Colorectal Cancer Screening, and GI and Liver Disease

This transcript has been edited for clarity.

hi I am Dr. Vivek Kaul, and I am a professor of medicine in the Division of Gastroenterology and Hepatology at the University of Rochester Medical Center in Rochester, New York. It is my great pleasure to partner with WebMD and Medscape again this year, and this issue focuses on the topics that I thought would appeal to our primary care colleagues. This is the best of the American College of Gastroenterology (ACG) 2022 Annual Meeting for Primary Care.

This edition will focus on three main areas, which include colorectal cancer screening, functional gastrointestinal (GI) disease and liver disease. In the first section, I will talk about some papers that refer to colorectal cancer screening and hemorrhoid therapy.

This first paper addresses differences in the rate of multi-target stool DNA test completion for colorectal cancer screening. This is an important study, because colorectal cancer screening remains an important aspect of both primary care and GI practices, but still has several challenges, as illustrated by this study, and the NordICC trial, which was recently published in The New England Journal of Medicinealso suggested.

This retrospective study over 15 months had approximately 800 patients, and almost half of them had previously undergone screening. The tests ordered are depicted on this pie chart, with approximately 80% ordered by primary care and a minority by other sectors, including resident clinics.

The results of the study showed that 483 patients, nearly 61%, completed the multi-target stool DNA test, and the median time to completion was approximately 25 days. The factors that positively influenced test completion were Asian race and previous history of colorectal cancer screening.

However, some factors negatively affected adherence to this test, including African American race and tests ordered from resident clinics or from other outreach programs.

Again, the study highlights that while we do have excellent colonoscopy-based and non-colonoscopy-based screening options out there, adherence can also be a challenge. Almost 30% of adults in the US who are eligible for colorectal cancer screening may not appear for that test for one reason or another.

This remains a challenge, awareness of these problems is important, and every effort, both at the clinical and investigative level, must be made to move the needle in this space.

Our second paper in the colon section addresses the evaluation of what fecal DNA tests and fecal immunochemical tests (FITs) really mean. In this paper, titled, “What do ‘false positive’ stool tests really mean?” data from the New Hampshire Colonoscopy Registry were evaluated.

This is a 5-year period that included 549 stool DNA tests and 410 FIT tests. The goal here was to understand when you have a positive DNA or FIT test, what are the colonoscopy findings and when do you call it a false discovery?

If you look at this slide, there are three categories of what constitutes a positive colonoscopy after a positive stool test. The DeeP-C study included any cancers, adenomas and advanced polyps.

The recommendations of the task force were that any colonoscopy that generates an earlier interval for screening or surveillance be considered positive, such as the finding of polyps, and then, of course, the clinically significant group included both these categories as well as those that included serrated polyps has.

The next slide here shows the false discovery rate, which is the number of positive stool tests with a negative colonoscopy – meaning a colonoscopy that doesn’t have any of the criteria I mentioned before – and the positive predictive value of these stool tests.

When they looked at both the DNA and the FIT populations that underwent these tests, they found that the false discovery rate really dropped when you included all three categories of positivity, including the clinically significant, including serrated adenomas.

The false discovery rate decreases and the positive predictive value increases in both of these populations. It is important to note that, when we do these stool tests, it is not only the patients with cancer that we count, but also the patients who have serrated adenomas and proximal hyperplastic polyps or any other findings that, according to the guideline, indicate an earlier surveillance colonoscopy. This is an important takeaway from this paper.

Finally, in the colon section, there was an interesting paper. We all know that hemorrhoids are a very important cause of morbidity, both in primary care and in GI practice. Many interventions, both surgical and non-surgical, have been tried over the years.

Here is a paper on a hemorrhoid specialist clinic or center, which is a unique center that focuses on a comprehensive approach to hemorrhoid management. The safety and efficacy of hemorrhoidal artery embolization were evaluated in this article.

A cohort of 126 patients underwent hemorrhoidal arterial embolization using polyvinyl alcohol foam particles and coils. The technical success rate in this population was 100%, which is very commendable. You can see that the patients underwent these procedures on an outpatient basis with no serious adverse events and only minor post-treatment effects.

The outcomes suggested that bleeding rates, quality of life scores, and hemorrhoid-related pain were much lower at the 3-month mark compared to the baseline score. This provides another option for our patients with significant hemorrhoidal disease who are unwilling to medical therapy and conservative measures. This raises hope in both our practices at primary care and GI levels, and it is likely that there will be more information about these approaches in the future.

In the next section, which is functional GI disease – still a large proportion of patients in both primary care and GI practice – I have selected a few papers, one related to dyspepsia and a new approach to management of dyspepsia, and another one about IBS.

As we all know, cognitive-behavioral therapy and the use of virtual reality-based algorithms and experiences have now come into play in the management of IBS and functional GI disease. Here is a paper looking at the impact of virtual reality on the symptoms of functional dyspepsia.

As a refresher, functional dyspepsia is diagnosed according to Rome 4 criteria in patients with one or more of the following symptoms, with a symptom frequency greater than or equal to twice a week: postprandial fullness, early satiety, epigastric pain and epigastric burning. . There should be no evidence of structural disease. These criteria must be met for at least 3 months, with symptom onset for longer than 6 months.

The researchers looked at the impact of virtual reality in this realm. There were 37 patients with functional dyspepsia, with 27 in the treatment arm and 10 in the control arm. Essentially, the patients were given a virtual reality headset where they had an immersive audio-visual experience, while the control population had a headset with two-dimensional nature videos.

Overall, 17 patients reported some non-serious adverse events, such as headache and dizziness, and one patient from the experimental group withdrew due to migraine.

The mean total Patient Rating of GI Disorders Symptom Severity Index, shown on the left, significantly decreased in the virtual reality group, and the total Nepean Dyspepsia Index improved in the virtual reality group and in the control group. Only the virtual reality group had significant improvements in abdominal pain compared to some of the other criteria.

The study tells us that there may be something here in terms of managing our patients with functional dyspepsia and functional pain over and above the lifestyle and medical therapy options. Virtual reality may play a role, if not in all, in a subset of patients going forward. Expect to see more data in this realm going forward as well.

Last but not least, in our liver department, I selected a study that reflects nearly three decades of data on the burden of obesity and, specifically, non-alcoholic fatty liver disease (NAFLD), which has now reached global epidemic proportions. reflect.

This paper is titled, “The Global Landscape of Nonalcoholic Fatty Liver Disease: Results From the Global Burden of Disease Study.” This is data collected from the Global Health Data Exchange results tool. The global incidence of NAFLD has increased by more than 50% over this period. The mortality attributable to this disease state increased from 93,000 to 169,000, and the disability-adjusted life years increased from 2.7 million years to 4.4 million years.

The highest prevalence of this condition is in the North African and Middle Eastern regions. This is a problem that, as I said, plagues the Western world and other parts of the world. It is a global epidemic at this point, with a global prevalence of 32%.

Not only does this portend negative prognostic implications from a chronic liver disease point of view, but also from a metabolic point of view, and it has major implications for cardiovascular disease and so on.

This is an area that is receiving a large amount of attention in medicine at all levels – in GI, cardiology, metabolic health, endocrine, primary care and lifestyle medicine. This is going to receive attention and focus from now on, and it is something that we as practitioners should be concerned about.

I hope you enjoyed getting an update on these very specific areas of GI from a primary care perspective, and that you find this information helpful in the care of your patients.

Thank you very much, and I’ll see you next time.

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