Association pour le Dépistage du Cancer colorectal dans le Haut-Rhin (ADECA 68), Colmar, FRANCE

1. Is upper endoscopy indicated in persons with a positive FOBT and a negative colonoscopy in a population-based colorectal cancer screening program ? Bernard DENIS, Philippe PERRIN, Frédéric VAGNE, André PETER, Jean Christophe PFEIFFER, Daniel BATTISTELLI Association pour le Dépistage du Cancer colorectal dans le Haut-Rhin (ADECA 68), Colmar, FRANCE

2. background • assessment of both feasibility and efficiency of a nation wide population-based colorectal cancer (CRC) FOBT screening program • 22 pilot areas

3. background • whether upper endoscopy is necessary… is controversial • few studies, most small sized, retrospective or individual screening • only 2 in mass screening programs which concluded that upper endoscopy was unjustified in asymptomatic persons… but… (Thomas WM Gut 1990; Rasmussen M Scand J Gastroenterol 2002)

4. aim to assess whether upper endoscopy is indicated in persons with a positive FOBT and a negative colonoscopy in a population-based CRC screening program ?

5. methods • pilot population-based colorectal cancer screening program • Haut-Rhin: 0.71 million inhabitants • all average risk residents aged 50-74 y • biennial non rehydrated guaiac FOBT (Hemoccult II) without dietary restriction

6. methods • prospective recording all upper endoscopies performed after positive FOBT and negative colonoscopy • data collection • detailed history (upper GI symptoms, drugs, documented anemia…) • upper abnormal findings • changes in management • adverse events

7. methods • inclusion criteria • Residents aged 50-74 y participating to CRC screening program • Positive FOBT • Complete colonoscopy • No lower bleeding lesion, CRC or polyp ≥ 1 cm • At the discretion of the endoscopist • Informed consent

8. methods • exclusion criteria • FOBT completed out of screening program • Incomplete colonoscopy • Lower bleeding lesion, CRC or polyp ≥ 1 cm • Documented upper GI disease • Recent upper endoscopy < 1 year • Patient refusal

9. methods

10. results • ongoing study: April 2005 (19 months) • 366 upper endoscopies / 1002 (36.6%) • 305 (50.4 %) with normal colonoscopy • 61 (15.4 %) with colorectal polyps < 1 cm

11. 1 pT1 esophageal adenocarcinoma 3 Barrett’s esophagus 33 reflux esophagitis (28 gr. 1 / 5 gr. 2) 2 angiodysplasia 12 gastric polyps 26 erosive gastritis 1 gastric ulcer 5 erosive duodenitis 2 duodenal ulcers 18 Hp positive diagnostic yield 80 / 366 (21.9 %) abnormal upper GI findings

12. diagnostic yield

13. 1 surgery 1 Argon plasma coagulation 46 PPI 18 antibiotics 4 NSAID discontinuation 3 endoscopic follow-up clinical impact 50 / 366 (15 %) change in clinical management

14. clinical impact

15. 213 asymptomatic persons • abnormal findings: 15 % • changes in management: 10.8% • clinically important lesions: 3.3 % • 3 erosive gastritis Hp + • 3 erosive duodenitis Hp + • 1 reflux esophagitis gr. 2 • no cancer • no Barrett’s

16. asymptomatic persons Number needed to screen to detect one clinically important lesion = 30

17. conclusions • upper endoscopy is not justified in asymptomatic persons with a positive FOBT when colonoscopy is normal or yields small polyps in a population-based CRC screening program • upper endoscopy must be performed in patients with relevant upper symptoms

18. future • upper abnormal findings • positive FOBT ? • by chance ? • control group with colorectal cancer or large polyps