Effect of flexible sigmoidoscopy-based screening on incidence and mortality of colorectal cancer: a systematic review and meta-analysis of randomized controlled trials.
Effect of flexible sigmoidoscopy-based screening on incidence and mortality of colorectal cancer: a systematic review and meta-analysis of randomized controlled trials.
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DOI：
10.1371/journal.pmed.1001352
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发表时间：
2012
期刊：
影响因子：
15.8
通讯作者：
Waljee AK
中科院分区：
文献类型：
--
作者：
Elmunzer BJ;Hayward RA;Schoenfeld PS;Saini SD;Deshpande A;Waljee AK
B. Joseph Elmunzer 及其同事对随机试验进行的系统回顾和荟萃分析报告称，与常规护理或不进行筛查相比，基于乙状结肠镜的灵活筛查可降低平均风险患者的结直肠癌发病率。随机对照试验 (RCT) 对柔性乙状结肠镜 (FS) 筛查结直肠癌 (CRC) 的益处得出了不同的估计。我们的目标是通过对已发表的随机对照试验进行荟萃分析，更准确地估计基于 FS 的筛查对 CRC 发病率和死亡率的影响。检索了 Medline 和 Embase 数据库，查找 1966 年至 2012 年 5 月 28 日期间发表的符合条件的文章。在筛选了 3,319 篇引用和 29 篇潜在相关文章后，两位评审员确定了 5 项随机对照试验，评估 FS 筛查对 CRC 发病率和死亡率的影响。评审人员独立提取相关数据；分歧以协商一致方式解决。使用循证胃肠病学指导小组制定的标准评估纳入研究的质量。进行了随机效应荟萃分析。符合资格标准的 5 项 RCT 被确定为具有较高的方法学质量，总共纳入了 416,159 名受试者。四项欧洲研究将 FS 与不筛查进行了比较，一项来自美国的研究将 FS 与常规护理进行了比较。通过意向治疗分析，基于 FS 的筛查与 CRC 发病率相对风险降低 18% 相关（0.82，95% CI 0.73–0.91，p<0.001，为预防 1 例 CRC = 361 病例所需筛查 [NNS] 的数量），左侧 CRC 发病率降低 33%（RR 0.67，95% CI） 0.59–0.76，p<0.001， NNS = 332），CRC 死亡率降低 28%（相对风险 [RR] 0.72，95% CI 0.65–0.80，p<0.001，NNS = 850）。疗效估计，即那些实际坚持推荐治疗的患者的获益量，表明 FS 筛查可将 CRC 发病率降低 32% (p<0.001)，并将 CRC 相关死亡率降低 50% (p<0.001)。这项荟萃分析的局限性包括纳入试验设计的异质性、缺乏来自非洲、亚洲或南美洲的研究，以及缺乏将 FS 与结肠镜检查或粪便检测进行比较的研究。这项随机对照试验的荟萃分析表明，基于 FS 的筛查可显着降低平均风险患者结直肠癌的发病率和死亡率。 请参阅本文后面的编辑摘要结直肠癌 (CRC) 是美国癌症相关死亡的第二大原因。定期 CRC 筛查已被证明可以将死于 CRC 的风险降低 16%，并且 CRC 筛查可以识别其他健康人群的早期癌症，从而可以及早治疗和管理疾病。结直肠癌筛查通常使用柔性乙状结肠镜 (FS) 进行，这是一种细而柔性的管，末端有一个微型摄像头和灯，使医生可以观察肠内壁并去除任何小的增生或息肉。尽管筛查可以发现早期癌症，但筛查对挽救生命和健康的益处尚不确定，因为息肉不一定会进展。这可能会导致接受筛查的人感到焦虑和不必要的干预和治疗。需要随机对照试验 (RCT) 来确定癌症筛查中涉及的所有风险，但是推荐基于 FS 的筛查的指南并不依赖于 RCT 数据。最近，评估 CRC FS 筛查的四项大规模随机对照试验的结果已发表。这些研究中关于结直肠癌发病率和死亡率的相互矛盾的结果使人们对内镜筛查的有效性产生了质疑。衡量 CRC 筛查风险和结果的随机对照试验结果显示，对使用 FS 筛查的益处有不同的估计。如果对 FS 筛查的风险和益处进行更好的估计，那么当前的 CRC 筛查指南可能会更新以反映这一新信息。在这项研究中，作者展示了已发表的随机对照试验的荟萃分析结果，该结果更准确地估计了基于 FS 的筛查对结直肠癌发病率和死亡率的影响。研究人员利用 Medline 和 Embase 数据库查找了 1966 年至 2012 年 5 月 28 日期间的相关研究。在筛选了 3,319 篇引用和 29 篇潜在相关文章后，确定了 5 项方法学质量较高的随机对照试验和 416,159 名受试者，评估 FS 筛查对 CRC 发病率和死亡率的影响。提取数据并进行随机效应荟萃分析。荟萃分析显示，基于 FS 的筛查与 CRC 发病率相对风险降低 18% 相关（0.82，95% CI 0.73–0.91，p<0.001，预防 1 例 CRC = 361 例所需筛查 (NNS) 的数量），左侧 CRC 发病率降低 33%（RR 0.67，95% CI） 0.59–0.76， p<0.001，NNS = 332），CRC 死亡率降低 28%（RR 0.72，95% CI 0.65–0.80，p<0.001，NNS = 850）。坚持推荐治疗的患者的获益量表明，FS 筛查可将 CRC 发病率降低 32% (p<0.001)，并将 CRC 相关死亡率降低 50% (p<0.001)。这项评估 FS 对 CRC 发病率和死亡率影响的随机对照试验荟萃分析表明，基于 FS 的筛查策略对于降低患者 CRC 的发病率和死亡率非常有效。目前内镜筛查的建议基于观察性研究，可能无法准确反映基于 FS 的筛查对 CRC 发病率和死亡率的影响。在这里，作者对最近的五项随机对照试验进行了系统回顾和荟萃分析，以更好地估计基于 FS 的筛查对 CRC 发病率和死亡率的真实影响。因此，这项荟萃分析的结果可能会影响卫生政策，并直接影响患者和临床医生。请通过此摘要的在线版本访问这些网站：http://dx.doi.org/10.1371/journal.pmed.1001352。英国癌症研究中心提供有关结肠直肠癌筛查的全面信息，英国国家筛查委员会 PubMed Health 也提供有关结肠癌的一般信息 英国国家癌症研究所还提供有关结肠直肠癌和治疗的全面资源 梅奥诊所提供结肠癌各个方面的概述
