70歲以上者進行結腸鏡檢查之效益不大


  【24drs.com】70歲以上者進行結腸鏡檢查之效益不大
  
  研究認為,70歲以上成人進行結腸鏡檢查預防結腸直腸癌(colorectal cancer,CRC)的效益很小,而且,手術相關的風險雖然低,但是隨著年齡增長。這篇研究線上發表於9月27日內科醫學誌。
  
  作者們結論指出,70歲至74歲的Medicare醫療保險受益人,結腸鏡檢查篩檢以預防CRC可能有適度的好處,75歲至79歲保險受益人的效益更小,而不良反應的風險雖然在較年輕者比較低,但是在年長者中增加。
  
  國家健康研究院資助的這篇研究,是由麻州波士頓哈佛T. H. Chan公衛學院流行病學系的Xabier Garcia-Albeniz博士等人所進行。
  
  Garcia-Albeniz博士等人寫道,結腸鏡檢查藉由識別無症狀、可治癒的癌症,而預期可降低CRC死亡率,藉由檢測和去除癌前息肉,而降低CRC發生率。
  
  不過,儘管它在美國被廣泛使用,卻未曾有過篩檢性結腸鏡檢查的隨機控制試驗。
  
  這是侵入性的檢查,需要徹底的大腸清洗,而且患者通常需接受鎮靜,它的相關併發症風險,如腸道穿孔。
  
  美國預防服務工作小組建議用任何方法進行例行性CRC篩檢,包括較少負擔的方法,例如糞便潛血檢查(FOBT)和乙狀結腸鏡檢查-建議用於50歲至75歲有CRC之一般風險者,而76歲至85歲者則是個別化進行篩檢決定。
  
  作者們指出,儘管未曾有過篩檢性結腸鏡檢查的隨機控制試驗,且進行中的試驗並未納入75歲以上者,Medicare醫療保險的受益人,不論年齡都可以核報結腸鏡檢查。
  
  目前這篇研究中,Garcia-Albeniz博士等人使用了2004至2012年間、70歲至79歲的1,355,692名Medicare醫療保險受益人的觀察資料。
  
  這些研究對象沒有CRC、腺瘤、發炎性腸道疾病或結腸切除術病史,過去5年內也未曾進行結腸鏡,乙狀結腸鏡檢查或FOBT等檢查。
  
  他們利用這些觀察數據,模擬結腸鏡篩檢目標試驗與沒有篩檢之比較,檢測CRC的8年風險與不良反應的30日風險。
  
  在70歲至74歲者中,CRC的8年風險在那些接受過篩檢性結腸鏡者是 2.19% (95%信賴區間[CI], 2.00% -2.37%),沒有接受過篩檢者則是2.62% (95% CI, 2.56%- 2.67%),絕對風險差異是 -0.42% (95% CI, -0.24% 至 -0.63%)。
  
  在75歲至79歲者中, CRC的8年風險在那些接受過篩檢性結腸鏡者是2.84% (95% CI, 2.54% -3.13%),沒有接受過篩檢者則是2.97% (95% CI, 2.92% -3.03%),絕對風險差異是-0.14% (95% CI, -0.41%至0.16%)。
  
  結腸鏡檢查的不良反應風險隨年齡而增加。
  
  70歲至74歲的結腸鏡檢組中, 30日以上、任何不良反應的風險是每1000人有5.6次事件(95% CI, 4.4 - 6.8)。
  
  75歲至79歲者中,前述數據是每1000人有10.3次(95% CI, 8.6 - 11.1)。
  
  作者們寫道,我們估計篩檢性結腸鏡檢查對年長者之CRC發生率與併發症的影響,這對於增加篩檢率的現行政策是相當重要的。
  
  他們評論指出,這篇研究對於70歲以上者進行篩檢性結腸鏡之效果與安全性提供了精確的估計,這群患者在隨機試驗中屬於代表性不足的一群。
  
  研究結果認為70歲至74歲的篩檢性結腸鏡檢查對於預防CRC有適度效益,而年長者效益相當有限。我們的研究結果有助於患者、醫師與政策制定者做出有關CRC篩檢的明智決定。
  
  資料來源: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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