Gregory S. Cooper

Survival after hepatic resection in metastatic colorectal cancer: A population-based study

Hepatectomy is the standard of care for patients with colorectal cancer who have isolated hepatic metastases; however, the long‐term survival benefits of hepatectomy in this population have not been characterized well outside of case series. For the current study, a population‐based database was used to compare the survival of patients with liver metastases from colorectal cancer who did and did not undergo hepatectomy.

Prospective assessment of the utility of EUS in the evaluation of gallstone pancreatitis

BACKGROUND The ability to identify common bile duct stones by noninvasive means in patients with acute biliary pancreatitis is limited. The aim of this study was to prospectively evaluate the ability of endosonography (EUS) to identify cholelithiasis and choledocholithiasis and predict disease severity in patients with nonalcoholic pancreatitis. METHODS EUS was performed immediately before endoscopic retrograde cholangiopancreatography (ERCP) by separate blinded examiners within 72 hours of admission. Gallbladder findings were compared between EUS and transabdominal ultrasonography (US). Using endoscopic extraction of a bile duct stone as the reference standard for choledocholithiasis, the diagnostic yield of EUS was compared with transabdominal US and ERCP. Features identified during endosonographic imaging of the pancreas were correlated with length of hospitalization. RESULTS Thirty-six patients were studied. EUS and transabdominal US were concordant in their interpretation of gallbladder findings in 92% of patients. The sensitivity of transabdominal US, EUS, and ERCP for identifying choledocholithiasis was 50%, 91%, and 92% and the accuracy was 83%, 97%, and 89%, respectively. Length of hospital stay was longer in patients with peripancreatic fluid (9.2 vs. 5.7 days, p < 0.1) and shorter in patients with coarse echo texture (2.6 vs. 7.2 days, p < 0.05) demonstrated on EUS. CONCLUSIONS EUS can reliably identify cholelithiasis and is more sensitive than transabdominal US in detecting choledocholithiasis in patients with biliary pancreatitis. EUS may be used early in the management of patients with acute pancreatitis to select those who would benefit from endoscopic stone extraction. The utility of EUS for predicting pancreatitis severity requires further investigation.

Early endoscopy in upper gastrointestinal hemorrhage: associations with recurrent bleeding, surgery, and length of hospital stay

BACKGROUND The impact of upper endoscopy in patients with upper gastrointestinal hemorrhage treated in community practice is unknown. Thus we examined the effectiveness of endoscopy performed within 24 hours of admission (early endoscopy). METHODS Medical records of 909 consecutive hospitalized patients with upper gastrointestinal hemorrhage who underwent endoscopy at 13 hospitals in a large metropolitan area were reviewed. We evaluated unadjusted and severity-adjusted associations of early endoscopy with recurrent bleeding or surgery to control hemorrhage, length of hospital stay, and associations of endoscopic therapy in patients with bleeding ulcers or varices. RESULTS Early endoscopy was performed in 64% of patients and compared with delayed endoscopy and was associated with clinically significant reductions in adjusted risk of recurrent bleeding or surgery (odds ratio [OR] 0.70: 95% CI [0.44, 1.13]) and a 31% decrease in adjusted length of stay (95% CI: [24%, 37%]). In patients at high risk for recurrent bleeding, the use of early endoscopic therapy to control hemorrhage was associated with reductions in recurrent bleeding or surgery (OR 0.21: 95% CI [0.10, 0.47]) and length of stay (-31%: 95% CI [-44%, -14%). CONCLUSION In this study of community-based practice, the routine use of endoscopy, and in selected cases endoscopic therapy, performed early in the clinical course of patients with upper gastrointestinal hemorrhage was associated with reductions in length of stay and, possibly, the risk of recurrent bleeding and surgery.

Familial aggregation of Barrett’s oesophagus, oesophageal adenocarcinoma, and oesophagogastric junctional adenocarcinoma in Caucasian adults

Background: Although familial clusters of Barrett’s oesophagus and oesophageal adenocarcinoma have been reported, a familial predisposition to these diseases has not been systematically investigated. Aims: To determine whether Barrett’s oesophagus and oesophageal (or oesophagogastric junctional) adenocarcinoma aggregate in families. Patients and methods: A structured questionnaire eliciting details on reflux symptoms, exposure history, and family history was given to Caucasian case (n=58) subjects with Barrett’s oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma, and to Caucasian control (n=106) subjects with symptomatic gastro-oesophageal reflux disease without Barrett’s oesophagus. Reported diagnoses of family members were confirmed by review of medical records. Results: The presence of a positive family history (that is, first or second degree relative with Barrett’s oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma) was significantly higher among case subjects compared with controls (24% v 5%; p<0.005). Case subjects were more likely to be older (p<0.001) and male (74% v 43% male; p<0.0005) compared with control subjects. In a multivariate logistic regression analysis, family history was independently associated with the presence of Barrett’s oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma (odds ratio 12.23, 95% confidence interval 3.34–44.76) after adjusting for age, sex, and the presence of obesity 10 or more years prior to study enrolment. Conclusions: Individuals with Barrett’s oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma are more likely to have a positive family history of Barrett’s oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma than individuals without Barrett’s oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma. A positive family history should be considered when making decisions about screening endoscopy in patients with symptoms of gastro-oesophageal reflux.

