Variations in the management of significant polyps and early colorectal cancer: results from a multicentre observational study of 383 patients.

AIM: The concept of significant polyps and early colorectal cancer (SPECC) encompasses complex polyps not amenable to routine snare polypectomy or where malignancy cannot be excluded. Surgical resection (SR) offers definitive treatment, but is overtreatment for the majority which are benign and amenable to less invasive endoscopic resection (ER). The aim of this study was to investigate variations in the management and outcomes of significant colorectal polyps. METHOD: This was a retrospective observational study of significant colorectal polyps, defined as nonpedunculated lesions of ≥ 20 mm size, diagnosed across nine UK hospitals in 2014. Inclusion criteria were endoscopically or histologically benign polyps at biopsy. RESULTS: A total of 383 patients were treated by primary ER (87.2%) or SR (12.8%). Overall, 108/383 (28%) polyps were detected in the Bowel Cancer Screening Programme (BCSP). Primary SR was associated with a significantly longer length of stay and major complications (P < 0.01). Of the ER polyps, 290/334 (86.8%) patients were treated without undergoing surgery. The commonest indication for secondary surgery was unexpected polyp cancer, and of these cases 60% had no residual cancer in the specimen. Incidence of unexpected cancer was 10.7% (n = 41) and was similar between ER and SR groups (P = 0.11). On multivariate analysis, a polyp size of > 30 mm and non-BCSP status were independent risk factors for primary SR [OR 2.51 (95% CI 1.08-5.82), P = 0.03]. CONCLUSION: ER is safe and feasible for treating significant colorectal polyps. Robust accreditation within the BCSP has led to improvements in management, with lower rates of SR compared with non-BCSP patients. Standardization, training in polyp assessment and treatment within a multidisciplinary team may help to select appropriate treatment strategies and improve outcomes.

Report of the Association of Coloproctology of Great Britain and Ireland/British Society of Gastroenterology Colorectal Polyp Working Group: the development of a complex colorectal polyp minimum dataset.

AIM: The management of large non-pedunculated colorectal polyps (LNPCPs) is complex, with widespread variation in management and outcome, even amongst experienced clinicians. Variations in the assessment and decision-making processes are likely to be a major factor in this variability. The creation of a standardized minimum dataset to aid decision-making may therefore result in improved clinical management. METHOD: An official working group of 13 multidisciplinary specialists was appointed by the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the British Society of Gastroenterology (BSG) to develop a minimum dataset on LNPCPs. The literature review used to structure the ACPGBI/BSG guidelines for the management of LNPCPs was used by a steering subcommittee to identify various parameters pertaining to the decision-making processes in the assessment and management of LNPCPs. A modified Delphi consensus process was then used for voting on proposed parameters over multiple voting rounds with at least 80% agreement defined as consensus. The minimum dataset was used in a pilot process to ensure rigidity and usability. RESULTS: A 23-parameter minimum dataset with parameters relating to patient and lesion factors, including six parameters relating to image retrieval, was formulated over four rounds of voting with two pilot processes to test rigidity and usability. CONCLUSION: This paper describes the development of the first reported evidence-based and expert consensus minimum dataset for the management of LNPCPs. It is anticipated that this dataset will allow comprehensive and standardized lesion assessment to improve decision-making in the assessment and management of LNPCPs.

Definition and taxonomy of interval colorectal cancers: a proposal for standardising nomenclature.

OBJECTIVE: Interval colorectal cancers (interval CRCs), that is, cancers occurring after a negative screening test or examination, are an important indicator of the quality and effectiveness of CRC screening and surveillance. In order to compare incidence rates of interval CRCs across screening programmes, a standardised definition is required. Our goal was to develop an internationally applicable definition and taxonomy for reporting on interval CRCs. DESIGN: Using a modified Delphi process to achieve consensus, the Expert Working Group on interval CRC of the Colorectal Cancer Screening Committee of the World Endoscopy Organization developed a nomenclature for defining and characterising interval CRCs. RESULTS: We define an interval CRC as a "colorectal cancer diagnosed after a screening or surveillance exam in which no cancer is detected, and before the date of the next recommended exam". Guidelines and principles for describing and reporting on interval CRCs are provided, and clinical scenarios to demonstrate the practical application of the nomenclature are presented. CONCLUSIONS: The Working Group on interval CRC of the World Endoscopy Organization endorses adoption of this standardised nomenclature. A standardised nomenclature will facilitate benchmarking and comparison of interval CRC rates across programmes and regions.

Management of complex colonic polyps in the English Bowel Cancer Screening Programme.

