Hello, everyone, and welcome to a presentation on what the updated surveillance colonoscopy intervals mean for your practice, sponsored by the GI Quality Improvement Consortium and its member societies, the American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy. Before we get started, just a few housekeeping items. There will be a question and answer session at the close of the presentation. Questions can be submitted at any time online by using the question box on the GoToWebinar panel 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-hand side of your screen. You can immediately access a copy of the slide deck from the handouts box of the GoToWebinar dialog panel. This session is being recorded. An email will be sent to you when the recording is available. Now it is my pleasure to introduce our featured speaker, Dr. Asma Shaukat. Dr. Shaukat is the GI Section Chief at the Minneapolis VA Medical Center and Professor of Medicine at the University of Minnesota. Her area of clinical research is colon cancer screening and long-term outcomes. She has published her results on the long-term follow-up of the participants of the Minnesota fecal occult blood trials in the New England Journal of Medicine and is now evaluating the age and gender-specific benefits of colon cancer screening. She also studies molecular markers of rapid colon cancer growth, as well as studying quality indicators for colonoscopy, such as adenoma detection rates and withdrawal times. She is studying the role of fecal microbiota transplant in recurrent C. diff infection. Her other areas of research include chemoprevention for colon cancer, biomarkers of risk of colon cancer, and evidence synthesis through systematic reviews and meta-analyses. I will now turn the presentation over to Dr. Shaukat. Thank you very much, Eden, and good morning, afternoon, or evening. It's a pleasure to be here, and we're going to talk about some very important bread-and-butter updates in colonoscopy surveillance. By means of disclosure, I am a member of the U.S. Multi-Society Task Force, which is responsible for updating these surveillance or follow-up intervals that we'll be discussing, so let's get started. I'll start with a case to frame our discussion today, and this is a common case that everybody probably sees in clinic on a routine basis. A 65-year-old male is seen for routine follow-up. He tells you that his last colonoscopy was three years ago, and he thinks he's due again. You look up his last colonoscopy, which thankfully is in your system. It was a complete exam to the CECM with good prep, and one tubular adenoma, one small tubular adenoma, five millimeters was found. The best recommendation for this patient is, and you can go through these options, reassure him that he's not due for another four to seven years, which would be seven to 10 years from his last exam, order colonoscopy now because he's worried and it's been three years, order a fit, or defer discussion of screening for another year. So think about this, and we'll come back to the answers, hopefully, with the information I'm going to present. So the purpose mainly today is to provide you an update and help you understand and answer questions about the updated recommendations of follow-up colonoscopy after polypectomy. And this is the consensus update by the U.S. Multi-Society Task Force. I'm one of the members, and you can see the other members on our team. So as we go forward, these are some of the terms I'll be using. You can refer back to this presentation, but essentially, when we talk about low-risk adenomas or non-advanced adenomas, we're generally referring to one to two small tubular adenomas that are less than 10 millimeters in size. Advanced adenomas are 10 millimeters or larger. They may have villus features or high-grade dysplasia. And then sessile serrated adenomas or polyps are histologically confirmed as sessile serrated adenomas, also called sessile serrated lesions. So let's get started with this. The largest changes that you'll see are in these two categories. And truly speaking from practice, the largest chunk of polyps we see fall in this first category. Generally, for a colonoscopy, we find individuals with low-risk adenomas, which are one to two small tubular adenomas. And throughout this presentation, by small, I'll be referring to 10 millimeters, smaller than 10 millimeters. And then in about 10 to 15% of our patients, we'll find an advanced adenoma. So this is where truly some of the updates are going to be. So I'm going to frame it right here for you. In the updated recommendations, the intervals for surveillance have been lengthened. So for one to two small tubular adenomas, the recommended interval for follow-up or surveillance colonoscopy has been moved from what used to be three to five to now seven to 10 years. And there's strong evidence for this, which I'll briefly review. And we've even separated out the category of three to four tubular adenomas, recognizing that this is a pretty common scenario with high-def endoscopes and good preps and all the time that we're