w w w . j c o l . o r g . b r
Journal
of
Coloproctology
Original
Article
Is
prevalence
of
colorectal
polyps
higher
in
patients
with
family
history
of
colorectal
cancer?
Sthela
Maria
Murad-Regadas
a,b,∗,
Carla
Camila
Rocha
Bezerra
c,
Ana
Ligia
Rocha
Peixoto
d,
Francisco
Sérgio
Pinheiro
Regadas
a,
Lusmar
Veras
Rodrigues
a,e,
José
Airton
Gonc¸alves
Siebra
c,
Graziela
Olivia
da
Silva
Fernandes
c,
Rafael
Aragão
Vasconcelos
c aDepartmentofSurgery,MedicineSchool,UniversidadeFederaldoCeará(UFC),Fortaleza,CE,BrazilbSectorofAnorectalandPelvicFloorPhysiology,HospitaldasClínicas,MedicineSchool,UniversidadeFederaldoCeará(UFC),
Fortaleza,CE,Brazil
cServiceofColoproctology,HospitalUniversitárioWalterCantídeo,UniversidadeFederaldoCeará(UFC),Fortaleza,CE,Brazil
dServiceofColoproctology,HospitalRegionaldoCariri,JuazeirodoNorte,CE,Brazil
eServiceofColoproctology,MedicineSchool,UniversidadeFederaldoCeará(UFC),Fortaleza,CE,Brazil
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Articlehistory:
Received29December2014 Accepted20February2015 Availableonline10June2015
Keywords:
Colonoscopy Polyps Prevention Colorectalcancer
a
b
s
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a
c
t
Objectives:Toassesstheprevalenceofpolypsinpatientswithafamilyhistoryofcolorectal cancer,incomparisontoasymptomaticindividualswithindicationforscreening.
Methods:Aprospectivestudyinagroupofpatientswhounderwentcolonoscopybetween 2012and2014.Patientsweredividedintotwogroups:GroupI:nofamilyhistoryofcolorectal cancer,andGroupII:withafamilyhistoryinfirst-degreerelatives.Demographic charac-teristics,findingsoncolonoscopy,presence,locationandhistologicaltypeofpolypswere evaluated,comparingthetwogroups.
Results:214patientswereevaluated:162inGroupIand52inGroupII.Thedistributionof patientswithpolypswassimilarinrelationtogender:polypswereevidencedinGroupI in33(20%)femalepatientsvs.10(6%)malepatients(p=1.00);inGroupII,thepresenceof polypswasevidencedin9(17%)femalepatientsvs.2(4%)malepatients(p=1.00).Polypoid lesionswerefoundin54patients(25%),with43(26%)inGroupIand11(21%)inGroupII.The prevalenceofadenomaswassimilarinbothgroups(GroupI=18/37%vs.GroupII=10/50%) (p=0.83).
Conclusion:Inthispreliminarystudy,nocorrelationwasfoundbetweenprevalenceofpolyps andafamilyhistoryofcolorectalcancer.
©2015SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.All rightsreserved.
∗ Correspondingauthor.
E-mail:smregadas@hospitalsaocarlos.com.br(S.M.Murad-Regadas).
http://dx.doi.org/10.1016/j.jcol.2015.02.010
A
prevalência
de
pólipos
colorretais
é
mais
elevada
em
pacientes
com
história
familiar
de
câncer
colorretal?
Palavras-chave:
Videocolonoscopia Pólipos
Prevenc¸ão Câncercolorretal
r
e
s
u
m
o
Objetivos: Avaliaraprevalênciadepóliposempacientescomhistóriafamiliardecâncer colorretalcomparandocomindivíduosassintomáticoscomindicac¸ãopararastreamento.
Métodos: Estudoprospectivorealizadoemumgrupodeindivíduossubmetidosà colono-scopia entre 2012 e 2014. Os pacientes foram distribuídos em dois grupos: Grupo I: semhistóriafamiliardecâncercolorretaleGrupoII:comhistóriafamiliaremparentes de primeiro grau.Avaliaram-se características demográficas,achados na colonoscopia, presenc¸a,localizac¸ãoetipohistológicodospólipos,comparandoosdoisgrupos.
Resultados: Foramavaliados214pacientes,162incluídasnogrupoIe52 nogrupoII.A distribuic¸ãodospacientescompóliposfoisimilaremrelac¸ãoaosexo,sendoevidenciado póliposnoGrupoIem33(20%)pacientesdosexofemininovs.10(6%)masculino(p=1,00) enoGrupoII,presenc¸adepóliposempacientesdosexofemininoem9(17%)vs.2(4%) masculino(p=1,00).Foramencontradaslesõespolipóidesem54pacientes(25%),sendo43 (26%)nogrupoIe11(21%)nogrupoII.Aprevalênciadeadenomasfoisimilaremambosos grupos(GrupoI=18/37%vs.GrupoII=10/50%)(p=0,83).
