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Browsing by Author "Glowinski, Elizabeth A."
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Item Derivation and Validation of a Scoring System to Stratify Risk for Advanced Colorectal Neoplasia in Asymptomatic Adults: A Cross-sectional Study(American College of Physicians, 2015-09-01) Imperiale, Thomas F.; Monahan, Patrick O.; Stump, Timothy E.; Glowinski, Elizabeth A.; Ransohoff, David F.; Department of Medicine, IU School of MedicineBACKGROUND: Several methods are recommended equally strongly for colorectal cancer screening in average-risk persons. Risk stratification would enable tailoring of screening within this group, with less invasive tests (sigmoidoscopy or occult blood tests) for lower-risk persons and colonoscopy for higher-risk persons. OBJECTIVE: To create a risk index for advanced neoplasia (colorectal cancer and adenomas or serrated polyps ≥1.0 cm, villous histology, or high-grade dysplasia) anywhere in the colorectum, using the most common risk factors for colorectal neoplasia. DESIGN: Cross-sectional study. SETTING: Multiple endoscopy units, primarily in the Midwest. PATIENTS: Persons aged 50 to 80 years undergoing initial screening colonoscopy (December 2004 to September 2011). MEASUREMENTS: Derivation and validation of a risk index based on points from regression coefficients for age, sex, waist circumference, cigarette smoking, and family history of colorectal cancer. RESULTS: Among 2993 persons in the derivation set, prevalence of advanced neoplasia was 9.4%. Risks for advanced neoplasia in persons at very low, low, intermediate, and high risk were 1.92% (95% CI, 0.63% to 4.43%), 4.88% (CI, 3.79% to 6.18%), 9.93% (CI, 8.09% to 12.0%), and 24.9% (CI, 21.1% to 29.1%), respectively (P < 0.001). Sigmoidoscopy to the descending colon in the low-risk groups would have detected 51 of 70 (73% [CI, 61% to 83%]) advanced neoplasms. Among 1467 persons in the validation set, corresponding risks for advanced neoplasia were 1.65% (CI, 0.20% to 5.84%), 3.31% (CI, 2.08% to 4.97%), 10.9% (CI, 8.26% to 14.1%), and 22.3% (CI, 16.9% to 28.5%), respectively (P < 0.001). Sigmoidoscopy would have detected 21 of 24 (87.5% [CI, 68% to 97%]) advanced neoplasms. LIMITATIONS: Split-sample validation; results apply to first-time screening. CONCLUSION: This index stratifies risk for advanced neoplasia among average-risk persons by identifying lower-risk groups for which noncolonoscopy strategies may be effective and efficient and a higher-risk group for which colonoscopy may be preferred. PRIMARY FUNDING SOURCE: National Cancer Institute, Walther Cancer Institute, Indiana University Simon Cancer Center, and Indiana Clinical and Translational Sciences Institute.Item Phenotypic features effectively stratify risk for advanced colorectal neoplasia in asymptomatic adults(Office of the Vice Chancellor for Research, 2015-04-17) Imperiale, Thomas F.; Monahan, Patrick O.; Stump, Timothy E.; Glowinski, Elizabeth A.; Ransohoff, David F.Background: While colorectal cancer (CRC) screening is effective and cost-effective for reducing CRC incidence and mortality, it is underutilized (nearly 40% of U.S. adults are either not current with or have never been screened), inefficient (low-risk persons undergo colonoscopy), and costly to the U.S. health care system. A simple and effective way of stratifying risk for advanced neoplasia (AN – CRC and advanced, precancerous polyps) could improve the efficiency and uptake of screening by tailoring colonoscopy toward persons at highrisk and giving low-risk persons less-invasive options. Although several risk factors for AN have been identified, they are not used in clinical practice in part because of inability to integrate the factors to produce a risk estimate. Objective: To derive and validate a risk index for AN (CRC, advanced adenomas, serrated polyps >= 1 cm) anywhere in the colorectum. Methods: We measured socio-demographic features, medical and family history, lifestyle factors, and physical features in 50-80 year old persons who underwent first-time screening colonoscopy between December 2004 and September 2011, and linked these factors to endoscopic and histologic findings. Using logistic regression, we derived a risk equation on a randomly selected 2/3s of the sample. A 12-variable model was selected based on optimal statistical metrics. Based on model coefficients, we assigned points to each variable to create a risk score, which ranged from -13 to 8. Scores with comparable magnitudes of risk were collapsed into 3 risk categories. The model was tested on the remaining third of the sample. Results: Among 3025 subjects in the derivation set (mean age 57.3 ± 6.5 years; 52% women), the prevalence of AN was 9.4% (including 26 CRCs). Model variables include age, sex, smoking, ethanol use, marital status, NSAID and aspirin use, physical activity, education level, and metabolic syndrome (P-value for fit = 0.09; cstatistic=0.78). Respective risks of AN in the low- (scores of -13 to -5), intermediate- (scores of -4 to 2) and high- (scores of 3 to 12) were 1.52% (95%, 0.07-2.8%), 6.86%, and 26.8% (P-value for trend < 0.001), with respective cohort proportions of 23%, 59% and 18%. Ten low-risk subjects had AN (0 CRCs, 6 distal). Based on finding a distal sentinel polyp, sigmoidoscopy to the descending colon would have detected 7(70%) ANs. Among the 1475 subjects in the test set (mean age 57.2 ± 6.5 years; 52% women), AN prevalence was 8.4%. Risk of AN in the low-risk subgroup was 2.73% (CI, 1.25-5.11%) and was 5.57% and 25.4% in the intermediate- and high-risk subgroups, respectively (P<0.001), with cohort proportions of 23%, 59%, and 18%. Nine low-risk subjects had AN (0 CRCs, 5 distal, 6 detectable by sigmoidoscopy. Conclusion: This new risk index effectively stratifies the risk for AN among asymptomatic adults, identifying a low-risk subgroup of 23% that may be screened effectively and efficiently with tests other than colonoscopy and a high-risk subgroup of 18% in which colonoscopy may be preferable. If validated in other settings, this index could increase both the efficiency and uptake of CRC screening.