Digestive Diseases and Sciences

, Volume 57, Issue 8, pp 2203–2212 | Cite as

Changing Epidemiology of Colorectal Cancer Makes Screening Sigmoidoscopy Less Useful for Identifying Carriers of Colorectal Neoplasms

Original Article

Abstract

Background

There is renewed interest in flexible sigmoidoscopy (FS) colorectal cancer (CRC) screening following trials showing significantly reduced CRC incidence and mortality.

Aims

To evaluate the potential usefulness of FS screening in our population.

Methods

We examined rectosigmoid (RS) cancer epidemiology in our Jewish population using Israel National Cancer Registry data, computed by CRC site, age groups, and gender. We also reviewed endoscopy-screening publications for prevalence of RS and proximal advanced adenomas (AAP) and having both or either.

Results

During 1980–2008, there were 64,559 CRCs registered; 31.6 % were RS cancer which has now decreased to 29 % of men’s and 26 % of women’s CRC (both P < 0.01). In <50 year olds, RS cancer occurred in 42 % of males’ and 35 % of females’ CRC, and in the last 2 decades this ratio is unchanged. In 50–74 year olds, RS cancer decreased to stable levels of 32 % of males’ and 29 % females’ CRC (both P < 0.01). In ≥75 year olds, RS cancer progressively decreased to 24 % of males’ and 22 % females’ CRC (both P < 0.001). From endoscopy screening reports in 40–79 year olds, RS AAPs occurred in 2.0–5.8 %, being least in women, most in men, and not increased with aging. Some 50–57 % of screenees had both RS and proximal AAPs, least when aged 40–49 years at 25 %, women were 35 %, and with aging 40 %, but most in men at 70 %.

Conclusions

With the changing CRC epidemiology, having fewer RS neoplasms but more proximal cancer, the effectiveness of FS screening for identifying significant neoplasms decreases with screenees’ age and especially in females. These make FS screening less suitable for our aging and increasingly female population.

Keywords

Adenoma Colorectal cancer Cancer site Colonoscopy Epidemiology Jews Recto-sigmoid Screening Sigmoidoscopy 

