IL II LIVELLO DEL PROGRAMMA DI SCREENING: LA COLONSCOPIA PAOLA CESARO

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1 IL II LIVELLO DEL PROGRAMMA DI SCREENING: LA COLONSCOPIA PAOLA CESARO

2 Study cohort of 1418 patients who had a complete colonoscopy during which one or more adenomas of the colon or rectum were removed The patients subsequently underwent periodic colonoscopy during an average follow-up of 5.9 years The incidence rate of colorectal cancer was compared with that in three reference groups, including two cohorts in which colonic polyps were not removed and one general-population registry

3 NO POLYP = NO CANCER EXPECTED OBSERVED 76-90%

4 COLORECTAL CANCER SCREENING We now have clearer insight into the natural history of colorectal cancer and clinical skills with which to intervene and make difference for many people. Colorectal cancer screening has come of age. Sidney J. Winawer, MD

5 2015 (22 years later)

6 COLORECTAL CANCER IN EUROPE (Ferlay, Parkin& Steliarova-Foucher 2010)

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8 COMPLIANCE TO CRC SCREENING (ANY METHOD) < 60% USA < 30% Europe

9 COMPLIANCE TO COLONOSCOPY

10 INTERVAL COLORECTAL CANCERS Some patients under close colonoscopic surveillance still develop CRC at short intervals Robertson DJ. Gastroenterology 2005; 129: 34-41

11 2002: Prime Raccomandazioni Raccomandaz ioni sulla Qualità della esecuz ione tecnica della Colonscopia e sul Processo di Miglioramento Continuo della Qualità della Colonscopia Scopo: Fornire Standards basati sulla Evidenza e sul Consenso per la esecuzione di Colonscopie di elevata Qualità Permettere lo sviluppo di programmi di Miglioramento Continuo della Qualità (CQI) Rex DK. Am J Gastroenterol, 2002

12 LINEE GUIDA E RACCOMANDAZIONI SULLA QUALITÀ DELLA COLONSCOPIA Segnan N., Atkin W., 2011

13 CRITERI DI QUALITY ASSURANCE (QA) PER LA COLONSCOPIA INDICATORI DI PERFORMANCE INDICATORI DI QUALITA (Quality Indicators) Risultati verificabili per i quali esiste una evidenza scientifica RISULTATI VERIFICABILI (Auditable Outcomes) Indicatori importanti per i quali non esiste però una chiara evidenza

14 INDICATORI DI QUALITA (QI) DELLA COLONSCOPIA (REX, 2006) PRE-PROCEDURALI Appropriatezza della indicazione Adesione ai corretti intervalli di sorveglianza Corretti intervalli di sorveglianza per IBD Consenso informato ottenuto correttamente Preparazione intestinale INTRA-PROCEDURALI Tasso di raggiungimento del cieco Tasso di identificazione di adenomi in soggetti asintomatici Durata dell esame in retrazione, dal cieco all ano Biopsie eseguite in pazienti con diarrea cronica Numero e sede delle biopsie in pazienti in sorveglianza per IBD Polipi <2 cm non inviati alla chirurgia, se non evidenza di infiltrazione POST-PROCEDURALI Incidenza di perforazione intestinale Incidenza di sanguinamento post-polipectomia Sanguinamenti post-polipectomia inviati alla chirurgia

15 COLONOSCOPY PRACTICE IN ITALY 13.7% Screening colonoscopies 44.9% No Sedation 19.3% Cecum not reached

16 SCREENING COLONOSCOPY Need for Colonoscopy Retraining Program!

17 Il Gold Standard nel futuro dello screening del cancro colonrettale sarà ancora una colonscopia tradizionale?

18 ROBOTIC AUTOMATION OF COLONOSCOPY Self-Propelled Endoscopes Colon Capsule Endoscopy

19 SELF-PROPELLED («EASIER») ENDOSCOPES E-Worm Aer-O-Scope Invendoscope NeoGuide Systems Stryker Colonosight

20 SELF-PROPELLED («EASIER») ENDOSCOPES E-Worm Aer-O-Scope Invendoscope NeoGuide Systems Stryker Colonosight

21 SELF-PROPELLED («EASIER») ENDOSCOPES E-Worm Aer-O-Scope Invendoscope NeoGuide Systems Stryker Colonosight

22 SELF-PROPELLED («EASIER») ENDOSCOPES E-Worm Aer-O-Scope Invendoscope NeoGuide Systems Stryker Colonosight

23 SELF-PROPELLED («EASIER») ENDOSCOPES E-Worm Aer-O-Scope Invendoscope NeoGuide Systems Stryker Colonosight

24 COLON CAPSULE ENDOSCOPY

25 PILLCAM COLON IMAGES: ANATOMICAL SITES ICV Ascending Transverse Descending Rectum

26 COLON CAPSULE ENDOSCOPY A noninvasive tool for visual examination of the colon has the potential to: Free capacity for therapeutic endoscopies Be an adjunct to incomplete colonoscopy Offer an alternative to patients who refuse standard colonoscopy

27 ACCURACY Eliakim Endoscopy % (95% CI, 68-86) 81% 89% (70-97%) 76% (72-78%) Spada GIE % (95% CI, 73-88) 81% 84% (74-95%) 64% (52-76%) *within 8 hours post ingestion ** for polyps 6 mm

28 ACCURACY Eliakim Endoscopy % (95% CI, 68-86) 81% 88% (56-98%) 89% (86-90%) Spada GIE % (95% CI, 73-88) 81% 88% (76-99%) 95% (90-100%) *within 8 hours post ingestion ** for polyps 10 mm

29 10/10 CRC CCE-DETECTED IN CCE-2 STUDIES Eliakim 2009; Spada 2011; Leen 2012; Rex 2013; Adler 2013

30 The ORCA/CCANDY trials new perspectives on screening CCE ready for primetime in CRC screening program?

31 CCE2 AND SCREENING CRC screening program standard No evidence POpulation colon cancer screening by CApsule endoscopy The ORCA trial Colon Capsule for Adenoma and Neoplasia Diagnostic Yield The CCANDY trial Hypothesis CCE filter Colonoscopy Costs (???) only therapeutic

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33 CTC FALSE NEGATIVE

34 TRADITIONAL COLONOSCOPY No alternative techniques ready for clinical use

35 ENDOSCOPIC TECHNIQUES FOR DETECTION OF EARLY GI CANCER Chromoendoscopy Magnification High-Resolution Narrow Band Imaging (NBI) FICE i-scan Confocal Laser Endomicroscopy Autofluorescence Optical Coherence Tomography (OCT) Endocytoscopy

36 PREDICTIVE FACTORS OF SUBMUCOSAL CANCERS Lateral Spreading Tumors Non Granular Type (LST-NGT) Moss A. et al Gastroenterology 2011;140:

37 PREDICTIVE FACTORS OF SUBMUCOSAL CANCERS Lateral Spreading Tumors-Non Granular Type (LST-NGT) Lesions classified as Paris type: IIc IIc + IIa Moss A. et al Gastroenterology 2011;140:

38 PREDICTIVE FACTORS OF SUBMUCOSAL CANCERS Lateral Spreading Tumors-Non Granular Type (LST-NGT) Lesions classified as Paris type: IIc IIa + IIc Lesions with Pit Pattern type V (Kudo) Moss A. et al Gastroenterology 2011;140:

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40 DIAGNOSIS AND THERAPY