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In the Clinic |

Screening for Colorectal Cancer

David S. Weinberg, MD, MSc; and Robert E. Schoen, MD, MPH
Ann Intern Med. 2014;160(9):ITC5-1. doi:10.7326/0003-4819-160-9-201405060-01005
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There is more to timing the follow up colonoscopy than just the polyp pathology
Posted on May 15, 2014
Joseph D. Feuerstein
Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School
Conflict of Interest: None Declared
I read the article by Drs. Weinberg and Schoen with great interest and commend the authors for a thorough review on colorectal cancer screening.1 While the authors published a very nice table (table 1) summarizing the recommended follow up surveillance intervals after a baseline screening colonoscopy, comments regarding the quality of the preparation and technique of the polypectomy is unfortunately missing.1 In its current state, it implies that an internist can just review the type and size of the polyp to determine the follow up interval for the next colonoscopy. The quality of the bowel preparation and how the polyp was removed (e.g. in one piece or piecemeal) is critical in determining the appropriate follow up colonoscopy interval.
As the authors mention, many interval cancers are believed to be secondary to inadequate bowel preparations.1 The current multi-society guideline on colon cancer screening as approved by the American Gastroenterological Association, American College of Gastroenterology and American Society of Gastrointestinal Endoscopy indicates that if a bowel preparation is poor then the colonoscopy should be repeated within 1 year, and if the preparation is only fair then the procedure should be repeated in a five year interval.2 Even a fair bowel preparation is associated with a high rate of missed adenomas. A recent study indicated a miss rate upwards of 28% when the procedure was repeated in three years. When a preparation is graded as poor or fair, a ten year interval is not appropriate if the endoscopist is unable to fully visualize the mucosa even if no adenomas were identified.2, 3 Based on the summary of the evidence and table provided by Drs. Weinberg and Schoen, a clinician reviewing the current recommendations may make a critical error in opting to wait ten years if there is no adenoma identified but the preparation was not adequate.
Similarly, the guidelines recommend that if a large adenomatous polyp is removed piecemeal, the multi-society task force recommends that the colonoscopy be repeated within 1 year to assess if there is any residual adenoma.2 Studies indicate that 19-27% of interval cancers develop in areas of incomplete polypectomy resections.4-6
Ultimately, the success of an adequate screening colonoscopy program to prevent cancer, is hinged on the program providing high quality colonoscopy with recommendations that are consistent with current practice guidelines. I commend the authors on summarizing the evidence nicely, but feel it is critical that the authors clarify the importance of the bowel prep and technique of the polypectomy in determining the timing of a follow up colonoscopy.
1. Weinberg DS, Schoen RE. Screening for Colorectal Cancer. Annals of Internal Medicine 2014;160:ITC5-1.
2. Lieberman DA, Rex DK, Winawer SJ, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2012;143:844-57.
3. Adler A, Wegscheider K, Lieberman D, et al. Factors determining the quality of screening colonoscopy: a prospective study on adenoma detection rates, from 12 134 examinations (Berlin colonoscopy project 3, BECOP-3). Gut 2013;62:236-241.
4. Robertson DJ, Greenberg ER, Beach M, et al. Colorectal cancer in patients under close colonoscopic surveillance. Gastroenterology 2005;129:34-41.
5. Farrar WD, Sawhney MS, Nelson DB, et al. Colorectal cancers found after a complete colonoscopy. Clin Gastroenterol Hepatol 2006;4:1259-64.
6. Robertson DJ, Lieberman DA, Winawer SJ, et al. Colorectal cancers soon after colonoscopy: a pooled multicohort analysis. Gut 2013.
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