taking to do a thorough exam. So for individuals with three to four small tubular adenomas, the recommended follow-up interval, instead of being three years, is now three to five. The evidence isn't as strong, and I'll be reviewing some of this. So again, in practice, the wide majority of our patients will fall in this normal category where nothing is found. And there, the recommended interval is 10 years. We're talking about average-risk individuals undergoing screening colonoscopy. And then a large majority of the individuals will fall in this category of one to two tubular adenomas or three to four. So really, these recommendations truly affect a large chunk of the patients we see. And then somewhere between five to 10% will have some of these more advanced polyps, and there's some changes in those intervals also. So let's look at low-risk adenomas. The Multi-Society Task Force recommends repeat colonoscopy in seven to 10 years instead of five to 10 in the previous guidelines. And this is because of several new pieces of evidence that are largely focused on two themes. One, many studies have now found that there is a similar risk of colon cancer in individuals with one to two small tubular adenomas as compared to individuals with normal exams. So we can reassure our patients with one to two small tubular adenomas that their long-term risk of colon cancer is no higher than individuals we find nothing in. And that this risk is lower than the general population, which tends to be a mixed bag of people with symptoms and attenuated risk. So that those two points should provide reassurance for our patients. And here's some of the evidence that has accumulated over the last 10 years that has helped support these recommendations. So this is a meta-analysis of eight studies with over 10,000 participants. And here again, they've stratified by what was found at the initial colonoscopy in terms of follow-up for having advanced neoplasia five years afterwards. And you can see that individuals where there was no adenoma and individuals with low risk adenomas defined as one to two small adenomas have very similar risk of subsequent advanced neoplasia. And obviously the risk is much higher for advanced neoplasia. And then there are two additional studies also published earlier this year. One of them was updated this year, again, showing that low risk adenoma is associated with a reduced risk of both incident and fatal CRC. So not only are they at lower risk of advanced neoplasia, they're also at lower risk of having colon cancer or risk of dying from colon cancer. So on the top right of your screen, you see this graph and you can see over 15 years of follow-up. And you can see how close the orange and the blue line are. Those represent individuals with either no adenomas or with non-advanced adenomas, again, defined as one to two small tubular adenomas. And they kind of are very similar and overlapping with each other compared to individuals with advanced adenomas. And then again, on the lower right side of your screen, you see the risk of fatal CRC, the risk of dying from a colon cancer in individuals with a single low risk adenoma is very similar to the general population. And so these data provide us some confidence that these individuals are at low risk. There's two more studies that essentially look at the same thing. Again, what I want you to notice is how close the lines for individuals with no polyps versus those with non-advanced adenomas are over 15 years of follow-up. And individuals with advanced adenomas truly are what we think are at the increased risk. However, individuals with non-advanced adenomas behave very much like individuals with no adenomas. And hence, if we are comfortable giving individuals with no polyps or no adenomas a 10-year pass, then there's no reason why that same interval can't be applied to individuals with one to two small non-advanced adenomas. It's high value care to be able to do that. So I hope that point is, you know, evidently clear. Next, I'm going to switch to why we changed from a five-year to a three-year follow-up for individuals with three to four adenomas smaller than 10 millimeters. So again, we are finding these more and more now, particularly in the era of high-depth colonoscopy, good preps. So essentially, there's a large population of patients in this group, and they also seem to have a low risk of colon cancer compared to individuals with more than four polyps, or five or more. And newer data seems to separate these individuals out, which is why we were able to do that for the guidelines. So individuals that are low risk for advanced neoplasia, it was found that individuals with one to two adenomas behave very similarly to individuals with three to four. And truly, the breakpoint seems to be when individuals have more than four or five or more adenomas, for both risk of advanced neoplasia, as well as risk of incident colon cancer. And this is truly the reason for feeling confident and giving these individuals perhaps a longer pass. All right. So now I'm going to, again, give you a