Trends in Adenoma Detection Rates During the First 10 Years of the German Screening Colonoscopy Program

doi:10.1053/j.gastro.2015.04.012

Gastroenterology

Volume 149, Issue 2, August 2015, Pages 356-366.e1

https://doi.org/10.1053/j.gastro.2015.04.012 Get rights and content

Background & Aims

The adenoma detection rate (ADR) is an important quality indicator of screening colonoscopy; it is inversely associated with risk of interval cancers and colorectal cancer mortality. We assessed trends in the ADR in the first 10 years of the German screening colonoscopy program.

Methods

We calculated age-adjusted and age-specific detection rates of nonadvanced adenomas and advanced adenomas for each calendar year based on 4.4 million screening colonoscopies conducted from 2003 through 2012 and reported to the German screening colonoscopy registry.

Results

We observed a steady and strong increase in rate of detection of nonadvanced adenomas in both sexes and all age groups. Age-adjusted rates of detection of nonadvanced adenomas increased from 13.3% to 22.3% among men and from 8.4% to 14.9% among women. This increase was mostly due to an increase in detection rates of adenomas <0.5 cm, and it is partly explained by an innovation effect (higher ADRs among incoming colonoscopists than among leaving colonoscopists, and relatively stable ADRs among continuing colonoscopists). Only modest increases were observed in detection rates of advanced adenomas (from 7.4% to 9.0% among men, and from 4.4% to 5.2% among women) and colorectal cancer. In 2012, overall ADR reached 31.3% and 20.1% in men and women, respectively.

Conclusions

We observed a strong increase in ADRs from 2003 through 2012 in Germany. Although we cannot exclude the effects of secular trends in colorectal neoplasm prevalence, the observed increase was mainly the result of a steady increase in detection of nonadvanced adenomas (especially adenomas <0.5 cm). Further research should address potential implications for defining screening and surveillance intervals.

Section snippets

Database

Our analysis is based on data of the German screening colonoscopy registry.¹⁴ Screening colonoscopy has been offered in Germany as a primary screening examination for early detection and prevention of CRC since October 2002. Women and men aged 55 years or older are eligible for a first screening colonoscopy. If this first screening colonoscopy is conducted before 65 years of age, a second screening colonoscopy is offered 10 years later. Certification to conduct screening colonoscopy is tightly

Results

Figure 1 shows the annual cumulative numbers of men and women participating in screening colonoscopy up to various ages. Among men, the total number of screening colonoscopies increased steeply between 2003 and 2004 and reached its peak at 239,970 in 2006. Since then, numbers of screening colonoscopies gradually declined, except for the youngest age group (55−59 years), in whom the number of screening colonoscopies continued to increase up to 2009 and remained essentially constant thereafter.

Discussion

In this study, we observed a strong increase in the detection rate of nonadvanced adenomas within the initial 10 years of the German screening colonoscopy program. This strong increase was seen consistently in both sexes and all age groups and was, to a large extent, due to a particularly strong increase in detection rates of small adenomas of <0.5 cm. By contrast, only a less pronounced increase was seen (in absolute terms) in detection rates of advanced adenomas and CRC. The increase in ADRs

References (33)

H. Brenner et al.
Reduced risk of colorectal cancer up to 10 years after screening, surveillance or diagnostic colonoscopy
Gastroenterology
(2014)
S.L. Peters et al.
Level of fellowship training increases adenoma detection rates
Clin Gastroenterol Hepatol
(2010)
H.S. Wang et al.
Adenoma detection rate is necessary but insufficient for distinguishing high versus low endoscopist performance
Gastrointest Endosc
(2013)
A.H. Calderwood et al.
Colonoscopy quality: metrics and implementation
Gastroenterol Clin North Am
(2013)
E. Ricci et al.
Inter-centre variability of the adenoma detection rate: a prospective, multicentre study
Dig Liver Dis
(2013)
D.K. Rex et al.
Quality indicators for colonoscopy
Gastrointest Endosc
(2006)
D. Lieberman et al.
Standardized colonoscopy reporting and data system: report of the Quality Assurance Task Group of the National Colorectal Cancer Roundtable
Gastrointest Endosc
(2007)
D.K. Rex et al.
Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer
Am J Gastroenterol
(2002)
H. Pohl et al.
Colorectal cancers detected after colonoscopy frequently result from missed lesions
Clin Gastroenterol Hepatol
(2010)
D.A. Lieberman et al.
Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer
Gastroenterology
(2012)

I.M. Gralnek et al.

Standard forward-viewing colonoscopy versus full-spectrum endoscopy: an international, multicenter, randomised tandem colonoscopy trial

Lancet Oncol

(2014)

C. Stock et al.

Identification of physicians with unusual performance in screening colonoscopy databases: a Bayesian approach

Gastrointest Endosc

(2015)

A.G. Zauber et al.

Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths

N Engl J Med

(2012)

C.A. Doubeni et al.

Screening colonoscopy and risk for incident late-stage colorectal cancer diagnosis in average-risk adults

Ann Intern Med

(2013)

R. Nishihara et al.

Long-term colorectal-cancer incidence and mortality after lower endoscopy

N Engl J Med

(2013)

H. Brenner et al.

Effect of screening sigmoidoscopy and screening colonoscopy on colorectal cancer incidence and mortality: systematic review and meta-analysis of randomised controlled trials and observational studies

BMJ

(2014)

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The proportion of colonoscopies with at least one adenoma (adenoma detection rate [ADR]) is inversely associated with colorectal cancer (CRC) risk and death. The aim of this study was to examine whether such associations exist for colonoscopy quality measures other than ADR.
We used data from the Polish Colorectal Cancer Screening Program collected in 2000–2011. For all endoscopists who performed ≥100 colonoscopies we calculated detection rates of adenomas (ADR), polyps (PDR), and advanced adenomas (≥10 mm/villous component/high-grade dysplasia [AADR]); and number of adenomas per colonoscopy (APC) and per colonoscopy with ≥1 adenoma (APPC). We followed patients until CRC diagnosed before recommended surveillance, death, or December 31, 2019. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) using Cox proportional-hazard models. We used Harrell’s C statistic to compare the predictive power of the quality measures.
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Citation Excerpt :
These findings suggest that although people with low-risk adenomas and low PRS might not require surveillance and could return to regular 10-year screening intervals, those with higher genetic risk might deserve more intensive surveillance. Notably, adenomas are detected in approximately 30% of initial screening colonoscopies,25 which implies that surveillance colonoscopies account for a large share of colonoscopy resources in colonoscopy-based CRC screening programs, such as in Germany and the United States. A considerable proportion of older adults never undergoes colonoscopy, whereas there is evidence of substantial overuse of surveillance colonoscopies, especially after detection and removal of low-risk adenomas.17–19
Polygenic risk scores (PRSs) could help to define personalized colorectal cancer (CRC) screening strategies. The aim of this study was to evaluate whether a PRS, along with adenoma characteristics, could help to define more personalized and risk-adapted surveillance intervals.
In a population-based, case-control study from Germany, detailed information on previous colonoscopies and a PRS based on 140 CRC-related, single-nucleotide polymorphisms was obtained from 4696 CRC cases and 3709 controls. Participants were classified as having low, medium, or high genetic risk according to tertiles of PRSs among controls. We calculated the absolute risk of CRC based on the PRS and colonoscopy history and findings.
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Consideration of genetic predisposition to CRC risk, as determined by a PRS, could help to define personalized, risk-adapted surveillance intervals after detection and removal of adenomas at screening colonoscopy. However, whether the risk variation is strong enough to direct clinical risk stratification needs to be explored further.

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: Conflicts of interest The authors disclose no conflicts.

: Funding The German screening colonoscopy registry is funded by the National Association of Statutory Health Insurance Physicians and the National Association of Statutory Health Insurance Funds. This study was further supported in part by grants from the German Research Council (Deutsche Forschungsgemeinschaft, grant number BR 1704/6-4) and the German Federal Ministry of Education and Research (grant number 01KH0404, 01ER0814). The sponsors did not have any role in this study.

: Author names in bold designate shared co-first authorship.

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Original ResearchFull Report: Clinical—Alimentary TractTrends in Adenoma Detection Rates During the First 10 Years of the German Screening Colonoscopy Program

Background & Aims

Methods

Results

Conclusions

Section snippets

Database

Results

Discussion

Gastroenterology

Clin Gastroenterol Hepatol

Gastrointest Endosc

Gastroenterol Clin North Am

Dig Liver Dis

Gastrointest Endosc

Gastrointest Endosc

Am J Gastroenterol

Clin Gastroenterol Hepatol

Gastroenterology

Lancet Oncol

Gastrointest Endosc

Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths

N Engl J Med

Screening colonoscopy and risk for incident late-stage colorectal cancer diagnosis in average-risk adults

Ann Intern Med

Long-term colorectal-cancer incidence and mortality after lower endoscopy

N Engl J Med

Effect of screening sigmoidoscopy and screening colonoscopy on colorectal cancer incidence and mortality: systematic review and meta-analysis of randomised controlled trials and observational studies

BMJ

Original Research
Full Report: Clinical—Alimentary Tract
Trends in Adenoma Detection Rates During the First 10 Years of the German Screening Colonoscopy Program