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Sex, Age, and Birth Cohort Effects in Colorectal Neoplasms: A Cohort Analysis

Hermann Brenner, MD, MPH; Lutz Altenhofen, PhD; and Michael Hoffmeister, PhD
[+] Article and Author Information

From German Cancer Research Center, Heidelberg, and Central Research Institute of Ambulatory Health Care in Germany, Berlin, Germany.


Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M09-2287.

Reproducible Research Statement:Study protocol, data set, and statistical code: Not available.

Requests for Single Reprints: Hermann Brenner, MD, MPH, Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Bergheimer Strasse 20, D-69115 Heidelberg, Germany.

Current Author Addresses: Drs. Brenner and Hoffmeister: Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Bergheimer Strasse 20, D-69115 Heidelberg, Germany.

Dr. Altenhofen: Central Research Institute of Ambulatory Health Care in Germany, Herbert-Lewin-Platz 3, D-10623 Berlin, Germany.

Author Contributions: Conception and design: H. Brenner.

Analysis and interpretation of the data: H. Brenner, L. Altenhofen.

Drafting of the article: H. Brenner.

Critical revision of the article for important intellectual content: H. Brenner, M. Hoffmeister.

Final approval of the article: H. Brenner, L. Altenhofen, M. Hoffmeister.

Provision of study materials or patients: L. Altenhofen.

Statistical expertise: H. Brenner.


Ann Intern Med. 2010;152(11):697-703. doi:10.7326/0003-4819-152-11-201006010-00002
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Background: Prevalence of advanced colorectal neoplasms increases with age and is higher among men than women. Cross-sectional analyses estimated that men reach an equivalent prevalence at a much younger age than women. However, cross-sectional estimates may be confounded by birth cohort effects.

Objective: To estimate age and cohort effects in advanced colorectal neoplasms and to adjust risk-advancement periods for men compared with women for birth cohort effects.

Design: Age-cohort analyses.

Setting: German screening colonoscopy program, 2003 to 2007.

Participants: 2 185 153 participants aged 55 to 75 years.

Measurements: Sex- and age-specific prevalence of colorectal cancer (CRC) and advanced neoplasms (CRC or advanced adenoma) were plotted with and without stratification by birth cohort. Risk-advancement periods with 95% CI for men compared with women were estimated from log-binomial regression models with and without cross-sectional analysis adjustment for birth cohort effects.

Results: Overall, 17 196 participants (0.8%) had CRC and 152 429 (7.0%) had any advanced neoplasm. Age-specific prevalence was higher in men than in women and in later birth cohorts. The apparent modest increase in prevalence by age in cross-sectional analysis was much steeper after birth cohort effects were controlled for. In cross-sectional analysis, risk-advancement periods (95% CI) for men compared with women were 8.4 years (CI, 7.7 to 9.0 years) and 16.1 years (CI, 15.8 to 16.5 years) for CRC and any advanced neoplasm, respectively, and 3.4 years (CI, 2.6 to 4.3 years) and 6.9 years (CI, 6.4 to 7.4 years) after controlling for birth cohort effects.

Limitation: Information on covariates that could explain cohort effects was lacking.

Conclusion: In this population, strong cohort effects reduced age gradients in advanced colorectal neoplasms and inflated risk-advancement periods for men compared with women, but major risk advancement persisted, even after birth cohort effects were controlled for.

Primary Funding Source: None.

Figures

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Figure 1.
Years of birth of screening participants in analysis, by age and calendar year of screening colonoscopy.
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Figure 2.
Prevalence of colorectal cancer and any advanced neoplasm, by sex and age, among participants in the German screening colonoscopy program, 2003 to 2007.

Advanced colorectal neoplasm included colorectal cancer and advanced adenomas.

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Figure 3.
Prevalence of colorectal cancer and any advanced colorectal neoplasm, by age and birth cohorts born 2 years apart among men in the German screening colonoscopy program, 2003 to 2007.

Advanced colorectal neoplasm included colorectal cancer and advanced adenomas. The solid and dotted lines correspond to the prevalence of birth cohorts indicated in the dark and light shaded cells in Figure 1.

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Grahic Jump Location
Figure 4.
Prevalence of colorectal cancer and advanced colorectal neoplasm, by age and birth cohorts born 2 years apart among women in the German screening colonoscopy program, 2003 to 2007.

Advanced colorectal neoplasm included colorectal cancer and advanced adenomas. The solid and dotted lines correspond to the prevalence of birth cohorts indicated in the dark and light shaded cells in Figure 1.

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Comments

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Colorectal cancer screening and Evidence-Based Policy
Posted on June 10, 2010
Alain Braillon
No Affiliation
Conflict of Interest: None Declared

Colorectal cancer screening and Evidence-Based Policy

Brener et al's cohort analysis showed that men and women must benefit from different programs regarding age for beginning and screening intervals(1). This important research was performed without funding indicating that the healthcare agencies (eg. national cancer institute, those who reimburse the screening, healthcare wathchdog, etc ) fail to evaluate their policies.

Implementation of Brener et al's findings in screening policies by the healthcare agencies is doubtful. Eg. in France calls for screening were published as early as 1995 (the results of the two 1996 Lancet papers being available since 1994)(2). However, screening was only implemented in 2003, in only 23 districts out of 100: Mean participation rate for the first intervention was 42% (five territories were over 50%, the best reaching 54%) and five territories were below 35% (3). Generalisation to all 100 districts only underwent in the late 2008, still using Fecal Occult Blood Test, and the was very few measure to improve participation.

Healthcare agencies call for better implementation of Evidence-Based Medicine by healthcare professionals but exhibit little accountability for either evaluation of their policies or acting quickly on new scientific evidence(4).

References

1 Brenner H, Altenhofen L, Hoffmeister M. Sex, age, and birth cohort effects in colorectal neoplasms: a cohort analysis. Ann Intern Med. 2010 1;152:697-703

2 Dubois G. Screening for colorectal cancer. French Working Group on Colorectal Cancer Screening. N Engl J Med 1995;333:460-1

3 Braillon A, Dubois G. [French health policy and screening for colorectal cancer]. Gastroenterol Clin Biol. 2010;34:142-3

4 Braillon A Implement research faster. CMAJ. 2010;182:176

Conflict of Interest:

None declared

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