breakdown table for when the second surveillance exam should be. So not only have we made recommendations, which I hope are now clear. Individuals with one to two tubular adenomas can get a seven to 10-year interval, and individuals with three to four tubular adenomas can get a three to five-year pass. And those with either five or more or large adenomas or advanced adenomas still are at a three-year follow-up interval. However, knowing these findings, now when individuals come for their first surveillance exam, we can start to re-stratify them even more. And the key here is that the stratification goes by the findings at the most recent colonoscopy. So, for instance, an individual that had one to two tubular adenomas in the past, you bring them back in seven years, now they have a normal colonoscopy, they go to 10 years. They don't stay at that seven-year or at that five-year, if that makes sense. However, now you find in advanced adenomas, then their follow-up would be three years. So if it makes sense, the most recent colonoscopy findings determine the next follow-up. So for individuals that had three to four small tubular adenomas, and you brought them back in, say, three to five years, now they have a normal exam. They don't stay at that three to five interval, they now go to a 10-year interval. So we're getting very comfortable at lengthening out these intervals, because having a single or multiple colonoscopies over a lifetime actually is a protective factor, if that makes sense. Individuals that had, say, an advanced adenoma at their last exam, and we gave them a three-year pass, well, now if they have nothing on their colonoscopy, then they would, again, go back to a much longer interval. So truly, their last colonoscopy determines their next follow-up. All right, so here's the same information for individuals that, for some of you that like flowcharts. And again, we're premising this on a high-quality colonoscopy, which is defined as an exam which is complete to the CECOM with, hopefully, photo-documentation of CECOM landmarks, adequate bowel prep, adequate colonoscopist adenoma detection rate, and complete polyp resection. Once those conditions are met for a high-quality colonoscopy, we can re-stratify individuals based on what was found, 10 years for a normal exam, 7 to 10 for 1 to 2 small adenomas, 5 to 10 for 1 to 2 CECA-inserated polyps, which I'll address shortly, 3 to 5 years for, if they have 3 to 4 adenomas, and 3 years if they have 5 or more adenomas, or large adenomas or adenomas with advanced features, and that also applies to findings of SSP. All right, so, you know, some of the questions that might come up for you as you hear this or have read this is that, why use a range of 7 to 10? It's very difficult, particularly in EHRs, including ours, to program ranges, so why not 7, why not 10, why give a range? It can be confusing to both providers as well as patients. And then, if you say 7 to 10, most people will default to 7. Well, that's totally fine. Because this is a shift, our task force recognized that, you know, there is some wiggle room here and we want to indicate that longer polyp surveillance intervals are supported by emerging evidence. However, we don't want to be, you know, very dogmatic about putting it at just one number. And allowing a range allows clinicians and patients to kind of have that discussion and come up with what works best for them, and it provides an opportunity for shared decision-making. And what that might look like is, if I'm seeing somebody that was colonoscoped with excellent prep, only two small tubular adenomas were found, they're otherwise healthy, maybe the patient is a female, then I'd be more comfortable giving them a 10-year follow-up, and I might throw in some other factors that might make me more comfortable with a 7-year follow-up. So just to give you that wiggle room and that decision-making ability was why 7 to 10-year was put in. From a systems perspective, you can choose to put in just 10 years for everyone or seven years for everyone, and that would be totally fine. All right, so again, I'm going to reiterate where most of the changes have occurred. So 1 to 2 small tubular adenomas, now the recommended interval is 7 to 10 years, the evidence for that is strong. And for 3 to small, the interval is 3 to 5 years. The reason there's a range there is that even though there is good evidence, it's still emerging. So again, we didn't want to be dogmatic and put it at 5 necessarily, but start thinking about shifting those patients from 3 to 5 years if you have them in your practice. All right, so going back to that case we started with, this is a 65-year-old who is seen for routine follow-up, his last colonoscopy was three years ago, and a single tubular adenoma was found and the colonoscopy was otherwise high quality. So the best recommendation for this patient, given what I just went over, is to reassure him that he's not due until 4 to 7 years later for the new guidelines, which would be 7 to 10 years after his last exam. And I'm sure we can discuss this and other