Hello, and welcome to the September 2022 edition of the GI QUIC Quick Bytes webinar series. My name is Laurie Parker, and I am the Executive Director of the GI Quality Improvement Consortium, or in short, GI QUIC. GI QUIC holds monthly webinars which historically have been geared towards those participating in the GI QUIC registry. We focus on specific pertinent topics associated with the registry. We allow ample time for questions and answers, and we post the webinars for future viewing on our participant registry website. This month, however, we are conducting this broader webinar inviting GI QUIC participants and also ACG and ASGE members to hear from leading experts with respect to colorectal cancer screening guidelines and recommendations. This webinar will be recorded and posted on the GI QUIC public-facing website, as well as available via ACG and ASGE virtual learning platforms. Let's focus on the agenda, and it will be as follows. First of all, I will give a brief overview of what GI QUIC is and why it was established. Our experts will then present and discuss three different patient cases, and then we will have time for questions and answers. For questions, they can be submitted online anytime during the webinar by using the question box on the right-hand side of your screen. If you do not see the question box, please click the white arrow in the orange box located on the right side of your screen. Now let's get into a little bit more of the details about GI QUIC and the registry. So what is GI QUIC? GI QUIC is a clinical data registry, which means the registry collects, organizes, and displays healthcare information. The registry launched in 2010 and is a joint collaboration of the American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy. The impetus to create GI QUIC stemmed from the endoscopy quality indicators, which were initially published in 2006. These quality indicators were deemed to be both feasible to measure and they were associated with improved patient outcomes. Therefore, the foresight of the ACG and ASGE physician leaders was to create a reliable, consistent way for providers to capture healthcare information, giving them the ability to analyze and benchmark performance at a provider level and also at a group or endoscopy center level and compare their data to the established performance targets and also to the national cohort, or in other words, all of those participating in the registry, in order to make quality improvements and to raise the level of healthcare provided to patients. So when we look more at the why of GI QUIC, so why was GI QUIC established, and to reiterate what I just said, the GI QUIC registry provides the ability to analyze and benchmark performance for both the provider at the provider level and at the group or the endoscopy unit level and compare it to the established performance targets and the national registry's study data in order to make quality improvements and raise the level of healthcare provided and ultimately to improve patient outcomes. Another why of GI QUIC is research. GI QUIC, as you can imagine, over 12 plus years has established a robust data set, which proves to be an invaluable resource for digestive disease research. And then thirdly on this slide, GI QUIC is an approved registry deemed by CMS a qualified clinical data registry to submit quality performance data to the CMS program called MIPS, or the Merit-Based Incentive Payment System. Before we introduce our physician experts for case discussion, you will see on this slide a sampling of the quality measures included in the registry. Colonoscopy and EGD measures are reported on currently with an expansion into ERCP procedures, endoscopic bariatric therapy procedures, as well as quality measures related to the management of patients with inflammatory bowel disease coming soon. The highlighted measure on this slide, Adherence to Colorectal Cancer Screening and Surveillance Recommendations, serves as the focus of the content of this webinar. From the GI QUIC registry, participants are able to generate reports on each quality measure indicating their performance on the specific measure. We'll show an example of that report within the next couple of slides. Each quality measure focuses on the most up-to-date evidence. And given that there have been recent updates in the area of colorectal cancer screening, we are thrilled tonight to have three leading experts in this field to present and discuss patient cases, therefore applying these recommendations and guidelines to day-to-day practice. And this slide just focuses on the recent and the last couple of years' updates that have been made in the area of colorectal cancer screening. And this chart shows the follow-up interval guidelines or recommendations based on the pathology or pathology results that are found in the screening colonoscopy. GI QUIC actually follows the guidance reflected on this chart and includes a quality measure that's related to each finding. So for example, there's a GI QUIC measure that is measuring the follow-up interval recommended in a normal or otherwise average risk screen. So on the left side of your screen, the 10-year follow-up, there is a 10-year follow-up measure. There's also a follow-up measure with respect to low-risk adenoma findings, a follow-up interval measure related to a patient with an advanced adenoma, and so on in accordance with the recommendations. And this last slide, before I turn it over to the panelists, is just a sample chart of the GI QUIC registry performance on the measure of