Summary Background: Adenoma detection rate ( ADR) is an essential quality indicator for endoscopists performing colonoscopies for colorectal cancer (CRC) screening, as it is associated with postcolonoscopy CRCs (PCCRC) . Currently, data on ADR of endoscopists performing colonoscopies in fecal immunochemical test (FIT)-based screening, the most common screening method, are scarce. Furthermore, the association between ADR and PCCRC has not been demonstrated in this setting. Aim: To evaluate the association between the risk of ADR and PCCRC in colonoscopies performed after a positive FIT result. Design: Population-based cohort. Adjustment: Dutch CRC screening programme, based on FIT. Participants: Patients undergoing colonoscopy, performed by accredited endoscopists, after a positive FIT result. Measurements: The performance of the quality indicator and the incidence of PCCRC for colonoscopies in FIT-positive screens were evaluated. PCCRCs were classified as interval, a cancer detected before recommended surveillance, or no interval. The association between ADR and interval PCCRC was evaluated with a multivariable Cox regression model, and the incidence of PCCRC for different ADRs was determined. Results: 362 endoscopists performed 116,360 colonoscopies with a median ADR of 67%. In total, 209 interval PCCRCs were identified. ADR was associated with the PCCRC interval, with an adjusted hazard ratio of 0.95 (95% CI, 0.92 to 0.97) per 1% increase in ADR. For every 1000 patients undergoing colonoscopy, the expected number of interval PCCRC diagnoses after 5 years was approximately 2 for endoscopists with ADR of 70%, compared with more than 2.5, almost 3.5, and more than 4 .5 for endoscopists with ADR of 65%, 60% and 55%, respectively. Limitation: The relatively short duration of follow-up (median, 52 months) could be considered a limitation. Conclusion: Endoscopists’ ADR is inversely associated with the risk of interval PCCRC in FIT-positive colonoscopies. Endoscopists performing colonoscopies in FIT-based screening should aim for markedly higher ADRs compared to primary colonoscopy. |
Comments
Colonoscopies in people with positive fecal immunochemical tests (FIT) require a much higher adenoma detection rate (ADR) than primary colonoscopy
A cohort study of adults undergoing colonoscopy after a positive fecal immunochemical test (FIT) result suggests that endoscopists performing colonoscopies in FIT-based screening programs should aim for markedly higher ADRs in comparison with programs using colonoscopy as the primary screening intervention. The study is published in Annals of Internal Medicine .
Screening reduces the incidence and mortality of colorectal cancer (CRC) by early detection and removal of colorectal cancers and polyps. One of the quality indicators of colonoscopies is the ADR, which is the proportion of colonoscopies in which at least one adenoma is detected.
ADR is often associated with the risk of postcolonoscopy reverse CRC (PCCRC), and many professional societies recommend that endoscopists have an ADR of at least 25 percent.
FIT-based screening programs have also become common around the world. Participants with a positive FIT result have a high prevalence of adenomas, leading to high ADRs for endoscopists performing colonoscopies in this setting. However, it is unknown whether the association between ADR and PCCRC is also present in colonoscopies performed after a positive FIT result.
Researchers at Erasmus University Medical Center, Rotterdam, conducted a population-based cohort study of 362 endoscopists performing 116,360 colonoscopies with a mean ADR of 67%.
In 426 participants diagnosed with PCCRC, 49% were classified as interval cancer and 51% were classified as non-interval cancer. The authors found that higher ADR was associated with a lower incidence of PCCRC, and that colonoscopy in FIT-positive individuals requires a markedly higher ADR target than primary colonoscopy.
They report that for an endoscopist with an ADR of 60%, the cumulative incidence of interval PCCRC for colonoscopies performed in response to positive FIT was almost 2 times higher than that for endoscopists with an ADR of 70%.
This risk was even higher for endoscopists with ADR less than 60%, with an expected number of patients diagnosed with PCCRC interval in 5 years of approximately 2 for endoscopists with an ADR of 70%, compared to almost 3.5 for RAM of 60%, and more than 4.5 for ADRs of 55%.
According to the authors, their findings support the use of ADR, with different objectives, as an important quality indicator for endoscopists in primary and FIT-based colonoscopy screening programs.
An accompanying editorial from Kaiser Permanente, Oakland, California, argues that this study provides an excellent framework for evaluating concepts related to effective quality metrics and how they can illustrate pathways to meaningful metrics for the care of other cancers and disorders.
It is highlighted that studies that evaluate quality metrics must be reliable, important, strategic, relevant, actionable and simple. He also adds that issues related to goals, plans for implementation of interventions, and application of goals while maintaining simplicity should be considered in the development of metrics.
