Quality assurance of colonoscopy within the Dutch national colorectal cancer screening program

A national survey on gastroenterology and hepatology training reveals dissimilar perceptions between trainees and trainers and an important need for improvement in training programs

OBJECTIVE

We aimed to collect data on gastroenterology and hepatology training from the viewpoint of trainees and trainers.

METHODS

A national online survey was distributed among trainees and specialists at certified training institutions between February and May 2024.

RESULTS

Overall, 226 respondents - 98 trainees, 78 trainers, 50 program directors, and department heads responded, with a national coverage of 70% of trainees and 85% of specialty-department heads. A training curriculum was reported by 56% of trainees and 84% of curriculum organizers, regular feedback and training progress meetings by 11% of trainees (57% if considered without assessment of training progress), but 88% of curriculum organizers. Training was rated as very good or good by 65% of trainees, 79% of trainers, and 100% of department heads. Quality of functional diagnostics, endoscopy, and ultrasound training was rated as very good or good by trainees in 16, 61, and 54%, by trainers in 27, 79, and 58%, and by department heads in 74, 89, and 85%. Much agreement was found concerning the wish for external rotations (trainees 65%, trainers 70%, and department heads 89%) and a new postcertification advanced-endoscopy training and accreditation.

CONCLUSION

Department heads seem to overestimate the quality of their training programs. Consequently, we found large discrepancies in the perception of specialty training that should stimulate efforts to standardize training and boost necessary train-the-trainer programs. Diagnosis of functional gastrointestinal disorders and abdominal ultrasound skills are areas with the largest room for improvement. Increased flexibility of hospital providers will be crucial for significant improvement of external training possibilities.

How Good Is Good Enough? What Should Be the Target for CRC Screening?

Colorectal Cancer (CRC) screening of average-risk individuals has been shown to reduce CRC mortality and incidence. Incidence is reduced by detection and removal of cancer precursor lesions (CPLs), resulting in cancer prevention. Mortality reduction is achieved with detection of curable CRC, as well as prevention by removing CPLs before cancer develops. Targets of screening include both curable CRC and CPLs. Non-invasive stool tests are a multi-step screening program which can detect curable cancers and less likely to detect CPLs than invasive screening. The non-invasive programs depend on completion of colonoscopy if the test is positive. Invasive screening with colonoscopy is a one-step test program, with excellent detection of both curable CRCs and CPLs, if performed with high-quality. Current evidence suggests that either program could be effective, despite different targets. Patient adherence and program quality are perhaps the important determinants of program effectiveness.

13-Year colorectal cancer risk after lower-quality, higher-quality and no screening colonoscopy: a cohort study

OBJECTIVES

A lower-quality colonoscopy has been shown to be less effective in reducing colorectal cancer (CRC) incidence than a higher-quality colonoscopy, but the comparison with no-screening colonoscopy (noSC) is lacking. We aimed to compare the 13-year risk of developing CRC between persons with I) a higher-quality screening colonoscopy (higherQualSC), II) a lower-quality screening colonoscopy (lowerQualSC), and III) without a screening colonoscopy.

STUDY DESIGN AND SETTING

A health-care database (∼20% of the German population) was used to emulate a target trial with three arms: higherQualSC vs lowerQualSC vs noSC at baseline. The quality of screening colonoscopy was categorized based on the polyp detection rate of the examining physician (cut-off: 21.8%). We included persons aged 55-69 years at average CRC risk and CRC screening naïve at baseline. We estimated adjusted cumulative CRC incidence over 13 years of follow-up.

RESULTS

The higherQualSC arm comprised 142,960 persons, the lowerQualSC arm 62,338 persons, and the noSC arm 124,040 persons. The adjusted 13-year CRC risk was 1.77% in the higherQualSC arm, 2.09% in the lowerQualSC arm, and 2.74% in the noSC arm. Compared to the noSC arm, the adjusted relative risk was 0.76 (95% CI: 0.70-0.84) in the lowerQualSC arm and 0.65 (95% CI: 0.60-0.69) in the higherQualSC arm.

CONCLUSION

Our study shows that a lowerQualSC is also effective in reducing CRC incidence compared to noSC. However, the effect is about one-third less than that of a higherQualSC.

Areas of improvement for colorectal cancer screening: Results of a screening initiative for 10,000 health care employees in Austria

Background and study aims Participation in and quality of colorectal cancer (CRC) screening varies greatly and it is unclear how much of CRC screening guideline quality metrics reach patients. The aims of this prospective observational study were to provide data from everyday practice in Austria. Patients and methods All employees aged ≥ 50 years were invited and received a stool-based-test (FIT (cut-off 25 mcg Hb/g) and M2PK), which could be dropped off at the workplace. All individuals with positive tests were called and offered a colonoscopy near their workplace/home in ≤ 3 weeks performed by unselected endoscopists. Non-attendees received email and telephone reminders. Results Of 10,239 eligible employees (2706 males, 7533 females), 2390 (23%) (plus 673 < 50 years) median age 53 (interquartile range 50;56) participated in the stool-based screening (18% males, 25% females). Of 3063 tests, 747 (24%) were positive. The follow-up rate for 616 individuals who accepted or eventually underwent colonoscopy was 84% (n = 517). The adenoma detection rate (ADR) was 20.5% (31% in men, 17% in women) and varied substantially, ranging from 15% in hospitals (excluding the study center) to 18.5% among office-based endoscopists, and up to 36% in the study center. Most European Society of Gastrointestinal Endoscopy-recommended performance indicators were unmet, including the polyp detection rate (PDR), ADR, reporting of polyp characteristics, and bowel preparation adequacy. Conclusions There is a serious gap between recommended standards and real-world CRC screening colonoscopy quality. Implementation of CRC screening should not only be accompanied by strategies to increase participation rates but focus on implementation of rigorous, mandatory colonoscopy quality assurance programs.

Risk factors for advanced colorectal neoplasia and colorectal cancer detected at surveillance: a nationwide study in the modern era

AIM

Recommendations for surveillance after colonoscopy are based on risk factors for metachronous advanced colorectal neoplasia (AN) and colorectal cancer (CRC). The value of these risk factors remains unclear in populations enriched by individuals with a positive faecal immunochemical test and were investigated in a modern setting.

METHODS AND RESULTS

This population-based cohort study included all individuals in the Netherlands of ≥55 years old with a first adenoma diagnosis in 2015. A total of 22,471 patients were included. Data were retrieved from the Dutch Nationwide Pathology Databank (Palga). Primary outcomes were metachronous AN and CRC. Patient and polyp characteristics were evaluated by multivariable Cox regression analyses. During follow-up, 2416 (10.8%) patients were diagnosed with AN, of which 557 (2.5% from the total population) were CRC. Adenomas with high-grade dysplasia (hazard ratio [HR] 1.60, 95% confidence interval [CI] 1.40-1.83), villous histology (HR 1.91, 95% CI 1.59-2.28), size ≥10 mm (HR 1.12, 95% CI 1.02-1.23), proximal location (HR 1.12, 95% CI 1.02-1.23), two or more adenomas (HR 1.28, 95% CI 1.16-1.41), and serrated polyps ≥10 mm (HR 1.67, 95% CI 1.42-1.97) were independent risk factors for metachronous AN. In contrast, only adenomas with high-grade dysplasia (HR 2.49, 95% CI 1.92-3.24) were an independent risk factor for metachronous CRC.

CONCLUSIONS

Risk factors for metachronous AN and CRC were identified for populations with access to a faecal immunochemical test (FIT)-based screening programme. If only risk factors for metachronous CRC are considered, a reduction in criteria for surveillance seems reasonable.

Risk of Cancers Proximal to the Colon in Fecal Immunochemical Test Positive Screenees in a Colorectal Cancer Screening Program

BACKGROUND & AIMS

In more than half of the colorectal cancer screening participants with a positive fecal immunochemical test (FIT) result, no advanced neoplasia (AN) is detected at colonoscopy. The positive FIT result could also be generated by cancers located proximal to the colon: upper gastrointestinal, oral cavity, nose, and throat cancers. We evaluated screenees' risk of being diagnosed with a cancer proximal to the colon within the 3 years and compared risks between those with a positive vs those with a negative FIT.

METHODS

Data of Dutch colorectal cancer screening participants who underwent biennial FIT-based screening 2014-2018 were collected from the national screening database and linked to the National Cancer Registry. Screenees were classified into 3 groups: FIT-positives with AN (FIT+/AN+), FIT-positives without AN (FIT+/AN-), and FIT-negatives (FIT-). We compared the cumulative incidence of cancers proximal to the colon in each group 3 years after FIT. A Cox regression analysis with left truncation and right censoring, using FIT positivity as time-dependent variable and stratified for sex, was performed to compare the hazard of cancers proximal to the colon in participants who were FIT-positive vs FIT-negative.

