Non-compliance in surveillance for patients with previous resection of large (≥ 1 cm) colorectal adenomas

Colonoscopy surveillance following adenoma removal to reduce the risk of colorectal cancer: a retrospective cohort study

BACKGROUND

Colonoscopy surveillance is recommended for some patients post polypectomy. The 2002 UK surveillance guidelines classify post-polypectomy patients into low, intermediate and high risk, and recommend different strategies for each classification. Limited evidence supports these guidelines.

OBJECTIVES

To examine, for each risk group, long-term colorectal cancer incidence by baseline characteristics and the number of surveillance visits; the effects of interval length on detection rates of advanced adenomas and colorectal cancer at first surveillance; and the cost-effectiveness of surveillance compared with no surveillance.

DESIGN

A retrospective cohort study and economic evaluation.

SETTING

Seventeen NHS hospitals.

PARTICIPANTS

Patients with a colonoscopy and at least one adenoma at baseline.

MAIN OUTCOME MEASURES

Long-term colorectal cancer incidence after baseline and detection rates of advanced adenomas and colorectal cancer at first surveillance.

DATA SOURCES

Hospital databases, NHS Digital, the Office for National Statistics, National Services Scotland and Public Health England.

METHODS

Cox regression was used to compare colorectal cancer incidence in the presence and absence of surveillance and to identify colorectal cancer risk factors. Risk factors were used to stratify risk groups into higher- and lower-risk subgroups. We examined detection rates of advanced adenomas and colorectal cancer at first surveillance by interval length. Cost-effectiveness of surveillance compared with no surveillance was evaluated in terms of incremental costs per colorectal cancer prevented and per quality-adjusted life-year gained.

RESULTS

Our study included 28,972 patients, of whom 14,401 (50%), 11,852 (41%) and 2719 (9%) were classed as low, intermediate and high risk, respectively. The median follow-up time was 9.3 years. Colorectal cancer incidence was 140, 221 and 366 per 100,000 person-years among low-, intermediate- and high-risk patients, respectively. Attendance at one surveillance visit was associated with reduced colorectal cancer incidence among low-, intermediate- and high-risk patients [hazard ratios were 0.56 (95% confidence interval 0.39 to 0.80), 0.59 (95% confidence interval 0.43 to 0.81) and 0.49 (95% confidence interval 0.29 to 0.82), respectively]. Compared with the general population, colorectal cancer incidence without surveillance was similar among low-risk patients and higher among high-risk patients [standardised incidence ratios were 0.86 (95% confidence interval 0.73 to 1.02) and 1.91 (95% confidence interval 1.39 to 2.56), respectively]. For intermediate-risk patients, standardised incidence ratios differed for the lower- (0.70, 95% confidence interval 0.48 to 0.99) and higher-risk (1.46, 95% confidence interval 1.19 to 1.78) subgroups. In each risk group, incremental costs per colorectal cancer prevented and per quality-adjusted life-year gained with surveillance were lower for the higher-risk subgroup than for the lower-risk subgroup. Incremental costs per quality-adjusted life-year gained were lowest for the higher-risk subgroup of high-risk patients at £7821.

LIMITATIONS

The observational design means that we cannot assume that surveillance caused the reductions in cancer incidence. The fact that some cancer staging data were missing places uncertainty on our cost-effectiveness estimates.

CONCLUSIONS

Surveillance was associated with reduced colorectal cancer incidence in all risk groups. However, in low-risk patients and the lower-risk subgroup of intermediate-risk patients, colorectal cancer incidence was no higher than in the general population without surveillance, indicating that surveillance might not be necessary. Surveillance was most cost-effective for the higher-risk subgroup of high-risk patients.

FUTURE WORK

Studies should examine the clinical effectiveness and cost-effectiveness of post-polypectomy surveillance without prior classification of patients into risk groups.

TRIAL REGISTRATION

This trial is registered as ISRCTN15213649.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 26. See the NIHR Journals Library website for further project information.

Long-term colorectal cancer incidence after adenoma removal and the effects of surveillance on incidence: a multicentre, retrospective, cohort study

OBJECTIVE

Postpolypectomy colonoscopy surveillance aims to prevent colorectal cancer (CRC). The 2002 UK surveillance guidelines define low-risk, intermediate-risk and high-risk groups, recommending different strategies for each. Evidence supporting the guidelines is limited. We examined CRC incidence and effects of surveillance on incidence among each risk group.

