Faculty Bibliography

BACKGROUND & AIMS/OBJECTIVE:The incidence of colorectal cancer (CRC) is increasing in individuals younger than 50 years, who do not usually undergo screening if they are of average risk. We sought to identify risk factors for CRC in this population. METHODS:We compared sociodemographic and medical characteristics of patients who received a diagnosis of CRC at an age of 18-49 years (early-onset) with patients who received a diagnosis of CRC at an age of 50 years or older (late-onset) and with age-matched, cancer-free individuals (controls) at a tertiary academic hospital. We collected data from all adult patients with a diagnosis of CRC from January 1, 2011 through April 3, 2017 from electronic health records. Associations with risk factors were assessed using univariable and multivariable logistic regression models. RESULTS:We identified 269 patients with early-onset CRC, 2802 with late-onset CRC, and 1122 controls. Compared with controls, patients with early-onset CRC were more likely to be male (odds ratio [OR], 1.87; 95% CI, 1.39-2.51), have inflammatory bowel disease (IBD) (3% vs 0.4% for controls; univariable P<.01), and have a family history of CRC (OR, 8.61; CI, 4.83-15.75). Prevalence values of well-established modifiable CRC risk factors, including obesity, smoking, and diabetes, were similar. Compared to patients with late-onset CRC, patients with early-onset CRC were more likely to be male (OR, 1.44; 95% CI, 1.11-1.87), black (OR, 1.73; 95% CI, 1.08-2.65) or Asian (OR, 2.60; 95% CI, 1.57-4.15), and have IBD (OR, 2.97; 95% CI, 1.16-6.63) or a family history of CRC (OR, 2.87; 95% CI, 1.89-4.25). Sensitivity analyses excluding IBD and family history of CRC showed comparable results. Early-onset CRC was more likely than late-onset disease to be detected in the left colon or rectum (75% vs 59%, P=.02) and at a late stage of tumor development (77% vs 62%, P=.01). CONCLUSIONS:In a retrospective study of patients with early-onset CRC vs late-onset CRC or no cancer, we identified non-modifiable risk factors, including sex, race, IBD, and family history of CRC, to be associated with early-onset CRC.

Background: During the novel coronavirus-2019 (COVID-19) pandemic, physicians in residency and fellowship training programs are serving as essential healthcare workers while also attempting to continue their preparation for eventual independent practice in their field. We aimed to determine how level of exposure patients with COVID-19 affected the experience of graduate medical trainees in terms of their safety, professional development, and well-being during March and April 2020 Methods: We administered an anonymous, voluntary, web-based survey to physicians enrolled in residency or fellowship training programs in any specialty worldwide A convenience sampling of trainees was obtained through distribution of the survey by email and social media posts from April 20th to May 11th, 2020 To investigate the impact of burden of exposure to COVID-19 the trainee experience, we categorized respondents according to their self-reported estimate of the number of patients with COVID-19 that they provided care for in March and April 2020 (0, 1-30, 31-60, >60). Descriptive statistics were performed and the chi square test was used to evaluate for statistical significance. A multivariable logistic regression analysis was conducted to determine independent predictors of physician burnout Results: Surveys were completed by 1420 trainees, of whom 1031 (73%) were residents Most of the fellows who responded to the survey were training in gastroenterology/ hepatology (27%, 85/280) Trainees who cared for a greater number of COVID-19 patients were more likely to report limited access to PPE and COVID-19 testing and more likely to report testing positive for COVID-19 (Figure 1A) Compared to trainees who did not take care of COVID-19 patients, those who took care of 1-30 patients (adjusted odds ratio [AOR] 1 80, 95% CI 1 29-2 51), 31-60 patients (AOR 3.30, 95% CI 1.86-5.88) and >60 patients (AOR 4.03, 95% CI 2 12-7 63) were increasingly more likely to report burnout More than half (835, 58%) of trainees reported concern about their future preparedness for independent practice Trainees who cared for >60 COVID-19 patients compared to those who did not care for any COVID-19 patients reported similar levels of concern about their preparedness for independent practice (56%, 372/636 vs 58%, 71/125 respectively, p-value 0 57, Figure 1B)
Conclusion(s): Physician trainees who were involved in the care of patients with COVID-19 were more likely to report unsafe working conditions and suffered from higher rates of physician burnout Trainees were concerned about the effects of lost training opportunities on their professional development irrespective of the number of COVID-19 patients they cared for

