70岁以上者进行结肠镜检查之效益不大


  【24drs.com】70岁以上者进行结肠镜检查之效益不大
  
  研究认为,70岁以上成人进行结肠镜检查预防结肠直肠癌(colorectal cancer,CRC)的效益很小,而且,手术相关的风险虽然低,但是随著年龄增长。这篇研究在线发表于9月27日内科医学志。
  
  作者们结论指出,70岁至74岁的Medicare医疗保险受益人,结肠镜检查筛检以预防CRC可能有适度的好处,75岁至79岁保险受益人的效益更小,而不良反应的风险虽然在较年轻者比较低,但是在年长者中增加。
  
  国家健康研究院资助的这篇研究,是由麻州波士顿哈佛T. H. Chan公卫学院流行病学系的Xabier Garcia-Albeniz博士等人所进行。
  
  Garcia-Albeniz博士等人写道,结肠镜检查藉由识别无症状、可治癒的癌症,而预期可降低CRC死亡率,藉由检测和去除癌前息肉,而降低CRC发生率。
  
  不过,尽管它在美国被广泛使用,却未曾有过筛检性结肠镜检查的随机控制试验。
  
  这是侵入性的检查,需要彻底的大肠清洗,而且患者通常需接受镇静,它的相关并发症风险,如肠道穿孔。
  
  美国预防服务工作小组建议用任何方法进行例行性CRC筛检,包括较少负担的方法,例如粪便潜血检查(FOBT)和乙状结肠镜检查-建议用于50岁至75岁有CRC之一般风险者,而76岁至85岁者则是个别化进行筛检决定。
  
  作者们指出,尽管未曾有过筛检性结肠镜检查的随机控制试验,且进行中的试验并未纳入75岁以上者,Medicare医疗保险的受益人,不论年龄都可以核报结肠镜检查。
  
  目前这篇研究中,Garcia-Albeniz博士等人使用了2004至2012年间、70岁至79岁的1,355,692名Medicare医疗保险受益人的观察资料。
  
  这些研究对象没有CRC、腺瘤、发炎性肠道疾病或结肠切除术病史,过去5年内也未曾进行结肠镜,乙状结肠镜检查或FOBT等检查。
  
  他们利用这些观察数据,模拟结肠镜筛检目标试验与没有筛检之比较,检测CRC的8年风险与不良反应的30日风险。
  
  在70岁至74岁者中,CRC的8年风险在那些接受过筛检性结肠镜者是 2.19% (95%信赖区间[CI], 2.00% -2.37%),没有接受过筛检者则是2.62% (95% CI, 2.56%- 2.67%),绝对风险差异是 -0.42% (95% CI, -0.24% 至 -0.63%)。
  
  在75岁至79岁者中, CRC的8年风险在那些接受过筛检性结肠镜者是2.84% (95% CI, 2.54% -3.13%),没有接受过筛检者则是2.97% (95% CI, 2.92% -3.03%),绝对风险差异是-0.14% (95% CI, -0.41%至0.16%)。
  
  结肠镜检查的不良反应风险随年龄而增加。
  
  70岁至74岁的结肠镜检组中, 30日以上、任何不良反应的风险是每1000人有5.6次事件(95% CI, 4.4 - 6.8)。
  
  75岁至79岁者中,前述数据是每1000人有10.3次(95% CI, 8.6 - 11.1)。
  
  作者们写道,我们估计筛检性结肠镜检查对年长者之CRC发生率与并发症的影响,这对于增加筛检率的现行政策是相当重要的。
  
  他们评论指出,这篇研究对于70岁以上者进行筛检性结肠镜之效果与安全性提供了精确的估计,这群患者在随机试验中属于代表性不足的一群。
  
  研究结果认为70岁至74岁的筛检性结肠镜检查对于预防CRC有适度效益,而年长者效益相当有限。我们的研究结果有助于患者、医师与政策制定者做出有关CRC筛检的明智决定。
  
  资料来源:http://www.24drs.com/
  
  Native link:Little Benefit for Screening Colonoscopy Over 70

Little Benefit for Screening Colonoscopy Over 70

By Fran Lowry
Medscape Medical News

The benefits of screening colonoscopy in preventing colorectal cancer (CRC) in adults 70 years of age appear scant, and the risks associated with the procedure, although low, increase with age, new research suggests.