Conclusão:Nesteestudoinicial,nãofoiencontradacorrelac¸ãoentreaprevalênciadepólipos eohistóricofamiliardecâncercolorretal.
©2015SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda. Todososdireitosreservados.
Introduction
Colorectalcancer(CRC)isthethirdmostcommoncause of cancer worldwidein bothgenders and the second leading causeindevelopedcountries.1InBrazil,theestimated inci-dence for the year 2014 is15.44 and 17.24 new cases per 100,000menandwomen,respectively.2Itiswellestablished thatthegreatmajorityofCRCcases(adenocarcinomas)isdue tobenigntumors(adenomas),aprocessknownas adenoma-carcinomasequence,originallydescribedbyVogelstein.3
Twenty-fivepercentofCRCcasesoccurinindividualswith atleast one first-degree relative (FDR) with a diagnosis of CRCnotassociatedwithaknowngeneticsyndrome.4These individualshave,onaverage,twicetheriskvs.general popu-lation’srisktodevelopCRCintheirlifetime.5
Patients withCRC and their families are candidates for different screeningstrategies, thanksto the increasedrisk ofdevelopingcolorectalcancerandtothepossibilityof pri-maryandsecondaryprevention,allowingforalongersurvival for patients treated in the early stages of this disease.6 Recentstudieshavefavoredcolonoscopyasthebestscreening method,forallowing diagnosis and treatmentofprecursor lesionsandobtainingbiopsiesofsuspiciouslesions.7,8
Currently, the reality of public health in Brazil, espe-cially in Northeast Region, does not allow full access to colonoscopyscreeningtestsforthewholeasymptomatic pop-ulation(includingthosewithafamilyhistory)fromtheageof 40to50yearsonward.
Inthesameline,therearefewstudiesevaluatingthe spe-cificgroupofasymptomaticindividualswithnofamilyhistory. Therefore,studiesareneededtoassesstheprevalenceofthese precursor lesions, aiming to demonstrate, for this popula-tion,thebenefitsofascreeningstrategy.Thisstudyaimsto
assesstheprevalenceofpolypsinpatientswithfamilyhistory ofcolorectalcancer,comparedtoasymptomaticindividuals undergoingcolonoscopywithindicationforascreening pro-cedure.
Methodology
This is a cross-sectional, analytical, prospective, compara-tivestudy,includingasymptomaticpatientswhounderwent screening colonoscopyatthe Hospital Universitário Walter Cantídio,UniversidadeFederaldoCeará(HUWC/UFC)andat theColoproctologyCenter,HospitalSãoCarlos,inthecityof Fortaleza–Ceará,fromJanuary2012toJanuary2014. Partici-pantsweredividedintotwogroups:GroupI–withoutfamily historyofCRC,andGroupII–withafamilyhistoryof spo-radic CRCinFDR.Screeningcolonoscopywasindicatedfor patients agedfrom 50years onwardinasymptomatic indi-vidualswithoutfamilyhistory(GroupI),andforthoseaged from40yearsonward,or10yearsbeforeCRCdiagnosisage inyoungerindividuals,inpatientswithfamilyhistory(Group II).
Demographic characteristics such as age, gender, body massindex(BMI)andfamilyhistoryofCRC,aswellasdata obtainedwithcolonoscopy(qualityofcolonpreparation[good, optimal or bad]), progression of the device until reaching cecum(fullexamination),presenceofpolyps,and histopatho-logicalexamination(histologytypeforpolyps).Thestudywas approvedbytheEthicsCommitteeofHospitalUniversitário WalterCantídio.
geneticsyndromethatarguablyincreasesCRCrisk; individ-ualswithahistoryofcolorectalsurgeryforanycause;witha diagnosisofinflammatoryboweldisease(IBD); immunosup-pressedindividuals,orwithsymptomsrelatedtocolorectal disorderswereexcluded.
Foranevaluationofnumericalvariables,Studentt,Fisher andChi-squaredtestswereused.Thestatisticalsignificance levelwassetatp<0.05.
Results
Atotalof214patientswereincluded:47(22%)maleand167 (78%)female.Asfortheassessmentofbodymassindex(BMI), 87 (40%) were eutrophic,67 (31%) with overweight and 60 (28%)were obese patients. In 183 (86%) colonoscopies,the colonwasvisualizedinitsentirety,andagoodandoptimal preparationwasdescribedin62%oftests.In54(25%) proce-dures,atotalof69colonicpolypswerefound.Thelocalization ofthepolypswas:rectum(18/26%polyps),ascendingcolon (12/17%polyps),descendingcolon(11/16%polyps),andcecum, transversecolonandsigmoid(10/14.5%10/14.5%8/12%polyps, respectively).