BACKGROUND: Large sessile or flat colonic polyps, defined as polyps at least 20 mm in size, are difficult to treat endoscopically and may harbour malignancy. The aim of this study was to describe their current management to provide insight into optimal management. METHODS: This retrospective observational study identified patients with large sessile or flat polyps detected in the English Bowel Cancer Screening Programme between 2006 and 2009. Initial therapeutic modality (surgical or endoscopic), subsequent management and outcomes were recorded. The main outcome measures analysed were: presence of malignancy, need for surgical treatment, complications, and residual or recurrent polyp at 12 months. RESULTS: In total, 557 large sessile or flat polyps with benign appearance or initial histology were identified in 557 patients. Some 436 (78.3 per cent) were initially managed endoscopically and 121 (21.7 per cent) were managed surgically from the outset. Seventy of those initially treated endoscopically subsequently required surgery owing to the presence of malignancy (19) or not being suitable for further endoscopic management (51). Residual or recurrent polyp was present at 12 months in 26 (6.0 per cent) of 436 patients managed endoscopically. There was wide variation between centres in the use of surgery as a primary therapy, ranging from 7 to 36 per cent. Endoscopic complications included bleeding in 13 patients (3.0 per cent) and perforation in two (0.5 per cent). CONCLUSION: Management of large sessile or flat colonic polyps is safe and effective in the English Bowel Cancer Screening Programme. Wide variation in the use of surgery suggests a need for standardized management algorithms. Presented to a meeting of the British Society of Gastroenterology, Birmingham, U.K., March 2011.

Longer mean colonoscopy withdrawal time is associated with increased adenoma detection: evidence from the Bowel Cancer Screening Programme in England.

BACKGROUND AND STUDY AIMS: Increasing colonoscopy withdrawal time (CWT) is thought to be associated with increasing adenoma detection rate (ADR). Current English guidelines recommend a minimum CWT of 6 minutes. It is known that in the Bowel Cancer Screening Programme (BCSP) in England there is wide variation in CWT. The aim of this observational study was to examine the relationship between CWT and ADR. PATIENTS AND METHODS: The study examined data from 31 088 colonoscopies by 147 screening program colonoscopists. Colonoscopists were grouped in four levels of mean CWT ( < 7, 7 - 8.9, 9 - 10.9, and ≥ 11 minutes). Univariable and multivariable analysis (binary logistic and negative binomial regression) were used to explore the relationship between CWT, ADR, mean number of adenomas and number of right-sided and advanced adenomas. RESULTS: In colonoscopists with a mean CWT < 7 minutes, the mean ADR was 42.5 % compared with 47.1 % in the ≥ 11-minute group (P < 0.001). The mean number of adenomas detected per procedure increased from 0.77 to 0.94, respectively (P < 0.001). The increase in adenoma detection was mainly of subcentimeter or proximal adenomas; there was no increase in the detection of advanced adenomas. Regression models showed an increase in ADR from 43 % to 46.5 % for mean CWT times ranging from 6 to 10 minutes. CONCLUSIONS: This study demonstrates that longer mean withdrawal times are associated with increasing adenoma detection, mainly of small or right-sided adenomas. However, beyond 10 minutes the increase in ADR is minimal. Mean withdrawal times longer than 6 minutes are not associated with increased detection of advanced adenomas. Withdrawal time remains an important quality metric of colonoscopy.

Management and short-term outcome of malignant colorectal polyps in the north of England(1).

AIM: Management of malignant colorectal polyps (MCP) is contentious, with no randomized controlled trials comparing endoscopic with surgical management. This study reviews the management and outcomes of MCPs across a UK region. METHOD: Patients with a malignant polyp were identified using the NORCCAG (NORthern Colorectal Cancer Audit Group) database between April 2006 and July 2010. All histopathology reports and follow-up procedures were reviewed. RESULTS: Of 386 patients identified, 165 (42.7%) had the polyp biopsied and 221 (57.3%) had an endoscopic local excision (37 piecemeal excision, 184 polypectomy). All patients having an endoscopic biopsy underwent surgery. 103 (46.6%) having a local excision had follow-up surgery, of whom 79 (76.7%) had no residual cancer. Of the 118 patients managed endoscopically, none had residual cancer on follow-up endoscopy. The 21 (5.4%) Dukes C cancers were associated with Kikuchi SM3/Haggitt 4 lesions (χ(2) =10.85, P=0.005) and lesions with an involved/unsure excision margin (χ(2) =7.44, P=0.017). Predictors of finding residual tumour at surgery after local excision were Kikuchi SM3/Haggitt Level 4 (χ(2) =17.07, P<0.001) and an involved/unsure excision margin (χ(2) =20.45, P<0.001). An excision margin >0 mm was associated with the finding of no residual tumour (χ(2) =25.21, P<0.001). There was no difference in survival between surgical and endoscopic management (χ(2) =0.634, P=0.426) after a mean follow-up of 25.1 months. CONCLUSION: Endoscopic management of a subgroup of MCPs appears safe. A clear resection margin (>0 mm) appears sufficient to avoid surgery, except in locally advanced lesions (Kikuchi 3/Haggitt 4) which have a greater risk of residual cancer at surgery and lymph node metastasis.

