María Elena Martínez*, PhD; Patricia Thompson, PhD; Karen Messer, PhD; Erin L. Ashbeck, MPH; David A. Lieberman, MD; John A. Baron, MD; Dennis J. Ahnen, MD; Douglas J. Robertson, MD; Elizabeth T. Jacobs, PhD; E. Robert Greenberg, MD; Amanda J. Cross, PhD; Wendy Atkin*, PhD
Disclaimer: The views expressed in this document are those of the authors and do not necessarily reflect the official position of the European Commission. Neither the European Commission nor any other organization nor any person acting alone or on behalf of others can be held responsible for any use that may be made of the information in this document.
Grant Support: By the European Union Health Programme (Development of European Guidelines for Quality Assurance of Colorectal Cancer Screening; grant agreement 2005317); the International Agency for Research on Cancer; and the U.S. Public Health Service grants CA-41108, CA-23074, CA95060, CA37287, CA104869, CA23108, CA59005, and CA26852 from the National Cancer Institute.
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-1274.
Reproducible Research Statement: Study protocol: Available from Dr. Martínez (e-mail, email@example.com). Statistical code and data set: Not available.
Requests for Single Reprints: María Elena Martínez, PhD, Moores Cancer Center, University of California, San Diego, 3855 Health Sciences Drive 0901, La Jolla, CA 92093-0901; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Martínez and Messer: Moores Cancer Center, University of California, San Diego, 3855 Health Sciences Drive 0901, La Jolla, CA 92093-0901.
Drs. Thompson, Ashbeck, and Jacobs: Arizona Cancer Center, 1515 North Campbell Avenue, PO Box 245024, Tucson, AZ 85724.
Dr. Lieberman: Division of Gastroenterology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, L461, Portland, OR 97239-3098.
Dr. Baron: University of North Carolina at Chapel Hill, 4160-B Bioinformatics Building CB 7080, Mason Farm Road, Chapel Hill, NC 27599-7080.
Dr. Ahnen: Denver Veterans Affairs Medical Center 111E, 1055 Clermont Street, Denver, CO 80220.
Dr. Robertson: The Geisel School of Medicine at Dartmouth and The Dartmouth Institute, Chief, Section of Gastroenterology, Veterans Affairs Medical Center, White River Junction, VT 05009.
Dr. Greenberg: Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, Seattle, WA 98109.
Dr. Cross: Division of Cancer Epidemiology and Genetics, National Cancer Institute, Executive Plaza South, Room 3050, Bethesda, MD 20892-7335.
Dr. Atkin: Department of Surgery and Cancer, Imperial College London, St. Mary's Campus, Norfolk Place, London W2 1PG, United Kingdom.
Author Contributions: Conception and design: M.E. Martínez, D.A. Lieberman, D.J. Ahnen, E.R. Greenberg, W. Atkin.
Analysis and interpretation of the data: M.E. Martínez, P. Thompson, K. Messer, E.L. Ashbeck, D.A. Lieberman, J.A. Baron, D.J. Ahnen, D.J. Robertson, E.T. Jacobs, E.R. Greenberg, A.J. Cross, W. Atkin.
Drafting of the article: M.E. Martínez, P. Thompson, K. Messer, E.L. Ashbeck, D.A. Lieberman, E.T. Jacobs, E.R. Greenberg, W. Atkin.
Critical revision of the article for important intellectual content: M.E. Martínez, P. Thompson, K. Messer, E.L. Ashbeck, D.A. Lieberman, J.A. Baron, D.J. Ahnen, D.J. Robertson, E.T. Jacobs, E.R. Greenberg, A.J. Cross, W. Atkin.
Final approval of the article: M.E. Martínez, P. Thompson, K. Messer, E.L. Ashbeck, D.A. Lieberman, J.A. Baron, D.J. Ahnen, D.J. Robertson, E.T. Jacobs, E.R. Greenberg, A.J. Cross, W. Atkin.
Provision of study materials or patients: M.E. Martínez, D.J. Ahnen, E.R. Greenberg.
Statistical expertise: K. Messer.
Obtaining of funding: M.E. Martínez, D.A. Lieberman, E.R. Greenberg, W. Atkin.
Administrative, technical, or logistic support: M.E. Martínez, P. Thompson, E.R. Greenberg.
Collection and assembly of data: M.E. Martínez, J.A. Baron, D.J. Ahnen, E.R. Greenberg, A.J. Cross.
Martínez* ME, Thompson P, Messer K, Ashbeck EL, Lieberman DA, Baron JA, et al. One-Year Risk for Advanced Colorectal Neoplasia: U.S. Versus U.K. Risk-Stratification Guidelines. Ann Intern Med. 2012;157:856-864. doi: 10.7326/0003-4819-157-12-201212180-00005
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Published: Ann Intern Med. 2012;157(12):856-864.
Guidelines from the United Kingdom and the United States on risk stratification after polypectomy differ, as do recommended surveillance intervals.
To compare risk for advanced colorectal neoplasia at 1-year colonoscopy among patients cross-classified by U.S. and U.K. surveillance guidelines.
Pooled analysis of 4 prospective studies between 1984 and 1998.
Academic and private clinics in the United States.
3226 postpolypectomy patients with 6- to 18-month follow-up colonoscopy.
Rates of advanced neoplasia (an adenoma ≥1 cm, high-grade dysplasia, >25% villous architecture, or invasive cancer) at 1 year, compared across U.S. and U.K. risk categories.
Advanced neoplasia was detected 1 year after polypectomy in 3.8% (95% CI, 2.7% to 4.9%) of lower-risk patients and 11.2% (CI, 9.8% to 12.6%) of higher-risk patients by U.S. criteria. According to U.K. criteria, 4.4% (CI, 3.3% to 5.4%) of low-risk patients, 9.9% (CI, 8.3% to 11.5%) of intermediate-risk patients, and 18.7% (CI, 14.8% to 22.5%) of high-risk patients presented with advanced neoplasia; U.K. high-risk patients comprised 12.1% of all patients. All U.S. lower-risk patients were low-risk by U.K. criteria; however, more patients were classified as low-risk, because the U.K. guidelines do not consider histologic features. Higher-risk U.S. patients were distributed across the 3 U.K. categories. Among all patients with advanced neoplasia, 26.3% were reclassified by the U.K. criteria to a higher-risk category and 7.0% to a lower-risk category, with a net 19.0% benefiting from detection 2 years earlier. Overall, substitution of U.K. for U.S. guidelines resulted in an estimated 0.03 additional colonoscopy every 5 years per patient.
Patients were enrolled 15 to 20 years ago, and quality measures for colonoscopy were unavailable. Patients lacking follow-up colonoscopy or with surveillance colonoscopy after 6 to 18 months and those with cancer or insufficient baseline adenoma characteristics were excluded (2076 of 5302).
Application of the U.K. guidelines in the United States could identify a subset of high-risk patients who may warrant a 1-year clearing colonoscopy without substantially increasing rates of colonoscopy.
European Union Public Health Programme.
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Colonoscopy/Sigmoidoscopy, Colorectal Cancer, Gastroenterology/Hepatology, Gastrointestinal Cancer, Hematology/Oncology.
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