rubrica

Screening

  • Paolo Giorgi Rossi1

  1. Laziosanità, Agenzia di sanità pubblica, Roma
Paolo Giorgi Rossi -

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Ricerca bibliografica periodo dal 1 novembre – 15 gennaio 2013

Per leggere le caratteristiche di questa ROUTINE di ricerca clicca qui

Stringa: ("mass screening"[MeSH Terms] OR cancer[Title/Abstract] AND screening[Title/Abstract] AND ("italy"[MeSH Terms] OR "italy"[All Fields]) AND ("2012/11/01"[PDAT] : "2013/01/15"[PDAT])

Breve commento a cura di P. Giorgi Rossi
In questo periodo è uscito il supplemento di E&P a cura dell’Osservatorio Nazionale Screening. Non troverete gli articoli del supplemento in questa rassegna, ma sull’homepage (http://epiprev.it/pubblicazione/epidemiol-prev-2012-36-6-suppl-1-solo-on...). Per questi 75 giorni abbiamo individuato 12 lavori prodotti da gruppi Italiani che a vario titolo parlano di screening. Ben tre lavori (Sali, Hassan, Regge) parlano dell’uso della cosiddetta colon-virtuale nello screening del colon retto, un trial per vedere se si può utilizzare per aumentare la compliance al secondo livello (Sali), un trial sull’uso della lettura computer assistita vs doppia lettura (Regge) e una valutazione di costo efficacia (Hassan). Altri 4 lavori riguardano il colon retto: una valutazione dei costi dello screening di Lecco (Parente); un lavoro dell’attivissimo Hassan sul management dei polipi piccoli; uno studio sui volatile organic compounds (VOCs) per l’identificazione di biomarker non invasivi; infine uno studio (Flora) sul ruolo del numero di copie di Epidermal Grow Factor Receptor nella progressione degli adenomi, un lavoro di biologia molecolare di base, ma che prende la sua casistica interamente dai programmi di screening. Due lavori sulla cervice uterina: l’ennesimo prodotto dello studio NTCC (Carozzi) che finisce su Lancet Oncology, una valutazione sull’uso del biomarcatore p16 come test di triage dopo HPV positivo; e una descrizione dell’implementazione di uno screening con HPV come test primario (Zappacosta). Due lavori sullo screening della mammella: una rassegna di linee guida per lo screening nelle donne con rischio eredo-familiare (Simone) e una valutazione del trend delle mastectomie in Italia (Piscitelli) che mostra come negli ultimi anni il tasso di mastectomie sia calato maggiormente dove sono stati più attivi i programmi di screening: un dato simile era emerso dall’analisi dei trend a Firenze e anche dallo studio Impatto. Un articolo (Dominioni) presenta invece dati di uno studio non randomizzato sullo screening del cancro del polmone portando conclusioni piuttosto forti relativamente alla debolezza intrinseca del disegno e delle dimensioni dello studio.

1. Dominioni L, Poli A, Mantovani W, Pisani S, Rotolo N, Paolucci M, Sessa F, Conti V, D'Ambrosio V, Paddeu A, Imperatori A. Assessment of lung cancer mortality reduction after chest X-ray screening in smokers: A population-based cohort study in Varese, Italy. Lung Cancer. 2013 Jan 4. pii: S0169-5002(12)00683-6. doi: 10.1016/j.lungcan.2012.12.014. [Epub ahead of print]
Center for Thoracic Surgery, University of Insubria, Ospedale di Circolo, Varese, Italy. Electronic address: lorenzo.dominioni@uninsubria.it.

Abstract
BACKGROUND: The effectiveness of screening for lung cancer (LC) in smokers on a population level, as distinct from the special circumstances that may apply in a randomized trial of selected volunteers, has not been thoroughly investigated. Here we evaluate by the standardized mortality ratio (SMR) indicator the impact of a chest X-ray (CXR) screening programme carried out at community level on LC mortality in smokers. METHODS: All smokers of >10 pack-years, of both genders, ages 45-75 years, resident in 50 communities of the Province of Varese, Italy, screening-eligible, in 1997 were invited by their National Health Service (NHS) general practitioner physicians to a nonrandomized programme of five annual CXR screenings. The entire invitation-to-screen cohort (n=5815 subjects) received NHS usual care, with the addition of CXR exams in volunteer participants (21% of invitees), and was observed through December 2006. To overcome participants' selection bias of LC mortality assessment, for the entire invitation-to-screen cohort we estimated the LC-specific SMR, based on the local reference population receiving the NHS usual care. RESULTS: Over the 8-year period 1999-2006, a total of 172 cumulative LC deaths were observed in the invitation-to-screen cohort; 210 were expected based on the reference population. Each year in the invited cohort the observed LC deaths were fewer than expected. The cumulative LC SMR was 0.82 (95%CI, 0.67-0.99; p=0.048), suggesting that LC mortality was reduced by 18% with CXR screening. CONCLUSION: Implementation of a CXR screening programme at community level was associated with a significant reduction of LC mortality in smokers

