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Effectiveness of colonoscopies questioned in new study – CTV News

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Colonoscopies are a dreaded rite of passage for many middle-age adults.

The promise has been that if you endure the awkwardness and invasiveness of having a camera travel the length of your large intestine once every decade after age 45, you have the best chance of catching — and perhaps preventing — colorectal cancer. It’s the second most common cause of cancer death in the United States. Some 15 million colonoscopies are performed in the U.S. each year.

Now, a landmark study suggests the benefits of colonoscopies for cancer screening may be overestimated.

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The study marks the first time colonoscopies have been compared head-to-head to no cancer screening in a randomized trial. The study found only meagre benefits for the group of people invited to get the procedure: an 18 per cent lower risk of getting colorectal cancer, and no significant reduction in the risk of cancer death. It was published Sunday in The New England Journal of Medicine.

Study researcher Dr. Michael Bretthauer, a gastroenterologist who leads the clinical effectiveness group at the University of Oslo in Norway, said he found the results disappointing.

But as a researcher, he has to follow the science, “so I think we have to embrace it,” he said. “And we may have oversold the message for the last 10 years or so, and we have to wind it back a little.”

Other experts say that as good as this study was, it has important limitations, and these results shouldn’t deter people from getting colonoscopies.

“I think it’s just hard to know the value of a screening test when the majority of people in the screening didn’t get it done,” said Dr. William Dahut, chief scientific officer at the American Cancer Society, who was not involved in the study.

Less than half of people invited to get a colonoscopy in the study — just 42 per cent — actually got one.

When the study authors restricted the results to the people who actually received colonoscopies — about 12,000 out of the more than 28,000 who were invited to do so — the procedure was found to be more effective. It reduced the risk of colorectal cancer by 31 per cent and cut the risk of dying of that cancer by 50 per cent.

Bretthauer said the true benefits of colonoscopy probably lie somewhere in the middle. He said he thinks of the results of the full study — including people who did and didn’t get colonoscopies after they were invited — as the minimum amount of benefit colonoscopies provide to a screened population. He thinks of the results from the subset of people who actually got the test as the maximum benefit people could expect from the procedure.

Based on his results, then, he expects that screening colonoscopy probably reduces a person’s chances of colorectal cancer by 18 per cent to 31 per cent, and their risk of death from 0 per cent to as much as 50 per cent.

But, he said, even 50 per cent is “on the low end what what I think everybody thought it would be.”

Other studies have estimated larger benefits for colonoscopies, reporting that these procedures could reduce the risk of dying of colorectal cancer by as much as 68%.

THE FIRST RANDOMIZED TRIAL OF COLONOSCOPY

The NordICC study, which stands for Northern-European Initiative on Colon Cancer, included more 84,000 men and women ages 55 to 64 from Poland, Norway and Sweden. None had gotten a colonoscopy before. The participants were randomly invited to have a screening colonoscopy between June 2009 and June 2014, or they were followed for the study without getting screened.

In the 10 years after enrollment, the group invited to get colonoscopies had an 18% lower risk of colorectal cancers than the group that wasn’t screened. Overall, the group invited to screening also had a small reduction in their risk of death from colorectal cancer, but that difference was not statistically significant — meaning it could simply be due to chance.

Before the NordiCC trial, the benefits of colonoscopies had been measured by observational studies that looked back in time to compare how often colorectal cancer is diagnosed in people who received colonoscopies versus those who did not.

These studies can be subject to bias, however, so scientists look to randomized trials that blindly sort people into two groups: those who are assigned to get an intervention, and those who are not. These studies then follow both groups forward in time to see if there are differences. Those studies have been difficult to do for colon cancer, which can be slow growing and may take years to be diagnosed.

The researchers say they’re going to continue to follow participants for another five years. It could be that because colon cancers can be slow-growing, more time will help refine their results and may show bigger benefits for colonoscopy screening.

RESULTS NEED CAREFUL INTERPRETATION

Normally, those kinds of disappointing results from such a large, strong study would be considered definitive enough to change medical practice.

But this study has some limitations that experts say need to be sorted out before doctors and patients give up on colonoscopies for cancer screening.

“I don’t think anyone should be canceling their colonoscopy,” said Dr. Jason Dominitz is the national director of gastroenterology for the Veterans Health Administration.

“We know that colon cancer screening works,” he said in an interview with CNN. Dominitiz co-authored an editorial which ran alongside the study.

There are several options for colorectal cancer screening. Those include stool tests which check for the presence of blood or cancer cells, and a test called sigmoidoscopy, which looks only at the lower part of the colon. Both have been shown to reduce both cancer incidence and colorectal cancer deaths.

“Those other tests work through colonoscopy,” Dominitz said. “They identify people at high risk who would benefit from colonoscopy, then the colonoscopy is done and removes polyps, for example, that prevents the individual from getting colon cancer in the first place, or it identifies colon cancer at a treatable stage.”