cases during our question-answer sessions. I wanted to take a few minutes and talk about follow-up colonoscopy for serrated polyps. Again, serrated polyps came up more recently than what we know about tubular adenomas. We didn't know much about their natural history. And then when we don't know about something, we tend to err on the side of caution. So we assumed that they were bad players, and we used very short intervals for them. However, lately more data has accumulated, which tells us that SSPs behave pretty similarly to tubular adenomas, and they don't predispose a person to increased risk of colon cancer as much as what was initially thought or we worried about. And they seem to increase risk for high-risk adenomas in those that have SSPs and conventional adenomas. And as you know, there's other challenges with serrated polyps. They're difficult to see, they have subtle borders, a lot of it results in incomplete polypectomy, they often have a mucous gap, and they require a really thorough exam and extensive washing and suctioning. So with all those caveats, even though we have good natural history data that they aren't as worrisome as we once thought, we still didn't quite put them with tubular adenomas. So again, here's some evidence, are serrated polyps truly bad players? And the answer is yes, but not as bad as we thought. This is a study comparing what was found at initial colonoscopy, and then subsequent risk of colon cancer at five years and 10 years. And compared to individuals with no polyps, individuals with serrated polyps just by itself, small serrated polyps, the risk was not any different. So it almost behaved what we would think of as tubular adenomas would. However, when the serrated polyps were more than three, or they started getting large, or they were coupled with advanced adenomas, that's when the risk of CRC started increasing. So these are some of the data that kind of provide us reassurance of how serrated polyps behave. So surveillance recommendations for serrated polyps are, again, summarized in this chart. So individuals with one to two small, sessile serrated polyps, the recommended interval is five to 10 years. So instead of seven to 10 years, we gave a little more wiggle room and put it at five to 10 years. It should not be three, but think of an interval between five to 10. For three to four small SSPs, the interval is three to five years, very similar to tubular adenomas. And for five or more SSPs, the interval is three years. Or if they have dysplasia, if they're large, if they have a special histology known as traditional serrated adenomas, then the interval is three years. So a little more conservative than tubular adenomas, but certainly longer than what we thought of them for before. And again, I went over these before. These are recommendations for the second surveillance interval stratified by the first findings. And again, the point to emphasize is, think of findings at this colonoscopy, and that determines the next follow-up much more than what was found previously. The only exception is if somebody had large or advanced adenomas, and even if they had a normal colonoscopy now, you would bring them at a shorter interval. So I'm going to summarize my take-home points. Surveillance colonoscopy in appropriate individuals is high-value care, and that's something we should be doing. New evidence supports one to two small adenomas or SSPs have similar outcomes as individuals with no adenomas or a normal colonoscopy. New follow-up colonoscopy intervals are lengthened because of multiple studies, giving us reassurance on this. Surveillance is extended to seven to 10 years for one to two small adenomas, and that's a change from five to 10. And surveillance, three to five years for those with three to four adenomas, which is a change from just three years. And future surveillance lengthened is going to be based on the first surveillance colonoscopy unless they had advanced adenomas on the previous exam. So more to come on this, but this is the general direction because we are getting good at doing high-quality colonoscopies. So we can reassure ourselves and our patients that we are finding the worrisome things. And I do want to emphasize why this is all so important. There's multiple reasons to be doing high-value care, and you're going to hear about this a little bit more. As you know, it's tied to how we're measured, tied to our reimbursements, our patient satisfaction, and there's multiple campaigns such as this one you might have heard of, which is from the ABIM called the Choose Wisely campaign. And it has several points relevant to GI just like it does for other specialties. And I do want to remind everybody that if you look at their bullet number three, it's essentially saying that high value care is not to repeat colonoscopy for at least five years in patients who have one or two small adenomas. So really, we shouldn't be automatically putting individuals on a three-year plan for one to two small tubular adenomas. And we should be extending from five, I'm sure these will be updated, to