Abbreviations

AAP

Advanced adenomatous polyp

ASR

Age-standardized rate

CRC

Colorectal cancer

FS

Flexible sigmoidoscopy

ICD-O

International Classification of Diseases for Oncology

INCR

Israel National Cancer Registry

RS

Rectosigmoid

References

  1. 1.
    Atkin WS, Edwards R, Kralj-Hans I, et al. Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet. 2010;375:1624–1633.PubMedCrossRefGoogle Scholar
  2. 2.
    Segnan N, Armaroli P, Bonelli L, et al. Once-only sigmoidoscopy in colorectal cancer screening: follow-up findings of the Italian randomized controlled trial–SCORE. J Natl Cancer Inst. 2011;103:1310–1322.PubMedCrossRefGoogle Scholar
  3. 3.
    Young G, Rozen P, Levin B. How should we screen for early colorectal neoplasia? In: Rozen P, Young G, Levin B, Spann S, eds. Colorectal Cancer in Clinical Practice: Prevention, Early Detection and Management. 2nd ed. London: Taylor & Francis; 2005:97–130.Google Scholar
  4. 4.
    Rozen P, Ron E, Fireman Z, et al. The relative value of fecal occult blood tests and flexible sigmoidoscopy in screening for large bowel neoplasia. Cancer. 1987;60:2553–2558.PubMedCrossRefGoogle Scholar
  5. 5.
    Rozen P. Screening for colorectal neoplasia in the Tel Aviv area: cumulative data 1979–89 and initial conclusions. Isr J Med Sci. 1992;28:8–20.PubMedGoogle Scholar
  6. 6.
    Rozen P, Liphshitz I, Barchana M. The changing epidemiology of colorectal cancer and its relevance for adapting screening guidelines and methods. Eur J Cancer Prev. 2011;20:46–53.PubMedCrossRefGoogle Scholar
  7. 7.
    Schub R, Steinheber FU. Rightward shift of colon cancer. A feature of the aging gut. J Clin Gastroenterol. 1986;8:630–634.PubMedCrossRefGoogle Scholar
  8. 8.
    Okamoto M, Shiratori Y, Yamaji Y, et al. Relationship between age and site of colorectal cancer based on colonoscopy findings. Gastrointest Endosc. 2002;55:548–551.PubMedCrossRefGoogle Scholar
  9. 9.
    Cucino C, Buchner AM, Sonnenberg A. Continued rightward shift of colorectal cancer. Dis Colon Rectum. 2002;45:1035–1040.PubMedCrossRefGoogle Scholar
  10. 10.
    Rabeneck L, Davila JA, El-Serag HB. Is there a true “shift” to the right colon in the incidence of colorectal cancer? Am J Gastroenterol. 2003;98:1400–1409.PubMedGoogle Scholar
  11. 11.
    Meza R, Jeon J, Renehan AG, Luebeck EG. Colorectal cancer incidence trends in the United States and United Kingdom: evidence of right- to left-sided biological gradients with implications for screening. Cancer Res. 2010;70:5419–5429.PubMedCrossRefGoogle Scholar
  12. 12.
    Thiis-Evensen E, Hoff GS, Sauar J, Majak BM, Vatn MH. Flexible sigmoidoscopy or colonoscopy as a screening modality for colorectal adenomas in older age groups? Findings in a cohort of the normal population aged 63–72 years. Gut. 1999;45:834–839.PubMedCrossRefGoogle Scholar
  13. 13.
    Rozen P, Shabtai EI, Liphshitz I, Barchana M. Risk for colorectal cancer in the elderly and possible methodologies for their screening. Eur J Gastoenterol Hepatol. 2011;23:431–437.CrossRefGoogle Scholar
  14. 14.
    Israel National Cancer Registry. http://www.health.gov.il/icr. Accessed 2012.
  15. 15.
    Rozen P, Rosner G, Liphshitz I, Barchana M. The changing incidence and sites of colorectal cancer in the Israeli Arab population and clinical implications. Int J Cancer. 2006;120:147–151.CrossRefGoogle Scholar
  16. 16.
    Statistical Abstract of Israel 2010. Central Bureau of Statistics publication. Government Press, Jerusalem. http://www1.cbs.gov.il/reader/. Accessed 2012.
  17. 17.
    Strul H, Kariv R, Leshno M, et al. The prevalence rate and anatomic location of colorectal adenoma and cancer detected by colonoscopy in average-risk individuals aged 40–80 years. Am J Gastroenterol. 2006;101:255–262.PubMedCrossRefGoogle Scholar
  18. 18.
    Atkin WS, Cook CF, Cuzick J, et al. Single flexible sigmoidoscopy screening to prevent colorectal cancer: baseline findings of a UK multicentre randomised trial. Lancet. 2002;359:1291–1300.PubMedCrossRefGoogle Scholar
  19. 19.
    Segnan N, Senore C, Andreoni B, et al. Baseline findings of the Italian multicenter randomized controlled trial of “once-only sigmoidoscopy”—SCORE. J Natl Cancer Inst. 2002;94:1763–1772.PubMedCrossRefGoogle Scholar
  20. 20.
    Gondal G, Grotmol T, Hofstad B, Bretthauer M, Eide TJ, Hoff G. The Norwegian Colorectal Cancer Prevention (NORCCAP) screening study: baseline findings and implementations for clinical work-up in age groups 50–64 years. Scand J Gastroenterol. 2003;38:635–642.PubMedCrossRefGoogle Scholar
  21. 21.
    Bleiberg H, Autier P, Huet F, et al. Colorectal cancer (CRC) screening using sigmoidoscopy followed by colonoscopy: a feasibility and efficacy study on a cancer institute based population. Ann Oncol. 2006;17:1328–1332.PubMedCrossRefGoogle Scholar
  22. 22.
    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.PubMedCrossRefGoogle Scholar
  23. 23.
    Viiala CH, Olynyk JK. Outcomes after 10 years of a community-based flexible sigmoidoscopy screening program for colorectal carcinoma. Med J Aust. 2007;187:274–277.PubMedGoogle Scholar
  24. 24.
    Weissfeld JL, Schoen RE, Pinsky PF, et al. Flexible sigmoidoscopy in the PLCO cancer screening trial: results from the baseline screening examination of a randomized trial. J Natl Cancer Inst. 2005;97:989–997.PubMedCrossRefGoogle Scholar
  25. 25.
