Roel Bogie

Chapter 7

factor for metachronous neoplasms, requiring intensified surveillance. 2, 7 A recent population-based study from Norway investigated the risk to develop CRC in patients with serrated polyps. 88 A total of 12,955 patients undergoing sigmoidoscopy were followed (mean follow-up period: 10.9 years). Patients with serrated polyps ≥10mm in size (n=81) had a significant higher risk of developing CRC than those without any polyps at baseline (HR 4.2, 95% CI: 1.3 – 13.3). A comparable risk of CRC was found in patients with advanced adenoma (HR 3.3, 95% CI: 2.1 – 5.2). Only one of the three CRCs diagnosed in patients with serrated polyps occurred in the same segment as a previous polypectomy. In 24 patients, a large serrated polyp was identified at baseline examination and not resected (biopsy alone), of whom only one developed CRC in a different colonic segment. 88 The authors concluded that presence of serrated polyps at baseline exam is a risk factor for CRC during follow-up, but is not necessarily a causal factor. Adherence to surveillance recommendations includes both physician compliance and patient compliance. Recent guidelines underscore the responsibility of the endoscopist for determining, documenting and communicating the correct surveillance interval, including written recommendations. 1, 89 Lack of compliance with the recommended surveillance intervals is a significant contributor to metachronous CRC. 90 Adherence to surveillance recommendations seems to vary among physicians, with both too short and too long intervals. 91-94 A Dutch retrospective cohort study found a high proportion of inappropriate surveillance intervals: 76% of patients before versus 89% after the implementation of revised guidelines. 94 In the past, patients were more likely to have their surveillance colonoscopy too late or not at all (57% of cases), whereas a substantial proportion of patients now receive their surveillance colonoscopy too early (48% of cases), perhaps reflecting an increased awareness. Data about physicians’ compliance with surveillance recommendations are controversial. A study from the USA found that endoscopists who received their education a long time ago were less compliant. 95 Others found that 97% of the recommendations were according to the guidelines. 96 Patient compliance with recommended post-polypectomy surveillance intervals ranges from 52 to 85%, 12, 92, 97 with as much as 41.6% non-compliance among patients with advanced adenoma at baseline. 92 Such compliance rates are similar to those in participants of CRC screening programs, and may increase with aging, female gender and repeat screening rounds. 98 Most common barriers to surveillance are procedural barriers (discomfort during colonoscopy and the need for bowel preparation) and facilitation barriers (lack of time, difficulty in making an appointment or transportation concerns). 99 Patients who do not attend their surveillance colonoscopies, are more likely to perceive barriers than the attenders. In contrast, patients with a higher degree of cancer worries or perceived benefits from colonoscopy are more likely to participate in surveillance programs. 99 Automatic systems sending reminders to patients and telephone calls may improve patient compliance. 97, 99, 100 What should be the upper age limit for surveillance? The majority of post-polypectomy surveillance guidelines acknowledge the benefit of surveillance up to the age of 75 years. 1, 2, 4, 5, 7 For patients aged 85+, it is unlikely that the benefits of Compliance with surveillance guidelines Adherence to surveillance recommendations

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