Left colon = splenic flexure to rectum or <60cm Right colon = cecum to transverse colonor ≥ 60cm

Tu1026

Mortality and Recurrence After Colorectal Cancer Resection With PreoperativeStenting - A Danish Nationwide Cohort StudyRune Erichsen, Erzsébet Horváth-Puhó, Jacob B. Jacobsen, Tove Nilsson, John A. Baron,Henrik T. Sørensen

Background: Self-expanding metal stents (SEMS) used as a bridge to surgery for obstructivecolorectal cancer (CRC) have fallen under suspicion for inducing tumor dissemination andthereby increasing CRC recurrence and long-term mortality, but data regarding these risksare sparse. Several attempts to compare SEMS with acute surgery in randomized settingshave failed and the existing evidence from observational studies is based primarily on single-center studies conducted in highly specialized settings with little or no information onpotential confounding factors. Methods: We conducted a nationwide population-based cohortstudy using Danish medical registries (2005-2010) by comparing overall mortality andrecurrence after CRC resection in patients with preoperative stenting (n=581) to patientsundergoing urgent (n=3,333) or elective resection (n=13,722). For patients surviving thefirst 30 days after CRC resection, we used the Kaplan Meier method to compute absolutesurvival. For CRC patients with localized and regional disease, the risk of CRC recurrencewas estimated treating death as a competing risk. We computed mortality rate ratios (MRRs)and cause specific hazard ratios of recurrence within 5 years, using Cox regression withadjustment for important covariates. Results: Crude 5-year survival was 49% (95% CI: 43%-55%) among patients with preoperative SEMS, 40% (95% CI: 38%-43%) among patientsundergoing urgent resection, and 65% (95% CI: 64%-66%) among patients with electiveresection. For SEMS vs. urgent resection, the adjusted MRR was 0.99 (95% CI: 0.91-1.07)and for SEMS vs. elective resection, the adjusted MRR was 1.39 (95% CI: 1.19-1.62). The5-year recurrence risk was 39% (95% CI: 31%-46%) after preoperative SEMS, 30% (95%CI: 27%-32%) after urgent resection, and 22% (95% CI: 21%-24%) after elective surgery.The adjusted cause-specific hazard ratios for recurrence were 1.13 (95% CI: 0.99-1.28) forSEMS vs. urgent resection and 1.81 (95% CI: 1.44-2.28) for SEMS vs. elective resection.Conclusions: Long-term mortality associated with use of SEMS as a bridge to surgery wascomparable to that of urgent resection, but higher than that observed following electiveresection. SEMS use may be associated with an increased risk of CRC recurrence.

Tu1027

Assessing Barriers for Screening Colonoscopy in an Urban UnderservedPopulationPrasanna L. Ponugoti, Jean S. Wang

Introduction: Colorectal cancer is the second leading cause of cancer related mortality inUnited States. Colorectal cancer screening rates are particularly low among low income andminority groups who receive services at Federally Qualified Health Centers. Aim: To identifythe factors influencing nonadherence for screening colonoscopy in an urban underservedpopulation at a Federally Qualified Health Center. Methods: We performed retrospectivereview of electronic health records over a 32 month period and compared various demo-graphic factors associated with nonadherence to screening colonoscopy. Results: A total of1314 patients between the ages of 50-75 who had been referred for screening colonoscopywere identified from June 2010-Feb 2013. Of these, 631 patients completed the screening.Patients who were younger were less likely to complete screening (OR 0.94 for each yearyounger [95% CI 0.93-0.96]. Males were less likely to complete colonoscopy compared tofemales (OR 0.68 [95% CI 0.54-0.86], p=0.001). Non-English speakers were less likely tocomplete colonoscopy compared to English speakers (OR 0.34 [95% CI 0.15-0.76], p=0.009). Those with less than high school education were less likely to complete colonoscopycompared to those who finished high school (OR 0.44 [95% CI 0.33-0.61], p<0.001).Patients with no insurance were less likely to complete colonoscopy compared to those withinsurance (OR 0.79 [95% CI 0.62-0.99], p=0.04) even though the cost of colonoscopy wascovered on a sliding scale based on income .Marital status (P=0.73) and African Americanrace (p=0.45) were not significantly associated with nonadherence. Conclusions: Youngerage, male gender, non-English speakers, less than high school education, and lack of insurancewere significant factors associated with not completing screening colonoscopy among anunderserved population at a Federally Qualified Health Center. More emphasis needs to beplaced on these groups to improve screening rates.

