Isn’t It Time to Stop Talking About Colonoscopy Quality and Start Doing Something About It?

Abstract

Colonoscopy is central to one of the great success stories of the war on cancer. Although colorectal cancer (CRC) is still the second leading cause of cancer death in the United States, both the incidence and mortality has been declining by 2-3% per year for the last 15 years. This decline has been largely attributed to increasing rates of CRC screening. Although guidelines list other screening options (stool tests/imaging/flexible sigmoidoscopy) colonoscopy has become the dominant CRC screening test in the US while fecal testing has declined slowly, and flexible sigmoidoscopy has declined markedly over the last decade [1].Colonoscopy is widely viewed in the US as the single best test for both detection and removal of pre-cancerous lesions. The efficacy of colonoscopic polypectomy was initially highlighted by the National Polyp Study (NPS), which estimated a 76-90% reduction in incidence of colorectal cancer after polyp removal [2]. Subsequent studies [3], which often have not shown as robust a CRC risk reduction as the NPS, have highlighted the importance of the quality of colonoscopy as a critical element in its efficacy.There is compelling evidence that colonoscopy quality is highly variable [4] and guidelines for a high-quality colonoscopy have been published [5], but in the end, quality needs to be assessed by whether a test accomplishes its primary goal. In the case of colonoscopy, directly measuring whether a colonoscopy has prevented a CRC is not feasible in the short term. Instead, more measurable surrogates of quality such as cecal intubation rates, withdrawal times, and particularly adenoma detection rates (ADR) have been used as quality measures. Kaminski et al. found that ADR appeared to be an acceptable surrogate for real colonoscopy quality as it was an independent predictor of the risk of interval colorectal cancer [6]. Numerous studies have demonstrated marked (twofold to sixfold) variability in ADRs among endoscopists working in the same endoscopy unit [4]. Although some of this variability might be due to patient factors such as age, gender, or adequacy of bowel preparation, individual endoscopists appear to be the single most predictive factor in adenoma detection [7], implying that the efficacy of colonoscopy is highly dependent on the individual skill of the endoscopist. To compound matters, Brenner [8] and Lakoff [9] presented data from Germany and Canada that showed that while colonoscopy does decrease the rate of distal CRCs by approximately 67-79%, it was not at all protective for proximal colon cancers, suggesting that there is a substantial need for improvement in colonoscopy quality by all endoscopists.The variability in colonoscopy quality among providers and the dubious utility of colonoscopy in preventing rightsided colon cancers have called into question the overall efficacy of colonoscopy as it is used today and would seem to be a clear mandate for endoscopists and professional organizations to critically examine colonoscopist performance and address areas in need of improvement...

Serrated polyps detected during screening colonoscopies

“…The screening colonoscopies performed in our center are characterized by their high quality, which is indicated by polyp removal in 25.9% of patients and cecal intubation in 92.2% [26]. The parameters of screening colonoscopy quality achieved by the team of doctor and nurses together with a very well or well-cleansed large intestine in 96% of cases are the basic factors that facilitated the detection, macroscopic evaluation, removal, and then the histopathological evaluation of the serrated polyps removed after polypectomy [15, 33, 34]. This type of polyp constitutes a heterogeneous group of abnormalities detected in the large intestine, among which hyperplastic polyps, or more ‘advanced’ adenomas such as traditional serrated adenomas, mixed serrated polyps or flat serrated polyps, are included [6, 35].…”

Neither Here Nor There: Negotiating Hybridity in Second Generation Latinx Canadian Identities

“…In a blog post titled Its Time to Start Talking About Second-Gen Canadians, the idea of having to choose 34 between cultures and between identities is expressed. Many second generation Canadians often feel as though they do not fit in to either of their cultural identities, be it Canadian or their parents' culture of origin (Patel, 2016). A very powerful Instagram post by Sahaj Kaur Kohli on a profile that advocates for the celebration of bicultural identities reads as follows: "For the children of immigrants, there's a constant duality in our hyphenated existence.…”

“…Not only is this confusion internalized on a personal basis, but there is also pressure coming from the outside (other people in mainstream Canadian society) telling the second generation that they need to choose between identities (Patel, 2016). A typical question that they are commonly asked is "which side are you really?"…”

“…As a response to this additional pressure, the hyphenated identity symbolizes the choice and celebration of multiple identities without having to feel guilty about picking one over the other (Reyes, 2016). It's about not having to give an identity up and the realization that "I can be both" (Patel, 2016). Therefore, the second generation is actively redefining what it means to belong to Canada (Patel, 2016); it is not necessarily about blending in to the mainstream or being rooted in a monolithic culture that may not have even been experienced firsthand.…”

“…It's about not having to give an identity up and the realization that "I can be both" (Patel, 2016). Therefore, the second generation is actively redefining what it means to belong to Canada (Patel, 2016); it is not necessarily about blending in to the mainstream or being rooted in a monolithic culture that may not have even been experienced firsthand. By contrast, identity is being understood as a hybrid entity that can be negotiated and embodied in a variety of different ways.…”