Polyps are benign growths that can turn into cancers. They are typically removed when identified during a screening colonoscopy, which can lower a person’s risk of colorectal cancer in the future.

Studies are underway in Spain and the U.S. testing colonoscopy head-to-head against stool tests to see which is most effective.

THE BEST WAY TO SCREEN FOR COLORECTAL CANCER

Dominitz said this randomized controlled trial was a test of advice as much as it was a test of the value of colonoscopy.

“If you ask the population to do something, how much of an impact will it have?” he said.

Overall, the study found that just inviting people to get a colonoscopy didn’t have a large beneficial impact across these countries, partly because so many people didn’t do it.

Dominitz thinks the low participation can be partly explained by the study’s setting. Colonoscopies are not as common in the countries involved in the study as they are in the United States. In Norway, he said, official colorectal cancer screening recommendations didn’t come until this past year.

“They don’t see the public service announcements. They don’t hear Katie Couric talking about getting screened for colon cancer. They don’t see the billboards in the airport and whatnot,” he said. “So an invitation to be screened in Europe is, I think, likely to be somewhat different than an invitation to be screened in the U.S.”

In the U.S., according to data from the U.S. Centers for Disease Control and Prevention, about 1 in 5 adults between the ages of 50 and 75 have never been screened for colorectal cancer.

If you feel squeamish about getting a colonoscopy, the U.S. Preventive Services Task Force says a variety of methods and regimens work to detect colorectal cancer. It recommends screening with tests that check for blood and/or cancer cells in stool every one to three years, a CT scan of the colon every five years, a flexible sigmoidoscopy every five years, a flexible sigmoidoscopy every 10 years paired with stool tests to check for blood annually, or a colonoscopy every 10 years.

In 2021, the task force lowered the recommended age to start routine screening for colorectal cancer from 50 to 45 because the cancer is becoming more common in younger adults.

When it comes to colorectal cancer, he said, tests can only be effective if people are willing to do them.

As proof, he points to early results from a large randomized trial from Sweden that’s testing colonoscopy, FIT testing and no screening at all.

Results collected from more than 278,000 people enrolled between March 2014 and the end of 2020 found that 35 per cent of the group assigned to get a colonoscopy actually got one, compared with 55 per cent who were assigned to the stool test group.

To date, slightly more cancers have been detected in the group assigned to stool testing than in the group assigned to get a colonoscopy — “so participation with screening really is key!” Dominitz said.

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Flu surges on heels of RSV, COVID-19 to overwhelm children’s hospitals in Canada – Stettler Independent

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A flu season that started early, hospitalized far more children than usual and overwhelmed emergency departments has revealed that Canada’s health-care system is chronically underfunded when it comes to the most vulnerable citizens, a pediatric infectious diseases specialist says.

Dr. Jesse Papenburg, who works at Montreal Children’s Hospital, said a system that was already struggling with a surge of respiratory syncytial virus, or RSV, on the heels of COVID-19 is now overwhelmed in much of the country.

“Certainly, Ontario and Alberta in particular have been hit very hard with an early and really quite explosive influenza season in pediatrics when it comes to more severe disease requiring complex hospitalization. And we’re also observing in Montreal as well that our influenza admissions are really starting to pick up,” he said.

The last week of November saw the highest number of pediatric hospitalizations for a single week in the past decade, said Papenburg, who is also an investigator for IMPACT, a program that monitors hospitalizations for vaccine-preventable diseases at 12 children’s hospitals across the country.

A typical flu season sees about 1,000 kids admitted to hospital. Due to pandemic public health measures, he said last season saw only 400 and there were none the season before that.

Up to the end of November, over 700 children had been hospitalized with the H3N2 strain of the flu, which typically takes a toll on older adults. But the season could continue until March or April, Papenburg said of the unexpected epidemic.

“When you’re already stretched to the limit under normal circumstances and there’s something exceptional that takes place, it really has a greater impact on the type of care that we can deliver to Canadian children,” he said. “It’s unacceptable, in my view, that this is happening, that we are having to delay important surgeries for children because we need those resources for dealing with acute respiratory infections.”

While the number of RSV hospitalizations is stabilizing, there’s still a “significant burden of disease requiring complex hospitalization,” he said of the Montreal hospital.

Alex Munter, president of Ottawa pediatric hospital CHEO, said the Red Cross will be helping take some of the pressure off critical-care staff starting this week.

He said two teams of nine people will work rotating overnight shifts and that some will be porters while others get supplies or sit with patients.

“Having these Red Cross teams on-site will allow us to send back redeployed staff to their home base,” he said.

“The test positivity rate last week for flu was 30 per cent compared to 10 per cent at the end of October. That’s a big increase and it’s still climbing so flu hospitalizations are increasing and RSV is plateauing,” Munter said.

