Colorectal Cancer Screening and Quality of Colonoscopy: Where Are We Now?CME/ABIM MOC/CE

Transcription

1 Colorectal Cancer Screening and Quality of Colonoscopy: Where Are We Now?CME/ABIM MOC/CE Supported by an independent educational grant from Aries Pharmaceuticals Pg.1

2 Colorectal Cancer Screening and Quality of Colonoscopy: Where Are We Now? CME/ABIM MOC/CE This article is a CME/ABIM MOC/CE certified activity. To earn credit for this activity visit: CME Released: 3/25/2018; Valid for credit through: 3/25/2019 Target Audience This activity is intended for gastroenterologists, emergency medicine physicians, and infectious disease (ID)/HIV specialists. Goal The goal of this activity is to improve clinicians knowledge regarding guidelines and available tools for colorectal cancer (CRC) screening, quality indicators for colonoscopy, and technologies that can improve detection of precancerous polyps. Learning Objectives Upon completion of this activity, participants will have increased knowledge regarding the: Recommendations for colorectal cancer (CRC) screening Relationship between adenoma detection rate (ADR) and the risk for CRC New technologies for improving ADRs in CRC screening Accreditation Statement In support of improving patient care, Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. For Physicians Medscape, LLC designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credit(s). Physicians should claim only the credit commensurate with the extent of their participation in the activity. ABIM MOC Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.50 MOC points in the American Board of Internal Medicine s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Aggregate participant data will be shared with commercial supporters of this activity. For Nurses Awarded 0.50 contact hour(s) of continuing nursing education for RNs and APNs; 0 contact hours are in the area of pharmacology. Pg.2

3 Instructions for Participation and Credit There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board. This activity is designed to be completed within the time designated on page 2; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on page 2. To receive AMA PRA Category 1 Credit, you must receive a minimum score of 75% on the post-test. Follow these steps to earn CME/CE credit*: 1. Read the target audience, learning objectives, and author disclosures. 2. Study the educational content online or printed out. 3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming. You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates from the CME/CE Tracker. *The credit that you receive is based on your user profile. Hardware/Software Requirements To access activities, users will need: A computer with an Internet connection. Internet Explorer 8.x or higher, the latest versions of Firefox or Safari, or any other W3C standards compliant browser. Adobe Flash Player and/or an HTML5 capable browser may be required for video or audio playback. Occasionally other additional software may be required such as PowerPoint or Adobe Acrobat Reader. Disclosures Roderick Smith, MS Scientific Director, Medscape, LLC Disclosure: Roderick Smith, MS, has disclosed no relevant financial relationships. Amy Bernard, MS, BSN, RN-BC Lead Nurse Planner, Medscape, LLC Disclosure: Amy Bernard, MS, BSN, RN-BC, has disclosed no relevant financial relationships. Pg.3

4 Colorectal Cancer Screening and Quality of Colonoscopy: Where Are We Now? CME/ABIM MOC/CE Hello. I m Douglas Rex, professor of medicine at the Indiana University School of Medicine and director of endoscopy at Indiana University Hospital. Welcome to this program titled CRC Screening and Quality of Colonoscopy: Where Are We Now? During this program, we will have a discussion of investigational agents not approved by the US Food and Drug Administration (FDA) for use in the United States at the time of recording. Pg.4

5 Colorectal cancer (CRC) is still a major problem in the United States. First, the good news: although there are still many cases, the incidence of CRC has been declining for decades. From 1985, the year that Ronald Reagan was diagnosed with CRC, up until about 2000, the rate of decline in incidence was approximately 1% to 2% per year. After 2000, the rate of decline increased to 3% to 4% annually, which coincided with the widespread adoption of screening colonoscopy in the United States. [1] Other factors have contributed to reduced CRC incidence, such as reduction in cigarette smoking. We have this very positive trend in declining CRC incidence rates but only in people aged 50 and older, which is the general screening population. For reasons that are not clear, incidence rates are increasing in people under age 50, which has everyone concerned. Presently in clinical practice, the only individuals we screen for CRC who are under age 50 are those with a positive family history. However, there is a lot of discussion about whether we should move the screening age for average-risk persons to below age 50. That conversation is likely to continue. Now we are going to talk about polyps. Polyps are a very important part of this discussion because in CRC we have the opportunity to not only identify early cancers, and thereby prevent mortality, but actually prevent the disease from developing. As screeners and as gastroenterologists who are colonoscopists, it is very important that we understand the 2 main types of precancerous lesions in the colon: the polyps and the flat lesions. Pg.5