RESULTS

Three-year cumulative incidence of cancers proximal to the colon in FIT+/AN+ (n = 65,767), FIT+/AN- (n = 50,661), and FIT- (n = 1,831,647) screenees was 0.7%, 0.6%, and 0.4%, respectively (P < .001). FIT-positives were older and more frequently male than FIT-negatives (P < .001). Significantly more cancers proximal to the colon were detected among FIT-positives (P < .001; hazard ratio, 1.55; 95% CI, 1.44-1.67).

CONCLUSION

FIT-positive screenees were at significantly increased risk of being diagnosed with a cancer proximal to the colon within 3 years after FIT, although the 3-year cumulative incidence was still less than 1%.

Feasibility and Colonoscopy Yield Using the Fecal Immunochemical Test (FIT)-Based Colorectal Cancer Screening in a Latin America Country

BACKGROUND & AIMS

Organized colorectal cancer (CRC) screening is not widely practiced in Latin America and the results of regional studies may help overcome barriers for implementation of national screening programs. We aimed to describe the implementation and findings of a fecal immunochemical test (FIT)-based program in Brazil.

METHODS

In a prospective population-based study, asymptomatic individuals (50-75 years old) from Sao Paulo city were invited to undergo FIT for CRC screening. Participants with positive FIT (≥10 μg Hb/g feces) were referred for colonoscopy. Subjects were classified into groups according to the presence of CRC, precursor lesions, and other benign findings, possibly related to bleeding.

RESULTS

Of a total of 9881 subjects, 7.8% had positive FIT and colonoscopy compliance was 68.9% (n = 535). Boston scale was considered adequate in 99% and cecal intubation rate was 99.4%. CRC was diagnosed in 5.9% of the cases, adenoma in 63.2%, advanced adenoma in 31.4%, and advanced neoplasia in 33.0%. Age was positively associated with CRC (P = .03). Higher FIT concentrations were associated with increased detection of CRC (P < .008), advanced adenoma (P < .001), and advanced neoplasia (P < .001).

CONCLUSIONS

Implementation of a FIT-based CRC screening program was feasible in a low-resource setting, and there was a high yield for neoplasia in individuals with a positive FIT. This approach could be used as a model to plan and disseminate organized CRC screening more broadly in Brazil and Latin America.

Do immigrants know less than natives about cancer screening tests? - the case of Netherlands

Introduction

The Netherlands was one of the first countries in Europe to offer breast, colorectal and cervical cancer screening tests free of charge. Yet, a significant share of migrants in the Netherlands forgo the use of these preventive screenings. Qualitative research suggests, that lack of system knowledge on how the healthcare system operates (e.g. age eligibility of cancer screenings), is one factor contributing to this underuse among migrants. However, little is known about the extent to which migrants differ from natives in their system knowledge and about potential causes of this ethnic gap. The contribution of this study is therefore twofold: First, we examine whether migrants in the Netherlands have lower system knowledge regarding cancer screenings than the natives. Second, we examine which factors explain potential ethnic differences in system knowledge between migrants and non-migrants.

Method

Using the Longitudinal Internet Study for Social Sciences (LISS), we matched newly collected data on system knowledge about healthcare with Health module (wave 14). To assess the difference in system knowledge among migrants and non-migrants, while taking into account potential selection bias, we applied propensity score matching, one-to-one matching procedure with no replacement. We compared first generation non - Western migrants (FNWM) and second-generation non-western migrants (SNWM) with their most similar non-migrants group regarding their knowledge about breast, colorectal, and cervical screening. A Blinder-Oaxaca decomposition with non-matched samples was used to examine which factors can explain the differences in system knowledge among migrants and non-migrants.

Results

Our results show that first generation migrants have lower system knowledge about all three screening tests, while second generation migrants differ from non-migrants only with regard to knowledge about breast and colorectal cancer screenings. The ethnic differences found are not caused by personal or social factors such as education or income.

Conclusion

We recommend Dutch healthcare policy makes to focus in the strengthen of cancer screening system knowledge among migrant populations in order to increase their participation in these screening programs.

Effect of an E-learning resource on endoscopists' proximal serrated polyp detection rate: a randomized controlled trial

BACKGROUND

Recent studies demonstrated that a higher proximal serrated polyp detection rate (PSPDR) among endoscopists is associated with a lower risk of post-colonoscopy colorectal cancer (PCCRC) incidence and death for their patients. Our objective was to evaluate the effect of an e-learning resource on PSPDR.

METHODS

We performed a multicenter randomized controlled trial within the Dutch fecal immunochemical test-based colorectal cancer screening program. Endoscopists were randomized using block randomization per center to either receive a 60-minute e-learning resource on serrated polyp detection or not. PSPDR was calculated based on all colonoscopies performed during a 27-month pre-intervention and a 17-month post-intervention period. The primary end point was difference in PSPDR between intervention and control arms (intention to treat) using mixed effect logistic regression modeling, with time (pre-intervention/post-intervention) and interaction between time and arm (intervention/control) as fixed effects, and endoscopists as random effects.

RESULTS

116 endoscopists (57 intervention, 59 controls) were included, and performed 27494 and 33888 colonoscopies, respectively. Median PSPDR pre-intervention was 13.6% (95%CI 13.0-14.1) in the intervention arm and 13.8% (95%CI 13.3-14.3) in controls. Post-intervention PSPDR was significantly higher over time in the intervention arm than in controls (17.1% vs. 15.4%, P=0.01).

CONCLUSION

In an era of increased awareness and increasing PSPDRs, endoscopists who undertook a one-time e-learning course significantly accelerated the increase in PSPDR compared with endoscopists who did not undertake the e-learning. Widespread implementation might reduce PCCRC incidence.

Post-colonoscopy colorectal cancers in a national fecal immunochemical test-based colorectal cancer screening program

BACKGROUND

Post-colonoscopy colorectal cancers (PCCRCs) decrease the effect of colorectal cancer (CRC) screening programs. To enable PCCRC incidence reduction in the long-term, we classified PCCRCs diagnosed after colonoscopies performed in a fecal immunochemical test (FIT)-based screening program.

METHODS

PCCRCs diagnosed after colonoscopies performed between 2014-2016 for a positive FIT in the Dutch CRC screening program were included. PCCRCs were categorized according to the World Endoscopy Organization consensus statement into (a) interval PCCRC (diagnosed before the recommended surveillance); (b) non-interval type A (diagnosed at the recommended surveillance interval); (c) non-interval type B (diagnosed after the recommended surveillance interval); or (d) non-interval type C (diagnosed after the intended recommended surveillance interval, with surveillance not implemented owing to co-morbidity). The most probable etiology was determined by root-cause analysis. Tumor stage distributions were compared between categories.

RESULTS

116362 colonoscopies were performed after a positive FIT with 9978 screen-detected CRCs. During follow-up, 432 PCCRCs were diagnosed. The 3-year PCCRC rate was 2.7%. PCCRCs were categorized as interval (53.5%), non-interval type A (14.6%), non-interval type B (30.6%), and non-interval type C (1.4%). The most common etiology for interval PCCRCs was possible missed lesion with adequate examination (73.6%); they were more often diagnosed at an advanced stage (stage III/IV; 53.2%) compared with non-interval type A (15.9%; P<0.001) and non-interval type B (40.9%; P=0.03) PCCRCs.

CONCLUSIONS

The 3-year PCCRC rate was low in this FIT-based CRC screening program. Approximately half of PCCRCs were interval PCCRCs. These were mostly caused by missed lesions and were diagnosed at a more advanced stage. This emphasizes the importance of high quality colonoscopy with optimal polyp detection.

The multitarget faecal immunochemical test for improving stool-based colorectal cancer screening programmes: a Dutch population-based, paired-design, intervention study

BACKGROUND

The faecal immunochemical test (FIT) is widely employed for colorectal cancer screening. However, its sensitivity for advanced precursor lesions remains suboptimal. The multitarget FIT (mtFIT), measuring haemoglobin, calprotectin, and serpin family F member 2, has demonstrated enhanced sensitivity for advanced neoplasia, especially advanced adenomas, at equal specificity to FIT. This study aimed to prospectively validate and investigate the clinical utlitity of mtFIT versus FIT in a setting of population-based colorectal cancer screening.

METHODS

Individuals aged 55-75 years and who were eligible for the Dutch national FIT-based colorectal cancer screening programme were invited to submit both a FIT and mtFIT sample collected from the same bowel movement. Positive FIT (47 μg/g haemoglobin cutoff) or mtFIT (based on decision-tree algorithm) led to a colonoscopy referral. The primary outcome was the relative detection rate of mtFIT versus FIT for all advanced neoplasia. Secondary outcomes were the relative detection rates of colorectal cancer, advanced adenoma, and advanced serrated polyps individually and the long-term effect of mtFIT-based versus FIT-based programmatic screening on colorectal cancer incidence, mortality, and cost, determined with microsimulation modelling. The study has been registered in ClinicalTrials.gov, NCT05314309, and is complete.

