Polyp size is associated with colorectal cancer death across histologic polyp subtypes: a retrospective study of a screening colonoscopy registry.

BACKGROUND: Surveillance colonoscopy after polyps have been detected at screening aims to reduce the risk for subsequent colorectal cancer, so-called post-colonoscopy colorectal cancer (PCCRC). Inconsistencies exist as to whether the risk should be stratified by histologic subtype. We aimed to compare the risk for PCCRC mortality in screening participants with sessile serrated lesions (SSLs)/traditional serrated adenomas (TSAs), hyperplastic polyps (HPPs), or conventional adenomas. METHODS: Screening colonoscopy registry data were linked to death registry data between 2010 and 2022. We assessed the association of PCCRC death after a diagnosis of SSL/TSA, conventional adenoma, or HPP by Cox regression, and stratified by polyp size ≥10 and <10 mm. RESULTS: 383,801 participants were included in the analysis. There were 1490 HPPs ≥10 mm (2.6%), compared with 1853 SSL/TSAs (19.6%) and 10,960 conventional adenomas (12.9%). When adjusted for polyp location, the association of polyp size ≥10 mm with PCCRC death was of similar magnitude in participants with conventional adenomas (hazard ratio [HR] 3.68, 95%CI 2.49-5.44), SSL/TSAs (HR 2.55, 95%CI 1.13-5.72), and HPPs (HR 5.01, 95%CI 2.45-10.22). Participants with HPPs mostly died of tumors in the distal colon (54.1%; n = 20), while participants with SSL/TSAs more frequently died of proximal tumors (33.3%; n = 3). CONCLUSIONS: Across all histologic types, participants with polyps ≥10 mm had at least a two-fold increase in the likelihood of PCCRC death compared with those with polyps <10 mm. These data suggest that size, rather than histologic subtype, should be a determinant for risk stratification after screening colonoscopy.

Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2024.

1: ESGE recommends cold snare polypectomy (CSP), to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of diminutive polyps (≤ 5 mm).Strong recommendation, high quality of evidence. 2: ESGE recommends against the use of cold biopsy forceps excision because of its high rate of incomplete resection.Strong recommendation, moderate quality of evidence. 3: ESGE recommends CSP, to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of small polyps (6-9 mm).Strong recommendation, high quality of evidence. 4: ESGE recommends hot snare polypectomy for the removal of nonpedunculated adenomatous polyps of 10-19 mm in size.Strong recommendation, high quality of evidence. 5: ESGE recommends conventional (diathermy-based) endoscopic mucosal resection (EMR) for large (≥ 20 mm) nonpedunculated adenomatous polyps (LNPCPs).Strong recommendation, high quality of evidence. 6: ESGE suggests that underwater EMR can be considered an alternative to conventional hot EMR for the treatment of adenomatous LNPCPs.Weak recommendation, moderate quality of evidence. 7: Endoscopic submucosal dissection (ESD) may also be suggested as an alternative for removal of LNPCPs of ≥ 20 mm in selected cases and in high-volume centers.Weak recommendation, low quality evidence. 8: ESGE recommends that, after piecemeal EMR of LNPCPs by hot snare, the resection margins should be treated by thermal ablation using snare-tip soft coagulation to prevent adenoma recurrence.Strong recommendation, high quality of evidence. 9: ESGE recommends (piecemeal) cold snare polypectomy or cold EMR for SSLs of all sizes without suspected dysplasia.Strong recommendation, moderate quality of evidence. 10: ESGE recommends prophylactic endoscopic clip closure of the mucosal defect after EMR of LNPCPs in the right colon to reduce to reduce the risk of delayed bleeding.Strong recommendation, high quality of evidence. 11: ESGE recommends that en bloc resection techniques, such as en bloc EMR, ESD, endoscopic intermuscular dissection, endoscopic full-thickness resection, or surgery should be the techniques of choice in cases with suspected superficial invasive carcinoma, which otherwise cannot be removed en bloc by standard polypectomy or EMR.Strong recommendation, moderate quality of evidence.

Association between endoscopist adenoma detection rate and serrated polyp detection: Retrospective analysis of over 200,000 screening colonoscopies.