S-731 AGA Abstracts

Tu1028

Assessment of Colorectal Cancer Screening in Average-Risk African AmericansAged 45-49 in Ambulatory Settings At an Academic Medical CenterJonathan P. Congeni, Christopher M. Esber, Samer El-Dika

Background: Colorectal cancer (CRC) is the second most common cause of cancer relateddeath in the United States. Between 1992 and 2002, the mortality rate from CRC decreased1.9% per year for whites but only 0.8% per year for African Americans. Evidence has alsoshown more proximal lesions and earlier onset of CRC in African Americans. As a result,CRC screening in African Americans appears to be more cost effective than any other racialor ethnic group. Despite these findings, African Americans are less likely to receive arecommendation for screening or undergo screening colonoscopy. Though the USPSTFhas not altered screening guidelines with regard to race, both the American College ofGastroenterology as well as the American Society for Gastrointestinal Endoscopy now recom-mend that CRC screening begin at age 45 for average-risk African Americans. Methods: Weperformed a retrospective cohort analysis of subjects eligible for CRC screening. A randomsample of charts of average risk African Americans aged 45-49 who presented either to theinternal medicine or family medicine clinic for an establish care visit were reviewed. Results:A total of 110 patients were included with an average age of 46.5 years, 67% of which hadinsurance coverage. There were 75 females and 35 males. The encounter note was reviewedwith each establish care visit. Only 1 patient (0.90%) was counseled and underwent screeningcolonoscopy prior to the age of 50. During their establish care visit, 12 patients (10.9%)received a recommendation to have screening colonoscopy at age 50. In 3 cases (2.7%),either rectal bleeding or constipation were present during the establish care visit whichprompted colonoscopy for non screening purposes. The rest of the encounters either docu-mented that screening colonoscopy was not indicated at that time or failed to mentionscreening at all (85.5%). Conclusion: There appears to be a number of barriers to successfulCRC screening prior to the age of 50 in average risk African Americans. Not only were thenumber of patients that underwent screening very low, often these patient's were advisedto forego screening until age 50. In the majority of patients, CRC screening was not discussedat all during the establish care visit. Though a lack of physician education or loyalty tocertain guidelines is likely contributing to poor screening rates, other factors such as lackof insurance, patient education, and limited time during an establish care appointment couldalso contribute. Further studies are needed to evaluate improvement in colorectal cancerscreening in this population. Specifically, determination of CRC screening pattern in thispopulation after an educational program for primary care providers has been implemented.

Tu1029

Endoscopic and Surgical Treatment of Malignant Colorectal Polyps: APopulation-Based Comparative StudySachin Wani, Roy D. Yen, Amit Rastogi, Ajay Bansal, Lindsay Hosford, Ananya Das

Background: Malignant colorectal polyps (MCP, adenocarcinoma in adenomatous polyp)that are detected during colonoscopy can either be resected endoscopically (when feasible)or treated by surgery. Although observational data suggest that endoscopic treatment (ET)is highly effective, especially for lesions with intramucosal cancer, long-term data comparingET with surgical resection (gold standard) are limited. Aims: In patients (pts) with MCP: i)To compare long-term cancer-specific mortality and survival between ET and surgery andii) To determine independent predictors of cancer-specific mortality. Methods: From theSurveillance Epidemiology and End Results (SEER) database, we identified pts with MCPwith modified American Joint Committee on Cancer (AJCC) stage 0 and stage 1 diseasebetween 1998 and 2009. Stage 0 (Tis) was defined as intraepithelial cancer or invasion intolamina propria and Stage 1 (T1 only) as infiltration of tumor into the submucosa withoutnodal involvement. Demographics, tumor size, type of treatment and survival informationwere compared between pts undergoing ET and surgery as their initial treatments. Coxproportional hazards regression models were used to evaluate association between treatmentsand colorectal cancer (CRC)-specific mortality. For individuals with sufficient follow-up, wecompared CRC-specific 2.5 and 5-year survival rates between ET and surgery. Results: Ofa total of 10,403 pts with MCP, 2688 (26%) underwent ET and 7715 (74%) underwentsurgery. Baseline characteristics between the 2 gps are shown in Table 1. Pts undergoingET were older (p<0.01), men (p<0.001) and more likely to be diagnosed with stage 0 disease(p<0.001). Patients in the surgery gp were more likely to be whites (p<0.001) with right-sided cancers (p<0.001). There was no difference in the 2.5-year and 5-year CRC-freesurvival rates between the two gps in pts with Stage 0 disease. In pts with stage 0 disease,Cox proportional hazards model showed no difference in CRC-specific mortality in the ETgp compared to surgery gp [RH: 1.02 (95% CI 0.6-1.6), p=0.92]. For stage 1 disease, surgerygp pts had higher 2.5-year (surgery: 97.8% vs. ET: 93.2%, p<0.001) and 5-year (96.6% vs.89.8%, p<0.001) CRC-free survival compared to the ET group. ET group was a significantpredictor for CRC-specific mortality in pts with stage 1 disease [RH: 2.46 (95% CI 1.81-3.27), p<0.001]. Other significant predictors of survival included age and stage 1 disease(compared to stage 0) (Table 2). Conclusions: Results of this population-based study demon-strate comparable mid and long-term CRC-free survival in patients with stage 0 CRC undergo-ing either ET or surgical resection. Given the differences in outcomes between the twogroups in patients with stage 1 (T1N0) MCP, surgical resection should be the standard ofcare when there is submucosal invasion in the lesion.Table 1: Comparison of baseline characteristics and survival between patients with malignantcolorectal polyps limited to Stage 0 (Tis) and 1 (T1N0) undergoing endoscopic treatmentand surgery

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