ACG 2022: Colorectal Cancer Screening, and GI and Liver Disease

Vivek Kaul, MD


December 13, 2022

This transcript has been edited for clarity.

Hi. I'm Dr Vivek Kaul, and I'm a professor of medicine in the Division of Gastroenterology and Hepatology at the University of Rochester Medical Center in Rochester, New York. It's my great pleasure to collaborate once again with WebMD and Medscape this year, and this edition focuses on the topics I thought would be appealing to our primary care colleagues. This is the best of the American College of Gastroenterology (ACG) 2022 annual meeting for primary care.

This edition will focus on three main areas, which include colorectal cancer screening, functional gastrointestinal (GI) disease, and liver disease. In the first section, I'll talk about a couple of papers referring to colorectal cancer screening and hemorrhoid therapy.

This first paper refers to disparities in the rates of multi-target stool DNA test completion for colorectal cancer screening. This is an important study because colorectal cancer screening remains an important aspect of both primary care and GI practices but still has several challenges, as this study depicts, and the NordICC trial, which was recently published in The New England Journal of Medicine, suggested as well.

This retrospective study over 15 months had about 800 patients, and nearly half of them had undergone screening before. The tests that were ordered are depicted on this pie chart, with about 80% ordered by primary care and a minority by other sectors, including resident clinics.

The results of the study showed that 483 patients, nearly 61%, completed the multi-target stool DNA test, and the median time to completion was about 25 days. The factors that were positively affecting test completion were Asian race and prior history of colorectal cancer screening.

However, some factors negatively affected the compliance with this test, including African American race and tests that were ordered out of resident clinics or from other outreach programs.

Once again, the study highlights that, whereas we do have excellent colonoscopy-based and non–colonoscopy-based screening options out there, compliance may be a challenge as well. Nearly 30% of adults in the US who are eligible for colorectal cancer screening may not present for that test for one reason or another.

This remains a challenge, awareness of these difficulties is important, and every effort, both at the clinical and investigational levels, needs to be made to move the needle in this space.

Our second paper in the colon section refers to evaluating what fecal DNA tests and fecal immunochemical tests (FITs) really mean. In this paper, titled, "What Do 'False Positive' Stool Tests Really Mean?" data from the New Hampshire Colonoscopy Registry were evaluated.

This is a 5-year time period that included 549 DNA tests from stool and 410 FIT tests. The goal here was to understand when you have a positive DNA or FIT test, what are the findings of colonoscopy and when do you call it a false discovery?

If you look at this slide, there are three categories of what constitutes a positive colonoscopy after a positive stool test. The DeeP-C study included any cancers, adenomas, and advanced polyps.

The task force recommendations were that any colonoscopy that generates an earlier interval for screening or surveillance is considered positive, such as finding of polyps, and then, of course, the clinically significant group included both these categories as well as those that had serrated polyps.

The next slide here shows the false discovery rate, which is the number of positive stool tests with a negative colonoscopy — that means a colonoscopy that does not have any of the criteria that I previously mentioned — and the positive predictive value of these stool tests.

When they looked at both the DNA and the FIT populations that underwent these tests, they found that the false discovery rate really dropped if you included all three categories of positivity, including the clinically significant ones, including serrated adenomas.

The false discovery rate goes down and the positive predictive value goes up in both these populations. It's important to note that, when we do these stool tests, it's not only the patients with cancer whom we are counting, but also those patients who have serrated adenomas and proximal hyperplastic polyps or any other findings that would necessitate, by guideline, an earlier surveillance colonoscopy. That's an important takeaway from this paper.

Finally, in the colon section, there was an interesting paper. We all know that hemorrhoids are a very significant cause of morbidity, both in primary care and in GI practice. Many interventions, both surgical and nonsurgical, have been tried over the years.

