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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Siegel RL, Giaquinto AN, Jemal A. Cancer statistics, 2024. CA Cancer J Clin 2024;74:12-49. Review/Other-Dx N/A Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths in the United States and compiles the most recent data on population-based cancer occurrence and outcomes using incidence data collected by central cancer registries (through 2020) and mortality data collected by the National Center for Health Statistics (through 2021). In 2024, 2,001,140 new cancer cases and 611,720 cancer deaths are projected to occur in the United States. Cancer mortality continued to decline through 2021, averting over 4 million deaths since 1991 because of reductions in smoking, earlier detection for some cancers, and improved treatment options in both the adjuvant and metastatic settings. However, these gains are threatened by increasing incidence for 6 of the top 10 cancers. Incidence rates increased during 2015-2019 by 0.6%-1% annually for breast, pancreas, and uterine corpus cancers and by 2%-3% annually for prostate, liver (female), kidney, and human papillomavirus-associated oral cancers and for melanoma. Incidence rates also increased by 1%-2% annually for cervical (ages 30-44 years) and colorectal cancers (ages <55 years) in young adults. Colorectal cancer was the fourth-leading cause of cancer death in both men and women younger than 50 years in the late-1990s but is now first in men and second in women. Progress is also hampered by wide persistent cancer disparities; compared to White people, mortality rates are two-fold higher for prostate, stomach and uterine corpus cancers in Black people and for liver, stomach, and kidney cancers in Native American people. Continued national progress will require increased investment in cancer prevention and access to equitable treatment, especially among American Indian and Alaska Native and Black individuals. No results stated in abstract. 4
2. National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP). Health and Economic Benefits of Colorectal Cancer Interventions.  Available at: https://www.cdc.gov/nccdphp/priorities/colorectal-cancer.html?CDC_AAref_Val=https://www.cdc.gov/chronicdisease/programs-impact/pop/colorectal-cancer.htm. Review/Other-Dx NA No abstract available No abstract available 4
3. Provenzale D, Ness RM, Llor X, et al. NCCN Guidelines Insights: Colorectal Cancer Screening, Version 2.2020. J Natl Compr Canc Netw 2020;18:1312-20. Review/Other-Dx NA To describe various colorectal screening modalities as well as recommended screening schedules for patients at average or increased risk of developing sporadic CRC. No results stated in the abstract. 4
4. Davidson KW, Barry MJ, Mangione CM, et al. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 325(19):1965-1977, 2021 05 18. Review/Other-Dx NA No abstract available No abstract available 4
5. Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. Jama. 2016;315(23):2564-2575. Review/Other-Dx N/A To update the 2008 US Preventive Services Task Force (USPSTF) recommendation on screening for colorectal cancer. The USPSTF concludes with high certainty that screening for colorectal cancer in average-risk, asymptomatic adults aged 50 to 75 years is of substantial net benefit. Multiple screening strategies are available to choose from, with different levels of evidence to support their effectiveness, as well as unique advantages and limitations, although there are no empirical data to demonstrate that any of the reviewed strategies provide a greater net benefit. Screening for colorectal cancer is a substantially underused preventive health strategy in the United States. 4
6. Boellaard TN, Venema HW, Streekstra GJ, Stoker J. Effective radiation dose in CT colonography: is there a downward trend?. Acad Radiol. 19(9):1127-33, 2012 Sep. Review/Other-Dx 62 institutions Our objective is to assess the effective radiation doses used for CT colonography and its trend over time. Sixty-two of 109 (57%) institutions responded, providing protocols for 58 institutions. Median effective dose for daily practice protocols was 7.6 mSv (4.3 mSv and 2.0 mSv for supine and prone, respectively) and for screening 4.4 mSv (2.6 mSv and 2.0 mSv, respectively; P = .01). For daily practice with and without contrast medium, the median effective doses were 10.5 mSv and 4.0 mSv (P < .001), respectively. Academic and nonacademic institutions used similar doses (all comparisons P > .05). For institutions also participating in the 2007 inventory, effective dose for both daily practice and screening protocols were similar (P > .05). 4
7. American College of Radiology. ACR-SABI-SAR Practice Parameter for the Performance of Computed Tomography (CT) Colonography in Adults. Available at https://www.acr.org/-/media/ACR/Files/Practice-Parameters/CT-Colonog.pdf. Review/Other-Dx N/A Guidance document to promote the safe and effective use of diagnostic and therapeutic radiology by describing specific training, skills and techniques. No abstract available. 4
8. Ozel B, Pickhardt PJ, Kim DH, Schumacher C, Bhargava N, Winter TC. Accuracy of routine nontargeted CT without colonography technique for the detection of large colorectal polyps and cancer. Diseases of the colon and rectum 2010;53:911-8. Observational-Dx 45 patients To assess the accuracy of routine contrast-enhanced computed tomography for the detection of large colorectal polyps and cancer. By-patient sensitivity/specificity for cancer detection for each reader was 69.0%/88.7%, 65.5%/84.5%, and 82.8%/77.5%, respectively. Pooled sensitivity, specificity, and accuracy for cancer was 72.4%, 83.6%, and 80.3%, respectively. The empiric area under the receiver operating characteristic curves for the readers ranged from 0.775 to 0.857. By-patient sensitivity for large polyps was poor with a pooled sensitivity of 14.5%. 3
9. Mangat S, Kozoriz MG, Bicknell S, Spielmann A. The Accuracy of Colorectal Cancer Detection by Computed Tomography in the Unprepared Large Bowel in a Community-Based Hospital. Can Assoc Radiol J 2018;69:92-96. Observational-Dx 924 patients This retrospective study examined the performance of general radiologists in a community-based hospital in detecting colorectal cancer (CRC) with computed tomography (CT) in the unprepared large bowel. Of the 924 biopsy proven CRC cases, 22% (207 of 924) of the patients had a CT prior to biopsy. Of these cases, 47% (97 of 207) presented on an emergency basis. Of the cases with imaging in the year prior, about 60% (125 of 207) had cancer prospectively detected by the radiologist. Upon re-examination of the cases in which CRC was not initially detected, 59% were visualized in retrospect. 3
10. Ye X, Chai H, Huang C, Liu M, Deng T. Can Next-generation Sequencing Replace Fecal Immunochemical Tests or CT in the Screening of Colorectal Cancer and Advanced Adenoma?. Jcpsp, Journal of the College of Physicians & Surgeons - Pakistan. 30(9):940-945, 2020 09. Observational-Dx 120 patients To explore the feasibility of next-generation sequencing (NGS) for the screening of colorectal cancer (CRC) and advanced adenoma (AA). NGS has a certain detection ability for CRC, with a sensitivity of 57.1% (8/14). This was higher than that of FIT and CT, and the combined positive rate of these three methods could reach 92.3% (12/13). The sensitivity of detection of AA could reach up to 75.0% (6/8) after combining with FIT and CT. The positive rate of the NGS test for postoperative CRC was 23.1% (3/13), which was significantly lower than preoperative CRC. The sensitivity of CT for preoperative CRC detection was only 45.5% (5/11), but the specificity could reach up to 98.2% (55/56), which was higher than NGS (71/78, 91.0%) and FIT (27/33, 81.8%). 3
11. Johnson CD, Flicek KT, Mead-Harvey C, Quillen JK. Strategies for improving colorectal cancer detection with routine computed tomography. Abdom Radiol (NY) 2023;48:1891-99. Observational-Dx 209 patients To report the detection rate of colorectal tumors with computed tomography (CT) performed within 1 year before diagnosis for indications other than colon abnormalities. Of 209 included patients, 106 (50.7%) had prospectively detected tumors, 66 (31.6%) had retrospectively detected tumors, and 37 (17.7%) had undetected tumors. Asymmetric bowel wall thickening and polypoid masses were present more often in the retrospective group than in the prospective group (27% vs. 10.5% and 26% vs. 17.1%, respectively). Tumors in the ascending colon were more likely to be detected retrospectively than prospectively (odds ratio, 2.75; 95% CI 1.07-7.08; P = 0.04). Undetected tumors were smaller on average (2.9 cm) than prospective (6.0 cm) and retrospective (4.9 cm) tumors (P = 0.03). Detection confidence was lower for retrospectively detected tumors than for prospectively detected tumors (P = 0.03). Indications other than abdominal pain were most common for retrospectively detected tumors (P = 0.03). Use of intravenous contrast material was lowest in the undetected group (P = 0.003). The prospective group had more pericolonic abnormalities, regional/retroperitoneal lymph node involvement (P < 0.001), and distant metastases than did the retrospective group (P = 0.01). 3