Surgery for colorectal cancer: Race-related differences in rates and survival among Medicare beneficiaries.

This study examined surgery for colorectal cancer among Medicare beneficiaries 65 years of age or older with an initial diagnosis in 1987 (n = 81 579). Black patients were less likely than White to undergo surgical resection (68% vs 78%), even after age, comorbidity, and location and extent of tumor were controlled for. Among those who underwent resection, Black patients were more likely to die (a 2-year mortality rate of 40.0% vs 33.5% in White patients); this disparity also remained after confounders had been controlled. The disparities were similar in teaching and nonteaching hospitals and in private and public hospitals. These data may indicate racially based differences among Medicare beneficiaries in access to and quality of care for colorectal cancer.

Complications following colonoscopy with anesthesia assistance: A population-based analysis

IMPORTANCE Deep sedation for endoscopic procedures has become an increasingly used option but, because of impairment in patient response, this technique also has the potential for a greater likelihood of adverse events. The incidence of these complications has not been well studied at a population level. DESIGN Population-based study. SETTING AND PARTICIPANTS Using a 5% random sample of cancer-free Medicare beneficiaries who resided in one of the regions served by a SEER (Surveillance, Epidemiology, and End Results) registry, we identified all procedural claims for outpatient colonoscopy without polypectomy from January 1, 2000, through November 30, 2009. INTERVENTION Colonoscopy without polypectomy, with or without the use of deep sedation (identified by a concurrent claim for anesthesia services). MAIN OUTCOME MEASURES The occurrence of hospitalizations for splenic rupture or trauma, colonic perforation, and aspiration pneumonia within 30 days of the colonoscopy. RESULTS We identified a total of 165 527 procedures in 100 359 patients, including 35 128 procedures with anesthesia services (21.2%). Selected postprocedure complications were documented after 284 procedures (0.17%) and included aspiration (n = 173), perforation (n = 101), and splenic injury (n = 12). (Some patients had >1 complication.) Overall complications were more common in cases with anesthesia assistance (0.22% [95% CI, 0.18%-0.27%]) than in others (0.16% [0.14%-0.18%]) (P < .001), as was aspiration (0.14% [0.11%-0.18%] vs 0.10% [0.08%-0.12%], respectively; P = .02). Frequencies of perforation and splenic injury were statistically similar. Other predictors of complications included age greater than 70 years, increasing comorbidity, and performance of the procedure in a hospital setting. In multivariate analysis, use of anesthesia services was associated with an increased complication risk (odds ratio, 1.46 [95% CI, 1.09-1.94]). CONCLUSIONS AND RELEVANCE Although the absolute risk of complications is low, the use of anesthesia services for colonoscopy is associated with a somewhat higher frequency of complications, specifically, aspiration pneumonia. The differences may result in part from uncontrolled confounding, but they may also reflect the impairment of normal patient responses with the use of deep sedation.

Prevalence and Predictors of Interval Colorectal Cancers in Medicare Beneficiaries

After a colonoscopy that is negative for cancer, a subset of patients may be diagnosed with colorectal cancer, also termed interval cancer. The frequency and predictors have not been well studied in a population‐based US cohort.

The Sensitivity of Medicare Claims Data for Case Ascertainment of Six Common Cancers