6 Colorectal Cancer Screening and Quality of Colonoscopy: Where Are We Now? CME/ABIM MOC/CE The overwhelming majority of colon cancers arise from these polyps, which are highly prevalent. Very high-level detectors performing colonoscopy will find 1 or more precancerous lesions in half of people aged 50 and older; however, only about 5% of these individuals will develop CRC. Obviously, the great majority of these precancerous lesions will never actually turn into cancer. Nevertheless, because we cannot predict which polyps will become cancerous, it is important that we find them and remove them. That is one of the fundamental strategies for preventing CRC. [1-3] Every clinician who does CRC screening should understand that there are 2 major classes of precancerous lesions in the colon. One of them is the one that you heard so much about in medical school: the adenomas. I like to refer to them as conventional adenomas. These lesions are uniformly dysplastic. To say that there is a dysplastic conventional adenoma is essentially redundant. The pathologist should characterize the dysplasia as either high grade or low grade. The overwhelming majority of adenomas are low grade; as the size of the adenoma increases, so does their risk of being high grade, and high grade is a step closer to cancer. [2] The other way we see polyps characterized on histopathology reports is according to their villosity. Lesions with more than 25% villous elements are termed tubulovillous and those with more than 75% villous elements are villous. In general, villous adenomas are much less common than tubular adenomas, tend to be larger, and are more likely to have high-grade dysplasia. [2] Pg.6

7 Conventional adenomas are fairly evenly distributed throughout the colon. Adenomas that are subtle and more difficult to detect, due to a flat or depressed morphology, are more likely to be found in the proximal colon. [2] This is a very important point. You may have heard that with colonoscopy, we are actually more effective at preventing cancer originating in the left side of the colon than cancer originating in the right side of the colon. This may be because these more subtle and difficult to detect lesions are more prevalent in the proximal colon. As I mentioned, the conventional adenomas are all dysplastic. A term you will hear sometimes in practice is the so-called advanced adenoma -- a lesion that is 1 cm or larger or has high-grade dysplasia or villous elements. [2] Part of the reason that is important is because our noninvasive screening tests, which we will discuss, do not actually target all adenomas. There are just too many adenomas, so if we tried to find every adenoma, including the small ones, everyone undergoing noninvasive screening would need a follow-up colonoscopy. Instead, we focus on the adenomas that are larger, the so-called advanced adenomas. Pg.7

8 Colorectal Cancer Screening and Quality of Colonoscopy: Where Are We Now? CME/ABIM MOC/CE Here are 2 images of conventional adenomas. These images were taken by using blue light. This is referred to as narrow-band imaging (NBI), which is a part of the visible light spectrum that is used to illuminate the colon. On the left is a very broad, flat lesion, and on the right, there are 2 tiny adenomas. One of the things you will notice is that when illuminated with blue light, the adenomas look brown. If you look closely, you will see there are tiny brown lines all over the surface of these lesions; these are blood vessels. These vessels are important when we talk about screening because when they get larger, conventional adenomas can be detected by the fecal immunochemical test (FIT). The FIT is pretty good for detecting conventional adenomas. However, it does not detect serrated lesions at all because they do not have these blood vessels on their surface. We will come back to that shortly. This segues into our second major class of major precancerous polyps: the serrated lesions. Here is the classification of the 3 major groups of serrated lesions. The first one is the hyperplastic polyps. These are mostly very small lesions found in the rectal sigmoid colon and, in particular, the distal colon. Hyperplastic polyps are not considered precancerous. [2] Pg.8