2. Sali L, Grazzini G, Ventura L, Falchini M, Borgheresi A, Castiglione G, Grimaldi M, Ianniciello N, Mallardi B, Zappa M, Mascalchi M. Computed tomographic colonography in subjects with positive faecal occult blood test refusing optical colonoscopy. Dig Liver Dis. 2012 Dec 19. pii: S1590-8658(12)00428-8. doi: 10.1016/j.dld.2012.11.008. [Epub ahead of print]
Radiodiagnostic Section, Department of Clinical Physiopathology, University of Florence, Viale G. Pieraccini 6, 50139 Florence, Italy. Electronic address: lapo.sali@unifi.it.

Abstract
BACKGROUND: Refusal of colonoscopy is a drawback of colorectal cancer screening programmes based on faecal occult blood test. Computed-tomographic-colonography is generally more accepted than colonoscopy. AIM: To compare adherence to computed-tomographic-colonography and second-invitation colonoscopy in subjects with positive faecal test refusing colonoscopy. METHODS: We performed a prospective study in 198 subjects with positive faecal test who refused first referral to colonoscopy in one endoscopy service of the Florence screening programme. Subjects were randomly invited to computed-tomographic-colonography (n=100) or re-invited to colonoscopy (n=98). Mail invitation was followed by a questionnaire administered by phone. Computed-tomographic-colonography findings were verified with colonoscopy. RESULTS: 32 subjects could not be reached, 71 (35.9%) had undergone colonoscopy on their own; 4 were excluded for contraindications; 30/48 (62.5%) in the computed-tomographic-colonography arm and 11/43 (25.6%) in the colonoscopy arm accepted the proposed examinations (p<0.001). Four advanced adenomas and 1 cancer were found in the 28 subjects who ultimately underwent computed-tomographic-colonography and 2 advanced adenomas and 2 cancers in the 9 subjects who ultimately underwent second-invitation colonoscopy. CONCLUSION: Subjects with positive faecal occult blood test refusing colonoscopy show a higher adherence to computed-tomographic-colonography than to second invitation colonoscopy.

3. Carozzi F, Gillio-Tos A, Confortini M, Del Mistro A, Sani C, De Marco L, Girlando S, Rosso S, Naldoni C, Palma PD, Zorzi M, Giorgi-Rossi P, Segnan N, Cuzick J, Ronco G; the NTCC working group. Risk of high-grade cervical intraepithelial neoplasia during follow-up in HPV-positive women according to baseline p16-INK4A results: a prospective analysis of a nested substudy of the NTCC randomised controlled trial. Lancet Oncol. 2012 Dec 20. pii: S1470-2045(12)70529-6. doi: 10.1016/S1470-2045(12)70529-6. [Epub ahead of print]
Istituto per lo Studio e la Prevenzione Oncologica, Florence, Italy.

