Efficacy of screening using annual fecal immunochemical test alone versus combined with one-time colonoscopy in reducing colorectal cancer mortality: the Akita Japan population-based colonoscopy screening trial (Akita pop-colon trial)

As screening programs using annual FIT were implemented nationwide in 1992 in Japan, it is not feasible to create a control group in which patients did not undergo CRC screening programs. Even if it was possible, it might not be ethical to include a control group of patients who did not undergo screening tests. Under these circumstances, FIT was provided to both groups, and colonoscopy was added to FIT as an intervention (intervention group). The study participants were assigned in a 1:1 ratio to the study arm and control arm. The trial was registered with the UMIN Clinical Trials Registry (number UMIN000001980).

The hypothesis is that addition of one-time colonoscopy to the screening program using annual FIT will result in a higher reduction in mortality from CRC than the existing program using annual FIT only. The main objective was to demonstrate that the screening program using one-time colonoscopy and annual FIT is more effective than the program using annual FIT only in terms of reduction in CRC mortality.

Three independent units were set up to manage the study. The executive office for the study was placed at Showa University and the secretariat office at National Cancer Center. In addition, the data center was set at the Japan Clinical Research Supporting Unit, which has been engaged in data center activity for many clinical trials since 2001. The executive office was responsible for managing the entire study and dispatching gastroenterologists, who performed colonoscopy screening. The secretariat office was responsible for the design of the study as well as the follow-up and management of the study including quality assurance. Data on screening tests and diagnostic follow-up results were collected by offices at the screening site set in the two city offices and sent to the data center through an electrical transmission system. The data were exclusively kept within the data center.

The study was originally conducted in the Semboku City in Akita Prefecture in 2009 and was expanded to Daisen City in 2011. The number of inhabitants aged 40–74 years in each city was 15,267 in 2009 and 43,135 in 2011 [19]. In both cities, population-based–organized CRC screening programs had been implemented since 1992 as a public health policy.

Study participants aged 40–74 years from both cities were enrolled. Asymptomatic, average-risk participants were chosen among those who submitted FIT kits. Average risk subjects were defined as those who were healthy and asymptomatic with regard to symptoms related to CRC. FIT kits were previously sent to those who agreed to participate in the CRC screening program organized by the municipalities. Individuals with a history of CRC, with hereditary non-polyposis CRC, with familial adenomatous polyposis, with inflammatory bowel diseases (ulcerative colitis or Crohn’s disease), with a history of cancer other than CRC within the past 5 years, and who were not expected to survive from comorbid illness for more than 5 years (Table 1) were excluded. Individuals who had severe comorbidity were defined as those who were forbidden to undergo endoscopy by their attending physicians due to their illness such as cardiovascular or respiratory diseases of a severe degree.

Screening history was not considered during patient selection. The most recent screening test modality and its duration were identified by administering a questionnaire at baseline and were recorded in the database at the data center. The questionnaire included information on lifestyle factors such as diet and physical activities and psychological factors. Colonoscopy screening performed outside the study and diagnostic colonoscopy were also identified using the questionnaire and were included in the analysis of the study results.

Participants were required to provide written informed consent after receiving an explanation about the study and the possible advantages and disadvantages from participating the study.

Randomization was performed using a sealed envelope with instructions for each of the two study arms assigned. Randomization procedures were explicitly designed at the data center. Block assignment was randomly generated on computer for each of the two study areas. In this study, the envelope method was performed based on requirements in order to preserve adequate allocation sequence concealment [20]. Key points of the envelope method in this study were as follows:

The dates of allocation were verified to be the same days as those of informed consent on all subjects. In addition, it was confirmed using a written record that all the envelopes were opened sequentially in the order of the serial numbers created for each envelope. Thus, the randomization was appropriately done in this study.

In this study, the risk-stratified allocation was not used, because the protocol committee of this study, which involved expert biostatisticians, concluded that it was not necessary for this study if the target numbers of subjects (5000 for each arm) could be recruited. Some variables related to the risk of CRC such as a history of preceding colonoscopy will be available with the questionnaire and used for comparison of the risk between the two arms.

