Simpler colonoscopies are safer
New research investigates whether physician specialty and experience affect rates of serious adverse events from colonoscopies
Colorectal cancer is the third most common cancer in both men and women and one of the deadliest. But, over the past few decades, more people are preventing and surviving colorectal cancer because of screening to find cancer early, when it’s easier to treat, and to find growths called polyps so they can be removed before they turn into cancer. The most common form of colorectal screening is a colonoscopy, which uses a flexible fiber-optic tube to check for cancer or polyps in the colon or rectum. According to the United States Centers for Disease Control and Prevention (CDC), the number of colonoscopy procedures is expected to surpass 14 million per year, and although colonoscopies are relatively safe, there are risks.
A new study by VCU Massey Cancer Center researchers discovered that as the complexity of colonoscopies increases, a higher risk of adverse events, such as GI bleeding or colonic perforation, are reported. Many factors affect the likelihood of those adverse events, including the surgeon’s colonoscopy volume and the type of the procedure and facility.
Published in the journal Gastrointestinal Endoscopy, the retrospective study was led by Aksar Chukmaitov, M.D., Ph.D., assistant professor in the Department of Healthcare Policy and Research at Virginia Commonwealth University School of Medicine. It analyzed hospitalizations that were linked to colonoscopy procedures that caused serious adverse events within 30 days.
The research found that the risks of adverse events were higher for procedures performed by low-volume endoscopists (less than 300 cases per year). Chukmaitov suggests: “This issue could be addressed by monitoring surgeon volume and by urging primary care physicians to refer patients to experienced endoscopists who perform a high volume of colonoscopies (more than 300 cases per year).”
Regarding facility type, the researchers found that outpatient colonoscopies provided at ambulatory surgery centers (ASCs) were associated with higher risks of adverse events than hospital outpatient departments (HOPDs). One explanation for the observed difference is that ASCs have less stringent quality regulation, oversight and reporting systems in contrast to HOPD’s requirements. “Although, there have been efforts to improve the quality of care in ASC settings,” Chukmaitov explains. “The Department of Health and Human Services recommends that the ASC industry should develop procedure-specific measures to ensure quality across the spectrum.”
The researchers also found that “simple” colonoscopies – ones without polypectomy (surgery to remove polyps) – are associated with the lowest risk of adverse events and that the use of cold biopsy forceps over hot biopsy forceps, when applicable, had better outcomes. As for colonoscopies with polypectomy, ablation (burning the polyps with laser-like devices) was associated with the fewest adverse events.
In summary, Chukmaitov advises endoscopists to weigh the risks and benefits associated with each polypectomy method in each clinical situation, and when clinically appropriate, use lower risk procedures. “Given the large number of colonoscopies performed each year in the United States, a reduction in the rates of adverse events will substantially reduce patient morbidity and mortality as well as health care costs,” he says.
Furthermore, Chukmaitov underscores that despite the risks, colonoscopies can save lives. The American Cancer Society recommends that people who have no identified risk factors should begin regular screening at age 50. Those who have a family history or other risk factors for colorectal polyps or cancer should talk with their doctor about starting screening at a younger age and/or getting screened more frequently. Other forms of screening include: sigmoidoscopy, which checks just the lower colon (rectum); double-contrast barium enema; CT colonography (virtual colonoscopy); fecal occult blood test; and fecal immunochemical test. Patients should consult their physicians to determine the best screening test for them. For more information about colorectal cancer, visit http://www.massey.vcu.edu/type-of-cancer-colorectal.htm.
Chukmaitov collaborated on this research with Cathy J. Bradley, Ph.D., M.P.A., RGC Professor for Cancer Research and co-leader of the Cancer Prevention and Control program at VCU Massey Cancer Center and chair of the Department of Healthcare Policy and Research at the VCU School of Medicine; Bassam Dahman, Ph.D., research member of the Cancer Prevention and Control program at VCU Massey Cancer Center and assistant professor in the Department of Healthcare Policy and Research at the VCU School of Medicine;Umaporn Siangphoe, M.S., VCU School of Medicine;and Joan I. Warren, Ph.D., and Carrie N. Klabunde, Ph.D., from the National Cancer Institute. This research was supported by VCU Massey Cancer Center’s NIH-NCI Cancer Center Support Grant P30 CA016059.
The full manuscript of this study is available online at: http://wp.vcu.edu/masseynews/files/2013/03/Chukmaitov.pdf.
Chukmaitov and his team recently examined whether physician specialty and experience affect the rates of serious adverse events after colonoscopy procedures. Published in the Journal of Surgical Oncology, the researchers discovered that, for simple procedures, physician specialty did not have a negative effect on the rates of serious adverse events and that physicians can learn these techniques by practicing. However, for complex colonoscopies, physician specialty did have an effect on the rates of adverse events. Primary care providers, which include primarily family practice, internal medicine, and a small number of obstetrics/gynecology physicians, who performed colonoscopies had poorer performance outcomes than specialists, such as gastroenterologists. His team recommends cross-training and continuing medical education for primary care providers who provide complex colonoscopy procedures.