Jordan J. Karlitz, MD
Potential Financial Conflicts of Interest: None disclosed.
Karlitz JJ. The Effectiveness of Colonoscopy in Reducing Mortality From Colorectal Cancer. Ann Intern Med. 2009;150:816. doi: 10.7326/0003-4819-150-11-200906020-00012
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Published: Ann Intern Med. 2009;150(11):816.
TO THE EDITOR:
Several issues in the article by Baxter and colleagues (1) raise concern about the adequacy of the examinations performed and therefore the clinical significance of the findings. First, the cecal intubation rates ranged from 79% to 83% among all colonoscopists. For gastroenterologists specifically, the cecal intubation rate was only 83%, which is well below current accepted rates. In subgroup analysis, the cecal intubation rate was even lower (73%) in the case patients. Baxter and colleagues appropriately performed additional subgroup analysis to compare complete versus incomplete colonoscopy in terms of cancer detection rates. However, it can be hypothesized that even if a complete colonoscopy was performed, a colonoscopist with a low cecal intubation rate may lack the experience and technical skill to adequately identify polyps, particularly flat lesions, during the examination. Supporting this is the fact that in the study, the polyp detection rate was 26% in case patients and 21% in control participants. A significant proportion of these polyps may have been hyperplastic and, therefore, the overall adenoma detection rate may have been significantly lower than the current standards in the gastroenterology literature, which suggest that adenomas be detected in 15% of women and 25% of men (2). In addition, one might expect that in this older, predominantly male case sample (54% male; median age, 73 years) in which cancer is already present, the adenoma detection rate in other parts of the colon would be even higher. In a recent study (3), fellow participation in colonoscopy yielded an adenoma detection rate of 37%, raising concern that our accepted adenoma detection rate may be too low.
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