Geisinger Health System, Department of Gastroenterology, Danville, Pennsylvania, USA.
Geisinger Health System, Division of Laboratory Medicine, Danville, Pennsylvania, USA.
Clin Transl Gastroenterol. 2014 Dec 4;5(12):e64. doi: 10.1038/ctg.2014.11.
The decision tree underlying current practice guidelines for post polypectomy surveillance relies on risk stratification based on predictive attributes gleaned from adenomas removed on screening colonoscopy examination. Our primary aim was to estimate the magnitude of association between baseline adenoma attributes and the risk of adenoma recurrence and invasive colorectal adenocarcinoma (CRC). Our secondary aims were to estimate the adenoma detection rate (ADR) of surveillance compared with screening colonoscopies and describe time trends in preventive colonoscopy utilization.
We used prospective analyses of retrospectively collected clinical data from electronic health records. A cohort of primary care patients eligible for colorectal cancer screening was assembled encompassing 110,452 subjects, of which 3,300 had adenomas removed on screening examination. Of those patients who had a follow-up surveillance colonoscopy (defined as a patient with a documented adenoma on prior colonoscopy) recorded during the study period, 537 had a recurrent adenoma.
Of those recurrent adenomas, 354 had a high-risk attributes. High-risk attributes were described at >3 adenomas, at least one adenoma >10 mm in size, high-grade dysplasia, or villous features. The risk of developing invasive CRC among post polypectomy patients was significantly higher if the baseline adenomas displayed any of the following attributes: more numerous than 3 (4.3-fold higher risk, 95% confidence interval (CI) low, high 1.4, 12.9), larger than 10 mm in size (5.2-fold higher risk, 95% CI low, high 1.8, 15.1), high-grade dysplasia (13.2-fold risk, 95% CI low, high 2.8, 62.1), or villous features (7.4-fold higher risk, 95% CI low, high 2.5, 21.5). These attributes combined added a net value of 22.8% to the probability of correctly predicting CRC. There was a threefold increase in surveillance utilization relative to screening from 2005 to 2011. The ADR of surveillance (34.1%) was 1.5-fold higher than that of screening (23.1%).
These results emphasize the need to mitigate excessive risk by performing timely surveillance colonoscopies in patients with baseline adenomas displaying high-risk attributes as recommended in practice guidelines.
当前基于预测属性的息肉切除后监测指南所依据的决策树，这些预测属性是从筛查结肠镜检查中切除的腺瘤中获取的。我们的主要目的是评估基线腺瘤属性与腺瘤复发和浸润性结直肠癌（CRC）风险之间的关联程度。我们的次要目的是评估与筛查结肠镜相比，监测的腺瘤检出率（ADR），并描述预防性结肠镜检查使用的时间趋势。
我们使用电子健康记录中回顾性收集的临床数据进行前瞻性分析。我们组建了一个符合结直肠癌筛查条件的初级保健患者队列，共纳入 110452 名患者，其中 3300 名患者在筛查检查中切除了腺瘤。在研究期间记录了接受随访监测结肠镜检查（定义为先前结肠镜检查中有记录的腺瘤患者）的患者中，有 537 名患者出现了复发性腺瘤。
在这些复发性腺瘤中，有 354 名患者具有高危属性。高危属性描述为：腺瘤数量超过 3 个、至少一个腺瘤大于 10mm、高级别异型增生或绒毛状特征。在息肉切除术后患者中，如果基线腺瘤显示以下任何一种属性，则发生浸润性 CRC 的风险显著增加：数量超过 3 个（风险增加 4.3 倍，95%置信区间（CI）低值、高值 1.4、12.9）、大于 10mm（风险增加 5.2 倍，95%CI 低值、高值 1.8、15.1）、高级别异型增生（风险增加 13.2 倍，95%CI 低值、高值 2.8、62.1）或绒毛状特征（风险增加 7.4 倍，95%CI 低值、高值 2.5、21.5）。这些属性结合起来，可以将正确预测 CRC 的概率提高 22.8%。与 2005 年至 2011 年相比，筛查后监测的利用率增加了两倍。监测的 ADR（34.1%）比筛查的 ADR（23.1%）高 1.5 倍。
这些结果强调了需要根据指南建议，对具有高危属性的基线腺瘤患者及时进行监测结肠镜检查，以降低过度风险。