Background and study aims Serrated lesions have been identified as precursor lesions for 20% to 35% of colorectal cancers (CRCs) and may contribute to a significant proportion of interval-cancer. Sessile-serrated-lesions (SSLs), in particular, tend to be flat and located in the proximal colon, making their detection challenging and requiring expertise. It remains unclear whether the detection rate for serrated polyps should be considered as a quality indicator in addition to the adenoma detection rate (ADR). This study sought to assess whether the ADR has an effect on the detection rate for serrated polyps. atients and methods In this retrospective analysis, prospectively collected data from 212,668 screening colonoscopies performed between 2012 and September 2018 were included. Spearman correlation and Whitney-Mann U-test were used to assess the association of ADR and the detection rate of SSLs with (SDR) and without hyperplastic polyps (SPADRs), the sessile serrated detection rate (SSLDR) as well as the clinically relevant serrated detection rate (CRSDR), including all SSLs and traditional serrated adenoma, hyperplastic polyps (HPs) >10 mm anywhere in the colon or HPs > 5 mm proximal to the sigmoid. Results The overall mean ADR was 21.78% (standard deviation [SD] 9.27), SDR 21.08% (SD 11.44), SPADR 2.19% (SD 2.49), and CRSDR was 3.81% (3.40). Significant correlations were found between the ADR and the SDR, SPADR, SSLDR, and CRSDR (rho=0.73 vs. rho=0.51 vs. rho=0.51 vs. rho=0.63; all P <0.001). Endoscopists with a mean ADR ≥25% had significantly higher SDR, SPADR, and CRSDR than endoscopists with a mean ADR <25% (all P <0.001; Mann-Whitney U-Test). Conclusions This study shows that endoscopists with higher ADR detect significantly more serrated lesions than those with a lower ADR.

Differences between men and women with respect to colorectal cancer mortality despite screening colonoscopy.

BACKGROUND AND AIMS: Women aged 55 to 59 years have a similar prevalence rate and number needed to screen for colorectal adenomas as men at a 10-year younger age. The aim of this study was to determine sex-specific differences in colorectal cancer mortality and estimate the association with adenomas at screening colonoscopy. METHODS: This retrospective study analyzed 323,139 individuals who underwent colonoscopy within a national colorectal cancer screening program in Austria between January 2007 and December 2020. RESULTS: Median patient age was 60 years (interquartile range, 54-67), and the sex distribution in all age groups was nearly identical. Men had significantly higher odds of having an adenoma or serrated polyp, low-risk polyp, high-risk polyp, or colorectal cancer detected at colonoscopy than women (odds ratio [OR] 1.83; 95% confidence interval [CI], 1.80-1.86; OR, 1.46; 95% CI, 1.44-1.49; OR, 1.74; 95% CI, 1.69-1.80; and OR, 1.87; 95% CI, 1.70-2.05, respectively). Strikingly, male sex, when compared with female sex, was associated with an almost 2-fold (hazard ratio, 1.67; 95% CI, 1.05-2.67) increased risk to die from colorectal cancer when an adenoma or serrated polyp was found at the screening colonoscopy and a 4-fold (hazard ratio, 4.14; 95% CI, 2.72-6.3) increased risk when a high-risk polyp was found at the screening colonoscopy. The cumulative incidence for death of colorectal cancer for 60-year-old individuals was 8.5-fold higher in men as compared with women. Markedly, this sex gap narrowed with increasing age, whereas the difference in deaths of other causes remained similar in all age groups. CONCLUSIONS: Our findings strengthen the necessity of sex-specific screening recommendations. Importantly, further prospective studies should focus on sex differences in tumor biology to propose personalized surveillance guidelines.

Detection of high-risk polyps at screening colonoscopy indicates risk for liver and biliary cancer death.

BACKGROUND: Hepatobiliary cancers share risk factors with colorectal cancer (CRC), but there are no combined screening programs for these conditions. AIMS: The aim of this study was to assess whether patients with high-risk colonic polyps are more likely to die from liver related tumors than patients with a negative colonoscopy. METHODS: In this retrospective analysis of mortality data, Austrian screening participants were included. The absolute risk for hepatobiliary cancer death was calculated using the cumulative incidence method. We aimed to identify an association with time to death of hepatobiliary cancer by Cox proportional hazards model. RESULTS: 343,838 colonoscopies performed between 01/2007 and 12/2020 were included in the analysis, of which 17,678 (5.14%) revealed high-risk polyps. Overall hepatobiliary cancer mortality was more than twice as high in patients with high risk polyps (cumulative incidence 0.39%, 95% CI 0.37-0.41%) compared to patients with a negative colonoscopy (cumulative incidence 0.17%, 95% CI 0.17-0.17%). When adjusting for age and sex, having high-risk polyps at screening colonoscopy was significantly associated with hepatobiliary cancer death (HR 1.83, 95% CI 1.29- 2.59, p < 0.001). CONCLUSIONS: Patients with certain colonic polyp characteristics are at increased risk for mortality of liver malignancies. Further studies are needed to determine whether a structured additional screening for liver diseases and consecutive malignancies might be beneficial in these patients.