9 However, 2 categories in the serrated class are considered precancerous. Far and away the most important one is the sessile serrated polyp (SSP), often also called the sessile serrated adenoma. The terms are virtually synonymous. I prefer the term SSP because, as we learned, all of the conventional adenomas are dysplastic. If I were to ask you whether the SSPs or sessile serrated adenomas are dysplastic, you might be tempted to say yes, especially if I was using the term sessile serrated adenoma. However, the overwhelming majority of these lesions have virtually no dysplasia histologically yet are considered precancerous. [2] The pathologist should designate an SSP as being without cytological dysplasia or with cytological dysplasia. SSPs with cytological dysplasia are much less common than are SSPs without. If you were to look at an SSP with cytological dysplasia under the microscope, you would see is a segment of the polyp that looks like a conventional adenoma and is actually dysplastic. This is a more advanced stage, closer to cancer. The final lesion subtype, the traditional serrated adenoma, is very uncommon. Unlike the SSPs, which are located primarily in the proximal colon, traditional serrated adenomas are found primarily in the distal colon. Traditional serrated adenomas are dysplastic lesions that tend to be bulky and are sometimes pedunculated. Often, they are mistaken by community pathologists for tubulovillous conventional adenomas. [2] Many gastroenterologists who perform a lot of colonoscopies never see the term traditional serrated adenoma on a colonoscopy report because the subtype is so rare. Pg.9

10 Colorectal Cancer Screening and Quality of Colonoscopy: Where Are We Now? CME/ABIM MOC/CE SSPs and traditional serrated adenomas are thought to account for approximately 15% to 30% of colon cancers. This is a smaller percentage than is found for the conventional adenomas, which account for the overwhelming majority of colon cancers. The SSPs are a relatively recent discovery, so both endoscopists and pathologists are still becoming familiar with them. Expert colonoscopists should find SSPs in about 8% to 9% of screening colonoscopies. Again, the SSPs are going to be distributed more toward the proximal colon. [2] Here are a couple of endoscopic images of SSPs using NBI. In the left image, you can see a very small, flat SSP in the proximal colon. In the right image is a somewhat irregular, much larger lesion. SSPs can be quite large. They also tend to be quite flat and, for that reason, can be difficult to detect. Computed tomography (CT) colonography or virtual colonoscopy is almost useless for the detection of SSPs because of their flat morphology. You will notice the near absence of blood vessels on the surface of these polyps. The FIT, which detects blood, is essentially useless for the detection of SSPs. The FIT-fecal DNA test, which we will talk about later, will detect some of these lesions. This may be because the FIT-fecal DNA test contains hypermethylation markers. The pathway of the SSP is hypermethylation, and hypermethylation is one of the mechanisms via which these polyps progress toward cancer. Pg.10

11 So, what is CRC screening? We gastroenterologists talk about it as the process of finding early cancers and precancerous lesions in patients who are asymptomatic and who have never had detected cancer or polyps. Screening is not the same as surveillance -- surveillance refers to the interval use of colonoscopy in people who have already had cancer or precancerous lesions. As soon as you have had a precancerous polyp or cancer, you now are in the world of surveillance. It is very important for clinicians to understand the different screening systems and how to decide which to use in their patients. [2] If we look at CRC screening on a nationwide or regional basis, there are 2 main ways it gets done. One is opportunistic screening, which refers to the interaction between a provider and a patient. It is a nonsystematic method and, in fact, is how CRC screening is done in most of the United States. Programmatic screening is done within a large healthcare system or even a national healthcare system. For example, Australia, the United Kingdom, and several European countries have programmatic colon cancer screening. This means that the healthcare system is generally offering screening systematically to the entire population. Programmatic CRC screening is considered more effective than opportunistic screening. We generally do not have programmatic CRC screening in the United States, except within large healthcare systems like Kaiser Permanente in California. [2] Pg.11