seven to 10. And that's truly being very evidence-based and being very up-to-date in doing our patients the right clinical decision-making. So with that, I'm going to turn the presentation over to Luke Williams from GI Quick, who's going to delve a little bit more into the reporting and the quality assurance aspect of this. Luke? Yeah, thank you very much, Dr. Shaka. I am Luke Williams, Manager of Data Quality and Analytics for the GI Quick Registry. And I'm here to talk a little about the impact of these updated surveillance colonoscopy recommendations to GI Quick's quality measures. So GI Quick is currently in the process of modifying the measures that are available in our real-time reports tool to best reflect the changing guidance. And in doing so, in some ways, we've adopted a shift in the design of our quality measures. In some instances, moving from having measures that were defined and organized by their shared recommended interval, such as combining all pathology types that may recommend a three-year follow-up interval, instead now really having our measures driven by the shared pathology, independent of what that follow-up interval might be. So what that means is that among the affected measures listed on this slide, a few are going to have multiple strata. And I'll explain what that means. The first here, our soon-to-be-released measure, appropriate follow-up interval for colonoscopies with findings of tubular adenomas less than 10 millimeters. So this new measure will include three separate strata and it's for these three rows that you see that I borrowed from Dr. Schachat's table. So depending on the number of tubular adenomas that are found on the exam, either one to two, three to four, or five to 10, the procedure will then land in one of these three strata. And the target follow-up interval that would put the procedure in, as meeting the measure numerator, will vary depending on the number of tubular adenomas that were found. Similarly, we've developed a multi-strata measure for findings of small dithalcerated polyps without dysplasia. A procedure with only small SSPs that ends up in one of the three strata, depending on the number found. And the target follow-up interval is, again, going to differ between those three strata. Now, in years past, we had a single measure that combined all pathology findings that would lead to a three-year recommended interval. Now, with the latest guidance, we've instead formatted these measures to look at advanced adenomas and advanced seriated lesions separately. So, you'll see here, this is for the appropriate follow-up interval of three years with colonoscopies with findings of advanced neoplasm. You'll see those three findings. And then, on this slide, we have the findings that would be included in a separate measure that look only at advanced seriated polyps. And then, finally, we have our measure, which actually has existed in the registry for some time, that looks at a 10-year recommended follow-up interval for colonoscopies with only hyperplastic polyps. Now, this measure has been changed based on this latest guidance. We're expanding it to include hyperplastic polyps that are found in any area of the colon rather than limiting it to just the rectum or sigmoid. And that's, again, based on the latest recommendations discussed today. This is a screenshot of a portion of GI-Quick's colonoscopy data collection form. And this page includes the various pathology fields and follow-up interval choices that are available today. And on the next slide here, we'll see zoomed in the specific follow-up interval choices that we now collect. Now, those highlighted in yellow, four, six, seven, eight, and nine years, are relatively recent additions that have been available to GI-Quick users at least via manual data entry for most of 2020. And depending upon your endorider and the version you're on, these fields are available to be uploaded, exported from your endorider and uploaded to the GI-Quick registry. So we wanna make sure that you and your physicians are using these intervals where available and that you might wanna check to make sure you're on the latest version of your endorider so that you have compatibility with these fields. Now, the measure reports discussed today will be available in the near term on GI-Quick and we'll provide an update on each measure's availability in the September GI-Quick newsletter. And now I am going to turn the presentation over to Eden to discuss surveillance measures and public reporting. Thank you, Luke, and thank you, Dr. Schottkut. What a wonderful presentation. So just touching on public reporting, for those of you reporting to the Merit-Based Incentive Payment System for the 2020 performance year via the GI-Quick Qualified Clinical Data Registry, which we also refer to as a QCDR, you have noted the measure set includes follow-up interval measures. Because adoption of the surveillance guidance presented today has been translating into practice over the year, we would expect widely variable performance on these measures and for performance