Colorectal Cancer and Precursor Lesion Prevalence in Adults Younger Than 50 Years Without Symptoms.

Importance: Incidence of colorectal cancer (CRC) is increasing among younger adults. However, data on precursor lesions in patients who are asymptomatic, especially those aged younger than 50 years, are lacking. Objective: To analyze the prevalence and number needed to screen (NNS) for adenomas, advanced adenomas, and serrated lesions, as well as the incidence of CRC in patients older than age 20 years. Design, Setting, and Participants: This cohort study was conducted among 296 170 patients who received a screening colonoscopy within a national screening colonoscopy registry from 2012 to 2018 in Austria, including 11 103 patients aged younger than 50 years. CRC incidence was analyzed using data from Statistic Austria from 1988 to 2018. Data were analyzed in September 2021. Main Outcome and Measures: The prevalence of adenomas and other lesions and the incidence of CRC in individuals aged 20 years or older were assessed. Results: Among 296 170 patients included in the study (median [IQR] age, 60 [54-68] years; 150 813 females [50.9%]), 11 103 patients (3.7%) were aged younger than 50 years and 285 067 patients (96.3%) were aged 50 years or older. Among patients younger than age 50 years, 1166 individuals (10.5%; NNS = 9) had adenomas and 389 individuals (3.9%; NNS = 26) had at least 1 advanced adenoma, while among those aged 50 years or older, 62 384 individuals (21.9%; NNS = 5) had adenomas and 19 680 individuals (6.9%; NNS = 15) had at least 1 advanced adenoma. Among 1128 males aged 40 to 44 years, 160 individuals (14.2%; NNS = 7) had at least 1 adenoma, and among 1398 females aged 40 to 44 years, 114 individuals (8.1%; NNS = 12) had at least 1 adenoma. The prevalence of adenomas for individuals aged 45 to 49 years vs 50 to 54 years was 490 of 2879 males (17.1%; NNS = 6) vs 8269 of 40 935 males (20.2%; NNS = 5) and 284 of 2792 females (10.2%; NNS = 10) vs 4997 of 40 303 females (12.4%; NNS = 8), respectively. Prevalence of adenomas changed from 61 of 498 individuals (12.4%) in 2008 to 150 of 1064 individuals (14.1%) in 2018 among those younger than 50 years and from 2646 of 12 166 individuals (21.8%) to 10 673 of 37 922 individuals (28.2%) among those aged 50 years and older. The prevalence of advanced adenomas changed from 20 individuals (4.0%) in 2008 to 55 individuals (5.2%) in 2018 in individuals younger than 50 years and from 888 individuals (7.3%) in 2008 to 2578 individuals (6.8%) in 2018 among those aged 50 years and older. Among individuals younger than age 50 years, CRC incidence per 100 000 individuals changed from 9.1 incidents in 1988 to 10.2 incidents in 2018 among males (average annual percentage change [AAPC], 0.5%; 95% CI, 0.1% to 1.0%) and from 9.7 incidents in 1988 to 7.7 incidents in 2018 among females, with a nonsignificant AAPC (-0.2%; 95% CI, -0.7% to 0.3%). Among individuals aged 50 years or older, CRC incidence per 100 000 individuals changed from 168 incidents in 1988 to 97 incidents in 2018 among females (AAPC, -1.8%; 95% CI, -1.9% to -1.6%), and 217 incidents in 1988 to 143 incidents in 2018 among males (AAPC, -1.2%; 95% CI, -1.3% to -1.1%). Conclusion: In this study, CRC incidence decreased after 1988 in Austria among individuals older than 50 years, while among patients younger than 50 years, incidence increased among males but decreased among females. Prevalence of adenomas increased in all age groups, while advanced adenoma prevalence increased among patients younger than 50 years but decreased in patients aged 50 years and older.

Polyp characteristics at screening colonoscopy and post-colonoscopy colorectal cancer mortality: a retrospective cohort study.

