Swati G. Patel

Physician Assessment and Management of Complex Colon Polyps: A Multicenter Video-Based Survey Study

Objectives:The management of complex colorectal polyps varies in practice. Accurate descriptions of the endoscopic appearance by using a standardized classification system (Paris classification) and size for complex colon polyps may guide subsequent providers regarding curative endoscopic resection vs. need for surgery. The accuracy of this assessment is not well defined. Furthermore, the factors associated with decisions for endoscopic vs. surgical management are unclear. To characterize the accuracy of physician assessment of polyp morphology, size, and suspicion for malignancy among physician subspecialists performing colonoscopy and colon surgery. In addition, we aimed to assess the influence of these polyp characteristics as well as physician type and patient demographics on recommendations for endoscopic vs. surgical resection of complex colorectal polyps.Methods:An online video-based survey was sent to gastroenterologists (GIs) and gastrointestinal surgeons affiliated with six tertiary academic centers. The survey consisted of high-definition video clips (30–60 s) of six complex colorectal polyps (one malignant) and clinical histories. Respondents were blinded to histology. Respondents were queried regarding polyp characteristics, suspicion for malignancy, and recommendations for resection.Results:The survey response rate was 154/317 (49%). Seventy-eight percent of respondents were attending physicians (91 GIs and 29 surgeons) and 22% were GI trainees. Sixteen percent of respondents self-identified as specialists in complex polypectomy. Accurate estimation of polyp size was poor (28.4%) with moderate interobserver agreement (k=0.52). Accuracy for Paris classification was 47.5%, also with moderate interobserver agreement (k=0.48). Specialists in complex polypectomy were most accurate, whereas surgeons were the least accurate in assigning Paris classification (66.0 vs. 28.7%, P<0.0001). Specialists in complex polypectomy were most likely to correctly identify the malignant lesion compared with other physicians (87.5 vs. 56.2%, P=0.008). Surgical removal of colon adenomas was recommended least frequently by specialists in complex polypectomy (3.1%) compared with nonspecialists in complex polypectomy (13.3%); surgeons were most likely to recommend surgical resection (17.2%, P=0.009). There were no differences in recommendations for endoscopic vs. surgical resection observed on the basis of years in practice, polyp morphology (polypoid vs. nonpolypoid), polyp location (right vs. left colon), or patient ASA class.Conclusions:In this large survey of GIs and surgeons, physician specialty was strongly associated with accurate polyp characterization and a recommendation for endoscopic resection of complex polyps. Surgeons were most likely to recommend surgical resection of complex nonmalignant colorectal polyps compared with specialists in complex polypectomy who were the least likely. Therefore, collaboration with specialists in complex polypectomy may be helpful in determining the appropriate management of complex colon polyps. Further teaching is needed among all specialists to improve accurate communication and ensure optimal management of these lesions.

Knowledge and Uptake of Genetic Counseling and Colonoscopic Screening Among Individuals at Increased Risk for Lynch Syndrome and their Endoscopists from the Family Health Promotion Project

OBJECTIVES:Individuals whose families meet the Amsterdam II clinical criteria for hereditary non-polyposis colorectal cancer are recommended to be referred for genetic counseling and to have colonoscopic screening every 1–2 years. To assess the uptake and knowledge of guideline-based genetic counseling and colonoscopic screening in unaffected members of families who meet Amsterdam II criteria and their treating endoscopists.METHODS:Participants in the Family Health Promotion Project who met the Amsterdam II criteria were surveyed regarding their knowledge of risk-appropriate guidelines for genetic counseling and colonoscopy screening. Endoscopy/pathology reports were obtained from patients screened during the study to determine the follow-up recommendations made by their endoscopists. Survey responses were compared using Fisher’s Exact and the χ2 test. Concordance in participant/provider-reported surveillance interval was assessed using the kappa statistic.RESULTS:Of the 165 participants, the majority (98%) agreed that genetics and family history are important predictors of CRC, and 63% had heard of genetic testing for CRC, although only 31% reported being advised to undergo genetic counseling by their doctor, and only 7% had undergone genetic testing. Only 26% of participants reported that they thought they should have colonoscopy every 1–2 years and 30% of endoscopists for these participants recommended 1–2-year follow-up colonoscopy. There was a 65% concordance (weighted kappa 0.42, 95% CI 0.24–0.61) between endoscopist recommendations and participant reports regarding screening intervals.CONCLUSIONS:A minority of individuals meeting Amsterdam II criteria in this series have had genetic testing and reported accurate knowledge of risk-appropriate screening, and only a small percentage of their endoscopists provided them with the appropriate screening recommendations. There was moderate concordance between endoscopist recommendations and participant knowledge suggesting that future educational interventions need to target both health-care providers and their patients.