12. Koo BC, Ng CS, J UK-I, Prevost AT, Freeman AH. Minimal preparation CT for the diagnosis of suspected colorectal cancer in the frail and elderly patient. Clin Radiol 2006;61:127-39. Review/Other-Dx NA To review the experience to date of MPCT in detecting colonic tumours, and compares its efficacy to the traditional methods. No results listed in abstract. 4
13. Yu Q, Liu J. The diagnostic value of contrast-enhanced computed tomography imaging for detection of colorectal tumors: A meta-analysis. J Cancer Res Ther 2016;12:C241-C43. Meta-analysis Nine studies To evaluate the application usage of contrast-enhanced computer tomography imaging for colorectal tumors diagnosis. Nine trials that included a total of 4797 patients were analyzed in this study. The summary diagnosis sensitivity and specificity of contrast-enhanced CT were 0.74 (95% confidence interval [CI]: 0.71–0.77) and 0.86 (0.85–0.87), respectively. The pooled area under the receiver operating characteristic curve was 0.90. Subgroup analysis: for intravenous contrast enhancement technology, the pooled diagnosis sensitivity and specificity were 0.63 (95% CI: 0.56–0.69) and 0.89 (95% CI: 0.86–0.92); for oral contrast enhancement technology, the pooled diagnosis sensitivity and specificity were 0.78 (95% CI: 0.74–0.81) and 0.86 (95% CI: 0.84–0.87). Good
14. Johnson CD, Chen MH, Toledano AY, et al. Accuracy of CT colonography for detection of large adenomas and cancers. N Engl J Med. 359(12):1207-17, 2008 Sep 18. Observational-Dx 2,531 patients To assess accuracy of CTC for detection of large adenomas and cancers. Complete data available for 2,531 participants. For large adenomas and cancers, the mean (+/-SE) per-patient estimates of the sensitivity, specificity, PPV, NPV, and AUC for CTC were 0.90+/-0.03, 0.86+/-0.02, 0.23+/-0.02, 0.99+/-<0.01, and 0.89+/-0.02, respectively. CTC identified 90% of subjects with adenomas or cancers =10 mm. 2
15. Pickhardt PJ, Choi JR, Hwang I, et al. Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med. 349(23):2191-200, 2003 Dec 04. Observational-Dx 1,233 patients Prospective, multicenter study to evaluate sensitivity and specificity of CTC in detecting colorectal neoplasia in an average-risk screening population. Virtual and optical colonoscopy was compared. Sensitivity and specificity of CTC for adenomas =10 mm were 94% and 96%, respectively. CT virtual colonoscopy with the use of a 3-D approach is an accurate screening method for the detection of colorectal neoplasia and compares favorably with optical colonoscopy. 3
16. Graser A, Stieber P, Nagel D, et al. Comparison of CT colonography, colonoscopy, sigmoidoscopy and faecal occult blood tests for the detection of advanced adenoma in an average risk population. Gut. 58(2):241-8, 2009 Feb. Observational-Dx 307 patients To compare the performance characteristics of five different screening tests in parallel for the detection of advanced colonic neoplasia: CTC, colonoscopy, flexible sigmoidoscopy, faecal immunochemical stool testing and FOBT. 221 adenomas were detected in 307 subjects who completed CTC (mean radiation dose, 4.5 mSv) and colonoscopy; 269 patients provided stool samples for both FOBT and faecal immunochemical stool testing. Sensitivities of colonoscopy, CTC, flexible sigmoidoscopy, faecal immunochemical stool testing and FOBT for advanced colonic neoplasia were 100% (95% CI, 88.4% to 100%), 96.7% (82.8% to 99.9%), 83.3% (95% CI, 65.3% to 94.4%), 32% (95% CI, 14.9% to 53.5) and 20% (95% CI, 6.8% to 40.7%), respectively. Combination of flexible sigmoidoscopy with FOBT or faecal immunochemical stool testing led to no relevant increase in sensitivity. 12/45 advanced adenomas were <10 mm. 46% of patients preferred CTC and 37% preferred colonoscopy (P<0.001). 3
17. Halligan S, Altman DG, Taylor SA, et al. CT colonography in the detection of colorectal polyps and cancer: systematic review, meta-analysis, and proposed minimum data set for study level reporting. [Review] [83 refs]. Radiology. 237(3):893-904, 2005 Dec. Meta-analysis 24 studies; 4,181 patients; 2 reviewers Systematic review and meta-analysis to assess the methodologic quality of available data in published reports of CTC. Meta-analysis of 2,610 patients, showed high per-patient average sensitivity (93%; 95% CI: 73%, 98%) and specificity (97%; 95% CI: 95%, 99%) for colonography; sensitivity and specificity decreased to 86% (95% CI: 75%, 93%) and 86% (95% CI: 76%, 93%), respectively, when the threshold was lowered to include medium polyps. When polyps of all sizes were included, studies were too heterogeneous in sensitivity (range 45%-97%) and specificity (range 26%-97%) to allow meaningful meta-analysis. Of 150 cancers, 144 were detected (sensitivity 95.9%; 95% CI: 91.4%, 98.5%). Good
18. Mulhall BP, Veerappan GR, Jackson JL. Meta-analysis: computed tomographic colonography. Ann Intern Med. 142(8):635-50, 2005 Apr 19. Meta-analysis 33 studies 6,393 patients Systematically review the test performance of CTC compared to colonoscopy or surgery and to assess variables that may affect test performance. Prospective studies with colonoscopy or surgery as gold standard were selected. Sensitivity of CTC was heterogeneous but improved as polyp size increased (48% [95% CI: 25%-70%] for detection of polyps <6 mm, 70% [CI: 55%-84%] for polyps 6 to 9 mm, and 85% [CI: 79%-91%] for polyps >9 mm). In contrast, specificity was homogenous (92% [CI: 89%-96%] for detection of polyps <6 mm, 93% [CI: 91%-95%] for polyps 6-9 mm, and 97% [CI: 96%-97%] for polyps >9 mm). Good
19. Cotton PB, Durkalski VL, Pineau BC, et al. Computed tomographic colonography (virtual colonoscopy): a multicenter comparison with standard colonoscopy for detection of colorectal neoplasia. JAMA. 291(14):1713-9, 2004 Apr 14. Observational-Dx 600 patients Multicenter study to evaluate the sensitivity and specificity of CTC in detecting colorectal neoplasia in patients referred for clinically indicated colonoscopy. Sensitivity of CTC for detecting subjects with one or more lesions =10 mm was 55%; Specificity for detecting subjects without lesions =10 mm was 96%. 3
20. Rockey DC, Paulson E, Niedzwiecki D, et al. Analysis of air contrast barium enema, computed tomographic colonography, and colonoscopy: prospective comparison. Lancet. 2005; 365(9456):305-311. Observational-Dx 614 patients Multicenter study to prospectively compare sensitivity and specificity of air contrast barium enema, CTC and colonoscopy in detecting colorectal polyps and cancers in patients at increased risk for colorectal neoplasia. For lesions =10 mm, per patient sensitivities of air contrast barium enema, CTC and colonoscopy were 48%, 59% and 98%, respectively, per lesion sensitivities were 45% 53% and 98.7%, respectively, and specificities were 90%, 96% and 99.6%, respectively. Colonoscopy was more sensitive compared to other tests. 3
21. Atkin W, Dadswell E, Wooldrage K, et al. Computed tomographic colonography versus colonoscopy for investigation of patients with symptoms suggestive of colorectal cancer (SIGGAR): a multicentre randomised trial. Lancet. 381(9873):1194-202, 2013 Apr 06. Experimental-Tx 1610 patients To compare rates of additional colonic investigation after CTC or colonoscopy for detection of colorectal cancer or large (>/=10 mm) polyps in symptomatic patients in clinical practice. 1610 patients were randomly assigned to receive either colonoscopy (n=1072) or CTC (n=538). 30 patients withdrew consent, leaving for analysis 1047 assigned to colonoscopy and 533 assigned to CTC. 160 (30.0%) patients in the CTC group had additional colonic investigation compared with 86 (8.2%) in the colonoscopy group (relative risk 3.65, 95% CI 2.87-4.65; p<0.0001). Almost half the referrals after CTC were for small (<10 mm) polyps or clinical uncertainty, with low predictive value for large polyps or cancer. Detection rates of colorectal cancer or large polyps in the trial cohort were 11% for both procedures. CTC missed 1 of 29 colorectal cancers and colonoscopy missed none (of 55). Serious adverse events were rare. 1
