Around 100,000 fewer colonoscopies expected to take place each year following updated NICE guidance

NICE 24th August 2023

Tens of thousands of people a year could be spared the need for a colonoscopy following new guidance from NICE.

People with signs or symptoms of colorectal cancer should be offered a home test with quantitative faecal immunochemical tests (FIT) from 1 of 2 technologies (HM-JACKarc or OC-Sensor). This could lead to faster diagnosis, with fewer people referred to secondary care for an unnecessary colonoscopy. People who require follow up investigation can then be prioritised for referral leading to colonoscopy services focusing on those people who need them most.

Analysis carried out by NICE shows if there is a 25% reduction in the number of people referred, 94,291 fewer colonoscopies would take place.

North Tees and Hartlepool NHS Foundation Trust is already using the approach recommended by NICE and found they detected more cancers using fewer colonoscopies, which is better for patients and more efficient for the NHS.

NICE’s diagnostic advisory committee has recommended a sample is sent in the post to a laboratory where the amount of blood in the faeces is measured. The results are usually available within a week and people with 10 or more micrograms of haemoglobin in their faeces should then be referred for further investigation.

Under previous NICE guidance, FIT was already offered to some people presenting to primary care with symptoms suggestive of colorectal cancer, while others were immediately referred on the suspected cancer pathway.

Further assessment using colonoscopy, or CT colonography, is required to diagnose cancer.

Colonoscopy capacity is limited, and there are sometimes long wait times. Using FIT could reduce the number of people referred for urgent colonoscopy, and so reduce the waiting times to allow people on non-urgent referral pathways to be seen more quickly. For people where there is strong clinical concern of cancer because of ongoing unexplained symptoms, the guidance remains to refer them immediately to secondary care.

Further information – Around 100,000 fewer colonoscopies expected to take place each year following updated NICE guidance

[NICE Technology Appraisal Guidance] Pembrolizumab for untreated metastatic colorectal cancer with high microsatellite instability or mismatch repair deficiency

NICE |  June 2021 | Pembrolizumab for untreated metastatic colorectal cancer with high microsatellite instability or mismatch repair deficiency

Evidence-based recommendations on pembrolizumab (Keytruda) for treating metastatic colorectal cancer with high microsatellite instability or mismatch repair deficiency in adults.

Pembrolizumab for untreated metastatic colorectal cancer with high microsatellite instability or mismatch repair deficiency

Risk of colorectal cancer in first degree relatives of patients with colorectal polyps: nationwide case-control study in Sweden

Song, M., Emilsson, L., Roelstraete, B., & Ludvigsson, J. F. | 2021| Risk of colorectal cancer in first degree relatives of patients with colorectal polyps: nationwide case-control study in Sweden| BMJ |  373 | n877| doi:10.1136/bmj.n877

Risk of colorectal cancer in first degree relatives of patients with colorectal polyps: nationwide case-control study in Sweden

This case-control study uses data from a Swedish database, in order to assess family history of colorectal polyps and risk of colorectal cancer (CRC).

What is already known on this topic

• Endoscopic screening reduces the incidence of and mortality from colorectal cancer (CRC) by removal of precursor lesions—namely, colorectal polyps
• A family history of CRC is an established risk factor for CRC
• Individuals with a history of advanced colorectal polyps are at higher risk of developing CRC

What this study adds

• Individuals with at least two first degree relatives with polyps or a first degree relative with polyps diagnosed at a young age, most of whom are not yet recommended for early screening according to existing guidelines, are at an increased risk of CRC, particularly early onset disease, and they might benefit from early screening
• Compared with the advanced histology of polyps, the higher number of first degree relatives with polyps and younger age at polyp diagnosis seemed to be more predictive of CRC risk in family members

Abstract

Objective To assess the risk of colorectal cancer (CRC) in first degree relatives (parents and full siblings) of patients with precursor lesions (polyps) for CRC.

Design Case-control study.

Setting Linkage to the multi-generation register and gastrointestinal ESPRESSO (Epidemiology Strengthened by histoPathology Reports in Sweden) histopathology cohort in Sweden.

Participants 68 060 patients with CRC and 333 753 matched controls.