FINDINGS

Between March 25 and Dec 7, 2022, 35 786 individuals were invited to participate in the study, of whom 15 283 (42·7%) consented, and 13 187 (86·3%) of 15 283 provided both mtFIT and FIT samples with valid results. Of the 13 187 participants, 6637 (50·3%) were male and 6550 (49·7%) were female. mtFIT showed a 9·11% (95% CI 8·62-9·61) positivity rate and 2·27% (95% CI 2·02-2·54) detection rate for advanced neoplasia, compared with a positivity rate of 4·08% (3·75-4·43) and a detection rate of 1·21% (1·03-1·41) for FIT. Detection rates of mtFIT versus FIT were 0·20% (95% CI 0·13-0·29) versus 0·17% (0·11-0·27) for colorectal cancer; 1·64% (1·43-1·87) versus 0·86% (0·72-1·04) for advanced adenoma, and 0·43% (0·33-0·56) versus 0·17% (0·11-0·26) for advanced serrated polyps. Modelling demonstrated that mtFIT-based screening could reduce colorectal cancer incidence by 21% and associated mortality by 18% compared with the current Dutch colorectal cancer screening programme, at feasible costs. Furthermore, at equal positivity rates, mtFIT outperformed FIT in terms of diagnostic yield. At an equally low positivity rate, mtFIT-based screening was predicted to further decrease colorectal cancer incidence by 5% and associated mortality by 4% compared with FIT-based screening.

INTERPRETATION

The higher detection rate of mtFIT for advanced adenoma compared with FIT holds the potential to translate into additional and clinically meaningful long-term colorectal cancer incidence and associated mortality reductions in programmatic colorectal cancer screening.

FUNDING

Stand Up to Cancer, Dutch Cancer Society, Dutch Digestive Foundation, and Health~Holland.

Differences in treatment of stage I colorectal cancers: a population-based study of colorectal cancers detected within and outside of a screening program

BACKGROUND

 Screen-detected colorectal cancers (CRCs) are often treated less invasively than stage-matched non-screen-detected CRCs, but the reasons for this are not fully understood. This study evaluated the treatment of stage I CRCs detected within and outside of the screening program in the Netherlands. METHODS : Data from the Netherlands Cancer Registry for all stage I CRCs diagnosed between January 1, 2008 and December 31, 2020 were analyzed, comparing patient, tumor, and treatment characteristics of screen-detected and non-screen-detected stage I CRCs. Multivariable logistic regression was used to assess the association between treatment (local excision only vs. surgical oncologic resection) and patient and tumor characteristics, stratified for T stage and tumor location.

RESULTS

 Screen-detected stage I CRCs were relatively more often T1 than T2 compared with non-screen-detected stage I CRCs (66.9 % vs. 53.3 %; P < 0.001). When only T1 tumors were considered, both screen-detected colon and rectal cancers were more often treated with local excision only than non-screen-detected T1 cancers (odds ratio [OR] 2.19, 95 %CI 1.93-2.49; and OR 1.29, 95 %CI 1.05-1.59, respectively), adjusted for sex, tumor location, lymphovascular invasion (LVI) status, and tumor differentiation. CONCLUSIONS : Less invasive treatment of screen-detected stage I CRC is partly explained by the higher rate of T1 cancers compared with non-screen-detected stage I CRCs. T1 stage I screen-detected CRCs were also more likely to undergo less invasive treatment than non-screen-detected CRCs, adjusted for risk factors such as LVI and tumor differentiation. Future research should investigate whether the choice of local excision was related to unidentified cancer-related factors or the expertise of the endoscopists.

Interval post-colonoscopy colorectal cancer following a negative colonoscopy in a fecal immunochemical test-based screening program

BACKGROUND

 In the Dutch colorectal (CRC) screening program, fecal immunochemical test (FIT)-positive individuals are referred for colonoscopy. If no relevant findings are detected at colonoscopy, individuals are reinvited for FIT screening after 10 years. We aimed to assess CRC risk after a negative colonoscopy in FIT-positive individuals.

METHODS

 In this cross-sectional cohort study, data were extracted from the Dutch national screening information system. Participants with a positive FIT followed by a negative colonoscopy between 2014 and 2018 were included. A negative colonoscopy was defined as a colonoscopy during which no more than one nonvillous, nonproximal adenoma < 10 mm or serrated polyp < 10 mm was found. The main outcome was interval post-colonoscopy CRC (iPCCRC) risk. iPCCRC risk was reviewed against the risk of interval CRC after a negative FIT (FIT IC) with a 2-year screening interval.

RESULTS

 35 052 FIT-positive participants had a negative colonoscopy and 24 iPCCRCs were diagnosed, resulting in an iPCCRC risk of 6.85 (95 %CI 4.60-10.19) per 10 000 individuals after a median follow-up of 1.4 years. After 2.5 years of follow-up, age-adjusted iPCCRC risk was approximately equal to FIT IC risk at 2 years.

CONCLUSION

 Risk of iPCCRC within a FIT-based CRC screening program was low during the first years after colonos-copy but, after 2.5 years, was the same as the risk in FIT-negative individuals at 2 years, when they are reinvited for screening. Colonoscopy quality may therefore require further improvement and FIT screening interval may need to be reduced after negative colonoscopy.

Colorectal Cancer Stage Distribution at First and Repeat Fecal Immunochemical Test Screening

BACKGROUND & AIMS

For colorectal cancer (CRC) screening to be effective, it is important that screen-detected cancers are found at an early stage. Studies on stage distribution of screen-detected CRC at repeat screening of large population-based fecal immunochemical test (FIT)-based screening programs and the impact of FIT cut-off values on staging currently are lacking.

METHODS

We obtained data for FIT-positive participants (FIT cut-off, 47 μg hemoglobin/g feces) at their first or second (ie, repeat) screening from the Dutch National Screening Database from 2014 to 2018. Tumor characteristics were acquired through linkage with The Netherlands Cancer Registry. We compared stage at diagnosis (I-II vs III-IV) of CRCs detected at a first or second screening. In addition, we analyzed the hypothetical yield and stage distribution of CRC for different FIT cut-off values up to 250 μg hemoglobin/g feces.

RESULTS

At the first and second screenings, respectively, 15,755 and 3304 CRCs were detected. CRCs detected at the first or second screening were equally likely to be stages I to II (66.5% vs 67.7%; relative risk, 1.02; 95% CI, 1.00-1.05). A hypothetical increase of the FIT cut-off value from 47 μg to 250 μg resulted in a reduction of detected CRCs by 88.3% and 79.0% at the first or second screening, respectively. Even then, the majority of detected CRCs (63%-64%) still would be diagnosed at stages I to II.

CONCLUSIONS

FIT-based screening is effective in downstaging CRC, and also at repeat screening. Increasingly, the FIT cut-off level has a limited impact on the stage distribution of detected CRCs, although it greatly affects CRC detection and thus is important to keep low.

Optimization of colonoscopy quality: Comprehensive review of the literature and future perspectives

Colonoscopy is crucial in preventing colorectal cancer (CRC) and reducing associated mortality. This comprehensive review examines the importance of high-quality colonoscopy and associated quality indicators, including bowel preparation, cecal intubation rate, withdrawal time, adenoma detection rate (ADR), complete resection, specimen retrieval, complication rates, and patient satisfaction, while also discussing other ADR-related metrics. Additionally, the review draws attention to often overlooked quality aspects, such as nonpolypoid lesion detection, as well as insertion and withdrawal skills. Moreover, it explores the potential of artificial intelligence in enhancing colonoscopy quality and highlights specific considerations for organized screening programs. The review also emphasizes the implications of organized screening programs and the need for continuous quality improvement. A high-quality colonoscopy is crucial for preventing postcolonoscopy CRC- and CRC-related deaths. Health-care professionals must develop a thorough understanding of colonoscopy quality components, including technical quality, patient safety, and patient experience. By prioritizing ongoing evaluation and refinement of these quality indicators, health-care providers can contribute to improved patient outcomes and develop more effective CRC screening programs.

