Are the current colonoscopy recommendations for interval surveillance in patients with polyps enough? Machine learning-augmented propensity score cohort analysis of 1840 patients.
Adenomatous polyps
Colon and rectal surgery
Colon polyps
Colonoscopy
Colorectal cancer
Gastroenterology
Polyp surveillance
Journal
Surgical endoscopy
ISSN: 1432-2218
Titre abrégé: Surg Endosc
Pays: Germany
ID NLM: 8806653
Informations de publication
Date de publication:
02 2022
02 2022
Historique:
received:
16
04
2020
accepted:
15
02
2021
pubmed:
26
3
2021
medline:
4
3
2022
entrez:
25
3
2021
Statut:
ppublish
Résumé
Colonoscopy remains the gold standard for screening and surveillance of colorectal neoplasms, and is associated with a lower risk of colorectal cancer (CRC)-related mortality. The current interval surveillance recommendations in patients with previous adenomas lack sufficient evidence. The prevalence of subsequent adenomas, and especially high-risk adenomas, during surveillance is not well known. The primary outcome of this study was to determine the prevalence of polyps upon surveillance colonoscopy in patients who have a history of adenomas on initial average-risk-screening colonoscopy, but then have a normal initial surveillance (second) colonoscopy between 2003 and 2017. This is the first known retrospective cohort study of adenoma detection rate (ADR) with sub-group analysis of patients with serial surveillance colonoscopies by abnormal and high-risk surveillance findings separately by prior abnormal colonoscopies and correct surveillance strategies based on the recent March 2020 updated guidelines. After ADR calculation, machine learning-augmented propensity score adjusted multivariable regression with augmented inverse-probability weighting propensity (AIPW) score analysis was used to assess the relationship between guideline adherence, as well as abnormal and high-risk surveillance findings. A total of 1840 patients with pathologically confirmed adenomas or cancer on an initial average-risk-screening (first) colonoscopy met study criteria. 837 (45.5%) had confirmed adenomas on second colonoscopy, and 1003 (54.5%) had normal findings. Of 837 patients with polyps on both first and second colonoscopy, 423 (50.5%) had adenomas on third colonoscopy. Of the 1003 patients without polyps on second colonoscopy, 406 (40.5%) had confirmed adenomas on third colonoscopy. Guideline adherence was low at 9.18%, though was associated in propensity score adjusted multivariable regression with increased odds of an abnormal third (but not high-risk) colonoscopy, with comparable AIPW results. This 14-year study demonstrates the ADR to be > 40% on the third colonoscopy for patients with adenomas on initial screening colonoscopy, who then have a normal second colonoscopy. Through advanced machine learning and propensity score analysis, we showed that correct adherence is associated with higher odds of abnormal, but not high-risk abnormal 3rd colonoscopy, with evidence that high-risk surveillance findings are reduced by providers shortening the time between surveillance colonoscopies in contrast to the guidelines for those for whom there is presumed greater clinical suspicion of eventual cancer. Larger prospective trials are needed to guide optimal surveillance for these patients.
Sections du résumé
BACKGROUND
Colonoscopy remains the gold standard for screening and surveillance of colorectal neoplasms, and is associated with a lower risk of colorectal cancer (CRC)-related mortality. The current interval surveillance recommendations in patients with previous adenomas lack sufficient evidence. The prevalence of subsequent adenomas, and especially high-risk adenomas, during surveillance is not well known.
METHODS
The primary outcome of this study was to determine the prevalence of polyps upon surveillance colonoscopy in patients who have a history of adenomas on initial average-risk-screening colonoscopy, but then have a normal initial surveillance (second) colonoscopy between 2003 and 2017. This is the first known retrospective cohort study of adenoma detection rate (ADR) with sub-group analysis of patients with serial surveillance colonoscopies by abnormal and high-risk surveillance findings separately by prior abnormal colonoscopies and correct surveillance strategies based on the recent March 2020 updated guidelines. After ADR calculation, machine learning-augmented propensity score adjusted multivariable regression with augmented inverse-probability weighting propensity (AIPW) score analysis was used to assess the relationship between guideline adherence, as well as abnormal and high-risk surveillance findings.
RESULTS
A total of 1840 patients with pathologically confirmed adenomas or cancer on an initial average-risk-screening (first) colonoscopy met study criteria. 837 (45.5%) had confirmed adenomas on second colonoscopy, and 1003 (54.5%) had normal findings. Of 837 patients with polyps on both first and second colonoscopy, 423 (50.5%) had adenomas on third colonoscopy. Of the 1003 patients without polyps on second colonoscopy, 406 (40.5%) had confirmed adenomas on third colonoscopy. Guideline adherence was low at 9.18%, though was associated in propensity score adjusted multivariable regression with increased odds of an abnormal third (but not high-risk) colonoscopy, with comparable AIPW results.
CONCLUSION
This 14-year study demonstrates the ADR to be > 40% on the third colonoscopy for patients with adenomas on initial screening colonoscopy, who then have a normal second colonoscopy. Through advanced machine learning and propensity score analysis, we showed that correct adherence is associated with higher odds of abnormal, but not high-risk abnormal 3rd colonoscopy, with evidence that high-risk surveillance findings are reduced by providers shortening the time between surveillance colonoscopies in contrast to the guidelines for those for whom there is presumed greater clinical suspicion of eventual cancer. Larger prospective trials are needed to guide optimal surveillance for these patients.