A systematic review and meta-analysis of randomized trials conducted by B. Joseph Elmunzer and colleagues reports that that flexible sigmoidoscopy-based screening reduces the incidence of colorectal cancer in average-risk patients, as compared to usual care or no screening. Randomized controlled trials (RCTs) have yielded varying estimates of the benefit of flexible sigmoidoscopy (FS) screening for colorectal cancer (CRC). Our objective was to more precisely estimate the effect of FS-based screening on the incidence and mortality of CRC by performing a meta-analysis of published RCTs. Medline and Embase databases were searched for eligible articles published between 1966 and 28 May 2012. After screening 3,319 citations and 29 potentially relevant articles, two reviewers identified five RCTs evaluating the effect of FS screening on the incidence and mortality of CRC. The reviewers independently extracted relevant data; discrepancies were resolved by consensus. The quality of included studies was assessed using criteria set out by the Evidence-Based Gastroenterology Steering Group. Random effects meta-analysis was performed. The five RCTs meeting eligibility criteria were determined to be of high methodologic quality and enrolled 416,159 total subjects. Four European studies compared FS to no screening and one study from the United States compared FS to usual care. By intention to treat analysis, FS-based screening was associated with an 18% relative risk reduction in the incidence of CRC (0.82, 95% CI 0.73–0.91, p<0.001, number needed to screen [NNS] to prevent one case of CRC = 361), a 33% reduction in the incidence of left-sided CRC (RR 0.67, 95% CI 0.59–0.76, p<0.001, NNS = 332), and a 28% reduction in the mortality of CRC (relative risk [RR] 0.72, 95% CI 0.65–0.80, p<0.001, NNS = 850). The efficacy estimate, the amount of benefit for those who actually adhered to the recommended treatment, suggested that FS screening reduced CRC incidence by 32% (p<0.001), and CRC-related mortality by 50% (p<0.001). Limitations of this meta-analysis include heterogeneity in the design of the included trials, absence of studies from Africa, Asia, or South America, and lack of studies comparing FS with colonoscopy or stool-based testing. This meta-analysis of randomized controlled trials demonstrates that FS-based screening significantly reduces the incidence and mortality of colorectal cancer in average-risk patients. Please see later in the article for the Editors' Summary Colorectal cancer (CRC) is the second leading cause of cancer-related death in the United States. Regular CRC screening has been shown to reduce the risk of dying from CRC by 16%, and CRC screening can identify early stage cancers in otherwise healthy people, which allows for early treatment and management of the disease. Screening for colorectal cancer is frequently performed using a flexible sigmoidoscopy (FS), which is a thin, flexible tube with a tiny camera and light on the end, allowing a doctor to look at the inside wall of the bowel and remove any small growths or polyps. Although screening may detect early cancers, the life-saving and health benefits of screening are uncertain because the polyp may not necessarily progress. This could lead to anxiety and unnecessary interventions and treatments amongst those screened. Randomized controlled trials (RCTs) are needed to determine all of the risks involved in cancer screenings, however the guidelines that recommend FS-based screening do not rely upon RCT data. Recently, the results of four large-scale RCTs evaluating FS screening for CRC have been published. The conflicting results with respect to the incidence and mortality of CRC in these studies have called into question the effectiveness of endoscopic