Dataset Information

Effects of screening and universal healthcare on long-term colorectal cancer mortality.

ABSTRACT:

Background

To evaluate the time trends of colorectal cancer (CRC) affected by a Nationwide Colorectal Cancer Screening (NCCS) programme with biennial faecal immunochemical testing (FIT) and Nationwide Healthcare Insurance (NHI).

Methods

Data from the national registries on cancer and death in Taiwan were separated into years 1984-1993, 1994-2003 and 2004-2013 based on the implementations of NHI (starting 1995) and NCCS (starting 2004). The adult population was divided into three age groups (young, 30-49; middle-aged, 50-69; and old, 70-84?years); only the middle-aged were eligible for NCCS. Crude and adjusted effects of NCCS and NHI were quantified by percentage change and 95% confidence interval (CI) with respect to CRC mortality, according to the attributions from incidence and survival.

Results

Within 335 million person-years of follow-up, 204?362 incident CRCs and 80?771 CRC-related deaths were identified. Increasing mortality trends were noted for 1994-2003 (post-NHI) vs 1984-1993 due to remarkable increasing incidence trends that could not be offset by improved survival as a result of NHI. During 2004-13 (post-NCCS), mortality continued to increase by 15% (95% CI: 10-21%) in young adults (30-49?years) and 8% (95% CI: 6-11%) in older adults (70-84?years), whereas middle-aged adults (50-69?years) had a reduction of 7% (95% CI: 5-9%) due to a remarkable stage shift and subsequent improvement in survival. In the middle-aged adults, increased incidence was less but survival improvement was more compared with other age groups.

Conclusions

Whereas universal healthcare insurance led to improvement in CRC survival, FIT-based screening has made an even greater contribution to reducing CRC mortality.

SUBMITTER: Lee YC

PROVIDER: S-EPMC6469303 | biostudies-literature | 2019 Apr

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Effects of screening and universal healthcare on long-term colorectal cancer mortality.

Lee Yi-Chia YC Hsu Chen-Yang CY Chen Sam Li-Sheng SL Yen Amy Ming-Fang AM Chiu Sherry Yueh-Hsia SY Fann Jean Ching-Yuan JC Chuang Shu-Lin SL Hsu Wen-Feng WF Chiang Tsung-Hsien TH Chiu Han-Mo HM Wu Ming-Shiang MS Chen Hsiu-Hsi HH

International journal of epidemiology 20190401 2

<h4>Background</h4>To evaluate the time trends of colorectal cancer (CRC) affected by a Nationwide Colorectal Cancer Screening (NCCS) programme with biennial faecal immunochemical testing (FIT) and Nationwide Healthcare Insurance (NHI).<h4>Methods</h4>Data from the national registries on cancer and death in Taiwan were separated into years 1984-1993, 1994-2003 and 2004-2013 based on the implementations of NHI (starting 1995) and NCCS (starting 2004). The adult population was divided into three a ...[more]

PMID: 30184208

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Project description:Colonoscopy and sigmoidoscopy provide protection against colorectal cancer, but the magnitude and duration of protection, particularly against cancer of the proximal colon, remain uncertain.We examined the association of the use of lower endoscopy (updated biennially from 1988 through 2008) with colorectal-cancer incidence (through June 2010) and colorectal-cancer mortality (through June 2012) among participants in the Nurses' Health Study and the Health Professionals Follow-up Study.Among 88,902 participants followed over a period of 22 years, we documented 1815 incident colorectal cancers and 474 deaths from colorectal cancer. With endoscopy as compared with no endoscopy, multivariate hazard ratios for colorectal cancer were 0.57 (95% confidence interval [CI], 0.45 to 0.72) after polypectomy, 0.60 (95% CI, 0.53 to 0.68) after negative sigmoidoscopy, and 0.44 (95% CI, 0.38 to 0.52) after negative colonoscopy. Negative colonoscopy was associated with a reduced incidence of proximal colon cancer (multivariate hazard ratio, 0.73; 95% CI, 0.57 to 0.92). Multivariate hazard ratios for death from colorectal cancer were 0.59 (95% CI, 0.45 to 0.76) after screening sigmoidoscopy and 0.32 (95% CI, 0.24 to 0.45) after screening colonoscopy. Reduced mortality from proximal colon cancer was observed after screening colonoscopy (multivariate hazard ratio, 0.47; 95% CI, 0.29 to 0.76) but not after sigmoidoscopy. As compared with colorectal cancers diagnosed in patients more than 5 years after colonoscopy or without any prior endoscopy, those diagnosed in patients within 5 years after colonoscopy were more likely to be characterized by the CpG island methylator phenotype (CIMP) (multivariate odds ratio, 2.19; 95% CI, 1.14 to 4.21) and microsatellite instability (multivariate odds ratio, 2.10; 95% CI, 1.10 to 4.02).Colonoscopy and sigmoidoscopy were associated with a reduced incidence of cancer of the distal colorectum; colonoscopy was also associated with a modest reduction in the incidence of proximal colon cancer. Screening colonoscopy and sigmoidoscopy were associated with reduced colorectal-cancer mortality; only colonoscopy was associated with reduced mortality from proximal colon cancer. Colorectal cancer diagnosed within 5 years after colonoscopy was more likely than cancer diagnosed after that period or without prior endoscopy to have CIMP and microsatellite instability. (Funded by the National Institutes of Health and others.).

