New Quality Indicators for Colonoscopy: More Issues Should Be Addressed

The work from Wieszczy et al1Wieszczy P. et al.Clin Gastroenterol Hepatol. 2023; 21: 200-209.e6Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar further confirmed the inverse connection between adenoma detection rate (ADR) and colorectal cancer (CRC) risk and death. New findings have indicated that the polyp detection rate (PDR) and the number of adenomas per colonoscopy (APC) seemed comparable with the ADR as quality indicators. However, several issues should be addressed to improve the robustness and generalizability of this finding. One of the most important quality measurements for screening colonoscopy is the ADR. The investigators indicated that the highest reduction in post-colonoscopy CRC (PCCRC) risk was observed for an ADR of 24.9% or greater and was equivalent to a PDR of 42.7% or greater and an APC of 37% or greater. However, the latest report by Schottinger et al2Schottinger J.E. et al.JAMA. 2022; 327: 2114-2122Crossref PubMed Scopus (12) Google Scholar further showed the relationship between ADR and PCCRC risk at a broader range (up to >50%), for which relevant data are sparse for PDR or APC to establish a robust conclusion as quality indicators. Specifically, Corley et al3Corley D.A. et al.N Engl J Med. 2014; 370: 1298-1306Crossref PubMed Scopus (1171) Google Scholar showed the progressive reduction in PCCRC risk up to an ADR of at least 33.5%, indicating that the accepted ADR threshold of 25% should be increased further. In addition, PDR and APC have several disadvantages as quality indicators, for example, the PDR could be gamed easily by removing clinically insignificant polyps, while the APC could lead to increased cost for pathological examination, although the application of artificial intelligence may help solve this challenge.4Gong D. et al.Lancet Gastroenterol Hepatol. 2020; 5: 352-361Abstract Full Text Full Text PDF PubMed Scopus (151) Google Scholar Before recommending APC and PDR as new indicators, the predictive power of APC and PDR for PCCRC risk among physicians with higher ADRs should be illustrated. Notably, Peng et al5Peng S.M. et al.Gut. 2021; 70: 1318-1324Crossref PubMed Scopus (5) Google Scholar showed in a previous cohort that the association between the ADR and PCCRC risk was nonsignificant in multivariable analysis after adjustment for subsequent fecal immunochemical tests. Presumably, multivariate regression with larger population-based studies or meta-analyses might be valuable to improve the robustness of the finding. Last, the proximal serrated polyp detection rate (PSPDR) also was associated strongly with PCCRC in a recent study.6van Toledo D. et al.Lancet Gastroenterol Hepatol. 2022; 7: 747-754Abstract Full Text Full Text PDF PubMed Google Scholar In the high ADR group, there was a markedly increased risk of PCCRC in the lower PSPDR compared with the higher PSPDR, indicating that PSPDR may be considered as an additional quality indicator alongside the ADR. The validation and implementation of PSPDR as a new quality indicator might further improve the quality of colonoscopies.