Program badań przesiewowych

Screening Program for the Early Detection of Colorectal Cancer
The Screening Program for the Early Detection of Colorectal Cancer (PBP) is the responsibility of the National Cancer Control Program. As part of PBP, free prophylactic colonoscopies have been performed since 2000. Since 2012, PBP has been sending personal, one-time invitations to colonoscopy to people aged 55-64.
The goal of PBP is to reduce the incidence and deaths of colorectal cancer.
Colorectal cancer is the second most common malignant neoplasm in Poland. Each year, more than 18,000 new cases are diagnosed. Colorectal cancer develops from benign lesions – polyps. Such a transformation usually takes several years. Therefore, by getting tested early and removing the polyps can prevent the development of cancer. Early cancer is also almost always curable .
Neither polyps nor early-stage cancer usually cause symptoms. The essence of prophylactic colonoscopy is to find these asymptomatic changes and remove them. Doing so reduces the risk of developing colorectal cancer by up to 60-90% .
Prophylactic examination should be performed between 55 and 64 years of age
The prevalence of polyps and the risk of developing them malignant increases with age. The vast majority of new cases occur in people over 55 years of age. The aim of the program for men and women between 55 and 64 years of age is to detect curable changes . At this age, 25-30% of people have polyps, and 5% have changes that threaten to develop cancer in the near future.
People who have received an invitation can participate in the study
Anyone who has received an invitation to colonoscopy screening is a candidate to participate in PBP. Contraindication to screening colonoscopy is myocardial infarction within the last 3 months, acute heart or respiratory failure, and active inflammatory bowel disease. In the case of severe chronic diseases, as well as any doubts, it is worth consulting with the attending physician. The diseases we ask about in the form are not a contraindication to colonoscopy. Information about them allows you to plan a safe and comfortable examination.
The invitation is personal and cannot be transferred to another person. The invitation contains a proposed date for the study. You can change the date. You can resign from the study at any time.
I have not received an invitation but would like to undergo a preventive examination
People who have not yet received an invitation will most likely receive it in the coming years. In addition, in the next four years, the possibility of undergoing the examination without invitation (under the so-called „opportunistic program”), provided that the qualifying conditions for the Program are met:

• all people aged 50-65 without symptoms such as gastrointestinal bleeding, diarrhea or constipation in the last few months for which the cause is unknown, and weight loss or anemia for no known reason.
• people aged 40-49 without symptoms of colorectal cancer who have had at least one first-degree relative (parents, siblings, children) in family (parents, siblings, children) with cancer of the colon.
• people aged 25-49 from a family with Lynch syndrome. In this group of people, it is necessary to confirm the diagnosis of belonging to a family with Lynch syndrome from a genetic clinic based on the fulfillment of the so-called the Amsterdam criteria and possible genetic testing. Only the first test can be performed under the Screening Program.
• people aged 20-49 from a family with familial adenomatous polyposis syndrome – FAP. In this case, a referral (confirmation) from the Genetic Clinic is necessary. Only the first test can be performed under the Screening Program.

People who have had a colonoscopy within the last 10 years are not eligible for the study.

You can sign up for a preventive colonoscopy by phone at 22 825 62 99 or in person at PFG endotherapy facilities at ul. Waryńskiego 10a and Aleja Niepodległości 18 in Warsaw, after filling in the questionnaire (which is also a referral). The questionnaire can be filled in by a physician of any specialty and can be downloaded here: . When signing up for the test, you will receive the necessary information on how to prepare for the test and its course (also available on the website www.przychodniapfg.pl / preparation-for-research / )

Research
Colonoscopy is an endoscopic examination of the large intestine. It is the best examination of the large intestine available, allowing for the direct and most accurate assessment of the large intestine, removal of polyps and sampling for histopathology. The examination is performed using a colonoscope, i.e. a flexible probe 130-160 cm long, equipped with a vision track. During the examination, the image of the inside of the intestine is displayed on the monitor and assessed by the doctor. During the examination, it is also possible to take a biopsy and take therapeutic measures, eg polypectomy, bleeding control, coagulation of vascular lesions, tattooing … Colonoscopy requires preparation (cleaning) of the large intestine before the examination (see Preparation).