INTRODUCTION: Gastric cancer is one of the most common cancers worldwide, but evidence for screening and surveillance in the US is limited by sparse clinical research. While recent immigrants from endemic regions such as East Asia are known to be at high risk, it's unclear what are the important risk factors in a population with fewer recent immigrants. Therefore, we conducted a matched case-control study in a VA medical center.
METHOD(S): We identified individuals with gastric cancer using both the tumor registry and electronic medical record at VA New York Harbor from 1/1/97 to 10/31/18. Diagnosis was confirmed by pathology report. Controls were identified from patients who underwent EGD during the same period. Variables of interest included age (at time of data extraction or death), sex, race/ethnicity, H. pylori status, smoking, alcohol use, pernicious anemia, and family history. Controls were matched to cases in a 2:1 ratio by age (1/- 3 years) and sex. Univariable and multivariable conditional logistic regression was performed to evaluate associations between potential risk factors and gastric cancer.
RESULT(S): A total of 504 patients (168 cases and 336 controls) were identified. The mean age was 76 years and 98% were men (Table 1). Among cancer patients, 40% were diagnosed with Stage IV disease and 80% had non-cardia cancer (Table 2). On univariable analysis, associations between gastric cancer and race/ethnicity, H. pylori status, alcohol use, and pernicious anemia were observed (Table 3). On multivariable analysis, Black individuals had higher risk of gastric cancer than White individuals (OR 2.73, 95% CI 1.12-6.68). Those with H. pylori eradication had lower risk than those who were H. pylori negative (OR 0.15, 95% CI 0.06-0.38). Former alcohol users also had lower risk than never users (OR 0.26, 95% CI 0.07-0.97).
CONCLUSION(S): In a single-center VA study, we found Black race increased risk for gastric cancer, while H. pylori eradication and former alcohol use reduced risk. While prior US-based studies have found increased risk in East Asian and Hispanic populations, our findings suggest Black individuals are at higher risk in a healthcare system with fewer recent immigrants. Further research is required to explore this potential health disparity. That H. pylori eradication and former alcohol use were protective against gastric cancer may indicate greater adherence to medical advice and healthier lifestyles in these individuals. (Figure Presented)

GOALS/OBJECTIVE:The goal of this study was to quantify the association between demographic factors and advanced colorectal cancer (CRC) in patients under age 50. BACKGROUND:CRC incidence in the United States has declined in older individuals but increased in those under age 50 (early-onset). More than 60% of early-onset CRC patients present with advanced disease (stage III/IV), but predictors of stage in this population are poorly defined. STUDY/METHODS:We analyzed CRC cases diagnosed between age 20 and 49 in the United States Surveillance, Epidemiology, and End Results (SEER) 18 database during 2004 to 2015. Logistic regression models were fit to assess the impact of age, sex, race, ethnicity, marital status, and cancer site on the probability of advanced disease. RESULTS:The analysis included 37,044 cases. On multivariable regression, age was inversely associated with advanced disease. Relative to 45 to 49-year-olds, 40 to 44-year-olds had 8% greater odds of having advanced CRC, and 20 to 24-year-olds had 53% greater odds. Asians, blacks, and Pacific Islanders had 10%, 12%, and 45% greater odds of advanced disease compared with whites. Compared with nonpartnered individuals, those with partners had 11% lower odds of advanced CRC. Both right-sided and left-sided colon cancer were more likely to be diagnosed at stage IV compared with rectal cancer. CONCLUSIONS:Among individuals with early-onset CRC, younger age, Asian, black, or Pacific Islander race, and being nonpartnered were predictors of advanced disease at presentation. Colon cancer was more likely to be diagnosed at stage IV than rectal cancer. Patient characteristics associated with advanced CRC may indicate both differences in tumor biology and disparities in health care access.

BACKGROUND:The adenoma detection rate (ADR) is a widely accepted quality benchmark for screening colonoscopy but can be burdensome to calculate. Previous studies have shown good correlation between polyp detection rate (PDR) and ADR, but this has not been validated in trainees. Additionally, the correlation between PDR and detection rates for sessile serrated polyps (SSPDR) and advanced neoplasia (ANDR) is not well studied. AIMS/OBJECTIVE:We investigated the relationship between PDR and ADR, SSPDR, and ANDR in trainees. METHODS:We examined 1600 outpatient colonoscopies performed by 24 trainees at a VA hospital from 2014 to 2017. Variables collected included patient demographics, year of fellowship, colonoscopy indication, and endoscopic and histologic findings. We calculated the overall ratios of PDR to ADR, SSPDR, and ANDR to assess the correlation between measured and calculated ADR, SSPDR, and ANDR, which is equivalent to the correlation between PDR and measured ADR, SSPDR, and ANDR. RESULTS:The overall PDR, ADR, SSPDR, and ANDR were 72%, 52%, 2%, and 14%. PDR (48%) was highest in the left colon, while ADR (32%) and ANDR (7%) were highest in the right colon (p < 0.001 for all). The overall ADR/PDR, SSPDR/PDR, and ANDR/PDR ratios were 0.73, 0.03, and 0.20. Correlation between PDR and ADR was highly positive overall (r = 0.87, p < 0.0001) and stronger in the right (r = 0.91) and transverse (r = 0.94) colon than the left colon (r = 0.80). Correlation between PDR and overall SSPDR and ANDR were not statistically significant. CONCLUSIONS:PDR can serve as a surrogate measure of ADR to monitor colonoscopy quality in gastroenterology fellowship.

