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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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 165 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
DefinitionsPredictor/endpoint Definition
Low risk adenoma/non-advanced adenoma 1-2 tubular adenomas, <10mm in size
Advanced adenoma Adenoma >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 <10mm, because of:
1) Similar CRC risk compared with having normal colonoscopy;
2) Lower CRC risk compared with the general population
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
<10mm
• Meta-analysis including 8 studies, 10,139 patients• Low risk = 1-2 <10mm adenomas Dube C Am J Gastro 2017
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 <10mm
Rationale Evidence/Argument
Increasinglycommon
• Focus on adenoma detection increases identification of 3-4 small adenomas
• ADR paradox: Patients have lower CRC risk but higher chance of aggressive surveillance
Low risk for AN
• 1.8% of 275 patients with 3-4 < 10mm adenomas, compared to 1.2% among 762 patients with 1-2 <10mm adenomas Vemulapalli KC 2014
• 6.3% among 79 pt with >3 1-5mm adenomas
• 3.5% among 231 with 1-2 1-5mm adenomas
• <10% for patients with 1-9 < 10mm adenomas Sneh Arbib O 2017
Low risk for incident CRC
• Rate of incident CRC:
• 10.2 per 10,000 person years follow up for >3 <10mm adenomas (n=572) vs.
• 8.9 per 10,000 for 1-2 <10mm adenomas (n=4,496) Click 2018
AN=advanced adenoma/advanced neoplasia
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 FindingRecommended 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 165 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% CICumulative 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 (<1cm)
adenomatous polyps”
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 findings of sessile serrated polyps < 10 mm without dysplasia
High-Priority
GIQIC 21 Appropriate follow-up interval of not less than 5 years for colonoscopies with findings of 1-2 tubular adenomas < 10 mm OR of 10 years for colonoscopies with only hyperplastic polyp findings in rectum or sigmoid
High-Priority
GIQuIC 2021 QCDR Measure SetGIQuIC 2021 QCDR Measure Set
• GIQuIC is retiring GIQIC 15, 17, and 21.
• GIQuIC will include in its 2021 QCDR self-nomination a selection of the measures based on the updated colonoscopy surveillance guidance. Ultimately, CMS approves the measures that will make up the GIQuIC 2021 QCDR measure set.
Questions?Questions?
Grab Tab – Click orange arrow to open/close Control Panel.
Please continue to submit your text questions and comments using the Questions Panel.
Note: Today’s presentation is being recorded and will be available for re-review in the near future. We will notify you via email.
If you have questions, please contact [email protected].
Your Participation
Additional Questions Additional Questions
GIQuIC/ACGBecca Adesanya, GIQuIC Registration
[email protected] or [email protected]
GIQuIC/ASGE Eden Essex
Assistant Director Quality & Health [email protected]
GIQuIC Data AnalystsJennifer Holub, [email protected]
Luke Williams, [email protected]
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