Colorectal Cancer Detection: How Well Do Appropriateness Criteria Perform?

CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2009;7:807– 808

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Colorectal Cancer Detection: How Well Do Appropriateness Criteria Perform? Dear Editor: We read with interest the article by Hassan et al,1 “Cost effectiveness of colonoscopy based on the appropriateness of an indication.” In this article, the authors pooled 12 studies published between 1998 and 2007 that compared the pre-endoscopic assessment of appropriateness of the indication for colonoscopy using the American Society for Gastrointestinal Endoscopy (ASGE) and/or European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) guidelines with the endoscopic detection of colorectal cancer (CRC) at a subsequent endoscopy. A total of 560 CRCs were detected by the 10,056 colonoscopies (6.4%) performed for an appropriate indication, whereas 38 CRCs were diagnosed by the 3522 colonoscopies (1.1%) with an inappropriate indication. A decisionanalysis model was constructed to represent the clinical and economic consequences of referring or not referring a patient with an appropriate or inappropriate indication for colonoscopy in relation to the eventual detection of CRC. Hassan et al1 concluded that current guidelines (ASGE, EPAGE) regarding the appropriateness of colonoscopy are relatively inefficient in excluding a clinically meaningful CRC risk in patients in whom colonoscopy generally is not indicated, raising serious concerns about their application in clinical practice. We think that these conclusions deserve at the very least a note of caution. Among the 12 studies analyzed by Hassan et al,1 2 of these, that of Bersani et al2 and that of Gonvers et al,3 should be looked at more closely. These 2 studies dealt with 7434 of the 14,160 patients analyzed by Hassan et al1 and were responsible for 31 of the 38 cancers found during colonoscopy for inappropriate indications. In the study by Bersani et al,2 15 cancers were diagnosed during an endoscopy performed for an indication not covered by the ASGE guidelines and therefore were judged as being inappropriate. It would have been necessary to know the age of the patients suffering from constipation, for example, because the ASGE guidelines on the use of endoscopy in the management of constipation recommend that patients older than 50 years of age who have not had prior CRC screening should undergo colonoscopy.4 In addition, the recent ASGE guidelines recommend colonoscopy approximately every 10 years after the age of 50 years for screening purposes in averagerisk individuals.5 It is highly likely that several of the patients studied by Bersani et al2 and in whom the indication for colonoscopy was inappropriate were older than 50 years of age and thus met the criteria for CRC screening. In the study by Gonvers et al,3 there were 19 patients who had an inappropriate indication and who in fact were diagnosed with CRC. Most of these patients’ indications were deemed inappropriate because the interval between the surveillance colonoscopy and the previous polypectomy or curative-intent resection of CRC was too short (often by only a few weeks) or because no treatment of an

identified bleeding source was given before colonoscopy or because an anoscopy/sigmoidoscopy was not performed in patients younger than 50 years old with hematochezia and no risk factor for CRC. Had the appropriateness criteria been adhered to strictly (3 years between surveillance endoscopies, treatment given for the identified bleeding source, anoscopy/sigmoidoscopy performed before colonoscopy in patients with hematochezia), 16 of the 19 CRCs would have been diagnosed. It obviously would be desirable that situations that are judged as inappropriate would not result in the detection of CRC, which is definitely not the case. However, the absolute difference in the detection rate between inappropriate (1.1%) and appropriate cases (6.4%) is 5.3%, which also can be interpreted as a substantial gain. It is well-known that the relationship between clinical signs, symptoms, patient and family history (used to define the appropriateness of the indication for a procedure), and endoscopic findings is imperfect, but this does not mean that one should not use the ASGE and EPAGE appropriateness criteria for fear of missing neoplastic disease. To perform endoscopy on any patient with any abdominal symptom at any age, as has been proposed,6 in the present climate of cost constraints, would be an overreaction. The appropriateness criteria should and indeed must be improved. The ASGE criteria are revised and updated regularly. The EPAGE appropriateness criteria for colonoscopy were updated completely in April 2008 by a group of leading European experts and have now been published in Endoscopy,7–12 as well as being freely available on the Internet (available: www.epage.ch). JEAN-JACQUES GONVERS, MD Department of Gastroenterology Centre Hospitalier Universitaire Vaudois and University of Lausanne Lausanne, Switzerland BERNARD BURNAND, MD, MPH Healthcare Evaluation Unit Institute of Social and Preventive Medicine (IUMSP) Centre Hospitalier Universitaire Vaudois and University of Lausanne Lausanne, Switzerland JOHN-PAUL VADER, MD, MPH Healthcare Evaluation Unit Institute of Social and Preventive Medicine (IUMSP) Centre Hospitalier Universitaire Vaudois and University of Lausanne Lausanne, Switzerland FLORIAN FROEHLICH, MD Department of Gastroenterology Centre Hospitalier Universitaire Vaudois and University of Lausanne Lausanne, Switzerland Department of Gastroenterology University of Basle, Basle, Switzerland

