Correspondence
Five-Year Risk of Colorectal Neoplasia after Negative Colonoscopy
N Engl J Med 2008; 359:2611-2612December 11, 2008
- Article
To the Editor:
The rate of 1.3% for advanced adenoma detected approximately 5 years after a negative colonoscopy, is indeed low, as Imperiale et al. report (Sept. 18 issue).1 The rate for detection of any adenoma was 16.0%. What is striking is the low proportion of patients with advanced adenoma relative to the proportion of patients with any adenoma (8.1%). Numerous factors may have contributed to this low observed rate, including a low risk of this condition in the study population, low rates of detection by endoscopists, and low rates observed by pathologists.
In the Study of Colonoscopy Utilization, an ancillary to the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, data from nine U.S. centers were tracked for 589 subjects with nonadenomatous findings on initial colonoscopy (494 subjects with hyperplastic polyps and 95 with no polyps), with repeat colonoscopy within 6 years.2 The rate of advanced adenoma was 4.4%, and the rate of any adenoma 20.5%. The risk of advanced adenoma was thus more than three times as high as that reported by Imperiale et al. Although there are limited follow-up data available for subjects with negative findings on the initial colonoscopy, the proportion of patients with advanced adenoma relative to the proportion with any adenoma in our study (21.5%) is more consistent with that seen in most colonoscopy cohorts.3-5
5 ReferencesRobert E. Schoen, M.D., M.P.H.
University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
rschoen@pitt.edu Paul F. Pinsky, Ph.D.
National Cancer Institute, Bethesda, MD 208921
Imperiale TF ,Glowinski EA ,Lin-Cooper C ,Larkin GN ,Rogge JD ,Ransohoff DF . Five-year risk of colorectal neoplasia after negative screening colonoscopy. N Engl J Med 2008;359:1218-1224
Full Text | Web of Science | Medline2
Pinsky PF, Schoen RE, Weissfeld JL, et al. The yield of surveillance colonoscopy by adenoma history and time to exam. Clin Gastroenterol Hepatol 2008 July 26 (Epub ahead of print).
3
Schoen RE . Surveillance after positive and negative colonoscopy examinations: issues, yields, and use. Am J Gastroenterol 2003;98:1237-1246
CrossRef | Web of Science | Medline4
Lieberman DA ,Weiss DG ,Harford WV , et al. Five-year colon surveillance after screening colonoscopy. Gastroenterology 2007;133:1077-1085
CrossRef | Web of Science | Medline5
Regula J ,Rupinski M ,Kraszewska E , et al. Colonoscopy in colorectal-cancer screening for detection of advanced neoplasia. N Engl J Med 2006;355:1863-1872
Full Text | Web of Science | Medline
To the Editor:
Imperiale et al. provide important evidence for a very low prevalence of colorectal cancer or advanced adenoma among persons with no colorectal neoplasia on initial screening colonoscopy conducted 5 years earlier. Reported prevalences of colorectal cancer (0.0%) and of advanced adenomas (0.6% in women, 1.8% in men) observed 5 years after initial screening are far below prevalences in age groups in the general population for which screening colonoscopy is recommended.1-3 In fact, the prevalences are about 50 to 70% lower than those reported for 40-to-49-year-old women and men with no family history of colorectal cancer, for whom screening colonoscopy is generally not recommended.2 In the light of these data, the authors' claim for a rescreening interval of 5 years or longer after a negative screening colonoscopy should be expanded to a claim against rescreening 5 years after a negative screening colonoscopy. Studies with much longer intervals between colonoscopies are needed to resolve the question of whether there should be any rescreening after a negative screening colonoscopy and, if so, at what interval.4
4 ReferencesHermann Brenner, M.D., M.P.H.
Ulrike Haug, Ph.D.
Michael Hoffmeister, Ph.D.
German Cancer Research Center, 69120 Heidelberg, Germany
h.brenner@dkfz. de 1
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;56:1585-1589
CrossRef | Web of Science | Medline2
Regula J ,Rupinski M ,Kraszewska E , et al. Colonoscopy in colorectal-cancer screening for detection of advanced neoplasia. N Engl J Med 2006;355:1863-1872
Full Text | Web of Science | Medline3
Levin B ,Lieberman DA ,McFarland B , et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology 2008;134:1570-1595
CrossRef | Web of Science | Medline4
Brenner H ,Chang-Claude J ,Seiler CM ,Sturmer T ,Hoffmeister M . Does a negative screening colonoscopy ever need to be repeated? Gut 2006;55:1145-1150
CrossRef | Web of Science | Medline
To the Editor:
Imperiale et al. performed a retrospective examination of data from 1256 asymptomatic subjects who underwent a first negative screening colonoscopy and a subsequent follow-up colonoscopy after 5 years. Although no cancer was found on rescreening, advanced adenomas were identified in a small proportion of subjects (1.3%), and at a higher frequency in men than in women, as was reported in another colonoscopy-based screening program.1
Although the authors did not provide an explanation for the excess of neoplasia in men, it could probably be explained by the difference in tobacco exposure between men and women.2 Tobacco exposure has been consistently associated with the development of adenomatous polyps, particularly high-risk adenomas,3 and earlier colorectal-cancer screening in long-term smokers has been proposed.4
It would be valuable if information on smoking habits could be retrieved at least for the 16 subjects in whom advanced adenoma was diagnosed. If there was a high proportion of smokers in this group, tobacco exposure may be an important factor to consider when determining the optimal interval for endoscopic rescreening after a first negative colonoscopy.
