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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Data on minor diagnoses
Colorectal cancer screening by family physicians
Outpatient Colonoscopy
Great Results on Office Colonoscopy
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Scott Strayer, Charlottesville, USA Assistant Professor, Dept. of Family Medicine, University of Virginia
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Would you be willing to share your data on minor findings? For example your diverticulitis, hemorrhoid, etc. rates. Thanks. Competing interests: None declared |
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Kalyanakrishnan Ramakrishnan, Oklahoma City, Oklahoma, U.S.A. Department of Family and Preventive Medicine, OUHSC
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About 60% of patients with colorectal cancer (CRC) have regional or distant metastases at the time of diagnosis.1 Estimated 5-year survival is 91% in persons with localized disease, 60% in persons with regional spread, and only 6% in those with distant metastases.2 The average patient dying of CRC loses 13 years of life.2 In addition to the mortality associated with CRC, this disease and its treatment-surgical resection, colostomies, chemotherapy, and radiotherapy-can produce significant morbidity. The majority of colon cancers arise from benign adenomatous polyps, and the long time horizon required for this malignant transformation (10 years or more) affords the opportunity to decrease colon cancer by removal of precursor adenomas detected at screening. Ensuring that CRC screening is performed in most, if not all, eligible patients remains a monumental challenge. Participation in CRC screening has much to do with a positive attitude towards health and health promotion.3 Persistent compliers are found to be from higher socioeconomic groups, to have more personal and family experiences of illness, and to visit their dentists more regularly. Adherence rates approach 100% in individuals older than age 50 with a family history of CRC. These data suggest that the more overt targeting of efforts at compliance enhancement is to be preferred.4 A physician’s emphasis on counseling patients repeatedly and continuing to offer CRC screening procedures also remains a powerful factor promoting CRC screening and improving patient adherence. A two-year study is currently being undertaken addressing the CRC screening strategies of the primary care provider members of the Oklahoma Physicians Resource/Research Network (OKPRN) to determine the most effective and efficient practices for each of the steps involved in CRC screening. It is hoped that combining the best practices for each step of CRC screening into at least one comprehensive best practices strategy will provide a road map to improving patient compliance with CRC screening, and maximizing its utilization. Colonoscopy, recommended at 10-year intervals for screening in those at average risk for CRC remains the gold standard, and is potentially capable of both detecting and removing all precancerous adenomas. This manuscript outlines how, with the requisite training and application, dedicated family physicians can offer this service as well as any gastroenterologist. Unfortunately the path to obtaining proficiency in colonoscopy for family physicians and providing this service to patients is another uphill battle, involving the good graces of medical and surgical gastroenterologists in assisting with the training, and insurance companies, hospital or surgicenter credentialing committees in obtaining endoscopy privileges. Other screening methods such as virtual colonoscopy and stool antigen testing may soon crop up as attractive, effective and cost-saving alternatives to screening colonoscopy. Perhaps family physicians like myself will offer better service by ensuring CRC screening in most of their eligible patient population by any available method, and not insisting on colonoscopy. References 1.Wingo PA, Tong T, Bolden S. Cancer statistics, 1995. CA Cancer J Clin 1995; 45:8-30. 2.Ries LAG, Miller BA, Hankey BF. SEER cancer statistics review 1973-1991: tables and graphs. Bethesda, MD: National Cancer Institute, 1994. 3.Frew E, Wolstenholme J, Whynes DK. Mass population screening for colorectal cancer: factors influencing subjects' choice of screening test. J Health Serv Res Policy 2001; 6:85-91. 4.Neilson AR, Whynes DK. Determinants of persistent compliance with screening for colorectal cancer. Soc Sci Med 1995; 41:365-374. Competing interests: None declared |
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Leo R. Leer, Eureka, USA Family Physician, Eureka Family Practice
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The article by Newman et al. on Outpatient Colonoscopy should be an inspiration for us all. All current and future family physicians should be encouraged by this and similar data to add such procedures to their repertoire. There is no reason a procedure such as colonoscopy should be the purview of sub specialists and surgeons. Colonoscopy is easy, is part of basic preventive medicine, and should be a basic part of all family medicine training in the future. I firmly believe that if our specialty is to survive, one of the reasons it does so will be because we continue to add procedures such as colonoscopy to our basic toolbox. Thus, I would like to share my experience with colonoscopy. Between December, 2003 and March, 2005, I have performed 200 colonoscopies at the local hospital outpatient GI lab. I have full hospital privileges to perform colonoscopy. Prior to beginning to perform colonoscopies, I had over 12 years of experience with office-based flexible sigmoidoscopy. During that period, patients who needed or preferred colonoscopy for screening were referred to either one of the two local gastroenterologists or one of several local surgeons. Upon the departure of one of the two