Abstract
BACKGROUND: Immunostaining for p16-INK4A (henceforth p16) is a sensitive and specific method for detection of high-grade cervical intraepithelial neoplasia (CIN) in women infected with human papillomavirus (HPV), but longitudinal data have not been obtained. We investigated the relation between p16 status and risk of CIN during 3 years of follow-up. METHODS: Women aged 25-60 years were enrolled between June 10, 2003, and Dec 31, 2004, in a multicentre randomised trial comparing HPV testing with cytology. HPV-positive women were referred for colposcopy and, in seven of nine centres, were tested for p16 overexpression by immunostaining. If no CIN was detected, these women were followed up at yearly intervals until clearance of HPV infection. The primary endpoint was histologically confirmed CIN of grade 2 or worse (CIN of grade 2 [CIN2], CIN of grade 3 [CIN3], or invasive cervical cancer) at recruitment or during follow-up. We calculated the absolute and relative risks by p16 status at recruitment. We also calculated the longitudinal sensitivity of p16 testing. Additionally, we assessed the relative sensitivity of an alternative strategy (referral to colposcopy and follow-up of only HPV-positive, p16-positive women) versus conventional cytology in two age groups. Percentages were weighted by the inverse of the tested fraction. The trial in which this study is nested is registered, number ISRCTN81678807. FINDINGS: Of 1042 HPV-positive women who were tested for p16 with no CIN detected during the first round of screening, 944 (91%) had further HPV tests. 793 (84%) of these 944 were followed up until detection of CIN2 or worse, HPV infection clearance, or for at least 3 years. CIN2 or worse was detected during follow-up in more p16-positive women (31 of 365, 8•8% [95% CI 5•8-11•8]) than in p16-negative women (17 of 579, 3•7% [1•9-5•4]; relative risk [RR] 2•61 [95% CI 1•49-4•59]). RR was higher in women aged 35-60 years at recruitment (3•37 [1•39-8•15]) than in those aged 25-34 years (2•15 [1•00-4•61]), but age was not a significant modifier. CIN3 or worse was detected during follow-up in more p16-positive women (16 of 365, 4•4% [2•3-6•6]) than in p16-negative women (six of 579, 1•3% [0•2-2•3]; RR 3•90 [95% CI 1•57-9•68]). Longitudinal sensitivity of p16 testing for detection of CIN3 or worse during follow-up at all ages was 77•8% (95% CI 63•9-91•6). The relative sensitivity of the alternative strategy compared with conventional cytology was 2•08 (1•13-3•56) in women aged 35-60 years and 2•86 (1•28-5•36) in those aged 25-34 years. HPV-positive, p16-negative women aged 35-60 years had a higher cumulative risk of CIN3 or worse during recruitment or follow-up (2•0%, 95% CI 0•3-3•7) than did HPV-negative women (0•01%, 0-0•04) or those who were cytologically normal (0•04%, 0•02-0•09) at recruitment. INTERPRETATION: p16 overexpression is a marker for CIN2 or worse or for development of CIN2 or worse within 3 years in HPV-positive women, especially those aged 35-60 years. HPV-positive, p16-positive women need immediate colposcopy and, if the assessment is negative, annual follow-up. Immediate colposcopy can be avoided in HPV-positive, p16-negative women, who can be safely managed with repeat screening after 2-3 year intervals. FUNDING: European Union; Italian Ministry of Health; Regional Health Administrations of Piemonte, Tuscany, Veneto and Emilia Romagna; and Public Health Agency of Lazio Region.

4. Parente F, Boemo C, Ardizzoia A, Costa M, Carzaniga P, Ilardo A, Moretti R, Cremaschini M, Parente EM, Pirola ME. Outcomes and cost evaluation of the first two rounds of a colorectal cancer screening program based on immunochemical fecal occult blood test in northern Italy. Endoscopy. 2013 Jan;45(1):27-34. doi: 10.1055/s-0032-1325800. Epub 2012 Dec 19.
Gastrointestinal Unit, A. Manzoni Hospital, Lecco, Italy.

Abstract
Background and study aims: Colorectal cancer (CRC) screening aims to reduce mortality by detecting cancers at an early stage and removing adenomatous polyps at an acceptable cost. The aim of the current study were to assess the outcomes and costs of the first two biennial rounds of a population-based CRC screening program using the immunochemical fecal occult blood test (i-FOBT) in a northern Italian province.Methods: All residents aged 50 - 69 years were invited to take part in a biennial screening program using a 1-day i-FOBT, followed by colonoscopy in positive individuals. The i-FOBT uptake, compliance to colonoscopy, detection rate for cancer or advanced adenomas according to age and sex, and direct cost analysis were carried out separately for the 1st and 2nd rounds of screening.Results: In 78 083 (1st round) and 81 619 (2nd round) individuals who were invited to screening, the participation rates were 49.7 % and 54.4 % and i-FOBT positivity rates were 6.2 % and 5.8 %, respectively. Detection rates for cancer and advanced adenomas were lower in the 2nd screening compared with the 1st one (1.6‰ vs. 2.5‰ for cancers and 15.8‰ vs. 17.9‰ for advanced adenomas, respectively), whereas positive predictive values for cancer and advanced adenoma were similar in both rounds. In 165 adenocarcinomas detected, 52 % were Dukes' stage A and 21 % were stage B. All cost indicators were slightly higher in the 1st round of screening compared with the 2nd. The direct cost per cancer or advanced adenoma detection was similar in the two rounds (€ 1252 and € 1260, respectively). Conclusions: Compliance and diagnostic yield of i-FOBT screening were satisfactory. Most detected cancers were at a very early stage. Program costs were reasonable and did not increase with repeat screening. Screening could contribute to decreasing the cost of CRC care by improving the stage at diagnosis.

