Perry J. Pickhardt, MD; David H. Kim, MD; Cesare Hassan, MD
Potential Financial Conflicts of Interest: None disclosed.
Pickhardt PJ, Kim DH, Hassan C. The Effectiveness of Colonoscopy in Reducing Mortality From Colorectal Cancer. Ann Intern Med. 2009;150:818-819. doi: 10.7326/0003-4819-150-11-200906020-00017
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Published: Ann Intern Med. 2009;150(11):818-819.
TO THE EDITOR:
We read with interest the recent article by Baxter and colleagues (1). This landmark article demonstrated a clear benefit of colonoscopy for left-sided colorectal cancer but failed to show any survival benefit for right-sided colorectal cancer. Plausible explanations for this important observation include unique tumor biology for a subset of right-sided colorectal cancer and technical factors resulting in missed right-sided colorectal cancer by colonoscopy. In fact, an alternate cancer pathway distinct from the typical adenoma–carcinoma sequence—the serrated polyp pathway—has been identified. The serrated polyp pathway is a predominately right-sided process and may account for 15% of sporadic colorectal cancer. However, the precursor serrated lesion is typically large and seems to have a very long dwell time, suggesting that neither cancer prevention nor detection should be diminished. No convincing evidence exists for a rapidly progressive or de novo sporadic colorectal cancer that favors the proximal colon. This leaves missed right-sided cancer at colonoscopy as the most likely explanation.
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