Optimizing Timing of Follow-up Colonoscopy

Overall Objective: To optimize timing of surveillance colonoscopy. Principal research question and specific aims: To assess the impact of access to a hand-held application on the timing of surveillance colonoscopy. To assess whether access to the tool improves adherence to recommended guidelines for follow-up colonoscopy intervals. Colonoscopy is commonly used for surveillance of patients with high risk of developing colorectal cancer, including those with family history of colorectal cancer and those with colorectal polyps. The recommended timing of surveillance colonoscopy varies by the estimated risk for development of colorectal cancer. The estimated risk varies by family history of colorectal cancer (number of affected individuals, age of the persons affected with CRC) and characteristics of the colorectal polyps (size, number, and histology of colorectal polyps (tubular or villous; high grade or low-grade dysplasia; sessile serrated polyp, sessile serrated polyp with dysplasia, hyperplastic polyp or traditional serrated adenomas). Guidelines take all of these factors into account in the recommendations for follow-up colonoscopy and hence are difficult to recall for the busy clinicians. Colonoscopy surveillance is frequently performed at shorter or longer than the recommended time intervals. The investigators have developed a smart phone application in which the characteristics of the patients can be inputted and the tool provides the recommended time interval for surveillance colonoscopy, based on North American guidelines. The investigators are proposing a pilot randomized trial to determine sample size estimates for a larger trial to assess the utility of this application in clinical practice.

Sex

All

Minimum age

50 Years

Maximum age

75 Years

Inclusion Criteria:

For physician participants, there are no age limits/parameters. All physicians performing colonoscopy on adult patients in Winnipeg will be eligible to participate (other than those involved in pilot testing and study investigators). Participating physicians will be informed that the introduced intervention will be an information tool to help improve care for individuals undergoing colonoscopy, and will be asked to consent to review of their patient records. Participating physicians will be informed that no individual-level information will be disclosed at any time and all analysis will be on anonymized data.

For patient participants:

* Patients must be older than 50 years and up to 75 years old for inclusion in the study data.
* Adequate bowel preparation defined by Boston Bowel Preparation Scale Score of ≥ 2 in each of segments of the colon (Boston bowel prep scale score recording is mandatory in the Winnipeg city-wide endoscopy reporting system);
* Colonoscopy completed to the cecum/ileocolonic anastomosis;
* Colonoscopy performed between 1 to 4 months before randomization of endoscopy physician (to determine baseline adherence) or between 3 to 7 months after randomization (to determine effect of the intervention).

Exclusion Criteria:

Physicians will be excluded if they are away for more than six weeks continuously in the six months after randomization. In this situation, an alternate physician will be recruited and randomized. Thus there is no anticipated loss of follow-up.

Patients will be excluded if any of the following criteria are met:

1. History of inherited CRC predisposition (Lynch Syndrome, Familial adenomatous polyposis, others);
2. Inflammatory bowel disease;
3. Partially excised polyp or endoscopy physician recommending early colonoscopy to document complete excision;
4. Endoscopy physician documenting a rationale for not repeating colonoscopy in future such as co-morbid conditions.

• BACKGROUNDPotet F, Soullard J. Polyps of the rectum and colon. Gut. 1971 Jun;12(6):468-82. doi: 10.1136/gut.12.6.468. PMID 5314569
• BACKGROUNDMuto T, Bussey HJ, Morson BC. The evolution of cancer of the colon and rectum. Cancer. 1975 Dec;36(6):2251-70. doi: 10.1002/cncr.2820360944. PMID 1203876
• BACKGROUNDStryker SJ, Wolff BG, Culp CE, Libbe SD, Ilstrup DM, MacCarty RL. Natural history of untreated colonic polyps. Gastroenterology. 1987 Nov;93(5):1009-13. doi: 10.1016/0016-5085(87)90563-4. PMID 3653628
• BACKGROUNDWinawer SJ, Zauber AG, Ho MN, O'Brien MJ, Gottlieb LS, Sternberg SS, Waye JD, Schapiro M, Bond JH, Panish JF, et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med. 1993 Dec 30;329(27):1977-81. doi: 10.1056/NEJM199312303292701. PMID 8247072
• BACKGROUNDRex DK, Sullivan AW, Perkins AJ, Vemulapalli KC. Colorectal polyp prevalence and aspirational detection targets determined using high definition colonoscopy and a high level detector in 2017. Dig Liver Dis. 2020 Jan;52(1):72-78. doi: 10.1016/j.dld.2019.08.019. Epub 2019 Sep 20. PMID 31543411
• BACKGROUNDLeddin D, Lieberman DA, Tse F, Barkun AN, Abou-Setta AM, Marshall JK, Samadder NJ, Singh H, Telford JJ, Tinmouth J, Wilkinson AN, Leontiadis GI. Clinical Practice Guideline on Screening for Colorectal Cancer in Individuals With a Family History of Nonhereditary Colorectal Cancer or Adenoma: The Canadian Association of Gastroenterology Banff Consensus. Gastroenterology. 2018 Nov;155(5):1325-1347.e3. doi: 10.1053/j.gastro.2018.08.017. Epub 2018 Aug 16. PMID 30121253
• BACKGROUNDSingh H, Demers AA, Xue L, Turner D, Bernstein CN. Time trends in colon cancer incidence and distribution and lower gastrointestinal endoscopy utilization in Manitoba. Am J Gastroenterol. 2008 May;103(5):1249-56. doi: 10.1111/j.1572-0241.2007.01726.x. Epub 2008 Jan 11.