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Zie ook literatuurlijst specifiek bij darmkanker van arts-bioloog drs. Engelbert Valstar

7 november 2019: Periodieke controle van mensen op ontstaan van darmkanker via met name de ontlastingstest en vervolgens door endoscopie enz. blijkt niet voor iedereen een voordeel te geven. Uit verschillende studies blijkt dat het voordeel van vroeg ontdekken geen effect heeft op overall overleving enz. 

Een panel van specialisten hebben nieuwe richtlijnen gemaakt. Zie daar voor dit rapport:  Colorectal cancer screening with faecal immunochemical testing, sigmoidoscopy or colonoscopy: a clinical practice guideline

Abstract staat onderaan artikel hier het advies gevisualiseerd in een beeldgrafiek:

Visual summary of recommendation

No screeningFITEvery yearFITEvery two yearsSigmoidoscopySingleColonoscopySingleFavours noscreeningFavoursscreeningWe suggest no screeningInterventions comparedRecommendationsScreening optionsPopulationWe suggest using a tool such as the QCancer® calculatorto estimate the risk of colorectal cancer for each personin the next 15 years. This calculates risk, based on:Understanding a person’s risk of cancer can help todetermine the benefits and harms of different screeningtests for their individual situation.Faecal testingwith a faecalimmunochemicaltest (FIT) everyyearFaecal testingwith a faecalimmunochemicaltest (FIT) everytwo yearsEndoscopicexamination ofonly the lowerpart of the colonEndoscopicexamination ofthe entire colonFavours noscreeningFavoursscreeningColonoscopy offered if FITor sigmoidoscopy positivePeople with an estimated 15 yearrisk of colorectal cancerbelow3%We suggest screening with oneof the four screening optionsPeople with an estimated 15 yearrisk of colorectal cancerabove3%Estimating riskHealthy adults with nohistory of screeningAged 50 to 79AgeSmoking statusMedical and family historyBMISexEthnicityLink to QCancer®calculatorqcancer.org/15yr/colorectal/StrongAll or nearly all informed people would likely want this option.Benefits outweigh harms for almost everyone.WeakMost people would likely want this option.Benefits outweigh harms for the majority, but not for everyone.WeakMost people would likely want this option.Benefits outweigh harms for the majority, but not for everyone.StrongAll or nearly all informed people would likely want this option.Benefits outweigh harms for almost everyone.StrongAll or nearly all informed people would likely want this option.Benefits outweigh harms for almost everyone.WeakMost people would likely want this option.Benefits outweigh harms for the majority, but not for everyone.WeakMost people would likely want this option.Benefits outweigh harms for the majority, but not for everyone.StrongAll or nearly all informed people would likely want this option.Benefits outweigh harms for almost everyone.
Visit the MAGICapp multiple comparison tool to compare and choose optionsEvidence summariesScreening options should be chosen in shared decision making, based on a person’s individual risk of cancer

7 januari 2019: Bron: BMJ GUT

Een thuis uit te voeren ontlastingstest spoort vaak vroegtijdig kwaadaardige poliepen en al ontstane darmkanker op. Door de vroegtijdige ontdekking en het operatief weghalen van de kwaadaardige poliepen hopen veel mensen het ontstaan van darmkanker te voorkomen. Dat dit echter geen zekerheid is blijkt uit een Engelse studie binnen de deelnemers van een screeningprogramma bij mensen met een gemiddeld risico op darmkanker. Patienten uit de grotere screeningstudie hadden 3 tot 4 kleine darmpoliepen laten weghalen of een poliep met een diameter van minimaal 10 mm. of groter. (leeftijd van de patiënten varieerde van 60 - 72 jaar).

Na drie jaar bleek een jaarlijkse ontlastingstest i.p.v. coloscopie weliswaar veel goedkoper en de zorgkosten te drukken. Maar de betrouwbaarheid liet veel te wensen over. Een jaarlijkse ontlastingstest had tegenover de coloscopie maar liefst 30 tot 40 procent van het ontwikkelen van darmkanker gemist en 50 tot 70 procent aanwezige adenocarcinomen waren niet opgemerkt.

prikken in ontlasting

Ook op het bevolkinsonderzoek via de ontlastingstest is al veel kritiek geweest en daaraan zal deze studie dus niet echt positief aan bijdragen denk ik.

