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Screening Colonoscopy: Is it on the Brink of Extinction ? Patrick R. Pfau, M.D. Associate Professor Chief of Clinical Gastroenterology University of Wisconsin.

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Presentation on theme: "Screening Colonoscopy: Is it on the Brink of Extinction ? Patrick R. Pfau, M.D. Associate Professor Chief of Clinical Gastroenterology University of Wisconsin."— Presentation transcript:

1 Screening Colonoscopy: Is it on the Brink of Extinction ? Patrick R. Pfau, M.D. Associate Professor Chief of Clinical Gastroenterology University of Wisconsin School of Medicine and Public Health

2 Learning Objectives To determine the present state of colorectal cancer screening with colonoscopy To identify the threats to screening colonoscopy To determine what will keep colonoscopy an important colon cancer screening modality

3 305,866,7775

4 Is screening colonoscopy going extinct ? Number of colonoscopies has risen steadily in U.S. while Flex-Sig and Barium Enemas has dropped significantly –Harewood G, Clin Gastroenterol Hepatol 2004 Colonoscopy most common endoscopic procedure performed in U.S. –Sonnenberg A, GIE 2008 Screening colonoscopy has increased greatly in Medicare population –Fenton JJ, Am J Prev Med 2008 Increased CRC screening rates primarily result of screening colonoscopy –Phillips K, Med Care 2007

5 Why screening colonoscopy is the king ? Two large cohort studies (Winawer, NEJM 1993 and Citarda Gut 2001) have demonstrated significant reductions in colon cancer incidence if colonoscopy with polypectomy are performed FOBT and sigmoidoscopy that lead to colonoscopy with polypectomy have been shown to significantly reduce colorectal cancer mortality Colon cancer incidence decreased 2.6 %/year since 1998 with sharp decrease since 2002 (Cancer 2007)

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7 What are the threats to screening colonoscopy ? iFOBT Fecal DNA CT Colonography Ourselves – how we perform screening colonoscopy

8 Quantitative immunochemical FOBT – Threat #1 Improved detection of hemoglobin as compared to guaic based FOBT tests –Immunochemical FOBT testing uses antibodies to human globin expressed in colorectal bleeding.

9 Colon Cancer Screening with iFOBT 94 % sensitivity for cancers and 67 % for advanced adenomas with approximate 90% sensitivity in high risk individuals (Levi Z, Ann Int Med 2007) 25 – 27 % sensitivity for advanced adenomas but different iFOBT tests vary (Hundt,Ann Int Med, 2009) 90 % - 256 % more sensitive than guaic based FOBT for advanced neoplasia ( Guittet L, Gut 2007) 7 % sensitivity for adenomas < 10 mm (Morikawa T Am J Gastro 2007) iFOBT should replace gFOBT in screening for patients who will not or cannot have total colon screening – only helps screening colonoscopy

10 Fecal DNA Analysis - Threat #2 Adenoma and carcinoma cells contain altered DNA that are shed continuously Multitarget DNA stool assay Requires entire stool specimen (must be mailed)

11 Fecal DNA and colon cancer screening Ahlquist D, Gastroenterology 2000 studied patients with colon cancers, large adenomas, and normal colons –Sensitivity of 91% for colon cancer, 82% for large adenomas and a specificity of 93% Imperiale T, NEJM 2004 studied patients in a screening population –Poor sensitivity for invasive cancers (52%) and advanced polyps (15%) Ahlquist D, Ann Int Med, 2009, Zou H, Gastroenterology 2009 –Latest assays approximately 2-3 times more sensitive than earlier assays – detected 46 % - 59% advanced adenomas Fecal DNA analysis will only lead to more colonoscopies and more positive/therapeutic colonoscopies

12 CT Colonography (CTC) – Threat # 3 Joint guideline from the ACS, US Multi-Society Task Force on CRC, and the ACR (Levin B, Gastro 2008) –CTC is comparable to colonoscopy for detection of polyps of a significant size –Panel concludes that there are sufficient data to include CTC as an acceptable option for CRC screening ACRIN study (Johnson C, NEJM, 2008) –CTC should have role in CRC screening for average risk patients

13 Does CTC screening affect screening with colonoscopy ? (Are our jobs in jeopardy ?) Van Dam J, Gastro 2004 – CTC would likely have a significant impact on the practice of gastroenterology in America Hur C, Clin Gastroenterol Hepatol 2004 - Mathematical Model –9-22 % reduction in colonoscopies –Reduction based on referral rate from CTC

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19 Impact of CTC on Colonoscopy Schwartz D, AJG 2007 –A fully operational third party insurer covered CTC program had no effect on colonoscopies performed, screening colonoscopies performed, colonoscopies with polypectomy performed, nor requests for screening colonoscopy after greater than 3 years

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21 Bucky and Colon Cancer Screening

22 CRC screening at UW five years after initiation of CTC program (2008) TestTotal Colonoscopy63.7% Barium enema.1% Flex Sig 1.3% FOBT27.6% CT Colonography 7.2%

23 Why has CTC not affected screening colonoscopy ? CTC does not replace colonoscopy but simply adds an additional test (there are a lot of colons out there) CTC has distinct disadvantages compared to colonoscopy If CTC employs selective polypectomy it will not lead to an additional # of therapeutic colonoscopies