Preparation

A thorough examination of the intestine from the inside requires its perfect cleaning of food debris. This is achieved by using the appropriate drug prepared and applied according to the instructions. The correct reaction to the preparation will be frequent bowel movements, at the end with transparent or yellow colored liquid, clear contents. Preparation should be divided into two stages – on the eve and on the day of the study. This method of preparation gives the best possible effect and is much better tolerated by patients than preparation in the evening, the day before the examination. There are several intestinal cleansing preparations available in Poland. In the Screening Program, we routinely use the best known and long-used polyethylene glycol preparation (Fortrans), but it is possible to use other preparations (Clensia, Citrafleet, Moviprep, Eziclen)

• download – Instructions for preparation for colonoscopy with FORTRANS

Below we also present preparation diagrams with the use of four other preparations. These diagrams are based on scientific guidelines from European societies and / or publications and may differ from the method proposed in the leaflet.

• download – EZICLEN

preparation guide

• download – MOVIPREP

preparation instructions

• download – Preparation of the intestine with CLENSIA
• download – Preparation with Citrafleet

Important information:

1. People who regularly take medications, e.g. for hypertension, heart disease, epilepsy, asthma and others on the day of the examination should take their morning dose of the drug with a little water – EVEN IF THE TEST IS DONE UNDER ANESTHESIA
2. People suffering from diabetes should inform their registration about diabetes in advance, and also consult the attending physician or an anaesthesiologist at our center on how to prepare for the examination. Oral diabetes medications should NOT be taken unless food is being consumed at the same time. / or: Oral antidiabetic drugs should be discontinued on the day of the examination, and in the case of colonoscopy, the evening dose of the previous day should also be omitted /
3. People taking medications that reduce blood clotting
   – do not discontinue acetylsalicylic acid preparations (e.g. Acard, Polocard, Acesan)
   – drugs from the group of new oral anticoagulants (Pradaxa, Xarelto, Eliquis, Lixiana) – should be discontinued on the day before and skip the morning dose on the day of the test.

– drugs from the group of oral anticoagulants (Acenocoumarol, Warfarin) – INR should be determined in the week preceding the test: if the result is in the range of 2-3, do not modify the doses of drugs, if higher, consult your doctor.
In the case of people with a high risk of thromboembolism, after heart attacks or strokes, the optimal procedure is to consult a doctor or an anesthesiologist at our center. It is advisable to switch to CLEXANE in doses of 40, 60 or 80 mg, depending on the body weight, 5 days before and 2 days after the procedure /.
If there is a need to perform a larger endoscopic procedure, e.g. removal of polyps, it may be necessary to repeat the procedure after modifying anticoagulant treatment (e.g. in people using Acenocoumarol, Warfarin, switching to low molecular weight heparin treatment, in case of doubt, OPTIMUM PROCEDURE) CONSULATION WITH A DOCTOR / anesthesiologist of our Center /.

4. Please bring it and show it to the doctor before examining your documentation
   medical, e.g. discharge cards from hospital treatment, descriptions of previously performed endoscopic examinations, ultrasound of the abdominal cavity, ECG, echocardiography, spirometry and others.
   For tests under anesthesia, current test results are required (they must not be older than 3 months) such as: morphology, electrolytes – sodium / potassium, total bilirubin, creatinine, glucose, APTT and INR (if the patient is taking anticoagulants), TSH (if The patient takes thyroid hormones – Euthyrox, Letrox), EKG. Patients should know the names and doses of the medications taken or have a list of them. It is advisable to take these medications with you.
   You should come for the examination under anesthesia with an adult accompanying person.
5. After the examination performed under anesthesia, the patient remains in the observation room. The time of observation depends on the type of surgery and the patient’s condition. After this time, under the supervision of an accompanying person, he can go home. There is a 12-hour absolute ban on driving vehicles, mechanical machines and drinking alcohol. In very rare cases, longer observation may be necessary. Please include this in your plans.
6. If you require reading glasses, please bring them with you.
7. The designated estimated time to start the examination may be delayed because the duration of endoscopic examinations is difficult to predict.