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1. Hassan C, Di Giulio E, Pickhardt PJ, et al. Cost effectiveness of colonoscopy, based on the appropriateness of an indication. Clin Gastroenterol Hepatol 2008;6:1231–1236. 2. Bersani G, Rossi A, Ricci G, et al. Do ASGE guidelines for the appropriate use of colonoscopy enhance the probability of finding relevant pathologies in an open access service? Dig Liver Dis 2005;37:609 – 614. 3. Gonvers JJ, Harris JK, Wietlisbach V, et al. A European view of diagnostic yield and appropriateness of colonoscopy. Hepatogastroenterology 2007;54:729–735. 4. Qureshi W, Adler DG, Davila RE, et al. ASGE guideline: guideline on the use of endoscopy in the management of constipation. Gastrointest Endosc 2005;62:199 –201. 5. Davila RE, Rajan E, Baron TH, et al. ASGE guideline: colorectal cancer screening and surveillance. Gastrointest Endosc 2006; 63:546 –557. 6. Andriulli A, Annese V, Terruzzi V, et al. “Appropriateness” or “prioritization” for GI endoscopic procedures? Gastrointest Endosc 2006;63:1034 –1036. 7. Arditi C, Peytremann-Bridevaux I, Burnand B, et al. Appropriateness of colonoscopy in Europe (EPAGE II)–screening for colorectal cancer. Endoscopy 2009;41:200 –208. 8. Arditi C, Gonvers J-J, Burnand B, et al. Appropriateness of colonoscopy in Europe (EPAGE II)–surveillance after polypectomy and after resection of colorectal cancer. Endoscopy 2009;41:209 –217. 9. Schusselé Filliettaz S, Juillerat P, Burnand B, et al. Appropriateness of colonoscopy in Europe (EPAGE II)– chronic diarrhea and known inflammatory bowel disease. Endoscopy 2009;41:218 – 226. 10. Peytremann-Bridevaux I, Arditi C, Froehlich F, et al. Appropriateness of colonoscopy in Europe (EPAGE II)–iron-deficiency anemia and hematochezia. Endoscopy 2009;41:227–233. 11. Schusselé Filliettaz S, Gonvers J-J, Peytremann-Bridevaux I, et al. Appropriateness of colonoscopy in Europe (EPAGE II)–functional bowel disorders: pain, constipation and bloating. Endoscopy 2009;41:234 –239. 12. Juillerat P, Peytremann-Bridevaux I, Vader J-P, et al. Appropriateness of colonoscopy in Europe (EPAGE II)–presentation of methodology, general results, and analysis of complications. Endoscopy 2009;41:240 –246.

Conflicts of interest The authors disclose no conflicts. doi:10.1016/j.cgh.2009.02.013

Reply. We agree with Gonvers et al on the importance of identifying the most frequent reasons for which an unexpected cancer is detected in an exam with an inappropriate indication. This should lead to a critical improvement of the efficiency of American Society for Gastrointestinal Endoscopy (ASGE)/European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) guidelines. In particular, the authors clarify

CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 7, No. 7

that in their experience, most of the unexpected cancers occurred in patients in follow-up for colorectal neoplasia or in ⬍50-year-old patients with rectal bleeding. Regarding the former, an unexpectedly high rate of cancer has already been shown in chemopreventive postpolypectomy trials. Because most of these cancers were detected at the first-year follow-up colonoscopy, a meaningful rate of false-negative results for cancer at baseline colonoscopy might be suggested. This raises some concern on the opportunity of considering appropriate 3to 10-year interval before the first postpolypectomy examination, prompting the need for further studies. Regarding the latter, colorectal cancer incidence begins its steep increase of incidence at 40 years of age, although such an increase in asymptomatic average-risk persons triggers screening procedures only 10 years later. However, the occurrence of rectal bleeding, well-known to increase colorectal cancer prevalence in unselected population, between 40 –50 years of age could be reconsidered as an appropriate indication for colonoscopy, in case a high rate of cancer is confirmed by future studies. We also agree with Gonvers et al on the substantial clinical implications of an absolute 5.3% cancer difference between appropriate and inappropriate procedures. However, the residual risk of cancer in patients with an inappropriate indication is clinically meaningful, because in the intention of these guidelines these patients should not be referred to an endoscopy. The 5-year cancer risk of a 60-year-old U.S. subject is 0.6%, and cancer prevalence is probably 0.2%. Therefore, a patient with an inappropriate indication is left with a cancer risk that is 2-fold and 5-fold increased as compared with these baseline data, raising some concern on the long-term acceptability of these guidelines. Indeed, the occurrence of 1 cancer every 91 subjects not undergoing colonoscopies because of an inappropriate indication could have a negative feedback, raising also medicallegal implications, on the referring physicians. Therefore, we hope that in the present and future development of ASGE/ EPAGE guidelines, all these new considerations, including our cost-effectiveness analysis, might change the degree of appropriateness of those few indications associated with a higher than expected cancer prevalence. CESARE HASSAN, MD Department of Gastroenterology Nuova Regina Margherita Hospital Rome, Italy

Conflicts of interest The author discloses no conflicts. doi:10.1016/j.cgh.2009.05.020