22. Pickhardt PJ, Taylor AJ, Kim DH, Reichelderfer M, Gopal DV, Pfau PR. Screening for colorectal neoplasia with CT colonography: initial experience from the 1st year of coverage by third-party payers. Radiology. 241(2):417-25, 2006 Nov. Review/Other-Dx 1,110 patients Retrospective study to evaluate 1st year of CTC screening since the initiation of local third-party payer coverage. Large colorectal polyps were identified at CTC in 3.9% and medium-sized lesions in 6.9% of patients. Concordant lesions were identified in 65/71 patients who had subsequent optical colonoscopy (PPV 91.5%). 4
23. Kim DH, Pooler BD, Weiss JM, Pickhardt PJ. Five year colorectal cancer outcomes in a large negative CT colonography screening cohort. Eur Radiol. 22(7):1488-94, 2012 Jul. Review/Other-Dx 1,011 patients To assess the 5-year incidence of clinically presenting CRCs following a negative CTC screening examination, as few patient outcome data regarding a negative CTC screening result exist. Of the 1,050 cohort (mean [+/-SD] age 56.9 +/- 7.4 years), 39 (3.7%) patients were excluded owing to lack of follow-up within our system beyond the initial screening CTC. The remaining 1,011 patients were followed for an average of 4.73 +/- 1.15 years. One incident colorectal adenocarcinoma represented a crude cancer incidence of 0.2 cancers per 1,000 patient years. Electronic medical record revealed 14 additional patients with clinically important gastrointestinal tumors including: advanced adenomas (n = 11), appendiceal goblet cell carcinoid (n = 1), appendiceal mucinous adenoma (n = 1) and metastatic ileocolonic carcinoid (n = 1). All positive patients including the incident carcinoma are alive at the time of review. 4
24. Kim DH, Pickhardt PJ, Hanson ME, Hinshaw JL. CT colonography: performance and program outcome measures in an older screening population. Radiology. 254(2):493-500, 2010 Feb. Observational-Dx 577 patients To evaluate CTC performance and program outcome measures in an older cohort (65-79 years) of an established large-scale CRC screening program. With a 6 mm threshold for positivity, the overall referral rate to optical colonoscopy was 15.3% (88/577), leading to 277 polypectomies and the removal of 103 nondiminutive adenomas. For adenomas, the per-patient positivity rates were 10.9% (63/577) and 6.8% (39/577) at the 6- and 10-mm thresholds, respectively. The prevalence of advanced neoplasia was 7.6% (44/577). 54 adenomas met advanced status, and 5 unsuspected cancers were detected. The advanced neoplasias identified were typically large, with a mean size of 21 mm. Potentially important extracolonic findings were seen in 15.4% (89/577) of patients, with a workup rate of 7.8% (45/577). The majority of important extracolonic diagnoses were vascular aneurysms (n = 18). No major complications were encountered. 4
25. Macari M, Nevsky G, Bonavita J, Kim DC, Megibow AJ, Babb JS. CT colonography in senior versus nonsenior patients: extracolonic findings, recommendations for additional imaging, and polyp prevalence. Radiology. 259(3):767-74, 2011 Jun. Observational-Dx 454 patients To retrospectively evaluate the frequency of recommendations for additional imaging for important extracolonic findings and polyp prevalence among a cohort of seniors (age =65 years) and nonseniors (age <65 years) undergoing low-dose CTC. The percentage of patients with at least one reported polyp was 14.2% (29/204) for the nonsenior group and 13.2% (33/250) for seniors, which was not significantly different (P=.772). The percentage of patients with at least one extracolonic finding was 55.4% (113/204) for nonseniors and 74.0% (185/250) for seniors (P<.0001). The percentage of patients in which an recommendations for additional imaging was suggested was 4.4% (9/204) for nonseniors and 6.0% (15/250) for seniors, which was not significantly different (P=.450). 4
26. Johnson CD, Herman BA, Chen MH, et al. The National CT Colonography Trial: assessment of accuracy in participants 65 years of age and older. Radiology. 263(2):401-8, 2012 May. Observational-Dx 477 patients To conduct post-hoc analysis of National CT Colonography Trial data and compare the sensitivity and specificity of CTC in participants <65 years with those in participants aged 65 years and older. Complete data were available for 477 participants 65 years of age or older (among 2,531 evaluable participants). Prevalence of adenomas =1 cm for the older participants vs the younger participants was 6.9% (33/477) vs 3.7% (76/2,054) (P<.004). For large neoplasms, mean estimates for CTC sensitivity and specificity among the older cohort were 0.82 (95% CI: 0.644, 0.944) and 0.83 (95% CI: 0.779, 0.883), respectively. For large neoplasms in the younger group, CTC sensitivity and specificity were 0.92 (95% CI: 0.837, 0.967) and 0.86 (95% CI: 0.816, 0.899), respectively. Per-polyp sensitivity for large neoplasms for the older and younger populations was 0.75 (95% CI: 0.578, 0.869) and 0.84 (95% CI: 0.717, 0.924), respectively. For the older and younger groups, per-participant sensitivity was 0.72 (95% CI: 0.565, 0.854) and 0.81 (95% CI: 0.745, 0.882) for detecting adenomas =6 mm in diameter. 3
27. Cash BD, Riddle MS, Bhattacharya I, et al. CT colonography of a Medicare-aged population: outcomes observed in an analysis of more than 1400 patients. AJR Am J Roentgenol. 199(1):W27-34, 2012 Jul. Observational-Dx 1,410 patients To evaluate outcomes of patients 65 years old and older who underwent CTC between 2004 and 2009. The frequency of referral to colonoscopy based on a polyp size threshold of 6 mm was 14.5%. Colorectal neoplasia was found in 9.3% of patients, with advanced neoplasia in 3.3%. Potentially important extracolonic findings were observed in 2.9% of patients. The low rates of referral to colonoscopy, prevalence of advanced neoplasia, and prevalence of extracolonic findings make CTC a viable option for Medicare-aged patients. 3
28. Kim DH, Matkowskyj KA, Lubner MG, et al. Serrated Polyps at CT Colonography: Prevalence and Characteristics of the Serrated Polyp Spectrum. Radiology. 280(2):455-63, 2016 08. Observational-Dx A final study cohort of 221 patients. To report the prevalence and characteristics of serrated polyps identified in a large, average-risk population undergoing screening computed tomographic (CT) colonography. Nondiminutive serrated lesions (>/=6 mm) were seen at CT colonography-based screening with a prevalence of 3.1% (254 of 8289 patients). Sessile serrated adenomas (SSAs) and traditional serrated adenomas (TSAs) constituted 36.8% (137 of 372) and 4.3% (16 of 372) of serrated lesions, respectively; hyperplastic polyps (HPs) accounted for 58.9% (219 of 372 lesions). SSA and TSA tended to be large (mean size, 10.6 mm and 14.1 mm, respectively), with size categories and polyp subgroups significantly associated (P < .0001). SSA tended to be proximal in location (91.2%, 125 of 137 lesions) and flat in morphologic appearance (39.4%, 54 of 137 lesions) compared with TSA and HP. The presence of high-grade dysplasia in serrated lesions was uncommon when compared with advanced adenomas (one of 372 lesions vs 22 of 395 lesions, respectively; P < .0001). Multivariate analysis showed that contrast material tagging markedly improved serrated polyp detection with an odds ratio of 40.4 (95% confidence interval: 10.1, 161.4). 4
29. Lin JS, Perdue LA, Henrikson NB, Bean SI, Blasi PR. Screening for Colorectal Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 325(19):1978-1998, 2021 05 18. Review/Other-Dx 33 studies To systematically review the effectiveness, test accuracy, and harms of screening for CRC to inform the US Preventive Services Task Force. The review included 33 studies (n = 10 776 276) on the effectiveness of screening, 59 (n = 3 491 045) on the test performance of screening tests, and 131 (n = 26 987 366) on the harms of screening. In randomized clinical trials (4 trials, n = 458 002), intention to screen with 1- or 2-time flexible sigmoidoscopy vs no screening was associated with a decrease in CRC-specific mortality (incidence rate ratio, 0.74 [95% CI, 0.68-0.80]). Annual or biennial guaiac fecal occult blood test (gFOBT) vs no screening (5 trials, n = 419 966) was associated with a reduction of CRC-specific mortality after 2 to 9 rounds of screening (relative risk at 19.5 years, 0.91 [95% CI, 0.84-0.98]; relative risk at 30 years, 0.78 [95% CI, 0.65-0.93]). In observational studies, receipt of screening colonoscopy (2 studies, n = 436 927) or fecal immunochemical test (FIT) (1 study, n = 5.4 million) vs no screening was associated with lower risk of CRC incidence or mortality. Nine studies (n = 6497) evaluated the test accuracy of screening computed tomography (CT) colonography, 4 of which also reported the test accuracy of colonoscopy; pooled sensitivity to detect adenomas 6 mm or larger was similar between CT colonography with bowel prep (0.86) and colonoscopy (0.89). In pooled values, commonly evaluated FITs (14 studies, n = 45 403) (sensitivity, 0.74; specificity, 0.94) and stool DNA with FIT (4 studies, n = 12 424) (sensitivity, 0.93; specificity, 0.85) performed better than high-sensitivity gFOBT (2 studies, n = 3503) (sensitivity, 0.50-0.75; specificity, 0.96-0.98) to detect cancers. Serious harms of screening colonoscopy included perforations (3.1/10 000 procedures) and major bleeding (14.6/10 000 procedures). CT colonography may have harms resulting from low-dose ionizing radiation. It is unclear if detection of extracolonic findings on CT colonography is a net benefit or harm. 4