High Concordance of CT Colonography and Colonoscopy Allows for the Distinguishing and Diagnosing of Intestinal Diseases

(1) Although new imaging methods for examining the GIT with high diagnostic capabilities were introduced, the improvement and implementation of safe, efficient, and cost-effective approaches continue, and GIT diseases are still challenging to diagnose; (2) Methods: We aim to show the possibilities of computed tomography (CT) colonography for early diagnosis of colon diseases using a multidetector 32-channel CT scanner after appropriate preparation; (3) Results: After a colonoscopy was performed earlier, 140 patients were examined with CT colonography. Complete colonoscopy was performed in 80 patients (57.1%) out of 140 who underwent CT colonography. Incomplete colonoscopy was observed in 52 patients (37.2%); in 5 patients (3.6%), it was contraindicated, and in 3 patients (2.1%), it was not performed because of patients' refusal. We determined that in cases of complete FCS in 95% of patients, CT colonography established the same clinical diagnosis as FCS. In cases of incomplete, refused, or contraindicated FCS in 32.7% (17 patients), FCS failed to diagnose correctly. The main reasons for incomplete colonoscopy were: intraluminal obturation of tumor nature-17 patients (33%), extraluminal obturation (compression) from a tumor formation-4 patients (8%), stenotic changes of non-tumor nature-11 patients (21%), congenital diseases with changes in the length of the lumen of the intestinal loops-7 patients (13%), and subjective factors (pain, poor preparation, contraindications) in 13 patients (25%); (4) Conclusions: Our results confirmed that CT colonography is a method of choice in cases of negative FCS results accompanied by clinical data for the neoplastic process and in cases of incomplete and contraindicated FCS. Also, the insufflation system we developed optimizes the method by improving the quality of the obtained images and ensuring good patient tolerance.

Diagnostic yield of a risk model versus faecal immunochemical test only: a randomised controlled trial in a colorectal cancer screening programme

BACKGROUND

Combining the faecal immunochemical test (FIT) result with risk factors for advanced neoplasia (AN) may increase the yield of colorectal cancer (CRC) screening without increasing the number of colonoscopies. We conducted a randomised controlled trial in the Dutch CRC screening programme to evaluate a previously developed risk model including FIT, age, sex, smoking status, and CRC family history.

METHODS

A total of 22,748 individuals aged 56-75 years were pre-randomised to the risk-model group or the FIT-only group. Both groups received the FIT; those allocated to the risk-model group also received a single-page questionnaire. Study participants with a positive result (FIT ≥ 15 µg Hb/g faeces and/or risk ≥0.10) were referred for colonoscopy. The primary outcome measure was the proportion of invitees in whom AN was detected.

RESULTS

In the risk-model group, 3113/11,364 invitees (27%) returned the FIT and questionnaire versus 3061/11,384 invitees (27%) in the FIT-only group (p = 0.40). The yield of AN was 3.70/1000 invitees in the risk-model group versus 3.43/1000 in the FIT-only group (absolute difference: 0.27/1000, 95%CI: -1.30 to 1.82, p = 0.82).

CONCLUSIONS

Combining FIT with risk factors for CRC did not increase the yield of AN compared to FIT-only in an existing CRC screening programme. There was no difference in participation between groups.

CLINICAL TRIAL REGISTRATION

NCT04490551 (ClinicalTrials.gov).

Development and validation of a web-based predictive model for preoperative diagnosis of localized colorectal cancer and colorectal adenoma

Background

Localized colorectal cancer (LCC) has obscure clinical signs, which are difficult to distinguish from colorectal adenoma (CA). This study aimed to develop and validate a web-based predictive model for preoperative diagnosis of LCC and CA.

Methods

We conducted a retrospective study that included data from 500 patients with LCC and 980 patients with CA who were admitted to Dongyang People's Hospital between November 2012 and June 2022. Patients were randomly divided into the training (n=1036) and validation (n=444) cohorts. Univariate logistic regression, least absolute shrinkage and selection operator regression, and multivariate logistic regression were used to select the variables for predictive models. The area under the curve (AUC), calibration curve, decision curve analysis (DCA), and clinical impact curve (CIC) were used to evaluate the performance of the model.

Results

The web-based predictive model was developed, including nine independent risk factors: age, sex, drinking history, white blood cell count, lymphocyte count, red blood cell distribution width, albumin, carcinoembryonic antigen, and fecal occult blood test. The AUC of the prediction model in the training and validation cohorts was 0.910 (0.892-0.929) and 0.894 (0.862-0.925), respectively. The calibration curve showed good consistency between the outcome predicted by the model and the actual diagnosis. DCA and CIC showed that the predictive model had a good clinical application value.

Conclusion

This study first developed a web-based preoperative prediction model, which can discriminate LCC from CA and can be used to quantitatively assess the risks and benefits in clinical practice.

Test performance metrics for breast, cervical, colon, and lung cancer screening: a systematic review

BACKGROUND

Multiple quality metrics have been recommended to ensure consistent, high-quality execution of screening tests for breast, cervical, colorectal, and lung cancers. However, minimal data exist evaluating the evidence base supporting these recommendations and the consistency of definitions and concepts included within and between cancer types.

METHODS

We performed a systematic review for each cancer type using MEDLINE, Embase, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) from 2010 to April 2020 to identify guidelines from screening programs or professional organizations containing quality metrics for tests used in breast, cervical, colorectal, and lung cancer screening. We abstracted metrics' definitions, target performance levels, and related supporting evidence for test completeness, adequacy (sufficient visualization or collection), accuracy, and safety.

RESULTS

We identified 11 relevant guidelines with 20 suggested quality metrics for breast cancer, 5 guidelines with 9 metrics for cervical cancer, 13 guidelines with 18 metrics for colorectal cancer (CRC), and 3 guidelines with 7 metrics for lung cancer. These included 54 metrics related to adequacy (n = 6), test completeness (n = 3), accuracy (n = 33), and safety (n = 12). Target performance levels were defined for 30 metrics (56%). Ten (19%) were supported by evidence, all from breast and CRC, with no evidence cited to support metrics from cervical and lung cancer screening.

CONCLUSIONS

Considerably more guideline-recommended test performance metrics exist for breast and CRC screening than cervical or lung cancer. The domains covered are inconsistent among cancers, and few targets are supported by evidence. Clearer evidence-based domains and targets are needed for test performance metrics.

REGISTRATION

PROSPERO 2020 CRD42020179139.

Advanced serrated polyps as a target of screening: detection rate and positive predictive value within a fecal immunochemical test-based colorectal cancer screening population

BACKGROUND : Advanced serrated polyps (ASPs) have a comparable risk to advanced adenomas for progression to colorectal cancer (CRC). The yield of most CRC screening programs, however, is based on advanced adenomas and CRC only. We assessed the ASP detection rate, and positive predictive value (PPV) including ASPs in a fecal immunochemical test (FIT)-based screening program. METHODS : We analyzed the findings of follow-up colonoscopies of FIT-positive screenees in the Dutch CRC screening program from 2014 until 2020. Data were retrieved from the national screening and pathology database. An ASP was defined as any serrated polyp of ≥ 10 mm, sessile serrated lesion with dysplasia, or traditional serrated adenoma. The ASP detection rate was defined as the proportion of colonoscopies with ≥ 1 ASP. PPV was originally defined as the proportion of individuals with a CRC or advanced adenoma. The updated PPV definition included CRCs, advanced adenomas, and/or ASPs. RESULTS : 322 882 colonoscopies were included in the analyses. The overall detection rate of ASPs was 5.9 %. ASPs were detected more often in women than men (6.3 % vs. 5.6 %; P < 0.001). ASP detection rates in individuals aged 55-59, 60-64, 65-69, and 70 + were 5.2 %, 6.1 %, 6.1 %, and 5.9 %, respectively (P < 0.001). The PPV for CRCs and advanced adenomas was 41.1 % and increased to 43.8 % when including ASPs. The PPV increase was larger in women than in men (3.2 vs. 2.4 percentage points). CONCLUSIONS : 5.9 % of FIT-positive screenees had ASPs, but half of these were detected in combination with a CRC or advanced adenoma. Therefore, including ASPs results in a small increase in the yield of FIT-based screening.

Faecal occult blood loss accurately predicts future detection of colorectal cancer. A prognostic model

OBJECTIVES

To examine the prognostic potential of repeated faecal haemoglobin (F-Hb) concentration measurements in faecal immunochemical test (FIT)-based screening for colorectal cancer (CRC).

DESIGN

Prognostic model.

SETTING

Dutch biennial FIT-based screening programme during 2014-2018.

PARTICIPANTS

265 881 participants completing three rounds of FIT, with negative test results (F-Hb <47 µg Hb/g faeces) in rounds 1 and 2.

INTERVENTIONS

Colonoscopy follow-up in participants with a positive FIT (F-Hb ≥47 µg Hb/g faeces).

MAIN OUTCOMES

We evaluated prognostic models for detecting advanced neoplasia (AN) and CRC in round 3, with as predictors, participant age, sex, F-Hb in rounds 1 and 2, and categories/combinations/non-linear transformations of F-Hb. Primary evaluation criteria included: risk prediction accuracy (calibration), discrimination of participants with versus without AN or CRC (optimism-adjusted C-statistics, range 0.5-1.0), the degree of risk stratification and C-statistics in external validation.