Contraindications
Colonoscopy is safe, but there are some general contraindications for performing it. The most important are:

• Large aortic aneurysm
• Recent heart attack
• Severe heart failure
• Respiratory failure
• Pulmonary embolism
• Severe enteritis
• Suspicion of bowel perforation
• Mechanical bowel obstruction
• Pregnancy (2nd and 3rd trimester)

Before the examination, you will fill in a questionnaire regarding your current health condition in which you will be able to mark this type of information. They will be taken into account when qualifying for the study. Also, the doctor conducting the examination will – if necessary and in doubt, ask questions about past illnesses, so that the examination is safe for you.
Complications
During the examination, air is administered to the intestine, so after the examination you may feel bloating, discomfort, a feeling of distension, excessive gas discharge – this is not a complication, but only a result of the presence of gas in the intestine. During the examination, the doctor injects air or carbon dioxide into the intestine, which allows for a good visualization of the entire surface of the mucosa. There are toilets in each screening center that you can freely use. Gassing away usually brings relief after the test.
Colonoscopy is a safe examination, although its success and complete safety cannot be guaranteed by any physician. Complications are extremely rare. The most serious of them, i.e. perforation (perforation of the intestinal wall) or bleeding, may require immediate or urgent surgery. In the Polish screening program, perforation occurred only in 5 out of 50,000 tests (0.01%). If any symptom resulting from the performed colnoscopy worries the Patient or the physician performing the colonoscopy, the Patient remains under the care of the examining physician, and if necessary, he / she is obliged to provide further treatment.

The New England Journal of Medicine – the world’s most renowned clinical journal – published two articles developed and written by scientists from the Gastroenterology Clinic of the Oncology Center in Warsaw (currently NIO-PIB). These are the only two publications in the history of this journal that were written exclusively by Polish authors.

The first one was published in November 2006. The first author is prof. Jarosław Reguła. This study investigated the risk factors of advanced neoplasia in people presenting for screening, i.e. people without colorectal symptoms ^[1] .
The data of people tested in the Screening Program in 2000-2004 were analyzed. At that time, the study was performed in 50,148 people without symptoms of the colon, including 43,042 people between 50 and 66 years of age, and 7,106 people between the age of 40 and 49 who had a positive family history of cancer. Women constituted 64% of the entire group. The complete examination, i.e. with reaching the cecum, was performed in 45,693 (91.1%) people.
Advanced neoplasia, defined as cancer or adenoma at least 10 mm in diameter, with high-grade dysplasia, villous or tubulovillous, was diagnosed in 2,553 (5.9%) people aged 50-66 and 243 ( 3.4%) of people aged 40-49. Adenocarcinoma was diagnosed in 416 people: in 169 stage I, in 91 stage II and 111 stage III.
Gender, age, and family history of colorectal cancer have been shown to be associated with the risk of advanced neoplasia.

The risk of developing advanced neoplasia at screening:

• is twice as high in men as in women (OR = 2.08, p & lt; 0.001),
• increases by about 60% with each subsequent 5 years of life, (50-54 vs 40-49 OR = 1.64, 55-59 vs 40-49 OR = 2.4, 60-66 vs 40-49 OR = 2.95 , p & lt; 0.0001),
• is approximately 2 times higher in people diagnosed with colorectal cancer in 2 1st-degree relatives or in one 1st-degree relative before the age of 60 than in those with no family history of cancer (OR = 2.1 , OR = 1.87, p & lt; 0.0001, respectively).
• is 40% higher in people diagnosed with colorectal cancer of one 1st degree relative over the age of 60 compared to those with no family history of cancer (OR = 1.43, p & lt; 0.0001).

