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High adenoma detection rate decreased risk for colorectal cancer, death
Physician adenoma detection rate in the highest quintile decreased a patient’s risk for any interval cancer, advanced-stage interval cancer and fatal interval cancer, according to study results.
“We found that higher levels of detection were associated with a decreased subsequent risk of cancer,” Douglas A. Corley, MD, PhD, a gastroenterologist and research scientist with the Kaiser Permanente Division of Research, said in a press release. “Taking out adenomas prevents cancers, and early detection likely prevents many cancers.”
The analysis included 136 gastroenterologists who performed 314,872 total colonoscopies, which equated to an average of 2,150 colonoscopies (range, 355-6,005) per physician.
Overall, the adenoma detection rates per physician ranged from 7.4% to 52.5% for all patients, from 9.7% to 60.5% for male patients, and from 3.9% to 45.9% for female patients.
Corley and colleagues then compared these data with the incidence of colorectal cancer diagnosed 6 months to 10 years after colonoscopy, as well as the incidence of cancer-related death. They identified 712 interval colorectal adenocarcinomas, which included 255 advanced-stage cancers and 147 interval colorectal cancer deaths.
Patients of physicians with the lowest quintile of adenoma detection rates had an unadjusted risk for interval cancer of 9.8 cases per 10,000 person-years of follow-up, whereas patients of physicians with the highest quintile of detection had a risk of 4.8 cases per 10,000 person-years.
Physician detection rates in the highest quintile were associated with a 0.52 HR (95% CI, 0.39-0.69) for any interval cancer, a 0.43 HR (95% CI, 0.29-0.64) for advanced-stage cancer and a 0.38 HR (95% CI, 0.22-0.65) for fatal interval cancer compared with rates in the lowest quintile.
Overall, a 1% increase in a physician’s rate of adenoma detection was associated with a 3% decrease in the patient’s risk for cancer (HR=0.97; 95% CI, 0.96-0.98).
“Given these results, to maximize the effectiveness of our screening programs, we have been providing feedback to physicians for 3 years as well as developing new methods to maximize detection rates,” Corley said.
Disclosure: The researchers report no relevant financial disclosures.
Perspective
Back to TopPhysicians and hospitals are increasingly being evaluated based on quality measures by governmental agencies and third-party payers. Identifying greater than 12 lymph nodes in a colorectal cancer resection specimen is a quality measure for colon cancer. Similarly, the proportion of a physician’s screening colonoscopies that detect at least one adenoma (the adenoma detection rate) is a recommended quality measure by gastrointestinal professional societies and proposed as a quality measure by CMS.
In this study, data on more than 300,000 colonoscopies performed by 136 Kaiser Permanente gastroenterologists between 1998 and 2010 were analyzed. Physicians in the highest quintile detected twice as many adenomas as physicians in the lowest quintile. There was a 48% decrease in risk for developing an interval colon cancer, a 57% decrease in risk for being diagnosed with advanced colon cancer and a 62% decreased risk for dying from colon cancer in patients of physicians with the highest adenoma detection rates compared to the lowest adenoma detection rate. The association of adenoma detection rate was linear across quintiles and adjusted for multiple co-variables.
The study showed that greater than 80% of physicians had the recommended adenoma detection rate of 20% or higher, which is reassuring. Whether physicians who performed more colonoscopies have a higher adenoma detection rate is not reported. Patients of physicians with higher adenoma detection rates may have had more frequent colonoscopies, which identified and removed pre-cancerous polyps and therefore a decreased rate of invasive colon cancer. The adenoma detection rate was, therefore, inversely associated with patients’ risk of interval colorectal cancer between colonoscopies and death.
This study provides further validity for using the adenoma detection rate as a quality measure for physicians who perform colonoscopies.