Advertisement

Detrimental impact of symptom-detected colorectal cancer

Abstract

Background

The incidence and mortality rates of colorectal cancer (CRC) have been steadily decreasing, largely attributable to screening colonoscopies that either remove precancerous lesions or identify CRC earlier. We aimed to assess the prognostic difference between colorectal cancers diagnosed by screening (SC), diagnostic (DC), or surveillance (SU) colonoscopies.

Methods

All 1809 surgically treated patients with primary CRC diagnosed through colonoscopy at our tertiary center (2004–2015) were extracted from a prospectively maintained database. Oncologic outcomes were compared, including multivariate Cox regression.

Results

Diagnostic patients presented with more advanced disease (15.0% vs. 53.2% (SC) and 55.3% (SU) AJCC I, P < 0.001), subsequently leading to impaired survival and higher recurrence rates (P < 0.001). After adjustment for age, ASA-score and gender, oncologic outcomes remained significantly worse after DC. Hazard ratios (HR) of overall mortality (OS) compared to DC were 0.36 for SC and 0.58 for SU (P < 0.001). Adjusted HRs of disease-free survival (DFS) were 0.43 and 0.32, respectively (P < 0.001). Worse outcomes in OS withstood adjustment for stage, tumor site and (neo)adjuvant treatment (SC: HR 0.46, P < 0.001; SU: HR 0.73, P = 0.036). The benefits of SC were particularly seen in colon cancer, stages I–II and female patients. With regard to DFS, outcomes were less profound and mainly true in early stage disease and surveillance patients.

Conclusions

This study demonstrates the enormous impact of asymptomatic screening in CRC. Patients with CRC diagnosed through screening or surveillance had a significantly better prognosis compared to patients who presented symptomatically. This emphasizes the importance of screening.

This is a preview of subscription content, log in to check access.

Access options

Buy single article

Instant unlimited access to the full article PDF.

US$ 39.95

Price includes VAT for USA

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Abbreviations

ACS:

American Cancer Society

AJCC:

American Joint Committee on Cancer

ASA:

American Society of Anesthesiologists

BMI:

Body Mass Index, kg/m2

CEA:

Carcinoembryonic Antigen

CI:

Confidence Interval

CRC:

Colorectal Cancer

CT:

Computed Tomography

DC:

Diagnostic Colonoscopy

DFS:

Disease-free Survival

FOBT:

Fecal Occult Blood Testing

HR:

Hazard Ratio

IBD:

Inflammatory Bowel Disease

IQR:

Interquartile Range

NCCN:

National Comprehensive Cancer Network

OS:

Overall Survival

SD:

Standard Deviation

SC:

Screening Colonoscopy

SU:

Surveillance Colonoscopy

TNM:

Tumor Node Metastasis classification

USPSTF:

US Preventive Services Task Force

References

  1. 1.

    Zauber AG, Lansdorp-Vogelaar I, Knudsen AB, Wilschut J, van Ballegooijen M, Kuntz KM (2008) Evaluating test strategies for colorectal cancer screening: a decision analysis for the U.S. Preventive Services Task Force. Ann Intern Med 149:659–669

  2. 2.

    Holme Ø, Løberg M, Kalager M, Bretthauer M, Hernán MA, Aas E, Eide TJ, Skovlund E, Schneede J, Tveit KM, Hoff G (2014) Effect of flexible sigmoidoscopy screening on colorectal cancer incidence and mortality: a randomized clinical trial. JAMA 312(6):606–615

  3. 3.

    Noone AM, Howlader N, Krapcho M, Miller D, Brest A, Yu M, Ruhl J, Tatalovich Z, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds) SEER cancer statistics review, 1975–2015. National Cancer Institute, Bethesda. http://seer.cancer.gov/csr/1975_2013/, based on November 2017 SEER data submission, posted to the SEER web site, April 2018

  4. 4.

    US Preventive Services Task Force (2016) Screening for colorectal cancer US Preventive Services Task Force recommendation statement. JAMA 315(23):2564–2575

  5. 5.

    Wolf AM, Fontham ET, Church TR, Flowers CR, Guerra CE, LaMonte SJ, Etzioni R, McKenna MT, 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

  6. 6.

    Meissner HI, Breen N, Klabunde CN, Vernon SW (2006) Patterns of colorectal cancer screening uptake among men and women in the United States. Cancer Epidemiol Biomark Prev 15(2):389–394

  7. 7.

    Klabunde CN, Joseph DA, King JB, White A, Plescia M (2013) Vital signs: colorectal cancer screening test use—United States, 2012. MMWR Morb Mortal Wkly Rep 62(44):881–888

  8. 8.

    Shapiro JA, Klabunde CN, Thompson TD, Nadel MR, Seeff LC, White A (2012) Patterns of colorectal cancer test use, including CT colonography, in the 2010 National Health Interview Survey. Cancer Epidemiol Biomark Prev 21(6):895–904

  9. 9.

    Centers for Disease Control and Prevention (CDC) (2013) Vital signs: colorectal cancer screening test use: United States, 2012. MMWR Morb Mortal Wkly Rep 62(44):881–888

  10. 10.