DESIGN

Retrospective study of 33 011 patients who underwent colonoscopy with adenoma removal at 17 UK hospitals, mostly (87%) from 2000 to 2010. Patients were followed up through 2016. Cox regression with time-varying covariates was used to estimate effects of surveillance on CRC incidence adjusted for patient, procedural and polyp characteristics. Standardised incidence ratios (SIRs) compared incidence with that in the general population.

RESULTS

After exclusions, 28 972 patients were available for analysis; 14 401 (50%) were classed as low-risk, 11 852 (41%) as intermediate-risk and 2719 (9%) as high-risk. Median follow-up was 9.3 years. In the low-risk, intermediate-risk and high-risk groups, CRC incidence per 100 000 person-years was 140 (95% CI 122 to 162), 221 (195 to 251) and 366 (295 to 453), respectively. CRC incidence was 40%-50% lower with a single surveillance visit than with none: hazard ratios (HRs) were 0.56 (95% CI 0.39 to 0.80), 0.59 (0.43 to 0.81) and 0.49 (0.29 to 0.82) in the low-risk, intermediate-risk and high-risk groups, respectively. Compared with the general population, CRC incidence without surveillance was similar among low-risk (SIR 0.86, 95% CI 0.73 to 1.02) and intermediate-risk (1.16, 0.97 to 1.37) patients, but higher among high-risk patients (1.91, 1.39 to 2.56).

CONCLUSION

Postpolypectomy surveillance reduces CRC risk. However, even without surveillance, CRC risk in some low-risk and intermediate-risk patients is no higher than in the general population. These patients could be managed by screening rather than surveillance.

Recurrence with malignancy after endoscopic resection of large colon polyps with high-grade dysplasia: incidence and risk factors

BACKGROUND

In the West, piecemeal endoscopic resection remains the primary treatment for large colon polyps (LCP), as most recurrences are believed to be benign and resectable with follow-up endoscopy. However, invasive malignancy at the site of prior piecemeal endoscopic mucosal resection has been reported in the Asian literature. This study aims to identify the incidence of and the risk factors for local recurrence with malignancy after endoscopic resection of LCP with high-grade dysplasia (HGD).

METHODS

In this retrospective cohort study, we identified patients undergoing complete endoscopic resection of LCPs (≥ 20 mm) with HGD at the Cleveland Clinic between January 2000 and December 2016. Demographic, endoscopic, and pathologic data were collected. All subsequent endoscopic and pathology reports were reviewed to identify recurrence. The cumulative incidence of malignancy at the polypectomy site was determined and univariate analysis was performed to assess risk factors.

RESULTS

A total of 254 LCPs with HGD were resected in 229 patients. Mean polyp size was 29.2 mm. There were 138 lesions resected in piecemeal fashion and 116 en-bloc. After a median follow-up of 28.7 months for the entire cohort, local recurrence with malignancy was diagnosed in six cases. Median time to malignancy diagnosis was 28.5 months. All malignant cases occurred after piecemeal resection and none after en-bloc resection (HR 11.4; 95% CI 0.48-273).

CONCLUSION

Malignancy after endoscopic resection of LCPs with HGD is uncommon and may be associated with piecemeal resection. When possible, en-bloc resection should be the goal for the management of LCPs.

The clinical effectiveness of different surveillance strategies to prevent colorectal cancer in people with intermediate-grade colorectal adenomas: a retrospective cohort analysis, and psychological and economic evaluations

BACKGROUND

The UK guideline recommends 3-yearly surveillance for patients with intermediate-risk (IR) adenomas. No study has examined whether or not this group has heterogeneity in surveillance needs.

OBJECTIVES

To examine the effect of surveillance on colorectal cancer (CRC) incidence; assess heterogeneity in risk; and identify the optimum frequency of surveillance, the psychological impact of surveillance, and the cost-effectiveness of alternative follow-up strategies.

DESIGN

Retrospective multicentre cohort study.

SETTING

Routine endoscopy and pathology data from 17 UK hospitals (n = 11,944), and a screening data set comprising three pooled cohorts (n = 2352), followed up using cancer registries.

SUBJECTS

Patients with IR adenoma(s) (three or four small adenomas or one or two large adenomas).

PRIMARY OUTCOMES

Advanced adenoma (AA) and CRC detected at follow-up visits, and CRC incidence after baseline and first follow-up.