BACKGROUND AND AIMS: Polyp size and high-grade dysplasia in polyps at screening colonoscopy are considered risk factors for post-colonoscopy colorectal cancer (PCCRC) development and death, which might be averted by surveillance colonoscopy. However, robust evidence backing these risk factors is lacking. We aimed to investigate whether polyp size or dysplasia grade is associated with PCCRC mortality. METHODS: This was a retrospective study including individuals of the Austrian Quality Certificate for Screening Colonoscopy who underwent a colonoscopy between January 2007 and December 2020. We investigated the association of polyp size and dysplasia in polyps with PCCRC mortality according to Cox regression analysis. In addition, whether patients with certain polyp characteristics had similar risk for CRC death compared with the Austrian population was assessed by calculating standardized mortality ratios (SMRs). RESULTS: A total of 316,001 individuals were included. After a median follow-up time of 5.27 years (95% confidence interval [CI], 5.25-5.29), a significant association of polyps 10 to 20 mm (hazard ratio, 4.00; 95% CI, 2.46-6.50; P < .001) as well as high-grade dysplasia (hazard ratio, 6.61; 95% CI, 3.31-13.2; P < .001) with PCCRC death was observed. PCCRC mortality was significantly lower than the expected CRC mortality in the general population in patients with polyps <10 mm and without high-grade dysplasia (SMR, .27; 95% CI, .21-.33; P < .001), which was not observed for patients with polyps ≥10 mm or with high-grade dysplasia (SMR, 2.05; 95% CI, 1.64-2.57; P < .001). CONCLUSIONS: Polyp size ≥10 mm and high-grade dysplasia are associated with PCCRC mortality in screening patients. The data suggest that these patients might benefit most from surveillance colonoscopy.

Comparison of adenoma detection rate and proximal serrated polyp detection rate and their effect on post-colonoscopy colorectal cancer mortality in screening patients.

BACKGROUND: Patients with serrated polyps are at increased risk for post-colonoscopy colorectal cancer (PCCRC); however, evidence for a dedicated serrated polyp detection rate is lacking. The aim of this study was to investigate the association of the proximal serrated polyp detection rate (PSDR) and adenoma detection rate (ADR) with PCCRC death. METHODS: This was a retrospective analysis within the Austrian quality assurance program for screening colonoscopy. Spearman's rank coefficient was calculated for the assessment of association between ADR and PSDR. Whether ADR or PSDR were associated with colorectal cancer mortality was assessed by Cox proportional hazards model. RESULTS: 229/729 screening colonoscopies performed by 308 endoscopists were analyzed. The ADR (hazard ratio [HR] per 1 percentage point increase 0.98, 95 %CI 0.96-0.99) as well as the PSDR (HR per 1 percentage point increase 0.97, 95 %CI 0.94-0.99) were significantly associated with PCCRC death. The correlation coefficient of the ADR and PSDR calculated at every colonoscopy was 0.70 (95 %CI 0.70-0.71), and the corresponding PSDR value for an ADR performance standard of 25 % was 11.1 %. At the end of the study period, 86 endoscopists (27.9 %) reached an ADR of > 25 % and a PSDR of > 11.1 %. CONCLUSIONS: The ADR as well as the PSDR were associated with PCCRC death. Striving for a high PSDR in addition to a high ADR might reduce the risk for PCCRC mortality in patients undergoing screening colonoscopy.

[Quality Assurance of Screening Colonoscopy in Austria and Europe]. / Qualitätssicherung in der Vorsorgekoloskopie in Österreich und europaweit.

Screening colonoscopy, an efficient tool for reducing the incidence and mortality of colorectal cancer, is only effective if it is performed under high quality standards. The European Society for Gastrointestinal Endoscopy has identified the following key performance measures for screening: adenoma detection rate, cecal intubation rate, and adequate bowel preparation rate. The Quality Certificate for Colorectal Cancer Screening-which was launched as a quality assurance program on a voluntary basis by the Austrian Society of Gastroenterology and Hepatology together with the umbrella organization of Austrian social insurance carriers and the Austrian Cancer Aid for endoscopists throughout Austria-monitors these quality parameters. The aim is to achieve the highest standards of colorectal cancer screening in order to achieve the best outcomes for patients. Interest in quality-assured screening colonoscopy is also high throughout Europe: many countries, e.g., the Netherlands, Norway, and the United Kingdom, have programs to monitor and improve the quality of screening.

Hepatic T1-Time Predicts Cardiovascular Risk in All-Comers Referred for Cardiovascular Magnetic Resonance: A Post-Hoc Analysis.

