Diagnostic yield from symptomatic lower gastrointestinal endoscopy in the UK: A British Society of Gastroenterology analysis using data from the National Endoscopy Database.
colonoscopy
colorectal cancer
diagnostic yield
flexible sigmoidoscopy
population health
Journal
Alimentary pharmacology & therapeutics
ISSN: 1365-2036
Titre abrégé: Aliment Pharmacol Ther
Pays: England
ID NLM: 8707234
Informations de publication
Date de publication:
18 Apr 2024
18 Apr 2024
Historique:
revised:
07
04
2024
received:
11
01
2024
accepted:
07
04
2024
medline:
18
4
2024
pubmed:
18
4
2024
entrez:
18
4
2024
Statut:
aheadofprint
Résumé
The value of lower gastrointestinal endoscopy (LGIE; colonoscopy or sigmoidoscopy) relates to its ability to detect clinically relevant findings, predominantly cancers, preneoplastic polyps or inflammatory bowel disease. There are concerns that many LGIEs are performed on low-risk patients with limited benefit. To determine the diagnostic outcomes of LGIE for common symptoms. We performed a cross-sectional study of diagnostic LGIE between March 2019 and February 2020 using the UK National Endoscopy Database. We used mixed-effects logistic regression models, incorporating random (endoscopist) and fixed (symptoms, patient age, and sex) effects upon two dependent variables (large polyp [≥10 mm] and cancer diagnosis). Adjusted positive predictive values (aPPVs) were calculated. We analysed 384,510 LGIEs; 33.2% were performed on patients aged under 50 and 53.6% on women. Regarding colonoscopies, the unadjusted PPV for cancer was 1.5% (95% CI: 1.4-1.5); higher for men than women (1.9% vs. 1.1%, p < 0.01). The PPV for large polyps was 3.2% (95% CI: 3.1-3.2). The highest colonoscopy cancer aPPVs were in the over 50s (1.9%) and in those with rectal bleeding (2.5%) or anaemia (2.1%). Cancer aPPVs for other symptoms were <1% despite representing 54.3% of activity. In patients under 50, aPPVs were 0.4% for cancer and 1.6% for large polyps. Results were similar for sigmoidoscopy. Most colonoscopies were performed on patients with low-risk symptoms, where cancer risk was similar to the general population. Cancer and large polyp yield was highest in elderly patients with rectal bleeding or anaemia, although still fell short of FIT-based screening yields.
Sections du résumé
BACKGROUND
BACKGROUND
The value of lower gastrointestinal endoscopy (LGIE; colonoscopy or sigmoidoscopy) relates to its ability to detect clinically relevant findings, predominantly cancers, preneoplastic polyps or inflammatory bowel disease. There are concerns that many LGIEs are performed on low-risk patients with limited benefit.
AIMS
OBJECTIVE
To determine the diagnostic outcomes of LGIE for common symptoms.
METHODS
METHODS
We performed a cross-sectional study of diagnostic LGIE between March 2019 and February 2020 using the UK National Endoscopy Database. We used mixed-effects logistic regression models, incorporating random (endoscopist) and fixed (symptoms, patient age, and sex) effects upon two dependent variables (large polyp [≥10 mm] and cancer diagnosis). Adjusted positive predictive values (aPPVs) were calculated.
RESULTS
RESULTS
We analysed 384,510 LGIEs; 33.2% were performed on patients aged under 50 and 53.6% on women. Regarding colonoscopies, the unadjusted PPV for cancer was 1.5% (95% CI: 1.4-1.5); higher for men than women (1.9% vs. 1.1%, p < 0.01). The PPV for large polyps was 3.2% (95% CI: 3.1-3.2). The highest colonoscopy cancer aPPVs were in the over 50s (1.9%) and in those with rectal bleeding (2.5%) or anaemia (2.1%). Cancer aPPVs for other symptoms were <1% despite representing 54.3% of activity. In patients under 50, aPPVs were 0.4% for cancer and 1.6% for large polyps. Results were similar for sigmoidoscopy.
CONCLUSIONS
CONCLUSIONS
Most colonoscopies were performed on patients with low-risk symptoms, where cancer risk was similar to the general population. Cancer and large polyp yield was highest in elderly patients with rectal bleeding or anaemia, although still fell short of FIT-based screening yields.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Informations de copyright
© 2024 The Authors. Alimentary Pharmacology & Therapeutics published by John Wiley & Sons Ltd.
Références
NHS‐Digital, Urgent suspected cancer referrals. Referral, conversion and detection rates, April 2009 to March 2021, N.D.R. Service, Editor. 2021, NHS Digital. https://www.cancerdata.nhs.uk/cwt_conversion_and_detection.
Ravindran S, Bassett P, Shaw T, Dron M, Broughton R, Johnston D, et al. National census of UK endoscopy services in 2019. Frontline Gastroenterol. 2020;12:451–460.
Breslin NP. Gastric cancer and other endoscopic diagnoses in patients with benign dyspepsia. Gut. 2000;46(1):93–97.