the average risk for normal colonoscopy. This is sample data. This is test data from the registry. The chart at the top shows the test physician names, and it shows their denominator and numerator for this measure. And then the graph below shows the performance of this measure in a bar chart. So this is exactly what the physician or the endoscopy unit would see when generating this measure report from the registry. This report is also showing a comparison line in the black for the entire registry or the study average. So let's turn it over. I will just take a minute to introduce our three leading experts this evening, and then I will turn it over to present and discuss the cases, and then questions will be addressed at the end. So tonight, we are thrilled to introduce Dr. Asma Shaukat, who is professor of medicine at New York University, a professor in the Department of Population Health, co-director of translational research education and careers, and director of outcomes research in the Division of Gastroenterology and Hepatology. We also have Dr. Carol Burke, who is the director of the Center for Colon, Polyps, and Cancer at the Cleveland Clinic in Cleveland, Ohio, and Dr. Audrey Calderwood, who is the director of the Comprehensive Gastroenterology Center and associate professor of medicine at Dartmouth. Dr. Shaukat, I turn the presentation over to you. Thank you so much, Laurie, for that kind introduction. Hello, and thank you so much for joining us. We're very excited to be here, and we're going to make this a very interactive discussion, so we'll be presenting three cases, give you some starting points, and then open it up to discussions. So please start thinking and queuing up your questions, and hopefully you'll have more as we go through some of our cases. These are meant to be very practical cases, all three of us. Our clinicians, first and foremost, spend a lot of time with patients, and then we spend some time kind of thinking about some of these questions. So I'm very excited to be joined by Carol and Audrey. So Audrey, I'll turn it over to you. Great. Thank you, Asma, and thank you to the GI Creek team, ACG, and ASGE. I'll start us off by asking Asma a case. So this is a 45-year-old white man who sees his PCP for his annual visit. His PCP orders a FIT, or fecal immunochemical test, that the patient completes, and the FIT turns positive, and he's referred to you now for further management. So Asma, can you guide us through how you think about this case and what you might do? Yes, thank you so much, Audrey. So this is a pretty common scenario. We see this pretty much in our clinics. And the first thing to think about is this patient's age. And that brings us to the most updated clinical guidelines. These are updated ACG clinical guidelines released in 2021. And many on the panel are authors on this guideline. And as many in the audience might know, the screening age for average risk men and women in the U.S. has now been dropped to age 45. So starting screening at age 45 is the new recommendation. And in terms of screening modalities, either screening colonoscopy or stool-based tests such as fecal immunochemical testing are primary screening modalities with lots of evidence behind them. And then in the fall of 2021, the U.S. Preventive Services Task Force also updated its recommendations to initiate screening for average risk men and women starting at age 45, giving it a grade B evidence suggesting that there's at least moderate certainty that there's a moderate net benefit to starting at that age. And they give a more expanded menu of screening options, which are listed on this slide. But the important thing is that anything the U.S. Preventive Services Task Force gives a grade A or B recommendation is generally covered by Medicare and generally most other payers follow. So this is rapidly covered by all insurers, which is great news for our patients and our endoscopy units. And I want us to think about how we can strategize to bring these patients to our practices and make sure that we're starting to develop strategies to screen them. And the U.S. Multisociety Task Force that many of us are members of also lowered the screening age to start at 45. They also recommend either a colonoscopy or FIT as Tier 1 screening test. And then if those tests are not available or acceptable, a test from Tier 2 can be selected. So now there's actually congruence in all the guidelines coming together to initiate screening at age 45. How well does screening work? Well, screening works very well, particularly when it's based on an organized outreach screening program such as FIT and colonoscopy. These are data from Kaiser Permanente in Northern California, where over a 15-year period, they've put together an organized screening program that is based on patient reminders and then navigation and follow-up of abnormal FITs or triage to colonoscopy. You can see the adherence to colon cancer screening over this 15-year period went up by 44%. And at the same time, there were decreases in colorectal cancer incidence as well as mortality, suggesting that improving screening reduces cancer incidence and mortality. It's a pretty compelling data that we should be thinking about organized approaches to boost screening adherence. Now I'll turn the case and ask you, Audrey, for this next one. Or actually, I might ask Carol this question. So, Carol. Asma, before we go on, I think Carol wanted to ask you something. Yeah. Go ahead, Carol. Thanks, Asma. So, there was some angst about 45-year-olds getting insurance coverage for