Surgeons as Good as Endoscopists at Finding Polyps

Megan Brooks

April 17, 2019

Surgeons are as good as endoscopy specialists at detecting polyps through colonoscopy, according to a new study that discounts prior studies suggesting that endoscopists are better at detecting polyps.

Endoscopist characteristics "should not influence the choice of endoscopist for colorectal cancer screening," the study team concluded.

The adenoma detection rate (ADR) is one measure of colonoscopy quality and higher ADRs have been tied to lower risk of developing colorectal cancer.  Some studies have found differences in polyp detection based on endoscopist characteristics including gender, specialty (gastroenterologist, surgeon, advanced endoscopist), and years in practice. However, many of the studies did not adjust for other risk factors associated with colonic neoplasia.

Based on their new analysis, Shashank Sarvepalli, MD, and colleagues from the Cleveland Clinic in Ohio think it is likely that residual confounding rather than true differences between specialists' abilities are responsible for the differing ADRs found in prior studies.

The study was published online today in JAMA Surgery.

The Cleveland Clinic team examined differences in the ADR and proximal sessile serrated polyp detection rate (pSSPDR) in relation to seven endoscopist characteristics: specialty (gastroenterologist, surgeon, advanced endoscopist), gender, location of medical school (in or outside the US), years since completing training, colonoscopy volume, practice setting (academic vs private practice), and presence of a trainee (yes/no). They had data on roughly 16,000 colonoscopies performed by 56 clinicians (34 gastroenterologists, 15 surgeons, 7 advanced endoscopists).

The average ADR in the study was 31.3%, which is higher than the minimum standards suggested by American Society for Gastrointestinal Endoscopy–American College of Gastroenterology quality task force guidelines. The average pSSPDR was 4.6%, roughly similar to findings from other recent studies.

When the researchers analyzed their data using methods from previous studies, they found differences in the ADR and pSSPDR based on endoscopist characteristics, in line with prior studies. However, these differences were no longer significant after adjusting for multiple confounding factors. 

In a multilevel, mixed-effects, logistic regression analysis, ADR was not significantly associated with any endoscopist characteristic, and pSSPDR was only associated with years in practice and number of annual colonoscopies performed.

However, clinicians further from training and those with lower colonoscopy volumes had a lower adjusted pSSPDR "and may need additional training to help increase pSSPDRs," Sarvepalli and colleagues note in their article.

To their knowledge, the authors say this is one of the largest single-center studies (both in number of colonoscopies evaluated and number of endoscopists included) assessing endoscopist characteristics as they relate to ADRs and pSSPDRs. "[W]e feel we have established that it is likely the lack of controlling for residual confounding in other studies that was responsible for endoscopist-based differences seen in prior studies," they write.

"This counters previously reported lower quality for colonoscopies and increased risk of missed adenomas and interval cancers by surgeons and confirms that colonoscopic quality indicators are adequately met by both gastroenterologists and nongastroenterologists," write Katerina Wells, MD, and James Fleshman, MD, from Baylor University Medical Center, Dallas, Texas in an accompanying editorial.

"This study validates the surgeon in providing a high-quality screening and, more importantly, broadens the limited pool of clinicians to address low national screening rates. The question becomes whether well-trained nonspecialty clinicians with an acceptable adenoma detection rate could also provide screening," say the editorialists.

The study had no specific funding. The authors and editorialists have disclosed no relevant financial relationships.

JAMA Surgery. Published online April 17, 2019. Abstract, Editorial

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