Roel Bogie

Optimizing post-polypectomy surveillance: A practical guide for the endoscopist

surveillance counterbalance the risks or increase the life-expectancy. 1, 2, 4, 5, 7 It is presently unknown whether surveillance between the ages of 75 and 85 years is beneficial. In a cross-sectional study, Lin and colleagues showed that the extension of life expectancy with screening can be up to 15 times lower in patients aged 80+ versus those aged 50 to 54 years. 101 The number of colonoscopies per life-year saved ranged from 4 to 16 in patients aged 80+ versus 0.5 to 2 in those aged 50-54 years, according to the assumptions made. The risk of detecting adenomas and especially advanced adenomas increases with age. 8, 15, 102 As the progression from adenoma to carcinoma is estimated to take approximately 10 years, it is reasonable to provide surveillance to patients with a life expectancy of 10 years. 7 However, complications in general, including perforations, are more common in the elderly (incidence ratio 1.7, 95% CI: 1.5 – 1.9 for having an adverse event at 80+ vs 65-80 years). 103 We should bear in mind that the risk of developing interval CRC also increases with age, possibly caused by a lower effectiveness of colonoscopy to prevent cancer in older, frail patients. Insufficient bowel preparation and presence of comorbidities, such as diverticular disease and cardiovascular disease, partly explain this. 19, 33, 102 It has been suggested that comorbidity is a better predictor for inadequate bowel preparation than age itself. 41, 104 Using model estimates of harm-benefit ratios, Lansdorp-Vogelaar and colleagues proposed tailoring of the decision to cease screening for breast cancer, prostate cancer and CRC, according to age and comorbidity. 105 For individuals with no, mild, moderate and severe comorbidities, the harm-benefit ratios of screening until the ages of 76, 74, 72 and 66 respectively were comparable with average-health individuals and consistent across cancer types. While awaiting more evidence, the clinical decision of when to stop surveillance needs to consider the severity of comorbidities, life-expectancy and patient preferences. Conclusion The present review summarized principles for optimizing the quality of post-polypectomy surveillance in practice. The majority of professional society guidelines now recommend: a high quality baseline colonoscopy before inclusion in a surveillance program; risk stratification based on clinicopathological profiles to guide surveillance intervals; and endoscopist responsibility for providing surveillance advice. The recommended surveillance intervals will always vary as a result of the level of scientific evidence, economic and logistic factors. Data from randomized controlled trials will form the basis for evidence-based surveillance intervals in the near future. The quality in performance of colonoscopy is a major driver for post-polypectomy surveillance intervals. Continuous monitoring of bowel preparation by using validated scales, adenoma detection, polyp resection and interval CRC rates are important steps. Quality photo-documentation is perhaps the most universally understood communication tool and improves education. Endoscopists should therefore consider providing documentation on bowel preparation, completeness of examination, and diagnosis and therapeutic steps, as illustrated in Figure 7.3 . Such a structured approach will permit, in turn, strict compliance with the recommended surveillance intervals. Finally, for a successful surveillance program, patient education and full compliance are critical. Patient counseling, taking into consideration individual risk profiles and life expectancy, paves the way towards cost-effective surveillance strategies.

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