screening, especially screening colonoscopy, you know, at a young age. We don't have a lot of Medicare patients that are 45 years old. So, I have not had any denials in my practice, but I was wondering, have you seen any insurance denials for colonoscopy in an asymptomatic individual who's 45 years old? Great question. So, as we know that, you know, once these guidelines come out, it takes all payers a little bit of time to deliberate and go over those decisions. So there was a period of gray zone. It might still be persisting. However, very quickly, it should be universally applied and covered, because this will become as part of the denominator for our reporting metrics. So coverage is pretty essential. Personally, I have not had that issue, but I see a lot of patients that also have Medicaid. Medicaid does do what Medicare follows, and even with commercial payers, I have not had a pushback on 45, but again, something we can bring up in the discussion. Thank you, Asma. And then one more question that I get asked a lot is, what is the time period between when a patient has a positive fit, is seen by a gastroenterologist, and the diagnostic colonoscopy should be done? Are there any metrics that should guide us, and could you just speak a little bit about that delay between positive fit and colonoscopy performance? Yeah, so that's a very important aspect of screening with anything other than colonoscopy. There really need to be strong processes of when that initial test is abnormal or positive, that those individuals have diagnostic colonoscopy completed, and completed in a timely manner. And that goes for fit, cologuards, colon capsules, CT colonography. Now with the fit specifically, that time period has been studied, and varies a little bit. The ideal recommendation would be, again, as soon as possible, understanding that that may not always be possible, but 60 days is what we consider in our healthcare system. The literature suggests up to six months might be okay. Anything above that, then we risk that late stage cancer diagnosis instead of early stage. So trying to get them in, again, the message should be as quickly as possible as your system allows. 60 days is ideal, but up to six months might be okay. And hopefully as we catch up after the pandemic backlog, we are able to bring individuals fairly quickly for diagnostic colonoscopy. Great, thank you so much, Asma. Yeah, thank you, Carol. So Carol, we'll turn the case to somebody with a family history. So a 40-year-old female is seen in clinic for dyspepsia. And she asks about colon cancer screening. And when I asked her about her family history, she reports that her mother had uterine cancer at age 40. So can you walk us through this case, and just in general, how to approach family history? Oh, sure. So based purely on the information that we're provided with, and oftentimes, you know, when a patient's either in the office or in a DOSP, we just ask about, do you have a family history of colorectal cancer? But so the current information, the patient is at average risk of colorectal cancer and should begin colorectal cancer screening at the age of 45. But as you had taken the family history and got that compelling uterine cancer at a young age, at the age of 40, any individual with young-onset cancer should raise the suspicion of a hereditary colorectal cancer syndrome. So it's important to obtain a family history from our patients. It seems onerous, but, you know, usually it takes about one minute. And you want to ascertain three generations, first-degree relatives, second-degree relatives, the age of any cancers that occurred in family members, you know, what those cancers were, and the age of death. Because if you have a patient who said, you know, my father was killed in a car accident at the age of 47, and my mother died at 53 of, you know, ASHD, heart disease, then you may not have the full family history. So you want to ascertain the age of death to make sure that you have an informative family history. And certainly, you want to think about the features of hereditary colorectal cancers, and we'll talk about, in particular, Lynch syndrome. The other thing is we need to think outside the colon. So did someone have extra-intestinal tumors? So in FAP, did they have osteomas, sebaceous cysts, are there brain tumors in a family? If people have had benign or malignant tumors removed, what is the pathology of those? Is there an unusual number or size of polyps? And then we talked a little bit about the extra-intestinal features, which could be, you know, outside of cancers, it could be, you know, things on the skin or other extra-intestinal features. It's important to recognize that Lynch syndrome is a cause of both endometrial and colorectal cancer to the tune of 3% to 5% of those cancers are caused by Lynch syndrome. So uterine cancer is a really important tip-off. So the entry points for hereditary cancer in our clinic could be at the time of the office visit, like this patient with asthma, or at the time of colonoscopy, since we have open-access colonoscopy. Increasingly, we are seeing patients referred to our practices or our practitioners, especially with some of the initiatives of the American College of Gastroenterology, practices are coupling with GastroGirl and having a commercial lab work with their patients to fill out a family history. And then those individuals that meet the National Comprehensive Cancer Network criteria for hereditary syndrome are being highlighted to the practice. And then the patient comes to your office and