BACKGROUND: Liver damage is frequently observed in patients with cardiovascular disease but infrequently quantified. We hypothesized that in patients with cardiovascular disease undergoing cardiac magnetic resonance, liver T1-times indicate liver damage and are associated with cardiovascular outcome. METHODS: We measured hepatic T1-times, displayed on standard cardiac T1-maps, in an all-comer cardiac magnetic resonance-cohort. At the time of cardiac magnetic resonance, we assessed validated general liver fibrosis scores. Kaplan-Meier estimates and Cox-regression models were used to investigate the association between hepatic T1-times and a composite endpoint of non-fatal myocardial infarction, heart failure hospitalization, and death. RESULTS: One thousand seventy-five participants (58±18 year old, 47% female) were included (972 patients, 50 controls, 53 participants with transient elastography). Hepatic T1-times were 590±89 ms in patients and 574±45 ms in controls (P=0.052). They were significantly correlated with cardiac size and function, presence of atrial fibrillation, NT-pro-BNP levels, and gamma-glutamyl-transferase levels (P<0.001 for all). During follow-up (58±31 months), a total of 280 (29%) events occurred. On Cox-regression, high hepatic T1-times yielded a significantly higher risk for events (adjusted hazard ratio, 1.66 [95% CI, 1.45-1.89] per 100 ms increase; P<0.001), even when adjusted for age, sex, left and right ventricular ejection fraction, NT-proBNP (N-terminal prohormone of brain natriuretic peptide), and myocardial T1-time. On receiver operating characteristic analysis and restricted cubic splines, we found that a hepatic T1-time exceeding 610 ms was associated with excessive risk. CONCLUSIONS: Hepatic T1-times on standard cardiac magnetic resonance scans were significantly associated with cardiac size and function, comorbidities, natriuretic peptides, and independently predicted cardiovascular mortality and morbidity. A hepatic T1-time >610 ms seems to indicate excessive risk. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT04220450.

Comparison of Hepatic Tissue Characterization between T1-Mapping and Non-Contrast Computed Tomography.

Background: Non-contrast computed tomography (CT) is frequently used to assess non-alcoholic/metabolic fatty liver disease (NAFLD/MAFLD), which is associated with cardiovascular risk. Although liver biopsy is considered the gold standard for diagnosis, standardized scores and non-contrast computed tomography (CT) are used instead. On standard cardiac T1-maps on cardiovascular imaging (CMR) exams for myocardial tissue characterization hepatic tissue is also visible. We hypothesized that there is a significant correlation between hepatic tissue T1-times on CMR and Hounsfield units (HU) on non-contrast CT. Methods: We retrospectively identified patients undergoing a non-contrast CT including the abdomen, a CMR including T1-mapping, and laboratory assessment within 30 days. Patients with storage diseases were excluded. Results: We identified 271 patients (62 ± 15 y/o, 49% female) undergoing non-contrast CT and CMR T1-mapping within 30 days. Mean hepatic HU values were 54 ± 11 on CT and native T1-times were 598 ± 102 ms on CMR and there was a weak, but significant, correlation between these parameters (r = −0.136, p = 0.025). On age and sex adjusted regression analysis, lower liver HU values indicated a dismal cardiometabolic risk profile, including higher HbA1C (p = 0.005) and higher body mass index (p < 0.001). In contrast, native hepatic T1-times yielded a more pronounced cardiac risk profile, including impaired systolic function (p = 0.045) and higher NT-proBNP values (N-Terminal Brain Natriuretic Peptide) (p = 0.004). Conclusions: Hepatic T1-times are easy to assess on standard T1-maps on CMR but only weakly correlated with hepatic HU values on CT and clinical NAFLD/MAFLD scores. Liver T1-times, however, are linked to impaired systolic function and higher natriuretic peptide levels. The prognostic value and clinical usefulness of hepatic T1-times in CMR cohorts warrants further research.

Gradient boosting for linear mixed models.

Gradient boosting from the field of statistical learning is widely known as a powerful framework for estimation and selection of predictor effects in various regression models by adapting concepts from classification theory. Current boosting approaches also offer methods accounting for random effects and thus enable prediction of mixed models for longitudinal and clustered data. However, these approaches include several flaws resulting in unbalanced effect selection with falsely induced shrinkage and a low convergence rate on the one hand and biased estimates of the random effects on the other hand. We therefore propose a new boosting algorithm which explicitly accounts for the random structure by excluding it from the selection procedure, properly correcting the random effects estimates and in addition providing likelihood-based estimation of the random effects variance structure. The new algorithm offers an organic and unbiased fitting approach, which is shown via simulations and data examples.

Impact of restrictions due to COVID-19 on a quality-assured screening colonoscopy program.

