Endoscopy in Gastrointestinal Oncology - Slide 17 - D. Fisher - Post-polypectomy surveillance


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  • Definitions – have everyone on the same page Discussion of points in quality measurement Screening and surveillance Colonoscopy itself regardless of indication Then closing remarks
  • On to surveillance
  • Maybe save for polyp talk
  • Maybe save for polyp talk
  • Maybe save for polyp talk
  • Maybe save for polyp talk
  • Maybe save for polyp talk
  • Because when we look at receipt of services vs recommendations for services we see over use and underuse
  • Caribbean
  • Endoscopy in Gastrointestinal Oncology - Slide 17 - D. Fisher - Post-polypectomy surveillance

    1. 1. Post-Polypectomy Surveillance Deborah A. Fisher, MD, MHS Associate Professor of Medicine Duke University Medical Center Durham, North Carolina, USA March 12, 2011
    2. 2. Outline <ul><li>Background & definitions </li></ul><ul><li>EU guidelines </li></ul><ul><li>Quality Issues </li></ul><ul><li>Closing remarks </li></ul>
    3. 3. Reminder: Surveillance <ul><li>The ongoing follow-up of patients at increased risk of disease </li></ul>
    4. 4. EU guiding principals <ul><li>Prior adenoma is a risk factor for recurrent adenoma and eventual cancer </li></ul><ul><li>Risk is mostly related to baseline colonoscopy findings: Polyp size, number, histological grade </li></ul><ul><li>Colonoscopy is costly and invasive and may strain resources for screening </li></ul><ul><li>Surveillance focus should be highest risk individuals and minimum frequency to provide protection against future cancer </li></ul><ul><li>Initial and surveillance colonoscopies should be of high quality </li></ul>
    5. 5. EU recommendations: adenoma surveillance <ul><li>Patients should be divided into low, intermediate and high risk groups </li></ul><ul><li>Low risk (1-2 small adenomas) should return to screening protocols </li></ul><ul><li>Intermediate risk (3-4 small adenomas or ≥ 1 adenoma 10-19mm) follow-up in 3 years </li></ul><ul><li>High risk (≥ 5 small adenomas or ≥ 1 adenoma 20 mm or larger) follow-up in 1 year </li></ul><ul><li>Risk may be adjusted based on subsequent colonoscopy results </li></ul>
    6. 6. EU guideline
    7. 7. EU recommendations: piecemeal resection <ul><li>The site of large sessile polyps removed piecemeal should be re-examined in 2-3 months </li></ul><ul><li>If small areas of residual tissue are treated endoscopically the site should be re-examined again in 2-3 months </li></ul><ul><li>Extensive residual tissue should be referred to an endoscopist with special expertise or a surgeon </li></ul>
    8. 8. EU recommendations: other considerations <ul><li>Surveillance should generally be stopped at age 75 years or earlier depending on comorbidity </li></ul><ul><li>Interval FOBT is NOT recommended </li></ul><ul><li>Patients with small (<10 mm) distal hyperplastic polyps should be returned to screening </li></ul><ul><li>Large hyperplastic polyps or multiple proximal hyperplastic polyps may confer increased risk of future cancer but there are no data to determine appropriate surveillance intervals </li></ul>
    9. 9. Opportunity costs <ul><li>Resources are limited </li></ul><ul><li>Fully following EU surveillance guidelines may prevent a country from offering timely colonoscopy for screening, follow-up of positive screening tests, or symptomatic patients </li></ul><ul><li>Depending on capacity some systems may only provide surveillance for the highest risk group </li></ul><ul><li>People can die from cancer, they do not die from polyps </li></ul>
    10. 10. Quality in receipt of medical services <ul><li>Underuse - Individuals who would benefit do not receive service </li></ul><ul><li>Overuse - Using resources for individuals with little potential for net benefit from the service </li></ul><ul><li>Misuse - Conducting the service in ways that reduce net benefit </li></ul>