BACKGROUND Although Medicare claims data have been used to identify cases of cancer in older Americans, there are few data about their relative sensitivity. OBJECTIVES To investigate the sensitivity of diagnostic and procedural coding for case ascertainment of breast, colorectal, endometrial, lung, pancreatic, and prostate cancer. SUBJECTS Three hundred and eighty nine thousand and two hundred and thirty-six patients diagnosed with cancer between 1984 and 1993 resided in one of nine Surveillance Epidemiology and End Results (SEER) areas. MEASURES The sensitivity of inpatient and Part B diagnostic and cancer-specific procedural codes for case finding were compared with SEER. RESULTS The sensitivity of inpatient and inpatient plus Part B claims for the corresponding cancer diagnosis was 77.4% and 91.2%, respectively. The sensitivity of inpatient claims alone was highest for colorectal (86.1%) and endometrial (84.1%) cancer and lowest for prostate cancer (63.6%). However, when Part B claims were included, the sensitivity for diagnosis of breast cancer was greater than for other cancers (93.6%). Inpatient claim sensitivity was highest for earlier years of the study, and, because of more complete data and longer follow up, the highest sensitivity of combined inpatient and Part B claims was achieved in the late 1980s or early 1990s. CONCLUSIONS Medicare claims provide reasonably high sensitivity for the detection of cancer in the elderly, especially if inpatient and Part B claims are combined. Because the study did not measure other dimensions of accuracy, such as specificity and predictive value, the potential costs of including false positive cases need to be assessed.

Colorectal Screening after Polypectomy: A National Survey Study of Primary Care Physicians

Context In many health systems, primary care physicians schedule surveillance colonoscopy after polyp removal. Their knowledge of the recommended surveillance intervals will affect the availability of colonoscopy resources. Contribution The authors surveyed a random sample of internists and family physicians by sending them a vignette that depicted a man with polyps on screening colonoscopy. Respondents chose a surveillance colonoscopy interval for each of several screening findings. Most respondents chose shorter surveillance intervals than recommended by professional society guidelines. Cautions A survey tests knowledge, not actual practice. The response rate was 57%. Implications Primary care physicians may order surveillance colonoscopy more frequently than necessary. The Editors Colonoscopy has been increasingly endorsed to screen for colorectal cancer in persons at average risk who are older than 50 years of age (19). As a result, detection and surveillance of polyps are increasing and represent the single most common use for colonoscopy in patients older than 50 years of age (10). However, there is concern that current physician manpower and endoscopic resources may not meet the demands for both surveillance and screening colonoscopy (4, 9, 1114). One potential approach to accommodate the demand for screening colonoscopy is to increase the surveillance intervals after identification of adenomatous polyps. Current guidelines by the U.S. Multisociety Task Force (USMSTF) on Colorectal Cancer suggest that average-risk persons with 1 or 2 small adenomas (<1 cm) should have surveillance colonoscopy after 5 to 10 years (4, 9). In patients with 3 or more adenomas, regardless of size, a 3-year surveillance interval is recommended (4, 9). Preliminary evidence indicates that even these intervals should be lengthened because the risk for colorectal cancer after removal of adenomas may be no greater than that in the general population (15, 16). Hyperplastic polyps are nonneoplastic polyps that have been identified in 10% of persons undergoing screening and are considered low risk for development of colon neoplasia (6, 7). Current recommendations are that these patients have surveillance examinations every 10 years (1, 4, 5, 9). Despite efforts to lengthen surveillance intervals, evidence indicates that physicians may still recommend more intensive follow-up colonoscopy. A recent survey of gastroenterologists and surgeons reported that 24% of gastroenterologists would recommended surveillance for a hyperplastic polyp in 5 years or less and most would recommend surveillance of a single adenoma in 3 years or less (17). However, in open-access endoscopy referral systems, in which physicians can refer patients for endoscopic examinations without previous consultations, decisions about follow-up are made by referring primary care physicians rather than gastroenterologists (18). There is concern that primary care physicians may be less familiar than gastroenterologists with surveillance guidelines (19), and in particular with frequently changing surveillance recommendations. We examined the interval at which primary care physicians refer patients for surveillance after a polyp is found on index colonoscopy and compared these intervals with those recommended in current guidelines. Methods Survey Development A 1-page cover letter (Appendix Figure 1) and survey (Appendix Figure 2) were developed and tested on primary care physicians within our institution. Questions that resulted in ambiguous answers were adjusted. All questions were created in a close-ended manner. Appendix Figure 1. Cover letter sent with the survey. Appendix Figure 2. Survey sent to 1000 primary care practitioners. The survey included the following hypothetical clinical history for all questions. The patient was a 55-year-old man in good health who underwent a screening colonoscopy. The colonoscopy was completed to the cecum, the quality of the colon cleansing was excellent, and the patient had no family history of colon cancer. The findings on index colonoscopy varied on individual questions and included a 6-mm hyperplastic polyp, a 6-mm tubular adenoma, two 6-mm tubular adenomas, a 12-mm tubulovillous adenoma, or a 12-mm pedunculated tubular adenoma with a focus of high-grade dysplasia. One vignette included a 55-year-old man with a 12-mm tubular adenoma on screening colonoscopy 3 years earlier who underwent surveillance colonoscopy on which no polyps were found. The practitioners were asked to select the follow-up interval that they would recommend from the following choices: colonoscopy at 6 months, colonoscopy at 1 year, colonoscopy at 3 years, colonoscopy at 5 years, colonoscopy at 10 years, or no repeated colonoscopy. Recruitment A simple random sample of 500 family practitioners and 500 general internists was obtained from among active, nonretired members of the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) in 2004. Because specialty type is an identifiable characteristic in the membership, only physicians designated as general internists were requested from the ACP membership. Survey Administration An initial mailing that included the cover letter and questionnaire was sent to the random sample. A repeated mailing that included a