says, hey, guess what, doc? You know, I had my genetic testing and it's positive. So increasingly, gastroenterologists are getting positive results on multi-gene panel testing. So it's important to think about this family history and the multi-gene panel testing that you will be confronted with and have to know how to manage. But in our busy practice, how do we quickly screen someone for hereditary cancer? And I love this. Faye Castrinos had published this more than, you know, roughly 15 years ago for someone in the office for the practice. And quite simply, it's three questions. Do you have a first-degree relative with either colorectal cancer or some of the prominent cancers in Lynch syndrome, and in particular, uterine, ovarian, gastric, small bowel, ureothelial, bile duct pancreas or brain? Have you had any of the following diagnosed before the age of 50? Colorectal cancer or colorectal polyps? And do you have three or more relatives with a history of colorectal cancer? When the answer is yes to these questions, it identified 77% of the high-risk individuals and 95% of patients that were Lynch syndrome pathogenic variant carriers. So a quick, easy screen that you can incorporate either into your office practice or even in the endoscopy suite. The next steps for this patient is I would tell her, above and beyond, that she's at average risk for colorectal cancer screening unless there is something genetic going on in the family. So the most informative person would be her mother who should be evaluated for Lynch syndrome either by having mom having her tumor tested for evidence of mismatch repair deficiency or she can go on to multi-gene panel testing. And if mom has the multi-gene panel testing, there's no hereditary syndrome. Our patient is at average risk of colorectal cancer and, as said before, screened for the average risk population beginning at the age of 45. If, let's say, mom died of early-onset cancer, she's not tested, then we can encourage our patient to see a genetic counselor and consider multi-gene panel testing. And if there is a hereditary cause of cancer detected, then the patient gets managed according to the test results. And I think that kind of summarizes how I think about a case where there is an early-onset of a cancer that could be within the Lynch syndrome spectrum. And I'd like to ask Audrey, a 78-year-old is seen in clinic and asks about his next colonoscopy. Looking up his records, you see his last colonoscopy was five years ago and the patient had one small non-advanced tubular adenoma in the ascending colon. So what is the discussion points that you'd like to have with this patient? Thank you, Carol. I think this is a great case and it's nice that this is in an office-based setting where a discussion is allowed. I think all of us, including probably many audience members, can relate to the same scenario, but the patient has already come back, let's say, and is right there at their surveillance. So we have a 78-year-old person with a history of one small adenoma five years ago. And for the purposes of this discussion, we don't really know any sort of past history of polyps, but we do assume that he hasn't had colon cancer. So for me, I think there's two important issues to sort out. The first is, when would his colonoscopy next be due per current recommendations purely based on polyp history and not accounting for his age? And then the second one is, would a colonoscopy at that time be appropriate for this 78-year-old man now, whatever age he will be down the road? And to get at this issue, I think we really have to answer the question of, would the benefit outweigh the harms at that time? So when would his colonoscopy next be recommended just based on his polyp history? Lori and Teresa showed this slide nicely at the beginning, but based on the 2020 US Multisociety Task Force Post-Polypectomy Guidelines, we want to check out a few things. One is that we'd like to know the quality of that colonoscopy, right? Is it high quality, meaning complete to the cecum with adequate bowel prep and withdrawal time for inspection? Assuming all those are true and this was a high quality colonoscopy, then we can follow down these arrows. And right now we're looking at that light green box, and you can see that he had one small adenoma, small being less than 10 millimeters. And so he would be due next in seven to 10 years from that colonoscopy, which was five years ago. So that would in effect be in two to five years from today, which is the office visit. So at that point, if he's 78 now, he'd be 80 to 83. So understanding that, our question then is, you know, is colonoscopy appropriate for this in the future, 80 to 83 year old man, recognizing that, right, we can't predict the future. We don't know necessarily what his health will be like, but we can make some decisions based on how he is today. And so if we go back to the U.S. Multisociety Task Force guidelines from 2012, which is when they last addressed this issue, I summarize here, but it says for patients age 75 to 85, so appropriate for our patient, the task Force argues for individualization based on comorbidities and findings of any prior colonoscopy. The decision to continue surveillance should be individualized based on an assessment of benefit, risk, and comorbidities. We can think about these benefits and harms in the context of this person. So does benefit outweigh harms? Well, I think we have to think about what is the benefit of another surveillance in the future for this older man with a small adenoma? We know increasingly