- 1.Conflicting guideline recommendations
- Surprisingly, one of the most critical questions about surveillance remains unanswered. Who benefits from surveillance colonoscopy and at what frequency should it be performed? Due to the lack of these data, global variations persist between surveillance guidelines issued by different professional societies.4,5,6For example, based on the number and size of the adenomas, the US MSTF dichotomizes patients into 2 risk categories,4low- and high-risk adenomas, whereas European guidelines5propose three patient classifications, low-, intermediate-, and high-risk groups. Although each guideline is supported by a thorough literature review, paucity of controlled trial data is an impediment to the development of robust evidence-based recommendations. Trials such as Five or Ten Years (FORTE) and European Polyp Surveillance Trial (EPOS) are underway to better inform future guidelines.
- 2.Conflicting polyp size estimations
- Accurate assessment of the polyp diameter is a crucial step in establishing the effectiveness of a size-dependent guideline for surveillance colonoscopy. However, research using artificial colon models shows that endoscopists often underestimate or overestimate polyp size, with an overall accuracy of merely 25%–60%.7,8Another notable consideration is the validity of the threshold polyp diameter of ≥1 cm, which signifies the need for aggressive surveillance. Does this recommendation have a biological reasoning? As a matter of fact, it was empirically identified from colonoscopy measurements that distinguished a group of individuals with an increased likelihood of subsequently developing advanced adenomas or carcinomas. For instance, the rate of advanced neoplasia on surveillance at 5 years was about 15% for polyps estimated to be ≥1 cm in diameter compared with 6% for 1 to 2 adenomas sized <1 cm in diameter.9But studies show that polyp diameter estimation at the time of colonoscopy could be flawed.7,8,10Thus, it is conceivable that present guidelines could be based on “contaminated” data in which many polyps with diameter ranging from 7 mm to 9 mm are incorrectly grouped as 10 mm or more.
- 3.Fear of missed cancers
- One study11showed that gastroenterologists chose a shorter surveillance interval than recommended by the guidelines due to the fears of missed cancers and malpractice concerns. Missing cancer is one of the greatest fears of endoscopists involved in screening and surveillance colonoscopies due to the perception that colon cancer is a preventable disease, and yet there is an undeniable, finite polyp miss rate.
- 4.Lack of familiarity with the guidelines
- Limited guideline knowledge obviously contributes to inappropriate timing of surveillance colonoscopies. Research shows that broad dissemination of guideline knowledge is challenging, and there is an estimated >10-year lag time between guideline publication and adoption.12Professional societies may need to devise physician outreach and educational programs or draw from other disciplines to disseminate guideline knowledge. Electronic health record systems could also help to develop clinical workflows or decision-support systems to facilitate incorporation of guidelines into clinical practice.
- 5.Processes and outcomes
- Although a recommendation from the endoscopist is a crucial step in adherence to appropriate surveillance intervals, a more significant clinical outcome is whether patients actually undergo surveillance examinations at suitable, guideline-concordant intervals. This underscores the interplay of several factors that extend beyond the physician’s recommendations when evaluating guideline-concordant care such as communication with primary care providers, patient preferences, and competing medical comorbidities. Thus, guideline-concordant care is an important process measure. But the ultimate outcome measure, although more difficult to quantify, is whether colon cancers are prevented among those with a history of adenomas.
- Colonoscopies in the United States.https://idataresearch.com/an-astounding-19-million-colonoscopies-are-performed-annually-in-the-united-states/Date accessed: February 11, 2022
- Colonoscopy utilization and outcomes 2000 to 2011.Gastrointest Endosc. 2014; 80: 133-143
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- Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US multi-society task force on colorectal cancer.Gastroenterology. 2012; 143: 844-857
- European guidelines for quality assurance in colorectal cancer screening and diagnosis. First edition–colonoscopic surveillance following adenoma removal.Endoscopy. 2012; 44: 25
- Post-polypectomy colonoscopy surveillance: European society of Gastrointestinal endoscopy (ESGE) guideline.Endoscopy. 2013; 45: 842-851
- Are endoscopic measurements of colonic polyps reliable?.Am J Gastroenterol. 1993; 88: 496-500
- Assessing the size of polyp phantoms in tandem colonoscopies.Anticancer Res. 2009; 29: 1539-1545
- Use of colonoscopy to screen asymptomatic adults for colorectal cancer. Veterans Affairs Cooperative Study Group 380.N Engl J Med. 2000; 343: 162-168
- Endoscopic over-estimation of colorectal polyp size.Gastrointest Endosc. 2016; 83: 201-208
- Post-polypectomy guideline adherence: importance of Belief in guidelines, not guideline knowledge or fear of missed cancer.Dig Dis Sci. 2015; 60: 2937-2945
- Successes and failures in the implementation of evidence-based guidelines for clinical practice.Med Care. 2001; 39: II46-II54
Conflicts of Interest: The authors disclose no conflicts.
Funding: This study was funded by Steve and Alex Cohen Foundation (A.S.) New York, NY.
Ethical Statement: This commentary did not require the approval of an institutional review board.
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