Fromthetotalof214individuals,162(76%)wereincludedin GroupI(meanage,56years;ofthese,125(77%)werefemale.In GroupII,52(24%)patientswereincluded(meanage,54years);
ofthese,42(81%)werefemale.Nostatisticaldifferencewas notedbetweengroups,regardingageandgender(Table1).
Colonoscopyandhistopathologyfindings
InGroupI,polypswereseenin43(26%)ofthe162examined patients.InGroupII,from52examinationsperformed,polyps werefoundin11(21%)patients,withoutstatisticaldifference betweengroups(p=0.47).Thelocationofthepolypsincolonic areaswassimilarinbothgroups(Table1).
Astogender,thedistributionofpatientswithpolypswas similar;inGroupI,polypswereevidencedin33(20%)female vs.10 (6%)malepatients(p=1.00).InGroupII,polypswere evidencedin9(17%)femalevs.2(4%)malepatients(p=1.00). Whencomparinggroups,nodifferencewasidentifiedinterms ofprevalenceofpolypsbygender,asfollows:malegenderin GroupIvs.GroupII(10/6%vs.2/4%,p=1.00)andfemalegender inGroupIvs.GroupII(33/20%vs.9/17%,p=0.68)(Table2).The meansizeofpolypsinGroupIwas0.4cm,whileinGroupII was0.3cm.
AstothehistologyofpolypsinGroupI,inthose43patients withpolyps,atotalof49polypswasdemonstrated,as fol-lows:18(37%)adenomatous,23(47%)hyperplasticand8(16%) inflammatorypolyps.InGroupII, atotalof20 polypswere identifiedin11patientswithpositivecolonoscopyfor pres-ence ofpolyps, as follows: 9(45%) adenomatous, 10 (50%)
Table1–Characteristicsofpatientscomparinggroupswithfamilyhistoryvs.nofamilystoryforcolorectalcancer.
WithnofamiliarhistoryofCRC WithapositivefamiliarhistoryforCRC p
GroupI GroupII
n(%) n(%)
Age 56±12 54±10 0.60
Gender
Male 37(23%) 10(19%) 0.70
Female 125(77%) 42(81%)
Presenceofpolyps 43(26%) 11(21%) 0.47
Locationofpolyps
Caecum 8(16%) 2(10%) 0.71
Ascendingcolon 8(16%) 4(20%) 0.73
Transversecolon 7(15%) 3(15%) 1.00
Descendingcolon 8(16%) 3(15%) 1.00
Sigmoid 5(10%) 3(15%) 0.68
Rectum 13(27%) 5(25%) 1.00
Totalnumberofpatients 162(76%) 52(24%)
CRC,colorectalcancer.
Table2–Prevalenceofpolypsdistributedbetweengendersingroupswithnofamilyhistoryvs.familystoryofcolorectal cancer.
Totalnumberofpatients Withoutpolyps Gender Withpolyps Gender
GroupI
162 27 M 10 M
92 F 33 F
GroupII
52 08 M 02 M
33 F 09 F
M,male;F,female.
Table3–Histologicalsubtypesofpolypscomparinggroupswithvs.withoutfamilyhistoryofcolorectalcancer.
Patientsn(%) Adenomatousn(%) Hyperplasticn(%) Inflammatoryn(%) Polypsna(%)
GroupI 43(26%) 18(37%) 23(47%) 08(16%) 49(71%)
GroupII 11(21%) 09(45%) 10(50%) 01(5%) 20(29%)
p=0.83.
a Insometests,morethanonepolypectomywasperformed,whichjustifiestheincreasednumberofhistologicalresultswhencomparedto
thenumberofexamswithpolyp.
hyperplasticand1(5%)inflammatorypolyps,withno statisti-callysignificantdifference(p=0.83)betweengroups(Table3).
