Colonoscopy quality and endoscopist factors: what are the required endoscopist conditions for high-quality colonoscopy to reduce colorectal cancer incidence and mortality?

Abstract

To maximize the effectiveness of colonoscopy in decreasing the incidence and mortality of colorectal cancer (CRC), high-quality colonoscopy procedures are essential. Considering that the colonoscopy quality varies among endoscopists, it is important to understand the endoscopist factors that influence the colonoscopy quality. In this paper, we reviewed the endoscopist factors related to colonoscopy quality. There are several quality indicators of colonoscopy, among which the adenoma detection rate is the most established indicator with evidence of its correlation with post-colonoscopy CRC. With respect to lesion detectability during colonoscopy, there are other measurements such as the sessile serrated lesion detection rate; however, further evidence on their relationships with post-colonoscopy CRC is needed. Previous studies that have examined the endoscopist characteristics influencing colonoscopy quality have suggested that several factors, including experience, the volume of colonoscopy procedures, and endoscopist specialty, are related to lesion detectability. However, discrepancies exist regarding the studies’ results; in particular, the influence of endoscopist specialty on coloscopy quality is controversial. Some recent studies have demonstrated that endoscopist specialty is not related to lesion detectability when considering confounding factors. Furthermore, it has been reported that nurse endoscopists can provide high-quality colonoscopy after training. It may be possible for endoscopists to improve their colonoscopy quality, regardless of specialty. Training, monitoring, and feedback of colonoscopy quality measurements are useful interventions for endoscopists to ensure high-quality procedures. Owing to the continuous development of endoscopic technologies, it is believed that training is useful for both inexperienced and experienced endoscopists.

Keywords

Adenoma detection rate / colonoscopy / colorectal cancer / endoscopist / feedback / quality indicators / screening / training

References

[1] Sung H,Siegel RL.Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.CA Cancer J Clin2021;71:209-49

[2] Schreuders EH,Rabeneck L.Colorectal cancer screening: a global overview of existing programmes.Gut2015;64:1637-49

[3] Zauber AG,Knudsen AB,van Ballegooijen M.Evaluating test strategies for colorectal cancer screening: a decision analysis for the U.S. Preventive Services Task Force.Ann Intern Med2008;149:659-69 PMCID:PMC2731975

[4] Lieberman DA.Clinical practice. Screening for colorectal cancer.N Engl J Med2009;361:1179-87

[5] Brenner H,Seiler CM,Hoffmeister M.Protection from colorectal cancer after colonoscopy: a population-based, case-control study.Ann Intern Med2011;154:22-30

[6] Winawer SJ,Ho MN.Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup.N Engl J Med1993;329:1977-81

[7] Zauber AG,O’Brien MJ.Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths.N Engl J Med2012;366:687-96 PMCID:PMC3322371

[8] Mandel JS,Church TR.Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study.N Engl J Med1993;328:1365-71

[9] Hardcastle JD,Robinson MH.Randomised controlled trial of faecal-occult-blood screening for colorectal cancer.Lancet1996;348:1472-7

[10] Kronborg O,Olsen J,Søndergaard O.Randomised study of screening for colorectal cancer with faecal-occult-blood test.Lancet1996;348:1467-71

[11] Mandel JS,Bond JH.The effect of fecal occult-blood screening on the incidence of colorectal cancer.N Engl J Med2000;343:1603-7

[12] Faivre J,Lejeune C.Reduction in colorectal cancer mortality by fecal occult blood screening in a French controlled study.Gastroenterology2004;126:1674-80

[13] Lindholm E,Haglind E.Survival benefit in a randomized clinical trial of faecal occult blood screening for colorectal cancer.Br J Surg2008;95:1029-36

[14] Baxter NN,Paszat LF,Urbach DR.Association of colonoscopy and death from colorectal cancer.Ann Intern Med2009;150:1-8

[15] Kahi CJ,Juliar BE.Effect of screening colonoscopy on colorectal cancer incidence and mortality.Clin Gastroenterol Hepatol2009;7:770-5; quiz 711

[16] Manser CN,Brunner J,Bauerfeind P.Colonoscopy screening markedly reduces the occurrence of colon carcinomas and carcinoma-related death: a closed cohort study.Gastrointest Endosc2012;76:110-7

[17] Nishihara R,Lochhead P.Long-term colorectal-cancer incidence and mortality after lower endoscopy.N Engl J Med2013;369:1095-105 PMCID:PMC3840160

[18] Doubeni CA,Quinn VP.Effectiveness of screening colonoscopy in reducing the risk of death from right and left colon cancer: a large community-based study.Gut2018;67:291-8 PMCID:PMC5868294

