Colonoscopies in FIT-positive persons requires much higher ADR than primary colonoscopy

1. Colonoscopies in FIT-positive persons requires much higher ADR than primary colonoscopy
Abstract: https://www.acpjournals.org/doi/10.7326/M22-0301
Editorial: https://www.acpjournals.org/doi/10.7326/M22-2646
URLs go live when the embargo lifts
A cohort study of adults undergoing a colonoscopy after a positive fecal immunochemical testing (FIT) result suggest that endoscopists performing colonoscopy in FIT-based screening programs should aim for markedly higher ADRs compared with programs that use colonoscopy as the primary screening intervention. The study is published in Annals of Internal Medicine.

Screening reduces colorectal cancer (CRC) incidence and mortality by early detection and removal of colorectal cancers and polyps. One of the quality indicators for colonoscopies is the ADR, which proportion of colonoscopies in which at least one adenoma is detected. ADR is often associated with inverse post-colonoscopy CRC (PCCRC) risk, and many professional societies recommended endoscopists have an ADR of at least 25 percent. FIT-based screening programs have also become common worldwide. Participants with a positive FIT result have a high prevalence of adenomas, leading to high ADRs for endoscopists performing colonoscopies in this setting. However, it is unknown whether the association between the ADR and PCCRC is also present in colonoscopies performed after a positive FIT result.

Researchers from Erasmus University Medical Center, Rotterdam, conducted a population-based cohort study of 362 endoscopists who performed 116,360 colonoscopies with a median ADR of 67%. In 426 participants diagnosed with PCCRCs, 49% were classified as interval cancer and 51% were classified as noninterval cancer. The authors found that higher ADR was associated with lower PCCRC incidence, and that colonoscopy in FIT-positive persons demands a markedly higher ADR target than primary colonoscopy. They report that for an endoscopist with an ADR of 60%, the cumulative incidence of interval PCCRC for colonsoscopies performed in response to positive FIT was almost 2 times higher than that of endoscopists with an ADR of 70%. This risk was even higher for endoscopists with ADRs less than 60%, with the expected number of patients diagnosed with interval PCCRC in 5 years was approximately 2 for endoscopists with an ADR of 70%, compared with almost 3.5 for ADRs of 60%, and more than 4.5 for ADRs of 55%. According to the authors, their findings support the use of ADR, with different targets, as an important quality indicator for endoscopists in FIT-based as well as primary colonoscopy screening programs.

An accompanying editorial from Kaiser Permanent, Oakland, California argues that this study provides an excellent framework for evaluating concepts regarding effective quality metrics and how these can illustrate pathways for meaningful metrics for the care of other cancers and disorders. He highlights that studies evaluating quality metrics must be trustworthy, important, strategic, relevant, actionable, simple, gaming-resistant, and owned. He also adds that questions concerning goals, plans for implementation of interventions, and the application of goals while maintaining simplicity must be considered in metric development.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author, Manon C.W. Spaander, please email v.spaander@erasmusmc.nl.
----------------------------
2. Anti-TNF continuation after 24 weeks of pregnancy beneficial to persons with IBD, does not affect neonatal outcomes
Abstract: https://www.acpjournals.org/doi/10.7326/M22-0819
URL goes live when the embargo lifts
A 10-year emulation trial of pregnant persons with inflammatory bowel disease (IBD) has found that continuation of anti–tumor necrosis factor (anti-TNF) treatment after 24 weeks of pregnancy appears beneficial regarding IBD activity and prematurity, while not affecting neonatal outcomes and serious infections in the offspring. The findings are published in Annals of Internal Medicine.

More than six million people in both North America and Europe live with the inflammatory bowel diseases Crohn’s disease (CD) and ulcerative colitis (UC). Many affected persons include women of childbearing age, who are at higher risk of increased rates of prematurity, low birthweight, and cesarean section during pregnancy and birth. Anti-TNF is commonly prescribed during pregnancy, but European guidelines advise to consider stopping anti-TNF treatment around 24 weeks of pregnancy in patients with sustained IBD remission.

Researchers from EPI-PHARE conducted a nationwide target trial emulation of 5,293 pregnancies. Anti-TNF treatment was discontinued before 24 weeks for 2,890 participants and continued beyond 24 weeks for 2,403. The authors found that continuation of anti-TNF was associated with decreased frequencies of maternal IBD relapse and prematurity. The authors also report no difference between groups concerning stillbirths, small weight for gestational age births, or serious infection in offspring. They note that discontinuation of anti-TNF treatment was associated with increased IBD activity and consequently with an increased rate of preterm birth. According to the authors, these results provide
strong evidence supporting the recommendation of maintaining anti-TNF throughout pregnancy in women with IBD.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Antoine Meyer, MD, PhD, please email antoinemeyer@gmail.com.
----------------------------
3. Harms reporting is inconsistent across organ cancer guidelines
Abstract: https://www.acpjournals.org/doi/10.7326/M22-1139
Editorial: https://www.acpjournals.org/doi/10.7326/M22-2599
URL goes live when the embargo lifts
A review of 33 organ-specific cancer screening guidelines has found that the reporting of harms related to screening tests and procedures is inconsistent across cancer types and at each stage of the screening process. The review is published in Annals of Internal Medicine.

Cancer screening research and guidelines have historically focused on the benefits, rather than harms, of screening tests and procedures. The delivery of cancer screening can result in pain or discomfort,
iatrogenic complications, distress from abnormal results, a cascade of additional tests and procedures accompanied by their own set of harms, and patient costs. Cancer screenings instead should only be recommended when the balance between harms and benefits is favorable.

Researchers from the Population-based Research to Optimize the Screening Process (PROSPR) consortium conducted a review of 33 guidelines for five organ-specific cancer types. The authors evaluated the guidelines using a taxonomy of screening harms as well as a conceptual model of the cancer screening process. They found that guidelines did not report all harms for any specific organ type or for any category of harm across organ types. They report that harms reporting was the most complete for prostate cancer screening and the least complete for colorectal cancer screening. The authors highlight opportunities to improve harms research and reporting, including providing reliable, quantitative estimates; measuring and reporting the cumulative risk for harms over multiple rounds of screening; and quantifying the denominator of persons entering each step of the screening process to understand how screening harms accrue. They also recommend that future work should consider nuances associated with each organ-specific process to screen for cancer, including which harms are most salient and where evidence gaps exist, and explicitly explore how to optimally weigh available evidence in determining net screening benefit. They suggest improved harms reporting could aid informed decision making, ultimately improving cancer screening delivery.

An accompanying editorial from the University of North Carolina, Chapel Hill highlights how a lack of research on and underrecognition of the harms of screening directly impacts both clinicians and patients. The authors then suggest that guideline groups collaborate to conduct thorough research and offer more transparency about how benefits and harms are weighed and included in guidelines.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, V. Paul Doria-Rose, DVM, PhD, please email the NCI press office at ncipressofficers@mail.nih.gov.
----------------------------