The study was published online September 27 in the Annals of Internal Medicine.

The authors conclude that screening colonoscopy may have a modest benefit in preventing CRC in Medicare beneficiaries aged 70 to 74 years, and an even smaller benefit in beneficiaries aged 75 to 79 years, but that the risks for adverse events, although low in younger individuals, increased among older persons.

The National Institutes of Health–funded study was conducted by Xabier Garcia-Albeniz, MD, PhD, from the Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, and colleagues.

"Colonoscopy is expected to reduce CRC mortality by identifying asymptomatic, curable cancer and decrease CRC incidence by detecting and removing precancerous polyps," Dr Garcia-Albeniz and colleagues write.

"However, despite its widespread use in the United States, no randomized, controlled trials of screening colonoscopy have been completed."

The procedure is invasive and requires a thorough large-bowel cleansing and, oftentimes, patient sedation. It is associated with a risk for complications such as bowel perforation.

The US Preventive Services Task Force recommends routine CRC screening with any method, including "less burdensome" methods, such as fecal occult blood testing (FOBT) and sigmoidoscopy, for people 50 to 75 years of age who are at average risk for CRC and suggests that screening decisions be individualized for those aged 76 to 85.

Despite the fact that no randomized, controlled trials of screening colonoscopy have been completed and that ongoing trials do not include people aged 75 years and older, Medicare reimburses screening colonoscopy at any age, the authors point out.

In the current study, Dr Garcia-Albeniz and his group used observational data on 1,355,692 Medicare beneficiaries aged 70 to 79 who were enrolled from 2004 to 2012.

Participants had no history of CRC, adenoma, inflammatory bowel disease, or colectomy and had not undergone colonoscopy, sigmoidoscopy, or FOBT within the past 5 years.

They used these observational data to emulate a target trial of colonoscopy screening vs no screening and to measure the 8-year risk for CRC and the 30-day risk for adverse events.

Among people aged 70 to 74 years, the 8-year risk for CRC was 2.19% (95% confidence interval [CI], 2.00% to 2.37%) for those who received screening colonoscopy and 2.62% (95% CI, 2.56% to 2.67%) for those who received no screening.

The absolute risk difference was -0.42% (95% CI, -0.24% to -0.63%).

Among people aged 75 to 79 years, the 8-year risk for CRC was 2.84% (95% CI, 2.54% to 3.13%) for those who received screening colonoscopy and 2.97% (95% CI, 2.92% to 3.03%) for those who received no screening.

The absolute risk difference was -0.14% (95% CI, -0.41% to 0.16%).

The risk for adverse events with colonoscopy increased with age.

Among the 70- to 74-year-olds in the colonoscopy group, the excess 30-day risk for any adverse event was 5.6 events per 1000 individuals (95% CI, 4.4 - 6.8).

Among 75- to 79-year-olds, it was 10.3 per 1000 patients (95% CI, 8.6 - 11.1).

"Our estimates of the effect of screening colonoscopy on CRC incidence and complication rates in older persons are particularly important in view of current policies to increase screening uptake," the authors write.

The study provides "precise estimates of the effectiveness and safety of screening colonoscopy in persons aged 70 and older, an underrepresented population in randomized trials," they comment.

The findings "suggest a modest benefit of screening colonoscopy for preventing CRC in persons aged 70 to 74 years and a smaller (if any) benefit in those who are older.... Our findings may help patients, physicians, and policymakers make informed decisions about CRC screening."

The study was funded by the National Institutes of Health. The authors report no relevant financial relationships.

Ann Intern Med. Published online September 27, 2016.

    
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