that there's a very low risk of colorectal cancer in someone with a history of low risk findings including one to two small adenomas. And that risk is actually similar to the risk of colon cancer in the general population and also in people who had colonoscopy and were found to have no polyps. So this slide here nicely shows in the dark sort of green at the top, if you look at that, that's the cumulative risk of cancer over time on the x-axis up to 15 years. And so in that dark green is people with a history of advanced adenoma. And you'll see that's higher and nicely separated from those who've had no adenomas in orange, but also those turquoise who've had only a non-advanced adenoma. And those orange and turquoise lines are fairly similar and overlapping. And that goes all the way out to 15 years. So in terms of benefit of ongoing colonoscopy, it may be pretty negligible in someone who's already going to be 83 and has had one small adenoma. In asking does benefit outweigh harms, we have to understand harms. So this slide is specific to this age group, so people 65, 70, and older. And it summarizes the risk of harms from colonoscopy with sedation. And the total risk, while small, is still 28 out of 1,000. And that is made up of cardiopulmonary bleeding, significant bleeding, and then one in 1,000 of perforation, and even one in 1,000 of death. And so these are not negligible, especially if we consider these potential harms in the context of very low benefit. So we think maybe harms will outweigh benefits based on the patient's pulp history. We don't know much about his comorbidities, his function, and all of that together synthesized to his life expectancy. Another important thing is if we think harms are balanced out by benefit, or benefits maybe do somewhat exceed harms, it really is important to elicit patient preferences on what matters most to them. In this case, in my opinion, I love to get the groups too, I do think harms likely outweigh the potential low benefit. So here I would advise against any planned routine surveillance in two to five years. But certainly if he had symptoms or something new or different, then we could reconsider a diagnostic colonoscopy at that time. I would agree, Audrey. I have to say that it's very disappointing when an elderly person shows up for a colonoscopy who is 83 years old and has AFib and been on Eliquis, and their primary care doctor just scheduled the exam because most patients after they drink their prep don't say, okay, fine, I'll go home. And we have to worry beyond the harms that you lay out here, but arrhythmias, renal insufficiency, electrolyte shifts, and the major complications that you cite here I think are not as common as some of the covert ones that we notice. It is hard to get patients once they're in a screening colonoscopy mode to feel comfortable not getting out of it. So I have a question now that the guidelines have changed is, maybe he was recalled at five years and now the guidance suggests seven to 10 years. And if you've had a negative exam, you're probably very well protected. But for this guy or patients in the practice that are being recalled at five years, how do you handle that discussion for changing their recall seven to 10 years? Yeah, that's a great question, Carol. It's especially difficult because it's hard to convey changes in medical literature and summarize the way the guidelines work and then do that in a way that patients can understand regardless of educational attainment. So for me and my sort of anecdotal experience, most patients I'm able to explain this to are relieved. And I try to do it when I'm not in the clinic at the time I'm consenting them for colonoscopy, especially in folks where I see they've come every five years for a history of a small polyp at some remote time. And I may not always have access to those past reports, but I'll counsel them before the current colonoscopy I'm about to do and say, you know, actually, we have a lot of new evidence that shows that these small polyps aren't as harmful as we once thought. And so in all likelihood, if you have those same small polyps this time, or no polyps, or even, you know, two of them, we're likely going to be able to see if we let you go for 10 years. And when I put it that way, I would say 95% of patients are like, oh, that's great. Wonderful. I haven't yet received pushback on that, but I do understand and have patients in my clinic where they have a remote family history, you know, a second degree relative at age 80, let's say, and they are stuck on that five years. And, you know, I do sort of compromise and let them do it because it offers so much peace of mind for them. So I probably would do the same in those scenarios since the guidelines just changed, but I'd love to hear what Asma does and, you know, others in the audience, if you want to put it in the chat. Yeah, thank you, Audrey. So I agree with you. I follow the same principles that you outlined. And what would be ideal would be to have a calculator or something that helps us weigh all these factors. I know there's some movement towards them, but at the moment, truly our clinical gestalt is probably the best. And, you know, we'll never have no small adenoma left behind situation. So we should definitely focus on the overall picture rather than, you know, be under pressure to do a procedure that's unlikely to benefit the patient. I was wondering if either of you have experience with any calculators for either risk of subsequent neoplasia or life expectancy ones that you found helpful or used in