Halasz JB, Burak KW, Dowling SK, Murray B, Williams J, Misra T, et al. Do low‐risk patients with dyspepsia need a gastroscopy? Use of gastroscopy for otherwise healthy patients with dyspepsia. J Can Assoc Gastroenterol. 2022;5(1):32–38.
Maurice JB, Siau K, Sebastian S, Ahuja N, Wesley E, Stableforth W, et al. Green endoscopy: a call for sustainability in the midst of COVID‐19. Lancet Gastroenterol Hepatol. 2020;5(7):636–638.
Li SJ, Seedher T, Sharples LD, Benton SC, Mathews C, Gabe R, et al. Impact of changes to the interscreening interval and faecal immunochemical test threshold in the national bowel cancer screening programme in England: results from the FIT pilot study. Br J Cancer. 2022;127(8):1525–1533.
Logan RFA, Patnick J, Nickerson C, Coleman L, Rutter MD, von Wagner C, et al. Outcomes of the bowel cancer screening Programme (BCSP) in England after the first 1 million tests. Gut. 2012;61(10):1439–1446.
Maringe C, Spicer J, Morris M, Purushotham A, Nolte E, Sullivan R, et al. The impact of the COVID‐19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population‐based, modelling study. Lancet Oncol. 2020;21(8):1023–1034.
Ravindran S, Thomas‐Gibson S, Bano M, Robinson E, Jenkins A, Marshall S, et al. National census of UK endoscopy services 2021. Frontline Gastroenterol. 2022;13(6):463–470.
Ho KMA, Banerjee A, Lawler M, Rutter MD, Lovat LB. Predicting endoscopic activity recovery in England after COVID‐19: a national analysis. Lancet Gastroenterol Hepatol. 2021;6(5):381–390.
Alderwick H, Charlesworth A. A long term workforce plan for the English NHS. BMJ. 2022;377:o1047.
Lee TJ, Siau K, Esmaily S, Docherty J, Stebbing J, Brookes MJ, et al. Development of a national automated endoscopy database: the United Kingdom National Endoscopy Database (NED). United European Gastroenterol J. 2019;7(6):798–806.
The National Endoscopy Database (NED). 2021. [cited 2021 10th April]. https://nedpilot.thejag.org.uk/.
NICE. NICE guideline [NG12]: suspected cancer: recognition and referral. 2015. [cited 2021 16th Apr]. https://www.nice.org.uk/guidance/ng12/chapter/Recommendations‐organised‐by‐symptom‐and‐findings‐of‐primary‐care‐investigations#abdominal‐symptoms.
Beaton D, Sharp L, Trudgill NJ, Thoufeeq M, Nicholson BD, Rogers P, et al. UK endoscopy workload and workforce patterns: is there potential to increase capacity? A BSG analysis of the National Endoscopy Database. Frontline Gastroenterol. 2022;14:103–110.
Williams U, Williams SP. txttool: utilities for text analysis in Stata. Stata J. 2014;14(4):817–829.
Edwin BW. Probable inference, the law of succession, and statistical inference. J Am Stat Assoc. 1927;22(158):209–212.
Brown H, Prescott R. Applied mixed models in medicine, in statistics in practice. West Sussex UK: John Wiley & Sons; 2006.
Lee D‐W, Koo JS, Choe JW, Suh SJ, Kim SY, Hyun JJ, et al. Diagnostic delay in inflammatory bowel disease increases the risk of intestinal surgery. World J Gastroenterol. 2017;23(35):6474–6481.
Sud A, Jones ME, Broggio J, Loveday C, Torr B, Garrett A, et al. Collateral damage: the impact on outcomes from cancer surgery of the COVID‐19 pandemic. Ann Oncol. 2020;31(8):1065–1074.
Frazzoni L, Laterza L, la Marca M, Zagari RM, Radaelli F, Hassan C, et al. Clinical value of alarm features for colorectal cancer: a meta‐analysis. Endoscopy. 2023;55(5):458–468.
Brenner H, Altenhofen L, Hoffmeister M. Sex, age, and birth cohort effects in colorectal neoplasms: a cohort analysis. Ann Intern Med. 2010;152(11):697–703.
Bretthauer M, Løberg M, Wieszczy P, Kalager M, Emilsson L, Garborg K, et al. Effect of colonoscopy screening on risks of colorectal cancer and related death. N Engl J Med. 2022;387(17):1547–1556.
Lawrenson R, Logie J, Marks C. Risk of colorectal cancer in general practice patients presenting with rectal bleeding, change in bowel habit or anaemia. Eur J Cancer Care. 2006;15(3):267–271.
Hamilton W, Lancashire R, Sharp D, Peters TJ, Cheng KK, Marshall T. The risk of colorectal cancer with symptoms at different ages and between the sexes: a case‐control study. BMC Med. 2009;7(1):17.
Neugut AI, Garbowski GC, Waye JD, Forde KA, Treat MR, Tsai JL, et al. Diagnostic yield of colorectal neoplasia with colonoscopy for abdominal pain, change in bowel habits, and rectal bleeding. Am J Gastroenterol. 1993;88(8):1179–1183.
