Performance targets for lesion detection in surveillance
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1 Performance targets for lesion detection in surveillance WEO CRC Meeting 2018, Washington DC Uri Ladabaum, M.D., M.S. Professor of Medicine; Director, GI Cancer Prevention Division of Gastroenterology and Hepatology Stanford University School of Medicine
2 Background Growing proportion of colonoscopies have surveillance as an indication Adenoma detection rate (ADR) has become the principal performance metric for screening Metrics for surveillance focus on appropriate utilization (intervals per guidelines) What should be the performance metrics for surveillance?
3 Aims Review: How did we get here for ADR in screening? Review: What do we know about lesion detection in surveillance? Discuss: - Collaborative research ideas - Policy statement or recommendation?
4 ADR in screening
5 ASGE Quality Indicators: Selected Indicator Type Target Surveillance Rec's Adherence Process 90% Document Prep Quality Process 98% Prep Adequate Process 85% Cecal Intubation with Photo Process 90% Cecal Intubation with Photo -- Screening ADR Process 95% Outcome 25% (M 30%, W 20%) Withdrawal Time measured Process 98% Withdrawal Time in Nl Screen Process 6 min Adapted from Rex et al., GIE 2015, 81:31
6 The path of the ADR in screening 2002: Adenoma detection targets proposed based on screening colonoscopy studies - Set at slightly below mean - Belief that very low ADRs were most troublesome - Men 25%; women 15% 2010 Polish study: validation that ADR<20% had CRC risk 10-fold vs. >20% Rex et al., GIE 2015, 81:31
7 Kaminski et al., NEJM 2010; 362:19
8 The path of the ADR in screening Evidence of ADRs > 40% Consideration that increasing target might have benefit 2014 Kaiser study: increasing benefit through ADR quintiles Rex et al., GIE 2015, 81:31
9 Adenoma detection and interval cancer Adenoma detection rate: 7-19% 19-24% 24-28% 28-34% 34-53% Corley DA et al. N Engl J Med 2014;370:
10 The path of the ADR in screening 2015: Performance target increased to 25% - Men 30%; women 20% - For quality improvement, not standard of care Rex et al., GIE 2015, 81:31
11 Lesion detection rates after adenoma removal
12 Surveillance after Nonadvanced Adenoma Study n Age (mean or median) Interval (yrs) ADR (%) AADR (%) Lieberman or Laiyemo Pinsky Martinez Chung <3+5 or < Martinez Gupta
13 Surveillance after Advanced Adenoma Study n Age (mean or median) Interval (yrs) ADR (%) AADR (%) Lieberman or Laiyemo Martinez Chung < < Martinez
14 Risk of Advanced Adenoma: Baseline LRA Dube at al., Am J Gastroenterol 2017; 112:
15 Risk of Advanced Adenoma: Baseline AA Dube at al., Am J Gastroenterol 2017; 112:
16 ADR and PDR by indication Boroff at al., Gastro Res Prac 2017; PMID:
17 ADR and PDR by indication Boroff at al., Gastro Res Prac 2017; PMID:
18 ADR and PDR by indication Boroff at al., Gastro Res Prac 2017; PMID:
19 ADR and PDR by indication Boroff at al., Gastro Res Prac 2017; PMID:
20 PLCO: Surveillance after Nonadvanced Adenoma Year Colonoscopy (cumulative) Advanced Adenoma (cumulative) Non-advanced Adenoma (cumulative) 3 21% 2% 6% 5 54% 4% 18% 7 72% 6% 27% 9 79% 8% 33% Click et al. JAMA 2018;319(19):
21 PLCO: Surveillance after Advanced Adenoma Year Colonoscopy (cumulative) Advanced Adenoma (cumulative) Non-advanced Adenoma (cumulative) 3 33% 4% 13% 5 63% 8% 27% 7 76% 10% 34% 9 83% 13% 40% Click et al. JAMA 2018;319(19):
22 PLCO data Cumulative detection rate increases with time Cumulative colonoscopy rate increases with time On casual inspection, it seems that cumulative detection rate closely follows cumulative colonoscopy rate Are most lesions missed at baseline (instead of truly metachronous)? Click et al. JAMA 2018;319(19):
23 Another higher-risk setting as guidance?
24 FIT+: Must find more lesions than in screening Study CRC detection Advanced neoplasia detection Screening Colonoscopy % 5 10 % In FIT+ patients % 34-54% Recommend ADR >45% in men, >35% in women if FIT+ with threshold of 20 mcg/g Robertson et al., Gastrointestinal Endoscopy 2017;85:2
25 Summary and Discussion
26 Summary After LRA: - ADR 29-54% at 3-5 years - AADR 2-8% at 1-5 years After HRA (AA): - ADR 37-57% at 2-5 years - AADR 9-16% at 1-5 years Missed vs. metachronous?
27 Potential impact and challenges Sensible performance targets would allow for quality assurance monitoring in surveillance Incentivize detection Disincentivize excessive utilization How easy to institute alongside ADR for screening? (more complex audit)
28 Discussion Ideas for collaborative research? Time to propose performance targets? Appropriate medium and process? Issues: - Baseline: LRA vs. HRA (AA)? - Target: ADR vs. AADR? - At what time point (interval)? By sex? - Simple vs. complex recommendation?
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