practice? There is a web-based tool called ColoSmart. Have you or Audrey utilized that? Yeah, I recently came across it, but haven't had a chance to use it much. Okay, it's quite simple. And basically what it does is help decide, and this is purely for screening, if screening colonoscopy is cost effective or not for a given elderly person. So it takes into consideration comorbidities, gender, age, and then what it presents to you, the outcome is cost effectiveness. So I just put in this patient's age at 78. I said he had moderate comorbidities. He's a male. And they don't have it for surveillance, which would be really helpful, but it's for screening. And it showed that the cost effectiveness or the quality was $196,000. So not cost effective for that particular patient. So ColoSmart is the name of that web-based app. Good to know. Thank you. Learned something. There is a great web-based calculator called e-prognosis. Many of you might've heard of it or used it on a UCSF group. And it has it for screening, again, not for surveillance, which is really a deficiency, I think, in our field that that doesn't exist yet. But there's one specific for colorectal cancer screening that input similar things to what Carol said, but then also family history, some lifestyle habits, a little bit, I think, BMI, smoking, exercise. And then it categorizes people into different low, average, high risk. Then it'll tell you if the benefit outweigh harms for that patient. Great. Thank you. So with that, we'll hand it over back to Laurie and see what questions the audience have for us. Thank you very much for those very practical discussions of what are likely common scenarios faced in day-to-day practice. Before we turn to the question and answer session, we do have a few upcoming events to highlight. The first is the ASGE improving safety and quality in your endoscopy unit. This virtual course takes place this Saturday, October 1st, and there is still time to register at ASGE's website via the education and event calendar. At this course, expert faculty will examine topics from the fundamentals to the latest trends and evidence in enhancing the delivery of safe, effective, efficient, and patient-centered care. The course is suited for all members of an endoscopy unit team. Then at the ACG annual meeting later in October, taking place in Charlotte, North Carolina, GI Quick will hold a lunch presentation session, taking place on Monday, October 24th at 1 o'clock. You will hear from GI Quick physician leadership about the current and future state of the registry and how to put the registry to use in your own practice. You can visit acgmeetings.gi.org to register for this lunch session. Also at the ACG annual meeting, GI Quick will have a booth in the exhibit hall, so please plan to visit us there where we can answer any questions you have in person and also take a few minutes to give you a live demonstration of the registry. Now we will move to the question and answer period, so Edem, I pass it over to you. Thanks, Lori. What a fabulous presentation. Thank you to our presenters. First, we're going to start with a scenario. One of your colleagues, Dr. Brodsky, submits this scenario for your consideration. You have an 82-year-old female who had a colonoscopy one and a half years ago. Boston Palliprex score was a 9, mild diverticulosis, and grade 2 internal hemorrhoids. The patient sees a new primary care provider who orders a fit, and that fit was positive. The hemoglobin is 15, no iron deficiency, no family history. So the question is, would you, one, repeat the colonoscopy at this time, or two, would you defer colonoscopy given the normal results 18 months ago? And a clarification was added. I guess there was the patient requested a colonoscopy at age 82, and the previous colonoscopy was at age 72. I guess those are the screens, and maybe there was one in between. The patient's in excellent health and on no medications. So under this scenario, the patient is 82, positive fit. Would we repeat a colonoscopy, or would we defer? Thoughts from the roundtable. She's had a high-quality colonoscopy that was essentially normal for any pathology. So really, I would ignore the fit. Fit should not be done for these screening surveillance purposes at all after colonoscopy until that patient's next interval would be due. So if she hasn't had polyps and she's 82, she probably doesn't need any more screening. There's a lot of benign causes of GI blood loss that fit might be picking up, for example, her hemorrhoids, probably less likely her diverticula if there's no overt bleeding, but certainly I would not act on that. But I welcome Asma and Carol to weigh in. I was going to say strategically, the 18 months is very much a gray area. I would totally agree with Audrey if it's one year since the colonoscopy. At two years, we generally would repeat the colonoscopy, again, discouraging interval fit and discouraging use of anything but a colonoscopy at the recommended interval. So 18 months is right about that gray spot where it could go either way. Go ahead, Carol. Yeah, thanks. I was going to say that Audrey is practicing in a scientific realm and not with a medical legal hat being worn. So that's the concern is people, physicians want to protect themselves and, of course, protect the patient as well. But there are data, especially from the Europeans, that looked at a normal colonoscopy and then a positive fit in the yield for colorectal cancer. And it's quite low out to one year, 18 months. It's 99% chance or 97% chance that there wasn't anything