De onderzoekers stellen deze conclusies:

  • Betekenis van deze studie
  • Hoe kan dit van invloed zijn op de klinische praktijk in de nabije toekomst?
  • Vervanging van 3 jaarlijkse colonoscopiebewaking bij intermediair risico-patiënten met een jaarlijkse FIT zou het aantal colonoscopieën met ≥70% kunnen verminderen en aanzienlijke kostenbesparingen opleveren.
  • De jaarlijkse FIT zou echter 30% -40% van de darmkankers (CRC's) en 40% -70% van de adenocarcinomen (AA's) kunnen missen, afhankelijk van de gebruikte grenzen voor wel of niet een coloscopie.
Figure 1

Participant flow diagram from invitation through to year 3 colonic examination. *Two hundred and ninety-five potentially eligible individuals were not invited as they were excluded after the eligibility assessment (186 in order to prevent over-investigation as they had already undergone more than one colonoscopy and 109 due to informed dissent, clinical reasons, death or emigration) and a further 1547 individuals were not invited as the sample size of 8000 had already been met.†Two thousand and fifty-five individuals were not recruited due to lack of consent; one consented but did not return their FIT; and four consented but returned a FIT that could not be analysed. AAs, advanced adenomas; CRC, colorectal cancer; FIT, faecal immunochemical test; gFOBT, guaiac faecal occult blood test. 

Of those invited, 2060 were not recruited: 2055 did not consent and five consented but did not return an analysable FIT. A further 11 were excluded due to withdrawal of consent, baseline CRC, baseline high-risk adenomas, prolonged baseline episode or symptomatic exam before year 1 (figure 1). Therefore, 5938 of 8009 (74.1%) invitees were recruited, having consented and returned an analysable FIT (table 1). Return of FIT was 97% at years 2 and 3 (table 2). Participation was similar among men and women and across age groups (online supplementary tables 1 and 2).

Figure 1

Het volledige studierapport: Faecal immunochemical tests (FIT) versus colonoscopy for surveillance after screening and polypectomy: a diagnostic accuracy and cost-effectiveness study is gratis in te zien.

Hier het abstract: 

Source: BMJ Gut: 

http://dx.doi.org/10.1136/gutjnl-2018-317297

Abstract

Objective The English Bowel Cancer Screening Programme (BCSP) recommends 3 yearly colonoscopy surveillance for patients at intermediate risk of colorectal cancer (CRC) postpolypectomy (those with three to four small adenomas or one ≥10 mm). We investigated whether faecal immunochemical tests (FITs) could reduce surveillance burden on patients and endoscopy services.

Design Intermediate-risk patients (60–72 years) recommended 3 yearly surveillance were recruited within the BCSP (January 2012–December 2013). FITs were offered at 1, 2 and 3 years postpolypectomy. Invitees consenting and returning a year 1 FIT were included. Participants testing positive (haemoglobin ≥40 µg/g) at years one or two were offered colonoscopy early; all others were offered colonoscopy at 3 years. Diagnostic accuracy for CRC and advanced adenomas (AAs) was estimated considering multiple tests and thresholds. We calculated incremental costs per additional AA and CRC detected by colonoscopy versus FIT surveillance.

Results 74% (5938/8009) of invitees were included in our study having participated at year 1. Of these, 97% returned FITs at years 2 and 3. Three-year cumulative positivity was 13% at the 40 µg/g haemoglobin threshold and 29% at 10 µg/g. 29 participants were diagnosed with CRC and 446 with AAs. Three-year programme sensitivities for CRC and AAs were, respectively, 59% and 33% at 40 µg/g, and 72% and 57% at 10 µg/g. Incremental costs per additional AA and CRC detected by colonoscopy versus FIT (40 µg/g) surveillance were £7354 and £180 778, respectively.

Conclusions Replacing 3 yearly colonoscopy surveillance in intermediate-risk patients with annual FIT could reduce colonoscopies by 71%, significantly cut costs but could miss 30%–40% of CRCs and 40%–70% of AAs.

Trial registration number ISRCTN18040196; Results.