RESULTS

Among study participants, 8806 (3.3%) had a positive FIT result, 3254 (1.2%) had AN detected and 557 (0.2%) had cancer. F-Hb concentrations in rounds 1 and 2 were the strongest outcome predictors, with adjusted ORs of up to 9.4 (95% CI 7.5 to 11.7) for the highest F-Hb category. Risk predictions matched the observed risk for most participants (calibration intercept -0.008 to -0.099; slope 0.982-0.998), and discriminated participants with versus without AN or CRC with C-statistics of 0.78 (95% CI 0.77 to 0.79) and 0.73 (95% CI 0.71 to 0.75), respectively. The predicted risk ranged from 0.4% to 36.7% for AN and from 0.0% to 5.5% for CRC across participants. In external validation, the model retained similar discrimination accuracy for AN (C-statistic 0.77, 95% CI 0.66 to 0.87) and CRC (C-statistic 0.78, 95% CI 0.66 to 0.91).

CONCLUSION

Participants at lower versus higher risk of future AN or CRC can be accurately identified based on their age, sex and particularly, prior F-Hb concentrations. Risk stratification should be considered based on this information.

The multitarget fecal immunochemical test versus the fecal immunochemical test for programmatic colorectal cancer screening: a cross-sectional intervention study with paired design

BACKGROUND

Many screening programs for colorectal cancer (CRC) use the fecal immunochemical test (FIT) to triage individuals for colonoscopy. Although these programs reduce CRC incidence and CRC-related mortality, the detection of advanced precursor lesions (advanced adenomas and advanced serrated polyps) by FIT could be improved. As an alternative for FIT, the antibody-based multitargetFIT (mtFIT) has been proposed. The mtFIT measures three protein markers: hemoglobin, calprotectin, and serpin family F member 2. In a retrospective diagnostic accuracy study in a large colonoscopy-controlled series (n = 1284), mtFIT showed increased sensitivity for advanced neoplasia (AN), at equal specificity, compared to FIT (42.9% versus 37.3%; p = 0.025). This increase was mainly due to a higher sensitivity of mtFIT for advanced adenomas (37.8% versus 28.1% for FIT; p = 0.006). The present mtFIT study aims to prospectively validate these findings in the context of the Dutch national CRC screening program.

METHOD

The mtFIT study is a cross-sectional intervention study with a paired design. Eligible subjects for the Dutch FIT-based national CRC screening program are invited to perform mtFIT in addition to FIT. Samples are collected at home, from the same bowel movement, and are shipped to a central laboratory by postal mail. If either one or both tests are positive, participants are referred for colonoscopy. Detailed colonoscopy and pathology data are centrally stored in a national screening database (ScreenIT; Topicus, Deventer, the Netherlands) that is managed by the screening organization, and will be retrieved for this study. We aim to determine the relative sensitivity for AN, comprising of CRC, advanced adenomas and advanced serrated polyps, of mtFIT compared to FIT at an equal positivity rate. Additionally, we will use the Adenoma and Serrated Pathway to Colorectal CAncer model to predict lifetime health effects and costs for programmatic mtFIT- versus FIT-based screening. The target sample size is 13,131 participants.

DISCUSSION

The outcome of this study will inform on the comparative clinical utility of mtFIT versus FIT in the Dutch national CRC screening program and is an important step forward in the development of a new non-invasive stool test for CRC screening.

TRIAL REGISTRATION

Clinicaltrials.gov ; NCT05314309, registered April 6th 2022, first inclusions March 25th 2022 https://clinicaltrials.gov/ct2/results?cond=&term=NCT05314309&cntry=&state=&city=&dist =.

Third Asia-Pacific consensus recommendations on colorectal cancer screening and postpolypectomy surveillance

The Asia-Pacific region has the largest number of cases of colorectal cancer (CRC) and one of the highest levels of mortality due to this condition in the world. Since the publishing of two consensus recommendations in 2008 and 2015, significant advancements have been made in our knowledge of epidemiology, pathology and the natural history of the adenoma-carcinoma progression. Based on the most updated epidemiological and clinical studies in this region, considering literature from international studies, and adopting the modified Delphi process, the Asia-Pacific Working Group on Colorectal Cancer Screening has updated and revised their recommendations on (1) screening methods and preferred strategies; (2) age for starting and terminating screening for CRC; (3) screening for individuals with a family history of CRC or advanced adenoma; (4) surveillance for those with adenomas; (5) screening and surveillance for sessile serrated lesions and (6) quality assurance of screening programmes. Thirteen countries/regions in the Asia-Pacific region were represented in this exercise. International advisors from North America and Europe were invited to participate.

Detecting Colorectal Adenomas and Cancer Using Volatile Organic Compounds in Exhaled Breath: A Proof-of-Principle Study to Improve Screening

INTRODUCTION

Early detection of colorectal cancer (CRC) by screening programs is crucial because survival rates worsen at advanced stages. However, the currently used screening method, the fecal immunochemical test (FIT), suffers from a high number of false-positives and is insensitive for detecting advanced adenomas (AAs), resulting in false-negatives for these premalignant lesions. Therefore, more accurate, noninvasive screening tools are needed. In this study, the utility of analyzing volatile organic compounds (VOCs) in exhaled breath in a FIT-positive population to detect the presence of colorectal neoplasia was studied.

METHODS

In this multicenter prospective study, breath samples were collected from 382 FIT-positive patients with subsequent colonoscopy participating in the national Dutch bowel screening program (n = 84 negative controls, n = 130 non-AAs, n = 138 AAs, and n = 30 CRCs). Precolonoscopy exhaled VOCs were analyzed using thermal desorption-gas chromatography-mass spectrometry, and the data were preprocessed and analyzed using machine learning techniques.

RESULTS

Using 10 discriminatory VOCs, AAs could be distinguished from negative controls with a sensitivity and specificity of 79% and 70%, respectively. Based on this biomarker profile, CRC and AA combined could be discriminated from controls with a sensitivity and specificity of 77% and 70%, respectively, and CRC alone could be discriminated from controls with a sensitivity and specificity of 80% and 70%, respectively. Moreover, the feasibility to discriminate non-AAs from controls and AAs was shown.

DISCUSSION

VOCs in exhaled breath can detect the presence of AAs and CRC in a CRC screening population and may improve CRC screening in the future.

Adenoma Detection Rate and Risk for Interval Postcolonoscopy Colorectal Cancer in Fecal Immunochemical Test-Based Screening : A Population-Based Cohort Study

BACKGROUND

The adenoma detection rate (ADR) is an essential quality indicator for endoscopists performing colonoscopies for colorectal cancer (CRC) screening as it is associated with postcolonoscopy CRCs (PCCRCs). Currently, data on ADRs of endoscopists performing colonoscopies in fecal immunochemical testing (FIT)-based screening, the most common screening method, are scarce. Also, the association between the ADR and PCCRC has not been demonstrated in this setting.

OBJECTIVE

To evaluate the association between the ADR and PCCRC risk in colonoscopies done after a positive FIT result.

DESIGN

Population-based cohort.

SETTING

Dutch, FIT-based, CRC screening program.

PARTICIPANTS

Patients undergoing colonoscopy, done by accredited endoscopists, after a positive FIT result.

MEASUREMENTS

Quality indicator performance and PCCRC incidence for colonoscopies in FIT-positive screenees were assessed. The PCCRCs were classified as interval, a cancer detected before recommended surveillance, or noninterval. The association between ADR and interval PCCRC was evaluated with a multivariable Cox regression model and PCCRC incidence was determined for different ADRs.

RESULTS

362 endoscopists performed 116 360 colonoscopies with a median ADR of 67%. In total, 209 interval PCCRCs were identified. The ADR was associated with interval PCCRC, with an adjusted hazard ratio of 0.95 (95% CI, 0.92 to 0.97) per 1% increase in ADR. For every 1000 patients undergoing colonoscopy, the expected number of interval PCCRC diagnoses after 5 years was approximately 2 for endoscopists with ADRs of 70%, compared with more than 2.5, almost 3.5, and more than 4.5 for endoscopists with ADRs of 65%, 60%, and 55%, respectively.

LIMITATION

The relative short duration of follow-up (median, 52 months) could be considered a limitation.

CONCLUSION

The ADR of endoscopists is inversely associated with the risk for interval PCCRC in FIT-positive colonoscopies. Endoscopists performing colonoscopy in FIT-based screening should aim for markedly higher ADRs compared with primary colonoscopy.

PRIMARY FUNDING SOURCE

None.

Colonoscopy may be weak link in organised colorectal cancer screening programme with faecal immunochemical test

OBJECTIVE

To evaluate the quality of colonoscopies performed after a positive faecal immunochemical test in the French colorectal cancer screening programme.