5. Altomare DF, Di Lena M, Porcelli F, Trizio L, Travaglio E, Tutino M, Dragonieri S, Memeo V, de Gennaro G. Exhaled volatile organic compounds identify patients with colorectal cancer. Br J Surg. 2013 Jan;100(1):144-50. doi: 10.1002/bjs.8942.
Department of Emergency and Organ Transplantation, University 'Aldo Moro' of Bari, Bari, Italy. donatofrancesco.altomare@uniba.it.

Abstract
BACKGROUND: An effective screening tool for colorectal cancer is still lacking. Analysis of the volatile organic compounds (VOCs) linked to cancer is a new frontier in cancer screening, as tumour growth involves several metabolic changes leading to the production of specific compounds that can be detected in exhaled breath. This study investigated whether patients with colorectal cancer have a specific VOC pattern compared with the healthy population. METHODS: Exhaled breath was collected in an inert bag (Tedlar(®) ) from patients with colorectal cancer and healthy controls (negative at colonoscopy), and processed offline by thermal-desorber gas chromatography-mass spectrometry to evaluate the VOC profile. During the trial phase VOCs of interest were identified and selected, and VOC patterns able to discriminate patients from controls were set up; in the validation phase their discriminant performance was tested on blinded samples. A probabilistic neural network (PNN) validated by the leave-one-out method was used to identify the pattern of VOCs that better discriminated between the two groups. RESULTS: Some 37 patients and 41 controls were included in the trial phase. Application of a PNN to a pattern of 15 compounds showed a discriminant performance with a sensitivity of 86 per cent, a specificity of 83 per cent and an accuracy of 85 per cent (area under the receiver operating characteristic (ROC) curve 0•852). The accuracy of PNN analysis was confirmed in the validation phase on a further 25 subjects; the model correctly assigned 19 patients, giving an overall accuracy of 76 per cent. CONCLUSION: The pattern of VOCs in patients with colorectal cancer was different from that in healthy controls. The PNN in this study was able to discriminate patients with colorectal cancer with an accuracy of over 75 per cent. Breath VOC analysis appears to have potential clinical application in colorectal cancer screening, although further studies are required to confirm its reliability in heterogeneous clinical settings.

6. Zappacosta R, Caraceni D, Ciccocioppo L, Rotondo T, Capanna S, Gatta DM, D'Angelo C, Rosini S. Implementing specificity of HPV-DNA primary screening in a successful organised cervical cancer prevention programme. Gynecol Oncol. 2012 Nov 28. pii: S0090-8258(12)00896-7. doi: 10.1016/j.ygyno.2012.11.030. [Epub ahead of print]
Cytopathology Unit, Clinical and Experimental Sciences Department, G. d'Annunzio University of Chieti-Pescara, Via dei Vestini, 66100, Chieti, Italy. Electronic address: zappacosta2@hotmail.com.

