Background
Colorectal cancer is one of the most common causes of cancer death globally each year, along with lung, liver, prostate, and breast cancer [
1]. Disease incidence of economically developed countries in Asia such as Japan, Korea and Singapore abruptly approached the level of the Western countries. Data from the National Cancer Institute of Thailand Cancer Registry also showed a gradual increase in the number of new colorectal cancer patients in recent years with increased advance stage cases identified [
2]. Colorectal cancer screening can diagnose cases in early stages, decrease cancer mortality and potentially prevent this disease [
3,
4]. Detection and proper management of advanced colorectal neoplasia which included malignant and some high risk colorectal lesions that need therapeutic interventions should prevent progression and worse outcomes in the affected cases.
Colonoscopy is one of the cancer screening tests that achieves goals of premalignant and early stage cancer detection and when it is coupled with polypectomy, it can prevent and reduce the incidence of disease, and finally of all results, decrease mortality from colorectal cancer [
3‐
5]. Therefore, colonoscopy is recommended in colorectal cancer screening guideline since 1997 [
6]. However, screening colonoscopy is presently not included in the national colorectal cancer screening policy in Thailand nor widely recommended for the Thai population. Most previous studies utilized fecal immunochemical test (FIT) as a first screening tool although the majority of the Thai population do not undergo such testing on a regular basis [
7‐
9]. This study aimed to provide essential information on consideration of implementation of a nation-wide colorectal cancer screening program in Thailand and developing countries. Screening colonoscopy was performed as a first screening tool in all cases while FIT was done as a comparison.
Methods
Study participants
After the study protocol had been approved by the Human Research Ethical Committee of Chulabhorn Research Institute, we enrolled participants between 50 and 65 years of age with no past medical history of colorectal cancer or poorly controlled underlying diseases in July 2009. In total, 1,612 applicants expressed their willingness to participate in this project. All participants were educated about colorectal cancer and screening methods that were to be used in this study as well as study objectives, details of each procedure including possible complications, and usage of data from the study. Some patients were excluded based on age, poor medical problem control, or the inability to be followed over a long-term period. Finally, 1,404 participants underwent colonoscopy between July 2009 and June 2010 after they provided informed consent. Their demographic data, medical history, physical examination, and pre-operative management were collected.
Screening colonoscopy and pathological diagnosis
Bowel preparation before colonoscopy was established by using 90 mL of sodium phosphate after a low fiber diet for 2 days. All participants underwent colonoscopy under intravenous anaesthesia. The colonoscopic findings in each colonic section were recorded. If abnormal mucosal findings or polyps were found, the removed tissue was sent for pathological diagnosis. We categorized abnormal tissue from colonoscopic findings and pathological reports into malignant, high-risk adenoma, low risk adenoma, and non-adenomatous polyps, for which each group underwent different appropriate management according to National Comprehensive Cancer Network (NCCN) guidelines for colorectal cancer screening. High-risk adenoma cases recommended to have repeat colonoscopy earlier than low risk adenoma cases included one of the following colonoscopic and pathological criteria: size ≥1 cm, ≥3 adenomas, or tubulovillous or villous adenoma or high grade dysplasia. All malignant cases were diagnosed by pathological staging using the Seventh edition of the Union for International Cancer Control (UICC) TNM Classification of Malignant Tumours [
10]. Patients with colorectal cancer were treated according to the NCCN Guidelines [
11]. Participants without malignancy were seen annually in the clinic for general evaluation, and FIT and follow-up colonoscopy was to be performed based on clinical findings and colorectal cancer risks. The second screening colonoscopy was respectively performed at 3, 4, and 5 years follow-up for high risk adenoma cases, low risk adenoma/hyperplastic polyp cases, and normal colonoscopy cases.
Screening fecal immunochemical test (FIT)
FIT was performed in parallel to screening colonoscopy by fecal occult blood (FOB) one-step test device, a rapid chromatographic immunoassay (Abon Biopharm Hangzhou, China) with relative sensitivity of 93.6 % and relative specificity of 99.1 % [
12,
13]. The FOB one-step test can detect fecal blood as low as 50 ng/mL or 6 μg/g feces and is specific for human hemoglobin at a concentration of 1.0 mg/mL. Fecal specimens were self-collected from the first bowel movement in the morning of the appointed date for FIT test which occurred before the start of bowel preparation for screening colonoscopy. The specimens were stored in a clean and dry container and brought in to the hospital by the participants at environmental temperature. The participants were instructed to hand in the samples to the laboratory within 6 h of collection.
