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

Vikram Boolchand, MD; Gregory Olds, MD; Joseph Singh, MD; Pankaj Singh, MD; Amitabh Chak, MD; and Gregory S. Cooper, MD
[+] Article and Author Information

From University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio; Henry Ford Hospital, Detroit, Michigan; and Central Texas Veterans Health Care System, Temple, Texas.


Note: This study was orally presented at the American College of Gastroenterology Annual Meeting, 28 October–2 November 2005, Honolulu, Hawaii, and published in abstract form (Am J Gastroenterol. 2005;100:S384-S385). It was selected for the ACG/Olympus Award for the category “Colorectal Cancer Prevention.”

Grant Support: Dr. Chak is supported by a K24 Midcareer Award in Patient Oriented Research (DK002800). Dr. Cooper is an Established Investigator in Cancer Prevention, Control and Population Science from the National Cancer Institute (K05 CA90677).

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Vikram Boolchand, MD, Division of Gastroenterology, Department of Medicine, University of Arizona, 1501 North Campbell Avenue, PO Box 245028, Tucson, AZ 85724; e-mail, vikramboolchand@yahoo.com.

Current Author Addresses: Drs. Boolchand and J. Singh: Department of Medicine, University Hospitals of Cleveland, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106.

Dr. Olds: Department of Gastroenterology, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202.

Dr. P. Singh: Division of Gastroenterology and Hepatology, Department of Medicine, Central Texas Veterans Health Care System, 1901 South 1st Street, Temple, TX 76504.

Drs. Chak and Cooper: Division of Gastroenterology, Department of Medicine, University Hospitals of Cleveland, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106.

Author Contributions: Conception and design: V. Boolchand, G. Olds, P. Singh, A. Chak, G.S. Cooper.

Analysis and interpretation of the data: V. Boolchand, A. Chak, G.S. Cooper.

Drafting of the article: V. Boolchand, J. Singh, A. Chak, G.S. Cooper.

Critical revision of the article for important intellectual content: V. Boolchand, G. Olds, P. Singh, A. Chak, G.S. Cooper.

Final approval of the article: V. Boolchand, G. Olds, P. Singh, A. Chak, G.S. Cooper.

Provision of study materials or patients: V. Boolchand, G. Olds, P. Singh.

Statistical expertise: G.S. Cooper.

Obtaining of funding: A. Chak.

Administrative, technical, or logistic support: V. Boolchand, G.S. Cooper.

Collection and assembly of data: V. Boolchand, J. Singh.


Ann Intern Med. 2006;145(9):654-659. doi:10.7326/0003-4819-145-9-200611070-00007
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A growing body of evidence indicates that physicians recommend surveillance of polyps in excess of guidelines (4, 11, 17, 21). Compared with a study by Mysliwiec and colleagues (17) in which 24% of gastroenterologists and 54% of general surgeons recommended surveillance of a hyperplastic polyp, of which the majority would perform colonoscopy in 5 years or less, we found that 61% of primary care physicians recommend surveillance of a hyperplastic polyp in 5 years or less. In that study, 97% of gastroenterologists and 89% of general surgeons recommended surveillance of small adenomas, and the majority would perform colonoscopy in 3 years or less (17). We found that 71% of primary care physicians recommend surveillance of a small adenoma in 3 years or less. Whereas Mysliwiec and colleagues surveyed gastroenterologists and surgeons (17), we examined the recommendations of primary care physicians in surveillance of polyps after an index colonoscopy. This group may be a more relevant one to survey in the era of open-access endoscopy, in which primary care practitioners make decisions about surveillance. We found that primary care physicians frequently recommended relatively close follow-up for lesions at low risk for subsequent cancer, including hyperplastic polyps and 1 or 2 small tubular adenomas. These surveillance recommendations are concerning and, if they truly reflect actual practice, represent a potential overutilization of limited colonoscopy resources in low-risk patients.

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Colonrectal screening after polypectomy in USAF communities
Posted on November 17, 2006
Hans F Otto
Department of Internal Medicine, 52 Medical Group, Spangdahlem Air Base, Germany
Conflict of Interest: None Declared

I am a General Internist who has now served in three major commands (the USA, the Pacific and the European commands). Colorectal cancer (CRC) screening has been a frequently under-recognized and under-optimized surveillance measure at the Primary Care level. This has been due to operations tempo with active duty, mission requirements, obstacles to retiree health and access to useable interventions for screening, especially overseas. In the USAF we have limited resources, facilities and physicians for CRC screening but I have never had insurmountable problems obtaining the interventions needed for initial or status-post polypectomy evaluation.