Project description:BackgroundScreening flexible sigmoidoscopy reduces incidence and mortality of colorectal cancer. Previously reported results from the Prostate, Lung, Colorectal, and Ovarian Cancer (PLCO) screening trial had a median follow-up of 12 years. Whether the benefit is sustained over the long term and remains so in both sexes and all age groups is uncertain. We report long-term results after an additional 5 years of follow-up.MethodsParticipants in the PLCO trial were recruited from the general population in the catchment areas of ten screening centres across the USA, without previous diagnosis of a prostate, lung, colorectal, or ovarian cancer or current cancer treatment. From 1993 to 2001, participants aged 55-74 years were randomly assigned to usual care or flexible sigmoidoscopy at baseline and again at 3 years or 5 years. Randomisation was done within blocks and stratified by centre, age, and sex. The primary endpoint was cause-specific mortality and secondary endpoints included incidence and tumour staging; cause of death was determined without knowledge of study arm. In this analysis, we assessed incidence and mortality rates overall, by time-period, and by combinations of sex, age at baseline (55-64 years/65-74 years), location (distal/proximal), and stage, on an intent-to-treat basis. This trial is registered with ClinicalTrials.gov, number NCT00002540.FindingsAfter a median follow-up of 15·8 years (IQR 13·2-18·0) for incidence and 16·8 years (14·4-18·9) for mortality, the incidence of colorectal cancer was significantly lower in the intervention arm (1461 cases; 12·55 per 10 000 person-years) than with usual care (1761 cases; 15·33 per 10 000 person-years; relative risk [RR] 0·82, 95% CI 0·76-0·88). Similarly, mortality was lower in the intervention arm (417 deaths; 3·37 per 10 000 person-years) than the usual care arm (549; 4·48 per 10 000 person-years; RR 0·75, 95% CI 0·66-0·85). The reduction in mortality was limited to the distal colon, with no significant effect in the proximal colon. Reductions in incidence were significantly larger in men than women (pinteraction=0·04) and reductions in mortality were significantly larger in the older age group (65-74 years vs 55-64 years at baseline; pinteraction=0·01).InterpretationReductions in colorectal cancer incidence and mortality from flexible sigmoidoscopy screening are sustained over the long term. Differences by sex and age should be examined in other ongoing trials of colorectal cancer screening to help clarify if different screening strategies would achieve greater risk reduction.FundingExtended follow-up was funded under NIH contract HHSN261201600007I.

Project description:Background:The long-term effects of sigmoidoscopy screening on colorectal cancer (CRC) incidence and mortality in women and men are unclear. Objective:To determine the effectiveness of flexible sigmoidoscopy screening after 15 years of follow-up in women and men. Design:Randomized controlled trial. (ClinicalTrials.gov: NCT00119912). Setting:Oslo and Telemark County, Norway. Participants:Adults aged 50 to 64 years at baseline without prior CRC. Intervention:Screening (between 1999 and 2001) with flexible sigmoidoscopy with and without additional fecal blood testing versus no screening. Participants with positive screening results were offered colonoscopy. Measurements:Age-adjusted CRC incidence and mortality stratified by sex. Results:Of 98 678 persons, 20 552 were randomly assigned to screening and 78 126 to no screening. Adherence rates were 64.7% in women and 61.4% in men. Median follow-up was 14.8 years. The absolute risks for CRC in women were 1.86% in the screening group and 2.05% in the control group (risk difference, -0.19 percentage point [95% CI, -0.49 to 0.11 percentage point]; HR, 0.92 [CI, 0.79 to 1.07]). In men, the corresponding risks were 1.72% and 2.50%, respectively (risk difference, -0.78 percentage point [CI, -1.08 to -0.48 percentage points]; hazard ratio [HR], 0.66 [CI, 0.57 to 0.78]) (P for heterogeneity = 0.004). The absolute risks for death from CRC in women were 0.60% in the screening group and 0.59% in the control group (risk difference, 0.01 percentage point [CI, -0.16 to 0.18 percentage point]; HR, 1.01 [CI, 0.77 to 1.33]). The corresponding risks for death from CRC in men were 0.49% and 0.81%, respectively (risk difference, -0.33 percentage point [CI, -0.49 to -0.16 percentage point]; HR, 0.63 [CI, 0.47 to 0.83]) (P for heterogeneity = 0.014). Limitation:Follow-up through national registries. Conclusion:Offering sigmoidoscopy screening in Norway reduced CRC incidence and mortality in men but had little or no effect in women. Primary Funding Source:Norwegian government and Norwegian Cancer Society.

Dataset Information

Effects of screening and universal healthcare on long-term colorectal cancer mortality.

Background

Methods

Results

Conclusions

Publications

Effects of screening and universal healthcare on long-term colorectal cancer mortality.

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