Interobserver agreement in the reporting of colorectal polyp pathology among bowel cancer screening pathologists in Wales.

AIMS: To assess the interobserver agreement in the reporting of colorectal polyps among histopathologists participating in the Welsh Bowel Cancer Screening (BCS) programme. METHODS AND RESULTS: Twelve benign polyps representative of BCS cases were identified from pathology files and reported by 28 BCS histopathologists using proforma sheets. The level of agreement between the participants and a gold standard was determined using kappa (κ) statistics. A moderate level of agreement was achieved in the reporting of polyp type [κ = 0.45; 95% confidence interval (CI) 0.34-0.59] and adenomatous lesions were distinguished from non-adenomatous lesions in 96% of cases. Substantial agreement was obtained in distinguishing low- and high-grade dysplasias (κ = 0.67; 95% CI 0.50-0.86), but there was only fair agreement in reporting excision margin status (κ = 0.24; 95% CI 0.07-0.43) with frequent use of the 'uncertain' category. Significant issues included categorizing serrated lesions, recognizing focal high-grade dysplasia and epithelial misplacement, and apparent overdiagnosis of villous change in adenomas. CONCLUSIONS: Interobserver variability in some aspects of reporting colorectal polyps by BCS pathologists is suboptimal, with a potential impact upon patient management and the efficient running of the screening service. Approaches to addressing this are discussed.

A prospective study of the accuracy and concordance between in-situ and postfixation measurements of colorectal polyp size and their potential impact upon surveillance.

OBJECTIVES: To determine the differences between in-situ, prefixation and postfixation colorectal polyp measurements, their clinical impact upon determining adenoma surveillance intervals, and to compare postfixation measurements using three different devices. PATIENTS AND METHODS: A prospective study of 107 colorectal polyps resected from 65 consecutive patients (45 men, 20 women) undergoing colonoscopy as part of the Bowel Cancer Screening Programme was undertaken. The polyps were measured in situ, prefixation (study gold standard) and using three measurement devices (ruler, callipers and magnifying lens) postfixation in formalin. RESULTS: Prefixation ruler measurements were significantly higher than in-situ (P=0.02) and postfixation ruler measurements (P=0.04). No significant difference was observed between in-situ and postfixation ruler measurements (P=0.36), although in-situ measurements were more variable. In-situ measurements also generated more variation in surveillance intervals than postfixation measurements (9.3 vs. 5.6%). No significant difference was seen between measurements obtained by the three different devices postfixation (P=0.89). CONCLUSION: This study provides evidence supporting the use of postfixation polyp size measurements as advised by recent European pathology colorectal cancer screening recommendations. In the absence of a clinically significant difference between measurement devices, we advise the ruler to be used as a standard for postfixation measurements because of its widespread availability.

Upper gastrointestinal cancer in its early stages is predominantly asymptomatic.

BACKGROUND: Current guidelines for urgent endoscopic investigation of dyspepsia are based on alarm features and age criteria. However, there is concern that this type of guideline may delay the diagnosis of upper gastrointestinal (GI) cancer. OBJECTIVE: To evaluate the timescale of symptoms in upper GI cancer, determining whether patients experience dyspepsia before developing alarm features, and hence whether the current guidelines may delay diagnosis. METHOD: A prospective study of patients diagnosed with upper GI cancer between May 2004 and January 2007. A structured interview was performed directly after endoscopic diagnosis regarding the nature and duration of symptoms. RESULTS: Alarm features were present in 56 of the 60 patients interviewed. Only eight patients reported dyspepsia before developing their alarm feature; three of these had complained of dyspepsia for >10 years, one reported dyspepsia preceding the alarm feature by 18 months and in four patients dyspepsia preceded the alarm feature by ≤8 weeks. Preceding dyspepsia did not cause significant delay in referral for endoscopy (p=0.670), or affect tumour stage at diagnosis (p=0.436) or length of survival (p=0.325). CONCLUSION: It is rare for patients with upper GI cancer to experience significant dyspepsia before the onset of their alarm symptoms, therefore limiting the prospect of an earlier diagnosis. Early upper GI cancer is largely asymptomatic, and guidelines should limit the availability of open-access gastroscopy in simple dyspepsia. Increased awareness of the need to urgently investigate patients with concurrent anaemia or weight loss is required.