However, I have learned that Primary Care clinics must work hand-in- hand with our gastroenterologists and/or surgical colleagues. As the Boolchard et al article highlights, some of us are missing that opportunity (1). In this current day, when we (civilian and military physicians alike), our patients or their insurance providers have very limited resources, we need to ensure that we are referring patients appropriately for surveillance colonoscopy. Over-referring patients creates a many problems, especially a delay in the evaluation of those patients who are high-risk. As this article highlights, many in primary care are unaware of the most recent guidelines. It is admittedly challenging when new/better data continues to be sought, such as the most recent NEJM article describing differences in colorectal neoplasia between the genders (2), but our responsibility nonetheless.

As "Guardians of the Gateway" to referral care, we have a responsibility to keep current on the most recent guidelines as well as the evidence behind those recommendations. I have had to hold lectures within my respective Primary Care clinics updating the staff on the guidelines and the impact on our local resources and referral processes. This continuous professional education and process improvement has improved our local population metrics for colorectal cancer from some of the worst to one of the best in USAF Europe. The staff as well as the surgeons performing colonoscopies have universally been appreciative. But, as always, it is the patients have benefited from our continued dedication to excellence in their care, even if they are largely unaware of local efforts.

The take home point from this article is that we as Primary Care physicians have the opportunity and responsibility to evaluate and appropriately refer our patients for CRC screening. We must do this while simultaneously balancing our clinical assessment, understanding that rather civilian or military, our quality or care given is constantly being measured, if not by insurance or chain of command than by the patients themselves.

1. Boolchand V, Olds G, Singh J, Singh P, Chak A, Cooper GS. Colorectal Screening after Polypectomy: A National Survey Study of Primary Care Physicians. Annaals of Internal Medicine. 2006;145:654-659.

2. Regula J, Rupinski M, Kraszewska E, Polkowski M, Pachlewski J, Orlowska J, Nowacki MP, Butruk E. Colonoscopy in Colorectal-Cancer Screening for Detection of Advanced Neoplasia. New England Journal of Medicine. 2006;355:1863-1872.

Conflict of Interest:

None declared

Guidelines keep changing!
Posted on November 21, 2006
Fadi Antaki
Erasme Hospital
Conflict of Interest: None Declared

We read with great interest this excellent study which confirms a trend we have all seen in our day-to-day Gastroenterology practice.

However, to be fair to our colleagues, it is important to mention that the old American Cancer Society (ACS) guidelines (published in 2003) recommended a surveillance colonoscopy in 3-6 years for patients with "single small adenomas" and "within 3 years from initial polypectomy" for patients with multiple adenomas. These were different from the 2003 recommendations by the U.S. Multisociety Task Force on Colorectal Cancer which recommended a 5-year interval for low-risk patients with 1-2 small adenomas. Therefore, some confusion among doctors should have been expected when professional societies issued different guidelines.

We welcome the revised, combined, guidelines issued by the ACS and USMTF hoping that having one set of guidelines endorsed by all these societies will lead to a better utilization of scarce resources and a more appropriate suveillance interval for all patients, no matter which doctor is making the recommendation.

References:

1- Vikram Boolchand, Gregory Olds, Joseph Singh, Pankaj Singh, Amitabh Chak, and Gregory S. Cooper Colorectal Screening after Polypectomy: A National Survey Study of Primary Care Physicians Ann Intern Med 2006; 145: 654-659

2- Smith RA, Cokkinides V, Eyre HJ. American Cancer Society guidelines for the early detection of cancer, 2003. CA Cancer J Clin 2003 Jan-Feb;53(1):27-43

3-Winawer S, Fletcher R, Rex D, Bond J, Burt R, Ferrucci J, Ganiats T, Levin T, Woolf S, Johnson D, Kirk L, Litin S, Simmang C, Gastrointestinal Consortium Panel. Colorectal cancer screening and surveillance: clinical guidelines and rationale. Update based on new evidence. Gastroenterology 2003 Feb;124(2):544-60

4-Winawer SJ, Zauber AG, Fletcher RH, Stillman JS, O'Brien MJ, Levin B, et al. Guidelines for colonoscopy surveillance after polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society. Gastroenterology. 2006;130:1872-85.

