Developing a score chart to improve risk stratification of patients with colorectal adenoma

Background and study aims: Current surveillance guidelines risk stratify patients with adenoma by using only one or two factors: adenoma multiplicity or presence of an advanced adenoma characteristic. Combinations of adenoma characteristics are not considered, which limits the predictive value of these guidelines. The aim of the study was to develop a scoring system for more refined risk stratification of patients with adenoma.

Patients and methods: The Dutch Pathology Registry (PALGA) was used to identify newly diagnosed patients with adenoma in 10 Dutch hospitals between 1988 and 2002. Medical records were reviewed until 1 December 2008 for follow-up. Logistic regression analysis was used to assess patient- and adenoma-related predictors of metachronous advanced neoplasia. The prediction model was validated by bootstrapping and cross-validation. A score chart was developed based on identified adenoma-related predictors. The discriminative ability of the prediction model was compared with currently used risk stratifications in surveillance guidelines.

Results: A total of 2914 patients with adenoma were included (mean age 61 years; 55 % male). The score chart consisted of characteristics that contributed 1 point (size ≥ 10 mm, villous histology, proximal location, having 2 – 4 adenomas) or 2 points (having ≥ 5 adenomas). A patient’s adenoma risk score could range from 0 to 5 points. A score of 5 for a 75-year-old man implied a 5-year risk of advanced neoplasia of 46 %. The discriminative ability of the model was moderate (c-statistic 0.712) but better than risk stratifications in current international guidelines, which had c-statistics of 0.642 – 0.674.

Conclusion: A score chart that combines adenoma-related predictors of advanced colorectal neoplasia optimized the risk stratification of patients with adenoma for appropriate surveillance colonoscopy intervals.

