Have you received a screening colonoscopy report back for one of your patients that reads: "Normal exam, recommend repeat colonoscopy in 5 years"?
If you have, turns out you're not alone.
Guidelines recommend screening colonoscopies only every 10 years because it takes many years for normal tissue in the colon to transform into cancer, but according to a new study, gastroenterologists do not consistently follow their own recommendations.
In the study, , investigators found that gastroenterologists often recommend more frequent screening intervals. The study involved an analysis of more than 1,400 adults between 50 and 65 years old without a history of colorectal cancer or adenomas who received a screening colonoscopy between 2001 and 2010.
As expected, the average interval between the screening and repeat colonoscopies depended on the findings of the screening exam. Appropriately, high-risk findings, such as large adenomas, led to repeat exams much earlier than normal exams.
But the researchers also stumbled across a remarkable trend: patients with normal colonoscopies had repeat colonoscopies years before they were due. In fact, the average time until repeat colonoscopy following a normal exam was just 6.9 years. And those with hyperplastic polyps on the initial exam received repeat endoscopies on average just 5.7 years later, despite recommendations that repeat screenings are not due for 10 years.
Patients with abnormal colonoscopy findings also frequently received follow-up exams before they were due. The researchers found that surveillance endoscopies following identification of an adenoma occurred more than a year before they were due half of the time. All told, the authors concluded that 88% of follow-up screenings following a normal exam and 49% of repeat colonoscopies after identification of an adenoma represented overuse.
We find these results disturbing. There is no evidence that more frequent colonoscopy exams benefit patients, and these procedures have harms associated with them.
According to , for every 1,000 colonoscopies performed there are nearly three serious complications -- defined as perforations, hemorrhage, diverticulitis, cardiovascular events, severe abdominal pain, and death. These risks are relatively small when a patient may derive significant benefit from the procedure; however, when the colonoscopy is not indicated, these risks are hard to justify.
The study's results also reveal a tragic paradox: while the patients in this analysis were overscreened for colon cancer, many in the U.S. lack access to appropriate screening -- including colonoscopy, sigmoidoscopy, or fecal occult blood testing. Such screening has been shown to decrease the risk of dying from colon cancer. Approximately 35% of eligible Americans , with low-income and minority populations at increased risk.
What can be done to address the simultaneous overuse of screening colonoscopy in some patients and underuse of appropriate colon cancer screening strategies in others?
A promising initial step is that the American Gastroenterological Association (AGA) has focused on overuse of screening colonoscopy in its . Specifically, the AGA recommends avoiding colon cancer screening within 10 years of a high-quality normal colonoscopy and avoiding repeat colonoscopies within five years of an exam showing "one or two small adenomatous polyps, without high-grade dysplasia, completely removed via a high-quality colonoscopy."
Perhaps insurers should not reimburse gastroenterologists for inappropriate studies, though care would need to be taken to ensure there is no gaming of the system by modifying billing codes to justify early exams.
As for the problem of underuse of colon cancer screening, we remain concerned that coverage expansion under the Affordable Care Act will not be sufficient to remedy this issue. It is difficult to find gastroenterologists in some areas who are willing to perform screening colonoscopies at Medicaid rates. Importantly, however, the United States Preventive Services Task Force concluded that annual fecal occult blood testing is an , and is likely to be much more accessible than colonoscopy in such settings.
In fact, even in settings where colonoscopy is easily accessible, patients and doctors should consider annual fecal occult blood testing or flexible sigmoidoscopy -- a safer and shorter procedure -- as screening options. Such an approach is likely to reduce the use of invasive and potentially harmful procedures while ensuring that patients get the care they need -- Slow Medicine at its best.