Thank you, Raj. That was really excellent. And I think we're off to a really great start. I think now we want to basically have an opportunity to hear from and have meaningful discussions with our audience, and so I think we can kick off the first roundtable, which is intended to be 20 minutes, and there's a handful of questions that have been submitted. So, Eden, why don't you kick us off? Thank you, Dr. Elmanzer. So our first question is, ADRs are lower when colonoscopy is performed by or with fellows. Should we alter surveillance intervals? And I guess what I'll say about that, though, is before discussing the intervals, do we know that's true, T.R. and Raj? I don't think that's universally true. I think it really depends on the quality of the supervising attending in the room. Raj may be familiar with the actual data on this, but my general impression is that I don't think it has to be lower, just how well-supervised people are. Yeah, we put together some work the last couple of years that we're writing up now, which shows that the polyp misrate for fellows when they're independently looking at the colon obviously is higher in the first and second year and lower in the third year. But as T.R. says, a lot of it has to do with the supervision, right? So a lot of the reasons fellows are missing polyps is they actually don't even know that a serrated polyp looks like. So if you're not, as a supervising faculty, teaching them what to see, yes, it's 100% going to be lower, but that's on us. We need to be ensuring that the patient who gets a colonoscopy with a trainee is getting as good a quality exam. For me with junior trainees, I'll let them do a right colon withdrawal, and then I'll do a second one myself. Or I let them focus on insertion and polypectomy, but not on the polyp detection when they're scoping when they're still a junior. So I think it's really on the trainer. Great. Eden, do you want to keep going? Sure, yeah. Let's get a few in, and then we'll just cut our break short today so that we'll keep on our same schedule if that's all right with everybody. So the next question is, would you consider FIT or Cologuard screening for adults with history of one to two small tubular adenomas? Do you guys want me to take that one? Absolutely. Yeah, so it is true that there are no guidelines that would recommend doing FIT for that patient. They are kind of a low risk group. There's a couple of examples I would give. One is if you happen to live in Ontario, Canada, if you're in that province, that is actually standard of care based on the availability of the evidence. And I would say that we're just commencing a randomized trial with Audrey Calderwood at Dartmouth to look particularly at that population. There's not really a tremendous amount of data. It seems to be kind of a logical decision to make, but you'd be kind of outside of guidelines. That's the main problem, is if there's an interval cancer in that setting, it might be hard to defend just based on the available evidence. But I think rationally, it makes a lot of sense based on the low risk nature of those one to two small adenomas. And our next question will direct to Dr. Keshwani. In your opening, you talked about pulling together a team to address quality improvement. How would you scale that for somebody who's in an ASC, who doesn't have quite the resources of a larger institution? Yeah, a larger institution can be helpful. It can also be a hindrance, right? There's less red tape in an ASC. You say you want to have a larger institution. You say you want to do something, and you have a leadership that says it's the priority, it'll happen. But the IT resources are certainly not available in ASCs like they are in large institutions. I think that's where finding an EHR solution or a registry is really critical. But a lot of these important work is done at ASCs where they basically make a commitment to quality improvement, right? They make a commitment. They have leadership that says this is what they're going to do. And they come to this course. They do the EURP. And so I don't think it's something that's impossible to do. But what most people would do is appoint someone in that ASC as the QI leader, as a physician leader, and then partner with the nurse, who's often the operational leader there as well. And I don't know if, TR, this is obviously a very important area for you too with your system. Do you have a different opinion on it? No, I think you hit it on the head in terms of the red tape and how you position it and getting buy-in by all the relevant stakeholders. In a smaller group, it's a little easier. And I think that endoscopy software is making it easier to do it. Certainly, some of the report generators that can integrate the pathology results. I have one colleague who works out of an ASC, and they basically tell their consulting pathologists that they have to put the data into their endoscopy tracking system in order for them to continue working with them. So they've got an agreement from their pathologist to put the histology information into their endoscopy reporting system. So you can work out those kinds of things. And certainly, a lot of fee-for-service practices have worked out special deals or improved reimbursement, I'd say, from different insurance companies when they can demonstrate that they're delivering high quality. They're adhering to surveillance intervals more accurately or have higher adenoma detection rate. You can use that as a bargaining chip in your negotiations with payers. So I think it can pay off. Some groups have been very successful with that. Wonderful. We might need a whole course on how that person got the pathologist to agree to enter their data. We have another question here from Dr. Cosgrove. How do you recommend handling serrated polyps with ADR calculations or ADR calculation? It seems that the official recommendation is to include adenomas only. And then she has in parens with the developing serrated polyp detection rate. But I have heard other centers including serrated polyps in their ADR calculations, which may artificially increase their ADR. For centers that calculate ADR without including serrated polyps, are we placing ourselves at a disadvantage regarding national benchmark if we limit ourselves by calculating ADR based on adenomas only? You want to start with us, Dr. Levin? Yeah. So I would say it's okay to lump them together, but I would expect that your benchmark would not be 25% according to the older guidelines. So be mindful of what is going into your measurement and what benchmark you're choosing. It's certainly easier. Definitely a lot of the endoscopists who are good, CESL serrated lesion detectors tend to be higher ADR adenoma detectors as well. So you can either try and report them separately or lump them. But if you're lumping them, definitely would expect you to be well north of 25% in terms of what your targets are. That would be kind of where I would land. Just I'll make a couple of comments. First, hi, Natalie. Second is it's a great question. And I think that the reason it can become a bit difficult is some places call things like serrated adenomas when they're not really serrated adenomas or CESL serrated polyps. And so that artificially inflates their adenoma detection rate. What we do is we have an ADR, an SDR, and then we have what we call a neoplastic detection rate, which is did you find either a serrated polyp or adenoma during the colonoscopy? And I think that if you wanted to then report something, because no one's specific, if you're going to use this for sort of marketing purposes, I think you can use that how often we find a precancerous polyp in someone's colon. I think that's probably the metric of most interest, the ADR plus the SDR. But I agree with what's being said. It's a very challenging thing because some people will game the system. Fortunately, right now, I don't think they don't really achieve much by gaming the system. They're just actually reducing the ability to sort of figure out outliers. So again, you're correct. It should be adenomas without serrated polyps when you're calculating ADR. Sneak in one more before we give ourselves a little break here. Dr. Levin, are there conditions under which you would not do a six-minute withdrawal time, maybe expand it? I can't imagine decrease it. But two scenarios here, if it's a diagnostic exam for anemia or if a patient has a positive coligard, would that in any way influence or change that six-minute withdrawal? No, and I think six minutes is just kind of a guide. It's been shown in screening colonoscopies when no polyps are found, endoscopists who take six minutes or longer tend to be the higher adenoma detectors. And I think there's kind of human nature that we might look more carefully on exams when we really are worried about something in a patient. But in reality, we should be applying that careful examination technique and that slow withdrawal for all of our patients, especially the screening colonoscopies, because there are a lot of polyps in there on the screen colonoscopy patients. And certainly, if we really are going to adhere to the 10-year interval, which is essentially what makes colonoscopy a cost-effective alternative to either FIT or coligard for screening, we really have to do high-quality exams. So I would say that it should be the same target withdrawal time. But remember, it's also the target withdrawal time in the exams where you are not finding polyps. The exams where you do find polyps, you'll definitely take longer than six minutes on the withdrawal.

colonoscopy

ADR

supervision

FIT

Cologuard screening