Colonoscopy in FIT-Based Screening Demands Higher ADR

Adenoma detection rate (ADR) targets for endoscopists performing colonoscopy after a positive fecal immunochemical test (FIT) should be markedly higher compared with ADR targets used in primary colonoscopy, researchers report.

Data from the Netherlands FIT-based screening program show that the ADR is “linearly and inversely” associated with interim colorectal cancer (CRC) occurrence, first author Pieter H.A. Wisse, MD, with Erasmus University Medical Center, Rotterdam, The Netherlands, told Medscape Medical News.

“Endoscopists should strive to obtain ADRs as high as possible” in FIT-positive screenees, Wisse said.

The study was published online September 26 in Annals of Internal Medicine.

Small Differences, Huge Consequences

The ADR is a key quality indicator for endoscopists performing colonoscopies for CRC because it reflects their ability to detect lesions and is inversely associated with the risk of interval post-colonoscopy CRC (PCCRC).

Adults with a positive FIT result have a high prevalence of adenomas, leading to high ADRs for endoscopists performing colonoscopies in this setting. However, data on optimal ADRs of endoscopists performing colonoscopies in FIT-based screening are scarce.

To investigate, Wisse and colleagues evaluated the association between the ADR and interval PCCRC in patients undergoing colonoscopy after a positive FIT result. The analysis included 362 accredited and audited endoscopists who performed 116,360 colonoscopies.

During a median follow-up of 52 months, 209 interval PCCRCs were identified.

The quality of the colonoscopic examinations in FIT-positive screenees was high; endoscopists’ ADRs ranged between 40% and 82%, with a median ADR of 67%.

A higher ADR was strongly associated with lower incidence of interval PCCRC, with an adjusted hazard ratio of 0.95 (95% CI, 0.92 – 0.97) per 1% increase in ADR.

For endoscopists with an ADR of 60%, the cumulative incidence of interval PCCRC was nearly two times as high as that of endoscopists with an ADR of 70%. The risk was even higher for endoscopists with ADRs less than 60%.

For every 1000 FIT-positive colonoscopies, the expected number of patients diagnosed with interval PCCRC in 5 years was roughly 2 for endoscopists with an ADR of 70%, compared with almost 3.5 for ADRs of 60% and more than 4.5 for ADRs of 55%.

The authors note that the relatively short duration of follow-up (median, 52 months) could be considered a study limitation.

Quality Metrics Needed

“These seemingly small ADR differences are deceptive — if an endoscopist increases their ADR by just 10%, their patients’ associated decrease in relative interval cancer risk is a remarkable 40% to 50%,” Douglas Corley, MD, PhD, MPH, from Kaiser Permanente, Oakland, California, points out in an accompanying editorial.

Wisse and colleagues add that FIT-based colonoscopy has now surpassed primary colonoscopy as the most commonly used primary CRC-screening method.

They say there is a need to determine specific ADR targets for FIT-positive screenees to assure quality of colonoscopies and optimize the effect of screening programs by reducing interval PCCRC risk.

For primary colonoscopy, most professional societies recommend an ADR of at least 25% as an indicator of adequate performance. The new study suggests that FIT-positive colonoscopy “demands a markedly higher ADR target than primary colonoscopy,” the authors write.

Corley said this study provides “an excellent framework for evaluating nine concepts regarding effective quality metrics and how these can illustrate pathways for meaningful metrics for the care of other cancers and disorders.”

Quality metrics must be trustworthy, important, strategic, relevant, actionable, simple, gaming-resistant, time-stamped, and owned, he explained.

Questions concerning goals, plans for implementation of interventions, and the application of goals while maintaining simplicity must be considered in metric development, Corley said.

The study had no funding. Disclosures for study authors are available with the original article.

Ann Intern Med. Published online September 26, 2022. Abstract, Editorial

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