    11. 11. More is not always good
    12. 12. Overuse: Why more is not better <ul><li>Opportunity loss for that patient - not getting another service </li></ul><ul><li>Risk of complications without additional benefit </li></ul><ul><li>Opportunity loss for another patient - not getting a needed service (colonoscopy a restricted resources </li></ul><ul><li>Opportunity loss for the system - money spent in one place cannot be spend it in another </li></ul>
    13. 13. US: Physician recommended overuse <ul><li>US surveys of physician recommendations: </li></ul><ul><li>GI, surgeons, primary care physicians all recommend colonoscopy more frequently than US guidelines recommend </li></ul><ul><li>Especially for hyperplastic polyps and low risk adenomas </li></ul><ul><li>Medical record documentation results are similar even in systems without a payment incentive (e.g. VA) </li></ul>Mysliwiec Ann Intern Med 2004; Boolchand Ann Intern Med 2006
    14. 14. US: Receipt of surveillance for adenomas <ul><li>US PLCO trial (community setting) </li></ul><ul><ul><li>Overuse: 27% with no adenomas had colonoscopy within 5 years (due in 10 years) </li></ul></ul><ul><ul><li>Underuse: 58% with advanced adenomas had colonoscopy within 5 years (due in 3 years) </li></ul></ul><ul><li>VA single site N= 119 </li></ul><ul><ul><li>96% of patients with adenomas recommended to follow-up in 3-5 years </li></ul></ul><ul><ul><li>4% no recommendation </li></ul></ul><ul><ul><li>68% of patients had a colonoscopy within 3-5 years (none earlier) </li></ul></ul><ul><li>Perhaps over recommendation is partly modified by patient nonadherence? </li></ul>Schoen Gastroenterol 2010; Siddiqui APT 2006
    15. 15. UK: Adherence to 2002 BSG guidelines on the colonoscopy wait list Pickard Colorectal Dis 2006; Shoaib Colorectal Dis 2006; Selinger GUT 2005 ; John Colorectal Dis 2008 Overuse Underuse Thomas 2005 65% (overall) 78% (low risk) 20% 6% Picard 2006 76% NR Shaoib 2006 38% 10% John 2008 82% 0%
    16. 16. Overuse UK: intervention <ul><li>Single center study </li></ul><ul><li>Patients who underwent colonoscopy </li></ul><ul><li>Baseline audit 16% adherence to BSG guidelines </li></ul><ul><li>Intervention: posting guideline </li></ul><ul><li>Follow-up audit 47% adherence </li></ul><ul><li>Non adherence predominantly overuse </li></ul><ul><li>Conclusion: additional intervention needed </li></ul>John Colorectal Dis 2008
    17. 17. Potential reasons for overuse <ul><li>Do not know guidelines </li></ul><ul><li>Do not agree with guidelines </li></ul><ul><li>Guidelines are vague (e.g. hyperplastic polyps) </li></ul><ul><li>Pressure, expectations from patients or referring doctors </li></ul><ul><li>Lack of confidence in quality of initial colonoscopy (bowel prep, skill, patient factors) </li></ul><ul><li>Fear of missing lesions </li></ul>
    18. 18. Overuse in other countries <ul><li>Limited by lack of research </li></ul><ul><li>Limited by lack of a benchmark </li></ul><ul><li>EU guidelines are new </li></ul><ul><li>“Underuse is a tragedy. Overuse is the researcher’s mistake” </li></ul>
    19. 19. Quality and surveillance <ul><li>Both EU and US guidelines emphasize the quality of the colonoscopy to diagnose and completely remove all polyps </li></ul><ul><li>Less frequent high quality colonoscopy is safer, more effective, and less costly than frequent, poor quality colonoscopy </li></ul>
    20. 20. Closing remarks <ul><li>Evaluation of polyp surveillance guideline adherence is understudied </li></ul><ul><li>While underuse is a quality issue with screening overuse is a documented problem with surveillance </li></ul><ul><li>Adherence to EU guidelines will be important to reduce strain on colonoscopy resources </li></ul><ul><li>Interventions to improve adherence will likely need to go beyond dissemination of guidelines </li></ul><ul><li>Quality colonoscopy is key to surveillance effectiveness </li></ul>