METHODS

Retrospective analysis of all colonoscopies performed between 2015 and 2019 after a positive quantitative faecal immunochemical test in the population-based colorectal cancer screening programme organised in Alsace, part of the French programme. The following indicators were evaluated: annual colonoscopy volume, caecal intubation rate, adenoma detection rate, proximal serrated lesion detection rate and proportion of patients referred directly to surgery for benign polyp management. Endoscopists who performed <30 faecal immunochemical test positive colonoscopies were non-assessable.

RESULTS

Overall, 13,455 faecal immunochemical test-positive colonoscopies performed by 116 community gastroenterologists were included, 13,067 of them by 80 assessable endoscopists. The overall caecal intubation, adenoma detection and proximal serrated lesion detection rates were 97.9%, 57.6% and 7.6%, respectively. They were <90%, <45% and <1% for 1.3%, 12.5% and 6.3% of the endoscopists, respectively. Overall, 1028 (7.9%) individuals were examined by 13 low-performing endoscopists and 328 (2.4%) individuals by 33 low-volume non-assessable endoscopists. Among 9133 individuals harbouring polyps, 155 (1.7%) had unwarranted surgery for a benign polyp. Overall, 1487 individuals (11.1%; 95% confidence interval 10.5-11.6) were not given the best possible chances, whereas 5545 individuals (41.2%; 95% confidence interval 40.4-42.0) were offered the best possible chances by 37 endoscopists.

CONCLUSIONS

At programme level, the key performance indicators evaluated largely exceeded the target standards. At individual level, at least one in nine individuals was not given the best possible chances during faecal immunochemical test-positive colonoscopies by a minority of poor-performing and/or low-volume endoscopists.

Evaluation of polypectomy quality indicators of large nonpedunculated colorectal polyps in a nonexpert, bowel cancer screening cohort

BACKGROUND AND AIMS

With the introduction of the national bowel cancer screening program, the detection of sessile and flat colonic lesions ≥20 mm in size, defined as large nonpedunculated colorectal polyps (LNPCPs), has increased. The aim of this study was to examine the quality of endoscopic treatment of LNPCPs in the Dutch screening program.

METHODS

This investigation comprised 2 related, but separate, substudies (1 with a cross-sectional design and 1 with a longitudinal design). The first examined prevalence and characteristics of LNPCPs in data from the national Dutch screening cohort from February 2014 until January 2017. The second, with screening data from 5 endoscopy units in the Southern part of the Netherlands from February 2014 until August 2015, examined performance on important quality indicators (technical and clinical successes, recurrence rate, adverse event rate, and surgery referral rate). All patients were part of the national Dutch screening cohort.

RESULTS

In the national cohort, an LNPCP was detected in 8% of participants. Technical and clinical success decreased with increasing LNPCP size, from 93% and 96% in 20- to 29-mm lesions to 85% and 86% in 30- to 39-mm lesions and to 74% and 81% in ≥40-mm lesions (P < .001; P = .034). The cumulative recurrence rate at 12 months increased with LNPCP size, from 9% to 22% and 26% in the respective size groups (P = .095). The adverse event rate was 5%. The overall surgical referral rate for noninvasive LNPCPs was 7%.

CONCLUSIONS

In this performance of 2 substudies, it was shown that quality parameters for endoscopic resection of large polyps in the Dutch screening cohort are not reached, especially in ≥30-mm polyps. Endoscopic resection of large polyps could benefit from additional training, quality monitoring, and centralization either within or between centers.

The national FIT-based colorectal cancer screening program in the Netherlands during the COVID-19 pandemic

The COVID-19 pandemic has affected many healthcare services worldwide. Like many other nations, the Netherlands experienced large numbers of individuals affected by COVID-19 in 2020, leading to increased demands on hospitals and intensive care units. The Dutch Ministry of Health decided to suspend the Dutch biennial fecal immunochemical test (FIT) based colorectal cancer (CRC) screening program from March 16, 2020. FIT invitations were resumed on June 3. In this study, we describe the short-term effects of this suspension on a myriad of relevant screening outcomes. As a result of the suspension, a quarter of the individuals due for screening between March and November 2020 had not received their invitation for FIT screening by November 30, 2020. Furthermore, 57.8% of those who received a consecutive FIT between the restart and November 30, 2020, received it outside the upper limit of the standard screening interval (26 months). Median time between positive FIT and colonoscopy did not change as a result of the pandemic. Participation rates of FIT screening and follow-up colonoscopy in the months just before and during the suspension were significantly lower than expected, but returned to normal levels after the suspension. Based on the anticipated 2020 cohort size, we estimate that the number of individuals with advanced neoplasia currently detected up until November 2020 was 31.2% lower compared to what would have been expected without a pandemic. Future studies should monitor the impact on long-term screening outcomes as a result of the pandemic.

A Pragmatic Randomized Controlled Trial of an Endoscopist Audit and Feedback Report for Colonoscopy

INTRODUCTION

Variation in endoscopist performance contributes to poor-quality colonoscopy. Audit and feedback (A/F) can be used to improve physician performance, particularly among lower performing physicians. In this large pragmatic randomized controlled trial, we compared A/F to improve endoscopists' colonoscopy performance to usual practice.

METHODS

Endoscopists practicing in Ontario, Canada, in 2014 were randomly assigned in October 2015 (index date) to receive (intervention group, n = 417) or not receive (control group, n = 416) an A/F report generated centrally using health administrative data. Colonoscopy performance was measured in both groups over two 12-month periods: prereport and postreport (relative to the index date). The primary outcome was polypectomy rate (PR). Secondary outcomes were cecal intubation rate, bowel preparation, and premature repeat after normal colonoscopy. A post hoc analysis used adenoma detection rate as the outcome. Outcomes were compared between groups for all endoscopists and for lower performing endoscopists using Poisson regression analyses under a difference-in-difference framework.

RESULTS

Among all endoscopists, PR did not significantly improve from prereport to postreport periods for those receiving the intervention (relative rate [RR], intervention vs control: 1.07 vs 1.05, P = 0.09). Among lower performing endoscopists, PR improved significantly (RR, intervention vs control 1.34 vs 1.11, P = 0.02) in the intervention group compared with controls. In this subgroup, adenoma detection rate also improved but not significantly (RR, intervention vs control 1.12 vs 1.04, P = 0.12). There was no significant improvement in secondary outcomes between the intervention and control groups.

DISCUSSION

A/F reports for colonoscopy improve performance in lower performing endoscopists (ClinicalTrials.gov: NCT02595775).

Impact of sedation on the Performance Indicator of Colonic Intubation

BACKGROUND

The Performance Indicator of Colonic Intubation (PICI) is a new measure of high-quality colonic intubation. Adequate PICI was defined as cecal intubation without significant discomfort and use of minimal sedation. This study assessed achievement of PICI within the Dutch colorectal cancer (CRC) screening program, and determined the association between PICI and adenoma detection rate (ADR). PICI achievement when using the Dutch median midazolam dose was also assessed.

METHODS

This retrospective study was conducted within the Dutch fecal immunochemical test-based CRC screening program. Colonoscopy and pathology data were prospectively collected in a national database. Data between January 2016 through January 2018 were analyzed. Adequate PICI was defined as successful cecal intubation, Gloucester Comfort Scale (GCS) of 1 - 3, and use of ≤ 2.5 mg midazolam.

RESULTS

107 328 colonoscopies were performed during the study period. Adequate PICI was achieved in 49 500 colonoscopies (46.1 %). In colonoscopies with inadequate PICI, inadequacy was due to higher sedation doses in 87.8 %. Adequate PICI was associated with higher ADR (odds ratio 1.16, 95 % confidence interval 1.12 - 1.20). When using a cutoff of 5 mg midazolam, median dose in this Dutch population, adequate PICI was achieved in 95 410 colonoscopies (88.9  %).

CONCLUSION

PICI appeared to be heavily dependent on sedation practice. Because of wide variation in sedation practice between individual endoscopists and countries, the benefit of PICI as a quality indicator is limited.

