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Articles: Vikram Boolchand, Gregory Olds, Joseph Singh, Pankaj Singh, Amitabh Chak, and Gregory S. Cooper Colorectal Screening after Polypectomy: A National Survey Study of Primary Care Physicians Ann Intern Med 2006; 145: 654-659 [Abstract] [Full text] [PDF]

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Response to comments

Vikram Boolchand, Gregory S. Cooper. MD, Case Medical Center   (3 January 2007)

C-SCOPES ARE SURGICAL PROCEEDURES

James M Duncan   (4 December 2006)

Comment on a national survey study on recommendations of colorectal screening after polypectomy

Masahiro Kami, Yasuo Kakugawa, and Naoko Murashige   (27 November 2006)

Who is Best Suited to Perform Colonoscopy and Manage the Findings: a Systems Perspective

Christine A. Sinsky   (27 November 2006)

Guidelines keep changing!

Fadi Antaki   (22 November 2006)

Colonrectal screening after polypectomy in USAF communities

Hans F Otto   (22 November 2006)

Response to comments 3 January 2007
Vikram Boolchand, MD University of Arizona, Gregory S. Cooper. MD, Case Medical Center Send rapid response to journal: Re: Response to comments vikramboolchand{at}yahoo.com Vikram Boolchand, et al.	We are pleased to see the interest of Dr. Antaki and Dr. Otto in our survey study of primary care physicians regarding post-polypectomy surveillance. (1) As we report, constantly changing guidelines from various societies remain an issue for the primary care physician. In 2003, the guidelines for colorectal cancer screening and surveillance from the U.S. Multi- society Task Force (USMSTF) on Colorectal Cancer were developed by a panel of both gastroenterology and primary care societies (2). The guidelines in 2003 from the American Cancer Society (ACS) were from a single society and included recommendations for the early detection of several types of cancers (3). As Dr. Antaki pointed out, there was an inconsistency between the ACS and USMSTF guidelines regarding surveillance for small adenomas, less than a 1 cm (3-6 years vs. 5 years, respectively). Although we did not ask our respondents the reasoning for their recommendations, it is unlikely the primary care practitioner weighed these two different sets of guidelines when deciding surveillance intervals. If respondents based their answer on the ACS guidelines, then an equal amount of the respondents would have chosen 3 years and 5 years for follow-up of a small tubular adenoma. In our survey almost the same number (25%) of respondents chose to survey a small tubular adenoma in 1 year or less as 5 years and 46% choose a 3 year surveillance interval. This suggests that when given a range of guideline based intervals, most respondents would tend to recommend surveillance at or before the earliest interval. We agree that the combined ACS and USMSTF guidelines from 2006 will hopefully decrease confusion over surveillance guidelines from multiple societies (4). We appreciate the comments from Dr. Otto regarding the need for communication between endoscopists and primary care physicians. As we mentioned, it remains clear that one conclusion from our study is that further educational efforts are necessary to change current inappropriate referral patterns. An important part of this change may include recommendations to the primary care physician for the next surveillance colonoscopy based upon the findings of the index colonoscopy after the pathology of polyps has been read. The excessive use of more frequent colonoscopy than necessary may need to be stressed to overcome current fears over small missed polyps and the development of colorectal neoplasia in very low risk patients. Vikram Boolchand, MD Gregory S. Cooper, MD References 1. Boolchand V, Olds G, Singh J, Singh P, Chak A, Cooper GS. Colorectal Screening after Polypectomy: A National Survey Study of Primary Care Physicians. Annals of Internal Medicine. 2006;145:654-659. 2. Winawer S, Fletcher R, Rex D, Bond J, Burt R, Ferrucci J, Ganiats T, Levin T, Woolf S, Johnson D, Kirk L, Litin S, Simmang C, Gastrointestinal Consortium Panel. Colorectal cancer screening and surveillance: clinical guidelines and rationale. Update based on new evidence. Gastroenterology 2003 Feb;124(2):544-60. 3. Smith RA, Cokkinides V, Eyre HJ. American Cancer Society guidelines for the early detection of cancer, 2003. CA Cancer J Clin 2003 Jan-Feb;53(1):27-43. 4. Winawer SJ, Zauber AG, Fletcher RH, Stillman JS, O'Brien MJ, Levin B, et al. Guidelines for colonoscopy surveillance after polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society. Gastroenterology. 2006;130:1872-85. Conflict of Interest: None declared
C-SCOPES ARE SURGICAL PROCEEDURES 4 December 2006
James M Duncan, MD BAMC,FSHTX(RET/DAC) Send rapid response to journal: Re: C-SCOPES ARE SURGICAL PROCEEDURES duncanjm1{at}yahoo.com James M Duncan	May it please all refering sources to remember that the CRC SCREENING/COLON POLYP patient is about to undergo a surgical proceedure with risks to include, but not exclusive of, dehdration, electrolyte abnormality induction, cardiopulmonary arrest, and/or bleeding to open surgery with general anesthesia, transfusion risks, and death. A pre-op evaluation is always appropriate using your institution's adopted Anesthesia Score in order to avoid character building experiences. If the refering source cannot or does not want to preform a pre-op evaluation, then a Consultation with the proceeduralist is in order before any proceedual encounter. The cursory pre-op check on the day of the C- Scope will not suffice! When bad outcomes occur in an otherwise healthy patient per the familiy's viewpoint, the referring souce and proceeduralist will all get sued! Conflict of Interest: None declared