gastroenterologists it became more difficult to get patients in for diagnostic and screening exams in a timely fashion. At the same time, more and more patients were becoming aware of the benefits of colonoscopy as a cancer screening tool, and were requesting it. Thus, our backlog grew, and our referral staff spent even more time – for which we of course were paying them – trying to arrange consultations, get insurance authorization, etc. It was at this point that I chose to learn the technique of colonoscopy. I attended the National Procedures Institute training courses on Colonoscopy and Advanced Colonoscopy. I then sought hospital privileges at local hospital at which I have active privileges in Family Medicine. I asked the remaining community gastroenterologist if he would proctor me, and he declined, stating concerns about quality, potential risk of putting patients through two colonoscopies (first by me, then by him to remove the polyps I couldn’t deal with), and difficulty recruiting a second gastroenterologist if family physicians should suddenly begin performing colonoscopies. Fortunately, two of my general surgery colleagues readily agreed to proctor me. After considerable discussion in the Credentials Committee and the Medical Executive Committee, I was granted provisional privileges with a requirement for direct, concurrent observation of my first 25 colonoscopies and at least 5 snare biopsy procedures. These proctored procedures were successfully completed over the first 3 months of 2004, and since then I have had unrestricted colonoscopy privileges. During the proctoring period, I used meperidine and midazolam, as was the practice of my proctors. Since then, all my patients save one have been pre-medicated with midazolam and fentanyl. All have been prepped with polyethylene glycol powder mixed in a sports drink (64 oz). Prep quality has uniformly been excellent [I would be happy to share details with anyone interested]. All the colonoscopies I have performed have been on referral from within my Family Medicine group, and have been for diagnostic as well as routine screening purposes. The outcomes from the first 200 cases are presented below. Sex distribution: 107 male; 93 female Age range: 43 - 90 Cecal intubation rate: 97% (194/200) Forceps biopsies (total # of pts): 57 Snare Biopsies (total # of pts): 32 Largest polyp removed: 4 cm long pedunculated descending colon lesion Pathology: Tubular adenoma: 39 Tubulovillous or villous: 2 Hyperplastic: 41 Carcinoma: 2 Other: 5 Competing interests: None declared |
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John L. Pfenninger, Midland, MI, USA Director, The National Procedures Institute
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The article by Newman et al. is right on target and exactly what we need in the literature. The summary is based on a large number of colonoscopies (731) and the article is succinct and to the point. I would like to add a few comments. When we began teaching colonoscopies through the National Procedures Institute (www.npinstitute.com) in 1991, we were lucky to have 5-10 physicians present. Now, our courses are often sold out (limited to 35) and the advanced colonoscopy course is generally full. Family docs certainly have an interest performing colonoscopy. The major obstacle has been obtaining privileges in hospital settings. These authors show what I have often advocated: colonoscopy can be performed with quality in an office setting! Patients with a high risk for complications (cardiac disease, respiratory problems, etc.) may still need to go to the hospital. However, the majority of patients can be seen and evaluated in the office. (It would be interesting to know if the authors turned away any patients.) Currently, the total cost for colonoscopy performed in our hospital GI lab runs between $2500-$3500. Consider a couple with no insurance. You are asking them to pay $5,000 - $7,000 for screening. Is this reasonable? I think not. When we performed 208 colonoscopies in our office over a period of two years, our average cost was $812 (averaging all colonoscopies including polypectomies). Physician share of reimbursements are currently higher from Medicare and some insurances when the procedure is done in the office vs. a facility ($344 vs. $195). Initial equipment costs are high but the differential in reimbursement and the time saved from going to the hospital make it worthwhile to do procedures in the office. The cost savings to many patients would certainly make it more likely that they would obtain screening. It should not be forgotten, too, that with these excessively high costs for screening, the ACS, the USPSTF, the ASGE, and others still recommend that patients be given a choice for screening. This includes hemoccults alone every year, flexible sigmoidoscopy alone every five years, flexible sigmoidoscopy every five years and hemoccults every year, colonoscopy every 10 years, and air contrast barium enema every five years. Virtual colonoscopy is still not recommenced. For those patients who simply cannot afford colonoscopy, physicians should offer other methods of screening. There are simply not enough gastroenterologists to perform all the colonoscopies needed purely on a screening basis. Family physicians should continue to move forward and learn colonoscopy and provide that service for the patients. Not only can we do it, we can do it very well and meet national guidelines. One of the challenges that I see is that physicians who are currently learning colonoscopy have often performed flexible sigmoidoscopy and are merely progressing on with colonoscopy. Many of the younger residents graduating from family practice programs are not learning flexible sigmoidoscopy skills and subsequently the learning curve for colonoscopy may be somewhat longer than in the past. Competing interests: None declared |
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