12 Colorectal Cancer Screening and Quality of Colonoscopy: Where Are We Now? CME/ABIM MOC/CE For office-based opportunistic screening, there is a lot of discussion about what is the best method. There are 3 different approaches to offering screening, but we do not yet have comparative data on them, so it is important for primary care physicians (PCPs) to think about how they want to do this. One approach is the so-called multiple options -- you present the options to the patient and he or she decides which one has the right combination of effectiveness, risk, and cost. It has been shown that offering more than 2 options does not increase adherence, so usually we tell people to pick the 2 best options. My preferences are colonoscopy and FIT, but we will come back to that. [2] Sequential testing is commonly used in the United States. With this method, the physician offers the best test first to the patient. Often, it is colonoscopy. If the patient agrees, you are done. If the patient says no, you move on to the next best test and continue down the list of options until the patient finds something with which he or she can agree. [2] Risk-stratified screenings refers to the idea that we have 80 million people in the United States who have risk for developing CRC but, in fact, the range of risk is quite wide. For example, you might offer a woman in her 50s a less invasive screening test because her pretest probability of having adenomas is lower. In this case, you might use FIT or another noninvasive test. For a man at age 60 or a woman at age 65, who is at higher risk for adenomas, you would offer colonoscopy. That is the concept of risk-stratified screening. There is a rationale for each of these screening approaches, and any of them is acceptable. [2] Pg.12

13 What are our screening options? Often, CRC screening tests are delineated between noninvasive and invasive tests. Noninvasive tests include the FIT and FIT-fecal DNA test. There is also a blood test, which we will discuss. The invasive tests include colonoscopy, flexible sigmoidoscopy, and CT colonography. [2,4] The FIT is a very important test because it has a number of advantages: it is inexpensive, has 80% sensitivity for cancer, detects 30% to 40% of large adenomas, and has excellent specificity; only about every 4 of every 100 patients will have a false-positive response to the FIT. One of the main drawbacks of this test it that is has to be done annually, which can be difficult in office practice if you are not part of a large healthcare system, as I alluded to earlier. FIT also has no sensitivity for serrated lesions. We are likely to detect serrated lesions using FIT only if the patient also has conventional adenomas. [2,4] Pg.13

14 Colorectal Cancer Screening and Quality of Colonoscopy: Where Are We Now? CME/ABIM MOC/CE A test we see advertised on TV is the FIT-fecal DNA test (Cologuard ). This test combines blood and DNA biomarkers and detects about 92% of CRCs and about 60% of large adenomas. It has approximately 40% sensitivity for large SSPs. In comparison, FIT alone does not detect any of these lesions. The drawbacks of the FIT-fecal DNA test are that it is rather expensive and has lower specificity than FIT, particularly in older patients. This is because we become more hypermethylated with age. In people older than 65 years, you can get false-positive rates in the range of 15% to 20%, which is rather high. However, this test is performed only every 3 years. If you have an annual false-positive rate of 4% with annual FIT, you may approach the false-positive rate of the FIT-fecal DNA test. [2] There is also the first FDA approved blood test for CRC screening, the Septin 9 DNA test (Epi procolon ). [5] This test has poor sensitivity for cancer and has no sensitivity for detecting precancerous polyps. It is expensive, and the optimal frequency of use is uncertain. The specificity is 80%, meaning that 1 of every 5 patients has a false-positive result. If you perform this test annually, after 5 years you will need for the entire population to undergo colonoscopy. Therefore, we need some improvements in this test before it can be recommended for routine use. It is presently indicated only for patients who have a poor history of compliance with other CRC screening modalities. [2,5] Pg.14

15 Colonoscopy is considered the gold standard for CRC screening and is often the first test offered sequentially. It is the best screening test for detecting CRC and precancerous lesions and is the only screening method offered at 10-year intervals. Colonoscopy has improved dramatically during the past 20 to 30 years. We are likely to see, even in my lifetime, that 1 or 2 negative colonoscopy examinations may confer lifetime protection for some patients. The downsides of colonoscopy are that it has the highest rate of complications, requires bowel preparation, and is operator dependent, which I will come back to. [2,4] Flexible sigmoidoscopy is a very good test. There are several randomized controlled trials showing that it reduces mortality from cancer in the distal colon. It also is relatively inexpensive, requires less bowel preparation than colonoscopy, and does not require sedation. Flexible sigmoidoscopy is recommended at 5- to 10-year intervals but is most often performed every 5 years. However, because it does not provide good protection against right-sided colon cancer, its use has declined dramatically in recent years. [2] Pg.15