Perforation and post-polypectomy bleeding complicating colonoscopy in a population-based screening program

Background and study aims We aimed to estimate the rate of hospital admissions for perforation and for post-polypectomy bleeding, after outpatient colonoscopy following a first positive fecal occult blood test screen through the population-based ColonCancerCheck program in Ontario, Canada. Patients and methods We identified all individuals aged 50 to 74 years with a first positive CCC gFOBT screening result from 2008 to 2017 who underwent outpatient colonoscopy ≤ 6 months later and who did not receive a diagnosis of CRC ≤ 24 months later. We identified inpatient hospital admissions for colonic perforation ≤ 7 days after and for post-polypectomy bleeding ≤ 14 days following colonoscopy. Results Among 121,626 individuals who underwent colonoscopy, the rate of perforation was 0.6 per 1000 from 2008 to 2012 and 0.4 per 1000 from 2013 to 2017. The rate was elevated among those aged 70 to 74 years; those with comorbidities; when colonoscopy was performed by endoscopists other than gastroenterologists or endoscopists with low prior year volume; and when polypectomy was performed during colonoscopy. The rate of bleeding was 4.3 per 1000 and was elevated among those aged 70 to 74 years, those with comorbidity, and with complex polypectomy. Both outcomes were more common among those aged 70 to 74 years, those with a 5-year cumulative Charlson score ≥ 1, those with prior hospitalization for ischemic heart disease, and those with endoscopists whose prior year colonoscopy volume was in the three lower quartiles. Conclusions Colonic perforation and post-polypectomy bleeding, among participants of population-based colorectal screening programs who test positive in the absence of colorectal cancer, are infrequent but serious complications, which increase with participant age and comorbidity, and with endoscopist characteristics.

Guidelines for accreditation of endoscopy units: quality measures from the Korean Society of Coloproctology

Purpose

Colonoscopy is an effective method of screening for colorectal cancer (CRC), and it can prevent CRC by detection and removal of precancerous lesions. The most important considerations when performing colonoscopy screening are the safety and satisfaction of the patient and the diagnostic accuracy. Accordingly, the Korean Society of Coloproctology (KSCP) herein proposes an optimal level of standard performance to be used in endoscopy units and by individual colonoscopists for screening colonoscopy. These guidelines establish specific criteria for assessment of safety and quality in screening colonoscopy.

Methods

The Colonoscopy Committee of the KSCP commissioned this Position Statement. Expert gastrointestinal surgeons representing the KSCP reviewed the published evidence to identify acceptable quality indicators and indicators that lacked sufficient evidence.

Results

The KSCP recommends an optimal standard list for quality control of screening colonoscopy in the following 6 categories: training and competency of the colonoscopist, procedural quality, facilities and equipment, performance indicators and auditable outcomes, disinfection of equipment, and sedation and recovery of the patient.

Conclusion

The KSCP recommends that endoscopy units performing CRC screening evaluate 6 key performance measures during daily practice.

Accreditation of digestive endoscopy services: a method of quality assuring?

INTRODUCTION

Accreditation is one method of assuring quality, but the evidence base in support of service accreditation is mixed. More recent experiences indicate that accreditation may accelerate improvements.

AREAS COVERED

Our aim is focused on endoscopy service accreditation and we conducted a literature search using Medline (via Pubmed) and the Cochrane Center Register of Controlled Trials up to January 2020.

EXPERT OPINION

Worldwide numerous centers fail to meet important quality indicators as suggested by international guidelines. Accreditation can provide means for detecting many problems and correcting them by implementing agreed standards.

Substantial and sustained improvement of serrated polyp detection after a simple educational intervention: results from a prospective controlled trial

OBJECTIVE

Serrated polyps (SPs) are an important cause of postcolonoscopy colorectal cancers (PCCRCs), which is likely the result of suboptimal SP detection during colonoscopy. We assessed the long-term effect of a simple educational intervention focusing on optimising SP detection.

DESIGN

An educational intervention, consisting of two 45 min training sessions (held 3 years apart) on serrated polyp detection, was given to endoscopists from 9 Dutch hospitals. Hundred randomly selected and untrained endoscopists from other hospitals were selected as control group. Our primary outcome measure was the proximal SP detection rate (PSPDR) in trained versus untrained endoscopists who participated in our faecal immunochemical test (FIT)-based population screening programme.

RESULTS

Seventeen trained and 100 untrained endoscopists were included, who performed 11 305 and 51 039 colonoscopies, respectively. At baseline, PSPDR was equal between the groups (9.3% vs 9.3%). After training, the PSPDR of trained endoscopists gradually increased to 15.6% in 2018. This was significantly higher than the PSPDR of untrained endoscopists, which remained stable around 10% (p=0.018). All below-average (ie, PSPDR ≤6%) endoscopists at baseline improved their PSPDR after training session 1, as did 57% of endoscopists with average PSPDR (6%-12%) at baseline. The second training session further improved the PSPDR in 44% of endoscopists with average PSPDR after the first training.

CONCLUSION

A simple educational intervention was associated with substantial long-term improvement of PSPDR in a prospective controlled trial within FIT-based population screening. Widespread implementation of such interventions might be an easy way to improve SP detection, which may ultimately result in fewer PCCRCs.

TRIAL REGISTRATION NUMBER

NCT03902899.

The gastrointestinal endoscopy satisfaction questionnaire captures patient satisfaction as a key quality indicator of gastrointestinal endoscopy

BACKGROUND

Patient satisfaction is a crucial indicator of gastrointestinal endoscopy quality. The gastrointestinal endoscopy satisfaction questionnaire (GESQ) was validated for the assessment of patient satisfaction undergoing endoscopy in English with good validity. We translated and validated the GESQ in Dutch.

METHODS

The original GESQ was translated in Dutch according to the WHO guidelines. First, an internal validation of the Dutch GESQ (D-GESQ) was established by the think-aloud method and subsequent expert panel analysis. Next, the D-GESQ was embedded in the computer-based education (CBE) program in our unit, with 30-day interval after endoscopy. Adult patients, informed via CBE after undergone endoscopy, were included. Exclusion criteria were conscious sedation, limited language skills, no e-mail address available, dementia and visual impairment. For statistical analysis, several psychometric analyses were performed to identify the underlying dimensions and assessed the questionnaire for reliability and validity.

RESULTS

In total, 227 of 1065 patients completed the D-GESQ, a response rate of 21.3%. Men comprised 52.6% (n = 129) of patients. Mean age was 62.7 ± 11.54 years. In total, 180 patients (79.3%) had previously undergone endoscopy, with 157 (87.2%) of them two or more times. The exploratory factor analysis showed the 21 questions could best be clustered into five clusters instead of four in the original GESQ. The D-GESQ had an overall Cronbach α of 0.88, confirming the high internal validity.

CONCLUSION

The Dutch version of the GESQ showed high internal validity and practicality. We recommend the D-GESQ for routine use in endoscopy practice to improve quality of patient care.

Delayed breast cancer diagnosis after repeated recall at biennial screening mammography: an observational follow-up study from the Netherlands

Background

Delay in detection of breast cancer may worsen tumour characteristics, with progression of tumour size and a higher risk of metastatic lymph nodes. The purpose of this study was to investigate delayed breast cancer diagnosis after repeated recall for the same mammographic abnormality at screening.

Methods

This was a retrospective study performed in two cohorts of women enrolled in a mammography screening programme in the Netherlands. All women aged 50−75 who underwent biennial screening mammography either between January 1, 1997 and December 31, 2006 (cohort 1) or between January 1, 2007 and December 31, 2016 (cohort 2) were included.

Results

The cohorts showed no difference in proportions of women with delayed breast cancer diagnosis of at least 2 years (2.2% versus 2.8%, P = 0.29). Most delays were caused by incorrect BI-RADS classifications after recall (74.2%). An increase in mean tumour size was seen when comparing sizes at initial false-negative recall and at diagnosis of breast cancer (P < 0.001).

Conclusions

The proportion of women with a long delay in breast cancer confirmation following repeated recall at screening mammography has not decreased during 20 years of screening. These delays lead to larger tumour size at detection and may negatively influence prognosis.

Addition of an online, validated family history questionnaire to the Dutch FIT-based screening programme did not improve its diagnostic yield

Background

Faecal immunochemical testing (FIT) is suboptimal in detecting advanced neoplasia (AN). To increase the sensitivity and yield of a FIT-based screening programme, FIT could be combined with risk factors for AN. We evaluated the incremental yield of adding a family history questionnaire (FHQ) on colorectal cancer (CRC) and Lynch syndrome-associated tumours to the Dutch FIT-based screening programme.

Methods

Six thousand screen-naive individuals, aged 59–75 years, were invited to complete a FIT (FOB-Gold, cut-off 47 µg Hb/g faeces) and a validated online FHQ. Participants with a positive FIT and/or positive FHQ, confirmed after genetic counselling, were referred for colonoscopy. Yield of detecting AN per 1000 invitees for the combined strategy was compared with the FIT-only strategy.

Results

Of the 5979 invitees, 1952 (32.6%) completed the FIT only, 2379 (39.8%) completed both the FIT and FHQ and 95 (1.6%) completed the FHQ only. Addition of the FHQ to FIT-based screening resulted in one extra case of AN detected after 16 additional colonoscopies, resulting in a yield of 19.6 (95% CI, 16.4–23.5) for the combined strategy versus 19.5 (95% CI, 16.3–23.3) for the FIT-only strategy (p = 1.0).

Conclusions

The addition of an FHQ to one round of FIT screening did not increase the detection of AN compared with FIT only (ClinicalTrials.gov NCT02698462).

