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

1. Upper gastrointestinal endoscopy is not justified in persons with a positive FOBT and a negative colonoscopy in a population-based colorectal cancer screening program Bernard DENIS, Philippe PERRIN, Frédéric VAGNE, Danièle KLINKERT, Daniel BATTISTELLI, André PETER, Jean Christophe PFEIFFER, Jean François VIES Association pour le Dépistage du Cancer colorectal dans le Haut-Rhin (ADECA 68), Colmar, FRANCE

2. background • assessment of both feasibility and effectiveness 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