• References

• 1 Ferlay J, Steliarova-Foucher E, Lortet-Tieulent J et al. Cancer incidence and mortality patterns in Europe: estimates for 40 countries in 2012. Eur J Cancer 2013; 49: 1374-1403
• 2 Siegel R, Desantis C, Jemal A. Colorectal cancer statistics, 2014. CA Cancer J Clin 2014; 64: 104-117
• 3 Siegel R, Ma J, Zou Z et al. Cancer statistics, 2014. CA Cancer J Clin 2014; 64: 9-29
• 4 Atkin WS, Edwards R, Kralj-Hans I et al. Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet 2010; 375: 1624-1633
• 5 Loberg M, Kalager M, Holme Ø et al. Long-term colorectal-cancer mortality after adenoma removal. N Engl J Med 2014; 371: 799-807
• 6 Winawer SJ, Zauber AG, Ho MN et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med 1993; 329: 1977-1981
• 7 Zauber AG, Winawer SJ, O’Brien MJ et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012; 366: 687-696
• 8 Cottet V, Jooste V, Fournel I et al. Long-term risk of colorectal cancer after adenoma removal: a population-based cohort study. Gut 2012; 61: 1180-1186
• 9 Jonkers D, Ernst J, Pladdet I et al. Endoscopic follow-up of 383 patients with colorectal adenoma: an observational study in daily practice. Eur J Cancer Prev 2006; 15: 202-210
• 10 Leung K, Pinsky P, Laiyemo AO et al. Ongoing colorectal cancer risk despite surveillance colonoscopy: the Polyp Prevention Trial Continued Follow-up Study. Gastrointest Endosc 2010; 71: 111-117
• 11 Martinez ME, Baron JA, Lieberman DA et al. A pooled analysis of advanced colorectal neoplasia diagnoses after colonoscopic polypectomy. Gastroenterology 2009; 136: 832-841
• 12 Atkin WS, Valori R, Kuipers EJ et al. International Agency for Research on Cancer. European guidelines for quality assurance in colorectal cancer screening and diagnosis. First edition – Colonoscopic surveillance following adenoma removal. Endoscopy 2012; 44: SE151-SE163
• 13 Cairns SR, Scholefield JH, Steele RJ et al. Guidelines for colorectal cancer screening and surveillance in moderate and high risk groups (update from 2002). Gut 2010; 59: 666-689
• 14 Lieberman DA, Rex D, Winawer SJ et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US multi-society task force on colorectal cancer. Gastroenterology 2012; 143: 844-857
• 15 Nagengast FM, Kaandorp CJ. [Revised CBO guideline ‘Follow-up after polypectomy’]. Ned Tijdschr Geneeskd 2001; 145: 2022-2025
• 16 Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of colorectal cancer. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN). 2011 publication no. 126
• 17 Hassan C, Quintero E, Dumonceau JM et al. Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2013; 45: 842-851
• 18 Lieberman DA, De Garmo PL, Fleischer DE et al. Patterns of endoscopy use in the United States. Gastroenterology 2000; 118: 619-624
• 19 Lieberman DA, Holub J, Eisen G et al. Utilization of colonoscopy in the United States: results from a national consortium. Gastrointest Endosc 2005; 62: 875-883
• 20 Lieberman DA, Williams JL, Holub JL et al. Colonoscopy utilization and outcomes 2000 to 2011. Gastrointest Endosc 2014; 80: 133-143
• 21 Terhaar Sive Droste JS, Craanen ME, van der Hulst RW et al. Colonoscopic yield of colorectal neoplasia in daily clinical practice. World J Gastroenterol 2009; 15: 1085-1092
• 22 van Heijningen EM, Lansdorp-Vogelaar I, Kuipers EJ et al. Features of adenoma and colonoscopy associated with recurrent colorectal neoplasia, based on a large, community-based study. Gastroenterology 2013; 144: 1410-1418
• 23 Casparie M, Tiebosch AT, Burger G et al. Pathology databanking and biobanking in The Netherlands, a central role for PALGA, the nationwide histopathology and cytopathology data network and archive. Cell Oncol 2007; 29: 19-24
• 24 Lansdorp-Vogelaar I, Fedewa S, Lin CC et al. Utilization of surveillance after polypectomy in the medicare population – a cohort study. PLoS One 2014; 9: e110937
• 25 Pinsky PF, Schoen RE, Weissfeld JL et al. The yield of surveillance colonoscopy by adenoma histology and time to examination. Clin Gastroenterol Hepatol 2009; 7: 86-92
• 26 Van Buuren S, Boshuizen HC, Knook DL. Multiple imputation of missing blood pressure covariates in survival analysis. Stat Med 1999; 18: 681-694
• 27 Steyerberg EW. Dealing with missing values. in: Steyerberg EW, ed A practical approach to development, validation, and updating. New York: Springer; 2009: 126
• 28 Harrell FE, Lee KL, Mark DB. Multivariate prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors. Statistics Med 1996; 15: 381-387
• 29 Bouwmeester W, Moons KG, Kappen TH et al. Internal validation of risk models in clustered data: a comparison of bootstrap schemes. Am J Epidemiol 2013; 177: 1209-1217
• 30 Conroy RM, Pyörälä K, Fitzgerald AP et al. Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J 2003; 24: 987-1003
• 31 Martinez ME, Thompson P, Messer K et al. One-year risk for advanced colorectal neoplasia: US. versus U.K. risk-stratification guidelines. Ann Intern Med 2012; 157: 856-864
• 32 Saini SD. Optimizing risk stratification in individuals with a personal history of colorectal adenomas. Gastroenterology 2013; 145: 682-684
• 33 de Jonge V, Sint NicolaasJ, van Leerdam ME et al. Systematic literature review and pooled analyses of risk factors for finding adenomas at surveillance colonoscopy. Endoscopy 2011; 43: 560-572
• 34 Brenner H, Altenhofen L, Kretschmann J et al. Trends in adenoma detection rates during the first 10 years of the German Screening Colonoscopy Program. Gastroenterology 2015; 149: 356-366 e1
• 35 Kapidzic A, Grobbee EJ, Hol L et al. Attendance and yield over three rounds of population-based fecal immunochemical test screening. Am J Gastroenterol 2014; 109: 1257-1264
• 36 Mulder SA, Ouwendijk RJ, van Leerdam ME et al. A nationwide survey evaluating adherence to guidelines for follow-up after polypectomy or treatment for colorectal cancer. J Clin Gastroenterol 2008; 42: 487-492