Correlation study between serum neuro-specific enolase and gastric and colorectal cancers

This study investigated the diagnostic value of preoperative serum neuro-specific enolase (NSE) in gastric cancer (GC) and colorectal cancer (CRC), and the diagnostic viability of combined serum NSE, carcinoembryonic antigen (CEA), cancer antigen (CA)19-9, and CA242.Patients with GC and CRC, and a healthy control group (n = 666 and 266, respectively) were compared with regard to NSE, CEA, CA19-9, and CA242 serum levels. NSE was analyzed for associations with clinicopathological parameters. To estimate the diagnostic potential of NSE, a receiver operating characteristic curve was constructed and the area under the curve (AUCs) was calculated for different patient subgroups.The median serum NSE level of the tumor group (20.925 ng/mL) was significantly higher than that of the control (15.190 ng/mL). Serum NSE was associated with pathological tumor-node-metastasis staging, lymph node metastasis, distant metastasis, vascular invasion, and nerve infiltration. The area under the receiver operating characteristic curve (AUC) for NSE in GC and CRC (0.769) was higher than for the other 3 markers (0.571-0.680). The AUC of the combined markers was higher than for any of the markers individually (0.778-0.810).The AUC for NSE alone suggests it may be an independent tumor marker, and useful for diagnosis of GC and CRC. However, the AUC for combined NSE, CEA, CA19-9, and CA242 was higher and thus potentially more diagnostic value.

Optical diagnosis of diminutive polyps in the Dutch Bowel Cancer Screening Program: Are we ready to start?

Background and study aims  Implementation of optical diagnosis of diminutive polyps may potentially increase the efficacy and cost-effectiveness of colonoscopies. To adopt such strategy in clinical practice, the Preservation and Incorporation of Valuable endoscopic Innovations (PIVI) thresholds provide the basis to be met: ≥ 90 % negative predictive value (NPV) for diagnosis of adenomatous histology and ≥ 90 % agreement on surveillance intervals. We evaluated this within the Dutch Bowel Cancer Screening Program (BCSP). Patients and methods  Endoscopic and histological data were collected from participants of the national bowel cancer screening program with an unfavorable fecal immunochemical test referred for colonoscopy between February 2014 and August 2015 at four endoscopy centers. The "resect and discard" scenario was studied, resecting diminutive polyps without histological evaluation. Agreement between optical diagnosis and histological diagnosis was measured for surveillance intervals according to Dutch, European and American post-polypectomy surveillance guideline. Results  Fifteen certified endoscopists participated in this study and included 3028 diminutive polyps. In 2,330 patients both optical and histological diagnosis were available. Optical diagnosis of diminutive polyps showed NPV of 84 % (95 % CI 80-87) for adenomatous histology in the rectosigmoid. Applying the 'resect and discard' strategy resulted in 90.6 %, 91.2 %, 90.9 % agreement on surveillance intervals for the Dutch, European and American guideline respectively. Conclusion  Our data representing current clinical practice in the Dutch BCSP practice on optical diagnosis of diminutive polyps showed that accuracy of predicting histology remains challenging, and risk of incorrect optical diagnosis is still significant. Therefore, it is too early to safely implement these strategies.

Multitarget Stool DNA Test Performance in an Average-Risk Colorectal Cancer Screening Population

INTRODUCTION

We set out to evaluate the performance of a multitarget stool DNA (MT-sDNA) in an average-risk colonoscopy-controlled colorectal cancer (CRC) screening population. MT-sDNA stool test results were evaluated against fecal immunochemical test (FIT) results for the detection of different lesions, including molecularly defined high-risk adenomas and several other tumor characteristics.

METHODS

Whole stool samples (n = 1,047) were prospectively collected and subjected to an MT-sDNA test, which tests for KRAS mutations, NDRG4 and BMP3 promoter methylation, and hemoglobin. Results for detecting CRC (n = 7), advanced precancerous lesions (advanced adenoma [AA] and advanced serrated polyps; n = 119), and non-AAs (n = 191) were compared with those of FIT alone (thresholds of 50, 75, and 100 hemoglobin/mL). AAs with high risk of progression were defined by the presence of specific DNA copy number events as measured by low-pass whole genome sequencing.

RESULTS

The MT-sDNA test was more sensitive than FIT alone in detecting advanced precancerous lesions (46% (55/119) vs 27% (32/119), respectively, P < 0.001). Specificities among individuals with nonadvanced or negative findings (controls) were 89% (791/888) and 93% (828/888) for MT-sDNA and FIT testing, respectively. A positive MT-sDNA test was associated with multiple lesions (P = 0.005), larger lesions (P = 0.03), and lesions with tubulovillous architecture (P = 0.04). The sensitivity of the MT-sDNA test or FIT in detecting individuals with high-risk AAs (n = 19) from individuals with low-risk AAs (n = 52) was not significantly different.

DISCUSSION

In an average-risk screening population, the MT-sDNA test has an increased sensitivity for detecting advanced precancerous lesions compared with FIT alone. AAs with a high risk of progression were not detected with significantly higher sensitivity by MT-sDNA or FIT.

False-Positive Results in a Population-Based Colorectal Screening Program: Cumulative Risk from 2000 to 2017 with Biennial Screening

BACKGROUND

The aim of this study was to estimate the cumulative risk of a false-positive (FP) result in a fecal occult blood test (FOBT) through 7 screening rounds and to identify its associated factors in a population-based colorectal cancer screening program.

METHODS

Retrospective cohort study, which included participants ages 50 to 69 years of a colorectal cancer screening program in Catalonia, Spain. During this period, 2 FOBTs were used (guaiac and immunochemical). A discrete-time survival model was performed to identify risk factors of receiving a positive FOBT with no high-risk adenoma or colorectal cancer in the follow-up colonoscopy. We estimated the probability of having at least 1 FP over 7 screening rounds.

RESULTS

During the period of 2000 to 2017, the cumulative FP risk was 16.3% (IC_95%: 14.6%-18.3%), adjusted by age, sex, and type of test. The median number of screens was 2. Participants who began screening at age 50 years had a 7.3% [95% confidence interval (CI), 6.35-8.51] and a 12.4% (95% CI, 11.00-13.94) probability of an FP with 4 screening rounds of guaiac-based test and immunochemical test, respectively. Age, the fecal immunochemical test, first screening, and number of personal screens were factors associated with an FP result among screenees.

CONCLUSIONS

The cumulative risk of an FP in colorectal screening using FOBT seems acceptable as the colonoscopy, with its high accuracy, lengthens the time until additional colorectal screening is required, while complication rates remain low.

IMPACT

It is useful to determine the cumulative FP risk in cancer screening for both advising individuals and for health resources planning.

Narrow-Band Imaging for Detection of Neoplasia at Colonoscopy: A Meta-analysis of Data From Individual Patients in Randomized Controlled Trials

BACKGROUND & AIMS

Adenoma detection rate (ADR) is an important quality assurance measure for colonoscopy. Some studies suggest that narrow-band imaging (NBI) may be more effective at detecting adenomas than white-light endoscopy (WLE) when bowel preparation is optimal. We conducted a meta-analysis of data from individual patients in randomized controlled trials that compared the efficacy of NBI to WLE in detection of adenomas.

METHODS

We searched MEDLINE, EMBASE, and Cochrane Library databases through April 2017 for randomized controlled trials that assessed detection of colon polyps by high-definition WLE vs NBI and from which data on individual patients were available. The primary outcome measure was ADR adjusted for bowel preparation quality. Multilevel regression models were used with patients nested within trials, and trial included as a random effect.

RESULTS

We collected data from 11 trials, comprising 4491 patients and 6636 polyps detected. Adenomas were detected in 952 of 2251 (42.3%) participants examined by WLE vs 1011 of 2239 (45.2%) participants examined by NBI (unadjusted odds ratio [OR] for detection of adenoma by WLE vs NBI, 1.14; 95% CI, 1.01-1.29; P = .04). NBI outperformed WLE only when bowel preparation was best: adequate preparation OR, 1.07 (95% CI, 0.92-1.24; P = .38) vs best preparation OR, 1.30 (95% CI, 1.04-1.62; P = .02). Second-generation bright NBI had a better ADR than WLE (second-generation NBI OR, 1.28; 95% CI, 1.05-1.56; P = .02), whereas first-generation NBI did not. NBI detected more non-adenomatous polyps than WLE (OR, 1.24; 95% CI, 1.06-1.44; P = .008) and flat polyps than WLE (OR, 1.24; 95% CI, 1.02-1.51; P = .03).

CONCLUSIONS

In a meta-analysis of data from individual patients in randomized controlled trials, we found NBI to have a higher ADR than WLE, and that this effect is greater when bowel preparation is optimal.