Abstract
OBJECTIVE: This two-arm longitudinal study was performed within a regional organized cervical-cancer-prevention program in which HPV-DNA test is used in primary screening. The aim was to analyze the diagnostic performances of p16INK4a/Ki-67 dual-test and E6/E7-mRNA test in identifying CIN2+ lesion among HPV-DNA positive (HPV-DNAve) women triaged for LSIL-or-worse liquid based cytology (LBC). METHODS: Thirty-six thousand thirty-one women participated to HPV-DNA screening program pilot study. Three thousand six hundred forty-one resulted HPV-DNAve; among these, 43% were LSIL-or-worse (LSIL+). HPV-DNAve/LSIL+ patients were submitted to colposcopy and histological assessment of any visible lesions. Dual-test was performed on 794 residual LBC specimens. In 405 cases, dual-test result was related to histology, considering CIN2+ as endpoint. mRNA test has been carried out retrospectively, on a subset of 173 residual LBC specimens. RESULTS: Agreement between dual-test and histological diagnosis was 59%. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of cytology-plus-dual-test approach were 62.3%, 76.8%, 63.1% and 84.2%, respectively. Dual-test improved specificity, PPV and NPV of cytological triage Agreement between mRNA testing and histology was 65%. Cytology-plus mRNA testing showing sensitivity, specificity, PPV and NPV reaching 32.1%, 94.9%, 75% and 50%, respectively; implemented specificity and PPV of cytology alone in triaging DNA-ve/LSIL+ patients (p<0.01). CONCLUSIONS: We provided promising data indicating the important role that p16(INK4)/Ki-67 dual-test, and mostly E6/E7 mRNA test, might have in triaging HPV-DNAve. These approaches would exclude the occurrence of cervical cancer and would avoid overtreatment, at the same time. Further longitudinal analysis has to be considered.

7. Hassan C, Pickhardt PJ. Cost-effectiveness of CT colonography. Radiol Clin North Am. 2013 Jan;51(1):89-97. doi: 10.1016/j.rcl.2012.09.006.
Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Roma 00153, Italy. cesareh@hotmail.com

Abstract
Simulation modeling is extensively applied to CT colonography (CTC) to define its long-term efficacy and cost-effectiveness for colorectal cancer (CRC) screening. CTC is effective in reducing CRC incidence and mortality (40%-77% and 58%-84%, respectively). Several factors may explain this variability. CTC is cost-effective compared with no screening, indicating that it represents an attractive test noncompliance with the available options. CTC needs to achieve a higher attendance rate or cost less than colonoscopy to be cost-effective relative to colonoscopy. Fortunately, both conditions appear to be achievable if CTC becomes a widely utilized and reimbursed screening tool.

8. Flora M, Piana S, Bassano C, Bisagni A, De Marco L, Ciarrocchi A, Tagliavini E, Gardini G, Tamagnini I, Banzi C, Bisagni G. Epidermal growth factor receptor (EGFR) gene copy number in colorectal adenoma-carcinoma progression. Radiol Clin North Am. 2013 Jan;51(1):89-97. doi: 10.1016/j.rcl.2012.09.006.
Pathology Unit, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS)-Arcispedale S. Maria Nuova, Reggio Emilia, Italy.

Abstract
Adenomas are the easily identifiable precursors of the vast majority of colorectal cancers. Some of their morphological features, such as dysplasia, are predictive of their biological evolution toward adenocarcinomas. A large body of evidence has demonstrated that the epidermal growth factor receptor (EGFR) signaling pathway is commonly activated in colorectal cancer and EGFR-target therapies have improved the outcome for colorectal cancer patients. Nevertheless, the mechanisms underlying the role of EGFR in the adenoma-carcinoma sequence are not entirely clear. We retrospectively analyzed EGFR gene copy number by fluorescence in situ hybridization (FISH) in paraffin-embedded tissue from 215 patients recruited through a prospective colorectal cancer screening procedure and undergoing surgical colectomy. We observed that in human colorectal carcinogenesis, EGFR copy number increases progressively, from adenomas with high-grade dysplasia to locally advanced adenocarcinomas, through early invasive adenocarcinomas, suggesting that deregulation of EGFR may correlate with the malignant progression.

9. Simone B, De Feo E, Nicolotti N, Ricciardi W, Boccia S. Methodological quality of English-language genetic guidelines on hereditary breast-cancer screening and management: an evaluation using the AGREE instrument. BMC Med. 2012 Nov 21;10:143. doi: 10.1186/1741-7015-10-143.
Institute of Hygiene, Università Cattolica del Sacro Cuore, L,go F, Vito 1, 00168 Rome, Italy. sboccia@rm.unicatt.it.

