Department of Colorectal Surgery, Ochsner Clinic, New Orleans, LA, USA.
Division of Internal Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Surg Endosc. 2022 Feb;36(2):1284-1292. doi: 10.1007/s00464-021-08403-3. Epub 2021 Mar 24.
Colonoscopy remains the gold standard for screening and surveillance of colorectal neoplasms, and is associated with a lower risk of colorectal cancer (CRC)-related mortality. The current interval surveillance recommendations in patients with previous adenomas lack sufficient evidence. The prevalence of subsequent adenomas, and especially high-risk adenomas, during surveillance is not well known.
The primary outcome of this study was to determine the prevalence of polyps upon surveillance colonoscopy in patients who have a history of adenomas on initial average-risk-screening colonoscopy, but then have a normal initial surveillance (second) colonoscopy between 2003 and 2017. This is the first known retrospective cohort study of adenoma detection rate (ADR) with sub-group analysis of patients with serial surveillance colonoscopies by abnormal and high-risk surveillance findings separately by prior abnormal colonoscopies and correct surveillance strategies based on the recent March 2020 updated guidelines. After ADR calculation, machine learning-augmented propensity score adjusted multivariable regression with augmented inverse-probability weighting propensity (AIPW) score analysis was used to assess the relationship between guideline adherence, as well as abnormal and high-risk surveillance findings.
A total of 1840 patients with pathologically confirmed adenomas or cancer on an initial average-risk-screening (first) colonoscopy met study criteria. 837 (45.5%) had confirmed adenomas on second colonoscopy, and 1003 (54.5%) had normal findings. Of 837 patients with polyps on both first and second colonoscopy, 423 (50.5%) had adenomas on third colonoscopy. Of the 1003 patients without polyps on second colonoscopy, 406 (40.5%) had confirmed adenomas on third colonoscopy. Guideline adherence was low at 9.18%, though was associated in propensity score adjusted multivariable regression with increased odds of an abnormal third (but not high-risk) colonoscopy, with comparable AIPW results.
This 14-year study demonstrates the ADR to be > 40% on the third colonoscopy for patients with adenomas on initial screening colonoscopy, who then have a normal second colonoscopy. Through advanced machine learning and propensity score analysis, we showed that correct adherence is associated with higher odds of abnormal, but not high-risk abnormal 3rd colonoscopy, with evidence that high-risk surveillance findings are reduced by providers shortening the time between surveillance colonoscopies in contrast to the guidelines for those for whom there is presumed greater clinical suspicion of eventual cancer. Larger prospective trials are needed to guide optimal surveillance for these patients.
结肠镜检查仍然是筛查和监测结直肠肿瘤的金标准，与结直肠癌（CRC）相关死亡率降低相关。目前，对于先前有腺瘤的患者，间隔监测建议缺乏足够的证据。在监测过程中，后续腺瘤的发生率，尤其是高危腺瘤的发生率尚不清楚。
本研究的主要结局是确定在 2003 年至 2017 年间，首次接受平均风险筛查结肠镜检查时存在腺瘤的患者在初次（第二次）正常监测结肠镜检查后的监测结肠镜检查中，息肉的发生率。这是首次已知的腺瘤检出率（ADR）的回顾性队列研究，对有连续监测结肠镜检查的患者进行了亚组分析，根据之前的异常结肠镜检查和基于最近 2020 年 3 月更新的指南的正确监测策略，分别对异常和高危监测结果进行了分析。在计算 ADR 后，使用基于机器增强的倾向评分调整的多变量回归和基于增强逆概率加权倾向（AIPW）评分分析来评估对指南的遵守情况，以及异常和高危监测结果之间的关系。
共有 1840 名在初次平均风险筛查（第一次）结肠镜检查时通过病理证实患有腺瘤或癌症的患者符合研究标准。837 名（45.5%）患者在第二次结肠镜检查中发现腺瘤，1003 名（54.5%）患者结果正常。在首次和第二次结肠镜检查中均有息肉的 837 名患者中，423 名（50.5%）患者在第三次结肠镜检查中发现腺瘤。在第二次结肠镜检查中无息肉的 1003 名患者中，406 名（40.5%）患者在第三次结肠镜检查中发现腺瘤。尽管在倾向评分调整的多变量回归中，遵循指南与第三次异常（但不是高危）结肠镜检查的可能性增加有关，但在 AIPW 结果中，其相关性相似，因此，指南的遵守率仅为 9.18%。
这项为期 14 年的研究表明，在初次结肠镜筛查时患有腺瘤的患者中，第三次结肠镜检查的 ADR 超过 40%，而第二次结肠镜检查结果正常。通过先进的机器学习和倾向评分分析，我们表明，正确的监测策略与异常（但非高危）第三次结肠镜检查的可能性增加有关，并且有证据表明，通过缩短监测结肠镜检查之间的时间，提供者可以减少高危监测结果，这与指南中针对那些最终癌症风险增加的患者的建议相反。需要更大规模的前瞻性试验来指导这些患者的最佳监测。