CHEO, including its emergency department and urgent care clinic, is also getting help from pediatricians, family doctors and nurses in the community while some patients are being transferred to adult hospitals, Munter said.

“We can’t run our hospital this way in perpetuity. I think the moral of the story here is that we have undersized child and youth health system in Canada.”

SickKids in Toronto continues to see high patient volumes in the pediatric intensive care unit and since November has reduced the number of surgeries so staff can be redeployed to provide care in that unit.

“We have been co-ordinating closely with other hospital partners that have the ability to care for some pediatric patients,” the hospital said in a statement, adding it is not currently seeking staffing support from external organizations.

Dr. Shazma Mithani, an emergency room doctor at both the Stollery Children’s Hospital and Royal Alexandra Hospital in Edmonton, said a temporary closure of a pediatric hospice in Calgary is “tragic” as staff are being diverted to a children’s hospital.

“It means that kids who are dying are not getting the palliative and comfort care that they deserve and need, and that acute care is taking priority over that,” Mithani said.

Federal Health Minister Jean-Yves Duclos has said Ottawa recently gave provinces an additional $2 billion as calls grow for both levels of government to do more to help hospitals facing unprecedented challenges.

Mithani said funding has to be targeted for children’s hospitals and could also go to staffing after-hours clinics, for example.

She said people planning large indoor gatherings over Christmas and for New Year’s Eve should consider scaling back, while schools should transition to temporary online learning if they have a large number of viral illnesses

Health officials also need to make a concerted effort to educate the public on the importance of vaccination amid misinformation on social media, Mithani said.

“The most vulnerable people in our society are suffering as a result of the decisions that adults made. That’s what’s happening here, that kids are suffering from the poor decisions of adult decision-makers who can’t seem to do the right thing in order to protect our kids.”

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B.C. to start public push to get more kids vaccinated against flu as cases climb – Energeticcity.ca

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VANCOUVER — British Columbia health officials are urging parents to get their young children vaccinated against influenza ahead of the holiday season as the province deals with crowded emergency rooms.

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Provincial health officer Dr. Bonnie Henry said after two years of low rates of flu, mostly due to travel restrictions, the province is seeing a “dramatic increase” in illness and it arrived sooner than normal. 

“We know, much more than COVID, influenza can cause more severe illness in children, especially young children, and it can lead to secondary bacterial infections with things like streptococcus and pneumococcus that can cause very severe pneumonia,” she said Monday.

“And so that’s the concern that we have now.”

Henry said there is still time for people to get a flu vaccine to protect themselves and their children, especially as the holiday season approaches. 

“We’re starting to see the impact of a large number of children who haven’t been exposed to influenza for a few years and a small proportion of them are getting severely ill,” she said.

“So now’s the time to really make a difference and get that vaccine now.”

According to the most recent numbers from the B.C. Centre for Disease Control, for the week of Nov. 20, 169 patients were in BC Children’s Hospital with some form of a respiratory virus. Of those, 71 had influenza.

Henry said the province started seeing influenza numbers climb about two weeks ago and that the flu season typically lasts about two months.

While the province is on track for a record number of people getting their flu shot this year, Dr. Penny Ballem, with BC Vaccine Operations, said Monday that only 20 per cent of children under five have been vaccinated.

The government will be using its provincial health registry to contact parents in an attempt to increase that number.

Ballem said they’ll be sending texts and emails to the families of about 150,000 children under five who are not part of the province’s vaccine booking system and inviting them to make appointments.

She said there’s also a significant social media campaign from the government and health authorities encouraging people to get vaccinated.

Health Minister Adrian Dix said visits to provincial emergency rooms had been averaging 6,700 per day, but that is now peaking up to 6,900 patients daily, with extra pressure on BC Children’s and Fraser Health hospitals. 

B.C. Children’s briefly called a code orange on Saturday, a step sometimes used in mass casualty events. It was lifted 28 minutes later.

Dix said it was determined the code did not need to be enacted in order to make the mandatory overtime call-out, which was required at the time.

This report by The Canadian Press was first published Dec. 5, 2022.

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B.C. ramps up appeal to vaccinate as influenza surges in children – Times Colonist

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The province is ramping up its flu-shot campaign, especially for young children, as hospital emergency departments deal with a flu-driven spike in visits.

Provincial health officer Dr. Bonnie Henry said the province is seeing a “dramatic increase” in cases of Influenza A, particularly H3N2, which can cause severe illness, especially in children.

The surge began about two weeks ago and while it’s leveling off in older teens, it continues to spike in younger children who — along with seniors — are most susceptible to serious illness and complications.

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Henry, speaking at a news conference in Vancouver Monday with Health Minister Adrian Dix, said it’s not too late for vaccination to make a difference. “We can blunt that and we can prevent that ongoing transmission to older adults as we come together over the holiday season, which is often when we see our influenza peaking.”