By family history of colorectal cancer:

• in 1 in 20 or 1 in 30 men aged 40-49, and
• 1 in 6 or 1 in 10 men aged 60-66 without bowel symptoms

diagnosed with advanced neoplasia.
Depending on the family history of colorectal cancer

• 1 in 32 or 1 in 52 women aged 40-49, and
• 1 in 16 or 1 in 19 women aged 60-66 without bowel symptoms

diagnosed with advanced neoplasia.
The above results may be the basis for the verification of recommendations for screening for colorectal cancer.

If men are recommended to perform the first test at the age of 50, it seems that the age limit for the first test in women can be extended to 55-60 years of age – the number of tests that should be performed to detect one advanced neoplasia in these groups is similar: 13 and 16 in people with a family history of colorectal cancer, and 18 and 19 in people with no family history of colorectal cancer.

The second publication appeared in May 2010, its first author is Dr. Michał F. Kamiński. In this study, the screening quality parameters related to the incidence of interval cancer ^[2] were investigated.
The data of people tested in the Screening Program in 2000-2004, who had sufficient bowel cleansing before the examination, had all found polyps removed, and no cancer diagnosed as a result of the screening, were analyzed.
Data from people examined by endoscopists who performed less than 30 tests as part of the screening program were excluded from the analysis.
The analysis included 45,026 people, mean age 55.1 years, of whom 35.7% were male. The full examination, i.e. the examination reaching the cecum, was performed in 41,552 (92.3%) subjects.
Interval cancer was defined as an adenocarcinoma of the colon that appeared between screening and the recommended time of follow-up, but no later than 5 years, in the part of the intestine that was viewed at the time of screening. The following were considered as study quality parameters defined for individual endoscopists:

• frequency of adenoma detection, which is the number of tests in which at least 1 adenoma was detected divided by the number of tests performed,
• frequency of tests to reach the contra-angle.

The analyzed group of people was examined by 186 endoscopists, including 149 (80.1%) men who performed 30 to 1,848 endoscopies. Half of the respondents performed more than 145 tests under the screening program. Half of the endoscopists detected adenomas more often than in 12.2% of the examined people. Half of the endoscopists achieved the contra-angle more often than in 94% of their examinations.
The total observation time of the study group was 188,788 person-years. At that time, 42 interval cancers were diagnosed, which is 22.3 events per 100,000 person-years of follow-up. 35 (83.3%) of interval cancers were reported in people with no family history of colorectal cancer and 39 (92.9%) in people who had no adenoma detected at screening.

It has been shown that the factors related to the occurrence of interval cancer are the age of the examined person and the frequency of adenomas detection by an endoscopist.
The risk of developing interval cancer in long-term follow-up is:

• many times greater in people aged 60-66 compared to those aged 40-49 (OR = 13.3, p = 0.01)
• more than 10 times higher in people examined by endoscopists, whose adenoma detection frequency does not exceed 20%, (15% -20% vs> 20% OR = 10.9, 11% -15% vs> 20% OR = 10.7, & lt; 11% vs & gt; 20% OR = 12.5%, p = 0.02)

The obtained results confirm the importance of the quality parameter, which is the frequency of adenomas detection by the endoscopist performing the examination. It is a factor significantly related to the occurrence of interval cancer in further observation. The prognostic significance of the frequency of examinations reaching the cecum has not been confirmed.

References

1. 1 . Regula J, Rupinski M, Kraszewska E, Polkowski M, Pachlewski J, Orlowska J, Nowacki MP, Butruk E, Colonoscopy in colorectal-cancer screening for detection of advanced neoplasia. N Engl J Med 2006; 355: 1863-72
   2 . Kaminski MF, Regula J, Kraszewska E, Polkowski M, Wojciechowska U, Didkowska J, Zwierko M, Rupinski M, Nowacki MP, Butruk E. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med. 2010; 362: 1795-803

Publications of work on colorectal cancer and screening tests, the authors or co-authors of which are the coordinators of the Colon Cancer Screening Program in Poland and the PBP team
European recommendations and initiatives to work on changes

1. Quality indicators for endoscopy laboratories: an initiative to improve the quality of the European Society for Gastrointestinal Endoscopy (ESGE).

