I read in a New York Times article, Colonoscopies Miss Many Cancers, Study Finds, that colonoscopy was recently shown to be less effective than expected for colon cancer prevention.
How does a colonoscopy at Digestive Health compare to the colonoscopies in the Canadian study?
On December 16, 2008 the Annals of Internal Medicine published an electronic early-release version of an article that has been the subject of numerous media reports calling the effectiveness of colonoscopy into question:
Association of Colonoscopy and Death From Colorectal Cancer: A Population-Based, Case-Control Study, by Nancy N. Baxter, MD, PhD; Meredith A. Goldwasser, ScD; Lawrence F. Paszat, MD, MS; Refik Saskin, MSc; David R. Urbach, MD, MSc; and Linda Rabeneck, MD, MPH
While colonoscopy has limitations, there is no question that it is a very effective procedure for reducing deaths from colon cancer. Even considering the limited protection described in this Ontario, Canada study (a 60-70% reduction in colon cancer mortality), when contrasted with other types of cancer screening, colonoscopy is a remarkably effective tool. For comparison, breast cancer screening reduces cancer mortality by 25% at best, and prostate cancer screening has not yet been proven to reduce mortality.
While the study raises questions about potential differences between right-sided and left-sided colon cancers with regard to tumor biology (which may affect the appearance and rate of growth of tumors), we believe that the colonoscopies performed in this study do not reflect the best that modern colonoscopy, as performed by experts practicing in an expert center, has to offer.
The study describes colonoscopy performed between 1992 and 2001. There have been improvements in colon cleansing preparation, instruments and sedation practices since this time.
The study describes colonoscopy performed primarily by nonspecialists. Only 31.4% of the colonoscopies in this study were performed by gastroenterologists. Gastroenterology is the only specialty for which colonoscopy represents a principal activity, and for which formal and extensive training in the procedure is provided. In Durango, nearly all colonoscopies are performed by experienced gastroenterologists. In the Four Corners area outside of Durango however, many colonoscopies are routinely performed by physicians who are not formally trained specialists in the field of gastrointestinal endoscopy.
The study shows a rate of completion (examination to the cecum) that is substandard and unacceptable in modern colonoscopy practice. The colonoscopies performed by general surgeons and internists in this study were complete in less than 80% of exams, and the group whose specialty was identified as "other" completed only 66% of examinations. Even the completion rate of the gastroenterologists in this study, 83%, is very low by modern standards. Colonoscopies at the Southwest Endoscopy Center are complete in 99% of cases.
From the New York Times editorial of December 19, Not Perfect, Still Essential.
"Patients who want the best results should pick an outstanding colonoscopist, cleanse their bowels scrupulously and probably take the final laxative dose shortly before the procedure. Colonoscopies have helped reduce the death rate from colorectal cancer. The main problem with colonoscopies is that too few people bother to get them."
What can I do to be sure that my colonoscopy is as good as it can be?
-Do your colon cleanse properly.
We understand that this is the most difficult part of your exam. It is critical though that you do your part properly, so that we can provide you with the best examination possible.
-Pick an expert doctor to do your colonoscopy
A well-trained gastroenterologist is the best doctor to perform your colonoscopy. Gastroenterologists undergo more extensive training in endoscopic procedures than doctors in any other specialty, and they devote a majority of their practice to performing colonoscopy. They are the specialists best prepared to provide you with a complete examination, and they have the experience necessary to identify subtle abnormalities, such as flat neoplasms, from which many right-sided colon cancers may arise. They are also best prepared to remove these growths at the time of your procedure.
-Schedule your colonoscopy at an expert endoscopy facility
A well-trained and experienced staff and dedicated facility systems are essential. Nurses and technicians who assist with colonoscopy procedures every day are of critical importance and are necessary to help the colonoscopy doctor provide a safe, comfortable and effective examination. An expert colonoscopy doctor is only as good as the facility's support staff. Endoscopy facilities should continuously evaluate the performance of the facility and its endoscopist physicians. Avoid facilities in which colonoscopy seems to be an afterthought or hobby, rather than its central purpose.
-Return for your next examination when advised.
Questions you may want to ask a doctor before choosing him or her to perform your colonoscopy...
How many colonoscopies do you do?
Digestive Health's gastroenterologists each perform over 775 colonoscopies annually.
Does colonoscopy represent a large percentage of your procedural practice?
Colonoscopy makes up over 60% of the procedures that each of Digestive Health's gastroenterologists perform.
Do you monitor your adenoma detection rate, and does it exceed currently accepted continuous quality improvement (CQI) measures?
This is important because a rate of finding adenomas (potentially premalignant growths) that is lower than the known expected rate for adenomas to occur in a general population suggests that the doctor is missing lesions (higher "miss rate").
Digestive Health monitors adenoma detection rates for its gastroenterologists for procedures performed at the Southwest Endoscopy Center, and each gastroenterologist's rates exceed current performance measures.
Do you monitor your colonoscopy withdrawal times, and do your withdrawal times exceed currently accepted CQI performance measures?
This is important because doing a colonoscopy using standardized and slow withdrawal of the instrument has been shown to lead to a higher rate of finding lesions (lower "miss rate").
Digestive Health monitors colonoscopy withdrawal times for its gastroenterologists for procedures performed at the Southwest Endoscopy Center, and each gastroenterologist's rates exceed current performance measures.
Questions you may want to ask a facility before choosing it as a place to have your colonoscopy...
How many colonoscopies do you do?
The Southwest Endoscopy Center performs nearly 2,200 colonoscopies yearly.
Does colonoscopy represent a large percentage of the procedures you perform?
Colonoscopy procedures make up over 70% of the procedures performed at the Southwest Endoscopy Center.
Press Releases responding to publication of the Canadian study:
American College of Gastroenterology
American Society for Gastrointestinal Endoscopy
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