Main outcome measures Multivariable adjusted odds ratios of CRC according to the number of first degree relatives with a colorectal polyp and the histology of polyps and age at diagnosis in first degree relatives. Subgroup analysis was also performed according to age at CRC diagnosis and evaluated the joint association of family history of colorectal polyps and family history of CRC.

Results After adjusting for family history of CRC and other covariates, having a first degree relative with a colorectal polyp (8.4 per cent (5742/68 060) in cases and 5.7 per cent (18 860/333 753) in controls) was associated with a higher risk of CRC (odds ratio 1.40, 95 per cent confidence interval 1.35 to 1.45). The odds ratios ranged from 1.23 for those with hyperplastic polyps to 1.44 for those with tubulovillous adenomas. To better put this risk in perspective, the age specific absolute risk of colon and rectal cancers was estimated according to family history of polyps based on the 2018 national CRC incidence in Sweden. For example, the absolute risk of colon cancer in individuals aged 60-64 years with and without a family history of colorectal polyp was, respectively, 94.3 and 67.9 per 100 000 for men and 89.1 and 64.1 per 100 000 for women. The association between family history of polyps and CRC risk was strengthened by the increasing number of first degree relatives with polyps (more than or equal to 2 first degree relatives: 1.70, 1.52 to 1.90, P less than 0.001 for trend) and decreasing age at polyp diagnosis (less than 50 years: 1.77, 1.57 to 1.99, P less than 0.001 for trend). A particularly strong association was found for early onset CRC diagnosed before age 50 years ( less than or equal to 2 first degree relatives: 3.34, 2.05 to 5.43, P equal to 0.002 for heterogeneity by age of CRC diagnosis). In the joint analysis, the odds ratio of CRC for individuals with two or more first degree relatives with polyps but no CRC was 1.79 (1.52 to 2.10), with one first degree relative with CRC but no polyps was 1.70 (1.65 to 1.76), and with two or more first degree relatives with both polyps and CRC was 5.00 (3.77 to 6.63) (P less than 0.001 for interaction).

Conclusions After adjusting for family history of CRC, the siblings and children of patients with colorectal polyps are still at higher risk of CRC, particularly early onset CRC. Early screening for CRC might be considered for first degree relatives of patients with polyps.

Risk of colorectal cancer in first degree relatives of patients with colorectal polyps: nationwide case-control study in Sweden

Colorectal cancer

Colorectal cancer | NICE guideline [NG151] | January 2020

This guideline covers managing colorectal (bowel) cancer in people aged 18 and over. It aims to improve quality of life and survival for adults with colorectal cancer through management of local disease and management of secondary tumours (metastatic disease).

Recommendations

This guideline includes recommendations on:

• prevention of colorectal cancer in people with Lynch syndrome
• information for people with colorectal cancer
• management of local disease
• molecular biomarkers to guide systemic anti-cancer therapy
• management of metastatic disease
• ongoing care and support

See also: Colorectal cancer (Quality Standard 20, updated from Aug 2012)

Robotic surgery for rectal cancer produces similar results to keyhole surgery

NIHR Signal | December 2019 |Robotic surgery for rectal cancer produces similar results to keyhole surgery

Robotic rectal cancer surgery does not appear technically easier than standard keyhole surgery. The researchers, in this trial, judged this by measuring the need to ‘convert’ a keyhole procedure to open surgery when operating. This NIHR-funded trial also found that robotic surgery produced similar clinical results to standard laparoscopic (keyhole) surgery in treating rectal cancer.

In the trial, 28 out of 230 patients (12%) who received keyhole surgery were converted to open surgery, compared with 19 out of 236 (8%) who received robotic surgery. This difference did not achieve statistical significance. There were also no differences in the likelihood of removing the whole tumour, surgery-related complications and bladder or sexual function. Longer-term outcomes such as three-year recurrence and overall survival were also similar.

These results suggest robotic rectal surgery, which costs £1,000 more than laparoscopic surgery due to ongoing equipment costs and longer operating time, may not be cost-effective (Source: NIHR).

The full details of the trial are available from the NIHR 

Full reference:

Jayne, D. | 2019| Robotic-assisted Surgery Compared With Laparoscopic Resection Surgery for Rectal Cancer: The ROLARR RCT | Efficacy and Mechanism Evaluation | DOI: 10.3310/eme06100

Abstract

Background

Robotic rectal cancer surgery is gaining popularity, but there are limited data about its safety and efficacy. Objective To undertake an evaluation of robotic compared with laparoscopic rectal cancer surgery to determine its safety, efficacy and cost-effectiveness.