Agreement of medicare claims and tumor registry data for assessment of cancer-related treatment

2 bill as an incentive was sent to physicians who did not respond after 6 weeks. To maximize response rates, the total design approach (20) was used. This approach included personalized cover letters, first-class stamps on the envelopes, enclosed first-class stamped return envelopes, close-ended questions, and a financial incentive on the repeated mailing. Statistical Analysis Data analysis was performed by using SAS for Windows, version 8 (SAS Institute, Inc., Cary, North Carolina). Descriptive statistics were performed on all variables. Frequencies of different answers to each question on the survey were calculated. Comparisons were made by using the chi-square test according to sex (male or female), specialty (family practitioners or internists), years in practice (<5 years, 5 to 10 years, 11 to 20 years, or >20 years), average number of patients seen in a week (<25, 25 to 50, 51 to 100, or >100) and routine use of an open-access colonoscopy system in their practice. A P value less than 0.01 was considered statistically significant for any difference in answers between groups to correct for multiple comparisons between groups. Paired responses were determined by using the McNemar test. Role of the Funding Source The study was funded by general research funds from the Division of Gastroenterology at University Hospitals of Cleveland, which had no role in the design, conduct, or reporting of the study or in the decision to submit the manuscript for publication. Results Survey Response and Physician Characteristics The overall response rate for both mailings was 57% (568 physicians). Three hundred thirty-seven responses were received after the first mailing, and 231 responses were received after the second mailing. Four hundred thirty-two (43%) responses were not received, including 202 responses from AAFP members and 230 from ACP members. Table 1 shows characteristics of the respondents. No information is available on characteristics of nonresponders other than whether they were members of ACP or AAFP. Table 1. Characteristics of Survey Respondents Recommendations and Comparisons with USMSTF Guidelines Table 2 shows the USMSTF guidelines at the time of the survey for each of the 6 clinical vignettes. Surveillance intervals recommended by the practitioners for various lesions identified on the index colonoscopy are also shown (Table 2). The intervals recommended by primary care physicians were generally shorter than those recommended by the USMSTF. Table 2. Postpolypectomy Surveillance by Primary Care Physicians, Compared with Guideline Recommendations Follow-Up Recommendations for Low-Risk Lesions Sixty-one percent of primary care physicians would survey a single 6-mm hyperplastic polyp in the sigmoid colon in 5 years or less (Table 2), and 71% would survey a single 6-mm tubular adenoma found in the sigmoid colon in 3 years or less. Similarly, 80% of primary care physicians would survey two 6-mm tubular adenomas in the sigmoid colon in 3 years or less. Furthermore, physicians were more likely to survey 2 adenomas than 1 adenoma at 1 year or less (37% vs. 25% [P< 0.001, McNemar test]) (Table 2). Eighty percent of primary care physicians would survey a patient who had a normal result on surveillance colonoscopy and a history of a 12-mm tubular adenoma 3 years earlier in 5 years or less (Table 2). Follow-Up Recommendations for High-Risk Lesions Fifty-nine percent of primary care physicians would survey a single 12-mm tubulovillous adenoma in the sigmoid colon in 1 year or less (Table 2). For follow-up of a single 12-mm pedunculated polyp with a focus of high-grade dysplasia away from the cautery margin, 85% would survey the patient in 1 year or less (Table 2). The differences in surveillance patterns between these 2 types of polyps were statistically significant at 1 year or less (P< 0.001, McNemar test). Physician Characteristics Associated with Recommendations Family practitioners were more likely than internists to recommend surveillance for a hyperplastic polyp at 1 year or less (19% vs. 10%) and 3 years (21% vs. 13%) (P= 0.001 for both comparisons). Internists were more likely than family practitioners to recommend surveillance for hyperplastic polyps at 5 years or more (76% vs. 60% [P= 0.001]). Otherwise, no consistent differences were found in surveillance of hyperplastic polyps, small adenomas, and high-risk polyps according to the sex of the physician, number of years in practice, number of patients seen per week, and use of open-access colonoscopy. Characteristics of Respondents to Each Mailing Physicians who responded to the second mailing were more likely than those