METHODS

The effects of surveillance on long-term CRC incidence and of interval length on findings at follow-up were examined using proportional hazards and logistic regression, adjusting for patient, procedural and polyp characteristics. Lower-intermediate-risk (LIR) subgroups and higher-intermediate-risk (HIR) subgroups were defined, based on predictors of CRC risk. A model-based cost-utility analysis compared 13 surveillance strategies. Between-group analyses of variance were used to test for differences in bowel cancer worry between screening outcome groups (n = 35,700). A limitation of using routine hospital data is the potential for missed examinations and underestimation of the effect of interval and surveillance.

RESULTS

In the hospital data set, 168 CRCs occurred during 81,442 person-years (pys) of follow-up [206 per 100,000 pys, 95% confidence interval (CI) 177 to 240 pys]. One surveillance significantly lowered CRC incidence, both overall [hazard ratio (HR) 0.51, 95% CI 0.34 to 0.77] and in the HIR subgroup (n = 9265; HR 0.50, 95% CI 0.34 to 0.76). In the LIR subgroup (n = 2679) the benefit of surveillance was less clear (HR 0.62, 95% CI 0.16 to 2.43). Additional surveillance lowered CRC risk in the HIR subgroup by a further 15% (HR 0.36, 95% CI 0.20 to 0.62). The odds of detecting AA and CRC at first follow-up (FUV1) increased by 18% [odds ratio (OR) 1.18, 95% CI 1.12 to 1.24] and 32% (OR 1.32, 95% CI 1.20 to 1.46) per year increase in interval, respectively, and the odds of advanced neoplasia at second follow-up increased by 22% (OR 1.22, 95% CI 1.09 to 1.36), after adjustment. Detection rates of AA and CRC remained below 10% and 1%, respectively, with intervals to 3 years. In the screening data set, 32 CRCs occurred during 25,745 pys of follow-up (124 per 100,000 pys, 95% CI 88 to 176 pys). One follow-up conferred a significant 73% reduction in CRC incidence (HR 0.27, 95% CI 0.10 to 0.71). Owing to the small number of end points in this data set, no other outcome was significant. Although post-screening bowel cancer worry was higher in people who were offered surveillance, worry was due to polyp detection rather than surveillance. The economic evaluation, using data from the hospital data set, suggested that 3-yearly colonoscopic surveillance without an age cut-off would produce the greatest health gain.

CONCLUSIONS

A single surveillance benefited all IR patients by lowering their CRC risk. We identified a higher-risk subgroup that benefited from further surveillance, and a lower-risk subgroup that may require only one follow-up. A surveillance interval of 3 years seems suitable for most IR patients. These findings should be validated in other studies to confirm whether or not one surveillance visit provides adequate protection for the lower-risk subgroup of intermediate-risk patients.

STUDY REGISTRATION

Current Controlled Trials ISRCTN15213649.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Knowledge of Polyp History and Recommended Follow-Up Among a Predominately African American Patient Population and the Impact of Patient Navigation

BACKGROUND AND AIMS

Colorectal screening (CRS) rates in minority and uninsured populations have increased through patient navigation (PN) interventions. However, patient knowledge of colonoscopy results and follow-up recommendations has not been described in an African American (AA) population or following PN. Our objectives were to determine patient knowledge of colonoscopy results and follow-up recommendations within an AA patient population and to compare post-colonoscopy knowledge among patients who received either PN or usual care.

METHODS

This is a prospective observational study of patients who completed a screening colonoscopy in 2014. A semi-structured telephone survey was completed by 96 participants (69 % AA, 78 % female, and mean age 63 years). The survey assessed patient recall of polyp results and follow-up recommendations. Responses were compared with the medical record.

RESULTS

Of 96 patients surveyed (response rate, 68 %), 83 % accurately reported if polyps were detected and 66 % accurately reported their recommended follow-up. The identification of adenomatous polyps on colonoscopy was a predictor of accurate recall of colonoscopy results and follow-up recommendations. Uninsured patients who completed PN (18 of 96) were more likely to accurately report polyp results (100 vs. 80 %; P = 0.036), but the rates of accurate follow-up recall were not statistically significant (44 vs. 71 %; P = 0.053) when compared to usual care patients.

CONCLUSIONS

In an AA population, post-colonoscopy polyp recall rates were similar to those described in white populations. Uninsured patients who completed PN were more likely than insured usual care patients to accurately report the presence of polyps on colonoscopy.