Design

This was a multicentre, randomised trial comparing robotic with laparoscopic rectal resection in patients with rectal adenocarcinoma.

Setting

The study was conducted at 26 sites across 10 countries and involved 40 surgeons. Participants The study involved 471 patients with rectal adenocarcinoma. Recruitment took place from 7 January 2011 to 30 September 2014 with final follow-up on 16 June 2015. Interventions Robotic and laparoscopic rectal cancer resections were performed by high anterior resection, low anterior resection or abdominoperineal resection. There were 237 patients randomised to robotic and 234 to laparoscopic surgery. Follow-up was at 30 days, at 6 months and annually until 3 years after surgery.

Main outcome measures The primary outcome was conversion to laparotomy. Secondary end points included intra- and postoperative complications, pathological outcomes, quality of life (QoL) [measured using the Short Form questionnaire-36 items version 2 (SF-36v2) and the Multidimensional Fatigue Inventory-20 (MFI-20)], bladder and sexual dysfunction [measured using the International Prostatic Symptom Score (I-PSS), the International Index of Erectile Function (IIEF) and the Female Sexual Function Index (FSFI)], and oncological outcomes. An economic evaluation considered the costs of robotic and laparoscopic surgery, including primary and secondary care costs up to 6 months post operation.

Results Among 471 randomised patients [mean age 64.9 years, standard deviation (SD) 11.0 years; 320 (67.9%) men], 466 (98.9%) patients completed the study. Data were analysed on an intention-to-treat basis. The overall rate of conversion to laparotomy was 10.1% and occurred in 19 (8.1%) patients in the robotic-assisted group and in 28 (12.2%) patients in the conventional laparoscopic group. Of the nine prespecified secondary end points, including circumferential resection margin positivity, intraoperative complications, postoperative complications, plane of surgery, 30-day mortality and bladder and sexual dysfunction, none showed a statistically significant difference between the groups. No difference between the treatment groups was observed for longer-term outcomes, disease-free and overall survival (OS). Males were at a greater risk of local recurrence than females and had worse OS rates. The costs of robotic and laparoscopic surgery, excluding capital costs, were £11,853 (SD £2940) and £10,874 (SD £2676) respectively.

Conclusions

There is insufficient evidence to conclude that robotic rectal surgery compared with laparoscopic rectal surgery reduces the risk of conversion to laparotomy. There were no statistically significant differences in resection margin positivity, complication rates or QoL at 6 months between the treatment groups. Robotic rectal cancer surgery was on average £980 more expensive than laparoscopic surgery, even when the acquisition and maintenance costs for the robot were excluded. Future work The lower rate of conversion to laparotomy in males undergoing robotic rectal cancer surgery deserves further investigation. The introduction of new robotic systems into the market may alter the cost-effectiveness of robotic rectal cancer surgery.

The full article is available from PubMed

Leeds’ findings: Bowel cancer rates after colonoscopy vary by provider

University of Leeds | November 2019 | Bowel cancer rates after colonoscopy vary by provider

New research led by the University of Leeds looked at the number of patients whose colonoscopy found no evidence of bowel cancer, but who were subsequently diagnosed with the disease.

They found that overall the rate of these post-colonoscopy bowel cancers decreased in England. However, they found that the rates of these potentially missed cancers were lower for colonoscopies performed by the NHS than those performed by independent providers on behalf of the NHS.

Co-author Professor Eva Morris, from the University of Leeds’ School of Medicine and the Leeds Institute for Data Analytics, said: “Overall we found the proportion of people whose bowel cancer is being missed by a colonoscopy procedure has declined, meaning that our diagnostic services are getting more and more accurate.

“However, this study reveals wide variation in the accuracy of colonoscopy tests depending on the provider, meaning that some cancers are still being missed. This urgently needs to be addressed to ensure we are detecting cancer cases as early as possible.”

Amongst people diagnosed with bowel cancer who had a colonoscopy within the NHS Bowel Cancer Screening Programme, 3.6% could potentially have been diagnosed at an earlier time point. In contrast, if a person’s colonoscopy was undertaken by an NHS commissioned independent provider 9.3% could potentially have been diagnosed sooner.

