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Simple score predicts risk of advanced proximal colon neoplasia

Clinical Question:
Can a risk score actually identify the likelihood of advanced proximal neoplasia among patients being screened for colorectal cancer?

Bottom Line:
A simple risk score can significantly reduce the need for colonoscopy, albeit at a risk of missing approximately 1 in 6 advanced proximal neoplasias (APNs). It is unclear whether this strategy will be acceptable in the United States, but it may be reasonable for patients resistant to colonoscopy or who cannot afford it. (LOE = 1b)

Reference:
Levitzky BE, Brown CC, Heeren TC, Schroy PC 3rd. Performance of a risk index for advanced proximal colorectal neoplasia among a racially/ethnically diverse patient population (Risk Index for Advanced Proximal Neoplasia). Am J Gastroenterol 2011;106(6):1099-1106.  [PMID:21326221]

Study Design:
Decision rule (validation)

Funding:
Self-funded or unfunded

Setting:
Outpatient (any)

Synopsis:
The cost of doing colonoscopy for every adult older than 50 years is enormous, and there are questions regarding capacity and allocation of resources. Flexible sigmoidoscopy can be easily done by primary care physicians and advance-practice nurses and is also appropriate in low-resource settings and countries. It has been shown in randomized trials to reduce mortality due to distal colorectal cancer. Because flexible sigmoidoscopy might miss proximal cancers, one strategy would be to limit colonoscopy to those patients at high risk for proximal cancer, and have the remainder undergo flexible sigmoidoscopy. In this study, a simple clinical score developed by Imperiale and colleagues was validated in an ethnically diverse group of patients (1481 white, 1329 black, and 689 Hispanic) undergoing screening colonoscopy. The score gave points for age (0 for 50-54 years, 1 for 55-59, 2 for 60-64, and 3 for 65 and older), sex (1 point for male), and the most advanced distal finding (0 for normal, 1 for hyperplastic polyp, 2 for tubular adenoma < 1 cm, and 3 for advanced neoplasia). Patients with 0 or 1 points were considered low risk, while those with 4 or more points were considered high risk. The authors found that the relative risk of APN was 0.6% to 1.0% for low-risk patients, 1.9% to 2.8% for moderate-risk patients, and 3.7% to 4.2% for high-risk patients (depending on the ethnic group). APN was defined as tubular adenoma greater than or equal to 1 cm, any adenoma with villous histology or high-grade dysplasia, or invasive cancer. Differences between low-risk and high-risk groups were signficant for all ethnic groups, and between low-risk and intermediate-risk groups for whites only (perhaps a sample size issue). Restricting colonoscopy to intermediate-risk and high-risk patients would reduce the need for colonoscopy by 33% to 46% and would still detect 82% to 83% of APNs. This compares with a reduction of 40% in the need for colonoscopy and a detection rate of 92% of the APNs in Imperiale's original study.

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