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25 Extinction of Screening Colonoscopy – Ourselves to Blame ? Threat # 4 Complication (Perforation) rate –.016 % (1 in 6000) Rathgaber S, GIE 2006 –.2 % (1 in 500) Kim D, NEJM 2007 –.85 per 1000 Rabeneck L, Gastro 2008

26 How good are we at detecting adenomas ? Adenoma detection rate (ADR) –Barclay R, NEJM 2006 – ADR ranged from.1 to 1.05 at institution –Chen AJG 2007 – patients detected with adenomas ranged from 16-41 % between 9 academic gastroenterologists with ADR varying from.21 -.86

27 Physician Cecal Intub. % Intub. time (min) W/drawal time. Polyp W/drawal time. No Polyp W/drawal time total % pts w/ Ademona Adenoma Det. Rate 11008.114.0 9.0 9.012.5 37 37.82.82 21006.013.5 8.7 8.710.9 30 30.73.73 31007.912.7 9.6 9.610.7 25 25.73.73 4 98 985.7 9.8 9.8 4.3 4.3 7.0 7.0 30 30.67.67 5 91 919.810.0 7.0 7.0 8.0 8.0 13 13.43.43 61007.0 7.2 7.2 4.5 4.5 5.6 5.6 21 21.39.39 71008.6 7.8 7.8 4.4 4.4 5.6 5.6 20 20.26.26 81008.9 5.5 5.5 3.4 3.4 4.0 4.0 21 21.24.24 9 98 989.8 9.8 9.8 6.2 6.2 7.4 7.4 16 16.23.23 10 95 959.6 8.4 8.4 5.4 5.4 6.2 6.2 7.09.09 VC 5.11.11 Benson, M Dig Dis Sci, 2009

28 How can screening colonoscopy be saved ? Do a better colonoscopy –Training –Time –Technology Use competing technologies to benefit screening colonoscopy Work to get more patients screened no matter the method – everything feeds into colonoscopy eventually Do not become addicted to screening colonoscopy

29 Doing a Better Screening Colonoscopy Training –ASGE and ACGME – 140 colonoscopies during GI fellowship Chak A GIE 1996 – Trainees do not achieve competence at 100 colonoscopies Lee S GIE 2008 – competence in screening colonoscopy requires more than 150 cases Spier B GIE/DDW 2009 –No trainee reached independence (>90% cecal intubation) after 140 cases –First fellow to achieve > 90% cecal intubation took over 300 cases –Not until 500 colonoscopies were performed that all fellows achieved > 90 % cecal intubation rate

30 Doing a Better Screening Colonoscopy Time –Sanchez W, AJG – Colonoscopy procedure time correlates with 3 – fold difference in polyp detection –Barclay R NEJM 2006 – Colonoscopists who had withdrawal times > 6 min. found more patients with adenomas (23.8 % vs. 11.8 %) and advanced adenomas (6.4 % vs. 2.6 %) –Simmons D Aliment Pharmacol Ther 2006 – Longer withdrawal time correlated with more polyps being found – suggested 7 minute withdrawal –Barclay R Clin Gastroenterol Hepatol – Implementation of 8 minute withdrawal time increased number of adenomas detected (34.7 % vs. 23.5 %) –Sawhney M, Gastro 2008 – increasing withdrawal times to 7 minutes did not increase adenoma detection rate

31 Physician Cecal Intub. % Intub. time (min) W/drawal time. Polyp W/drawal time. No Polyp W/drawal time total % pts w/ Ademona Adenoma Det. Rate 11008.114.0 9.0 9.012.5 37 37.82.82 21006.013.5 8.7 8.710.9 30 30.73.73 31007.912.7 9.6 9.610.7 25 25.73.73 4 98 985.7 9.8 9.8 4.3 4.3 7.0 7.0 30 30.67.67 5 91 919.810.0 7.0 7.0 8.0 8.0 13 13.43.43 61007.0 7.2 7.2 4.5 4.5 5.6 5.6 21 21.39.39 71008.6 7.8 7.8 4.4 4.4 5.6 5.6 20 20.26.26 81008.9 5.5 5.5 3.4 3.4 4.0 4.0 21 21.24.24 9 98 989.8 9.8 9.8 6.2 6.2 7.4 7.4 16 16.23.23 10 95 959.6 8.4 8.4 5.4 5.4 6.2 6.2 7.09.09 VC 5.11.11 Benson, M Dig Dis Sci, 2009

32 Doing a Better Screening Colonoscopy Technology –Colonoscopes Self-propelling scopes Retro scopes Capsule colonoscopy Wide - angle –Auxillary Devices Hoods and caps Chromoendoscopy –Imaging Narrow Band Imaging MagnifyingAutofluorescence Optical Coherence Tomography Confocal Microscopy –Added last night – better sedation with propofol

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36 Screening Colonoscopy – Is it Dying ? External Threats – No real threats at present –No test matches colonoscopy for CRC screening –External threats actually benefit colonoscopy Internal Threats – Do a better colonoscopy –Know and improve your own personal complication and adenoma detection rates – each gastroenterologist has to meet a minimum of standards

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