Quality measures improving endoscopic screening of colorectal cancer: a review of the literature

ABSTRACT

Introduction: Colorectal cancer (CRC) is a major health-care problem all over the world and CRC screening is effective in reducing mortality and increasing the 5-year survival. Colonoscopy has a central role in CRC screening. It can be performed as a primary test, as a recall policy after a positive result of another screening test, and for surveillance. Since effectiveness of endoscopic screening depends on adequate detection and removal of colonic polyps, consistent quality measures, which are useful in enhancing the diagnostic yield of examination, are essential.

Areas covered: The aim of this review is to analyze current evidence from literature supporting quality measures able to refine endoscopic screening of colorectal cancer.

Expert commentary: Quality measures namely a) time slot allotted to colonoscopy, b) assessment of indication, c) bowel preparation, d) Cecal intubation, e) withdrawal time, f) adenoma detection rate, g) proper management of lesions (polypectomy technique, polyps retrieval rate and tattooing of resection sites), and h) adequate follow-up intervals play a key role in identifying malignant and at-risk lesions and improving the outcome of screening. Adherence to these quality measures is critical to maximize the effectiveness of CRC screening, as well as, a proper technique of colonoscopy and a quality report of the procedure. Among all recommended measures, adenoma detection rate is the most important and must be kept above the recommended quality threshold by all physicians practicing in the setting of screening.

KEYWORDS:

• Colorectal cancer
• screening
• surveillance
• colonscopy
• quality measures

Article highlights

• Colorectal cancer (CRC) is a major health-care problem all over the world. It is the third most common cancer in males, the second in females, and the fourth cause of cancer death worldwide.

• Colonoscopy has a central role in CRC screening. It can be performed as a primary screening test, as a recall policy after a positive result of another screening test, and for surveillance. Since the effectiveness of endoscopic screening depends on adequate detection and removal of colonic polyps, quality measures are essential.

• Proper time slots have to be allocated for every colonoscopy, ensuring a minimum of 30 min for each diagnostic and primary screening colonoscopy and a minimum of 45 min for every recall colonoscopy following a positive fecal occult blood test.

• An adequate cleansing of the colon is a key element and needs to be reported using a validated scale. The ASGE/ACG task force recommends that the examination can be considered adequate if it allows the detection of polyps >5 mm in size, while ESGE guidelines define as adequate an examination with a Boston Bowel Preparation Scale ≥6 (with a minimum of 2 points for each segment) or by an Ottawa Scale ≤7.

• The completeness of colonoscopy with the cecal intubation and the iconographic documentation of anatomical landmarks is a prerequisite for a quality examination. To ensure the quality of screening, ESGE recommends a minimum cecal intubation rate greater than 90%, with a target of more than 95%, while ASGE recommends a cecal intubation rate greater than 95%.

• The accuracy of the examination is essential for polyp detection, especially when colonoscopy is performed for screening or surveillance for CRC. In this line, the time spent to examine the entire colon is a surrogate of accuracy that can be used as a quality standard. ASGE and ESGE recommend an average withdrawal time of at least 6 min.

• ADR is the most important primary quality measure since it is associated both with the risk of interval cancer and the risk of death. ESGE and ASGE guidelines recommend an ADR ≥25% and, in addition, ASGE suggests a sex-based threshold of ADR (≥30 for men and ≥20 for women).

• A proper management of lesions including an adequate polypectomy technique, a minimal retrieval rate ≥90%, and tattooing of resection sites is necessary to maximize the outcome of endoscopic screening.

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Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosure

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.