4 ReferencesPatrick Maisonneuve, Eng.
Edoardo Botteri, M.Sc.
European Institute of Oncology, 20141 Milan, Italy
patrick.maisonneuve@ieo. it Albert B. Lowenfels, M.D.
New York Medical College, Valhalla, NY 105951
Regula J ,Rupinski M ,Kraszewska E , et al. Colonoscopy in colorectal-cancer screening for detection of advanced neoplasia. N Engl J Med 2006;355:1863-1872
Full Text | Web of Science | Medline2
Shopland DR ,Hartman AM ,Gibson JT ,Mueller MD ,Kessler LG ,Lynn WR . Cigarette smoking among U.S. adults by state and region: estimates from the Current Population Survey. J Natl Cancer Inst 1996;88:1748-1758
CrossRef | Web of Science | Medline3
Botteri E ,Iodice S ,Raimondi S ,Maisonneuve P ,Lowenfels AB . Cigarette smoking and adenomatous polyps: a meta-analysis. Gastroenterology 2008;134:388-395
CrossRef | Web of Science | Medline4
Peppone LJ ,Mahoney MC ,Cummings KM , et al. Colorectal cancer occurs earlier in those exposed to tobacco smoke: implications for screening. J Cancer Res Clin Oncol 2008;134:743-751
CrossRef | Web of Science | Medline
Author/Editor Response
Schoen and Pinsky express surprise at the low rate of advanced adenoma in our study, yet our findings are consistent with studies that are comparable with respect to population and design.1-3 Subjects in the PLCO trial may not be comparable to those in our study because in the PLCO trial all subjects were required to have some finding on sigmoidoscopy in order to be referred for colonoscopy; this may explain the high proportion of subjects with hyperplastic polyps relative to those with no detected findings at baseline — 84.6% (494 of 584) — as compared with only 199 of 1256 (15.8%) of our subjects. Despite these differences, the 5-year risk of advanced adenoma among the 199 subjects with baseline hyperplastic polyps in our study (2.0%; 95% confidence interval [CI], 0.5 to 5.0) overlaps with the 4.4% risk (95% CI, 2.9 to 6.4) reported in the PLCO ancillary study.
Brenner et al. comment on the low risk of cancer and advanced adenoma in our rescreened population, as compared with the prevalence among subgroups of a screened population. We believe the difference in risk results from comparing measures of incidence (in a population with initially negative findings) with prevalence among unselected, screened subjects. We agree with their suggestion that the optimal rescreening interval may be much longer than 5 years; however, our study does not contain the direct evidence required to make a strong recommendation about whether and when to rescreen.
Maisonneuve et al. suggest that the increased risk of advanced adenoma among the men in our study may be due to tobacco exposure. Although we agree that a difference in exposure between men and women may account for the increased risk of advanced adenoma among the men, so may factors such as body-mass index, family history, level of physical activity, and alcohol consumption.4 Unfortunately, we have no data on these risk factors in our follow-up cohort. We believe that a multivariable assessment of known and candidate risk factors for advanced colorectal neoplasia is needed so that risk stratification can be used to increase the accuracy and cost-effectiveness of screening and perhaps surveillance.
4 ReferencesThomas F. Imperiale, M.D.
Indiana University Medical Center, Indianapolis, IN 46202-5121David F. Ransohoff, M.D.
University of North Carolina, Chapel Hill, NC 275991
Neugut AI ,Jacobson JS ,Ahsan H , et al. Incidence and recurrence rates of colorectal adenomas: a prospective study. Gastroenterology 1995;108:402-408
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Rex DK ,Cummings OW ,Helper DJ , et al. 5-Year incidence of adenomas after negative colonoscopy in asymptomatic average-risk persons. Gastroenterology 1996;111:1178-1181
CrossRef | Web of Science | Medline3
Squillace S ,Berggreen P ,Jaffe P , et al. A normal initial colonoscopy after age 50 does not predict a polyp-free status for live. Am J Gastroenterol 1994;89:1156-1159
Web of Science | Medline4
Kahi CJ ,Rex DK ,Imperiale TF . Screening, surveillance, and primary prevention for colorectal cancer: a review of the recent literature. Gastroenterology 2008;135:380-399
CrossRef | Web of Science | Medline
- Citing Articles (1)
Citing Articles
1
Hermann Brenner, Ulrike Haug, Volker Arndt, Christa Stegmaier, Lutz Altenhofen, Michael Hoffmeister. (2010) Low Risk of Colorectal Cancer and Advanced Adenomas More Than 10 Years After Negative Colonoscopy. Gastroenterology 138:3, 870-876
CrossRef