Background and study aims On February 25, 2020, the first patient was diagnosed with COVID-19 in Austria. On March 16, 2020, the Austrian government imposed restrictions and subsequently the Austrian Medical Association recommended minimizing screening examinations in compliance with government restrictions. The aims of this study were to evaluate the impact of this recommendation on the number of colonoscopies performed weekly and detection of non-advanced adenomas, advanced adenomas (AA) and colorectal cancer (CRC) and to calculate how many undetected adenomas could have developed into CRC. Methods We analyzed the number of colonoscopies and pathological findings within a quality assured national colorectal cancer screening program before the COVID-19 pandemic (March 1, t 2019 to September 1, 2019, Period 1) and compared those rates to months during which access to colonoscopy was limited (March 1, 2020 and September 1, 2020, Period 2) with a Wilcoxon-rank-test and a chi-square test. Results A total of 29,199 screening colonoscopies were performed during Period 1 and 24,010 during Period 2. The mean rate of colonoscopies per week during Period 1 was significantly higher than during Period 2 (808,35 [SD = 163,75] versus 594,50 [SD = 282,24], P  = 0.005). A total of 4,498 non-advanced adenomas were detected during Period 1 versus 3,562 during Period 2 ( P  < 0.001). In total 1,317 AAs and 140 CRCs were detected during Period 1 versus 919 AAs and 106 CRCs during Period 2. These rates did not differ significantly ( P  = 0.2 and P  = 0.9). Conclusions During the COVID-19 crisis, the number of colonoscopies performed per week was significantly lower compared to the year before, but there was no difference in the detection of CRCs and AAs.

New risk stratification after colorectal polypectomy reduces burden of surveillance without increasing mortality.

BACKGROUND: The 2020 postpolypectomy surveillance guideline update of European Society for Gastrointestinal Endoscopy defines a more restrictive group of individuals in need for surveillance 3 years after colonoscopy. AIM: The aim of this cohort study was to validate the new guideline recommendation. METHODS: Based on a national quality assurance program, we compared the 2020 risk group definition with the previous 2013 recommendations for their strength of association with (1) colorectal cancer death, and (2) all-cause death. RESULTS: A total of 265,608 screening colonoscopies were included in the study. Mean age was 61.1 years (SD ±9.0), and 50.6% were women. During a mean follow-up of 59.3 months (SD ±35.0), 170 CRC deaths and 7723 deaths of any cause were identified. 62.4% of colonoscopies were negative and 4.9% were assigned to surveillance after 3 years according to the 2020 guidelines versus 10.4% following the 2013 guidelines, which corresponds to a relative reduction in colonoscopies by 47%. The strength of association with CRC mortality was markedly higher with the 2020 surveillance group as compared to the 2013 guidelines (HR 2.56, 95% CI 1.62-4.03 vs. HR 1.73, 95% CI 1.13-2.62), while the magnitude of association with CRC mortality for low risk individuals was lower (HR 1.17, 95% CI 0.83-1.63 vs. 1.25, 95% CI 0.88-1.76). CONCLUSIONS: Adherence to the updated guidelines reduces the burden of surveillance colonoscopies by 47% while preserving the efficacy of surveillance in preventing CRC mortality.

More than one way: exploring the capabilities of different estimation approaches to joint models for longitudinal and time-to-event outcomes.

The development of physical functioning after a caesura in an aged population is still widely unexplored. Analysis of this topic would need to model the longitudinal trajectories of physical functioning and simultaneously take terminal events (deaths) into account. Separate analysis of both results in biased estimates, since it neglects the inherent connection between the two outcomes. Thus, this type of data generating process is best modelled jointly. To facilitate this several software applications were made available. They differ in model formulation, estimation technique (likelihood-based, Bayesian inference, statistical boosting) and a comparison of the different approaches is necessary to identify their capabilities and limitations. Therefore, we compared the performance of the packages JM, joineRML, JMbayes and JMboost of the R software environment with respect to estimation accuracy, variable selection properties and prediction precision. With these findings we then illustrate the topic of physical functioning after a caesura with data from the German ageing survey (DEAS). The results suggest that in smaller data sets and theory driven modelling likelihood-based methods (expectation maximation, JM, joineRML) or Bayesian inference (JMbayes) are preferable, whereas statistical boosting (JMboost) is a better choice with high-dimensional data and data exploration settings.

Association of Adenoma Detection Rate and Adenoma Characteristics With Colorectal Cancer Mortality After Screening Colonoscopy.

