Smoking status informs about the risk of advanced serrated polyps in a screening population

Background and study aims: Evidence has accumulated that approximately 15 % to 30 % of colorectal cancers (CRC) arise from serrated polyps (SP). Population screening, therefore, should be designated to detect advanced SP, in addition to advanced adenomas and CRC. We aimed to evaluate whether CRC risk factors also act as risk factors for advanced SP.

Patients and methods: Data were collected in the colonoscopy arm of a multicenter randomized trial comparing colonoscopy with CT-colonography for primary population screening. Information on risk factors was obtained by screening participants before colonoscopy with a validated risk questionnaire. Advanced SP were defined as SP ≥ 10 mm and/or with dysplasia. Endoscopists were instructed to resect all detected lesions. Odds ratios (OR) for the detection of advanced SP as most advanced lesion were calculated using multiple logistic regression analysis.

Results: Of 6 600 invited participants, 1 426 underwent a colonoscopy and 1 236 also completed the questionnaire. In 40 participants an advanced SP was the most advanced lesion detected. Multivariate analysis demonstrated a strong association between current smoking and the presence of at least one advanced SP (OR 4.50; 95 % CI 2.23 – 8.89; P < 0.001). A significant association was also demonstrated for higher fiber intake (OR 1.36 per 20 gram intake; CI 1.07 – 1.73; P = 0.01). Other clinical CRC risk factors did not show a significant association with the presence of at least one advanced SP in the univariate analyses. Fecal haemoglobin levels were also not significantly associated with the presence of advanced SPs (OR 1.00 per 10 ng/mL CI 0.97 – 1.03, P = 0.99).

Conclusions: Current smoking is a strong clinical risk factor for the presence of advanced SPs. As such, smoking status could contribute to risk stratification in targeted CRC population screening.

Dutch Trial Register: NTR1829 (www.trialregister.nl)