    Gupta S, Halm EA, Rockey DC, Hammons M, Koch M, Carter E, Valdez L, Tong L, Ahn C, Kashner M, Argenbright K, Tiro J, Geng Z, Pruitt S, Skinner CS (2013) Comparative effectiveness of fecal immunochemical test outreach, colonoscopy outreach, and usual care for boosting colorectal cancer screening among the underserved: a randomized clinical trial. JAMA Intern Med 173:1725–1732

  11. 11.

    Amri R, Bordeianou LG, Sylla P, Berger DL (2013) Impact of screening colonoscopy on outcomes in colon cancer surgery. JAMA Surg 148:747–754

  12. 12.

    ASGE Standards of Practice Committee, Early DS, Ben-Menachem T, Decker GA, Evans JA, Fanelli RD, Fisher DA, Fukami N, Hwang JH, Jain R, Jue TL, Khan KM, Malpas PM, Maple JT, Sharaf RS, Dominitz JA, Cash BD (2012) Appropriate use of GI endoscopy. Gastrointest Endosc 75:1127–1131

  13. 13.

    Vader JP, Froehlich F, Dubois RW, Beglinger C, Wietlisbach V, Pittet V, Ebel N, Gonvers JJ, Burnand B (1999) European panel for the appropriateness of gastrointestinal endoscopy (EPAGE): conclusion and WWW Site. Endoscopy 31:687–694

  14. 14.

    Edge SB, Compton CC (2010) The American Joint Committee on Cancer: the 7th edition of the AJCC cancer staging manual and the future of TNM. Ann Surg Oncol 17(6):1471–1474

  15. 15.

    National Comprehensive Cancer Network. Colon cancer (Version 2.2017)

  16. 16.

    National Comprehensive Cancer Network. Rectal cancer (Version 3.2017)

  17. 17.

    Rex DK, Kahi CJ, Levin B, Smith RA, Bond JH, Brooks D et al (2006) Guidelines for colonoscopy surveillance after cancer resection: a consensus update by the American Cancer Society and the US Multi Society Task Force on Colorectal Cancer. Gastroenterology 130(6):1865–1871

  18. 18.

    U.S. Preventive Services Task Force (2002) Screening for colorectal cancer: recommendation and rationale. Ann Intern Med 137:129–131

  19. 19.

    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

  20. 20.

    Lin JS, Piper MA, Perdue LA, Rutter C, Webber EM, O’Connor E, Smith N, Whitlock EP (2016) Screening for colorectal cancer: a systematic review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 135. AHRQ Publication No. 14-05203-EF-1. Rockville: Agency for Healthcare Research and Quality

  21. 21.

    Brenner H, Chang-Claude J, Jansen L, Knebel P, Stock C, Hoffmeister M (2014) Reduced risk of colorectal cancer up to 10 years after screening, surveillance, or diagnostic colonoscopy. Gastroenterology 146:709–717

  22. 22.

    Friedrich K, Grüter L, Gotthardt D, Eisenback C, Stremmel W, Scholl SG, Rex DK, Sieg A (2015) Survival in patients with colorectal cancer diagnosed by screening colonoscopy. Gastrointest Endosc 82:133–137

  23. 23.

    Brenner H, Jansen L, Ulrich A, Chang-Clause J, Hoffmeister M (2016) Survival of patients with symptom- and screening-detected colorectal cancer. Oncotarget 7(28):44695–44704

  24. 24.

    White A, Thompson TD, White MC, Sabatino SA, de Moor J, Doria-Rose PV, Geiger AN, Richardson LC (2017) Cancer screening test use—United States, 2015. MMWR Morb Mortal Wkly Rep 66:201–206

  25. 25.

    Peterson EB, Ostroff JS, DuHamel KN, D’Agostino TA, Hernandez M, Canzona MR, Bylund CL (2016) Impact of provider-patient communication on cancer screening adherence: a systematic review. Prev Med 93:96–105

  26. 26.

    Singal AG, Gupta S, Tiro JA, Skinner CS, McCallister K, Sanders JM, Bishop WP, Agrawal D, Mayorga CA, Ahn C, Loewen AC, Santini NO, Halm EA (2016) Outreach invitations for FIT and colonoscopy improve colorectal cancer screening rates: a randomized controlled trial in a safety-net health system. Cancer 122:456–463

  27. 27.

    Denberg TD, Coombes JM, Byers TE, Marcus AC, Feinberg LE, Steiner JF, Ahnen DJ (2006) Effect of a mailed brochure on appointment-keeping for screening colonoscopy: a randomized trial. Ann Intern Med 145:895–900

Download references

Author information

All authors have contributed to this manuscript in the following way: substantial contributions to the conception or design of the work, or the acquisition, analysis or interpretation of the data. Furthermore, all authors drafted or revised the manuscript critically for important intellectual content. All authors approved the final version and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Correspondence to David L. Berger.

Ethics declarations

Disclosures

Lieve Leijssen, Anne Dinaux, Hiroko Kunitake, Liliana Bordeianou, David Berger have no conflicts of interest or financial ties to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 14 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Leijssen, L.G.J., Dinaux, A.M., Kunitake, H. et al. Detrimental impact of symptom-detected colorectal cancer. Surg Endosc 34, 569–579 (2020). https://doi.org/10.1007/s00464-019-06798-8

Download citation

Keywords

  • Colorectal cancer
  • Colonoscopy
  • Early detection
  • Disease recurrence
  • Survival