Abstract
ABSTRACT:BACKGROUND: We examined the methodological quality of guidelines on syndromes conferring genetic susceptibility to breast cancer. METHODS: PubMed, EMBASE, and Google were searched for guidelines published up to October 2010. All guidelines in English were included. The Appraisal of Guidelines, Research and Evaluation (AGREE) instrument was used to assess the quality of the guidelines, and their reported evidence base was evaluated. RESULTS: Thirteen guidelines were deemed eligible: seven had been developed by independent associations, and the other six had national/state endorsements. Four guidelines performed satisfactorily, achieving a score of greater than 50% in all six AGREE domains. Mean ± SD standardized scores for the six AGREE domains were: 90 ± 9% for 'scope and purpose', 51 ± 18% for 'stakeholder involvement', 55 ± 27% for 'rigour of development', 80 ± 11% for 'clarity and presentation', 37 ± 32% for 'applicability', and 47 ± 38% for 'editorial independence'. Ten of the thirteen guidelines were found to be based on research evidence. CONCLUSIONS: Given the ethical implications and the high costs of genetic testing for hereditary breast cancer, guidelines on this topic should provide clear and evidence-based recommendations. Our analysis shows that there is scope for improving many aspects of the methodological quality of current guidelines. The AGREE instrument is a useful tool, and could be used profitably by guidelines developers to improve the quality of recommendations.

10. Piscitelli P, Barba M, Crespi M, Di Maio M, Santoriello A, D'Aiuto M, Fucito A, Losco A, Pentimalli F, Maranta P, Chitano G, Argentiero A, Neglia C, Distante A, Di Tanna GL, Brandi ML, Mazza A, Marino IR, Giordano A; on behalf of the Human Health Foundation Study Group, in memory of Prof. Giovan Giacomo Giordano. The burden of breast cancer in Italy: mastectomies and quadrantectomies performed between 2001 and 2008 based on nationwide hospital discharge records. J Exp Clin Cancer Res. 2012 Nov 20;31(1):96.
Sbarro Institute for Cancer Research and Molecular Medicine and Center of Biotechnology, College of Science and Technology Temple University, BioLife Science, Bldg, Suite 431 1900 N 12th Street, Philadelphia, PA, 19122, USA. giordano@temple.edu.

Abstract
ABSTRACT: BACKGROUND: Where population coverage is limited, the exclusive use of Cancer Registries might limit ascertainment of incident cancer cases. We explored the potentials of Nationwide hospital discharge records (NHDRs) to capture incident breast cancer cases in Italy. METHODS: We analyzed NHDRs for mastectomies and quadrantectomies performed between 2001 and 2008. The average annual percentage change (AAPC) and related 95% Confidence Interval (CI) in the actual number of mastectomies and quadrantectomies performed during the study period were computed for the full sample and for subgroups defined by age, surgical procedure, macro-area and singular Region. Re-admissions of the same patients were separately presented. RESULTS: The overall number of mastectomies decreased, with an AAPC of -2.1% (-2.3 -1.8). This result was largely driven by the values observed for women in the 45 to 64 and 65 to 74 age subgroups (-3.0%, -3.4 -3.6 and -3.3%, -3.8 -2.8, respectively). We observed no significant reduction in mastectomies for women in the remaining age groups. Quadrantectomies showed an overall +4.7 AAPC (95%CI:4.5-4.9), with no substantial differences by age. Analyses by geographical area showed a remarkable decrease in mastectomies, with inter-regional discrepancies possibly depending upon variability in mammography screening coverage and adherence. Quadrantectomies significantly increased, with Southern Regions presenting the highest average rates. Data on repeat admissions within a year revealed a total number of 46,610 major breast surgeries between 2001 and 2008, with an overall +3.2% AAPC (95%CI:2.8-3.6). CONCLUSIONS: In Italy, NHDRs might represent a valuable supplemental data source to integrate Cancer Registries in cancer surveillance.

11. Hassan C, Pickhardt PJ. Management of subcentimetric polyps detected by CT colonography. Nat Rev Gastroenterol Hepatol. 2012 Nov 20. doi: 10.1038/nrgastro.2012.222. [Epub ahead of print]
Digestive Endoscopy Unit, "Nuovo Regina Margherita" Hospital, Via Morosini 30, 00153 Rome, Italy.

Abstract
The advent of CT colonography (CTC) has generated conservative policies for the management of diminutive (<5 mm) and small (6-9 mm) polyps to prevent inefficient duplication of screening tests. The effect of not referring subcentimetric polyps for polypectomy on the efficacy of colorectal cancer screening is still uncertain but depends on the natural history of diminutive and small polyps, as well as on the distribution of advanced neoplasia within these lesions. Simulation modelling enables the efficacy and cost-effectiveness of conservative strategies for the management of subcentimetric lesions to be tested (such as nonreferral to polypectomy for diminutive polyps and early CTC surveillance for small polyps). These policies might be further refined by the inclusion of patient and polyp-related predictive factors for advanced neoplasia, enabling a patient-tailored approach for the management of these lesions.