Outcome of 12-month surveillance colonoscopy in high-risk patients in the National Health Service Bowel Cancer Screening Programme.

AIM: Current British guidelines recommend surveillance colonoscopy at 12 months for individuals found to have five or more adenomas, or three or more adenomas of which at least one is ≥ 1 cm in size. This study describes the yield of surveillance colonoscopy in this group and explores patient and clinical factors that may be associated with the presence of advanced adenomas or cancer at surveillance. METHOD: Data were retrieved from the national database of the National Health Service Bowel Cancer Screening Programme. The detection of advanced colonic neoplasia (ACN, cancer or advanced adenoma) was used as the main outcome variable. Multivariable analysis was used to analyse relationships between patient factors (age, gender, body mass index, smoking and alcohol use) and clinical findings (number, size and nature of adenomas detected during index colonoscopy) with the outcome variable. RESULTS: One-thousand, seven-hundred and sixty individuals were included in the study. The yield of ACN at 12-month surveillance was 6.6% (116/1760), of which 14/1760 (0.8%) had colorectal cancer. Nine (64.3%) of these 14 cancers were Dukes A at diagnosis. The presence of a villous adenoma or a right-sided adenoma at screening colonoscopy was associated with ORs of 1.98 (95% CI: 1.11-3.53, P = 0.012) and 1.76 (95% CI: 1.13-2.74, P = 0.020), respectively, for detection of ACN at surveillance. CONCLUSION: Twelve-month surveillance colonoscopy is necessary in this group of patients. The presence of villous or proximal lesions at baseline is associated with increased risk of ACN at surveillance. Site and histological type of baseline lesions may be relevant for determining the surveillance interval.

A retrospective observational study examining the characteristics and outcomes of tumours diagnosed within and without of the English NHS Bowel Cancer Screening Programme.

BACKGROUND: Colorectal cancer is common in England and, with long-term survival relatively poor, improving outcomes is a priority. A major initiative to reduce mortality from the disease has been the introduction of the National Health Service (NHS) Bowel Cancer Screening Programme (BCSP). Combining data from the BCSP with that in the National Cancer Data Repository (NCDR) allows all tumours diagnosed in England to be categorised according to their involvement with the BCSP. This study sought to quantify the characteristics of the tumours diagnosed within and outside the BCSP and investigate its impact on outcomes. METHODS: Linkage of the NCDR and BCSP data allowed all tumours diagnosed between July 2006 and December 2008 to be categorised into four groups; screen-detected tumours, screening-interval tumours, tumours diagnosed in non-participating invitees and tumours diagnosed in those never invited to participate. The characteristics, management and outcome of tumours in each category were compared. RESULTS: In all, 76 943 individuals were diagnosed with their first primary colorectal cancer during the study period. Of these 2213 (2.9%) were screen-detected, 623 (0.8%) were screening-interval cancers, 1760 (2.3%) were diagnosed in individuals in non-participating invitees and 72 437 (94.1%) were diagnosed in individuals not invited to participate in the programme due to its ongoing roll-out over the time period studied. Screen-detected tumours were identified at earlier Dukes' stages, were more likely to be managed with curative intent and had significantly better outcomes than tumours in other categories. CONCLUSION: Screen-detected cancers had a significantly better prognosis than other tumours and this would suggest that the BCSP should reduce mortality from colorectal cancer in England.

Lower gastrointestinal symptoms are prevalent among individuals colonoscoped within the Bowel Cancer Screening Programme.

