Upper gastrointestinal endoscopy is not justified in persons

Upper gastrointestinal endoscopy is not justified in persons with a positive FOBT and a negative colonoscopy in a population-based colorectal cancer screening program Bernard DENIS, Philippe PERRIN, Frédéric VAGNE, Danièle KLINKERT, Daniel BATTISTELLI, André PETER, Jean Christophe PFEIFFER, Jean François VIES Association pour le Dépistage du Cancer colorectal dans le Haut-Rhin (ADECA 68), Colmar, FRANCE

background l assessment of both feasibility and effectiveness of a nation wide population-based colorectal cancer (CRC) FOBT screening program l 22 pilot areas B. Denis - UEGW 2005 - Copenhagen

background l whether upper endoscopy is necessary… is controversial l few studies, most small sized, retrospective or individual screening l 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) B. Denis - UEGW 2005 - Copenhagen

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 ? B. Denis - UEGW 2005 - Copenhagen

methods l pilot population-based colorectal cancer screening program l Haut-Rhin: 0. 71 million inhabitants l all average risk residents aged 50 -74 y l biennial non rehydrated guaiac FOBT (Hemoccult II) without dietary restriction B. Denis - UEGW 2005 - Copenhagen

methods l prospective recording all upper endoscopies performed after positive FOBT and negative colonoscopy l data collection s detailed history (upper GI symptoms, drugs, documented anemia…) s upper abnormal findings s changes in management s adverse events B. Denis - UEGW 2005 - Copenhagen

methods l inclusion criteria s Residents aged 50 -74 y participating to CRC screening program s Positive FOBT s Complete colonoscopy s No lower bleeding lesion, CRC or polyp ≥ 1 cm s At the discretion of the endoscopist s Informed consent B. Denis - UEGW 2005 - Copenhagen

methods l exclusion criteria s FOBT completed out of screening program s Incomplete colonoscopy s Lower bleeding lesion, CRC or polyp ≥ 1 cm s Documented upper GI disease s Recent upper endoscopy < 1 year s Patient refusal B. Denis - UEGW 2005 - Copenhagen

methods 185, 000 p. 50 -74 y invited 15, 642 p. excluded 68, 777 FOBT completed 2, 559 FOBT + 1, 705 colonoscopies 703 CRC or polyps > 1 cm 397 polyps < 1 cm 605 normal B. Denis - UEGW 2005 - Copenhagen

results l ongoing study: April 2005 (19 months) l 366 upper endoscopies / 1002 (36. 6%) u 305 (50. 4 %) with normal colonoscopy u 61 (15. 4 %) with colorectal polyps < 1 cm B. Denis - UEGW 2005 - Copenhagen

diagnostic yield 80 / 366 (21. 9 %) abnormal upper GI findings l 1 p. T 1 esophageal adenocarcinoma l 3 Barrett’s esophagus l 33 reflux esophagitis (28 gr. 1 / 5 gr. 2) l 2 angiodysplasia l 12 gastric polyps l 26 erosive gastritis l 1 gastric ulcer l 5 erosive duodenitis l 2 duodenal ulcers l 18 Hp positive B. Denis - UEGW 2005 - Copenhagen

diagnostic yield age < 65 46 (21. 5%) > 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%) p=0. 02 upper symptoms present 29 (37. 2%) absent 32 (15%) p<0. 01 B. Denis - UEGW 2005 - Copenhagen

clinical impact 50 / 366 (15 %) change in clinical management l 1 surgery l 1 Argon plasma coagulation l 46 PPI l 18 antibiotics l 4 NSAID discontinuation l 3 endoscopic follow -up B. Denis - UEGW 2005 - Copenhagen

clinical impact age < 65 31 (14. 5%) > 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%) p=0. 01 upper symptoms present 20 (25. 6%) absent 23 (10. 8%) p<0. 01 B. Denis - UEGW 2005 - Copenhagen

213 asymptomatic persons l abnormal findings: 15 % l changes in management: 10. 8% l clinically important lesions: 3. 3 % s 3 erosive gastritis Hp + s 3 erosive duodenitis Hp + s 1 reflux esophagitis gr. 2 s no cancer s no Barrett’s B. Denis - UEGW 2005 - Copenhagen

asymptomatic persons Number needed to screen to detect one clinically important lesion = 30 B. Denis - UEGW 2005 - Copenhagen

conclusions l 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 l upper endoscopy must be performed in patients with relevant upper symptoms B. Denis - UEGW 2005 - Copenhagen

future l upper abnormal findings u positive FOBT ? u by chance ? l control group with colorectal cancer or large polyps B. Denis - UEGW 2005 - Copenhagen