BACKGROUND & AIMS: The adenoma detection rate (ADR) and characteristics of previously resected adenomas are associated with colorectal cancer (CRC) incidence and mortality. However, the combined effect of both factors on CRC mortality is unknown. PATIENTS AND METHODS: Using data of the Austrian quality assurance program for screening colonoscopy, we evaluated the combined effect of ADR and lesion characteristics on subsequent risk for CRC mortality. We analyzed mortality rates for individuals with low-risk adenomas (1-2 adenomas <10 mm), individuals with high-risk adenomas (advanced adenomas or ≥3 adenomas), and after negative colonoscopy (negative colonoscopy or small hyperplastic polyps) performed by endoscopists with an ADR <25% compared with ≥25%. Cox regression was used to determine the association of combined risk groups with CRC mortality, adjusted for age and sex. RESULTS: We evaluated 259,885 colonoscopies performed by 361 endoscopists. A total of 165 CRC-related deaths occurred during the follow-up period, up to 12.2 years. In all risk groups, CRC mortality was higher when colonoscopy was performed by an endoscopist with an ADR <25%. Compared with negative colonoscopy with an ADR ≥25%, CRC mortality was similar for individuals with low-risk adenomas irrespective of ADR (for ADR ≥25%: adjusted hazard ratio [HR], 1.22; 95% confidence interval [CI], 0.59-2.49; for ADR <25%: adjusted HR, 1.25; 95% CI, 0.64-2.43) and after negative colonoscopy with ADR <25% (adjusted HR, 1.27; 95% CI, 0.81-2.00). Individuals with high-risk adenomas were at significantly higher risk for CRC death if colonoscopy was performed by an endoscopist with an ADR <25% (adjusted HR, 2.25; 95% CI, 1.18-4.31) but not if performed by an endoscopist with an ADR ≥25% (adjusted HR, 1.35; 95% CI, 0.61-3.02). CONCLUSIONS: Our study adds important evidence for mandatory assessment and monitoring of performance quality in screening colonoscopy. High-quality colonoscopy was associated with a lower risk for CRC death, and the impact of ADR was strongest for individuals with high-risk adenomas.

Colonoscopist Performance and Colorectal Cancer Risk After Adenoma Removal to Stratify Surveillance: Two Nationwide Observational Studies.

BACKGROUND AND AIMS: Colonoscopy surveillance after adenoma removal is an increasing burden in many countries. Surveillance recommendations consider characteristics of removed adenomas, but not colonoscopist performance. We investigated the impact of colonoscopist performance on colorectal cancer risk after adenoma removal. METHODS: We compared colorectal cancer risk after removal of high-risk adenomas, low-risk adenomas, and after negative colonoscopy for all colonoscopies performed by colonoscopists with low vs high performance quality (adenoma detection rate <20% vs ≥20%) in the Polish screening program between 2000 and 2011, with follow-up until 2017. Findings were validated in the Austrian colonoscopy screening program. RESULTS: A total of 173,288 Polish colonoscopies were included in the study. Of 262 colonoscopists, 160 (61.1%) were low performers, and 102 (38.9%) were high performers; 11.1% of individuals had low-risk and 6.6% had high-risk adenomas removed at screening; 82.2% had no adenomas. During 10 years of follow-up, 443 colorectal cancers were diagnosed. For low-risk adenoma individuals, colorectal cancer incidence was 0.55% (95% confidence interval [CI] 0.40-0.75) with low-performing colonoscopists vs 0.22% (95% CI 0.14-0.34) with high-performing colonoscopists (hazard ratio [HR] 2.35; 95% CI 1.31-4.21; P = .004). For individuals with high-risk adenomas, colorectal cancer incidence was 1.14% (95% CI 0.87-1.48) with low-performing colonoscopists vs 0.43% (95% CI 0.27-0.69) with high-performing colonoscopists (HR 2.69; 95% CI 1.62-4.47; P < .001). After negative colonoscopy, colorectal cancer incidence was 0.30% (95% CI 0.27-0.34) for individuals examined by low-performing colonoscopists, vs 0.15% (95% CI 0.11-0.20) for high-performing (HR 2.10; 95% CI 1.52-2.91; P < .001). The observed trends were reproduced in the Austrian validation cohort. CONCLUSIONS: Our results suggest that endoscopist performance may be an important contributor in addition to polyp characteristics in determining colorectal cancer risk after colonoscopy screening.

Interval cancer after colonoscopy in the Austrian National Screening Programme: influence of physician and patient factors.