30. Sosna J, Sella T, Sy O, et al. Critical analysis of the performance of double-contrast barium enema for detecting colorectal polyps > or = 6 mm in the era of CT colonography. [Review] [126 refs]. AJR Am J Roentgenol. 190(2):374-85, 2008 Feb. Meta-analysis Barium enema–11 studies (5,995 patients, 1,548 polyps) CT–30 studies (6,573 patients, 2,348 polyps) Meta-analysis comparing accuracy of DCBE with CTC for the detection of colorectal polyps =6 mm with endoscopy as gold standard. Prospective studies were identified. Polyps =10 mm; 0.121-per-patient sensitivity difference favored CTC (DCBE 0.702; CTC 0.823). Polyps =10 mm; 0.031-per-polyp sensitivity difference favored CTC (DCBE 0.715; CTC 0.746). Polyps =10 mm; specificity difference of 0.104 favored CTC (DCBE 0.850; CTC 0.954). DCBE has lower sensitivity and specificity than CTC for detecting colorectal polyps = 6 mm. Good
31. Hsu WF, Su CW, Hsu CY, et al. Double-contrast barium enema is no longer justified as a backup examination for colonoscopy in the population screening program: Population study in an organized fecal immunochemical test-based screening program. Journal of Gastroenterology & Hepatology. 38(8):1299-1306, 2023 Aug. Observational-Dx 102,761 colonoscopies and 5885 DCBEs To compare the performance of colonoscopy and DCBE in terms of the risk of incident CRC after negative results in the fecal immunochemical test (FIT)-based Taiwan Colorectal Cancer Screening Program. A total of 102 761 colonoscopies and 5885 DCBEs were performed after positive FITs without neoplastic findings during the study period. By the end of 2018, 2113 CRCs (2.7 per 1000 person-years) and 368 CRCs (7.6 per 1000 person-years) occurred in the colonoscopy and DCBE subcohorts, respectively. After adjusting for major confounders, DCBE had a significantly higher risk of incident CRC than colonoscopy, with an adjusted HR of 2.81 (95% CI = 2.51-3.14). 4
32. Ott DJ, Chen YM, Gelfand DW, Wu WC, Munitz HA. Single-contrast vs double-contrast barium enema in the detection of colonic polyps. AJR Am J Roentgenol. 1986; 146(5):993-996. Observational-Dx 139 patients; 234 polyps 5-year review of radiographic and colonoscopic records to compare the sensitivity of single-contrast with DCBE in the detection of colonic polyps. Sensitivity for DCBE for adenomas >1 cm was 96%. Sensitivity for single-contrast barium enema for adenomas >1 cm was 94%. DCBE was more effective than single-contrast examination only for detection of polyps <1 cm. 3
33. Macari M, Bini EJ, Jacobs SL, et al. Colorectal polyps and cancers in asymptomatic average-risk patients: evaluation with CT colonography. Radiology. 230(3):629-36, 2004 Mar. Observational-Dx 68 patients To compare thin-section MDCT colonography with conventional colonoscopy in the evaluation of colorectal polyps and cancer in asymptomatic average-risk patients. At colonoscopy, 98 polyps were identified in 39 patients; 21 (21.4%) of 98 were detected at CTC. Sensitivity was 11.5% for polyps 1-5 mm, 52.9% for polyps 6-9 mm, and 100% for polyps >10 mm. The per-patient specificity of CT was 89.7%. 2
34. Kim YS, Kim N, Kim SH, et al. The efficacy of intravenous contrast-enhanced 16-raw multidetector CT colonography for detecting patients with colorectal polyps in an asymptomatic population in Korea. J Clin Gastroenterol. 42(7):791-8, 2008 Aug. Observational-Dx 241 asymptomatic adults that underwent intravenous contrast-enhanced CTC and colonoscopy successively on the same day To compare the sensitivity of computed tomography (CT) colonography (CTC) with that of colonoscopy for detecting patients with colorectal polyps in an asymptomatic screening population in Korea, thus to evaluate a possibility, whether CTC could be used as a screening tool for colorectal polyps. The per-patient sensitivities of CTC were 68.5% (37/54) and 86.7% (13/15) for polyp > or = 6 and > or = 10 mm, inferior to those of colonoscopy, 92.6% (50/54) and 100% (15/15), respectively. The per-polyp sensitivities of CTC were 60.4% (61/101) and 72.7% (16/22) for polyp > or = 6 and > or = 10 mm, respectively. The low sensitivity of CTC was related with flat morphology. CTC detected only 37.5% (9/24) of flat polyps > or = 6 mm. Bowel preparation by sodium phosphate further decreased the positive predictive value and specificity than by polyethylene glycol. 3
35. Stoop EM, de Haan MC, de Wijkerslooth TR, et al. Participation and yield of colonoscopy versus non-cathartic CT colonography in population-based screening for colorectal cancer: a randomised controlled trial. Lancet Oncol. 13(1):55-64, 2012 Jan. Experimental-Dx 8,844 patients To compare participation and diagnostic yield between screening with colonoscopy and with non-cathartic CTC. 1,276 (22%) of 5,924 colonoscopy invitees participated, compared with 982 (34%) of 2,920 CTC invitees (relative risk 1.56, 95% CI, 1.46-1.68; P<0.0001). Of the participants in the colonoscopy group, 111 (9%) had advanced neoplasia of whom 7 (<1%) had a carcinoma. Of CTC participants, 84 (9%) were offered colonoscopy, of whom 60 (6%) had advanced neoplasia of whom 5 (<1%) had a carcinoma; 82 (8%) were offered surveillance. The diagnostic yield for all advanced neoplasia was 8.7 per 100 participants for colonoscopy vs 6.1 per 100 for CTC (relative risk 1.46, 95% CI, 1.06-2.03; P=0.02) and 1.9 per 100 invitees for colonoscopy and 2.1 per 100 invitees for CTC (relative risk 0.91, 0.66-2.03; P=0.56). The diagnostic yield for advanced neoplasia of 10 mm or more was 1.5 per 100 invitees for colonoscopy and 2.0 per 100 invitees for CTC, respectively (relative risk 0.74, 95% CI, 0.53-1.03; P=0.07). Serious adverse events related to the screening procedure were post-polypectomy bleedings: two in the colonoscopy group and three in the CTC group. 3
36. Zalis ME, Blake MA, Cai W, et al. Diagnostic accuracy of laxative-free computed tomographic colonography for detection of adenomatous polyps in asymptomatic adults: a prospective evaluation. Ann Intern Med. 156(10):692-702, 2012 May 15. Observational-Dx 605 patients To assess the performance of detecting adenomas 6 mm or larger and patient experience of laxative-free CTC. For adenomas =10 mm, per-patient sensitivity of CTC was 0.91 (95% CI, 0.71 to 0.99) and specificity was 0.85 (CI, 0.82 to 0.88); sensitivity of optical colonoscopy was 0.95 (CI, 0.77 to 1.00) and specificity was 0.89 (CI, 0.86 to 0.91). Sensitivity of CTC was 0.70 (CI, 0.53 to 0.83) for adenomas =8 mm and 0.59 (CI, 0.47 to 0.70) for those =6 mm; sensitivity of optical colonoscopy for adenomas =8 mm was 0.88 (CI, 0.73 to 0.96) and 0.76 (CI, 0.64 to 0.85) for those =6 mm. The specificity of optical colonoscopy at the threshold of =8 mm was 0.91 and at =6 mm was 0.94. Specificity for optical colonoscopy was greater than that for CTC, which was 0.86 at the threshold of =8 mm and 0.88 at =6 mm (P=0.02). Reported participant experience for comfort and difficulty of examination preparation was better with CTC than optical colonoscopy. 2
37. Lefere P, Silva C, Gryspeerdt S, et al. Teleradiology based CT colonography to screen a population group of a remote island; at average risk for colorectal cancer. Eur J Radiol. 82(6):e262-7, 2013 Jun. Observational-Dx 514 patients with CT colonography and optical colonoscopy To prospectively assess the performance of teleradiology-based CT colonography to screen a population group of an island, at average risk for colorectal cancer. 510 patients were included in the study. CT colonography obtained a per-patient sensitivity, specificity, PPV and, NPV for adenomas >/=6 mm of 98.11% (88.6-99.9% 95% CI), 90.97% (87.8-93.4% 95% CI), 56.52% (45.8-66.7% 95% CI), 99.75% (98.4-99.9% 95% CI). For advanced neoplasia >/=6 mm per-patient sensitivity, specificity, PPV and, NPV were 100% (86.7-100% 95% CI), 87.07% (83.6-89.9% 95% CI), 34.78% (25.3-45.5% 95% CI) and 100% (98.8-100% 95% CI), respectively. 3
