结肠镜检查医生的表现与腺瘤切除后的结直肠癌风险分层监测：两项全国性观察性研究。
Colonoscopist Performance and Colorectal Cancer Risk After Adenoma Removal to Stratify Surveillance: Two Nationwide Observational Studies.
机构信息
Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland; Department of Oncological Gastroenterology and Department of Cancer Prevention, the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland; Department of Transplantation Medicine Oslo University Hospital, Oslo, Norway.
Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria; Quality Assurance Working Group of the Austrian Society for Gastroenterology and Hepatology, Vienna, Austria; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Frontier Science Foundation, Boston, Brookline, Massachusetts.
出版信息
Gastroenterology. 2021 Mar;160(4):1067-1074.e6. doi: 10.1053/j.gastro.2020.10.009. Epub 2020 Oct 14.
BACKGROUND AND AIMS
Colonoscopy surveillance after adenoma removal is an increasing burden in many countries. Surveillance recommendations consider characteristics of removed adenomas, but not colonoscopist performance. We investigated the impact of colonoscopist performance on colorectal cancer risk after adenoma removal.
METHODS
We compared colorectal cancer risk after removal of high-risk adenomas, low-risk adenomas, and after negative colonoscopy for all colonoscopies performed by colonoscopists with low vs high performance quality (adenoma detection rate <20% vs ≥20%) in the Polish screening program between 2000 and 2011, with follow-up until 2017. Findings were validated in the Austrian colonoscopy screening program.
RESULTS
A total of 173,288 Polish colonoscopies were included in the study. Of 262 colonoscopists, 160 (61.1%) were low performers, and 102 (38.9%) were high performers; 11.1% of individuals had low-risk and 6.6% had high-risk adenomas removed at screening; 82.2% had no adenomas. During 10 years of follow-up, 443 colorectal cancers were diagnosed. For low-risk adenoma individuals, colorectal cancer incidence was 0.55% (95% confidence interval [CI] 0.40-0.75) with low-performing colonoscopists vs 0.22% (95% CI 0.14-0.34) with high-performing colonoscopists (hazard ratio [HR] 2.35; 95% CI 1.31-4.21; P = .004). For individuals with high-risk adenomas, colorectal cancer incidence was 1.14% (95% CI 0.87-1.48) with low-performing colonoscopists vs 0.43% (95% CI 0.27-0.69) with high-performing colonoscopists (HR 2.69; 95% CI 1.62-4.47; P < .001). After negative colonoscopy, colorectal cancer incidence was 0.30% (95% CI 0.27-0.34) for individuals examined by low-performing colonoscopists, vs 0.15% (95% CI 0.11-0.20) for high-performing (HR 2.10; 95% CI 1.52-2.91; P < .001). The observed trends were reproduced in the Austrian validation cohort.
CONCLUSIONS
Our results suggest that endoscopist performance may be an important contributor in addition to polyp characteristics in determining colorectal cancer risk after colonoscopy screening.
背景与目的
在许多国家，腺瘤切除后的结肠镜检查监测工作负担日益加重。监测建议考虑到了切除腺瘤的特征，但没有考虑结肠镜医生的操作水平。我们研究了结肠镜医生的操作水平对腺瘤切除后结直肠癌风险的影响。
方法
我们比较了 2000 年至 2011 年期间在波兰筛查计划中，结肠镜医生操作水平较低（腺瘤检出率<20%）与较高（腺瘤检出率≥20%）的结肠镜检查者，在切除高危腺瘤、低危腺瘤和阴性结肠镜检查后，结直肠癌的风险，随访至 2017 年。结果在奥地利结肠镜筛查计划中得到验证。
结果
共纳入 173288 例波兰结肠镜检查。262 名结肠镜医生中，160 名（61.1%）为低水平医生，102 名（38.9%）为高水平医生；11.1%的人在筛查时切除了低危腺瘤，6.6%的人切除了高危腺瘤，82.2%的人没有腺瘤。在 10 年的随访期间，诊断出 443 例结直肠癌。对于低危腺瘤患者，低水平医生的结直肠癌发病率为 0.55%（95%置信区间 0.40-0.75），高水平医生的结直肠癌发病率为 0.22%（95%置信区间 0.14-0.34）（风险比[HR] 2.35；95%置信区间 1.31-4.21；P=0.004）。对于高危腺瘤患者，低水平医生的结直肠癌发病率为 1.14%（95%置信区间 0.87-1.48），高水平医生的结直肠癌发病率为 0.43%（95%置信区间 0.27-0.69）（HR 2.69；95%置信区间 1.62-4.47；P<0.001）。对于阴性结肠镜检查患者，低水平医生的结直肠癌发病率为 0.30%（95%置信区间 0.27-0.34），高水平医生的结直肠癌发病率为 0.15%（95%置信区间 0.11-0.20）（HR 2.10；95%置信区间 1.52-2.91；P<0.001）。在奥地利验证队列中观察到了相似的趋势。
结论
我们的研究结果表明，除了息肉特征外，内镜医生的操作水平可能是决定结肠镜筛查后结直肠癌风险的一个重要因素。
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