on these particular measures to go down. So you're going to ask, so why can't we just use the updated measures, use those for 2020 reporting? Well, it's just not possible. Here's the deal. Measures used for reporting cannot be updated in the middle of the year. GI-Quick applies in the summer prior to the reporting year to be a QCDR and that whole process is finalized many months before February when the updated guidance was published. So we just wanted to flag this issue for you so you're aware of it as you see your measure results and determine which measures you will be using for public reporting if you're reporting through us. Now, as we start to look to 2021, as I just mentioned, we self-nominate to be a QCDR in the summer before the reporting year. So we are currently in that process for the 2021 performance period. Here are the changes we have proposed to CMS for the GI-Quick 2021 QCDR measure set. So we're absolutely retiring GI-Quick 15, 17, and 21, and then we have recommended some of the surveillance measures be included in the 2021 measure set. So we'll let you know what CMS finalizes for the GI-Quick 2021 QCDR measure set in December. So with that said, let's go ahead and move into the Q&A session. I know I've seen quite a few hands raised. We're not opening the phone lines today, so if you would please go ahead and type in your questions, we would appreciate that. One of the questions that we've already gotten so far is about handouts. So when it comes to, there is the handout box in the GoToWebinar dialog panel. So if you would please just go ahead and download it from there, you'll be able to print it out right away. And with that said, we will just go ahead to our first question. Our first question is for you, Dr. Shawcutt. Do you have data about adherence to 10-year interval among individual where it's clear that they should get a recommendation for a 10-year interval? Specifically, the only indication was average risk, CRC screening, and endoscopy report indicates normal, high-quality colonoscopy. And so they just simply define CEQL intubation, adequate bowel prep, and no biopsies performed. Great, thank you, Eden. So it sounds like the provider has a report in front of them. A lot of the time, we don't always have a report, and then we're kind of left trying to make some decisions based on what we think might have happened. So if they have a report that said 10 years ago there was, or the colonoscopy was complete to the CEQL with good prep and nothing was found, no biopsies and no polyps, that would be a 10-year interval. And in terms of adherence to the 10-year interval, no, I don't have data that how good it is. And as you can imagine, it varies practice to practice. However, there is lots of emerging information that putting these individuals in some kind of recall is probably the best approach rather than leaving it up to the patient. I know a lot of EMRs, including ours, has automatic clinical reminders that flash in 10 years. I know practices have implemented several things such as sending patients reminders starting at about nine years so that they can schedule their colonoscopy and be done by the 10-year mark. So there's several innovative things that can be done from kind of low budget to very high-end things, and probably a combination of those things targeting the individual themselves, the practice, and the EMR, including the referring provider is probably the most effective approach. So we should be bringing them in in the intervals that we recommend. And I would argue bringing somebody in at 10 years is probably more difficult because it falls off everybody's radar. So having some good system-based practices to make sure that happens is what we should be doing. All right, Dr. Shaka, the questions are rolling in for you. Are right-sided hyperplastic polyps still considered to be a subset of sessile serrated polyps, in which case surveillance intervals follow SSP guidelines, five years for those with less than 10-millimeter polyp? That's correct. Because there's still a lot of how the pathologists read and interpret sessile serrated polyps, due to error on the side of caution, we still recommend large hyperplastic right-sided polyps should be treated as SSPs. However, every time you see a report, please pick up your phone and talk to your pathology group and say, hey, any chance this could be a sessile serrated lesion or a sessile serrated adenoma? The WHO classification for SSLs was updated as recently as last year. So unfortunately, it's gonna take a little while for our pathology colleagues to get caught up on it. And even then, there's a lot of variability. So for now, treat right-sided large hyperplastic polyps as SSPs, but do have that dialogue with your pathologist so it's on their radar, and something that they could easily integrate into the practice. I know it worked for us pretty well, so I'm hopeful it works for others too. Wonderful. And our next question is, so we have somebody in a unit who is looking for kind of just more of a snapshot. If you had one to two pages, and maybe it's