Here's a paper from a hemorrhoid specialty clinic or center, which is a one-of-a-kind center that focuses on a comprehensive approach to hemorrhoid management. The safety and efficacy of hemorrhoid artery embolization were evaluated in this paper.

A cohort of 126 patients underwent hemorrhoid arterial embolization using polyvinyl alcohol foam particles and coils. The technical success rate in this population was 100%, which is quite commendable. You can see that the patients underwent these procedures on an outpatient basis with no serious adverse events and only minor post-treatment effects.

The outcomes suggested that bleeding rates, quality-of-life scores, and hemorrhoid-related pain were much lower at the 3-month mark compared with the baseline score. This presents yet another option for our patients with significant hemorrhoid disease who are refractory to medical therapy and conservative measures. This raises hope in both our practices at the primary care and GI levels, and likely, there will be more data to come on these approaches in the future.

In the next section, which is functional GI disease — another huge subset of patients in both primary care and GI practices — I picked a couple of papers, one relating to dyspepsia and a novel approach to the management of dyspepsia, and another one on IBS.

As we all know, cognitive-behavioral therapy and the utilization of virtual reality–based algorithms and experiences have now come into play in the management of IBS and functional GI disease. Here's a paper that looks at the impact of virtual reality on the symptoms of functional dyspepsia.

As a refresher, functional dyspepsia, by Rome 4 criteria, is diagnosed in patients with one or more of the following symptoms, with a symptom frequency more than or equal to twice per week: postprandial fullness, early satiety, epigastric pain, and epigastric burning. There should be no evidence of structural disease. These criteria should be fulfilled at least for 3 months, with a symptom onset for longer than 6 months.

The investigators looked at the impact of virtual reality in this realm. There were 37 patients with functional dyspepsia, with 27 in the treatment arm and 10 in the control arm. Essentially, the patients were given a virtual reality headset where they had an immersive audiovisual experience, whereas the control population had a headset with two-dimensional nature videos.

Overall, 17 patients reported some nonserious adverse events, such as headache and dizziness, and one patient from the experimental group withdrew because of migraines.

The mean total Patient Assessment of GI Disorders Symptom Severity Index, which is shown on the left side, significantly decreased in the virtual reality group, and the total Nepean Dyspepsia Index improved in the virtual reality group and in the control group. Only the virtual reality group had significant improvements in abdominal pain compared with some of the other criteria.

The study tells us that there may be something here in terms of managing our patients with functional dyspepsia and functional pain over and above the lifestyle and medical therapy options. Virtual reality may have a role to play, if not in everybody, in a subset of patients going forward. Expect to see more data in this realm going forward as well.

Last but not least, in our liver section, I picked a study that reflects nearly three decades of data assessing the burden of obesity and, specifically, nonalcoholic fatty liver disease (NAFLD), which now has assumed global epidemic proportions.

This paper is titled, "The Global Landscape of Nonalcoholic Fatty Liver Disease: Results From the Global Burden of Disease Study." These are data collected from the Global Health Data Exchange results tool. The global prevalence of NAFLD has increased by more than 50% over this time period. The mortality attributed to this disease state has increased from 93,000 to 169,000, and the disability-adjusted life-years increased from 2.7 million years to 4.4 million years.

The highest prevalence of this condition is in the North African and Middle Eastern regions. This is a problem that plagues, as I said, the Western world and other parts of the world. It's a global epidemic at this point, with a worldwide prevalence of 32%.

Not only does it portend negative prognostic implications from a chronic liver disease standpoint, but also from a metabolic standpoint, and it has major implications for cardiovascular disease and such.

This is an area that is receiving a large amount of attention in medicine at all levels — in GI, cardiology, metabolic health, endocrine, primary care, and lifestyle medicine. This is going to continue to receive attention and focus going forward, and it is something that we should be concerned about as practitioners.

I hope you enjoyed getting an update in these very specific areas of GI from a primary care perspective, and that you find this information useful in the care of your patients.

Thank you very much, and I'll see you next time.

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