Colonoscopy quality: metrics and implementation

Colonoscopy is an excellent area for quality improvement because it is high volume, has significant associated risk and expense, and there is evidence that variability in its performance affects outcomes. The best end point for validation of quality metrics in colonoscopy is colorectal cancer incidence and mortality, but a more readily accessible metric is the adenoma detection rate. Fourteen quality metrics were proposed in 2006, and these are described in this article. Implementation of quality improvement initiatives involves rapid assessments and changes on an iterative basis, and can be done at the individual, group, or facility level.

Physician recommendations and patient adherence after inadequate bowel preparation on screening colonoscopy

BACKGROUND AND AIMS

It has been suggested that bowel preparation quality may influence decision-making about appropriate follow-up interval after screening colonoscopy. We sought: (1) to assess physician recommendations for timing of subsequent colonoscopy in average-risk patients with inadequate bowel preparation on initial screening, and (2) to measure the association between physician recommendations and patient adherence to repeat colonoscopy.

METHODS

Patients undergoing average-risk screening colonoscopy from 2004 to 2009 found to have inadequate bowel preparation were identified. Physician recommendations for timing of subsequent colonoscopy and patient adherence to repeat colonoscopy were assessed through examination of endoscopy records. Data from repeat colonoscopies were collected through August 2010.

RESULTS

There were 373 patients with inadequate bowel preparation on initial screening colonoscopy. There was a wide range of physician recommendations for timing of repeat colonoscopy: next day (4.6 % of patients), 2 days to 6 months (9.9 %), 7 months to 1 year (34.0 %), 2-5 years (38.3 %), 6-10 years (5.1 %), and timing not specified (8.0 %). Physicians were significantly more likely to recommend repeat colonoscopy within 1 year if any polyps were detected (OR = 2.2, p = 0.001). Patients instructed to have next day follow-up were significantly more likely to adhere to the recommendation compared to patients who were instructed to return after longer intervals (OR 4.4, p = 0.005).

CONCLUSIONS

Patients with inadequate bowel preparation on screening colonoscopy were subject to a wide range of physician recommendations for follow-up. Patient adherence to physician recommendations was significantly higher when repeat colonoscopy was recommended the next day.

Patients do not recall important details about polyps, required for colorectal cancer prevention

BACKGROUND & AIMS

Guidelines recommend that the age of initiation and frequency of colorectal cancer screening or surveillance be based on patients' personal and family histories of colorectal neoplasia. However, it is not clear whether patients accurately recall results from their colonoscopy examinations or features of specific polyps.

METHODS

Between 2008 and 2011, a 35-question survey was given to outpatients at the Digestive Disease Institute at the Cleveland Clinic who had previously undergone colonoscopy there. We collected responses from 233 participants (mean age, 59 y; 49% male); they provided demographic information, along with responses to questions on past colonoscopies, personal and family history of colorectal neoplasia, detection of polyps by colonoscopy, and number and other key features of polyps detected. Patient responses were compared with medical records.

RESULTS

Of the patients surveyed, 82% correctly recalled the presence or absence of polyp(s). Of the 118 who correctly reported having polyps, 61% correctly recalled the number, 26% recalled the size, and 6%-33% recalled features of polyp pathology. Only 8% of individuals correctly recalled all 3 key features of polyps (size, number, and pathology). The patients' age when they underwent colonoscopy, current age, sex, education, or method by which they received their colonoscopy results did not significantly affect the accuracy with which they recalled the presence or key features of polyps.

CONCLUSIONS

Eighty-two percent of patients examined by colonoscopy correctly recalled whether or not they had polyp(s). However, most patients did not recall key details about their polyps (number, size, or pathology features) required to establish appropriate screening and surveillance intervals. New tools are needed to ensure that patients understand the importance of their colonoscopy findings and improve their recall accuracy.

Predictors of colorectal polyp recurrence after the first polypectomy in private practice settings: a cohort study

Background

Supplementary observational data in the community setting are required to better assess the predictors of colorectal polyp recurrence and the effectiveness of colonoscopy surveillance under real circumstances.

Aim

The goal of this study was to identify patient characteristics and polyp features at baseline colonoscopy that are associated with the recurrence of colorectal polyps (including hyperplastic polyps) among patients consulting private practice physicians.