38. Fletcher JG, Silva AC, Fidler JL, et al. Noncathartic CT colonography: Image quality assessment and performance and in a screening cohort. AJR Am J Roentgenol. 201(4):787-94, 2013 Oct. Observational-Dx 564 asymptomatic subjects To examine noncathartic CT colonography (CTC) quality and performance using four similar bowel-tagging regimens in an asymptomatic screening cohort. Of the 556 subjects, 7% (37/556) and 3% (16/556) of patients had 52 and 20 adenomatous polyps >/= 6 and >/= 10 mm, respectively. The addition of iodine significantly improved the percentage of labeled stool (p </= 0.0002) and specificity (80% vs 89-93%, respectively; p = 0.046). The overall sensitivity of noncathartic CTC for adenomatous polyps >/= 6 mm was 76% (28/37; 95% CI, 59-88%), which is similar to the sensitivity of the iodinated regimens with most patients (sensitivity: 231 patients, 74% [14/19; 95% CI, 49-91%]; 229 patients, 80% [12/15; 95% CI, 52-96%]). The negative predictive value was 98% (481/490), and the lone cancer was detected (0.2%, 1/556). EC was thought to improve conspicuity of 10 of 21 visible polyps >/= 10 mm. 2
39. Regge D, Iussich G, Segnan N, et al. Comparing CT colonography and flexible sigmoidoscopy: a randomised trial within a population-based screening programme. Gut. 66(8):1434-1440, 2017 08. Observational-Dx 980 patients To compare participation and detection rate (DR) with sigmoidoscopy (flexible sigmoidoscopy (FS)) and CTC in a screening setting. Participation was 30.4% (298/980) for CTC and 27.4% (267/976) for FS (relative risk (RR) 1.1; 95% CI 0.98 to 1.29). Among men, participation was higher with CTC than with FS (34.1% vs 26.5%, p=0.011). In the detection RCT, 2673 subjects had FS and 2595 had CTC: the AN DR was 4.8% (127/2673, including 9 CRCs) with FS and 5.1% (133/2595, including 10 CRCs) with CTC (RR 1.08; 95% CI 0.85 to 1.37). Distal AN DR was 3.9% (109/2673) with FS and 2.9% (76/2595) with CTC (RR 0.72; 95% CI 0.54 to 0.96); proximal AN DR was 1.2% (34/2595) for FS vs 2.7% (69/2595) for CTC (RR 2.06; 95% CI 1.37 to 3.10). 2
40. Pickhardt PJ, Hassan C, Halligan S, Marmo R. Colorectal cancer: CT colonography and colonoscopy for detection--systematic review and meta-analysis. [Review]. Radiology. 259(2):393-405, 2011 May. Meta-analysis 49 studies To perform a systematic review and meta-analysis of published studies assessing the sensitivity of both computed tomographic (CT) colonography and optical colonoscopy (OC) for colorectal cancer detection. Forty-nine studies provided data on 11,151 patients with a cumulative colorectal cancer prevalence of 3.6% (414 cancers). The sensitivity of CT colonography for colorectal cancer was 96.1% (398 of 414; 95% confidence interval [CI]: 93.8%, 97.7%). No heterogeneity (I(2) = 0%) was detected. No cancers were missed at CT colonography when both cathartic and tagging agents were combined in the bowel preparation. The sensitivity of OC for colorectal cancer, derived from a subset of 25 studies including 9223 patients, was 94.7% (178 of 188; 95% CI: 90.4%, 97.2%). A moderate degree of heterogeneity (I(2) = 50%) was present. Good
41. Kim DH, Pickhardt PJ, Taylor AJ, et al. CT colonography versus colonoscopy for the detection of advanced neoplasia. N Engl J Med. 357(14):1403-12, 2007 Oct 04. Observational-Dx 3,120 patients on CTC; 3,163 patients on optical colonoscopy To compare CTC with colonoscopy for detection of advanced neoplasia. During CTC and optical colonoscopy, 123 and 121 advanced neoplasms were found, including 14 and 4 invasive cancers, respectively. Advanced neoplasia was confirmed in 100/3,120 (CTC group) and in 107/3,163 (optical colonoscopy group). CTC-detected polyps of 6-9 mm. Findings support the use of CTC as a primary screening test before therapeutic colonoscopy. 3
42. Pickhardt PJ, Pooler BD, Mbah I, Weiss JM, Kim DH. Colorectal Findings at Repeat CT Colonography Screening after Initial CT Colonography Screening Negative for Polyps Larger than 5 mm. Radiology. 282(1):139-148, 2017 Jan. Observational-Dx 5640 patients To determine the rate and types of polyps detected at repeat computed tomographic (CT) colonography screening after initial negative findings at CT colonography screening. For all patients with positive findings at repeat CT colonography, the findings were directly compared against the initial CT colonography findings. Fisher exact, Pearson chi(2), and Student t tests were applied as indicated. Results Repeat CT colonography screening was positive for lesions 6 mm or larger in 173 (12.1%) adults (compared with 14.3% at initial CT colonography screening, P = .29). In the 173 patients, 29.5% (61 of 207) of nondiminutive polyps could be identified as diminutive at the initial CT colonography and 12.6% (26 of 207) were missed. Large polyps, advanced neoplasia (advanced adenomas and cancer), and invasive cancer were seen in 3.8% (55 of 1429), 2.8% (40 of 1429), and 0.14% (two of 1429), respectively, at follow-up, compared with 5.2% (P = .02), 3.2% (P = .52), and 0.45% (P = .17), respectively, at initial screening. Of 42 advanced lesions in 40 follow-up screenings, 33 (78.6%) were right sided and 22 (52.4%) were flat, compared with 45.4% (P < .001) and 11.3% (P < .001), respectively, at initial screening. Large right-sided serrated lesions were confirmed in 20 individuals (1.4%), compared with 0.5% (P < .001) confirmed at initial screening. Conclusion Positive rates for large polyps at repeat CT colonography screening (3.7%) were lower compared with those at initial screening (5.2%). 3
43. Pooler BD, Kim DH, Matkowskyj KA, et al. Natural History of Colorectal Polyps Undergoing Longitudinal in Vivo CT Colonography Surveillance. Radiology 2024;310:e232078. Observational-Dx 475 asymptomatic adult patients To assess the natural history of colorectal polyps followed with CTC in a clinical screening program, with histopathologic correlation for resected polyps. Of these 639 polyps, 398 (62.3%) underwent resection and histopathologic evaluation, and 41 (6.4%) proved to be histopathologically advanced (adenocarcinoma, high-grade dysplasia, or villous content), including two cancers and 38 tubulovillous adenomas. Advanced polyps showed mean volume growth of +178% per year (752% per year for adenocarcinomas) compared with +33% per year for nonadvanced polyps and -3% per year for unresected, unretrieved, or resolved polyps (P < .001). In addition, 90% of histologically advanced polyps achieved a volume of 100 mm(3) and/or volume growth rate of 100% per year, compared with 29% of nonadvanced and 16% of unresected or resolved polyps (P < .001). Polyp volume-to-diameter ratio was also significantly greater for advanced polyps. 4
44. Regge D, Laudi C, Galatola G, et al. Diagnostic accuracy of computed tomographic colonography for the detection of advanced neoplasia in individuals at increased risk of colorectal cancer. JAMA. 301(23):2453-61, 2009 Jun 17. Observational-Dx 937 patients Multicenter, cross-sectional study to assess the accuracy of CTC in detecting advanced colorectal neoplasia in asymptomatic individuals at increased risk of CRC. Unblinded colonoscopy was used as reference standard. CTC identified 151/177 participants with advanced neoplasia =6 mm (sensitivity, 85.3%; 95% CI, 79.0%-90.0%) and correctly classified results as negative for 667/760 participants without such lesions (specificity, 87.8%; 95% CI, 85.2%-90.0%). PPV and NPV were 61.9% (95% CI, 55.4%-68.0%) and 96.3% (95% CI, 94.6%-97.5%), respectively; after group stratification, a significantly lower NPV was found for the FOBTs-positive group (84.9%; 95% CI, 76.2%-91.3%; P<.001). 3