AIM: The National Health Service Bowel Cancer Screening Programme (BCSP) aims to detect earlier stage cancer in asymptomatic individuals. Early experience suggested that many participants had lower gastrointestinal symptoms before screening. The study evaluated the prevalence of lower gastrointestinal symptoms and consultation behaviour among individuals undergoing colonoscopy at the South of Tyne BCSP Centre. METHOD: Data were collected on all undergoing clinic assessment and colonoscopy. Symptoms were categorized as altered bowel habit (ABH), rectal bleeding (RB), abdominal pain (AP) and unexplained weight loss (UWL). RESULTS: Symptoms were present in 65.1% (492/756) of subjects, 64.4% (431/669) of those with a non-cancer diagnosis and 70.1% (61/87) of those with cancer. Among those with a non-cancer diagnosis, symptoms were ABH in 52% (224/431), RB in 81.4% (351/431), AP in 15.3% (66/431) and UWL in 3.0% (13/431). In those with cancer symptoms they were ABH in 33.3% (29/87), RB in 55.2% (48/87) and AP in 11.5% (10/87). There was no significant difference in the prevalence of symptoms in those with a cancer or non-cancer diagnosis. A total of 34.2% (157/459) of individuals with symptoms had consulted their general practitioner, 28.1% (16/57) of those with cancer and 35.1% (141/402) without. CONCLUSION: A large proportion of individuals colonoscoped in the BCSP reported symptoms predating screening. Their prevalence did not differ significantly between cancer and non-cancer diagnoses. The majority had not consulted their general practitioner. Health promotion regarding the importance of lower gastrointestinal symptoms and a risk assessment tool to help select those needing urgent specialist assessment are required.

Achieving high quality colonoscopy: using graphical representation to measure performance and reset standards.

AIM: Completeness and thoroughness of colonoscopy are measured by the caecal intubation rate (CIR) and the adenoma detection rate (ADR). National standards are ≥ 90% and ≥ 10% respectively. Variability in CIR and ADR have been demonstrated but comparison between individuals and units is difficult. We aimed to assess the performance of colonoscopy in endoscopy units in the northeast of England. METHOD: Data on colonoscopy performance and sedation use were collected over 3 months from 12 units. Colonoscopies performed by screening colonoscopists were included for the CIR only. Funnel plots with upper and lower 95% confidence limits for CIR and ADR were created. RESULTS: CIR was 92.5% (n = 5720) and ADR 15.9% (n = 4748). All units and 128 (99.2%) colonoscopists were above the lower limit for CIR. All units achieved the ADR standard with 10 above the upper limit. Ninety-nine (76.7%) colonoscopists were above 10%, 16 (12.4%) above the upper limit and 7 (5.4%) below the lower limit. Median medication doses were 2.2 mg midazolam, 29.4 mg pethidine and 83.3 µg fentanyl. In all, 15.1% of colonoscopies were unsedated. Complications were bleeding (0.10%) and perforation (0.02%). There was one death possibly related to bowel preparation. CONCLUSION: Results indicate that colonoscopies are performed safely and to a high standard. Funnel plots can highlight variability and areas for improvement. Analyses of ADR presented graphically around the global mean suggest that the national standard should be reset at 15%.

An international survey of polypectomy training and assessment.

Background and study aims Colonic polypectomy is acknowledged to be a technically challenging part of colonoscopy. Training in polypectomy is recognized to be often inconsistent. This study aimed to ascertain worldwide practice in polypectomy training. Patients and methods An electronic survey was distributed to endoscopic trainees and trainers in 19 countries asking about their experiences of receiving and delivering training. Participants were also asked about whether formal polypectomy training guidance existed in their country. Results Data were obtained from 610 colonoscopists. Of these responses, 348 (57.0 %) were from trainers and 262 (43.0 %) from trainees; 6.6 % of trainers assessed competency once per year or less often. Just over half (53.1 %) of trainees had ever had their polypectomy technique formally assessed by any trainer. Approximately half the trainees surveyed (51.1 %) stated that the principles of polypectomy had only ever been taught to them intermittently. Of those trainees with the most colonoscopy experience, who had performed over 500 procedures, 48.2 % had had training on removing large polyps of over 10 mm; 46.2 % (121 respondents) of trainees surveyed held no record of the polypectomies they had performed. Only four of the 19 countries surveyed had specific guidelines on polypectomy training. Conclusions A significant number of competent colonoscopists have never been taught how to perform polypectomy. Training guidelines worldwide generally give little direction as to how trainees should acquire polypectomy skills. The learning curve for polypectomy needs to be defined to provide reliable guidance on how to train colonoscopists in this skill.

Management of colonic polyps and the NHS Bowel Cancer Screening Programme.

This article describes the NHS Bowel Cancer Screening Programme and the management of large colonic polyps, many of which are diagnosed and managed successfully during bowel cancer screening, in addition to non-endoscopic management options.

The one-stop dyspepsia clinic--an alternative to open-access endoscopy for patients with dyspepsia.

