Gastroenterology

Gastroenterology

Volume 146, Issue 4, April 2014, Pages 950-960
Gastroenterology

Original Research
Full Report: Clinical-Alimentary Tract
Characteristics of Missed or Interval Colorectal Cancer and Patient Survival: A Population-Based Study

https://doi.org/10.1053/j.gastro.2014.01.013Get rights and content

Background & Aims

Colorectal cancers (CRCs) diagnosed within a few years after an index colonoscopy can arise from missed lesions or the development of a new tumor. We investigated the proportion, characteristics, and factors that predict interval CRCs that develop within 6-60 months of colonoscopy.

Methods

We performed a population-based cohort study of Utah residents who underwent colonoscopy examinations from 1995 through 2009 at Intermountain Healthcare or the University of Utah Health System, which provide care to more than 85% of state residents. Colonoscopy results were linked with cancer histories from the Utah Population Database to identify patients who underwent colonoscopy 6-60 months before a diagnosis of CRC (interval cancer). Logistic regression was performed to identify risk factors associated with interval cancers.

Results

Of 126,851 patients who underwent colonoscopies, 2659 were diagnosed with CRC; 6% of these CRCs (159 of 2659) developed within 6 to 60 months of a colonoscopy. Sex and age were not associated with interval CRCs. A higher percentage of patients with interval CRC were found to have adenomas at their index colonoscopy (57.2%), compared with patients found to have CRC detected at colonoscopy (36%) or patients who did not develop cancer (26%) (P < .001). Interval CRCs tended to be earlier-stage tumors than those detected at index colonoscopy, and to be proximally located (odds ratio, 2.24; P < .001). Patients with interval CRC were more likely to have a family history of CRC (odds ratio, 2.27; P = .008) and had a lower risk of death than patients found to have CRC at their index colonoscopy (hazard ratio, 0.63; P < .001).

Conclusions

In a population-based study in Utah, 6% of all patients with CRC had interval cancers (cancer that developed within 6 to 60 months of a colonoscopy). Interval CRCs were associated with the proximal colon, earlier-stage cancer, lower risk of death, higher rate of adenoma, and family history of CRC. These findings indicate that interval colorectal tumors may arise as the result of distinct biologic features and/or suboptimal management of polyps at colonoscopy.

Section snippets

Design

This study was approved by the Institutional Review Boards of the University of Utah and Intermountain Healthcare (IHC), and by the Resource for Genetic and Epidemiologic Research (http://www.research.utah.edu/rge/), an administrative oversight board created to govern access to the Utah Population Database (UPDB).

We performed a population-based retrospective cohort study of residents in the state of Utah, between 50 and 80 years of age, who underwent colonoscopy between February 15, 1995, and

Proportion of Interval Cancers

When combined and accounting for patients who had procedures performed in both hospital systems there were 127,205 individuals who received a colonoscopy during our study timeframe. A total of 340 patients with a history of CRC before 1995 (beginning of study window) and 14 individuals with a diagnosis of CRC more than 60 months after colonoscopy were excluded, leaving 126,851 unique individuals. There were 2659 patients who had a diagnosis of CRC at or within 60 months of their index

Discussion

This study was a US population-based study to reflect usual clinical care colonoscopy and comprises colonoscopy data from a large academic medical center and managed care organization, that together provide care to more than 85% of the state population. We found that 3.5%-6% of colorectal cancers may be "missed" at colonoscopy in usual clinical practice in Utah. The proportion of interval CRCs found in this study was nearly identical to that reported from a population-based study from Ontario,5

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    Conflicts of interest These authors disclose the following: Randall Burt has been a consultant for Myriad Genetics, and N. Jewel Samadder has been a consultant for Cook Medical and Covidien, Inc. The remaining authors disclose no conflicts. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government.

    Funding Support for this project was provided by National Cancer Institute grants P01-CA073992 (R.W.B.) and R01-CA040641 (R.W.B.), an Endoscopic Research Award from the American Society for Gastrointestinal Endoscopy (N.J.S.), and a junior faculty career development award from the American College of Gastroenterology (N.J.S.). Partial support for the Utah Population Database and this project have been provided by the Huntsman Cancer Institute Cancer Center support grant (P30CA042014) from the National Cancer Institute and the Huntsman Cancer Foundation. Support for the Utah Cancer Registry is provided by contract HHSN 261201000026C from the National Cancer Institute with additional support from the Utah Department of Health and the University of Utah.

    The funding sources did not play a role in the design, conduct, or reporting of the study, or in the decision to submit the manuscript for publication.

    Author names in bold designate shared co-first authorship.

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