45. Fini L, Laghi L, Hassan C, et al. Noncathartic CT colonography to screen for colorectal neoplasia in subjects with a family history of colorectal cancer. Radiology. 270(3):784-90, 2014 Mar. Observational-Dx 304 To prospectively assess the diagnostic performance of noncathartic computed tomographic (CT) colonography in the detection of clinically relevant colorectal lesions (=6 mm polyps or masses) in a well-defined cohort of first-degree relatives of patients with colorectal cancer (CRC), using colonoscopy and histologic review as the standard of reference. Three hundred four first-degree relatives (median age, 47 years; age range, 40-79 years; 46.7% women) identified from 221 index cases were included. Overall, CT colonography helped identify 17 of 22 subjects with polyps measuring at least 6 mm (sensitivity, 0.77; 95% confidence interval [CI]: 0.59, 0.95) and helped correctly classify as negative 278 of 282 subjects without lesions measuring at least 6 mm (specificity, 0.99; 95% CI: 0.97, 1.00). CT colonography helped detect eight of nine subjects with polyps measuring at least 10 mm as well as eight of nine subjects with advanced neoplasia measuring at least 6 mm (sensitivity, 0.89 for both). Per-subject positive and negative predictive values for lesions measuring at least 6 mm were 0.81 (17 of 21 subjects; 95% CI: 0.65, 0.97) and 0.98 (282 of 287 subjects; 95% CI: 0.96, 0.99), respectively. 2
46. Van Gelder RE, Nio CY, Florie J, et al. Computed tomographic colonography compared with colonoscopy in patients at increased risk for colorectal cancer. Gastroenterology 2004;127:41-8. Observational-Dx 249 patients To investigate the ability of CT colonography to identify individuals with large (>or=10 mm) colorectal polyps in consecutive patients at increased risk for colorectal cancer. In total, 31 patients (12%) had 48 large polyps at colonoscopy. This included 8 patients with 8 large polyps that were overlooked initially and detected at the second-look colonoscopy. In 6 of 8 patients, the missed polyp was the only large lesion. With CT colonography, 84% of patients (26/31) with large polyp(s) were identified, paired for a specificity of 92% (200-201/218). Positive and negative predictive values were 59%-60% (26/43-44) and 98% (200-201/205-206), respectively. CT colonography detected 75%-77% (36-37/48) of large polyps, with 9 of the missed lesions being flat. 3
47. Devir C, Kebapci M, Temel T, Ozakyol A. Comparison of 64-Detector CT Colonography and Conventional Colonoscopy in the Detection of Colorectal Lesions. Iran J Radiol 2016;13:e19518. Observational-Dx 31 patients To compare CT colonography and conventional colonoscopy results and to evaluate the accuracy of CT colonography for detecting colorectal lesions. Regardless of the size, MDCT colonography showed 83% sensitivity and 95% specificity, with a positive predictive value of 95% and a negative predictive value of 83% for the detection of colorectal polyps and masses. MDCT colonography displayed 92% sensitivity and 95% specificity, with a positive predictive value of 92% and a negative predictive value of 95% for polyps = 10 mm. For polyps between 6mm and 9 mm, MDCT colonography displayed 75% sensitivity and 100% specificity, with a positive predictive value of 100% and a negative predictive value of 90%. For polyps = 5 mm MDCT colonography displayed 88% sensitivity and 100% specificity with a positive predictive value of 100% and a negative predictive value of 95%. 2
48. Pickhardt PJ, Mbah I, Pooler BD, et al. CT Colonographic Screening of Patients With a Family History of Colorectal Cancer: Comparison With Adults at Average Risk and Implications for Guidelines. AJR Am J Roentgenol. 208(4):794-800, 2017 Apr. Review/Other-Dx 9013 patients To compare rates of lesion detection at CT colonographic (CTC) screening of adults without symptoms who had and who did not have a family history of colorectal cancer according to American Cancer Society guidelines and to consider the clinical implications. For the family history versus no family history cohorts, the frequency of all nondiminutive polyps (>/= 6 mm) reported at CTC was 23.7% versus 15.5% (p = 0.007); small polyps (6-9 mm), 13.5% versus 9.1% (p = 0.068); and large polyps (>/= 10 mm), 10.2% versus 6.5% (p = 0.068). The rate of referral for colonoscopy was greater for the family history cohort (16.0% vs 10.5%; p = 0.035). However, the frequencies of proven advanced adenoma (4.5% vs 3.2%; p = 0.357), nonadvanced adenoma (5.1% vs 2.6%; p = 0.070), and cancer (0.0% vs 0.4%; p = 0.999) were not significantly increased. The difference in positive rates between the two cohorts (11.5% vs 4.3%; p < 0.001) was primarily due to nonneoplastic findings of no colorectal cancer relevance, such as small hyperplastic polyps, diverticular disease, and false-positive CTC findings. 4
49. Eaden JA, Abrams KR, Mayberry JF. The risk of colorectal cancer in ulcerative colitis: a meta-analysis. Gut. 2001;48(4):526-535. Meta-analysis 116 studies and 54,478 patients were studied. To give an overall estimate of the risk in all patients with UC by decade, define the risk for children and those with extensive colitis, and give CRC incidence rates by country where possible. The overall prevalence of CRC in any UC patient, based on 116 studies, was estimated to be 3.7% (95% CI 3.2-4.2%). Of the 116 studies, 41 reported colitis duration. From these the overall incidence rate was 3/1000 person years duration (pyd), (95% CI 2/1000 to 4/1000). The overall incidence rate for any child was 6/1000 pyd (95% CI 3/1000 to 13/1000). Of the 41 studies, 19 reported results stratified into 10 year intervals of disease duration. For the first 10 years the incidence rate was 2/1000 pyd (95% CI 1/1000 to 2/1000), for the second decade the incidence rate was estimated to be 7/1000 pyd (95% CI 4/1000 to 12/1000), and in the third decade the incidence rate was 12/1000 pyd (95% CI 7/1000 to 19/1000). These incidence rates corresponded to cumulative probabilities of 2% by 10 years, 8% by 20 years, and 18% by 30 years. The worldwide cancer incidence rates varied geographically, being 5/1000 pyd in the USA, 4/1000 pyd in the UK, and 2/1000 pyd in Scandinavia and other countries. Over time the cancer risk has increased since 1955 but this finding was not significant (p=0.8). Good
50. Giardiello FM, Allen JI, Axilbund JE, et al. Guidelines on genetic evaluation and management of Lynch syndrome: a consensus statement by the US Multi-Society Task Force on Colorectal Cancer. Diseases of the colon and rectum 2014;57:1025-48. Review/Other-Dx NA No objective listed in abstract. No results listed in abstract. 4
51. van Liere E, de Boer NKH, Dekker E, van Leerdam ME, de Meij TGJ, Ramsoekh D. Systematic review: non-endoscopic surveillance for colorectal neoplasia in individuals with Lynch syndrome. Aliment Pharmacol Ther 2022;55:778-88. Meta-analysis 7 studies To outline the performance of non-endoscopic screening modalities for Lynch-associated CRC and adenomas. Two studies evaluated either CT colonography or MR colonography; both techniques were unable to detect CRC and (advanced) adenomas <10 mm. The other five studies evaluated plasma methylated-SEPTIN9, faecal immunochemical test (FIT), faecal tumour DNA markers (BAT-26, hMLH1, p53, D9S171, APC, D9S162, IFNA and DCC) and faecal microbiome as screening modalities. Sensitivity for CRC varied from 33% (BAT-26) to 70% (methylated-SEPTIN9) to 91% (hMLH1). High specificity (94-100%) for CRC and/or adenomas was observed for methylated-SEPTIN9, FIT and BAT-26. Desulfovibrio was enriched in the stool of patients having adenomas. However, all these studies were characterised by small populations, high/unclear risk of bias and/or low prevalence of adenomas. Good
52. Jarvinen HJ, Mecklin JP, Sistonen P. Screening reduces colorectal cancer rate in families with hereditary nonpolyposis colorectal cancer. Gastroenterology. 1995; 108(5):1405-1411. Observational-Dx 133 screened; 118 controls without screening To evaluate the effectiveness of long-term screening by comparing screened and unscreened subjects with HNPCC for incidence CRC. CRC occurred in 6 study subjects (4.5%) and 14 controls (11.9%; P=0.03), a difference of 7.4% in favor of the study group, which corresponds to a reduction by 62% that is presumably because of polypectomies. The 3-year interval screening more than halves the CRC rate in at-risk members of families with HNPCC and prevent CRC deaths. 3
53. Franco DL, Leighton JA, Gurudu SR. Approach to Incomplete Colonoscopy: New Techniques and Technologies. Gastroenterol Hepatol (N Y) 2017;13:476-83. Review/Other-Dx NA To review the potential causes of and preventive measures for incomplete colonoscopy, as well as techniques and technologies that may improve the rate of complete colonoscopy. No results listed in abstract. 4