[19] Quintero E,Bujanda L.COLONPREV Study InvestigatorsColonoscopy versus fecal immunochemical testing in colorectal-cancer screening.N Engl J Med2012;366:697-706

[20] Kaminski MF,Zauber AG.The NordICC Study: rationale and design of a randomized trial on colonoscopy screening for colorectal cancer.Endoscopy2012;44:695-702 PMCID:PMC5435368

[21] Saito H,Takahashi N.Efficacy of screening using annual fecal immunochemical test alone versus combined with one-time colonoscopy in reducing colorectal cancer mortality: the Akita Japan population-based colonoscopy screening trial (Akita pop-colon trial).Int J Colorectal Dis2020;35:933-9

[22] Fritzell K,Wangmar J,Bottai M.Gender, having a positive FIT and type of hospital are important factors for colonoscopy experience in colorectal cancer screening - findings from the SCREESCO study.Scand J Gastroenterol2020;55:1354-62

[23] Zhao S,Pan P.Magnitude, risk factors, and factors associated with adenoma miss rate of tandem colonoscopy: a systematic review and meta-analysis.Gastroenterology2019;156:1661-74.e11

[24] Rex DK,Cohen J.Quality indicators for colonoscopy.Gastrointest Endosc2015;81:31-53

[25] Rees CJ,Rutter MD.British Society of Gastroenterologythe Joint Advisory Group on GI Endoscopythe Association of Coloproctology of Great Britain and IrelandUK key performance indicators and quality assurance standards for colonoscopy.Gut2016;65:1923-9 PMCID:PMC5136732

[26] Rees CJ,Zimmermann-Fraedrich K.Expert opinions and scientific evidence for colonoscopy key performance indicators.Gut2016;65:2045-60 PMCID:PMC5136701

[27] Kaminski MF,Bugajski M.Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative.Endoscopy2017;49:378-97

[28] Kaminski MF,Kraszewska E.Quality indicators for colonoscopy and the risk of interval cancer.N Engl J Med2010;362:1795-803

[29] Corley DA,Doubeni CA.Adenoma detection rate and risk of colorectal cancer and death.N Engl J Med2014;370:2541

[30] Kaminski MF,Rupinski M.Increased rate of adenoma detection associates with reduced risk of colorectal cancer and death.Gastroenterology2017;153:98-105

[31] Brenner H,Kretschmann J.Trends in adenoma detection rates during the first 10 years of the German screening colonoscopy program.Gastroenterology2015;149:356-66.e1

[32] Sekiguchi M,Matsumoto M.A scoring model for predicting advanced colorectal neoplasia in a screened population of asymptomatic Japanese individuals.J Gastroenterol2018;53:1109-19

[33] Leggett B.Role of the serrated pathway in colorectal cancer pathogenesis.Gastroenterology2010;138:2088-100

[34] East JE,Bateman AC.British Society of Gastroenterology position statement on serrated polyps in the colon and rectum.Gut2017;66:1181-96 PMCID:PMC5530473

[35] Sekiguchi M,Matsumoto M.Prevalence of serrated lesions, risk factors, and their association with synchronous advanced colorectal neoplasia in asymptomatic screened individuals.J Gastroenterol Hepatol2020;35:1938-44

[36] Kudo S.Endoscopic mucosal resection of flat and depressed types of early colorectal cancer.Endoscopy1993;25:455-61

[37] Matsuda T,Sano Y.Randomised comparison of postpolypectomy surveillance intervals following a two-round baseline colonoscopy: the Japan Polyp Study Workgroup.Gut2020;70:1469-78 PMCID:PMC8292600

[38] Saito Y,Kawamura T.Colonoscopy screening and surveillance guidelines.Dig Endosc2021;33:486-519

[39] Lee TJ,Blanks RG.Colonoscopy quality measures: experience from the NHS Bowel Cancer Screening Programme.Gut2012;61:1050-7

[40] Kozbial K,Heinze G.High quality of screening colonoscopy in Austria is not dependent on endoscopist specialty or setting.Endoscopy2015;47:207-16

[41] Zorzi M,Da Re F.Equipe Working GroupQuality of colonoscopy in an organised colorectal cancer screening programme with immunochemical faecal occult blood test: the EQuIPE study (Evaluating Quality Indicators of the Performance of Endoscopy).Gut2015;64:1389-96

[42] Jover R,Bujanda L.COLONPREV Study InvestigatorsEndoscopist characteristics that influence the quality of colonoscopy.Endoscopy2016;48:241-7

[43] Mehrotra A,Gourevitch RA.Physician characteristics associated with higher adenoma detection rate.Gastrointest Endosc2018;87:778-86.e5 PMCID:PMC5817032

[44] Crockett SD,Morris M.Endoscopist factors that influence serrated polyp detection: a multicenter study.Endoscopy2018;50:984-92 PMCID:PMC6160341