The most sensitive investigative tool for the upper gastrointestinal tract is endoscopy, and many gastroenterologists offer an open-access endoscopy service to general practitioners. However, for patients with dyspepsia, endoscopy is not always the most appropriate initial investigation, and the one-stop dyspepsia clinic allows for different approaches. We have audited, over one year, the management and outcomes of patients attending a one-stop dyspepsia clinic. All patients seen in the clinic were included, and for those not endoscoped the notes were reviewed one year after the end of the study to check for reattendances and diagnoses originally missed. Patients' and general practitioners' views of the service were assessed by questionnaire. 485 patients were seen, of whom 301 (62%) were endoscoped at first attendance. In 66 patients (14%), endoscopy was deemed inappropriate and only one of these returned subsequently for endoscopy. 118 patients (24%) were symptom-free when seen in the clinic and were asked to telephone for an appointment if and when symptoms recurred; half of these returned and were endoscoped. Oesophagitis and duodenal ulcer were significantly more common in this 'telephone endoscopy' group than in those endoscoped straight from the clinic. Overall, 25% of patients referred were not endoscoped. Important additional diagnoses were made from the clinic consultation. General practitioners and patients valued the system, in particular the telephone endoscopy service. 84% of general practitioners said they would prefer the one-stop dyspepsia clinic to open-access endoscopy.

A novel method for determining the difficulty of colonoscopic polypectomy.

INTRODUCTION: Endoscopists are now expected to perform polypectomy routinely. Colonic polypectomy varies in difficulty, depending on polyp morphology, size, location and access. The measurement of the degree of difficulty of polypectomy, based on polyp characteristics, has not previously been described. OBJECTIVE: To define the level of difficulty of polypectomy. METHODS: Consensus by nine endoscopists regarding parameters that determine the complexity of a polyp was achieved through the Delphi method. The endoscopists then assigned a polyp complexity level to each possible combination of parameters. A scoring system to measure the difficulty level of a polyp was developed and validated by two different expert endoscopists. RESULTS: Through two Delphi rounds, four factors for determining the complexity of a polypectomy were identified: size (S), morphology (M), site (S) and access (A). A scoring system was established, based on size (1-9 points), morphology (1-3 points), site (1-2 points) and access (1-3 points). Four polyp levels (with increasing level of complexity) were identified based on the range of scores obtained: level I (4-5), level II (6-9), level III (10-12) and level IV (>12). There was a high degree of interrater reliability for the polyp scores (interclass correlation coefficient of 0.93) and levels (κ=0.888). CONCLUSIONS: The scoring system is feasible and reliable. Defining polyp complexity levels may be useful for planning training, competency assessment and certification in colonoscopic polypectomy. This may allow for more efficient service delivery and referral pathways.

Bowel cancer screening is safe, detects earlier stage cancer and adenomas in 50% of cases: experience of the prevalent round of screening from two first wave centres in the North East of England.

OBJECTIVE: The NHS Bowel Cancer Screening Programme (BCSP) began roll-out in 2006 aiming to reduce cancer mortality through detection at an earlier stage. We report results from the prevalent round of screening at two first wave centres and compare with the UK pilot study. DESIGN: This is a service evaluation study. Data were collected prospectively for all individuals undergoing faecal occult blood testing (FOBt) and colonoscopy including: uptake and outcomes of FOBt, colonoscopic performance, findings, histological data and complications. Continuous data were compared using a two-tailed test of two proportions. SETTING: The South of Tyne and Tees Bowel Cancer Screening centres. PATIENTS: Participants of the BCSP. MAIN OUTCOME MEASURES: 1) Colonoscopy Quality Assurance and 2) Cancer stage shift. RESULTS: 195,772 individuals were invited to participate. Uptake was 54% and FOBt positivity 1.7%. 1524 underwent colonoscopy with caecal intubation in 1485 (97%). 180 (12%) cancers were detected. Dukes stages were: 76 (42%) A; 47 (26%) B; 47 (26%) C; 8 (4%) D and 2 (1%) unknown. This demonstrates a significantly earlier stage at diagnosis compared with data from 2867 non-screening detected cancers (p<0.001). Adenomas were detected in 758 (50%). One perforation occurred (0.07%) and two intermediate bleeds requiring transfusion only (0.12%). Both caecal intubation and adenoma detection were significantly higher than in the UK pilot study (p<0.001). CONCLUSIONS: The prevalent round of screening demonstrates a high adenoma and cancer detection rate and significantly earlier stage at diagnosis. Complications were few providing reassurance regarding safety. Efforts are required to improve uptake.