screening. The results of RCTs measuring the risks and outcomes of CRC screening have shown varying estimates of the benefits of using FS screening. If better estimates of the risks and benefits of FS screening are developed, then the current CRC screening guidelines may be updated to reflect this new information. In this study, the authors show the results of a meta-analysis of published RCTs, which more precisely estimates the effects of FS-based screening on the incidence and mortality of colorectal cancer. The researchers used the Medline and Embase databases to find relevant studies from 1966 to May 28, 2012. After screening 3,319 citations and 29 potentially relevant articles, five RCTs of high methodologic quality and 416,159 total subjects evaluating the effect of FS screening on the incidence and mortality of CRC were identified. The data were extracted and random effects meta-analysis was performed. The meta-analysis revealed that FS-based screening was associated with an 18% relative risk reduction in the incidence of CRC (0.82, 95% CI 0.73–0.91, p<0.001, number needed to screen (NNS) to prevent one case of CRC = 361), a 33% reduction in the incidence of left-sided CRC (RR 0.67, 95% CI 0.59–0.76, p<0.001, NNS = 332), and a 28% reduction in the mortality of CRC (RR 0.72, 95% CI 0.65–0.80, p<0.001, NNS = 850). The amount of benefit for those who adhered to the recommended treatment suggested that FS screening reduced CRC incidence by 32% (p<0.001), and CRC-related mortality by 50% (p<0.001). This meta-analysis of RCTs evaluating the effect of FS on CRC incidence and mortality demonstrates that a FS-based strategy for screening is very effective in reducing the incidence and mortality of CRC in patients. The current recommendations for endoscopic screening are based on observational studies, which may not accurately reflect the effect of FS-based screening on the incidence and mortality of CRC. Here, the authors performed a systematic review and meta-analysis of five recent RCTs to better estimate the true effect of FS-based screening on the incidence and mortality of CRC. Thus, the results of this meta-analysis may affect health policy, and directly impact patients and clinicians. Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001352. Cancer research UK provides comprehensive information about screening for colorectal cancers as does the UK National Screening Committee PubMed Health has general information about colon cancer The National Cancer Institute also has comprehensive resources on colorectal cancer and treatment The Mayo Clinic provides an overview of all aspects of colon cancer
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影响因子：
9.3
作者：
Kaminski MF;Bretthauer M;Zauber AG;Kuipers EJ;Adami HO;van Ballegooijen M;Regula J;van Leerdam M;Stefansson T;Påhlman L;Dekker E;Hernán MA;Garborg K;Hoff G
通讯作者：
Hoff G
影响因子：
105.7
作者：
Hoff, Geir;Grotmol, Tom;Bretthauer, Michael
通讯作者：
Bretthauer, Michael
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50.5
作者：
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通讯作者：
Grivegnee, A.
影响因子：
0.6
作者：
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通讯作者：
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影响因子：
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作者：
Federici, Antonio;Marinacci, Chiara;Guasticchi, Gabriella
通讯作者：
Guasticchi, Gabriella