Identifiants
pubmed: 33763746
doi: 10.1007/s00464-021-08403-3
pii: 10.1007/s00464-021-08403-3
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
1284-1292Informations de copyright
© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.
Références
Siegel RL, Miller KD, Fedewa SA et al (2017) Colorectal cancer statistics, 2017. CA Cancer J Clin 67:177–193
doi: 10.3322/caac.21395
Click B, Pinsky PF, Hickey T et al (2018) Association of colonoscopy adenoma findings with long-term colorectal cancer incidence. JAMA 319(19):2021–2031. https://doi.org/10.1001/jama.2018.5809
doi: 10.1001/jama.2018.5809
pubmed: 29800214
pmcid: 6583246
U.S. Preventive Services Task Force (2008) Screening for Colorectal Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 149:627–637
Lieberman DA, Rex DK, Winawer SJ et al (2012) Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 143:844–857
doi: 10.1053/j.gastro.2012.06.001
Winawer S, Fletcher R, Rex D et al (2003) Colorectal cancer screening and surveillance: clinical guidelines and rationale-updated based on new evidence. Gastroenterology 124:544–560
doi: 10.1053/gast.2003.50044
American Cancer Society/US Multisociety Task Force on Colorectal Cancer/American College of Radiology (ACS/USMSTF/ACR) (2008) Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the ACS, the USMSTF, and the ACR. CA Cancer J Clin 58(3):130–160
Rex DK, Schoenfeld PS, Cohen J, Pike IM, Adler DG, Fennerty MB, Lieb JG 2nd, Park WG, Rizk MK, Sawhney MS, Shaheen NJ, Wani S, Weinberg DS (2015) Quality indicators for colonoscopy. Gastrointest Endosc 81(1):31–53
doi: 10.1016/j.gie.2014.07.058
Ferlitsch M, Reinhart K, Pramhas S, Wiener C, Gal O, Bannert C, Hassler M, Kozbial K, Dunkler D, Trauner M, Weiss W (2011) Sex-specific prevalence of adenomas, advanced adenomas, and colorectal cancer in individuals undergoing screening colonoscopy. JAMA 306(12):1352
doi: 10.1001/jama.2011.1362
Corley DA, Jensen CD, Marks AR, Zhao WK, Lee JK, Doubeni CA, Zauber AG, de Boer J, Fireman BH, Schottinger JE, Quinn VP, Ghai NR, Levin TR, Quesenberry CP (2014) Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med 70(14):1298–1306
doi: 10.1056/NEJMoa1309086
Dvorin E, Lamb MC, Monlezun DJ, Boese AC, Bazzano LA, Price-Haywood EG (2018) High frequency of systemic corticosteroid use for acute respiratory tract illnesses in ambulatory settings. JAMA Intern Med 178(6):852–854
doi: 10.1001/jamainternmed.2018.0103
Monlezun DJ, Dart L, Vanbeber A, Smith-Barbaro P et al (2018) Machine learning-augmented propensity score-adjusted multilevel mixed effects panel analysis of hands-on cooking and nutrition education versus traditional curriculum for medical students as preventive cardiology: multisite cohort study of 3,248 trainees over 5 years. BioMed Res Int 2018(2018):5051289
pubmed: 29850526
pmcid: 5925138
Price-Haywood E, Luo Q, Monlezun DJ (2018) Dose effect of patient-care team communication via secure portal messaging on glucose and blood pressure control. J Am Med Inform Assoc 25(6):702–708
doi: 10.1093/jamia/ocx161
Johnson KW, Torres Soto J, Glicksberg BS et al (2018) Artificial intelligence in cardiology. J Am Coll Cardiol 71:2668–2679
doi: 10.1016/j.jacc.2018.03.521
Chen JH, Asch SM (2017) Machine learning and prediction in medicine-beyond the peak of inflated expectations. N Engl J Med 376(26):2507–2509
doi: 10.1056/NEJMp1702071
Obermeyer Z, Emanuel EJ (2016) Predicting the future-big data, machine learning, and clinical medicine. N Engl J Med 375(13):1216–1219
doi: 10.1056/NEJMp1606181
Glyn A, Quinn K (2010) An Introduction to the augmented inverse propensity weighted estimator. Polit Anal 18:36–56
doi: 10.1093/pan/mpp036
Austin PC, Stuart EA (2015) Moving towards best practice when using inverse probability of treatment weighting (IPTW) using the propensity score to estimate causal treatment effects in observational studies. Stat Med 34(28):3661–3679. https://doi.org/10.1002/sim.6607
doi: 10.1002/sim.6607
pubmed: 26238958
pmcid: 4626409
Brookhart et al (2013) Propensity score methods for confounding control in non-experimental research. Circ Cardiovasc Qual Outcomes 6(5):604–611
doi: 10.1161/CIRCOUTCOMES.113.000359
Gupta S, Lieberman D, Anderson JC et al (2020) Recommendations for follow-up after colonoscopy and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 115(3):415–434
doi: 10.14309/ajg.0000000000000544