Conflict of Interest:

None declared

Who is Best Suited to Perform Colonoscopy and Manage the Findings: a Systems Perspective
Posted on November 27, 2006
Christine A. Sinsky
Medical Associates Clinic and Health Plan
Conflict of Interest: None Declared

Boolchand et al (1) found that clinicians who perform colonoscopy recommend follow-up more appropriately than those who do not. This should surprise no one. Two questions follow from their article: who is best suited to manage abnormalities found at colonoscopy and, in a manpower shortage, who can be trained to perform colonoscopy?

From a systems perspective, clinicians who perform a procedure are in the best position to keep up-to-date on relevant recommendations and to establish the office systems needed to assure appropriate follow-up; it is an invitation for error to divert these responsibilities to others.

Rather than wish that 200,000 primary care physicians would keep track of the "ever-changing guidelines" it is more efficient to unambiguously assign this responsibility to the much smaller pool of colonoscopists. It is a cumbersome and misdirected approach that requires every primary care physician to remember that patients with a 6 mm tubular adenoma should have a 5 year follow-up colonoscopy, those with a 12 mm tubulovillous adenoma should have one in 3 years, those with a 12 mm tubular adenoma 3 years earlier need a 5 year follow-up, those with two 6 mm tubular adenomas need 5 year follow-up, but those with 3 or more adenomas, regardless of size, require a 3 year follow-up, and that for those with a 12 mm tubular adenoma with high-grade dysplasia there are no specific recommendations. It is better to concentrate the effort at the level of the provider of the procedure. In addition, from a business perspective, the organizational costs of managing the follow-up of patients with abnormalities are bundled into the payment for the colonoscopy, which currently flows to the proceduralist, not to the primary care physician.

Boolchand also raises the issue of a manpower shortage for colonoscopy. It is time to reassess the skill set required for this procedure and develop more efficient systems of care. In one model nurse practitioners would be taught the technical and cognitive skills associated with screening colonoscopy. Groups of primary care physicians would then hire such colonoscopists to provide screening for their patients. This model would allow the volume and the reimbursement to justify developing integrated systems for appropriate follow-up. Protocols for management of polyps would be instituted through collaboration between the colonoscopist and a member of the primary care physician staff. Procedures for follow-up would be implemented from a systems perspective.

When Pap smear screening became more common, the pathology workforce could not meet the demand, and cytotechnologists were trained in this narrow scope of practice. A similar restructuring and retraining of the colonoscopy workforce to match capacity with demand, and provider skill set with the technical skill requirements, will help improve the availability, efficiency and accuracy of colon cancer prevention.

1. Boolchand V. et al. Colorectal screening after polypectomy: a national survey of primary care physicians. Ann Intern Med 2006;145:654- 659.

Conflict of Interest:

None declared

Comment on a national survey study on recommendations of colorectal screening after polypectomy
Posted on November 23, 2006
Masahiro Kami
the Institute of Medical Science, the University of Tokyo
Conflict of Interest: None Declared

Letter to the Editor

Comment on a national survey study on recommendations of colorectal screening after polypectomy Boolchand et al. reported a national survey study on recommendations of colorectal screening after polypectomy (1). The present study showed that colonoscopic surveillance was conducted as scheduled by guidelines only in 15-57% of the patients and with widely varied frequencies. While the authors noted the difference by physician type (internists vs. family practitioners), it would solely be insufficient to explain the results. Most clinicians would like to know other factors such as the effects of popularity of the latest guidelines, physicians' age, medical career, numbers of referrals to colonoscopy, and medical insurance system. It is appreciated if the authors can share such information with the readers. (106 words)

References

1. Boolchand V, Olds G, Singh J, Singh P, Chak A, Cooper GS. Colorectal screening after polypectomy: a national survey study of primary care physicians. Ann Intern Med. 2006;145(9):654-9.

Conflict of Interest:

None declared

C-SCOPES ARE SURGICAL PROCEEDURES
Posted on December 4, 2006
James M Duncan
BAMC,FSHTX(RET/DAC)
Conflict of Interest: None Declared

May it please all refering sources to remember that the CRC SCREENING/COLON POLYP patient is about to undergo a surgical proceedure with risks to include, but not exclusive of, dehdration, electrolyte abnormality induction, cardiopulmonary arrest, and/or bleeding to open surgery with general anesthesia, transfusion risks, and death.

