Gastroenterologists Should Read CT Colonography

Screening for colorectal neoplasms has become the standard of care in advanced medical settings worldwide. Identifying asymptomatic colorectal neoplastic lesions has been shown to reduce colorectal cancer incidence and the overall cost of medical care. Clinicians have several alternatives at their disposal as they consider screening for their respective patient population. Two important methods to consider are optical colonoscopy and computed tomographic colonography (CTC). The purpose of this article is to make the case that gastroenterologists should read CTC. Central to the argument that gastroenterologists read CTC is the benefit of experience with video-assisted colonic imaging and the physician-patient relationship.

Screening for colorectal neoplasms has become the standard of care in advanced medical settings worldwide. Identifying asymptomatic colorectal neoplastic lesions has been shown to reduce colorectal cancer incidence and the overall cost of medical care. Clinicians have several alternatives at their disposal as they consider screening for their respective patient population. Many different organizations have spent considerable time weighing the evidence to establish appropriate evidence-based guidelines directing clinicians how to appropriately manage screening; 2 important methods to consider are optical colonoscopy and computed tomographic colonography (CTC).

The purpose of this article is to make the case that gastroenterologists should read CTC. By virtue of their training, there is no question that radiologists may provide this service competently. Gastroenterologists are well trained to detect and remove colonic abnormalities using optical colonoscopy. In training and practice, gastroenterologists develop considerable experience in colonic pathology and anatomic variation. Given this experience in three-dimensional intracolonic imaging, gastroenterologists are also well suited to interpret intracolonic images obtained via CTC. Furthermore, gastroenterologists work within a patient care infrastructure that provides a personal relationship with patients, and leads patients effectively and efficiently through their options for effective colorectal cancer screening. Central to the argument that gastroenterologists read CTC is the benefit of experience with three-dimensional video-assisted colonic imaging and the physician-patient relationship.

Optical colonoscopy

Clinicians use optical colonoscopy as a primary means to screen the entire colon not only for cancer but also for precancerous adenomatous lesions. Most adenomas may be removed at the time of optical colonoscopy. The size, location, shape, and pathologic nature of polyps may be determined during this single clinical encounter, providing the patient and clinician with valuable information to guide the future colorectal cancer screening strategy. Often, the clinician doing the endoscopic procedure has an established relationship with the patient and may provide recommendations regarding care at a subsequent clinical encounter. Established Centers of Digestive Health, worldwide, have proved to be successful in driving the colorectal cancer effort.

Clearly, many patients and health care providers are comfortable with this protocol of patient care; however, optical colonoscopy does have its disadvantages. The procedure requires adequate colon cleansing to allow for complete mucosal evaluation, and many patients state that the arduous task of colonic preparation is a major drawback to the entire process. Often, colonoscopy requires moderate conscious sedation, requiring the clinician to reflect on the patient’s overall underlying medical condition: “Can my patient tolerate this degree of sedation?” From the patient’s perspective, moderate conscious sedation provides them with a comfortable medical procedure but also requires that the patient have access to reliable transportation from the medical setting. As a result, the patients not only have to absent themselves from their daily responsibilities, but their transporter must also take time from their routines to ensure safe passage home. This is a significant issue to consider when reviewing the overall cost of the colorectal cancer screening effort. During the insertion procedural phase and, if need be, polypectomy, perforation of the colon may occur. Although this is a relatively rare complication, it can and does occur in the care of asymptomatic patients. In addition, bleeding even after the most simple of polypectomies may occur and thus may require hospitalization or even administration of blood products. Because of the potential for colonic perforation, postpolypectomy bleeding, and other complications, adequately trained medical personnel must carefully discuss these possibilities to obtain meaningful informed consent from all patients before the procedure. There is simply no substitute for an excellent patient-physician relationship.

Optical colonoscopy is not a perfect screening modality. Several tandem colonoscopy studies demonstrate that, for many reasons, adenomatous colon polyps may be missed during the procedure. Polyps may be behind folds, obscured by colonic debris, or simply not seen by the endoscopist. This issue has prompted considerable focus by gastrointestinal societies on quality parameters such as adenoma detection rate, cecal intubation rate, and colonoscopic withdrawal times. Many endoscopy centers have initiated routine documentation of these important quality measures and, collectively, we hope these developments can improve the overall colorectal cancer screening effort. Several studies demonstrate that adequate training and experience translate into improved quality; but we require additional experienced endoscopists. As the age of our patients increases and the population grows, we need to train more endoscopists with a firm grasp on the limitations of endoscopy and their role in the overall improvement of quality colorectal cancer screening.

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