Chaplin A, Curless R, Thomson R, Barton R. Prevalence of lower gastrointestinal symptoms and associated consultation behaviour in a British elderly population determined by face‐to‐face interview. Br J Gen Pract. 2000;50(459):798–802.
Hamilton W. Diagnosis of colorectal cancer in primary care: the evidence base for guidelines. Fam Pract. 2004;21(1):99–106.
Wong MCS, Huang J, Huang JLW, Pang TWY, Choi P, Wang J, et al. Global prevalence of colorectal neoplasia: a systematic review and meta‐analysis. Clin Gastroenterol Hepatol. 2020;18(3):553–561.e10.
Burr NE, Derbyshire E, Taylor J, Whalley S, Subramanian V, Finan PJ, et al. Variation in post‐colonoscopy colorectal cancer across colonoscopy providers in English National Health Service: population based cohort study. BMJ. 2019;367:l6090.
Dominitz J, Holub J, Issaka R, Ko C, Robertson D, Ladabaum U. Endoscopist adenoma detection rate is associated with detection of colorectal cancer AT colonoscopy performed for screening or evaluation of abnormal stool test. Gastrointest Endosc. 2023;97(6):AB239–AB240.
Liang PS, Williams JL, Dominitz JA, Corley DA, Zauber AG. Age‐stratified prevalence and predictors of neoplasia among U.S. adults undergoing screening colonoscopy in a National Endoscopy Registry. Gastroenterology. 2022;163(3):742–753.e4.
Trivedi PD, Mohapatra A, Morris MK, Thorne SA, Smith SC, Ward AM, et al. Prevalence and predictors of young‐onset colorectal neoplasia: insights from a nationally representative colonoscopy registry. Gastroenterology. 2022;162(4):1136–1146.e5.
Brenner H, Hoffmeister M, Stegmaier C, Brenner G, Altenhofen L, Haug U. Risk of progression of advanced adenomas to colorectal cancer by age and sex: estimates based on 840 149 screening colonoscopies. Gut. 2007;56(11):1585–1589.
Van Rheenen PF, Van De Vijver E, Fidler V. Faecal calprotectin for screening of patients with suspected inflammatory bowel disease: diagnostic meta‐analysis. BMJ. 2010;341:c3369.
Moss S, Mathews C, Day TJ, Smith S, Seaman HE, Snowball J, et al. Increased uptake and improved outcomes of bowel cancer screening with a faecal immunochemical test: results from a pilot study within the national screening programme in England. Gut. 2017;66(9):1631–1644.
Monahan KJ, Davies MM, Abulafi M, Banerjea A, Nicholson BD, Arasaradnam R, et al. Faecal immunochemical testing (FIT) in patients with signs or symptoms of suspected colorectal cancer (CRC): a joint guideline from the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the British Society of Gastroenterology (BSG). Gut. 2022;71:1939–1962.
Brands HJ, van Dijk B, Brohet RM, van Westreenen HL, de Groot JWB, Moons LMG, et al. Possible value of faecal immunochemical test (FIT) when added in symptomatic patients referred for colonoscopy: a systematic review. Cancers (Basel). 2023;15(7):2011.
Pin‐Vieito N, Tejido‐Sandoval C, de Vicente‐Bielza N, Sánchez‐Gómez C, Cubiella J. Faecal immunochemical tests safely enhance rational use of resources during the assessment of suspected symptomatic colorectal cancer in primary care: systematic review and meta‐analysis. Gut. 2022;71(5):950–960.
Van Rosendaal GMA, Sutherland LR, Verhoef MJ, Bailey RJ, Blustein PK, Lalor EA, et al. Defining the role of fiberoptic sigmoidoscopy in the investigation of patients presenting with bright red rectal bleeding. Am J Gastroenterol. 2000;95(5):1184–1187.
Cross AJ, Wooldrage K, Robbins EC, Pack K, Brown JP, Hamilton W, et al. Whole‐colon investigation vs. flexible sigmoidoscopy for suspected colorectal cancer based on presenting symptoms and signs: a multicentre cohort study. Br J Cancer. 2019;120(2):154–164.
Digby J, Strachan JA, McCann R, Steele RJC, Fraser CG, Mowat C. Measurement of faecal haemoglobin with a faecal immunochemical test can assist in defining which patients attending primary care with rectal bleeding require urgent referral. Ann Clin Biochem. 2020;57(4):325–327.
Lewis J, Askari A, Mehta A, Razak Y, Patel P, Misra R, et al. A novel digital rectoscope for the triage of lower gastrointestinal symptoms in primary care: a prospective multicentre feasibility study. BJGP Open. 2022;6(3):BJGPO.2022.0036.
Rutter MD, Brookes M, Lee TJ, Rogers P, Sharp L. Impact of the COVID‐19 pandemic on UK endoscopic activity and cancer detection: a National Endoscopy Database Analysis. Gut. 2020;70:537–543.