54. Kim SY, Park SH, Choi EK, et al. Automated carbon dioxide insufflation for CT colonography: effectiveness of colonic distention in cancer patients with severe luminal narrowing. AJR Am J Roentgenol. 190(3):698-706, 2008 Mar. Observational-Dx 74 patients To determine the effectiveness of automated CO2 insufflation in colonic distention for CT colonography (CTC) in patients with severe luminal narrowing by colorectal cancer and preliminarily evaluate its safety performed shortly after colonoscopic polypectomy or biopsy. Distention was not significantly different between the stenotic and nonstenotic groups in any colonic segments in both supine and prone positions. The mean distention grade +/- SD of the colonic segments proximal to the luminal narrowing in the stenotic group (n = 143 segments) was 3.7 +/- 0.7 and 3.8 +/- 0.7 for the supine and prone positions, respectively. Colonic perforation was not noted in any of the 74 patients, including 65 patients who underwent CTC within 24 hours after colonoscopy (62 snare polypectomies, two polypectomies using biopsy forceps, 63 routine mucosal biopsies). 3
55. Adloff M, Arnaud JP, Bergamaschi R, Schloegel M. Synchronous carcinoma of the colon and rectum: prognostic and therapeutic implications. Am J Surg 1989;157:299-302. Review/Other-Dx NA No objective stated in abstract. No results stated in abstract. 4
56. Mulder SA, Kranse R, Damhuis RA, et al. Prevalence and prognosis of synchronous colorectal cancer: a Dutch population-based study. Cancer Epidemiol 2011;35:442-7. Observational-Dx 13,683 patients To determine the prevalence and prognosis of synchronous colorectal cancer. Of the 13,683 patients diagnosed with CRC, 534 patients (3.9%) were diagnosed with synchronous CRC. The risk of having synchronous CRC was significantly higher in men (OR 1.54, 95% CI 1.29-1.84) and in patients aged >70 years (OR 1.83, 95% CI 1.39-2.40). Synchronous CRC patients had a significantly higher risk of distant metastases (OR 1.69, 95% CI 1.27-2.26). In 34% (184/534) the two tumours were located in different surgical segments. Five-year relative survival of synchronous CRC was similar to patients with solitary CRC after multivariate adjustment for the presence of distant metastases. 4
57. Huang CS, Yang SH, Lin CC, et al. Synchronous and Metachronous Colorectal Cancers: Distinct Disease Entities or Different Disease Courses? Hepatogastroenterology 2015;62:838-42. Review/Other-Dx 5346 patients To investigate the clinicopathological characteristics of synchronous and metachronous colorectal cancers (CRCs). The overall prevalence of the synchronous CRC was 2.2% and the 10-year cumulative incidence of metachronous cancer was 0.84%. 29 (64%) metachronous cancers were diagnosed within 3 years of the index cancer and the mean time interval was 3.2 years. Male gender and presence of associated adenoma were significant risk factors for both synchronous and metachronous CRC. Synchronous and metachronous CRC patients shared similar clinicopathological features except that the former were older than the latter by 3.7 years. The five-year survival rates were not different among the three groups. 4
58. Bat L, Neumann G, Shemesh E. The association of synchronous neoplasms with occluding colorectal cancer. Diseases of the colon and rectum 1985;28:149-51. Review/Other-Dx 50 patients To determine the association synchronous neoplasms with occluding colorectal cancer Synchronous, frequently multiple adenomas were found in 29 (58 percent) of these patients. Three patients (6 percent) had synchronous invasive cancer as well. None of these lesions was detected by intraoperative palpation, even though 46 percent of them measured more than 1.0 cm in diameter. Synchronous neoplasms were found significantly more often in patients with occluding cancer than in patients with non-occluding cancer, investigated concurrently at the same hospital. The former patients appear to be in double jeopardy with respect to synchronous neoplasms, these being more prevalent and less accessible than in patients with non-occluding tumors. Moreover, most of the synchronous lesions are undetectable by palpation 4
59. Park SH, Lee JH, Lee SS, et al. CT colonography for detection and characterisation of synchronous proximal colonic lesions in patients with stenosing colorectal cancer. Gut. 61(12):1716-22, 2012 Dec. Observational-Dx 411 patients To investigate CT colonography (CTC) performance for detecting and characterising synchronous lesions proximal to a stenosing colorectal cancer and to suggest patient management strategies according to the CTC findings. Both per-patient and per-lesion CTC detection sensitivities for proximal synchronous cancers were 100% (6/6 patients and 8/8 lesions; 95% CI 64.3% to 100% and 70.7% to 100%, respectively) with the corresponding per-patient negative predictive value (NPV) of a negative CTC of 100% (194/194 patients; 95% CI 98.3% to 100%). Per-patient NPV of a negative CTC for advanced neoplasia (ie, advanced adenomas and colorectal cancers) was 97.4% (189/194 patients; 95% CI 93.9% to 99.1%). A lesion size >/=15 mm on CTC as the criterion to specifically diagnose proximal cancer yielded 87.5% (7/8 lesions; 95% CI 50.8% to 99.9%) per-lesion sensitivity, rendering one 8-mm submucosal cancer mischaracterised as a non-cancerous lesion, and 70% (7/10 lesions; 95% CI 39.2% to 89.7%) per-lesion PPV. Additional CTC findings did not improve the sensitivity. 3
60. Horvat N, Raj A, Ward JM, Smith JJ, Markowitz AJ, Gollub MJ. Clinical Value of CT Colonography Versus Preoperative Colonoscopy in the Surgical Management of Occlusive Colorectal Cancer. AJR Am J Roentgenol. 210(2):333-340, 2018 Feb. Observational-Dx 65 patients To evaluate changes in preoperative surgical planning after CTC is performed for patients with occlusive CRC and IC in an oncologic hospital. CTC contributed to a change in the initial surgical plan of the surgeon for 14 of 65 patients (21.5%). In these 14 patients, CTC detected five synchronous proximal colon polyps (35.7%), five synchronous proximal cancers (35.7%), two imprecise CRC locations (14.3%), one case of proximal colon ischemia (7.1%), and one instance of tumor infiltration of the urinary bladder (7.1%). All CTC findings were confirmed at surgery, and all proximal colon polyps were subsequently confirmed to be advanced adenomas. 3
61. American College of Radiology. ACR–SIR Practice Parameter For Minimal and/or Moderate Sedation/Analgesia.  Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/Sed-Analgesia.pdf. Review/Other-Dx N/A Guidance document to promote the safe and effective use of diagnostic and therapeutic radiology by describing specific training, skills and techniques. No abstract available. 4
62. Macari M, Berman P, Dicker M, Milano A, Megibow AJ. Usefulness of CT colonography in patients with incomplete colonoscopy. AJR Am J Roentgenol. 1999; 173(3):561-564. Review/Other-Dx 10 patients To examine the usefulness of CTC after incomplete colonoscopy. Report initial experience with both CTC and DCBE in finishing the colonic examination of patients with incomplete colonoscopy. In 2 patients, CTC demonstrated solitary polyps in the portion of the colon not evaluated by colonoscopy. CTC is effective in evaluating portions of the colon not seen during colonoscopy and may have an adjunctive role. 4
63. Morrin MM, Kruskal JB, Farrell RJ, Goldberg SN, McGee JB, Raptopoulos V. Endoluminal CT colonography after an incomplete endoscopic colonoscopy. AJR Am J Roentgenol. 1999; 172(4):913-918. Observational-Dx 40 patients Prospective study to evaluate the clinical usefulness of CTC after incomplete colonoscopy. 26 patients (65%) had barium enema after endoluminal CTC. CTC adequately demonstrated 96% of all colonic segments while barium enema revealed 91% of all segments. 2
64. Neri E, Giusti P, Battolla L, et al. Colorectal cancer: role of CT colonography in preoperative evaluation after incomplete colonoscopy. Radiology. 223(3):615-9, 2002 Jun. Observational-Dx 34 patients; 20 controls To evaluate CTC in patients with clinical suspicion of CRC in whom colonoscopy was incomplete. CTC demonstrated 10 CRC and 3 synchronous cancers that were missed at colonoscopy. Sensitivity and specificity for detection of CRC were 56% and 92%, respectively, for incomplete colonoscopy and 100% and 96%, respectively, for CTC (P<.01). Sensitivity and specificity of CTC in detection of polyps were 86% and 70%, respectively, for diameters =5 mm; 100% and 80%, respectively, for 5-10 mm diameters; and 100% for diameters =10 mm. Spiral CT of the liver revealed 4 metastases (2-5 cm); sensitivity and specificity were 100% and 43% for nonenhanced scans and 100% for contrast-enhanced scans (P<.01). 2