Comment on a national survey study on recommendations of colorectal screening after polypectomy 27 November 2006
Masahiro Kami, MD the Institute of Medical Science, the University of Tokyo, Yasuo Kakugawa, and Naoko Murashige Send rapid response to journal: Re: Comment on a national survey study on recommendations of colorectal screening after polypectomy kami-tky{at}umin.net Masahiro Kami, et al.	Letter to the Editor Comment on a national survey study on recommendations of colorectal screening after polypectomy Boolchand et al. reported a national survey study on recommendations of colorectal screening after polypectomy (1). The present study showed that colonoscopic surveillance was conducted as scheduled by guidelines only in 15-57% of the patients and with widely varied frequencies. While the authors noted the difference by physician type (internists vs. family practitioners), it would solely be insufficient to explain the results. Most clinicians would like to know other factors such as the effects of popularity of the latest guidelines, physicians’ age, medical career, numbers of referrals to colonoscopy, and medical insurance system. It is appreciated if the authors can share such information with the readers. (106 words) References 1. Boolchand V, Olds G, Singh J, Singh P, Chak A, Cooper GS. Colorectal screening after polypectomy: a national survey study of primary care physicians. Ann Intern Med. 2006;145(9):654-9. Conflict of Interest: None declared
Who is Best Suited to Perform Colonoscopy and Manage the Findings: a Systems Perspective 27 November 2006
Christine A. Sinsky, MD Medical Associates Clinic and Health Plan Send rapid response to journal: Re: Who is Best Suited to Perform Colonoscopy and Manage the Findings: a Systems Perspective csinsky1{at}mahealthcare.com Christine A. Sinsky	Boolchand et al (1) found that clinicians who perform colonoscopy recommend follow-up more appropriately than those who do not. This should surprise no one. Two questions follow from their article: who is best suited to manage abnormalities found at colonoscopy and, in a manpower shortage, who can be trained to perform colonoscopy? From a systems perspective, clinicians who perform a procedure are in the best position to keep up-to-date on relevant recommendations and to establish the office systems needed to assure appropriate follow-up; it is an invitation for error to divert these responsibilities to others. Rather than wish that 200,000 primary care physicians would keep track of the “ever-changing guidelines” it is more efficient to unambiguously assign this responsibility to the much smaller pool of colonoscopists. It is a cumbersome and misdirected approach that requires every primary care physician to remember that patients with a 6 mm tubular adenoma should have a 5 year follow-up colonoscopy, those with a 12 mm tubulovillous adenoma should have one in 3 years, those with a 12 mm tubular adenoma 3 years earlier need a 5 year follow-up, those with two 6 mm tubular adenomas need 5 year follow-up, but those with 3 or more adenomas, regardless of size, require a 3 year follow-up, and that for those with a 12 mm tubular adenoma with high-grade dysplasia there are no specific recommendations. It is better to concentrate the effort at the level of the provider of the procedure. In addition, from a business perspective, the organizational costs of managing the follow-up of patients with abnormalities are bundled into the payment for the colonoscopy, which currently flows to the proceduralist, not to the primary care physician. Boolchand also raises the issue of a manpower shortage for colonoscopy. It is time to reassess the skill set required for this procedure and develop more efficient systems of care. In one model nurse practitioners would be taught the technical and cognitive skills associated with screening colonoscopy. Groups of primary care physicians would then hire such colonoscopists to provide screening for their patients. This model would allow the volume and the reimbursement to justify developing integrated systems for appropriate follow-up. Protocols for management of polyps would be instituted through collaboration between the colonoscopist and a member of the primary care physician staff. Procedures for follow-up would be implemented from a systems perspective. When Pap smear screening became more common, the pathology workforce could not meet the demand, and cytotechnologists were trained in this narrow scope of practice. A similar restructuring and retraining of the colonoscopy workforce to match capacity with demand, and provider skill set with the technical skill requirements, will help improve the availability, efficiency and accuracy of colon cancer prevention. 1. Boolchand V. et al. Colorectal screening after polypectomy: a national survey of primary care physicians. Ann Intern Med 2006;145:654- 659. Conflict of Interest: None declared
Guidelines keep changing! 22 November 2006