Screening for Colon Polyps and Cancer

Colorectal cancer (CRC) carries a significant health burden, accounting for 610,000 deaths worldwide in 2008. CRC is the fourth most common malignancy and the second leading cause of cancer-related death in the United States. Colon screening is arguably the greatest cancer prevention success story of the last 25 years contributing substantially to over a 40 % reduction in CRC mortality in the USA since 1975. Screening rates in the USA currently exceed 60 % and are steadily rising. Randomized screening trials have demonstrated a 33 % reduction in CRC mortality with the use of annual fecal occult blood testing (FOBT) and a 27–31 % reduction in CRC mortality with flexible sigmoidoscopy (FS). Despite this robust evidence for FOBT and FS, colonoscopy use has been on the rise in the USA and has emerged as the preferred colon screening modality. Colonoscopy has a conceptual advantage as it is the only single-step test that allows visualization of the entire colon and removal of polyps simultaneously. Retrospective data suggests that colonoscopy may not be as protective of colon cancer in the proximal colon; however, prospective data on the impact of colonoscopy screening on incidence and mortality is not yet available. Computerized tomography colonography (CTC) and fecal DNA testing are newer technologies that have a great deal of potential as screening modalities as technology advances. Although colon screening can be expensive depending on the test used, any type of screening appears to be cost-effective when taking into account the rising costs of CRC treatment.

Isn’t It Time to Stop Talking About Colonoscopy Quality and Start Doing Something About It?

Colonoscopy is central to one of the great success stories of the war on cancer. Although colorectal cancer (CRC) is still the second leading cause of cancer death in the United States, both the incidence and mortality has been declining by 2–3% per year for the last 15 years. This decline has been largely attributed to increasing rates of CRC screening. Although guidelines list other screening options (stool tests/imaging/flexible sigmoidoscopy) colonoscopy has become the dominant CRC screening test in the US while fecal testing has declined slowly, and flexible sigmoidoscopy has declined markedly over the last decade [1]. Colonoscopy is widely viewed in the US as the single best test for both detection and removal of pre-cancerous lesions. The efficacy of colonoscopic polypectomy was initially highlighted by the National Polyp Study (NPS), which estimated a 76–90% reduction in incidence of colorectal cancer after polyp removal [2]. Subsequent studies [3], which often have not shown as robust a CRC risk reduction as the NPS, have highlighted the importance of the quality of colonoscopy as a critical element in its efficacy. There is compelling evidence that colonoscopy quality is highly variable [4] and guidelines for a high-quality colonoscopy have been published [5], but in the end, quality needs to be assessed by whether a test accomplishes its primary goal. In the case of colonoscopy, directly measuring whether a colonoscopy has prevented a CRC is not feasible in the short term. Instead, more measurable surrogates of quality such as cecal intubation rates, withdrawal times, and particularly adenoma detection rates (ADR) have been used as quality measures. Kaminski et al. found that ADR appeared to be an acceptable surrogate for real colonoscopy quality as it was an independent predictor of the risk of interval colorectal cancer [6]. Numerous studies have demonstrated marked (twofold to sixfold) variability in ADRs among endoscopists working in the same endoscopy unit [4]. Although some of this variability might be due to patient factors such as age, gender, or adequacy of bowel preparation, individual endoscopists appear to be the single most predictive factor in adenoma detection [7], implying that the efficacy of colonoscopy is highly dependent on the individual skill of the endoscopist. To compound matters, Brenner [8] and Lakoff [9] presented data from Germany and Canada that showed that while colonoscopy does decrease the rate of distal CRCs by approximately 67–79%, it was not at all protective for proximal colon cancers, suggesting that there is a substantial need for improvement in colonoscopy quality by all endoscopists. The variability in colonoscopy quality among providers and the dubious utility of colonoscopy in preventing rightsided colon cancers have called into question the overall efficacy of colonoscopy as it is used today and would seem to be a clear mandate for endoscopists and professional organizations to critically examine colonoscopist performance and address areas in need of improvement. Is it possible to identify provider characteristics that are predictive of quality procedures? If so, can we incorporate these findings into endoscopic training, continuing medical education and ultimately ongoing quality assurance programs? Any such efforts are dependent, in part, on an understanding of the relationships between endoscopist characteristics and quality outcomes and there is growing literature examining one aspect of this relationship—the S. G. Patel D. J. Ahnen (&) Department of Medicine, Division of Gastroenterology, Denver VA Medical Center and University of Colorado School of Medicine, Denver, CO, USA e-mail: dennis.ahnen@ucdenver.edu

