Failure of colonoscopy to detect colorectal cancer: evaluation of 47 cases in 20 hospitals,☆☆,,★★

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Abstract

Background: Colonoscopy is the gold standard for the detection of colon polyps and cancers, but failed detections can occur and the reasons are incompletely understood. Methods: During a retrospective evaluation of the sensitivity of barium enema and colonoscopy in 20 Indiana Hospitals, we encountered 47 cases of colorectal cancer in which a colonoscopy performed within 3 years of the diagnosis had not detected the cancer. Cases were reviewed for location of tumor, extenuating factors, pathologic features, delay in diagnosis from failed detection, and who performed the examination. Results: Failed detection was more likely when colonoscopy was performed by a nongastroenterologist than a gastroenterologist (odds ratio 5:36, 95% CI [2.94,9.77]). Twenty-seven cancers were “missed,” and 20 were estimated to be not reached. However, the location of missed tumors and a general absence of adequate documentation of cecal intubation suggested that some cecal and ascending colon cancers recorded as missed may actually have been not reached. Variation in sensitivity among gastroenterologists suggested that meticulous examination is also important in maximizing sensitivity. Conclusions: These cases suggest several factors that might improve the quality and sensitivity of colonoscopy: (1) examiners should receive adequate training, (2) cecal intubation rates should be high, (3) cecal intubation should be verified by specific landmarks in all cases, (4) failure to reach the cecum should be followed by prompt barium enema, and (5) meticulous examination would appear to improve sensitivity for cancer detection. (Gastrointest Endosc 1997;45:451-5.)

Section snippets

Methods

The study was approved by the Institutional Review Board at Indiana University/Purdue University at Indianapolis, and subsequently by the Institutional Review Boards or ad hoc tumor research committees at all participating hospitals.

Invited hospitals were selected for geographic distribution across central Indiana and for varying hospital size and community size. Data were ultimately collected from a total of 20 hospitals that agreed to participate.

Chart reviews were conducted by

Results

There were 941 colorectal cancer cases in which colonoscopy was used as a primary diagnostic modality. Failure to detect the cancer occurred in 47 cases, for a sensitivity of 95%.

The mean age of the 47 patients was 72 years, compared to 69.8 years for the entire study group. Only 1 patient with a failed detection was under 50 years of age, and 3 were in their sixth decade.

The indications for colonoscopy in cases diagnosed by primary colonoscopy and in cases of failed primary colonoscopy

Discussion

In this report we describe 47 cases of colorectal cancer that were not detected by a colonoscopy performed within 3 years of the date the diagnosis was made. To our knowledge this is the largest reported series of this type. Our findings confirm that while colonoscopy is the gold standard for diagnosis of colonic neoplasia, it is not a perfect test.

We arbitrarily chose a 3-year interval prior to diagnosis to search for procedures that missed the diagnosis of colorectal cancer. This interval

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From the Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana.

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Supported by an Endoscopic Research Award from the American Society for Gastrointestinal Endoscopy.

Reprint requests: Douglas K. Rex, MD, Indiana University Hospital, Room 2300, 550 University Blvd., Indianapolis, IN 46032.

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