[45] Mandaliya R,Barnhill M.Significant variation in the detection rates of proximal serrated polyps among academic gastroenterologists, community gastroenterologists, and colorectal surgeons in a single tertiary care center.Dig Dis Sci2019;64:2614-21

[46] Sarvepalli S,Rothberg MB.Association of adenoma and proximal sessile serrated polyp detection rates with endoscopist characteristics.JAMA Surg2019;154:627-35 PMCID:PMC6583839

[47] Muthukuru S,Bisen R.Quality of colonoscopy: a comparison between gastroenterologists and nongastroenterologists.Dis Colon Rectum2020;63:980-7

[48] Baxter NN,Barrett MJ,Doria-Rose VP.Association between colonoscopy and colorectal cancer mortality in a US cohort according to site of cancer and colonoscopist specialty.J Clin Oncol2012;30:2664-9 PMCID:PMC3413278

[49] Cooper GS,Barnholtz Sloan JS,Koroukian SM.Prevalence and predictors of interval colorectal cancers in medicare beneficiaries.Cancer2012;118:3044-52 PMCID:PMC3258472

[50] Singh H,Demers AA,Mahmud SM.The reduction in colorectal cancer mortality after colonoscopy varies by site of the cancer.Gastroenterology2010;139:1128-37

[51] Pfeifer UG.Non-physician endoscopy: how far can we go?.Visc Med2016;32:13-20 PMCID:PMC4988257

[52] Maslekar S,Gardiner A,Duthie GS.Patient satisfaction with lower gastrointestinal endoscopy: doctors, nurse and nonmedical endoscopists.Colorectal Dis2010;12:1033-8

[53] Koornstra JJ,Giezen-Beintema WM,van Dullemen HM.Colonoscopy training for nurse endoscopists: a feasibility study.Gastrointest Endosc2009;69:688-95

[54] Limoges-Gonzalez M,Al-Juburi A,Inadomi J.Comparisons of screening colonoscopy performed by a nurse practitioner and gastroenterologists: a single-center randomized controlled trial.Gastroenterol Nurs2011;34:210-6

[55] van Putten PG,Adang RP.Nurse endoscopists perform colonoscopies according to the international standard and with high patient satisfaction.Endoscopy2012;44:1127-32

[56] Massl R,Steyerberg EW.Comparing quality, safety, and costs of colonoscopies performed by nurse vs physician trainees.Clin Gastroenterol Hepatol2014;12:470-7

[57] Hui AJ,Lam PP.Comparison of colonoscopic performance between medical and nurse endoscopists: a non-inferiority randomised controlled study in Asia.Gut2015;64:1058-62

[58] Riegert M,Thul B.Experience of nurse practitioners performing colonoscopy after endoscopic training in more than 1,000 patients.Endosc Int Open2020;8:E1423-8 PMCID:PMC7508647

[59] Coe SG,Diehl NN.An endoscopic quality improvement program improves detection of colorectal adenomas.Am J Gastroenterol2013;108:219-26; quiz 227

[60] Kaminski MF,Valori R.Leadership training to improve adenoma detection rate in screening colonoscopy: a randomised trial.Gut2016;65:616-24 PMCID:PMC4819605

[61] Wallace MB,Thomas CS,Parker L.Effect of an endoscopic quality improvement program on adenoma detection rates: a multicenter cluster-randomized controlled trial in a clinical practice setting (EQUIP-3).Gastrointest Endosc2017;85:538-45.e4

[62] Lim S,Park J.Training interventions to improve adenoma detection rates during colonoscopy: a systematic review and meta-analysis.Surg Endosc2020;34:3870-82

[63] Bishay K,Scaffidi MA.Associations between endoscopist feedback and improvements in colonoscopy quality indicators: a systematic review and meta-analysis.Gastrointest Endosc2020;92:1030-40.e9

[64] Spada C,Hassan C.Colonoscopy quality across Europe: a report of the European Colonoscopy Quality Investigation (ECQI) Group.Endosc Int Open2021;9:E1456-62 PMCID:PMC8445680

[65] Spada C,Hassan C.Factors Associated with Withdrawal Time in European Colonoscopy Practice: Findings of the European Colonoscopy Quality Investigation (ECQI) Group.Diagnostics (Basel)2022;12:503 PMCID:PMC8871420

[66] Matsuda K,Fujishiro M.Design paper: Japan Endoscopy Database (JED): a prospective, large database project related to gastroenterological endoscopy in Japan.Dig Endosc2018;30:5-19

[67] Saito Y,Matsuda T.Current status of diagnostic and therapeutic colonoscopy in Japan: the Japan Endoscopic Database Project.Dig Endosc2022;34:144-52