Tailoring Colorectal Cancer Screening by Considering Risk of Advanced Proximal Neoplasia

BackgroundQuantifying the risk of advanced proximal colorectal neoplasia might allow tailoring of colorectal cancer screening, with colonoscopy for those at high risk and less invasive screening for very low-risk persons.MethodsWe analyzed findings from 10,124 consecutive adults aged ≥ 50 years who underwent screening colonoscopy to the cecum. We quantified the risk of advanced neoplasia (tubular adenoma ≥ 1 cm, a polyp with villous histology or high-grade dysplasia, or adenocarcinoma) both proximally (cecum to splenic flexure) and distally (descending colon to anus). The prevalence of advanced proximal neoplasia was quantified by age, gender, and distal findings.ResultsThe mean (standard deviation) age was 57.5 (6.0) years; 44% were women; 7835 (77%) had no neoplasia, and 1856 (18%) had 1 or more nonadvanced adenomas. Overall, 433 subjects (4.3%) had advanced neoplasia (267 distally, 196 proximally, 30 both), 33 (0.33%) of which were adenocarcinoma (18 distal, 15 proximal). The risk of advanced proximal neoplasia increased with age decade (1.13%, 2.00%, and 5.26%, respectively; P = .001) and was higher in men (relative risk [RR], 1.91; confidence interval [CI], 1.32-2.77). In women aged less than 70 years, the risk was 1.1% overall (vs 2.2% in men; RR, 1.98; CI, 1.42-2.76) and 0.86% in those with no distal neoplasia (vs 1.54% in men; RR, 1.81; CI, 1.20-2.74).ConclusionsRisk of advanced proximal neoplasia is a function of age and gender. Women aged less than 60 to 70 years have a very low risk, particularly those with no distal adenoma. Sigmoidoscopy with or without occult blood testing may be sufficient and even preferable for screening these subgroups.