Prior to the COVID-19 pandemic, the flu season usually lasted six weeks to two months, peaking after the winter holidays when people gather indoors. Typically in Canada every year, 15,000 to 20,000 people would be hospitalized with the flu and 2,500 to 3,000 would die.

Now, however, it’s surging earlier and the number of cases of Influenza A is way up, said Henry.

Children’s hospitals across the country have seen a surge in patients, including those affected by COVID-19, flu and respiratory syncytial virus, or RSV, for which there is no vaccine.

On Monday, children’s critical care beds in the province were at 63 per cent capacity, with high acuity/pediatric ICU beds at 85 per cent. (On the Island, the numbers were slightly lower: Children’s critical care bed capacity at Nanaimo Regional General Hospital was at 44 per cent capacity and Victoria General Hospital was at 50 per cent. High acuity/pediatric ICU beds at Victoria General Hospital were at 60 per cent capacity.)

At B.C. Children’s Hospital, where ER wait times were reported as 10 hours on Friday and nine on Saturday, a “code orange” that’s generally used for disasters and mass-casualty incidents was called at 6:35 a.m. Saturday and cancelled 28 minutes later.

Dix said the alert was based on information “available at the time” and promptly cancelled with new information.

Henry said while other respiratory viruses, including RSV, are levelling off in B.C., pediatricians and children’s hospitals are reporting more severe influenza and in some cases complications from influenza. Many children haven’t been exposed to the flu virus during the restrictions of the pandemic and thus haven’t built immunity.

Prime Minster Justin Trudeau said Monday he is “extremely worried” about a rise in respiratory illnesses among children as hospitals across the country report they are struggling to keep up with high volumes of patients.

Trudeau said it’s everyone’s responsibility to get vaccinated against both COVID-19 and influenza. He said health officials will consider measures such as mandatory masks.

Influenza A H3N2, which causes more severe illness, particularly in children age five and younger, is the main strain in circulation. Influenza is more concerning in young children than COVID because it can lead to secondary bacterial infections such as streptococcus or pneumococcus that can cause serious bacterial pneumonia, said Henry.

The vaccine offered this year includes H1N1 and H3N2 and two B strains, and appears to be a “very good” match to the virus circulating, offering 50 to 70 per cent protection against infection and illness, said Henry.

In B.C., influenza vaccine is free to anyone six months and older through health clinics, doctors’ offices, and pharmacies — with enhanced vaccines for seniors and FluMist for children who can’t tolerate needles.

So far, about 1.5 million British Columbians — including more than 50 per cent of those age 65 and older — have been vaccinated, using about 70 per cent of the current vaccine stock, with more expected.

However, only 20 per cent of children ages six months to 11 are vaccinated against the flu, and just 15 per cent of those age 12 to 17, said Dix, who urged parents to vaccinate their children. “What we’re seeing amongst children is a more significant influenza season by a very significant margin than last year and that reflects on the presentation at emergency departments.”

Emergency room visits in September and October of about 6,700 have increased to 6,800 to 6,900, he said.

Dr. Penny Ballem, executive lead of Immunized B.C. vaccine operations, said the province will host a vaccination blitz Dec. 9, 10, and 11 to get more people vaccinated through pharmacists, family doctors or health authority clinics designed for children, with thousands of appointments available on the GetVaccinated system.

The province will also send out emails and texts to the families of about 150,000 children age 5 and younger inviting them to make appointments.

B.C. Green Leader Sonia Furstenau, MLA for Cowichan Valley, called on the province to take steps beyond vaccination, including focusing on ventilation, masks and physical distancing.

A high number of children and teachers are missing school because they are sick, children’s wards and ERs are overwhelmed, and operations for children and infants are being cancelled, said Furstenau at a news conference Monday at the Pan Pacific Hotel in Vancouver. “I am deeply concerned for children and families in this province right now,” she said.

Dr. Sanjiv Gandhi, a pediatric cardiovascular and thoracic surgeon at B.C. Children’s Hospital who joined Furstenau at the news conference, said mandating masks is a reasonable and effective tool that should be used in addition to vaccination.

As a heart surgeon, Gandhi said, he’s seeing kids with viral infections who are sicker than he’s seen in decades. “We have all the tools to change the trajectory of this horrible situation — and it’s horrible. The only missing ingredient is courage, the courage for our leaders to be transparent to the public about what’s happening in our hospitals.”

Henry said masking in schools now is “very unlikely” to have any effect on the trajectory of the several viruses that are circulating.

Masks continue to be required in health-care settings, she said, but a general mask mandate is a “heavy handed” measure used as a “last resort when it’s something that is absolutely needed, everywhere, all the time.”

ceharnett@timescolonist.com

>>> To comment on this article, write a letter to the editor: letters@timescolonist.com

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