema (DCBE) With this conventional radiological technique, a liquid barium mixture is instilled into the colorectum and afterwards air is insufflated, followed by x-ray examination in various positions 275, 194. The patient usually prepares with dietary restrictions and an enema or laxatives the day before. It is a standard radiological technique and was considered as a potential screening tool. It does have the advantage of a higher sensitivity compared to FOBT, the ability to visualise the entire colon compared to FS and a better safety and lower cost compared to colonoscopy. It does not permit, however, to take samples meaning that colonoscopy will still be needed when suspicious lesions are detected by DCBE. The Scientific Steering Committee considered DCBE as an obsolete technique for mass screening purposes. 5.4.5 Virtual colonoscopy Virtual colonoscopy (also known as CT colonography, CT pneumocolon, MRI colonoscopy) refers to essentially preoperative (i.e. diagnostic) radiological tumor staging techniques 319 using computer generated images of the colon constructed from data obtained from an abdominal CT 194, 320-323 or MRI examination 324-327. The preparation is similar to standard colonoscopy. Air or carbon dioxide is insufflated into the colon and data are acquired by the scanner, generating images of the colon. Data are presented as two-dimensional images while suspicious areas can be rendered as three-dimensional images 328. Sedation is normally not required although mild discomfort is reported from the insufflation of air during the procedure 231. Theoretically, virtual colonoscopy has several potential advantages over endoscopic colonoscopy for use in colorectal cancer diagnosis and potentially even screening. It enables to visualise the entire colon non-invasively and can also identify malignancies in areas that are difficult to assess with colonoscopy. Therefore, it has been argued that, in a diagnostic setting, it might be the favoured examination technique when colonoscopy failed, was incomplete or when the performance of a colonoscopy was contra-indicated or refused by the patient 329, 330. It is a rapidly evolving technique as witnessed by the wealth of
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