Discussion
TheriskofdevelopingCRCisof5%,withanincreasedriskfor peoplewhohavecloserelativeswithCRC,especiallyif diag-nosedatanearlyage.10,11 Dependingonthe familyhistory andthepresenceofaninheritedmutationforCRC,therisk variabilityforthisneoplasiacanreachupto70%.11Screening programs,includingcolonoscopy,inindividualswithfamilial CRCaswellasinthepopulationingeneral,reducethe inci-denceofneoplasiaandappeartopreventCRCmortality.7,12,13 Thereisstillmuchdiscussiontodetermineiftheprevalence andfrequencyofadenomasinindividualswithafamily his-toryofCRCarehigherthaninthegeneralpopulation.14–17
Thisstudyevaluatedtheprevalenceofpolypsin asymp-tomatic patients with CRC history in first-degree relatives (GroupI)andcompareditsfindingsvs.anasymptomatic pop-ulationwithnofamilyhistory(GroupII)whoperformedtheir firstexaminationwithindicationforscreeningpurposes.It hasbeen shownthatthe distributionofpolypswassimilar inbothgroups,andnoevidenceofacorrelationwasfound betweenthe number ofpolyps and patients’ gender, since thedistributionofthepolypswassimilarinacomparisonof femalevs.malegenderinbothgroups.Thelargestnumber ofpolypsinfemales wasproportional tothe greater num-berofwomeninthegeneralpopulationstudied,justifyingthe similarityofdistributionofpolypsbygender.
Inthisstudy,“familyhistory”wasconsideredasthe pres-enceofadiagnosisofCRCinfirst-degreerelatives,including the patient’s father, mother and children.18 Using this cri-terion,thedistribution ofpolypsand the histologicaltype, including adenomatous polyps, were also similar in both groups.
Byanalyzingthedataobtained,itwasobservedthatthe numberofwomenundergoingpreventiveproceduresisstill higherthanthatinmen,whichcanbeexplainedbymen’s historicalresistancetoseekmedicalservicesandalsoby prej-udicesrelatedtocolonoscopyproceduresinmen.
Itwasalsoobservedthatthegroupwithapositivefamily historyforCRC(GroupII)presentedalowermeanage(54vs. 56years),whencomparedtothegroupwithnofamilyhistory (GroupI),butthisfindinghadnostatisticalsignificance,even withtheadviceforstartingthescreeningprocedure10years beforethe ageofthatrelativewhowasdiagnosedwiththe disease.
Itwas expectedabigger difference betweenmean ages whencomparingthetwogroups.Thisfindingmayreflectthe
lackofinformationandthedifficultyofmonitoringprograms targetedtothisriskgroupinNortheastRegionofthiscountry. Twenty-sixpercentofindividuals withnofamily history ofCRC(GroupI)underwentpolypectomy,whichisin agree-mentwiththeliterature,althoughthispercentagecanvary between17and21%,eventuallyreachingupto50%,depending ontheagegroupinquestion.6,10Inthegroupwithapositive family historyforCRC(GroupII),21% hadpolypsdetected, withnostatisticaldifferencevs.GroupI.Theseresultswere similartothosedescribedbyZandonáetal.,19whoevaluated patientswithafamilyhistoryofcolorectalcancercompared withpatientsundergoingcolonoscopywithawide rangeof indications, showinga percentage of18% of polypsin the groupwithapositivefamilyhistoryand14%inthepopulation withanindicationforcolonoscopicevaluation.
In a multicenter study, the histology revealed that 37.5% of polyps were adenomatous, mostof them tubular adenomas.6,10InananalysisoftypesofpolypsinGroupsIand II,ourdataweresimilar(37%and45%ofadenomatouspolyps, respectively). Corroborating the results of this study, Zan-donáetal.19confirmedthattherewasnostatisticaldifference intheprevalenceofadenomatouspolyps,whencomparing patients with a positive family history for CRC vs. symp-tomatic patients and/or individuals with an indicationfor colonoscopy.
Astothelocationofpolyps,itisknownthatan examina-tionofthedistalcolon(rectum,sigmoidcolon,anddescending colon)candetect60–80%ofthepolyps.6Inthisstudy, approxi-mately54%ofthepolypswerelocatedinleftcolonandrectum inbothgroups,whichisinagreementwiththeliterature. How-ever,itisimportanttonotethatwhenoneevaluatesonlythe rectum andsigmoid, thispercentageofpolypdetection, or evenofmalignantlesiondetection,canfallto40%.8Thesedata reinforcetheimportanceofafullcolonoscopy,andnotonlya flexiblerectosigmoidoscopy,asamethodofdetectingpolyps andforpreventionofCRC.Studiesshowthatcolonoscopyis consideredthemethodofchoiceforearlydetectionof colo-rectalcancer.6,20 However,thisisnotamethodavailablein allservices,notcoveringevenallpatientswithindicationsfor thistypeofassessment.
obtained,aswellasforcomparisonwithotherreference cen-ters.
Conclusion
Inthispreliminarystudy,nocorrelationbetweenthe preva-lenceofpolypsandpresenceofafamilyhistoryforCRCwas evidenced,since the prevalenceand distributionof polyps accordingtogenderandhistologicsubtypeofthisgroupwere similartothepopulationofpatientswithnofamilyhistory, whowereexaminedwithanindicationforCCRscreening.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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