Adherence to surveillance guidelines after removal of colorectal adenomas: a large, community-based study

Else-Mariëtte B van Heijningen, Iris Lansdorp-Vogelaar, Ewout W Steyerberg, S Lucas Goede, Evelien Dekker, Wilco Lesterhuis, Frank ter Borg, Juda Vecht, Pieter Spoelstra, Leopold Engels, Clemens J M Bolwerk, Robin Timmer, Jan H Kleibeuker, Jan J Koornstra, Harry J de Koning, Ernst J Kuipers, Marjolein van Ballegooijen, Else-Mariëtte B van Heijningen, Iris Lansdorp-Vogelaar, Ewout W Steyerberg, S Lucas Goede, Evelien Dekker, Wilco Lesterhuis, Frank ter Borg, Juda Vecht, Pieter Spoelstra, Leopold Engels, Clemens J M Bolwerk, Robin Timmer, Jan H Kleibeuker, Jan J Koornstra, Harry J de Koning, Ernst J Kuipers, Marjolein van Ballegooijen

Abstract

Objective: To determine adherence to recommended surveillance intervals in clinical practice.

Design: 2997 successive patients with a first adenoma diagnosis (57% male, mean age 59 years) from 10 hospitals, who underwent colonoscopy between 1998 and 2002, were identified via Pathologisch Anatomisch Landelijk Geautomatiseerd Archief: Dutch Pathology Registry. Their medical records were reviewed until 1 December 2008. Time to and findings at first surveillance colonoscopy were assessed. A surveillance colonoscopy occurring within ± 3 months of a 1-year recommended interval and ± 6 months of a recommended interval of 2 years or longer was considered appropriate. The analysis was stratified by period per change in guideline (before 2002: 2-3 years for patients with 1 adenoma, annually otherwise; in 2002: 6 years for 1-2 adenomas, 3 years otherwise). We also assessed differences in adenoma and colorectal cancer recurrence rates by surveillance timing.

Results: Surveillance was inappropriate in 76% and 89% of patients diagnosed before 2002 and in 2002, respectively. Patients eligible under the pre-2002 guideline mainly received surveillance too late or were absent (57% of cases). For patients eligible under the 2002 guideline surveillance occurred mainly too early (48%). The rate of advanced neoplasia at surveillance was higher in patients with delayed surveillance compared with those with too early or appropriate timed surveillance (8% vs 4-5%, p<0.01).

Conclusions: There is much room for improving surveillance practice. Less than 25% of patients with adenoma receive appropriate surveillance. Such practice seriously hampers the effectiveness and efficiency of surveillance, as too early surveillance poses a considerable burden on available resources while delayed surveillance is associated with an increased rate of advanced adenoma and especially colorectal cancer.

Keywords: COLONOSCOPY; COLORECTAL ADENOMAS; ENDOSCOPIC POLYPECTOMY; SURVEILLANCE.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Figures

Figure 1
Figure 1
Identification of the study cohort and the subgroups.
Figure 2
Figure 2
(A) Kaplan-Meier probability curve for surveillance colonoscopy use by month from index colonoscopy for patients with one adenoma, stratified by active guideline. The shaded areas indicate appropriate intervals around 2–3 years (

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