Colonoscopic Polypectomy and Long-Term Prevention of Colorectal Cancer Deaths

Zauber, Ann G.; Winawer, Sidney J.; O’Brien, Michael J.; Lansdorp–Vogelaar, Iris; Ballegooijen, Marjolein van; Hankey, Benjamin F.; Shi, Wei; Bond, John H.; Schapiro, Melvin; Panish, Joel F.; Steward, Edward T.; Waye, Jerome D.

doi:10.1097/ogx.0b013e31825bc1f5

Cited by 294 publications

(380 citation statements)

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“…This has been well established by the findings in the National Polyp Study 28. A 2012 follow-up study aimed at evaluating the long-term effects of colonoscopic polypectomy on CRC-related mortality further demonstrated that polypectomy reduced CRC-associated mortality by 53% 28. Colonoscopy has also been shown to be a more sensitive tool in detecting adenomas when compared with faecal immunochemical testing 29.…”

Section: Discussionmentioning

confidence: 90%

Training mid-career internists to perform high-quality colonoscopy: a pilot training programme to meet increasing demands for colonoscopy

Shah-Ghassemzadeh

Jackson²,

Juma

et al. 2017

Postgraduate Medical Journal

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Background Colorectal cancer (CRC) is the second leading cause of cancer deaths in the USA. Despite a recent rise in CRC screening there remains an increasing demand for colonoscopy, yet a limited supply of gastroenterologists who can meet this need. Objective To determine if a mid-career general internist (GIN) could be trained to perform high-quality colonoscopes via an intensive training programme. Design A GIN trained 2-3 days/week, 4-5 hours/day, for 7 months with an experienced gastroenterologist. Their independent performance was then compared with that of a gastroenterology attending (GA), with and without a gastroenterology fellow (GF). Main measures The primary outcome was to compare caecal intubation rates, adenoma detection rates (ADRs), interval CRC rates and complications between the three groups. Key results 989 patients were initially included in the study, and 818 were included in the final analysis. Caecal intubation rates were 95%, 94% and 93% for the GIN, GA+GF and GA, respectively ( p=0.31). The overall polyp detection rates were 68%, 39% and 44% among the GIN, GA+GF and GA, respectively ( p<0.0001). The ADRs were 56%, 33% and 34% for the GIN, GA+GF and GA, respectively ( p<0.0001). Three complications occurred, all within the GA group. No interval cancers were diagnosed within a 5-year surveillance period, across all three groups. Conclusions The GIN attained high success rates in all quality measures. Training mid-career GINs to perform high-quality screening colonoscopes, through a standardised curriculum, may be a reasonable approach to address the growing demand for colonoscopists. BACKGROUND

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Section: Discussionmentioning

confidence: 90%

Training mid-career internists to perform high-quality colonoscopy: a pilot training programme to meet increasing demands for colonoscopy

Shah-Ghassemzadeh

Jackson²,

Juma

et al. 2017

Postgraduate Medical Journal

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“…The association of colorectal cancer (CRC) with pre-existing adenomatous polyps was challenged for decades until the National Polyp Study (NPS) demonstrated that colonoscopic polypectomy prevented deaths from CRC 1. In a follow-up of the Minnesota Colon Cancer Control study (46 551 participants), those randomly assigned to annual screening with a sensitive faecal occult blood test, sustained a 32% CRC mortality reduction over 30 years which was consistent with the effect of polypectomy 2.…”

Section: Contextmentioning

confidence: 86%

Long-term follow-up after removal of colorectal adenomas provides evidence for risk stratification of patients at colonoscopic polypectomy