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

 

Based on benefits, harms, and burdens of screening, the panel inferred that most informed individuals with a 15-year risk of colorectal cancer of 3% or higher are likely to choose screening, and most individuals with a risk of below 3% are likely to decline screening. Given varying values and preferences, optimal care will require shared decision making.

Practice Rapid Recommendations

Colorectal cancer screening with faecal immunochemical testing, sigmoidoscopy or colonoscopy: a clinical practice guideline

BMJ 2019367 doi: https://doi.org/10.1136/bmj.l5515 (Published 02 October 2019)Cite this as: BMJ 2019;367:l5515

Visual summary of recommendation

No screeningFITEvery yearFITEvery two yearsSigmoidoscopySingleColonoscopySingleFavours noscreeningFavoursscreeningWe suggest no screeningInterventions comparedRecommendationsScreening optionsPopulationWe suggest using a tool such as the QCancer® calculatorto estimate the risk of colorectal cancer for each personin the next 15 years. This calculates risk, based on:Understanding a person’s risk of cancer can help todetermine the benefits and harms of different screeningtests for their individual situation.Faecal testingwith a faecalimmunochemicaltest (FIT) everyyearFaecal testingwith a faecalimmunochemicaltest (FIT) everytwo yearsEndoscopicexamination ofonly the lowerpart of the colonEndoscopicexamination ofthe entire colonFavours noscreeningFavoursscreeningColonoscopy offered if FITor sigmoidoscopy positivePeople with an estimated 15 yearrisk of colorectal cancerbelow3%We suggest screening with oneof the four screening optionsPeople with an estimated 15 yearrisk of colorectal cancerabove3%Estimating riskHealthy adults with nohistory of screeningAged 50 to 79AgeSmoking statusMedical and family historyBMISexEthnicityLink to QCancer®calculatorqcancer.org/15yr/colorectal/StrongAll or nearly all informed people would likely want this option.Benefits outweigh harms for almost everyone.WeakMost people would likely want this option.Benefits outweigh harms for the majority, but not for everyone.WeakMost people would likely want this option.Benefits outweigh harms for the majority, but not for everyone.StrongAll or nearly all informed people would likely want this option.Benefits outweigh harms for almost everyone.StrongAll or nearly all informed people would likely want this option.Benefits outweigh harms for almost everyone.WeakMost people would likely want this option.Benefits outweigh harms for the majority, but not for everyone.WeakMost people would likely want this option.Benefits outweigh harms for the majority, but not for everyone.StrongAll or nearly all informed people would likely want this option.Benefits outweigh harms for almost everyone.
Visit the MAGICapp multiple comparison tool to compare and choose optionsEvidence summariesScreening options should be chosen in shared decision making, based on a person’s individual risk of cancer
For a person with a 2% risk of colorectal cancer within 15 years
For a person with a 3% risk of colorectal cancer within 15 years
For a person with a 4% risk of colorectal cancer within 15 years
Key practical issuesWhile most of the evidence relates to people aged 50-79, these recommendations may also apply to those aged below 50. However, as cancer risk is usually very low in this group, few people will have a 15 year colorectal cancer risk over 3%Other agesThe panel found convincing evidence that people’s values and preferences on whether to test and what test to have varies considerably, and this is one factor driving a weak recommendationValues and preferencesFITSigmoidoscopyDone at home every year or every two years for 15 yearsDone once in 15 years at an outpatient clinic/hospitalStool from one bowel movement is collected with a stick and mailed for analysisPreparation with bowel enema on the day of the procedure. Sometimes combined with oral laxativesPreparation with oral laxatives starting the day before procedureIndividuals with a positive test are offered colonoscopyUsually performed with no sedation, so no recovery time necessary after procedureOften performed under conscious sedation. Also performed under general anesthesia or with no sedationMost individuals will experience no or only mild pain during and shortly after the procedure, but some will experience moderate to severe painIf sedation or anesthesia is used, recovery time will be needed after the procedureIf performed without sedation, the majority of individuals will experience no or only mild pain during and shortly after the procedure, but some will experience moderate to severe painColonoscopyPreparationDuring theprocessAfterwardsTiming

©BMJ Publishing Group Limited.

