GIQuIC ACG ASGE Surveillance guidelines 2020 Microsoft PowerPoint - GIQuIC ACG ASGE Surveillance guidelines

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  • What the Updated Surveillance Colonoscopy Intervals Mean for Your

    Practice

    What the Updated Surveillance Colonoscopy Intervals Mean for Your

    Practice

    Aasma Shaukat, MD MPH

    Professor of Medicine

    GI section Chief, Minneapolis VAMC

    Minneapolis MN

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    Your Participation

  • Updates in Colonoscopy Surveillance in 2020

    Aasma Shaukat, MD MPH, FACG, FASGE, FACP, AGAF GI Section Chief, Minneapolis VAMC

    Professor of Medicine, University of Minnesota

  • Case 1 65 year old male seen for routine follow up. Tell you his last colonoscopy was 3 years ago and he thinks he’s due again. You look up his last colonoscopy: complete, good prep and 1 polyp (tubular adenoma). The best recommendation for this patient is:

    A. Reassure him that he is not due for 4-7 years (7-10 years after his last exam)

    B. Order a colonoscopy because patient is worried

    C. Order a FIT

    D. Defer discussion of colon cancer screening for 1 year

  • Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update by the US Multi- Society Task Force on Colorectal Cancer. Gastrointest Endosc. 2020;91(3):463-485.e5. doi:10.1016/j.gie.2020.01.014

  • Definitions Predictor/endpoint Definition

    Low risk adenoma/non-advanced adenoma 1-2 tubular adenomas, 10mm, villous features, and/or high grade dysplasia

    Advanced neoplasia Advanced adenoma or colorectal cancer (CRC)

    High risk adenoma Advanced neoplasia or 3 or more adenomas any size

    Sessile serrated adenoma/polyp (SSA/P) Histologically confirmed lesion

    Serrated polyp SSA/P or hyperplastic polyp

  • 50-60%

    30-40%

    5-10%

  • Low risk adenomas

    MSTF recommends repeat colonoscopy in 7 to 10 years, instead of 5 to 10 yrs, for patients with 1-2 tubular adenomas

  • 3.3% 4.9%

    17.3%

    No Adenoma "Low Risk" Adenoma Advanced Adenoma

    Baseline Finding

    Observed risk for metachronous advanced neoplasia up to 5 years follow up among individuals with 1 to 2 adenomas

  • Low risk adenoma is associated with reduced risk for incident and fatal CRC

    • CRC incidence and mortality in LRA similar to those who had no adenoma

    • RR 1.2 (0.8-1.7)

    • Incidence 1.4 vs. 1.2% LRA vs normal group Click 2018

    • Risk for fatal CRC reduced among those with single LRA compared to general population

    • SMR 0.75, 95% CI, 0.63 to 0.88 Løberg 2014

  • Risk associated with 1-2 adenomas < 10mm

    He et al.

     HR incident CRC compared to no polyp: 1.23 (0.65-2.31)

    Lee et al.

     HR incident CRC compared to no adenoma: 1.29 (0.89-1.88)

     HR fatal CRC compared to no adenoma: 0.65 (0.19-2.18)

  • 3-year changed to 5 year follow up for patients with 3 to 4 adenomas

  • Why use intervals such as 7 to 10 years instead of a firm recommendation for one or the other?

    Additional concerns:

     Potentially confusing to primary docs, colonoscopists, and patients

     Most will recommend the shorter 7 year interval

    Response:

     Ranges indicate where longer polyp surveillance intervals are supported by emerging evidence

     Ranges allow for the clinician to consider available evidence to determine best interval for a given patient, and also indicate scenarios where new evidence is likely to favor safety of the longer polyp surveillance interval

     Opportunity for shared decision making  Patient with excellent prep, only two small adenomas may feel relieved to have option

    of 10 year follow up

     Patient with small adenomas at a 5 year follow up for small adenomas may feel more comfortable with an extension to 7 rather than 10 years

  • 2020 USMSTF recommendations for post colonoscopy follow up in average risk adults with normal colonoscopy or adenomas

    Baseline Colonoscopy Finding Recommended Interval for Surveillance Colonoscopy

    Strength of Recommendation

    Quality of Evidence

    Normal or < hyperplastic polyps < 10 mm 10 years Strong High

    1 to 2 tubular adenomas < 10 mm 7 to 10 years Strong Moderate

    3 to 4 tubular adenomas < 10 mm 3 to 5 years Weak Very Low

    5 to 10 tubular adenomas < 10 mm 3 years Strong Moderate

    Adenoma >10mm 3 years Strong High

    Adenoma with tubulovillous or villous histology 3 years Strong Moderate

    Adenoma with high grade dysplasia 3 years Strong Moderate

  • Case 1 65 year old male seen for routine follow up. Tell you his last colonoscopy was 3 years ago and he thinks he’s due again. You look up his last colonoscopy: complete, good prep and 1 polyp (tubular adenoma). The best recommendation for this patient is:

    A. Reassure him that he is not till 4-7 years later (7-10 years after his last exam)

    B. Order a colonoscopy because patient is worried

    C. Order a FIT

    D. Defer discussion of colon cancer screening for 1 year

  • Follow-up Colonoscopy for Serrated polyps

    • Very little data, supporting a cautious approach

    • Available data suggests having an SSP increases risk for future serrated polyp

    • Increased risk for high risk adenoma mainly seen in those with concurrent SSP and conventional adenoma

  • Are Serrated polyps bad players? He Gastro 2019

    Baseline Finding HR, 95% CI Cumulative CRC

    incidence

    5 years 10 years

    No polyp (n=112,107) Ref 0.2 0.4

    Serrated polyps < 10mm (n=5,010) 1.25; 95% CI, 0.76-2.08 0.1 0.4

    1-2 serrated polyps any size (n=4,957) 1.41; 95% CI, 0.89-2.25 n/a n/a

    >=3 serrated polyps any size (n=579) 2.5; 95% CI, 0.82-8.09 n/a n/a

    Large serrated polyp >=10mm (n=566) 3.35; 95% CI, 1.37–8.15 0.4 1.1

    Advanced adenoma (n=2,453) 4.07; 95% CI, 2.89–5.72 0.6 1.7

    HR adjusted for # age at first endoscopy, study cohort, family history of crc, pack year smoking, bmi, physical activity, alcohol, aspirin, and # of surveillance endoscopies. Serrated polyp = TSA, SSA/P or HP

  • Surveillance recommendations Serrated polyps

  • Take Home Points

     Surveillance colonoscopy in appropriate individuals—High Value Care

     New evidence shows 1-2 small adenomas or SSP have similar outcome as normal colonoscopy

     New follow up colonoscopy intervals are lengthened

     Surveillance extended to 7-10 years for 1-2 small adenoma

     Surveillance 3-5 years for those with 3-4 adenoma

     Future surveillance lengthened based on first surveillance colonoscopy

  • “Do not repeat colonoscopy for at least 5 years for

    patients who have one or two small (

  • GIQuIC Real-Time ReportsGIQuIC Real-Time Reports

    • Appropriate follow-up interval for colonoscopies with findings of tubular adenomas < 10 mm

    • Appropriate follow-up interval for colonoscopies with findings of sessile serrated polyps < 10 mm without dysplasia

    • Appropriate follow-up interval of 3 years for colonoscopies with findings of advanced neoplasm

    • Appropriate follow-up interval of 3 years for colonoscopies with findings of advanced serrated lesion

    • Appropriate follow-up interval of 10 years for colonoscopies with findings of hyperplastic polyps

  • Appropriate follow-up interval for colonoscopies with findings of tubular adenomas < 10 mm

    Appropriate follow-up interval for colonoscopies with findings of tubular adenomas < 10 mm

  • Appropriate follow-up interval for colonoscopies with findings of sessile serrated polyps < 10 mm without

    dysplasia

    Appropriate follow-up interval for colonoscopies with findings of sessile serrated polyps < 10 mm without

    dysplasia

  • Appropriate follow-up interval of 3 years for colonoscopies with findings of advanced neoplasm

    Appropriate follow-up interval of 3 years for colonoscopies with findings of advanced neoplasm

  • Appropriate follow-up interval of 3 years for colonoscopies with findings of advanced serrated lesion

    Appropriate follow-up interval of 3 years for colonoscopies with findings of advanced serrated lesion

  • Appropriate follow-up interval of 10 years for colonoscopies with findings of hyperplastic polyps

    Appropriate follow-up interval of 10 years for colonoscopies with findings of hyperplastic polyps

  • Data CollectionData Collection

  • Data CollectionData Collection

  • GIQuIC 2020 QCDR Measure SetGIQuIC 2020 QCDR Measure Set

    ID Title Bonus

    GIQIC 15 Appropriate follow-up interval of 3 years recommended based on pathology findings from screening colonoscopy in average-risk patients

    High-Priority

    GIQIC 17 Appropriate follow-up interval of 5 years for colonoscopies with