16 Colorectal Cancer Screening and Quality of Colonoscopy: Where Are We Now? CME/ABIM MOC/CE The US Multi-Society Task Force (USMSTF), which is composed of the major gastrointestinal (GI) societies, has different recommendation tiers for CRC tests. In tier 3, you see that the Septin 9, the blood test, is not recommended. Capsule colonoscopy, which has comparable sensitivity to CT colonography and is a pretty good test, is also recommended as tier 3 -- that is, it would be the last recommendation. This is because the bowel preparation is quite difficult and because, unfortunately, the test is usually not reimbursed by insurance. [2] Let s talk about the tier 1 and tier 2 tests. This schematic suggests that the tier 1 tests are offered first. No matter how you offer CRC screening, the 2 main options are colonoscopy every 10 years and annual FIT. Where you are offering multiple options, it is probably best in most cases to start with these 2 options. If you are using sequential screening, you would probably start with colonoscopy. If the patient declines, you go on to the FIT. We talked about how you might use these tests in the risk-stratified approach. If the patient declines both tests, then tier 2 tests should be offered. [2] As I mentioned previously, there is a lot of discussion about the FIT-fecal DNA test that is being marketed directly to consumers. Patients who see the TV ads may come in and ask you about this test and ask you to order it. Flexible sigmoidoscopy, as I said, has really fallen off the radar. CT colonography has been around since 1994, yet has had little impact on screening. This is because it requires bowel preparation, it is not very sensitive, and we have seen recent data showing that it does not detect SSPs. [2] Pg.16

17 For the general population, we want to begin CRC screening at age 50. In African Americans, it is age 45. African Americans get more colon cancer and at a younger age, so we try to adjust for those factors. We talked about how to offer screening and that colonoscopy and FIT should be the first-tier options. As I mentioned, the one population in which we have decreased screening age in practice is in those with a family history of colon cancer. [2] How do you evaluate family history? We want to count cancers or advanced adenomas. This means if a patient tells you that his or her father or sister had polyps but you do not actually know whether it was an advanced lesion, it should probably not be counted as a positive family history. On the other hand, if you have the pathology report documenting an advanced lesion or if the patient tells you that his or her father had surgery for polyps, you can probably assume it was an advanced adenoma. Pg.17

18 Colorectal Cancer Screening and Quality of Colonoscopy: Where Are We Now? CME/ABIM MOC/CE Advanced adenomas and cancers are counted the same. We focus on 2 questions: Was the patient s relative who had an advanced adenoma and cancer a first-degree relative, meaning a parent, sibling, or child? At what age was the relative diagnosed? For a patient with the most common history of a first-degree relative with cancer or advanced adenoma who diagnosed after age 60, our guidelines now say to recommend CRC screening to the patient starting at age 40. Your screening options would be the same as they would be for an average-risk person: colonoscopy every 10 years or annual FIT. In the case of CRC or an advanced adenoma in either 2 first-degree relatives diagnosed at any age or 1 first-degree relative diagnosed before the age of 60 years, the recommendation is colonoscopy every 5 years starting 10 years before the age at which the youngest relative was diagnosed or at age 40, whichever is earlier. [2] Let s talk about the role of the PCP versus the specialist in CRC screening. In general, the role of the PCP is to recommend CRC screening, perform high-quality FIT, and ensure that there is a system in place for follow-up with the patient. The PCP also needs to ensure that positive noninvasive test results are referred to a GI specialist for colonoscopy and to refer screening patients for colonoscopy at the appropriate age. The role of the gastroenterologist is to provide high-quality colonoscopy. [2] Pg.18

19 I want to now move on to colonoscopy and return to the issue of operator dependence. Operator dependence is relevant to a number of different tests. In radiology, for example, we say that ultrasound (US) is much more operator dependent than CT. With CT, the patient moves through the machine while holding his or her breath, and then the radiologist reads the study. US requires an operator who knows how to use the US probe to obtain the correct images. Colonoscopy is like US except even more so. One of the questions that everybody wants to know is: how can I get a good colonoscopy performed for my patients, for myself, and for my family? Operator dependence applies to everything about colonoscopy: detection of cancer and polyps, selection of surveillance intervals, and how effectively polyps are resected. [2] We have a measure that we believe is the best way to determine the performance and skill of the colonoscopist -- in other words, one who is really good at finding precancerous lesions in the colon -- the adenoma detection rate (ADR). We now recommend that everyone performing screening colonoscopies measure and know their ADR. We recommend that patients ask a prospective colonoscopist for his or her ADR and that endoscopists be willing to provide it. The ADR has been endorsed by the professional GI societies and by the Centers for Medicaid and Medicare Services (CMS) as a quality standard for colonoscopy. Pg.19