   Valori, R., Cortas, G., de Lange, T., Salem Balfaqih, O., de Pater, M., Eisendrath, P., Falt, P., Koruk, I., Ono, A., Rustemovic, N., Schoon, E., Veitch, A., Senore, C., Bellisario, C., Minozzi, S., Bennett, C., Bretthauer, M., Dinis-Ribeiro, M., Domagk, D., Hassan, C., Kaminski, MF, Rees, CJ, Spada, C., Bisschops, R. and Rutter, M. Performance measures for endoscopy services: A European Society of Gastrointestinal Endoscopy (ESGE) quality improvement initiative. United European Gastroenterol J 2019; 7: 21-44.

2. Polypectomy and endoscopic mucosal resection (EMR) of the colon: clinical guidelines of the European Society of Gastrointestinal Endoscopy.

   Ferlitsch, M., Moss, A., Hassan, C., Bhandari, P., Dumonceau, JM, Paspatis, G., Jover, R., Langner, C., Bronzwaer, M., Nalankilli, K., Fockens , P., Hazzan, R., Gralnek, IM, Gschwantler, M., Waldmann, E., Jeschek, P., Penz, D., Heresbach, D., Moons, L., Lemmers, A., Paraskeva, K., Pohl, J., Ponchon, T., Regula, J., Repici, A., Rutter, MD, Burgess, NG and Bourke, MJ Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2017; 49: 270-297.

3. Lower gastrointestinal endoscopy quality indicators: an initiative to improve the quality of the European Society for Gastrointestinal Endoscopy (ESGE).
   Kaminski, MF, Thomas-Gibson, S., Bugajski, M., Bretthauer, M., Rees, C. .J, Dekker, E, Hoff, G., Jover, R., Suchanek, S. and Ferlitsch, M . Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) quality improvement initiative . Endoscopy 2017; 49: 378-397.
4. Gastrointestinal Endoscopy Reporting Systems: Requirements and Standards to Facilitate Quality Improvement: Statement by the European Society for Gastrointestinal Endoscopy.
   Bretthauer, M., Aabakken, L., Dekker, E., Kaminski, MF, Rosch, T., Hultcrantz, R., Suchanek, S., Jover, R., Kuipers, EJ, Bisschops, R., Spada, C., Valori, R., Domagk, D., Rees, C. and Rutter, MD Reporting systems in gastrointestinal endoscopy: Requirements and standards facilitating quality improvement: European Society of Gastrointestinal Endoscopy position statement. United European Gastroenterol J 2016; 4: 172-6.
5. European Code Against Cancer – 4th edition – screening tests.
   Armaroli, P., Villain, P., Suonio, E., Almonte, M., Anttila, A., Atkin, WS, Dean, PB, de Koning, HJ, Dillner, L., Herrero, R., Kuipers, EJ, Lansdorp-Vogelaar, I., Minozzi, S., Paci, E., Regula, J., Tornberg, S. and Segnan, N. European Code against Cancer, 4th Edition: Cancer screening. Cancer Epidemiol 2015; 39 Suppl 1: S139-52.