of any concern for the patient. And I think the more compelling thing Dr. Brodsky had brought out, and Eden, I think you said that the patient had two prior colonoscopies that had been negative. So really, individuals that make it to the age of 76 that have had one, let alone two, normal previous examinations are a much lower risk for colorectal cancer than individuals even with no adenomas. So likely this person is not going to have anything, but Asma is right. Most guidance would suggest the further you are from that last colonoscopy. And the only high quality colonoscopy is the one that you do yourself for your patients would be a time to consider intervening. But again, as Audrey had mentioned before, you need to discuss the evidence as well as the patient's preferences and go from there to make a decision together. Thank you. So we got two questions in from your colleagues. They're very similar. I'm going to read them both because they take a little bit of a different angle. So the first is, would you consider FIT or Cologuard screening for adults with history of one to two small tubular adenomas? And then a similar question came in. Is there emerging data in the use of school-based testing in average risk, so no family history of CRC in the patients with low risk adenomas? So they gave us an example of one to two patients, tubular adenomas as well. So what are your thoughts on that? Let's start with Dr. Shakhat. Yeah, so sorry, cut out for just a second. One to two small tubular adenomas? Yes. Would you consider FIT or Cologuard screening for adults with a history of one to two small tubular adenomas? So anybody with one to two small tubular adenomas, like the data, some of the data that Audrey went over and was reviewed in the follow-up polypectomy guidelines are generally low risk individuals, meaning their risk of having subsequent neoplasia, colon cancer, or dying from colon cancer is very low and comparable to individuals without any findings on a colonoscopy. However, because there's still a small group in there that is at risk and we don't have direct stronger evidence, the only recommended test for follow-up is still colonoscopy in the US, whereas in Europe, and they updated the guidelines recently, they would actually go to a FIT. But in the US, the only recommended modality for follow-up is a colonoscopy and it should be done in seven to 10 years. Another point to make is that Cologuard is not FDA approved for anyone but average risk colorectal cancer screening individuals. And individuals with one to two small tubular adenomas are really, their risk is low, but they're not an average risk population. So Cologuard is not FDA approved for that population. In addition to Europe, in Ontario, their cancer care guidelines for anyone of screening age who's found to have one to two small adenomas, they go to FIT after five years from that colonoscopy that detected the adenomas. So they're already incorporating that for surveillance purposes, which we don't have any guidance to do in the US right now. Yeah, it's a great question. And I think more data will accumulate and things might evolve. But at the moment, colonoscopy is the only follow-up recommended test in seven to 10 years. To get to the questioner's point is, these mixed strategies are something that hasn't been studied well in the United States, but in Europe, in Canada and other places. And I think there is a role for FIT. FIT is an excellent test to pick up colorectal cancer, not so good for advanced neoplasia. But with COVID, there's been a lot of organizations that didn't have the bandwidth to perform colonoscopy. And even in some symptomatic patients, they were triaging those with positive FIT that didn't have evidence of unanticipated weight loss, rectal bleeding, any of the high risk signs to a FIT. So I think that there are emerging data, especially with COVID and its utility for individuals that may have had a previous colonoscopy and who would benefit from FIT. So I think, keep your eyes out. I think FIT and these mixed strategies are going to be something that we're going to see more and more of. And it will come into the United States as we look at costs and cost effectiveness. And my team that also includes ASMA, we're about to launch a trial starting this spring, 2023, randomizing 9,000 older adults, 70 and older, who have small polyps recently to either annual FIT or their surveillance colonoscopy. So it'll take some time to create data, but hopefully we'll be able to at least answer some of the questions and provide evidence for that, including like patient preferences and patient reported outcomes in five to six years. Okay, here's an interesting question. When indication for colonoscopy is FIT, do you consider it a screening for colorectal cancer or diagnostic? Yeah, great question. So strictly speaking, they were considered diagnostic, but we know it's part of the screening cascade. And for years and years, as efforts of ASGE, ACG, and many, many, many members, we've argued successfully that it should be considered as part of the screening cascade, such that the patient should not be penalized for that being a diagnostic test, because it was prompted by an initial screening test. As we know, these first tier tests like FIT or Cologuard, they don't protect patients just by virtue of getting the test done, but it's the patients that have a positive test that undergo colonoscopy. So in that context, it's considered part of the screening cascade. And as many in the audience might know, the recent legislature has now