Patients and Methods

This cohort study was conducted from March 2004 to December 2010 in 26 private gastroenterology practices (France). It included 1023 patients with a first-time diagnosis of histologically confirmed polyp removed during a diagnostic or screening colonoscopy. At enrollment, interviews were conducted to obtain data on socio-demographic variables and risk factors. Pathology reports were reviewed to abstract data on polyp features at baseline colonoscopy. Colorectal polyps diagnosed at the surveillance colonoscopy were considered as end points. The time to event was analyzed with an accelerated failure time model assuming a Weibull distribution.

Results

Among the 1023 patients with colorectal polyp at baseline, 553 underwent a surveillance colonoscopy. The mean time interval from baseline colonoscopy to first surveillance examination was 3.42 (standard deviation, 1.45) years. The recurrence rates were 50.5% and 32.9% for all polyps and adenomas, respectively. In multivariate models, the number of polyps at baseline was the only significant predictor for both polyp recurrence (hazard ratio [HR] 1.19, 95% CI 1.06 to 1.33), and adenoma recurrence (HR 1.17, 95% CI 1.03 to 1.34).

Conclusion

The efficacy of surveillance colonoscopy in community gastroenterology practice compared favorably with academic settings. This study provides further evidence that the number of initial colorectal polyps is useful for predicting the risk of polyp recurrence, even in the community setting.

Awareness of surveillance recommendations among patients with colorectal adenomas

BACKGROUND & AIMS

The efficacy of colorectal cancer screening programs depends on the rate of attendance at surveillance colonoscopy examinations. Increasing patients' awareness about the importance of surveillance might improve attendance, but it is not clear how much they know about their follow-up recommendations. We assessed the awareness of patients with adenomas about their surveillance recommendations.

METHODS

Ten endoscopy departments provided access to their colonoscopy database for quality assurance; 2 datasets were obtained. We analyzed data from 4000 colonoscopies (400 per department) performed on patients with adenomas. All the patients were mailed a survey to determine how much information they had about their colonoscopy results and their follow-up recommendations. Data from 549 patients were included in the analysis. We also assessed surveillance attendance among 500 patients (50 per department) who had adenomas removed.

RESULTS

Of the patients analyzed, 85% recalled retrieval of polyps during their colonoscopy, and 85% recalled whether they needed surveillance or not. The indication for surveillance was recalled by 69% of patients (range between departments, 55%-83%; P < .01). Factors that were associated with awareness of recommendations were younger age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.06-1.09), treatment by a gastroenterologist (OR, 5.53; 95% CI, 3.28-9.32), and presence of 3 or more adenomas (OR, 2.97; 95% CI, 1.29-6.85). Attendance among patients with adenomas varied among departments, from 60% to 89% (P < .01), and was not associated with awareness of patients about their recommendations per department (P = .59).

CONCLUSIONS

Not enough patients (only 85%) who receive colonoscopies are aware of their results or surveillance recommendations. Although awareness of findings and recommendations did not correlate with follow-up attendance, patients should be better informed about findings and their need for surveillance.

Importance of postpolypectomy surveillance and postpolypectomy compliance to follow-up screening--review of literature

INTRODUCTION

Approximately 150,000 people are diagnosed with colorectal cancer each year and 56,000 may die from it annually in the United States. Colorectal cancer is the second leading cause of cancer deaths in the USA and yet, when diagnosed at an early stage, it is one of the most preventable cancers. According to the US Preventive Services Task Force, initial screening for colorectal cancer is recommended in people above 50 years of age with average risk and earlier in people with a strong family history and other risk factors. Adenomatous polyps are considered as precursors of colorectal cancer. Removal of polyps and postpolypectomy surveillance reduces the overall mortality from colorectal cancer.

DISCUSSION

According to updated guidelines in 2006, a 3-year-follow-up colonoscopy is recommended in patients with adenomatous polyps>or=1 cm. An important factor in the surveillance and prevention of colorectal cancer in postpolypectomy patients is compliance with follow-up colonoscopy. In the present article, we provide an overview of the importance of postpolypectomy surveillance and summarize the compliance data for postpolypectomy surveillance. Compliance to postpolypectomy surveillance varies from one study to another and it should be expected that the compliance with follow-up would be low outside of clinical trials. Some measures that can improve patient compliance include patient education regarding a need of follow-up screening, reminder letters, and alerts in patient's charts.

CONCLUSION

In conclusion, effective surveillance screening with good patient compliance in postpolypectomy patients will contribute significantly in reducing colon cancer morbidity and mortality.