20 Colorectal Cancer Screening and Quality of Colonoscopy: Where Are We Now? CME/ABIM MOC/CE Recommendations state that the proportion of screening colonoscopies that detect 1 or more conventional adenomas in a general screening population (patients aged 50 or older) be 25% or greater. If you are screening a population that is shifted more toward 1 sex -- for example, perhaps a female endoscopist who has many female patients -- an adjustment should be made for that. We adjust this recommendation only for the patient s age and sex, as these have been shown to be powerful predictors of the patient s risk for developing cancer after a colonoscopy. [2,6] In a large data set from Kaiser Permanente in California, 712 CRCs developed after screening colonoscopy (interval cancers). [7] You can see that 136 gastroenterologists were evaluated in the study and that their ADRs vary quite widely, from 7.4% to 52.5%. This really illustrates how operator dependent colonoscopy is. This study showed that for each 1% increase in a physician s ADR, there was a 3% reduction in the risk for developing interval CRC and a 5% reduction in the risk of a fatal interval CRC. [7] Another screening study from Poland validated this concept, so we know that the ADR is an extremely important quality endpoint for endoscopists. [8] Pg.20

21 A variety of factors can affect the ADR and can be improved. Endoscopists can become better educated about the appearance of subtle lesions in the colon and can become better at performing a more effective examination, such as looking behind nooks and crannies, haustral folds, and valves in the colon, to find lesions hidden from easy view during withdrawal. Just the process of reporting the ADR to colonoscopists seems to improve their performance. We know that effective bowel preparation, particularly taking half or even all the preparation on the day of examination, is also helpful. [6] In the United States, gastroenterologists generally have very high cecal intubation rates, so this is not much of a problem. We get into a lot of variation in withdrawal technique -- some endoscopists withdraw too quickly or do not examine areas that are difficult to access. The right colon, as I have mentioned, is subject to a higher rate of cancers occurring after colonoscopy. So, it is becoming common for gastroenterologists to examine the right colon twice, either performing a second examination in the forward view or via retroflexion. Pg.21

22 Colorectal Cancer Screening and Quality of Colonoscopy: Where Are We Now? CME/ABIM MOC/CE We also have devices and techniques that can help improve ADRs. For example, there are ways of highlighting lesions or exposing more of the mucosa. High definition (HD) is one way of highlighting the mucosa, and it has been used increasingly since the early 2000s. [9] HD colonoscopy has been shown to increase the ADR compared with standard-definition colonoscopy, although not necessarily the detection of advanced adenomas. [9] In practical terms, the modern therapeutic colonoscopist has to have an HD instrument, and all the instruments currently sold and purchased should be HD. Electronic chromoendoscopy refers to shining a special light on the colon or using a computer to process the image. The purpose is to highlight blood vessels in a different color and enhance contrast between the polyp and normal tissue. Chromoendoscopy means spraying dye onto the colon during the procedure. Unfortunately, this is a tedious process, so it is used primarily in patients with inflammatory bowel disease and not much in routine colonoscopy. In addition, there are the devices that will better enable you to visualize the mucosa, which I will discuss. [9] Pg.22

23 Here are 2 photographs showing NBI. These are conventional adenomas. The colon looks either greenish or brownish, and the mucus looks pink instead of yellow. The blood vessels, the little brown lines, are highlighted. NBI can help detect very flat lesions, at least with some of the newer, brighter forms. The older, darker forms of NBI were generally not shown to be effective. Overall, I would have to say that chromoendoscopy is routinely used in clinical practice to improve polyp detection. However, the newer, brighter forms, such as NBI and blue light imaging, have been positive in initial studies and warrant further investigation. One of the new ways of getting dye more easily onto the colon is to take it orally with the bowel preparation. These are a couple of photographs of lesions highlighted with methylene blue MMXä. Many gastroenterologists are familiar with MMX technology because of MMX 5-aminosalicycitate or MMX budesonide. Methylene blue is a vital stain. In some cases, it is taken up more by the polyps than by the surrounding tissue, like these flat polyps in the left image; in other instances, it is taken up more by the normal mucosa. You can see that the flat lesion in the center of the image on the right is actually understained. However, it is the contrast between the lesion and the normal mucosa that really improves visualization. Methylene blue MMX is currently under FDA review for its potential use in screening colonoscopy. Pg.23