For those in the intervention group, one-time colonoscopy screening in addition to 2-day FIT was performed. For those in the control group, only FIT was performed. Patients in the intervention group were scheduled to undergo colonoscopy within 4 months of recruitment in the study. Colonoscopy was performed at Kakunodate Hospital or Akita Red Cross Hospital by trained endoscopists. Those individuals who were found to have cancers or adenomas ≥ 5 mm in diameter were treated on another day of screening colonoscopy. Minute lesions of < 5 mm in diameter primarily remained untreated.

Annual FIT was performed in both groups. Patients with positive FIT results underwent diagnostic colonoscopy within 3 months of the announcement of the FIT results primarily at Kakunodate Hospital, Akita Red Cross Hospital, or other hospitals, if they requested to undergo the procedure at a specific hospital where expert colonoscopists were available.

Follow-up was conducted in two ways. First, the list of participants was obtained from the database of the resident registry annually to identify those who died and those who moved outside the two cities. The cancer registry was used to identify the incidence of CRC in the study cohort.

National Vital Statistics was also utilized to identify deceased individuals and causes of deaths among study subjects. The data center was responsible for performing those procedures. Second, the health status of each participant was identified by conducting an annual survey using a questionnaire sent to the participants via mail. This questionnaire was used for analyses of risk factors but could also be used as a complimentary method to identify conditions related to health status, including endpoints and the eligibility of each participant to remain in the study. The follow-up period was set at 10 years after enrollment. However, it could be extended adaptively to achieve significant results regarding relevant variables such as mortality and incidence.

Adverse events to be monitored were defined as disorders requiring treatment upon admission. All adverse events were reported to the data center and secretariat office. Among the events, those of a serious grade were reported to the secretariat office immediately after occurrence.

CRC mortality was the primary endpoint; several secondary endpoints were employed: cumulative incidence of advanced CRC (cancer invaded into the muscle layer or deeper); cumulative incidence of invasive cancer; screening sensitivities and specificities toward invasive CRC, whole CRC, and advanced neoplasia; and prevalence of adverse events. Mortality and incidence data were obtained as previously described.

There is limited evidence on the efficacy of endoscopic screening. However, two case-control studies that evaluated the efficacy of the rigid sigmoidoscopic screening or flexible sigmoidoscopic screening showed lower risk in individuals who had a history of screening than in those who did not [22, 23]. One study using rigid sigmoidoscopy reported that the risk of death due to CRC after screening was 0.41 [95% confidence interval (CI), 0.25–0.69] [22]. Among individuals whose most recent screening had been 9 to 10 years before, the odds ratio was 0.12 (95% CI, 0.02–0.93). There was no reduction in the risk of dying from proximal colon cancer (odds ratio 0.96; 95% CI, 0.61–1.50). The other study using flexible sigmoidoscopy and rigid sigmoidoscopy (approximately 60% of patients underwent sigmoidoscopy) reported the risk of 0.21 (95% CI, 0.08–0.52) for dying from CRC [23]. As sigmoidoscopy could not detect cancers proximal to the sigmoid colon, the odds ratio of death due to cancer in the rectum and sigmoid colon was estimated to be 0.05 (95% CI, 0.01–0.43) [23]. Consequently, the relative risk of 0.1 was hypothesized for the intervention group (90% reduction in mortality compared with those who did not undergo screening). By contrast, the relative risk after FIT was reported to be 0.2–0.4 in the case-control studies, and the relative risk for the control group was hypothesized to be 0.4 (60% reduction compared with the group did not undergo screening) [24‐28]. As this RCT was explanatory in nature and randomization was performed after obtaining informed consent, the rate of compliance to colonoscopy was assumed to be nearly 100%. The sample size was computed assuming that the rate of compliance to colonoscopy was 100%. Regarding FIT, individuals who submitted the FIT kits and those who eventually completed the screening test were recruited. It was considered appropriate to use the relative risk obtained from the case-control studies, which represents the risk in responders (in whom compliance was 100%) compared with that in nonresponders.