774 Perceptions of Training Among Program Directors and Trainees in Complex Endosopic Procedures (CEPs): A Nationwide Survey of US ACGME Accredited Gastroenterology Training Programs

Background: Insufficient inhibition of gastric acid during Helicobacter pylori treatment and bacterial resistance to antibiotics frequently results in failure to eradicate infection. Twicedaily dosing (b.i.d.) of a proton pump inhibitor (PPI) using standard eradication therapy has shown difficulty in maintaining high gastric pH values for 24 h in patients. However, four-times-daily dosing (q.i.d.) achieves these goals, irrespective of CYP2C19 genotype status, and might therefore be an optimal regimen for use in eradicating H. pylori infection. The fluoroquinolone sitafloxacin (STFX) was recently reported to have a lower minimum inhibitory concentration for H. pylori compared with levofloxacin and has become clinically available as a third-line treatment and for patients with penicillin allergy. An STFX-based eradication regimen with maintenance of acid inhibition might therefore have a high success rate. We investigated the efficacy of this treatment and maintenance of acid inhibition by PPI q.i.d. treatment. Methods: In 136 H. pylori-positive Japanese patients (for first-line treatment: n=40, second-line: n=30, third-line: n=66), the efficacy of the following treatment regimen was investigated: a PPI (rabeprazole 10 mg, q.i.d.), metronidazole (250 mg, b.i.d.), and STFX (100 mg, b.i.d.) for 1 week, irrespective of CYP2C19 genotype status and numbers of previous eradication therapy. At four to eight weeks after treatment, patients underwent the [13C]-urea breath test to assess successful eradication. Results: First-resistance to antimicrobial agents was 51.4% for clarithromycin, 56.7% for metronidazole and 30.0% for levofloxacin. The intention-to-treat eradication rate in the tailored group was 93.4% (95%CI: 87.8%-96.9%, 127/136). Although the eradication rate in patients treated as first-line therapy (100%, 95%CI: 92.8%-100%, 40/40) was higher than that in those treated as second-line (93.3%, 95%CI: 77.9%-99.2%, 28/30) and third-line therapy (89.4%, 95%CI: 87.8%-96.9%, 59/66), no significant differences were shown among numbers of previous eradication therapy (p = 0.08). The eradication rates were similar among all three CYP2C19 genotype groups (extensive metabolizer, 91.7% [66/73]; intermediate metabolizer, 96.1% [49/51]; poor metabolizer, 91.7% [11/12]), exceeding 90% for all genotypes. Conclusions: A sitafloxacinbased H. pylori eradication regimen based on maintaining acid secretion (rabeprazole 10 mg, q.i.d.) achieved an eradication rate of more than 90%, irrespective of eradication history and CYP2C19 genotype. In addition, as this regimen reduces the cost of CYP2C19 genotyping and culture tests, it might be more cost-effective than CYP2C19 genotype-based treatments.

Reply to Sharma.

Procedural training, which requires acquisition of both motor and cognitive skills, carries unique challenges in comparison with purely cognitive learning. We agree that educational methods should focus on information processing, not just information delivery. Our study clearly demonstrates that trainees and program directors endorse the concept of competency-based medical education and that trainees value performance feedback. Unfortunately, a minority of programs (43%) utilize online training modules and the majority still assess competency based on procedure volume (85%) and subjective global evaluations (96%). Implementation of the techniques outlined can facilitate a shift away from passive skill acquisition via procedure volume. Th e use of targeted feedback acknowledges variability in learning curves to ensure that each trainee achieves competency in specifi c cognitive and motor skills. However, these techniques will need to be further evaluated to determine how best to apply them to endoscopic training. Th ere are currently two ongoing multicenter prospective studies designed to assess learning curves and competence in endoscopic ultrasound and endoscopic retrograde cholangiopancreatography. As part of these studies, a novel centralized and web-based tool allowing for comprehensive data collection ( 8 ), has been created to create continuous learning curves (that can be accessed on tablet or mobile devices) and allow trainees and program directors to identify skill defi ciencies in endoscopic training in real-time. Although still in the investigative phase, tools like this will prove extremely helpful in applying some of the educational techniques outlined above. Th ere is a clear need to improve endoscopy curricula to accommodate a shift from apprenticeship to competency-based medical education. Th e techniques outlined have traditionally been applied to the acquisition of cognitive skills in medical education and will need to be tailored to procedural training. A variety of educational approaches, including incorporation of technology to facilitate some of the techniques proposed, will likely be required to complete the shift to competency-based medical education in endoscopy training. Reply to Sharma