24 Colorectal Cancer Screening and Quality of Colonoscopy: Where Are We Now? CME/ABIM MOC/CE We are also seeing more interest in fold-flattening devices. The left image is of Endocuffä, and the right image is of EndoRingsä. These devices fit over the tip of the scope. After you pass the scope into the cecum, you use the little fingers or rings to flatten the haustral folds. It is like reaching between the folds of a drape and pulling it flat. Endocuff Vision (on the left) and the first Endocuff, which had 2 rings of fingers, have been studied extensively. In a randomized study of 498 patients who underwent CRC screening with colonoscopy, Endocuff improved the ADR by 8% vs standard colonoscopy and increased the number of adenomas detected per patient by 86%. [6] Pg.24

25 I have reviewed some of the key aspects of CRC screening. Remember that there are 2 main types of precancerous lesions: the conventional adenomas and the serrated lesions. These lesions differ in appearance, in their propensity to bleed, and in their location in the colon. It is critical for PCPs to encourage CRC screening, as it is the only form of screening that receives a grade A recommendation from the US Preventive Services Task Force. The 2 first-tier tests are colonoscopy every 10 years and annual FIT. It is also important for PCPs to understand the pros and cons of the FIT-fecal DNA test because some patients who see the direct-to-consumer advertising will come in and ask about it. We want to get the best colonoscopy we can for our patients. The whole purpose of colonoscopy is to prevent our patients from getting CRC. To achieve that goal, colonoscopists need to measure and achieve high levels of quality. Thank you for participating in this activity. I hope it helped improve your understanding about screening for CRC, and the tools we have available to accomplish this very important aspect of preventive care. Pg.25

26 Colorectal Cancer Screening and Quality of Colonoscopy: Where Are We Now? CME/ABIM MOC/CE References 1. American Cancer Society. Colorectal cancer facts & figures Atlanta, GA: American Cancer Society; colorectal-cancer-facts-and-figures pdf. Accessed March 6, Rex DK, Boland R, Dominitz JA, et al. Colorectal cancer screening: recommendations for physicians and patients from the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol. 2017;112: Esplin E, Snyder MP. Genomic era diagnosis and management of hereditary and sporadic colon cancer. World J Clin Oncol. 2014;5: Issa IA, Noureddine M. Colorectal cancer screening: an updated review of the available options. World J Gastroenterol. 2017;23: Epi procolon [package insert]. Berlin, Germany: Epigenomics AG; Anderson JC, Butterfly LF. Colonoscopy: quality indicators. Clin Translat Gastroenterol. 2015;e77. doi: /ctg Corely DA, Jensen CD, Marks AR, et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. 2014;370: Kaminski MF, Regula J, Kraszewska W, et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med. 2010;362: Aranda-Hernandez J, Hwang J, Kandel G. Seeing better -- evidence based recommendations on optimizing colonoscopy adenoma detection rate. World J Gastroenterol. 2016;22: Biecker E, Floer M, Heinecke A, et al. Novel Endocuff-assisted colonoscopy significantly increases the polyp detection rate: a randomized, controlled trial. J Clin Gastroenterol. 2015;49: Abbreviations ACG/ASGE = American College of Gastroenterology/ American Society for Gastrointestinal Endoscopy ADR = adenoma detection rate CMS = Centers for Medicare and Medicaid Services CRC = colorectal cancer CT = computed tomography FDA = US Food and Drug Administration FIT = fecal immunochemical test GI = gastrointestinal HD = high definition NBI = narrow band imaging PCP = primary care provider RCT = randomized controlled trial SSP = sessile serrated polyp US = ultrasound USMSTF = US Multi-Society Task Force Pg.26