The researchers say that if the lower rate had been achieved over the entire nine-year study period, more than 3,900 cases of colorectal cancer could have been prevented or diagnosed earlier (Source: University of Leeds).

Read the news release from the University of Leeds in full here

The study’s findings have now been published in the BMJ 

Burr, N.E., et al. | 2019| Variation in post-colonoscopy colorectal cancer across colonoscopy providers in English National Health Service: population based cohort study| BMJ | 367 |l6090 | doi: https://doi.org/10.1136/bmj.l6090

Abstract

Objectives To quantify post-colonoscopy colorectal cancer (PCCRC) rates in England by using recent World Endoscopy Organisation guidelines, compare incidence among colonoscopy providers, and explore associated factors that could benefit from quality improvement initiatives.

 

Design Population based cohort study.

Setting National Health Service in England between 2005 and 2013.

Population All people undergoing colonoscopy and subsequently diagnosed as having colorectal cancer up to three years after their investigation (PCCRC-3yr).

 

Main outcome measures National trends in incidence of PCCRC (within 6-36 months of colonoscopy), univariable and multivariable analyses to explore factors associated with occurrence, and funnel plots to measure variation among providers.

Results The overall unadjusted PCCRC-3yr rate was 7.4% (9317/126 152), which decreased from 9.0% in 2005 to 6.5% in 2013 (P<0.01). Rates were lower for colonoscopies performed under the NHS bowel cancer screening programme (593/16 640, 3.6%), while they were higher for those conducted by non-NHS providers (187/2009, 9.3%). Rates were higher in women, in older age groups, and in people with inflammatory bowel disease or diverticular disease, in those with higher comorbidity scores, and in people with previous cancers. Substantial variation in rates among colonoscopy providers remained after adjustment for case mix.

Conclusions Wide variation exists in PCCRC-3yr rates across NHS colonoscopy providers in England. The lowest incidence was seen in colonoscopies performed under the NHS bowel cancer screening programme. Quality improvement initiatives are needed to address this variation in rates and prevent colorectal cancer by enabling earlier diagnosis, removing premalignant polyps, and therefore improving outcomes.

The full article is available from The BMJ 

Visual abstract 

 

 

Case study: ADENOMA – impact case study

NIHR | September 2019 | Case study: ADENOMA – impact case study

NIHR has produced an impact case study on adenoma, a polyp that grows in the bowel that has become cancerous.  Currently, a colonoscopy is regarded as the ‘gold standard’ treatment for adenoma.

Although experienced endoscopists perform the colonoscopies, polyps can get missed for various reasons including the size, shape and location of the lesions, and many colorectal cancer screening programmes have been proposed to improve adenoma detection rate (ADR). Improving the ADR and cancer detection through increased colonoscopy performance brings patient benefits, and earlier diagnosis of cancer is also associated with lower healthcare costs (Cancer Research UK 2014).

The study recruited 1800 participants from across seven sites, with patients being referred to the trial because of symptoms, surveillance or following a positive faecal occult blood test as part of the Bowel Cancer Screening Programme.

These patients were randomized across two arms of the trial: with one group having treatment as usual (the colonoscopy) and the other having the Endocuff Vision arm

The researchers report that the participants in the Endocuff Vision arm of the trial, had a higher Adenoma Detection Rate, increased globally from 36.2 per cent to 40.9 per cent (P=0.02). the increase was driven by a 10.8 per cent increase in FOBt-positive screening patients (50.9 per cent vs 61.7 per cent, P less than 0.001).

The research team conclude that the ADENOMA trial showed that Endocuff Vision significantly improved ADR in bowel cancer screening patients and should be used to improve colonoscopic detection.

The success of the trial led to NHS England announcing Endocuff Vision as one of only four technologies to be fast-tracked into use through NHS England’s Innovation and Technology Payment programme in April 2018.

NICE updated its guidelines for use in June 2019 and NHS trusts across England have significantly increased use of the product.
The Endocuff Vision device has also been adopted internationally and there has been a large rise in the use of the device over the last four years (Source: NIHR).