A pre-op evaluation is always appropriate using your institution's adopted Anesthesia Score in order to avoid character building experiences. If the refering source cannot or does not want to preform a pre-op evaluation, then a Consultation with the proceeduralist is in order before any proceedual encounter. The cursory pre-op check on the day of the C- Scope will not suffice!

When bad outcomes occur in an otherwise healthy patient per the familiy's viewpoint, the referring souce and proceeduralist will all get sued!

Conflict of Interest:

None declared

Response to comments
Posted on December 27, 2006
Vikram Boolchand
University of Arizona
Conflict of Interest: None Declared

We are pleased to see the interest of Dr. Antaki and Dr. Otto in our survey study of primary care physicians regarding post-polypectomy surveillance. (1)

As we report, constantly changing guidelines from various societies remain an issue for the primary care physician. In 2003, the guidelines for colorectal cancer screening and surveillance from the U.S. Multi- society Task Force (USMSTF) on Colorectal Cancer were developed by a panel of both gastroenterology and primary care societies (2). The guidelines in 2003 from the American Cancer Society (ACS) were from a single society and included recommendations for the early detection of several types of cancers (3). As Dr. Antaki pointed out, there was an inconsistency between the ACS and USMSTF guidelines regarding surveillance for small adenomas, less than a 1 cm (3-6 years vs. 5 years, respectively). Although we did not ask our respondents the reasoning for their recommendations, it is unlikely the primary care practitioner weighed these two different sets of guidelines when deciding surveillance intervals. If respondents based their answer on the ACS guidelines, then an equal amount of the respondents would have chosen 3 years and 5 years for follow-up of a small tubular adenoma. In our survey almost the same number (25%) of respondents chose to survey a small tubular adenoma in 1 year or less as 5 years and 46% choose a 3 year surveillance interval. This suggests that when given a range of guideline based intervals, most respondents would tend to recommend surveillance at or before the earliest interval. We agree that the combined ACS and USMSTF guidelines from 2006 will hopefully decrease confusion over surveillance guidelines from multiple societies (4).

We appreciate the comments from Dr. Otto regarding the need for communication between endoscopists and primary care physicians. As we mentioned, it remains clear that one conclusion from our study is that further educational efforts are necessary to change current inappropriate referral patterns. An important part of this change may include recommendations to the primary care physician for the next surveillance colonoscopy based upon the findings of the index colonoscopy after the pathology of polyps has been read. The excessive use of more frequent colonoscopy than necessary may need to be stressed to overcome current fears over small missed polyps and the development of colorectal neoplasia in very low risk patients.

Vikram Boolchand, MD Gregory S. Cooper, MD

References

1. Boolchand V, Olds G, Singh J, Singh P, Chak A, Cooper GS. Colorectal Screening after Polypectomy: A National Survey Study of Primary Care Physicians. Annals of Internal Medicine. 2006;145:654-659.

2. Winawer S, Fletcher R, Rex D, Bond J, Burt R, Ferrucci J, Ganiats T, Levin T, Woolf S, Johnson D, Kirk L, Litin S, Simmang C, Gastrointestinal Consortium Panel. Colorectal cancer screening and surveillance: clinical guidelines and rationale. Update based on new evidence. Gastroenterology 2003 Feb;124(2):544-60.

3. Smith RA, Cokkinides V, Eyre HJ. American Cancer Society guidelines for the early detection of cancer, 2003. CA Cancer J Clin 2003 Jan-Feb;53(1):27-43.

4. Winawer SJ, Zauber AG, Fletcher RH, Stillman JS, O'Brien MJ, Levin B, et al. Guidelines for colonoscopy surveillance after polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society. Gastroenterology. 2006;130:1872-85.

Conflict of Interest:

None declared

Submit a Comment

Summary for Patients

Colorectal Cancer Screening in Patients after Polyp Removal: A Survey of Primary Care Physicians

The summary below is from the full report titled “Colorectal Screening after Polypectomy: A National Survey Study of Primary Care Physicians.” It is in the 7 November 2006 issue of Annals of Internal Medicine (volume 145, pages 654-659). The authors are V. Boolchand, G. Olds, J. Singh, P. Singh, A. Chak, and G.S. Cooper.

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