Disclaimer: This infographic is not a validated clinical decision aid. This information is provided without any representations, conditions or warranties that it is accurate or up to date. BMJ and its licensors assume no responsibility for any aspect of treatment administered with the aid of this information. Any reliance placed on this information is strictly at the user's own risk. For the full disclaimer wording see BMJ's terms and conditions: https://www.bmj.com/company/legal-information/

Find recommendations, evidence summaries and consultation decision aids for use in your practice
  1. Lise M Helsingen, methods co-chair, medical doctor3,  
  2. Per Olav Vandvik, general internist, methodologist5,  
  3. Henriette C Jodal, medical doctor3,  
  4. Thomas Agoritsas, general internist, methodologist7,  
  5. Lyubov Lytvyn, patient partnership liaison7,  
  6. Joseph C Anderson, gastroenterologist10,  
  7. Reto Auer, general practicioner11 12,  
  8. Silje Bjerkelund Murphy, registered nurse13,  
  9. Majid Abdulrahman Almadi, gastroenterologist14 15,  
  10. Douglas A Corley, gastroenterologist16 17,  
  11. Casey Quinlan, patient partner18 19 20,  
  12. Jonathan M Fuchs, patient partner21,  
  13. Annette McKinnon, patient partner22,  
  14. Amir Qaseem, medical doctor, methodologist23,  
  15. Anja Fog Heen, general internist, methodologist24,  
  16. Reed A C Siemieniuk, general internist, methodologist7,  
  17. Mette Kalager, surgeon, researcher3,  
  18. Juliet A Usher-Smith, general practitioner25,  
  19. Iris Lansdorp-Vogelaar, modeller26,  
  20. Michael Bretthauer, gastroenterologist3,  
  21. Gordon Guyatt, chair, general internist, methodologist7
Author affiliations
  1. Correspondence: L M Helsingen lisemhe@medisin.uio.no

Abstract

Clinical question Recent 15-year updates of sigmoidoscopy screening trials provide new evidence on the effectiveness of colorectal cancer screening. Prompted by the new evidence, we asked: “Does colorectal cancer screening make an important difference to health outcomes in individuals initiating screening at age 50 to 79? And which screening option is best?”

Current practice Numerous guidelines recommend screening, but vary on recommended test, age and screening frequency. This guideline looks at the evidence and makes recommendations on screening for four screening options: faecal immunochemical test (FIT) every year, FIT every two years, a single sigmoidoscopy, or a single colonoscopy.

Recommendations These recommendations apply to adults aged 50-79 years with no prior screening, no symptoms of colorectal cancer, and a life expectancy of at least 15 years. For individuals with an estimated 15-year colorectal cancer risk below 3%, we suggest no screening (weak recommendation). For individuals with an estimated 15-year risk above 3%, we suggest screening with one of the four screening options: FIT every year, FIT every two years, a single sigmoidoscopy, or a single colonoscopy (weak recommendation). With our guidance we publish the linked research, a graphic of the absolute harms and benefits, a clear description of how we reached our value judgments, and linked decision aids.

How this guideline was created A guideline panel including patients, clinicians, content experts and methodologists produced these recommendations using GRADE and in adherence with standards for trustworthy guidelines. A linked systematic review of colorectal cancer screening trials and microsimulation modelling were performed to inform the panel of 15-year screening benefits and harms. The panel also reviewed each screening option’s practical issues and burdens. Based on their own experience, the panel estimated the magnitude of benefit typical members of the population would value to opt for screening and used the benefit thresholds to inform their recommendations.

The evidence Overall there was substantial uncertainty (low certainty evidence) regarding the 15-year benefits, burdens and harms of screening. Best estimates suggested that all four screening options resulted in similar colorectal cancer mortality reductions. FIT every two years may have little or no effect on cancer incidence over 15 years, while FIT every year, sigmoidoscopy, and colonoscopy may reduce cancer incidence, although for FIT the incidence reduction is small compared with sigmoidoscopy and colonoscopy. Screening related serious gastrointestinal and cardiovascular adverse events are rare. The magnitude of the benefits is dependent on the individual risk, while harms and burdens are less strongly associated with cancer risk.

Understanding the recommendation Based on benefits, harms, and burdens of screening, the panel inferred that most informed individuals with a 15-year risk of colorectal cancer of 3% or higher are likely to choose screening, and most individuals with a risk of below 3% are likely to decline screening. Given varying values and preferences, optimal care will require shared decision making.


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