Winawer

2014

Evid Based Med

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Commentary on: Loberg M, Kalager M, Holme O, et al. Longterm colorectal-cancer mortality after adenoma removal. N Engl J Med 2014;371:799-807. ContextThe association of colorectal cancer (CRC) with pre-existing adenomatous polyps was challenged for decades until the National Polyp Study (NPS) demonstrated that colonoscopic polypectomy prevented deaths from CRC. 1 In a follow-up of the Minnesota Colon Cancer Control study (46 551 participants), those randomly assigned to annual screening with a sensitive faecal occult blood test, sustained a 32% CRC mortality reduction over 30 years which was consistent with the effect of polypectomy. 2 In the Nurses' Health Study and the Health Professional Follow-up Study (88 902 participants followed over 22 years), lower endoscopy was associated with a 43% CRC mortality reduction compared to no endoscopy. 3 MethodsLoberg and colleagues reported a study in which they linked the Norwegian Cancer Registry and the Cause of Death Registry to estimate the cause of death in 40 826 patients in whom colorectal adenomas were removed compared to what was expected in the general population. Standardised mortality ratios (SMR) were calculated comparing expected to observed deaths. FindingsDuring a median of 7.7 years of follow-up, no CRC mortality reduction in the entire cohort (SMR 0.96, 95% CI 0.87 to 1.06) was observed. However, Loberg and colleagues did observe a mortality reduction in those with low-risk adenomas (SMR 0.75, 95% CI 0.63 to 0.88) but not in those with high-risk adenomas (SMR 1.16, 95% CI 1.02 to 1.31). CommentaryIn contrast to this study, the NPS cohort, which consisted of 55% highrisk adenoma participants, observed a 53% mortality reduction compared to the US general population. The term 'high-risk adenomas' (advanced adenomas in other studies) has usually been applied to adenomas that have high-grade dysplasia, or are ≥1 cm in size, or have ≥25% villous components, or are ≥3 in number. 'Low-risk adenomas' (non-advanced adenomas) have none of these features. There is evidence that the risk for future high-risk adenomas and CRC is higher in patients having high-risk adenomas at initial colonoscopy. Most guidelines recommend stratifying postpolypectomy patients into low and high risk for longer (5-10 years) or shorter (3 years) surveillance intervals. 4 There are several possible explanations for the lack of CRC mortality reduction observed by Loberg and colleagues in patients with high-risk adenomas. Future CRC risk correlates with the initial colonoscopy quality benchmarks including: the rate of caecal intubation, adenoma detection rate, cleansing thoroughness and mean withdrawal time. Completeness of polypectomy, especially of large (high risk) adenomas that are often removed 'piece-meal', is also important to minimise subsequent (interval) CRC. Approximately 70% of interval CRC's are a result of either missed lesions or incomplete polypectomy. 4 It would be of interest if the authors could link their mortality data to colonoscopy performance. This information was not...

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“…Laparoscopic colorectal surgery mandates accurate localization of early lesions, therefore endoscopic lesion marking methods are being increasingly used (13,14). All these advantages and new applications ultimately reflect positively on the treatment of patients, by both increasing the success of surgery and patient comfort.…”

Section: Discussionmentioning

confidence: 99%

The effect of the endoscopist on the wait-time for colorectal cancer surgery

Karıp

İşcan

Ağca

et al. 2014

UCD

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Objective: The effect of the specialty of physicians who perform endoscopy on preoperative wait-time of colorectal cancer patients was evaluated. Material and Methods:Data from 86 patients who have been operated with a diagnosis of colorectal cancer from January 2011-February 2013 regarding age, sex, tumor location, colonoscopy date, surgery date, the expertise and institution of the endoscopist were retrospectively examined. The time between colonoscopy and surgery was accepted as the pre-operative wait time (PWT). Results:Out of 86 patients, 24 (27.9%) colonoscopies were performed by general surgeons (GS), and 62 (72.1%) by gastroenterologists (GE). When patients who underwent colonoscopy in other centers were extracted, the PWT for our center was 20.4±10.8 days. When grouped according to specialties, the PWT of patients who had their colonoscopy performed by GS was significantly shorter than patients who underwent colonoscopy by GE at the same center (p<0.05). Patient's age, sex and location of the tumor had no effect on PWT (p>0.05). Conclusion:The preparation time for surgery in colorectal cancer patients is influenced by the specialty of the physician performing the procedure. In order to standardize this period, a common flow diagram after endoscopy should be established for patients with suspected malignancy.

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Colonoscopic Polypectomy and Long-Term Prevention of Colorectal Cancer Deaths

Cited by 294 publications

References 40 publications

Training mid-career internists to perform high-quality colonoscopy: a pilot training programme to meet increasing demands for colonoscopy

Training mid-career internists to perform high-quality colonoscopy: a pilot training programme to meet increasing demands for colonoscopy

Long-term follow-up after removal of colorectal adenomas provides evidence for risk stratification of patients at colonoscopic polypectomy

The effect of the endoscopist on the wait-time for colorectal cancer surgery

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