OBJECTIVE: Postscreening colorectal cancer (PSCRC) after screening colonoscopy is associated with endoscopists' performance and characteristics of resected lesions. Prior studies have shown that adenoma detection rate (ADR) is a decisive factor for PSCRC, but correlations with other parameters need further analysis and ADR may change over time. DESIGN: Cohort study including individuals undergoing screening colonoscopy between 1/2008 and 12/2019 performed by physicians participating in a quality assurance programme in Austria. Data were linked with hospitalisation data for the diagnosis of PSCRC (defined as CRC diagnosis >6 months after colonoscopy). ADR was defined dynamically in relation to the time point of subsequent colonoscopies; high-risk groups of patients were those with an adenoma ≥10 mm, or with high-grade dysplasia, or villous or tubulovillous histology, or a serrated lesion ≥10 mm or with dysplasia, or colonoscopies with ≥3 lesions. Main outcome was PSCRC for each risk group (negative colonoscopy, hyperplastic polyps, low-risk and high-risk group of patients) after colonoscopy by endoscopists with an ADR <20% compared with endoscopists with an ADR ≥20%. RESULTS: 352 685 individuals were included in the study (51.0% women, median age 60 years) of which 10.5% were classified as high-risk group. During a median follow-up of 55.4 months, 241 (0.06%) PSCRC were identified; of 387 participating physicians, 19.6% had at least one PSCRC (8.4% two or more). While higher endoscopist ADR decreased PSCRC incidence (HR per 1% increase 0.97, 95% CI 0.95 to 0.98), affiliation to the high-risk group of patients was also associated with higher PSCRC incidence (HR 3.27, 95% CI 2.36 to 4.00). Similar correlations were seen with regards to high-risk, and advanced adenomas. The risk for PSCRC was significantly higher after colonoscopy by an endoscopist with an ADR <20% as compared with an endoscopist with an ADR ≥20% in patients after negative colonoscopy (HR 2.01, 95% CI 1.35 to 3.0, p<0.001) and for the high-risk group of patients (HR 2.51, 95% CI 1.49 to 4.22, p<0.001). CONCLUSION: A dynamic calculation of the ADR takes into account changes over time but confirms the correlation of ADR and interval cancer. Both lesion characteristics and endoscopists ADR may play a similar role for the risk of PSCRC. This should be considered in deciding about appropriate surveillance intervals in the future.

Impact of adenoma detection rate on detection of advanced adenomas and endoscopic adverse events in a study of over 200,000 screening colonoscopies.

BACKGROUND AND AIMS: Adenoma detection rate (ADR) is the best established quality parameter for screening colonoscopy. Guidelines recommend a target ADR >25% because previous studies have shown that patients of endoscopists with higher ADRs have a lower risk of postcolonoscopy interval cancers. However, studies have shown that improvement in ADR mainly results in increased detection of clinically irrelevant nonadvanced adenomas (NAAs). The impact of ADR on the detection of advanced adenomas (AAs) as well as adverse event rates has yet to be determined. METHODS: A total of 218,193 screening colonoscopies performed between 2007 and 2010 by 262 endoscopists within the Austrian quality assurance program were analyzed. We divided endoscopists into quintiles based on ADRs and calculated mean advanced ADRs (AADRs), NAA detection rates (NAADRs), and adverse event rates for each quintile. Spearman rank-order was used to calculate overall correlations between ADRs and AADRs as well as adverse event rates. Endoscopists with an ADR <25% were compared with those with an ADR >25%. RESULTS: Fifty-one percent of patients were women. Mean ADR was 23.03% (95% confidence interval [CI], 21.93-24.13), AADRs 7.72% (95% CI, 7.19-8.25), and NAADRs 15.31% (95% CI, 14.36-16.27). Overall, there was a significant correlation between ADR and AADR (rho = .51; P < .001). When ADR was divided into quintiles, mean AADR increased with increasing ADR. Even in the highest ADR group (ADR, 31.36%-52.27%) there was a further increase in AADR with a mean of 10.75% (95% CI, 9.31-12.19). Importantly, NAADRs increased continuously with improvement in ADRs but never dissociated from a simultaneous improvement in AADRs. However, there was also a significant correlation of ADRs and endoscopic adverse events (rho = .26, P < .001), even if the perforation rate of .028% (95% CI, .004-.052) in the highest ADR group still remained within the accepted limits based on guidelines. CONCLUSIONS: Increasing ADR is associated with improved detection of AAs and therefore is likely to prevent more cases of colorectal cancer. However, higher ADR was also associated with a higher rate of adverse events, although the adverse event rate was low.