• References

• 1 Zauber AAG, Winawer SSJ, O'Brien MJ et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012; 67: 355-356
• 2 Løberg M, Kalager M, Holme Ø et al. Long-term colorectal-cancer mortality after adenoma removal. N Engl J Med 2014; 371: 799-807
• 3 Lansdorp-Vogelaar I, Knudsen AB, Brenner H. Cost-effectiveness of colorectal cancer screening. Epidemiol Rev 2011; 33: 88-100
• 4 Rex DK, Johnson DA, Anderson JC et al. American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected]. Am J Gastroenterol 2009; 104: 739-750
• 5 Van Rossum LGM, van Rijn AF, Verbeek ALM et al. Colorectal cancer screening comparing no screening, immunochemical and guaiac fecal occult blood tests: a cost-effectiveness analysis. Int J Cancer 2011; 128: 1908-1917
• 6 Parente F, Boemo C, Ardizzoia A et al. Outcomes and cost evaluation of the first two rounds of a colorectal cancer screening program based on immunochemical fecal occult blood test in northern Italy. Endoscopy 2013; 45: 27-34
• 7 Kapidzic A, Grobbee EJ, Hol L et al. Attendance and Yield Over Three Rounds of Population-Based Fecal Immunochemical Test Screening. Am J Gastroenterol 2014; 8: 1-9
• 8 De Wijkerslooth TR, Stoop EM, Bossuyt PM et al. Immunochemical fecal occult blood testing is equally sensitive for proximal and distal advanced neoplasia. Am J Gastroenterol 2012; 107: 1570-1578
• 9 Stegeman I, de Wijkerslooth TR, Stoop EM et al. Combining risk factors with faecal immunochemical test outcome for selecting CRC screenees for colonoscopy. Gut 2014; 63: 466-471
• 10 Imperiale TF, Ransohoff DF, Itzkowitz SH et al. Multitarget stool DNA testing for colorectal-cancer screening. N Engl J Med 2014; 370: 1287-97
• 11 Snover DC, Ahnen DJ, Burt RW et al. Serrated polyps of the colon and rectum and serrated polyposis. In: Bosman T, Carneiro F, Hruban R, et al. WHO Classification of Tumours of the digestive system. Lyon: 2010: 160-165
• 12 Rex DK, Ahnen DJ, Baron JA et al. Serrated lesions of the colorectum: review and recommendations from an expert panel. Am J Gastroenterol 2012; 107: 1315-1329 quiz 1314, 1330.
• 13 Rosty C, Hewett DG, Brown IS et al. Serrated polyps of the large intestine: current understanding of diagnosis, pathogenesis, and clinical management. J Gastroenterol 2013; 48: 287-302
• 14 Snover DC. Update on the serrated pathway to colorectal carcinoma. Hum Pathol 2011; 42: 1-10
• 15 Arain MA, Sawhney M, Sheikh S et al. CIMP status of interval colon cancers: another piece to the puzzle. Am J Gastroenterol 2010; 105: 1189-1195
• 16 Nishihara R, Wu K, Lochhead P et al. Long-term colorectal-cancer incidence and mortality after lower endoscopy. N Engl J Med 2013; 369: 1095-1105
• 17 Hassan C, Quintero E, Dumonceau J-M et al. Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2013; 45: 842-851
• 18 Heigh RI, Yab TC, Taylor WR et al. Detection of colorectal serrated polyps by stool DNA testing: comparison with fecal immunochemical testing for occult blood (FIT). PLoS One 2014; 9: e85659
• 19 De Wijkerslooth TR, de Haan MC, Stoop EM et al. Study protocol: population screening for colorectal cancer by colonoscopy or CT colonography: a randomized controlled trial. BMC Gastroenterol 2010; 10: 47
• 20 Stegeman I, de Wijkerslooth TR, Stoop EM et al. Colorectal cancer risk factors in the detection of advanced adenoma and colorectal cancer. Cancer Epidemiol 2013; 37: 278-283
• 21 Colkesen EB, Ferket BS, Tijssen JGP et al. Effects on cardiovascular disease risk of a web-based health risk assessment with tailored health advice: A follow-up study. Vasc Health Risk Manag 2011; 7: 67-74
• 22 Van den Brink C, Ocke M, Houben A et al. Validering van standaardvraagstelling voeding voor Lokale en Nationale Monitor Volksgezondheid (validation of a community health services food consumption questionnaire in the Netherlands). RIVM Rapp 260854008 2005 : 1-43
• 23 Yusuf PS, Hawken S, Ôunpuu S et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): Case-control study. Lancet 2004; 364: 937-952
• 24 Rex DK, Petrini JL, Baron TH et al. Quality indicators for colonoscopy. Am J Gastroenterol 2006; 101: 873-85
• 25 Rostom A, Jolicoeur E. Validation of a new scale for the assessment of bowel preparation quality. Gastrointest Endosc 2004; 59: 482-486
• 26 Schlemper RJ. The Vienna classification of gastrointestinal epithelial neoplasia. Gut 2000; 47: 251-255
• 27 Streiner DL. The case of the missing data: Methods of dealing with dropouts and other research vagaries. Can J Psychiatry 2002; 47: 68-75
• 28 Hazewinkel Y, de Wijkerslooth TR, Stoop EM et al. Prevalence of serrated polyps and association with synchronous advanced neoplasia in screening colonoscopy. Endoscopy 2014; 46: 219-224
• 29 Lieberman DA, Prindiville S, Weiss DG et al. Risk factors for advanced colonic neoplasia and hyperplastic polyps in asymptomatic individuals. JAMA 2003; 290: 2959-2967
• 30 Morimoto LM, Newcomb PA, Ulrich CM et al. Risk factors for hyperplastic and adenomatous polyps: Evidence for malignant potential?. Cancer Epidemiol Biomarkers Prev 2002; 11: 1012-1018
• 31 Burnett-Hartman AN, Newcomb PA, Potter JD et al. Genomic aberrations occurring in subsets of serrated colorectal lesions but not conventional adenomas. Cancer Res 2013; 73: 2863-2872
• 32 Ji BT, Weissfeld JL, Chow WH et al. Tobacco smoking and colorectal hyperplastic and adenomatous polyps. Cancer Epidemiol Biomarkers Prev 2006; 15: 897-901
• 33 Fu Z, Shrubsole MJ, Smalley WE et al. Lifestyle factors and their combined impact on the risk of colorectal polyps. Am J Epidemiol 2012; 176: 766-776
• 34 Buda A, De Bona M, Dotti I et al. Prevalence of different subtypes of serrated polyps and risk of synchronous advanced colorectal neoplasia in average-risk population undergoing first-time colonoscopy. Clin Transl Gastroenterol 2012; 3: e6
• 35 Anderson JC, Rangasamy P, Rustagi T et al. Risk factors for sessile serrated adenomas. J Clin Gastroenterol 2011; 45: 694-699
• 36 Figueiredo JC, Crockett SD, Snover DC et al. Smoking-associated risks of conventional adenomas and serrated polyps in the colorectum. Cancer Causes Control 2014; 26: 377-386
• 37 Rustagi T, Rangasamy P, Myers M et al. Sessile serrated adenomas in the proximal colon are likely to be flat, large and occur in smokers. World J Gastroenterol 2013; 19: 5271-5277
• 38 Zeilinger S, Kühnel B, Klopp N et al. Tobacco smoking leads to extensive genome-wide changes in DNA methylation. PLoS One 2013; 8: e63812
• 39 Tahara T, Yamamoto E, Suzuki H et al. Fusobacterium in colonic flora and molecular features of colorectal carcinoma. Cancer Res 2014; 74: 1311-1318