12. Regge D, Monica PD, Galatola G, Laudi C, Zambon A, Correale L, Asnaghi R, Barbaro B, Borghi C, Campanella D, Cassinis MC, Ferrari R, Ferraris A, Hassan C, Iafrate F, Iussich G, Laghi A, Massara R, Neri E, Sali L, Venturini S, Gandini G. Efficacy of Computer-aided Detection as a Second Reader for 6-9-mm Lesions at CT Colonography: Multicenter Prospective Trial. Radiology. 2013 Jan;266(1):168-176. Epub 2012 Nov 14.
Radiology Unit, Institute for Cancer Research and Treatment, Candiolo, Italy; Gastroenterology Unit, Institute for Cancer Research and Treatment, Candiolo, Italy; Unit of Biostatistics-Department of Statistics, Bicocca Universiy of Milano, Milan, Italy; im3D, Torino, Italy; Radiology Unit, Salvatore Maugeri IRCCS Foundation, Novara, Italy; Department of Bioimaging and Radiological Sciences, Catholic University of Rome, A. Gemelli Hospital, Rome, Italy; Radiology Unit, Valduce Hospital, Como, Italy; Diagnostic Imaging Division-Department of Medical and Surgical Disciplines University of Turin, AOU S. Giovanni Battista, Turin, Italy; Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome Polo Pontino, Rome, Italy; Radiology Unit-Department of Digestive Disease and Internal Medicine, S. Orsola-Malpighi Hospital, Bologna, Italy; Gastroenterology Unit, Ospedale Nuovo Regina Margherita, Via Morosini 30, 00153 Rome, Italy; Department of Radiological Sciences, Sapienza University of Rome, Rome, Italy; Diagnostic and Interventional Radiology-Department of Oncology Transplants and Advanced Technologies in Medicine, University of Pisa, Pisa, Italy; Radiodiagnostic Section-Department of Clinical Physiopathology, University of Florence, Florence, Italy.

Abstract
Purpose: To assess the effect of computer-aided detection (CAD) as a second reader on the sensitivity and specificity of computed tomographic (CT) colonography in detecting 6-9-mm colorectal cancer (CRC) lesions. Materials and Methods: Individuals with clinical indications for colonoscopy-either for symptoms or as part of participating in a surveillance program or CRC screening-were prospectively enrolled at one of 10 academic centers between July 2007 and May 2009. Institutional review board approval was obtained at each clinical site, and all participants provided written informed consent. All participants underwent CT colonography and colonoscopy on the same day. Experienced readers interpreted the CT colonography images unassisted and then reviewed all colorectal lesion-like structures pinpointed by the CAD algorithm. Segmental unblinding of CT colonoscopy findings at colonoscopy was utilized. The sensitivity and specificity of unassisted and CAD-assisted reading in identifying individuals with 6-9-mm lesions were calculated and compared by means of pairwise analysis. Results: A total of 618 participants (mean age, 57.9 years; 54.5% male) were included in the final analysis. Of these participants, 464 (75.1%) had no lesions 6 mm or larger, and 52 (8.4%) had 6-9-mm lesions. The sensitivity of CT colonography with unassisted reading and that with CAD-assisted reading in identifying individuals with 6-9-mm lesions was 65.4% (95% confidence interval [CI]: 50.9%, 78.0%) and 76.9% (95% CI: 63.2%, 87.5%; P = .016), respectively. No significant change in specificity was observed: The specificity of CT colonography with unassisted and that with CAD-assisted reading was 91.8% (95% CI: 88.9%, 94.1%) and 90.9% (95% CI: 88.0%, 93.4%; P = .063), respectively. Evaluation of CAD candidates required an additional 1.6 minutes (25th-75th percentile: 1.0 minute to 3.4 minutes). Conclusion: The addition of CAD to reading performed by experienced readers resulted in a significant benefit in the detection of 6-9-mm polyps at CT colonography in this cohort. © RSNA, 2012 Supplemental material: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12120376/-/DC1.

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