Angemessener Einsatz der Koloskopie in Europa (EPAGE II)

Zusammenfassung

Hintergrund und Studienziele: Das europäische Expertengremium zur Eignung / Anwendung der gastrointestinalen Endoskopie 2008, EPAGE II hat die publizierten Arbeiten zur Bewertung des Einsatzes des koloskopischen Screenings des kolo­rektalen Karzinoms (CRC) bei asymptomatischen Individuen ohne CRC oder Polypen in der Anamnese zusammengefasst und Kriterien für den angemessenen Einsatz entwickelt. Methoden: Es wurde eine systematische Analyse von Leitlinien, systematischen Übersichten und primären Studien zum Einsatz der Koloskopie beim kolorektalen Karzinomscreening durchgeführt. Die RAND / UCLA-Bewertungsmethode wurde angewandt, um Eignungskriterien der Koloskopie in diesem Zusammenhang zu entwickeln. Ergebnisse: Die verfügbare Evidenz für das kolorektale Karzinomscreening stammt aus kleinen Fallkontrollstudien mit heterogenen Ergebnissen und aus einer indirekten Evidenz randomisierter kontrollierter Studien (RCTs) zum Screening mit dem fäkalen occulten Bluttest (ROPT) und aus Studien zum Screening mit flexibler Sigmo­idos­kopie. Die meisten Leitlinien empfehlen für ­Patienten mit durchschnittlichem Risiko Screeningkontrollen alle 10 Jahre ab einem Alter von 50 Jahren. Probanden mit einem höheren CRC-Risiko aufgrund der Familienanamnese sollten Screeningkoloskopien auch vor Erreichen des 50. Lebensjahres angeboten werden. EPAGE II hält Screeningkoloskopien bei Patienten mit durchschnittlichem Risiko ab einem Alter von über 50 Jahren für angemessen. Bei Patienten, bei ­denen ein erhöhtes familiäres oder persön­liches Risiko an kolorektalem Karzinom zu erkranken besteht, sollte das koloskopische Screening in einem jüngeren Lebensalter beginnen und in kürzeren Intervallen erfolgen. Ein positiver FOBT oder die Entdeckung von Adenomen bei der Sigmoidoskopie sind ebenfalls geeignete Indikationen. Schlussfolgerungen: Trotz des Fehlens evidenzbasierter Daten aus randomisierten kontrollierten Studien (RCPs) wird die ­Koloskopie von den meisten publizierten Leitlinien und EPAGE II (www.epage.ch) als eine Screeningoption für Patienten mit ­einem durchschnittlichen CRC-Risiko empfohlen. Unstrittig ist sie das wichtigste Screeninginstrument bei vorhandenem mittleren oder hohen CRC-Risiko.

Abstract

Background and study aims: To summarize the published literature on assessment of appro­priateness of colonoscopy for screening for colorectal cancer (CRC) in asymptomatic individuals with­out personal history of CRC or polyps, and ­report ­appropriateness criteria developed by an expert panel, the 2008 European Panel on the Appro­pri­ate­ness of Gastrointestinal Endoscopy, EPAGE II. Methods: A systematic search of guidelines, sys­tem­atic reviews, and primary studies regarding ­colonoscopy for screening for colorectal cancer was performed. The RAND / UCLA Appropriateness Method was applied to develop appropriateness criteria for colonoscopy in these circumstances. Results: Available evidence for CRC screening ­comes from small case-controlled studies, with ­heterogeneous results, and from indirect evidence from randomized controlled trials (RCTs) on fecal occult blood test (FOBT) screening and studies on flexible sigmoidoscopy screening. Most guidelines recommend screening colonoscopy every 10 years starting at age 50 in average-risk individuals. In individuals with a higher risk of CRC due to family history, there is a consensus that it is appropriate to offer screening colonos­copy at < 50 years. EPAGE II considered screening colonoscopy appropriate above 50 years in aver­age-risk individuals. Panelists deemed screening colonoscopy appropriate for younger patients, with shorter surveillance intervals, where family or personal risk of colorectal cancer is higher. A positive FOBT or the discovery of adenomas at ­sigmoidoscopy are considered appropriate indications. Conclusions: Despite the lack of evidence based on randomized controlled trials (RCTs), colo­noscopy is recommended by most published guide­lines and EPAGE II criteria available online (http://www.epage.ch), as a screening option for CRC in individ­uals at average risk of CRC, and undisputedly as the main screen­ing tool for CRC in individuals at moderate and high risk of CRC.

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1 Institutionen
¹ Healthcare Evaluation Unit, Institute of Social and Preventive Medicine (IUMSP), Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland