PAOLA CESAROPAOLA CESAROPAOLA CESAROPAOLA CESARO

IL II LIVELLO DEL PROGRAMMA DI IL II LIVELLO DEL PROGRAMMA DI IL II LIVELLO DEL PROGRAMMA DI IL II LIVELLO DEL PROGRAMMA DI

SCREENING: SCREENING: SCREENING: SCREENING:

LA COLONSCOPIALA COLONSCOPIALA COLONSCOPIALA COLONSCOPIA

� Study cohort of 1418 patients who had a complete colonoscopyduring which one or more adenomas of the colon or rectum wereremoved

� The patients subsequently underwent periodic colonoscopy during anaverage follow-up of 5.9 years

� The incidence rate of colorectal cancer was compared with that inthree reference groups, including two cohorts in which colonic polypswere not removed and one general-population registry

76-90%

EXPECTED

OBSERVED

NO POLYP = NO CANCER

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

2015(22 years later )

COLORECTAL CANCER IN EUROPE

(Ferlay, Parkin & Steliarova-Foucher 2010)

COMPLIANCE TO CRC SCREENING(ANY METHOD)

< 60% USA

< 30% Europe

COMPLIANCE TO COLONOSCOPY

�Some patients under close colonoscopicsurveillance still develop CRC at short intervals

INTERVAL COLORECTAL CANCERS

Robertson DJ. Gastroenterology 2005; 129: 34-41

� “Raccomandazioni sul laQual i tà del la esecuzionetecnica del la Colonscopia esul Processo di Migl ioramentoContinuo del la Qual i tà del laColonscopia”

� Scopo:

� Fornire Standards basati sullaEvidenza e sul Consenso perla esecuzione di Colonscopiedi elevata Qualità

� Permettere lo sviluppo diprogrammi di MiglioramentoContinuo della Qualità (CQI)

2002: Prime Raccomandazioni

Rex DK. Am J Gastroenterol, 2002

Segnan N., Atkin W., 2011

LINEE GUIDA E RACCOMANDAZIONI SULLA QUALITÀ DELLA COLONSCOPIA

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

INDICATORI DI PERFORMANCE

CRITERI DI QUALITY ASSURANCE (QA)PER LA COLONSCOPIA

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

COLONOSCOPY PRACTICE IN ITALY

� 13.7% Screening colonoscopies

� 44.9% No Sedation

� 19.3% Cecum not reached

Need for Colonoscopy Retraining Program !

SCREENING COLONOSCOPY

Il Gold Standard nel futuro dello screening

del cancro colonrettalesarà ancora

una colonscopia tradizionale?

� Self-Propelled Endoscopes

� Colon Capsule Endoscopy

“ROBOTIC” AUTOMATIONOF COLONOSCOPY

�E-Worm

�Aer-O-Scope

� Invendoscope

�NeoGuide Systems

�Stryker Colonosight

SELF-PROPELLED (« EASIER ») ENDOSCOPES

�E-Worm

�Aer-O-Scope

� Invendoscope

�NeoGuide Systems

�Stryker Colonosight

SELF-PROPELLED (« EASIER ») ENDOSCOPES

�E-Worm

�Aer-O-Scope

� Invendoscope

�NeoGuide Systems

�Stryker Colonosight

SELF-PROPELLED (« EASIER ») ENDOSCOPES

�E-Worm

�Aer-O-Scope

� Invendoscope

�NeoGuide Systems

�Stryker Colonosight

SELF-PROPELLED (« EASIER ») ENDOSCOPES

�E-Worm

�Aer-O-Scope

� Invendoscope

�NeoGuide Systems

�Stryker Colonosight

SELF-PROPELLED (« EASIER ») ENDOSCOPES

COLON CAPSULE ENDOSCOPY

PILLCAM COLON IMAGES:ANATOMICAL SITES

ICV Ascending Transverse Descending Rectum

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

COLON CAPSULE ENDOSCOPY

EliakimEndoscopy 2009

9878%

(95% CI, 68-

86)

81%89%

(70-97%)

76% (72-78%)

SpadaGIE 2011

10985%

(95% CI, 73-

88)

81%84%

(74-95%)

64% (52-76%)

*within 8 hours post ingestion

** for polyps ≥ 6 mm

ACCURACY

EliakimEndoscopy 2009

9878%

(95% CI, 68-

86)

81%88%

(56-98%)

89% (86-90%)

SpadaGIE 2011

10985%

(95% CI, 73-

88)

81%88%

(76-99%)

95% (90-100%)

*within 8 hours post ingestion

** for polyps ≥ 10 mm

ACCURACY

10/10 CRC CCE-DETECTED

IN CCE-2 STUDIES

Eliakim 2009; Spada 2011;Leen 2012; Rex 2013; Adler 2013

CCE ready for primetime in CRC screening program?

The ORCA/CCANDY trialsnew perspectives on screening

� CRC screening program standard

� No evidence

� Hypothesis• CCE filter• Colonoscopy only therapeutic

� Costs (???)

CCE2 AND SCREENING

POpulation colon cancer sc Reening by CApsule endoscopyThe ORCA trialCo lon Capsu le for A denoma and Neoplas ia Diagnost ic Yie ldThe CCANDY tr ia l

CTC FALSE NEGATIVE

No

alternative techniques

ready for clinical use

TRADITIONAL COLONOSCOPY

� Chromoendoscopy� Magnification� High-Resolution� Narrow Band Imaging (NBI)� FICE� i-Scan� Confocal Laser Endomicroscopy� Autofluorescence� Optical Coherence Tomography (OCT)� Endocytoscopy

ENDOSCOPIC TECHNIQUES FOR DETECTION OF EARLY GI CANCER

PREDICTIVE FACTORS OF SUBMUCOSAL CANCERS

�Lateral Spreading Tumors Non Granular Type (LST-NGT)

Moss A. et al Gastroenterology 2011;140: 1907-18

�Lateral Spreading Tumors-Non Granular Type (LST-NGT)

�Lesions classified as Paris type:• IIc • IIc + IIa

Moss A. et al Gastroenterology 2011;140: 1907-18

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: 1907-18

PREDICTIVE FACTORS OF SUBMUCOSAL CANCERS

DIAGNOSIS AND THERAPY