Endoscopy Training Is More Important Than Technology in Reducing Interval Colorectal Cancer

Despite many technological advances, better training and education are the most important factors to boost the detection of adenomas in the colon and reduce interval colorectal cancer, according to Michael B. Wallace, MD, MPH, professor of medicine, Mayo Clinic, Jacksonville, FL.

“Our eyes and hands are our best technology. There’s no substitute for a good exam,” Wallace said, noting that technology should be viewed more as an adjunct tool for clinicians when assessing for adenomas.

Wallace reviewed advanced imaging techniques for the colon and discussed the importance of education during a presentation at the 2014 American Gastroenterological Association Clinical Congress of Gastroenterology and Hepatology in Miami Beach, FL, on Jan 18.

A thorough physical and visual assessment for possible adenomas is important in light of today’s emphasis on cost savings, Wallace added. Bundled payments and pay for performance will force clinicians to reconsider sending extra samples for staining that might not be necessary. “Health care reform will demand lower costs and better outcomes,” he said.

Although optical biopsy is not yet standard for adenoma detection, Wallace said it will be important to use it with care. There’s a potential $1 billion-plus annual cost savings associated with lowering optical biopsy use. Additionally, the approach has a small risk of incorrect assignment of surveillance and a very small risk of the missed diagnosis of cancer.

More common imaging techniques for colon adenoma detection include standard, high-definition, zoom, and confocal endoscopy, Wallace said. Clinicians should take advantage of training and education on how and when to use the appropriate imaging techniques. Current studies show mixed results in terms of how technology actually assists in boosting adenoma detection rates, Wallace said.

However, studies show a clearer connection to clinician education and adenoma detection rates, Wallace said. For example, Coe et al. reported in 2013 in the American Journal of Gastroenterology that endoscopists who received an educational intervention for adenoma detection raised their baseline detection from 36% to 47%, said Wallace, who was one of the study’s co-authors. A larger trial may be necessary to involve a greater number of endoscopists and evaluate whether improvements in adenoma detection actually led to reduced colorectal cancer, the study authors reported.

The detection of serrated polyps is “the next frontier” for adenoma detection, as these polyps can be easily missed, Wallace said. However, these polyps can be a source of interval cancers.

Clinicians should also be on the watch for improper polyp resection. As Pohl et al. stated in 2013 in Gastroenterology, neoplastic polyps are often incompletely resected, and that could lead to the development of interval cancers.

The importance of adenoma detection even at seemingly small percentages can make a difference for patients, said. He noted that an upcoming study from Kaiser Permanente will show that for every 1% gain in adenoma detection, there appears to be a 3% reduction in colorectal cancer rates. “Adenoma detection rates drive colorectal cancer rates,” he said.