Should patients expect their colonoscopy to reach the standards experienced by bowel cancer screening patients?

Abstract

OPINION 122Although the administrative burden of the endoscopy quality improvement programme is immense, these measures have undoubtedly had a very positive impact on patient-centred endoscopic care in the UK.The first large UK audit of colonoscopy standards undertaken by Bowles et al revealed a caecal intubation rate (CIR) of only 56.9% from 9223 procedures. 1 The potential implications of this poor national performance were significant. One of the most important indications for colonoscopy is to prevent colorectal cancer deaths by detecting cancer at a curative stage or removing potentially cancerous polyps. Low CIRs are associated with colorectal cancer in patients who have undergone a colonoscopy in the past; 2 therefore, the number of 'missed' cancers was likely to be unacceptably high in the UK at the time of this audit. The audit also highlighted that improvements needed to be made before the introduction of colorectal screening.Following this audit, the Joint Advisory Group on Gastrointestinal Endoscopy introduced a quality improvement programme involving training standards, peer review and the implementation of the Global Rating Scale. The most recent multicentre audit of 16 064 colonoscopies by Verma et al 3 demonstrated the impact that this programme has had. Data over a 2-year period from 2008 to 2009 were collected from six hospitals, 120 endoscopists and 16 064 colonoscopies, demonstrating a marked improvement in the CIR to 90.57%. This is a remarkable achievement in such a short period of time.As one would expect, the CIR was greater for bowel cancer screening colonoscopies than for non-screening colonoscopies (97.71% vs 88.31%). This difference is likely to be related to a variety of factors including the skill of the screening colonoscopists who are required to pass a summative assessment test before undertaking screening lists, but also the extended time allocated for each screening colonoscopy allowing for a longer withdrawal time, quality of bowel preparation, patient selection and fitness and nurse preassessment. A very clear outcome of the study was that operators undertaking less than 100 procedures per year were less likely to achieve a CIR greater than 90%. Furthermore, non-gastroenterologist/surgeons failed to reach the caecum in nearly 22% of cases. The operator skill therefore plays a clear role in the success of the procedure and is supported by circumstantial evidence from earlier studies. Haseman et al demonstrated that colorectal cancers were more likely to be missed by non-gastroenterologists than gastroenterologists. 4 In this study, if the caecum was reached, the miss rates were equal, further supporting the importance of a complete colonoscopy.In addition to the CIR, there are other evidence based markers of diagnostic quality, including adenoma detection rate (ADR), polyp detection rate, colonoscopy withdrawal time, CIR, rectal retroversion rate, polyp retrieval rate and bowel preparation. These markers are routinely collected from screening colonoscopies by a dedicated nurse ...

Colorectal Cancer Screening within Colonoscopy Capacity Constraints: Can FIT-Based Programs Save More Lives by Trading off More Sensitive Test Cutoffs against Longer Screening Intervals?

“…This may overestimate the effectiveness of the procedure, as studies have shown that this proportion can be lower. 52,53 Finally, recent evidence has shown an increase in the incidence of CRC in European adults younger than 50 y. 54 The model presented here does not represent such trends in CRC incidence and so may underestimate the potential benefits of policies that offer earlier start ages as a tradeoff against higher screening frequency.…”

Colorectal cancer screening within colonoscopy capacity constraints: can FIT-based programmes save more lives by trading-off more sensitive test cut-offs against longer screening intervals?

“…Finally, the model assumes 95% of colonoscopies reach the caecum. This may overestimate the effectiveness of the procedure as studies have shown that this can be lower[46,47]. Despite these simplifications, we are confident that the analysis valuably illustrates the relevance of considering a broad range of policy alternatives and a clear indication of how a national bowel cancer screening programme could save more lives.…”