Fadi Antaki, MD Erasme Hospital Send rapid response to journal: Re: Guidelines keep changing! fantaki{at}hotmail.com Fadi Antaki	We read with great interest this excellent study which confirms a trend we have all seen in our day-to-day Gastroenterology practice. However, to be fair to our colleagues, it is important to mention that the old American Cancer Society (ACS) guidelines (published in 2003) recommended a surveillance colonoscopy in 3-6 years for patients with "single small adenomas" and "within 3 years from initial polypectomy" for patients with multiple adenomas. These were different from the 2003 recommendations by the U.S. Multisociety Task Force on Colorectal Cancer which recommended a 5-year interval for low-risk patients with 1-2 small adenomas. Therefore, some confusion among doctors should have been expected when professional societies issued different guidelines. We welcome the revised, combined, guidelines issued by the ACS and USMTF hoping that having one set of guidelines endorsed by all these societies will lead to a better utilization of scarce resources and a more appropriate suveillance interval for all patients, no matter which doctor is making the recommendation. References: 1- Vikram Boolchand, Gregory Olds, Joseph Singh, Pankaj Singh, Amitabh Chak, and Gregory S. Cooper Colorectal Screening after Polypectomy: A National Survey Study of Primary Care Physicians Ann Intern Med 2006; 145: 654-659 2- Smith RA, Cokkinides V, Eyre HJ. American Cancer Society guidelines for the early detection of cancer, 2003. CA Cancer J Clin 2003 Jan-Feb;53(1):27-43 3-Winawer S, Fletcher R, Rex D, Bond J, Burt R, Ferrucci J, Ganiats T, Levin T, Woolf S, Johnson D, Kirk L, Litin S, Simmang C, Gastrointestinal Consortium Panel. Colorectal cancer screening and surveillance: clinical guidelines and rationale. Update based on new evidence. Gastroenterology 2003 Feb;124(2):544-60 4-Winawer SJ, Zauber AG, Fletcher RH, Stillman JS, O'Brien MJ, Levin B, et al. Guidelines for colonoscopy surveillance after polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society. Gastroenterology. 2006;130:1872-85. Conflict of Interest: None declared
Colonrectal screening after polypectomy in USAF communities 22 November 2006
Hans F Otto, MD Department of Internal Medicine, 52 Medical Group, Spangdahlem Air Base, Germany Send rapid response to journal: Re: Colonrectal screening after polypectomy in USAF communities hans.otto{at}spangdahlem.af.mil Hans F Otto	I am a General Internist who has now served in three major commands (the USA, the Pacific and the European commands). Colorectal cancer (CRC) screening has been a frequently under-recognized and under-optimized surveillance measure at the Primary Care level. This has been due to operations tempo with active duty, mission requirements, obstacles to retiree health and access to useable interventions for screening, especially overseas. In the USAF we have limited resources, facilities and physicians for CRC screening but I have never had insurmountable problems obtaining the interventions needed for initial or status-post polypectomy evaluation. However, I have learned that Primary Care clinics must work hand-in- hand with our gastroenterologists and/or surgical colleagues. As the Boolchard et al article highlights, some of us are missing that opportunity (1). In this current day, when we (civilian and military physicians alike), our patients or their insurance providers have very limited resources, we need to ensure that we are referring patients appropriately for surveillance colonoscopy. Over-referring patients creates a many problems, especially a delay in the evaluation of those patients who are high-risk. As this article highlights, many in primary care are unaware of the most recent guidelines. It is admittedly challenging when new/better data continues to be sought, such as the most recent NEJM article describing differences in colorectal neoplasia between the genders (2), but our responsibility nonetheless. As "Guardians of the Gateway" to referral care, we have a responsibility to keep current on the most recent guidelines as well as the evidence behind those recommendations. I have had to hold lectures within my respective Primary Care clinics updating the staff on the guidelines and the impact on our local resources and referral processes. This continuous professional education and process improvement has improved our local population metrics for colorectal cancer from some of the worst to one of the best in USAF Europe. The staff as well as the surgeons performing colonoscopies have universally been appreciative. But, as always, it is the patients have benefited from our continued dedication to excellence in their care, even if they are largely unaware of local efforts. The take home point from this article is that we as Primary Care physicians have the opportunity and responsibility to evaluate and appropriately refer our patients for CRC screening. We must do this while simultaneously balancing our clinical assessment, understanding that rather civilian or military, our quality or care given is constantly being measured, if not by insurance or chain of command than by the patients themselves. 1. Boolchand V, Olds G, Singh J, Singh P, Chak A, Cooper GS. Colorectal Screening after Polypectomy: A National Survey Study of Primary Care Physicians. Annaals of Internal Medicine. 2006;145:654-659. 2. Regula J, Rupinski M, Kraszewska E, Polkowski M, Pachlewski J, Orlowska J, Nowacki MP, Butruk E. Colonoscopy in Colorectal-Cancer Screening for Detection of Advanced Neoplasia. New England Journal of Medicine. 2006;355:1863-1872. Conflict of Interest: None declared