Read the full story from NIHR

 

Increasing incidence of colorectal cancer in young adults in Europe over the last 25 years

Vuik, F.E., et al | 2019| Increasing incidence of colorectal cancer in young adults in Europe over the last 25 years| Gut|68| P.1820-1826|

Research published in the journal Gut analyses trends in the incidence of colorectal cancer (CRC) and mortality in subjects under the age of 50. The experts used data on over 143 million people across European countries to explore . While the researchers observed that CRC incidence continues to rise among young adults in Europe; they indicate further research is necessary to find out the reasons for this trend need to be discovered and if the trend continues, screening guidelines may need to be reconsidered.

The full article is available from the journal Gut

Abstract

Objective The incidence of colorectal cancer (CRC) declines among subjects aged 50 years and above. An opposite trend appears among younger adults. In Europe, data on CRC incidence among younger adults are lacking. We therefore aimed to analyse European trends in CRC incidence and mortality in subjects younger than 50 years.

 

Design Data on age-related CRC incidence and mortality between 1990 and 2016 were retrieved from national and regional cancer registries. Trends were analysed by Joinpoint regression and expressed as annual percent change.

 

Results We retrieved data on 143.7 million people aged 20–49 years from 20 European countries. Of them, 187 918 (0.13%) were diagnosed with CRC. On average, CRC incidence increased with 7.9% per year among subjects aged 20–29 years from 2004 to 2016. The increase in the age group of 30–39 years was 4.9% per year from 2005 to 2016, the increase in the age group of 40–49 years was 1.6% per year from 2004 to 2016. This increase started earliest in subjects aged 20–29 years, and 10–20 years later in those aged 30–39 and 40–49 years. This is consistent with an age-cohort phenomenon. Although in most European countries the CRC incidence had risen, some heterogeneity was found between countries. CRC mortality did not significantly change among the youngest adults, but decreased with 1.1%per year between 1990 and 2016 and 2.4% per year between 1990 and 2009 among those aged 30–39 years and 40–49 years, respectively.

 

Conclusion CRC incidence rises among young adults in Europe. The cause for this trend needs to be elucidated. Clinicians should be aware of this trend. If the trend continues, screening guidelines may need to be reconsidered.

Full article available from the BMJ

 

See also:

Reuters Colorectal cancer becoming more common at younger ages

Cancer Research UK Bowel cancer rates are rising in young adults, but do we know what’s behind the increase?

Oral antibiotic use and risk of colorectal cancer in the United Kingdom, 1989–2012: a matched case–control study

Zhang, J., Haines, C., Watson, A.J.M., et al | 2019| 

Oral antibiotic use and risk of colorectal cancer in the United Kingdom, 1989–2012: a matched case–control study | Gut |  doi: 10.1136/gutjnl-2019-318593

 

Researchers behind a population-based study of oral antibiotic exposure and risk   looked at the association between oral antibiotic use and (colorectal cancer) CRC risk have published their findings in the BMJ Journal Gut. 

Abstract

Background Microbiome dysbiosis predisposes to colorectal cancer (CRC), but a population-based study of oral antibiotic exposure and risk patterns is lacking.

Objective To assess the association between oral antibiotic use and CRC risk.

Design A matched case–control study (incident CRC cases and up to five matched controls) was performed using the Clinical Practice Research Datalink from 1989 to 2012.

Results 28 980 CRC cases and 137 077 controls were identified. Oral antibiotic use was associated with CRC risk, but effects differed by anatomical location. Antibiotic use increased the risk of colon cancer in a dose-dependent fashion. The risk was observed after minimal use, and was greatest in the proximal colon and with antibiotics with anti-anaerobic activity. In contrast, an inverse association was detected between antibiotic use and rectal cancers, particularly with length of antibiotic exposure more than 60 days as compared with no antibiotic exposure. Penicillins, particularly ampicillin/amoxicillin increased the risk of colon cancer, whereas tetracyclines reduced the risk of rectal cancer. Significant interactions were detected between antibiotic use and tumour location. The antibiotic–cancer association was found for antibiotic exposure occurring more than 10 years before diagnosis.

