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Prevention of colorectal cancer by colonoscopic surveillance in individuals with a family history of colorectal cancer: 16 year, prospective, follow-up study

BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.38606.794560.EB (Published 03 November 2005) Cite this as: BMJ 2005;331:1047
  1. Isis Dove-Edwin, clinical research fellow (peter.sasieni{at}cancer.org.uk)1,
  2. Peter Sasieni, professor of biostatistics and cancer epidemiology2,
  3. Joanna Adams, statistician2,
  4. Huw J W Thomas, consultant gastroenterologist1
  1. 1 Family Cancer Group, Cancer Research UK Colorectal Cancer Unit, St Mark's Hospital, Harrow, Middlesex HA1 3UJ
  2. 2 Cancer Research UK Centre for Epidemiology, Mathematics and Statistics, Wolfson Institute of Preventive Medicine, London EC1M 6BQ
  1. Correspondence to: P Sasieni
  • Accepted 16 August 2005

Abstract

Objective To determine to what extent individuals with various family histories of colorectal cancer (from one to three or more affected first degree relatives) benefit from colonoscopic surveillance.

Design Prospective, observational study of high risk families, followed up over 16 years.

Setting Tertiary referral family cancer clinic in London.

Participants 1678 individuals from families registered with the clinic. Individuals were classified according to the strength of their family history: hereditary non-polyposis colorectal cancer (if they fulfilled the Amsterdam criteria), and one, two, or three affected first degree relatives (moderate risk).

Interventions Colonoscopy was initially offered at five year intervals or three year intervals if an adenoma was detected.

Main outcome measures The incidence of adenomas with high risk pathological features or cancer. This was analysed by age, the extent of the family history, and findings on previous colonoscopies. The cohort was flagged for cancer and death. Incidence of colorectal cancer and mortality during over 15 000 person years of follow-up were compared with those expected in the absence of surveillance.

Results High risk adenomas and cancer were most common in families with hereditary non-polyposis colorectal cancer (on initial colonoscopy 5.7% and 0.9%, respectively). In the families with moderate risk, these findings were particularly uncommon under age 45 (1.1% and 0%) and on follow-up colonoscopy if advanced neoplasia was absent initially (1.7% and 0.1%). The incidence of colorectal cancer was substantially lower—80% in families with moderate risk (P = 0.00004), and 43% in families with hereditary non-polyposis colorectal cancer (P = 0.06)—than the expected incidence in the absence of surveillance when the family history was taken into account.

Conclusions Colonoscopic surveillance reduces the risk of colorectal cancer in people with a strong family history. This study confirms that members of families with hereditary non-polyposis colorectal cancer require surveillance with short intervals. Individuals with a lesser family history may not require surveillance under age 45, and if advanced neoplasia is absent on initial colonoscopy, surveillance intervals may be lengthened. This would reduce the demand for colonoscopic surveillance.

Footnotes

  • Embedded ImageStatistical methods and a supplemental table are on bmj.com

  • Contributors IDE wrote the first draft of the paper. PS supervised the analysis of the data. JA analysed the data and coordinated the writing of the paper. HJWT is responsible for the clinical management of the patients at the family cancer group and initiated the analysis of the follow-up colonoscopies. All authors contributed to the writing of the paper. HJWT is the guarantor. He accepts full responsibility for the conduct of the study, had access to the data, and controlled the decision to publish.

  • Funding North Thames Regional Health Authority Responsive Funding R&D Committee provided the salary of a research fellow (IDE).

  • Competing interests None declared.

  • Ethical approval Harrow Research Ethics Committee, for “flagging on NHS Central Register of family cancer clinic patients undergoing colonoscopic surveillance.”

  • Accepted 16 August 2005
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