BACKGROUND & AIMS/OBJECTIVE:Early-onset colorectal cancer (CRC, in persons younger than 50 years old) is increasing in incidence; yet, in the absence of a family history of CRC, this population lacks harmonized recommendations for prevention. We aimed to determine whether a polygenic risk score (PRS) developed from 95 CRC-associated common genetic risk variants was associated with risk for early-onset CRC. METHODS:We studied risk for CRC associated with a weighted PRS in 12,197 participants younger than 50 years old vs 95,865 participants 50 years or older. PRS was calculated based on single-nucleotide polymorphisms associated with CRC in a large-scale genome-wide association study as of January 2019. Participants were pooled from 3 large consortia that provided clinical and genotyping data: the Colon Cancer Family Registry, the Colorectal Transdisciplinary study, and the Genetics and Epidemiology of Colorectal Cancer Consortium and were all of genetically defined European descent. Findings were replicated in an independent cohort of 72,573 participants. RESULTS:). When we compared the highest with the lowest quartiles in this group, risk increased 4.3-fold for early-onset CRC (95% CI, 3.61-5.01) vs 2.9-fold for late-onset CRC (95% CI, 2.70-3.00). Sensitivity analyses were consistent with these findings. CONCLUSIONS:In an analysis of associations with CRC per standard deviation of PRS, we found the cumulative burden of CRC-associated common genetic variants to associate with early-onset cancer, and to be more strongly associated with early-onset than late-onset cancer-particularly in the absence of CRC family history. Analyses of PRS, along with environmental and lifestyle risk factors, might identify younger individuals who would benefit from preventative measures.

Colorectal cancer (CRC) screening has increased substantially in New York City in recent years. However, screening uptake measured by telephone surveys may not fully capture rates among underserved populations. We measured screening completion within one year of a primary care visit among previously unscreened patients in a large urban safety-net hospital and identified sociodemographic and health-related predictors of screening. We identified 21,256 patients aged 50-75 who were seen by primary care providers (PCPs) in 2014, of whom 14,425 (67.9%) were not up-to-date with screening. Since PCPs facilitate the majority of screening, we compared patients who received screening within one year of an initial PCP visit to those who remained unscreened using multivariable logistic regression. Among patients not up-to-date with screening at study outset, 11.5% (1,658 patients) completed screening within one year of a PCP visit. Asian race, more PCP visits, and higher area-level income were associated with higher screening completion. Factors associated with remaining unscreened included morbid obesity, ever smoking, Elixhauser comorbidity index of 0, and having Medicaid/Medicare insurance. Age, sex, language, and travel time to the hospital were not associated with screening status. Overall, 39.9% of patients were up-to-date with screening by 2015. In an underserved urban population, CRC screening disparities remain, and overall screening uptake was low. Since more PCP visits were associated with modestly higher screening completion at one year, additional community-level education and outreach may be crucial to increase CRC screening in underserved populations.

PURPOSE OF REVIEW/OBJECTIVE:This review highlights the history, recent advances, and ongoing challenges of artificial intelligence (AI) technology in colonic polyp detection. RECENT FINDINGS/RESULTS:Hand-crafted AI algorithms have recently given way to convolutional neural networks with the ability to detect polyps in real-time. The first randomized controlled trial comparing an AI system to standard colonoscopy found a 9% increase in adenoma detection rate, but the improvement was restricted to polyps smaller than 10 mm and the results need validation. As this field rapidly evolves, important issues to consider include standardization of outcomes, dataset availability, real-world applications, and regulatory approval. AI has shown great potential for improving colonic polyp detection while requiring minimal training for endoscopists. The question of when AI will enter endoscopic practice depends on whether the technology can be integrated into existing hardware and an assessment of its added value for patient care.

INTRODUCTION/BACKGROUND:Race, ethnicity, and socioeconomic status are known to influence staging and survival in colorectal cancer (CRC). It is unclear how these relationships are affected by geographic factors and changes in insurance coverage for CRC screening. We examined the temporal trends in the association between sociodemographic and geographic factors and staging and survival among Medicare beneficiaries. METHODS:We identified patients 65 years or older with CRC using the 1991-2010 Surveillance, Epidemiology, and End Results-Medicare database and extracted area-level sociogeographic data. We constructed multinomial logistic regression models and the Cox proportional hazards models to assess factors associated with CRC stage and survival in 4 periods with evolving reimbursement and screening practices: (i) 1991-1997, (ii) 1998-June 2001, (iii) July 2001-2005, and (iv) 2006-2010. RESULTS:We observed 327,504 cases and 102,421 CRC deaths. Blacks were 24%-39% more likely to present with distant disease than whites. High-income areas had 7%-12% reduction in distant disease. Compared with whites, blacks had 16%-21% increased mortality, Asians had 32% lower mortality from 1991 to 1997 but only 13% lower mortality from 2006 to 2010, and Hispanics had 20% reduced mortality only from 1991 to 1997. High-education areas had 9%-12% lower mortality, and high-income areas had 5%-6% lower mortality after Medicare began coverage for screening colonoscopy. No consistent temporal trends were observed for the associations between geographic factors and CRC survival. DISCUSSION/CONCLUSIONS:Disparities in CRC staging and survival persisted over time for blacks and residents from areas of low socioeconomic status. Over time, staging and survival benefits have decreased for Asians and disappeared for Hispanics.