Conclusion Oral antibiotic use is associated with an increased risk of colon cancer but a reduced risk of rectal cancer. This effect heterogeneity may suggest differences in gut microbiota and carcinogenesis mechanisms along the lower intestinal tract. (Source: Zhang et al, 2019)

The full article is available from BMJ Gut 

In the news:

OnMedica Oral antibiotic use linked to heightened bowel cancer risk

NIHR: Whole-body MRI is effective for identifying metastatic disease in colorectal cancer patients

NIHR| July 2019 |Whole-body MRI is effective for identifying metastatic disease in colorectal cancer patients

A new NIHR Signal showcases the findings of annitial investigation which includes whole-body magnetic resonance imaging (MRI) is as good as standard pathways for detecting metastatic disease in adults with newly diagnosed colorectal cancer. This NIHR-funded study also found that whole-body MRI reduces the number of investigations needed, the length of the staging process, and costs less than standard pathways.

The treatment options for colorectal cancer depend on the stage of the cancer. For example, if a patient has metastatic disease (secondary tumours in other parts of the body), the aims of surgery and chemotherapy can be different. So, an accurate staging process is very important.

Current NICE guidance recommends a sequence of investigations for staging, with MRI only recommended after biopsies and other imaging investigations. This study suggests that MRI could be used earlier in the process, instead of the currently recommended investigations. However, any changes to guidance would need to take into account the availability of this resource (Source: NIHR).

Summary

Background

Whole-body MRI (WB-MRI) could be an alternative to multimodality staging of colorectal cancer, but its diagnostic accuracy, effect on staging times, number of tests needed, cost, and effect on treatment decisions are unknown. We aimed to prospectively compare the diagnostic accuracy and efficiency of WB-MRI-based staging pathways with standard pathways in colorectal cancer.

Methods

The Streamline C trial was a prospective, multicentre trial done in 16 hospitals in England. Eligible patients were 18 years or older, with newly diagnosed colorectal cancer. Exclusion criteria were severe systemic disease, pregnancy, contraindications to MRI, or polyp cancer. Patients underwent WB-MRI, the result of which was withheld until standard staging investigations were complete and the first treatment decision made. The multidisciplinary team recorded its treatment decision based on standard investigations, then on the WB-MRI staging pathway (WB-MRI plus additional tests generated), and finally on all tests. The primary outcome was difference in per-patient sensitivity for metastases between standard and WB-MRI staging pathways against a consensus reference standard at 12 months, in the per-protocol population. Secondary outcomes were difference in per-patient specificity for metastatic disease detection between standard and WB-MRI staging pathways, differences in treatment decisions, staging efficiency (time taken, test number, and costs), and per-organ sensitivity and specificity for metastases and per-patient agreement for local T and N stage. This trial is registered with the International Standard Randomised Controlled Trial registry, number ISRCTN43958015, and is complete.

 

Findings

Between March 26, 2013, and Aug 19, 2016, 1020 patients were screened for eligibility. 370 patients were recruited, 299 of whom completed the trial; 68 (23%) had metastasis at baseline. Pathway sensitivity was 67% (95% CI 56 to 78) for WB-MRI and 63% (51 to 74) for standard pathways, a difference in sensitivity of 4% (−5 to 13, p=0·51). No adverse events related to imaging were reported. Specificity did not differ between WB-MRI (95% [95% CI 92–97]) and standard pathways (93% [90–96], p=0·48). Agreement with the multidisciplinary team’s final treatment decision was 96% for WB-MRI and 95% for the standard pathway. Time to complete staging was shorter for WB-MRI (median, 8 days [IQR 6–9]) than for the standard pathway (13 days [11–15]); a 5-day (3–7) difference. WB-MRI required fewer tests (median, one [95% CI 1 to 1]) than did standard pathways (two [2 to 2]), a difference of one (1 to 1). Mean per-patient staging costs were £216 (95% CI 211–221) for WB-MRI and £285 (260–310) for standard pathways.

 

Interpretation

WB-MRI staging pathways have similar accuracy to standard pathways and reduce the number of tests needed, staging time, and cost.

 

NIHR Whole-body MRI is effective for identifying metastatic disease in colorectal cancer patients

Read the full journal article from The Lancet Gastroenterology & Hepatology 

Article 

Taylor, S.A . et al | 2019| Diagnostic accuracy of whole-body MRI versus standard imaging pathways for metastatic disease in newly diagnosed colorectal cancer: the prospective Streamline C trial | The Lancet Gastroenterology & Hepatology | DOI:https://doi.org/10.1016/S2468-1253(19)30056-1