Digestive EndoscopyInter-centre variability of the adenoma detection rate: A prospective, multicentre study
Introduction
Colorectal cancer (CRC) is a major cause of morbidity and mortality [1]. Colonoscopy is highly effective in detecting advanced neoplasia, and CRC prevention by endoscopic polypectomy reduces disease-specific incidence and mortality [2]. As such, its use as a preferred screening and diagnostic strategy is supported by official guidelines [3].
The long-term efficacy of colonoscopy in preventing CRC incidence and/or mortality has been addressed in cohort and case-control studies [2], [4], [5], [6], [7], [8], [9]. Although the majority of these studies showed a very high CRC prevention rate [2], [4], [5], [6], [7], some studies showed a suboptimal CRC protection rate [8], [9], [10]. This appeared to be related to an unexpectedly high risk of post-colonoscopy CRC in the early years after colonoscopy. In a large administrative cohort of patients with negative colonoscopy, the CRC prevention rate appeared to be markedly higher when assessed 10 years after colonoscopy rather than after 5 years – i.e. 72% vs. 41% – because of the unexpected occurrence of interval cancer in the early years following colonoscopy [9]. In a large case-control study, Baxter et al. showed a substantially lower CRC mortality prevention rate in the first 2 years following colonoscopy compared with the following period [8]. The higher risk of post-colonoscopy CRC also appeared to be better represented in the proximal than in the distal colon [9], [11], [12].
The quality of colonoscopy has been strictly related to the risk of post-colonoscopy CRC [13]. In large administrative cohort or case-control studies, the risk of interval cancer – including its proximal localization – appeared to be independently predicted by a relatively low rate of polyp/adenoma detection [12], [14], [15], [16]. It was similarly lower when the adenoma/polyp detection rates of the selected endoscopist were ranked as moderate to high [14], [15], [16], [17].
Only a few studies addressed the variability of the polyp/adenoma detection rate within the endoscopic community. Although these studies usually showed a high degree of variability in the polyp/adenoma detection rate with a wide range of 10–40% among different endoscopists, whether there is also inter-centre variability in the adenoma detection rate is still controversial [18], [19]. This may be relevant when considering that an endoscopic centre usually has two or more endoscopists, which are simpler to monitor than a single endoscopist.
Although in Italy the National Health System is running a screening programme with immunochemical faecal testing, no systematic approach to monitoring or improving colonoscopy quality has yet been implemented. Moreover, although nurses are not yet allowed to perform colonoscopy, all physicians are, irrespectively of their specialty. This would appear to be an ideal scenario for assessing whether any intervention would really be needed.
The aim of our prospective, multicentre study was to measure the inter-centre variability in the adenoma detection rate in a large unselected endoscopic population, and whether such variability was explained by patient- or endoscopist-related variables.
Section snippets
Materials and methods
A prospective, multicentre study involving 28 open-access Endoscopy Units, uniformly distributed throughout Italy, was performed between March and October 2010. According to the protocol, all patients referred to the participating centres for routine colonoscopy over 1 month were prospectively enrolled. Patients were excluded only when referred for emergency colonoscopy. Colonoscopies were performed according to predefined weekly schedules, the referring physicians being unaware of the purpose
Study population
A cohort of 3150 (males: 52%; mean age: 60 years, range 19–95 years) patients were included in the 28 centres. The median number of patients included in each centre was 100 (range: 48–281). A positive family history was present in 604 patients (19%). BMI was <25 in 1386 (44%), and was ≥25 in the remaining cases. A history of smoking or alcohol consumption was reported by 1050 (33%) and 1087 (35%) patients respectively. The clinical indication for colonoscopy was an alarm symptom or sign in 944
Discussion
According to our study, there is a substantial variability in the detection rate of both neoplasia and advanced neoplasia among different endoscopic centres. The detection rate of colorectal lesions depends not only on endoscopist performance, it is also affected by the prevalence rate of neoplastic lesions. For this reason, we adjusted the expected prevalence of colorectal lesions for each centre, according to the patient-related factors identified by the logistic regression model in our study
Conflict of interest
None declared.
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On behalf of the Quality SIED Group. See Appendix A.