2011-04-08 05:45:26 UTC

The Future Of Endoscopy, Post-Colonoscopy

April 8, 2011


Mandeep S. Sawhney, MBBS, MS

Assistant Professor of Medicine, Harvard Medical School; Staff Physician, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA


In July 2001, Medicare approved payments for colonoscopy to screen average-risk individuals for colon cancer. Since then, gastroenterologists have abandoned inpatient wards in favor of newly minted endoscopy suites. It is estimated that in 2002, 14.2 million colonoscopies were performed in the U.S. alone.1 Of these, 82.5 percent were performed by gastroenterologists. Colonoscopy performed for colon cancer screening and surveillance has come to dominate the clinical practice of gastroenterology. It accounted for 65 percent of all endoscopic procedures performed by a group of 59 community gastroenterologists in Minnesota, numbers not dissimilar to our academic medical center in Boston.2

Colonoscopy is also a major revenue generator, accounting for more than 60 percent of all revenues for some private practices. Ambulatory endoscopy centers are unlikely to be financially viable without a steady stream of colonoscopy. There are still 40 million eligible individuals in the U.S. who have not undergone colon cancer screening, and so the future demand for colonoscopy appears relentless.

Colonoscopy: a thing of the past?

With all this upbeat assessment about colonsocopy, why are we then talking about a post-colonoscopy era? While celebrity and medical society endorsements have helped make colonoscopy the dominant colon cancer screening strategy in the U.S., colonoscopy now appears vulnerable at its lofty perch.

First, colonoscopy is inherently cumbersome and expensive, and has unfortunately become more so over time. In an abundance of over-caution, most hospitals now require that patients be accompanied home after colonoscopy by an adult. An otherwise healthy patient who is determined by their physician to be fully alert and oriented after their procedure cannot go home in a taxi. Thus, not one, but two persons now have to coordinate time off from work. Rules recommending that a nurse administering conscious sedation may not be involved in other activities like biopsy and polypectomy have necessitated that there be a second nurse or a technician present. FDA-issued black box warnings and stiff opposition from anesthesiologists have left the issue of gastroenterologist-administered propofol sedation unresolved. While these rules have had little measureable impact on patient safety, they have made colonoscopy less attractive.

Second, recent studies have challenged the efficacy of colonoscopy as a screening tool. An analysis combining patients from three large polyp prevention trials found no reduction in the incidence of colon cancer in a cohort of patients undergoing very close colonoscopy-based colon cancer surveillance.3 Population-based studies from Canada and Germany have found that colonoscopy was ineffective in reducing mortality from right-sided cancers.4, 5

Third, competing technologies like DNA-based fecal testing, capsule endoscopy and CT colonography (CTC) have made substantial progress.

CTC versus colonoscopy

Of these competing technologies, CTC stands out as being the most viable competitor for colonoscopy. In expert hands, CTC has the same accuracy as colonoscopy for cancers and large polyps.6 However, CTC has its own limitations regarding cost, availability, radiation exposure, low accuracy for small polyps and the inability to remove polyps. These limitations notwithstanding, it appears that in the future, it may be possible to perform CTC without a bowel preparation. If this were to happen, there is little doubt in my mind that the balance will be tilted in its favor and that patients will flock to this new technology with an irresistible moniker — virtual colonoscopy. Unlike earlier estimates, it appears that CTC will result in a dramatic reduction in colonoscopy volume. In a study from Wisconsin, only 8 percent of those screened with CTC were referred for colonoscopy.7 This low referral rate reflects the now well-accepted practice by radiologists of “selective polypectomy” whereby polyps less than 5 mm are not reported and a repeat CTC at a shorter interval is recommended for those with polyps 6 to 9 mm.

The role of endoscopic procedures

If colonoscopy rates decline, is there an endoscopic procedure on the horizon that could fill the void? The most notable advance in gastrointestinal endoscopy over the last two decades has been endoscopic ultrasound (EUS). Even with generous assumptions, it is estimated that about 90,000 patients would benefit from EUS/year — a far cry from 14.2 million.8 Endoscopic treatment for GERD and obesity, and Natural Orifice Translumenal Surgery® offer great potential, but there has yet to be a breakthrough technology that has made its way into routine clinical practice. Endoscopy in the post-colonoscopy era will look very much like it did in the colonoscopy era, except there will be a lot less of it. For endoscopic technology, clearly the best is yet to come. However, that may not be true for the endoscopist. It’s time for us gastroenterologists to recognize and prepare for a post-colonoscopy era that will inevitably be dawning, otherwise we may find out that “the future ain’t what it used to be.”


1. Seeff LC, Richards TB, Shapiro JA, Nadel MR, Manninen DL, Given LS, Dong FB, Winges LD, McKenna MT. How many endoscopies are performed for colorectal cancer screening? Results from CDC’s survey of endoscopic capacity. Gastroenterology 2004 Dec;127(6):1670-7.

2. Qualities and Outcomes Report 2008. Accessed July 25th 2010. http://mngastro.advantagelabs.com/sites/mngastro.com/files/mngi_quality_outcomes_2008.pdf.

3. Robertson DJ, Greenberg ER, Beach M, Sandler RS, Ahnen D, Haile RW, Burke CA, Snover DC, Bresalier RS, McKeown-Eyssen G, Mandel JS, Bond JH, Van Stolk RU, Summers RW, Rothstein R, Church TR, Cole BF, Byers T, Mott L, Baron JA. Colorectal cancer in patients under close colonoscopic surveillance. Gastroenterology 2005 Jul;129(1):34-41.

4. Baxter NN, Goldwasser MA, Paszat LF, Saskin R, Urbach DR, Rabeneck L. Association of colonoscopy and death from colorectal cancer. Ann Intern Med 2009 Jan 6;150(1):1-8.

5. Brenner H, Hoffmeister M, Arndt V, Stegmaier C, Altenhofen L, Haug U. Protection from right- and left-sided colorectal neoplasms after colonoscopy: population-based study. J Natl Cancer Inst 2010 Jan 20;102(2):89-95.

6. Pickhardt PJ, Choi JR, Hwang I, Butler JA, Puckett ML, Hildebrandt HA, Wong RK, Nugent PA, Mysliwiec PA, Schindler WR.Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med 2003 Dec 4;349(23):2191-200.

7. Schwartz DC, Dasher KJ, Said A, Gopal DV, Reichelderfer M, Kim DH, Pickhardt PJ, Taylor AJ, Pfau PR. Impact of a CT colonography screening program on endoscopic colonoscopy in clinical practice. Am J Gastroenterol 2008 Feb;103(2):346-51.

8. Parada SK, Peng R, Erickson RA et al. A resource utilization projection study of EUS. Gastrointest Endosc 2002;55:328-34.

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