Statistical analysis
Statistical analyses were performed with STATA version 12.1. Data of the participants were reported as means and standard deviation for continuous variables and as proportions and absolute counts for categorical variables. We also estimated FIT sensitivity, specificity and predictive values in detecting colorectal cancer.
Discussion
The discovery rate of high risk adenoma and invasive colorectal cancer in this study (8.15 %) was nearly twice that of advanced colorectal neoplasia in the asymptomatic population (4.5 %) as reported from multiple studies in Asia but comparable to that of the symptomatic population (7.8 %) [
14]. These patients should receive therapeutic intervention before progression to more advanced disease. When we excluded the amount criteria from the high risk adenoma group, the prevalence of advanced colorectal neoplasia in our study (3 %) and also adenocarcinoma (1.3 %) were still comparable to the country with a high incidence of colorectal cancer [
14,
15]. Prior hospital-based reports and retrospective studies from Thailand also showedcancer detection rate by colonoscopy of 0.6–7.1 % in different studied population [
7‐
9,
16,
17]. These previous studies utilized FIT as a first screening tool and were unlike our study whereby colonoscopy was performed as a first screening tool.
The abnormal colonic tissue (29.3 %) findings from our screening colonoscopy study are in the range of polyp detection rates (25–37 %) reported in other studies from within and outside Thailand [
16‐
20]. Both adenomatous polyp and hyperplastic polyposis can accumulate worse genetic changes and become malignant [
21,
22]. Therefore, colorectal cancer screening would benefit this population. Although most abnormalities that required tissue diagnosis were found in the left side of the colon, complete colonoscopy should be done to include low and high risk adenomas in the second most common locations, the transverse and ascending colon.
There are some key differences in the selection of subjects for our study compared with others: our study included screening criteria for an age group at high risk of colorectal cancer [
23], while others included data from a symptom-related group. Moreover, this result might not represent the incidence of colorectal cancer from all regions in Thailand because most (81.8 %) of the participants were from the Bangkok metropolitan region and territories. If this finding represented the real incidence of colorectal cancer in our population, or perhaps even in urban and suburban areas, launching a national colorectal cancer screening policy should be considered for specific groups. Other factors that might affect a high yield of colorectal cancer findings include public information that may stimulate awareness and access to reluctant cancer patients.
Problems related to colonoscopy screening include its invasiveness, complications, high financial cost, and need of specialized endoscopists; these reasons were reported as causes of low colorectal screening adherence in well developed countries [
24,
25]. Therefore, other more practical screening methods were utilized instead of colonoscopy. The sensitivity of FIT for cancer detection in our study (55 %) was comparable to Guaiac fecal occult blood test (37–79 %) but somewhat lower than results of FIT in other studies (79 %) [
26,
27]. In some resource-limited countries, fecal-based screening may play a major role in decreasing colorectal cancer mortality with high subject acceptance rates [
28,
29]. However, in our study, the sensitivity of FIT of 55.6 % was deemed inadequate to detect colorectal cancer cases and 8/18 cancer cases had negative FITs.
There are no recommendations for any other surveillance procedure after screening colonoscopy, but endoscopic management after colonoscopic and pathologic findings have been suggested [
30‐
34]. However, in this study, cases of colorectal cancer were found before the recommended period of surveillance colonoscopy, which were similar to the findings of other studies [
5,
24,
35‐
39]. Moreover, some cases also suffered from unrelated types of cancer. Thus, some individual risk criteria such as smoking, a family history of biliary tract cancer which are common in Thailand should be concerned for improvement of screening benefits in specific groups of patients [
40,
41]. Quality indices [
42,
43], technology of colonoscopy [
44] and other predictors [
45‐
48] should be included for detection of these interval cancers. Particularly, with the aging population in Thailand, proper screening and surveillance programsneed to be further evaluated [
3].
The mortality caused by colorectal cancer in our study after monitoring for 5 years was only two cases from colorectal cancer. Another case died from unrelated hepatobiliary cancer. So the 5-yearsurvival rate after screening colonoscopy and standard treatment of detected colorectal cancer cases in this study, even including five cases (27.8 %) with stage IIA and IIIB, was excellent at 88.9 %. This survival rate was comparable to survival of stage I colorectal cancer (87–92 %) after standard staging and treatment [
49].
Acknowledgements
We appreciated all volunteer participants and Chulabhorn Hospital staff, particularly the Colorectal Cancer Care Team, the Nursing Division and the Data Management Unit, who generously spared their time for the accomplishment and fulfillment of this project.
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