one to two slides out of this presentation to share in the endocenter, so everybody was aware of the change in these guidelines, where would we direct them? Is there a particular, is it the flowchart maybe, or what would you refer them to, Dr. Shaka? Yeah, so we were very mindful of exactly that need when we put this guideline together, this guidance together, and the flowchart is truly meant for that purpose. In fact, these flowcharts are available free of cost. So if you have access to the article, you can actually get a nice glossy colored picture. The boxes are color-coded, as you saw. So I would say, we can reference what slide number that is, but I would say that flowchart, where it says high-quality colonoscopy, now what, you know, 10 years if nothing found, that one piece of paper printed conveys a lot of information. We have cut and pasted that in our endoscopy writing area, in our discharge areas, and in most of the procedure rooms, as well as in our training rooms. So that's what we should disseminate. Wonderful. Another question has come in about adherence. So for those with inadequate bowel prep, we should be giving a one year or less follow-up interval for repeat colonoscopy. So this is just somebody coming in for an average risk screen. They've had an inadequate bowel prep. Do we know how people are adhering to that? How well adherence is to that? Right. And you bring up a good point. There's a few studies that show adherence to that is actually pretty poor. And a lot of individuals, a lot of endoscopists or practices do recognize that those intervals should be short. However, people tend to custom make those. People come up with numbers like two years, three years, two and a half years. Let me tell you, none of those are evidence-based. Truly, if the exam did not have adequate prep, it's not considered an adequate exam. And we should be bringing those individuals at next available. Now, next available might look different for different practices. The reason we said within a year was to give practices wiggle room because we recognize and understand a lot of practices might be booked out longer and patients might want to wait a few months. So the less than one year is truly based on that. But if you have a appointment in the next few weeks and the patient is willing and motivated, by all means do it sooner than later, but within a year. So that year should be considered kind of the longest range. It doesn't mean a year. It means within that year, it could be in two days or it could be in two months and that's totally fine. So adherence to that is poor and something that we should be improving. Anything that's poor prep should be repeated next available, whatever that looks like for your practice. And then the repeat interval should be based on that follow-up. And then at a systems level, if you're having a lot of poor preps, that's something to look at your prep instructions or the type of prep you're using, because we even have a metric for that. It should be no less than 90% of exams that should have a good prep. If it's less than that or 85% total and 90% of screening colonoscopies, if it's less than that, then take a look at what's going on the instruction and scheduling level and try to improve that process. Wonderful. And so this next question, it's really a clarifying question. This person says, I believe Dr. Shaka said that there is a difference in the colonoscopy intervals for small SSAs and tubular adenomas. Did I get that correctly? And if so, why would those intervals be different? Right, so you did get that correctly. For small tubular adenomas, it's seven to 10 years. For small SSPs, one to two small SSPs, we left it at five to 10 years. You have a little more wiggle room with the SSPs. And the reason we did that is again, because of lower quality evidence with SSPs, they're more recently recognized. There's a lot of other issues with trying to diagnose and understand what the risk they confer. So we left it at five to 10 instead of seven to 10. So that's the only difference, but they do overlap. So this question is kind of touching off on that seven to 10 range. Are there cases when ranges are given that you would give an interval of say eight or nine years versus seven to 10? Yes, absolutely. So within seven to 10, you can pick a number. It could be seven, it could be eight, it could be nine, or it could be 10. The idea is as long as it's longer than seven, but shorter than 10, you will be considered adherent to guidelines. And again, it's hard to give just one number because again, we don't want people scheduling at 10 years and getting their exam at 11 years because of scheduling conflicts or because they have to often cancel and reschedule. So if you can get them in anywhere between seven to 10, that's totally fine. What I was referring to from a systems perspective, we're often, so we have a recall reminder system. And obviously you can't put a range in there. So I either pick seven or I pick 10, but I can also pick eight or nine, and that's totally fine. Wonderful. So we have, this person