Badania naukowe

1. Effect of low volume versus large bowel preparation volume on reportingability for screening colonoscopy: a randomized public health study.
   Pisera, M., Franczyk, R., Wieszczy, P., Polkowski, M., Rupinski, M., Chaber-Ciopinska, A., Kotowski, B., Kula, Z., Kielek, S., Buszkiewicz, M ., Rupinska, M., Kobiela, J., Kaminski, MF and Regula, J. The impact of low- versus standard-volume bowel preparation on participation in primary screening colonoscopy: a randomized health services study. Endoscopy 2019; 51: 227-236.
2. Modifiable factors related to patient-reported pain during and after screening colonoscopy.
   Bugajski, M., Wieszczy, P., Hoff, G., Rupinski, M., Regula, J. and Kaminski, MF Modifiable factors associated with patient-reported pain during and after screening colonoscopy. Gut 2018; 67: 1958-1964.
3. Relationship between obesity and findings during screening colonoscopy in a large population study. 2017
   Kobiela J, Wieszczy P, Regula J, and Kaminski MF Association of obesity with colonic findings in screening colonoscopy in a large population-based study. United European Gastroenterol J 2018; 6: 1538-1546.
4. Increasing the detection rate of colorectal adenomas reduces the risk of developing and dying from colorectal cancer.
   Kaminski, MF, Wieszczy, P., Rupinski, M., Wojciechowska, U., Didkowska, J., Kraszewska, E., Kobiela, J., Franczyk, R., Rupinska, M., Kocot, B., Chaber -Ciopinska, A., Pachlewski, J., Polkowski, M. and Regula, J. Increased Rate of Adenoma Detection Associates With Reduced Risk of Colorectal Cancer and Death. Gastroenterology 2017; 153: 98-105.
5. Detection frequency of serrated polyps and serrated polyposis syndrome in colorectal cancer screening cohorts: a European review.
   JEG, I. Jspeert, Bevan, R., Senore, C., Kaminski, MF, Kuipers, EJ, Mroz, A., Bessa, X., Cassoni, P., Hassan, C., Repici, A., Balaguer , F., Rees, CJ and Dekker, E. Detection rate of serrated polyps and serrated polyposis syndrome in colorectal cancer screening cohorts: a European overview. Gut 2017; 66: 1225-1232.
6. Colon cancer screening by colonoscopy: a randomized clinical trial.
   Bretthauer, M., Kaminski, MF, Loberg, M., Zauber, AG, Regula, J., Kuipers, EJ, Hernan, MA, McFadden, E., Sunde, A., Kalager, M., Dekker, E. , Lansdorp-Vogelaar, I., Garborg, K., Rupinski, M., Spaander, MC, Bugajski, M., Hoie, O., Stefansson, T., Hoff, G. and Adami, HO Population-Based Colonoscopy Screening for Colorectal Cancer: A Randomized Clinical Trial. JAMA Intern Med 2016; 176: 894-902.
7. Re-invitation to screening colonoscopy – randomized follow-up study of the effect of a reminder letter and educational meeting on the enrollment of people who did not respond to the original invitation to screening colonoscopy.
   Pisera, M., Kaminski, MF, Kraszewska, E., Rupinski, M. and Regula, J. Reinvitation to screening colonoscopy: a randomized-controlled trial of reminding letter and invitation to educational meeting on attendance in nonresponders to initial invitation to screening colonoscopy (REINVITE). Eur J Gastroenterol Hepatol 2016; 28: 538-42.
8. Training of endoscopy lab leaders to improve adenoma detection rate during screening colonoscopy – randomized trial.
   Kaminski, MF, Anderson, J., Valori, R., Kraszewska, E., Rupinski, M., Pachlewski, J., Wronska, E., Bretthauer, M., Thomas-Gibson, S., Kuipers, EJ and Regula, J. Leadership training to improve adenoma detection rate in screening colonoscopy: a randomized trial. Gut 2016; 65: 616-24.
9. Project of the Polish Colon Cancer Screening Program: a randomized public health study.
   Kaminski, MF, Kraszewska, E., Rupinski, M., Laskowska, M., Wieszczy, P. and Regula, J. Design of the Polish Colonoscopy Screening Program: a randomized health services study. Endoscopy 2015; 47: 1144-50.

Review works

1. How to ensure that patients are enrolled in the colon cancer screening program and supervised in your practice.
   Hassan C., Kaminski MF, Repici A. How to Ensure Patient Adherence to Colorectal Cancer Screening and Surveillance in Your Practice. Gastroenterology 2018; 155: 252-257.
2. The detectability of adenomas and the risk of colorectal cancer.
   Wieszczy P., Regula J., Kaminski M.F. Adenoma detection rate and risk of colorectal cancer. Best Pract Res Clin Gastroenterol 2017; 31: 441-446.
3. Surveillance of colorectal cancer in gastroenterological practice.
   Kaminski M.F., Bretthauer M. Cancer surveillance in gastroenterology practice. Best Pract Res Clin Gastroenterol 2016; 30: 853-854.

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