Is upper endoscopy indicated in persons with a positive FOBT and a negative colonoscopy in a population-based colorectal cancer screening program ?

1
Is upper endoscopy indicated in persons with a
positive FOBT and a negative colonoscopy in a
population-based colorectal cancer screening
program ?
Bernard DENIS, Philippe PERRIN, Frédéric VAGNE,
André PETER, Jean Christophe PFEIFFER, Daniel
BATTISTELLI
Association pour le Dépistage du Cancer
colorectal dans le Haut-Rhin (ADECA 68), Colmar,
FRANCE
2
background

• assessment of both feasibility and efficiency of
  a nation wide population-based colorectal cancer
  (CRC) FOBT screening program
• 22 pilot areas

3
background

• whether upper endoscopy is necessary is
  controversial
• few studies, most small sized, retrospective or
  individual screening
• only 2 in mass screening programs which
  concluded that upper endoscopy was unjustified in
  asymptomatic persons but
• (Thomas WM Gut 1990 Rasmussen M Scand J
  Gastroenterol 2002)

4
aim

• to assess whether upper endoscopy
  is indicated in persons with
  a positive FOBT and
  a negative colonoscopy in a
  population-based CRC screening
  program ?

5
methods

• pilot population-based
  colorectal cancer
  screening program
• Haut-Rhin 0.71 million inhabitants
• all average risk residents aged 50-74 y
• biennial non rehydrated guaiac FOBT (Hemoccult
  II) without dietary restriction

6
methods

• prospective recording
  all upper endoscopies performed after positive
  FOBT and negative colonoscopy
• data collection
• detailed history (upper GI symptoms, drugs,
  documented anemia)
• upper abnormal findings
• changes in management
• adverse events

7
methods

• inclusion criteria
• Residents aged 50-74 y participating to CRC
  screening program
• Positive FOBT
• Complete colonoscopy
• No lower bleeding lesion, CRC or polyp 1 cm
• At the discretion of the endoscopist
• Informed consent

8
methods

• exclusion criteria
• FOBT completed out of screening program
• Incomplete colonoscopy
• Lower bleeding lesion, CRC or polyp 1 cm
• Documented upper GI disease
• Recent upper endoscopy lt 1 year
• Patient refusal

9
methods
10
results

• ongoing study April 2005 (19 months)
• 366 upper endoscopies / 1002 (36.6)
• 305 (50.4 ) with normal colonoscopy
• 61 (15.4 ) with colorectal polyps lt 1 cm

11
diagnostic yield
80 / 366 (21.9 ) abnormal upper GI
findings

• 1 pT1 esophageal adenocarcinoma
• 3 Barretts esophagus
• 33 reflux esophagitis (28 gr. 1 / 5 gr.
  2)
• 2 angiodysplasia

• 12 gastric polyps
• 26 erosive gastritis
• 1 gastric ulcer
• 5 erosive duodenitis
• 2 duodenal ulcers
• 18 Hp positive

12
diagnostic yield
age lt 65 46 (21.5) gt 65 34 (22.5) NS
colonoscopy normal 61 (20) polyps 19 (31.1) NS
doc. anemia present 0 (0) absent 58 (20.5) -
aspirin present 12 (27.9) absent 49 (19.6) NS
NSAID present 8 (33.3) absent 53 (19.9) NS
gender male 43 (27.6) female 37 (17.7) p0.02
upper symptoms present 29 (37.2) absent 32 (15) plt0.01
13
clinical impact
50 / 366 (15 ) change in clinical
management

• 1 surgery
• 1 Argon plasma coagulation
• 46 PPI

• 18 antibiotics
• 4 NSAID discontinuation
• 3 endoscopic follow-up

14
clinical impact
age lt 65 31 (14.5) gt 65 24 (15.8) NS
colonoscopy normal 42 (13.8) polyps 13 (21.3) NS
doc. anemia present 0 (0) absent 41 (14.5) -
aspirin present 10 (23.3) absent 34 (13.6) NS
NSAID present 7 (29.2) absent 37 (13.9) -
gender male 32 (20.5) female 23 (11) p0.01
upper symptoms present 20 (25.6) absent 23 (10.8) plt0.01
15
213 asymptomatic persons

• abnormal findings 15
• changes in management 10.8
• clinically important lesions 3.3
• 3 erosive gastritis Hp
• 3 erosive duodenitis Hp
• 1 reflux esophagitis gr. 2
• no cancer
• no Barretts

16
asymptomatic persons

• Number needed to screen to detect
  one clinically
  important lesion 30

17
conclusions

• upper endoscopy is not justified in asymptomatic
  persons with a positive FOBT when colonoscopy is
  normal or yields small polyps in a
  population-based CRC screening program
• upper endoscopy must be performed in patients
  with relevant upper symptoms

18
future

• upper abnormal findings
• positive FOBT ?
• by chance ?
• control group
  with colorectal cancer or large polyps