is asking how did they become more familiar with GI-QUIC? So we have on screen here, we have contact information for GI-QUIC, and I would encourage those folks who are interested in learning more about GI-QUIC, whether it is data entry or research opportunities or whatnot, you can go to our website. You can email us at info at giquic.org. That's a whole presentation in itself. What is GI-QUIC? So we won't go there today, but we would refer you to that, and we would be happy to set up some time with you and walk you through GI-QUIC. That would certainly be our pleasure. And again, just a reminder, if you have any questions, I know a few folks had their hands raised earlier. If you could just go ahead and type that into the question box. We aren't opening the phone lines today here. We do have a question. I'm not sure if you need a little bit more than this, Dr. Shakhat, if a patient has a history of colon cancer, they're in remission and they require surveillance, what is recommended as an interval for surveillance? Would that be based on their polyp findings or? Yeah, great question. So these guidelines apply to individuals where no cancers were found. We have a separate, surprise, surprise, we have another guideline for follow-up colonoscopy after cancer is found. And the general idea is that cancers from stages one to three so as long as they're not metastatic or palliation is a different category. However, for cancers that are either resected and plus minus chemo radiation, the interval is one year after the first colonoscopy, whenever that was, or after the cancer resection. And then three years after that, and every five years from then on, regardless of what's found. So even if they have no findings on the subsequent colonoscopy, which we often see, they should still be coming back at one year, three year, and then every five, as long as they have a good life expectancy and are able to undergo colonoscopy safely. And how would that apply to a patient? They're coming in for a screen and they do have a family history of colon cancer. So maybe they have no personal history, but they have a first degree relative with a history of colon cancer. What would be the recommended intervals for surveillance for those folks? Right, so again, this particular guideline applies to individuals that are average risk, meaning they have no high risk family or personal history of cancer. And like I mentioned, there is a separate guideline that goes over it. And if you search US Multistudy Task Force, it's also on the ASGE website. We can send the link afterwards. So for individuals that have a family history of colon cancer, there are three important pieces of information that you need. One, which family members? It has to either be two second degree or one first degree. So an aunt, an uncle, a grandfather does not count as the only relative. So two first degrees, so either siblings or one of the parents and a sibling. So those would be considered, or children, first degree. And then what their age was. If the first degree relative was older than age 60, then the recommendation is to start screening them at age 40 or 10 years younger than when they were diagnosed, but to use regular intervals after that. However, if the first degree relative was younger than 60 when they were first diagnosed, then they would undergo colon cancer screening every five years because they're considered at increased risk. So the three important pieces of information are which relatives, are they first degree or not? And what was their age? And what is this person's age? All these recommendations are applicable to individuals that are younger, if they're 30s, 40s, 50s. After the age of 60, the individual's risk pretty much catches up to the general population. And therefore, it becomes less relevant if they have a family history or not. So the question, if somebody tells me they have a family member, I ask, who is the family member? And what was the age that they were diagnosed? And if the answers are, it was a first degree relative and they were diagnosed younger than 60, well, they started 40 and go every five years. Otherwise, they started 40 and go every 10 years. I hope that helps. This has been absolutely wonderful, Dr. Shaka. We cannot thank you enough for your time. We know how valuable it is and our community has had a lot of questions and I think you've cleared a lot of questions today. Oh, we're getting a lot of kudos in through the box here. Thank you, much appreciation. And we'd like to thank all of you for joining us today for this GI Quick ACG, ASGE sponsored webinar, what the updated surveillance colonoscopy intervals mean for your practice. Following today's webinar, you will receive a brief survey. Please take a moment to complete it. This concludes our webinar. We hope this information is useful to you and your practice.

webinar

Updated Surveillance Colonoscopy Intervals

GI Quality Improvement Consortium

American College of Gastroenterology

American Society for Gastrointestinal Endoscopy

Dr. Asma Shaukat

follow-up colonoscopy

polypectomy