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Surveillance colonoscopy should be targeted to high-risk patients

Overuse of widely accepted test can be excessively costly or even harmful, according to study published in Gastroenterology

--added 6/28/10

Ann Arbor, MI -- Surveillance colonoscopy is effective and cost-effective when targeted to high-risk patients, according to new research from a University of Michigan physician. However, overuse of surveillance colonoscopy could be excessively costly or even harmful.

"Surveillance colonoscopy is a widely accepted and utilized practice that has the potential to decrease the burden of colorectal cancer. Yet, this practice also carries considerable monetary and resource costs as well as the risk of procedure-related complications," said the study's lead author, Sameer Dev Saini, M.D., M.S., a clinical lecturer in the U-M Department of Internal Medicine and an investigator for Ann Arbor VA Health Services Research & Development Center of Excellence.

"Despite these concerns, data supporting the long-term effectiveness of surveillance colonoscopy and the choice of optimal surveillance strategy are limited."

The study was published this month in study in Gastroenterology, the official journal of the American Gastroenterological Association (AGA) Institute.

Current guidelines recommend that patients with colonic adenomas undergo periodic surveillance colonoscopy. But, is doing so cost-effective? Saini and colleagues sought to answer this question by using existing data to make projections about the effectiveness and cost-utility of surveillance.

According to study results, colonoscopy every three years in high-risk patients and every 10 years in low-risk patients (3/10 strategy) was more costly, but also more effective than no surveillance. A cost-utility analysis suggested that the 3/10 strategy is the optimal strategy under the vast majority of clinical circumstances.

A 3/5 strategy (colonoscopy every three years in high-risk patients and every five years in low-risk patients) was considerably more costly, but only marginally more effective. Compared to the 3/10 strategy, the 3/5 strategy resulted in five fewer cancers and one fewer cancer-related death per 1,000 patients entering surveillance.

A 3/3 strategy (colonoscopy every three years in both high- and low-risk patients), which may be attractive to gastroenterologists with medico-legal concerns over missed neoplasia, is cost-ineffective and potentially harmful in comparison to less intensive surveillance. Compared to the 3/5 strategy, the 3/3 strategy resulted in two fewer cancers and one fewer cancer-related death per 1,000 patients entering surveillance. However, this small incremental benefit was potentially outweighed by the inconvenience of frequent colonoscopies under this strategy.

"There is evidence that we are over-using colonoscopy in low-risk patients and under-using colonoscopy in high-risk patients. We need to focus our efforts on high-risk patients, who have the most to gain from these procedures," said Saini.

Saini added that future improvements in risk stratification could further enhance physicians' ability to target surveillance to those patients most likely to benefit from this practice.

Journal reference: 10.1053/j.gastro.2010.03.004.

Funding: The authors have no relevant financial disclosures.

The University of Michigan's Gastroenterology Division provides full endoscopic services including esophagogastroduodenoscopy, small bowel enteroscopy, colonoscopy, dilation (esophageal, pyloric/gastric, biliary), endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), laser therapies, polypectomy (both upper and lower), variceal sclerosis and laparoscopy. Find out more here.

To learn more about colonoscopy, visit the patient center on the AGA Web site at http://www.gastro.org/patient-center.

About the AGA Institute

The American Gastroenterological Association is the trusted voice of the GI community. Founded in 1897, the AGA has grown to include 17,000 members from around the globe who are involved in all aspects of the science, practice and advancement of gastroenterology. The AGA Institute administers the practice, research and educational programs of the organization: www.gastro.org.

About Gastroenterology

Gastroenterology, the official journal of the AGA Institute, is the most prominent scientific journal in the specialty and is in the top 1% of indexed medical journals internationally. The journal publishes clinical and basic science studies of all aspects of the digestive system, including the liver and pancreas, as well as nutrition. The journal is abstracted and indexed in Biological Abstracts, CABS, Chemical Abstracts, Current Contents, Excerpta Medica, Index Medicus, Nutrition Abstracts and Science Citation Index. For more information, visit www.gastrojournal.org.


Written by Mary Masson; contact at telephone 734-764-2220, or email mfmasson@med.umich.edu.


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