65. Sali L, Falchini M, Bonanomi AG, et al. CT colonography after incomplete colonoscopy in subjects with positive faecal occult blood test. World J Gastroenterol. 14(28):4499-504, 2008 Jul 28. Observational-Dx 42 patients A prospective study to report results of CTC after incomplete colonoscopy in subjects with positive FOBT. CTC correctly identified 2 colonic masses and 20 polyps. PPV for masses or polyps >9 mm was 87.5%. Per-lesion and per-segment PPV were, respectively, 83.3% and 83.3% for polyps =10 mm, and 77.8% and 85.7% for polyps of 6-9 mm. CTC has potential to become a useful technique for evaluation of the nonvisualized part of the colon after incomplete colonoscopy. 3
66. Copel L, Sosna J, Kruskal JB, Raptopoulos V, Farrell RJ, Morrin MM. CT colonography in 546 patients with incomplete colonoscopy. Radiology. 244(2):471-8, 2007 Aug. Observational-Dx 546 patients To retrospectively evaluate the PPV of CTC in patients referred for further examination after incomplete colonoscopy. Per-patient and per-lesion PPV of CTC for masses, large polyps, and medium polyps were 90.9% and 91.7%, 64.7% and 70%, and 33.3% and 30.4%, respectively. 3
67. Spada C, Hassan C, Barbaro B, et al. Colon capsule versus CT colonography in patients with incomplete colonoscopy: a prospective, comparative trial. Gut. 64(2):272-81, 2015 Feb. Experimental-Dx 100 patients To compare colon capsule endoscopy (CCE) and CT colonography (CTC) in a prospective cohort of patients with incomplete colonoscopy. 100 patients were enrolled. CCE and CTC were able to achieve complete colonic evaluation in 98% of cases. In a per-patient analysis for polyps >/=6 mm, CCE detected 24 patients (24.5%) and CTC 12 patients (12.2%). The relative sensitivity of CCE compared to CTC was 2.0 (95% CI 1.34 to 2.98), indicating a significant increase in sensitivity for lesions >/=6 mm. Of larger polyps (>/=10 mm), these values were 5.1% for CCE and 3.1% for CTC (relative sensitivity: 1.67 (95% CI 0.69 to 4.00)). Positive predictive values for polyps >/=6 mm and >/=10 mm were 96% and 85.7%, and 83.3% and 100% for CCE and CTC, respectively. No missed cancer occurred at clinical follow-up of a mean of 20 months. 1
68. Pullens HJ, van Leeuwen MS, Laheij RJ, Vleggaar FP, Siersema PD. CT-colonography after incomplete colonoscopy: what is the diagnostic yield?. Diseases of the Colon & Rectum. 56(5):593-9, 2013 May. Review/Other-Dx 136 consecutive CT-colonographies To investigate the yield of CT-colonography of relevant intra- and extracolonic findings in patients after incomplete colonoscopy. Major indications for colonoscopy included iron-deficiency anemia (25.7%), hematochezia (20.6%), change in bowel habits (18.4%), and colorectal cancer screening or surveillance (11.0%). Major reasons for incomplete colonoscopy were a fixed colon (34.6%) and strong angulation of the sigmoid colon (17.6%). Introduction of the colonoscope was limited to the left-sided colon in 53.7% of cases. Incomplete colonoscopy detected colorectal cancer in 12 (8.8%) patients and adenomatous polyps in 27 (19.9%) patients. CT-colonography after incomplete colonoscopy additionally revealed 19 polyps in 15 (11.0%) and a nonsynchronous colorectal cancer in 4 (2.9%) patients. CT-colonography also detected extracolonic findings with clinical consequences in 8 (5.9%) patients, including fistulizing diverticulitis (n = 3), gastric tumor (n = 2), liver abscess (n = 1), osteomyelitis (n = 1), and an infected embolus in both renal arteries (n = 1). 4
69. Theis J, Kim DH, Lubner MG, Munoz del Rio A, Pickhardt PJ. CT colonography after incomplete optical colonoscopy: bowel preparation quality at same-day vs. deferred examination. Abdom Radiol. 41(1):10-8, 2016 Jan. Observational-Dx 15 patients To objectively compare the volume, density, and distribution of luminal fluid for same-day oral-contrast-enhanced CTC following incomplete optical colonoscopy (OC) vs. deferred CTC on a separate day utilizing a dedicated CTC bowel preparation. Opacified luminal fluid extended to the rectum in 56% (58/103) of same-day CTC vs. 100% (151/151) of deferred separate-day CTC (p < 0.0001). For same-day CTC, contrast failed to reach the colon in 11% (11/103) and failed to reach the left colon in 26% (27/103). Volumetric colonic fluid segmentation for fluid analysis (successful in 80 same-day and 147 separate-day cases) showed significantly more fluid in the same-day cohort (mean, 227 vs. 166 mL; p < 0.0001); the actual difference is underestimated due to excluded cases. Mean colonic fluid attenuation was significantly lower in the same-day cohort (545 vs. 735 HU; p < 0.0001). Similar findings were identified in the smaller cohort with direct intra-patient CTC comparison. 3
70. Kao KT, Tam M, Sekhon H, Wijeratne R, Haigh PI, Abbas MA. Should barium enema be the next step following an incomplete colonoscopy? Int J Colorectal Dis. 2010;25(11):1353-1357. Review/Other-Dx 233 patients To determine the value of DCBE following an incomplete colonoscopy. The incomplete colonoscopy rate was 1.6%. The mean age was 62 years with a predominance of females. The most common indication for colonoscopy was screening. The most frequent reason attributed to an incomplete colonoscopy was patient discomfort. Two hundred thirty three patients underwent DCBE and 42 patients underwent a repeat colonoscopy without DCBE; 13.3% of the DCBE were of poor quality and could not be interpreted. A repeat colonoscopy following DCBE was performed in 7% of patients. In 50% of these patients, the repeat colonoscopy revealed significant findings not noted on the DCBE or ruled out positive DCBE findings. In patients who had repeat colonoscopy without DCBE, completion rate was 95%. 4
71. Brown AL, Skehan SJ, Greaney T, Rawlinson J, Somers S, Stevenson GW. Value of double-contrast barium enema performed immediately after incomplete colonoscopy. AJR Am J Roentgenol. 2001;176(4):943-945. Observational-Dx 103 patients To evaluate the ease, completeness, and clinical utility of double-contrast barium enema (DCBE) performed immediately after incomplete colonoscopy. DCBE revealed the entire colon in 97 patients (94%). Incomplete DCBE was a result of obstruction and incontinence in three patients each. The mean score for ease of performing DCBE was 5.0. In 14 patients (14%), significant additional diagnostic information was provided by the immediate DCBE. In eight patients, abnormalities were identified on DCBE that had not been seen at colonoscopy (five malignant neoplasms, one diverticular mass, two extrinsic masses, and multiple strictures). In four patients, a suspected colonoscopic abnormality was excluded with DCBE findings; and in two patients, a colonoscopic abnormality was further characterized with DCBE. 4
72. Martinez F, Kondylis P, Reilly J. Limitations of barium enema performed as an adjunct to incomplete colonoscopy. Diseases of the colon and rectum 2005;48:1951-4. Observational-Dx 485 patients To assess completion barium enema for both completeness and quality of proximal visualization. In 485 patients (2.9 percent), colonoscopy was incomplete. One hundred eighteen patients underwent barium enema after incomplete colonoscopy. In these patients, sharp angulation (42 percent) or redundancy/looping (31 percent) most often limited endoscopy. Among the barium enema studies, 91 (77 percent) were technically adequate. Twenty-seven studies were suboptimal (poor preparation/intolerance = 7, redundancy = 6, poor filling = 6, stricture/narrowing = 6, severe diverticulosis = 2). Two patients demonstrated additional polyps. There was no correlation between reasons for endoscopic failure and inadequacy of barium enema. Completeness of barium enema was not affected by previous pelvic surgery. Immediate barium enema was no less complete than a delayed study. 3
73. National Academies of Sciences, Engineering, and Medicine; Division of Behavioral and Social Sciences and Education; Committee on National Statistics; Committee on Measuring Sex, Gender Identity, and Sexual Orientation. Measuring Sex, Gender Identity, and Sexual Orientation. In: Becker T, Chin M, Bates N, eds. Measuring Sex, Gender Identity, and Sexual Orientation. Washington (DC): National Academies Press (US) Copyright 2022 by the National Academy of Sciences. All rights reserved.; 2022. Review/Other-Dx N/A Sex and gender are often conflated under the assumptions that they are mutually determined and do not differ from each other; however, the growing visibility of transgender and intersex populations, as well as efforts to improve the measurement of sex and gender across many scientific fields, has demonstrated the need to reconsider how sex, gender, and the relationship between them are conceptualized. No abstract available. 4
74. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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