allowed that or closed that loophole such that it is considered on the spectrum of screening. So how, in terms of indication, I think it would be better to just indicate or create a field that this was either FIT or Cologuard positive, or in the future, as we have more tests available, but it was as part of the screening cascade. That's a great question, Asma, and a great answer also, because it keeps us up to date on what's happening with the legislature. But interesting at the Cleveland Clinic, we were advised, you know, I don't do coding and billing myself. I just document in my endoscopy report writing system what I've done. And we were instructed that individuals that are in for a positive FIT or a positive Cologuard are screening colonoscopies. So at the Cleveland Clinic, and maybe it's the insurance providers that we have, are looking at it as a screening test, not as a diagnostic test. Same here at Dartmouth. And I think the legislature changed on this recently, as I think October, November, where that will be the case, that it will all be considered screening. But I think it took some time to get there. Yeah, absolutely. So we put it under screening, but we have its own indication, which is FIT or Cologuard positive, just to separate it out from purely screening ones, so that they're not part of the denominator, say for ADR or other quality indicator calculations. And I'll just add in that the GI societies have reached out to CMS for guidance for coding for Medicare patients for these cases. So once we have that guidance, and again, if anything changes in how you document, so that cases enter correctly into GI-QUIC for those GI-QUIC users online, we do want to make sure your ADR is calculated correctly. And as Dr. Shaka pointed out, these cases would not be in the denominator. So we will keep you informed on that. That's a great question. Dr. Calderwood, I'll start with you on this one. Any fast track ideas to get patients to colonoscopy for FIT or Cologuard positive, or do all patients need to go to the clinic first, as this can cause delays in getting patients to colonoscopy? Yeah, great question, because we've already highlighted how important it is to try to get patients with positive tests as soon as possible, at least within six months, because the risk of later stage cancer goes up by about eight or nine months. So we want to get them ahead of that. So in my practice, we have those patients come for direct access. We don't have a clinic visit. In fairness, most of our cases come as direct access. We just don't have the bandwidth or staff to see everyone who needs a procedure in the office first. I know there are some models where maybe like an APP might be able to see them, but we don't have that capacity here. So those patients do take priority above regular surveillance or average risk screening. So we do try to prioritize them by directly booking. That's the same as in Cleveland. And we kind of, the COVID forced us to set up a triage system of who really needs to be done and who can be delayed. And those individuals, as they do at Dartmouth, are triaged too. Usually we can get them in within 30 days. And this will probably be our last question. Then let's start with Dr. Burke. When an open access patient states had prior polyp with another GI and is asking me to do the five-year exam, I ask for records and try to confirm histology, complete exam, good prep, et cetera. If guidelines suggest they don't need a follow-up exam, do you feel comfortable telling this to a patient you have never seen? Would you make them come to the office to discuss this? Thoughts, Dr. Burke? Yeah. So I guess I got a little bit confused of whether I'm meeting this patient for the first time in the endoscopy suite when they said, oh, I've had polyps in the past. It's an open access patient. Oh, yeah. So they're already prepped and they're at the endoscopy suite. So I'll go ahead and perform the examination. I will get the outside records. And if the individual had a normal exam with me and in a hyperplastic polyp in the past, I would say, listen, you don't need anything for 10 years. So I know a lot of providers said, well, getting records is a hassle. And I guess I'm lucky enough to work with a team because I do a lot of hereditary cancer work. But I would say 99% of the time, I can get the patient that's in front of mine records, as well as oftentimes, they can get their family's medical records. So I don't let not having information at the time dissuade me from doing a colonoscopy. But then I would get the outside records. And I do tell a patient that I've never met before, once I get the records is, hey, you're done or you have a 10-year interval. I hope I got the essence of the question. Okay. We are at the top of the hour. So I'm going to send it back to GI Quick Executive Director, Lori Parker. We appreciate greatly the time that the attendees of this webinar have given, the great questions that were asked. Thank you to our panelists for the presentation of the cases and the question and answer discussion. We hope that everyone has found this webinar informative and applicable to everyday practice. Please do take a few minutes and answer the questions when you exit the webinar. We do value your feedback. And also, please do not hesitate to contact us at GI Quick with any questions or to obtain more information about participation in this Quality Improvement Registry. Have a good evening.

colorectal cancer screening

guidelines

webinar

ACG

ASGE

patient cases

FIT results

family history

follow-up test