    Imperiale TF, Wagner DR, Lin CY, Larkin GN, Rogge JD, Ransohoff DF. Risk of advanced proximal neoplasms in asymptomatic adults according to the distal colorectal findings. N Engl J Med. 2000;343:169–174.PubMedCrossRefGoogle Scholar
  26. 26.
    Lieberman DA, Veterans Affairs Cooperative Study Group 380. One-time screening for colorectal cancer with combined fecal occult-blood testing and examination of the distal colon. N Engl J Med. 2001;345:555–560.PubMedCrossRefGoogle Scholar
  27. 27.
    Schoenfeld P, Cash B, Flood A, et al. Colonoscopic screening of average-risk women for colorectal neoplasia. N Engl J Med. 2005;352:2061–2068.PubMedCrossRefGoogle Scholar
  28. 28.
    Imperiale TF, Wagner DR, Lin CY, Larkin GN, Rogge JD, Ransohoff DF. Results of screening colonoscopy among persons 40 to 49 years of age. N Engl J Med. 2000;346:1781–1785.CrossRefGoogle Scholar
  29. 29.
    Bonelli L, Sciallero S, Senore C, et al. History of negative colorectal endoscopy and risk of rectosigmoid neoplasms at screening flexible sigmoidoscopy. Int J Colorectal Dis. 2006;21:105–113.PubMedCrossRefGoogle Scholar
  30. 30.
    Doria-Rose VP, Levin TR, Selby JV, Newcomb PA, Richert-Boe KE, Weiss NS. The incidence of colorectal cancer following a negative screening sigmoidoscopy: implications for screening interval. Gastroenterology. 2004;127:714–722.PubMedCrossRefGoogle Scholar
  31. 31.
    Rabeneck L, Lewis JD, Paszat LF, Saskin R, Stukel TA. Risk of proximal and distal colorectal cancer following flexible sigmoidoscopy: a population-based cohort study. Am J Gastroenterol. 2008;103:2075–2082.PubMedCrossRefGoogle Scholar
  32. 32.
    Rozen P, Rattan J, Gilat T. Colonoscopy, clinical experience in 100 examinations. Harefuah. 1975; 88:404–407 (in Hebrew).Google Scholar
  33. 33.
    Lubin F, Rozen P, Arieli B, et al. Nutritional and lifestyle habits and water-fiber interaction in colorectal adenoma etiology. Cancer Epidemiol Biomarkers Prev. 1997;6:79–85.PubMedGoogle Scholar
  34. 34.
    Dozois EJ, Boardman LA, Suwanthanma W, et al. Young-onset colorectal cancer in patients with no known genetic predisposition: can we increase early recognition and improve outcome? Medicine. 2008;87:259–263.PubMedCrossRefGoogle Scholar
  35. 35.
    Siegel RL, Jemal A, Ward EM. Increase in incidence of colorectal cancer among young men and women in the United States. Cancer Epidemiol Biomarkers Prev. 2009;18:1695–1698.PubMedCrossRefGoogle Scholar
  36. 36.
    Meyer JE, Narang T, Schnoll-Sussman FH, Pochapin MB, Christos PJ, Sherr DL. Increasing incidence of rectal cancer in patients aged younger than 40 years: an analysis of the surveillance, epidemiology, and end results database. Cancer. 2010;116:4354–4359.PubMedCrossRefGoogle Scholar
  37. 37.
    Cooley EK, McPhee JT, Simons JP, Sweeney WB, Tseng JF, Alavi K. Colorectal neoplasia screening before age 50?: current epidemiologic trends in the United States. Dis Colon Rectum. 2009;52:222–229.PubMedCrossRefGoogle Scholar
  38. 38.
    Davis DM, Marcet JE, Frattini JC, Prather AD, Mateka JJ, Nfonsam VN. Is it time to lower the recommended screening age for colorectal cancer? J Am Coll Surg. 2011;213:352–361.PubMedCrossRefGoogle Scholar
  39. 39.
    Svensson E, Grotmol T, Hoff G, Langmark F, Norstein J, Tretli S. Trend in colorectal cancer incidence in Norway by gender and anatomic site: an age-period-cohort analysis. Eur J Cancer Prev. 2002;11:489–495.PubMedCrossRefGoogle Scholar
  40. 40.
    Diamond SJ, Enestvedt BK, Jiang Z, et al. Adenoma detection rate increases with each decade of life after 50 years of age. Gastrointest Endosc. 2011;74:135–140.PubMedCrossRefGoogle Scholar
  41. 41.
    Rozen P, Liphshitz I, Barchana M. Follow-up of patients undergoing both semiquantitated immunochemical fecal occult blood and colonoscopy examinations. Eur J Cancer Prev. Epub. 09/27/2011.Google Scholar
  42. 42.
    Senore C, Segnan N, Bonelli L, et al. Predicting proximal advanced neoplasms at screening sigmoidoscopy. Dis Colon Rectum. 2004;47:1331–1340.PubMedCrossRefGoogle Scholar
  43. 43.
    Gondal G, Grotmol T, Hofstad B, Bretthauer M, Eide TJ, Hoff G. Grading of distal colorectal adenomas as predictors for proximal colonic neoplasia and choice of endoscope in population screening: experience from the Norwegian Colorectal Cancer Prevention study (NORCCAP). Gut. 2003;52:398–403.PubMedCrossRefGoogle Scholar
  44. 44.
    You YN, Xing Y, Feig BW, Chang GJ, Cormier JN. Young-onset colorectal cancer: Is it time to pay attention? Arch Intern Med. 2012;172:287–289.Google Scholar
  45. 45.
    Ko CW, Sonnenberg A. Comparing risks and benefits of colorectal cancer screening in elderly patients. Gastroenterology. 2005;129:1163–1170.PubMedCrossRefGoogle Scholar
  46. 46.
    Walter LC, de Garmo P, Covinsky KE. Association of older age and female sex with inadequate reach of screening flexible sigmoidoscopy. Am J Med. 2004;116:174–178.PubMedCrossRefGoogle Scholar
  47. 47.
    Pabby A, Suneja A, Heeren T, Farraye FA. Flexible sigmoidoscopy for colorectal cancer screening in the elderly. Dig Dis Sci. 2005;50:2147–2152.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.Sestopali Fund for Gastrointestinal Cancer Prevention, Department of GastroenterologyTel Aviv Medical CenterTel AvivIsrael
  2. 2.Tel Aviv University Medical SchoolTel AvivIsrael
  3. 3.Israel National Cancer RegistryMinistry of HealthJerusalemIsrael
  4. 4.School of Public HealthHaifa UniversityHaifaIsrael

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